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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] [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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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] [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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3
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Esmaeili B, Weisholtz D, Tobochnik S, Dworetzky B, Friedman D, Kaffashi F, Cash S, Cha B, Laze J, Reich D, Farooque P, Gholipour T, Singleton M, Loparo K, Koubeissi M, Devinsky O, Lee JW. Association between postictal EEG suppression, postictal autonomic dysfunction, and sudden unexpected death in epilepsy: Evidence from intracranial EEG. Clin Neurophysiol 2023; 146:109-117. [PMID: 36608528 DOI: 10.1016/j.clinph.2022.12.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/26/2022] [Revised: 11/18/2022] [Accepted: 12/02/2022] [Indexed: 12/23/2022]
Abstract
OBJECTIVE The association between postictal electroencephalogram (EEG) suppression (PES), autonomic dysfunction, and Sudden Unexpected Death in Epilepsy (SUDEP) remains poorly understood. We compared PES on simultaneous intracranial and scalp-EEG and evaluated the association of PES with postictal heart rate variability (HRV) and SUDEP outcome. METHODS Convulsive seizures were analyzed in patients with drug-resistant epilepsy at 5 centers. Intracranial PES was quantified using the Hilbert transform. HRV was quantified using root mean square of successive differences of interbeat intervals, low-frequency to high-frequency power ratio, and RR-intervals. RESULTS There were 64 seizures from 63 patients without SUDEP and 11 seizures from 6 SUDEP patients. PES occurred in 99% and 87% of seizures on intracranial-EEG and scalp-EEG, respectively. Mean PES duration in intracranial and scalp-EEG was similar. Intracranial PES was regional (<90% of channels) in 46% of seizures; scalp PES was generalized in all seizures. Generalized PES showed greater decrease in postictal parasympathetic activity than regional PES. PES duration and extent were similar between patients with and without SUDEP. CONCLUSIONS Regional intracranial PES can be present despite scalp-EEG demonstrating generalized or no PES. Postictal autonomic dysfunction correlates with the extent of PES. SIGNIFICANCE Intracranial-EEG demonstrates changes in autonomic regulatory networks not seen on scalp-EEG.
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Affiliation(s)
- Behnaz Esmaeili
- Department of Neurology, University of Washington, Seattle, WA, USA; Department of Neurology, Brigham and Women's Hospital, Boston, MA, USA.
| | - Daniel Weisholtz
- Department of Neurology, Brigham and Women's Hospital, Boston, MA, USA
| | - Steven Tobochnik
- Department of Neurology, Brigham and Women's Hospital, Boston, MA, USA
| | - Barbara Dworetzky
- Department of Neurology, Brigham and Women's Hospital, Boston, MA, USA
| | - Daniel Friedman
- Department of Neurology, New York University School of Medicine, New York, NY, USA
| | - Farhad Kaffashi
- Department of Electrical, Computer and Systems Engineering, Case Western Reserve University, Cleveland, OH, USA
| | - Sydney Cash
- Department of Neurology, Massachusetts General Hospital, Boston, MA, USA
| | - Brannon Cha
- Department of Neurology, Brigham and Women's Hospital, Boston, MA, USA
| | - Juliana Laze
- Department of Neurology, New York University School of Medicine, New York, NY, USA
| | - Dustine Reich
- Department of Neurology, Brigham and Women's Hospital, Boston, MA, USA
| | - Pue Farooque
- Department of Neurology, Yale School of Medicine, New Haven, CT, USA
| | - Taha Gholipour
- Department of Neurology, George Washington University, Washington, DC, USA
| | - Michael Singleton
- Institute of Translational Health Sciences, University of Washington, Seattle, WA, USA
| | - Kenneth Loparo
- Department of Electrical, Computer and Systems Engineering, Case Western Reserve University, Cleveland, OH, USA
| | - Mohamad Koubeissi
- Department of Neurology, George Washington University, Washington, DC, USA
| | - Orrin Devinsky
- Department of Neurology, New York University School of Medicine, New York, NY, USA
| | - Jong Woo Lee
- Department of Neurology, Brigham and Women's Hospital, Boston, MA, USA
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4
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Abnormal heart rate variability during non-REM sleep and postictal generalized EEG suppression in focal epilepsy. Clin Neurophysiol 2022; 140:40-44. [DOI: 10.1016/j.clinph.2022.05.011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/15/2021] [Revised: 05/07/2022] [Accepted: 05/13/2022] [Indexed: 11/19/2022]
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5
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Yang X, Yang X, Liu B, Sun A, Zhao X. Risk factors for postictal generalized EEG suppression in generalized convulsive seizure: a systematic review and meta-analysis. Seizure 2022; 98:19-26. [DOI: 10.1016/j.seizure.2022.03.018] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/07/2021] [Revised: 03/23/2022] [Accepted: 03/26/2022] [Indexed: 11/27/2022] Open
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6
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Zhao X, Vilella L, Zhu L, Rani MRS, Hampson JP, Hampson J, Hupp NJ, Sainju RK, Friedman D, Nei M, Scott C, Allen L, Gehlbach BK, Schuele S, Harper RM, Diehl B, Bateman LM, Devinsky O, Richerson GB, Zhang GQ, Lhatoo SD, Lacuey N. Automated Analysis of Risk Factors for Postictal Generalized EEG Suppression. Front Neurol 2021; 12:669517. [PMID: 34046007 PMCID: PMC8148040 DOI: 10.3389/fneur.2021.669517] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/19/2021] [Accepted: 04/13/2021] [Indexed: 11/25/2022] Open
Abstract
Rationale: Currently, there is some ambiguity over the role of postictal generalized electro-encephalographic suppression (PGES) as a biomarker in sudden unexpected death in epilepsy (SUDEP). Visual analysis of PGES, known to be subjective, may account for this. In this study, we set out to perform an analysis of PGES presence and duration using a validated signal processing tool, specifically to examine the association between PGES and seizure features previously reported to be associated with visually analyzed PGES. Methods: This is a prospective, multicenter epilepsy monitoring study of autonomic and breathing biomarkers of SUDEP in adult patients with intractable epilepsy. We studied videoelectroencephalogram (vEEG) recordings of generalized convulsive seizures (GCS) in a cohort of patients in whom respiratory and vEEG recording were carried out during the evaluation in the epilepsy monitoring unit. A validated automated EEG suppression detection tool was used to determine presence and duration of PGES. Results: We studied 148 GCS in 87 patients. PGES occurred in 106/148 (71.6%) seizures in 70/87 (80.5%) of patients. PGES mean duration was 38.7 ± 23.7 (37; 1–169) seconds. Presence of tonic phase during GCS, including decerebration, decortication and hemi-decerebration, were 8.29 (CI 2.6–26.39, p = 0.0003), 7.17 (CI 1.29–39.76, p = 0.02), and 4.77 (CI 1.25–18.20, p = 0.02) times more likely to have PGES, respectively. In addition, presence of decerebration (p = 0.004) and decortication (p = 0.02), older age (p = 0.009), and hypoxemia duration (p = 0.03) were associated with longer PGES durations. Conclusions: In this study, we confirmed observations made with visual analysis, that presence of tonic phase during GCS, longer hypoxemia, and older age are reliably associated with PGES. We found that of the different types of tonic phase posturing, decerebration has the strongest association with PGES, followed by decortication, followed by hemi-decerebration. This suggests that these factors are likely indicative of seizure severity and may or may not be associated with SUDEP. An automated signal processing tool enables objective metrics, and may resolve apparent ambiguities in the role of PGES in SUDEP and seizure severity studies.
