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Simeone KA, Martenz DM, Iyer SH, Booth CP, Herr SE, Matthews SA, Draves SB, Heinemann LL, Greenberg PL, Lhatoo SD, Donner E, Simeone TA. Personalization of SUDEP risk: A survey of transient subclinical comorbid changes. Epilepsy Res 2024; 199:107259. [PMID: 38086218 DOI: 10.1016/j.eplepsyres.2023.107259] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/07/2023] [Revised: 10/29/2023] [Accepted: 11/13/2023] [Indexed: 01/13/2024]
Abstract
OBJECTIVE Preclinical data report within subject modifiable ailments emerge weeks prior to SUDEP, including sleep disorders and cardiorespiratory changes; findings which support anecdotal clinical data. Here, we bridge preclinical findings with future clinical/preclinical studies, and survey whether caretakers or family members of victims noticed transient changes prior to SUDEP. The aim of this pilot study is to identify potential modifiable changes that may synergistically increase SUDEP risk for future research. METHODS A mobile electronic survey was posted on SUDEP community websites. The survey queried whether changes in seizures, sleep, physical well-being, emotional well-being, cognition, breathing, or heart rate were noticed before SUDEP. RESULTS The most profound finding was that 85% of victims had multiple transient ailments prior to SUDEP. Changes in seizures (28/54), and sleep (30/58) occurred in more than 50% of the victims and represent the most influential changes identified. The second and third most influential changes were a reduction in physical well-being (25/57) and emotional well-being (26/56). Changes were observed within the last two months of life in approximately one third of the cases, and more than four months prior to SUDEP in approximately one third of cases, indicating a potential time frame for proactive preventative strategies. Respondents also noted changes in cognition (16/55), breathing (9/54) or heart rate (8/55). Data indicate these changes may be associated with increased SUDEP risk within subject. Study limitations include the responses were based on memory, there was a potential for data to be over reported, and caretakers were not prompted to observe changes a priori, thus some existing changes may have gone unnoticed. SIGNIFICANCE Data support the preclinical findings that transient, subclinical (i.e., not severe enough to require medical intervention), modifiable ailments may increase risk of SUDEP. This suggests that just as an epilepsy type can change over a lifetime and epilepsy type-specific treatments can reduce SUDEP risk, further personalization of SUDEP risk will improve our understanding as to whether variables contribute to risk differently across lifespan. Thus, with a dynamic capacity to change, differing factors may contribute to the distribution of risk probability within an individual at any given time. Understanding whether different combinations of transient changes are specific to epilepsy type, age, or sex needs to be determined to move the field forward in hopes of developing a personalized approach to preventative strategies.
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Affiliation(s)
- Kristina A Simeone
- Department of Pharmacology and Neuroscience, Creighton University School of Medicine, United States.
