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Lacuey N, Talavera B, Magana-Tellez O, Mancera-Páez O, Hupp N, Luo X, Hampson JP, Hampson J, Rani RS, Ochoa-Urrea M, Alamoudi OA, Melius S, Pati S, Gavvala J, Tandon N, Mosher JC, Lhatoo SD. Ictal Central Apnea Is Predictive of Mesial Temporal Seizure Onset: An Intracranial Investigation. Ann Neurol 2024; 95:998-1008. [PMID: 38400804 PMCID: PMC11061876 DOI: 10.1002/ana.26888] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/26/2023] [Revised: 12/27/2023] [Accepted: 01/23/2024] [Indexed: 02/26/2024]
Abstract
OBJECTIVE Ictal central apnea (ICA) is a semiological sign of focal epilepsy, associated with temporal and frontal lobe seizures. In this study, using qualitative and quantitative approaches, we aimed to assess the localizational value of ICA. We also aimed to compare ICA clinical utility in relation to other seizure semiological features of focal epilepsy. METHODS We analyzed seizures in patients with medically refractory focal epilepsy undergoing intracranial stereotactic electroencephalographic (SEEG) evaluations with simultaneous multimodal cardiorespiratory monitoring. A total of 179 seizures in 72 patients with reliable artifact-free respiratory signal were analyzed. RESULTS ICA was seen in 55 of 179 (30.7%) seizures. Presence of ICA predicted a mesial temporal seizure onset compared to those without ICA (odds ratio = 3.8, 95% confidence interval = 1.3-11.6, p = 0.01). ICA specificity was 0.82. ICA onset was correlated with increased high-frequency broadband gamma (60-150Hz) activity in specific mesial or basal temporal regions, including amygdala, hippocampus, and fusiform and lingual gyri. Based on our results, ICA has an almost 4-fold greater association with mesial temporal seizure onset zones compared to those without ICA and is highly specific for mesial temporal seizure onset zones. As evidence of symptomatogenic areas, onset-synchronous increase in high gamma activity in mesial or basal temporal structures was seen in early onset ICA, likely representing anatomical substrates for ICA generation. INTERPRETATION ICA recognition may help anatomoelectroclinical localization of clinical seizure onset to specific mesial and basal temporal brain regions, and the inclusion of these regions in SEEG evaluations may help accurately pinpoint seizure onset zones for resection. ANN NEUROL 2024;95:998-1008.
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Affiliation(s)
- Nuria Lacuey
- Texas Institute of Restorative Neurotechnologies (TIRN), University of Texas Health Science Center (UTHealth), Houston, Texas, USA
| | - Blanca Talavera
- Texas Institute of Restorative Neurotechnologies (TIRN), University of Texas Health Science Center (UTHealth), Houston, Texas, USA
| | - Oman Magana-Tellez
- Texas Institute of Restorative Neurotechnologies (TIRN), University of Texas Health Science Center (UTHealth), Houston, Texas, USA
| | - Oscar Mancera-Páez
- Texas Institute of Restorative Neurotechnologies (TIRN), University of Texas Health Science Center (UTHealth), Houston, Texas, USA
| | - Norma Hupp
- Texas Institute of Restorative Neurotechnologies (TIRN), University of Texas Health Science Center (UTHealth), Houston, Texas, USA
| | - Xi Luo
- Texas Institute of Restorative Neurotechnologies (TIRN), University of Texas Health Science Center (UTHealth), Houston, Texas, USA
- Department of Biostatistics and Data Science, University of Texas Health Science Center (UTHealth), School of Public Health, Houston, Texas, USA
| | - Johnson P. Hampson
- Texas Institute of Restorative Neurotechnologies (TIRN), University of Texas Health Science Center (UTHealth), Houston, Texas, USA
| | - Jaison Hampson
- Texas Institute of Restorative Neurotechnologies (TIRN), University of Texas Health Science Center (UTHealth), Houston, Texas, USA
| | - R. Sandhya Rani
- Texas Institute of Restorative Neurotechnologies (TIRN), University of Texas Health Science Center (UTHealth), Houston, Texas, USA
| | - Manuela Ochoa-Urrea
- Texas Institute of Restorative Neurotechnologies (TIRN), University of Texas Health Science Center (UTHealth), Houston, Texas, USA
- Memorial Hermann, Texas Medical Center, Houston, TX, USA
| | - Omar A. Alamoudi
- Texas Institute of Restorative Neurotechnologies (TIRN), University of Texas Health Science Center (UTHealth), Houston, Texas, USA
- Biomedical Engineering Program, Faculty of Engineering, King Abdulaziz University, Jeddah, Saudi Arabia
| | - Stephen Melius
- Memorial Hermann, Texas Medical Center, Houston, TX, USA
| | - Sandipan Pati
- Texas Institute of Restorative Neurotechnologies (TIRN), University of Texas Health Science Center (UTHealth), Houston, Texas, USA
| | - Jay Gavvala
- Texas Institute of Restorative Neurotechnologies (TIRN), University of Texas Health Science Center (UTHealth), Houston, Texas, USA
| | - Nitin Tandon
- Texas Institute of Restorative Neurotechnologies (TIRN), University of Texas Health Science Center (UTHealth), Houston, Texas, USA
| | - John C. Mosher
- Texas Institute of Restorative Neurotechnologies (TIRN), University of Texas Health Science Center (UTHealth), Houston, Texas, USA
| | - Samden D. Lhatoo
- Texas Institute of Restorative Neurotechnologies (TIRN), University of Texas Health Science Center (UTHealth), Houston, Texas, USA
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Talavera B, Chaitanya G, Hupp N, Pati S, Hampson JP, Luo X, Hampson J, Vakilna YS, Rani MRS, Noor R, Mosher JC, Tandon N, Lhatoo SD, Lacuey N. Stimulation-induced respiratory enhancement in corticothalamic regions. Epilepsia 2023; 64:1925-1938. [PMID: 37119434 DOI: 10.1111/epi.17635] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/23/2023] [Revised: 04/26/2023] [Accepted: 04/27/2023] [Indexed: 05/01/2023]
Abstract
OBJECTIVE We aimed to identify corticothalamic areas and electrical stimulation paradigms that optimally enhance breathing. METHODS Twenty-nine patients with medically intractable epilepsy were prospectively recruited in an epilepsy monitoring unit while undergoing stereoelectroencephalographic evaluation. Direct electrical stimulation in cortical and thalamic regions was carried out using low (<1 Hz) and high (≥10 Hz) frequencies, and low (<5 mA) and high (≥5 mA) current intensities, with pulse width of .1 ms. Electrocardiography, arterial oxygen saturation (SpO2 ), end-tidal carbon dioxide (ETCO2 ), oronasal airflow, and abdominal and thoracic plethysmography were monitored continuously during stimulations. Airflow signal was used to estimate breathing rate, tidal volume, and minute ventilation (MV) changes during stimulation, compared to baseline. RESULTS Electrical stimulation increased MV in the amygdala, anterior cingulate, anterior insula, temporal pole, and thalamus, with an average increase in MV of 20.8% ± 28.9% (range = 0.2%-165.6%) in 19 patients. MV changes were associated with SpO2 and ETCO2 changes (p < .001). Effects on respiration were parameter and site dependent. Within amygdala, low-frequency stimulation of the medial region produced 78.49% greater MV change (p < .001) compared to high-frequency stimulation. Longer stimulation produced greater MV changes (an increase of 4.47% in MV for every additional 10 s, p = .04). SIGNIFICANCE Stimulation of amygdala, anterior cingulate gyrus, anterior insula, temporal pole, and thalamus, using certain stimulation paradigms, enhances respiration. Among tested paradigms, low-frequency, low-intensity, long-duration stimulation of the medial amygdala is the most effective breathing enhancement stimulation strategy. Such approaches may pave the way for the future development of neuromodulatory techniques that aid rescue from seizure-related apnea, potentially as a targeted sudden unexpected death in epilepsy prevention method.
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Affiliation(s)
- Blanca Talavera
- Texas Institute of Restorative Neurotechnologies, University of Texas Health Science Center, Houston, Texas, USA
| | - Ganne Chaitanya
- Texas Institute of Restorative Neurotechnologies, University of Texas Health Science Center, Houston, Texas, USA
| | - Norma Hupp
- Texas Institute of Restorative Neurotechnologies, University of Texas Health Science Center, Houston, Texas, USA
| | - Sandipan Pati
- Texas Institute of Restorative Neurotechnologies, University of Texas Health Science Center, Houston, Texas, USA
| | - Johnson P Hampson
- Texas Institute of Restorative Neurotechnologies, University of Texas Health Science Center, Houston, Texas, USA
| | - Xi Luo
- Texas Institute of Restorative Neurotechnologies, University of Texas Health Science Center, Houston, Texas, USA
- Department of Biostatistics and Data Science, University of Texas Health Science Center, School of Public Health, Houston, Texas, USA
| | - Jaison Hampson
- Texas Institute of Restorative Neurotechnologies, University of Texas Health Science Center, Houston, Texas, USA
| | - Yash S Vakilna
- Texas Institute of Restorative Neurotechnologies, University of Texas Health Science Center, Houston, Texas, USA
| | - M R Sandhya Rani
- Texas Institute of Restorative Neurotechnologies, University of Texas Health Science Center, Houston, Texas, USA
| | - Rabeha Noor
- Epilepsy Monitoring Unit, Memorial Hermann Houston Medical Center, Houston, Texas, USA
| | - John C Mosher
- Texas Institute of Restorative Neurotechnologies, University of Texas Health Science Center, Houston, Texas, USA
| | - Nitin Tandon
- Texas Institute of Restorative Neurotechnologies, University of Texas Health Science Center, Houston, Texas, USA
- Department of Neurosurgery, University of Texas Health Science Center, School of Public Health, Houston, Texas, USA
| | - Samden D Lhatoo
- Texas Institute of Restorative Neurotechnologies, University of Texas Health Science Center, Houston, Texas, USA
| | - Nuria Lacuey
- Texas Institute of Restorative Neurotechnologies, University of Texas Health Science Center, Houston, Texas, USA
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Ciumas C, Bolay M, Bouet R, Rheims S, Ibarrola D, Hampson JP, Lhatoo SD, Ryvlin P. Subject-Specific Activation of Central Respiratory Centers during Breath-Holding Functional Magnetic Resonance Imaging. Respiration 2023; 102:274-286. [PMID: 36750046 DOI: 10.1159/000529388] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/02/2022] [Accepted: 01/06/2023] [Indexed: 02/09/2023] Open
Abstract
BACKGROUND Voluntary breath-holding (BH) triggers responses from central neural control and respiratory centers in order to restore breathing. Such responses can be observed using functional MRI (fMRI). OBJECTIVES We used this paradigm in healthy volunteers with the view to develop a biomarker that could be used to investigate disorders of the central control of breathing at the individual patient level. METHOD In 21 healthy human subjects (mean age±SD, 32.8 ± 9.9 years old), fMRI was used to determine, at both the individual and group levels, the physiological neural response to expiratory and inspiratory voluntary apneas, within respiratory control centers in the brain and brainstem. RESULTS Group analysis showed that expiratory BH, but not inspiratory BH, triggered activation of the pontine respiratory group and raphe nuclei at the group level, with a significant relationship between the levels of activation and drop in SpO2. Using predefined ROIs, expiratory BH, and to a lesser extent, inspiratory BH were associated with activation of most respiratory centers. The right ventrolateral nucleus of the thalamus, right pre-Bötzinger complex, right VRG, right nucleus ambiguus, and left Kölliker-Fuse-parabrachial complex were only activated during inspiratory BH. Individual analysis identified activations of cortical/subcortical and brainstem structures related to respiratory control in 19 out of 21 subjects. CONCLUSION Our study shows that BH paradigm allows to reliably trigger fMRI response from brainstem and cortical areas involved in respiratory control at the individual level, suggesting that it might serve as a clinically relevant biomarker to investigate conditions associated with an altered central control of respiration.
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Affiliation(s)
- Carolina Ciumas
- Department of Clinical Neurosciences, Lausanne University Hospital and University of Lausanne, Lausanne, Switzerland
- Lyon Neuroscience Research Center, Institut National de la Santé et de la Recherche Médicale U1028/CNRS UMR 5292 Lyon 1 University, Bron, France
- IDEE Epilepsy Institute, Lyon, France
| | - Mayara Bolay
- Department of Clinical Neurosciences, Lausanne University Hospital and University of Lausanne, Lausanne, Switzerland
| | - Romain Bouet
- Eduwell team, Lyon Neuroscience Research Center (CRNL), Inserm U1028, CNRS UMR5292, UCBL1, UJM, Lyon, France
| | - Sylvain Rheims
- Lyon Neuroscience Research Center, Institut National de la Santé et de la Recherche Médicale U1028/CNRS UMR 5292 Lyon 1 University, Bron, France
- IDEE Epilepsy Institute, Lyon, France
- Department of Functional Neurology and Epileptology, Hospices Civils de Lyon, Lyon, France
| | | | - Johnson P Hampson
- Department of Neurology, McGovern Medical School, University of Texas Health Science Center at Houston, Houston, Texas, USA
| | - Samden D Lhatoo
- Department of Neurology, McGovern Medical School, University of Texas Health Science Center at Houston, Houston, Texas, USA
| | - Philippe Ryvlin
- Department of Clinical Neurosciences, Lausanne University Hospital and University of Lausanne, Lausanne, Switzerland
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Li X, Tao S, Lhatoo SD, Cui L, Huang Y, Hampson JP, Zhang GQ. A multimodal clinical data resource for personalized risk assessment of sudden unexpected death in epilepsy. Front Big Data 2022; 5:965715. [PMID: 36059922 PMCID: PMC9428292 DOI: 10.3389/fdata.2022.965715] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/10/2022] [Accepted: 07/11/2022] [Indexed: 02/03/2023] Open
Abstract
Epilepsy affects ~2-3 million individuals in the United States, a third of whom have uncontrolled seizures. Sudden unexpected death in epilepsy (SUDEP) is a catastrophic and fatal complication of poorly controlled epilepsy and is the primary cause of mortality in such patients. Despite its huge public health impact, with a ~1/1,000 incidence rate in persons with epilepsy, it is an uncommon enough phenomenon to require multi-center efforts for well-powered studies. We developed the Multimodal SUDEP Data Resource (MSDR), a comprehensive system for sharing multimodal epilepsy data in the NIH funded Center for SUDEP Research. The MSDR aims at accelerating research to address critical questions about personalized risk assessment of SUDEP. We used a metadata-guided approach, with a set of common epilepsy-specific terms enforcing uniform semantic interpretation of data elements across three main components: (1) multi-site annotated datasets; (2) user interfaces for capturing, managing, and accessing data; and (3) computational approaches for the analysis of multimodal clinical data. We incorporated the process for managing dataset-specific data use agreements, evidence of Institutional Review Board review, and the corresponding access control in the MSDR web portal. The metadata-guided approach facilitates structural and semantic interoperability, ultimately leading to enhanced data reusability and scientific rigor. MSDR prospectively integrated and curated epilepsy patient data from seven institutions, and it currently contains data on 2,739 subjects and 10,685 multimodal clinical data files with different data formats. In total, 55 users registered in the current MSDR data repository, and 6 projects have been funded to apply MSDR in epilepsy research, including three R01 projects and three R21 projects.
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Affiliation(s)
- Xiaojin Li
- Department of Neurology, The University of Texas Health Science Center at Houston, Houston, TX, United States,Texas Institute for Restorative Neurotechnologies, The University of Texas Health Science Center at Houston, Houston, TX, United States
| | - Shiqiang Tao
- Department of Neurology, The University of Texas Health Science Center at Houston, Houston, TX, United States,Texas Institute for Restorative Neurotechnologies, The University of Texas Health Science Center at Houston, Houston, TX, United States
| | - Samden D. Lhatoo
- Department of Neurology, The University of Texas Health Science Center at Houston, Houston, TX, United States,Texas Institute for Restorative Neurotechnologies, The University of Texas Health Science Center at Houston, Houston, TX, United States
| | - Licong Cui
- Texas Institute for Restorative Neurotechnologies, The University of Texas Health Science Center at Houston, Houston, TX, United States,School of Biomedical Informatics, The University of Texas Health Science Center at Houston, Houston, TX, United States
| | - Yan Huang
- Department of Neurology, The University of Texas Health Science Center at Houston, Houston, TX, United States,Texas Institute for Restorative Neurotechnologies, The University of Texas Health Science Center at Houston, Houston, TX, United States
| | - Johnson P. Hampson
- Department of Neurology, The University of Texas Health Science Center at Houston, Houston, TX, United States,Texas Institute for Restorative Neurotechnologies, The University of Texas Health Science Center at Houston, Houston, TX, United States
| | - Guo-Qiang Zhang
- Department of Neurology, The University of Texas Health Science Center at Houston, Houston, TX, United States,Texas Institute for Restorative Neurotechnologies, The University of Texas Health Science Center at Houston, Houston, TX, United States,School of Biomedical Informatics, The University of Texas Health Science Center at Houston, Houston, TX, United States,*Correspondence: Guo-Qiang Zhang
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Hampson JP, Lacuey N, Rani MRS, Hampson JS, Simeone KA, Simeone TA, Narayana PA, Lemieux L, Lhatoo SD. Functional MRI Correlates of Carbon Dioxide Chemosensing in Persons With Epilepsy. Front Neurol 2022; 13:896204. [PMID: 35873766 PMCID: PMC9301231 DOI: 10.3389/fneur.2022.896204] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/14/2022] [Accepted: 06/03/2022] [Indexed: 11/17/2022] Open
Abstract
Objectives Sudden unexpected death in epilepsy (SUDEP) is a catastrophic epilepsy outcome for which there are no reliable premortem imaging biomarkers of risk. Percival respiratory depression is seen in monitored SUDEP and near SUDEP cases, and abnormal chemosensing of raised blood carbon dioxide (CO2) is thought to contribute. Damage to brainstem respiratory control and chemosensing structures has been demonstrated in structural imaging and neuropathological studies of SUDEP. We hypothesized that functional MRI (fMRI) correlates of abnormal chemosensing are detectable in brainstems of persons with epilepsy (PWE) and are different from healthy controls (HC). Methods We analyzed fMRI BOLD activation and brain connectivity in 10 PWE and 10 age- and sex-matched HCs during precisely metered iso-oxic, hypercapnic breathing challenges. Segmented brainstem responses were of particular interest, along with characterization of functional connectivity metrics between these structures. Regional BOLD activations during hypercapnic challenges were convolved with hemodynamic responses, and the resulting activation maps were passed on to group-level analyses. For the functional connectivity analysis, significant clusters from BOLD results were used as seeds. Each individual seed time-series activation map was extracted for bivariate correlation coefficient analyses to study changes in brain connectivity between PWE and HCs. Results (1) Greater brainstem BOLD activations in PWE were observed compared to HC during hypercapnic challenges in several structures with respiratory/chemosensing properties. Group comparison between PWE vs. HC showed significantly greater activation in the dorsal raphe among PWE (p < 0.05) compared to HCs. (2) PWE had significantly greater seed-seed connectivity and recruited more structures during hypercapnia compared to HC. Significance The results of this study show that BOLD responses to hypercapnia in human brainstem are detectable and different in PWE compared to HC. Increased dorsal raphe BOLD activation in PWE and increased seed-seed connectivity between brainstem and adjacent subcortical areas may indicate abnormal chemosensing in these individuals. Imaging investigation of brainstem respiratory centers involved in respiratory regulation in PWE is an important step toward identifying suspected dysfunction of brainstem breathing control that culminates in SUDEP and deserve further study as potential imaging SUDEP biomarkers.
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Affiliation(s)
- Johnson P. Hampson
- Department of Neurology, McGovern Medical School, University of Texas Health Science Center at Houston, Houston, TX, United States
| | - Nuria Lacuey
- Department of Neurology, McGovern Medical School, University of Texas Health Science Center at Houston, Houston, TX, United States
| | - MR Sandhya Rani
- Department of Neurology, McGovern Medical School, University of Texas Health Science Center at Houston, Houston, TX, United States
| | - Jaison S. Hampson
- Department of Neurology, McGovern Medical School, University of Texas Health Science Center at Houston, Houston, TX, United States
| | - Kristina A. Simeone
- Department of Pharmacology and Neuroscience, Creighton University School of Medicine, Omaha, NE, United States
| | - Timothy A. Simeone
- Department of Pharmacology and Neuroscience, Creighton University School of Medicine, Omaha, NE, United States
| | - Ponnada A. Narayana
- Department of Diagnostic and Interventional Imaging, McGovern Medical School, University of Texas Health Science Center at Houston, Houston, TX, United States
| | - Louis Lemieux
- Department of Clinical and Experimental Epilepsy, University College London (UCL) Institute of Neurology, National Hospital for Neurology and Neurosurgery, London, United Kingdom
| | - Samden D. Lhatoo
- Department of Neurology, McGovern Medical School, University of Texas Health Science Center at Houston, Houston, TX, United States
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Ganne C, Hampson JP, Toth E, Hupp NJ, Hampson JS, Mosher JC, Pati S, Lhatoo SD, Lacuey N. Limbic and paralimbic respiratory modulation: from inhibition to enhancement. Epilepsia 2022; 63:1799-1811. [PMID: 35352347 DOI: 10.1111/epi.17244] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/04/2021] [Revised: 03/25/2022] [Accepted: 03/28/2022] [Indexed: 11/27/2022]
Abstract
OBJECTIVE Increased understanding of the role of cortical structures in respiratory control may help the understanding of seizure-induced respiratory dysfunction that leads to sudden death in epilepsy (SUDEP). The aim of this study was to characterize respiratory responses to electrical stimulation (ES), including inhibition and enhancement of respiration. METHODS We prospectively recruited 19 consecutive patients with intractable epilepsy undergoing stereotactic EEG evaluation from June 2015 to June 2018. Inclusion criteria were patients ≥18 years and in whom ES was indicated for clinical mapping of ictal onset or eloquent cortex as part of the presurgical evaluation. ES was carried out at 50 Hz, 0.2 ms and 1-10 mA current intensity. Common brain regions sampled across all patients were- amygdala (AMY), hippocampus (HG), anterior cingulate gyrus (CING), orbitofrontal cortex (OrbF), temporal neocortex (TNC), temporal pole (TP) and entorhinal cortex (ERC). 755 stimulations were conducted. Quantitative analysis of breathing signal i.e., changes in breathing rate (BR), depth (TV), and minute ventilation (MV) was carried out during ES using the BreathMetrics breathing waveform analysis toolbox. Electrocardiogram, arterial oxygen saturation, end-tidal and transcutaneous carbon dioxide, nasal airflow, and abdominal and thoracic plethysmography were continuously monitored during stimulations. RESULTS Electrical stimulation of TP and CING (at lower current strengths <3mA) increased TV and MV. At 7-10mA, CING decreased TV and MV. On the other hand, decreased TV and MV occurred with stimulation of mesial temporal structures such as AMY and HG. Breathing changes were dependent on stimulation intensity. Lateral temporal, entorhinal, and orbitofrontal cortices did not affect breathing either way. SIGNIFICANCE These findings suggest that breathing responses other than apnea can be induced by ES. Identification of two regions, the temporal pole and anterior cingulate gyrus, for enhancement of breathing may be important in paving the way to future development of strategies for prevention of SUDEP.
