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Vogrig A, Bellizzi F, Burini A, Gigli GL, Girardi L, Honnorat J, Valente M. Sudden unexpected death in epilepsy and ictal asystole in patients with autoimmune encephalitis: a systematic review. Neurol Sci 2024; 45:2811-2823. [PMID: 38194197 PMCID: PMC11081980 DOI: 10.1007/s10072-023-07280-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/27/2023] [Accepted: 12/18/2023] [Indexed: 01/10/2024]
Abstract
OBJECTIVE As autoimmune encephalitis (AE) often involves the mesial temporal structures which are known to be involved in both sudden unexpected death in epilepsy (SUDEP) and ictal asystole (IA), it may represent a good model to study the physiopathology of these phenomena. Herein, we systematically reviewed the occurrence of SUDEP and IA in AE. METHODS We searched 4 databases (MEDLINE, Scopus, Embase, and Web of Science) for studies published between database inception and December 20, 2022, according to the PRISMA guidelines. We selected articles reporting cases of definite/probable/possible/near-SUDEP or IA in patients with possible/definite AE, or with histopathological signs of AE. RESULTS Of 230 records assessed, we included 11 cases: 7 SUDEP/near-SUDEP and 4 IA. All patients with IA were female. The median age at AE onset was 30 years (range: 15-65), and the median delay between AE onset and SUDEP was 11 months; 0.9 months for IA. All the patients presented new-onset seizures, and 10/11 also manifested psychiatric, cognitive, or amnesic disorders. In patients with SUDEP, 2/7 were antibody-positive (1 anti-LGI1, 1 anti-GABABR); all IA cases were antibody-positive (3 anti-NMDAR, 1 anti-GAD65). Six patients received steroid bolus, 3 intravenous immunoglobulin, and 3 plasmapheresis. A pacemaker was implanted in 3 patients with IA. The 6 survivors improved after treatment. DISCUSSION SUDEP and IA can be linked to AE, suggesting a role of the limbic system in their pathogenesis. IA tends to manifest in female patients with temporal lobe seizures early in AE, highlighting the importance of early diagnosis and treatment.
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Affiliation(s)
- Alberto Vogrig
- Clinical Neurology, Department of Medicine (DAME), University of Udine, Udine, Italy.
- Clinical Neurology, Department of Head-Neck and Neuroscience, Azienda Sanitaria Universitaria Friuli Centrale (ASU FC), Piazzale Santa Maria della Misericordia, 15, 33010, Udine, Italy.
| | - Fabrizio Bellizzi
- Clinical Neurology, Department of Medicine (DAME), University of Udine, Udine, Italy
| | - Alessandra Burini
- Clinical Neurology, Department of Medicine (DAME), University of Udine, Udine, Italy
| | - Gian Luigi Gigli
- Clinical Neurology, Department of Medicine (DAME), University of Udine, Udine, Italy
| | - Luca Girardi
- Department of Environmental Systems Science, Swiss Federal Institute of Technology (ETH) Zürich, Zurich, Switzerland
| | - Jérôme Honnorat
- French Reference Center for Paraneoplastic Neurological Syndromes and Autoimmune Encephalitis, Hospital for Neurology and Neurosurgery Pierre Wertheimer, Lyon University Hospital, Lyon, France
- MeLiS Institute - UCBL-CNRS UMR 5284 - INSERM U1314, Université Claude Bernard Lyon 1, Lyon, France
| | - Mariarosaria Valente
- Clinical Neurology, Department of Medicine (DAME), University of Udine, Udine, Italy
- Clinical Neurology, Department of Head-Neck and Neuroscience, Azienda Sanitaria Universitaria Friuli Centrale (ASU FC), Piazzale Santa Maria della Misericordia, 15, 33010, Udine, Italy
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Kouchi H, Smith J, Georges B, Cracknell F, Bezin L, Rheims S. Serotonin 2C receptor in a rat model of temporal lobe epilepsy: From brainstem expression to pharmacological blockade in relation to ventilatory function. Epilepsia 2024. [PMID: 38738911 DOI: 10.1111/epi.18006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/16/2023] [Revised: 04/25/2024] [Accepted: 04/25/2024] [Indexed: 05/14/2024]
Abstract
Because of its involvement in breathing control and neuronal excitability, dysregulation of the serotonin (5-HT) 2C receptor (5-HT2C) might play a key role in sudden unexpected death in epilepsy. Seizure-induced respiratory arrest is thus prevented by a 5-HT2B/C agonist in different seizure model. However, the specific contribution of 5-HT2C in chronic epilepsy-related respiratory dysfunction remains unknown. In a rat model of temporal lobe epilepsy (EPI rats), in which we previously reported interictal respiratory dysfunctions and a reduction of brainstem 5-HT tone, quantitative reverse transcriptase polymerase chain reaction showed overexpression of TPH2 (5-HT synthesis enzyme), SERT (5-HT reuptake transporter), and 5-HT2C transcript levels in the brainstem of EPI rats, and of RNA-specific adenosine deaminase (ADAR1, ADAR2) involved in the production of 5-HT2C isoforms. Interictal ventilation was assessed with whole-body plethysmography before and 2 h after administration of SB242084 (2 mg/kg), a specific antagonist of 5-HT2C. As expected, SB242084 administration induced a progressive decrease in ventilatory parameters and an alteration of breathing stability in both control and EPI rats. However, the size of the SB242084 effect was lower in EPI rats than in controls. Increased 5-HT2C gene expression in the brainstem of EPI rats could be part of a compensatory mechanism against epilepsy-related low 5-HT tone and expression of 5-HT2C isoforms for which 5-HT affinity might be lower.
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Affiliation(s)
- Hayet Kouchi
- Lyon Neuroscience Research Center, Inserm U1028, CNRS UMR5292, Lyon 1 University, Lyon, France
| | - Jonathon Smith
- Lyon Neuroscience Research Center, Inserm U1028, CNRS UMR5292, Lyon 1 University, Lyon, France
| | - Béatrice Georges
- Lyon Neuroscience Research Center, Inserm U1028, CNRS UMR5292, Lyon 1 University, Lyon, France
| | - Freya Cracknell
- Lyon Neuroscience Research Center, Inserm U1028, CNRS UMR5292, Lyon 1 University, Lyon, France
| | - Laurent Bezin
- Lyon Neuroscience Research Center, Inserm U1028, CNRS UMR5292, Lyon 1 University, Lyon, France
| | - Sylvain Rheims
- Lyon Neuroscience Research Center, Inserm U1028, CNRS UMR5292, Lyon 1 University, Lyon, France
- Department of Functional Neurology and Epileptology, Hospices Civils de Lyon and Lyon 1 University, Lyon, France
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Umezu HL, Bittencourt-Silva PG, Mourão FAG, Moreira FA, Moraes MFD, Santos VR, da Silva GSF. Respiratory activity during seizures induced by pentylenetetrazole. Respir Physiol Neurobiol 2024; 323:104229. [PMID: 38307440 DOI: 10.1016/j.resp.2024.104229] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/25/2023] [Revised: 01/27/2024] [Accepted: 01/29/2024] [Indexed: 02/04/2024]
Abstract
This study investigated the respiratory activity in adult Wistar rats across different behavioral seizure severity induced by pentylenetetrazole (PTZ). Animals underwent surgery for electrodes implantation, allowing simultaneous EEG and diaphragm EMG (DIAEMG) recordings and the respiratory frequency and DIAEMG amplitude were measured. Seizures were acutely induced through PTZ injection and classified based on a pre-established score, with absence-like seizures (spike wave discharge (SWD) events on EEG) representing the lowest score. The respiratory activity was grouped into the different seizure severities. During absence-like and myoclonic jerk seizures, the breathing frequency decreased significantly (∼50% decrease) compared to pre- and post-ictal periods. Pronounced changes occurred with more severe seizures (clonic and tonic) with periods of apnea, especially during tonic seizures. Apnea duration was significantly higher in tonic compared to clonic seizures. Notably, during PTZ-induced tonic seizures the apnea events were marked by tonic DIAEMG contraction (tonic-phase apnea). In the majority of animals (5 out of 7) this was a fatal event in which the seizure-induced respiratory arrest preceded the asystole. In conclusion, we provide an assessment of the respiratory activity in the PTZ-induced acute seizures and showed that breathing dysfunction is more pronounced in seizures with higher severity.
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Affiliation(s)
- Hanna L Umezu
- Department of Physiology and Biophysics, Institute of Biological Science, Federal University of Minas Gerais (ICB/UFMG), Belo Horizonte, Brazil
| | - Paloma G Bittencourt-Silva
- Department of Physiology and Biophysics, Institute of Biological Science, Federal University of Minas Gerais (ICB/UFMG), Belo Horizonte, Brazil
| | - Flávio A G Mourão
- Department of Physiology and Biophysics, Institute of Biological Science, Federal University of Minas Gerais (ICB/UFMG), Belo Horizonte, Brazil; Graduate Program in Neuroscience, Institute of Biological Science, Federal University of Minas Gerais (ICB/UFMG), Belo Horizonte, Brazil
| | - Fabrício A Moreira
- Department of Pharmacology, Institute of Biological Science, Federal University of Minas Gerais (ICB/UFMG), Belo Horizonte, Brazil
| | - Márcio Flávio D Moraes
- Department of Physiology and Biophysics, Institute of Biological Science, Federal University of Minas Gerais (ICB/UFMG), Belo Horizonte, Brazil; Graduate Program in Neuroscience, Institute of Biological Science, Federal University of Minas Gerais (ICB/UFMG), Belo Horizonte, Brazil
| | - Victor R Santos
- Department of Morphology, Institute of Biological Science, Federal University of Minas Gerais (ICB/UFMG), Belo Horizonte, Brazil
| | - Glauber S F da Silva
- Department of Physiology and Biophysics, Institute of Biological Science, Federal University of Minas Gerais (ICB/UFMG), Belo Horizonte, Brazil.
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Engel C, Chevarin M, Piard J, Abad M, Thomas Q, Carmignac V, Duffourd Y, Lemesle-Martin M, Tarris G, Thauvin-Robinet C, Vabres P, Faivre L, Kuentz P. Allelic heterogeneity in a patient with postzygotic MTOR-related hypomelanosis of Ito with neurodevelopmental abnormalities. Clin Genet 2024; 105:581-583. [PMID: 38379111 DOI: 10.1111/cge.14511] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2023] [Revised: 01/25/2024] [Accepted: 02/12/2024] [Indexed: 02/22/2024]
Abstract
A case of mosaic MTOR-associated hemimegalencephaly and hypomelanosis of Ito, died at 33 probably because of sudden unexpected death in epilepsy. Assessment of the variant allele fraction (VAF) in different tissues postmortem showed high variability not correlated with clinical features, representing the most detailed assessment of VAFs in different tissues to date.
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Affiliation(s)
- Camille Engel
- Centre de Génétique Humaine, CHU Besançon, Besançon, France
- INSERM UMR1231 GAD "Génétique des Anomalies du Développement", Université de Bourgogne Franche-Comté, Dijon, France
| | - Martin Chevarin
- INSERM UMR1231 GAD "Génétique des Anomalies du Développement", Université de Bourgogne Franche-Comté, Dijon, France
- Unité Fonctionnelle Innovation Diagnostique dans les Maladies Rares, FHU-TRANSLAD, CHU Dijon Bourgogne, Dijon, France
| | - Juliette Piard
- Centre de Génétique Humaine, CHU Besançon, Besançon, France
- INSERM UMR1231 GAD "Génétique des Anomalies du Développement", Université de Bourgogne Franche-Comté, Dijon, France
| | - Marine Abad
- Service d'Anatomie Pathologique, CHU Besançon, Besançon, France
| | - Quentin Thomas
- INSERM UMR1231 GAD "Génétique des Anomalies du Développement", Université de Bourgogne Franche-Comté, Dijon, France
- Service de Neurologie, CHU Dijon Bourgogne, Dijon, France
| | - Virginie Carmignac
- INSERM UMR1231 GAD "Génétique des Anomalies du Développement", Université de Bourgogne Franche-Comté, Dijon, France
| | - Yannis Duffourd
- INSERM UMR1231 GAD "Génétique des Anomalies du Développement", Université de Bourgogne Franche-Comté, Dijon, France
- Unité Fonctionnelle Innovation Diagnostique dans les Maladies Rares, FHU-TRANSLAD, CHU Dijon Bourgogne, Dijon, France
| | | | - Georges Tarris
- Service de Neurologie, CHU Dijon Bourgogne, Dijon, France
| | - Christel Thauvin-Robinet
- INSERM UMR1231 GAD "Génétique des Anomalies du Développement", Université de Bourgogne Franche-Comté, Dijon, France
- Unité Fonctionnelle Innovation Diagnostique dans les Maladies Rares, FHU-TRANSLAD, CHU Dijon Bourgogne, Dijon, France
- Centre de Génétique et Centres de référence Anomalies du Développement et Déficience Intellectuelle, FHU-TRANSLAD et Institut GIMI, CHU Dijon Bourgogne, Dijon, France
| | - Pierre Vabres
- INSERM UMR1231 GAD "Génétique des Anomalies du Développement", Université de Bourgogne Franche-Comté, Dijon, France
- Centre de référence MAGEC "Maladies Génétiques à Expression Cutanée", FHU-TRANSLAD et Institut GIMI, CHU Dijon Bourgogne, Dijon, France
| | - Laurence Faivre
- INSERM UMR1231 GAD "Génétique des Anomalies du Développement", Université de Bourgogne Franche-Comté, Dijon, France
- Centre de Génétique et Centres de référence Anomalies du Développement et Déficience Intellectuelle, FHU-TRANSLAD et Institut GIMI, CHU Dijon Bourgogne, Dijon, France
| | - Paul Kuentz
- INSERM UMR1231 GAD "Génétique des Anomalies du Développement", Université de Bourgogne Franche-Comté, Dijon, France
- Oncobiologie Génétique Bioinformatique, FHU-TRANSLAD et Institut GIMI, CHU Besançon, Besançon, France
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Sullivan J, Benítez A, Roth J, Andrews JS, Shah D, Butcher E, Jones A, Cross JH. A systematic literature review on the global epidemiology of Dravet syndrome and Lennox-Gastaut syndrome: Prevalence, incidence, diagnosis, and mortality. Epilepsia 2024; 65:1240-1263. [PMID: 38252068 DOI: 10.1111/epi.17866] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/29/2023] [Revised: 12/14/2023] [Accepted: 12/14/2023] [Indexed: 01/23/2024]
Abstract
Dravet syndrome (DS) and Lennox-Gastaut syndrome (LGS) are rare developmental and epileptic encephalopathies associated with seizure and nonseizure symptoms. A comprehensive understanding of how many individuals are affected globally, the diagnostic journey they face, and the extent of mortality associated with these conditions is lacking. Here, we summarize and evaluate published data on the epidemiology of DS and LGS in terms of prevalence, incidence, diagnosis, genetic mutations, and mortality and sudden unexpected death in epilepsy (SUDEP) rates. The full study protocol is registered on PROSPERO (CRD42022316930). After screening 2172 deduplicated records, 91 unique records were included; 67 provided data on DS only, 17 provided data on LGS only, and seven provided data on both. Case definitions varied considerably across studies, particularly for LGS. Incidence and prevalence estimates per 100 000 individuals were generally higher for LGS than for DS (LGS: incidence proportion = 14.5-28, prevalence = 5.8-60.8; DS: incidence proportion = 2.2-6.5, prevalence = 1.2-6.5). Diagnostic delay was frequently reported for LGS, with a wider age range at diagnosis reported than for DS (DS, 1.6-9.2 years; LGS, 2-15 years). Genetic screening data were reported by 63 studies; all screened for SCN1A variants, and only one study specifically focused on individuals with LGS. Individuals with DS had a higher mortality estimate per 1000 person-years than individuals with LGS (DS, 15.84; LGS, 6.12) and a lower median age at death. SUDEP was the most frequently reported cause of death for individuals with DS. Only four studies reported mortality information for LGS, none of which included SUDEP. This systematic review highlights the paucity of epidemiological data available for DS and especially LGS, demonstrating the need for further research and adoption of standardized diagnostic criteria.
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Affiliation(s)
- Joseph Sullivan
- Department of Neurology, University of California, San Francisco, San Francisco, California, USA
| | - Arturo Benítez
- Takeda Development Center Americas, Cambridge, Massachusetts, USA
| | - Jeannine Roth
- Takeda Pharmaceuticals International, Zurich, Switzerland
| | - J Scott Andrews
- Takeda Development Center Americas, Cambridge, Massachusetts, USA
| | - Drishti Shah
- Takeda Development Center Americas, Cambridge, Massachusetts, USA
| | | | | | - J Helen Cross
- University College London, National Institute for Health and Care Research Biomedical Research Centre, London, UK
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Pace A, Watkins L, Fiott D, Bassett P, Laugharne R, James C, Shankar R. Identifying co-morbidities and risk in people with epilepsy: The Maltese experience. Epilepsy Behav 2024; 155:109795. [PMID: 38643661 DOI: 10.1016/j.yebeh.2024.109795] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/09/2023] [Revised: 02/24/2024] [Accepted: 04/14/2024] [Indexed: 04/23/2024]
Abstract
BACKGROUND People with epilepsy are at increased risk of multiple co-morbidities that may influence risk of adverse outcomes including impact on quality of life and premature mortality. These risk factors include potentially modifiable clinical characteristics associated with sudden unexpected death in epilepsy (SUDEP). For services to tackle risk, the clinical complexity of the target epilepsy population needs to be defined. While this has been comprehensively studied in large, economically developed countries little knowledge of these issues exist in small economically developed countries, like Malta (population: 500,000). METHODS This was a single centre study focused exclusively on patients attending Gozo General Hospital (GGH) Malta. STROBE guidance for reporting cross sectional studies was used to design and report the study. This was a retrospective review of standard care and SUDEP and seizure risks provided to all adults (over 18 years) with epilepsy attending GGH (2018-2021). RESULTS The review identified 68 people and 92% were compliant with their anti-seizure medication. A fifth (21%) had an intellectual disability. Despite only one patient having a psychotic illness, 19% were on antipsychotic medication. Only 18% of patients had a specific epilepsy care plan, 6% nocturnal surveillance and none had received advice on SUDEP. DISCUSSION Patient outcomes may be improved with increasing rates of personalized epilepsy care plans, appropriate nocturnal surveillance and reducing the prescription of antipsychotic medication as it is associated with greater risk of mortality. Issues such as stigma and shame appear to play a significant role in small communities and their access to care.
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Affiliation(s)
| | - Lance Watkins
- University of South Wales, Pontypridd, UK; Swansea Bay University Health Board, Port Talbot, UK; Cornwall Intellectual Disability Equitable Research (CIDER) University of Plymouth Peninsula School of Medicine, Truro, UK
| | | | | | - Richard Laugharne
- Cornwall Intellectual Disability Equitable Research (CIDER) University of Plymouth Peninsula School of Medicine, Truro, UK; Cornwall Intellectual Disability Equitable Research (CIDER), Cornwall Partnership NHS Foundation Trust Truro, UK
| | | | - Rohit Shankar
- Cornwall Intellectual Disability Equitable Research (CIDER) University of Plymouth Peninsula School of Medicine, Truro, UK; Statsconsultancy Ltd, Bucks, UK.
