| 1. |
- Stenimahitis, Vasilios, et al.
(author)
-
Long-term Outcomes After Periprocedural and Spontaneous Spinal Cord Infarctions : A Population-Based Cohort Study
- 2023
-
In: Neurology. - : Ovid Technologies (Wolters Kluwer Health). - 0028-3878 .- 1526-632X. ; 101:2, s. E114-E124
-
Journal article (peer-reviewed)abstract
- Background and Objectives: Spinal cord infarction (SCInf) is a rare condition where consensus regarding diagnostic criteria is lacking, and misdiagnosis or delayed diagnosis can be detrimental. The aim of this study was to describe baseline findings and predictors of long-term functional outcome in a population-based cohort of patients with SCInf.Methods: All adult patients (aged 18 years or older) treated at the spinal cord injury unit of the study center, between 2006 and 2019, and discharged with a G95 diagnosis (other and unspecified disease of the spinal cord) were screened for inclusion. The diagnostic criteria proposed by Zalewski et al. were retrospectively applied to evaluate the certainty of the SCInf diagnosis.Results: A total of 270 patients were screened and 57 were included in the study, of whom 30 had a spontaneous SCInf and 27 had a periprocedural SCInf. The median American Spinal Cord Injury Association Impairment Scale (AIS) on admission was C, which at a median follow-up of 2.1 years had improved to D (p = 0.002). Compared with periprocedural cases, those with spontaneous SCInf showed significantly better admission AIS (median AIS D vs B, p < 0.001), fewer multilevel SCInf (27% vs 59%, p = 0.029), shorter hospital stay (median 22 vs 44 days, p < 0.001), and better AIS (median AIS D vs C, p < 0.001) and ambulatory status on long-term follow-up (66% vs 1%, p < 0.001). Regression analyses revealed that spontaneous SCInfs (odds ratio [OR] 5.91 [1.92-18.1], p = 0.002) and more favorable admission AIS (OR 33.6 [7.72-146], p < 0.001) were significant predictors of more favorable AIS at follow-up, with admission AIS demonstrating independent predictive ability (OR 35.9 [8.05-160], p < 0.001).Discussion: SCInf is a rare neurologic emergency lacking specific management guidelines. While the presumptive diagnosis is based on the typical presentation and clinical findings, T2-weighted and diffusion-weighted MRI were the most useful diagnostic tools in establishing a definitive diagnosis. Our data show that spontaneous SCInf mostly affected a single spinal cord segment, whereas periprocedural cases were more extensive, had poorer AIS on admission, poorer ambulatory function, and longer hospital stays. Regardless of the etiology, significant neurologic improvements were seen at long-term follow-up, highlighting the importance of active rehabilitation.
|
|
| 2. |
- Sveinsson, Olafur, et al.
(author)
-
Clinical risk factors in SUDEP : A nationwide population-based case-control study
- 2020
-
In: Neurology. - 0028-3878 .- 1526-632X. ; 94:4, s. e419-e429
-
Journal article (peer-reviewed)abstract
- OBJECTIVE: We conducted a nationwide case-control study in Sweden to test the hypothesis that specific clinical characteristics are associated with increased risk of sudden unexpected death in epilepsy (SUDEP).METHODS: The study included 255 SUDEP cases (definite and probable) and 1,148 matched controls. Clinical information was obtained from medical records and the National Patient Register. The association between SUDEP and potential risk factors was assessed by odds ratios (ORs) and 95% confidence intervals (CIs) and interaction assessed by attributable proportion due to interaction (AP).RESULTS: Experiencing generalized tonic-clonic seizures (GTCS) during the preceding year was associated with a 27-fold increased risk (OR 26.81, 95% CI 14.86-48.38), whereas no excess risk was seen in those with exclusively non-GTCS seizures (OR 1.15, 95% CI 0.54-48.38). The presence of nocturnal GTCS during the last year of observation was associated with a 15-fold risk (OR 15.31, 95% CI 9.57-24.47). Living alone was associated with a 5-fold increased risk of SUDEP (OR 5.01, 95% CI 2.93-8.57) and interaction analysis showed that the combination of not sharing a bedroom and having GTCS conferred an OR of 67.10 (95% CI 29.66-151.88), with AP estimated at 0.69 (CI 0.53-0.85). Among comorbid diseases, a previous diagnosis of substance abuse or alcohol dependence was associated with excess risk of SUDEP.CONCLUSIONS: Individuals with GTCS who sleep alone have a dramatically increased SUDEP risk. Our results indicate that 69% of SUDEP cases in patients who have GTCS and live alone could be prevented if the patients were not unattended at night or were free from GTCS.
