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Assessing epilepsy-related autonomic manifestations: Beyond cardiac and respiratory investigations. Neurophysiol Clin 2023; 53:102850. [PMID: 36913775 DOI: 10.1016/j.neucli.2023.102850] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/05/2023] [Revised: 02/15/2023] [Accepted: 02/19/2023] [Indexed: 03/13/2023] Open
Abstract
The Autonomic Nervous System (ANS) regulates many critical physiological functions. Its control relies on cortical input, especially limbic areas, which are often involved in epilepsy. Peri-ictal autonomic dysfunction is now well documented, but inter-ictal dysregulation is less studied. In this review, we discuss the available data on epilepsy-related autonomic dysfunction and the objective tests available. Epilepsy is associated with sympathetic-parasympathetic imbalance and a shift towards sympathetic dominance. Objective tests report alterations in heart rate, baroreflex function, cerebral autoregulation, sweat glands activity, thermoregulation, gastrointestinal and urinary function. However, some tests have found contradictory results and many tests suffer from a lack of sensitivity and reproducibility. Further study on interictal ANS function is required to further understand autonomic dysregulation and the potential association with clinically-relevant complications, including risk of Sudden Unexpected Death In Epilepsy (SUDEP).
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Chen SF, Pan HY, Huang CR, Huang JB, Tan TY, Chen NC, Hsu CY, Chuang YC. Autonomic Dysfunction Contributes to Impairment of Cerebral Autoregulation in Patients with Epilepsy. J Pers Med 2021; 11:jpm11040313. [PMID: 33920691 PMCID: PMC8073240 DOI: 10.3390/jpm11040313] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/22/2021] [Revised: 04/16/2021] [Accepted: 04/16/2021] [Indexed: 12/26/2022] Open
Abstract
Patients with epilepsy frequently experience autonomic dysfunction and impaired cerebral autoregulation. The present study investigates autonomic function and cerebral autoregulation in patients with epilepsy to determine whether these factors contribute to impaired autoregulation. A total of 81 patients with epilepsy and 45 healthy controls were evaluated, assessing their sudomotor, cardiovagal, and adrenergic functions using a battery of autonomic nervous system (ANS) function tests, including the deep breathing, Valsalva maneuver, head-up tilting, and Q-sweat tests. Cerebral autoregulation was measured by transcranial Doppler examination during the breath-holding test, the Valsalva maneuver, and the head-up tilting test. Autonomic functions were impaired during the interictal period in patients with epilepsy compared to healthy controls. The three indices of cerebral autoregulation—the breath-holding index (BHI), an autoregulation index calculated in phase II of the Valsalva maneuver (ASI), and cerebrovascular resistance measured in the second minute during the head-up tilting test (CVR2-min)—all decreased in patients with epilepsy. ANS dysfunction correlated significantly with impairment of cerebral autoregulation (measured by BHI, ASI, and CVR2-min), suggesting that the increased autonomic dysfunction in patients with epilepsy may augment the dysregulation of cerebral blood flow. Long-term epilepsy, a high frequency of seizures, and refractory epilepsy, particularly temporal lobe epilepsy, may contribute to advanced autonomic dysfunction and impaired cerebral autoregulation. These results have implications for therapeutic interventions that aim to correct central autonomic dysfunction and impairment of cerebral autoregulation, particularly in patients at high risk for sudden, unexplained death in epilepsy.
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Affiliation(s)
- Shu-Fang Chen
- Department of Neurology, Kaohsiung Chang Gung Memorial Hospital, Kaohsiung 83301, Taiwan; (S.-F.C.); (H.-Y.P.); (C.-R.H.); (J.-B.H.); (T.-Y.T.); (N.-C.C.)
- College of Medicine, Chang Gung University, Taoyuan 33302, Taiwan
| | - Hsiu-Yung Pan
- Department of Neurology, Kaohsiung Chang Gung Memorial Hospital, Kaohsiung 83301, Taiwan; (S.-F.C.); (H.-Y.P.); (C.-R.H.); (J.-B.H.); (T.-Y.T.); (N.-C.C.)
- Department of Emergency Medicine, Kaohsiung Chang Gung Memorial Hospital, Kaohsiung 83301, Taiwan
| | - Chi-Ren Huang
- Department of Neurology, Kaohsiung Chang Gung Memorial Hospital, Kaohsiung 83301, Taiwan; (S.-F.C.); (H.-Y.P.); (C.-R.H.); (J.-B.H.); (T.-Y.T.); (N.-C.C.)