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Hawkins NA, Speakes N, Kearney JA. Fine Mapping and Candidate Gene Analysis of Dravet Syndrome Modifier Loci on Mouse Chromosomes 7 and 8. bioRxiv 2024:2024.04.15.589561. [PMID: 38659879 PMCID: PMC11042286 DOI: 10.1101/2024.04.15.589561] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 04/26/2024]
Abstract
Dravet syndrome is a developmental and epileptic encephalopathy (DEE) characterized by intractable seizures, comorbidities related to developmental, cognitive, and motor delays, and a high mortality burden due to sudden unexpected death in epilepsy (SUDEP). Most Dravet syndrome cases are attributed to SCN1A haploinsufficiency, with genetic modifiers and environmental factors influencing disease severity. Mouse models with heterozygous deletion of Scn1a recapitulate key features of Dravet syndrome, including seizures and premature mortality; however, severity varies depending on genetic background. Here, we refined two Dravet survival modifier (Dsm) loci, Dsm2 on chromosome 7 and Dsm3 on chromosome 8, using interval-specific congenic (ISC) mapping. Dsm2 was complex and encompassed at least two separate loci, while Dsm3 was refined to a single locus. Candidate modifier genes within these refined loci were prioritized based on brain expression, strain-dependent differences, and biological relevance to seizures or epilepsy. High priority candidate genes for Dsm2 include Nav2, Ptpn5, Ldha, Dbx1, Prmt3 and Slc6a5, while Dsm3 has a single high priority candidate, Psd3. This study underscores the complex genetic architecture underlying Dravet syndrome and provides insights into potential modifier genes that could influence disease severity and serve as novel therapeutic targets.
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Affiliation(s)
- Nicole A. Hawkins
- Department of Pharmacology, Northwestern University Feinberg School of Medicine, Chicago, IL, USA 60611
| | - Nathan Speakes
- Department of Pharmacology, Northwestern University Feinberg School of Medicine, Chicago, IL, USA 60611
| | - Jennifer A. Kearney
- Department of Pharmacology, Northwestern University Feinberg School of Medicine, Chicago, IL, USA 60611
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Aurlien DB, Taubøll E. Antiseizure medication and SUDEP - a need for unifying methodology in research. Front Neurol 2024; 15:1385468. [PMID: 38694773 PMCID: PMC11061368 DOI: 10.3389/fneur.2024.1385468] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/12/2024] [Accepted: 04/03/2024] [Indexed: 05/04/2024] Open
Abstract
The risk of sudden unexpected death in epilepsy (SUDEP) increases with the frequency of generalized tonic-clonic seizures. Carbamazepine (CBZ) and lamotrigine (LTG) have been suggested to increase the risk. However, the prevailing viewpoint is that the choice of antiseizure medication (ASM) does not influence the occurrence. We have explored the approach to addressing this question in relevant studies to evaluate the validity of the conclusions reached. A systematic search was performed in PubMed to identify all controlled studies on SUDEP risk in individuals on CBZ or LTG. Studies were categorized according to whether idiopathic generalized epilepsy (IGE) or females were considered separately, and whether data were adjusted for seizure frequency. Eight studies on CBZ and six studies on LTG were identified. For CBZ, one study showed a significantly increased risk of SUDEP without adjustment for seizure frequency. Another study found significantly increased risk after statistical adjustment for seizure frequency and one study found increased risk with high blood levels. Five other studies found no increase in risk. For LTG, one study showed a significantly increased risk in patients with IGE as opposed to focal epilepsy, and another study showed a significantly increased risk in females. None of the subsequent studies on LTG and none of the studies on CBZ considered females with IGE separately. Taken together the available studies suggest that LTG, and possibly CBZ, may increase occurrence of SUDEP when used in females with IGE. Additional studies with sub-group analysis of females with IGE are needed.
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Affiliation(s)
- Dag Bruheim Aurlien
- Neuroscience Research Group and Department of Neurology, Stavanger University Hospital, Stavanger, Norway
| | - Erik Taubøll
- Department of Neurology, Oslo University Hospital, Oslo, Norway
- Faculty of Medicine, University of Oslo, Oslo, Norway
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Sridech W, Intamul K, Saengsin K, Wiwattanadittakul N, Sittiwangkul R, Katanyuwong K, Silvilairat S, Sanguansermsri C. Cardiac dysfunctions in children with drug-resistant epilepsy. Front Neurol 2024; 15:1381293. [PMID: 38689875 PMCID: PMC11058992 DOI: 10.3389/fneur.2024.1381293] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/03/2024] [Accepted: 04/02/2024] [Indexed: 05/02/2024] Open
Abstract
Objective There were reports of cardiac dysfunction that led to sudden unexpected death in epilepsy (SUDEP) in patients with epilepsy. Early detection of cardiac dysfunction can lead to early management to prevent sudden cardiac death in these patients. The objective of our study is to assess cardiac functions in children with drug-resistant epilepsy (DRE) compared with the normal population by using a standard echocardiogram (SE), tissue Doppler imaging (TDI) and myocardial strain evaluations (MSE). Method Twenty-seven children who have been diagnosed with DRE based on the International League against Epilepsy (ILAE) were included in the study, along with 27 children whose ages match those of the normal control group. Results Seventeen children, median age 12 years old, were using more than four anti-seizure medications. Structural brain lesions were the most common cause of epilepsy, 55.6% (15). Generalized tonic-clonic seizures were the most common seizure type, 55.6% (15). Children with DRE had a lower early mitral valve E wave inflow velocity compared with the control group (p < 0.05). They also had lowered early diastolic velocities (e') and myocardial performance index (MPI) when compared with the control group (p < 0.05). There was a statistically significant difference in left ventricular myocardial strain in children with DRE, with an average of -21.1 (IQR -23.5 and -19.4) and control, -25.5 (IQR -27.3 and -24.2). Significance Children with DRE have an impairment of left ventricular diastolic function and myocardial strain, which could indicate decreased myocardial deformation and contraction compared with controls. These cardiological assessments can be used to evaluate children with DRE for early diagnosis and management of their cardiac dysfunction.
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Affiliation(s)
- Watthana Sridech
- Department of Pediatrics, Faculty of Medicine, Chiang Mai University, Chiang Mai, Thailand
| | - Kamonchanok Intamul
- Cardiology Division, Department of Pediatrics, Faculty of Medicine, Chiang Mai University, Chiang Mai, Thailand
| | - Kwannapas Saengsin
- Cardiology Division, Department of Pediatrics, Faculty of Medicine, Chiang Mai University, Chiang Mai, Thailand
| | | | - Rekwan Sittiwangkul
- Cardiology Division, Department of Pediatrics, Faculty of Medicine, Chiang Mai University, Chiang Mai, Thailand
| | - Kamornwan Katanyuwong
- Neurology Division, Department of Pediatrics, Faculty of Medicine, Chiang Mai University, Chiang Mai, Thailand
| | - Suchaya Silvilairat
- Cardiology Division, Department of Pediatrics, Faculty of Medicine, Chiang Mai University, Chiang Mai, Thailand
| | - Chinnuwat Sanguansermsri
- Neurology Division, Department of Pediatrics, Faculty of Medicine, Chiang Mai University, Chiang Mai, Thailand
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Guo J, Min D, Farrell EK, Zhou Y, Faingold CL, Cotten JF, Feng HJ. Enhancing the action of serotonin by three different mechanisms prevents spontaneous seizure-induced mortality in Dravet mice. Epilepsia 2024. [PMID: 38593237 DOI: 10.1111/epi.17966] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/17/2023] [Revised: 03/12/2024] [Accepted: 03/13/2024] [Indexed: 04/11/2024]
Abstract
OBJECTIVE Sudden unexpected death in epilepsy (SUDEP) is an underestimated complication of epilepsy. Previous studies have demonstrated that enhancement of serotonergic neurotransmission suppresses seizure-induced sudden death in evoked seizure models. However, it is unclear whether elevated serotonin (5-HT) function will prevent spontaneous seizure-induced mortality (SSIM), which is characteristic of human SUDEP. We examined the effects of 5-HT-enhancing agents that act by three different pharmacological mechanisms on SSIM in Dravet mice, which exhibit a high incidence of SUDEP, modeling human Dravet syndrome. METHODS Dravet mice of both sexes were evaluated for spontaneous seizure characterization and changes in SSIM incidence induced by agents that enhance 5-HT-mediated neurotransmission. Fluoxetine (a selective 5-HT reuptake inhibitor), fenfluramine (a 5-HT releaser and agonist), SR 57227 (a specific 5-HT3 receptor agonist), or saline (vehicle) was intraperitoneally administered over an 8-day period in Dravet mice, and the effect of these treatments on SSIM was examined. RESULTS Spontaneous seizures in Dravet mice generally progressed from wild running to tonic seizures with or without SSIM. Fluoxetine at 30 mg/kg, but not at 20 or 5 mg/kg, significantly reduced SSIM compared with the vehicle control. Fenfluramine at 1-10 mg/kg, but not .2 mg/kg, fully protected Dravet mice from SSIM, with all mice surviving. Compared with the vehicle control, SR 57227 at 20 mg/kg, but not at 10 or 5 mg/kg, significantly lowered SSIM. The effect of these drugs on SSIM was independent of sex. SIGNIFICANCE Our data demonstrate that elevating serotonergic function by fluoxetine, fenfluramine, or SR 57227 significantly reduces or eliminates SSIM in Dravet mice in a sex-independent manner. These findings suggest that deficits in serotonergic neurotransmission likely play an important role in the pathogenesis of SSIM, and fluoxetine and fenfluramine, which are US Food and Drug Administration-approved medications, may potentially prevent SUDEP in at-risk patients.
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Affiliation(s)
- Jialing Guo
- National Health Commission Key Laboratory of Birth Defect Research and Prevention, Hunan Provincial Maternal and Child Health Care Hospital, Changsha, China
- Department of Anesthesia, Critical Care, and Pain Medicine, Massachusetts General Hospital, Boston, Massachusetts, USA
- Department of Anesthesia, Harvard Medical School, Boston, Massachusetts, USA
| | - Daniel Min
- Department of Anesthesia, Critical Care, and Pain Medicine, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Emory K Farrell
- Department of Anesthesia, Critical Care, and Pain Medicine, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Yupeng Zhou
- Department of Anesthesia, Critical Care, and Pain Medicine, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Carl L Faingold
- Department of Pharmacology, Southern Illinois University School of Medicine, Springfield, Illinois, USA
| | - Joseph F Cotten
- Department of Anesthesia, Critical Care, and Pain Medicine, Massachusetts General Hospital, Boston, Massachusetts, USA
- Department of Anesthesia, Harvard Medical School, Boston, Massachusetts, USA
| | - Hua-Jun Feng
- Department of Anesthesia, Critical Care, and Pain Medicine, Massachusetts General Hospital, Boston, Massachusetts, USA
- Department of Anesthesia, Harvard Medical School, Boston, Massachusetts, USA
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11
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Ito Y, Hata N, Maesawa S, Tanei T, Ishizaki T, Mutoh M, Hashida M, Kobayashi Y, Saito R. Characteristics of deceased subjects transported to a postmortem imaging center due to unusual death related to epilepsy. Epilepsia Open 2024; 9:592-601. [PMID: 38173171 PMCID: PMC10984304 DOI: 10.1002/epi4.12891] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/13/2023] [Revised: 12/13/2023] [Accepted: 12/16/2023] [Indexed: 01/05/2024] Open
Abstract
OBJECTIVE Patients with epilepsy have high risk of experiencing uncommon causes of death. This study aimed to evaluate patients who underwent unusual deaths related to epilepsy and identify factors that may contribute to these deaths and may also include sudden unexpected death in epilepsy (SUDEP). METHODS We analyzed 5291 cases in which a postmortem imaging (PMI) study was performed using plane CT, because of an unexplained death. A rapid troponin T assay was performed using peripheral blood samples. Clinical information including the cause of death suspected by the attending physician, body position, place of death, medical history, and antiseizure medications was evaluated. RESULTS A total of 132 (2.6%) patients had an obvious history of epilepsy, while 5159 individuals had no history of epilepsy (97.4%). Cerebrovascular disease was the cause of death in 1.6% of patients in the group with epilepsy, and this was significantly lower than that in the non-epilepsy group. However, drowning was significantly higher (9.1% vs. 4.4%). Unspecified cause of death was significantly more frequent in the epilepsy group (78.0% vs. 57.8%). Furthermore, the proportion of patients who demonstrated elevation of troponin T levels without prior cardiac disease was significantly higher in the epilepsy group (37.9% vs. 31.1%). At discovery of death, prone position was dominant (30.3%), with deaths occurring most commonly in the bedroom (49.2%). No antiseizure medication had been prescribed in 12% of cases, while 29.5% of patients were taking multiple antiseizure medications. SIGNIFICANCE The prevalence of epilepsy in individuals experiencing unusual death was higher than in the general population. Despite PMI studies, no definitive cause of death was identified in a significant proportion of cases. The high troponin T levels may be explained by long intervals between death and examination or by higher incidence of myocardial damage at the time of death. PLAIN LANGUAGE SUMMARY This study investigated unusual deaths in epilepsy patients, analyzing 5291 postmortem imaging cases. The results showed that 132 cases (2.6%) had a clear history of epilepsy. In these cases, only 22% cases were explained after postmortem examination, which is less than in non-epilepsy group (42.2%). Cerebrovascular disease was less common in the epilepsy group, while drowning was more common. Elevated troponin T levels, which suggest possibility of myocardial damage or long intervals between death and examination, were also more frequent in the epilepsy group compared to non-epilepsy group.
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Affiliation(s)
- Yoshiki Ito
- Department of NeurosurgeryNagoya University School of MedicineNagoyaAichiJapan
- Department of Neurosurgery, Sakura General HospitalAichiJapan
| | - Nobuhiro Hata
- Department of Neurosurgery, Sakura General HospitalAichiJapan
| | - Satoshi Maesawa
- Department of NeurosurgeryNagoya University School of MedicineNagoyaAichiJapan
| | - Takafumi Tanei
- Department of NeurosurgeryNagoya University School of MedicineNagoyaAichiJapan
| | - Tomotaka Ishizaki
- Department of NeurosurgeryNagoya University School of MedicineNagoyaAichiJapan
| | - Manabu Mutoh
- Department of NeurosurgeryNagoya University School of MedicineNagoyaAichiJapan
| | - Miki Hashida
- Department of NeurosurgeryNagoya University School of MedicineNagoyaAichiJapan
| | | | - Ryuta Saito
- Department of NeurosurgeryNagoya University School of MedicineNagoyaAichiJapan
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12
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Ricordeau F, Chouchou F, Pichot V, Roche F, Petitjean T, Gormand F, Bastuji H, Charbonnier E, Le Cam P, Stauffer E, Rheims S, Peter-Derex L. Impaired post-sleep apnea autonomic arousals in patients with drug-resistant epilepsy. Clin Neurophysiol 2024; 160:1-11. [PMID: 38367308 DOI: 10.1016/j.clinph.2024.02.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/09/2023] [Revised: 12/20/2023] [Accepted: 02/04/2024] [Indexed: 02/19/2024]
Abstract
OBJECTIVE Sudden and unexpected deaths in epilepsy (SUDEP) pathophysiology may involve an interaction between respiratory dysfunction and sleep/wake state regulation. We investigated whether patients with epilepsy exhibit impaired sleep apnea-related arousals. METHODS Patients with drug-resistant (N = 20) or drug-sensitive (N = 20) epilepsy and obstructive sleep apnea, as well as patients with sleep apnea but without epilepsy (controls, N = 20) were included. We explored (1) the respiratory arousal threshold based on nadir oxygen saturation, apnea-hypopnea index, and fraction of hypopnea among respiratory events; (2) the cardiac autonomic response to apnea/hypopnea quantified as percentages of changes from the baseline in RR intervals (RRI), high (HF) and low (LF) frequency powers, and LF/HF. RESULTS The respiratory arousal threshold did not differ between groups. At arousal onset, RRI decreased (-9.42%) and LF power (179%) and LF/HF ratio (190%) increased. This was followed by an increase in HF power (118%), p < 0.05. The RRI decrease was lower in drug-resistant (-7.40%) than in drug-sensitive patients (-9.94%) and controls (-10.91%), p < 0.05. LF and HF power increases were higher in drug-resistant (188%/126%) than in drug-sensitive patients (172%/126%) and controls (177%/115%), p < 0.05. CONCLUSIONS Cardiac reactivity following sleep apnea is impaired in drug-resistant epilepsy. SIGNIFICANCE This autonomic dysfunction might contribute to SUDEP pathophysiology.
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Affiliation(s)
- François Ricordeau
- Centre for Sleep Medicine and Respiratory Diseases, Hospices Civils de Lyon, Lyon, France; Department of Functional Neurology and Epileptology, Hospices Civils de Lyon, Lyon, France
| | - Florian Chouchou
- IRISSE Laboratory (EA4075), UFR SHE, University of La Réunion, Le Tampon, France
| | - Vincent Pichot
- SAINBIOSE, INSERM U1059, Saint-Etienne Jean-Monnet University, Mines Saint-Etienne, France; Clinical Physiology and Exercise, Visas Center, Saint Etienne University Hospital, France
| | - Frédéric Roche
- SAINBIOSE, INSERM U1059, Saint-Etienne Jean-Monnet University, Mines Saint-Etienne, France; Clinical Physiology and Exercise, Visas Center, Saint Etienne University Hospital, France
| | - Thierry Petitjean
- Centre for Sleep Medicine and Respiratory Diseases, Hospices Civils de Lyon, Lyon, France
| | - Frédéric Gormand
- Centre for Sleep Medicine and Respiratory Diseases, Hospices Civils de Lyon, Lyon, France
| | - Hélène Bastuji
- Centre for Sleep Medicine and Respiratory Diseases, Hospices Civils de Lyon, Lyon, France; Lyon Neuroscience Research Center, CNRS UMR 5292 / INSERM U1028 and Lyon 1 University, Lyon, France
| | - Eléna Charbonnier
- Centre for Sleep Medicine and Respiratory Diseases, Hospices Civils de Lyon, Lyon, France
| | - Pierre Le Cam
- Centre for Sleep Medicine and Respiratory Diseases, Hospices Civils de Lyon, Lyon, France
| | - Emeric Stauffer
- Centre for Sleep Medicine and Respiratory Diseases, Hospices Civils de Lyon, Lyon, France; Inter-university Laboratoryof Human MovementBiology (LIBM) EA7424, Team « Vascular Biology and Red Blood Cell », Lyon 1 University, Lyon, France; Respiratory Functional Investigation & Physical Activity Department, Hospices Civils de Lyon, Lyon, France
| | - Sylvain Rheims
- Department of Functional Neurology and Epileptology, Hospices Civils de Lyon, Lyon, France; Lyon Neuroscience Research Center, CNRS UMR 5292 / INSERM U1028 and Lyon 1 University, Lyon, France; Lyon 1 University, Lyon, France
| | - Laure Peter-Derex
- Centre for Sleep Medicine and Respiratory Diseases, Hospices Civils de Lyon, Lyon, France; Lyon Neuroscience Research Center, CNRS UMR 5292 / INSERM U1028 and Lyon 1 University, Lyon, France; Lyon 1 University, Lyon, France.
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13
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Goldenholz DM, Karoly PJ, Viana PF, Nurse E, Loddenkemper T, Schulze-Bonhage A, Vieluf S, Bruno E, Nasseri M, Richardson MP, Brinkmann BH, Westover MB. Minimum clinical utility standards for wearable seizure detectors: A simulation study. Epilepsia 2024; 65:1017-1028. [PMID: 38366862 PMCID: PMC11018505 DOI: 10.1111/epi.17917] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/12/2023] [Revised: 01/11/2024] [Accepted: 02/01/2024] [Indexed: 02/18/2024]
Abstract
OBJECTIVE Epilepsy management employs self-reported seizure diaries, despite evidence of seizure underreporting. Wearable and implantable seizure detection devices are now becoming more widely available. There are no clear guidelines about what levels of accuracy are sufficient. This study aimed to simulate clinical use cases and identify the necessary level of accuracy for each. METHODS Using a realistic seizure simulator (CHOCOLATES), a ground truth was produced, which was then sampled to generate signals from simulated seizure detectors of various capabilities. Five use cases were evaluated: (1) randomized clinical trials (RCTs), (2) medication adjustment in clinic, (3) injury prevention, (4) sudden unexpected death in epilepsy (SUDEP) prevention, and (5) treatment of seizure clusters. We considered sensitivity (0%-100%), false alarm rate (FAR; 0-2/day), and device type (external wearable vs. implant) in each scenario. RESULTS The RCT case was efficient for a wide range of wearable parameters, though implantable devices were preferred. Lower accuracy wearables resulted in subtle changes in the distribution of patients enrolled in RCTs, and therefore higher sensitivity and lower FAR values were preferred. In the clinic case, a wide range of sensitivity, FAR, and device type yielded similar results. For injury prevention, SUDEP prevention, and seizure cluster treatment, each scenario required high sensitivity and yet was minimally influenced by FAR. SIGNIFICANCE The choice of use case is paramount in determining acceptable accuracy levels for a wearable seizure detection device. We offer simulation results for determining and verifying utility for specific use case and specific wearable parameters.