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Affiliation(s)
- Chaitanya Ganne
- Texas Institute of Restorative Neurotechnologies (TIRN), University of Texas Health Science Center (UTHealth), Houston, Texas, USA.,Department of Neurology, University of Texas Health Science Center (UTHealth), Houston, Texas, USA
| | - Johnson P Hampson
- Texas Institute of Restorative Neurotechnologies (TIRN), University of Texas Health Science Center (UTHealth), Houston, Texas, USA.,Department of Neurology, University of Texas Health Science Center (UTHealth), Houston, Texas, USA.,The NINDS Center for SUDEP Research
| | - Emilia Toth
- Texas Institute of Restorative Neurotechnologies (TIRN), University of Texas Health Science Center (UTHealth), Houston, Texas, USA.,Department of Neurology, University of Texas Health Science Center (UTHealth), Houston, Texas, USA
| | - Norma J Hupp
- Texas Institute of Restorative Neurotechnologies (TIRN), University of Texas Health Science Center (UTHealth), Houston, Texas, USA.,Department of Neurology, University of Texas Health Science Center (UTHealth), Houston, Texas, USA.,The NINDS Center for SUDEP Research
| | - Jaison S Hampson
- Texas Institute of Restorative Neurotechnologies (TIRN), University of Texas Health Science Center (UTHealth), Houston, Texas, USA.,Department of Neurology, University of Texas Health Science Center (UTHealth), Houston, Texas, USA
| | - John C Mosher
- Texas Institute of Restorative Neurotechnologies (TIRN), University of Texas Health Science Center (UTHealth), Houston, Texas, USA.,Department of Neurology, University of Texas Health Science Center (UTHealth), Houston, Texas, USA
| | - Sandipan Pati
- Texas Institute of Restorative Neurotechnologies (TIRN), University of Texas Health Science Center (UTHealth), Houston, Texas, USA.,Department of Neurology, University of Texas Health Science Center (UTHealth), Houston, Texas, USA
| | - Samden D Lhatoo
- Texas Institute of Restorative Neurotechnologies (TIRN), University of Texas Health Science Center (UTHealth), Houston, Texas, USA.,Department of Neurology, University of Texas Health Science Center (UTHealth), Houston, Texas, USA.,The NINDS Center for SUDEP Research
| | - Nuria Lacuey
- Texas Institute of Restorative Neurotechnologies (TIRN), University of Texas Health Science Center (UTHealth), Houston, Texas, USA.,Department of Neurology, University of Texas Health Science Center (UTHealth), Houston, Texas, USA.,The NINDS Center for SUDEP Research
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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] [What about the content of this article? (0)] [Affiliation(s)] [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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8
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Ochoa-Urrea M, Lacuey N, Vilella L, Zhu L, Jamal-Omidi S, Rani MRS, Hampson JP, Dayyani M, Hampson J, Hupp NJ, Tao S, Sainju RK, Friedman D, Nei M, Scott C, Allen L, Gehlbach BK, Reick-Mitrisin V, Schuele S, Ogren J, Harper RM, Diehl B, Bateman LM, Devinsky O, Richerson GB, Zhang GQ, Lhatoo SD. Seizure Clusters, Seizure Severity Markers, and SUDEP Risk. Front Neurol 2021; 12:643916. [PMID: 33643216 PMCID: PMC7907515 DOI: 10.3389/fneur.2021.643916] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2020] [Accepted: 01/25/2021] [Indexed: 11/13/2022] Open
Abstract
Rationale: Seizure clusters may be related to Sudden Unexpected Death in Epilepsy (SUDEP). Two or more generalized convulsive seizures (GCS) were captured during video electroencephalography in 7/11 (64%) patients with monitored SUDEP in the MORTEMUS study. It follows that seizure clusters may be associated with epilepsy severity and possibly with SUDEP risk. We aimed to determine if electroclinical seizure features worsen from seizure to seizure within a cluster and possible associations between GCS clusters, markers of seizure severity, and SUDEP risk. Methods: Patients were consecutive, prospectively consented participants with drug-resistant epilepsy from a multi-center study. Seizure clusters were defined as two or more GCS in a 24-h period during the recording of prolonged video-electroencephalography in the Epilepsy monitoring unit (EMU). We measured heart rate variability (HRV), pulse oximetry, plethysmography, postictal generalized electroencephalographic suppression (PGES), and electroencephalography (EEG) recovery duration. A linear mixed effects model was used to study the difference between the first and subsequent seizures, with a level of significance set at p < 0.05. Results: We identified 112 GCS clusters in 105 patients with 285 seizures. GCS lasted on average 48.7 ± 19 s (mean 49, range 2-137). PGES emerged in 184 (64.6%) seizures and postconvulsive central apnea (PCCA) was present in 38 (13.3%) seizures. Changes in seizure features from seizure to seizure such as seizure and convulsive phase durations appeared random. In grouped analysis, some seizure features underwent significant deterioration, whereas others improved. Clonic phase and postconvulsive central apnea (PCCA) were significantly shorter in the fourth seizure compared to the first. By contrast, duration of decerebrate posturing and ictal central apnea were longer. Four SUDEP cases in the cluster cohort were reported on follow-up. Conclusion: Seizure clusters show variable changes from seizure to seizure. Although clusters may reflect epilepsy severity, they alone may be unrelated to SUDEP risk. We suggest a stochastic nature to SUDEP occurrence, where seizure clusters may be more likely to contribute to SUDEP if an underlying progressive tendency toward SUDEP has matured toward a critical SUDEP threshold.
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Affiliation(s)
- Manuela Ochoa-Urrea
- National Institute of Neurological Disorders and Stroke Center for Sudden Unexpected Death in Epilepsy Research (CSR), 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 Center for Sudden Unexpected Death in Epilepsy Research (CSR), 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
| | - Laura Vilella
- National Institute of Neurological Disorders and Stroke Center for Sudden Unexpected Death in Epilepsy Research (CSR), 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 & 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
| | - Shirin Jamal-Omidi
- National Institute of Neurological Disorders and Stroke Center for Sudden Unexpected Death in Epilepsy Research (CSR), 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
| | - M R Sandhya Rani
- National Institute of Neurological Disorders and Stroke Center for Sudden Unexpected Death in Epilepsy Research (CSR), 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 Center for Sudden Unexpected Death in Epilepsy Research (CSR), 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
| | - Mojtaba Dayyani
- National Institute of Neurological Disorders and Stroke Center for Sudden Unexpected Death in Epilepsy Research (CSR), 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 Center for Sudden Unexpected Death in Epilepsy Research (CSR), 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 Center for Sudden Unexpected Death in Epilepsy Research (CSR), 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
| | - Shiqiang Tao
- National Institute of Neurological Disorders and Stroke Center for Sudden Unexpected Death in Epilepsy Research (CSR), 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 Center for Sudden Unexpected Death in Epilepsy Research (CSR), McGovern Medical School, University of Texas Health Science Center at Houston, Houston, TX, United States.,University of Iowa Carver College of Medicine, Iowa City, IA, United States
| | - Daniel Friedman
- National Institute of Neurological Disorders and Stroke Center for Sudden Unexpected Death in Epilepsy Research (CSR), McGovern Medical School, University of Texas Health Science Center at Houston, Houston, TX, United States.,New York University Langone School of Medicine, New York, NY, United States
| | - Maromi Nei
- National Institute of Neurological Disorders and Stroke Center for Sudden Unexpected Death in Epilepsy Research (CSR), 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 Center for Sudden Unexpected Death in Epilepsy Research (CSR), McGovern Medical School, University of Texas Health Science Center at Houston, Houston, TX, United States.,Department of Clinical and Experimental Epilepsy, Institute of Neurology, University College London, London, United Kingdom
| | - Luke Allen
- National Institute of Neurological Disorders and Stroke Center for Sudden Unexpected Death in Epilepsy Research (CSR), McGovern Medical School, University of Texas Health Science Center at Houston, Houston, TX, United States.,Department of Clinical and Experimental Epilepsy, Institute of Neurology, University College London, London, United Kingdom
| | - Brian K Gehlbach
- National Institute of Neurological Disorders and Stroke Center for Sudden Unexpected Death in Epilepsy Research (CSR), McGovern Medical School, University of Texas Health Science Center at Houston, Houston, TX, United States.,University of Iowa Carver College of Medicine, Iowa City, IA, United States
| | | | - Stephan Schuele
- National Institute of Neurological Disorders and Stroke Center for Sudden Unexpected Death in Epilepsy Research (CSR), 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
| | - Jennifer Ogren
- National Institute of Neurological Disorders and Stroke Center for Sudden Unexpected Death in Epilepsy Research (CSR), 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 (UCLA), Los Angeles, CA, United States
| | - Ronald M Harper
- National Institute of Neurological Disorders and Stroke Center for Sudden Unexpected Death in Epilepsy Research (CSR), 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 (UCLA), Los Angeles, CA, United States
| | - Beate Diehl
- National Institute of Neurological Disorders and Stroke Center for Sudden Unexpected Death in Epilepsy Research (CSR), McGovern Medical School, University of Texas Health Science Center at Houston, Houston, TX, United States.,Department of Clinical and Experimental Epilepsy, Institute of Neurology, University College London, London, United Kingdom
| | - Lisa M Bateman
- National Institute of Neurological Disorders and Stroke Center for Sudden Unexpected Death in Epilepsy Research (CSR), 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 Center for Sudden Unexpected Death in Epilepsy Research (CSR), McGovern Medical School, University of Texas Health Science Center at Houston, Houston, TX, United States.,New York University Langone School of Medicine, New York, NY, United States
| | - George B Richerson
- National Institute of Neurological Disorders and Stroke Center for Sudden Unexpected Death in Epilepsy Research (CSR), McGovern Medical School, University of Texas Health Science Center at Houston, Houston, TX, United States.,University of Iowa Carver College of Medicine, Iowa City, IA, United States
| | - Guo-Qiang Zhang
- National Institute of Neurological Disorders and Stroke Center for Sudden Unexpected Death in Epilepsy Research (CSR), 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 Center for Sudden Unexpected Death in Epilepsy Research (CSR), 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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9
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Vilella L, Lacuey N, Hampson JP, Zhu L, Omidi S, Ochoa-Urrea M, Tao S, Rani MRS, Sainju RK, Friedman D, Nei M, Strohl K, Scott C, Allen L, Gehlbach BK, Hupp NJ, Hampson JS, Shafiabadi N, Zhao X, Reick-Mitrisin V, Schuele S, Ogren J, Harper RM, Diehl B, Bateman LM, Devinsky O, Richerson GB, Ryvlin P, Zhang GQ, Lhatoo SD. Association of Peri-ictal Brainstem Posturing With Seizure Severity and Breathing Compromise in Patients With Generalized Convulsive Seizures. Neurology 2020; 96:e352-e365. [PMID: 33268557 DOI: 10.1212/wnl.0000000000011274] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/18/2019] [Accepted: 08/17/2020] [Indexed: 12/24/2022] Open
Abstract
OBJECTIVE To analyze the association between peri-ictal brainstem posturing semiologies with postictal generalized electroencephalographic suppression (PGES) and breathing dysfunction in generalized convulsive seizures (GCS). METHODS In this prospective, multicenter analysis of GCS, ictal brainstem semiology was classified as (1) decerebration (bilateral symmetric tonic arm extension), (2) decortication (bilateral symmetric tonic arm flexion only), (3) hemi-decerebration (unilateral tonic arm extension with contralateral flexion) and (4) absence of ictal tonic phase. Postictal posturing was also assessed. Respiration was monitored with thoracoabdominal belts, video, and pulse oximetry. RESULTS Two hundred ninety-five seizures (180 patients) were analyzed. Ictal decerebration was observed in 122 of 295 (41.4%), decortication in 47 of 295 (15.9%), and hemi-decerebration in 28 of 295 (9.5%) seizures. Tonic phase was absent in 98 of 295 (33.2%) seizures. Postictal posturing occurred in 18 of 295 (6.1%) seizures. PGES risk increased with ictal decerebration (odds ratio [OR] 14.79, 95% confidence interval [CI] 6.18-35.39, p < 0.001), decortication (OR 11.26, 95% CI 2.96-42.93, p < 0.001), or hemi-decerebration (OR 48.56, 95% CI 6.07-388.78, p < 0.001). Ictal decerebration was associated with longer PGES (p = 0.011). Postictal posturing was associated with postconvulsive central apnea (PCCA) (p = 0.004), longer hypoxemia (p < 0.001), and Spo2 recovery (p = 0.035). CONCLUSIONS Ictal brainstem semiology is associated with increased PGES risk. Ictal decerebration is associated with longer PGES. Postictal posturing is associated with a 6-fold increased risk of PCCA, longer hypoxemia, and Spo2 recovery. Peri-ictal brainstem posturing may be a surrogate biomarker for GCS severity identifiable without in-hospital monitoring. CLASSIFICATION OF EVIDENCE This study provides Class III evidence that peri-ictal brainstem posturing is associated with the GCS with more prolonged PGES and more severe breathing dysfunction.
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Affiliation(s)
- Laura Vilella
- From the NINDS Center for SUDEP Research (L.V., N.L., S.O., M.O.-U., S.T., M.R.S.R., R.K.S., D.F., M.N., C.S., L.A., B.K.G., J.S.H., S.S., J.O., R.M.H., B.D., L.M.B., O.D., G.B.R., P.R., G.-Q.Z., S.D.L.) and Department of Neurology (L.V., N.L., J.P.H., S.O., M.O.-U., S.T., M.R.S.R., N.J.H., J.S.H., G.-Q.Z., S.D.L.), McGovern Medical School, and Biostatistics and Epidemiology Research Design Core (L.Z., G.B.R.), Division of Clinical and Translational Sciences, University of Texas Health Science Center at Houston; Departament de Medicina (L.V.), Universitat Autonoma de Barcelona, Spain; University of Iowa Carver College of Medicine (R.K.S., B.K.G.), Iowa City; NYU Langone School of Medicine (D.F., O.D.), New York; Sidney Kimmel Medical College (M.N.), Thomas Jefferson University, Philadelphia, PA; Division of Pulmonary (K.S.), Critical Care and Sleep Medicine, University Hospitals Medical Center, Cleveland, OH; Institute of Neurology (C.S., L.A., B.D.), University College London, UK; Case Western Reserve University (N.S., X.Z., V.R.-M.), Cleveland, OH; Feinberg School of Medicine (S.S.), Northwestern University, Chicago, IL; Department of Neurobiology and the Brain Research Institute (J.O., R.M.H.), University of California, Los Angeles; Department of Neurology (L.M.B.), Columbia University, New York, NY; and Department of Clinical Neuroscience (P.R.), Centre Hospitalier Universitaire Vaudois, Lausanne, Switzerland.
| | - Nuria Lacuey
- From the NINDS Center for SUDEP Research (L.V., N.L., S.O., M.O.-U., S.T., M.R.S.R., R.K.S., D.F., M.N., C.S., L.A., B.K.G., J.S.H., S.S., J.O., R.M.H., B.D., L.M.B., O.D., G.B.R., P.R., G.-Q.Z., S.D.L.) and Department of Neurology (L.V., N.L., J.P.H., S.O., M.O.-U., S.T., M.R.S.R., N.J.H., J.S.H., G.-Q.Z., S.D.L.), McGovern Medical School, and Biostatistics and Epidemiology Research Design Core (L.Z., G.B.R.), Division of Clinical and Translational Sciences, University of Texas Health Science Center at Houston; Departament de Medicina (L.V.), Universitat Autonoma de Barcelona, Spain; University of Iowa Carver College of Medicine (R.K.S., B.K.G.), Iowa City; NYU Langone School of Medicine (D.F., O.D.), New York; Sidney Kimmel Medical College (M.N.), Thomas Jefferson University, Philadelphia, PA; Division of Pulmonary (K.S.), Critical Care and Sleep Medicine, University Hospitals Medical Center, Cleveland, OH; Institute of Neurology (C.S., L.A., B.D.), University College London, UK; Case Western Reserve University (N.S., X.Z., V.R.-M.), Cleveland, OH; Feinberg School of Medicine (S.S.), Northwestern University, Chicago, IL; Department of Neurobiology and the Brain Research Institute (J.O., R.M.H.), University of California, Los Angeles; Department of Neurology (L.M.B.), Columbia University, New York, NY; and Department of Clinical Neuroscience (P.R.), Centre Hospitalier Universitaire Vaudois, Lausanne, Switzerland
| | - Johnson P Hampson
- From the NINDS Center for SUDEP Research (L.V., N.L., S.O., M.O.-U., S.T., M.R.S.R., R.K.S., D.F., M.N., C.S., L.A., B.K.G., J.S.H., S.S., J.O., R.M.H., B.D., L.M.B., O.D., G.B.R., P.R., G.-Q.Z., S.D.L.) and Department of Neurology (L.V., N.L., J.P.H., S.O., M.O.-U., S.T., M.R.S.R., N.J.H., J.S.H., G.-Q.Z., S.D.L.), McGovern Medical School, and Biostatistics and Epidemiology Research Design Core (L.Z., G.B.R.), Division of Clinical and Translational Sciences, University of Texas Health Science Center at Houston; Departament de Medicina (L.V.), Universitat Autonoma de Barcelona, Spain; University of Iowa Carver College of Medicine (R.K.S., B.K.G.), Iowa City; NYU Langone School of Medicine (D.F., O.D.), New York; Sidney Kimmel Medical College (M.N.), Thomas Jefferson University, Philadelphia, PA; Division of Pulmonary (K.S.), Critical Care and Sleep Medicine, University Hospitals Medical Center, Cleveland, OH; Institute of Neurology (C.S., L.A., B.D.), University College London, UK; Case Western Reserve University (N.S., X.Z., V.R.-M.), Cleveland, OH; Feinberg School of Medicine (S.S.), Northwestern University, Chicago, IL; Department of Neurobiology and the Brain Research Institute (J.O., R.M.H.), University of California, Los Angeles; Department of Neurology (L.M.B.), Columbia University, New York, NY; and Department of Clinical Neuroscience (P.R.), Centre Hospitalier Universitaire Vaudois, Lausanne, Switzerland
| | - Liang Zhu
- From the NINDS Center for SUDEP Research (L.V., N.L., S.O., M.O.-U., S.T., M.R.S.R., R.K.S., D.F., M.N., C.S., L.A., B.K.G., J.S.H., S.S., J.O., R.M.H., B.D., L.M.B., O.D., G.B.R., P.R., G.-Q.Z., S.D.L.) and Department of Neurology (L.V., N.L., J.P.H., S.O., M.O.-U., S.T., M.R.S.R., N.J.H., J.S.H., G.-Q.Z., S.D.L.), McGovern Medical School, and Biostatistics and Epidemiology Research Design Core (L.Z., G.B.R.), Division of Clinical and Translational Sciences, University of Texas Health Science Center at Houston; Departament de Medicina (L.V.), Universitat Autonoma de Barcelona, Spain; University of Iowa Carver College of Medicine (R.K.S., B.K.G.), Iowa City; NYU Langone School of Medicine (D.F., O.D.), New York; Sidney Kimmel Medical College (M.N.), Thomas Jefferson University, Philadelphia, PA; Division of Pulmonary (K.S.), Critical Care and Sleep Medicine, University Hospitals Medical Center, Cleveland, OH; Institute of Neurology (C.S., L.A., B.D.), University College London, UK; Case Western Reserve University (N.S., X.Z., V.R.-M.), Cleveland, OH; Feinberg School of Medicine (S.S.), Northwestern University, Chicago, IL; Department of Neurobiology and the Brain Research Institute (J.O., R.M.H.), University of California, Los Angeles; Department of Neurology (L.M.B.), Columbia University, New York, NY; and Department of Clinical Neuroscience (P.R.), Centre Hospitalier Universitaire Vaudois, Lausanne, Switzerland
| | - Shirin Omidi
- From the NINDS Center for SUDEP Research (L.V., N.L., S.O., M.O.-U., S.T., M.R.S.R., R.K.S., D.F., M.N., C.S., L.A., B.K.G., J.S.H., S.S., J.O., R.M.H., B.D., L.M.B., O.D., G.B.R., P.R., G.-Q.Z., S.D.L.) and Department of Neurology (L.V., N.L., J.P.H., S.O., M.O.-U., S.T., M.R.S.R., N.J.H., J.S.H., G.-Q.Z., S.D.L.), McGovern Medical School, and Biostatistics and Epidemiology Research Design Core (L.Z., G.B.R.), Division of Clinical and Translational Sciences, University of Texas Health Science Center at Houston; Departament de Medicina (L.V.), Universitat Autonoma de Barcelona, Spain; University of Iowa Carver College of Medicine (R.K.S., B.K.G.), Iowa City; NYU Langone School of Medicine (D.F., O.D.), New York; Sidney Kimmel Medical College (M.N.), Thomas Jefferson University, Philadelphia, PA; Division of Pulmonary (K.S.), Critical Care and Sleep Medicine, University Hospitals Medical Center, Cleveland, OH; Institute of Neurology (C.S., L.A., B.D.), University College London, UK; Case Western Reserve University (N.S., X.Z., V.R.-M.), Cleveland, OH; Feinberg School of Medicine (S.S.), Northwestern University, Chicago, IL; Department of Neurobiology and the Brain Research Institute (J.O., R.M.H.), University of California, Los Angeles; Department of Neurology (L.M.B.), Columbia University, New York, NY; and Department of Clinical Neuroscience (P.R.), Centre Hospitalier Universitaire Vaudois, Lausanne, Switzerland
| | - Manuela Ochoa-Urrea