| | | | - Shruthi H Iyer
- Department of Pharmacology and Neuroscience, Creighton University School of Medicine, United States
| | - Cameron P Booth
- Department of Pharmacology and Neuroscience, Creighton University School of Medicine, United States
| | - Shelby E Herr
- Department of Pharmacology and Neuroscience, Creighton University School of Medicine, United States
| | - Stephanie A Matthews
- Department of Pharmacology and Neuroscience, Creighton University School of Medicine, United States
| | - Samantha B Draves
- Department of Pharmacology and Neuroscience, Creighton University School of Medicine, United States
| | - Laura L Heinemann
- Department of Pharmacology and Neuroscience, Creighton University School of Medicine, United States
| | - Pierce L Greenberg
- Department of Pharmacology and Neuroscience, Creighton University School of Medicine, United States
| | - Samden D Lhatoo
- Department of Neurology, University of Texas Health Science Center at Houston John P and Katherine G McGovern Medical School, United States
| | - Elizabeth Donner
- Department of Paediatrics, Division of Neurology, Hospital for Sick Children, Canada
| | - Timothy A Simeone
- Department of Pharmacology and Neuroscience, Creighton University School of Medicine, United States
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Giussani G, Falcicchio G, La Neve A, Costagliola G, Striano P, Scarabello A, Mostacci B, Beghi E. Sudden unexpected death in epilepsy: A critical view of the literature. Epilepsia Open 2023; 8:728-757. [PMID: 36896633 PMCID: PMC10472423 DOI: 10.1002/epi4.12722] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/17/2022] [Accepted: 03/04/2023] [Indexed: 03/11/2023] Open
Abstract
Sudden unexpected death in epilepsy (SUDEP) is a sudden, unexpected, witnessed or unwitnessed, non-traumatic and non-drowning death, occurring in benign circumstances, in an individual with epilepsy, with or without evidence for a seizure and excluding documented status epilepticus in which postmortem examination does not reveal other causes of death. Lower diagnostic levels are assigned when cases met most or all of these criteria, but data suggested more than one possible cause of death. The incidence of SUDEP ranged from 0.09 to 2.4 per 1000 person-years. Differences can be attributed to the age of the study populations (with peaks in the 20-40-year age group) and the severity of the disease. Young age, disease severity (in particular, a history of generalized TCS), having symptomatic epilepsy, and the response to antiseizure medications (ASMs) are possible independent predictors of SUDEP. The pathophysiological mechanisms are not fully known due to the limited data available and because SUDEP is not always witnessed and has been electrophysiologically monitored only in a few cases with simultaneous assessment of respiratory, cardiac, and brain activity. The pathophysiological basis of SUDEP may vary according to different circumstances that make that particular seizure, in that specific moment and in that patient, a fatal event. The main hypothesized mechanisms, which could contribute to a cascade of events, are cardiac dysfunction (included potential effects of ASMs, genetically determined channelopathies, acquired heart diseases), respiratory dysfunction (included postictal arousal deficit for the respiratory mechanism, acquired respiratory diseases), neuromodulator dysfunction, postictal EEG depression and genetic factors.
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Affiliation(s)
- Giorgia Giussani
- Laboratory of Neurological Disorders, Mario Negri Institute for Pharmacological Research IRCCSMilanItaly
| | - Giovanni Falcicchio
- Department of Basic Medical Sciences, Neurosciences and Sense OrgansUniversity of BariBariItaly
| | - Angela La Neve
- Department of Basic Medical Sciences, Neurosciences and Sense OrgansUniversity of BariBariItaly
| | | | - Pasquale Striano
- IRCCS Istituto “Giannina Gaslini”GenovaItaly
- Department of Neurosciences, Rehabilitation, Ophthalmology, Genetics, Maternal and Child HealthUniversity of GenovaGenovaItaly
| | - Anna Scarabello
- IRCCS Istituto delle Scienze Neurologiche di BolognaBolognaItaly
| | - Barbara Mostacci
- IRCCS Istituto delle Scienze Neurologiche di BolognaBolognaItaly
| | - Ettore Beghi
- Laboratory of Neurological Disorders, Mario Negri Institute for Pharmacological Research IRCCSMilanItaly
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Argo A, Puntarello M, Malta G, Buscemi R, Scalzo G, Triolo V, Albano GD, Zerbo S. The analysis of SUDEP forensic autopsies leading to preventable events. Front Neurol 2023; 14:1231515. [PMID: 37456625 PMCID: PMC10346851 DOI: 10.3389/fneur.2023.1231515] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/30/2023] [Accepted: 06/12/2023] [Indexed: 07/18/2023] Open