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Affiliation(s)
- Daniel M Goldenholz
- Department of Neurology, Harvard Medical School, Boston, Massachusetts, USA
- Department of Neurology, Beth Israel Deaconess Medical Center, Boston, Massachusetts, USA
| | - Philippa J Karoly
- Department of Neurology, University of Melbourne, Melbourne, Victoria, Australia
| | - Pedro F Viana
- School of Neuroscience, Institute of Psychiatry, Psychology, and Neuroscience, King's College London, London, UK
- Faculty of Medicine, University of Lisbon, Lisbon, Portugal
| | - Ewan Nurse
- Seer Medical, Melbourne, Victoria, Australia
| | - Tobias Loddenkemper
- Department of Neurology, Harvard Medical School, Boston, Massachusetts, USA
- Department of Neurology, Boston Children's Hospital, Boston, Massachusetts, USA
| | - Andreas Schulze-Bonhage
- Epilepsy Center, University Medical Center Freiburg-University of Freiburg, Freiburg, Germany
| | - Solveig Vieluf
- Department of Neurology, Harvard Medical School, Boston, Massachusetts, USA
- Department of Neurology, Boston Children's Hospital, Boston, Massachusetts, USA
| | - Elisa Bruno
- School of Neuroscience, Institute of Psychiatry, Psychology, and Neuroscience, King's College London, London, UK
| | - Mona Nasseri
- Department of Neurology, Mayo Clinic, Rochester, Minnesota, USA
| | - Mark P Richardson
- School of Neuroscience, Institute of Psychiatry, Psychology, and Neuroscience, King's College London, London, UK
| | | | - M Brandon Westover
- Department of Neurology, Harvard Medical School, Boston, Massachusetts, USA
- Department of Neurology, Beth Israel Deaconess Medical Center, Boston, Massachusetts, USA
- Department of Neurology, Massachusetts General Hospital, Boston, Massachusetts, USA
- McCace Center, Boston, Massachusetts, USA
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14
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Petrucci AN, Jones AR, Kreitlow BL, Buchanan GF. Peri-ictal activation of dorsomedial dorsal raphe serotonin neurons reduces mortality associated with maximal electroshock seizures. Brain Commun 2024; 6:fcae052. [PMID: 38487550 PMCID: PMC10939444 DOI: 10.1093/braincomms/fcae052] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/23/2023] [Revised: 12/13/2023] [Accepted: 03/08/2024] [Indexed: 03/17/2024] Open
Abstract
Over one-third of patients with epilepsy will develop refractory epilepsy and continue to experience seizures despite medical treatment. These patients are at the greatest risk for sudden unexpected death in epilepsy. The precise mechanisms underlying sudden unexpected death in epilepsy are unknown, but cardiorespiratory dysfunction and arousal impairment have been implicated. Substantial circumstantial evidence suggests serotonin is relevant to sudden unexpected death in epilepsy as it modulates sleep/wake regulation, breathing and arousal. The dorsal raphe nucleus is a major serotonergic center and a component of the ascending arousal system. Seizures disrupt the firing of dorsal raphe neurons, which may contribute to reduced responsiveness. However, the relevance of the dorsal raphe nucleus and its subnuclei to sudden unexpected death in epilepsy remains unclear. The dorsomedial dorsal raphe may be a salient target due to its role in stress and its connections with structures implicated in sudden unexpected death in epilepsy. We hypothesized that optogenetic activation of dorsomedial dorsal raphe serotonin neurons in TPH2-ChR2-YFP (n = 26) mice and wild-type (n = 27) littermates before induction of a maximal electroshock seizure would reduce mortality. In this study, pre-seizure activation of dorsal raphe nucleus serotonin neurons reduced mortality in TPH2-ChR2-YFP mice with implants aimed at the dorsomedial dorsal raphe. These results implicate the dorsomedial dorsal raphe in this novel circuit influencing seizure-induced mortality. It is our hope that these results and future experiments will define circuit mechanisms that could ultimately reduce sudden unexpected death in epilepsy.
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Affiliation(s)
- Alexandra N Petrucci
- Interdisciplinary Graduate Program in Neuroscience, Carver College of Medicine, University of Iowa, Iowa City, IA 52242, USA
- Department of Neurology, Carver College of Medicine, University of Iowa, Iowa City, IA 52242, USA
- Iowa Neuroscience Institute, Carver College of Medicine, University of Iowa, Iowa City, IA 52242, USA
| | - Allysa R Jones
- Department of Neurology, Carver College of Medicine, University of Iowa, Iowa City, IA 52242, USA
- Iowa Neuroscience Institute, Carver College of Medicine, University of Iowa, Iowa City, IA 52242, USA
| | - Benjamin L Kreitlow
- Interdisciplinary Graduate Program in Neuroscience, Carver College of Medicine, University of Iowa, Iowa City, IA 52242, USA
- Department of Neurology, Carver College of Medicine, University of Iowa, Iowa City, IA 52242, USA
- Iowa Neuroscience Institute, Carver College of Medicine, University of Iowa, Iowa City, IA 52242, USA
| | - Gordon F Buchanan
- Department of Neurology, Carver College of Medicine, University of Iowa, Iowa City, IA 52242, USA
- Iowa Neuroscience Institute, Carver College of Medicine, University of Iowa, Iowa City, IA 52242, USA
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15
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Thamby J, Prange L, Boggs A, Subei MO, Myers C, Uchitel J, ElMallah M, Bartlett-Lee B, Riviello JJ, Mikati MA. Characteristics of non-sleep related apneas in children with alternating hemiplegia of childhood. Eur J Paediatr Neurol 2024; 48:101-108. [PMID: 38096596 DOI: 10.1016/j.ejpn.2023.12.002] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/29/2023] [Revised: 10/17/2023] [Accepted: 12/03/2023] [Indexed: 03/23/2024]
Abstract
BACKGROUND Non-sleep related apnea (NSA) has been observed in alternating hemiplegia of childhood (AHC) but has yet to be characterized. GOALS Investigate the following hypotheses: 1) AHC patients manifest NSA that is often severe. 2) NSA is usually triggered by precipitating events. 3) NSA is more likely in patients with ATP1A3 mutations. METHODS Retrospective review of 51 consecutive AHC patients (ages 2-45 years) enrolled in our AHC registry. NSAs were classified as mild (not needing intervention), moderate (needing intervention but not perceived as life threatening), or severe (needing intervention and perceived as life threatening). RESULTS 19/51 patients (37 %) had 52 NSA events (6 mild, 11 moderate, 35 severe). Mean age of onset of NSA (± Standard Error of the Mean (SEM)): 3.8 ± 1.5 (range 0-24) years, frequency during follow up was higher at younger ages as compared to adulthood (year 1: 2.2/year, adulthood: 0.060/year). NSAs were associated with triggering factors, bradycardia and with younger age (p < 0.008 in all) but not with mutation status (p = 0.360). Triggers, observed in 17 patients, most commonly included epileptic seizures in 9 (47 %), anesthesia, AHC spells and intercurrent, stressful, conditions. Management included use of pulse oximeter at home in nine patients, home oxygen in seven, intubation/ventilatory support in seven, and basic CPR in six. An additional patient required tracheostomy. There were no deaths or permanent sequalae. CONCLUSIONS AHC patients experience NSAs that are often severe. These events are usually triggered by seizures or other stressful events and can be successfully managed with interventions tailored to the severity of the NSA.
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Affiliation(s)
- Julie Thamby
- Department of Pediatrics, Division of Neurology and Developmental Pediatrics, Duke University School of Medicine, Durham, NC, United States
| | - Lyndsey Prange
- Department of Pediatrics, Division of Neurology and Developmental Pediatrics, Duke University School of Medicine, Durham, NC, United States
| | - April Boggs
- Department of Pediatrics, Division of Neurology and Developmental Pediatrics, Duke University School of Medicine, Durham, NC, United States
| | - M Omar Subei
- Department of Neurology, Division of Epilepsy and Clinical Neurophysiology, Duke University School of Medicine, Durham, NC, United States
| | - Cory Myers
- Department of Neurology, Division of Epilepsy and Clinical Neurophysiology, Duke University School of Medicine, Durham, NC, United States
| | - Julie Uchitel
- Department of Pediatrics, Division of Neurology and Developmental Pediatrics, Duke University School of Medicine, Durham, NC, United States; Stanford University Medical School, Palo Alto, CA, United States
| | - Mai ElMallah
- Department of Pediatrics, Division of Pulmonary Medicine, Duke University School of Medicine, United States
| | | | - James J Riviello
- Department of Pediatrics, Baylor College of Medicine, Houston, TX, United States
| | - Mohamad A Mikati
- Department of Pediatrics, Division of Neurology and Developmental Pediatrics, Duke University School of Medicine, Durham, NC, United States.
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16
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Finsterer J. Detection of pathogenic mutations in epilepsy-associated genes does not necessarily mean seizures or SUDEP. Seizure 2024; 114:125-126. [PMID: 38246699 DOI: 10.1016/j.seizure.2023.12.003] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/25/2023] [Accepted: 12/02/2023] [Indexed: 01/23/2024] Open
Affiliation(s)
- Josef Finsterer
- Neurology & Neurophysiology Center, Postfach 20, Vienna 1180, Austria.
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17
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Smith J, Richerson G, Kouchi H, Duprat F, Mantegazza M, Bezin L, Rheims S. Are we there yet? A critical evaluation of sudden and unexpected death in epilepsy models. Epilepsia 2024; 65:9-25. [PMID: 37914406 DOI: 10.1111/epi.17812] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/04/2023] [Revised: 10/11/2023] [Accepted: 10/31/2023] [Indexed: 11/03/2023]
Abstract
Although animal models have helped to elaborate meaningful hypotheses about the pathophysiology of sudden and unexpected death in epilepsy (SUDEP), specific prevention strategies are still lacking, potentially reflecting the limitations of these models and the intrinsic difficulties of investigating SUDEP. The interpretation of preclinical data and their translation to diagnostic and therapeutic developments in patients thus require a high level of confidence in their relevance to model the human situation. Preclinical models of SUDEP are heterogeneous and include rodent and nonrodent species. A critical aspect is whether the animals have isolated seizures exclusively induced by a specific trigger, such as models where seizures are elicited by electrical stimulation, pharmacological intervention, or DBA mouse strains, or whether they suffer from epilepsy with spontaneous seizures, with or without spontaneous SUDEP, either of nongenetic epilepsy etiology or from genetically based developmental and epileptic encephalopathies. All these models have advantages and potential disadvantages, but it is important to be aware of these limitations to interpret data appropriately in a translational perspective. The majority of models with spontaneous seizures are of a genetic basis, whereas SUDEP cases with a genetic basis represent only a small proportion of the total number. In almost all models, cardiorespiratory arrest occurs during the course of the seizure, contrary to that in patients observed at the time of death, potentially raising the issue of whether we are studying models of SUDEP or models of periseizure death. However, some of these limitations are impossible to avoid and can in part be dependent on specific features of SUDEP, which may be difficult to model. Several preclinical tools are available to address certain gaps in SUDEP pathophysiology, which can be used to further validate current preclinical models.
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Affiliation(s)
- Jonathon Smith
- Lyon Neuroscience Research Center (CRNL, INSERM U1028/CNRS UMR 5292, Lyon 1 University), Lyon, France
| | - George Richerson
- Department of Neurology, University of Iowa, Iowa City, Iowa, USA
| | - Hayet Kouchi
- Lyon Neuroscience Research Center (CRNL, INSERM U1028/CNRS UMR 5292, Lyon 1 University), Lyon, France
| | - Fabrice Duprat
- University Cote d'Azur, Valbonne-Sophia Antipolis, France
- CNRS UMR 7275, Institute of Molecular and Cellular Pharmacology, Valbonne-Sophia Antipolis, France
- Inserm, Valbonne-Sophia Antipolis, France
| | - Massimo Mantegazza
- University Cote d'Azur, Valbonne-Sophia Antipolis, France
- CNRS UMR 7275, Institute of Molecular and Cellular Pharmacology, Valbonne-Sophia Antipolis, France
- Inserm, Valbonne-Sophia Antipolis, France
| | - Laurent Bezin
- Lyon Neuroscience Research Center (CRNL, INSERM U1028/CNRS UMR 5292, Lyon 1 University), Lyon, France
| | - Sylvain Rheims
- Lyon Neuroscience Research Center (CRNL, INSERM U1028/CNRS UMR 5292, Lyon 1 University), Lyon, France
- Department of Functional Neurology and Epileptology, Hospices Civils de Lyon and Lyon 1 University, Lyon, France
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18
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Simeone KA, Martenz DM, Iyer SH, Booth CP, Herr SE, Matthews SA, Draves SB, Heinemann LL, Greenberg PL, Lhatoo SD, Donner E, Simeone TA. Personalization of SUDEP risk: A survey of transient subclinical comorbid changes. Epilepsy Res 2024; 199:107259. [PMID: 38086218 DOI: 10.1016/j.eplepsyres.2023.107259] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/07/2023] [Revised: 10/29/2023] [Accepted: 11/13/2023] [Indexed: 01/13/2024]
Abstract
OBJECTIVE Preclinical data report within subject modifiable ailments emerge weeks prior to SUDEP, including sleep disorders and cardiorespiratory changes; findings which support anecdotal clinical data. Here, we bridge preclinical findings with future clinical/preclinical studies, and survey whether caretakers or family members of victims noticed transient changes prior to SUDEP. The aim of this pilot study is to identify potential modifiable changes that may synergistically increase SUDEP risk for future research. METHODS A mobile electronic survey was posted on SUDEP community websites. The survey queried whether changes in seizures, sleep, physical well-being, emotional well-being, cognition, breathing, or heart rate were noticed before SUDEP. RESULTS The most profound finding was that 85% of victims had multiple transient ailments prior to SUDEP. Changes in seizures (28/54), and sleep (30/58) occurred in more than 50% of the victims and represent the most influential changes identified. The second and third most influential changes were a reduction in physical well-being (25/57) and emotional well-being (26/56). Changes were observed within the last two months of life in approximately one third of the cases, and more than four months prior to SUDEP in approximately one third of cases, indicating a potential time frame for proactive preventative strategies. Respondents also noted changes in cognition (16/55), breathing (9/54) or heart rate (8/55). Data indicate these changes may be associated with increased SUDEP risk within subject. Study limitations include the responses were based on memory, there was a potential for data to be over reported, and caretakers were not prompted to observe changes a priori, thus some existing changes may have gone unnoticed. SIGNIFICANCE Data support the preclinical findings that transient, subclinical (i.e., not severe enough to require medical intervention), modifiable ailments may increase risk of SUDEP. This suggests that just as an epilepsy type can change over a lifetime and epilepsy type-specific treatments can reduce SUDEP risk, further personalization of SUDEP risk will improve our understanding as to whether variables contribute to risk differently across lifespan. Thus, with a dynamic capacity to change, differing factors may contribute to the distribution of risk probability within an individual at any given time. Understanding whether different combinations of transient changes are specific to epilepsy type, age, or sex needs to be determined to move the field forward in hopes of developing a personalized approach to preventative strategies.
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Affiliation(s)
- Kristina A Simeone
- Department of Pharmacology and Neuroscience, Creighton University School of Medicine, United States.
| | | | - Shruthi H Iyer
- Department of Pharmacology and Neuroscience, Creighton University School of Medicine, United States
| | - Cameron P Booth
- Department of Pharmacology and Neuroscience, Creighton University School of Medicine, United States
| | - Shelby E Herr
- Department of Pharmacology and Neuroscience, Creighton University School of Medicine, United States
| | - Stephanie A Matthews
- Department of Pharmacology and Neuroscience, Creighton University School of Medicine, United States
| | - Samantha B Draves
- Department of Pharmacology and Neuroscience, Creighton University School of Medicine, United States
| | - Laura L Heinemann
- Department of Pharmacology and Neuroscience, Creighton University School of Medicine, United States
| | - Pierce L Greenberg
- Department of Pharmacology and Neuroscience, Creighton University School of Medicine, United States
| | - Samden D Lhatoo
- Department of Neurology, University of Texas Health Science Center at Houston John P and Katherine G McGovern Medical School, United States
| | - Elizabeth Donner
- Department of Paediatrics, Division of Neurology, Hospital for Sick Children, Canada
| | - Timothy A Simeone
- Department of Pharmacology and Neuroscience, Creighton University School of Medicine, United States
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19
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Misirocchi F, Vaudano AE, Florindo I, Zinno L, Zilioli A, Mannini E, Parrino L, Mutti C. Imaging biomarkers of sleep-related hypermotor epilepsy and sudden unexpected death in epilepsy: a review. Seizure 2024; 114:70-78. [PMID: 38088013 DOI: 10.1016/j.seizure.2023.12.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/06/2023] [Revised: 11/28/2023] [Accepted: 12/01/2023] [Indexed: 01/23/2024] Open
Abstract
In recent years, imaging has emerged as a promising source of several intriguing biomarkers in epilepsy, due to the impressive growth of imaging technology, supported by methodological advances and integrations of post-processing techniques. Bearing in mind the mutually influencing connection between sleep and epilepsy, we focused on sleep-related hypermotor epilepsy (SHE) and sudden unexpected death in epilepsy (SUDEP), aiming to make order and clarify possible clinical utility of emerging multimodal imaging biomarkers of these two epilepsy-related entities commonly occurring during sleep. Regarding SHE, advanced structural techniques might soon emerge as a promising source of diagnostic and predictive biomarkers, tailoring a targeted therapeutic (surgical) approach for MRI-negative subjects. Functional and metabolic imaging may instead unveil SHE's extensive and night-related altered brain networks, providing insights into distinctions and similarities with non-epileptic sleep phenomena, such as parasomnias. SUDEP is considered a storm that strikes without warning signals, but objective subtle structural and functional alterations in autonomic, cardiorespiratory, and arousal centers are present in patients eventually experiencing SUDEP. These alterations could be seen both as susceptibility and diagnostic biomarkers of the underlying pathological ongoing loop ultimately ending in death. Finally, given that SHE and SUDEP are rare phenomena, most evidence on the topic is derived from small single-center experiences with scarcely comparable results, hampering the possibility of performing any meta-analytic approach. Multicenter, longitudinal, well-designed studies are strongly encouraged.