- College of Medicine, Chang Gung University, Taoyuan 33302, Taiwan
| | - Jyun-Bin Huang
- Department of Neurology, Kaohsiung Chang Gung Memorial Hospital, Kaohsiung 83301, Taiwan; (S.-F.C.); (H.-Y.P.); (C.-R.H.); (J.-B.H.); (T.-Y.T.); (N.-C.C.)
- Department of Emergency Medicine, Kaohsiung Chang Gung Memorial Hospital, Kaohsiung 83301, Taiwan
| | - Teng-Yeow Tan
- Department of Neurology, Kaohsiung Chang Gung Memorial Hospital, Kaohsiung 83301, Taiwan; (S.-F.C.); (H.-Y.P.); (C.-R.H.); (J.-B.H.); (T.-Y.T.); (N.-C.C.)
- College of Medicine, Chang Gung University, Taoyuan 33302, Taiwan
| | - Nai-Ching Chen
- Department of Neurology, Kaohsiung Chang Gung Memorial Hospital, Kaohsiung 83301, Taiwan; (S.-F.C.); (H.-Y.P.); (C.-R.H.); (J.-B.H.); (T.-Y.T.); (N.-C.C.)
- College of Medicine, Chang Gung University, Taoyuan 33302, Taiwan
| | - Chung-Yao Hsu
- Department of Neurology, School of Medicine, College of Medicine, Kaohsiung Medical University Hospital, Kaohsiung Medical University, Kaohsiung 80708, Taiwan;
| | - Yao-Chung Chuang
- Department of Neurology, Kaohsiung Chang Gung Memorial Hospital, Kaohsiung 83301, Taiwan; (S.-F.C.); (H.-Y.P.); (C.-R.H.); (J.-B.H.); (T.-Y.T.); (N.-C.C.)
- College of Medicine, Chang Gung University, Taoyuan 33302, Taiwan
- Department of Neurology, School of Medicine, College of Medicine, Kaohsiung Medical University Hospital, Kaohsiung Medical University, Kaohsiung 80708, Taiwan;
- Institute for Translation Research in Biomedicine, Kaohsiung Chang Gung Memorial Hospital, Kaohsiung 83301, Taiwan
- Department of Biological Science, National Sun Yat-sen University, Kaohsiung 80424, Taiwan
- Correspondence:
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Vieluf S, El Atrache R, Hammond S, Touserkani FM, Loddenkemper T, Reinsberger C. Peripheral multimodal monitoring of ANS changes related to epilepsy. Epilepsy Behav 2019; 96:69-79. [PMID: 31100658 DOI: 10.1016/j.yebeh.2019.02.018] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/16/2018] [Revised: 02/12/2019] [Accepted: 02/18/2019] [Indexed: 11/19/2022]
Abstract
The goal of this study was to evaluate and summarize the current literature on multimodal changes of the autonomic nervous system (ANS) in people with epilepsy (PWE). We included studies reporting ANS measures of at least two modalities and with a minimum of one group of people with epilepsy. We screened two hundred eighty-three abstracts and sixty-six full texts, of which twenty-two met our inclusion criteria. Eleven studies reported ictal and interictal cardiac and respiratory changes. Three studies investigated the correlation between cardiac and respiratory markers, whereby two found no correlation and one showed a relation. Six studies evaluated electrodermal and cardiac parameters and showed effects on both ANS subsystems that jointly indicate a shift toward increased sympathetic activity for people with epilepsy during rest and during activity. Two studies assessed three modalities and reveal epilepsy-related alterations within the ANS. In summary, there is a growing interest in multimodal monitoring approaches, such as combining at least two ANS modalities, to describe epilepsy-related changes in ANS activity and to test for the potential to use ANS markers for seizure detection and prediction. Most studies report multiple unimodal analyses while only few studies analyzed multimodal patterns. Patterns of changes depend on the type of epilepsy and differ on an individual level; therefore, a multimodal approach might offer an approach to more individualized monitoring and, ultimately, management.
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Affiliation(s)
- Solveig Vieluf
- Institute of Sports Medicine, Department Sports & Health, Paderborn University, Paderborn, Germany; Boston Children's Hospital, Department of Neurology, Harvard Medical School, Boston, USA
| | - Rima El Atrache
- Boston Children's Hospital, Department of Neurology, Harvard Medical School, Boston, USA
| | - Sarah Hammond
- Boston Children's Hospital, Department of Neurology, Harvard Medical School, Boston, USA
| | - Fatemeh Mohammadpour Touserkani
- Boston Children's Hospital, Department of Neurology, Harvard Medical School, Boston, USA; Department of Neurology, SUNY Downstate Medical Center, Brooklyn, NY, USA
| | - Tobias Loddenkemper
- Boston Children's Hospital, Department of Neurology, Harvard Medical School, Boston, USA
| | - Claus Reinsberger
- Institute of Sports Medicine, Department Sports & Health, Paderborn University, Paderborn, Germany; Edward B. Bromfield Epilepsy Center, Department of Neurology, Brigham and Women's Hospital, Boston, MA, USA.
