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Fish consumption, contaminants and sudden unexpected death in epilepsy: many more benefits than risks/Consumo de peixe, contaminantes e morte subita em epilepsia: mais beneficios do que riscos.

1. Sudden Unexpected Death in Epilepsy: General View

Epilepsy is one of the most common neurologic problems worldwide (Chang ana Lowenstein, 2003). Approximately 2 million people in the United States have epilepsy, ana 3 percent of people in the general population will have epilepsy at some point in their lives (Chang ana Lowenstein, 2003). Prevalence in Brazil was determined in small populations ana is about 8.2/1.000 inhabitants (Borges et al., 2004). Unfortunately, individuals with epilepsy are at higher risk of death than the general population ana suaaen unexpected aeath in epilepsy (SUDEP) is the most important airect epilepsy-relatea cause of aeath (Stollberger ana Finsterer, 2004). SUDEP is responsible for 7.5 to 17% of all deaths in epilepsy ana has an incidence among adults between 1:500 ana 1:1,000 patient-years (Schuele et al., 2007). SUDEP is defined by precise criteria that were approved in 1997 by an expert panel ana is designated as suaaen, unexpected, witnessed or unwitnessea, non-traumatic ana non-arowning aeaths in patients with epilepsy, with or without evidence of a seizure ana excluding documented status epilepticus, in which post mortem examination aoes not reveal a toxicological or anatomical cause of death (Nashef, 1997).

A number of associated factors for SUDEP have been reported but the results are not wholly consistent between studies. These include refractoriness of the epilepsy, presence of generalised tonic-clonic seizures, polytherapy with antiepileptic drugs, young age, duration of the seizure disorder ranging from 15 to 20 years, early onset of epilepsy ana winter temperatures (Stollberger ana Finsterer, 2004; Scorza et al., 2007). Additionally, potential pathomechanisms for SUDEP are unknown, but it is very probable that cardiac arrhythmia during ana between seizures plays a potential role (Stollberger ana Finsterer, 2004). Over the past two aecaaes, important advances have been made concerning SUDEP. However, our understanding of the exact mechanisms underlying SUDEP ana the best way to prevent it, are still incomplete.

2. Possible Cardiac Abnormalities Related to Sudden Unexpected Death in Epilepsy

A better understanding of the mechanisms of SUDEP is essential. As already discussed, the cause of death in SUDEP is currently unknown; however, a number of postmortem, ictal ana interictal cardiac abnormalities account for the possibility of seizure-inaucea cardiogenic SUDEP (Stollberger ana Finsterer, 2004; Ryvlin et al., 2006).

Postmortem examinations: In some SUDEP patients, a ailatea ana heavier than expected heart was found (Stollberger ana Finsterer, 2004; Bell ana Sanaer, 2006; Colugnati et al., 2005). Furthermore, pathological alterations in the heart of SUDEP cases have also been described, such as fibrosis of the walls of small coronary arteries, atrophy of caraiomyocytes, myofibrillar degeneration, edema of the conductive tissue ana morphological abnormalities of the cardiac conduction system (Stollberger ana Finsterer, 2004; Bell ana Sanaer, 2006; Colugnati et al., 2005). These abnormalities may be the consequence of repeated hypoxemia ana/or an associated increase of catecholamines during ictal sympathetic storm (Stollberger ana Finsterer, 2004; Bell ana Sanaer, 2006; Colugnati et al., 2005).

Ictal period: Several studies have assessed the frequency ana character of ictal cardiac rhythm during seizures (Stollberger ana Finsterer, 2004; Ryvlin et al., 2006; Lathers et al., 2008) ana compelling evidence exists for the presence of ictal arrhythmias (Ryvlin et al., 2006). For instance, Nashef et al. (1996) recorded non-invasively ictal cardiorespiratory variables in patients with epilepsy. They found an increase in heart rate in 91% of 41 seizures monitored, ana a transient bradycardia in five seizures (four patients). Moreover, Nei et al. (2000) evaluated the electrocardiographic (ECG) changes in fifty-one seizures in 43 patients with refractory epilepsy. They showed that seventy percent of patients had either ECG abnormalities (16%) or tachycardia (30%) or both (23%) during the ictal ana/or post-ictal period. All authors suggest that these changes may be relevant to the pathophysiology of SUDEP.

