Downloaded from http://jnnp.bmj.com/ on June 23, 2017 - Published by group.bmj.com
J Neurol Neurosurg Psychiatry October 2015 Vol 86 No 10
5–25, 14.8, 15
5–30, 13.8, 11
Type II: 4 (12.9%) Type III: 16 (51.6%) Type IV: 11 (35.5%) Type II: 3 (11.5%) Type III: 14 (53.8%) Type IV: 9 (34.6%) Type II: 1 (20%) Type III: 2 (40%) Type IV: 2 (40%) 5–30, 14, 12
1–45, 21, 12 0–9, 3.6, 4
HH, hypothalamic hamartoma.
3 (60%): 2 (40%) 5 (16.1%) patients without ictal tachycardia
7–53, 26, 19
14(53.8%):12 (46.2%) 26 (83.9%) patients with ictal tachycardia
3–44, 21, 19
0–15, 4.6, 3
1–40, 17, 13
Right: 11 (35.5) Medial: 10 (32.3%) Left: 10 (32.3%) Right: 10 (38.5) Medial: 8 (30.8%) Left: 8 (30.8%) Right: 1 (20%) Medial: 2 (40%) Left: 2 (40%) 1–45, 17, 13 0–15, 4.5, 3 3–53, 22, 19 17 (54.8%):14 (45.2%)
Male:Female
31 (100%) patients
Size of the HH (maximum diameter in mm: range, mean, median) Localisation of the HH Duration of the epilepsy (years: range, mean, median) Age at epilepsy onset (years: range, mean, median)
Epileptic seizures may lead to changes in autonomic function. Among these, changes in heart rate (HR) constitute an easily measurable biomarker that may provide an extracerebral indicator of an ictal onset in some patients, whereby new stimulation therapies triggered by tachycardia detection are being developed. Understanding the prevalence and magnitude of HR changes associated with seizures, as well as their mode of presentation, especially, the timing of such changes relative to seizure onset is fundamental to the development of HR-based algorithms for seizure detection. Likewise, identification of groups of patients presenting more likely with ictal tachycardia is important since these patients can be good candidates for stimulation therapies triggered by tachycardia detection. Ictal tachycardia has been assessed in several studies and has been found in average in 82% of patients and in 76% of seizures, both focal and generalised, occurring early from several seconds before to several seconds after the seizure onset, raising a possibility for intervention.1 2 Most studies refer to patients with temporal or frontal lobe epilepsy or to consecutive patients who underwent video-EEG monitoring (VEM), regardless the type of epilepsy. Patients with hypothalamic hamartoma (HH) constitute a special group among patients suffering from epilepsy. Owing to high rates of pharmacoresistance, surgical therapy, including electrical stimulation, can be used to improve the control of their seizures. The location of the HH at the crossroad of neurovegetative, neuroendocrine and limbic systems may render this group of patients particularly susceptible to vegetative changes. The presence of vegetative signs and especially tachycardia during seizures in patients with HH has been reported, 3 but has not been assessed in detail so far. The purpose of our study is to provide data on the frequency of occurrence, timing and characteristics of ictal tachycardia in patients with HH who underwent longterm VEM in a tertiary referral epilepsy centre. We retrospectively reviewed seizures of 31 patients (17 male, mean age 22 years) with HH who underwent VEM at the University Hospital Freiburg, Germany.