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Ruthirago D, Julayanont P, Karukote A, Shehabeldin M, Nugent K. Sudden unexpected death in epilepsy: ongoing challenges in finding mechanisms and prevention. Int J Neurosci 2018; 128:1052-1060. [PMID: 29667458 DOI: 10.1080/00207454.2018.1466780] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/02/2023]
Abstract
Purpose/aim of the study: To summarize recent studies on the pathophysiology and preventive strategies for SUDEP. Materials and methods: Databases and literature review. Results: Patients with epilepsy have a significantly higher risk of death than the general population. Sudden unexpected death in epilepsy (SUDEP) is the leading cause of sudden death among patients with epilepsy. Despite on-going research, there are still deficits in our knowledge about the mechanisms, genetic factors, and prevention of SUDEP. Current evidence suggests that cardiac arrhythmias, respiratory dysfunction, and brainstem arousal system dysfunction are the major mechanisms of SUDEP, and animal models support the role of neurotransmitters, especially serotonin and adenosine, in pathophysiology of SUDEP. Several mutations in the neurocardiogenic channelopathy genes have been identified as a possible cause of epilepsy and increased SUDEP risk. The lack of awareness that SUDEP can be a potential cause of premature death has been found in several surveys. In addition, medical legal cases demonstrate the need for more education about this condition. Several preventive strategies to reduce SUDEP have been proposed, including effective seizure control, nocturnal supervision, seizure monitoring, devices to protect the airway, and selective serotonin reuptake inhibitors. Further research is needed to determine the efficacy of these interventions. Conclusions: The major mechanisms of SUDEP include cardiac arrhythmias, respiratory dysfunction, and brainstem arousal system dysfunction. Effective control of seizures is the only effective strategy to prevent SUDEP. Other preventive interventions require more research.
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Affiliation(s)
- Doungporn Ruthirago
- a Department of Neurology , Texas Tech University Health Science Center , Lubbock , TX , USA
| | - Parunyou Julayanont
- a Department of Neurology , Texas Tech University Health Science Center , Lubbock , TX , USA
| | - Amputch Karukote
- b Department of Internal Medicine, Faculty of Medicine, Ramathibodi Hospital , Mahidol University , Bangkok , Thailand
| | - Mohamed Shehabeldin
- a Department of Neurology , Texas Tech University Health Science Center , Lubbock , TX , USA
| | - Kenneth Nugent
- c Department of Internal Medicine , Texas Tech University Health Science Center , Lubbock , TX , USA
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Compromised Dynamic Cerebral Autoregulation in Patients with Epilepsy. BIOMED RESEARCH INTERNATIONAL 2018; 2018:6958476. [PMID: 29568762 PMCID: PMC5820585 DOI: 10.1155/2018/6958476] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 11/10/2017] [Revised: 12/18/2017] [Accepted: 12/26/2017] [Indexed: 12/17/2022]
Abstract
Objective The aim of this study is to analyze dynamic cerebral autoregulation (dCA) in patients with epilepsy. Methods One hundred patients with epilepsy and 100 age- and sex-matched healthy controls were recruited. Noninvasive continuous cerebral blood flow velocity of the bilateral middle artery and arterial blood pressure were recorded. Transfer function analyses were used to analyze the autoregulatory parameters (phase difference and gain). Results The overall phase difference of patients with epilepsy was significantly lower than that of the healthy control group (p = 0.046). Furthermore, patients with interictal slow wave had significant lower phase difference than the slow-wave-free patients (p = 0.012). There was no difference in overall phase between focal discharges and multifocal discharges in patients with epilepsy. Simultaneously, there was no difference in mean phase between the affected and unaffected hemispheres in patients with unilateral discharges. In particular, interictal slow wave was an independent factor that influenced phase difference in patients with epilepsy (p = 0.016). Conclusions Our study documented that dCA is impaired in patients with epilepsy, especially in those with interictal slow wave. The impairment of dCA occurs irrespective of the discharge location and type. Interictal slow wave is an independent factor to predict impaired dCA in patients with epilepsy. Clinical Trial Identifier This trial is registered with NCT02775682.
