Sudden unexpected death in epilepsy: is death by seizures a cardiac disease?

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Tigaran S, Dalager-Pedersen S, Baandrup U, Dam M, and Vesterby A(2005) Sudden unexpected death in epilepsy: is death by seizures a cardiac disease? Am J Forensic Med Pathol 26:2 99–105.

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Abstract: Sudden unexpected death in epilepsy (SUDEP) gains more and more acknowledgment across the various interdisciplinary fields. Accordingly, we performed in a prospective setting a case-control study of all SUDEP cases in a well-defined part of Denmark (Northern Jutland), between January 1998 and September 2000. We attempted to look into the cardiopathologic mechanism behind this phenomenon by assessing the degree of myocardial fibrosis in SUDEP patients versus controls. The histologic evaluation was possible in 65% of the cases (15/23) whose death was attributed to SUDEP and in 71% (15/21) of controls. Forty percent of the SUDEP cases (6/15) presented several foci of fibrotic changes in the deep and subendocardial myocardium in contrast to 1 control (6.6%, P = 0.03). None of the subjects from the SUDEP group showed fibrotic changes in their conduction system as compared with 1 control (6.6%). The quantitative evaluation of fibrosis demonstrated a trend toward more fibrosis in the deep and subendocardial myocardium of the SUDEP cases. Forty percent of cases in the SUDEP group were men (6/15), characteristically young at time of death (mean age 38 years) and with a late epilepsy onset (mean age 21 years). Antemortem, 73% of the SUDEP patients (11/15) had experienced infrequent seizures (self-reported). We conclude that the SUDEP cases displayed significant fibrosis of the myocardium when this was assessed by qualitative means. This fibrosis may be the consequence of myocardial ischemia as a direct result of repetitive epileptic seizures, which, associated with the ictal sympathetic storm, may lead to lethal arrhythmias.

Keywords: epilepsy, SUDEP, infrequent epileptic seizures, seizure concealment, myocardial fibrosis, myocardial ischemia, atherosclerosis, AED, hypoxia

Context

  • Danish study comparing Fibrosis of cardiac tissue from SUDEP victims to that from non-SUDEP deaths using anatomic block locations. Though the tissue sampling is systematic the total number of patients in each group is relatively low at 15 in each group. Subendocardial fibrosis is seen in more of the SUDEP cases than in controls.

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