Incidence and risk factors in sudden unexpected death in epilepsy: A prospective cohort study

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Walczak TS, Leppik IE, D’Amelio M, Rarick J, So E, Ahman P, Ruggles K, Cascino GD, Annegers JF, and Hauser WA (2001) Incidence and risk factors in sudden unexpected death in epilepsy: A prospective cohort study. Neurology 56:4 519– 25.

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Abstract: OBJECTIVE: To determine incidence of and risk factors for sudden unexpected death in epilepsy (SUDEP). METHODS: Three epilepsy centers enrolled 4,578 patients and prospectively followed these patients for 16,463 patient-years. The cohort was screened for death annually. Deaths were investigated to determine whether SUDEP occurred. Potential risk factors were compared in SUDEP cases and in controls enrolled contemporaneously at the same center. RESULTS: Incidence of SUDEP was 1.21/1,000 patient-years and was higher among women (1.45/1,000) than men (0.98/1,000). SUDEP accounted for 18% of all deaths. Occurrence of tonic-clonic seizures, treatment with more than two anticonvulsant medications, and full-scale IQ less than 70 were independent risk factors for SUDEP. The number of tonic-clonic seizures was a risk factor only in women. The presence of cerebral structural lesions and use of psychotropic drugs at the last visit were not risk factors for SUDEP in this cohort. Subtherapeutic anticonvulsant levels at the last visit were equally common in the two groups. No particular anticonvulsant appeared to be associated with SUDEP. CONCLUSIONS: These results support the idea that tonic-clonic seizures are an important proximate cause of SUDEP. This information creates a risk profile for SUDEP that may help direct preventative efforts.



  • Prospective cohort study involving >4,500 patients at 3 centers. Incidence of SUDEP was 1.21 per 1,000 patient-years. Independent risk factors were mental retardation, treatment with 3 or more AED, and occurrence of tonic-clonic seizures . Of note, subtherapeutic AED levels were equally common in non-SUDEP and SUDEP deaths, and no individual AED was associated with SUDEP. The effectiveness of statistical methods to distinguish the risk of refractory disease from that of polytherpy is not clear.


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