Abstracts

Rationale: Sudden unexpected death in epilepsy (SUDEP) is a relatively commen cause of death in patients with epilepsy. In patients with refractory epilepsy it is even more common. Cardiac arrhythmia, suffocation, and apnea have all been suggested as causes of SUDEP. We recorded a near SUDEP in our EMU in a patient with severe postictal laryngospasm.Methods: The patient, a 42 year old right handed man, was admitted to the EMU at the Cleveland Clinic for a presurgical evaluation for medically refractory epilepsy. He had viral encephalitis at age 2 years and his first seizure was at age 6 years. He had an indescribable aura followed by impaired awareness with or without automatisms. Sometimes he had secondary generalization. Seizures lasted several minutes and were followed by confusion. Seizure frequency was up to 4 per month. He had failed to achieve seizure control despite trials of 5 major anticonvulsants. On admission he was taking lamotrigine 600 mg daily. General medical and neurological exams were normal except for post traumatic (during a seizure) right eye blindness. As part of a presurgical evaluation, he was admitted to the EMU at the Cleveland Clinic for continuous EEG/video monitoring. Lamotrigine was discontinued after admission.Results: MRI scan revealed an atrophic left hippocampus and atrophic left temporal lobe and a cyst in the left temporal region. Interictal EEG revealed frequent sharp waves at the left sphenoidal electrode and somewhat less frequent sharp waves at TP9, T7, and T9. Ictal EEG revealed paroxysmal fast activity over the left hemisphere with maximal amplitude in the temporal leads. During 48 hours of recording, the patient had one aura, 3 partial and 2 partial seizures with secondary generalization. Seizure number 6 occurred during morning rounds and with 2 of the authors present (HM and JT). It began with tonic stiffening of the body followed by extension of the right arm, flexion of the left arm, version to the right and secondary generalization; seizure duration was approximately 3 minutes. Following termination of the seizure, the patient developed loud inspiratory stridor and marked cyanosis; oxygen saturation ranged from 50 to 60%. Attempts improve ventilation by positioning the patient, administering oxygen and use of the emergency Ambu bag did not improve his oxygen saturation. The patient did maintain normal blood pressures. An emergency team was called and the patient was promptly intubated in the epilepsy monitoring unit and transferred to the intensive care unit. The anesthesiologist consultant noted frothy secretions from his airways and a pulmonologist stated the cause for the respiratory emergency was laryngospasm probably triggered by aspiration. He recovered and was discharged home after several days.Conclusions: This well documented case indicates that severe hypoxia resulting from postictal laryngospasm, triggered by aspiration, is one of multiple mechanisms of SUDEP.