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Affiliation(s)
| | - Anna Elisabetta Vaudano
- Neurology Unit, OCB Hospital, AOU Modena, Modena, Italy; Department of Biomedical, Metabolic, and Neural Sciences, University of Modena and Reggio Emilia, Modena, Italy
| | - Irene Florindo
- Neurology Unit, University Hospital of Parma, Parma, Italy
| | - Lucia Zinno
- Neurology Unit, University Hospital of Parma, Parma, Italy
| | | | - Elisa Mannini
- Department of Medicine and Surgery, University of Parma, Parma, Italy
| | - Liborio Parrino
- Department of Medicine and Surgery, University of Parma, Parma, Italy; Neurology Unit, University Hospital of Parma, Parma, Italy; Department of General and Specialized Medicine, Sleep Disorders Center, University Hospital of Parma, Parma, Italy.
| | - Carlotta Mutti
- Neurology Unit, University Hospital of Parma, Parma, Italy; Department of General and Specialized Medicine, Sleep Disorders Center, University Hospital of Parma, Parma, Italy
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20
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Zeicu C, Legouhy A, Scott CA, Oliveira JFA, Winston GP, Duncan JS, Vos SB, Thom M, Lhatoo S, Zhang H, Harper RM, Diehl B. Altered amygdala volumes and microstructure in focal epilepsy patients with tonic-clonic seizures, ictal, and post-convulsive central apnea. Epilepsia 2023; 64:3307-3318. [PMID: 37857465 PMCID: PMC10952501 DOI: 10.1111/epi.17804] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/11/2023] [Revised: 10/16/2023] [Accepted: 10/16/2023] [Indexed: 10/21/2023]
Abstract
OBJECTIVES Sudden unexpected death in epilepsy (SUDEP) is a leading cause of death for patients with epilepsy; however, the pathophysiology remains unclear. Focal-to-bilateral tonic-clonic seizures (FBTCS) are a major risk factor, and centrally-mediated respiratory depression may increase the risk further. Here, we determined the volume and microstructure of the amygdala, a key structure that can trigger apnea in people with focal epilepsy, stratified by the presence or absence of FBTCS, ictal central apnea (ICA), and post-convulsive central apnea (PCCA). METHODS Seventy-three patients with focal impaired awareness seizures without FBTC seizures (FBTCneg group) and 30 with FBTCS (FBTCpos group) recorded during video electroencephalography (VEEG) with respiratory monitoring were recruited prospectively during presurgical investigations. We acquired high-resolution T1-weighted anatomic and multi-shell diffusion images, and computed neurite orientation dispersion and density imaging (NODDI) metrics in all patients with epilepsy and 69 healthy controls. Amygdala volumetric and microstructure alterations were compared between three groups: healthy subjects, FBTCneg and FBTCpos groups. The FBTCpos group was further subdivided by the presence of ICA and PCCA, verified by VEEG. RESULTS Bilateral amygdala volumes were significantly increased in the FBTCpos cohort compared to healthy controls and the FBTCneg group. Patients with recorded PCCA had the highest increase in bilateral amygdala volume of the FBTCpos cohort. Amygdala neurite density index (NDI) values were decreased significantly in both the FBTCneg and FBTCpos groups relative to healthy controls, with values in the FBTCpos group being the lowest of the two. The presence of PCCA was associated with significantly lower NDI values vs the non-apnea FBTCpos group (p = 0.004). SIGNIFICANCE Individuals with FBTCpos and PCCA show significantly increased amygdala volumes and disrupted architecture bilaterally, with greater changes on the left side. The structural alterations reflected by NODDI and volume differences may be associated with inappropriate cardiorespiratory patterns mediated by the amygdala, particularly after FBTCS. Determination of amygdala volumetric and architectural changes may assist identification of individuals at risk.
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Affiliation(s)
- Claudia Zeicu
- Department of Clinical and Experimental Epilepsy, UCL Queen Square Institute of NeurologyUniversity College LondonLondonUK
| | - Antoine Legouhy
- Centre for Medical Image Computing and Department of Computer ScienceUniversity College LondonLondonUK
| | - Catherine A. Scott
- Department of Clinical and Experimental Epilepsy, UCL Queen Square Institute of NeurologyUniversity College LondonLondonUK
- Department of Clinical NeurophysiologyUniversity College London Hospitals NHS Foundation Trust National Hospital for Neurology and NeurosurgeryLondonUK
| | - Joana F. A. Oliveira
- Department of Clinical and Experimental Epilepsy, UCL Queen Square Institute of NeurologyUniversity College LondonLondonUK
- Department of Clinical NeurophysiologyUniversity College London Hospitals NHS Foundation Trust National Hospital for Neurology and NeurosurgeryLondonUK
| | - Gavin P. Winston
- Department of Clinical and Experimental Epilepsy, UCL Queen Square Institute of NeurologyUniversity College LondonLondonUK
- Epilepsy Society MRI UnitChalfont St PeterUK
- Department of Medicine, Division of NeurologyQueen's UniversityKingstonOntarioCanada
| | - John S. Duncan
- Department of Clinical and Experimental Epilepsy, UCL Queen Square Institute of NeurologyUniversity College LondonLondonUK
| | - Sjoerd B. Vos
- Centre for Medical Image Computing and Department of Computer ScienceUniversity College LondonLondonUK
- Neuroradiological Academic Unit, UCL Queen Square Institute of NeurologyUniversity College LondonLondonUK
- Centre for Microscopy, Characterisation, and AnalysisThe University of Western AustraliaNedlandsWestern AustraliaAustralia
| | - Maria Thom
- Department of Clinical and Experimental Epilepsy, UCL Queen Square Institute of NeurologyUniversity College LondonLondonUK
| | - Samden Lhatoo
- Department of NeurologyUniversity of Texas Health Sciences Center at HoustonHoustonTexasUSA
| | - Hui Zhang
- Centre for Medical Image Computing and Department of Computer ScienceUniversity College LondonLondonUK
| | - Ronald M. Harper
- Brain Research InstituteUniversity of California at Los AngelesLos AngelesCaliforniaUSA
- Department of Neurobiology, David Geffen School of MedicineUniversity of California at Los AngelesLos AngelesCaliforniaUSA
| | - Beate Diehl
- Department of Clinical and Experimental Epilepsy, UCL Queen Square Institute of NeurologyUniversity College LondonLondonUK
- Department of Clinical NeurophysiologyUniversity College London Hospitals NHS Foundation Trust National Hospital for Neurology and NeurosurgeryLondonUK
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21
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Watkins LV, Dunstall H, Musicha C, Lawthom C, John K, Bright C, Richings C, Harding K, Moon S, Pape SE, Winterhalder R, Allgar V, Thomas RH, McLean B, Laugharne R, Shankar R. Rapid switching from levetiracetam to brivaracetam in pharmaco-resistant epilepsy in people with and without intellectual disabilities: a naturalistic case control study. J Neurol 2023; 270:5889-5902. [PMID: 37610448 DOI: 10.1007/s00415-023-11959-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/02/2023] [Revised: 08/17/2023] [Accepted: 08/18/2023] [Indexed: 08/24/2023]
Abstract
BACKGROUND Approximately one quarter of people with an intellectual disability (PwID) have epilepsy of whom nearly three-quarters are pharmaco-resistant. There are higher reported neuropsychiatric side-effects to anti-seizure medication (ASM) in this group. Levetiracetam (LEV) is a first-line ASM with a stronger association with neuropsychiatric symptoms for PwID than other ASMs. Brivaracetam (BRV) is a newer ASM. Recent studies suggest a beneficial effect of swapping people who experience neuropsychiatric events with LEV to BRV. However, there is limited evidence of this for PwID. This evaluation analyses real world outcomes of LEV to BRV swap for PwID compared to those without ID. METHODS We performed a multicentre, retrospective review of clinical records. Demographic, clinical characteristics and reported adverse events of patients switched from LEV to BRV (2016-2020) were recorded at 3 months pre and 6- and 12-month post-BRV initiation. Outcomes were compared between PwID and those without and summarised using cross-tabulations and logistic regression models. A Bonferroni correction was applied. RESULTS Of 77 participants, 46 had ID and 52% had a past psychiatric illness. 71% participants switched overnight from LEV to BRV. Seizure reduction of > 50% was seen in 40% patients. Psychiatric illness history was predictive of having neuropsychiatric side-effects with LEV but not BRV (p = 0.001). There was no significant difference for any primary outcomes between PwID versus without ID. CONCLUSIONS Switching from LEV to BRV appears as well tolerated and efficacious in PwID as those without ID with over 90% still on BRV after 12 months.
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Affiliation(s)
- L V Watkins
- Swansea Bay University Health Board, Port Talbot, UK
- University of South Wales, Aberdare, UK
- University of Plymouth, Plymouth, UK
| | - H Dunstall
- Swansea Bay University Health Board, Port Talbot, UK
| | - C Musicha
- University of Plymouth, Plymouth, UK
| | - C Lawthom
- Aneurin Bevan University Health Board, Newport, UK
- Swansea University, Swansea, UK
| | - K John
- Aneurin Bevan University Health Board, Newport, UK
| | - C Bright
- University of South Wales, Aberdare, UK
- Aneurin Bevan University Health Board, Newport, UK
| | - C Richings
- Aneurin Bevan University Health Board, Newport, UK
| | - K Harding
- Aneurin Bevan University Health Board, Newport, UK
| | - S Moon
- Swansea Bay University Health Board, Port Talbot, UK
| | - S E Pape
- Oxleas NHS Foundation Trust, Kent, UK
| | | | - V Allgar
- University of Plymouth, Plymouth, UK
| | - R H Thomas
- Newcastle University, Newcastle upon Tyne, UK
- The Newcastle Upon Tyne Hospital NHS Foundation Trust, Newcastle upon Tyne, UK
| | - B McLean
- University of Plymouth, Plymouth, UK
| | | | - Rohit Shankar
- University of Plymouth, Plymouth, UK.
- Cornwall Partnership NHS Foundation Trust, Threemilestone Industrial Estate, Truro, TR4 9LD, UK.
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22
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Brodovskaya A, Sun H, Adotevi N, Wenker IC, Mitchell KE, Clements RT, Kapur J. Neuronal plasticity contributes to postictal death. Prog Neurobiol 2023; 231:102531. [PMID: 37778436 PMCID: PMC10842614 DOI: 10.1016/j.pneurobio.2023.102531] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2023] [Revised: 08/07/2023] [Accepted: 09/25/2023] [Indexed: 10/03/2023]
Abstract
Repeated generalized tonic-clonic seizures (GTCSs) are the most critical risk factor for sudden unexpected death in epilepsy (SUDEP). GTCSs can cause fatal apnea. We investigated neuronal plasticity mechanisms that precipitate postictal apnea and seizure-induced death. Repeated seizures worsened behavior, precipitated apnea, and enlarged active neuronal circuits, recruiting more neurons in such brainstem nuclei as periaqueductal gray (PAG) and dorsal raphe, indicative of brainstem plasticity. Seizure-activated neurons are more excitable and have enhanced AMPA-mediated excitatory transmission after a seizure. Global deletion of the GluA1 subunit of AMPA receptors abolishes postictal apnea and seizure-induced death. Treatment with a drug that blocks Ca2+-permeable AMPA receptors also renders mice apnea-free with five-fold better survival than untreated mice. Repeated seizures traffic the GluA1 subunit-containing AMPA receptors to synapses, and blocking this mechanism decreases the probability of postictal apnea and seizure-induced death.
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Affiliation(s)
| | - Huayu Sun
- Department of Neurology, University of Virginia, Charlottesville, VA 22908, USA
| | - Nadia Adotevi
- Department of Neurology, University of Virginia, Charlottesville, VA 22908, USA
| | - Ian C Wenker
- Department of Anesthesiology, University of Virginia, Charlottesville, VA 22908, USA
| | - Keri E Mitchell
- Department of Chemistry, University of Virginia, Charlottesville, VA 22908, USA
| | - Rachel T Clements
- Department of Neuroscience, University of Virginia, Charlottesville, VA 22908, USA
| | - Jaideep Kapur
- Department of Neurology, University of Virginia, Charlottesville, VA 22908, USA; UVA Brain Institute, University of Virginia, Charlottesville, VA 22908, USA.
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23
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Chen C, Ziobro J, Robinson-Cooper L, Hodges SL, Chen Y, Edokobi N, Lopez-Santiago L, Habig K, Moore C, Minton J, Bramson S, Scheuing C, Daddo N, Štěrbová K, Weckhuysen S, Parent JM, Isom LL. Epilepsy and sudden unexpected death in epilepsy in a mouse model of human SCN1B-linked developmental and epileptic encephalopathy. Brain Commun 2023; 5:fcad283. [PMID: 38425576 PMCID: PMC10903178 DOI: 10.1093/braincomms/fcad283] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/13/2023] [Revised: 07/13/2023] [Accepted: 10/18/2023] [Indexed: 03/02/2024] Open
Abstract
Voltage-gated sodium channel β1 subunits are essential proteins that regulate excitability. They modulate sodium and potassium currents, function as cell adhesion molecules and regulate gene transcription following regulated intramembrane proteolysis. Biallelic pathogenic variants in SCN1B, encoding β1, are linked to developmental and epileptic encephalopathy 52, with clinical features overlapping Dravet syndrome. A recessive variant, SCN1B-c.265C>T, predicting SCN1B-p.R89C, was homozygous in two children of a non-consanguineous family. One child was diagnosed with Dravet syndrome, while the other had a milder phenotype. We identified an unrelated biallelic SCN1B-c.265C>T patient with a clinically more severe phenotype than Dravet syndrome. We used CRISPR/Cas9 to knock-in SCN1B-p.R89C to the mouse Scn1b locus (Scn1bR89/C89). We then rederived the line on the C57BL/6J background to allow comparisons between Scn1bR89/R89 and Scn1bC89/C89 littermates with Scn1b+/+ and Scn1b-/- mice, which are congenic on C57BL/6J, to determine whether the SCN1B-c.265C>T variant results in loss-of-function. Scn1bC89/C89 mice have normal body weights and ∼20% premature mortality, compared with severely reduced body weight and 100% mortality in Scn1b-/- mice. β1-p.R89C polypeptides are expressed in brain at comparable levels to wild type. In heterologous cells, β1-p.R89C localizes to the plasma membrane and undergoes regulated intramembrane proteolysis similar to wild type. Heterologous expression of β1-p.R89C results in sodium channel α subunit subtype specific effects on sodium current. mRNA abundance of Scn2a, Scn3a, Scn5a and Scn1b was increased in Scn1bC89/C89 somatosensory cortex, with no changes in Scn1a. In contrast, Scn1b-/- mouse somatosensory cortex is haploinsufficient for Scn1a, suggesting an additive mechanism for the severity of the null model via disrupted regulation of another Dravet syndrome gene. Scn1bC89/C89 mice are more susceptible to hyperthermia-induced seizures at post-natal Day 15 compared with Scn1bR89/R89 littermates. EEG recordings detected epileptic discharges in young adult Scn1bC89/C89 mice that coincided with convulsive seizures and myoclonic jerks. We compared seizure frequency and duration in a subset of adult Scn1bC89/C89 mice that had been exposed to hyperthermia at post-natal Day 15 versus a subset that were not hyperthermia exposed. No differences in spontaneous seizures were detected between groups. For both groups, the spontaneous seizure pattern was diurnal, occurring with higher frequency during the dark cycle. This work suggests that the SCN1B-c.265C>T variant does not result in complete loss-of-function. Scn1bC89/C89 mice more accurately model SCN1B-linked variants with incomplete loss-of-function compared with Scn1b-/- mice, which model complete loss-of-function, and thus add to our understanding of disease mechanisms as well as our ability to develop new therapeutic strategies.
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Affiliation(s)
- Chunling Chen
- Department of Pharmacology, University of Michigan Medical School, Ann Arbor, MI 48109, USA
| | - Julie Ziobro
- Department of Pediatrics, University of Michigan Medical School, Ann Arbor, MI 48109, USA
| | | | - Samantha L Hodges
- Department of Pharmacology, University of Michigan Medical School, Ann Arbor, MI 48109, USA
| | - Yan Chen
- Department of Pharmacology, University of Michigan Medical School, Ann Arbor, MI 48109, USA
| | - Nnamdi Edokobi
- Department of Pharmacology, University of Michigan Medical School, Ann Arbor, MI 48109, USA
| | - Luis Lopez-Santiago
- Department of Pharmacology, University of Michigan Medical School, Ann Arbor, MI 48109, USA
| | - Karl Habig
- Department of Pharmacology, University of Michigan Medical School, Ann Arbor, MI 48109, USA
| | - Chloe Moore
- Department of Pharmacology, University of Michigan Medical School, Ann Arbor, MI 48109, USA
| | - Joe Minton
- Department of Pharmacology, University of Michigan Medical School, Ann Arbor, MI 48109, USA
| | - Sabrina Bramson
- Department of Pharmacology, University of Michigan Medical School, Ann Arbor, MI 48109, USA
| | - Caroline Scheuing
- Department of Pharmacology, University of Michigan Medical School, Ann Arbor, MI 48109, USA
| | - Noor Daddo
- Department of Neurology, University of Michigan Medical School, Ann Arbor, MI 48109, USA
| | - Katalin Štěrbová
- Department of Pediatric Neurology, Charles University and Motol Hospital, V Úvalu 84, 150 06 Prague 5, Czech Republic
| | - Sarah Weckhuysen
- Applied & Translational Neurogenomics Group, VIB Center for Molecular Neurology, VIB, Universiteitsplein 1 B-2610 Antwerpen, Belgium
- Translational Neurosciences, Faculty of Medicine and Health Science, University of Antwerp, Universiteitsplein 1 B-2610 Antwerpen, Belgium
- Department of Neurology, Antwerp University Hospital, Universiteitsplein 1B-2610 Antwerpen, Belgium
- µNEURO Research Centre of Excellence, University of Antwerp, Universiteitsplein 1B-2610 Antwerpen, Belgium
| | - Jack M Parent
- Department of Neurology, University of Michigan Medical School, Ann Arbor, MI 48109, USA
- Michigan Neuroscience Institute, University of Michigan Medical School, Ann Arbor, MI 48109, USA
- Department of Neurology, VA Ann Arbor Healthcare System, Ann Arbor, MI 48105, USA
| | - Lori L Isom
- Department of Pharmacology, University of Michigan Medical School, Ann Arbor, MI 48109, USA
- Department of Neurology, University of Michigan Medical School, Ann Arbor, MI 48109, USA
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24
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Manis AD, Cook-Snyder DR, Duffy E, Osmani WA, Eilbes M, Dillard M, Palygin O, Staruschenko A, Hodges MR. Repeated seizures lead to progressive ventilatory dysfunction in SS Kcnj16-/- rats. J Appl Physiol (1985) 2023; 135:872-885. [PMID: 37535709 PMCID: PMC10642517 DOI: 10.1152/japplphysiol.00072.2023] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/06/2023] [Revised: 08/01/2023] [Accepted: 08/01/2023] [Indexed: 08/05/2023] Open
Abstract
Patients with uncontrolled epilepsy experience repeated seizures putting them at increased risk for sudden unexpected death in epilepsy (SUDEP). Data from human patients have led to the hypothesis that SUDEP results from severe cardiorespiratory suppression after a seizure, which may involve pathological deficiencies in the brainstem serotonin (5-HT) system. Rats with a genomic Kcnj16 mutation (SSKcnj16-/- rats) are susceptible to sound-induced generalized tonic-clonic seizures (GTCS) which, when repeated once daily for up to 10 days (10-day seizure protocol), increased mortality, particularly in male rats. Here, we test the hypothesis that repeated seizures across the 10-day protocol will cause a progressive ventilatory dysfunction due to time-dependent 5-HT deficiency. Initial severe seizures led to ictal and postictal apneas and transient decreases in breathing frequency, ventilatory drive, breath-to-breath variability, and brief hypoventilation. These seizure-induced effects on ventilation were exacerbated with increasing seizures and ventilatory chemoreflexes became further impaired after repeated seizures. Tissue analyses of key brainstem regions controlling breathing showed time-dependent 5-HT system suppression and increased immunoreactivity for IBA-1 (microglial marker) without changes in overall cell counts at 3, 7, and 10 days of seizures. Fluoxetine treatment in SSKcnj16-/- rats prevented repeated seizure-induced progressive respiratory suppression but failed to prevent seizure-related mortality. We conclude that repeated seizures cause a progressive compromise of ventilatory control in the immediate postictal period largely mediated by serotonin system suppression in brainstem regions of respiratory control. However, other unknown factors contribute to overall survival following repeated seizures in this model.NEW & NOTEWORTHY This study demonstrated that repeated seizures in a novel rat model (SSKcnj16-/- rats) caused a progressively greater ventilatory dysfunction in the immediate postictal period associated with brainstem serotonin (5-HT) suppression. Augmenting brain 5-HT with a selective serotonin reuptake inhibitor prevented the progressive ventilatory dysfunction induced by repeated seizures but failed to prevent seizure-related mortality, suggesting that repeated seizures may lead to cardiorespiratory suppression and failure through multiple mechanisms.