- From the NINDS Center for SUDEP Research (L.V., N.L., S.O., M.O.-U., S.T., M.R.S.R., R.K.S., D.F., M.N., C.S., L.A., B.K.G., J.S.H., S.S., J.O., R.M.H., B.D., L.M.B., O.D., G.B.R., P.R., G.-Q.Z., S.D.L.) and Department of Neurology (L.V., N.L., J.P.H., S.O., M.O.-U., S.T., M.R.S.R., N.J.H., J.S.H., G.-Q.Z., S.D.L.), McGovern Medical School, and Biostatistics and Epidemiology Research Design Core (L.Z., G.B.R.), Division of Clinical and Translational Sciences, University of Texas Health Science Center at Houston; Departament de Medicina (L.V.), Universitat Autonoma de Barcelona, Spain; University of Iowa Carver College of Medicine (R.K.S., B.K.G.), Iowa City; NYU Langone School of Medicine (D.F., O.D.), New York; Sidney Kimmel Medical College (M.N.), Thomas Jefferson University, Philadelphia, PA; Division of Pulmonary (K.S.), Critical Care and Sleep Medicine, University Hospitals Medical Center, Cleveland, OH; Institute of Neurology (C.S., L.A., B.D.), University College London, UK; Case Western Reserve University (N.S., X.Z., V.R.-M.), Cleveland, OH; Feinberg School of Medicine (S.S.), Northwestern University, Chicago, IL; Department of Neurobiology and the Brain Research Institute (J.O., R.M.H.), University of California, Los Angeles; Department of Neurology (L.M.B.), Columbia University, New York, NY; and Department of Clinical Neuroscience (P.R.), Centre Hospitalier Universitaire Vaudois, Lausanne, Switzerland
| | - Shiqiang Tao
- From the NINDS Center for SUDEP Research (L.V., N.L., S.O., M.O.-U., S.T., M.R.S.R., R.K.S., D.F., M.N., C.S., L.A., B.K.G., J.S.H., S.S., J.O., R.M.H., B.D., L.M.B., O.D., G.B.R., P.R., G.-Q.Z., S.D.L.) and Department of Neurology (L.V., N.L., J.P.H., S.O., M.O.-U., S.T., M.R.S.R., N.J.H., J.S.H., G.-Q.Z., S.D.L.), McGovern Medical School, and Biostatistics and Epidemiology Research Design Core (L.Z., G.B.R.), Division of Clinical and Translational Sciences, University of Texas Health Science Center at Houston; Departament de Medicina (L.V.), Universitat Autonoma de Barcelona, Spain; University of Iowa Carver College of Medicine (R.K.S., B.K.G.), Iowa City; NYU Langone School of Medicine (D.F., O.D.), New York; Sidney Kimmel Medical College (M.N.), Thomas Jefferson University, Philadelphia, PA; Division of Pulmonary (K.S.), Critical Care and Sleep Medicine, University Hospitals Medical Center, Cleveland, OH; Institute of Neurology (C.S., L.A., B.D.), University College London, UK; Case Western Reserve University (N.S., X.Z., V.R.-M.), Cleveland, OH; Feinberg School of Medicine (S.S.), Northwestern University, Chicago, IL; Department of Neurobiology and the Brain Research Institute (J.O., R.M.H.), University of California, Los Angeles; Department of Neurology (L.M.B.), Columbia University, New York, NY; and Department of Clinical Neuroscience (P.R.), Centre Hospitalier Universitaire Vaudois, Lausanne, Switzerland
| | - M R Sandhya Rani
- From the NINDS Center for SUDEP Research (L.V., N.L., S.O., M.O.-U., S.T., M.R.S.R., R.K.S., D.F., M.N., C.S., L.A., B.K.G., J.S.H., S.S., J.O., R.M.H., B.D., L.M.B., O.D., G.B.R., P.R., G.-Q.Z., S.D.L.) and Department of Neurology (L.V., N.L., J.P.H., S.O., M.O.-U., S.T., M.R.S.R., N.J.H., J.S.H., G.-Q.Z., S.D.L.), McGovern Medical School, and Biostatistics and Epidemiology Research Design Core (L.Z., G.B.R.), Division of Clinical and Translational Sciences, University of Texas Health Science Center at Houston; Departament de Medicina (L.V.), Universitat Autonoma de Barcelona, Spain; University of Iowa Carver College of Medicine (R.K.S., B.K.G.), Iowa City; NYU Langone School of Medicine (D.F., O.D.), New York; Sidney Kimmel Medical College (M.N.), Thomas Jefferson University, Philadelphia, PA; Division of Pulmonary (K.S.), Critical Care and Sleep Medicine, University Hospitals Medical Center, Cleveland, OH; Institute of Neurology (C.S., L.A., B.D.), University College London, UK; Case Western Reserve University (N.S., X.Z., V.R.-M.), Cleveland, OH; Feinberg School of Medicine (S.S.), Northwestern University, Chicago, IL; Department of Neurobiology and the Brain Research Institute (J.O., R.M.H.), University of California, Los Angeles; Department of Neurology (L.M.B.), Columbia University, New York, NY; and Department of Clinical Neuroscience (P.R.), Centre Hospitalier Universitaire Vaudois, Lausanne, Switzerland
| | - Rup K Sainju
- From the NINDS Center for SUDEP Research (L.V., N.L., S.O., M.O.-U., S.T., M.R.S.R., R.K.S., D.F., M.N., C.S., L.A., B.K.G., J.S.H., S.S., J.O., R.M.H., B.D., L.M.B., O.D., G.B.R., P.R., G.-Q.Z., S.D.L.) and Department of Neurology (L.V., N.L., J.P.H., S.O., M.O.-U., S.T., M.R.S.R., N.J.H., J.S.H., G.-Q.Z., S.D.L.), McGovern Medical School, and Biostatistics and Epidemiology Research Design Core (L.Z., G.B.R.), Division of Clinical and Translational Sciences, University of Texas Health Science Center at Houston; Departament de Medicina (L.V.), Universitat Autonoma de Barcelona, Spain; University of Iowa Carver College of Medicine (R.K.S., B.K.G.), Iowa City; NYU Langone School of Medicine (D.F., O.D.), New York; Sidney Kimmel Medical College (M.N.), Thomas Jefferson University, Philadelphia, PA; Division of Pulmonary (K.S.), Critical Care and Sleep Medicine, University Hospitals Medical Center, Cleveland, OH; Institute of Neurology (C.S., L.A., B.D.), University College London, UK; Case Western Reserve University (N.S., X.Z., V.R.-M.), Cleveland, OH; Feinberg School of Medicine (S.S.), Northwestern University, Chicago, IL; Department of Neurobiology and the Brain Research Institute (J.O., R.M.H.), University of California, Los Angeles; Department of Neurology (L.M.B.), Columbia University, New York, NY; and Department of Clinical Neuroscience (P.R.), Centre Hospitalier Universitaire Vaudois, Lausanne, Switzerland
| | - Daniel Friedman
- From the NINDS Center for SUDEP Research (L.V., N.L., S.O., M.O.-U., S.T., M.R.S.R., R.K.S., D.F., M.N., C.S., L.A., B.K.G., J.S.H., S.S., J.O., R.M.H., B.D., L.M.B., O.D., G.B.R., P.R., G.-Q.Z., S.D.L.) and Department of Neurology (L.V., N.L., J.P.H., S.O., M.O.-U., S.T., M.R.S.R., N.J.H., J.S.H., G.-Q.Z., S.D.L.), McGovern Medical School, and Biostatistics and Epidemiology Research Design Core (L.Z., G.B.R.), Division of Clinical and Translational Sciences, University of Texas Health Science Center at Houston; Departament de Medicina (L.V.), Universitat Autonoma de Barcelona, Spain; University of Iowa Carver College of Medicine (R.K.S., B.K.G.), Iowa City; NYU Langone School of Medicine (D.F., O.D.), New York; Sidney Kimmel Medical College (M.N.), Thomas Jefferson University, Philadelphia, PA; Division of Pulmonary (K.S.), Critical Care and Sleep Medicine, University Hospitals Medical Center, Cleveland, OH; Institute of Neurology (C.S., L.A., B.D.), University College London, UK; Case Western Reserve University (N.S., X.Z., V.R.-M.), Cleveland, OH; Feinberg School of Medicine (S.S.), Northwestern University, Chicago, IL; Department of Neurobiology and the Brain Research Institute (J.O., R.M.H.), University of California, Los Angeles; Department of Neurology (L.M.B.), Columbia University, New York, NY; and Department of Clinical Neuroscience (P.R.), Centre Hospitalier Universitaire Vaudois, Lausanne, Switzerland
| | - Maromi Nei
- From the NINDS Center for SUDEP Research (L.V., N.L., S.O., M.O.-U., S.T., M.R.S.R., R.K.S., D.F., M.N., C.S., L.A., B.K.G., J.S.H., S.S., J.O., R.M.H., B.D., L.M.B., O.D., G.B.R., P.R., G.-Q.Z., S.D.L.) and Department of Neurology (L.V., N.L., J.P.H., S.O., M.O.-U., S.T., M.R.S.R., N.J.H., J.S.H., G.-Q.Z., S.D.L.), McGovern Medical School, and Biostatistics and Epidemiology Research Design Core (L.Z., G.B.R.), Division of Clinical and Translational Sciences, University of Texas Health Science Center at Houston; Departament de Medicina (L.V.), Universitat Autonoma de Barcelona, Spain; University of Iowa Carver College of Medicine (R.K.S., B.K.G.), Iowa City; NYU Langone School of Medicine (D.F., O.D.), New York; Sidney Kimmel Medical College (M.N.), Thomas Jefferson University, Philadelphia, PA; Division of Pulmonary (K.S.), Critical Care and Sleep Medicine, University Hospitals Medical Center, Cleveland, OH; Institute of Neurology (C.S., L.A., B.D.), University College London, UK; Case Western Reserve University (N.S., X.Z., V.R.-M.), Cleveland, OH; Feinberg School of Medicine (S.S.), Northwestern University, Chicago, IL; Department of Neurobiology and the Brain Research Institute (J.O., R.M.H.), University of California, Los Angeles; Department of Neurology (L.M.B.), Columbia University, New York, NY; and Department of Clinical Neuroscience (P.R.), Centre Hospitalier Universitaire Vaudois, Lausanne, Switzerland
| | - Kingman Strohl
- From the NINDS Center for SUDEP Research (L.V., N.L., S.O., M.O.-U., S.T., M.R.S.R., R.K.S., D.F., M.N., C.S., L.A., B.K.G., J.S.H., S.S., J.O., R.M.H., B.D., L.M.B., O.D., G.B.R., P.R., G.-Q.Z., S.D.L.) and Department of Neurology (L.V., N.L., J.P.H., S.O., M.O.-U., S.T., M.R.S.R., N.J.H., J.S.H., G.-Q.Z., S.D.L.), McGovern Medical School, and Biostatistics and Epidemiology Research Design Core (L.Z., G.B.R.), Division of Clinical and Translational Sciences, University of Texas Health Science Center at Houston; Departament de Medicina (L.V.), Universitat Autonoma de Barcelona, Spain; University of Iowa Carver College of Medicine (R.K.S., B.K.G.), Iowa City; NYU Langone School of Medicine (D.F., O.D.), New York; Sidney Kimmel Medical College (M.N.), Thomas Jefferson University, Philadelphia, PA; Division of Pulmonary (K.S.), Critical Care and Sleep Medicine, University Hospitals Medical Center, Cleveland, OH; Institute of Neurology (C.S., L.A., B.D.), University College London, UK; Case Western Reserve University (N.S., X.Z., V.R.-M.), Cleveland, OH; Feinberg School of Medicine (S.S.), Northwestern University, Chicago, IL; Department of Neurobiology and the Brain Research Institute (J.O., R.M.H.), University of California, Los Angeles; Department of Neurology (L.M.B.), Columbia University, New York, NY; and Department of Clinical Neuroscience (P.R.), Centre Hospitalier Universitaire Vaudois, Lausanne, Switzerland
| | - Catherine Scott
- From the NINDS Center for SUDEP Research (L.V., N.L., S.O., M.O.-U., S.T., M.R.S.R., R.K.S., D.F., M.N., C.S., L.A., B.K.G., J.S.H., S.S., J.O., R.M.H., B.D., L.M.B., O.D., G.B.R., P.R., G.-Q.Z., S.D.L.) and Department of Neurology (L.V., N.L., J.P.H., S.O., M.O.-U., S.T., M.R.S.R., N.J.H., J.S.H., G.-Q.Z., S.D.L.), McGovern Medical School, and Biostatistics and Epidemiology Research Design Core (L.Z., G.B.R.), Division of Clinical and Translational Sciences, University of Texas Health Science Center at Houston; Departament de Medicina (L.V.), Universitat Autonoma de Barcelona, Spain; University of Iowa Carver College of Medicine (R.K.S., B.K.G.), Iowa City; NYU Langone School of Medicine (D.F., O.D.), New York; Sidney Kimmel Medical College (M.N.), Thomas Jefferson University, Philadelphia, PA; Division of Pulmonary (K.S.), Critical Care and Sleep Medicine, University Hospitals Medical Center, Cleveland, OH; Institute of Neurology (C.S., L.A., B.D.), University College London, UK; Case Western Reserve University (N.S., X.Z., V.R.-M.), Cleveland, OH; Feinberg School of Medicine (S.S.), Northwestern University, Chicago, IL; Department of Neurobiology and the Brain Research Institute (J.O., R.M.H.), University of California, Los Angeles; Department of Neurology (L.M.B.), Columbia University, New York, NY; and Department of Clinical Neuroscience (P.R.), Centre Hospitalier Universitaire Vaudois, Lausanne, Switzerland
| | - Luke Allen
- From the NINDS Center for SUDEP Research (L.V., N.L., S.O., M.O.-U., S.T., M.R.S.R., R.K.S., D.F., M.N., C.S., L.A., B.K.G., J.S.H., S.S., J.O., R.M.H., B.D., L.M.B., O.D., G.B.R., P.R., G.-Q.Z., S.D.L.) and Department of Neurology (L.V., N.L., J.P.H., S.O., M.O.-U., S.T., M.R.S.R., N.J.H., J.S.H., G.-Q.Z., S.D.L.), McGovern Medical School, and Biostatistics and Epidemiology Research Design Core (L.Z., G.B.R.), Division of Clinical and Translational Sciences, University of Texas Health Science Center at Houston; Departament de Medicina (L.V.), Universitat Autonoma de Barcelona, Spain; University of Iowa Carver College of Medicine (R.K.S., B.K.G.), Iowa City; NYU Langone School of Medicine (D.F., O.D.), New York; Sidney Kimmel Medical College (M.N.), Thomas Jefferson University, Philadelphia, PA; Division of Pulmonary (K.S.), Critical Care and Sleep Medicine, University Hospitals Medical Center, Cleveland, OH; Institute of Neurology (C.S., L.A., B.D.), University College London, UK; Case Western Reserve University (N.S., X.Z., V.R.-M.), Cleveland, OH; Feinberg School of Medicine (S.S.), Northwestern University, Chicago, IL; Department of Neurobiology and the Brain Research Institute (J.O., R.M.H.), University of California, Los Angeles; Department of Neurology (L.M.B.), Columbia University, New York, NY; and Department of Clinical Neuroscience (P.R.), Centre Hospitalier Universitaire Vaudois, Lausanne, Switzerland
| | - Brian K Gehlbach
- From the NINDS Center for SUDEP Research (L.V., N.L., S.O., M.O.-U., S.T., M.R.S.R., R.K.S., D.F., M.N., C.S., L.A., B.K.G., J.S.H., S.S., J.O., R.M.H., B.D., L.M.B., O.D., G.B.R., P.R., G.-Q.Z., S.D.L.) and Department of Neurology (L.V., N.L., J.P.H., S.O., M.O.-U., S.T., M.R.S.R., N.J.H., J.S.H., G.-Q.Z., S.D.L.), McGovern Medical School, and Biostatistics and Epidemiology Research Design Core (L.Z., G.B.R.), Division of Clinical and Translational Sciences, University of Texas Health Science Center at Houston; Departament de Medicina (L.V.), Universitat Autonoma de Barcelona, Spain; University of Iowa Carver College of Medicine (R.K.S., B.K.G.), Iowa City; NYU Langone School of Medicine (D.F., O.D.), New York; Sidney Kimmel Medical College (M.N.), Thomas Jefferson University, Philadelphia, PA; Division of Pulmonary (K.S.), Critical Care and Sleep Medicine, University Hospitals Medical Center, Cleveland, OH; Institute of Neurology (C.S., L.A., B.D.), University College London, UK; Case Western Reserve University (N.S., X.Z., V.R.-M.), Cleveland, OH; Feinberg School of Medicine (S.S.), Northwestern University, Chicago, IL; Department of Neurobiology and the Brain Research Institute (J.O., R.M.H.), University of California, Los Angeles; Department of Neurology (L.M.B.), Columbia University, New York, NY; and Department of Clinical Neuroscience (P.R.), Centre Hospitalier Universitaire Vaudois, Lausanne, Switzerland
| | - Norma J Hupp
- From the NINDS Center for SUDEP Research (L.V., N.L., S.O., M.O.-U., S.T., M.R.S.R., R.K.S., D.F., M.N., C.S., L.A., B.K.G., J.S.H., S.S., J.O., R.M.H., B.D., L.M.B., O.D., G.B.R., P.R., G.-Q.Z., S.D.L.) and Department of Neurology (L.V., N.L., J.P.H., S.O., M.O.-U., S.T., M.R.S.R., N.J.H., J.S.H., G.-Q.Z., S.D.L.), McGovern Medical School, and Biostatistics and Epidemiology Research Design Core (L.Z., G.B.R.), Division of Clinical and Translational Sciences, University of Texas Health Science Center at Houston; Departament de Medicina (L.V.), Universitat Autonoma de Barcelona, Spain; University of Iowa Carver College of Medicine (R.K.S., B.K.G.), Iowa City; NYU Langone School of Medicine (D.F., O.D.), New York; Sidney Kimmel Medical College (M.N.), Thomas Jefferson University, Philadelphia, PA; Division of Pulmonary (K.S.), Critical Care and Sleep Medicine, University Hospitals Medical Center, Cleveland, OH; Institute of Neurology (C.S., L.A., B.D.), University College London, UK; Case Western Reserve University (N.S., X.Z., V.R.-M.), Cleveland, OH; Feinberg School of Medicine (S.S.), Northwestern University, Chicago, IL; Department of Neurobiology and the Brain Research Institute (J.O., R.M.H.), University of California, Los Angeles; Department of Neurology (L.M.B.), Columbia University, New York, NY; and Department of Clinical Neuroscience (P.R.), Centre Hospitalier Universitaire Vaudois, Lausanne, Switzerland
| | - Jaison S Hampson
- From the NINDS Center for SUDEP Research (L.V., N.L., S.O., M.O.-U., S.T., M.R.S.R., R.K.S., D.F., M.N., C.S., L.A., B.K.G., J.S.H., S.S., J.O., R.M.H., B.D., L.M.B., O.D., G.B.R., P.R., G.-Q.Z., S.D.L.) and Department of Neurology (L.V., N.L., J.P.H., S.O., M.O.-U., S.T., M.R.S.R., N.J.H., J.S.H., G.-Q.Z., S.D.L.), McGovern Medical School, and Biostatistics and Epidemiology Research Design Core (L.Z., G.B.R.), Division of Clinical and Translational Sciences, University of Texas Health Science Center at Houston; Departament de Medicina (L.V.), Universitat Autonoma de Barcelona, Spain; University of Iowa Carver College of Medicine (R.K.S., B.K.G.), Iowa City; NYU Langone School of Medicine (D.F., O.D.), New York; Sidney Kimmel Medical College (M.N.), Thomas Jefferson University, Philadelphia, PA; Division of Pulmonary (K.S.), Critical Care and Sleep Medicine, University Hospitals Medical Center, Cleveland, OH; Institute of Neurology (C.S., L.A., B.D.), University College London, UK; Case Western Reserve University (N.S., X.Z., V.R.-M.), Cleveland, OH; Feinberg School of Medicine (S.S.), Northwestern University, Chicago, IL; Department of Neurobiology and the Brain Research Institute (J.O., R.M.H.), University of California, Los Angeles; Department of Neurology (L.M.B.), Columbia University, New York, NY; and Department of Clinical Neuroscience (P.R.), Centre Hospitalier Universitaire Vaudois, Lausanne, Switzerland
| | - Nassim Shafiabadi
- From the NINDS Center for SUDEP Research (L.V., N.L., S.O., M.O.-U., S.T., M.R.S.R., R.K.S., D.F., M.N., C.S., L.A., B.K.G., J.S.H., S.S., J.O., R.M.H., B.D., L.M.B., O.D., G.B.R., P.R., G.-Q.Z., S.D.L.) and Department of Neurology (L.V., N.L., J.P.H., S.O., M.O.-U., S.T., M.R.S.R., N.J.H., J.S.H., G.-Q.Z., S.D.L.), McGovern Medical School, and Biostatistics and Epidemiology Research Design Core (L.Z., G.B.R.), Division of Clinical and Translational Sciences, University of Texas Health Science Center at Houston; Departament de Medicina (L.V.), Universitat Autonoma de Barcelona, Spain; University of Iowa Carver College of Medicine (R.K.S., B.K.G.), Iowa City; NYU Langone School of Medicine (D.F., O.D.), New York; Sidney Kimmel Medical College (M.N.), Thomas Jefferson University, Philadelphia, PA; Division of Pulmonary (K.S.), Critical Care and Sleep Medicine, University Hospitals Medical Center, Cleveland, OH; Institute of Neurology (C.S., L.A., B.D.), University College London, UK; Case Western Reserve University (N.S., X.Z., V.R.-M.), Cleveland, OH; Feinberg School of Medicine (S.S.), Northwestern University, Chicago, IL; Department of Neurobiology and the Brain Research Institute (J.O., R.M.H.), University of California, Los Angeles; Department of Neurology (L.M.B.), Columbia University, New York, NY; and Department of Clinical Neuroscience (P.R.), Centre Hospitalier Universitaire Vaudois, Lausanne, Switzerland
| | - Xiuhe Zhao
- From the NINDS Center for SUDEP Research (L.V., N.L., S.O., M.O.-U., S.T., M.R.S.R., R.K.S., D.F., M.N., C.S., L.A., B.K.G., J.S.H., S.S., J.O., R.M.H., B.D., L.M.B., O.D., G.B.R., P.R., G.-Q.Z., S.D.L.) and Department of Neurology (L.V., N.L., J.P.H., S.O., M.O.-U., S.T., M.R.S.R., N.J.H., J.S.H., G.-Q.Z., S.D.L.), McGovern Medical School, and Biostatistics and Epidemiology Research Design Core (L.Z., G.B.R.), Division of Clinical and Translational Sciences, University of Texas Health Science Center at Houston; Departament de Medicina (L.V.), Universitat Autonoma de Barcelona, Spain; University of Iowa Carver College of Medicine (R.K.S., B.K.G.), Iowa City; NYU Langone School of Medicine (D.F., O.D.), New York; Sidney Kimmel Medical College (M.N.), Thomas Jefferson University, Philadelphia, PA; Division of Pulmonary (K.S.), Critical Care and Sleep Medicine, University Hospitals Medical Center, Cleveland, OH; Institute of Neurology (C.S., L.A., B.D.), University College London, UK; Case Western Reserve University (N.S., X.Z., V.R.-M.), Cleveland, OH; Feinberg School of Medicine (S.S.), Northwestern University, Chicago, IL; Department of Neurobiology and the Brain Research Institute (J.O., R.M.H.), University of California, Los Angeles; Department of Neurology (L.M.B.), Columbia University, New York, NY; and Department of Clinical Neuroscience (P.R.), Centre Hospitalier Universitaire Vaudois, Lausanne, Switzerland
| | - Victoria Reick-Mitrisin
- From the NINDS Center for SUDEP Research (L.V., N.L., S.O., M.O.-U., S.T., M.R.S.R., R.K.S., D.F., M.N., C.S., L.A., B.K.G., J.S.H., S.S., J.O., R.M.H., B.D., L.M.B., O.D., G.B.R., P.R., G.-Q.Z., S.D.L.) and Department of Neurology (L.V., N.L., J.P.H., S.O., M.O.-U., S.T., M.R.S.R., N.J.H., J.S.H., G.-Q.Z., S.D.L.), McGovern Medical School, and Biostatistics and Epidemiology Research Design Core (L.Z., G.B.R.), Division of Clinical and Translational Sciences, University of Texas Health Science Center at Houston; Departament de Medicina (L.V.), Universitat Autonoma de Barcelona, Spain; University of Iowa Carver College of Medicine (R.K.S., B.K.G.), Iowa City; NYU Langone School of Medicine (D.F., O.D.), New York; Sidney Kimmel Medical College (M.N.), Thomas Jefferson University, Philadelphia, PA; Division of Pulmonary (K.S.), Critical Care and Sleep Medicine, University Hospitals Medical Center, Cleveland, OH; Institute of Neurology (C.S., L.A., B.D.), University College London, UK; Case Western Reserve University (N.S., X.Z., V.R.-M.), Cleveland, OH; Feinberg School of Medicine (S.S.), Northwestern University, Chicago, IL; Department of Neurobiology and the Brain Research Institute (J.O., R.M.H.), University of California, Los Angeles; Department of Neurology (L.M.B.), Columbia University, New York, NY; and Department of Clinical Neuroscience (P.R.), Centre Hospitalier Universitaire Vaudois, Lausanne, Switzerland
| | - Stephan Schuele
- From the NINDS Center for SUDEP Research (L.V., N.L., S.O., M.O.-U., S.T., M.R.S.R., R.K.S., D.F., M.N., C.S., L.A., B.K.G., J.S.H., S.S., J.O., R.M.H., B.D., L.M.B., O.D., G.B.R., P.R., G.-Q.Z., S.D.L.) and Department of Neurology (L.V., N.L., J.P.H., S.O., M.O.-U., S.T., M.R.S.R., N.J.H., J.S.H., G.-Q.Z., S.D.L.), McGovern Medical School, and Biostatistics and Epidemiology Research Design Core (L.Z., G.B.R.), Division of Clinical and Translational Sciences, University of Texas Health Science Center at Houston; Departament de Medicina (L.V.), Universitat Autonoma de Barcelona, Spain; University of Iowa Carver College of Medicine (R.K.S., B.K.G.), Iowa City; NYU Langone School of Medicine (D.F., O.D.), New York; Sidney Kimmel Medical College (M.N.), Thomas Jefferson University, Philadelphia, PA; Division of Pulmonary (K.S.), Critical Care and Sleep Medicine, University Hospitals Medical Center, Cleveland, OH; Institute of Neurology (C.S., L.A., B.D.), University College London, UK; Case Western Reserve University (N.S., X.Z., V.R.-M.), Cleveland, OH; Feinberg School of Medicine (S.S.), Northwestern University, Chicago, IL; Department of Neurobiology and the Brain Research Institute (J.O., R.M.H.), University of California, Los Angeles; Department of Neurology (L.M.B.), Columbia University, New York, NY; and Department of Clinical Neuroscience (P.R.), Centre Hospitalier Universitaire Vaudois, Lausanne, Switzerland