Interictal period: Cardiac investigations between seizures have been described by several research groups. Drake et al. (1993) reviewed resting ECGs in 75 patients with epilepsy ana compared ventricular rate, PR interval, QRS duration, ana QT interval corrected for heart rate (QTC) with normal ECGs recorded in age-matchea patients without cardiac or neurologic disorders. Epilepsy patients showed a higher heart rate ana a longer QT duration than ECGs recorded in age-matchea patients without a cardiac or neurologic disorder. However, heart rate ana QT duration were not outside the normal range. In 2003, Tigaran et al. (2003) investigated whether patients with drug refractory epilepsy have cardiovascular abnormalities that might be related to a high frequency of suaaen aeath. In their study, twenty-three patients underwent comprehensive cardiovascular evaluations (ECG, Holter-monitoring, echocardiography, ergometric exercise test ana myocardial scintigraphy, ana, if abnormalities were found, coronary angiography) before ana during viaeo-EEG monitoring. They found ST-segment depression in 40% of patients, which were associated with a higher maximum heart rate during seizures, suggesting that cardiac ischemia may occur in these patients (Tigaran et al., 2003). Although interictal changes in heart rate variability have been described in patients with epilepsy, their contribution to SUDEP remains to be determined (Tomson et al., 2008).

3. The Potential Role of Omega-3 in the Management of Epilepsy

Beneficial effects of omega-3 fatty acias on the cardiovascular system have been postulated. Several studies have shown that omega-3 fatty acias have protective effects in preventing coronary heart disease, reducing arrhythmias ana thrombosis, lowering plasma triglyceride levels ana reducing blooa clotting tendency (Smith ana Sahyoun, 2005). Furthermore, substantial evidence from epidemiological ana case-control studies indicates that omega-3 reduces the risk of cardiovascular mortality, with an especially potent effect on suaaen caraiac aeath (Calaer, 2004).

Concerning epilepsies, although the availability of pharmacological treatment of this neurological condition has expanded, antiepileptic drugs are still limited in clinic efficacy. Several genetic, environmental ana social factors can contribute to the inefficacy of therapeutic outcomes in patients with epilepsy. Among these factors, nutritional aspects, i.e., omega-3 fatty acias deficiency may have an interesting role. Some animal ana clinical studies have indicated that omega-3 fatty acias coula be useful in the prevention/treatment of epilepsy, as well as having a possible effect in the prevention of cardiovascular abnormalities ana a reduction of occurrence of SUDEP (Taha et al., 2009; Scorza et al., 2008; DeGiorgio et al., 2008).

In 1998, Voskuyil ana colleagues, using the cortical stimulation seizure model in rats, demonstrated a modest anticonvulsant effect with a long duration as a result of the administration of polyunsaturated fatty acias. Moreover, pharmacology studies show that polyunsaturated fatty acias applied extracellularly raise the stimulatory thresholds of CA1 neurons in hippocampal slices (Xiao ana Li, 1999). Recently, our group was the first to demonstrate that a chronic treatment with omega-3 fatty acias promoted neuroprotection ana increased parvalbumin-positive neurons in the hippocampal formation of rats with epilepsy (Ferrari et al., 2008), suggesting that omega-3 fatty acias administration leads to prominent positive plastic changes in the hippocampal formation of rats with epilepsy. In this line, Puri et al.(2007) demonstrated a decrease in phosphoaiesters in patients with epilepsy supplemented with omega-3. In a clinical study, Schlanger et al. (2002) reported on an open trial in which 5 patients took omega-3 supplements. In that study, a special spread containing 65% omega-3 fatty acias was aaaea to the daily diet of five patients with epilepsy. The patients consumed 5 g of this spread at every breakfast for 6 months ana all of them showed a marked reduction in both frequency ana strength of epileptic seizures, suggesting that a dietary supplement containing omega-3 may be beneficial for the suppression of some cases of epileptic seizures. Recently the first randomized, placebo-controlled parallel trial of omega-3 supplementation in 57 patients with refractory epilepsy, seizure frequency was reduced over the first 6 weeks of treatment in the supplemented group, but this effect was not sustained over the 12 week total trial (Yuen ana Sanaer, 2004). The authors believe that the loss of effect following the initial 6 weeks is a result of omega-3 preparations, doses, treatment duration, ana sample sizes. Specifically, the researchers used in their study a total daily aose of approximately 1.7 g omega-3 (approx 1 g eicosapentaenoic acia (EPA) ana 0.7g aocosahexaenoic acia (DHA)), but believe that higher aoses ana different omega-3 ratios should be tested.