|
|
| 3. |
- Sveinsson, Olafur, et al.
(author)
-
Pharmacologic treatment and SUDEP risk : A nationwide, population-based, case-control study
- 2020
-
In: Neurology. - 0028-3878 .- 1526-632X. ; 95:18, s. E2509-E2518
-
Journal article (peer-reviewed)abstract
- Objective We conducted a nationwide case–control study in Sweden to test the hypothesis that antiepileptic drugs (AEDs) mono- or polytherapy, adherence, antidepressants, neuroleptics, β-blockers, and statins are associated with sudden unexpected death in epilepsy (SUDEP) risk.Methods Included were 255 SUDEP cases and 1,148 matched controls. Information on clinical factors and medications came from medical records and the National Patient and Prescription Registers. The association between SUDEP and medications was assessed by odds ratios (ORs) with 95% confidence intervals (CIs) adjusted for potential risk factors including type of epilepsy, living conditions, comorbidity, and frequency of generalized tonic-clonic seizures (GTCS).Results Polytherapy, especially taking 3 or more AEDs, was associated with a substantially reduced risk of SUDEP (OR 0.31, 95% CI 0.14–0.67). Combinations including lamotrigine (OR 0.55, 95% CI 0.31–0.97), valproic acid (OR 0.53, 95% CI 0.29–0.98), and levetiracetam (OR 0.49, 95% CI 0.27–0.90) were associated with reduced risk. No specific AED was associated with increased risk. Regarding monotherapy, although numbers were limited, the lowest SUDEP risk was seen in users of levetiracetam (0.10, 95% CI 0.02–0.61). Having nonadherence mentioned in the medical record was associated with an OR of 2.75 (95% CI 1.58–4.78). Statin use was associated with a reduced SUDEP risk (OR 0.34, 95% CI 0.11–0.99) but selective serotonin reuptake inhibitor use was not.Conclusion These results provide support for the importance of medication adherence and intensified AED treatment for patients with poorly controlled GTCS in the effort to reduce SUDEP risk and suggest that comedication with statins may reduce risk.
|
|
| 4. |
- Sveinsson, Olafur
(author)
-
Sudden unexpected death in epilepsy, incidence, circumstances and risk factors
- 2020
-
Doctoral thesis (other academic/artistic)abstract
- Although Sudden Unexpected Death in Epilepsy (SUDEP) has attracted increasing attention from the scientific community during the last 20 years, important gaps in knowledge still exist that hamper the development of methods aiming at prevention of this, the most devastating consequence of epilepsy. We are still missing large population-based studies on the incidence of SUDEP. Our understanding of the circumstances surrounding SUDEP is incomplete which is a major limitation when it comes to development of potential SUDEP-preventing devices. Finally, our understanding of risk factors for SUDEP is limited to a few established risk factors. The purpose of this study was to examine the incidence, circumstances and risk factors for SUDEP in Sweden. The project is based on a study population (n=78 524) which comprises all persons living in Sweden at 1. July 2006, who at some point during 1998-2005 where registered with the diagnosis code for epilepsy (ICD G 40) in the Swedish National Patient Register (SNPR). To identify cases of SUDEP, the study population was linked to the National Cause-of- Death Register. During the follow-up time from July 1, 2006 to December 31, 2011, we identified 9605 deaths. All death certificates in the study population between 1 July 2006 and 31 December 2011 with epilepsy mentioned on death certificate and all deaths during 2008 (n=3166) were reviewed. Based on the information in the death certificates, obvious non-SUDEP deaths were excluded from further analysis. For all others we analyzed patient medical records, autopsy and police reports and information was extracted using a standardized protocol. From the study population, five epilepsy controls