Abstract
Introduction The diagnosis of unexpected death by excluding non-natural causes, particularly in subjects with epilepsy, is a topic of interest and it is difficult to identify in the forensic field. Health professionals sometimes are faced with cases of sudden death, generally in young adults with a long history of epilepsy that require, for judicial purposes, an explanation in terms of cause and means to determine the death. SUDEP is an entity diagnosed by the exclusion of other causes that may have led to death, and then for forensic purposes, it requires particular attention and knowledge, and there is difficulty in identifying it. Our contribution aims to illustrate the scientific community pathological findings, medical history, and circumstantial evidence of four cases of sudden death in epileptic subjects. Method We illustrated four cases of judicial autopsies from the Institute of Forensic Medicine of Palermo, Italy; the purpose was to exclude the criminal intervention in determining the death as non-natural. The study of victims' medical history, the toxicological investigations, and the autopsy findings analyzed both from macroscopic and microscopic aspects have made it possible to highlight some findings that can be traced back to SUDEP despite the small sample of subjects studied. Results These presented findings of four SUDEP cases could help forensic pathologists in recognizing this entity, by highlighting its characteristics, and allowing for a pathological classification, also in relation to the use of drugs for epilepsy treatment and circumstances of death. Discussion To obtain a definite diagnosis of SUDEP, a complex investigation process is required in a multidisciplinary approach. Considering the literature review with criticism, it could allow health professionals to select the characteristics of epileptic patients at risk of sudden death. Processing human behaviors, molecular and histopathological findings of the autopsies, but also the physiological, and pathological human body system functions thanks to Artificial Intelligence, could be the key to explaining SUDEP mechanisms and the future results to prevent it.
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Affiliation(s)
- Antonina Argo
- Department of Health Promotion, Mother and Child Care, Internal Medicine and Medical Specialties, Section of Legal Medicine, University of Palermo, Palermo, Italy
| | - Maria Puntarello
- Department of Health Promotion, Mother and Child Care, Internal Medicine and Medical Specialties, Section of Legal Medicine, University of Palermo, Palermo, Italy
| | - Ginevra Malta
- Department of Health Promotion, Mother and Child Care, Internal Medicine and Medical Specialties, Section of Legal Medicine, University of Palermo, Palermo, Italy
| | - Roberto Buscemi
- Department of Health Promotion, Mother and Child Care, Internal Medicine and Medical Specialties, Section of Legal Medicine, University of Palermo, Palermo, Italy
| | - Giovanni Scalzo
- Department of Health Promotion, Mother and Child Care, Internal Medicine and Medical Specialties, Section of Legal Medicine, University of Palermo, Palermo, Italy
| | | | - Giuseppe Davide Albano
- Department of Health Promotion, Mother and Child Care, Internal Medicine and Medical Specialties, Section of Legal Medicine, University of Palermo, Palermo, Italy
| | - Stefania Zerbo
- Department of Health Promotion, Mother and Child Care, Internal Medicine and Medical Specialties, Section of Legal Medicine, University of Palermo, Palermo, Italy
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Sun D, Wang Q. The application of SUDEP in forensic diagnosis: a mini review. Front Neurol 2023; 14:1169003. [PMID: 37181558 PMCID: PMC10169668 DOI: 10.3389/fneur.2023.1169003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/18/2023] [Accepted: 03/20/2023] [Indexed: 05/16/2023] Open
Abstract
In the epilepsy population, the risk of sudden death from epilepsy is rare but is ~24 times greater than the risk of sudden death from other causes. Sudden unexpected death in epilepsy (SUDEP) has been widely recognized in clinical studies. Despite its significance as a cause of death, SUDEP is rarely used in forensic practice. This review focuses on the forensic characteristics of SUDEP, analyzed the reasons for its underuse in forensic practice, and illustrated the prospect of establishing uniform diagnostic criteria for sudden unexpected death in epilepsy and molecular anatomy in aiding forensic diagnosis.