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Affiliation(s)
- Xiuhe Zhao
- Department of Neurology, Qilu Hospital of Shandong University, Jinan, China
| | - Laura Vilella
- National Institute of Neurological Disorders and Stroke (NINDS) Center for Sudden Unexpected Death in Epilepsy (SUDEP) Research, McGovern Medical School, University of Texas Health Science Center at Houston, Houston, TX, United States.,Department of Neurology, McGovern Medical School, University of Texas Health Science Center at Houston, Houston, TX, United States
| | - Liang Zhu
- Biostatistics and Epidemiology Research Design Core, Division of Clinical and Translational Sciences, McGovern Medical School, University of Texas Health Science Center at Houston, Houston, TX, United States
| | - M R Sandhya Rani
- National Institute of Neurological Disorders and Stroke (NINDS) Center for Sudden Unexpected Death in Epilepsy (SUDEP) Research, McGovern Medical School, University of Texas Health Science Center at Houston, Houston, TX, United States.,Department of Neurology, McGovern Medical School, University of Texas Health Science Center at Houston, Houston, TX, United States
| | - Johnson P Hampson
- National Institute of Neurological Disorders and Stroke (NINDS) Center for Sudden Unexpected Death in Epilepsy (SUDEP) Research, McGovern Medical School, University of Texas Health Science Center at Houston, Houston, TX, United States.,Department of Neurology, McGovern Medical School, University of Texas Health Science Center at Houston, Houston, TX, United States
| | - Jaison Hampson
- National Institute of Neurological Disorders and Stroke (NINDS) Center for Sudden Unexpected Death in Epilepsy (SUDEP) Research, McGovern Medical School, University of Texas Health Science Center at Houston, Houston, TX, United States.,Department of Neurology, McGovern Medical School, University of Texas Health Science Center at Houston, Houston, TX, United States
| | - Norma J Hupp
- National Institute of Neurological Disorders and Stroke (NINDS) Center for Sudden Unexpected Death in Epilepsy (SUDEP) Research, McGovern Medical School, University of Texas Health Science Center at Houston, Houston, TX, United States.,Department of Neurology, McGovern Medical School, University of Texas Health Science Center at Houston, Houston, TX, United States
| | - Rup K Sainju
- National Institute of Neurological Disorders and Stroke (NINDS) Center for Sudden Unexpected Death in Epilepsy (SUDEP) Research, McGovern Medical School, University of Texas Health Science Center at Houston, Houston, TX, United States.,Department of Neurology, University of Iowa Carver College of Medicine, Iowa City, IA, United States
| | - Daniel Friedman
- National Institute of Neurological Disorders and Stroke (NINDS) Center for Sudden Unexpected Death in Epilepsy (SUDEP) Research, McGovern Medical School, University of Texas Health Science Center at Houston, Houston, TX, United States.,New York University (NYU) Grossman School of Medicine, New York, NY, United States
| | - Maromi Nei
- National Institute of Neurological Disorders and Stroke (NINDS) Center for Sudden Unexpected Death in Epilepsy (SUDEP) Research, McGovern Medical School, University of Texas Health Science Center at Houston, Houston, TX, United States.,Sidney Kimmel Medical College, Thomas Jefferson University, Philadelphia, PA, United States
| | - Catherine Scott
- National Institute of Neurological Disorders and Stroke (NINDS) Center for Sudden Unexpected Death in Epilepsy (SUDEP) Research, McGovern Medical School, University of Texas Health Science Center at Houston, Houston, TX, United States.,Department of Neurology, Institute of Neurology, University College London, London, United Kingdom
| | - Luke Allen
- National Institute of Neurological Disorders and Stroke (NINDS) Center for Sudden Unexpected Death in Epilepsy (SUDEP) Research, McGovern Medical School, University of Texas Health Science Center at Houston, Houston, TX, United States.,Department of Neurology, Institute of Neurology, University College London, London, United Kingdom
| | - Brian K Gehlbach
- National Institute of Neurological Disorders and Stroke (NINDS) Center for Sudden Unexpected Death in Epilepsy (SUDEP) Research, McGovern Medical School, University of Texas Health Science Center at Houston, Houston, TX, United States.,Department of Neurology, University of Iowa Carver College of Medicine, Iowa City, IA, United States
| | - Stephan Schuele
- National Institute of Neurological Disorders and Stroke (NINDS) Center for Sudden Unexpected Death in Epilepsy (SUDEP) Research, McGovern Medical School, University of Texas Health Science Center at Houston, Houston, TX, United States.,Feinberg School of Medicine, Northwestern University, Chicago, IL, United States
| | - Ronald M Harper
- National Institute of Neurological Disorders and Stroke (NINDS) Center for Sudden Unexpected Death in Epilepsy (SUDEP) Research, McGovern Medical School, University of Texas Health Science Center at Houston, Houston, TX, United States.,Department of Neurobiology and the Brain Research Institute, University of California, Los Angeles, Los Angeles, CA, United States
| | - Beate Diehl
- National Institute of Neurological Disorders and Stroke (NINDS) Center for Sudden Unexpected Death in Epilepsy (SUDEP) Research, McGovern Medical School, University of Texas Health Science Center at Houston, Houston, TX, United States.,Department of Neurology, Institute of Neurology, University College London, London, United Kingdom
| | - Lisa M Bateman
- National Institute of Neurological Disorders and Stroke (NINDS) Center for Sudden Unexpected Death in Epilepsy (SUDEP) Research, McGovern Medical School, University of Texas Health Science Center at Houston, Houston, TX, United States.,Department of Neurology, Cedars-Sinai Medical Center, Los Angeles, CA, United States
| | - Orrin Devinsky
- National Institute of Neurological Disorders and Stroke (NINDS) Center for Sudden Unexpected Death in Epilepsy (SUDEP) Research, McGovern Medical School, University of Texas Health Science Center at Houston, Houston, TX, United States.,New York University (NYU) Grossman School of Medicine, New York, NY, United States
| | - George B Richerson
- National Institute of Neurological Disorders and Stroke (NINDS) Center for Sudden Unexpected Death in Epilepsy (SUDEP) Research, McGovern Medical School, University of Texas Health Science Center at Houston, Houston, TX, United States.,Department of Neurology, University of Iowa Carver College of Medicine, Iowa City, IA, United States
| | - Guo-Qiang Zhang
- National Institute of Neurological Disorders and Stroke (NINDS) Center for Sudden Unexpected Death in Epilepsy (SUDEP) Research, McGovern Medical School, University of Texas Health Science Center at Houston, Houston, TX, United States.,Department of Neurology, McGovern Medical School, University of Texas Health Science Center at Houston, Houston, TX, United States
| | - Samden D Lhatoo
- National Institute of Neurological Disorders and Stroke (NINDS) Center for Sudden Unexpected Death in Epilepsy (SUDEP) Research, McGovern Medical School, University of Texas Health Science Center at Houston, Houston, TX, United States.,Department of Neurology, McGovern Medical School, University of Texas Health Science Center at Houston, Houston, TX, United States
| | - Nuria Lacuey
- National Institute of Neurological Disorders and Stroke (NINDS) Center for Sudden Unexpected Death in Epilepsy (SUDEP) Research, McGovern Medical School, University of Texas Health Science Center at Houston, Houston, TX, United States.,Department of Neurology, McGovern Medical School, University of Texas Health Science Center at Houston, Houston, TX, United States
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7
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Grigg-Damberger M, Foldvary-Schaefer N. Bidirectional relationships of sleep and epilepsy in adults with epilepsy. Epilepsy Behav 2021; 116:107735. [PMID: 33561767 DOI: 10.1016/j.yebeh.2020.107735] [Citation(s) in RCA: 24] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/15/2020] [Revised: 11/15/2020] [Accepted: 12/19/2020] [Indexed: 12/14/2022]
Abstract
This targeted review addresses the best accepted and most intriguing recent observations on the complex relationships between sleep and epilepsy. Ten to 15% of all epilepsies are sleep-related. Included in these is sleep-related hypermotor epilepsy, renamed from nocturnal frontal lobe epilepsy by a 2016 consensus conference since 30% of cases are extra-frontal, seizures are related to sleep rather than clock time, and the predominant semiology is hypermotor. Stereo-EEG is providing crucial insights into network activation in sleep-related epilepsies and definition of the epileptogenic zone. Pathologic high-frequency oscillations, a promising biomarker for identifying the epileptogenic zone, are most frequent in NREM sleep, lowest in wakefulness and REM sleep, similar to interictal epileptiform discharges (IEDs). Most sleep-related seizures are followed by awakening or arousal and IEDs cause arousals and increase after arousals, likely contributing to sleep/wake complaints. Sleep/wake disorders are 2-3 times more common in adults with epilepsy than the general population; these comorbidities are associated with poorer quality of life and may impact seizure control. Treatment of sleep apnea reduces seizures in many cases. An emerging area of research is in circadian biology and epilepsy. Over 90% of people with epilepsy have seizures with circadian periodicity, in part related to sleep itself, and the majority of SUDEP cases occur in sleep. Recognizing these bidirectional relationships is important for patient and caregiver education and counseling and optimizing epilepsy outcomes.
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Affiliation(s)
| | - Nancy Foldvary-Schaefer
- Sleep Disorders and Epilepsy Center, Neurological Institute, Cleveland Clinic, Cleveland, OH, USA.
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8
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Sivathamboo S, Constantino TN, Chen Z, Sparks PB, Goldin J, Velakoulis D, Jones NC, Kwan P, Macefield VG, O'Brien TJ, Perucca P. Cardiorespiratory and autonomic function in epileptic seizures: A video-EEG monitoring study. Epilepsy Behav 2020; 111:107271. [PMID: 32653843 DOI: 10.1016/j.yebeh.2020.107271] [Citation(s) in RCA: 17] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/16/2020] [Revised: 06/14/2020] [Accepted: 06/17/2020] [Indexed: 10/23/2022]
Abstract
PURPOSE Seizure-induced cardiorespiratory and autonomic dysfunction has long been recognized, and growing evidence points to its implication in sudden unexpected death in epilepsy (SUDEP). However, a comprehensive understanding of cardiorespiratory function in the preictal, ictal, and postictal periods are lacking. METHODS We examined continuous cardiorespiratory and autonomic function in 157 seizures (18 convulsive and 139 nonconvulsive) from 70 consecutive patients who had a seizure captured on concurrent video-encephalogram (EEG) monitoring and polysomnography between February 1, 2012 and May 31, 2017. Heart and respiratory rates, heart rate variability (HRV), and oxygen saturation were assessed across four distinct periods: baseline (120 s), preictal (60 s), ictal, and postictal (300 s). Heart and respiratory rates were further followed for up to 60 min after seizure termination to assess return to baseline. RESULTS Ictal tachycardia occurred during both convulsive and nonconvulsive seizures, but the maximum rate was higher for convulsive seizures (mean: 138.8 beats/min, 95% confidence interval (CI): 125.3-152.4) compared with nonconvulsive seizures (mean: 105.4 beats/min, 95% CI: 101.2-109.6; p < 0.001). Convulsive seizures were associated with a lower ictal minimum respiratory rate (mean: 0 breaths/min, 95% CI: 0-0) compared with nonconvulsive seizures (mean: 11.0 breaths/min, 95% CI: 9.5-12.6; p < 0.001). Ictal obstructive apnea was associated with convulsive compared with nonconvulsive seizures. The low-frequency (LF) power band of ictal HRV was higher among convulsive seizures than nonconvulsive seizures (ratio of means (ROM): 2.97, 95% CI: 1.34-6.60; p = 0.008). Postictal tachycardia was substantially prolonged, characterized by a longer return to baseline for convulsive seizures (median: 60.0 min, interquartile range (IQR): 46.5-60.0) than nonconvulsive seizures (median: 0.26 min, IQR: 0.008-0.9; p < 0.001). For postictal hyperventilation, the return to baseline was longer in convulsive seizures (median: 25.3 min, IQR: 8.1-60) than nonconvulsive seizures (median: 1.0 min, IQR: 0.07-3.2; p < 0.001). The LF power band of postictal HRV was lower in convulsive seizures than nonconvulsive seizures (ROM: 0.33, 95% CI: 0.11-0.96; p = 0.043). Convulsive seizures with postictal generalized EEG suppression (PGES; n = 12) were associated with lower postictal heart and respiratory rate, and increased HRV, compared with those without (n = 6). CONCLUSIONS Profound cardiorespiratory and autonomic dysfunction associated with convulsive seizures may explain why these seizures carry the greatest risk of SUDEP.
