Hyperventilation induces sympathetic overactivation in mesial temporal epilepsy

Assenza, Giovanni; Mecarelli, Oriano; Tombini, Mario; Pulitano, Patrizia; Pellegrino, Giovanni; Benvenga, Antonella; Assenza, Federica; Campana, Chiara; Pino, Giovanni Di; Lazzaro, Vincenzo Di

doi:10.1016/j.eplepsyres.2014.12.003

Cited by 17 publications

(11 citation statements)

References 37 publications

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“…This observation is surprising since hyperventilation is an activating procedure, which should not be executed with a mask. Even if data on putative pathophysiological pathways inducing epileptiform EEG "activation" during hyperventilation is not conclusive [7], the main hypothesis point towards hemodynamic cerebral changes.…”

Section: Discussionmentioning

confidence: 99%

Electroencephalography at the time of Covid-19 pandemic in Italy

et al. 2020

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Objective During the Covid-19 pandemic, government restrictions limited health care to urgent needs. Neurophysiology centers had to suddenly reschedule their activities, with a lack of specific recommendations about electroencephalography (EEG) execution. During the pandemic phase 1, we launched an online survey to understand the flaws and strengths of the EEG management in Italy at the time of Covid-19 pandemic. Methods A 45-item online survey (published from April 16 to 30, 2020), endorsed by the Italian Society of Clinical Neurophysiology (SINC), the Italian League Against epilepsy (LICE), and the Italian Association of Neurophysiology technologists (AITN), collected EEG management data (EEG's number and type, indications, personnel and patients safety, devices' sanification) during the Covid-19 pandemic. Results We received responses from 206 centers. The number of EEGs performed was reduced by 76 ± 20%, and several types of specific EEG (video-EEG, ambulatory-EEG, LTM, polysomnography) were reduced at a minimum. Half of the centers performed inpatient EEGs only for urgencies. Repetitive seizures, encephalitis, and non-convulsive status epilepticus were the most common indications. Covid-19-positive patients received less EEG than negative ones (p < 0.0001). EEG requests came mainly not only from neurologists (n = 176) but also from general practitioners (n = 40), emergentists (n = 79), intensivists (n = 72), and other specialists (n = 53). Those centers which continued performing outpatient EEG examinations were instructed to perform the EEG after a Covid-19-related symptom screening for patients and using personal protective equipment (PPE) through all the procedure. Inpatient EEGs were performed using FFP2/FFP3 masks by neurophysiology technologists in only 50% of cases. Patients executed hyperventilation only for real clinical needs, but often (56%) with a mask. Conclusions Italian neurophysiology centers strongly adhered to government restrictions of lockdown. Some issues emerged, ranging from the evaluation of a proper indication for EEG, technical procedures of EEG recording, and protection of neurophysiology technicians.

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Section: Discussionmentioning

confidence: 99%

Electroencephalography at the time of Covid-19 pandemic in Italy

et al. 2020

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“…Hyperventilation may provoke focal seizures, especially temporal lobe seizures [4]. This may explain the episodes of crying triggering the seizures, given the left temporal lesion.…”

Section: Discussionmentioning

confidence: 99%

“Breath holding spells” in a child with SCN8A-related epilepsy: Expanding the clinical spectrum

