Finsterer, Dr. Josef

Scorza, Dr. Carla Alexandra

Scorza, Dr. Fulvio A

English

International Journal of Medical Studies

                  International Journal of Medical Studies                                                                                                                                                                                                                                                                                  www.ijmsonline.in                              Diagnose SUDEP not exclusively upon autopsy reportsJosef Finsterer, MD, PhD1, Fulvio A Scorza 1Klinik Landstrasse, Messerli Institute, Austria2Disciplina de Neurociência. Universidade Federal de São Paulo/Escola Paulista de Medicina (UNIFESP/EPM). São Paulo, Brasil3Disciplina de Neurociência. Universidade Federal de São Paulo/Escola Paulista de Medicina (UNIFESP/EPM). São Paulo, Brasil.Corresponding author: Dr. Finsterer J, Postfach 20, 1180 Vienna, AustriaArticle history Received 11 Feb 2021 Received in revised form 21 Feb 2021Accepted 24 Feb 2021 Available online 28 Feb 2021  Keywords: Epilepsy, Seizures, SUDEP, Sudden Death, Side EThis article reviewed by Dr. Prateekonline 28 Feb 2021. IJMS, all rights reserved.  Letter to the Editor With interest we read the article by Keller et al. about a forensic autopsy study of 167 patients with sudden unexpected death in epilepsy (SUDEP), in which electronic autopsy reports were electronically screened for appropriate search terms and selected fconsensus decision about SUDEP as the cause of death (COD) according to the Nashef Available online at www.ijmsonline.in                 IJMS 6(2),                  Print ISSN   2542 Letter to the Edit                                International Journal of Medical , MD2, Carla Alexandra Scorza, MD3 . .    ffects , Dr. Ram. Edited by Dr. Pradeep J., Dr. S Gaur 20-23 (2021)                                                              -2766 or  Studies      20 . Available or                                Dr. Josef Finsterer et al.  www.ijmsonline.in                                                                International Journal of Medical Studies    21  criteria by two independent neurologists [1]. It was found that 108 patients had definite, 34 definite-plus, 22 possible, 1 probable, and 2 near-SUDEP and concluded that the frequency of SUDEP correlates negatively with age and that SUDEP may be underappreciated in elder adults [1]. The approach is appealing but has several limitations. The first shortcoming is that several risk factors for SUDEP were not included in the algorithm for identifying SUDEP patients, which include adherence to anti-seizure drug (ASD) therapy, drug-drug interactions, seizure frequency, seizure type, and ASD serum levels [2]. Among the comorbidities, terms such as heart failure, arrhythmias, atrial fibrillation, QT-prolongation, pulmonary edema, or autonomic neuropathy were not considered.  A second limitation is that autopsies were not carried out with regard to the presence of acute heart failure or Takotsubo syndrome (TTS), also known as stress cardiomyopathy or broken-heart syndrome. TTS is suspected to play a pathophysiological role in SUDEP [3]. Though having been identified and documented as the cause of SUDEP in only a few cases [4]. TTS may be under diagnosed because alertness for TTS as the cause of SUDEP is still low and because autopsy has limited possibilities to confirm TTS as COD.  A third limitation is that troponin or pro-brain natriuretic peptide (pro-BNP) levels were not determined post mortem to assess if there was acute heart failure or TTS. Pro BNP remains stable after death and is applicable as a forensic biomarker for acute heart failure due to any type of cardiomyopathy, arrhythmia, myocarditis, or coronary heart disease [5]. The value of post mortem troponin is controversially discussed. On the one hand, there are studies confirming its value for the documentation of myocardial damage [6]. On the other hand, there are studies showing that post mortem troponin is neither specific nor useful for documenting myocardial damage as COD [7].  