| | - Jennifer Ogren
- From the NINDS Center for SUDEP Research (L.V., N.L., S.O., M.O.-U., S.T., M.R.S.R., R.K.S., D.F., M.N., C.S., L.A., B.K.G., J.S.H., S.S., J.O., R.M.H., B.D., L.M.B., O.D., G.B.R., P.R., G.-Q.Z., S.D.L.) and Department of Neurology (L.V., N.L., J.P.H., S.O., M.O.-U., S.T., M.R.S.R., N.J.H., J.S.H., G.-Q.Z., S.D.L.), McGovern Medical School, and Biostatistics and Epidemiology Research Design Core (L.Z., G.B.R.), Division of Clinical and Translational Sciences, University of Texas Health Science Center at Houston; Departament de Medicina (L.V.), Universitat Autonoma de Barcelona, Spain; University of Iowa Carver College of Medicine (R.K.S., B.K.G.), Iowa City; NYU Langone School of Medicine (D.F., O.D.), New York; Sidney Kimmel Medical College (M.N.), Thomas Jefferson University, Philadelphia, PA; Division of Pulmonary (K.S.), Critical Care and Sleep Medicine, University Hospitals Medical Center, Cleveland, OH; Institute of Neurology (C.S., L.A., B.D.), University College London, UK; Case Western Reserve University (N.S., X.Z., V.R.-M.), Cleveland, OH; Feinberg School of Medicine (S.S.), Northwestern University, Chicago, IL; Department of Neurobiology and the Brain Research Institute (J.O., R.M.H.), University of California, Los Angeles; Department of Neurology (L.M.B.), Columbia University, New York, NY; and Department of Clinical Neuroscience (P.R.), Centre Hospitalier Universitaire Vaudois, Lausanne, Switzerland
| | - Ronald M Harper
- From the NINDS Center for SUDEP Research (L.V., N.L., S.O., M.O.-U., S.T., M.R.S.R., R.K.S., D.F., M.N., C.S., L.A., B.K.G., J.S.H., S.S., J.O., R.M.H., B.D., L.M.B., O.D., G.B.R., P.R., G.-Q.Z., S.D.L.) and Department of Neurology (L.V., N.L., J.P.H., S.O., M.O.-U., S.T., M.R.S.R., N.J.H., J.S.H., G.-Q.Z., S.D.L.), McGovern Medical School, and Biostatistics and Epidemiology Research Design Core (L.Z., G.B.R.), Division of Clinical and Translational Sciences, University of Texas Health Science Center at Houston; Departament de Medicina (L.V.), Universitat Autonoma de Barcelona, Spain; University of Iowa Carver College of Medicine (R.K.S., B.K.G.), Iowa City; NYU Langone School of Medicine (D.F., O.D.), New York; Sidney Kimmel Medical College (M.N.), Thomas Jefferson University, Philadelphia, PA; Division of Pulmonary (K.S.), Critical Care and Sleep Medicine, University Hospitals Medical Center, Cleveland, OH; Institute of Neurology (C.S., L.A., B.D.), University College London, UK; Case Western Reserve University (N.S., X.Z., V.R.-M.), Cleveland, OH; Feinberg School of Medicine (S.S.), Northwestern University, Chicago, IL; Department of Neurobiology and the Brain Research Institute (J.O., R.M.H.), University of California, Los Angeles; Department of Neurology (L.M.B.), Columbia University, New York, NY; and Department of Clinical Neuroscience (P.R.), Centre Hospitalier Universitaire Vaudois, Lausanne, Switzerland
| | - Beate Diehl
- From the NINDS Center for SUDEP Research (L.V., N.L., S.O., M.O.-U., S.T., M.R.S.R., R.K.S., D.F., M.N., C.S., L.A., B.K.G., J.S.H., S.S., J.O., R.M.H., B.D., L.M.B., O.D., G.B.R., P.R., G.-Q.Z., S.D.L.) and Department of Neurology (L.V., N.L., J.P.H., S.O., M.O.-U., S.T., M.R.S.R., N.J.H., J.S.H., G.-Q.Z., S.D.L.), McGovern Medical School, and Biostatistics and Epidemiology Research Design Core (L.Z., G.B.R.), Division of Clinical and Translational Sciences, University of Texas Health Science Center at Houston; Departament de Medicina (L.V.), Universitat Autonoma de Barcelona, Spain; University of Iowa Carver College of Medicine (R.K.S., B.K.G.), Iowa City; NYU Langone School of Medicine (D.F., O.D.), New York; Sidney Kimmel Medical College (M.N.), Thomas Jefferson University, Philadelphia, PA; Division of Pulmonary (K.S.), Critical Care and Sleep Medicine, University Hospitals Medical Center, Cleveland, OH; Institute of Neurology (C.S., L.A., B.D.), University College London, UK; Case Western Reserve University (N.S., X.Z., V.R.-M.), Cleveland, OH; Feinberg School of Medicine (S.S.), Northwestern University, Chicago, IL; Department of Neurobiology and the Brain Research Institute (J.O., R.M.H.), University of California, Los Angeles; Department of Neurology (L.M.B.), Columbia University, New York, NY; and Department of Clinical Neuroscience (P.R.), Centre Hospitalier Universitaire Vaudois, Lausanne, Switzerland
| | - Lisa M Bateman
- From the NINDS Center for SUDEP Research (L.V., N.L., S.O., M.O.-U., S.T., M.R.S.R., R.K.S., D.F., M.N., C.S., L.A., B.K.G., J.S.H., S.S., J.O., R.M.H., B.D., L.M.B., O.D., G.B.R., P.R., G.-Q.Z., S.D.L.) and Department of Neurology (L.V., N.L., J.P.H., S.O., M.O.-U., S.T., M.R.S.R., N.J.H., J.S.H., G.-Q.Z., S.D.L.), McGovern Medical School, and Biostatistics and Epidemiology Research Design Core (L.Z., G.B.R.), Division of Clinical and Translational Sciences, University of Texas Health Science Center at Houston; Departament de Medicina (L.V.), Universitat Autonoma de Barcelona, Spain; University of Iowa Carver College of Medicine (R.K.S., B.K.G.), Iowa City; NYU Langone School of Medicine (D.F., O.D.), New York; Sidney Kimmel Medical College (M.N.), Thomas Jefferson University, Philadelphia, PA; Division of Pulmonary (K.S.), Critical Care and Sleep Medicine, University Hospitals Medical Center, Cleveland, OH; Institute of Neurology (C.S., L.A., B.D.), University College London, UK; Case Western Reserve University (N.S., X.Z., V.R.-M.), Cleveland, OH; Feinberg School of Medicine (S.S.), Northwestern University, Chicago, IL; Department of Neurobiology and the Brain Research Institute (J.O., R.M.H.), University of California, Los Angeles; Department of Neurology (L.M.B.), Columbia University, New York, NY; and Department of Clinical Neuroscience (P.R.), Centre Hospitalier Universitaire Vaudois, Lausanne, Switzerland
| | - Orrin Devinsky
- From the NINDS Center for SUDEP Research (L.V., N.L., S.O., M.O.-U., S.T., M.R.S.R., R.K.S., D.F., M.N., C.S., L.A., B.K.G., J.S.H., S.S., J.O., R.M.H., B.D., L.M.B., O.D., G.B.R., P.R., G.-Q.Z., S.D.L.) and Department of Neurology (L.V., N.L., J.P.H., S.O., M.O.-U., S.T., M.R.S.R., N.J.H., J.S.H., G.-Q.Z., S.D.L.), McGovern Medical School, and Biostatistics and Epidemiology Research Design Core (L.Z., G.B.R.), Division of Clinical and Translational Sciences, University of Texas Health Science Center at Houston; Departament de Medicina (L.V.), Universitat Autonoma de Barcelona, Spain; University of Iowa Carver College of Medicine (R.K.S., B.K.G.), Iowa City; NYU Langone School of Medicine (D.F., O.D.), New York; Sidney Kimmel Medical College (M.N.), Thomas Jefferson University, Philadelphia, PA; Division of Pulmonary (K.S.), Critical Care and Sleep Medicine, University Hospitals Medical Center, Cleveland, OH; Institute of Neurology (C.S., L.A., B.D.), University College London, UK; Case Western Reserve University (N.S., X.Z., V.R.-M.), Cleveland, OH; Feinberg School of Medicine (S.S.), Northwestern University, Chicago, IL; Department of Neurobiology and the Brain Research Institute (J.O., R.M.H.), University of California, Los Angeles; Department of Neurology (L.M.B.), Columbia University, New York, NY; and Department of Clinical Neuroscience (P.R.), Centre Hospitalier Universitaire Vaudois, Lausanne, Switzerland
| | - George B Richerson
- From the NINDS Center for SUDEP Research (L.V., N.L., S.O., M.O.-U., S.T., M.R.S.R., R.K.S., D.F., M.N., C.S., L.A., B.K.G., J.S.H., S.S., J.O., R.M.H., B.D., L.M.B., O.D., G.B.R., P.R., G.-Q.Z., S.D.L.) and Department of Neurology (L.V., N.L., J.P.H., S.O., M.O.-U., S.T., M.R.S.R., N.J.H., J.S.H., G.-Q.Z., S.D.L.), McGovern Medical School, and Biostatistics and Epidemiology Research Design Core (L.Z., G.B.R.), Division of Clinical and Translational Sciences, University of Texas Health Science Center at Houston; Departament de Medicina (L.V.), Universitat Autonoma de Barcelona, Spain; University of Iowa Carver College of Medicine (R.K.S., B.K.G.), Iowa City; NYU Langone School of Medicine (D.F., O.D.), New York; Sidney Kimmel Medical College (M.N.), Thomas Jefferson University, Philadelphia, PA; Division of Pulmonary (K.S.), Critical Care and Sleep Medicine, University Hospitals Medical Center, Cleveland, OH; Institute of Neurology (C.S., L.A., B.D.), University College London, UK; Case Western Reserve University (N.S., X.Z., V.R.-M.), Cleveland, OH; Feinberg School of Medicine (S.S.), Northwestern University, Chicago, IL; Department of Neurobiology and the Brain Research Institute (J.O., R.M.H.), University of California, Los Angeles; Department of Neurology (L.M.B.), Columbia University, New York, NY; and Department of Clinical Neuroscience (P.R.), Centre Hospitalier Universitaire Vaudois, Lausanne, Switzerland
| | - Philippe Ryvlin
- From the NINDS Center for SUDEP Research (L.V., N.L., S.O., M.O.-U., S.T., M.R.S.R., R.K.S., D.F., M.N., C.S., L.A., B.K.G., J.S.H., S.S., J.O., R.M.H., B.D., L.M.B., O.D., G.B.R., P.R., G.-Q.Z., S.D.L.) and Department of Neurology (L.V., N.L., J.P.H., S.O., M.O.-U., S.T., M.R.S.R., N.J.H., J.S.H., G.-Q.Z., S.D.L.), McGovern Medical School, and Biostatistics and Epidemiology Research Design Core (L.Z., G.B.R.), Division of Clinical and Translational Sciences, University of Texas Health Science Center at Houston; Departament de Medicina (L.V.), Universitat Autonoma de Barcelona, Spain; University of Iowa Carver College of Medicine (R.K.S., B.K.G.), Iowa City; NYU Langone School of Medicine (D.F., O.D.), New York; Sidney Kimmel Medical College (M.N.), Thomas Jefferson University, Philadelphia, PA; Division of Pulmonary (K.S.), Critical Care and Sleep Medicine, University Hospitals Medical Center, Cleveland, OH; Institute of Neurology (C.S., L.A., B.D.), University College London, UK; Case Western Reserve University (N.S., X.Z., V.R.-M.), Cleveland, OH; Feinberg School of Medicine (S.S.), Northwestern University, Chicago, IL; Department of Neurobiology and the Brain Research Institute (J.O., R.M.H.), University of California, Los Angeles; Department of Neurology (L.M.B.), Columbia University, New York, NY; and Department of Clinical Neuroscience (P.R.), Centre Hospitalier Universitaire Vaudois, Lausanne, Switzerland
| | - Guo-Qiang Zhang
- From the NINDS Center for SUDEP Research (L.V., N.L., S.O., M.O.-U., S.T., M.R.S.R., R.K.S., D.F., M.N., C.S., L.A., B.K.G., J.S.H., S.S., J.O., R.M.H., B.D., L.M.B., O.D., G.B.R., P.R., G.-Q.Z., S.D.L.) and Department of Neurology (L.V., N.L., J.P.H., S.O., M.O.-U., S.T., M.R.S.R., N.J.H., J.S.H., G.-Q.Z., S.D.L.), McGovern Medical School, and Biostatistics and Epidemiology Research Design Core (L.Z., G.B.R.), Division of Clinical and Translational Sciences, University of Texas Health Science Center at Houston; Departament de Medicina (L.V.), Universitat Autonoma de Barcelona, Spain; University of Iowa Carver College of Medicine (R.K.S., B.K.G.), Iowa City; NYU Langone School of Medicine (D.F., O.D.), New York; Sidney Kimmel Medical College (M.N.), Thomas Jefferson University, Philadelphia, PA; Division of Pulmonary (K.S.), Critical Care and Sleep Medicine, University Hospitals Medical Center, Cleveland, OH; Institute of Neurology (C.S., L.A., B.D.), University College London, UK; Case Western Reserve University (N.S., X.Z., V.R.-M.), Cleveland, OH; Feinberg School of Medicine (S.S.), Northwestern University, Chicago, IL; Department of Neurobiology and the Brain Research Institute (J.O., R.M.H.), University of California, Los Angeles; Department of Neurology (L.M.B.), Columbia University, New York, NY; and Department of Clinical Neuroscience (P.R.), Centre Hospitalier Universitaire Vaudois, Lausanne, Switzerland
| | - Samden D Lhatoo
- From the NINDS Center for SUDEP Research (L.V., N.L., S.O., M.O.-U., S.T., M.R.S.R., R.K.S., D.F., M.N., C.S., L.A., B.K.G., J.S.H., S.S., J.O., R.M.H., B.D., L.M.B., O.D., G.B.R., P.R., G.-Q.Z., S.D.L.) and Department of Neurology (L.V., N.L., J.P.H., S.O., M.O.-U., S.T., M.R.S.R., N.J.H., J.S.H., G.-Q.Z., S.D.L.), McGovern Medical School, and Biostatistics and Epidemiology Research Design Core (L.Z., G.B.R.), Division of Clinical and Translational Sciences, University of Texas Health Science Center at Houston; Departament de Medicina (L.V.), Universitat Autonoma de Barcelona, Spain; University of Iowa Carver College of Medicine (R.K.S., B.K.G.), Iowa City; NYU Langone School of Medicine (D.F., O.D.), New York; Sidney Kimmel Medical College (M.N.), Thomas Jefferson University, Philadelphia, PA; Division of Pulmonary (K.S.), Critical Care and Sleep Medicine, University Hospitals Medical Center, Cleveland, OH; Institute of Neurology (C.S., L.A., B.D.), University College London, UK; Case Western Reserve University (N.S., X.Z., V.R.-M.), Cleveland, OH; Feinberg School of Medicine (S.S.), Northwestern University, Chicago, IL; Department of Neurobiology and the Brain Research Institute (J.O., R.M.H.), University of California, Los Angeles; Department of Neurology (L.M.B.), Columbia University, New York, NY; and Department of Clinical Neuroscience (P.R.), Centre Hospitalier Universitaire Vaudois, Lausanne, Switzerland
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Lacuey N, Hampson JP, Theeranaew W, Zonjy B, Vithala A, Hupp NJ, Loparo KA, Miller JP, Lhatoo SD. Cortical Structures Associated With Human Blood Pressure Control. JAMA Neurol 2019; 75:194-202. [PMID: 29181526 DOI: 10.1001/jamaneurol.2017.3344] [Citation(s) in RCA: 48] [Impact Index Per Article: 9.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
Importance A better understanding of the role of cortical structures in blood pressure control may help us understand cardiovascular collapse that may lead to sudden unexpected death in epilepsy (SUDEP). Objective To identify cortical control sites for human blood pressure regulation. Design, Setting, and Participants Patients with intractable epilepsy undergoing intracranial electrode implantation as a prelude to epilepsy surgery in the Epilepsy Monitoring Unit at University Hospitals Cleveland Medical Center were potential candidates for this study. Inclusion criteria were patients 18 years or older who had electrodes implanted in one or more of the regions of interest and in whom deep brain electrical stimulation was indicated for mapping of ictal onset or eloquent cortex as a part of the presurgical evaluation. Twelve consecutive patients were included in this prospective case series from June 1, 2015, to February 28, 2017. Main Outcomes and Measures Changes in continuous, noninvasive, beat-by-beat blood pressure parameter responses from amygdala, hippocampal, insular, orbitofrontal, temporal, cingulate, and subcallosal stimulation. Electrocardiogram, arterial oxygen saturation, end-tidal carbon dioxide, nasal airflow, and abdominal and thoracic plethysmography were monitored. Results Among 12 patients (7 female; mean [SD] age, 44.25 [12.55] years), 9 electrodes (7 left and 2 right) all in Brodmann area 25 (subcallosal neocortex) in 4 patients produced striking systolic hypotensive changes. Well-maintained diastolic arterial blood pressure and narrowed pulse pressure indicated stimulation-induced reduction in sympathetic drive and consequent probable reduction in cardiac output rather than bradycardia or peripheral vasodilation-induced hypotension. Frequency-domain analysis of heart rate and blood pressure variability showed a mixed picture. No other stimulated structure produced significant blood pressure changes. Conclusions and Relevance These findings suggest that Brodmann area 25 has a role in lowering systolic blood pressure in humans. It is a potential symptomatogenic zone for peri-ictal hypotension in patients with epilepsy.
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Affiliation(s)
- Nuria Lacuey
- Epilepsy Center, University Hospitals Cleveland Medical Center, Cleveland, Ohio
| | - Johnson P Hampson
- Epilepsy Center, University Hospitals Cleveland Medical Center, Cleveland, Ohio
| | - Wanchat Theeranaew
- The Center for SUDEP Research, National Institute of Neurological Disorders and Stroke, Cleveland, Ohio.,Department of Electrical Engineering and Computer Sciences, Case School of Engineering, Case Western Reserve University, Cleveland, Ohio
| | - Bilal Zonjy
- The Center for SUDEP Research, National Institute of Neurological Disorders and Stroke, Cleveland, Ohio
| | - Ajay Vithala
- Epilepsy Center, University Hospitals Cleveland Medical Center, Cleveland, Ohio
| | - Norma J Hupp
- Epilepsy Center, University Hospitals Cleveland Medical Center, Cleveland, Ohio
| | - Kenneth A Loparo
- The Center for SUDEP Research, National Institute of Neurological Disorders and Stroke, Cleveland, Ohio.,Department of Electrical Engineering and Computer Sciences, Case School of Engineering, Case Western Reserve University, Cleveland, Ohio
| | - Jonathan P Miller
- Epilepsy Center, University Hospitals Cleveland Medical Center, Cleveland, Ohio
| | - Samden D Lhatoo
- Epilepsy Center, University Hospitals Cleveland Medical Center, Cleveland, Ohio.,The Center for SUDEP Research, National Institute of Neurological Disorders and Stroke, Cleveland, Ohio
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11
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Murugesan A, Rani MRS, Vilella L, Lacuey N, Hampson JP, Faingold CL, Friedman D, Devinsky O, Sainju RK, Schuele S, Diehl B, Nei M, Harper RM, Bateman LM, Richerson G, Lhatoo SD. Postictal serotonin levels are associated with peri-ictal apnea. Neurology 2019; 93:e1485-e1494. [PMID: 31484709 DOI: 10.1212/wnl.0000000000008244] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/27/2018] [Accepted: 05/15/2019] [Indexed: 12/15/2022] Open
Abstract
OBJECTIVE To determine the relationship between serum serotonin (5-HT) levels, ictal central apnea (ICA), and postconvulsive central apnea (PCCA) in epileptic seizures. METHODS We prospectively evaluated video EEG, plethysmography, capillary oxygen saturation (SpO2), and ECG for 49 patients (49 seizures) enrolled in a multicenter study of sudden unexpected death in epilepsy (SUDEP). Postictal and interictal venous blood samples were collected after a clinical seizure for measurement of serum 5-HT levels. Seizures were classified according to the International League Against Epilepsy 2017 seizure classification. We analyzed seizures with and without ICA (n = 49) and generalized convulsive seizures (GCS) with and without PCCA (n = 27). RESULTS Postictal serum 5-HT levels were increased over interictal levels for seizures without ICA (p = 0.01), compared to seizures with ICA (p = 0.21). In patients with GCS without PCCA, serum 5-HT levels were increased postictally compared to interictal levels (p < 0.001), but not in patients with seizures with PCCA (p = 0.22). Postictal minus interictal 5-HT levels also differed between the 2 groups with and without PCCA (p = 0.03). Increased heart rate was accompanied by increased serum 5-HT levels (postictal minus interictal) after seizures without PCCA (p = 0.03) compared to those with PCCA (p = 0.42). CONCLUSIONS The data suggest that significant seizure-related increases in serum 5-HT levels are associated with a lower incidence of seizure-related breathing dysfunction, and may reflect physiologic changes that confer a protective effect against deleterious phenomena leading to SUDEP. These results need to be confirmed with a larger sample size study.
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Affiliation(s)
- Arun Murugesan
- From the Department of Neurology (A.M.), Case Western Reserve University; Department of Neurology (M.R.S.R., L.V., N.L., J.P.H., S.D.L.), McGovern Medical School, University of Texas Health Science Center at Houston; Department of Pharmacology and Neurology (C.L.F.), Southern Illinois University School of Medicine, Springfield; Department of Neurology (D.F., O.D.), New York University School of Medicine, New York; Department of Neurology (R.K.S., G.R.), University of Iowa Carver College of Medicine, Iowa City; Department of Neurology (S.S.), Northwestern University Feinberg School of Medicine, Chicago, IL; Institute of Neurology (B.D.), University College London, UK; Department of Neurology (M.N.), Sidney Kimmel Medical College at Thomas Jefferson University, Philadelphia, PA; Department of Neurobiology (R.M.H.), David Geffen School of Medicine at UCLA, Los Angeles, CA; Department of Neurology (L.M.B.), Columbia University Medical Center, New York, NY; and Center for SUDEP Research (M.R.S.R., L.V., N.L., D.F., O.D., R.K.S., S.S., B.D., M.N., R.M.H., L.M.B., G.R., S.D.L.), National Institute for Neurological Disorders and Stroke, Bethesda, MD
| | - M R Sandhya Rani
- From the Department of Neurology (A.M.), Case Western Reserve University; Department of Neurology (M.R.S.R., L.V., N.L., J.P.H., S.D.L.), McGovern Medical School, University of Texas Health Science Center at Houston; Department of Pharmacology and Neurology (C.L.F.), Southern Illinois University School of Medicine, Springfield; Department of Neurology (D.F., O.D.), New York University School of Medicine, New York; Department of Neurology (R.K.S., G.R.), University of Iowa Carver College of Medicine, Iowa City; Department of Neurology (S.S.), Northwestern University Feinberg School of Medicine, Chicago, IL; Institute of Neurology (B.D.), University College London, UK; Department of Neurology (M.N.), Sidney Kimmel Medical College at Thomas Jefferson University, Philadelphia, PA; Department of Neurobiology (R.M.H.), David Geffen School of Medicine at UCLA, Los Angeles, CA; Department of Neurology (L.M.B.), Columbia University Medical Center, New York, NY; and Center for SUDEP Research (M.R.S.R., L.V., N.L., D.F., O.D., R.K.S., S.S., B.D., M.N., R.M.H., L.M.B., G.R., S.D.L.), National Institute for Neurological Disorders and Stroke, Bethesda, MD.
