Audit of practice in sudden unexpected death in epilepsy (SUDEP) post mortems and neuropathological findings

Abstract

AimsSudden unexpected death in epilepsy (SUDEP) is one of the leading causes of death in people with epilepsy. For classification of definite SUDEP, a post mortem (PM), including anatomical and toxicological examination, is mandatory to exclude other causes of death. We audited PM practice as well as the value of brain examination in SUDEP.MethodsWe reviewed 145 PM reports in SUDEP cases from four UK neuropathology centres. Data were extracted for clinical epilepsy details, circumstances of death and neuropathological findings.ResultsMacroscopic brain abnormalities were identified in 52% of cases. Mild brain swelling was present in 28%, and microscopic pathologies relevant to cause or effect of seizures were seen in 89%. Examination based on whole fixed brains (76.6% of all PMs), and systematic regional sampling was associated with higher detection rates of underlying pathology (P < 0.01). Information was more frequently recorded regarding circumstances of death and body position/location than clinical epilepsy history and investigations.ConclusionOur findings support the contribution of examination of the whole fixed brain in SUDEP, with high rates of detection of relevant pathology. Availability of full clinical epilepsy‐related information at the time of PM could potentially further improve detection through targeted tissue sampling. Apart from confirmation of SUDEP, complete neuropathological examination contributes to evaluation of risk factors as well as helping to direct future research into underlying causes.

Hippocampal morphometry in sudden and unexpected death in epilepsy (SUDEP)

“…HMAL (or incomplete hippocampal inversion) has been implicated as an underlying pathological substrate for febrile seizures 24 as well as some SUDC 10,19 . We have previously noted severe HMAL in 9.7% of SUDEP cases, but a systematic series review is lacking 25 .…”

“…Dentate granule cell dispersion has been anecdotally recorded in 4% of SUDEP PM reports 12,22 , but not systematically evaluated through review of histology sections. In this current retrospective study, based on a similar archival review protocol to the published SIDS studies 8 , but incorporating quantitative rather than qualitative evaluation, GCL measurements did not reveal excessive dispersion or broadening in SUDEP.…”

Sudden unexpected death in epilepsy: Identifying risk and preventing mortality

“…This collaboration will examine a large collection of formalin‐fixed SUDEP brains, along with prospectively collected frozen brain tissue from epilepsy surgery. Systematic neuropathologic analysis will provide a comparative reference map of histopathologic and neurochemical abnormalities that are altered in SUDEP …”

“…Systematic neuropathologic analysis will provide a comparative reference map of histopathologic and neurochemical abnormalities that are altered in SUDEP. 28…”

Comment on falling status epilepticus mortality rates in England and Wales: 2001–2013

“…5 In 2005, SUDEP was included in the guidelines for best practice in epilepsy deaths, issued by the Royal College of Pathologists. 6 This led to a considerable increase in recordings of SUDEP as cause of death, and awareness increased substantially over recent years 7,8 Deaths now classified as SUDEP might well have been classified as "status epilepticus deaths" before 2005. 9 Therefore, the conclusions that fewer SE deaths could be a result of policy changes (i.e., earlier treatment of SE following the new SE definition) are not certain.…”