“Saved by the Bell”: Near <scp>SUDEP</scp> during intracranial <scp>EEG</scp> monitoring

Baarmah, Duaa; Donner, Elizabeth; Ochi, Ayako; Go, Cristina; McCoy, Bláthnaid; Snead, Carter; Drake, James M.; Jones, Kay S.

doi:10.1002/epi4.12093

Cited by 8 publications

(7 citation statements)

References 18 publications

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“…Our second clinical case of prolonged PCCA accompanied by asystole, resembles the clinical phenotype described in the MORTEMUS study and in a recent analysis of this cohort in a smaller number of patients ( 14 ). Invasive monitoring did not show ongoing seizure activity that was concurrent with apnea, reinforcing once again, the different pathophysiologies of ICA, and PCCA, with higher likelihood of involvement of subcortical structures, such as the brainstem, in PCCA ( 53 , 54 ).…”

Section: Discussionmentioning

confidence: 56%

“…Lastly, our study was based on surface EEG and persistence of intracranial seizure in deep, apnea causing structures ( 12 ) cannot be completely excluded in patients with PCCA. However, Case 2 above, along with a previous case reported in literature, suggest that apnea in epileptic patients can occur in the absence of electrographic seizure ( 53 ).…”

Section: Discussionmentioning

confidence: 81%

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Incidence, Recurrence, and Risk Factors for Peri-ictal Central Apnea and Sudden Unexpected Death in Epilepsy

et al. 2019

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Introduction: Peri-ictal breathing dysfunction was proposed as a potential mechanism for SUDEP. We examined the incidence and risk factors for both ictal (ICA) and post-convulsive central apnea (PCCA) and their relationship with potential seizure severity biomarkers (i. e., post-ictal generalized EEG suppression (PGES) and recurrence.Methods: Prospective, multi-center seizure monitoring study of autonomic, and breathing biomarkers of SUDEP in adults with intractable epilepsy and monitored seizures. Video EEG, thoraco-abdominal excursions, capillary oxygen saturation, and electrocardiography were analyzed. A subgroup analysis determined the incidences of recurrent ICA and PCCA in patients with ≥2 recorded seizures. We excluded status epilepticus and obscured/unavailable video. Central apnea (absence of thoracic-abdominal breathing movements) was defined as ≥1 missed breath, and ≥5 s. ICA referred to apnea preceding or occurring along with non-convulsive seizures (NCS) or apnea before generalized convulsive seizures (GCS).Results: We analyzed 558 seizures in 218 patients (130 female); 321 seizures were NCS and 237 were GCS. ICA occurred in 180/487 (36.9%) seizures in 83/192 (43.2%) patients, all with focal epilepsy. Sleep state was related to presence of ICA [RR 1.33, CI 95% (1.08–1.64), p = 0.008] whereas extratemporal epilepsy was related to lower incidence of ICA [RR 0.58, CI 95% (0.37–0.90), p = 0.015]. ICA recurred in 45/60 (75%) patients. PCCA occurred in 41/228 (18%) of GCS in 30/134 (22.4%) patients, regardless of epilepsy type. Female sex [RR 11.30, CI 95% (4.50–28.34), p < 0.001] and ICA duration [RR 1.14 CI 95% (1.05–1.25), p = 0.001] were related to PCCA presence, whereas absence of PGES was related to absence of PCCA [0.27, CI 95% (0.16–0.47), p < 0.001]. PCCA duration was longer in males [HR 1.84, CI 95% (1.06–3.19), p = 0.003]. In 9/17 (52.9%) patients, PCCA was recurrent.Conclusion: ICA incidence is almost twice the incidence of PCCA and is only seen in focal epilepsies, as opposed to PCCA, suggesting different pathophysiologies. ICA is likely to be a recurrent semiological phenomenon of cortical seizure discharge, whereas PCCA may be a reflection of brainstem dysfunction after GCS. Prolonged ICA or PCCA may, respectively, contribute to SUDEP, as evidenced by two cases we report. Further prospective cohort studies are needed to validate these hypotheses.