| | - Laura Vilella
- From the Department of Neurology (A.M.), Case Western Reserve University; Department of Neurology (M.R.S.R., L.V., N.L., J.P.H., S.D.L.), McGovern Medical School, University of Texas Health Science Center at Houston; Department of Pharmacology and Neurology (C.L.F.), Southern Illinois University School of Medicine, Springfield; Department of Neurology (D.F., O.D.), New York University School of Medicine, New York; Department of Neurology (R.K.S., G.R.), University of Iowa Carver College of Medicine, Iowa City; Department of Neurology (S.S.), Northwestern University Feinberg School of Medicine, Chicago, IL; Institute of Neurology (B.D.), University College London, UK; Department of Neurology (M.N.), Sidney Kimmel Medical College at Thomas Jefferson University, Philadelphia, PA; Department of Neurobiology (R.M.H.), David Geffen School of Medicine at UCLA, Los Angeles, CA; Department of Neurology (L.M.B.), Columbia University Medical Center, New York, NY; and Center for SUDEP Research (M.R.S.R., L.V., N.L., D.F., O.D., R.K.S., S.S., B.D., M.N., R.M.H., L.M.B., G.R., S.D.L.), National Institute for Neurological Disorders and Stroke, Bethesda, MD
| | - Nuria Lacuey
- From the Department of Neurology (A.M.), Case Western Reserve University; Department of Neurology (M.R.S.R., L.V., N.L., J.P.H., S.D.L.), McGovern Medical School, University of Texas Health Science Center at Houston; Department of Pharmacology and Neurology (C.L.F.), Southern Illinois University School of Medicine, Springfield; Department of Neurology (D.F., O.D.), New York University School of Medicine, New York; Department of Neurology (R.K.S., G.R.), University of Iowa Carver College of Medicine, Iowa City; Department of Neurology (S.S.), Northwestern University Feinberg School of Medicine, Chicago, IL; Institute of Neurology (B.D.), University College London, UK; Department of Neurology (M.N.), Sidney Kimmel Medical College at Thomas Jefferson University, Philadelphia, PA; Department of Neurobiology (R.M.H.), David Geffen School of Medicine at UCLA, Los Angeles, CA; Department of Neurology (L.M.B.), Columbia University Medical Center, New York, NY; and Center for SUDEP Research (M.R.S.R., L.V., N.L., D.F., O.D., R.K.S., S.S., B.D., M.N., R.M.H., L.M.B., G.R., S.D.L.), National Institute for Neurological Disorders and Stroke, Bethesda, MD
| | - Johnson P Hampson
- From the Department of Neurology (A.M.), Case Western Reserve University; Department of Neurology (M.R.S.R., L.V., N.L., J.P.H., S.D.L.), McGovern Medical School, University of Texas Health Science Center at Houston; Department of Pharmacology and Neurology (C.L.F.), Southern Illinois University School of Medicine, Springfield; Department of Neurology (D.F., O.D.), New York University School of Medicine, New York; Department of Neurology (R.K.S., G.R.), University of Iowa Carver College of Medicine, Iowa City; Department of Neurology (S.S.), Northwestern University Feinberg School of Medicine, Chicago, IL; Institute of Neurology (B.D.), University College London, UK; Department of Neurology (M.N.), Sidney Kimmel Medical College at Thomas Jefferson University, Philadelphia, PA; Department of Neurobiology (R.M.H.), David Geffen School of Medicine at UCLA, Los Angeles, CA; Department of Neurology (L.M.B.), Columbia University Medical Center, New York, NY; and Center for SUDEP Research (M.R.S.R., L.V., N.L., D.F., O.D., R.K.S., S.S., B.D., M.N., R.M.H., L.M.B., G.R., S.D.L.), National Institute for Neurological Disorders and Stroke, Bethesda, MD
| | - Carl L Faingold
- From the Department of Neurology (A.M.), Case Western Reserve University; Department of Neurology (M.R.S.R., L.V., N.L., J.P.H., S.D.L.), McGovern Medical School, University of Texas Health Science Center at Houston; Department of Pharmacology and Neurology (C.L.F.), Southern Illinois University School of Medicine, Springfield; Department of Neurology (D.F., O.D.), New York University School of Medicine, New York; Department of Neurology (R.K.S., G.R.), University of Iowa Carver College of Medicine, Iowa City; Department of Neurology (S.S.), Northwestern University Feinberg School of Medicine, Chicago, IL; Institute of Neurology (B.D.), University College London, UK; Department of Neurology (M.N.), Sidney Kimmel Medical College at Thomas Jefferson University, Philadelphia, PA; Department of Neurobiology (R.M.H.), David Geffen School of Medicine at UCLA, Los Angeles, CA; Department of Neurology (L.M.B.), Columbia University Medical Center, New York, NY; and Center for SUDEP Research (M.R.S.R., L.V., N.L., D.F., O.D., R.K.S., S.S., B.D., M.N., R.M.H., L.M.B., G.R., S.D.L.), National Institute for Neurological Disorders and Stroke, Bethesda, MD
| | - Daniel Friedman
- From the Department of Neurology (A.M.), Case Western Reserve University; Department of Neurology (M.R.S.R., L.V., N.L., J.P.H., S.D.L.), McGovern Medical School, University of Texas Health Science Center at Houston; Department of Pharmacology and Neurology (C.L.F.), Southern Illinois University School of Medicine, Springfield; Department of Neurology (D.F., O.D.), New York University School of Medicine, New York; Department of Neurology (R.K.S., G.R.), University of Iowa Carver College of Medicine, Iowa City; Department of Neurology (S.S.), Northwestern University Feinberg School of Medicine, Chicago, IL; Institute of Neurology (B.D.), University College London, UK; Department of Neurology (M.N.), Sidney Kimmel Medical College at Thomas Jefferson University, Philadelphia, PA; Department of Neurobiology (R.M.H.), David Geffen School of Medicine at UCLA, Los Angeles, CA; Department of Neurology (L.M.B.), Columbia University Medical Center, New York, NY; and Center for SUDEP Research (M.R.S.R., L.V., N.L., D.F., O.D., R.K.S., S.S., B.D., M.N., R.M.H., L.M.B., G.R., S.D.L.), National Institute for Neurological Disorders and Stroke, Bethesda, MD
| | - Orrin Devinsky
- From the Department of Neurology (A.M.), Case Western Reserve University; Department of Neurology (M.R.S.R., L.V., N.L., J.P.H., S.D.L.), McGovern Medical School, University of Texas Health Science Center at Houston; Department of Pharmacology and Neurology (C.L.F.), Southern Illinois University School of Medicine, Springfield; Department of Neurology (D.F., O.D.), New York University School of Medicine, New York; Department of Neurology (R.K.S., G.R.), University of Iowa Carver College of Medicine, Iowa City; Department of Neurology (S.S.), Northwestern University Feinberg School of Medicine, Chicago, IL; Institute of Neurology (B.D.), University College London, UK; Department of Neurology (M.N.), Sidney Kimmel Medical College at Thomas Jefferson University, Philadelphia, PA; Department of Neurobiology (R.M.H.), David Geffen School of Medicine at UCLA, Los Angeles, CA; Department of Neurology (L.M.B.), Columbia University Medical Center, New York, NY; and Center for SUDEP Research (M.R.S.R., L.V., N.L., D.F., O.D., R.K.S., S.S., B.D., M.N., R.M.H., L.M.B., G.R., S.D.L.), National Institute for Neurological Disorders and Stroke, Bethesda, MD
| | - Rup K Sainju
- From the Department of Neurology (A.M.), Case Western Reserve University; Department of Neurology (M.R.S.R., L.V., N.L., J.P.H., S.D.L.), McGovern Medical School, University of Texas Health Science Center at Houston; Department of Pharmacology and Neurology (C.L.F.), Southern Illinois University School of Medicine, Springfield; Department of Neurology (D.F., O.D.), New York University School of Medicine, New York; Department of Neurology (R.K.S., G.R.), University of Iowa Carver College of Medicine, Iowa City; Department of Neurology (S.S.), Northwestern University Feinberg School of Medicine, Chicago, IL; Institute of Neurology (B.D.), University College London, UK; Department of Neurology (M.N.), Sidney Kimmel Medical College at Thomas Jefferson University, Philadelphia, PA; Department of Neurobiology (R.M.H.), David Geffen School of Medicine at UCLA, Los Angeles, CA; Department of Neurology (L.M.B.), Columbia University Medical Center, New York, NY; and Center for SUDEP Research (M.R.S.R., L.V., N.L., D.F., O.D., R.K.S., S.S., B.D., M.N., R.M.H., L.M.B., G.R., S.D.L.), National Institute for Neurological Disorders and Stroke, Bethesda, MD
| | - Stephan Schuele
- From the Department of Neurology (A.M.), Case Western Reserve University; Department of Neurology (M.R.S.R., L.V., N.L., J.P.H., S.D.L.), McGovern Medical School, University of Texas Health Science Center at Houston; Department of Pharmacology and Neurology (C.L.F.), Southern Illinois University School of Medicine, Springfield; Department of Neurology (D.F., O.D.), New York University School of Medicine, New York; Department of Neurology (R.K.S., G.R.), University of Iowa Carver College of Medicine, Iowa City; Department of Neurology (S.S.), Northwestern University Feinberg School of Medicine, Chicago, IL; Institute of Neurology (B.D.), University College London, UK; Department of Neurology (M.N.), Sidney Kimmel Medical College at Thomas Jefferson University, Philadelphia, PA; Department of Neurobiology (R.M.H.), David Geffen School of Medicine at UCLA, Los Angeles, CA; Department of Neurology (L.M.B.), Columbia University Medical Center, New York, NY; and Center for SUDEP Research (M.R.S.R., L.V., N.L., D.F., O.D., R.K.S., S.S., B.D., M.N., R.M.H., L.M.B., G.R., S.D.L.), National Institute for Neurological Disorders and Stroke, Bethesda, MD
| | - Beate Diehl
- From the Department of Neurology (A.M.), Case Western Reserve University; Department of Neurology (M.R.S.R., L.V., N.L., J.P.H., S.D.L.), McGovern Medical School, University of Texas Health Science Center at Houston; Department of Pharmacology and Neurology (C.L.F.), Southern Illinois University School of Medicine, Springfield; Department of Neurology (D.F., O.D.), New York University School of Medicine, New York; Department of Neurology (R.K.S., G.R.), University of Iowa Carver College of Medicine, Iowa City; Department of Neurology (S.S.), Northwestern University Feinberg School of Medicine, Chicago, IL; Institute of Neurology (B.D.), University College London, UK; Department of Neurology (M.N.), Sidney Kimmel Medical College at Thomas Jefferson University, Philadelphia, PA; Department of Neurobiology (R.M.H.), David Geffen School of Medicine at UCLA, Los Angeles, CA; Department of Neurology (L.M.B.), Columbia University Medical Center, New York, NY; and Center for SUDEP Research (M.R.S.R., L.V., N.L., D.F., O.D., R.K.S., S.S., B.D., M.N., R.M.H., L.M.B., G.R., S.D.L.), National Institute for Neurological Disorders and Stroke, Bethesda, MD
| | - Maromi Nei
- From the Department of Neurology (A.M.), Case Western Reserve University; Department of Neurology (M.R.S.R., L.V., N.L., J.P.H., S.D.L.), McGovern Medical School, University of Texas Health Science Center at Houston; Department of Pharmacology and Neurology (C.L.F.), Southern Illinois University School of Medicine, Springfield; Department of Neurology (D.F., O.D.), New York University School of Medicine, New York; Department of Neurology (R.K.S., G.R.), University of Iowa Carver College of Medicine, Iowa City; Department of Neurology (S.S.), Northwestern University Feinberg School of Medicine, Chicago, IL; Institute of Neurology (B.D.), University College London, UK; Department of Neurology (M.N.), Sidney Kimmel Medical College at Thomas Jefferson University, Philadelphia, PA; Department of Neurobiology (R.M.H.), David Geffen School of Medicine at UCLA, Los Angeles, CA; Department of Neurology (L.M.B.), Columbia University Medical Center, New York, NY; and Center for SUDEP Research (M.R.S.R., L.V., N.L., D.F., O.D., R.K.S., S.S., B.D., M.N., R.M.H., L.M.B., G.R., S.D.L.), National Institute for Neurological Disorders and Stroke, Bethesda, MD
| | - Ronald M Harper
- From the Department of Neurology (A.M.), Case Western Reserve University; Department of Neurology (M.R.S.R., L.V., N.L., J.P.H., S.D.L.), McGovern Medical School, University of Texas Health Science Center at Houston; Department of Pharmacology and Neurology (C.L.F.), Southern Illinois University School of Medicine, Springfield; Department of Neurology (D.F., O.D.), New York University School of Medicine, New York; Department of Neurology (R.K.S., G.R.), University of Iowa Carver College of Medicine, Iowa City; Department of Neurology (S.S.), Northwestern University Feinberg School of Medicine, Chicago, IL; Institute of Neurology (B.D.), University College London, UK; Department of Neurology (M.N.), Sidney Kimmel Medical College at Thomas Jefferson University, Philadelphia, PA; Department of Neurobiology (R.M.H.), David Geffen School of Medicine at UCLA, Los Angeles, CA; Department of Neurology (L.M.B.), Columbia University Medical Center, New York, NY; and Center for SUDEP Research (M.R.S.R., L.V., N.L., D.F., O.D., R.K.S., S.S., B.D., M.N., R.M.H., L.M.B., G.R., S.D.L.), National Institute for Neurological Disorders and Stroke, Bethesda, MD
| | - Lisa M Bateman
- From the Department of Neurology (A.M.), Case Western Reserve University; Department of Neurology (M.R.S.R., L.V., N.L., J.P.H., S.D.L.), McGovern Medical School, University of Texas Health Science Center at Houston; Department of Pharmacology and Neurology (C.L.F.), Southern Illinois University School of Medicine, Springfield; Department of Neurology (D.F., O.D.), New York University School of Medicine, New York; Department of Neurology (R.K.S., G.R.), University of Iowa Carver College of Medicine, Iowa City; Department of Neurology (S.S.), Northwestern University Feinberg School of Medicine, Chicago, IL; Institute of Neurology (B.D.), University College London, UK; Department of Neurology (M.N.), Sidney Kimmel Medical College at Thomas Jefferson University, Philadelphia, PA; Department of Neurobiology (R.M.H.), David Geffen School of Medicine at UCLA, Los Angeles, CA; Department of Neurology (L.M.B.), Columbia University Medical Center, New York, NY; and Center for SUDEP Research (M.R.S.R., L.V., N.L., D.F., O.D., R.K.S., S.S., B.D., M.N., R.M.H., L.M.B., G.R., S.D.L.), National Institute for Neurological Disorders and Stroke, Bethesda, MD
| | - George Richerson
- From the Department of Neurology (A.M.), Case Western Reserve University; Department of Neurology (M.R.S.R., L.V., N.L., J.P.H., S.D.L.), McGovern Medical School, University of Texas Health Science Center at Houston; Department of Pharmacology and Neurology (C.L.F.), Southern Illinois University School of Medicine, Springfield; Department of Neurology (D.F., O.D.), New York University School of Medicine, New York; Department of Neurology (R.K.S., G.R.), University of Iowa Carver College of Medicine, Iowa City; Department of Neurology (S.S.), Northwestern University Feinberg School of Medicine, Chicago, IL; Institute of Neurology (B.D.), University College London, UK; Department of Neurology (M.N.), Sidney Kimmel Medical College at Thomas Jefferson University, Philadelphia, PA; Department of Neurobiology (R.M.H.), David Geffen School of Medicine at UCLA, Los Angeles, CA; Department of Neurology (L.M.B.), Columbia University Medical Center, New York, NY; and Center for SUDEP Research (M.R.S.R., L.V., N.L., D.F., O.D., R.K.S., S.S., B.D., M.N., R.M.H., L.M.B., G.R., S.D.L.), National Institute for Neurological Disorders and Stroke, Bethesda, MD
| | - Samden D Lhatoo
- From the Department of Neurology (A.M.), Case Western Reserve University; Department of Neurology (M.R.S.R., L.V., N.L., J.P.H., S.D.L.), McGovern Medical School, University of Texas Health Science Center at Houston; Department of Pharmacology and Neurology (C.L.F.), Southern Illinois University School of Medicine, Springfield; Department of Neurology (D.F., O.D.), New York University School of Medicine, New York; Department of Neurology (R.K.S., G.R.), University of Iowa Carver College of Medicine, Iowa City; Department of Neurology (S.S.), Northwestern University Feinberg School of Medicine, Chicago, IL; Institute of Neurology (B.D.), University College London, UK; Department of Neurology (M.N.), Sidney Kimmel Medical College at Thomas Jefferson University, Philadelphia, PA; Department of Neurobiology (R.M.H.), David Geffen School of Medicine at UCLA, Los Angeles, CA; Department of Neurology (L.M.B.), Columbia University Medical Center, New York, NY; and Center for SUDEP Research (M.R.S.R., L.V., N.L., D.F., O.D., R.K.S., S.S., B.D., M.N., R.M.H., L.M.B., G.R., S.D.L.), National Institute for Neurological Disorders and Stroke, Bethesda, MD
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Lacuey N, Martins R, Vilella L, Hampson JP, Rani MRS, Strohl K, Zaremba A, Hampson JS, Sainju RK, Friedman D, Nei M, Scott C, Gehlbach BK, Hupp NJ, Schuele S, Ogren J, Harper RM, Allen L, Diehl B, Bateman LM, Devinsky O, Richerson GB, Lhatoo S. The association of serotonin reuptake inhibitors and benzodiazepines with ictal central apnea. Epilepsy Behav 2019; 98:73-79. [PMID: 31301453 PMCID: PMC8975169 DOI: 10.1016/j.yebeh.2019.06.029] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/08/2019] [Revised: 06/14/2019] [Accepted: 06/15/2019] [Indexed: 12/01/2022]
Abstract
OBJECTIVE Ictal (ICA) and postconvulsive central apnea (PCCA) have been implicated in sudden unexpected death in epilepsy (SUDEP) pathomechanisms. Previous studies suggest that serotonin reuptake inhibitors (SRIs) and benzodiazepines (BZDs) may influence breathing. The aim of this study was to investigate if chronic use of these drugs alters central apnea occurrence in patients with epilepsy. METHODS Patients with epilepsy admitted to epilepsy monitoring units (EMUs) in nine centers participating in a SUDEP study were consented. Polygraphic physiological parameters were analyzed, including video-electroencephalography (VEEG), thoracoabdominal excursions, and pulse oximetry. Outpatient medication details were collected. Patients and seizures were divided into SRI, BZD, and control (no SRI or BZD) groups. Ictal central apnea and PCCA, hypoxemia, and electroclinical features were assessed for each group. RESULTS Four hundred and seventy-six seizures were analyzed (204 patients). The relative risk (RR) for ICA in the SRI group was half that of the control group (p = 0.02). In the BZD group, ICA duration was significantly shorter than in the control group (p = 0.02), as was postictal generalized EEG suppression (PGES) duration (p = 0.021). Both SRI and BZD groups were associated with smaller seizure-associated oxygen desaturation (p = 0.009; p ≪ 0.001). Neither presence nor duration of PCCA was significantly associated with SRI or BZD (p ≫ 0.05). CONCLUSIONS Seizures in patients taking SRIs have lower occurrence of ICA, and patients on chronic treatment with BZDs have shorter ICA and PGES durations. Preventing or shortening ICA duration by using SRIs and/or BZD in patients with epilepsy may play a possible role in SUDEP risk reduction.
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Affiliation(s)
- Nuria Lacuey
- Epilepsy Center, University Hospitals Cleveland Medical Center, Cleveland, OH, USA.
| | - Rita Martins
- Hospital Prof. Doutor Fernando Fonseca, Amadora, Portugal
| | - Laura Vilella
- NINDS Center for SUDEP Research (CSR), Cleveland, OH, USA
| | - Johnson P. Hampson
- Epilepsy Center, University Hospitals Cleveland Medical Center, Cleveland, OH, USA
| | | | - Kingman Strohl
- Division of Pulmonary, Critical Care and Sleep Medicine, University Hospitals Medical Center, Cleveland, OH, USA
| | - Anita Zaremba
- NINDS Center for SUDEP Research (CSR), Cleveland, OH, USA
| | | | - Rup K. Sainju
- NINDS Center for SUDEP Research (CSR), Cleveland, OH, USA,University of Iowa Carver College of Medicine, Iowa City, IA, USA
| | - Daniel Friedman
- NINDS Center for SUDEP Research (CSR), Cleveland, OH, USA,NYU Langone School of Medicine, New York, NY, USA
| | - Maromi Nei
- NINDS Center for SUDEP Research (CSR), Cleveland, OH, USA,Sidney Kimmel Medical College, Thomas Jefferson University, Philadelphia, PA, USA
| | - Catherine Scott
- NINDS Center for SUDEP Research (CSR), Cleveland, OH, USA,Institute of Neurology, University College London, London, UK
| | - Brian K Gehlbach
- NINDS Center for SUDEP Research (CSR), Cleveland, OH, USA,University of Iowa Carver College of Medicine, Iowa City, IA, USA
| | - Norma J. Hupp
- NINDS Center for SUDEP Research (CSR), Cleveland, OH, USA
| | - Stephan Schuele
- NINDS Center for SUDEP Research (CSR), Cleveland, OH, USA,Northwestern University, Feinberg School of Medicine, Chicago
| | - Jennifer Ogren
- NINDS Center for SUDEP Research (CSR), Cleveland, OH, USA,Department of Neurobiology and the Brain Research Institute, University of California, Los Angeles (UCLA), Los Angeles, CA, USA
| | - Ronald M. Harper
- Hospital Prof. Doutor Fernando Fonseca, Amadora, Portugal,Department of Neurobiology and the Brain Research Institute, University of California, Los Angeles (UCLA), Los Angeles, CA, USA
| | - Luke Allen
- NINDS Center for SUDEP Research (CSR), Cleveland, OH, USA,Institute of Neurology, University College London, London, UK
| | - Beate Diehl
- NINDS Center for SUDEP Research (CSR), Cleveland, OH, USA,Institute of Neurology, University College London, London, UK
| | - Lisa M. Bateman
- NINDS Center for SUDEP Research (CSR), Cleveland, OH, USA,Department of Neurology, Columbia University, New York, NY, USA
| | - Orrin Devinsky
- NINDS Center for SUDEP Research (CSR), Cleveland, OH, USA,NYU Langone School of Medicine, New York, NY, USA
| | - George B. Richerson
- NINDS Center for SUDEP Research (CSR), Cleveland, OH, USA,University of Iowa Carver College of Medicine, Iowa City, IA, USA
| | - Samden Lhatoo
- Epilepsy Center, University Hospitals Cleveland Medical Center, Cleveland, OH, USA,NINDS Center for SUDEP Research (CSR), Cleveland, OH, USA
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Vilella L, Lacuey N, Hampson JP, Rani MRS, Loparo K, Sainju RK, Friedman D, Nei M, Strohl K, Allen L, Scott C, Gehlbach BK, Zonjy B, Hupp NJ, Zaremba A, Shafiabadi N, Zhao X, Reick-Mitrisin V, Schuele S, Ogren J, Harper RM, Diehl B, Bateman LM, Devinsky O, Richerson GB, Tanner A, Tatsuoka C, Lhatoo SD. Incidence, Recurrence, and Risk Factors for Peri-ictal Central Apnea and Sudden Unexpected Death in Epilepsy. Front Neurol 2019; 10:166. [PMID: 30890997 PMCID: PMC6413671 DOI: 10.3389/fneur.2019.00166] [Citation(s) in RCA: 49] [Impact Index Per Article: 9.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/02/2018] [Accepted: 02/08/2019] [Indexed: 02/01/2023] Open
Abstract
Introduction: Peri-ictal breathing dysfunction was proposed as a potential mechanism for SUDEP. We examined the incidence and risk factors for both ictal (ICA) and post-convulsive central apnea (PCCA) and their relationship with potential seizure severity biomarkers (i. e., post-ictal generalized EEG suppression (PGES) and recurrence. Methods: Prospective, multi-center seizure monitoring study of autonomic, and breathing biomarkers of SUDEP in adults with intractable epilepsy and monitored seizures. Video EEG, thoraco-abdominal excursions, capillary oxygen saturation, and electrocardiography were analyzed. A subgroup analysis determined the incidences of recurrent ICA and PCCA in patients with ≥2 recorded seizures. We excluded status epilepticus and obscured/unavailable video. Central apnea (absence of thoracic-abdominal breathing movements) was defined as ≥1 missed breath, and ≥5 s. ICA referred to apnea preceding or occurring along with non-convulsive seizures (NCS) or apnea before generalized convulsive seizures (GCS). Results: We analyzed 558 seizures in 218 patients (130 female); 321 seizures were NCS and 237 were GCS. ICA occurred in 180/487 (36.9%) seizures in 83/192 (43.2%) patients, all with focal epilepsy. Sleep state was related to presence of ICA [RR 1.33, CI 95% (1.08–1.64), p = 0.008] whereas extratemporal epilepsy was related to lower incidence of ICA [RR 0.58, CI 95% (0.37–0.90), p = 0.015]. ICA recurred in 45/60 (75%) patients. PCCA occurred in 41/228 (18%) of GCS in 30/134 (22.4%) patients, regardless of epilepsy type. Female sex [RR 11.30, CI 95% (4.50–28.34), p < 0.001] and ICA duration [RR 1.14 CI 95% (1.05–1.25), p = 0.001] were related to PCCA presence, whereas absence of PGES was related to absence of PCCA [0.27, CI 95% (0.16–0.47), p < 0.001]. PCCA duration was longer in males [HR 1.84, CI 95% (1.06–3.19), p = 0.003]. In 9/17 (52.9%) patients, PCCA was recurrent. Conclusion: ICA incidence is almost twice the incidence of PCCA and is only seen in focal epilepsies, as opposed to PCCA, suggesting different pathophysiologies. ICA is likely to be a recurrent semiological phenomenon of cortical seizure discharge, whereas PCCA may be a reflection of brainstem dysfunction after GCS. Prolonged ICA or PCCA may, respectively, contribute to SUDEP, as evidenced by two cases we report. Further prospective cohort studies are needed to validate these hypotheses.
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Affiliation(s)
- Laura Vilella
- Department of Neurology, University of Texas Health Science Center at Houston, Houston, TX, United States
| | - Nuria Lacuey
- Epilepsy Center, University Hospitals Cleveland Medical Center, Cleveland, OH, United States
| | - Johnson P Hampson
- Department of Neurology, University of Texas Health Science Center at Houston, Houston, TX, United States
| | - M R Sandhya Rani
- Department of Neurology, Case Western Reserve University, Cleveland, OH, United States
| | - Kenneth Loparo
- Department of Electrical Engineering and Computer Science, Case Western Reserve University, Cleveland, OH, United States
| | - Rup K Sainju
- Department of Neurology, University of Iowa School of Medicine, Iowa City, IA, United States
| | | | - Maromi Nei
- Sidney Kimmel Medical College, Thomas Jefferson University, Philadelphia, PA, United States
| | - Kingman Strohl
- Division of Pulmonary, Critical Care and Sleep Medicine, University Hospitals Medical Center, Cleveland, OH, United States
| | - Luke Allen
- Institute of Neurology, University College London, London, United Kingdom
| | - Catherine Scott
- Institute of Neurology, University College London, London, United Kingdom
| | - Brian K Gehlbach
- Department of Neurology, University of Iowa School of Medicine, Iowa City, IA, United States
| | - Bilal Zonjy
- Department of Neurology, Case Western Reserve University, Cleveland, OH, United States
| | - Norma J Hupp
- Department of Neurology, University of Texas Health Science Center at Houston, Houston, TX, United States
| | - Anita Zaremba
- Department of Neurology, Case Western Reserve University, Cleveland, OH, United States
| | - Nassim Shafiabadi
- Epilepsy Center, University Hospitals Cleveland Medical Center, Cleveland, OH, United States.,Department of Neurology, Case Western Reserve University, Cleveland, OH, United States
| | - Xiuhe Zhao
- Epilepsy Center, University Hospitals Cleveland Medical Center, Cleveland, OH, United States
| | - Victoria Reick-Mitrisin
- Epilepsy Center, University Hospitals Cleveland Medical Center, Cleveland, OH, United States
| | - Stephan Schuele
- Feinberg School of Medicine, Northwestern University, Chicago, IL, United States
| | - Jennifer Ogren
- Department of Neurobiology and the Brain Research Institute, University of California, Los Angeles, Los Angeles, CA, United States
| | - Ronald M Harper
- Department of Neurobiology and the Brain Research Institute, University of California, Los Angeles, Los Angeles, CA, United States
| | - Beate Diehl
- Institute of Neurology, University College London, London, United Kingdom
| | - Lisa M Bateman
- Department of Neurology, Columbia University, New York, NY, United States
| | - Orrin Devinsky
- NYU Langone School of Medicine, New York, NY, United States
| | - George B Richerson
- Department of Neurology, University of Iowa School of Medicine, Iowa City, IA, United States
| | - Adriana Tanner
- Mercy Health St. Mary's Campus, Grand Rapids, MI, United States
| | - Curtis Tatsuoka
- Department of Neurology, Case Western Reserve University, Cleveland, OH, United States
| | - Samden D Lhatoo
- Department of Neurology, University of Texas Health Science Center at Houston, Houston, TX, United States
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Vilella L, Lacuey N, Hampson JP, Rani MRS, Sainju RK, Friedman D, Nei M, Strohl K, Scott C, Gehlbach BK, Zonjy B, Hupp NJ, Zaremba A, Shafiabadi N, Zhao X, Reick-Mitrisin V, Schuele S, Ogren J, Harper RM, Diehl B, Bateman L, Devinsky O, Richerson GB, Ryvlin P, Lhatoo SD. Postconvulsive central apnea as a biomarker for sudden unexpected death in epilepsy (SUDEP). Neurology 2019; 92:e171-e182. [PMID: 30568003 PMCID: PMC6340388 DOI: 10.1212/wnl.0000000000006785] [Citation(s) in RCA: 111] [Impact Index Per Article: 22.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/18/2018] [Accepted: 08/29/2018] [Indexed: 12/16/2022] Open
Abstract
OBJECTIVE To characterize peri-ictal apnea and postictal asystole in generalized convulsive seizures (GCS) of intractable epilepsy. METHODS This was a prospective, multicenter epilepsy monitoring study of autonomic and breathing biomarkers of sudden unexpected death in epilepsy (SUDEP) in patients ≥18 years old with intractable epilepsy and monitored GCS. Video-EEG, thoracoabdominal excursions, nasal airflow, capillary oxygen saturation, and ECG were analyzed. RESULTS We studied 148 GCS in 87 patients. Nineteen patients had generalized epilepsy; 65 had focal epilepsy; 1 had both; and the epileptogenic zone was unknown in 2. Ictal central apnea (ICA) preceded GCS in 49 of 121 (40.4%) seizures in 23 patients, all with focal epilepsy. Postconvulsive central apnea (PCCA) occurred in 31 of 140 (22.1%) seizures in 22 patients, with generalized, focal, or unknown epileptogenic zones. In 2 patients, PCCA occurred concurrently with asystole (near-SUDEP), with an incidence rate of 10.2 per 1,000 patient-years. One patient with PCCA died of probable SUDEP during follow-up, suggesting a SUDEP incidence rate 5.1 per 1,000 patient-years. No cases of laryngospasm were detected. Rhythmic muscle artifact synchronous with breathing was present in 75 of 147 seizures and related to stertorous breathing (odds ratio 3.856, 95% confidence interval 1.395-10.663, p = 0.009). CONCLUSIONS PCCA occurred in both focal and generalized epilepsies, suggesting a different pathophysiology from ICA, which occurred only in focal epilepsy. PCCA was seen in 2 near-SUDEP cases and 1 probable SUDEP case, suggesting that this phenomenon may serve as a clinical biomarker of SUDEP. Larger studies are needed to validate this observation. Rhythmic postictal muscle artifact is suggestive of post-GCS breathing effort rather than a specific biomarker of laryngospasm.