Age (years: range, mean, median)
Ictal tachycardia in patients with hypothalamic hamartoma
Inclusion criteria were: (1) epilepsy due to HH with no prior surgical or radiosurgical treatment, (2) at least one seizure recorded in long-term VEM and (3) at least one brain MRI study. A minimum of 1 and a maximum of 10 (mean 8, median 10) consecutive seizures per patient were analysed, resulting in a total of 251 seizures. HR was assessed visually during the seizures and compared with the baseline HR 1 min before the seizure onset, defined as the first clinical or electrographical sign documented. For each seizure, the maximum increase in the HR expressed in percentage from baseline and the time from seizure onset occurring ictal tachycardia, defined by convention as an increase in the HR by at least 33%, and the maximum increase were described. Data were related to seizure types and patient characteristics including age at the epilepsy onset, duration of the epilepsy and location and size of the HH. Ictal tachycardia was present in 125 (49.8%) seizures and in 26 (83.9%) patients and occurred from 0 to 166 (median 4) s after the seizure onset. Seven (22.6%) patients presented with ictal tachycardia in all of their seizures. Ictal tachycardia occurred independently of patient clinical characteristics (table 1). The maximum increase in the HR ranged from 33% to 206% (median 58%) and occurred from 0 to 166 (median 15) s after the seizure onset. In 31 (12.4%) seizures the HR reached the maximum from the beginning of the tachycardia and remained stable. In 81 (32.3%) seizures and in 21 (67.7%) patients the increase of the HR reached 50% or more; in 11 (4.4%) seizures and in 5 (16.1%) patients reached 100% or more; an increase in HR greater than 161% (from 184% to 206%, mean 192.6) was only seen in 3 seizures in 2 patients with evolution to bilateral convulsive seizures, presenting 46–68 (mean 59) s after the seizure onset. However, in 8 of the only 11 seizures with major motor phenomena, ictal tachycardia appeared 6– 39 (median 26) s before the occurrence of the major motor activity. Tachycardia occurred in all seizure types but was more frequent in seizures with more complex semiology; it occurred in 13/68 (19%) isolated auras, in 5/20 (25%) gelastic–motor seizures, in 5/19 (26%) dyscognitive seizures, in 21/46 (46%) gelastic seizures, in 16/24 (67%) gelastic–dyscognitive seizures, in 14/18 (78%) motor seizures, in 27/30 (90%) dyscognitive–motor seizures and in 24/26 (92%) gelastic–dyscognitive– motor seizures. It was also more frequent in longer seizures. HR increase by at least 33% was more frequent in seizures arising
Table 1 Clinical data of patients with and without ictal tachycardia
LETTERS
Delalande classification4
PostScript
1163
Downloaded from http://jnnp.bmj.com/ on June 23, 2017 - Published by group.bmj.com
PostScript from sleep, presenting in 88% in contrast to 40.3% in seizures arising from wakefulness; but occurred similarly frequent with (89.7%) and without (81.8%) arousal. An increase in the HR by less than 33% (from 2 to 31%, mean 15%) was observed in another 77 (30.7%) seizures. In 49 (19.5%) seizures, no increase was observed at all. Only one (3.2%) patient showed no increase of the HR in any of his seizures. Interestingly, a decrease in the HR by 33% was observed in one (0.4%) seizure, and a lesser HR decrease (between 14 and 28%, mean 22.3) was observed in six (2.4%) seizures from another patient. In patients with HH, ictal tachycardia occurs frequently and independently of clinical data such as gender, age at the recording, age at the epilepsy onset, duration of the epilepsy and localisation and size of the HH. Despite intraindividual variability, more than 20% of patients showed tachycardia in all their seizures, and only one patient showed no HR increase in any of his seizures. The early occurrence (in the first 4 s in more than half of the cases) and the presence in different seizure types suggest that ictal tachycardia in patients with HH is not secondary to motor phenomena or arousals, but probably reflects the location at the crossroad of neurovegetative, neuroendocrine and limbic systems, and may render these patients, who often suffer from pharmacoresistant epilepsy, ideal candidates for stimulation therapies triggered by tachycardia detection.
REFERENCES 1 2 3
4
Sevcencu C, Struijk JJ. Autonomic alterations and cardiac changes in epilepsy. Epilepsia 2010;51:725–37. Eggleston KS, Olin BD, Fisher RS. Ictal tachycardia: the head-heart connection. Seizure 2014;23:496–505. Oehl B, Brandt A, Fauser S, et al. Semiologic aspects of epileptic seizures in 31 patients with hypothalamic hamartoma. Epilepsia 2010;51:2116–23. Delalande O, Fohlen M. Disconnecting surgical treatment of hypothalamic hamartoma in children and adults with refractory epilepsy and proposal of a new classification. Neurol Med Chir (Tokyo) 2003;43:61–8.