per SUDEP case, of the same sex, who were alive at the case´s time of death, were randomly selected by the National Board of Health and Welfare. During 2008, 1890 individuals from the study population died. Of these, 99 met Annegers‘ SUDEP criteria (49 definite, 19 probable, and 31 possible) (paper I). Definite and probable SUDEP accounted for 3.6% of all deaths in the study population during 2008, and 5.2% when possible was included. In the age group 0-15 years, the relative contribution of SUDEP (definite, probable and possible) to overall deaths was 36.0%. SUDEP incidence was 1.20/1000 person-years (definite/ probable) and 1.74/1000 if possible SUDEP was included. Epilepsy was mentioned in any position of the death certificate in 63.6% of the 99 SUDEP cases. Of the 329 SUDEP deaths identified from July 1, 2006 to December 31, 2011 (167 definite, 89 probable, 73 possible), more than half (58%) occurred at night and 91% died at home, whereof 65% were found deceased in bed (paper II). Death was witnessed in 17% of all SUDEP cases and when a seizure was witnessed in conjunction with SUDEP (n=49) all were generalized tonic-clonic seizures (GTCS). Where a body position was documented (43%), more than two thirds (70%) were found prone. Dying at night made it more likely (80%) to be found prone than other times (55%) (p<0.001). Among adult SUDEP cases, 75% were living alone, and only 14% of all SUDEP cases shared a bedroom. In papers III and IV, 255 SUDEP cases (167 definite, 88 probable) were compared to their matched 1148 controls. Those with a history of GTCS had a tenfold increased SUDEP risk and the risk was increased to 32-fold with 4-10 GTCS during the last year of observation. When a history of nocturnal GTCS was present, a nine-fold SUDEP risk was observed and a 15-fold risk was seen if nocturnal GTCS were present during the last year of observation. No increased risk of SUDEP was seen in those experiencing exclusively non-GTCS during the preceding year. There was a fivefold increased risk of SUDEP among those living alone, while the risk was reduced to twofold when sharing household but not bedroom. Individuals experiencing ≥1 GTCS and not sharing a bedroom with someone had 67-fold increased risk of SUDEP compared to individuals not having GTCS, who shared their bedroom with someone, with attributable proportion due to interaction estimated at 0.69 (95% confidence interval, CI 0.53-0.85). Polytherapy, especially taking three or more AEDs was associated with a 69% reduced SUDEP risk after adjusting for GTCS frequency and other covariates. Levetiracetam as monotherapy was associated with a significantly lower SUDEP risk when compared to no AED treatment (odds ratio, OR 0.10, 95% CI 0.03-0.61). Lamotrigine, valproic acid and levetiracetam were associated with a significantly reduced risk when used as part of a polytherapy. Use of statins was associated with a reduced risk of SUDEP (OR 0.34, 95% CI 0.11-0.99). Our results show that SUDEP is an important contributor to mortality in epilepsy patients, and accounts for one third of deaths in children with epilepsy and one fifth of deaths among young adults with epilepsy. Since the majority died at home in bed, at night with indications of a previous GTCS, SUDEP can be considered an event related to night time and unobserved GTCS. We found no excess risk of SUDEP among individuals experiencing non-GTCS only, which has important clinical implications. GTCS and lack of supervision were the main risk factors. Moreover, our results suggest that up to 69% of SUDEP cases could be prevented in individuals with GTCS who live alone, if they were made free from GTCS or did not sleep alone. Polytherapy was associated with a substantially reduced SUDEP risk indicating that physicians should to consider AED polytherapy more pro-actively for patients with poorly controlled GTCS.
|
|
