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Chapter 12 - The Role of the Insula in Sudden Unexpected Death in Epilepsy (SUDEP)

from Section 2 - The Spectrum of Epilepsies Involving the Insula

Published online by Cambridge University Press:  09 June 2022

By
Nuria Lacuey  and
Samden Lhatoo
Edited by
Dang Nguyen ,
Jean Isnard  and
Philippe Kahane
Dang Nguyen
Affiliation:
Université de Montréal
Jean Isnard
Affiliation:
Claude Bernard University Lyon
Philippe Kahane
Affiliation:
Grenoble-Alpes University Hospital
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Summary

The insula is known to play a central role in the regulation of autonomic function, although the precise nature and localization of such functions have not been conclusively identified. Autonomic and particularly cardiac disturbances are strongly implicated in sudden unexpected death in epilepsy (SUDEP). Herein, we discuss the contribution of the insula to seizure-related cardiac dysfunction and SUDEP. We also present two illustrative cases of intractable epilepsy patients with structural damage to the insula who succumbed to SUDEP. Both had progressive changes in heart rate variability (HRV), a standard measure of cardiac autonomic function, which noninvasively reflects sympathetic and parasympathetic balance using EKG recordings. In addition, further evidence of insular resection leading to autonomic changes is suggested in patients with intractable epilepsy and radiological evidence of insular damage after epilepsy surgery. The presence of intrinsic insular lesions or acquired insular damage in patients with refractory epilepsy may predispose to cardiac dysfunction and contribute to SUDEP pathomechanisms; however, a definitive association to SUDEP is still undetermined.

Keywords

SUDEPinsular autonomic functionarrhythmiasdeath
Type
Chapter
Information
Insular Epilepsies , pp. 134 - 140
Publisher: Cambridge University Press
Print publication year: 2022