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Affiliation(s)
- Shobi Sivathamboo
- Department of Neuroscience, Central Clinical School, Monash University, Melbourne 3000, Victoria, Australia; Department of Neurology, The Royal Melbourne Hospital, Parkville 3050, Victoria, Australia; The Epilepsy Unit, Alfred Health, Melbourne 3004, Victoria, Australia; Department of Medicine (The Royal Melbourne Hospital), The University of Melbourne, Parkville 3050, Victoria, Australia.
| | - Thomas N Constantino
- Monash Centre for Astrophysics, School of Physics and Astronomy, Monash University, Clayton 3800, Australia
| | - Zhibin Chen
- Department of Neuroscience, Central Clinical School, Monash University, Melbourne 3000, Victoria, Australia; The Epilepsy Unit, Alfred Health, Melbourne 3004, Victoria, Australia
| | - Paul B Sparks
- Department of Cardiology, The Royal Melbourne Hospital, Parkville 3050, Victoria, Australia
| | - Jeremy Goldin
- Department of Respiratory and Sleep Disorders Medicine, The Royal Melbourne Hospital, Parkville 3050, Victoria, Australia
| | - Dennis Velakoulis
- Neuropsychiatry Unit, Department of Psychiatry, The Royal Melbourne Hospital, Parkville 3050, Victoria, Australia
| | - Nigel C Jones
- Department of Neuroscience, Central Clinical School, Monash University, Melbourne 3000, Victoria, Australia; The Epilepsy Unit, Alfred Health, Melbourne 3004, Victoria, Australia
| | - Patrick Kwan
- Department of Neuroscience, Central Clinical School, Monash University, Melbourne 3000, Victoria, Australia; Department of Neurology, The Royal Melbourne Hospital, Parkville 3050, Victoria, Australia; The Epilepsy Unit, Alfred Health, Melbourne 3004, Victoria, Australia; Department of Medicine (The Royal Melbourne Hospital), The University of Melbourne, Parkville 3050, Victoria, Australia
| | - Vaughan G Macefield
- Human Autonomic Neurophysiology, Baker Heart and Diabetes Institute, Melbourne 3004, Victoria, Australia
| | - Terence J O'Brien
- Department of Neuroscience, Central Clinical School, Monash University, Melbourne 3000, Victoria, Australia; Department of Neurology, The Royal Melbourne Hospital, Parkville 3050, Victoria, Australia; The Epilepsy Unit, Alfred Health, Melbourne 3004, Victoria, Australia; Department of Medicine (The Royal Melbourne Hospital), The University of Melbourne, Parkville 3050, Victoria, Australia
| | - Piero Perucca
- Department of Neuroscience, Central Clinical School, Monash University, Melbourne 3000, Victoria, Australia; Department of Neurology, The Royal Melbourne Hospital, Parkville 3050, Victoria, Australia; The Epilepsy Unit, Alfred Health, Melbourne 3004, Victoria, Australia; Department of Medicine (The Royal Melbourne Hospital), The University of Melbourne, Parkville 3050, Victoria, Australia
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9
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Arbune AA, Jeppesen J, Conradsen I, Ryvlin P, Beniczky S. Peri-ictal heart rate variability parameters as surrogate markers of seizure severity. Epilepsia 2020; 61 Suppl 1:S55-S60. [PMID: 32436605 DOI: 10.1111/epi.16491] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
This study aims at defining objective parameters reflecting the severity of peri-ictal autonomic changes and their relation to post-ictal generalized electroencephalography (EEG) suppression (PGES), with the view that such changes could be detected by wearable seizure detection systems and prove useful to assess the risk of sudden unexpected death in epilepsy (SUDEP). To this purpose, we assessed peri-ictal changes in heart rate variability (HRV) and correlated them with seizure duration, intensity of electromyography-based ictal muscle activity, and presence and duration of post-ictal generalized EEG suppression (PGES). We evaluated 75 motor seizures from 40 patients, including 61 generalized tonic-clonic seizures (GTCS) and 14 other major motor seizure types. For all major motor seizures, HRV measurements demonstrated a significantly decreased parasympathetic activity and increased sympathetic activity in the post-ictal period. The post-ictal increased sympathetic activity was significantly higher for GTCS as compared with non-GTCS. The degree of peri-ictal decreased parasympathetic activity and increased sympathetic activity was associated with longer PGES (>20 s), longer seizure duration, and greater intensity of ictal muscle activity. Mean post-ictal heart rate (HR) was an independent predictor of PGES duration, seizure duration, and intensity of ictal muscle contraction. Our results indicate that peri-ictal changes in HRV are potential biomarkers of major motor seizure severity.
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Affiliation(s)
- Anca A Arbune
- Department of Clinical Neurophysiology, Danish Epilepsy Centre, Dianalund, Denmark.,Department of Clinical Neurosciences, "Carol Davila" University of Medicine and Pharmacy, Bucharest, Romania
| | - Jesper Jeppesen
- Department of Clinical Neurophysiology, Aarhus University Hospital, Aarhus, Denmark.,Department of Clinical Medicine, Aarhus University, Aarhus, Denmark
| | | | - Philippe Ryvlin
- Department of Clinical Neurosciences, CHUV, Lausanne, Switzerland
| | - Sándor Beniczky
- Department of Clinical Neurophysiology, Danish Epilepsy Centre, Dianalund, Denmark.,Department of Clinical Neurophysiology, Aarhus University Hospital, Aarhus, Denmark.,Department of Clinical Medicine, Aarhus University, Aarhus, Denmark
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10
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Tang Y, Xia W, Yan B, Zhao L, An D, Zhou D. Periictal electroclinical characteristics of postictal generalized electroencephalographic suppression after generalized convulsive seizures. Medicine (Baltimore) 2020; 99:e19940. [PMID: 32443294 PMCID: PMC7254049 DOI: 10.1097/md.0000000000019940] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/05/2023] Open
Abstract
The aim of this study was to investigate the demographic, clinical, and electrophysiological characteristics of postictal generalized electroencephalography (EEG) suppression (PGES), thereby facilitating the recognition of PGES and providing clues regarding its risk factors, pathophysiology, and relationship with sudden unexpected death in epilepsy patients (SUDEP).We retrospectively reviewed 237 generalized convulsive seizures (GCSs) in 126 patients during long-term video-EEG (VEEG) recordings. The associations of PGES and prolonged PGES (duration >20 seconds) with person- and seizure-specific variables were evaluated independently using SPSS software.Eighty patients (63.5%, 80/126) exhibited PGES after 127 GCSs (53.6%, 127/237) with an average PGES duration of 41.31 ± 24.03 seconds. The tonic phase was significantly prolonged in patients with PGES and prolonged PGES. PGES was independently associated with ictal semiology, which was attributable to the different proportions of GCS type 1. After seizure termination, patients with PGES had a higher percentage of postictal unresponsiveness and immobility, including oropharyngeal immobility. Between prolonged and short-duration PGES, the former was more likely to phase out gradually followed by immediate body movement, whereas the latter tended to have an abrupt, evoked termination followed by delayed body movement.Prolonged tonic duration, GCS type 1, postictal unresponsiveness, and immobility were more prone to occur with PGES, which might imply that hyperactivation of inhibitory neural networks underlies the pathophysiology of PGES and subsequent SUDEP. Any form of periictal bedside care, whether it constitutes effective medical intervention or not, is advisable due to its possible contribution to the interruption of PGES. Regardless of the PGES termination pattern, the neural network resuscitation process was progressive.