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Affiliation(s)
| | - Qiang Wang
- Forensic Science Center, East China University of Political Science and Law, Shanghai, China
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Gravitis AC, Tufa U, Zukotynski K, Streiner DL, Friedman D, Laze J, Chinvarun Y, Devinsky O, Wennberg R, Carlen PL, Bardakjian BL. Ictal ECG-based assessment of sudden unexpected death in epilepsy. Front Neurol 2023; 14:1147576. [PMID: 36994379 PMCID: PMC10040863 DOI: 10.3389/fneur.2023.1147576] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/18/2023] [Accepted: 02/21/2023] [Indexed: 03/16/2023] Open
Abstract
IntroductionPrevious case-control studies of sudden unexpected death in epilepsy (SUDEP) patients failed to identify ECG features (peri-ictal heart rate, heart rate variability, corrected QT interval, postictal heart rate recovery, and cardiac rhythm) predictive of SUDEP risk. This implied a need to derive novel metrics to assess SUDEP risk from ECG.MethodsWe applied Single Spectrum Analysis and Independent Component Analysis (SSA-ICA) to remove artifact from ECG recordings. Then cross-frequency phase-phase coupling (PPC) was applied to a 20-s mid-seizure window and a contour of −3 dB coupling strength was determined. The contour centroid polar coordinates, amplitude (alpha) and angle (theta), were calculated. Association of alpha and theta with SUDEP was assessed and a logistic classifier for alpha was constructed.ResultsAlpha was higher in SUDEP patients, compared to non-SUDEP patients (p < 0.001). Theta showed no significant difference between patient populations. The receiver operating characteristic (ROC) of a logistic classifier for alpha resulted in an area under the ROC curve (AUC) of 94% and correctly classified two test SUDEP patients.DiscussionThis study develops a novel metric alpha, which highlights non-linear interactions between two rhythms in the ECG, and is predictive of SUDEP risk.
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Affiliation(s)
- Adam C. Gravitis
- Institute of Biomedical Engineering, University of Toronto, Toronto, ON, Canada
| | - Uilki Tufa
- Institute of Biomedical Engineering, University of Toronto, Toronto, ON, Canada
| | - Katherine Zukotynski
- Department of Radiology, McMaster University, Hamilton, ON, Canada
- Department of Electrical and Computer Engineering, University of Toronto, Toronto, ON, Canada
| | - David L. Streiner
- Faculty of Health Sciences, McMaster University, Hamilton, ON, Canada
| | - Daniel Friedman
- Grossman School of Medicine, New York University, New York, NY, United States
| | - Juliana Laze
- Grossman School of Medicine, New York University, New York, NY, United States
| | - Yotin Chinvarun
- Department of Medicine, Phramongkutklao Royal Army Hospital, Bangkok, Thailand
| | - Orrin Devinsky
- Grossman School of Medicine, New York University, New York, NY, United States
| | - Richard Wennberg
- Department of Medicine (Neurology), University of Toronto, Toronto, ON, Canada
| | - Peter L. Carlen
- Institute of Biomedical Engineering, University of Toronto, Toronto, ON, Canada
- Department of Medicine (Neurology), University of Toronto, Toronto, ON, Canada
| | - Berj L. Bardakjian
- Institute of Biomedical Engineering, University of Toronto, Toronto, ON, Canada
- Department of Electrical and Computer Engineering, University of Toronto, Toronto, ON, Canada
- *Correspondence: Berj L. Bardakjian
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Zhang Q, Suller-Marti A, Ding JJ, Deng G, He W, Burneo JG, Hammond RR, Ang LC. Epilepsy-associated death in the Southwestern Ontario: A clinicopathological correlation study. Brain Pathol 2022; 33:e13121. [PMID: 36180818 PMCID: PMC10041075 DOI: 10.1111/bpa.13121] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/24/2022] [Accepted: 09/13/2022] [Indexed: 11/30/2022] Open
Abstract
