1. SUDEP (Sudden Unexpected Death in Epilepsy)
Rebecca Liu
Consultant Neurologist
Epilepsy Initiative Group, Royal Free London NHS Foundation Trust

2. AIMS Develop greater awareness and understanding of SUDEP
Recognise those at high risk
Understand possible mechanisms
Practical measures that may reduce risk

3. What is SUDEP (Sudden Unexpected Death in Epilepsy)?
Sudden and Unexpected death in person with epilepsy
Witnessed or unwitnessed
May or may not have been related to a recent seizure
Not related to trauma
Not due to drowning
Not due to status epilepticus
Definite SUDEP – autopsy shows no anatomical / toxic cause
Probable SUDEP – no autopsy

4. TEST YOUR KNOWLEDGE The same as for the general population
Compared to the general population, premature death in epilepsy is:
The same as for the general population
3X greater
10X greater

5. TEST YOUR KNOWLEDGE 2. The commonest cause of death in epilepsy is:
Accidents
Drowning
Status Epilepticus
SUDEP
Suicide
Medication side effects

6. TEST YOUR KNOWLEDGE
3. In epilepsy surgery candidates, the risk of SUDEP is approximately:
1 in 10,000 people each year
1 in 1000 people each year
1 in 100 people each year
1 in 10 people each year

7. TEST YOUR KNOWLEDGE The single greatest risk factor for SUDEP is: Male
Seizures at night
AED polytherapy
Long duration of epilepsy
Frequent generalised convulsions

8. TEST YOUR KNOWLEDGE
What is the most important factor in preventing SUDEP?
Supervision after seizures
Sleeping on your back
Cutting down alcohol intake
Bed monitor
Achieving best seizure control possible
Keeping antiepileptic medication to a minimum

9. Epilepsy surgery candidates
SUDEP – some facts
PWE have 3X increased mortality
PWE are 24X more likely to die of sudden death
SUDEP is the commonest cause of death in epilepsy
Each year, 500 people die from SUDEP in the UK
Commonest in age years
1:1000 – 1:10,000 person years
Average
1:200 / year
High risk groups
1:100 / year
Epilepsy surgery candidates

10. RISK FACTORS FOR SUDEP Frequent seizures especially GTCS
Long epilepsy duration
Early epilepsy onset
Poor drug concordance
AED polytherapy / change of AED doses
Learning disability
Young adults years
Male Sex
Alcohol abuse

11. Why might SUDEP occur?

12. Heart Tachycardia during seizures is usual
Bradycardia during seizures rare (2%)
16% had sinus arrest resulting in a pacemaker (Rugg Gunn 2004)
Gene mutations associated with cardiological conditions have been found postmortem in 13% pts with SUDEP.

13. Lung Seizure-related apnoea recorded on VT units and animal models
Low oxygen levels are common during seizures
Apnoea due to CENTRALhypoventilation > obstructive
Patients often lying on their front
Hypoxia more in: temporal lobe seizures, long seizures and spread of seizure activity through brain
Postictal hypoxaemia may lead to cardiac arrhythmias

14. Brain ‘Cerebral electrical shutdown’ seen in SUDEP patients
Postictal generalised EEG suppression (PGES) often occurs after generalised convulsions
?PGES longer in patients with SUDEP
More likely to be motionless after seizure and need help
Does stimulation help?

15. Interaction between predisposing factors and triggers for SUDEP
Individual
Chronic epilepsy
Seizure
AED changes
Unknown factors
Arrhythmia, Apnoea, Cerebral shutdown

16. HIGH RISK PATIENTS Young men Early onset refractory seizures
Symptomatic focal epilepsy
Frequent convulsions
Large number of AED drugs

17. What can we do to help prevent SUDEP?
Control seizures as best we can!
Encourage good drug concordance
Avoid seizure triggers
Consider specialist referral
Stay with patient during recovery period
Ensure nothing obstructing their breathing
Position - Lie in recovery position, sleep on back
Stimulate patient after a seizure
Administer oxygen if necessary
Consider nocturnal alarm, monitoring device, supervision

18. THE AFTERMATH Contact their GP, epilepsy specialist
Emotional support / Counselling
Put in touch with Epilepsy Bereaved