Victoria San Antonio-Arce, Andreas Schulze-Bonhage Epilepsy Center, University Hospital Freiburg, Freiburg, Germany Correspondence to Dr Victoria San Antonio-Arce, Epilepsy Center, University Hospital Freiburg, Breisacher Str. 64, Freiburg 79106, Germany; [email protected] Competing interests None. Provenance and peer review Not commissioned; externally peer reviewed.
To cite San Antonio-Arce V, Schulze-Bonhage A. J Neurol Neurosurg Psychiatry 2015;86:1163–1164. Received 13 October 2014 Revised 24 November 2014 Accepted 3 December 2014 Published Online First 17 December 2014 J Neurol Neurosurg Psychiatry 2015;86:1163–1164. doi:10.1136/jnnp-2014-309681 1164
J Neurol Neurosurg Psychiatry October 2015 Vol 86 No 10
Downloaded from http://jnnp.bmj.com/ on June 23, 2017 - Published by group.bmj.com
Ictal tachycardia in patients with hypothalamic hamartoma Victoria San Antonio-Arce and Andreas Schulze-Bonhage J Neurol Neurosurg Psychiatry 2015 86: 1163-1164 originally published online December 17, 2014
doi: 10.1136/jnnp-2014-309681 Updated information and services can be found at: http://jnnp.bmj.com/content/86/10/1163
These include:
References Email alerting service
This article cites 4 articles, 0 of which you can access for free at: http://jnnp.bmj.com/content/86/10/1163#BIBL Receive free email alerts when new articles cite this article. Sign up in the box at the top right corner of the online article.
Notes
To request permissions go to: http://group.bmj.com/group/rights-licensing/permissions To order reprints go to: http://journals.bmj.com/cgi/reprintform To subscribe to BMJ go to: http://group.bmj.com/subscribe/
J Neurol Neurosurg Psychiatry October 2015 Vol 86 No 10
5–25, 14.8, 15
5–30, 13.8, 11
Type II: 4 (12.9%) Type III: 16 (51.6%) Type IV: 11 (35.5%) Type II: 3 (11.5%) Type III: 14 (53.8%) Type IV: 9 (34.6%) Type II: 1 (20%) Type III: 2 (40%) Type IV: 2 (40%) 5–30, 14, 12
1–45, 21, 12 0–9, 3.6, 4
HH, hypothalamic hamartoma.
3 (60%): 2 (40%) 5 (16.1%) patients without ictal tachycardia
7–53, 26, 19
14(53.8%):12 (46.2%) 26 (83.9%) patients with ictal tachycardia
3–44, 21, 19
0–15, 4.6, 3
1–40, 17, 13
Right: 11 (35.5) Medial: 10 (32.3%) Left: 10 (32.3%) Right: 10 (38.5) Medial: 8 (30.8%) Left: 8 (30.8%) Right: 1 (20%) Medial: 2 (40%) Left: 2 (40%) 1–45, 17, 13 0–15, 4.5, 3 3–53, 22, 19 17 (54.8%):14 (45.2%)
Male:Female
31 (100%) patients
Size of the HH (maximum diameter in mm: range, mean, median) Localisation of the HH Duration of the epilepsy (years: range, mean, median) Age at epilepsy onset (years: range, mean, median)
Epileptic seizures may lead to changes in autonomic function. Among these, changes in heart rate (HR) constitute an easily measurable biomarker that may provide an extracerebral indicator of an ictal onset in some patients, whereby new stimulation therapies triggered by tachycardia detection are being developed. Understanding the prevalence and magnitude of HR changes associated with seizures, as well as their mode of presentation, especially, the timing of such changes relative to seizure onset is fundamental to the development of HR-based algorithms for seizure detection. Likewise, identification of groups of patients presenting more likely with ictal tachycardia is important since these patients can be good candidates for stimulation therapies triggered by tachycardia detection. Ictal tachycardia has been assessed in several studies and has been found in average in 82% of patients and in 76% of seizures, both focal and generalised, occurring early from several seconds before to several seconds after the seizure onset, raising a possibility for intervention.1 2 Most studies refer to patients with temporal or frontal lobe epilepsy or to consecutive patients who underwent video-EEG monitoring (VEM), regardless the type of epilepsy. Patients with hypothalamic hamartoma (HH) constitute a special group among patients suffering from epilepsy. Owing to high rates of pharmacoresistance, surgical therapy, including electrical stimulation, can be used to improve the control of their seizures. The location of the HH at the crossroad of neurovegetative, neuroendocrine and limbic systems may render this group of patients particularly susceptible to vegetative changes. The presence of vegetative signs and especially tachycardia during seizures in patients with HH has been reported, 3 but has not been assessed in detail so far. The purpose of our study is to provide data on the frequency of occurrence, timing and characteristics of ictal tachycardia in patients with HH who underwent longterm VEM in a tertiary referral epilepsy centre. We retrospectively reviewed seizures of 31 patients (17 male, mean age 22 years) with HH who underwent VEM at the University Hospital Freiburg, Germany.
Age (years: range, mean, median)
Ictal tachycardia in patients with hypothalamic hamartoma
Inclusion criteria were: (1) epilepsy due to HH with no prior surgical or radiosurgical treatment, (2) at least one seizure recorded in long-term VEM and (3) at least one brain MRI study. A minimum of 1 and a maximum of 10 (mean 8, median 10) consecutive seizures per patient were analysed, resulting in a total of 251 seizures. HR was assessed visually during the seizures and compared with the baseline HR 1 min before the seizure onset, defined as the first clinical or electrographical sign documented. For each seizure, the maximum increase in the HR expressed in percentage from baseline and the time from seizure onset occurring ictal tachycardia, defined by convention as an increase in the HR by at least 33%, and the maximum increase were described. Data were related to seizure types and patient characteristics including age at the epilepsy onset, duration of the epilepsy and location and size of the HH. Ictal tachycardia was present in 125 (49.8%) seizures and in 26 (83.9%) patients and occurred from 0 to 166 (median 4) s after the seizure onset. Seven (22.6%) patients presented with ictal tachycardia in all of their seizures. Ictal tachycardia occurred independently of patient clinical characteristics (table 1). The maximum increase in the HR ranged from 33% to 206% (median 58%) and occurred from 0 to 166 (median 15) s after the seizure onset. In 31 (12.4%) seizures the HR reached the maximum from the beginning of the tachycardia and remained stable. In 81 (32.3%) seizures and in 21 (67.7%) patients the increase of the HR reached 50% or more; in 11 (4.4%) seizures and in 5 (16.1%) patients reached 100% or more; an increase in HR greater than 161% (from 184% to 206%, mean 192.6) was only seen in 3 seizures in 2 patients with evolution to bilateral convulsive seizures, presenting 46–68 (mean 59) s after the seizure onset. However, in 8 of the only 11 seizures with major motor phenomena, ictal tachycardia appeared 6– 39 (median 26) s before the occurrence of the major motor activity. Tachycardia occurred in all seizure types but was more frequent in seizures with more complex semiology; it occurred in 13/68 (19%) isolated auras, in 5/20 (25%) gelastic–motor seizures, in 5/19 (26%) dyscognitive seizures, in 21/46 (46%) gelastic seizures, in 16/24 (67%) gelastic–dyscognitive seizures, in 14/18 (78%) motor seizures, in 27/30 (90%) dyscognitive–motor seizures and in 24/26 (92%) gelastic–dyscognitive– motor seizures. It was also more frequent in longer seizures. HR increase by at least 33% was more frequent in seizures arising
Table 1 Clinical data of patients with and without ictal tachycardia
LETTERS
Delalande classification4
PostScript
1163