Patients with epilepsy are at elevated risk for premature mortality, of which sudden unexpected death in epilepsy (SUDEP) is one of the leading causes. SUDEP incidence varies significantly depending on the population and the methods used to document the cause of death. We performed retrospective case review at the London Health Sciences Centre for the period of 2000 to 2018. Clinical information, scene investigations, general pathology findings, toxicology, and neuropathology findings were obtained, examined, and confirmed by two neuropathologists and one epileptologist. The characteristics were compared and summarized. We also evaluated the impact of 2010 revision of Ontario Coroner Act Regulation, which significantly limited whole brain examination. Among the 12,206 cases reviewed, we identified 152 cases with a known history of epilepsy. Ninety-seven cases (64%) were classified as SUDEP. There were significantly more SUDEP decedents found dead unwitnessed at night in prone position, than non-SUDEP. Generalized seizures were strongly associated with SUDEP. A male predominance was observed in SUDEP group between 15 and 35 years old. Near half of the brains examined were "unremarkable." There was no difference in neuropathology findings between SUDEP and non-SUDEP groups. After implementation of the 2010 revision of Ontario Coroner Act Regulation, fixed whole brain examination was reduced from 88% to 7% of the epilepsy-related death investigation. Except a lower diagnosis rate of "inflammatory/infectious changes," there were no significant differences in neuropathology findings. This is the first detailed clinical-pathological study on epilepsy-related death based on a Canadian cohort. This study reinforces the previously reported findings in SUDEP and highlights the importance of clinicopathological correlation for accurate classification of epilepsy-related death.
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Affiliation(s)
- Qi Zhang
- Department of Pathology and Lab Medicine, London Health Sciences Centre, Western University, London, Ontario, Canada.,Department of Clinical Neurological Sciences, Schulich School of Medicine and Dentistry, Western University, London, Ontario, Canada
| | - Ana Suller-Marti
- Department of Clinical Neurological Sciences, Schulich School of Medicine and Dentistry, Western University, London, Ontario, Canada.,Department of Pediatrics, Schulich School of Medicine and Dentistry, Western University, London, Ontario, Canada.,Department of Psychiatry, Schulich School of Medicine and Dentistry, Western University, London, Ontario, Canada
| | - Jane Jian Ding
- Department of Pathology and Lab Medicine, London Health Sciences Centre, Western University, London, Ontario, Canada
| | - Gansen Deng
- Department of Statistical and Actuarial Sciences, Western University, London, Ontario, Canada
| | - Wenqing He
- Department of Statistical and Actuarial Sciences, Western University, London, Ontario, Canada
| | - Jorge G Burneo
- Department of Clinical Neurological Sciences, Schulich School of Medicine and Dentistry, Western University, London, Ontario, Canada.,Neuroepidemiology Unit, Schulich School of Medicine and Dentistry, Western University, London, Ontario, Canada
| | - Robert R Hammond
- Department of Pathology and Lab Medicine, London Health Sciences Centre, Western University, London, Ontario, Canada.,Department of Clinical Neurological Sciences, Schulich School of Medicine and Dentistry, Western University, London, Ontario, Canada
| | - Lee-Cyn Ang
- Department of Pathology and Lab Medicine, London Health Sciences Centre, Western University, London, Ontario, Canada.,Department of Clinical Neurological Sciences, Schulich School of Medicine and Dentistry, Western University, London, Ontario, Canada
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Kløvgaard M, Sabers A, Ryvlin P. Update on Sudden Unexpected Death in Epilepsy. Neurol Clin 2022; 40:741-754. [DOI: 10.1016/j.ncl.2022.06.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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Eslami V, Kimberley Molina D, Ákos Szabó C. Definite SUDEP population in Bexar County, Texas: A 36-year data registry. Epilepsy Behav 2021; 121:108005. [PMID: 34052632 DOI: 10.1016/j.yebeh.2021.108005] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/03/2021] [Revised: 04/14/2021] [Accepted: 04/15/2021] [Indexed: 11/19/2022]
Abstract
