Objective-To record non-invasively ictal cardiorespiratory variables. Methods-Techniques employed in polysomnography were used in patients with epilepsy undergoing EEG-video recording at a telemetry unit. Results-Apnoea (> 10, range > 10-63, mean 24 s) was seen in 20 of 47 clinical seizures (three secondary generalised, 16 complex partial, and one tonic) and 10 of 17 patients. Apnoea was central in 10 patients, but obstructive apnoea was also recorded in three of 10. Oxyhaemoglobin saturation (Spo,) dropped to less than 85% in 10 seizures (six patients). An increase in heart rate was common (91% of seizures). Bradycardia/sinus arrest was documented in four patients (mean maximum RR interval 5 36, range 2-8-8-6 s) but always in the context of a change in respiratory pattern. Conclusion-Ictal apnoea was often seen. The occurrence ofbradycardia in association with apnoea suggests the involvement of cardiorespiratory reflexes. Similar mechanisms may operate in cases of sudden death in epilepsy.

Summary: Anecdotal evidence and data from small studies suggest that respiratory changes occur in both complex partial and generalized seizures. Our understanding of sudden unexpected death in epilepsy (SUDEP) may be furthered by recording and analyzing these changes. Investigators at the Jules Thorn Telemetry Unit at the National Hospital for Neurology and Neurosurgery have documented a range of respiratory parameters (respiratory effort, airflow, oxygen saturation) in conjunction with time-locked audio-video electroencephalograms and electrocardiograms to provide a more complete picture of the physiologic changes that occur during seizures. Cardiorespiratory information on 79 seizures (70 complex partial, nine generalized) in 37 patients (20 male, 17 female) is presented. Whereas tachycardia was a common ictal feature, bradycardia was seen only rarely and tended to follow a period of apnea. Apnea occurred in 100% of generalized seizures and 39% of complex partial seizures. Apnea was predominantly central and lasted for 10-75 s (mean duration 29 s). Central apnea may be one of the major, although by no means exclusive, ictal events predisposing to SUDEP. Key Words: SUDEP-SeizuresEpilepsyxentral apnea-Tachycardia-Bradycardia.To date, little has been done to document ictal respiratory changes. That such changes take place during both partial and generalized seizures has been previously reported in anecdotal cases and small selected patient series. In 1968, Nelson and Ray (1) described a case study in which recurrent prolonged apneic attacks were believed to be ictal in nature. Work by Chatrian et al. ( 2 ) in 197 I demonstrated that respiratory changes were the most common autonomic alteration that occurred in a group of patients with tonic seizures. In this study, 21 of 28 patients experienced clinically observable autonomic changes, of whom 20 had cessation of or changes in the rate or depth of respiration. More recently, James et al. ( 3 ) described decreases in the oxygen saturation of patients experiencing generalized tonic-clonic seizures in the emergency room. Hewertson et al. in 1994 (4) described respiratory changes occurring with partial seizures in a group of six children, which included apneic periods associated with hypoxemia after electroencephalographic (EEG) changes. In addition, they reported sinus tachycardia, but not cardiac arrhythmias, accompanying these events. The frequency of such events may be grossly underestimated by simple observation because periods of hypoxia may pass unrecognized even by a skilled observer unless the oxvp_en saturation of the Address correspondence and reprint requests to Ms. F. Walker at Jules

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Ninety-eight medical and surgical inpatients were interviewed 24-72 hours prior to discharge. Thirty-five (36%) had clinical levels of anxiety and depression as defined by the SCL-90-R, a self-report symptom inventory. Compared with patients with normal SCL-90-R subtest scores, anxious and depressed patients more often had the following characteristics: older age, black race, lower socioeconomic class, a recent previous hospitalization, and impaired functional status prior to admission. Three to four weeks after discharge, 25 of the 35 anxious and depressed patients were again interviewed. Thirteen remained anxious and depressed, while 11 patients had returned to normative distress levels. Older, black, poor inpatients with a recent prior hospitalization and impaired functional status are at high risk for clinical anxiety and depression. Half of those with anxiety and depression may remain anxious and depressed after discharge. Intervention should be considered for these patients.

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