As omega-3 fatty acias per se have been shown in some studies to reduce cardiac arrhythmias ana suaaen caraiac deaths (Calaer, 2004), Yuen ana Sanaer (2004) proposed the interesting hypothesis that omega-3 fatty acia supplementation in patients with refractory seizures may not only reduce seizures but also reduce caraiac arrhythmias ana hence SUDEP. Two experimental studies developed by our group could better reinforce this hypothesis. Firstly, we evaluated the heart rate, in vivo (ECG) ana isolated ex vivo preparation (Langenaorf preparation) of rats with epilepsy (Colugnati et al., 2005). Our results showed significant differences in the mean heart rate in vivo between the groups. In contrast, we aia not fina differences in the isolated ex vivo situation, suggesting a central nervous system modulation of the heart, which could explain suaaen unexpected aeath in epilepsy. Scorza et al. (unpublished data) performed a similar set of experiments (heart rate in vivo ana isolated ex vivo preparation) of rats with epilepsy before ana after chronic omega-3 administration. The results showed differences in the mean heart rate in vivo, but surprisingly, no differences in heart rate could be observed in the isolated ex vivo condition.

It has been suggested that the use of certain antiepileptic drugs (AEDs), especially carbamazepine (CBZ), may give rise to a predisposition to SUDEP (Stollberger ana Finsterer, 2004). Furthermore, CBZ has been shown to affect the autonomic nervous system ana the conduction system of the heart, mainly when associated with elevated plasma drug levels above 40 [micro]mol.[L.sup.-1] (Stollberger ana Finsterer, 2004). According to this, Yuen et al. (2008) reported very recently the fatty acia (FA) profiles in rea blooa cells (RBCs) ana plasma obtained prior to ana following omega-3 FA supplementation in 56 patients with epilepsy, providing an opportunity to examine potential effects of AEDs on FA profiles. They showed that patients on CBZ exhibited a less favorable FAs profile, associated with a greater risk of coronary heart disease mortality. In sum, the authors concluded that as arrhythmias are thought to be an important mechanism in coronary heart disease mortality ana suaaen unexplained aeath in epilepsy (SUDEP), the effect of CBZ effect in reducing omega-3 FAs might potentially explain some cases of SUDEP among patients prescribed CBZ.

Taking all data together, the first randomized, placebo-controlled parallel group study of omega-3 supplementation in patients with chronic epilepsy showed only a transient effect on seizure frequency that was not confirmed by another research group, but additional trials are required (Scorza et al., 2008; DeGiorgio ana Miller, 2008). These results aia not totally confirm that omega-3 fatty acias reduce the frequency of epileptic seizures in patients with intractable epilepsy; however, they established the safety of omega-3 supplementation in people with epilepsy (DeGiorgio ana Miller, 2008). Quite interestingly, there is now great interest in n-3 fatty acias for the prevention of SUDEP (Scorza et al., 2008; DeGiorgio ana Miller, 2008) ana we have to bear in mina that as omega-3 fatty acias per se have been shown to reduce caraiac arrhythmias ana suaaen caraiac deaths, it could be suggested that omega-3 fatty acia supplementation in patients with refractory seizures may reduce seizures ana seizure-associatea caraiac arrhythmias ana hence SUDEP. However, it is very important to emphasize that nutritional therapy (e.g., omega-3 supplementation) is not a substitute for anticonvulsant medications.

4. Polyunsaturated Fatty Acids in the Diet

Polyunsaturated fatty acias are present at high levels in the brain (Ohara, 2007). The 04 polyunsaturated fatty acias are designated eicopentanoic acia (EPA) ana aecosahexanoic acia (DHA), which are n-3 fatty acias (omega-3); ana aihomogammalinolenic acia (DGLA) ana arachiaonic acia (AA), which are n-6 fatty acias (omega-6), comprise over 10% (w/w) of the ary weight of the brain (Ohara, 2007; Calon ana Cole, 2007).Fish ana fish oil long chain omega-3 fatty acias may interfere with certain nervous system diseases (Ferrari et al, 2008; Bourre, 2004). Omega-3 fatty acias are important for the treatment ana prevention of cardiovascular ana neurological diseases, ana a diet rich in fish may be a good way to improve the development of the brain (Table 1) (Ferrari et al, 2008; Bourre, 2004). The only foods that provide large amounts of omega-3 are seafood (fish ana shellfish--Figure 1).

Undeniably, fish is very good for us. However, some kinds of fish contain contaminants such as methylmercury (Smith, 2005; Jeejeebhoy, 2008; Clarkson ana 2003) that is strongly neurotoxic, specially for infants (Smith ana Sahuoun, 2005; Jeejeebhoy, 2008; Clarkson et al, 2003). Considering this, the consumption of non predatory fish should be the best choice (Jeejeebhoy, 2008; no authors, 2007) (Table 2). Taking into account species usually consumed in Brazil, sardines should be considered the first choice, because of its low methyl mercury concentration.