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Hampel KG, Jahanbekam A, Elger CE, Surges R. Seizure-related modulation of systemic arterial blood pressure in focal epilepsy. Epilepsia 2016; 57:1709-1718. [DOI: 10.1111/epi.13504] [Citation(s) in RCA: 30] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/25/2016] [Indexed: 11/29/2022]
Affiliation(s)
- Kevin G. Hampel
- Department of Epileptology; University Hospital of Bonn; Bonn Germany
| | | | | | - Rainer Surges
- Department of Epileptology; University Hospital of Bonn; Bonn Germany
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Dlouhy BJ, Gehlbach BK, Richerson GB. Sudden unexpected death in epilepsy: basic mechanisms and clinical implications for prevention. J Neurol Neurosurg Psychiatry 2016; 87:402-13. [PMID: 26979537 DOI: 10.1136/jnnp-2013-307442] [Citation(s) in RCA: 57] [Impact Index Per Article: 7.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/09/2014] [Accepted: 05/13/2015] [Indexed: 12/14/2022]
Abstract
Sudden unexpected death in epilepsy (SUDEP) is the most common cause of death in patients with intractable epilepsy. The substantial lifetime risk of SUDEP and the lack of a clear pathophysiological connection between epilepsy itself and sudden death have fuelled increased attention to this phenomenon. Understanding the mechanisms underlying SUDEP is paramount to developing preventative strategies. In this review, we discuss SUDEP population studies, case-control studies, witnessed and monitored cases, as well as human seizure cardiorespiratory findings related to SUDEP, and SUDEP animal models. We integrate these data to suggest the most probable mechanisms underlying SUDEP. Understanding the modifiable risk factors and pathophysiology allows us to discuss potential preventative strategies.
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Affiliation(s)
- Brian J Dlouhy
- Department of Neurosurgery, University of Iowa, Iowa City, Iowa, USA
| | - Brian K Gehlbach
- Department of Internal Medicine, University of Iowa, Iowa City, Iowa, USA
| | - George B Richerson
- Department of Neurology, University of Iowa, Iowa City, Iowa, USA Department of Molecular Physiology and Biophysics, University of Iowa, Iowa City, Iowa, USA Interdisciplinary Graduate Program in Neuroscience, University of Iowa, Iowa City, Iowa, USA
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Transfer function analysis for the assessment of cerebral autoregulation using spontaneous oscillations in blood pressure and cerebral blood flow. Med Eng Phys 2014; 36:563-75. [DOI: 10.1016/j.medengphy.2014.02.001] [Citation(s) in RCA: 46] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2013] [Revised: 01/31/2014] [Accepted: 02/03/2014] [Indexed: 12/21/2022]
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Abstract
Sudden unexpected death in epilepsy (SUDEP) is the leading cause of death in patients with refractory epilepsy, with an estimated 35% lifetime risk in this patient population. There is a surprising lack of awareness among patients and physicians of this increased risk of sudden death: in a recent survey, only 33% of Canadian paediatricians who treated patients with epilepsy knew the term SUDEP. Controversy prevails over whether cardiac arrhythmia or respiratory arrest is more important as the primary cause of death. Effective preventive strategies in high-risk patients will rely on definition of the mechanisms that lead from seizures to death. Here, we summarize evidence for the mechanisms that cause cardiac, respiratory and arousal abnormalities during the ictal and postictal period. We highlight potential cellular mechanisms underlying these abnormalities, such as a defect in the serotonergic system, ictal adenosine release, and changes in autonomic output. We discuss genetic mutations that cause Dravet and long QT syndromes, both of which are linked with increased risk of sudden death. We then highlight possible preventive interventions that are likely to decrease SUDEP incidence, including respiratory monitoring in epilepsy monitoring units and overnight supervision. Finally, we discuss treatments, such as selective serotonin reuptake inhibitors, that might be personalized to a specific genetic or pathological defect.
