Sudden unexpected death in epilepsy in patients treated with brain‐responsive neurostimulation

Devinsky, Orrin; Friedman, Daniel; Duckrow, Robert B.; Fountain, Nathan B.; Gwinn, Ryder P.; Leiphart, James W.; Murro, Anthony M.; Ness, Paul C. Van

doi:10.1111/epi.13998

Cited by 59 publications

(51 citation statements)

References 15 publications

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“…Establishment of nonseizure SUDEP as an entity 38 suggests that brainstem dysfunction may initiate the agonal event independently of cortical seizures. 39,40 Whereas spreading depression in cardiorespiratory suppression is unproven in humans, increasing evidence from imaging 41,42 and pathologic studies 43 suggests that key cardiorespiratory control structures are significantly damaged in patients with intractable epilepsy who succumb to SUDEP. Imaging studies 42 have shown increased right hippocampal and parahippocampal gray matter volume in patients experiencing SUDEP and high-SUDEP-risk patients, setting the stage for possible autonomic and respiratory output dysregulation.…”

Section: Discussionmentioning

confidence: 99%

Postconvulsive central apnea as a biomarker for sudden unexpected death in epilepsy (SUDEP)

et al. 2019

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ObjectiveTo characterize peri-ictal apnea and postictal asystole in generalized convulsive seizures (GCS) of intractable epilepsy. MethodsThis 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. ResultsWe 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). ConclusionsPCCA 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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Section: Discussionmentioning

confidence: 99%

Postconvulsive central apnea as a biomarker for sudden unexpected death in epilepsy (SUDEP)

et al. 2019

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“…Several studies have demonstrated submillimeter precision, 83,84 thus enabling high‐fidelity targeting in compact, highly eloquent regions. One such location could be the anterior nucleus of the thalamus, which is the current target for deep brain stimulation 73 . Other potential applications would be the acoustic ablation of amygdala, hippocampus, and piriform cortex for temporal lobe epilepsy, or ablation of lesional tissues such as focal cortical dysplasia, periventricular heterotopia, tuber, hypothalamic hamartoma, and small neoplasm 85‐87 .…”

Section: Future Directions: High Intensity Focused Ultrasound (Hifu)mentioning

confidence: 99%

“…This response seemed to be independent of lobe and 15% of the patients had seizure‐free periods greater than 1 year 70 . Furthermore, there did not appear to be neuropsychological decline, and there was quality of life improvement, decreased sudden unexpected death in epilepsy (SUDEP) rates, and real potential to serve as a tool for long‐term chronic monitoring 71‐73 . RNS‐like systems could also be used to document the effectiveness of anti‐epileptic medication 74 .…”

Section: Introductionmentioning

confidence: 99%

How technology is driving the landscape of epilepsy surgery

et al. 2020

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This article emphasizes the role of the technological progress in changing the landscape of epilepsy surgery and provides a critical appraisal of robotic applications, laser interstitial thermal therapy, intraoperative imaging, wireless recording, new neuromodulation techniques, and high-intensity focused ultrasound. Specifically, (a) it relativizes the current hype in using robots for stereo-electroencephalography (SEEG) to increase the accuracy of depth electrode placement and save operating time; (b) discusses the drawback of laser interstitial thermal therapy (LITT) when it comes to the need for adequate histopathologic specimen and the fact that the concept of stereotactic disconnection is not new; (c) addresses the ratio between the benefits and expenditure of using intraoperative magnetic resonance imaging (MRI), that is, the high technical and personnel expertise needed that might restrict its use to centers with a high case load, including those unrelated to epilepsy; (d) soberly reviews the advantages, disadvantages, and future potentials of neuromodulation techniques with special emphasis on the differences between closed and open-loop systems; and (e) provides a critical outlook on the clinical implications of focused ultrasound, wireless recording, and multipurpose electrodes that are already on the horizon. This outlook shows that although current ultrasonic systems do have some limitations in delivering the acoustic energy, further advance of this technique may lead to novel treatment paradigms. Furthermore, it highlights that new data streams from multipurpose electrodes and wireless transmission of intracranial recordings will become available soon once some critical developments will be achieved such as electrode fidelity, data processing and storage, heat conduction as well as rechargeable technology. A better understanding of modern epilepsy surgery will help to demystify epilepsy surgery for the patients and the treating physicians and thereby reduce the surgical treatment gap. K E Y W O R D Sepilepsy surgery, high-intensity focused ultrasound, intraoperative MRI, laser ablation, neuromodulation, robots 842 |

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“…Bei zwei Drittel der Menschen mit Epilepsie kann durch konsequente Antikonvulsivaeinnahme dauerhafte Anfallsfreiheit erreicht werden. Im verbleibenden Drittel sollten auch nicht medikamentöse, an Epilepsiezentren angebotene Verfahren wie die resektive Epilepsiechirurgie als effektivste Therapieoption, aber auch die Neurostimulationsverfahren oder ketogene Diäten erwogen werden, zumal all diese Verfahren eine Reduktion der Anfalls-häufigkeit und der SUDEP-Rate im Menschen [67,68] oder im Tiermodell gezeigt haben [69]. Eine Aufklärung der betroffenen Patienten und ihrer Betreuungspersonen über das Risiko von SUDEP und der Rolle der Pharmakoadhärenz in der Risikominderung wurde mittlerweile in die Leitlinien der Deutschen Gesellschaft für Neurologie (DGN) aufgenommen [70].…”

Section: Risikoeinschätzung Prävention Und Aufklärungunclassified

Plötzlicher, unerwarteter Tod bei Epilepsie

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Surges²

2019

Nervenheilkunde

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ZUSAMMENFASSUNGDer plötzliche, unerwartete Tod eines Menschen mit Epilepsie wird mit dem englischen Akronym SUDEP bezeichnet (sudden unexpected death in epilepsy). Etwa einer von 1000 Epilepsiepatienten stirbt hieran, vor allem jene mit häufigeren nächtlichen generalisierten konvulsiven Anfällen. Die Mehrzahl der SUDEP-Fälle ist durch postiktuale Störungen der Atem- und Kreislauffunktion mit primärer zentraler Apnoe und sekundärer Asystolie verursacht. Die beteiligten zellulären Pathomechanismen sind jedoch noch ungeklärt. Die Aufklärung aller Patienten und Angehörigen wird durch angloamerikanische Fachgesellschaften empfohlen und von den meisten auch gewünscht. Entscheidend für die Prävention ist eine konsequente Anfallskontrolle. Zudem kann eine nächtliche Supervision das Risiko für SUDEP relevant mindern, dafür stehen klinisch geprüfte alltagstaugliche Anfallsdetektionssysteme zur Verfügung.

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Sudden unexpected death in epilepsy in patients treated with brain‐responsive neurostimulation

Cited by 59 publications

References 15 publications

Postconvulsive central apnea as a biomarker for sudden unexpected death in epilepsy (SUDEP)

Postconvulsive central apnea as a biomarker for sudden unexpected death in epilepsy (SUDEP)

How technology is driving the landscape of epilepsy surgery

Plötzlicher, unerwarteter Tod bei Epilepsie

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