Association of Peri-ictal Brainstem Posturing With Seizure Severity and Breathing Compromise in Patients With Generalized Convulsive Seizures

Laura Vilella¹, Nuria Lacuey², Johnson P Hampson², Liang Zhu², Shirin Omidi², Manuela Ochoa-Urrea², Shiqiang Tao², M R Sandhya Rani², Rup K Sainju², Daniel Friedman², Maromi Nei², Kingman Strohl², Catherine Scott², Luke Allen², Brian K Gehlbach², Norma J Hupp², Jaison S Hampson², Nassim Shafiabadi², Xiuhe Zhao², Victoria Reick-Mitrisin², Stephan Schuele², Jennifer Ogren², Ronald M Harper², Beate Diehl², Lisa M Bateman², Orrin Devinsky², George B Richerson², Philippe Ryvlin², Guo-Qiang Zhang², Samden D Lhatoo²

Affiliations

¹ 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. Lvilellabertran@gmail.com.
² 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.

PMID: 33268557
PMCID: PMC7884980
DOI: 10.1212/WNL.0000000000011274

Association of Peri-ictal Brainstem Posturing With Seizure Severity and Breathing Compromise in Patients With Generalized Convulsive Seizures

Laura Vilella et al. Neurology. 2021.

. 2021 Jan 19;96(3):e352-e365.

doi: 10.1212/WNL.0000000000011274. Epub 2020 Dec 2.

Authors

Affiliations

¹ 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. Lvilellabertran@gmail.com.
² 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.

PMID: 33268557
PMCID: PMC7884980
DOI: 10.1212/WNL.0000000000011274

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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Comment in

Peri-ictal Brainstem-Driven Posturing and Its Meaning.
Goldman AM. Goldman AM. Neurology. 2021 Jan 19;96(3):89-90. doi: 10.1212/WNL.0000000000011277. Epub 2020 Dec 2. Neurology. 2021. PMID: 33268564 No abstract available.
The Underappreciated But Potentially Lethal Role of Brainstem Dysfunction in Epilepsy.
Englot DJ. Englot DJ. Epilepsy Curr. 2021 Apr 19;21(4):250-251. doi: 10.1177/15357597211004281. eCollection 2021 Jul-Aug. Epilepsy Curr. 2021. PMID: 34690558 Free PMC article. No abstract available.

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Association of Peri-ictal Brainstem Posturing With Seizure Severity and Breathing Compromise in Patients With Generalized Convulsive Seizures

Affiliations

Association of Peri-ictal Brainstem Posturing With Seizure Severity and Breathing Compromise in Patients With Generalized Convulsive Seizures

Authors

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Abstract

Comment in

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Medical

Research Materials