Download SUDEP

SUDEP
(Sudden Unexpected Death in Epilepsy)
Rebecca Liu
Consultant Neurologist
Epilepsy Initiative Group, Royal Free London NHS Foundation Trust
AIMS
 Develop greater awareness and understanding of SUDEP
 Recognise those at high risk
 Understand possible mechanisms
 Practical measures that may reduce risk
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
TEST YOUR KNOWLEDGE
1. Compared to the general
population, premature
death in epilepsy is:
 The same as for the general
population
 3X greater
 10X greater
TEST YOUR KNOWLEDGE
2. The commonest cause of
death in epilepsy is:
 Accidents
 Drowning
 Status Epilepticus
 SUDEP
 Suicide
 Medication side effects
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
TEST YOUR KNOWLEDGE
 The single greatest risk
factor for SUDEP is:
 Male
 Seizures at night
 AED polytherapy
 Long duration of epilepsy
 Frequent generalised convulsions
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
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 20-40 years
1:1000 – 1:10,000
person years
Average
1:200 / year
High risk groups
1:100 / year
Epilepsy surgery
candidates
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 20-40 years
 Male Sex
 Alcohol abuse
Why might SUDEP occur?
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.
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
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?
Interaction between predisposing
factors and triggers for SUDEP
Seizure
AED
changes
Chronic
epilepsy
Individual
factors
Unknown
factors
SUDEP
Arrhythmia,
Apnoea,
Cerebral
shutdown
HIGH RISK PATIENTS
 Young men
 Early onset refractory seizures
 Symptomatic focal epilepsy
 Frequent convulsions
 Large number of AED drugs
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
THE AFTERMATH
 Contact their GP, epilepsy specialist
 Emotional support / Counselling
 Put in touch with Epilepsy Bereaved