Ictal Cardiac Ryhthym Abnormalities

Cardiac rhythm abnormalities in the context of epilepsy are a well-known phenomenon. However, they are under-recognized and often missed. The pathophysiology of these events is unclear. Bradycardia and asystole are preceded by seizure onset suggesting ictal propagation into the cortex impacting cardiac autonomic function, and the insula and amygdala being possible culprits. Sudden unexpected death in epilepsy (SUDEP) refers to the unanticipated death of a patient with epilepsy not related to status epilepticus, trauma, drowning, or suicide. Frequent refractory generalized tonic-clonic seizures, anti-epileptic polytherapy, and prolonged duration of epilepsy are some of the commonly identified risk factors for SUDEP. However, the most consistent risk factor out of these is an increased frequency of generalized tonic–clonic seizures (GTC). Prevention of SUDEP is extremely important in patients with chronic, generalized epilepsy. Since increased frequency of GTCS is the most consistently reported risk factor for SUDEP, effective seizure control is the most important preventive strategy.

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Interictal autonomic dysfunction in patients with epilepsy

The Egyptian Journal of Neurology Psychiatry and Neurosurgery ◽

10.1186/s41983-021-00422-0 ◽

2021 ◽

Vol 57 (1) ◽

Author(s):

Kanar K. Shaker ◽

Akram M. Al Mahdawi ◽

Farqad B. Hamdan

Keyword(s):

Temporal Lobe ◽

Autonomic Function ◽

Mental Arithmetic ◽

Valsalva Maneuver ◽

Sympathetic Skin Response ◽

Deep Breathing ◽

Unexpected Death ◽

Hand Grip ◽

Skin Response ◽

Generalized Epilepsy

Abstract Background Autonomic nervous system (ANS) symptoms are frequently present in people with epilepsy (PwE). They are generally more prominent when they originate from the temporal lobe. We aim to investigate the alterations of autonomic functions during the interictal period in patient with temporal lobe epilepsy (TLE) and idiopathic generalized epilepsy (IGE) using heart-based tests, blood pressure (BP)-based tests and sympathetic skin response (SSR). Forty-eight PwE with disease duration ranging from 2 to 15 years and 51 healthy individuals were studied. Long-term electroencephalography (EEG) monitoring, the heart rate variability (HRV) during normal breathing, deep breathing, Valsalva maneuver and standing, BP responses during standing, to isometric hand grip and to mental arithmetic, and the SSR was recorded for all participants. Results 31 patients with TLE and 17 with IGE showed lower RR-IV values during deep breathing, Valsalva maneuver and standing, but not during rest, impaired BP responses during standing, isometric hand grip, and mental arithmetic. Also, prolonged SSR latencies. Within PwE group, no difference was noticed between males and females, nor between the left and right temporal lobes. Conclusion Abnormal autonomic (sympathetic and parasympathetic) regulatory functions suggest that epilepsy may alter the autonomic function and this is not only in TLE but rather in IGE too. These autonomic changes are irrespective of the localization of epilepsy between the two hemispheres. The ANS changes in epileptic patients, particularly those with autonomic symptoms, confirm that electrophysiologic measures of autonomic function may be of value in preventing sudden unexpected death in epilepsy.

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Sudden Unexpected Death in Epilepsy - An Overview of Current Understanding and Future Perspectives

European Neurological Review ◽

10.17925/enr.2012.07.01.67 ◽

2012 ◽

Vol 7 (1) ◽

pp. 67 ◽

Cited By ~ 1

Author(s):

Daniel Friedman ◽

Lawrence J Hirsch ◽

◽

Keyword(s):

Seizure Control ◽

Healthy Person ◽

Sudden Unexpected Death ◽

Future Perspectives ◽

Prevention Strategies ◽

Treatment Resistant ◽

Unexpected Death ◽

Cerebral Dysfunction ◽

Clonic Seizures ◽

Related Mortality

Sudden unexpected death in epilepsy (SUDEP) is likely to be the most common cause of disease-related mortality in people with epilepsy. The most commonly encountered scenario is that a previously healthy person is found dead in bed by family. Patients with frequent generalised tonic-clonic seizures are at highest risk but SUDEP can occur in patients who have never had convulsions. The mechanisms of SUDEP are poorly understood but seem to be related to seizure-related cardiac, respiratory or cerebral dysfunction. Seizure control is the only clear strategy to prevent SUDEP but that is not possible in the 30 % of patients with treatment-resistant epilepsy. Understanding the pathophysiology of SUDEP may lead to prevention strategies for patients who continue to have seizures despite maximal therapy.