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Section: Discussionmentioning

confidence: 56%

Section: Discussionmentioning

confidence: 81%

Incidence, Recurrence, and Risk Factors for Peri-ictal Central Apnea and Sudden Unexpected Death in Epilepsy

et al. 2019

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“…37 Longer PGES duration was found in patients with delayed compared to immediate PCCA, suggesting a possible relationship between cerebral shutdown and brainstem dysfunction. Establishment of nonseizure SUDEP as an entity 38 suggests that brainstem dysfunction may initiate the agonal event independently of cortical seizures. 39,40 Whereas spreading depression in cardiorespiratory suppression is unproven in humans, increasing evidence from imaging 41,42 and pathologic studies 43 suggests that key cardiorespiratory control structures are significantly damaged in patients with intractable epilepsy who succumb to SUDEP.…”

Section: Discussionmentioning

confidence: 99%

Postconvulsive central apnea as a biomarker for sudden unexpected death in epilepsy (SUDEP)

et al. 2019

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ObjectiveTo characterize peri-ictal apnea and postictal asystole in generalized convulsive seizures (GCS) of intractable epilepsy. MethodsThis was a prospective, multicenter epilepsy monitoring study of autonomic and breathing biomarkers of sudden unexpected death in epilepsy (SUDEP) in patients ≥18 years old with intractable epilepsy and monitored GCS. Video-EEG, thoracoabdominal excursions, nasal airflow, capillary oxygen saturation, and ECG were analyzed. ResultsWe studied 148 GCS in 87 patients. Nineteen patients had generalized epilepsy; 65 had focal epilepsy; 1 had both; and the epileptogenic zone was unknown in 2. Ictal central apnea (ICA) preceded GCS in 49 of 121 (40.4%) seizures in 23 patients, all with focal epilepsy. Postconvulsive central apnea (PCCA) occurred in 31 of 140 (22.1%) seizures in 22 patients, with generalized, focal, or unknown epileptogenic zones. In 2 patients, PCCA occurred concurrently with asystole (near-SUDEP), with an incidence rate of 10.2 per 1,000 patient-years. One patient with PCCA died of probable SUDEP during follow-up, suggesting a SUDEP incidence rate 5.1 per 1,000 patient-years. No cases of laryngospasm were detected. Rhythmic muscle artifact synchronous with breathing was present in 75 of 147 seizures and related to stertorous breathing (odds ratio 3.856, 95% confidence interval 1.395-10.663, p = 0.009). ConclusionsPCCA occurred in both focal and generalized epilepsies, suggesting a different pathophysiology from ICA, which occurred only in focal epilepsy. PCCA was seen in 2 near-SUDEP cases and 1 probable SUDEP case, suggesting that this phenomenon may serve as a clinical biomarker of SUDEP. Larger studies are needed to validate this observation. Rhythmic postictal muscle artifact is suggestive of post-GCS breathing effort rather than a specific biomarker of laryngospasm.

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“…The event was primarily characterized by diffuse EEG slowing and attenuation with apnea, followed by bradycardia. 47 Among the mechanisms that lead to non-typical seizure-triggered SUDEP, a fatal cerebral edema was reported in a 21-year-old DS patient, three hours after a single seizure. 48 Sodium channel dysfunction may have contributed to an excessive delayed postictal brain swelling.…”

Section: From Sudep Mechanisms To Novel Biomarkersmentioning

confidence: 99%

Risks and predictive biomarkers of sudden unexpected death in epilepsy patient

Ryvlin

Rheims

Lhatoo

2019

Current Opinion in Neurology

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Purpose of review: This review updates our knowledge regarding SUDEP risks, risk factors, and investigations of putative biomarkers based on suspected mechanisms of SUDEP.-Recent findings: The overall incidence of SUDEP in adults with epilepsy is 1.2/1000 patientyears, with surprisingly comparable figures in children in recently published population-based studies. This risk was found to decrease over time in several cohorts at a rate of −7% per year, for unknown reasons. Well-established risk factors include frequency of generalized tonic-clonic seizures, while adding antiepileptic treatment, nocturnal supervision and use of nocturnal listening device appear to be protective. In contrast, recent data failed to demonstrate the predictive value of heart rate variability, periictal cardiorespiratory dysfunction, and postictal generalized EEG suppression. Preliminary findings suggest that brainstem and thalamic atrophy may be associated with a higher risk of SUDEP. Novel experimental and human data support the primary role of GTCS-triggered respiratory dysfunction and the likely contribution of altered brainstem serotoninergic neurotransmission, in SUDEP pathophysiology.

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“Saved by the Bell”: Near SUDEP during intracranial EEG monitoring

Cited by 8 publications

References 18 publications

Incidence, Recurrence, and Risk Factors for Peri-ictal Central Apnea and Sudden Unexpected Death in Epilepsy

Incidence, Recurrence, and Risk Factors for Peri-ictal Central Apnea and Sudden Unexpected Death in Epilepsy

Postconvulsive central apnea as a biomarker for sudden unexpected death in epilepsy (SUDEP)

Risks and predictive biomarkers of sudden unexpected death in epilepsy patient

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