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Affiliation(s)
- Anna D Manis
- Department of Physiology, Medical College of Wisconsin, Milwaukee, Wisconsin, United States
| | - Denise R Cook-Snyder
- Department of Physiology, Medical College of Wisconsin, Milwaukee, Wisconsin, United States
| | - Erin Duffy
- Department of Physiology, Medical College of Wisconsin, Milwaukee, Wisconsin, United States
| | - Wasif A Osmani
- Department of Physiology, Medical College of Wisconsin, Milwaukee, Wisconsin, United States
| | - Melissa Eilbes
- Department of Physiology, Medical College of Wisconsin, Milwaukee, Wisconsin, United States
| | - Matthew Dillard
- Department of Physiology, Medical College of Wisconsin, Milwaukee, Wisconsin, United States
| | - Oleg Palygin
- Department of Physiology, Medical College of Wisconsin, Milwaukee, Wisconsin, United States
- Division of Nephrology, Department of Medicine, Medical University of South Carolina, Charleston, South Carolina, United States
| | - Alexander Staruschenko
- Department of Physiology, Medical College of Wisconsin, Milwaukee, Wisconsin, United States
- Department of Molecular Pharmacology & Physiology, University of South Florida, Tampa, Florida, United States
- James A. Haley Veterans' Hospital, Tampa, Florida, United States
| | - Matthew R Hodges
- Department of Physiology, Medical College of Wisconsin, Milwaukee, Wisconsin, United States
- Neuroscience Research Center, Medical College of Wisconsin, Milwaukee, Wisconsin, United States
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25
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Serrand C, Faucanié M, Jaussent A, Crespel A, Denuelle M, Bartolomei F, Vercueil L, Derambure P, Tyvaert L, Marchal C, Landre E, Szurhaj W, Mura T, Navarro V, Rheims S, Picot MC. How valid are proxy assessment of mental health and sleep comorbidities of patients with epilepsy using standardized questionnaires? Seizure 2023; 111:151-157. [PMID: 37634353 DOI: 10.1016/j.seizure.2023.08.011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/26/2023] [Revised: 08/06/2023] [Accepted: 08/18/2023] [Indexed: 08/29/2023] Open
Abstract
BACKGROUND The study aimed to determine the level of agreement between patients with epilepsy and their proxies when assessing psychiatric comorbidities, sleep disorders, and medication adherence using standardized questionnaires. METHODS This agreement study is an ancillary analysis of the PRERIES study, a matched case-control study exploring SUDEP risk factors. Controls aged 15 years and older, with active epilepsy or in remission for less than 5 years were recruited between 01/01/2011 and 03/31/2019. An interview was carried out by a trained psychologist on both the patient and a proxy-respondent. During these independent interviews, the following comorbidities were explored: psychiatric comorbidities using the MINI, the STAI- Y2 and NDDI-E scales, sleep disorders with the SDQ-SA and Epworth scales and medication adherence. Level of agreement between patient and their proxy was estimated using Gwet's AC1&2. RESULTS Among the 107 patient-proxy dyads recruited, proxy respondents were mainly family members (65.4%) or spouses (30.8%). Exploration of present major depression showed excellent agreement at 0.81 [0.65;0.97], as well as exploration of dysthymia at 0.96 [0.61;1]. Suicidal risk evaluation had a lesser agreement at 0.77 [0.60;0.94]. Agreement on anxiety was moderate 0.5 [0.38;0.62]. For sleep disorder, SDQ-SA presented a better agreement than the Epworth questionnaire with respectively 0.73 [0.51;0.95] and 0.45 [0.26;0.63]. For medication adherence, the overall agreement rate was excellent (0.90 [0.78;1]). CONCLUSION Exploration of potential risk factors through families can give valuable and relatively robust information, especially if the respondent lives with the patient, and should be retrieved, when possible, in usual clinical setting.
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Affiliation(s)
- Chris Serrand
- Department of Biostatistics, Epidemiology, Public Health and Innovation in Methodology, CHU Nîmes, Univ. Montpellier, Nîmes, France; CESP, Villejuif Paris, France
| | | | | | | | | | | | | | | | | | | | | | - William Szurhaj
- Clinical Neurophysiology Department, CHU Amiens, UR 7516, CHIMERE, University of Picardie Jules Verne, Amiens, France
| | - Thibault Mura
- Department of Biostatistics, Epidemiology, Public Health and Innovation in Methodology, CHU Nîmes, Univ. Montpellier, Nîmes, France
| | - Vincent Navarro
- Sorbonne Université, AP-HP, Pitié-Salpêtrière Hospital, Epilepsy Unit, Paris Brain Institute, ICM, Reference Center for Rare epilepsies, 75013, Paris, France
| | - Sylvain Rheims
- Department of Functional Neurology and Epileptology, Hospices Civils de Lyon and University of Lyon, Lyon, France
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Leosuthamas D, Limotai C, Unwanatham N, Rattanasiri S. Is anti-seizure medication the culprit of SUDEP? Neurol Sci 2023; 44:3659-3668. [PMID: 37248425 DOI: 10.1007/s10072-023-06871-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2023] [Accepted: 05/19/2023] [Indexed: 05/31/2023]
Abstract
BACKGROUND Heart rate variability (HRV) reduction is a potential biomarker for sudden cardiac death. This study aimed to study the effects of anti-seizure medications (ASMs), adjusted with reported factors associated with sudden unexpected death in epilepsy (SUDEP) on HRV parameters. METHODS We recruited patients who were admitted in our epilepsy monitoring unit between January 2013 and December 2021. Two 5-min electrocardiogram epochs during wakefulness and sleep were selected in each patient. HRV analysis with Python® software was performed. The imputed datasets were used for linear regression analysis to assess association between each ASM item and all HRV parameters. The effects of ASM on HRV parameters were subsequently adjusted with the significant clinical characteristics and the concomitant use of other ASMs, respectively. RESULTS Carbamazepine (CBZ), levetiracetam (LEV), lamotrigine (LTG), and clonazepam (CZP) were statistically significantly associated with changes of sleep HRV parameters. Only CBZ showed negative effects with reduction in HRV, evidenced as lower standard deviation of RR interval (SDNN), even when adjusted with concomitant use of other ASMs (p = 0.045) and had a trend of significance when adjusted with significant clinical characteristics of concurrent taking of beta-blocker drug (p = 0.052). LEV and CZP showed opposite effects with increased HRV even when adjusted with significant clinical characteristics and the concomitant use of other ASMs. CONCLUSIONS CBZ showed negative effects on HRV. We proposed that CBZ should be cautiously used in patients with known risks for SUDEP. In addition, HRV assessment should be performed prior to commencing CBZ and re-performed in follow-up in cases of prolonged use.
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Affiliation(s)
- Danist Leosuthamas
- Division of Neurology, Department of Medicine, Faculty of Medicine, Chulalongkorn University, Bangkok, Thailand
| | - Chusak Limotai
- Division of Neurology, Department of Medicine, Faculty of Medicine, Chulalongkorn University, Bangkok, Thailand.
- Chulalongkorn Comprehensive Epilepsy Center of Excellence (CCEC), King Chulalongkorn Memorial Hospital, The Thai Red Cross Society, Bangkok, Thailand.
- Division of Neurology, King Chulalongkorn Memorial Hospital, 1873 Seventh Floor Bhumisiri Building, Rama IV Road, Pathumwan, Bangkok, 10330, Thailand.
| | - Nattawut Unwanatham
- Department of Clinical Epidemiology and Biostatistics, Faculty of Medicine Ramathibodi Hospital, Mahidol University, Bangkok, Thailand
| | - Sasivimol Rattanasiri
- Department of Clinical Epidemiology and Biostatistics, Faculty of Medicine Ramathibodi Hospital, Mahidol University, Bangkok, Thailand
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Pasini E, Michelucci R. The Heart and Seizures: Friends or Enemies? J Clin Med 2023; 12:5805. [PMID: 37762746 PMCID: PMC10532013 DOI: 10.3390/jcm12185805] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/19/2023] [Revised: 08/23/2023] [Accepted: 08/30/2023] [Indexed: 09/29/2023] Open
Abstract
The heart and seizures are closely linked by an indissoluble relationship that finds its basis in the cerebral limbic circuit whose mechanisms remain largely obscure. The differential diagnosis between seizures and syncopes has always been a cornerstone of the collaboration between cardiologists and neurologists and is renewed as a field of great interest for multidisciplinary collaboration in the era of the diffusion of prolonged telemonitoring units. The occurrence of ictal or post-ictal arrhythmias is currently a cause of great scientific debate with respect to the role and risks that these complications can generate (including sudden unexpected death in epilepsy). Furthermore, the study of epileptic seizures and the arrhythmological complications they cause (during and after seizures) also allows us to unravel the mechanisms that link them. Finally, intercritical arrhythmias may represent great potential in terms of the prevention of cardiological risk in epileptic patients as well as in the possible prediction of the seizures themselves. In this paper, we review the pertaining literature on this subject and propose a scheme of classification of the cases of arrhythmia temporally connected to seizures.
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Sainju RK, Dragon DN, Winnike HB, Vilella L, Li X, Lhatoo S, Eyck PT, Wendt LH, Richerson GB, Gehlbach BK. Interictal respiratory variability predicts severity of hypoxemia after generalized convulsive seizures. Epilepsia 2023; 64:2373-2384. [PMID: 37344924 PMCID: PMC10538446 DOI: 10.1111/epi.17691] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/05/2023] [Revised: 06/19/2023] [Accepted: 06/19/2023] [Indexed: 06/23/2023]
Abstract
OBJECTIVE Severe respiratory dysfunction induced by generalized convulsive seizures (GCS) is now thought to be a common mechanism for sudden unexpected death in epilepsy (SUDEP). In a mouse model of seizure-induced death, increased interictal respiratory variability was reported in mice that later died of respiratory arrest after GCS. We studied respiratory variability in epilepsy patients as a predictive tool for severity of postictal hypoxemia, a potential biomarker for SUDEP risk. We then explored the relationship between respiratory variability and central CO2 drive, measured by the hypercapnic ventilatory response (HCVR). METHODS We reviewed clinical, video-electroencephalography, and respiratory (belts, airflow, pulse oximeter, and HCVR) data of epilepsy patients. Mean, SD, and coefficient of variation (CV) of interbreath interval (IBI) were calculated. Primary outcomes were: (1) nadir of capillary oxygen saturation (SpO2 ) and (2) duration of oxygen desaturation. Poincaré plots of IBI were created. Covariates were evaluated in univariate models, then, based on Akaike information criteria (AIC), multivariate regression models were created. RESULTS Of 66 GCS recorded in 131 subjects, 30 had interpretable respiratory data. In the multivariate model with the lowest AIC value, duration of epilepsy was a significant predictor of duration of oxygen desaturation. Duration of tonic phase and CV of IBI during the third postictal minute correlated with SpO2 nadir, whereas CV of IBI during non-rapid eye movement sleep had a negative correlation. Poincaré plots showed that long-term variability was significantly greater in subjects with ≥200 s of postictal oxygen desaturation after GCS compared to those with <200 s desaturation. Finally, HCVR slope showed a negative correlation with measures of respiratory variability. SIGNIFICANCE These results indicate that interictal respiratory variability predicts severity of postictal oxygen desaturation, suggesting its utility as a potential biomarker. They also suggest that interictal respiratory control may be abnormal in some patients with epilepsy.
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Affiliation(s)
- Rup K. Sainju
- Department of Neurology University of Iowa Hospitals and Clinics, Iowa City, IA
| | - Deidre N. Dragon
- Department of Neurology University of Iowa Hospitals and Clinics, Iowa City, IA
| | - Harold B. Winnike
- Institute for Clinical and Translational Science University of Iowa, Iowa City, IA
| | - Laura Vilella
- Department of Neurology, McGovern Medical School, University of Texas Health Science Center at Houston, Houston, TX
| | - Xiaojin Li
- Department of Neurology, McGovern Medical School, University of Texas Health Science Center at Houston, Houston, TX
| | - Samden Lhatoo
- Department of Neurology, McGovern Medical School, University of Texas Health Science Center at Houston, Houston, TX
| | - Patrick Ten Eyck
- Institute for Clinical and Translational Science University of Iowa, Iowa City, IA
| | - Linder H Wendt
- Institute for Clinical and Translational Science University of Iowa, Iowa City, IA
| | - George B. Richerson
- Department of Neurology University of Iowa Hospitals and Clinics, Iowa City, IA
- Department of Molecular Physiology and Biophysics, University of Iowa, Iowa City, IA
- Iowa Neuroscience Institute, University of Iowa, IA
- VA Medical Center, Iowa City, IA
| | - Brian K. Gehlbach
- Department of Internal Medicine, University of Iowa Hospitals and Clinics, Iowa City, IA
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Giussani G, Falcicchio G, La Neve A, Costagliola G, Striano P, Scarabello A, Mostacci B, Beghi E. Sudden unexpected death in epilepsy: A critical view of the literature. Epilepsia Open 2023; 8:728-757. [PMID: 36896633 PMCID: PMC10472423 DOI: 10.1002/epi4.12722] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/17/2022] [Accepted: 03/04/2023] [Indexed: 03/11/2023] Open
Abstract
Sudden unexpected death in epilepsy (SUDEP) is a sudden, unexpected, witnessed or unwitnessed, non-traumatic and non-drowning death, occurring in benign circumstances, in an individual with epilepsy, with or without evidence for a seizure and excluding documented status epilepticus in which postmortem examination does not reveal other causes of death. Lower diagnostic levels are assigned when cases met most or all of these criteria, but data suggested more than one possible cause of death. The incidence of SUDEP ranged from 0.09 to 2.4 per 1000 person-years. Differences can be attributed to the age of the study populations (with peaks in the 20-40-year age group) and the severity of the disease. Young age, disease severity (in particular, a history of generalized TCS), having symptomatic epilepsy, and the response to antiseizure medications (ASMs) are possible independent predictors of SUDEP. The pathophysiological mechanisms are not fully known due to the limited data available and because SUDEP is not always witnessed and has been electrophysiologically monitored only in a few cases with simultaneous assessment of respiratory, cardiac, and brain activity. The pathophysiological basis of SUDEP may vary according to different circumstances that make that particular seizure, in that specific moment and in that patient, a fatal event. The main hypothesized mechanisms, which could contribute to a cascade of events, are cardiac dysfunction (included potential effects of ASMs, genetically determined channelopathies, acquired heart diseases), respiratory dysfunction (included postictal arousal deficit for the respiratory mechanism, acquired respiratory diseases), neuromodulator dysfunction, postictal EEG depression and genetic factors.
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Affiliation(s)
- Giorgia Giussani
- Laboratory of Neurological Disorders, Mario Negri Institute for Pharmacological Research IRCCSMilanItaly
| | - Giovanni Falcicchio
- Department of Basic Medical Sciences, Neurosciences and Sense OrgansUniversity of BariBariItaly
| | - Angela La Neve
- Department of Basic Medical Sciences, Neurosciences and Sense OrgansUniversity of BariBariItaly
| | | | - Pasquale Striano
- IRCCS Istituto “Giannina Gaslini”GenovaItaly
- Department of Neurosciences, Rehabilitation, Ophthalmology, Genetics, Maternal and Child HealthUniversity of GenovaGenovaItaly
| | - Anna Scarabello
- IRCCS Istituto delle Scienze Neurologiche di BolognaBolognaItaly
| | - Barbara Mostacci
- IRCCS Istituto delle Scienze Neurologiche di BolognaBolognaItaly
| | - Ettore Beghi
- Laboratory of Neurological Disorders, Mario Negri Institute for Pharmacological Research IRCCSMilanItaly
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Chen Z, Brodie MJ, Ding D, Kwan P. Editorial: Epidemiology of epilepsy and seizures. Front Epidemiol 2023; 3:1273163. [PMID: 38455942 PMCID: PMC10911047 DOI: 10.3389/fepid.2023.1273163] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/05/2023] [Accepted: 08/21/2023] [Indexed: 03/09/2024]
Affiliation(s)
- Zhibin Chen
- Department of Neuroscience, Central Clinical School, Monash University, Melbourne, VIC, Australia
- Department of Medicine—Royal Melbourne Hospital, University of Melbourne, Parkville, Melbourne, VIC, Australia
| | - Martin J. Brodie
- Department of Medicine and Clinical Pharmacology, University of Glasgow, Glasgow, United Kingdom
| | - Ding Ding
- Department of Biostatistics and Epidemiology, Institute of Neurology, Fudan University Huashan Hospital, Shanghai, China
| | - Patrick Kwan
- Department of Neuroscience, Central Clinical School, Monash University, Melbourne, VIC, Australia
- Department of Medicine—Royal Melbourne Hospital, University of Melbourne, Parkville, Melbourne, VIC, Australia
- Department of Neurology, Alfred Health, Melbourne, VIC, Australia
- Department of Neurology, The First Affiliated Hospital of Chongqing Medical University, Chongqing Key Laboratory of Neurology, Chongqing, China
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Singh V, Ryan JM, Auerbach DS. It is premature for a unified hypothesis of sudden unexpected death in epilepsy: A great amount of research is still needed to understand the multisystem cascade. Epilepsia 2023; 64:2006-2010. [PMID: 37129136 DOI: 10.1111/epi.17636] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2023] [Revised: 04/10/2023] [Accepted: 05/01/2023] [Indexed: 05/03/2023]
Affiliation(s)
- Veronica Singh
- Department of Pharmacology, SUNY Upstate Medical University, Syracuse, New York, USA
| | - Justin M Ryan
- Department of Pharmacology, SUNY Upstate Medical University, Syracuse, New York, USA
| | - David S Auerbach
- Department of Pharmacology, SUNY Upstate Medical University, Syracuse, New York, USA
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Aljumah TK, Al-Attas AA, Alqahtani AA, Masuadi EM, Aldahi AS, Alshammari MA, Heji AT, Alanazi A. Sudden unexpected death in epilepsy: What Saudi people with epilepsy want to know-A cross-sectional study. Epileptic Disord 2023; 25:528-533. [PMID: 37202837 DOI: 10.1002/epd2.20079] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/21/2023] [Revised: 04/27/2023] [Accepted: 05/13/2023] [Indexed: 05/20/2023]
Abstract
OBJECTIVE Sudden unexpected death in epilepsy (SUDEP) is a significant cause of mortality in people with epilepsy (PWE), with an incidence of 1 per 1000 members of the population. In Saudi Arabia, no data are available that inform local clinical practitioners about the attitudes of PWE regarding SUDEP. The aim of this study was to investigate the perspectives of Saudi PWE toward SUDEP and to assess their knowledge of SUDEP. METHODS A cross-sectional questionnaire-based study was conducted at the neurology clinics of King Abdul-Aziz Medical City, Riyadh and Prince Sultan Military Medical City, Riyadh. RESULTS Of the 377 patients who met the inclusion criteria, 325 completed the questionnaire. The mean age of the respondents was 32.9 ± 12.6 years. Of the study subjects, 50.5% were male. Only 41 patients (12.6%) had heard about SUDEP. Most patients (94.5%) wanted to know about SUDEP, of whom 313 (96.3%) wanted to receive this information from a neurologist. A total of 148 patients (45.5%) thought that the appropriate time to receive information about SUDEP was after the second visit, whereas only 75 (23.1%) wanted to learn about SUDEP during the first visit. However, 69 patients (21.2%) thought that the appropriate time to be informed about SUDEP was when seizure control had become more difficult. Almost half (172, 52.9%) of the patients thought that SUDEP could be prevented. SIGNIFICANCE Our findings suggest that most Saudi PWE do not know about SUDEP and want to be counseled about their risk of SUDEP by their physicians. Therefore, education of Saudi PWE about SUDEP must be improved.