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Sudden Unexpected Death in Epilepsy—An Overview of Current Understanding and Future Perspectives

US Neurology ◽

10.17925/usn.2012.08.01.42 ◽

2012 ◽

Vol 08 (01) ◽

pp. 42

Author(s):

Daniel Friedman ◽

Lawrence J Hirsch ◽

◽

Keyword(s):

Seizure Control ◽

Healthy Person ◽

Sudden Unexpected Death ◽

Future Perspectives ◽

Prevention Strategies ◽

Treatment Resistant ◽

Unexpected Death ◽

Cerebral Dysfunction ◽

Clonic Seizures ◽

Related Mortality

Sudden unexpected death in epilepsy (SUDEP) is likely to be the most common cause of disease-related mortality in people with epilepsy. The most commonly encountered scenario is that a previously healthy person is found dead in bed by family. Patients with frequent generalized tonic-clonic seizures are at highest risk but SUDEP can occur in patients who have never had convulsions. The mechanisms of SUDEP are poorly understood but seem to be related to seizure-related cardiac, respiratory or cerebral dysfunction. Seizure control is the only clear strategy to prevent SUDEP but that is not possible in the 30 % of patients with treatment-resistant epilepsy. Understanding the pathophysiology of SUDEP may lead to prevention strategies for patients who continue to have seizures despite maximal therapy.

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P5346The effect of seizure type on ictal and early post-ictal Heart Rate Variability in patients with focal resistant epilepsy

European Heart Journal ◽

10.1093/eurheartj/ehz746.0313 ◽

2019 ◽

Vol 40 (Supplement_1) ◽

Author(s):

M T Faria ◽

S Rodrigues ◽

D Dias ◽

R Rego ◽

H Rocha ◽

...

Keyword(s):

Heart Rate ◽

Heart Rate Variability ◽

Refractory Epilepsy ◽

Ethics Committee ◽

Wilcoxon Test ◽

Seizure Type ◽

Seizure Onset ◽

Unexpected Death ◽

Clonic Seizures ◽

Epilepsy Monitoring

Abstract Background Seizures commonly affect the heart rate and its variability. The increased interest in this area of research is related to the possible connection with sudden unexpected death in epilepsy (SUDEP). Generalized tonic-clonic seizures (GTCS) are reported as the most consistent risk factor for SUDEP. However, the general risk of seizures (and their type) on cardiac function still remains uncertain. Purpose To evaluate the influence of seizure type (GTCS vs non-GTCS) on ictal and early post-ictal Heart Rate Variability (HRV) in patients with refractory epilepsy. Methods From January 2015 to July 2018, we prospectively evaluated 121 patients admitted to our institution's Epilepsy Monitoring Unit with focal resistant epilepsy. All patients underwent a 48-hour Holter recording. We included only patients who had both GTCS and non-GTCS during the recording and selected the first seizure of each type to analyze. HRV (AVNN, SDNN, RMSSD, pNN50, and LF/HF) was evaluated by analyzing 5-min-ECG epochs, starting with the seizure onset (ictal and early post-ictal period). The study was approved by our Institution Ethics Committee and all patients gave informed consent. Results Fourteen patients were included (7 Females, 4 patients with Temporal Lobe Epilepsy). The median age was 39 years (min-max, 18–57). Thirty-six percent presented cardiovascular risk factors without known cardiac disease. A significant statistical reduction was found for AVNN (p=0.013), RMSSD (p=0.008), pNN50 (p=0.005) and HF (p=0.003), during GTCS when compared with non-GTCS (Wilcoxon test, p<0.05; two tailed). Conclusion Our study shows a significant reduced vagal tone during GTCS when compared with non-GTCS. Hence, GTCS had a more pronounced impact on HRV changes than other seizure types, which can be associated with higher SUDEP risk after GTCS.

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Prevention of Sudden Unexpected Death in Epilepsy

European Neurological Review ◽

10.17925/enr.2018.13.2.72 ◽

2018 ◽

Vol 13 (2) ◽

pp. 72

Author(s):

Philippe Ryvlin ◽

Torbjörn Tomson ◽

Orrin Devinsky ◽

◽

...

Keyword(s):

Risk Factors ◽

Seizure Control ◽

Predictive Biomarkers ◽

Treatment Resistance ◽

Sudden Unexpected Death ◽

Preventive Strategies ◽

Preventive Interventions ◽

Unexpected Death ◽

Clonic Seizures ◽

Underlying Mechanisms

Sudden unexpected death in epilepsy (SUDEP) is the most common cause of death related to epilepsy and is associated with treatment resistance and the presence of generalised tonic-clonic seizures (GTCS, of either focal or generalised onset). While the causative mechanisms of SUDEP are yet to be fully elucidated, it is thought that seizure-induced brainstem suppression, and respiratory and cardiac dysfunction may be involved. Research into SUDEP has identified several risk factors (including frequency of GTCS and male gender) but has also indicated proven or potential preventive strategies, including more effective seizure control. Despite increasing awareness and research into SUDEP, its underlying mechanisms and preventive strategies remain poorly defined. More research is needed into the pathophysiology of SUDEP and to identify predictive biomarkers. Furthermore, clinical trials are warranted to assess outcomes with preventive interventions. We review SUDEP epidemiology and risk factors, and discuss potential measures to reduce SUDEP risk.

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