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Affiliation(s)
- Yingying Tang
- Department of Neurology, West China Hospital of Sichuan University
| | - Wei Xia
- Department of Obstetrics and Gynecology, West China Second University Hospital of Sichuan University, Chengdu Sichuan, China
| | - Bo Yan
- Department of Neurology, West China Hospital of Sichuan University
| | - Lili Zhao
- Department of Neurology, West China Hospital of Sichuan University
| | - Dongmei An
- Department of Neurology, West China Hospital of Sichuan University
| | - Dong Zhou
- Department of Neurology, West China Hospital of Sichuan University
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11
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Petrucci AN, Joyal KG, Purnell BS, Buchanan GF. Serotonin and sudden unexpected death in epilepsy. Exp Neurol 2019; 325:113145. [PMID: 31866464 DOI: 10.1016/j.expneurol.2019.113145] [Citation(s) in RCA: 58] [Impact Index Per Article: 11.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/30/2019] [Revised: 11/12/2019] [Accepted: 12/10/2019] [Indexed: 12/20/2022]
Abstract
Epilepsy is a highly prevalent disease characterized by recurrent, spontaneous seizures. Approximately one-third of epilepsy patients will not achieve seizure freedom with medical management and become refractory to conventional treatments. These patients are at greatest risk for sudden unexpected death in epilepsy (SUDEP). The exact etiology of SUDEP is unknown, but a combination of respiratory, cardiac, neuronal electrographic dysfunction, and arousal impairment is thought to underlie SUDEP. Serotonin (5-HT) is involved in regulation of breathing, sleep/wake states, arousal, and seizure modulation and has been implicated in the pathophysiology of SUDEP. This review explores the current state of understanding of the relationship between 5-HT, epilepsy, and respiratory and autonomic control processes relevant to SUDEP in epilepsy patients and in animal models.
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Affiliation(s)
- Alexandra N Petrucci
- Interdisciplinary Graduate Program in Neuroscience, University of Iowa, Iowa City, IA 52242, United States of America; Iowa Neuroscience Institute, Carver College of Medicine, University of Iowa, Iowa City, IA 52242, United States of America
| | - Katelyn G Joyal
- Interdisciplinary Graduate Program in Neuroscience, University of Iowa, Iowa City, IA 52242, United States of America; Iowa Neuroscience Institute, Carver College of Medicine, University of Iowa, Iowa City, IA 52242, United States of America
| | - Benton S Purnell
- Interdisciplinary Graduate Program in Neuroscience, University of Iowa, Iowa City, IA 52242, United States of America; Iowa Neuroscience Institute, Carver College of Medicine, University of Iowa, Iowa City, IA 52242, United States of America
| | - Gordon F Buchanan
- Interdisciplinary Graduate Program in Neuroscience, University of Iowa, Iowa City, IA 52242, United States of America; Department of Neurology, University of Iowa, Iowa City, IA 52242, United States of America; Iowa Neuroscience Institute, Carver College of Medicine, University of Iowa, Iowa City, IA 52242, United States of America.
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12
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Affiliation(s)
- Jorge G Burneo
- From the Epilepsy Program, Departments of Clinical Neurological Sciences and Epidemiology & Biostatistics, Schulich School of Medicine and Dentistry, Western University, London, Canada.
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13
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Purnell BS, Thijs RD, Buchanan GF. Dead in the Night: Sleep-Wake and Time-Of-Day Influences on Sudden Unexpected Death in Epilepsy. Front Neurol 2018; 9:1079. [PMID: 30619039 PMCID: PMC6297781 DOI: 10.3389/fneur.2018.01079] [Citation(s) in RCA: 33] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/10/2018] [Accepted: 11/27/2018] [Indexed: 11/13/2022] Open
Abstract
Sudden unexpected death in epilepsy (SUDEP) is the leading cause of epilepsy-related death in patients with refractory epilepsy. Convergent lines of evidence suggest that SUDEP occurs due to seizure induced perturbation of respiratory, cardiac, and electrocerebral function as well as potential predisposing factors. It is consistently observed that SUDEP happens more during the night and the early hours of the morning. The aim of this review is to discuss evidence from patient cases, clinical studies, and animal research which is pertinent to the nocturnality of SUDEP. There are a number of factors which might contribute to the nighttime predilection of SUDEP. These factors fall into four categories: influences of (1) being unwitnessed, (2) lying prone in bed, (3) sleep-wake state, and (4) circadian rhythms. During the night, seizures are more likely to be unwitnessed; therefore, it is less likely that another person would be able to administer a lifesaving intervention. Patients are more likely to be prone on a bed following a nocturnal seizure. Being prone in the accouterments of a bed during the postictal period might impair breathing and increase SUDEP risk. Sleep typically happens at night and seizures which emerge from sleep might be more dangerous. Lastly, there are circadian changes to physiology during the night which might facilitate SUDEP. These possible explanations for the nocturnality of SUDEP are not mutually exclusive. The increased rate of SUDEP during the night is likely multifactorial involving both situational factors, such as being without a witness and prone, and physiological changes due to the influence of sleep and circadian rhythms. Understanding the causal elements in the nocturnality of SUDEP may be critical to the development of effective preventive countermeasures.
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Affiliation(s)
- Benton S Purnell
- Department of Neurology, Carver College of Medicine, University of Iowa, Iowa City, IA, United States.,Neuroscience Program, University of Iowa, Iowa City, IA, United States.,Iowa Neuroscience Institute, Carver College of Medicine, University of Iowa, Iowa City, IA, United States
| | - Roland D Thijs
- Stichting Epilepsie Instellingen Nederland (SEIN), Heemstede, Netherlands.,NIHR University College London Hospitals Biomedical Research Centre, UCL Institute of Neurology, London, United Kingdom.,Department of Neurology, LUMC Leiden University Medical Center, Leiden, Netherlands
| | - Gordon F Buchanan
- Department of Neurology, Carver College of Medicine, University of Iowa, Iowa City, IA, United States.,Neuroscience Program, University of Iowa, Iowa City, IA, United States.,Iowa Neuroscience Institute, Carver College of Medicine, University of Iowa, Iowa City, IA, United States
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14
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Myers KA, Sivathamboo S, Perucca P. Heart rate variability measurement in epilepsy: How can we move from research to clinical practice? Epilepsia 2018; 59:2169-2178. [PMID: 30345509 DOI: 10.1111/epi.14587] [Citation(s) in RCA: 47] [Impact Index Per Article: 7.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/15/2018] [Revised: 09/07/2018] [Accepted: 09/27/2018] [Indexed: 11/26/2022]
Abstract
Our objective was to critically evaluate the literature surrounding heart rate variability (HRV) in people with epilepsy and to make recommendations as to how future research could be directed to facilitate and accelerate integration into clinical practice. We reviewed relevant HRV publications including those involving human subjects with seizures. HRV has been studied in patients with epilepsy for more than 30 years and, overall, patients with epilepsy display altered interictal HRV, suggesting a shift in autonomic balance toward sympathetic dominance. This derangement appears more severe in those with temporal lobe epilepsy and drug-resistant epilepsy. Normal diurnal variation in HRV is also disturbed in at least some people with epilepsy, but this aspect has received less study. Some therapeutic interventions, including vagus nerve stimulation and antiepileptic medications, may partially normalize altered HRV, but studies in this area are sometimes contradictory. During seizures, the changes in HRV may be complex, but the general trend is toward a further increase in sympathetic overactivity. Research in HRV in people with epilepsy has been limited by inconsistent experimental protocols and studies that are often underpowered. HRV measurement has the potential to aid clinical epilepsy management in several possible ways. HRV may be useful in predicting which patients are likely to benefit from surgical interventions such as vagus nerve stimulation and focal cerebral resection. As well, HRV could eventually have utility as a biomarker of risk for sudden unexpected death in epilepsy (SUDEP). However, at present, the inconsistent measurement protocols used in research are hindering translation into clinical practice. A minimum protocol for HRV evaluation, to be used in all studies involving epilepsy patients, is necessary to eventually allow HRV to become a useful tool for clinicians. We propose a straightforward protocol, involving 5-minute measurements of root mean square of successive differences in wakefulness and light sleep.
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Affiliation(s)
- Kenneth A Myers
- Research Institute of the McGill University Health Centre, Montreal, Quebec, Canada.,Division of Child Neurology, Department of Pediatrics, Montreal Children's Hospital, McGill University Health Centre, Montreal, Quebec, Canada
| | - Shobi Sivathamboo
- Department of Medicine, The Royal Melbourne Hospital, The University of Melbourne, Parkville, Victoria, Australia.,Department of Neurology, The Royal Melbourne Hospital, Parkville, Victoria, Australia.,Department of Neuroscience, Central Clinical School, Monash University, Melbourne, Victoria, Australia.,Department of Neurology, Alfred Health, Melbourne, Victoria, Australia
| | - Piero Perucca
- Department of Medicine, The Royal Melbourne Hospital, The University of Melbourne, Parkville, Victoria, Australia.,Department of Neurology, The Royal Melbourne Hospital, Parkville, Victoria, Australia.,Department of Neuroscience, Central Clinical School, Monash University, Melbourne, Victoria, Australia.,Department of Neurology, Alfred Health, Melbourne, Victoria, Australia
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15
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Two predictors of postictal generalized EEG suppression: Tonic phase duration and postictal immobility period. Seizure 2018; 61:135-138. [DOI: 10.1016/j.seizure.2018.08.009] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/08/2018] [Revised: 08/09/2018] [Accepted: 08/11/2018] [Indexed: 11/23/2022] Open
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16
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Ruthirago D, Julayanont P, Karukote A, Shehabeldin M, Nugent K. Sudden unexpected death in epilepsy: ongoing challenges in finding mechanisms and prevention. Int J Neurosci 2018; 128:1052-1060. [PMID: 29667458 DOI: 10.1080/00207454.2018.1466780] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/02/2023]
Abstract
Purpose/aim of the study: To summarize recent studies on the pathophysiology and preventive strategies for SUDEP. Materials and methods: Databases and literature review. Results: Patients with epilepsy have a significantly higher risk of death than the general population. Sudden unexpected death in epilepsy (SUDEP) is the leading cause of sudden death among patients with epilepsy. Despite on-going research, there are still deficits in our knowledge about the mechanisms, genetic factors, and prevention of SUDEP. Current evidence suggests that cardiac arrhythmias, respiratory dysfunction, and brainstem arousal system dysfunction are the major mechanisms of SUDEP, and animal models support the role of neurotransmitters, especially serotonin and adenosine, in pathophysiology of SUDEP. Several mutations in the neurocardiogenic channelopathy genes have been identified as a possible cause of epilepsy and increased SUDEP risk. The lack of awareness that SUDEP can be a potential cause of premature death has been found in several surveys. In addition, medical legal cases demonstrate the need for more education about this condition. Several preventive strategies to reduce SUDEP have been proposed, including effective seizure control, nocturnal supervision, seizure monitoring, devices to protect the airway, and selective serotonin reuptake inhibitors. Further research is needed to determine the efficacy of these interventions. Conclusions: The major mechanisms of SUDEP include cardiac arrhythmias, respiratory dysfunction, and brainstem arousal system dysfunction. Effective control of seizures is the only effective strategy to prevent SUDEP. Other preventive interventions require more research.