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Affiliation(s)
- Talal K Aljumah
- Division of Neurology, King Abdulaziz Medical City, Ministry of the National Guard-Health Affairs, Riyadh, Saudi Arabia
- King Abdullah International Medical Research Center, Riyadh, Saudi Arabia
| | | | - Ahmed A Alqahtani
- King Saud bin Abdulaziz University for Health Sciences, Riyadh, Saudi Arabia
| | - Emad M Masuadi
- King Abdullah International Medical Research Center, Riyadh, Saudi Arabia
- King Saud bin Abdulaziz University for Health Sciences, Riyadh, Saudi Arabia
| | - Ahmed S Aldahi
- Prince Sultan Military Medical City, Riyadh, Saudi Arabia
| | - Mohammed A Alshammari
- Division of Neurology, King Abdulaziz Medical City, Ministry of the National Guard-Health Affairs, Riyadh, Saudi Arabia
- King Abdullah International Medical Research Center, Riyadh, Saudi Arabia
| | - Alaa T Heji
- Prince Sultan Military Medical City, Riyadh, Saudi Arabia
| | - Ali Alanazi
- Division of Neurology, King Abdulaziz Medical City, Ministry of the National Guard-Health Affairs, Riyadh, Saudi Arabia
- King Abdullah International Medical Research Center, Riyadh, Saudi Arabia
- King Saud bin Abdulaziz University for Health Sciences, Riyadh, Saudi Arabia
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van Westrhenen A, Lazeron RHC, van Dijk JP, Leijten FSS, Thijs RD. Multimodal nocturnal seizure detection in children with epilepsy: A prospective, multicenter, long-term, in-home trial. Epilepsia 2023; 64:2137-2152. [PMID: 37195144 DOI: 10.1111/epi.17654] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/08/2023] [Revised: 05/14/2023] [Accepted: 05/15/2023] [Indexed: 05/18/2023]
Abstract
OBJECTIVE There is a pressing need for reliable automated seizure detection in epilepsy care. Performance evidence on ambulatory non-electroencephalography-based seizure detection devices is low, and evidence on their effect on caregiver's stress, sleep, and quality of life (QoL) is still lacking. We aimed to determine the performance of NightWatch, a wearable nocturnal seizure detection device, in children with epilepsy in the family home setting and to assess its impact on caregiver burden. METHODS We conducted a phase 4, multicenter, prospective, video-controlled, in-home NightWatch implementation study (NCT03909984). We included children aged 4-16 years, with ≥1 weekly nocturnal major motor seizure, living at home. We compared a 2-month baseline period with a 2-month NightWatch intervention. The primary outcome was the detection performance of NightWatch for major motor seizures (focal to bilateral or generalized tonic-clonic [TC] seizures, focal to bilateral or generalized tonic seizures lasting >30 s, hyperkinetic seizures, and a remainder category of focal to bilateral or generalized clonic seizures and "TC-like" seizures). Secondary outcomes included caregivers' stress (Caregiver Strain Index [CSI]), sleep (Pittsburgh Quality of Sleep Index), and QoL (EuroQol five-dimension five-level scale). RESULTS We included 53 children (55% male, mean age = 9.7 ± 3.6 years, 68% learning disability) and analyzed 2310 nights (28 173 h), including 552 major motor seizures. Nineteen participants did not experience any episode of interest during the trial. The median detection sensitivity per participant was 100% (range = 46%-100%), and the median individual false alarm rate was .04 per hour (range = 0-.53). Caregiver's stress decreased significantly (mean total CSI score = 8.0 vs. 7.1, p = .032), whereas caregiver's sleep and QoL did not change significantly during the trial. SIGNIFICANCE The NightWatch system demonstrated high sensitivity for detecting nocturnal major motor seizures in children in a family home setting and reduced caregiver stress.
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Affiliation(s)
- Anouk van Westrhenen
- Stichting Epilepsie Instellingen Nederland (SEIN), Heemstede and Zwolle, the Netherlands
- Department of Neurology and Clinical Neurophysiology, Leiden University Medical Center, Leiden, the Netherlands
| | - Richard H C Lazeron
- Academic Center of Epileptology Kempenhaeghe, Heeze, the Netherlands
- Faculty of Electrical Engineering, Eindhoven University of Technology, Eindhoven, the Netherlands
| | - Johannes P van Dijk
- Academic Center of Epileptology Kempenhaeghe, Heeze, the Netherlands
- Faculty of Electrical Engineering, Eindhoven University of Technology, Eindhoven, the Netherlands
- Department of Orthodontics, Ulm University, Ulm, Germany
| | - Frans S S Leijten
- Brain Center, Department of Neurology, University Medical Center Utrecht, Utrecht, the Netherlands
| | - Roland D Thijs
- Stichting Epilepsie Instellingen Nederland (SEIN), Heemstede and Zwolle, the Netherlands
- Department of Neurology and Clinical Neurophysiology, Leiden University Medical Center, Leiden, the Netherlands
- UCL Queen Square Institute of Neurology, London, UK
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Bagnall RD, Perucca P. ILAE Genetic Literacy Series: Postmortem Genetic Testing in Sudden Unexpected Death in Epilepsy. Epileptic Disord 2023; 25:472-479. [PMID: 37340991 DOI: 10.1002/epd2.20090] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2023] [Revised: 05/31/2023] [Accepted: 06/17/2023] [Indexed: 06/22/2023]
Abstract
A 24-year-old man with non-lesional bitemporal lobe epilepsy since age 16 years was found dead in bed around midday. He was last seen the previous night when he was witnessed to have a tonic-clonic seizure. Before his death, he was experiencing weekly focal impaired awareness seizures and up to two focal-to-bilateral tonic-clonic seizures each year. He had trialed several antiseizure medications and was on levetiracetam 1500 mg/day, lamotrigine 400 mg/day, and clobazam 10 mg/day at the time of death. Other than epilepsy, his medical history was unremarkable. Of note, he had an older brother with a history of febrile seizures and a paternal first cousin with epilepsy. No cause of death was identified following a comprehensive postmortem investigation. The coroner classified the death as "sudden unexpected death in epilepsy" (SUDEP), and it would qualify as "definite SUDEP" using the current definitions.1 This left the family with many questions unanswered; in particular, they wish to know what caused the death and whether it could happen to other family members. Could postmortem genetic testing identify a cause of death, provide closure to the family, and facilitate cascade genetic testing of first-degree family members who may be at risk of sudden death? While grieving family members struggle with uncertainty about the cause of death, we as clinicians also face similar uncertainties about genetic contributions to SUDEP, especially when the literature is sparse, and the utility of genetic testing is still being worked out. We aim to shed some light on this topic, highlighting areas where data is emerging but also areas where uncertainty remains, keeping our case in mind as we examine this clinically important area.
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Affiliation(s)
- Richard D Bagnall
- Agnes Ginges Centre for Molecular Cardiology at Centenary Institute, University of Sydney, Sydney, New South Wales, Australia
- Faculty of Medicine and Health, University of Sydney, Sydney, New South Wales, Australia
| | - Piero Perucca
- Department of Medicine (Austin Health), Epilepsy Research Centre, The University of Melbourne, Melbourne, Victoria, Australia
- Bladin-Berkovic Comprehensive Epilepsy Program, Department of Neurology, Austin Health, Melbourne, Victoria, Australia
- Department of Neuroscience, Central Clinical School, Monash University, Melbourne, Victoria, Australia
- Department of Neurology, Alfred Health, Melbourne, Victoria, Australia
- Department of Neurology, The Royal Melbourne Hospital, Melbourne, Victoria, Australia
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Zhou Y, Hao N, Sander JW, Lin X, Xiong W, Zhou D. KCNH2 variants in a family with epilepsy and long QT syndrome: A case report and literature review. Epileptic Disord 2023; 25:492-499. [PMID: 36946251 DOI: 10.1002/epd2.20046] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/23/2022] [Revised: 03/07/2023] [Accepted: 03/12/2023] [Indexed: 03/23/2023]
Abstract
OBJECTIVE Genes associated with Long QT syndromes (LQTS), such as KCNQ1, KCNH2, and SCN5A, are common causes of epilepsy. The Arg 744* variant of KCNH2 has been previously reported in people with epilepsy or LQTS, but none of these patients were reported to simultaneously suffer from epilepsy and LQTS. Herein, we report the case of a family with epilepsy and cardiac disorders. METHOD The proband, a 25-year-old woman, with a family history of epilepsy and LQTS was followed at West China Hospital. The proband experienced her first seizure at the age of seven. Video electroencephalograms (vEEGs) showed epileptic discharges. Her 24-h dynamic electrocardiograms 2 (ECGs) showed QTc prolongation. The proband's mother, who is 50 years old, had her first generalized tonic-clonic seizure (GTCS) at the age of 18 years old. After she gave birth at the age of 25, the frequency of seizures increased, so antiepileptic therapy was initiated. When she was 28 years old, she complained of palpitations and syncope for the first time, and QTc prolongation was detected on her 24-h dynamic ECGs. The proband's grandmother also had complaints of palpitations and syncope at the age of 73. Her 24-h dynamic ECGs indicated supraventricular arrhythmia, with the lowest heart rate being 41 bpm, so she agreed to a pacemaker. Considering the young patient's family history, blood samples of the patient and her parents were collected for genetic analysis. RESULTS A heterozygous variant of KCNH2 [c.2230 (exon9) C>T, p. Arg744Ter, 416, NM_000238, rs189014161] was found in the proband and her mother. According to the guidelines of the American College of Medical Genetics and Genomics and the Association for Molecular Pathology, we classified the KCNH2 variant as pathogenic. SIGNIFICANCE This study expands the clinical phenotype of the Arg 744* KCNH2 pathogenic variant. In the context of channelopathies, because of the genetic susceptibility of the brain and the heart, the risk of comorbidity should be considered. This also indicates the importance of precise antiepileptic drug (AED) management and regular ECG monitoring for patients with channelopathies.
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Affiliation(s)
- Yu Zhou
- Department of Neurology, West China Hospital of Sichuan University, Chengdu, China
- Institute of Brain Science and Brain-inspired technology of West China Hospital, Sichuan University, Chengdu, China
| | - Nanya Hao
- Department of Neurology, West China Hospital of Sichuan University, Chengdu, China
- Institute of Brain Science and Brain-inspired technology of West China Hospital, Sichuan University, Chengdu, China
| | - Josemir W Sander
- Department of Neurology, West China Hospital of Sichuan University, Chengdu, China
- Institute of Brain Science and Brain-inspired technology of West China Hospital, Sichuan University, Chengdu, China
- NIHR University College London Hospitals Biomedical Research Centre, UCL Queen Square Institute of Neurology, Queen Square, London, WC1N 3BG, UK
- Chalfont Centre for Epilepsy, Chalfont St Peter, United Kingdom & Stichting Epilepsie Instellingen Nederland (SEIN), Heemstede, Netherlands
| | - Xu Lin
- Department of Neurology, The Affiliated Chengdu 363 Hospital of Southwest Medical University, Chengdu, Sichuan, China
| | - Weixi Xiong
- Department of Neurology, West China Hospital of Sichuan University, Chengdu, China
- Institute of Brain Science and Brain-inspired technology of West China Hospital, Sichuan University, Chengdu, China
| | - Dong Zhou
- Department of Neurology, West China Hospital of Sichuan University, Chengdu, China
- Institute of Brain Science and Brain-inspired technology of West China Hospital, Sichuan University, Chengdu, China
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Teran FA, Sainju RK, Bravo E, Wagnon J, Kim Y, Granner A, Gehlbach BK, Richerson GB. Seizures Cause Prolonged Impairment of Ventilation, CO 2 Chemoreception and Thermoregulation. J Neurosci 2023; 43:4959-4971. [PMID: 37160367 PMCID: PMC10324997 DOI: 10.1523/jneurosci.0450-23.2023] [Citation(s) in RCA: 7] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/11/2023] [Revised: 04/24/2023] [Accepted: 04/30/2023] [Indexed: 05/11/2023] Open
Abstract
Sudden unexpected death in epilepsy (SUDEP) has been linked to respiratory dysfunction, but the mechanisms underlying this association remain unclear. Here we found that both focal and generalized convulsive seizures (GCSs) in epilepsy patients caused a prolonged decrease in the hypercapnic ventilatory response (HCVR; a measure of respiratory CO2 chemoreception). We then studied Scn1a R1407X/+ (Dravet syndrome; DS) and Scn8a N1768D/+ (D/+) mice of both sexes, two models of SUDEP, and found that convulsive seizures caused a postictal decrease in ventilation and severely depressed the HCVR in a subset of animals. Those mice with severe postictal depression of the HCVR also exhibited transient postictal hypothermia. A combination of blunted HCVR and abnormal thermoregulation is known to occur with dysfunction of the serotonin (5-hydroxytryptamine; 5-HT) system in mice. Depleting 5-HT with para-chlorophenylalanine (PCPA) mimicked seizure-induced hypoventilation, partially occluded the postictal decrease in the HCVR, exacerbated hypothermia, and increased postictal mortality in DS mice. Conversely, pretreatment with the 5-HT agonist fenfluramine reduced postictal inhibition of the HCVR and hypothermia. These results are consistent with the previous observation that seizures cause transient impairment of serotonergic neuron function, which would be expected to inhibit the many aspects of respiratory control dependent on 5-HT, including baseline ventilation and the HCVR. These results provide a scientific rationale to investigate the interictal and/or postictal HCVR as noninvasive biomarkers for those at high risk of seizure-induced death, and to prevent SUDEP by enhancing postictal 5-HT tone.SIGNIFICANCE STATEMENT There is increasing evidence that seizure-induced respiratory dysfunction contributes to the pathophysiology of sudden unexpected death in epilepsy (SUDEP). However, the cellular basis of this dysfunction has not been defined. Here, we show that seizures impair CO2 chemoreception in some epilepsy patients. In two mouse models of SUDEP we found that generalized convulsive seizures impaired CO2 chemoreception, and induced hypothermia, two effects reported with serotonergic neuron dysfunction. The defects in chemoreception and thermoregulation were exacerbated by chemical depletion of serotonin and reduced with fenfluramine, suggesting that seizure-induced respiratory dysfunction may be due to impairment of serotonin neuron function. These findings suggest that impaired chemoreception because of transient inhibition of serotonergic neurons may contribute to the pathophysiology of SUDEP.
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Affiliation(s)
- Frida A Teran
- Department of Neurology, University of Iowa, Iowa City, Iowa 52242
- Medical Scientist Training Program, University of Iowa, Iowa City, Iowa 52242
- Iowa Neuroscience Institute, University of Iowa, Iowa City, Iowa 52242
| | - Rup K Sainju
- Department of Neurology, University of Iowa, Iowa City, Iowa 52242
| | - Eduardo Bravo
- Department of Neurology, University of Iowa, Iowa City, Iowa 52242
- Iowa Neuroscience Institute, University of Iowa, Iowa City, Iowa 52242
| | - Jacy Wagnon
- Department of Neuroscience, The Ohio State University, Columbus, Ohio 43210
| | - YuJaung Kim
- Department of Neurology, University of Iowa, Iowa City, Iowa 52242
| | - Alex Granner
- Department of Neurology, University of Iowa, Iowa City, Iowa 52242
| | - Brian K Gehlbach
- Department of Internal Medicine, University of Iowa, Iowa City, Iowa 52242
| | - George B Richerson
- Department of Neurology, University of Iowa, Iowa City, Iowa 52242
- Iowa Neuroscience Institute, University of Iowa, Iowa City, Iowa 52242
- Department of Molecular Physiology and Biophysics, University of Iowa, Iowa City, Iowa 52242
- Neurology, Veterans Affairs Medical Center, Iowa City, Iowa 52242
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Whitney R, Sharma S, Jones KC, RamachandranNair R. Genetics and SUDEP: Challenges and Future Directions. Seizure 2023; 110:188-193. [PMID: 37413779 DOI: 10.1016/j.seizure.2023.07.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/04/2023] [Revised: 06/30/2023] [Accepted: 07/02/2023] [Indexed: 07/08/2023] Open
Abstract
Sudden unexpected death in epilepsy (SUDEP) is the leading cause of epilepsy-related deaths in children and adults with epilepsy. The incidence of SUDEP in children and adults is equal, approximately 1.2 per 1000-person years. Although inroads have been made in our understanding of SUDEP, its pathophysiology remains unknown. The most important risk factor for SUDEP is the presence of tonic-clonic seizures. Recently there has been growing interest in the contribution of genetic risk factors to SUDEP deaths. Pathogenic variants in epilepsy-related and cardiac genes have been found in some cases of SUDEP post-mortem. Pleiotropy may occur in which a single gene when altered may cause multiple phenotypes (i.e., epilepsy and cardiac arrhythmia). Recently it has been shown that some developmental and epileptic encephalopathies (DEEs) may also be at heightened risk of SUDEP. In addition, polygenic risk has been postulated to effect SUDEP risk with current models evaluating the additive effect of variants in multiple genes. However, the mechanisms underpinning polygenic risk in SUDEP are likely more complex than this. Some preliminary studies also highlight the feasibility of detecting genetic variants in brain tissue post-mortem. Despite the advances in the field of SUDEP genetics, the use of molecular autopsy remains underutilized in SUDEP cases. Several challenges exist concerning genetic testing post-mortem in SUDEP cases, such as interpretation, cost of testing, and availability. In this focused review, we highlight the current landscape of genetic testing in SUDEP cases, its challenges, and future directions.
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Affiliation(s)
- Robyn Whitney
- Division of Neurology, Department of Paediatrics, McMaster University, Hamilton, Ontario, Canada.
| | - Suvasini Sharma
- Neurology Division, Department of Pediatrics, Lady Hardinge Medical College and associated Kalawati Saran Children Hospital, New Delhi, India
| | - Kevin C Jones
- Division of Neurology, Department of Paediatrics, McMaster University, Hamilton, Ontario, Canada
| | - Rajesh RamachandranNair
- Division of Neurology, Department of Paediatrics, McMaster University, Hamilton, Ontario, Canada
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Argo A, Puntarello M, Malta G, Buscemi R, Scalzo G, Triolo V, Albano GD, Zerbo S. The analysis of SUDEP forensic autopsies leading to preventable events. Front Neurol 2023; 14:1231515. [PMID: 37456625 PMCID: PMC10346851 DOI: 10.3389/fneur.2023.1231515] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/30/2023] [Accepted: 06/12/2023] [Indexed: 07/18/2023] Open
Abstract
Introduction The diagnosis of unexpected death by excluding non-natural causes, particularly in subjects with epilepsy, is a topic of interest and it is difficult to identify in the forensic field. Health professionals sometimes are faced with cases of sudden death, generally in young adults with a long history of epilepsy that require, for judicial purposes, an explanation in terms of cause and means to determine the death. SUDEP is an entity diagnosed by the exclusion of other causes that may have led to death, and then for forensic purposes, it requires particular attention and knowledge, and there is difficulty in identifying it. Our contribution aims to illustrate the scientific community pathological findings, medical history, and circumstantial evidence of four cases of sudden death in epileptic subjects. Method We illustrated four cases of judicial autopsies from the Institute of Forensic Medicine of Palermo, Italy; the purpose was to exclude the criminal intervention in determining the death as non-natural. The study of victims' medical history, the toxicological investigations, and the autopsy findings analyzed both from macroscopic and microscopic aspects have made it possible to highlight some findings that can be traced back to SUDEP despite the small sample of subjects studied. Results These presented findings of four SUDEP cases could help forensic pathologists in recognizing this entity, by highlighting its characteristics, and allowing for a pathological classification, also in relation to the use of drugs for epilepsy treatment and circumstances of death. Discussion To obtain a definite diagnosis of SUDEP, a complex investigation process is required in a multidisciplinary approach. Considering the literature review with criticism, it could allow health professionals to select the characteristics of epileptic patients at risk of sudden death. Processing human behaviors, molecular and histopathological findings of the autopsies, but also the physiological, and pathological human body system functions thanks to Artificial Intelligence, could be the key to explaining SUDEP mechanisms and the future results to prevent it.