OBJECTIVE Sudden unexplained death in epilepsy (SUDEP) is one of the leading causes of mortality in epilepsy. In this study, cases of definite SUDEP are reported for Bexar County from a 36-year period. METHODS Death reports by Bexar County Medical Examiner (BCME) from 1983 to 2018 were reviewed to identify cases with definite SUDEP. The findings were based upon investigators' reports, which included medical history, medication list, sleep position, time of death, and pathology reports. In addition to these potential risk factors, body mass indices (BMI), as well as heart, lung, and brain weights were compared between SUDEP victims with therapeutic vs subtherapeutic anti-seizure medication (ASM) levels. RESULTS Definite SUDEP was identified in 286 cases. The incidence of definite SUDEP was 0.51 ± 0.26/1000 person-years among PWE and 0.56 ± 0.29 per 100,000 person-years among the general population in Bexar County. The median age was 37 years old (interquartile range 27-48), and the majority were male (65%). While 171 (60%) people were prescribed at least one ASM, ASM levels were subtherapeutic in 239 cases (83.6%). Risk factors for SUDEP did not differ between SUDEP victims with therapeutic vs subtherapeutic ASM levels. While BMIs were only slightly increased in adherent vs nonadherent SUDEP victims, they were significantly associated with subtherapeutic ASM levels. Abnormal lung, heart, and brain weights were reported in 48 (16.8%), 67 (23.4%), and 43 (15.0%) SUDEP cases, respectively. SIGNIFICANCE This study is one of the largest autopsy-based registries of definite SUDEP. Subtherapeutic ASM levels measured in post-mortem blood samples suggest that nonadherence to ASM therapy was a leading risk factor for SUDEP. As BMI was elevated in this cohort, and obesity was significantly associated with subtherapeutic ASM levels, it may also be a risk factor for SUDEP. Case-controlled studies are needed to validate the specific role of obesity and related comorbidities in this population.
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Affiliation(s)
- Vahid Eslami
- Department of Neurology, University of Health Science Center at San Antonio, TX, United States
| | - D Kimberley Molina
- Bexar County's Medical Examiner's Office, San Antonio, TX, United States
| | - Charles Ákos Szabó
- Department of Neurology, University of Health Science Center at San Antonio, TX, United States; South Texas Comprehensive Epilepsy Center, San Antonio, TX, United States.
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Harowitz J, Crandall L, McGuone D, Devinsky O. Seizure-related deaths in children: The expanding spectrum. Epilepsia 2021; 62:570-582. [PMID: 33586153 PMCID: PMC7986159 DOI: 10.1111/epi.16833] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/26/2020] [Revised: 01/12/2021] [Accepted: 01/13/2021] [Indexed: 12/26/2022]
Abstract
Although seizures are common in children, they are often overlooked as a potential cause of death. Febrile and nonfebrile seizures can be fatal in children with or without an epilepsy diagnosis and may go unrecognized by parents or physicians. Sudden unexpected infant deaths, sudden unexplained death in childhood, and sudden unexpected death in epilepsy share clinical, neuropathological, and genetic features, including male predominance, unwitnessed deaths, death during sleep, discovery in the prone position, hippocampal abnormalities, and variants in genes regulating cardiac and neuronal excitability. Additionally, epidemiological studies reveal that miscarriages are more common among individuals with a personal or family history of epilepsy, suggesting that some fetal losses may result from epileptic factors. The spectrum of seizure-related deaths in pediatrics is wide and underappreciated; accurately estimating this mortality and understanding its mechanism in children is critical to developing effective education and interventions to prevent these tragedies.
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Affiliation(s)
- Jenna Harowitz
- University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania, USA
| | - Laura Crandall
- Comprehensive Epilepsy Center, New York University Grossman School of Medicine, New York, New York, USA.,SUDC Foundation, Herndon, Virginia, USA
| | - Declan McGuone
- Department of Pathology, Yale School of Medicine, New Haven, Connecticut, USA
| | - Orrin Devinsky
- Comprehensive Epilepsy Center, New York University Grossman School of Medicine, New York, New York, USA
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