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Affiliation(s)
- Doungporn Ruthirago
- a Department of Neurology , Texas Tech University Health Science Center , Lubbock , TX , USA
| | - Parunyou Julayanont
- a Department of Neurology , Texas Tech University Health Science Center , Lubbock , TX , USA
| | - Amputch Karukote
- b Department of Internal Medicine, Faculty of Medicine, Ramathibodi Hospital , Mahidol University , Bangkok , Thailand
| | - Mohamed Shehabeldin
- a Department of Neurology , Texas Tech University Health Science Center , Lubbock , TX , USA
| | - Kenneth Nugent
- c Department of Internal Medicine , Texas Tech University Health Science Center , Lubbock , TX , USA
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17
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Geertsema EE, Thijs RD, Gutter T, Vledder B, Arends JB, Leijten FS, Visser GH, Kalitzin SN. Automated video-based detection of nocturnal convulsive seizures in a residential care setting. Epilepsia 2018; 59 Suppl 1:53-60. [DOI: 10.1111/epi.14050] [Citation(s) in RCA: 35] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/24/2017] [Indexed: 11/30/2022]
Affiliation(s)
- Evelien E. Geertsema
- Stichting Epilepsie Instellingen Nederland (SEIN); Heemstede The Netherlands
- Image Sciences Institute; University Medical Center Utrecht; Utrecht The Netherlands
| | - Roland D. Thijs
- Stichting Epilepsie Instellingen Nederland (SEIN); Heemstede The Netherlands
- Department of Neurology; Leiden University Medical Center; Leiden The Netherlands
| | - Therese Gutter
- Stichting Epilepsie Instellingen Nederland (SEIN); Heemstede The Netherlands
| | - Ben Vledder
- Stichting Epilepsie Instellingen Nederland (SEIN); Heemstede The Netherlands
| | - Johan B. Arends
- Academic Center for Epileptology Kempenhaeghe; Heeze The Netherlands
- Technological University Eindhoven; Eindhoven The Netherlands
| | - Frans S. Leijten
- Brain Center Rudolf Magnus; University Medical Center Utrecht; Utrecht The Netherlands
| | - Gerhard H. Visser
- Stichting Epilepsie Instellingen Nederland (SEIN); Heemstede The Netherlands
| | - Stiliyan N. Kalitzin
- Stichting Epilepsie Instellingen Nederland (SEIN); Heemstede The Netherlands
- Image Sciences Institute; University Medical Center Utrecht; Utrecht The Netherlands
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18
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Shmuely S, Bauer PR, van Zwet EW, van Dijk JG, Thijs RD. Differentiating motor phenomena in tilt-induced syncope and convulsive seizures. Neurology 2018; 90:e1339-e1346. [DOI: 10.1212/wnl.0000000000005301] [Citation(s) in RCA: 29] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/24/2017] [Accepted: 01/08/2018] [Indexed: 12/14/2022] Open
Abstract
ObjectiveWe assessed motor phenomena in syncope and convulsive seizures to aid differential diagnosis and understand the pathophysiologic correlates.MethodsWe studied video-EEG recordings of tilt-induced syncope and convulsive seizures in participants aged 15 years and older. Syncope was defined as (1) loss of consciousness (video-assessed), (2) circulatory changes (accelerating blood pressure decrease with or without bradycardia/asystole), and (3) EEG changes (“slow” or “slow-flat-slow”). We assessed myoclonic jerks and tonic postures of the arms and noted time of occurrence, laterality, synchrony, and rhythmicity (mean consecutive differences of interclonic intervals).ResultsVideo-EEG records of 65 syncope cases and 50 convulsive seizures were included. In syncope, postures occurred in 42 cases (65%) and jerks in 33 (51%). Fewer jerks occurred in syncope (median 2, range 1–19) compared to convulsive seizures (median 48, range 20–191; p < 0.001). Jerks were more rhythmic in seizures compared to syncope (p < 0.001). Atonia was seen in all syncope cases, while this was not observed in any seizure. Jerks predominantly occurred during the slow and postures during the flat EEG phase.ConclusionsJerks and tonic postures were common in syncope, but semiology differed from convulsive seizures. The lack of overlap in the number of jerks suggests that less than 10 indicates syncope and more than 20 a convulsive seizure: the “10/20 rule.” Loss of tone strongly favors syncope. The EEG correlates imply that jerks in syncope are likely of cortical origin, whereas tonic postures may result from brainstem disinhibition.
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19
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Ali A, Wu S, Issa NP, Rose S, Towle VL, Warnke P, Tao JX. Association of sleep with sudden unexpected death in epilepsy. Epilepsy Behav 2017; 76:1-6. [PMID: 28917499 DOI: 10.1016/j.yebeh.2017.08.021] [Citation(s) in RCA: 40] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/22/2017] [Revised: 08/11/2017] [Accepted: 08/14/2017] [Indexed: 01/22/2023]
Abstract
OBJECTIVE The objective of this study was to determine the association of sleep with sudden unexpected death in epilepsy (SUDEP). METHODS We conducted a systematic review and meta-analysis based on literature search from databases PubMed, Web of Science, and Scopus using keywords "SUDEP", or "sudden unexpected death in epilepsy", or "sudden unexplained death in epilepsy". Sudden unexpected death in epilepsy was considered to occur during sleep if the patient was found in bed, if the SUDEP cases were documented as in sleep, or if the patient was found at bedside on the bedroom floor. RESULTS Circadian pattern was documented in 880 of the 1025 SUDEP cases in 67 studies meeting the inclusion and exclusion criteria. Of the 880 SUDEP cases, 69.3% occurred during sleep and 30.7% occurred during wakefulness. Sudden unexpected death in epilepsy was significantly associated with sleep as compared to wakefulness (P<0.001). In the subgroup of 272 cases in which circadian pattern and age were documented, patients 40years old or younger were more likely to die in sleep than those older than 40years (OR: 2.0; 95% CI=1.0, 3.8; P=0.05). In the subgroup of 114 cases in which both circadian pattern and body position at the time of death were documented, 87.6% (95% CI=81.1%, 94.2%) of patients who died during sleep were in the prone position, whereas 52.9% (95% CI=24.7%, 81.1%) of patients who died during wakefulness were in the prone position. Patients with nocturnal seizures were 6.3 times more likely to die in a prone position than those with diurnal seizures (OR: 6.3; 95% CI=2.0, 19.5; P=0.002). CONCLUSIONS There is a strong association of SUDEP with sleep, suggesting that sleep is a significant risk factor for SUDEP. Although the risks of SUDEP associated with sleep are unknown and likely multifactorial, the prone position might be an important contributory factor.
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Affiliation(s)
- Ahmer Ali
- Department of Neurology, The University of Chicago, Chicago, IL 60637, USA
| | - Shasha Wu
- Department of Neurology, The University of Chicago, Chicago, IL 60637, USA
| | - Naoum P Issa
- Department of Neurology, The University of Chicago, Chicago, IL 60637, USA
| | - Sandra Rose
- Department of Neurology, The University of Chicago, Chicago, IL 60637, USA
| | - Vernon L Towle
- Department of Neurology, The University of Chicago, Chicago, IL 60637, USA
| | - Peter Warnke
- Department of Neurosurgery, The University of Chicago, Chicago, IL 60637, USA
| | - James X Tao
- Department of Neurology, The University of Chicago, Chicago, IL 60637, USA.
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20
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Bauer PR, Thijs RD, Lamberts RJ, Velis DN, Visser GH, Tolner EA, Sander JW, Lopes da Silva FH, Kalitzin SN. Dynamics of convulsive seizure termination and postictal generalized EEG suppression. Brain 2017; 140:655-668. [PMID: 28073789 DOI: 10.1093/brain/aww322] [Citation(s) in RCA: 25] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/14/2016] [Accepted: 10/31/2016] [Indexed: 12/21/2022] Open
Abstract
It is not fully understood how seizures terminate and why some seizures are followed by a period of complete brain activity suppression, postictal generalized EEG suppression. This is clinically relevant as there is a potential association between postictal generalized EEG suppression, cardiorespiratory arrest and sudden death following a seizure. We combined human encephalographic seizure data with data of a computational model of seizures to elucidate the neuronal network dynamics underlying seizure termination and the postictal generalized EEG suppression state. A multi-unit computational neural mass model of epileptic seizure termination and postictal recovery was developed. The model provided three predictions that were validated in EEG recordings of 48 convulsive seizures from 48 subjects with refractory focal epilepsy (20 females, age range 15-61 years). The duration of ictal and postictal generalized EEG suppression periods in human EEG followed a gamma probability distribution indicative of a deterministic process (shape parameter 2.6 and 1.5, respectively) as predicted by the model. In the model and in humans, the time between two clonic bursts increased exponentially from the start of the clonic phase of the seizure. The terminal interclonic interval, calculated using the projected terminal value of the log-linear fit of the clonic frequency decrease was correlated with the presence and duration of postictal suppression. The projected terminal interclonic interval explained 41% of the variation in postictal generalized EEG suppression duration (P < 0.02). Conversely, postictal generalized EEG suppression duration explained 34% of the variation in the last interclonic interval duration. Our findings suggest that postictal generalized EEG suppression is a separate brain state and that seizure termination is a plastic and autonomous process, reflected in increased duration of interclonic intervals that determine the duration of postictal generalized EEG suppression.