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Tobaldini E, Nobili L, Strada S, Casali KR, Braghiroli A, Montano N. Heart rate variability in normal and pathological sleep. Front Physiol 2013; 4:294. [PMID: 24137133 PMCID: PMC3797399 DOI: 10.3389/fphys.2013.00294] [Citation(s) in RCA: 176] [Impact Index Per Article: 16.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/09/2013] [Accepted: 09/26/2013] [Indexed: 01/15/2023] Open
Abstract
Sleep is a physiological process involving different biological systems, from molecular to organ level; its integrity is essential for maintaining health and homeostasis in human beings. Although in the past sleep has been considered a state of quiet, experimental and clinical evidences suggest a noteworthy activation of different biological systems during sleep. A key role is played by the autonomic nervous system (ANS), whose modulation regulates cardiovascular functions during sleep onset and different sleep stages. Therefore, an interest on the evaluation of autonomic cardiovascular control in health and disease is growing by means of linear and non-linear heart rate variability (HRV) analyses. The application of classical tools for ANS analysis, such as HRV during physiological sleep, showed that the rapid eye movement (REM) stage is characterized by a likely sympathetic predominance associated with a vagal withdrawal, while the opposite trend is observed during non-REM sleep. More recently, the use of non-linear tools, such as entropy-derived indices, have provided new insight on the cardiac autonomic regulation, revealing for instance changes in the cardiovascular complexity during REM sleep, supporting the hypothesis of a reduced capability of the cardiovascular system to deal with stress challenges. Interestingly, different HRV tools have been applied to characterize autonomic cardiac control in different pathological conditions, from neurological sleep disorders to sleep disordered breathing (SDB). In summary, linear and non-linear analysis of HRV are reliable approaches to assess changes of autonomic cardiac modulation during sleep both in health and diseases. The use of these tools could provide important information of clinical and prognostic relevance.
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Affiliation(s)
- Eleonora Tobaldini
- Division of Medicine and Pathophysiology, Department of Biomedical and Clinical Sciences "L. Sacco," L. Sacco Hospital, University of Milan Milan, Italy
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Nobili L, Proserpio P, Rubboli G, Montano N, Didato G, Tassinari CA. Sudden unexpected death in epilepsy (SUDEP) and sleep. Sleep Med Rev 2011; 15:237-46. [DOI: 10.1016/j.smrv.2010.07.006] [Citation(s) in RCA: 98] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/23/2009] [Revised: 07/12/2010] [Accepted: 07/16/2010] [Indexed: 11/30/2022]
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Sudden unexpected death in epilepsy. Epilepsy Behav 2011; 21:344-51. [PMID: 21665551 DOI: 10.1016/j.yebeh.2011.04.056] [Citation(s) in RCA: 34] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/08/2011] [Revised: 04/15/2011] [Accepted: 04/18/2011] [Indexed: 11/22/2022]
Abstract
Sudden unexpected death in epilepsy (SUDEP) has an incidence ranging between 0.09 and 9 per 1000 patient-years depending on the patient population and the study methodology. It is the commonest cause of death directly attributable to epilepsy, and occurs at or around the time of a seizure. The principal risk factor for SUDEP is poorly controlled generalized tonic-clonic seizures. Other risk factors include polytherapy, male sex, early age at onset of epilepsy, symptomatic etiology, and, possibly, treatment with lamotrigine. The mechanisms underlying SUDEP are poorly understood, but autonomic dysfunction, central apnea, cerebral depression, and cardiac arrthymias have all been described in animal models of SUDEP and during human seizures. Prevention of this fatal event should be aimed at optimizing control of seizures, including prompt referral for consideration of epilepsy surgery. All patients should be told about the risks of SUDEP and informed that complete seizure control appears to be the one proven way of preventing the phenomenon.
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Abstract
Sudden unexpected death in epilepsy (SUDEP) is the most common cause of death directly related to epilepsy, and most frequently occurs in people with chronic epilepsy. The main risk factors for SUDEP are associated with poorly controlled seizures, suggesting that most cases of SUDEP are seizure-related events. Dysregulation in cardiac and respiratory physiology, dysfunction in systemic and cerebral circulation physiology, and seizure-induced hormonal and metabolic changes might all contribute to SUDEP. Cardiac factors include bradyarrhythmias and asystole, as well as tachyarrhythmias and alterations to cardiac repolarization. Altered electrolytes and blood pH, as well as the release of catecholamines, modulate cardiac excitability and might facilitate arrhythmias. Respiratory symptoms are not uncommon during seizures and comprise central apnea or bradypnea, and, less frequently, obstruction of the airways and neurogenic pulmonary edema. Alterations to autonomic function, such as a reduction in heart rate variability or disturbed baroreflex sensitivity, can impair the body's capacity to cope with challenging situations of elevated stress, such as seizures. Here, we summarize data on the incidence of and risk factors for SUDEP, and consider the pathophysiological aspects of chronic epilepsy that might lead to sudden death. We suggest that SUDEP is caused by the fatal coexistence of several predisposing and triggering factors.
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