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Affiliation(s)
- Antonina Argo
- Department of Health Promotion, Mother and Child Care, Internal Medicine and Medical Specialties, Section of Legal Medicine, University of Palermo, Palermo, Italy
| | - Maria Puntarello
- Department of Health Promotion, Mother and Child Care, Internal Medicine and Medical Specialties, Section of Legal Medicine, University of Palermo, Palermo, Italy
| | - Ginevra Malta
- Department of Health Promotion, Mother and Child Care, Internal Medicine and Medical Specialties, Section of Legal Medicine, University of Palermo, Palermo, Italy
| | - Roberto Buscemi
- Department of Health Promotion, Mother and Child Care, Internal Medicine and Medical Specialties, Section of Legal Medicine, University of Palermo, Palermo, Italy
| | - Giovanni Scalzo
- Department of Health Promotion, Mother and Child Care, Internal Medicine and Medical Specialties, Section of Legal Medicine, University of Palermo, Palermo, Italy
| | | | - Giuseppe Davide Albano
- Department of Health Promotion, Mother and Child Care, Internal Medicine and Medical Specialties, Section of Legal Medicine, University of Palermo, Palermo, Italy
| | - Stefania Zerbo
- Department of Health Promotion, Mother and Child Care, Internal Medicine and Medical Specialties, Section of Legal Medicine, University of Palermo, Palermo, Italy
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Mbizvo GK, Schnier C, Ramsay J, Duncan SE, Chin RF. Epilepsy-related mortality during the COVID-19 pandemic: A nationwide study of routine Scottish data. Seizure 2023; 110:160-168. [PMID: 37393862 PMCID: PMC10257947 DOI: 10.1016/j.seizure.2023.06.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/03/2023] [Revised: 05/25/2023] [Accepted: 06/11/2023] [Indexed: 07/04/2023] Open
Abstract
OBJECTIVE To examine whether epilepsy-related deaths increased during the COVID-19 pandemic and if the proportion with COVID-19 listed as the underlying cause is different between people experiencing epilepsy-related deaths and those experiencing deaths unrelated to epilepsy. METHODS This was a Scotland-wide, population-based, cross-sectional study of routinely-collected mortality data pertaining to March-August of 2020 (COVID-19 pandemic peak) compared to the corresponding periods in 2015-2019. ICD-10-coded causes of death of deceased people of any age were obtained from a national mortality registry of death certificates in order to identify those experiencing epilepsy-related deaths (coded G40-41), deaths with COVID-19 listed as a cause (coded U07.1-07.2), and deaths unrelated to epilepsy (death without G40-41 coded). The number of epilepsy-related deaths in 2020 were compared to the mean observed through 2015-2019 on an autoregressive integrated moving average (ARIMA) model (overall, men, women). Proportionate mortality and odds ratios (OR) for deaths with COVID-19 listed as the underlying cause were determined for the epilepsy-related deaths compared to deaths unrelated to epilepsy, reporting 95% confidence intervals (CIs). RESULTS A mean number of 164 epilepsy-related deaths occurred through March-August of 2015-2019 (of which a mean of 71 were in women and 93 in men). There were subsequently 189 epilepsy-related deaths during the pandemic March-August 2020 (89 women, 100 men). This was 25 more epilepsy-related deaths (18 women, 7 men) compared to the mean through 2015-2019. The increase in women was beyond the mean year-to-year variation seen in 2015-2019. Proportionate mortality with COVID-19 listed as the underlying cause was similar between people experiencing epilepsy-related deaths (21/189, 11.1%, CI 7.0-16.5%) and deaths unrelated to epilepsy (3,879/27,428, 14.1%, CI 13.7-14.6%), OR 0.76 (CI 0.48-1.20). Ten of 18 excess epilepsy-related deaths in women had COVID-19 listed as an additional cause. CONCLUSIONS There is little evidence to suggest there have been any major increases in epilepsy-related deaths in Scotland during the COVID-19 pandemic. COVID-19 is a common underlying cause of both epilepsy-related and unrelated deaths.
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Affiliation(s)
- Gashirai K Mbizvo
- Muir Maxwell Epilepsy Centre, Centre for Clinical Brain Sciences, The University of Edinburgh, Edinburgh, United Kingdom; Pharmacology and Therapeutics, Institute of Systems, Molecular and Integrative Biology, University of Liverpool, United Kingdom; Liverpool Centre for Cardiovascular Science, University of Liverpool and Liverpool Heart & Chest Hospital, Liverpool, United Kingdom.
| | - Christian Schnier
- Usher Institute, The University of Edinburgh, Edinburgh, United Kingdom
| | - Julie Ramsay
- Vital Events Statistics, National Records of Scotland, Edinburgh, United Kingdom
| | - Susan E Duncan
- Muir Maxwell Epilepsy Centre, Centre for Clinical Brain Sciences, The University of Edinburgh, Edinburgh, United Kingdom; Department of Clinical Neurosciences, Edinburgh Royal Infirmary, Edinburgh, United Kingdom
| | - Richard Fm Chin
- Muir Maxwell Epilepsy Centre, Centre for Clinical Brain Sciences, The University of Edinburgh, Edinburgh, United Kingdom; Royal Hospital for Children and Young People, Edinburgh, United Kingdom
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Whitney R, Strohm S, Jeffs T, Jones KC, Jack SM, RamachandranNair R. SUDEP: Living with the knowledge. Epilepsy Res 2023; 194:107177. [PMID: 37295320 DOI: 10.1016/j.eplepsyres.2023.107177] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/19/2023] [Revised: 05/17/2023] [Accepted: 06/01/2023] [Indexed: 06/12/2023]
Abstract
OBJECTIVE To understand how knowledge of sudden unexpected death in epilepsy (SUDEP) impacted the lives of adult persons with epilepsy (PWE) and primary caregivers of both adults and children with epilepsy. METHODS The principles of fundamental qualitative description guided this descriptive and exploratory qualitative study to document patients' and caregivers' perceptions and experiences. A purposeful sample of individuals (18 years or older) diagnosed with epilepsy or primary caregivers of PWE completed a single in-depth, semi-structured, one-to-one telephone interview. Categories of findings were developed using directed content analysis. RESULTS A total of twenty-seven participants completed the study. This consisted of eight adult females and six adult males with epilepsy, ten female caregivers, and three male caregivers of PWE. All participants had become aware of SUDEP at least 12 months before their interview. Most were not informed about SUDEP by their treating neurologist and instead learned about SUDEP via alternative sources (e.g., the internet). All participants believed that knowledge of SUDEP outweighed the risks of being informed about it. Anxiety/fear related to SUDEP disclosure was generally not long-lasting. Caregivers of PWE were more directly impacted by SUDEP disclosure than adult PWE. Caregivers were more likely to make lifestyle/management changes due to learning about SUDEP (e.g., increased supervision and co-sleeping). Participants agreed that follow-up clinical support should be provided after SUDEP disclosure. CONCLUSIONS Disclosure of SUDEP risk may have more significant impacts on caregivers of PWE than adult PWE in the form of lifestyle changes and epilepsy management. After SUDEP disclosure, follow-up support should be offered to PWE and their caregivers, which should be incorporated into future guidelines.
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Affiliation(s)
- Robyn Whitney
- Division of Neurology, Department of Paediatrics, McMaster University, Hamilton, Ontario, Canada
| | - Sonya Strohm
- School of Nursing, McMaster University, Hamilton, Ontario, Canada
| | | | - Kevin C Jones
- Division of Neurology, Department of Paediatrics, McMaster University, Hamilton, Ontario, Canada
| | - Susan M Jack
- School of Nursing, McMaster University, Hamilton, Ontario, Canada
| | - Rajesh RamachandranNair
- Division of Neurology, Department of Paediatrics, McMaster University, Hamilton, Ontario, Canada.
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Wojcik MH, Poduri AH, Holm IA, MacRae CA, Goldstein RD. The fundamental need for unifying phenotypes in sudden unexpected pediatric deaths. Front Med (Lausanne) 2023; 10:1166188. [PMID: 37332751 PMCID: PMC10273404 DOI: 10.3389/fmed.2023.1166188] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/14/2023] [Accepted: 05/03/2023] [Indexed: 06/20/2023] Open
Abstract
A definitive, authoritative approach to evaluate the causes of unexpected, and ultimately unexplained, pediatric deaths remains elusive, relegating final conclusions to diagnoses of exclusion in the vast majority of cases. Research into unexplained pediatric deaths has focused primarily on sudden infant deaths (under 1 year of age) and led to the identification of several potential, albeit incompletely understood, contributory factors: nonspecific pathology findings, associations with sleep position and environment that may not be uniformly relevant, and the elucidation of a role for serotonin that is practically difficult to estimate in any individual case. Any assessment of progress in this field must also acknowledge the failure of current approaches to substantially decrease mortality rates in decades. Furthermore, potential commonalities with pediatric deaths across a broader age spectrum have not been widely considered. Recent epilepsy-related observations and genetic findings, identified post-mortem in both infants and children who died suddenly and unexpectedly, suggest a role for more intense and specific phenotyping efforts as well as an expanded role for genetic and genomic evaluation. We therefore present a new approach to reframe the phenotype in sudden unexplained deaths in the pediatric age range, collapsing many distinctions based on arbitrary factors (such as age) that have previously guided research in this area, and discuss its implications for the future of postmortem investigation.
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Affiliation(s)
- Monica H. Wojcik
- Robert’s Program for Sudden Unexpected Death in Pediatrics, Boston Children’s Hospital, Boston, MA, United States
- Division of Newborn Medicine, Department of Pediatrics, Boston Children’s Hospital, Boston, MA, United States
- Division of Genetics and Genomics, Department of Pediatrics, Boston Children’s Hospital, Boston, MA, United States
- Harvard Medical School, Boston, MA, United States
| | - Annapurna H. Poduri
- Robert’s Program for Sudden Unexpected Death in Pediatrics, Boston Children’s Hospital, Boston, MA, United States
- Harvard Medical School, Boston, MA, United States
- F.M. Kirby Neurobiology Center, Boston Children's Hospital, Boston, MA, United States
- Epilepsy Genetics Program, Department of Neurology, Boston Children's Hospital and Harvard Medical School, Boston, MA, United States
| | - Ingrid A. Holm
- Robert’s Program for Sudden Unexpected Death in Pediatrics, Boston Children’s Hospital, Boston, MA, United States
- Division of Genetics and Genomics, Department of Pediatrics, Boston Children’s Hospital, Boston, MA, United States
- Harvard Medical School, Boston, MA, United States
| | - Calum A. MacRae
- Harvard Medical School, Boston, MA, United States
- Department of Medicine, Brigham and Women's Hospital, Boston, MA, United States
| | - Richard D. Goldstein
- Robert’s Program for Sudden Unexpected Death in Pediatrics, Boston Children’s Hospital, Boston, MA, United States
- Harvard Medical School, Boston, MA, United States
- Division of General Pediatrics, Department of Pediatrics, Boston Children's Hospital, Boston, MA, United States
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Crone SA, Dlouhy BJ, Gross C, Ray RS. Editorial: Forebrain control of breathing and sudden death in epilepsy. Front Neural Circuits 2023; 17:1212172. [PMID: 37288286 PMCID: PMC10242160 DOI: 10.3389/fncir.2023.1212172] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/25/2023] [Accepted: 05/09/2023] [Indexed: 06/09/2023] Open
Affiliation(s)
- Steven A. Crone
- Division of Pediatric Neurosurgery, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, United States
- Division of Developmental Biology, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, United States
- Department of Neurosurgery, University of Cincinnati College of Medicine, Cincinnati, OH, United States
| | - Brian J. Dlouhy
- Department of Neurosurgery, University of Iowa, Iowa City, IA, United States
- Iowa Neuroscience Institute, University of Iowa, Iowa City, IA, United States
- Pappajohn Biomedical Institute, University of Iowa, Iowa City, IA, United States
| | - Christina Gross
- Division of Neurology, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, United States
- Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, OH, United States
| | - Russell S. Ray
- Memory Brain Research Center, Baylor College of Medicine, Houston, TX, United States
- Department of Neuroscience, Baylor College of Medicine, Houston, TX, United States
- McNair Medical Institute, Houston, TX, United States
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Sharma S, Rana AK, Rahmatkar SN, Patial V, Singh D. Protective effect of Nardostachys jatamansi extract against lithium-pilocarpine-induced spontaneous recurrent seizures and associated cardiac irregularities in a rat model. J Ethnopharmacol 2023; 308:116280. [PMID: 36813245 DOI: 10.1016/j.jep.2023.116280] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/10/2022] [Revised: 02/09/2023] [Accepted: 02/12/2023] [Indexed: 06/18/2023]
Abstract
ETHNOPHARMACOLOGICAL RELEVANCE Nardostachys jatamansi (D.Don) DC. is a perennial herbaceous medicinal plant widely used for the ethnomedical treatment of various ailments. The underground parts of the plants are used in traditional medicine to manage epilepsy and other cardiovascular conditions. AIM OF THE STUDY The present study was undertaken to investigate the efficacy of a characterized hydroalcoholic extract (NJET) of Nardostachys jatamansi in the lithium-pilocarpine rat model of spontaneous recurrent seizures (SRS) and associated cardiac irregularities. MATERIALS AND METHODS NJET was prepared by percolation using 80% ethanol. The dried NEJT was subjected to UHPLC-qTOF-MS/MS for chemical characterization. Molecular docking studies were performed using the characterized compounds to understand mTOR interactions. The animals showing SRS following lithium-pilocarpine administration were treated with NJET for 6 weeks. Afterward, seizure severity, cardiac parameters, serum biochemistry, and histopathological parameters were studied. The cardiac tissue was processed for specific protein and gene expression studies. RESULTS The UHPLC-qTOF-MS/MS characterized 13 compounds in NJET. The identified compounds subjected to molecular docking showed promising binding affinities toward mTOR. There was a dose-dependent decrease in the severity of SRS following the extract administration. A reduction in mean arterial pressure and serum biochemical markers (lactate dehydrogenase and creatine kinase) was also observed following NJET treatment in epileptic animals. Histopathological investigations revealed reduced degenerative changes and decreased fibrosis following the extract treatment. The cardiac mRNA level of Mtor, Rps6, Hif1a, and Tgfb3 was reduced in the extract-treated groups. Further, a similar reduction in the protein expression of p-mTOR and HIF-1α was also observed following NJET treatment in the cardiac tissue. CONCLUSIONS The results concluded that NJET treatment reduces lithium-pilocarpine-induced recurrent seizures and associated cardiac irregularities via downregulation of the mTOR signalling pathway.
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Affiliation(s)
- Supriya Sharma
- Pharmacology and Toxicology Laboratory, Dietetics and Nutrition Technology Division, CSIR-Institute of Himalayan Bioresource Technology, Palampur, 176061, Himachal Pradesh, India; Academy of Scientific and Innovative Research (AcSIR), Ghaziabad, 201002, India
| | - Anil Kumar Rana
- Pharmacology and Toxicology Laboratory, Dietetics and Nutrition Technology Division, CSIR-Institute of Himalayan Bioresource Technology, Palampur, 176061, Himachal Pradesh, India; Academy of Scientific and Innovative Research (AcSIR), Ghaziabad, 201002, India
| | - Shubham Nilkanth Rahmatkar
- Pharmacology and Toxicology Laboratory, Dietetics and Nutrition Technology Division, CSIR-Institute of Himalayan Bioresource Technology, Palampur, 176061, Himachal Pradesh, India; Academy of Scientific and Innovative Research (AcSIR), Ghaziabad, 201002, India
| | - Vikram Patial
- Pharmacology and Toxicology Laboratory, Dietetics and Nutrition Technology Division, CSIR-Institute of Himalayan Bioresource Technology, Palampur, 176061, Himachal Pradesh, India; Academy of Scientific and Innovative Research (AcSIR), Ghaziabad, 201002, India
| | - Damanpreet Singh
- Pharmacology and Toxicology Laboratory, Dietetics and Nutrition Technology Division, CSIR-Institute of Himalayan Bioresource Technology, Palampur, 176061, Himachal Pradesh, India; Academy of Scientific and Innovative Research (AcSIR), Ghaziabad, 201002, India.
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Kassinopoulos M, Rolandi N, Alphan L, Harper RM, Oliveira J, Scott C, Kozák LR, Guye M, Lemieux L, Diehl B. Brain Connectivity Correlates of Breathing and Cardiac Irregularities in SUDEP: A Resting-State fMRI Study. bioRxiv 2023:2023.05.19.541412. [PMID: 37293113 PMCID: PMC10245782 DOI: 10.1101/2023.05.19.541412] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/10/2023]
Abstract
Sudden unexpected death in epilepsy (SUDEP) is the leading cause of premature mortality among people with epilepsy. Evidence from witnessed and monitored SUDEP cases indicate seizure-induced cardiovascular and respiratory failures; yet, the underlying mechanisms remain obscure. SUDEP occurs often during the night and early morning hours, suggesting that sleep or circadian rhythm-induced changes in physiology contribute to the fatal event. Resting-state fMRI studies have found altered functional connectivity between brain structures involved in cardiorespiratory regulation in later SUDEP cases and in individuals at high-risk of SUDEP. However, those connectivity findings have not been related to changes in cardiovascular or respiratory patterns. Here, we compared fMRI patterns of brain connectivity associated with regular and irregular cardiorespiratory rhythms in SUDEP cases with those of living epilepsy patients of varying SUDEP risk, and healthy controls. We analysed resting-state fMRI data from 98 patients with epilepsy (9 who subsequently succumbed to SUDEP, 43 categorized as low SUDEP risk (no tonic-clonic seizures (TCS) in the year preceding the fMRI scan), and 46 as high SUDEP risk (>3 TCS in the year preceding the scan)) and 25 healthy controls. The global signal amplitude (GSA), defined as the moving standard deviation of the fMRI global signal, was used to identify periods with regular ('low state') and irregular ('high state') cardiorespiratory rhythms. Correlation maps were derived from seeds in twelve regions with a key role in autonomic or respiratory regulation, for the low and high states. Following principal component analysis, component weights were compared between the groups. We found widespread alterations in connectivity of precuneus/posterior cingulate cortex in epilepsy compared to controls, in the low state (regular cardiorespiratory activity). In the low state, and to a lesser degree in the high state, reduced anterior insula connectivity (mainly with anterior and posterior cingulate cortex) in epilepsy appeared, relative to healthy controls. For SUDEP cases, the insula connectivity differences were inversely related to the interval between the fMRI scan and death. The findings suggest that anterior insula connectivity measures may provide a biomarker of SUDEP risk. The neural correlates of autonomic brain structures associated with different cardiorespiratory rhythms may shed light on the mechanisms underlying terminal apnea observed in SUDEP.
