Can sudden unexplained death in epilepsy be prevented?
Hirsch LJ and Hauser WA(2004) Can sudden unexplained death in epilepsy be prevented? Lancet 364:9452 2157–8.
First Paragraph: Each year, about one in a 1000 patients with chronic epilepsy will die suddenly, unexpectedly, and without explanation, even with postmortem examination. This phenomenon is called sudden unexplained death in epilepsy (SUDEP). Incidence increases with severity of epilepsy, reaching 1% a year in candidates for epilepsy sur- gery.1,2 Proposed causes of SUDEP include cardiac arrhyth- mias, central apnoea, and neurogenic pulmonary oedema. In this issue of The Lancet, Fergus Rugg-Gunn and col- leagues report findings in people with intractable epilepsy who were implanted with subcutaneous electrocardiogram loop recorders for an average of 18 months. Four of the 19 patients (21%) developed bradycardia or asystole for which a permanent pacemaker was deemed appropriate. Three of these episodes occurred at the time of a clinical seizure and one was not associated with a known clinical event. For example, a 42-year-old man with refractory epilepsy in the left temporal lobe had an 18-s period of asystole during an apparently typical complex partial seizure after more than a year of recording, despite having shown ictal tachycardia during hundreds of previous seizures. The investigators concluded that potentially fatal peri-ictal cardiac arrhythmias are under-recognised, can be detected with loop recorders, can explain some cases of SUDEP, and might be preventable with permanent pace-maker insertion.
Context
- Commentary on Rugg-Gunn et al. Highlights the finding that after hundreds of seizures without cardiac effect a seizure may suddenly cause arrhythmia or asystole. They also mention the possibility that asystole occurs in normal individuals an would be detected if patients were recorded for 18 months. They lament the recording of EKG in only 15% of clinical seizures, and mention problems like pseudoasystole. Overall their view is that the study of Rugg-Gunn et al. This valuable but needs to be replicated.