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Affiliation(s)
- Laura Vilella
- From the NINDS Center for SUDEP Research (L.V., M.R.S.R., R.K.S., D.F., M.N., C.S., B.K.G., B.Z., A.Z., S.S., J.O., R.M.H., B.D., L.B., O.D., G.B.R., P.R., S.D.L.); Epilepsy Center (L.V., N.L., J.P.H., N.J.H., N.S., X.Z., V.R.-M., S.D.L.) and Division of Pulmonary, Critical Care and Sleep Medicine (K.S.), University Hospitals Cleveland Medical Center, OH; University of Iowa School of Medicine (R.K.S., B.K.G., G.B.R.), Iowa City; NYU Langone School of Medicine (D.F., O.D.), New York; Sidney Kimmel Medical College (M.N.), Thomas Jefferson University, Philadelphia, PA; Institute of Neurology (C.S., B.D.), University College London, UK; Feinberg School of Medicine (S.S.), Northwestern University, Chicago, IL; Department of Neurobiology and Brain Research Institute (J.O., R.M.H.), University of California, Los Angeles (UCLA); Department of Neurology (L.B.), Columbia University, New York, NY; and Department of Clinical Neuroscience (P.R.), Centre Hospitalier Universitaire Vaudois, Lausanne, Switzerland.
| | - Nuria Lacuey
- From the NINDS Center for SUDEP Research (L.V., M.R.S.R., R.K.S., D.F., M.N., C.S., B.K.G., B.Z., A.Z., S.S., J.O., R.M.H., B.D., L.B., O.D., G.B.R., P.R., S.D.L.); Epilepsy Center (L.V., N.L., J.P.H., N.J.H., N.S., X.Z., V.R.-M., S.D.L.) and Division of Pulmonary, Critical Care and Sleep Medicine (K.S.), University Hospitals Cleveland Medical Center, OH; University of Iowa School of Medicine (R.K.S., B.K.G., G.B.R.), Iowa City; NYU Langone School of Medicine (D.F., O.D.), New York; Sidney Kimmel Medical College (M.N.), Thomas Jefferson University, Philadelphia, PA; Institute of Neurology (C.S., B.D.), University College London, UK; Feinberg School of Medicine (S.S.), Northwestern University, Chicago, IL; Department of Neurobiology and Brain Research Institute (J.O., R.M.H.), University of California, Los Angeles (UCLA); Department of Neurology (L.B.), Columbia University, New York, NY; and Department of Clinical Neuroscience (P.R.), Centre Hospitalier Universitaire Vaudois, Lausanne, Switzerland
| | - Johnson P Hampson
- From the NINDS Center for SUDEP Research (L.V., M.R.S.R., R.K.S., D.F., M.N., C.S., B.K.G., B.Z., A.Z., S.S., J.O., R.M.H., B.D., L.B., O.D., G.B.R., P.R., S.D.L.); Epilepsy Center (L.V., N.L., J.P.H., N.J.H., N.S., X.Z., V.R.-M., S.D.L.) and Division of Pulmonary, Critical Care and Sleep Medicine (K.S.), University Hospitals Cleveland Medical Center, OH; University of Iowa School of Medicine (R.K.S., B.K.G., G.B.R.), Iowa City; NYU Langone School of Medicine (D.F., O.D.), New York; Sidney Kimmel Medical College (M.N.), Thomas Jefferson University, Philadelphia, PA; Institute of Neurology (C.S., B.D.), University College London, UK; Feinberg School of Medicine (S.S.), Northwestern University, Chicago, IL; Department of Neurobiology and Brain Research Institute (J.O., R.M.H.), University of California, Los Angeles (UCLA); Department of Neurology (L.B.), Columbia University, New York, NY; and Department of Clinical Neuroscience (P.R.), Centre Hospitalier Universitaire Vaudois, Lausanne, Switzerland
| | - M R Sandhya Rani
- From the NINDS Center for SUDEP Research (L.V., M.R.S.R., R.K.S., D.F., M.N., C.S., B.K.G., B.Z., A.Z., S.S., J.O., R.M.H., B.D., L.B., O.D., G.B.R., P.R., S.D.L.); Epilepsy Center (L.V., N.L., J.P.H., N.J.H., N.S., X.Z., V.R.-M., S.D.L.) and Division of Pulmonary, Critical Care and Sleep Medicine (K.S.), University Hospitals Cleveland Medical Center, OH; University of Iowa School of Medicine (R.K.S., B.K.G., G.B.R.), Iowa City; NYU Langone School of Medicine (D.F., O.D.), New York; Sidney Kimmel Medical College (M.N.), Thomas Jefferson University, Philadelphia, PA; Institute of Neurology (C.S., B.D.), University College London, UK; Feinberg School of Medicine (S.S.), Northwestern University, Chicago, IL; Department of Neurobiology and Brain Research Institute (J.O., R.M.H.), University of California, Los Angeles (UCLA); Department of Neurology (L.B.), Columbia University, New York, NY; and Department of Clinical Neuroscience (P.R.), Centre Hospitalier Universitaire Vaudois, Lausanne, Switzerland
| | - Rup K Sainju
- From the NINDS Center for SUDEP Research (L.V., M.R.S.R., R.K.S., D.F., M.N., C.S., B.K.G., B.Z., A.Z., S.S., J.O., R.M.H., B.D., L.B., O.D., G.B.R., P.R., S.D.L.); Epilepsy Center (L.V., N.L., J.P.H., N.J.H., N.S., X.Z., V.R.-M., S.D.L.) and Division of Pulmonary, Critical Care and Sleep Medicine (K.S.), University Hospitals Cleveland Medical Center, OH; University of Iowa School of Medicine (R.K.S., B.K.G., G.B.R.), Iowa City; NYU Langone School of Medicine (D.F., O.D.), New York; Sidney Kimmel Medical College (M.N.), Thomas Jefferson University, Philadelphia, PA; Institute of Neurology (C.S., B.D.), University College London, UK; Feinberg School of Medicine (S.S.), Northwestern University, Chicago, IL; Department of Neurobiology and Brain Research Institute (J.O., R.M.H.), University of California, Los Angeles (UCLA); Department of Neurology (L.B.), Columbia University, New York, NY; and Department of Clinical Neuroscience (P.R.), Centre Hospitalier Universitaire Vaudois, Lausanne, Switzerland
| | - Daniel Friedman
- From the NINDS Center for SUDEP Research (L.V., M.R.S.R., R.K.S., D.F., M.N., C.S., B.K.G., B.Z., A.Z., S.S., J.O., R.M.H., B.D., L.B., O.D., G.B.R., P.R., S.D.L.); Epilepsy Center (L.V., N.L., J.P.H., N.J.H., N.S., X.Z., V.R.-M., S.D.L.) and Division of Pulmonary, Critical Care and Sleep Medicine (K.S.), University Hospitals Cleveland Medical Center, OH; University of Iowa School of Medicine (R.K.S., B.K.G., G.B.R.), Iowa City; NYU Langone School of Medicine (D.F., O.D.), New York; Sidney Kimmel Medical College (M.N.), Thomas Jefferson University, Philadelphia, PA; Institute of Neurology (C.S., B.D.), University College London, UK; Feinberg School of Medicine (S.S.), Northwestern University, Chicago, IL; Department of Neurobiology and Brain Research Institute (J.O., R.M.H.), University of California, Los Angeles (UCLA); Department of Neurology (L.B.), Columbia University, New York, NY; and Department of Clinical Neuroscience (P.R.), Centre Hospitalier Universitaire Vaudois, Lausanne, Switzerland
| | - Maromi Nei
- From the NINDS Center for SUDEP Research (L.V., M.R.S.R., R.K.S., D.F., M.N., C.S., B.K.G., B.Z., A.Z., S.S., J.O., R.M.H., B.D., L.B., O.D., G.B.R., P.R., S.D.L.); Epilepsy Center (L.V., N.L., J.P.H., N.J.H., N.S., X.Z., V.R.-M., S.D.L.) and Division of Pulmonary, Critical Care and Sleep Medicine (K.S.), University Hospitals Cleveland Medical Center, OH; University of Iowa School of Medicine (R.K.S., B.K.G., G.B.R.), Iowa City; NYU Langone School of Medicine (D.F., O.D.), New York; Sidney Kimmel Medical College (M.N.), Thomas Jefferson University, Philadelphia, PA; Institute of Neurology (C.S., B.D.), University College London, UK; Feinberg School of Medicine (S.S.), Northwestern University, Chicago, IL; Department of Neurobiology and Brain Research Institute (J.O., R.M.H.), University of California, Los Angeles (UCLA); Department of Neurology (L.B.), Columbia University, New York, NY; and Department of Clinical Neuroscience (P.R.), Centre Hospitalier Universitaire Vaudois, Lausanne, Switzerland
| | - Kingman Strohl
- From the NINDS Center for SUDEP Research (L.V., M.R.S.R., R.K.S., D.F., M.N., C.S., B.K.G., B.Z., A.Z., S.S., J.O., R.M.H., B.D., L.B., O.D., G.B.R., P.R., S.D.L.); Epilepsy Center (L.V., N.L., J.P.H., N.J.H., N.S., X.Z., V.R.-M., S.D.L.) and Division of Pulmonary, Critical Care and Sleep Medicine (K.S.), University Hospitals Cleveland Medical Center, OH; University of Iowa School of Medicine (R.K.S., B.K.G., G.B.R.), Iowa City; NYU Langone School of Medicine (D.F., O.D.), New York; Sidney Kimmel Medical College (M.N.), Thomas Jefferson University, Philadelphia, PA; Institute of Neurology (C.S., B.D.), University College London, UK; Feinberg School of Medicine (S.S.), Northwestern University, Chicago, IL; Department of Neurobiology and Brain Research Institute (J.O., R.M.H.), University of California, Los Angeles (UCLA); Department of Neurology (L.B.), Columbia University, New York, NY; and Department of Clinical Neuroscience (P.R.), Centre Hospitalier Universitaire Vaudois, Lausanne, Switzerland
| | - Catherine Scott
- From the NINDS Center for SUDEP Research (L.V., M.R.S.R., R.K.S., D.F., M.N., C.S., B.K.G., B.Z., A.Z., S.S., J.O., R.M.H., B.D., L.B., O.D., G.B.R., P.R., S.D.L.); Epilepsy Center (L.V., N.L., J.P.H., N.J.H., N.S., X.Z., V.R.-M., S.D.L.) and Division of Pulmonary, Critical Care and Sleep Medicine (K.S.), University Hospitals Cleveland Medical Center, OH; University of Iowa School of Medicine (R.K.S., B.K.G., G.B.R.), Iowa City; NYU Langone School of Medicine (D.F., O.D.), New York; Sidney Kimmel Medical College (M.N.), Thomas Jefferson University, Philadelphia, PA; Institute of Neurology (C.S., B.D.), University College London, UK; Feinberg School of Medicine (S.S.), Northwestern University, Chicago, IL; Department of Neurobiology and Brain Research Institute (J.O., R.M.H.), University of California, Los Angeles (UCLA); Department of Neurology (L.B.), Columbia University, New York, NY; and Department of Clinical Neuroscience (P.R.), Centre Hospitalier Universitaire Vaudois, Lausanne, Switzerland
| | - Brian K Gehlbach
- From the NINDS Center for SUDEP Research (L.V., M.R.S.R., R.K.S., D.F., M.N., C.S., B.K.G., B.Z., A.Z., S.S., J.O., R.M.H., B.D., L.B., O.D., G.B.R., P.R., S.D.L.); Epilepsy Center (L.V., N.L., J.P.H., N.J.H., N.S., X.Z., V.R.-M., S.D.L.) and Division of Pulmonary, Critical Care and Sleep Medicine (K.S.), University Hospitals Cleveland Medical Center, OH; University of Iowa School of Medicine (R.K.S., B.K.G., G.B.R.), Iowa City; NYU Langone School of Medicine (D.F., O.D.), New York; Sidney Kimmel Medical College (M.N.), Thomas Jefferson University, Philadelphia, PA; Institute of Neurology (C.S., B.D.), University College London, UK; Feinberg School of Medicine (S.S.), Northwestern University, Chicago, IL; Department of Neurobiology and Brain Research Institute (J.O., R.M.H.), University of California, Los Angeles (UCLA); Department of Neurology (L.B.), Columbia University, New York, NY; and Department of Clinical Neuroscience (P.R.), Centre Hospitalier Universitaire Vaudois, Lausanne, Switzerland
| | - Bilal Zonjy
- From the NINDS Center for SUDEP Research (L.V., M.R.S.R., R.K.S., D.F., M.N., C.S., B.K.G., B.Z., A.Z., S.S., J.O., R.M.H., B.D., L.B., O.D., G.B.R., P.R., S.D.L.); Epilepsy Center (L.V., N.L., J.P.H., N.J.H., N.S., X.Z., V.R.-M., S.D.L.) and Division of Pulmonary, Critical Care and Sleep Medicine (K.S.), University Hospitals Cleveland Medical Center, OH; University of Iowa School of Medicine (R.K.S., B.K.G., G.B.R.), Iowa City; NYU Langone School of Medicine (D.F., O.D.), New York; Sidney Kimmel Medical College (M.N.), Thomas Jefferson University, Philadelphia, PA; Institute of Neurology (C.S., B.D.), University College London, UK; Feinberg School of Medicine (S.S.), Northwestern University, Chicago, IL; Department of Neurobiology and Brain Research Institute (J.O., R.M.H.), University of California, Los Angeles (UCLA); Department of Neurology (L.B.), Columbia University, New York, NY; and Department of Clinical Neuroscience (P.R.), Centre Hospitalier Universitaire Vaudois, Lausanne, Switzerland
| | - Norma J Hupp
- From the NINDS Center for SUDEP Research (L.V., M.R.S.R., R.K.S., D.F., M.N., C.S., B.K.G., B.Z., A.Z., S.S., J.O., R.M.H., B.D., L.B., O.D., G.B.R., P.R., S.D.L.); Epilepsy Center (L.V., N.L., J.P.H., N.J.H., N.S., X.Z., V.R.-M., S.D.L.) and Division of Pulmonary, Critical Care and Sleep Medicine (K.S.), University Hospitals Cleveland Medical Center, OH; University of Iowa School of Medicine (R.K.S., B.K.G., G.B.R.), Iowa City; NYU Langone School of Medicine (D.F., O.D.), New York; Sidney Kimmel Medical College (M.N.), Thomas Jefferson University, Philadelphia, PA; Institute of Neurology (C.S., B.D.), University College London, UK; Feinberg School of Medicine (S.S.), Northwestern University, Chicago, IL; Department of Neurobiology and Brain Research Institute (J.O., R.M.H.), University of California, Los Angeles (UCLA); Department of Neurology (L.B.), Columbia University, New York, NY; and Department of Clinical Neuroscience (P.R.), Centre Hospitalier Universitaire Vaudois, Lausanne, Switzerland
| | - Anita Zaremba
- From the NINDS Center for SUDEP Research (L.V., M.R.S.R., R.K.S., D.F., M.N., C.S., B.K.G., B.Z., A.Z., S.S., J.O., R.M.H., B.D., L.B., O.D., G.B.R., P.R., S.D.L.); Epilepsy Center (L.V., N.L., J.P.H., N.J.H., N.S., X.Z., V.R.-M., S.D.L.) and Division of Pulmonary, Critical Care and Sleep Medicine (K.S.), University Hospitals Cleveland Medical Center, OH; University of Iowa School of Medicine (R.K.S., B.K.G., G.B.R.), Iowa City; NYU Langone School of Medicine (D.F., O.D.), New York; Sidney Kimmel Medical College (M.N.), Thomas Jefferson University, Philadelphia, PA; Institute of Neurology (C.S., B.D.), University College London, UK; Feinberg School of Medicine (S.S.), Northwestern University, Chicago, IL; Department of Neurobiology and Brain Research Institute (J.O., R.M.H.), University of California, Los Angeles (UCLA); Department of Neurology (L.B.), Columbia University, New York, NY; and Department of Clinical Neuroscience (P.R.), Centre Hospitalier Universitaire Vaudois, Lausanne, Switzerland
| | - Nassim Shafiabadi
- From the NINDS Center for SUDEP Research (L.V., M.R.S.R., R.K.S., D.F., M.N., C.S., B.K.G., B.Z., A.Z., S.S., J.O., R.M.H., B.D., L.B., O.D., G.B.R., P.R., S.D.L.); Epilepsy Center (L.V., N.L., J.P.H., N.J.H., N.S., X.Z., V.R.-M., S.D.L.) and Division of Pulmonary, Critical Care and Sleep Medicine (K.S.), University Hospitals Cleveland Medical Center, OH; University of Iowa School of Medicine (R.K.S., B.K.G., G.B.R.), Iowa City; NYU Langone School of Medicine (D.F., O.D.), New York; Sidney Kimmel Medical College (M.N.), Thomas Jefferson University, Philadelphia, PA; Institute of Neurology (C.S., B.D.), University College London, UK; Feinberg School of Medicine (S.S.), Northwestern University, Chicago, IL; Department of Neurobiology and Brain Research Institute (J.O., R.M.H.), University of California, Los Angeles (UCLA); Department of Neurology (L.B.), Columbia University, New York, NY; and Department of Clinical Neuroscience (P.R.), Centre Hospitalier Universitaire Vaudois, Lausanne, Switzerland
| | - Xiuhe Zhao
- From the NINDS Center for SUDEP Research (L.V., M.R.S.R., R.K.S., D.F., M.N., C.S., B.K.G., B.Z., A.Z., S.S., J.O., R.M.H., B.D., L.B., O.D., G.B.R., P.R., S.D.L.); Epilepsy Center (L.V., N.L., J.P.H., N.J.H., N.S., X.Z., V.R.-M., S.D.L.) and Division of Pulmonary, Critical Care and Sleep Medicine (K.S.), University Hospitals Cleveland Medical Center, OH; University of Iowa School of Medicine (R.K.S., B.K.G., G.B.R.), Iowa City; NYU Langone School of Medicine (D.F., O.D.), New York; Sidney Kimmel Medical College (M.N.), Thomas Jefferson University, Philadelphia, PA; Institute of Neurology (C.S., B.D.), University College London, UK; Feinberg School of Medicine (S.S.), Northwestern University, Chicago, IL; Department of Neurobiology and Brain Research Institute (J.O., R.M.H.), University of California, Los Angeles (UCLA); Department of Neurology (L.B.), Columbia University, New York, NY; and Department of Clinical Neuroscience (P.R.), Centre Hospitalier Universitaire Vaudois, Lausanne, Switzerland
| | - Victoria Reick-Mitrisin
- From the NINDS Center for SUDEP Research (L.V., M.R.S.R., R.K.S., D.F., M.N., C.S., B.K.G., B.Z., A.Z., S.S., J.O., R.M.H., B.D., L.B., O.D., G.B.R., P.R., S.D.L.); Epilepsy Center (L.V., N.L., J.P.H., N.J.H., N.S., X.Z., V.R.-M., S.D.L.) and Division of Pulmonary, Critical Care and Sleep Medicine (K.S.), University Hospitals Cleveland Medical Center, OH; University of Iowa School of Medicine (R.K.S., B.K.G., G.B.R.), Iowa City; NYU Langone School of Medicine (D.F., O.D.), New York; Sidney Kimmel Medical College (M.N.), Thomas Jefferson University, Philadelphia, PA; Institute of Neurology (C.S., B.D.), University College London, UK; Feinberg School of Medicine (S.S.), Northwestern University, Chicago, IL; Department of Neurobiology and Brain Research Institute (J.O., R.M.H.), University of California, Los Angeles (UCLA); Department of Neurology (L.B.), Columbia University, New York, NY; and Department of Clinical Neuroscience (P.R.), Centre Hospitalier Universitaire Vaudois, Lausanne, Switzerland
| | - Stephan Schuele
- From the NINDS Center for SUDEP Research (L.V., M.R.S.R., R.K.S., D.F., M.N., C.S., B.K.G., B.Z., A.Z., S.S., J.O., R.M.H., B.D., L.B., O.D., G.B.R., P.R., S.D.L.); Epilepsy Center (L.V., N.L., J.P.H., N.J.H., N.S., X.Z., V.R.-M., S.D.L.) and Division of Pulmonary, Critical Care and Sleep Medicine (K.S.), University Hospitals Cleveland Medical Center, OH; University of Iowa School of Medicine (R.K.S., B.K.G., G.B.R.), Iowa City; NYU Langone School of Medicine (D.F., O.D.), New York; Sidney Kimmel Medical College (M.N.), Thomas Jefferson University, Philadelphia, PA; Institute of Neurology (C.S., B.D.), University College London, UK; Feinberg School of Medicine (S.S.), Northwestern University, Chicago, IL; Department of Neurobiology and Brain Research Institute (J.O., R.M.H.), University of California, Los Angeles (UCLA); Department of Neurology (L.B.), Columbia University, New York, NY; and Department of Clinical Neuroscience (P.R.), Centre Hospitalier Universitaire Vaudois, Lausanne, Switzerland
| | - Jennifer Ogren
- From the NINDS Center for SUDEP Research (L.V., M.R.S.R., R.K.S., D.F., M.N., C.S., B.K.G., B.Z., A.Z., S.S., J.O., R.M.H., B.D., L.B., O.D., G.B.R., P.R., S.D.L.); Epilepsy Center (L.V., N.L., J.P.H., N.J.H., N.S., X.Z., V.R.-M., S.D.L.) and Division of Pulmonary, Critical Care and Sleep Medicine (K.S.), University Hospitals Cleveland Medical Center, OH; University of Iowa School of Medicine (R.K.S., B.K.G., G.B.R.), Iowa City; NYU Langone School of Medicine (D.F., O.D.), New York; Sidney Kimmel Medical College (M.N.), Thomas Jefferson University, Philadelphia, PA; Institute of Neurology (C.S., B.D.), University College London, UK; Feinberg School of Medicine (S.S.), Northwestern University, Chicago, IL; Department of Neurobiology and Brain Research Institute (J.O., R.M.H.), University of California, Los Angeles (UCLA); Department of Neurology (L.B.), Columbia University, New York, NY; and Department of Clinical Neuroscience (P.R.), Centre Hospitalier Universitaire Vaudois, Lausanne, Switzerland
| | - Ronald M Harper
- From the NINDS Center for SUDEP Research (L.V., M.R.S.R., R.K.S., D.F., M.N., C.S., B.K.G., B.Z., A.Z., S.S., J.O., R.M.H., B.D., L.B., O.D., G.B.R., P.R., S.D.L.); Epilepsy Center (L.V., N.L., J.P.H., N.J.H., N.S., X.Z., V.R.-M., S.D.L.) and Division of Pulmonary, Critical Care and Sleep Medicine (K.S.), University Hospitals Cleveland Medical Center, OH; University of Iowa School of Medicine (R.K.S., B.K.G., G.B.R.), Iowa City; NYU Langone School of Medicine (D.F., O.D.), New York; Sidney Kimmel Medical College (M.N.), Thomas Jefferson University, Philadelphia, PA; Institute of Neurology (C.S., B.D.), University College London, UK; Feinberg School of Medicine (S.S.), Northwestern University, Chicago, IL; Department of Neurobiology and Brain Research Institute (J.O., R.M.H.), University of California, Los Angeles (UCLA); Department of Neurology (L.B.), Columbia University, New York, NY; and Department of Clinical Neuroscience (P.R.), Centre Hospitalier Universitaire Vaudois, Lausanne, Switzerland
| | - Beate Diehl
- From the NINDS Center for SUDEP Research (L.V., M.R.S.R., R.K.S., D.F., M.N., C.S., B.K.G., B.Z., A.Z., S.S., J.O., R.M.H., B.D., L.B., O.D., G.B.R., P.R., S.D.L.); Epilepsy Center (L.V., N.L., J.P.H., N.J.H., N.S., X.Z., V.R.-M., S.D.L.) and Division of Pulmonary, Critical Care and Sleep Medicine (K.S.), University Hospitals Cleveland Medical Center, OH; University of Iowa School of Medicine (R.K.S., B.K.G., G.B.R.), Iowa City; NYU Langone School of Medicine (D.F., O.D.), New York; Sidney Kimmel Medical College (M.N.), Thomas Jefferson University, Philadelphia, PA; Institute of Neurology (C.S., B.D.), University College London, UK; Feinberg School of Medicine (S.S.), Northwestern University, Chicago, IL; Department of Neurobiology and Brain Research Institute (J.O., R.M.H.), University of California, Los Angeles (UCLA); Department of Neurology (L.B.), Columbia University, New York, NY; and Department of Clinical Neuroscience (P.R.), Centre Hospitalier Universitaire Vaudois, Lausanne, Switzerland
| | - Lisa Bateman
- From the NINDS Center for SUDEP Research (L.V., M.R.S.R., R.K.S., D.F., M.N., C.S., B.K.G., B.Z., A.Z., S.S., J.O., R.M.H., B.D., L.B., O.D., G.B.R., P.R., S.D.L.); Epilepsy Center (L.V., N.L., J.P.H., N.J.H., N.S., X.Z., V.R.-M., S.D.L.) and Division of Pulmonary, Critical Care and Sleep Medicine (K.S.), University Hospitals Cleveland Medical Center, OH; University of Iowa School of Medicine (R.K.S., B.K.G., G.B.R.), Iowa City; NYU Langone School of Medicine (D.F., O.D.), New York; Sidney Kimmel Medical College (M.N.), Thomas Jefferson University, Philadelphia, PA; Institute of Neurology (C.S., B.D.), University College London, UK; Feinberg School of Medicine (S.S.), Northwestern University, Chicago, IL; Department of Neurobiology and Brain Research Institute (J.O., R.M.H.), University of California, Los Angeles (UCLA); Department of Neurology (L.B.), Columbia University, New York, NY; and Department of Clinical Neuroscience (P.R.), Centre Hospitalier Universitaire Vaudois, Lausanne, Switzerland
| | - Orrin Devinsky
- From the NINDS Center for SUDEP Research (L.V., M.R.S.R., R.K.S., D.F., M.N., C.S., B.K.G., B.Z., A.Z., S.S., J.O., R.M.H., B.D., L.B., O.D., G.B.R., P.R., S.D.L.); Epilepsy Center (L.V., N.L., J.P.H., N.J.H., N.S., X.Z., V.R.-M., S.D.L.) and Division of Pulmonary, Critical Care and Sleep Medicine (K.S.), University Hospitals Cleveland Medical Center, OH; University of Iowa School of Medicine (R.K.S., B.K.G., G.B.R.), Iowa City; NYU Langone School of Medicine (D.F., O.D.), New York; Sidney Kimmel Medical College (M.N.), Thomas Jefferson University, Philadelphia, PA; Institute of Neurology (C.S., B.D.), University College London, UK; Feinberg School of Medicine (S.S.), Northwestern University, Chicago, IL; Department of Neurobiology and Brain Research Institute (J.O., R.M.H.), University of California, Los Angeles (UCLA); Department of Neurology (L.B.), Columbia University, New York, NY; and Department of Clinical Neuroscience (P.R.), Centre Hospitalier Universitaire Vaudois, Lausanne, Switzerland
| | - George B Richerson
- From the NINDS Center for SUDEP Research (L.V., M.R.S.R., R.K.S., D.F., M.N., C.S., B.K.G., B.Z., A.Z., S.S., J.O., R.M.H., B.D., L.B., O.D., G.B.R., P.R., S.D.L.); Epilepsy Center (L.V., N.L., J.P.H., N.J.H., N.S., X.Z., V.R.-M., S.D.L.) and Division of Pulmonary, Critical Care and Sleep Medicine (K.S.), University Hospitals Cleveland Medical Center, OH; University of Iowa School of Medicine (R.K.S., B.K.G., G.B.R.), Iowa City; NYU Langone School of Medicine (D.F., O.D.), New York; Sidney Kimmel Medical College (M.N.), Thomas Jefferson University, Philadelphia, PA; Institute of Neurology (C.S., B.D.), University College London, UK; Feinberg School of Medicine (S.S.), Northwestern University, Chicago, IL; Department of Neurobiology and Brain Research Institute (J.O., R.M.H.), University of California, Los Angeles (UCLA); Department of Neurology (L.B.), Columbia University, New York, NY; and Department of Clinical Neuroscience (P.R.), Centre Hospitalier Universitaire Vaudois, Lausanne, Switzerland
| | - Philippe Ryvlin
- From the NINDS Center for SUDEP Research (L.V., M.R.S.R., R.K.S., D.F., M.N., C.S., B.K.G., B.Z., A.Z., S.S., J.O., R.M.H., B.D., L.B., O.D., G.B.R., P.R., S.D.L.); Epilepsy Center (L.V., N.L., J.P.H., N.J.H., N.S., X.Z., V.R.-M., S.D.L.) and Division of Pulmonary, Critical Care and Sleep Medicine (K.S.), University Hospitals Cleveland Medical Center, OH; University of Iowa School of Medicine (R.K.S., B.K.G., G.B.R.), Iowa City; NYU Langone School of Medicine (D.F., O.D.), New York; Sidney Kimmel Medical College (M.N.), Thomas Jefferson University, Philadelphia, PA; Institute of Neurology (C.S., B.D.), University College London, UK; Feinberg School of Medicine (S.S.), Northwestern University, Chicago, IL; Department of Neurobiology and Brain Research Institute (J.O., R.M.H.), University of California, Los Angeles (UCLA); Department of Neurology (L.B.), Columbia University, New York, NY; and Department of Clinical Neuroscience (P.R.), Centre Hospitalier Universitaire Vaudois, Lausanne, Switzerland
| | - Samden D Lhatoo
- From the NINDS Center for SUDEP Research (L.V., M.R.S.R., R.K.S., D.F., M.N., C.S., B.K.G., B.Z., A.Z., S.S., J.O., R.M.H., B.D., L.B., O.D., G.B.R., P.R., S.D.L.); Epilepsy Center (L.V., N.L., J.P.H., N.J.H., N.S., X.Z., V.R.-M., S.D.L.) and Division of Pulmonary, Critical Care and Sleep Medicine (K.S.), University Hospitals Cleveland Medical Center, OH; University of Iowa School of Medicine (R.K.S., B.K.G., G.B.R.), Iowa City; NYU Langone School of Medicine (D.F., O.D.), New York; Sidney Kimmel Medical College (M.N.), Thomas Jefferson University, Philadelphia, PA; Institute of Neurology (C.S., B.D.), University College London, UK; Feinberg School of Medicine (S.S.), Northwestern University, Chicago, IL; Department of Neurobiology and Brain Research Institute (J.O., R.M.H.), University of California, Los Angeles (UCLA); Department of Neurology (L.B.), Columbia University, New York, NY; and Department of Clinical Neuroscience (P.R.), Centre Hospitalier Universitaire Vaudois, Lausanne, Switzerland
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15
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Lacuey N, Hampson JP, Harper RM, Miller JP, Lhatoo S. Limbic and paralimbic structures driving ictal central apnea. Neurology 2019; 92:e655-e669. [PMID: 30635481 DOI: 10.1212/wnl.0000000000006920] [Citation(s) in RCA: 34] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/13/2018] [Accepted: 12/14/2018] [Indexed: 11/15/2022] Open
Abstract
OBJECTIVE To precisely identify cortical regions that modulate breathing, and delineate a network of cortical structures that underpin ictal central apnea (ICA) during epileptic seizures. METHODS We electrically stimulated multiple cortical structures in patients undergoing stereotactic EEG (SEEG) evaluation before epilepsy surgery. Structures investigated were orbitofrontal cortex, anterior and posterior cingulate and subcallosal gyri, insula, hippocampus, parahippocampal gyrus, amygdala, temporo-polar cortex, antero-mesial fusiform gyrus, and lateral and basal temporal cortices. Chest/abdominal excursions using thoracic/abdominal belts, peripheral capillary oxygen saturation, end tidal and transcutaneous carbon dioxide, and airflow were continuously monitored. RESULTS Nineteen consecutive adult patients (10 female) aged 18-69 years were investigated. Transient central apnea was elicited in 13/19 patients with amygdala, hippocampus head and body, anterior parahippocampal gyrus, and antero-mesial fusiform gyrus. Insula, cingulate, subcallosal, orbitofrontal, lateral, and basal temporal cortices stimulation did not induce apnea. Apnea duration was associated with stimulus duration (p < 0.001) and current intensity (p = 0.004). CONCLUSIONS These findings suggest a limbic/paralimbic mesial temporal breathing modulation network that includes amygdala, hippocampus, anterior parahippocampal, and antero-mesial fusiform gyri. These structures likely represent anatomical and functional substrates for ICA, a putative sudden unexpected death in epilepsy (SUDEP) breathing biomarker. Damage to such areas is known to occur in high SUDEP risk patients and SUDEP victims, and may underpin the prolonged ICA that is thought to be particularly dangerous. Furthermore, inclusive targeting of apnea-producing structures in SEEG implantations, peri-ictal breathing signal recordings, and stringent analysis of apneic sequences in seizure semiology may enhance accurate identification of symptomatogenic and seizure onset zones for epilepsy surgery.
