Sudden unexpected death in epilepsy

PURPOSE OF REVIEW

Sudden unexpected death in epilepsy (SUDEP) is a major contributor to premature mortality in people with epilepsy. This review provides an update on recent findings on the epidemiology of SUDEP, clinical risk factors and potential mechanisms.

RECENT FINDINGS

The overall risk rate of SUDEP is approximately 1 per 1000 patients per year in the general epilepsy population and that children and older adults have a similar incidence. Generalized convulsive seizures (GCS), perhaps through their effects on brainstem cardiopulmonary networks, can cause significant postictal respiratory and autonomic dysfunction though other mechanisms likely exist as well. Work in animal models of SUDEP has identified multiple neurotransmitter systems, which may be future targets for pharmacological intervention. There are also chronic functional and structural changes in autonomic function in patients who subsequently die from SUDEP suggesting that some SUDEP risk is dynamic. Modifiable risks for SUDEP include GCS seizure frequency, medication adherence and nighttime supervision.

SUMMARY

Current knowledge of SUDEP risk factors has identified multiple targets for SUDEP prevention today as we await more specific therapeutic targets that are emerging from translational research studies.

Acute colonic pseudo-obstruction (Ogilvie syndrome) leading to respiratory compromise and death

Here, we present an unusual case of acute colonic pseudo-obstruction (ACPO), also known as Ogilvie syndrome, which resulted in respiratory failure and sudden death. The patient was a 19-year-old man with a history of cerebral palsy (CP) and severe autism who experienced marked abdominal distension that progressed over several days in his skilled nursing facility. He developed shortness of breath and episodic diarrhea, before having an unwitnessed cardiac arrest and subsequently expiring after prehospital and emergency department care. Autopsy revealed developmental deformities consistent with CP, rectal prolapse, and significant abdominal distension. Postmortem radiography showed diffuse bowel distension with bilateral upward displacement of the diaphragm and consequent lung compression. Thorough examination of the gastrointestinal tract failed to reveal any perforation or obstruction. The cause of death was determined to be respiratory compromise secondary to diaphragmatic compression as a result of ACPO, a condition defined as colonic distension without a mechanical explanation for obstruction. This case highlights the challenges that ACPO can pose to a forensic pathologist at autopsy, and serves as a teaching point to clinicians on the warning signs and treatment measures for ACPO.

Fatal ventriculoperitoneal shunt occlusions diagnosed at autopsy

The placement of a ventriculoperitoneal (VP) shunt is frequently used in the management of chronic hydrocephalus. Failure of the shunt may occur due to physical obstruction, which is a recognized complication. Autopsy examination of deceased individuals with chronic disability is often not performed, which contributes to the difficulty in determining the frequency of mortality from VP shunts. Examination, when it does occur, should focus on the patency and positioning of the shunt, and this evaluation is especially important when the cause of death is poorly defined. In this report, we describe two cases of death caused by obstruction of VP shunts documented at autopsy. The first death was determined to be secondary to cerebellar edema with uncal and tonsillar herniation after posterior left VP shunt occlusion. The second was due to VP shunt occlusion resulting in diffuse cerebral edema and ventricular enlargement with compression and hemorrhage of the cerebellar tonsils and medulla.