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The role of convulsive seizures in SUDEP

  • Maromi Nei
    Correspondence
    Corresponding author.
    Affiliations
    Sidney Kimmel Medical College at Thomas Jefferson University, Jefferson Comprehensive Epilepsy Center, Department of Neurology, 901 Walnut Street, Suite 400, Philadelphia, PA 19107, United States of America
    Search for articles by this author
  • Allyson Pickard
    Affiliations
    Sidney Kimmel Medical College at Thomas Jefferson University, Jefferson Comprehensive Epilepsy Center, Department of Neurology, 901 Walnut Street, Suite 400, Philadelphia, PA 19107, United States of America
    Search for articles by this author

      Highlights

      • Convulsive seizures are the most consistently reported risk factor for SUDEP.
      • Nocturnal/sleep-onset seizures, ictal brainstem posturing, and ictal prone positioning may confer increased risk.
      • Post-convulsive central apnea may be a biomarker for SUDEP.
      • Ictal activation of specific cortical and subcortical regions may trigger lethal cardiopulmonary dysfunction.
      • Repetitive seizures may cause progressive structural changes in the brainstem and thalamus involved in SUDEP.
      • Post-ictal repositioning, stimulation, and supplemental oxygen are promising interventions that may mitigate SUDEP risk.

      Abstract

      Convulsive seizures are the most consistently reported risk factor for SUDEP. However, the precise mechanisms by which convulsive seizures trigger fatal cardiopulmonary changes are still unclear. Additionally, it is not clear why some seizures cause death when most do not. This article reviews the physiologic changes that occur during and after convulsive seizures and how these may contribute to SUDEP. Seizures activate specific cortical and subcortical regions that can cause potentially lethal cardiorespiratory changes. Clinical factors, including sleep state, medication treatment and withdrawal, positioning and posturing during seizures, and underlying structural or genetic conditions may also affect specific aspects of seizures that may contribute to SUDEP. While seizure control, either through medication or surgical treatment, is the primary intervention that reduces SUDEP risk, unfortunately, seizures cannot be fully controlled despite maximal treatment in a significant proportion of people with epilepsy. Thus specific interventions to prevent adverse seizure-related cardiopulmonary consequences are needed. The potential roles of repositioning/stimulation after seizures, oxygen supplementation, cardiopulmonary resuscitation and clinical treatment options in reducing SUDEP risk are explored. Ultimately, understanding of these factors may lead to interventions that could reduce or prevent SUDEP.

      Keywords

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