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Affiliation(s)
- Michalis Kassinopoulos
- UCL Queen Square Institute of Neurology, University College London, London, United Kingdom
- Epilepsy Society, Chalfont St. Peter, Buckinghamshire, United Kingdom
| | - Nicolo Rolandi
- UCL Queen Square Institute of Neurology, University College London, London, United Kingdom
- Epilepsy Society, Chalfont St. Peter, Buckinghamshire, United Kingdom
| | - Laren Alphan
- UCL Queen Square Institute of Neurology, University College London, London, United Kingdom
| | - Ronald M. Harper
- UCLA Brain Research Institute, Los Angeles, CA, United States
- Department of Neurobiology, David Geffen School of Medicine at UCLA, Los Angeles, CA, United States
| | - Joana Oliveira
- UCL Queen Square Institute of Neurology, University College London, London, United Kingdom
- Department of Clinical Neurophysiology, National Hospital for Neurology and Neurosurgery, UCLH, London, United Kingdom
| | - Catherine Scott
- UCL Queen Square Institute of Neurology, University College London, London, United Kingdom
- Department of Clinical Neurophysiology, National Hospital for Neurology and Neurosurgery, UCLH, London, United Kingdom
| | - Lajos R. Kozák
- UCL Queen Square Institute of Neurology, University College London, London, United Kingdom
- Department of Neuroradiology, Medical Imaging Centre, Semmelweis University, Budapest, Hungary
| | - Maxime Guye
- Aix Marseille Univ, CNRS, CRMBM UMR 7339, Marseille, France
- APHM, Hôpital de la Timone, CEMEREM, Marseille, France
| | - Louis Lemieux
- UCL Queen Square Institute of Neurology, University College London, London, United Kingdom
- Epilepsy Society, Chalfont St. Peter, Buckinghamshire, United Kingdom
| | - Beate Diehl
- UCL Queen Square Institute of Neurology, University College London, London, United Kingdom
- Epilepsy Society, Chalfont St. Peter, Buckinghamshire, United Kingdom
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Paulhus K, Glasscock E. Novel Genetic Variants Expand the Functional, Molecular, and Pathological Diversity of KCNA1 Channelopathy. Int J Mol Sci 2023; 24:8826. [PMID: 37240170 PMCID: PMC10219020 DOI: 10.3390/ijms24108826] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/26/2023] [Revised: 05/11/2023] [Accepted: 05/13/2023] [Indexed: 05/28/2023] Open
Abstract
The KCNA1 gene encodes Kv1.1 voltage-gated potassium channel α subunits, which are crucial for maintaining healthy neuronal firing and preventing hyperexcitability. Mutations in the KCNA1 gene can cause several neurological diseases and symptoms, such as episodic ataxia type 1 (EA1) and epilepsy, which may occur alone or in combination, making it challenging to establish simple genotype-phenotype correlations. Previous analyses of human KCNA1 variants have shown that epilepsy-linked mutations tend to cluster in regions critical for the channel's pore, whereas EA1-associated mutations are evenly distributed across the length of the protein. In this review, we examine 17 recently discovered pathogenic or likely pathogenic KCNA1 variants to gain new insights into the molecular genetic basis of KCNA1 channelopathy. We provide the first systematic breakdown of disease rates for KCNA1 variants in different protein domains, uncovering potential location biases that influence genotype-phenotype correlations. Our examination of the new mutations strengthens the proposed link between the pore region and epilepsy and reveals new connections between epilepsy-related variants, genetic modifiers, and respiratory dysfunction. Additionally, the new variants include the first two gain-of-function mutations ever discovered for KCNA1, the first frameshift mutation, and the first mutations located in the cytoplasmic N-terminal domain, broadening the functional and molecular scope of KCNA1 channelopathy. Moreover, the recently identified variants highlight emerging links between KCNA1 and musculoskeletal abnormalities and nystagmus, conditions not typically associated with KCNA1. These findings improve our understanding of KCNA1 channelopathy and promise to enhance personalized diagnosis and treatment for individuals with KCNA1-linked disorders.
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Affiliation(s)
| | - Edward Glasscock
- Department of Biological Sciences, Southern Methodist University, Dallas, TX 75275, USA;
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Li J, Cossette-Roberge H, Toffa DH, Deacon C, Keezer MR. Sudden unexpected death in epilepsy ( SUDEP): A bibliometric analysis. Epilepsy Res 2023; 193:107159. [PMID: 37167883 DOI: 10.1016/j.eplepsyres.2023.107159] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/12/2023] [Revised: 04/19/2023] [Accepted: 05/01/2023] [Indexed: 05/13/2023]
Abstract
OBJECTIVE The literature on sudden unexpected death in epilepsy (SUDEP) has been evolving at a staggering rate. We conducted a bibliometric analysis of the SUDEP literature with the aim of presenting its structure, performance, and trends. METHODS The Scopus database was searched in April 2023 for documents explicitly detailing SUDEP in their title, abstract, or keywords. After the removal of duplicate documents, bibliometric analysis was performed using the R package bibliometrix and the program VOSviewer. Performance metrics were computed to describe the literature's annual productivity, most relevant authors and countries, and most important publications. Science mapping was performed to visualize the relationships between research constituents by constructing a country collaboration network, co-authorship network, keyword co-occurrence network, and document co-citation network. RESULTS A total of 2140 documents were analyzed. These documents were published from 1989 onward, with an average number of citations per document of 25.78. Annual productivity had been on the rise since 2006. Out of 6502 authors, five authors were in both the list of the ten most productive and the list of the ten most cited authors: Devinsky O, Sander JW, Tomson T, Ryvlin P, and Lhatoo SD. The USA and the United Kingdom were the most productive and cited countries. Collaborations between American authors and European authors were particularly rich. Prominent themes in the literature included those related to pathophysiology (e.g., cardiac arrhythmia, apnea, autonomic dysfunction), epilepsy characteristics (e.g., epilepsy type, refractoriness, antiseizure medications), and epidemiology (e.g., incidence, age, sex). Emerging themes included sleep, genetics, epilepsy refractoriness, and non-human studies. SIGNIFICANCE The body of literature on SUDEP is rich, fast-growing, and benefiting from frequent international collaborations. Some research themes such as sleep, genetics, and animal studies have become more prevalent over recent years.
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Affiliation(s)
- Jimmy Li
- Neurology Division, Centre Hospitalier de l'Université de Sherbrooke (CHUS), Sherbrooke, QC, Canada; Centre de recherche du Centre Hospitalier de l'Université de Montréal (CRCHUM), Montreal, QC, Canada
| | - Hélène Cossette-Roberge
- Centre de recherche du Centre Hospitalier de l'Université de Montréal (CRCHUM), Montreal, QC, Canada; Faculty of Medicine, Université de Sherbrooke, Sherbrooke, QC, Canada
| | - Dènahin Hinnoutondji Toffa
- Centre de recherche du Centre Hospitalier de l'Université de Montréal (CRCHUM), Montreal, QC, Canada; Department of Neurosciences, Université de Montréal, Montreal, QC, Canada
| | - Charles Deacon
- Neurology Division, Centre Hospitalier de l'Université de Sherbrooke (CHUS), Sherbrooke, QC, Canada
| | - Mark Robert Keezer
- Centre de recherche du Centre Hospitalier de l'Université de Montréal (CRCHUM), Montreal, QC, Canada; Department of Neurosciences, Université de Montréal, Montreal, QC, Canada; School of Public Health, Université de Montréal, Montreal, QC, Canada; Neurology Division, Centre Hospitalier de l'Université de Montréal (CHUM), Montreal, QC, Canada.
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Legouhy A, Allen LA, Vos SB, Oliveira JFA, Kassinopoulos M, Winston GP, Duncan JS, Ogren JA, Scott C, Kumar R, Lhatoo SD, Thom M, Lemieux L, Harper RM, Zhang H, Diehl B. Volumetric and microstructural abnormalities of the amygdala in focal epilepsy with varied levels of SUDEP risk. Epilepsy Res 2023; 192:107139. [PMID: 37068421 DOI: 10.1016/j.eplepsyres.2023.107139] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/24/2022] [Revised: 02/24/2023] [Accepted: 04/06/2023] [Indexed: 04/19/2023]
Abstract
Although the mechanisms of sudden unexpected death in epilepsy (SUDEP) are not yet well understood, generalised- or focal-to-bilateral tonic-clonic seizures (TCS) are a major risk factor. Previous studies highlighted alterations in structures linked to cardio-respiratory regulation; one structure, the amygdala, was enlarged in people at high risk of SUDEP and those who subsequently died. We investigated volume changes and the microstructure of the amygdala in people with epilepsy at varied risk for SUDEP since that structure can play a key role in triggering apnea and mediating blood pressure. The study included 53 healthy subjects and 143 patients with epilepsy, the latter separated into two groups according to whether TCS occur in years before scan. We used amygdala volumetry, derived from structural MRI, and tissue microstructure, derived from diffusion MRI, to identify differences between the groups. The diffusion metrics were obtained by fitting diffusion tensor imaging (DTI) and neurite orientation dispersion and density imaging (NODDI) models. The analyses were performed at the whole amygdala level and at the scale of amygdaloid nuclei. Patients with epilepsy showed larger amygdala volumes and lower neurite density indices (NDI) than healthy subjects; the left amygdala volumes were especially enhanced. Microstructural changes, reflected by NDI differences, were more prominent on the left side and localized in the lateral, basal, central, accessory basal and paralaminar amygdala nuclei; basolateral NDI lowering appeared bilaterally. No significant microstructural differences appeared between epilepsy patients with and without current TCS. The central amygdala nuclei, with prominent interactions from surrounding nuclei of that structure, project to cardiovascular regions and respiratory phase switching areas of the parabrachial pons, as well as to the periaqueductal gray. Consequently, they have the potential to modify blood pressure and heart rate, and induce sustained apnea or apneusis. The findings here suggest that lowered NDI, indicative of reduced dendritic density, could reflect an impaired structural organization influencing descending inputs that modulate vital respiratory timing and drive sites and areas critical for blood pressure control.
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Affiliation(s)
- Antoine Legouhy
- Department of Clinical and Experimental Epilepsy, UCL Queen Square Institute of Neurology, London, UK; Centre for Medical Image Computing, Department of Computer Science, University College London, London, UK.
| | - Luke A Allen
- Department of Clinical and Experimental Epilepsy, UCL Queen Square Institute of Neurology, London, UK; Epilepsy Society MRI Unit, Chalfont St Peter, Buckinghamshire, UK; The Center for SUDEP Research, National Institute of Neurological Disorders and Stroke, Bethesda, MD, USA
| | - Sjoerd B Vos
- Department of Clinical and Experimental Epilepsy, UCL Queen Square Institute of Neurology, London, UK; Centre for Medical Image Computing, Department of Computer Science, University College London, London, UK; Neuroradiological Academic Unit, UCL Queen Square Institute of Neurology, UCL, London, UK; Centre for Microscopy, Characterisation, and Analysis, The University of Western Australia, Nedlands, Australia
| | - Joana F A Oliveira
- Department of Clinical and Experimental Epilepsy, UCL Queen Square Institute of Neurology, London, UK
| | - Michalis Kassinopoulos
- Department of Clinical and Experimental Epilepsy, UCL Queen Square Institute of Neurology, London, UK; Epilepsy Society MRI Unit, Chalfont St Peter, Buckinghamshire, UK
| | - Gavin P Winston
- Department of Clinical and Experimental Epilepsy, UCL Queen Square Institute of Neurology, London, UK; Epilepsy Society MRI Unit, Chalfont St Peter, Buckinghamshire, UK; Division of Neurology, Department of Medicine, Queen's University, Kingston, Ontario, Canada
| | - John S Duncan
- Department of Clinical and Experimental Epilepsy, UCL Queen Square Institute of Neurology, London, UK; Epilepsy Society MRI Unit, Chalfont St Peter, Buckinghamshire, UK
| | - Jennifer A Ogren
- The Center for SUDEP Research, National Institute of Neurological Disorders and Stroke, Bethesda, MD, USA; Brain Research Institute, UCLA, Los Angeles, CA, USA
| | - Catherine Scott
- Department of Clinical and Experimental Epilepsy, UCL Queen Square Institute of Neurology, London, UK; The Center for SUDEP Research, National Institute of Neurological Disorders and Stroke, Bethesda, MD, USA
| | - Rajesh Kumar
- Brain Research Institute, UCLA, Los Angeles, CA, USA; Department of Anesthesiology, David Geffen School of Medicine at UCLA, Los Angeles, CA, USA; Department of Radiological Sciences, David Geffen School of Medicine at UCLA, Los Angeles, CA, USA; Department of Bioengineering, David Geffen School of Medicine at UCLA, Los Angeles, CA, USA
| | - Samden D Lhatoo
- Department of Neurology, University of Texas Health Sciences Center at Houston, Houston, TX, USA
| | - Maria Thom
- Department of Clinical and Experimental Epilepsy, UCL Queen Square Institute of Neurology, London, UK
| | - Louis Lemieux
- Department of Clinical and Experimental Epilepsy, UCL Queen Square Institute of Neurology, London, UK; Epilepsy Society MRI Unit, Chalfont St Peter, Buckinghamshire, UK
| | - Ronald M Harper
- The Center for SUDEP Research, National Institute of Neurological Disorders and Stroke, Bethesda, MD, USA; Brain Research Institute, UCLA, Los Angeles, CA, USA; Department of Neurobiology, David Geffen School of Medicine at UCLA, Los Angeles, CA, USA
| | - Hui Zhang
- Centre for Medical Image Computing, Department of Computer Science, University College London, London, UK
| | - Beate Diehl
- Department of Clinical and Experimental Epilepsy, UCL Queen Square Institute of Neurology, London, UK; Epilepsy Society MRI Unit, Chalfont St Peter, Buckinghamshire, UK; The Center for SUDEP Research, National Institute of Neurological Disorders and Stroke, Bethesda, MD, USA
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Sun D, Wang Q. The application of SUDEP in forensic diagnosis: a mini review. Front Neurol 2023; 14:1169003. [PMID: 37181558 PMCID: PMC10169668 DOI: 10.3389/fneur.2023.1169003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/18/2023] [Accepted: 03/20/2023] [Indexed: 05/16/2023] Open
Abstract
In the epilepsy population, the risk of sudden death from epilepsy is rare but is ~24 times greater than the risk of sudden death from other causes. Sudden unexpected death in epilepsy (SUDEP) has been widely recognized in clinical studies. Despite its significance as a cause of death, SUDEP is rarely used in forensic practice. This review focuses on the forensic characteristics of SUDEP, analyzed the reasons for its underuse in forensic practice, and illustrated the prospect of establishing uniform diagnostic criteria for sudden unexpected death in epilepsy and molecular anatomy in aiding forensic diagnosis.
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Affiliation(s)
| | - Qiang Wang
- Forensic Science Center, East China University of Political Science and Law, Shanghai, China
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Nunes KZ, Scorza FA, Cavalheiro EA, Vassallo DV. Reduction of vascular reactivity in rat aortas following pilocarpine-induced status epilepticus. Clinics (Sao Paulo) 2023; 78:100195. [PMID: 37099815 PMCID: PMC10149400 DOI: 10.1016/j.clinsp.2023.100195] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/06/2022] [Revised: 03/20/2023] [Accepted: 03/28/2023] [Indexed: 04/28/2023] Open
Abstract
OBJECTIVE The authors investigated changes in vascular reactivity in rats following pilocarpine-induced status epilepticus. METHOD Male Wistar rats weighing between 250g and 300g were used. Status epilepticus was induced using 385 mg/kg i.p. pilocarpine. After 40 days the thoracic aorta was dissected and divided into 4 mm rings and the vascular smooth muscle reactivity to phenylephrine was evaluated. RESULTS Epilepsy decreased the contractile responses of the aortic rings to phenylephrine (0.1 nM-300 mM). To investigate if this reduction was induced by increasing NO production with/or hydrogen peroxide L-NAME and Catalase were used. L-NAME (N-nitro-L arginine methyl ester) increased vascular reactivity but the contractile response to phenylephrine increased in the epileptic group. Catalase administration decreased the contractile responses only in the rings of rats with epilepsy. CONCLUSIONS Our findings demonstrated for the first time that epilepsy is capable of causing a reduction of vascular reactivity in rat aortas. These results suggest that vascular reactivity reduction is associated with increased production of Nitric Oxide (NO) as an organic attempt to avoid hypertension produced by excessive sympathetic activation.
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Affiliation(s)
- Karolini Zuqui Nunes
- Postgraduate Program in Nutrition and Health, Universidade Federal do Espírito Santo, Vitória, ES, Brazil.
| | - Fulvio Alexandre Scorza
- Discipline of Neuroscience, Universidade Federal de São Paulo/Escola Paulista de Medicina, São PauloSP, Brazil
| | - Esper Abrão Cavalheiro
- Discipline of Neuroscience, Universidade Federal de São Paulo/Escola Paulista de Medicina, São PauloSP, Brazil
| | - Dalton Valentim Vassallo
- Graduate Program in Physiological Sciences, Universidade Federal do Espírito Santo, Vitória, ES, Brazil
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50
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Baltos JA, Casillas-Espinosa PM, Rollo B, Gregory KJ, White PJ, Christopoulos A, Kwan P, O'Brien TJ, May LT. The Role of the Adenosine System in Epilepsy and its Comorbidities. Br J Pharmacol 2023. [PMID: 37076128 DOI: 10.1111/bph.16094] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/25/2022] [Revised: 03/09/2023] [Accepted: 04/13/2023] [Indexed: 04/21/2023] Open
Abstract
Epilepsy is one of the most serious and common chronic neurological conditions, characterised by recurrent hypersynchronous electrical activity in the brain that lead to seizures. Despite over 50 million people being affected worldwide, only ~70% of people with epilepsy have their seizures successfully controlled with current pharmacotherapy, and many experience significant psychiatric and physical comorbidities. Adenosine, a ubiquitous purine metabolite, is a potent endogenous anti-epileptic substance that can abolish seizure activity via the adenosine A1 G protein-coupled receptor (A1 R). A1 R activation decreases seizure activity in animal models, including models of drug-resistant epilepsy. Recent advances have increased our understanding of epilepsy comorbidities, highlighting the potential for adenosine receptors to modulate epilepsy-associated comorbidities, including cardiovascular dysfunction, sleep, and cognition. This review provides an accessible resource of the current advances in understanding the adenosine system as a therapeutic target for epilepsy and epilepsy-associated comorbidities.
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Affiliation(s)
- Jo-Anne Baltos
- Drug Discovery Biology, Monash Institute of Pharmaceutical Sciences, Monash University, Parkville, VIC, 3052, Australia
| | - Pablo M Casillas-Espinosa
- Department of Neuroscience, Central Clinical School, Monash University, Melbourne, VIC, 3004, Australia
- Department of Medicine, The Royal Melbourne Hospital, University of Melbourne, Parkville, VIC, 3052, Australia
- Department of Neurology, Alfred Hospital, Melbourne, VIC, 3004, Australia
| | - Ben Rollo
- Department of Neuroscience, Central Clinical School, Monash University, Melbourne, VIC, 3004, Australia
| | - Karen J Gregory
- Drug Discovery Biology, Monash Institute of Pharmaceutical Sciences, Monash University, Parkville, VIC, 3052, Australia
- ARC Centre for Cryo-Electron Microscopy of Membrane Proteins, Monash Institute of Pharmaceutical Sciences, Parkville, VIC, 3052, Australia
| | - Paul J White
- Drug Discovery Biology, Monash Institute of Pharmaceutical Sciences, Monash University, Parkville, VIC, 3052, Australia
| | - Arthur Christopoulos
- Drug Discovery Biology, Monash Institute of Pharmaceutical Sciences, Monash University, Parkville, VIC, 3052, Australia
- Neuromedicines Discovery Centre, Monash University
| | - Patrick Kwan
- Department of Neuroscience, Central Clinical School, Monash University, Melbourne, VIC, 3004, Australia
- Department of Medicine, The Royal Melbourne Hospital, University of Melbourne, Parkville, VIC, 3052, Australia
- Department of Neurology, Alfred Hospital, Melbourne, VIC, 3004, Australia
- Department of Neurology, Royal Melbourne Hospital, Parkville, VIC, 3050, Australia
| | - Terence J O'Brien
- Department of Neuroscience, Central Clinical School, Monash University, Melbourne, VIC, 3004, Australia
- Department of Medicine, The Royal Melbourne Hospital, University of Melbourne, Parkville, VIC, 3052, Australia
- Department of Neurology, Alfred Hospital, Melbourne, VIC, 3004, Australia
- Department of Neurology, Royal Melbourne Hospital, Parkville, VIC, 3050, Australia
| | - Lauren T May
- Drug Discovery Biology, Monash Institute of Pharmaceutical Sciences, Monash University, Parkville, VIC, 3052, Australia
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