Downloaded from http://jnnp.bmj.com/ on June 23, 2017 - Published by group.bmj.com
PostScript from sleep, presenting in 88% in contrast to 40.3% in seizures arising from wakefulness; but occurred similarly frequent with (89.7%) and without (81.8%) arousal. An increase in the HR by less than 33% (from 2 to 31%, mean 15%) was observed in another 77 (30.7%) seizures. In 49 (19.5%) seizures, no increase was observed at all. Only one (3.2%) patient showed no increase of the HR in any of his seizures. Interestingly, a decrease in the HR by 33% was observed in one (0.4%) seizure, and a lesser HR decrease (between 14 and 28%, mean 22.3) was observed in six (2.4%) seizures from another patient. In patients with HH, ictal tachycardia occurs frequently and independently of clinical data such as gender, age at the recording, age at the epilepsy onset, duration of the epilepsy and localisation and size of the HH. Despite intraindividual variability, more than 20% of patients showed tachycardia in all their seizures, and only one patient showed no HR increase in any of his seizures. The early occurrence (in the first 4 s in more than half of the cases) and the presence in different seizure types suggest that ictal tachycardia in patients with HH is not secondary to motor phenomena or arousals, but probably reflects the location at the crossroad of neurovegetative, neuroendocrine and limbic systems, and may render these patients, who often suffer from pharmacoresistant epilepsy, ideal candidates for stimulation therapies triggered by tachycardia detection.
REFERENCES 1 2 3
4
Sevcencu C, Struijk JJ. Autonomic alterations and cardiac changes in epilepsy. Epilepsia 2010;51:725–37. Eggleston KS, Olin BD, Fisher RS. Ictal tachycardia: the head-heart connection. Seizure 2014;23:496–505. Oehl B, Brandt A, Fauser S, et al. Semiologic aspects of epileptic seizures in 31 patients with hypothalamic hamartoma. Epilepsia 2010;51:2116–23. Delalande O, Fohlen M. Disconnecting surgical treatment of hypothalamic hamartoma in children and adults with refractory epilepsy and proposal of a new classification. Neurol Med Chir (Tokyo) 2003;43:61–8.
Victoria San Antonio-Arce, Andreas Schulze-Bonhage Epilepsy Center, University Hospital Freiburg, Freiburg, Germany Correspondence to Dr Victoria San Antonio-Arce, Epilepsy Center, University Hospital Freiburg, Breisacher Str. 64, Freiburg 79106, Germany; [email protected] Competing interests None. Provenance and peer review Not commissioned; externally peer reviewed.
To cite San Antonio-Arce V, Schulze-Bonhage A. J Neurol Neurosurg Psychiatry 2015;86:1163–1164. Received 13 October 2014 Revised 24 November 2014 Accepted 3 December 2014 Published Online First 17 December 2014 J Neurol Neurosurg Psychiatry 2015;86:1163–1164. doi:10.1136/jnnp-2014-309681 1164
J Neurol Neurosurg Psychiatry October 2015 Vol 86 No 10
Downloaded from http://jnnp.bmj.com/ on June 23, 2017 - Published by group.bmj.com
Ictal tachycardia in patients with hypothalamic hamartoma Victoria San Antonio-Arce and Andreas Schulze-Bonhage J Neurol Neurosurg Psychiatry 2015 86: 1163-1164 originally published online December 17, 2014
doi: 10.1136/jnnp-2014-309681 Updated information and services can be found at: http://jnnp.bmj.com/content/86/10/1163
These include:
References Email alerting service
This article cites 4 articles, 0 of which you can access for free at: http://jnnp.bmj.com/content/86/10/1163#BIBL Receive free email alerts when new articles cite this article. Sign up in the box at the top right corner of the online article.
Notes
To request permissions go to: http://group.bmj.com/group/rights-licensing/permissions To order reprints go to: http://journals.bmj.com/cgi/reprintform To subscribe to BMJ go to: http://group.bmj.com/subscribe/
