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Commentary Although epilepsy-related mortality and sudden unexplained death in epilepsy (SUDEP) have been recognized for centuries, our understanding of the pathophysiology remains limited. For patients with epilepsy, an increased standardized mortality of two to three times has been reported, with multiple factors accounting for this risk, including accidental death and deaths secondary to the underlying etiology for seizures (e.g., stroke, tumor) (1). The incidence of SUDEP varies between studies and patient populations but ranges from 0.09 and 0.35 per 1,000 person years in the general epilepsy population to between 6.3 and 9.3 per 1,000 person years in treatment resistant epilepsy (TRE) who have failed epilepsy surgery (2). Efforts to understand SUDEP are limited by both its relatively infrequent occurrence and the limited number of direct observations during or preceding the patient’s death. Although a number of studies have, largely retrospectively, identified risk factors associated with SUDEP, methodologic issues limit comparisons between studies and the generalizability to broader populations with epilepsy (e.g., definition of SUDEP and choice of control population) (2). A review of ten case-controlled studies utilizing living patients with epilepsy as controls identified several common risk factors, including poor seizure control, longer duration of epilepsy, and younger age at onset of seizures (2). Effects of antiepileptic drug (AED) therapy varied between studies. Polytherapy was associated with an increased risk of SUDEP in four studies, two studies identified carbamazepine as an independent risk, and one study identified absence of treatment with AEDs as a significant SUDEP risk (2–4). Although these data provide a potential method for identifying higher risk populations, they provide only limited insights into the underlying pathophysiology. Most theories on SUDEP focus on either cardiac or pulmonary mechanisms, although specific physiologic biomarkers of susceptibility to SUDEP remain elusive. In two cases undergoing scalp EEG monitoring, SUDEP was preceded by profound postictal generalized EEG suppression (PGES) (5, 6). Lhatoo et al. investigated the risk of SUDEP relative to the duration of PGES, studying ten definite SUDEP patients (from 1997–2009) with at least one prior seizure in the video EEG monitoring unit along with 30 consecutive patients who had undergone monitoring prior to March 2009. All patients had TRE. EEG and clinical data were reviewed by two blinded teams. PGES was defined as a generalized absence of background activity above 10 μV beginning within 30 seconds An Electroclinical Case-Control Study of Sudden Unexpected Death in Epilepsy.

Generalized Postictal EEG Background Suppression: A Marker of SUDEP Risk