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Key points Sudden unexpected death in epilepsy (SUDEP) is the leading cause of premature death in patients with refractory epilepsy. SUDEP typically occurs during the night, although the reason for this is unclear. We found that, in normally entrained mice, time‐of‐day alters vulnerability to seizure‐induced death. We found that, in free‐running mice, circadian phase alters the vulnerability to seizure‐induced death. These findings suggest that circadian rhythmicity may be responsible for the increased night‐time prevalence of SUDEP Abstract Sudden unexpected death in epilepsy (SUDEP) is the leading cause of epilepsy‐related death. SUDEP typically occurs during the night following a seizure. Many aspects of mammalian physiology are regulated by circadian rhythms in ways that might make seizures occuring during the night more dangerous. Using two mouse models of seizure‐induced death, we demonstrate that time‐of‐day and circadian rhythms alter vulnerability to seizure‐induced death. We exposed normally entrained DBA/1 mice to a potentially seizure‐inducing acoustic stimulus at different times of day and compared the characteristics and outcomes of the seizures. Time‐of‐day did not alter the probability of a seizure but it did alter the probability of seizure‐induced death. To determine whether circadian rhythms alter vulnerability to seizure‐induced death, we induced maximal electroshock seizures in free‐running C57BL/6J mice at different circadian time points at the same time as measuring breathing via whole body plethysmography. Circadian phase did not affect seizure severity but it did alter postictal respiratory outcomes and the probability of seizure‐induced death. By contrast to our expectations, in entrained and free‐running mice, vulnerability to seizure‐induced death was greatest during the night and subjective night, respectively. These findings suggest that circadian rhythmicity may be responsible for the increased night‐time prevalence of SUDEP and that the underlying mechanism is phase conserved between nocturnal and diurnal mammals. All of the seizures in the present study were induced during wakefulness, indicating that the effect of time point on vulnerability to seizure‐induced death was not the result of sleep. Understanding why SUDEP occurs more frequently during the night may inform future preventative countermeasures.

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AbstractSudden unexpected death in epilepsy (SUDEP) is the leading cause of death in patients with refractory epilepsy. A proposed risk marker for SUDEP is the duration of post-ictal generalized EEG suppression (PGES). The mechanisms underlying PGES are unknown. Serotonin (5-HT) has been implicated in SUDEP pathophysiology. Seizures suppress activity of 5-HT neurons in the dorsal raphe nucleus (DRN). We hypothesized that suppression of DRN 5-HT neuron activity contributes to PGES and increasing 5-HT neurotransmission or stimulating the DRN before a seizure would decrease PGES duration. Adult C57BL/6 and Pet1-Cre mice received EEG/EMG electrodes, a bipolar stimulating/recording electrode in the right basolateral amygdala, and either a microdialysis guide cannula or an injection of adeno-associated virus (AAV) allowing expression of channelrhodopsin2 plus an optic fiber into the DRN. Systemic application of the selective 5-HT reuptake inhibitor citalopram (20 mg/kg) decreased PGES duration from seizures induced during wake (n = 23) and NREM sleep (n = 13) whereas fluoxetine (20 mg/kg) pretreatment decreased PGES duration following seizures induced from wake (n = 11), but not NREM sleep (n = 9). Focal chemical (n = 6) or optogenetic (n = 8) stimulation of the DRN reduced PGES duration following kindled seizures and reduced morality following maximal electroshock seizures (n = 6) induced during wake. During PGES, animals exhibited immobility and suppression of EEG activity that was reduced by citalopram pretreatment. These results indicate that 5-HT and the DRN may regulate PGES and seizure-induced mortality.Highlights-PGES consistently follows seizures induced by amygdala stimulation in amygdala-kindled mice.-Seizure-induced dysregulation of 5-HT neurotransmission from the dorsal raphe nucleus may contribute to PGES.-Systemic administration of 5-HT enhancing drugs and stimulation of the DRN reduces PGES duration.-PGES is associated with post-ictal immobility in kindled mice that can be reduced by pretreatment with citalopram.-Recovery of EEG frequencies to baseline occurs in a stepwise manner with the lowest frequencies recovering first.