Postictal Generalized EEG Supression Poh MZ 2012 Neurology
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Postictal Generalized EEG Supression Poh MZ, 2012, Neurology
• 10 v. EEG of PWE who later died of SUDEP • PGES 50% of seizures in patients who later died of SUDEP • PGES >50 seconds in duration associated with an increased risk of SUDEP • >50 seconds OR 5. 22 • >90 seconds OR 23. 46
SUDEP in the EMU • 16 cases occurred in EMUs reported in literature • 11 SUDEP • 5 near SUDEP • 11/11 SUDEP and 5/6 Near SUDEP occurred after GTC seizure, 1 after CPS • Postictal respiratory & cardiac dysfunction • Postictal tachypnea • Postictal bradycardia • Followed within 3 minutes by transient or terminal apnea and bradycardia Ryvlin et al Lancet Neurol 2013
• Cardiorespiratory abnormalities within 3 minutes post ictal • Terminal apnea always precedes asystole Ryvlin et al Lancet Neurol 2013
• Case control study of PGES in SUDEP patients and controls • 122 seizures in 57 patients • 15% of seizures were associated with PGES in 26% of patients • PGES was associated significantly with secondarily generalized seizures • BUT, frequency and duration of PGES were not more common in SUDEP group Epilepsy & Behav, 2011
PGES is common following GTC • Following 16 -90% of GTC in adult studies • 32% of children admitted for v. EEG • Sickkids cohort • 6. 5% of 399 ictal v. EEG at Sick. Kids • 54% of 41 children with GTC Mosely, 2013; Okanari, in preparation
PGES is associated with GTC with all limb tonic posturing 30 # of GTCS 25 20 * PGES ― PGES + 15 10 5 0 PGES ― ALTP + PGES + ALTP *p<0. 001
PGES duration and seizure type Duration of PGES (sec) 50, 0 40, 0 30, 0 20, 0 10, 0 2 GTCS 37 GTCS 5 GTS 5 GCS 1 * p < 0. 005
Duration of PGES & Age Duration of PGES (sec) 60, 0 50, 0 40, 0 30, 0 20, 0 10, 0 0 5 10 Age (y) 15 20 R = 0. 74, p < 0. 001
EEG background & duration of PGES * 45, 0 ** * Duration of PGES (sec) 40, 0 35, 0 30, 0 25, 0 20, 0 15, 0 10, 0 5, 0 0, 0 Normal Disorganized 14 Awake 11 19 6 Sleep spindle 18 7 REM sleep *p<0. 005, **p<0. 001
Conclusions • PGES is relatively common and may be predicted based on seizure characteristics. • Prolonged PGES may be a biomarker for SUDEP risk. • PGES in association with other stressors, environmental factors, other dynamics may be a more powerful biomarker. • More human and experimental data is needed. • The best way to reduce SUDEP risk is to reduce the frequency of convulsive seizures.
Education is the most accessible tool we have to reduce the burden of mortality in epilepsy. #iamsudepaware 13
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