Prevention of sudden unexpected death in epilepsy: current status and future perspectives

Abstract

Sudden unexpected death in epilepsy (SUDEP) affects about 1 in 1000 people with epilepsy, and even more in medically refractory epilepsy. As most people are between 20 and 40 years when dying suddenly, SUDEP leads to a considerable loss of potential life years. The most important risk factors are nocturnal and tonic-clonic seizures, underscoring that supervision and effective seizure control are key elements for SUDEP prevention. The question of whether specific antiepileptic drugs are linked to SUDEP is still controversially discussed. Knowledge and education about SUDEP among healthcare professionals, patients and relatives are of outstanding importance for preventive measures to be taken, but still poor and widely neglected.

Wearables bei Epilepsien

“…Eine Konsensusgruppe der International League against Epilepsy und International Federation of Clinical Neurophysiology) erklärt, dass Geräte zur Detektion von TKA empfohlen werden können, v. a. dann, wenn daraus eine zeitnahe Intervention resultiert [58]. Der breite Einsatz TKA-detektierender Wearables lässt eine Reduktion der SUDEP Inzidenz erwarten [1]. Zudem scheint der Einsatz von Wearables die Lebensqualität von Epilepsiepatienten und ihren Angehörigen zu verbessern [59].…”

“…Vor allem fokale zu bilateral und generalisierte tonisch-klonische Anfälle (TKA) sind mit einem erhöhten Risiko assoziiert, plötzlich und unerwartet zu versterben (sog. SUDEP, Infobox 1)[1]. Anfälle treten für Betroffene meist nicht vorhersagbar auf[2] und werden zu einem größeren Teil nicht wahrgenommen oder nicht erinnert, was eine fehlerhafte Dokumentation in Anfallstagebüchern zur Folge hat[3].…”

Can We Prevent Sudden Unexpected Death in Epilepsy (SUDEP)?

“…12 Intrinsic brain mechanisms leading to or associated with seizure termination have been postulated to lead to a centrally mediated neurovegetative breakdown and postictal generalized electroencephalogram (EEG) suppression. 7,12 Animal studies have implicated postictal dysfunction of brainstem structures which control autonomic functions, which can lead to sudden cardiorespiratory arrest in SUDEP. [13][14][15] The first crucial step toward SUDEP prevention is to correctly identify the subgroup of people with epilepsy who are at high risk for developing SUDEP.…”

“…This can be done by evaluating the patient using safety checklists, inventories such as SUDEP-7 inventory, and genetic testing, and by studying specific EEG changes which have been associated with SUDEP. 7,16,17 Checklist and Inventory Past studies have highlighted the possible role of 17 factors associated with increased risk of SUDEP, some of which are potentially modifiable. These form the background of the seizure and SUDEP safety checklist.…”

“…Till date, the proposed SUDEP preventive strategies include effective epilepsy control (medical or surgical), evaluating and managing ictal or postictal cardiorespiratory distress, nocturnal supervision, and drugs such as selective serotonergic reuptake inhibitors, and opiate and adenosine antagonists which may help to prevent central apnea. 7 In a recent Cochrane review, except for low-quality evidence of preventive effect of nocturnal supervision for SUDEP, no evidence was found for the effectiveness of seizure detection devices, safety pillows, early surgical evaluation, serotonin reuptake inhibitors (SSRIs), educational programs, and opiate and adenosine antagonists in preventing SUDEP in patients with epilepsy. 8 Conducting randomized controlled trials for evaluating modalities to prevent SUDEP is not feasible; hence, alternative surrogate endpoints such as emergency room attendance, injuries, post-seizure apnea, and heart rate variability (HRV) have been used.…”