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Affiliation(s)
- Prisca R Bauer
- Stichting Epilepsie Instellingen Nederland (SEIN), Achterweg 5, 2103 SW Heemstede, The Netherlands.,NIHR University College London Hospitals Biomedical Research Centre, UCL Institute of Neurology, Queen Square, London WC1N 3BG, UK
| | - Roland D Thijs
- Stichting Epilepsie Instellingen Nederland (SEIN), Achterweg 5, 2103 SW Heemstede, The Netherlands.,NIHR University College London Hospitals Biomedical Research Centre, UCL Institute of Neurology, Queen Square, London WC1N 3BG, UK.,Department of Neurology, Leiden University Medical Centre, Albinusdreef 2, 2333 ZA Leiden, The Netherlands
| | - Robert J Lamberts
- Stichting Epilepsie Instellingen Nederland (SEIN), Achterweg 5, 2103 SW Heemstede, The Netherlands
| | - Demetrios N Velis
- Stichting Epilepsie Instellingen Nederland (SEIN), Achterweg 5, 2103 SW Heemstede, The Netherlands
| | - Gerhard H Visser
- Stichting Epilepsie Instellingen Nederland (SEIN), Achterweg 5, 2103 SW Heemstede, The Netherlands
| | - Else A Tolner
- Department of Neurology, Leiden University Medical Centre, Albinusdreef 2, 2333 ZA Leiden, The Netherlands
| | - Josemir W Sander
- Stichting Epilepsie Instellingen Nederland (SEIN), Achterweg 5, 2103 SW Heemstede, The Netherlands.,NIHR University College London Hospitals Biomedical Research Centre, UCL Institute of Neurology, Queen Square, London WC1N 3BG, UK.,Epilepsy Society, Chalfont St Peter SL9 0RJ, UK
| | - Fernando H Lopes da Silva
- Center of Neurosciences, Swammerdam Institute of Life Sciences, University of Amsterdam, P.O. Box 94215 1090 GE, The Netherlands.,Instituto Superior Técnico, University of Lisbon, 1049-001, Lisbon, Portugal
| | - Stiliyan N Kalitzin
- Stichting Epilepsie Instellingen Nederland (SEIN), Achterweg 5, 2103 SW Heemstede, The Netherlands.,Image Sciences Institute, University Medical Center Utrecht, P.O. Box 85500, 3508 GA Utrecht, The Netherlands
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21
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Kalitzin SN, Bauer PR, Lamberts RJ, Velis DN, Thijs RD, Lopes Da Silva FH. Automated Video Detection of Epileptic Convulsion Slowing as a Precursor for Post-Seizure Neuronal Collapse. Int J Neural Syst 2016; 26:1650027. [DOI: 10.1142/s0129065716500271] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
Automated monitoring and alerting for adverse events in people with epilepsy can provide higher security and quality of life for those who suffer from this debilitating condition. Recently, we found a relation between clonic slowing at the end of a convulsive seizure (CS) and the occurrence and duration of a subsequent period of postictal generalized EEG suppression (PGES). Prolonged periods of PGES can be predicted by the amount of progressive increase of interclonic intervals (ICIs) during the seizure. The purpose of the present study is to develop an automated, remote video sensing-based algorithm for real-time detection of significant clonic slowing that can be used to alert for PGES. This may help preventing sudden unexpected death in epilepsy (SUDEP). The technique is based on our previously published optical flow video sequence processing paradigm that was applied for automated detection of major motor seizures. Here, we introduce an integral Radon-like transformation on the time–frequency wavelet spectrum to detect log–linear frequency changes during the seizure. We validate the automated detection and quantification of the ICI increase by comparison to the results from manually processed electroencephalography (EEG) traces as “gold standard”. We studied 48 cases of convulsive seizures for which synchronized EEG-video recordings were available. In most cases, the spectral ridges obtained from Gabor-wavelet transformations of the optical flow group velocities were in close proximity to the ICI traces detected manually from EEG data during the seizure. The quantification of the slowing-down effect measured by the dominant angle in the Radon transformed spectrum was significantly correlated with the exponential ICI increase factors obtained from manual detection. If this effect is validated as a reliable precursor of PGES periods that lead to or increase the probability of SUDEP, the proposed method would provide an efficient alerting device.
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Affiliation(s)
- Stiliyan N. Kalitzin
- Foundation Epilepsy Institutes Netherlands (SEIN), Achterweg 5, 2103 SW Heemstede, The Netherlands
- Image Sciences Institute, University Medical Center Utrecht, 3508 GA Utrecht, The Netherlands
| | - Prisca R. Bauer
- Foundation Epilepsy Institutes Netherlands (SEIN), Achterweg 5, 2103 SW Heemstede, The Netherlands
- NIHR University College London Hospitals Biomedical Research Centre, UCL Institute of Neurology, Queen Square, London WC1N 3BG, UK
| | - Robert J. Lamberts
- Foundation Epilepsy Institutes Netherlands (SEIN), Achterweg 5, 2103 SW Heemstede, The Netherlands
| | - Demetrios N. Velis
- Foundation Epilepsy Institutes Netherlands (SEIN), Achterweg 5, 2103 SW Heemstede, The Netherlands
- Department of Neurosurgery, Free University Medical Center Amsterdam, 1007 MB Amsterdam, The Netherlands
| | - Roland D. Thijs
- Foundation Epilepsy Institutes Netherlands (SEIN), Achterweg 5, 2103 SW Heemstede, The Netherlands
| | - Fernando H. Lopes Da Silva
- Swammerdam Institute for Life Sciences, University of Amsterdam, 1098 SM Amsterdam, The Netherlands
- Department of Bioengineering, Instituto Superior Técnico, University of Lisbon, 1049-001 Lisboa, Portugal
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Devinsky O, Hesdorffer DC, Thurman DJ, Lhatoo S, Richerson G. Sudden unexpected death in epilepsy: epidemiology, mechanisms, and prevention. Lancet Neurol 2016; 15:1075-88. [DOI: 10.1016/s1474-4422(16)30158-2] [Citation(s) in RCA: 369] [Impact Index Per Article: 46.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/09/2016] [Revised: 06/29/2016] [Accepted: 06/29/2016] [Indexed: 12/24/2022]
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Altenmüller DM, Schulze-Bonhage A, Elger CE, Surges R. Local brain activity persists during apparently generalized postictal EEG suppression. Epilepsy Behav 2016; 62:218-24. [PMID: 27494359 DOI: 10.1016/j.yebeh.2016.07.008] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/24/2016] [Revised: 07/01/2016] [Accepted: 07/02/2016] [Indexed: 11/30/2022]
Abstract
OBJECTIVES Postictal generalized EEG suppression (PGES) frequently occurs after generalized convulsive seizures (GCS) and may be involved in the pathophysiology of sudden unexpected death in epilepsy (SUDEP). It is usually determined using conventional scalp EEG which is likely to miss cerebral activity in deeper brain structures. Here, we examined intracranial EEG activity after GCS to unravel the pattern and extent of local brain activity during apparent PGES on scalp EEG (s-PGES). METHODS We retrospectively reviewed electroencephalographic data of people with chronic epilepsy who had GCS during presurgical video-EEG monitoring using simultaneous intracranial and scalp EEG (10-20 system) electrodes. RESULTS Twenty-five GCS (20 with s-PGES) of 15 patients with an average number of 88±42 intracranial electrode contacts were included. The majority of GCS with s-PGES (18 of 20) displayed persisting or reemerging intracranial EEG activity during apparent PGES on scalp EEG. Three patterns were identified: Pattern 1 (11 GCS, 6 patients) consisted of continuous local interictal activity; Pattern 2 (5 GCS, 5 patients) displayed suppressed EEG activity at all intracranial contacts in the early phase of s-PGES, but reemerging local brain activity before s-PGES dissolved; and Pattern 3 (2 GCS, 2 patients) showed persistent local ictal activity during s-PGES. Persisting intracranial EEG activity at PGES onset on scalp EEG was present in 10±14% (range: 0 to 42%) of all intracranial contacts and mostly in the temporal lobe. CONCLUSIONS Our results reveal that, during apparently generalized postictal EEG suppression, local brain activity persists or reemerges in most GCS. Possible implications of this localized neuronal activity in the context of SUDEP are discussed in the paper.