A fourth shortcoming is that autopsies did not specifically look for neurogenic pulmonary edema (NPE), also known as Takotsubo of the lungs [8]. NPE has been speculated to play a pathophysiologic role in the occurrence of SUDEP [8]. NPE may be triggered by seizures and may result in impaired oxygen uptake, leading to generalised hypoxia and eventually death. A fifth shortcoming is that the brain was not included in autopsy. Since seizures may trigger cerebral vasoconstriction syndrome [9] and cerebral vasoconstriction syndrome may lead to ischemic stroke, [10] it should be excluded that SUDEP patients died from seizure-induced ischemic stroke.                                Dr. Josef Finsterer et al.  www.ijmsonline.in                                                                International Journal of Medical Studies    22  Overall, this interesting study has limitations, which should be accomplished before drawing conclusions as those presented. The pathophysiology associated with SUDEP is more complex than anticipated why autopsy may not be the only means to confirm SUDEP. The retrospective evaluation of electronic autopsy reports may lead to underestimation of the SUDEP prevalence.  DECLARATION OF COMPETING INTEREST There are no conflicts of interest.  FUNDING SOURCE No funding was received.  USEFUL INFO Author contribution: JF: design, literature search, discussion, first draft, critical comments. Informed consent: was obtained. The study was approved by the institutional review board.  REFERENCES  1. Keller AE, Ho J, Whitney R, Li SA, Williams AS, Pollanen MS, Donner EJ. Autopsy-reported cause of death in a population-based cohort of sudden unexpected death in epilepsy. Epilepsia 2021 Jan 5. doi: 10.1111/epi.16793.  2. May TW, Israel CW. Plötzlicher unerwarteter Tod bei Epilepsie (SUDEP): Epidemiologie, kardiale und andere Risikofaktoren [Sudden unexpected death in epilepsy (SUDEP): Epidemiology, cardiac and other risk factors]. Herzschrittmacherther Elektrophysiol 2019; 30: 274-286.  3. Stöllberger C, Wegner C, Finsterer J. Seizure-associated Takotsubo cardiomyopathy. Epilepsia 2011; 52: e160-7.                                 Dr. Josef Finsterer et al.  www.ijmsonline.in                                                                International Journal of Medical Studies    23  4. Finsterer J, Bersano A. Seizure-triggered Takotsubo syndrome rarely causes SUDEP. Seizure 2015; 31: 84-7.  5. Sabatasso S, Vaucher P, Augsburger M, Donzé N, Mangin P, Michaud K. Sensitivity and specificity of NT-proBNP to detect heart failure at post mortem examination. Int J Legal Med 2011; 125: 849-56.  6. Aissaoui A, Haj Salem N, Zaqout A, Boughattas M, Belhaj M, Mosrati MA, Chadly A. Intérêt du dosage post-mortem des troponines I cardiaques dans l'identification des lésions myocardiques Cardiac troponin I and the post-mortem diagnosis of myocardial damage. Ann Cardiol Angeiol (Paris) 2013; 62: 248-52. 7. Rahimi R, Dahili ND, Anuar Zainun K, Mohd Kasim NA, Md Noor S. Post mortem troponin T analysis in sudden death: Is it useful? Malays J Pathol. 2018 Aug; 40 (2): 143-148.  8. Finsterer J. Neurological Perspectives of Neurogenic Pulmonary Edema. Eur Neurol 2019; 81: 94-102. 9. Hess R. Epilepsie und Kopfschmerzen Epilepsy and headaches (author's transl). EEG EMG Z Elektroenzephalogr Elektromyogr Verwandte Geb 1977; 8: 125-36.  10. Caria F, Zedde M, Gamba M, Bersano A, Rasura M, Adami A, Piantadosi C, Quartuccio L, Azzini C, Melis M, Luisa Delodovici M, Dallocchio C, Gandolfo C, Cerrato P, Motto C, Melis F, Chiti A, Gentile M, Bignamini V, Morotti A, Maria Lotti E, Toriello A, Costa P, Silvestrelli G, Zini A, De Giuli V, Poli L, Paciaroni M, Lodigiani C, Marcheselli S, Sanguigni S, Del Sette M, Monaco S, Lochner P, Zanferrari C, Anticoli S, Padovani A, Pezzini A; Italian Project on Stroke at Young Age (IPSYS) Investigators. The clinical spectrum of reversible cerebral vasoconstriction syndrome: The Italian Project on Stroke at Young Age (IPSYS). Cephalalgia 2019; 39: 1267-1276.   

Diagnose SUDEP not exclusively upon autopsy reports

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Diagnose SUDEP not exclusively upon autopsy reports

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