Sudden unexpected death in young adults including four cases of SADS: a 10-year review from the west of Ireland (1985-1994)

Sudden unexpected non-cardiac death in the Genoa Medico-Legal District: A six year study (2014-2019) and literature review

Sudden death is described as a natural but unexpected death occurring within one hour from the onset of the patient's final symptoms. Despite cardiac disease being recognised as the cause of death in most people, sudden and unexpected death can also be non-cardiac related. Often a natural but sudden death is not subject to an autopsy, but only to an external examination, and this runs the risk of wrongly attributing the death to a cardiac cause. The present review is a retrospective-observational study which looks into the cases of sudden non-cardiac death recorded in the Genoa District (Italy) from 2014 to 2019 and investigated through complete autopsy examinations. Amongst these cases, 39 (31.5%) were attributable to gastrointestinal diseases, mostly due to the rupture of oesophageal varices; 39 (31.5%) to respiratory diseases, especially pulmonary infections; 31 (25%) to peripheral vascular disease, mostly attributable to pulmonary thromboembolisms or the acute dissection of aneurysms whilst the remaining 15 cases (12%) were attributable to intracranial haemorrhages.

A review of sudden unexpected death in epilepsy: prediction of patients at risk

This review attempts to provide up-to-date quantitative data from published reports on sudden unexpected death in epilepsy (SUDEP) appearing on Medline and, especially, to provide a means to predict the probability of SUDEP in a given patient. The mean incidence of SUDEP was 1.8/1000, similar to the median of 1.5. The mean standardized mortality ratio was 6.8, and the mean percentage of SUDEP cases among deaths from epilepsy was 16.6. Seventeen risk factors were identified, each given a value according to the number of studies in the literature that specified that condition as a significant risk. The addition of these 17 values then indicated the risk for a given patient. The author calculated these for a group of 91 patients who died of SUDEP and also for 91 live patients. Many of their values for the different risks were significantly different. The sensitivity of these SUDEP values was 71.3%, the specificity 81.8%, and the positive predictive value 84.6%. A discussion includes the question of whether the death in SUDEP is primarily cardiac or pulmonary and the suggestion that it may be either or both in a given patient. The most important risk factor in this study was noncompliance with antiepileptic medication, and the main message of this study to caregivers is that therapeutic drug levels are crucial to avoid SUDEP.

Stress and sudden death

Cardiac patients, psychiatric patients, and certain ethnic groups experiencing acute stressful circumstances are at risk for unexpected sudden death. Although stress is associated with changes in autonomic neural function, its role as a potential risk factor for sudden unexpected death in epilepsy (SUDEP) is not known. The association of epilepsy with cardiac abnormalities, such as neurogenic arrhythmias and microscopic perivascular and interstitial fibrosis, and with depression and anxiety indicates that emotional stress should be evaluated as a potential risk factor for SUDEP. The impact of adverse emotional states on the autonomic control of cardiac rhythm is a known important factor leading to cardiac dysrhythmias in humans and other species. The interaction between emotional factors and the arrythmogenic potential of epileptiform discharges and the possibility of benefit from stress management intervention need to be investigated.

Mortality in epilepsy in the west of Ireland: a 10-year review

BACKGROUND

Sudden and unexpected death is not an uncommon event in otherwise healthy epileptics.

AIMS

To study the autopsied cases of sudden death in known epileptic patients in the West of Ireland.

METHODS

A retrospective study was carried out which involved the review of 3,103 autopsy reports over a 10-year period in Galway University Hospital.

RESULTS

Twenty-two cases were classified as sudden, unexpected death in epilepsy (SUDEP). Forty-five per cent had been found dead in bed. The mean age was 38 years and 68% were males. Of 16 cases with data about antiepileptic drug (AED) levels, 68% had absent or low levels at postmortem. Eighty-eight per cent of the cases had a past history of a generalised seizure. Pulmonary oedema was present in 86% of cases at postmortem.

CONCLUSIONS

Compliance with treatment and frequent nightly observations to those at high risk of sudden death may help to minimise its incidence. The patients and their families should be aware of this potential outcome.

Sudden unexplained death syndrome

A retrospective investigation of 51 cases of sudden unexplained death syndrome (SUDS) reported to the Medico-Legal Centre in Dammam during the period January 1995 to June 1997 was carried out. The vast majority of SUDS victims were Indians (43%). The study reports SUDS in non-East Asian subjects, including indigenous Saudis, for the first time. Autopsy examination was carried out on 22 subjects and did not reveal any significant pathological lesions which could fully explain the sudden death. However, seven cases showed mild to moderate cardiac hypertrophy (of whom two had mild to moderate coronary stenosis), and another four showed a similar degree of coronary narrowing without any evidence of myocardial hypertrophy. Severe pulmonary congestion and alveolar haemorrhage were noticed in 18 of the autopsied cases. Microbiological tests were performed on different specimens from 27 subjects and showed significant bacterial growth in seven cases. The paper reviews different hypotheses explaining SUDS and suggests areas of further study in such deaths.