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Affiliation(s)
- Dirk-Matthias Altenmüller
- Epilepsy Center, Department of Neurosurgery, Medical Center, University of Freiburg, Faculty of Medicine, Breisacher Strasse 64, 79106 Freiburg im Breisgau, Germany.
| | - Andreas Schulze-Bonhage
- Epilepsy Center, Department of Neurosurgery, Medical Center, University of Freiburg, Faculty of Medicine, Breisacher Strasse 64, 79106 Freiburg im Breisgau, Germany.
| | - Christian E Elger
- Department of Epileptology, University Hospital Bonn, Sigmund-Freud-Str. 25, 53127 Bonn, Germany.
| | - Rainer Surges
- Department of Epileptology, University Hospital Bonn, Sigmund-Freud-Str. 25, 53127 Bonn, Germany.
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Shmuely S, Surges R, Sander JW, Thijs RD. Prone sleeping and SUDEP risk: The dynamics of body positions in nonfatal convulsive seizures. Epilepsy Behav 2016; 62:176-9. [PMID: 27490904 DOI: 10.1016/j.yebeh.2016.06.017] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/24/2016] [Revised: 06/15/2016] [Accepted: 06/16/2016] [Indexed: 10/21/2022]
Abstract
BACKGROUND Most victims of sudden unexpected death in epilepsy (SUDEP) are found prone with signs suggestive of an unwitnessed convulsive seizure (CS). Prone sleeping has been proposed as a risk factor for SUDEP. Little is known, however, about the change of body position during the course of CSs. METHODS We retrospectively reviewed video-EEG data and assessed body positions during the course of CSs, until there was a physical interaction by nursing staff with the subject. RESULTS We identified 180 CSs in 90 individuals. In 16 of the 180 CSs (9%), the subject started in or turned to the prone position. Of the seven CSs that started in the prone position, three turned to a lateral position during the CS. In 13 CSs, the subject was in prone position at time of nursing intervention; nine (69%) of these started in a nonprone position. DISCUSSION Our data suggest that the prone position occurs infrequently in closely supervised nonfatal CSs, a notable contrast to the number of victims of SUDEP found prone. Whether prone sleeping prior to CSs increases SUDEP risk, however, remains speculative, as body position during the course of a CS appeared to be dynamic.
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Affiliation(s)
- Sharon Shmuely
- Stichting Epilepsie Instellingen Nederland (SEIN), 2103 SW Heemstede, The Netherlands; NIHR University College London Hospitals Biomedical Research Centre, UCL Institute of Neurology, Queen Square, London WC1N 3BG, United Kingdom; Epilepsy Society, Chalfont St Peters, Bucks, SL9 0RJ, United Kingdom
| | - Rainer Surges
- Department of Epileptology, University of Bonn, University Medical Center, 53127 Bonn, Germany
| | - Josemir W Sander
- Stichting Epilepsie Instellingen Nederland (SEIN), 2103 SW Heemstede, The Netherlands; NIHR University College London Hospitals Biomedical Research Centre, UCL Institute of Neurology, Queen Square, London WC1N 3BG, United Kingdom; Epilepsy Society, Chalfont St Peters, Bucks, SL9 0RJ, United Kingdom
| | - Roland D Thijs
- Stichting Epilepsie Instellingen Nederland (SEIN), 2103 SW Heemstede, The Netherlands; NIHR University College London Hospitals Biomedical Research Centre, UCL Institute of Neurology, Queen Square, London WC1N 3BG, United Kingdom; Epilepsy Society, Chalfont St Peters, Bucks, SL9 0RJ, United Kingdom; Department of Neurology, LUMC Leiden University Medical Center, Leiden, The Netherlands.
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Kuo J, Zhao W, Li CS, Kennedy JD, Seyal M. Postictal immobility and generalized EEG suppression are associated with the severity of respiratory dysfunction. Epilepsia 2016; 57:412-7. [PMID: 26763069 DOI: 10.1111/epi.13312] [Citation(s) in RCA: 57] [Impact Index Per Article: 7.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/15/2015] [Indexed: 11/27/2022]
Abstract
OBJECTIVE The pathophysiology of sudden unexpected death in epilepsy (SUDEP) remains undetermined. Seizures are accompanied by respiratory dysfunction (RD). Postictal generalized electroencephalography (EEG) suppression (PGES) may follow generalized tonic-clonic seizures (GTCS). Following GTCS patients have impaired arousal and may be motionless. Patients with SUDEP are usually prone. Postictal immobility (PI) may contribute to SUDEP by not permitting repositioning of the head to allow unimpeded ventilation. To determine whether RD and/or ictal characteristics are associated with PI, we analyzed patients with GTCS in the epilepsy monitoring unit. METHOD We investigated for associations between PI duration and PGES, ictal/postictal oxygen saturation (SpO2 ), end-tidal CO2 (ETCO2 ), seizure localization, duration, and tonic and total convulsive phase duration. We investigated for linkage between PGES and these measures. RESULTS Seventy patients with 181 GTCS and available SpO2 and/or ETCO2 data were studied. Simple linear regression analysis by seizures showed that PI duration was associated with peak periictal ETCO2 (p = 0.03), duration of oxygen desaturation (p = 0.005) and with SpO2 nadir (p = 0.02). PI duration was not associated with tonic, convulsive phase or total seizure duration. Analysis by patients also showed significant association of PI with RD. Duration of PI was longer following seizures with PGES (p < 0.001). PGES was not associated with the tonic, convulsive phase or total seizure duration. SpO2 nadir was lower in seizures with PGES (p = 0.046), ETCO2 peak change (p = 0.003) was higher, and duration of ETCO2 elevation (p = 0.03) was longer. Multivariable regression analysis showed that PGES and severe RD were associated with PI duration. SIGNIFICANCE The duration of PI and presence of PGES are associated with periictal RD. The duration of PI is also associated with the presence of PGES. Seizure duration or duration of the convulsive phase is not associated with PI or PGES. Interventions aimed at reversing impaired arousal and PI may reduce SUDEP risk.
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Affiliation(s)
- Jonathan Kuo
- Department of Neurology, University of California, Davis, California, U.S.A
| | - Wenjie Zhao
- Department of Statistics, University of California, Davis, California, U.S.A
| | - Chin-Shang Li
- Division of Biostatistics, Department of Public Health Sciences, University of California, Davis, California, U.S.A
| | - Jeffrey D Kennedy
- Department of Neurology, University of California, Davis, California, U.S.A
| | - Masud Seyal
- Department of Neurology, University of California, Davis, California, U.S.A
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Abstract
SUMMARY Sudden unexpected death in epilepsy (SUDEP) remains a leading cause of epilepsy-related death, and yet, its pathogenic mechanisms remain ill-defined. Although epidemiological studies of SUDEP in heterogenous populations have established a number of clinical associations, evaluation and stratification of individual risk remains difficult. Thus, potential markers as predictors of risk of SUDEP are important not only clinically but also for research on SUDEP prevention. Recordings from rare monitored cases of SUDEP demonstrate postictal generalized EEG suppression after terminal seizures, raising expectations that postictal generalized EEG suppression may identify individuals at higher risk. In this review, we consider the literature on postictal generalized EEG suppression and evaluate its relevance and utility as a possible marker of SUDEP.
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27
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Autonomic changes following generalized tonic clonic seizures: An analysis of adult and pediatric patients with epilepsy. Epilepsy Res 2015. [DOI: 10.1016/j.eplepsyres.2015.06.005] [Citation(s) in RCA: 83] [Impact Index Per Article: 9.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
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Abstract
PURPOSE OF REVIEW Human and experimental research has identified cardioautonomic and respiratory dysfunction as a frequent accompaniment in human and animal model events of sudden unexpected death in epilepsy (SUDEP). This review aims to provide an overview of the scientific evidence behind the currently accepted risk factors and working hypotheses regarding SUDEP pathophysiology. RECENT FINDINGS Epidemiological analysis of public health burden of SUDEP has shown that it rates second only to stroke in the years of potential life lost. Clinical and experimental studies uncovered the dynamic cardiorespiratory dysfunction interictally and imminently to SUDEP, and model systems have facilitated discoveries in SUDEP mechanistic understanding and application of pilot therapeutic interventions. Pilot molecular profiling of human SUDEP has uncovered complex genomic structure in the candidate gene network. SUMMARY Extensive clinical and experimental work has established a rationale for the conceptual thinking about SUDEP mechanisms. The application of the global molecular profiling will be invaluable in unraveling the individually unique genomic complexities and interactions that underlie the physiological signature of each patient. At the same time, sophisticated model systems will be critical in the iterative translation of human genetics, physiology, pharmacological interventions, and in testing preventive interventions.
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Affiliation(s)
- Alica M Goldman
- Department of Neurology, Baylor College of Medicine, Houston, Texas, USA
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30
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Abstract
Sudden unexpected death in epilepsy (SUDEP) is the leading cause of death in patients with refractory epilepsy, with an estimated 35% lifetime risk in this patient population. There is a surprising lack of awareness among patients and physicians of this increased risk of sudden death: in a recent survey, only 33% of Canadian paediatricians who treated patients with epilepsy knew the term SUDEP. Controversy prevails over whether cardiac arrhythmia or respiratory arrest is more important as the primary cause of death. Effective preventive strategies in high-risk patients will rely on definition of the mechanisms that lead from seizures to death. Here, we summarize evidence for the mechanisms that cause cardiac, respiratory and arousal abnormalities during the ictal and postictal period. We highlight potential cellular mechanisms underlying these abnormalities, such as a defect in the serotonergic system, ictal adenosine release, and changes in autonomic output. We discuss genetic mutations that cause Dravet and long QT syndromes, both of which are linked with increased risk of sudden death. We then highlight possible preventive interventions that are likely to decrease SUDEP incidence, including respiratory monitoring in epilepsy monitoring units and overnight supervision. Finally, we discuss treatments, such as selective serotonin reuptake inhibitors, that might be personalized to a specific genetic or pathological defect.
