The Underappreciated But Potentially Lethal Role of Brainstem Dysfunction in Epilepsy.

Abstract

Association of Peri-Ictal Brainstem Posturing With Seizure Severity and Breathing Compromise in Patients With Generalized Convulsive Seizures Vilella L, Lacuey N, Hampson JP, et al. Neurology. 2021;96(3):e352-e365. doi:10.1212/WNL.0000000000011274Objective: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 (41.4%) of 295, decortication in 47 (15.9%) of 295, and hemi-decerebration in 28 (9.5%) of 295 seizures. Tonic phase was absent in 98 (33.2%) of 295 seizures. Postictal posturing occurred in 18 (6.1%) of 295 seizures. Postictal generalized electroencephalographic suppression risk increased with ictal decerebration (odds ratio [OR]: 14.79, 95% CI: 6.18-35.39, P < .001), decortication (OR: 11.26, 95% CI: 2.96-42.93, P < .001), or hemi-decerebration (OR: 48.56, 95% CI: 6.07-388.78, P < .001). Ictal decerebration was associated with longer PGES (P = .011). Postictal posturing was associated with postconvulsive central apnea (PCCA; P = .004), longer hypoxemia (P < .001), and Spo2 recovery (P = .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.