sudep (sudden unexpected death in epilepsy) rebecca liu consultant neurologist epilepsy initiative...
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SUDEP (Sudden Unexpected Death in Epilepsy)
Rebecca LiuConsultant Neurologist
Epilepsy Initiative Group, Royal Free London NHS Foundation Trust
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AIMS Develop greater awareness and understanding of SUDEP Recognise those at high risk Understand possible mechanisms Practical measures that may reduce risk
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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
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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
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2. The commonest cause of death in epilepsy is:
Accidents Drowning Status Epilepticus SUDEP Suicide Medication side effects
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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
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The single greatest risk factor for SUDEP is:
Male Seizures at night AED polytherapy Long duration of epilepsy Frequent generalised convulsions
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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
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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
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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
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Why might SUDEP occur?
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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.
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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
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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?
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Interaction between predisposing factors and triggers for SUDEP
SUDEP
Individualfactors
Chronic epilepsy
SeizureAED changesUnknown
factorsArrhythmia,
Apnoea, Cerebral shutdown
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HIGH RISK PATIENTS Young men Early onset refractory seizures Symptomatic focal epilepsy Frequent convulsions Large number of AED drugs
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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
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THE AFTERMATH Contact their GP, epilepsy specialist Emotional support / Counselling Put in touch with Epilepsy Bereaved