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Moghimi N, Lhatoo SD. Sudden Unexpected Death in Epilepsy or Voodoo Heart: Analysis of Heart/Brain Connections. Curr Cardiol Rep 2013; 15:424. [DOI: 10.1007/s11886-013-0424-9] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
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Ryvlin P, Nashef L, Lhatoo SD, Bateman LM, Bird J, Bleasel A, Boon P, Crespel A, Dworetzky BA, Høgenhaven H, Lerche H, Maillard L, Malter MP, Marchal C, Murthy JMK, Nitsche M, Pataraia E, Rabben T, Rheims S, Sadzot B, Schulze-Bonhage A, Seyal M, So EL, Spitz M, Szucs A, Tan M, Tao JX, Tomson T. Incidence and mechanisms of cardiorespiratory arrests in epilepsy monitoring units (MORTEMUS): a retrospective study. Lancet Neurol 2013; 12:966-77. [PMID: 24012372 DOI: 10.1016/s1474-4422(13)70214-x] [Citation(s) in RCA: 686] [Impact Index Per Article: 62.4] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
BACKGROUND Sudden unexpected death in epilepsy (SUDEP) is the leading cause of death in people with chronic refractory epilepsy. Very rarely, SUDEP occurs in epilepsy monitoring units, providing highly informative data for its still elusive pathophysiology. The MORTEMUS study expanded these data through comprehensive evaluation of cardiorespiratory arrests encountered in epilepsy monitoring units worldwide. METHODS Between Jan 1, 2008, and Dec 29, 2009, we did a systematic retrospective survey of epilepsy monitoring units located in Europe, Israel, Australia, and New Zealand, to retrieve data for all cardiorespiratory arrests recorded in these units and estimate their incidence. Epilepsy monitoring units from other regions were invited to report similar cases to further explore the mechanisms. An expert panel reviewed data, including video electroencephalogram (VEEG) and electrocardiogram material at the time of cardiorespiratory arrests whenever available. FINDINGS 147 (92%) of 160 units responded to the survey. 29 cardiorespiratory arrests, including 16 SUDEP (14 at night), nine near SUDEP, and four deaths from other causes, were reported. Cardiorespiratory data, available for ten cases of SUDEP, showed a consistent and previously unrecognised pattern whereby rapid breathing (18-50 breaths per min) developed after secondary generalised tonic-clonic seizure, followed within 3 min by transient or terminal cardiorespiratory dysfunction. Where transient, this dysfunction later recurred with terminal apnoea occurring within 11 min of the end of the seizure, followed by cardiac arrest. SUDEP incidence in adult epilepsy monitoring units was 5·1 (95% CI 2·6-9·2) per 1000 patient-years, with a risk of 1·2 (0·6-2·1) per 10,000 VEEG monitorings, probably aggravated by suboptimum supervision and possibly by antiepileptic drug withdrawal. INTERPRETATION SUDEP in epilepsy monitoring units primarily follows an early postictal, centrally mediated, severe alteration of respiratory and cardiac function induced by generalised tonic-clonic seizure, leading to immediate death or a short period of partly restored cardiorespiratory function followed by terminal apnoea then cardiac arrest. Improved supervision is warranted in epilepsy monitoring units, in particular during night time. FUNDING Commission of European Affairs of the International League Against Epilepsy.
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Affiliation(s)
- Philippe Ryvlin
- Hospices Civils de Lyon and CRNL, INSERM U1028, CNRS 5292, Lyon, France.
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Lee A, Wu S, Zhou X, Liebenthal J, Rose S, Tao JX. Periictal autonomic dysfunction and generalized postictal EEG suppression in convulsive seizures arising from sleep and wakefulness. Epilepsy Behav 2013; 28:439-43. [PMID: 23891764 DOI: 10.1016/j.yebeh.2013.06.010] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/19/2013] [Revised: 06/05/2013] [Accepted: 06/13/2013] [Indexed: 11/30/2022]
Abstract
Sleep appears to be an independent risk factor of sudden unexpected death in epilepsy (SUDEP). We retrospectively determined the periictal electrophysiological characteristics of nocturnal and diurnal generalized convulsive seizures (GCSs) in 109 patients. Our data showed that preictal heart rate (HR) was significantly lower in 46 patients with nocturnal GCSs than in 63 patients with diurnal GCSs (p=0.002). However, there was no significant difference in postictal HR and respiratory rate (RR), total seizure duration, total convulsive phase, tonic phase, and clonic phase. Meanwhile, postictal generalized EEG suppression (PGES) was observed in 52.4% of the patients with diurnal GCSs and 67.4% of the patients with nocturnal GCSs. Duration of PGES was 38.2±17.3s in patients with diurnal GCSs and 49.5±21.7s in patients with nocturnal GCSs. There was also no significant difference in the prevalence (p=0.118) and duration (p=0.044, Bonferroni-corrected significant level: α=0.00625) of PGES in the two patient groups. Therefore, there is no clear evidence to attribute the SUDEP risk associated with sleep to postictal autonomic dysfunction and PGES, as compared to wakefulness.
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Affiliation(s)
- Anthony Lee
- Department of Neurology, The University of Chicago, Chicago, IL 60637, USA
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Lamberts RJ, Gaitatzis A, Sander JW, Elger CE, Surges R, Thijs RD. Postictal generalized EEG suppression: an inconsistent finding in people with multiple seizures. Neurology 2013; 81:1252-6. [PMID: 23966251 DOI: 10.1212/wnl.0b013e3182a6cbeb] [Citation(s) in RCA: 89] [Impact Index Per Article: 8.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
OBJECTIVE To determine the consistency and facilitating cofactors of postictal generalized EEG suppression (PGES) of >20 seconds after convulsive seizures (CS), a suggested predictor of sudden unexpected death in epilepsy risk. METHODS We retrospectively reviewed video-EEG data of people with ≥2 recorded CS. Presence and duration of PGES were assessed by 2 independent observers blinded to patient status. Intraindividual consistency of PGES >20 seconds was determined and correlations with clinical characteristics were analyzed after correction for individual effects and the varying number of seizures. RESULTS One hundred fifty-four seizures in 59 people were analyzed. PGES >20 seconds was found in 37 individuals (63%) and 57 (37%) of CS. The proportion of persons in whom PGES occurred consistently (presence or absence of PGES >20 seconds in all CS) was lower in those with more CS. PGES of >20 seconds was more frequent in seizures arising from sleep (odds ratio 3.29, 95% confidence interval 1.21-8.96) and when antiepileptic medication was tapered (odds ratio 4.80, 95% confidence interval 1.27-18.14). CONCLUSION Apparent PGES consistency was less frequent in people with more CS recorded, suggesting that PGES is an inconsistent finding in any one individual. Thus, we believe that PGES >20 seconds is not a reliable predictor of sudden unexpected death in epilepsy. Sleep and antiepileptic drug reduction appear to facilitate the occurrence of PGES.
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Affiliation(s)
- Robert J Lamberts
- From the SEIN-Stichting Epilepsie Instellingen Nederland (R.J.L., A.G., J.W.S., R.D.T.), Heemstede, the Netherlands; NIHR University College London Hospitals Biomedical Research Centre (J.W.S., R.D.T.), UCL Institute of Neurology, Queen Square, London, and Epilepsy Society, Chalfont St. Peter, UK; Department of Epileptology (C.E.E., R.S.), University Hospital Bonn, Germany; and Department of Neurology (R.D.T.), LUMC Leiden University Medical Center, Leiden, the Netherlands
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Sowers LP, Massey CA, Gehlbach BK, Granner MA, Richerson GB. Sudden unexpected death in epilepsy: fatal post-ictal respiratory and arousal mechanisms. Respir Physiol Neurobiol 2013; 189:315-23. [PMID: 23707877 DOI: 10.1016/j.resp.2013.05.010] [Citation(s) in RCA: 62] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/04/2013] [Revised: 05/13/2013] [Accepted: 05/14/2013] [Indexed: 01/04/2023]
Abstract
Sudden unexplained death in epilepsy (SUDEP) is the cause of premature death of up to 17% of all patients with epilepsy and as many as 50% with chronic refractory epilepsy. However, SUDEP is not widely recognized to exist. The etiology of SUDEP remains unclear, but growing evidence points to peri-ictal respiratory, cardiac, or autonomic nervous system dysfunction. How seizures affect these systems remains uncertain. Here we focus on respiratory mechanisms believed to underlie SUDEP. We highlight clinical evidence that indicates peri-ictal hypoxemia occurs in a large percentage of patients due to central apnea, and identify the proposed anatomical regions of the brain governing these responses. In addition, we discuss animal models used to study peri-ictal respiratory depression. We highlight the role 5-HT neurons play in respiratory control, chemoreception, and arousal. Finally, we discuss the evidence that 5-HT deficits contribute to SUDEP and sudden infant death syndrome and the striking similarities between the two.
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Affiliation(s)
- Levi P Sowers
- Department of Neurology, University of Iowa Hospitals and Clinics, 200 Hawkins Drive, Iowa City, IA 52242, United States; Roy J. and Lucille A. Carver College of Medicine, University of Iowa Hospitals and Clinics, 200 Hawkins Drive, Iowa City, IA 52242, United States
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