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Affiliation(s)
- Nuria Lacuey
- From the Epilepsy Center (N.L., J.P.H., J.P.M., S.L.), University Hospitals Cleveland Medical Center, OH; Department of Neurobiology and the Brain Research Institute (R.M.H.), University of California, Los Angeles; and NINDS Center for SUDEP Research (R.M.H., S.L.), Case Western Reserve University, Cleveland, OH.
| | - Johnson P Hampson
- From the Epilepsy Center (N.L., J.P.H., J.P.M., S.L.), University Hospitals Cleveland Medical Center, OH; Department of Neurobiology and the Brain Research Institute (R.M.H.), University of California, Los Angeles; and NINDS Center for SUDEP Research (R.M.H., S.L.), Case Western Reserve University, Cleveland, OH
| | - Ronald M Harper
- From the Epilepsy Center (N.L., J.P.H., J.P.M., S.L.), University Hospitals Cleveland Medical Center, OH; Department of Neurobiology and the Brain Research Institute (R.M.H.), University of California, Los Angeles; and NINDS Center for SUDEP Research (R.M.H., S.L.), Case Western Reserve University, Cleveland, OH
| | - Jonathan P Miller
- From the Epilepsy Center (N.L., J.P.H., J.P.M., S.L.), University Hospitals Cleveland Medical Center, OH; Department of Neurobiology and the Brain Research Institute (R.M.H.), University of California, Los Angeles; and NINDS Center for SUDEP Research (R.M.H., S.L.), Case Western Reserve University, Cleveland, OH
| | - Samden Lhatoo
- From the Epilepsy Center (N.L., J.P.H., J.P.M., S.L.), University Hospitals Cleveland Medical Center, OH; Department of Neurobiology and the Brain Research Institute (R.M.H.), University of California, Los Angeles; and NINDS Center for SUDEP Research (R.M.H., S.L.), Case Western Reserve University, Cleveland, OH
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16
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Harper DE, Ichesco E, Schrepf A, Hampson JP, Clauw DJ, Schmidt-Wilcke T, Harris RE, Harte SE. Resting Functional Connectivity of the Periaqueductal Gray Is Associated With Normal Inhibition and Pathological Facilitation in Conditioned Pain Modulation. J Pain 2018; 19:635.e1-635.e15. [PMID: 29360608 DOI: 10.1016/j.jpain.2018.01.001] [Citation(s) in RCA: 49] [Impact Index Per Article: 8.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Received: 06/19/2017] [Revised: 12/18/2017] [Accepted: 01/03/2018] [Indexed: 12/14/2022]
Abstract
Conditioned pain modulation (CPM), a psychophysical paradigm that is commonly used to infer the integrity of endogenous pain-altering systems by observation of the effect of one noxious stimulus on another, has previously identified deficient endogenous analgesia in fibromyalgia (FM) and other chronic pain conditions. The mechanisms underlying this deficiency, be they insufficient inhibition and/or active facilitation, are largely unknown. The present cross-sectional study used a combination of behavioral CPM testing, voxel-based morphometry, and resting state functional connectivity to identify neural correlates of CPM in healthy controls (HC; n = 14) and FM patients (n = 15), and to probe for differences that could explain the pain-facilitative CPM that was observed in our patient sample. Voxel-based morphometry identified a cluster encompassing the periaqueductal gray (PAG) that contained significantly less gray matter volume in FM patients. Higher resting connectivity between this cluster and cortical pain processing regions was associated with more efficient inhibitory CPM in both groups, whereas PAG connectivity with the dorsal pons was associated with greater CPM inhibition only in HC. Greater PAG connectivity to the caudal pons/rostral medulla, which was pain-inhibitory in HC, was associated with pain facilitation in FM patients. PERSPECTIVE These findings indicate that variation in the strength of the PAG resting functional connectivity can explain some of the normal variability in CPM. In addition, pain-facilitative CPM observed in FM patients likely involves attenuation of pain inhibitory as well as amplification of pain facilitative processes in the central nervous system.
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Affiliation(s)
- Daniel E Harper
- Chronic Pain and Fatigue Research Center, Department of Anesthesiology, University of Michigan, Ann Arbor, Michigan.
| | - Eric Ichesco
- Chronic Pain and Fatigue Research Center, Department of Anesthesiology, University of Michigan, Ann Arbor, Michigan
| | - Andrew Schrepf
- Chronic Pain and Fatigue Research Center, Department of Anesthesiology, University of Michigan, Ann Arbor, Michigan
| | - Johnson P Hampson
- Chronic Pain and Fatigue Research Center, Department of Anesthesiology, University of Michigan, Ann Arbor, Michigan
| | - Daniel J Clauw
- Chronic Pain and Fatigue Research Center, Department of Anesthesiology, University of Michigan, Ann Arbor, Michigan
| | - Tobias Schmidt-Wilcke
- Department of Neurology, St. Mauritius Therapieklinik, Meerbusch, Germany; Department of Clinical Neuroscience and Medical Psychology, Medical Faculty, Heinrich-Heine-University, Düsseldorf, Germany
| | - Richard E Harris
- Chronic Pain and Fatigue Research Center, Department of Anesthesiology, University of Michigan, Ann Arbor, Michigan
| | - Steven E Harte
- Chronic Pain and Fatigue Research Center, Department of Anesthesiology, University of Michigan, Ann Arbor, Michigan
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17
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Lacuey N, Zonjy B, Hampson JP, Rani MRS, Zaremba A, Sainju RK, Gehlbach BK, Schuele S, Friedman D, Devinsky O, Nei M, Harper RM, Allen L, Diehl B, Millichap JJ, Bateman L, Granner MA, Dragon DN, Richerson GB, Lhatoo SD. The incidence and significance of periictal apnea in epileptic seizures. Epilepsia 2018; 59:573-582. [PMID: 29336036 DOI: 10.1111/epi.14006] [Citation(s) in RCA: 93] [Impact Index Per Article: 15.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/19/2017] [Indexed: 11/27/2022]
Abstract
OBJECTIVE The aim of this study was to investigate periictal central apnea as a seizure semiological feature, its localizing value, and possible relationship with sudden unexpected death in epilepsy (SUDEP) pathomechanisms. METHODS We prospectively studied polygraphic physiological responses, including inductance plethysmography, peripheral capillary oxygen saturation (SpO2 ), electrocardiography, and video electroencephalography (VEEG) in 473 patients in a multicenter study of SUDEP. Seizures were classified according to the International League Against Epilepsy (ILAE) 2017 seizure classification based on the most prominent clinical signs during VEEG. The putative epileptogenic zone was defined based on clinical history, seizure semiology, neuroimaging, and EEG. RESULTS Complete datasets were available in 126 patients in 312 seizures. Ictal central apnea (ICA) occurred exclusively in focal epilepsy (51/109 patients [47%] and 103/312 seizures [36.5%]) (P < .001). ICA was the only clinical manifestation in 16/103 (16.5%) seizures, and preceded EEG seizure onset by 8 ± 4.9 s, in 56/103 (54.3%) seizures. ICA ≥60 s was associated with severe hypoxemia (SpO2 <75%). Focal onset impaired awareness (FOIA) motor onset with automatisms and FOA nonmotor onset semiologies were associated with ICA presence (P < .001), ICA duration (P = .002), and moderate/severe hypoxemia (P = .04). Temporal lobe epilepsy was highly associated with ICA in comparison to extratemporal epilepsy (P = .001) and frontal lobe epilepsy (P = .001). Isolated postictal central apnea was not seen; in 3/103 seizures (3%), ICA persisted into the postictal period. SIGNIFICANCE ICA is a frequent, self-limiting semiological feature of focal epilepsy, often starting before surface EEG onset, and may be the only clinical manifestation of focal seizures. However, prolonged ICA (≥60 s) is associated with severe hypoxemia and may be a potential SUDEP biomarker. ICA is more frequently seen in temporal than extratemporal seizures, and in typical temporal seizure semiologies. ICA rarely persists after seizure end. ICA agnosia is typical, and thus it may remain unrecognized without polygraphic measurements that include breathing parameters.
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Affiliation(s)
- Nuria Lacuey
- Epilepsy Center, University Hospitals Cleveland Medical Center, Cleveland, OH, USA
| | - Bilal Zonjy
- NINDS Center for SUDEP Research (CSR), Cleveland, OH, USA
| | - Johnson P Hampson
- Epilepsy Center, University Hospitals Cleveland Medical Center, Cleveland, OH, USA
| | | | - Anita Zaremba
- NINDS Center for SUDEP Research (CSR), Cleveland, OH, USA
| | - Rup K Sainju
- NINDS Center for SUDEP Research (CSR), Cleveland, OH, USA.,University of Iowa School of Medicine, Iowa City, IA, USA
| | - Brian K Gehlbach
- NINDS Center for SUDEP Research (CSR), Cleveland, OH, USA.,University of Iowa School of Medicine, Iowa City, IA, USA
| | - Stephan Schuele
- NINDS Center for SUDEP Research (CSR), Cleveland, OH, USA.,Feinberg School of Medicine, Northwestern University, Chicago, IL, USA
| | - Daniel Friedman
- NINDS Center for SUDEP Research (CSR), Cleveland, OH, USA.,NYU Langone School of Medicine, New York, NY, USA
| | - Orrin Devinsky
- NINDS Center for SUDEP Research (CSR), Cleveland, OH, USA.,NYU Langone School of Medicine, New York, NY, USA
| | - Maromi Nei
- NINDS Center for SUDEP Research (CSR), Cleveland, OH, USA.,Sidney Kimmel Medical College, Thomas Jefferson University, Philadelphia, PA, USA
| | - Ronald M Harper
- NINDS Center for SUDEP Research (CSR), Cleveland, OH, USA.,Department of Neurobiology and the Brain Research Institute, University of California, Los Angeles (UCLA), Los Angeles, CA, USA
| | - Luke Allen
- NINDS Center for SUDEP Research (CSR), Cleveland, OH, USA.,Institute of Neurology, University College London, London, UK
| | - Beate Diehl
- NINDS Center for SUDEP Research (CSR), Cleveland, OH, USA.,Institute of Neurology, University College London, London, UK
| | - John J Millichap
- NINDS Center for SUDEP Research (CSR), Cleveland, OH, USA.,Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, IL, USA
| | - Lisa Bateman
- NINDS Center for SUDEP Research (CSR), Cleveland, OH, USA.,Department of Neurology, Columbia University, New York, NY, USA
| | - Mark A Granner
- NINDS Center for SUDEP Research (CSR), Cleveland, OH, USA
| | | | - George B Richerson
- NINDS Center for SUDEP Research (CSR), Cleveland, OH, USA.,University of Iowa School of Medicine, Iowa City, IA, USA
| | - Samden D Lhatoo
- Epilepsy Center, University Hospitals Cleveland Medical Center, Cleveland, OH, USA.,NINDS Center for SUDEP Research (CSR), Cleveland, OH, USA
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18
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Kutch JJ, Ichesco E, Hampson JP, Labus JS, Farmer MA, Martucci KT, Ness TJ, Deutsch G, Apkarian AV, Mackey SC, Klumpp DJ, Schaeffer AJ, Rodriguez LV, Kreder KJ, Buchwald D, Andriole GL, Lai HH, Mullins C, Kusek JW, Landis JR, Mayer EA, Clemens JQ, Clauw DJ, Harris RE. Brain signature and functional impact of centralized pain: a multidisciplinary approach to the study of chronic pelvic pain (MAPP) network study. Pain 2017; 158:1979-1991. [PMID: 28692006 PMCID: PMC5964335 DOI: 10.1097/j.pain.0000000000001001] [Citation(s) in RCA: 91] [Impact Index Per Article: 13.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/20/2023]
Abstract
Chronic pain is often measured with a severity score that overlooks its spatial distribution across the body. This widespread pain is believed to be a marker of centralization, a central nervous system process that decouples pain perception from nociceptive input. Here, we investigated whether centralization is manifested at the level of the brain using data from 1079 participants in the Multidisciplinary Approach to the Study of Chronic Pelvic Pain Research Network (MAPP) study. Participants with a clinical diagnosis of urological chronic pelvic pain syndrome (UCPPS) were compared to pain-free controls and patients with fibromyalgia, the prototypical centralized pain disorder. Participants completed questionnaires capturing pain severity, function, and a body map of pain. A subset (UCPPS N = 110; fibromyalgia N = 23; healthy control N = 49) underwent functional and structural magnetic resonance imaging. Patients with UCPPS reported pain ranging from localized (pelvic) to widespread (throughout the body). Patients with widespread UCPPS displayed increased brain gray matter volume and functional connectivity involving sensorimotor and insular cortices (P < 0.05 corrected). These changes translated across disease diagnoses as identical outcomes were present in patients with fibromyalgia but not pain-free controls. Widespread pain was also associated with reduced physical and mental function independent of pain severity. Brain pathology in patients with centralized pain is related to pain distribution throughout the body. These patients may benefit from interventions targeting the central nervous system.
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Affiliation(s)
- Jason J. Kutch
- Division of Biokinesiology and Physical Therapy, University of Southern California, Los Angeles, CA, USA
| | - Eric Ichesco
- Department of Anesthesiology, Chronic Pain and Fatigue Research Center, University of Michigan, Ann Arbor, MI, USA
| | - Johnson P. Hampson
- Department of Anesthesiology, Chronic Pain and Fatigue Research Center, University of Michigan, Ann Arbor, MI, USA
| | - Jennifer S. Labus
- Oppenheimer Center for Neurobiology of Stress, Pain and Interoception Network (PAIN), David Geffen School of Medicine at UCLA, Los Angeles, CA, USA
| | - Melissa A. Farmer
- Department of Physiology, Northwestern University, Feinberg School of Medicine, Chicago, IL, USA
| | - Katherine T. Martucci
- Department of Anesthesiology, Perioperative and Pain Medicine, Division of Pain Medicine, Stanford University Medical Center, Stanford, CA, USA
| | - Timothy J. Ness
- Departments of Radiology and Anesthesiology, University of Alabama, Birmingham Medical Center, Birmingham, AL, USA
| | - Georg Deutsch
- Departments of Radiology and Anesthesiology, University of Alabama, Birmingham Medical Center, Birmingham, AL, USA
| | - A. Vania Apkarian
- Department of Physiology, Northwestern University, Feinberg School of Medicine, Chicago, IL, USA
| | - Sean C. Mackey
- Department of Anesthesiology, Perioperative and Pain Medicine, Division of Pain Medicine, Stanford University Medical Center, Stanford, CA, USA
| | - David J. Klumpp
- Department of Urology, Northwestern University, Feinberg School of Medicine, Chicago, IL, USA
| | - Anthony J. Schaeffer
- Department of Urology, Northwestern University, Feinberg School of Medicine, Chicago, IL, USA
| | | | - Karl J. Kreder
- Department of Urology, University of Iowa, Iowa City, IA, USA
| | - Dedra Buchwald
- College of Medicine, Washington State University, Seattle, WA, USA
| | | | - H. Henry Lai
- Department of Urology, Washington University, Saint Louis, MO, USA
| | - Chris Mullins
- National Institute of Diabetes and Digestive and Kidney Diseases, NIH, Bethesda, MD, USA
| | - John W. Kusek
- National Institute of Diabetes and Digestive and Kidney Diseases, NIH, Bethesda, MD, USA
| | - J. Richard Landis
- Department of Biostatistics and Epidemiology, University of Pennsylvania, Philadelphia, PA, USA
| | - Emeran A. Mayer
- Oppenheimer Center for Neurobiology of Stress, Pain and Interoception Network (PAIN), David Geffen School of Medicine at UCLA, Los Angeles, CA, USA
| | | | - Daniel J. Clauw
- Department of Anesthesiology, Chronic Pain and Fatigue Research Center, University of Michigan, Ann Arbor, MI, USA
| | - Richard E. Harris
- Department of Anesthesiology, Chronic Pain and Fatigue Research Center, University of Michigan, Ann Arbor, MI, USA
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19
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Puiu T, Kairys AE, Pauer L, Schmidt-Wilcke T, Ichesco E, Hampson JP, Napadow V, Clauw DJ, Harris RE. Association of Alterations in Gray Matter Volume With Reduced Evoked-Pain Connectivity Following Short-Term Administration of Pregabalin in Patients With Fibromyalgia. Arthritis Rheumatol 2017; 68:1511-21. [PMID: 26816332 DOI: 10.1002/art.39600] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/10/2015] [Accepted: 01/14/2016] [Indexed: 01/10/2023]
Abstract
OBJECTIVE Pregabalin (PGB) is an α2 δ calcium-channel subunit ligand that has previously been shown to reduce chronic pain in multiple conditions. Preclinical studies indicate that PGB may down-regulate brain glutamate release while also inhibiting astrocyte induction of glutamatergic synapse formation, and recent clinical findings support the notion that PGB modulates glutamatergic activity and functional brain connectivity in order to produce analgesia. The present study was undertaken to examine concurrent changes in brain gray matter volume (GMV) or evoked-pain connectivity in humans receiving PGB. METHODS Sixteen female fibromyalgia patients participated in a randomized double-blind 2-period crossover study of PGB versus placebo. Before and after each period, patients underwent high-resolution structural and evoked pressure-pain functional brain imaging. GMV was analyzed using voxel-based morphometry, and functional connectivity during evoked pressure-pain was assessed. RESULTS PGB administration significantly reduced GMV within the posterior insula bilaterally, whereas there were no significant changes in insular GMV following placebo treatment. GMV reductions in the medial frontal gyrus were also observed when comparing PGB versus placebo treatment, and were associated with reduced clinical pain. These reductions in insular GMV were associated with concomitant reductions in connectivity to the default mode network, which was also associated with reduced clinical pain. CONCLUSION Short-term PGB treatment altered brain structure and evoked-pain connectivity, and these decreases were associated with reduced clinical pain. We speculate that these fairly rapid changes in GMV may be related to brain neuroplasticity. It is unknown whether these effects are generalizable to other chronic pain states.
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Affiliation(s)
| | - Anson E Kairys
- University of Michigan, Ann Arbor, and University of Colorado Denver
| | - Lynne Pauer
- Pfizer Global Research and Development, Groton, Connecticut
| | | | | | | | - Vitaly Napadow
- Massachusetts General Hospital and Harvard Medical School, Boston
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20
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Harris RE, Ichesco E, Cummiford C, Hampson JP, Chenevert TL, Basu N, Zick SM. Brain Connectivity Patterns Dissociate Action of Specific Acupressure Treatments in Fatigued Breast Cancer Survivors. Front Neurol 2017; 8:298. [PMID: 28690587 PMCID: PMC5481304 DOI: 10.3389/fneur.2017.00298] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/13/2017] [Accepted: 06/09/2017] [Indexed: 11/13/2022] Open
Abstract
Persistent fatigue is a pernicious symptom in many cancer survivors. Existing treatments are limited or ineffective and often lack any underlying biologic rationale. Acupressure is emerging as a promising new intervention for persistent cancer-related fatigue; however, the underlying mechanisms of action are unknown. Our previous investigations suggested that fatigued breast cancer survivors have alterations in brain neurochemistry within the posterior insula and disturbed functional connectivity to the default mode network (DMN), as compared to non-fatigued breast cancer survivors. Here, we investigated if insula and DMN connectivity were modulated by self-administered acupressure by randomizing breast cancer survivors (n = 19) to two distinct treatments: relaxing acupressure or stimulating acupressure. All participants underwent proton magnetic resonance spectroscopy of the posterior insula and functional connectivity magnetic resonance imaging at baseline and immediately following 6 weeks of acupressure self-treatment. As compared to baseline measures, relaxing acupressure decreased posterior insula to dorsolateral prefrontal cortex connectivity, whereas stimulating acupressure enhanced this connectivity (p < 0.05 corrected). For relaxing but not stimulating acupressure, reduced connectivity was associated with sleep improvement. In addition, connectivity of the DMN to the superior colliculus was increased with relaxing acupressure and decreased with stimulating acupressure, whereas DMN connectivity to the bilateral pulvinar was increased with stimulating and decreased with relaxing acupressure (p < 0.05 corrected). These data suggest that self-administered acupressure at different acupoints has specificity in relation to their mechanisms of action in fatigued breast cancer survivors.