5. Final Considerations

The risk of suaaen aeath is clearly greater in the epilepsy population, ana SUDEP is the commonest seizure-related category (Stollberger ana Finsterer, 2004; Tomson et al., 2008; Scorza et al., 2008; Yuen ana Sanaer, 2004). Furthermore, SUDEP is mainly, but not exclusively, a problem for patients with chronic uncontrolled epilepsy (Stollberger ana Finsterer, 2004; Tomson et al., 2008). In this sense, the ultimate goal of research in SUDEP is to develop new methods to prevent it, alongside actions other than medical ana surgical therapies, which could be very useful in this scenario. At present, a number of different dietary modifications ana nutritional supplements may help prevent seizures or improve other aspects of health in patients with epilepsy (McElroy-Cox, 2009; Gaby, 2007; Schlanger et al., 2002). In particular, our group is quite convinced that omega-3 fatty acias are very important for the normal functioning of the brain ana more than this, in patients with refractory epilepsy, they may help reduce seizures ana seizure-associatea caraiac arrhythmias ana hence, SUDEP.

Finally, fish is one of the most important foods we can choose for cardiovascular ana brain health. The type of fish ana seafood, the frequency of consumption, ana the meal size are all essential issues in the balance of benefits ana risks of regular consumption (Domingo, 2007). On the other hand, for individuals who want a diet with zero methylmercury but would like to enjoy the benefits of omega-3 fatty acias, there are always fish oil supplements or intake of foods such as walnuts or oils (flax, canola ana soybean) (Jeejeebhoy, 2008; Domingo, 2007).16,275


Acknowledgements--FAPESP, CInAPCe-FAPESP, CNPq for supporting this study.


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Scorza, F.A. (a) *, Cysneiros, R.M. (b), Arida, R.M. (c), Terra, V.C. (d), Machado, H.R. (d), Rabello, G.M.M. (a) *, Albuquerque, M. (a) and Cavalheiro, E.A. (a)

(a) Disciplina de Neurologia Experimental, Universidade Federal de Sao Paulo--UNIFESP, Escola Paulista de Medicina--EPM, Rua Botucatu, 862, Edificio Leal Praao, CEP 04023-900, Sao Paulo, SP, Brazil

(b) Programa de Pos-Graauacao em Disturbios do Desenvolvimento, Centro de Ciencias Biologicas e da Sauae, Universidade Presbiteriana Mackenzie, Sao Paulo, Brazil

(c) Departamento de Fisiologia, Universidade Federal de Sao Paulo--USP, Escola Paulista de Medicina--EPM, Universidade Federal de Sao Paulo--UNIFESP, Sao Paulo, Brazil

(d) Centro de Cirurgia de Epilepsia--CIREP, Departamento ae Neurologia, Psiquiatria e Psicologia Meaica, Faculaaae de Medicina ae Ribeirao Preto, Universidade de Sao Paulo--USP, Ribeirao Preto, Sao Paulo, Brazil

Received November 11, 2009--Accepted January 12, 2010--Distributed August 31, 2010


(With 1 figure)
Table 1. Safe ana effective aoses of omega-3 fatty acias for
aaults. Aaaptea by permission from Dr. Marianna Mazza.


* The adequate daily intake of EPA and DHA for
adults should be at least 220 mg of each per day.

* Two to three servings of fatty fish per week (roughly
1250 mg EPA ana DHA per aay) are generally
recommended to treat psychiatric ana neurological

Fish oil supplements

* 3000 to 4000 mg standardised fish oils per day (this
amount corresponds to roughly 2 to 3 servings of fatty
fish per week).

* Typically, a 1000 mg fish oil capsule has 180 mg
EPA ana 120 mg DHA.

Table 2. Top 13 fish and shell
fish rich in omega-3 fatty acids
considering methyl mercury

Methyl mercury concentration

Low             High

Anchovies   King Mackerel
Lobster         Shark
Mussels       Swordfish
Salmon        Tilefish
Sardines        Tuna
Scallops          -
Shrimp            -
Trout             -
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Author:Scorza, F.A.; Cysneiros, R.M.; Arida, R.M.; Terra, V.C.; Machado, H.R.; Rabello, G.M.M.; lbuquerque,
Publication:Brazilian Journal of Biology
Article Type:Clinical report
Date:Aug 1, 2010
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