Jain

Gulati

Morrison‐Levy

et al. 2019

Seizure

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A 14-month-old, developmentally-normal girl presented with daily events since 6-months of age. The events were characterized by crying (provoked by fall/anger) followed by cessation of crying, peri-oral cyanosis, and tonic stiffening of the limbs and jerking. She also had a microcytic/ hypochromic anemia. Initially she was diagnosed with breath-holding spells with reflex-anoxic seizures and started on iron with no effect. Subsequently, these episodes started happening without crying. On suspicion of seizures, she received phenobarbital and levetiracetam (minimal response) and then oxcarbazepine. After adding oxcarbazepine, the episodes markedly reduced (once/month) and she is now seizure free for 2 months.Magnetic-resonance-imaging (MRI) of the brain demonstrated high T2 signal in the white matter of the left anterior temporal lobe, suspicious for focal cortical dysplasia type I. Positron-Emission-Tomography was concordant. Video-EEG captured generalized seizures (induced by breath-holding and spontaneous) with unclear lateralization (Video 1). Rarely, sharply contoured slow waves were seen in the left temporal region. Magneto-encephalography revealed occasional spike dipoles (without EEG spikes) over the left posterior insula and posterior portion of left superior temporal gyrus. Targeted epilepsy gene panel revealed a de novo previously described pathogenic variant [c.5630 A > G, p.Asn1877Ser (N1877S)] in the SCN8A gene, which has been associated with milder phenotypes [1]. She is being managed medically at the moment. Epilepsy surgery may be considered in future if she develops drug-resistant focal seizures. DiscussionSCN8A-related epilepsy presents with a variable phenotype from benign infantile seizures to a severe epileptic encephalopathy. The epilepsy is usually drug-refractory, although response to sodiumchannel blockers has been described [2].Gardella et al. [2] reported nine (40.9%) patients with SCN8A mutation with tonic-clonic seizures preceded by cyanosis and autonomic features. Our patient presented with a brief breath-holding spell (with perioral cyanosis) followed by behavioral-arrest, and then generalized tonic-clonic seizures. These events were consistently triggered by "breath-holding" before oxcarbazepine. The sequence of provoked crying, breath-holding, bluish discoloration of lips followed by behavioral arrest, and then tonic-clonic limb movements, in a developmentally normal child, was mistaken as isolated breath holding spells with possible reflex-anoxic-seizures. However, video-EEG monitoring proved these events were generalized epileptic seizures following breath-holding spells and prompted the search for a cause. Yamamoto [3] described three developmentally-normal infants with normal neuro-imaging with generalized tonic-clonic seizures induced by crying who were thought to have "breath-holding spells." Inter-ictal EEG showed frontal spike-waves and ictal-onset was generalized. No

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“…When compared to healthy, age‐matched controls, most studies found that awake and 24‐hour HRV measures are lower, including variance, HF, LF, and LF/HF ratio, suggesting a shift toward sympathetic dominance . One study found that with hyperventilation, an exaggerated sympathetic response was seen in patients with mesial TLE when compared to controls …”

Section: Interictal Hrv Patterns In Different Epilepsy Typesmentioning

confidence: 99%

Heart rate variability measurement in epilepsy: How can we move from research to clinical practice?

2018

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Our objective was to critically evaluate the literature surrounding heart rate variability (HRV) in people with epilepsy and to make recommendations as to how future research could be directed to facilitate and accelerate integration into clinical practice. We reviewed relevant HRV publications including those involving human subjects with seizures. HRV has been studied in patients with epilepsy for more than 30 years and, overall, patients with epilepsy display altered interictal HRV, suggesting a shift in autonomic balance toward sympathetic dominance. This derangement appears more severe in those with temporal lobe epilepsy and drug-resistant epilepsy. Normal diurnal variation in HRV is also disturbed in at least some people with epilepsy, but this aspect has received less study. Some therapeutic interventions, including vagus nerve stimulation and antiepileptic medications, may partially normalize altered HRV, but studies in this area are sometimes contradictory. During seizures, the changes in HRV may be complex, but the general trend is toward a further increase in sympathetic overactivity. Research in HRV in people with epilepsy has been limited by inconsistent experimental protocols and studies that are often underpowered. HRV measurement has the potential to aid clinical epilepsy management in several possible ways. HRV may be useful in predicting which patients are likely to benefit from surgical interventions such as vagus nerve stimulation and focal cerebral resection. As well, HRV could eventually have utility as a biomarker of risk for sudden unexpected death in epilepsy (SUDEP). However, at present, the inconsistent measurement protocols used in research are hindering translation into clinical practice. A minimum protocol for HRV evaluation, to be used in all studies involving epilepsy patients, is necessary to eventually allow HRV to become a useful tool for clinicians. We propose a straightforward protocol, involving 5-minute measurements of root mean square of successive differences in wakefulness and light sleep.

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Hyperventilation induces sympathetic overactivation in mesial temporal epilepsy

Cited by 17 publications

References 37 publications

Electroencephalography at the time of Covid-19 pandemic in Italy

Electroencephalography at the time of Covid-19 pandemic in Italy

“Breath holding spells” in a child with SCN8A-related epilepsy: Expanding the clinical spectrum

Heart rate variability measurement in epilepsy: How can we move from research to clinical practice?

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