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Affiliation(s)
- Richard E Harris
- Department of Anesthesiology, University of Michigan, Ann Arbor, MI, United States.,Neuroscience Graduate Program, University of Michigan, Ann Arbor, MI, United States
| | - Eric Ichesco
- Department of Anesthesiology, University of Michigan, Ann Arbor, MI, United States
| | - Chelsea Cummiford
- Department of Anesthesiology, University of Michigan, Ann Arbor, MI, United States.,Neuroscience Graduate Program, University of Michigan, Ann Arbor, MI, United States
| | - Johnson P Hampson
- Department of Anesthesiology, University of Michigan, Ann Arbor, MI, United States
| | - Thomas L Chenevert
- Department of Radiology, University of Michigan, Ann Arbor, MI, United States
| | - Neil Basu
- Department of Anesthesiology, University of Michigan, Ann Arbor, MI, United States.,Department of Epidemiology, University of Aberdeen, Aberdeen, United Kingdom
| | - Suzanna M Zick
- Department of Family Medicine, University of Michigan, Ann Arbor, MI, United States.,Nutritional Sciences, University of Michigan, Ann Arbor, MI, United States
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Ichesco E, Puiu T, Hampson JP, Kairys AE, Clauw DJ, Harte SE, Peltier SJ, Harris RE, Schmidt-Wilcke T. Altered fMRI resting-state connectivity in individuals with fibromyalgia on acute pain stimulation. Eur J Pain 2016; 20:1079-89. [PMID: 26773435 DOI: 10.1002/ejp.832] [Citation(s) in RCA: 37] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/29/2015] [Indexed: 12/29/2022]
Abstract
BACKGROUND Fibromyalgia is a chronic widespread pain condition, with patients commonly reporting other symptoms such as sleep difficulties, memory complaints and fatigue. The use of magnetic resonance imaging (MRI) in fibromyalgia has allowed for the detection of neural abnormalities, with alterations in brain activation elicited by experimental pain and alterations in resting state connectivity related to clinical pain. METHODS In this study, we sought to monitor state changes in resting brain connectivity following experimental pressure pain in fibromyalgia patients and healthy controls. Twelve fibromyalgia patients and 15 healthy controls were studied by applying discrete pressure stimuli to the thumbnail bed during MRI. Resting-state functional MRI scanning was performed before and immediately following experimental pressure pain. We investigated changes in functional connectivity to the thalamus and the insular cortex. RESULTS Acute pressure pain increased insula connectivity to the anterior cingulate and the hippocampus. Additionally, we observed increased thalamic connectivity to the precuneus/posterior cingulate cortex, a known part of the default mode network, in patients but not in controls. This connectivity was correlated with changes in clinical pain. CONCLUSIONS These data reporting changes in resting-state brain activity following a noxious stimulus suggest that the acute painful stimuli may contribute to the alteration of the neural signature of chronic pain. WHAT DOES THIS STUDY/ADD?: In this study acute pain application shows an echo in functional connectivity and clinical pain changes in chronic pain.
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Affiliation(s)
- E Ichesco
- Chronic Pain and Fatigue Research Center, Department of Anesthesiology, University of Michigan, Ann Arbor, USA
| | - T Puiu
- Chronic Pain and Fatigue Research Center, Department of Anesthesiology, University of Michigan, Ann Arbor, USA
| | - J P Hampson
- Chronic Pain and Fatigue Research Center, Department of Anesthesiology, University of Michigan, Ann Arbor, USA
| | - A E Kairys
- Chronic Pain and Fatigue Research Center, Department of Anesthesiology, University of Michigan, Ann Arbor, USA
- Department of Psychology, University of Colorado Denver, USA
| | - D J Clauw
- Chronic Pain and Fatigue Research Center, Department of Anesthesiology, University of Michigan, Ann Arbor, USA
| | - S E Harte
- Chronic Pain and Fatigue Research Center, Department of Anesthesiology, University of Michigan, Ann Arbor, USA
| | - S J Peltier
- Functional MRI Laboratory, University of Michigan, Ann Arbor, USA
| | - R E Harris
- Chronic Pain and Fatigue Research Center, Department of Anesthesiology, University of Michigan, Ann Arbor, USA
| | - T Schmidt-Wilcke
- Chronic Pain and Fatigue Research Center, Department of Anesthesiology, University of Michigan, Ann Arbor, USA
- Department of Neurology, BG Universitätsklinik Bergmannsheil, Ruhr University Bochum, Germany
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Darbari DS, Hampson JP, Ichesco E, Kadom N, Vezina G, Evangelou I, Clauw DJ, Taylor Vi JG, Harris RE. Frequency of Hospitalizations for Pain and Association With Altered Brain Network Connectivity in Sickle Cell Disease. J Pain 2015; 16:1077-86. [PMID: 26291276 DOI: 10.1016/j.jpain.2015.07.005] [Citation(s) in RCA: 68] [Impact Index Per Article: 7.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/15/2015] [Revised: 07/11/2015] [Accepted: 07/28/2015] [Indexed: 12/23/2022]
Abstract
UNLABELLED Sickle cell disease (SCD) is a hemoglobinopathy that affects more than 100,000 individuals in the United States. The disease is characterized by the presence of sickle hemoglobin and recurrent episodes of pain. Some individuals with SCD experience frequent hospitalizations and a high burden of pain. The role of central mechanisms in SCD pain has not been explored. Twenty-five adolescents and young adults with SCD underwent functional magnetic resonance imaging. Participants were stratified into groups with high pain or low pain based on the number of hospitalizations for pain in the preceding 12 months. Resting state functional connectivity was analyzed using seed-based and dual regression independent component analysis. Intrinsic brain connectivity was compared between the high pain and low pain groups, and association with fetal hemoglobin, a known modifier of SCD, was explored. Patients in the high pain group displayed an excess of pronociceptive connectivity such as between anterior cingulate and default mode network structures, such as the precuneus, whereas patients in the low pain group showed more connectivity to antinociceptive structures such as the perigenual and subgenual cingulate. Although a similar proportion of patients in both groups reported that they were on hydroxyurea, the fetal hemoglobin levels were significantly higher in the low pain group and were associated with greater connectivity to antinociceptive structures. These findings support the role of central mechanisms in SCD pain. Intrinsic brain connectivity should be explored as a complementary and objective outcome measure in SCD pain research. PERSPECTIVE Altered connectivity patterns associated with high pain experience in patients with sickle cell disease suggest a possible role of central mechanisms in sickle cell pain. Resting state brain connectivity studies should be explored as an effective methodology to investigate pain in SCD.
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Affiliation(s)
- Deepika S Darbari
- Division of Hematology, Center for Cancer and Blood Disorders, Children's National Health System, Washington, DC; Department of Pediatrics, The George Washington University School of Medicine and Health Sciences, Washington, DC; Genomic Medicine Section, Hematology Branch, National Heart, Lung and Blood Institute, National Institutes of Health, Bethesda, Maryland.
| | - Johnson P Hampson
- Chronic Pain and Fatigue Research Center, Department of Anesthesiology, University of Michigan, Ann Arbor, Michigan
| | - Eric Ichesco
- Chronic Pain and Fatigue Research Center, Department of Anesthesiology, University of Michigan, Ann Arbor, Michigan
| | - Nadja Kadom
- Department of Radiology, Boston University Medical Center, Boston, Massachusetts
| | - Gilbert Vezina
- Department of Pediatrics, The George Washington University School of Medicine and Health Sciences, Washington, DC; Department of Diagnostic Imaging and Radiology, Children's National Health System, Washington, District of Columbia
| | - Iordanis Evangelou
- Genomic Medicine Section, Hematology Branch, National Heart, Lung and Blood Institute, National Institutes of Health, Bethesda, Maryland; Department of Diagnostic Imaging and Radiology, Children's National Health System, Washington, District of Columbia
| | - Daniel J Clauw
- Chronic Pain and Fatigue Research Center, Department of Anesthesiology, University of Michigan, Ann Arbor, Michigan
| | - James G Taylor Vi
- Genomic Medicine Section, Hematology Branch, National Heart, Lung and Blood Institute, National Institutes of Health, Bethesda, Maryland
| | - Richard E Harris
- Chronic Pain and Fatigue Research Center, Department of Anesthesiology, University of Michigan, Ann Arbor, Michigan
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Hampson JP, Zick SM, Khabir T, Wright BD, Harris RE. Altered resting brain connectivity in persistent cancer related fatigue. Neuroimage Clin 2015; 8:305-13. [PMID: 26106555 PMCID: PMC4474178 DOI: 10.1016/j.nicl.2015.04.022] [Citation(s) in RCA: 50] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 01/15/2015] [Revised: 04/27/2015] [Accepted: 04/29/2015] [Indexed: 12/20/2022]
Abstract
There is an estimated 3 million women in the US living as breast cancer survivors and persistent cancer related fatigue (PCRF) disrupts the lives of an estimated 30% of these women. PCRF is associated with decreased quality of life, decreased sleep quality, impaired cognition and depression. The mechanisms of cancer related fatigue are not well understood; however, preliminary findings indicate dysfunctional activity in the brain as a potential factor. Here we investigate the relationship between PCRF on intrinsic resting state connectivity in this population. Twenty-three age matched breast cancer survivors (15 fatigued and 8 non-fatigued) who completed all cancer-related treatments at least 12 weeks prior to the study, were recruited to undergo functional connectivity magnetic resonance imaging (fcMRI). Intrinsic resting state networks were examined with both seed based and independent component analysis methods. Comparisons of brain connectivity patterns between groups as well as correlations with self-reported fatigue symptoms were performed. Fatigued patients displayed greater left inferior parietal lobule to superior frontal gyrus connectivity as compared to non-fatigued patients (P < 0.05 FDR corrected). This enhanced connectivity was associated with increased physical fatigue (P = 0.04, r = 0.52) and poor sleep quality (P = 0.04, r = 0.52) in the fatigued group. In contrast greater connectivity in the non-fatigued group was found between the right precuneus to the periaqueductal gray as well as the left IPL to subgenual cortex (P < 0.05 FDR corrected). Mental fatigue scores were associated with greater default mode network (DMN) connectivity to the superior frontal gyrus (P = 0.05 FDR corrected) among fatigued subjects (r = 0.82) and less connectivity in the non-fatigued group (r = -0.88). These findings indicate that there is enhanced intrinsic DMN connectivity to the frontal gyrus in breast cancer survivors with persistent fatigue. As the DMN is a network involved in self-referential thinking we speculate that enhanced connectivity between the DMN and the frontal gyrus may be related to mental fatigue and poor sleep quality. In contrast, enhanced connectivity between the DMN and regions in the subgenual cingulate and brainstem may serve a protective function in the non-fatigued group.
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Key Words
- BA, Brodmann area
- BCS, breast cancer survivors
- BFI, brief fatigue inventory
- BOLD, blood-oxygen level dependence
- Breast cancer survivors
- CFS, chronic fatigue syndrome
- DMN, default mode network
- Default mode network (DMN)
- FDR, false discovery rate
- FWHM, Full width at half maximum
- Functional connectivity magnetic resonance imaging (fcMRI)
- HADS, hospital anxiety and depression scale
- ICA, independent component analysis
- IPL, inferior parietal lobule
- Independent component analysis (ICA)
- MFI, multidimensional fatigue Inventory
- MNI, Montreal Neurological Institute
- PC, posterior cingulate
- PCRF, persistent cancer related fatigue
- PSQI, Pittsburgh sleep quality index
- Persistent cancer related fatigue (PCRF)
- SFG, superior frontal gyrus
- SPM, statistical parametric mapping
- STR, spatio-temporal regression
- fcMRI, functional connectivity magnetic resonance imaging
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Affiliation(s)
- Johnson P. Hampson
- Chronic Pain and Fatigue Research Center, Department of Anesthesiology, University of Michigan, Ann Arbor, MI 48106, USA
- Corresponding author at: Chronic Pain and Fatigue Research Center, Department of Anesthesiology, 24 Frank Lloyd Wright Drive, P.O. Box 385, Lobby M, Ann Arbor, MI 48106, USA. Tel.: +1 734 998 7019; fax: +1 734 998 6900.
| | - Suzanna M. Zick
- Department of Family Medicine, University of Michigan, Ann Arbor, MI, USA
| | - Tohfa Khabir
- Department of Family Medicine, University of Michigan, Ann Arbor, MI, USA
| | - Benjamin D. Wright
- Department of Family Medicine, University of Michigan, Ann Arbor, MI, USA
| | - Richard E. Harris
- Chronic Pain and Fatigue Research Center, Department of Anesthesiology, University of Michigan, Ann Arbor, MI 48106, USA
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Ichesco E, Schmidt-Wilcke T, Bhavsar R, Clauw DJ, Peltier SJ, Kim J, Napadow V, Hampson JP, Kairys AE, Williams DA, Harris RE. Altered resting state connectivity of the insular cortex in individuals with fibromyalgia. J Pain 2014; 15:815-826.e1. [PMID: 24815079 DOI: 10.1016/j.jpain.2014.04.007] [Citation(s) in RCA: 112] [Impact Index Per Article: 11.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/17/2014] [Revised: 04/07/2014] [Accepted: 04/15/2014] [Indexed: 12/27/2022]
Abstract
UNLABELLED The insular cortex (IC) and cingulate cortex (CC) are critically involved in pain perception. Previously we demonstrated that fibromyalgia (FM) patients have greater connectivity between the insula and default mode network at rest, and that changes in the degree of this connectivity were associated with changes in the intensity of ongoing clinical pain. In this study we more thoroughly evaluated the degree of resting-state connectivity to multiple regions of the IC in individuals with FM and healthy controls. We also investigated the relationship between connectivity, experimental pain, and current clinical chronic pain. Functional connectivity was assessed using resting-state functional magnetic resonance imaging in 18 FM patients and 18 age- and sex-matched healthy controls using predefined seed regions in the anterior, middle, and posterior IC. FM patients exhibited greater connectivity between 1) right mid IC and right mid/posterior CC and right mid IC, 2) right posterior IC and left CC, and 3) right anterior IC and left superior temporal gyrus. Healthy controls displayed greater connectivity between left anterior IC and bilateral medial frontal gyrus/anterior cingulate cortex; and left posterior IC and right superior frontal gyrus. Within the FM group, greater connectivity between the IC and CC was associated with decreased pressure-pain thresholds. PERSPECTIVE These data provide further support for altered resting-state connectivity between the IC and other brain regions known to participate in pain perception/modulation, which may play a pathogenic role in conditions such as FM. We speculate that altered IC connectivity is associated with the experience of chronic pain in individuals with FM.
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Affiliation(s)
- Eric Ichesco
- Department of Anesthesiology, Chronic Pain and Fatigue Research Center, University of Michigan, Ann Arbor, Michigan.
| | - Tobias Schmidt-Wilcke
- Department of Anesthesiology, Chronic Pain and Fatigue Research Center, University of Michigan, Ann Arbor, Michigan; Department of Neurology, Bergmannsheil, Ruhr University Bochum, Bochum, Germany
| | - Rupal Bhavsar
- Department of Anesthesiology, Chronic Pain and Fatigue Research Center, University of Michigan, Ann Arbor, Michigan; Neurology Department, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Daniel J Clauw
- Department of Anesthesiology, Chronic Pain and Fatigue Research Center, University of Michigan, Ann Arbor, Michigan
| | - Scott J Peltier
- Functional MRI Laboratory, University of Michigan, Ann Arbor, Michigan
| | - Jieun Kim
- MGH/MIT/HMS Athinoula A. Martinos Center for Biomedical Imaging, Charlestown, Massachusetts
| | - Vitaly Napadow
- MGH/MIT/HMS Athinoula A. Martinos Center for Biomedical Imaging, Charlestown, Massachusetts; Department of Anesthesiology, Perioperative and Pain Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts; Department of Radiology, Logan College of Chiropractic, Chesterfield, Missouri
| | - Johnson P Hampson
- Department of Anesthesiology, Chronic Pain and Fatigue Research Center, University of Michigan, Ann Arbor, Michigan
| | - Anson E Kairys
- Department of Anesthesiology, Chronic Pain and Fatigue Research Center, University of Michigan, Ann Arbor, Michigan; Department of Psychology, University of Colorado Denver, Denver, Colorado
| | - David A Williams
- Department of Anesthesiology, Chronic Pain and Fatigue Research Center, University of Michigan, Ann Arbor, Michigan
| | - Richard E Harris
- Department of Anesthesiology, Chronic Pain and Fatigue Research Center, University of Michigan, Ann Arbor, Michigan
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Hampson JP, Reed BD, Clauw DJ, Bhavsar R, Gracely RH, Haefner HK, Harris RE. Augmented central pain processing in vulvodynia. J Pain 2013; 14:579-89. [PMID: 23578957 DOI: 10.1016/j.jpain.2013.01.767] [Citation(s) in RCA: 70] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/16/2012] [Revised: 01/15/2013] [Accepted: 01/19/2013] [Indexed: 10/27/2022]
Abstract
UNLABELLED Vulvodynia (VVD) is a chronic pain disorder wherein women display sensitivity to evoked stimuli at the vulva and/or spontaneous vulvar pain. Our previous work suggests generalized hyperalgesia in this population; however, little is known about central neurobiological factors that may influence pain in VVD. Here we investigated local (vulvar) and remote (thumb) pressure-evoked pain processing in 24 VVD patients compared to 13 age-matched, pain-free healthy controls (HCs). As a positive control we also examined thumb pressure pain in 24 fibromyalgia patients. The VVD and fibromyalgia patients displayed overlapping insular brain activations that were greater than HCs in response to thumb stimulation (P < .005 corrected). Compared to HCs, VVD participants displayed greater levels of activation during thumb stimulation within the insula, dorsal midcingulate, posterior cingulate, and thalamus (P < .005 corrected). Significant differences between VVD subgroups (primary versus secondary and provoked versus unprovoked) were seen within the posterior cingulate with thumb stimulation and within the precuneus region with vulvar stimulation (provoked versus unprovoked only). The augmented brain activation in VVD patients in response to a stimulus remote from the vulva suggests central neural pathology in this disorder. Moreover, differing central activity between VVD subgroups suggests heterogeneous pathologies within this diagnosis. PERSPECTIVE The presence of augmented brain responses to pressure stimuli remote from the vulva was observed in vulvodynia patients. These findings may guide treatment decisions for better response, as brain mechanisms may be a factor in some VVD patients.
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Affiliation(s)
- Johnson P Hampson
- Chronic Pain and Fatigue Research Center, Department of Anesthesiology, University of Michigan, Ann Arbor, Michigan 48106, USA.
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Abstract
A case report of a 67-year-old man who suffered a hypersensitivity reaction to atorvastatin is described. He suffered collapse and was in shock characterised by marked hypotension, facial oedema and eosinophilia. His initial condition led the surgeons to think he might have had an abdominal sepsis. The reaction with angio-oedema reoccurred on rechallenge. The literature on statin hypersensitivity reactions which can occur several months after commencing therapy is reviewed. Although the estimated prevalence is rare (0.1%), prescribers and pharmacists should be aware of this important reaction which can be quite debilitating.
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Affiliation(s)
- J P Hampson
- North East Wales NHS Trust, Maelor Hospital, Wrexham, UK.
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Hampson JP, Harvey JN. Postmarketing surveillance and black box warnings. JAMA 2002; 288:956; author reply 958-9. [PMID: 12190359] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/26/2023]
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Abstract
AIMS To conduct a systematic review of drug induced adverse ocular effects in diabetes to determine if this approach identified any previously unrecognised adverse drug effects; to make a preliminary assessment of the feasibility of this approach in identifying adverse drug reactions; and to assess the current accessibility of this information to prescribing physicians. METHODS Literature search of online biomedical databases. The search strategy linked eye disorders with adverse drug reactions and diabetes. Source journals were classified as medical, pharmaceutical, diabetes related, or ophthalmological. It was determined whether the reactions identified were recorded in drug datasheets and the British National Formulary. RESULTS 63 references fulfilled the selection criteria, of which 45 were considered to be relevant to the study. The majority of these were case reports but cross sectional surveys, case-control and cohort studies, and review articles were also identified. 61% of the reactions were not recorded in the British National Formulary and 41% were not recorded in the datasheets. 55% appeared in specialist ophthalmology journals. CONCLUSIONS This is a feasible approach to the identification of adverse drug reactions. Adverse reactions not listed in the most commonly used reference sources were found. The majority were published in specialist ophthalmology journals which might not be seen by prescribing physicians.
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Affiliation(s)
- J P Hampson
- University of Wales College of Medicine, Gwenfro Academic Unit, Wrexham Technology Park Centre, Croesnewydd Road, Wrexham LL13 7YP
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Abstract
This discussion reviews published papers on the role and action of metronidazole in reducing or eradicating odour from malignant wounds and pressure sores
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Abstract
This review examines broad issues of concern regarding the primary/secondary care interface. The main purpose was to identify areas of good practice which could be adapted for more general use. One of the most fundamental aspects identified was communication, which is discussed in some detail. Also covered are shared prescribing and disease management. The data suggest that the most effective system(s) of shared care has yet to be established. Further qualitative and economic evaluations are required, taking into account patient preferences. Although the literature does describe certain practice exemplars, it is clear that inter- and intra-professional communication continues to be a problem. Whilst information technology may provide some of the solutions, it is concluded that a culture change, which compels health professionals to make sharing of patient information a much higher priority, is required.
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Affiliation(s)
- J P Hampson
- Pharmacy Academic Practice Unit, Wrexham Medical Institute, UK
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Christie G, Coleman JW, Newby S, McDiarmaid-Gordon A, Hampson JP, Breckenridge AM, Park BK. A survey of the prevalence of penicillin-specific IgG, IgM and IgE antibodies detected by ELISA and defined by hapten inhibition, in patients with suspected penicillin allergy and in healthy volunteers. Br J Clin Pharmacol 1988; 25:381-6. [PMID: 3358899 PMCID: PMC1386363 DOI: 10.1111/j.1365-2125.1988.tb03317.x] [Citation(s) in RCA: 29] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/05/2023] Open
Abstract
1. IgG, IgM and IgE anti-benzylpenicilloyl (BPO) antibody activities were determined by enzyme-linked immunosorbent assay (ELISA) in sera from 100 patients who claimed to be allergic to penicillin, and from 50 healthy volunteers. Continuous frequency distributions for all three classes of anti-BPO antibody, defined as differential binding (delta OD) to BPO-human serum albumin (HSA) and HSA, were obtained for both groups. 2. For IgM and IgE classes the anti-BPO activities were slightly but statistically significantly higher in the patient group compared with the volunteer group. 3. Hapten inhibition ELISAs were performed to confirm specificity for the BPO determinant. On the basis of antibody activities (delta OD values) greater than or equal to 0.3 and 50% inhibition of binding in the presence of 100 micrograms ml-1 BPO-caproate, BPO-specific IgG antibody was identified in 4/100 of the patients' sera and in 1/50 of the volunteers' sera; BPO-specific IgM was identified in 7/100 patients' sera and 1/50 volunteers' sera; and BPO-specific IgE in 5/100 patients' sera and 1/50 volunteers' sera. 4. Not all sera with differential antibody binding to BPO-HSA/HSA were inhibited by the BPO hapten. Hence, hapten inhibition assays are essential for the unambiguous demonstration of drug specific antibodies.
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Affiliation(s)
- G Christie
- Department of Pharmacology and Therapeutics, University of Liverpool
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Griffiths LR, Bartzokas CA, Hampson JP, Ghose AR. Antibiotic costs and prescribing patterns in a recently commissioned Liverpool teaching hospital. Part I: Antimicrobial therapy. J Hosp Infect 1986; 8:159-67. [PMID: 2876031 DOI: 10.1016/0195-6701(86)90042-3] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/03/2023]
Abstract
All antibiotics prescribed in a major teaching hospital were prospectively surveyed during 31 consecutive days. Of 2350 patients admitted during that period, 577 (24.6%) received antibiotics, 238 (10.1%) for prophylaxis and 417 (17.7%) for treatment. A total of 483 infections occurred in the treated patients, mainly in the chest (33.9%) and urinary tract (27.7%). Two hundred and forty-four infections (50.5%) were community-acquired and the remaining 239 hospital-acquired infections occurred in 8% of patients admitted. The cost of treating nosocomial sepsis was 4453 pounds (48% of the antibiotic expenditure for treatment). The average cost of treatment per patient varied considerably between hospital specialties; one-third of therapeutic antibiotic expenditure was consumed by haematological patients. Thirty-one antimicrobials alone or in 45 different combinations were issued; ampicillins were the most frequently prescribed antibiotics (31%), followed by co-trimoxazole (14%) and trimethoprim (8%). The patterns of antibiotic usage are discussed and inappropriate prescriptions examined.
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Griffiths LR, Bartzokas CA, Hampson JP, Ghose AR. Antibiotic costs and prescribing patterns in a recently commissioned Liverpool teaching hospital. Part II: Antimicrobial chemoprophylaxis. J Hosp Infect 1986; 8:168-77. [PMID: 2876032 DOI: 10.1016/0195-6701(86)90043-5] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/03/2023]
Abstract
All antibiotics prescribed for prophylaxis in a major teaching hospital were prospectively surveyed during 31 consecutive days. Of 2350 patients admitted during that period, 238 (10.1%) received antibiotics for prophylaxis. A total of 1238 operations were performed during the period of study, of which 201 (16.2%) were covered with antibiotics, at a cost of 3472 pounds. The use of prophylaxis increased according to the risk of peri-operative wound contamination, from 15.8% in Class I to 52.4% in Class III operations. The average cost of chemoprophylaxis also increased correspondingly. A further 40 regimens were issued for non-surgical prophylaxis at a cost of 258 pounds. Twenty antibiotics were prescribed either alone or in 37 different combinations for surgical prophylaxis, the most frequent being cephradine (22%), metronidazole (17%), penicillin (12%), and tobramycin (11%). The mean duration of antibiotic administration for all surgical procedures was 6.1 days.
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