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References

Zhang, ZH, Rashba, S, Oppenheimer, SM. Insular cortex lesions alter baroreceptor sensitivity in the urethane-anesthetized rat. Brain Res. 1998;813(1):73–81.Google Scholar
Marins, FR, Limborco-Filho, M, Xavier, CH, Biancardi, VC, Vaz, GC, Stern, JE, et al. Functional topography of cardiovascular regulation along the rostrocaudal axis of the rat posterior insular cortex. Clin Exp Pharmacol Physiol. 2016;43(4):484–493.CrossRefGoogle ScholarPubMed
Oppenheimer, SM, Cechetto, DF. Cardiac chronotropic organization of the rat insular cortex. Brain Res. 1990;533(1):66–72.Google Scholar
Hoffman, BL, Rasmussen, T. Stimulation studies of insular cortex of Macaca mulatta. J Neurophysiol. 1953;16(4):343–351.Google Scholar
Kaada, BR. Somato-motor, autonomic and electrocorticographic responses to electrical stimulation of rhinencephalic and other structures in primates, cat, and dog; a study of responses from the limbic, subcallosal, orbito-insular, piriform and temporal cortex, hippocampus-fornix and amygdala. Acta Physiol Scand Suppl. 1951;24(83):1–262.Google Scholar
Chouchou, F, Mauguiere, F, Vallayer, O, Catenoix, H, Isnard, J, Montavont, A, et al. How the insula speaks to the heart: Cardiac responses to insular stimulation in humans. Hum Brain Mapp. 2019;40(9):2611–2622.Google Scholar
Lacuey, N, Hampson, JP, Harper, RM, Miller, JP, Lhatoo, S. Limbic and paralimbic structures driving ictal central apnea. Neurology. 2019;92(7):e655–e669.Google Scholar
Oppenheimer, S, Cechetto, D. The insular cortex and the regulation of cardiac function. Compr Physiol. 2016;6(2):1081–1133.CrossRefGoogle ScholarPubMed
Penfield, W, Faulk, ME Jr. The insula; further observations on its function. Brain. 1955;78(4):445–470.CrossRefGoogle ScholarPubMed
Stephani, C, Fernandez-Baca Vaca, G, Maciunas, R, Koubeissi, M, Luders, HO. Functional neuroanatomy of the insular lobe. Brain Struct Funct. 2011;216(2):137–149.CrossRefGoogle ScholarPubMed
Cechetto, DF, Chen, SJ. Subcortical sites mediating sympathetic responses from insular cortex in rats. Am J Physiol. 1990;258(1 p. 2):R245–R255.Google Scholar
Vogt, BA. Pain and emotion interactions in subregions of the cingulate gyrus. Nat Rev Neurosci. 2005;6(7):533–544.CrossRefGoogle ScholarPubMed
Pugnaghi, M, Meletti, S, Castana, L, Francione, S, Nobili, L, Mai, R, et al. Features of somatosensory manifestations induced by intracranial electrical stimulations of the human insula. Clin Neurophysiol. 2011;122(10):2049–2058.Google Scholar
Ruiz Vargas, E, Soros, P, Shoemaker, JK, Hachinski, V. Human cerebral circuitry related to cardiac control: A neuroimaging meta-analysis. Ann Neurol. 2016;79(5):709–716.Google Scholar
Beissner, F, Meissner, K, Bar, KJ, Napadow, V. The autonomic brain: an activation likelihood estimation meta-analysis for central processing of autonomic function. J Neurosci. 2013;33(25):10503–10511.Google Scholar
Seeck, M, Zaim, S, Chaves-Vischer, V, Blanke, O, Maeder-Ingvar, M, Weissert, M, et al. Ictal bradycardia in a young child with focal cortical dysplasia in the right insular cortex. Eur J Paediatr Neurol. 2003;7(4):177–181.CrossRefGoogle Scholar
Tayah, T, Savard, M, Desbiens, R, Nguyen, DK. Ictal bradycardia and asystole in an adult with a focal left insular lesion. Clin Neurol Neurosurg. 2013;115(9):1885–1887.Google Scholar
Rocamora, R, Kurthen, M, Lickfett, L, Von Oertzen, J, Elger, CE. Cardiac asystole in epilepsy: Clinical and neurophysiologic features. Epilepsia. 2003;44(2):179–185.Google Scholar
Surges, R, Scott, CA, Walker, MC. Peri-ictal atrioventricular conduction block in a patient with a lesion in the left insula: Case report and review of the literature. Epilepsy Behav. 2009;16(2):347–349.Google Scholar
Catenoix, H, Mauguiere, F, Guenot, M, Isnard, J, Ryvlin, P. Recording the insula during ictal asystole. Int J Cardiol. 2013;169(2):e28–e30.Google Scholar
Schuele, SU, Bermeo, AC, Locatelli, E, Burgess, RC, Luders, HO. Ictal asystole: A benign condition? Epilepsia. 2008;49(1):168–171.CrossRefGoogle ScholarPubMed
Ryvlin, P, Nashef, L, Lhatoo, SD, Bateman, LM, Bird, J, Bleasel, A, et al. Incidence and mechanisms of cardiorespiratory arrests in epilepsy monitoring units (MORTEMUS): A retrospective study. Lancet Neurol. 2013;12(10):966–977.Google Scholar
Oppenheimer, SM, Cechetto, DF, Hachinski, VC. Cerebrogenic cardiac arrhythmias. Cerebral electrocardiographic influences and their role in sudden death. Arch Neurol. 1990;47(5):513–519.CrossRefGoogle ScholarPubMed
Ryvlin, P. Avoid falling into the depths of the insular trap. Epileptic Disord. 2006;8 suppl 2:S37–S56.Google ScholarPubMed
Laowattana, S, Zeger, SL, Lima, JA, Goodman, SN, Wittstein, IS, Oppenheimer, SM. Left insular stroke is associated with adverse cardiac outcome. Neurology. 2006;66(4):477–483; discussion 463.Google Scholar
Colivicchi, F, Bassi, A, Santini, M, Caltagirone, C. Prognostic implications of right-sided insular damage, cardiac autonomic derangement, and arrhythmias after acute ischemic stroke. Stroke. 2005;36(8):1710–1715.CrossRefGoogle ScholarPubMed
Laredo, C, Zhao, Y, Rudilosso, S, Renu, A, Pariente, JC, Chamorro, A, et al. Prognostic significance of infarct size and location: The case of insular stroke. Sci Rep. 2018;8(1):9498.CrossRefGoogle ScholarPubMed
Christensen, H, Boysen, G, Christensen, AF, Johannesen, HH. Insular lesions, ECG abnormalities, and outcome in acute stroke. J Neurol Neurosurg Psychiatry. 2005;76(2):269–271.CrossRefGoogle ScholarPubMed
Song, X, Roy, B, Fonarow, GC, Woo, MA, Kumar, R. Brain structural changes associated with aberrant functional responses to the Valsalva maneuver in heart failure. J Neurosci Res. 2018;96(9):1610–1622.Google Scholar
Allen, LA, Harper, RM, Kumar, R, Guye, M, Ogren, JA, Lhatoo, SD, et al. Dysfunctional brain networking among autonomic regulatory structures in temporal lobe epilepsy patients at high risk of sudden unexpected death in epilepsy. Front Neurol. 2017;8:544.Google Scholar
Ogren, JA, Tripathi, R, Macey, PM, Kumar, R, Stern, JM, Eliashiv, DS, et al. Regional cortical thickness changes accompanying generalized tonic-clonic seizures. Neuroimage Clin. 2018;20:205–215.Google Scholar
Lacuey, N, Zonjy, B, Theerannaew, W, Loparo, KA, Tatsuoka, C, Sahadevan, J, et al. Left-insular damage, autonomic instability, and sudden unexpected death in epilepsy. Epilepsy Behav. 2016;55:170–173.Google Scholar
Jeppesen, J, Fuglsang-Frederiksen, A, Brugada, R, Pedersen, B, Rubboli, G, Johansen, P, et al. Heart rate variability analysis indicates preictal parasympathetic overdrive preceding seizure-induced cardiac dysrhythmias leading to sudden unexpected death in a patient with epilepsy. Epilepsia. 2014;55(7):e67–e71.Google Scholar
Task Force of the European Society of Cardiology and the North American Society of Pacing and Electrophysiology. Heart rate variability: Standards of measurement, physiological interpretation, and clinical use. Eur Heart J. 1996;17(3):354–381.CrossRefGoogle Scholar
Stein, PK, Fauchier, L, Babuty, D. Sudden death, arrhythmic events and measurements of heart rate variability. J Am Coll Cardiol. 1999;34(7):2148–2149.CrossRefGoogle ScholarPubMed
Ogren, JA, Tripathi, R, Macey, PM, Kumar, R, Stern, JM, Eliashiv, DS, et al. Regional cortical thickness changes accompanying generalized tonic-clonic seizures. Neuroimage: Clinical. 2018;20:205–215.Google Scholar
Sperling, MR, Feldman, H, Kinman, J, Liporace, JD, O’Connor, MJ. Seizure control and mortality in epilepsy. Ann Neurol. 1999;46(1):45–50.Google Scholar
Sperling, MR, Barshow, S, Nei, M, Asadi-Pooya, AA. A reappraisal of mortality after epilepsy surgery. Neurology. 2016;86(21):1938–1944.CrossRefGoogle ScholarPubMed

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