Saturday, August 27, 2016

A risk for sudden death in epilepsy that often goes unmentioned

Shena Pearson nearly froze in her seat, terrified, as she stared at a power-point slide. She was at her first meeting of an epilepsy foundation, seeking help for her 12-year-old son Trysten, when a neurologist flashed the slide about something called Sudep.

It stands for sudden unexpected death in epilepsy. Her son’s neurologist had never mentioned it.

“Oh dear God, my child is at risk, seriously at risk,” Ms. Pearson thought to herself.

Sudden death in epilepsy is a little-known and seldom-mentioned phenomenon, but now, after a push by advocates, the federal government has begun a concerted program to understand it. Yet a question remains: When, if ever, should patients be warned?...

Neurologists say sudden unexpected death in epilepsy is second to stroke as a cause of years of life lost because of a neurological disorder. Sudep kills an estimated 2,600 people a year in the United States — some neurologists say the real figure is almost certainly higher — or one in 1,000 people with epilepsy. For people whose seizures are not controlled with the medication, the fatality rate is one in 150.

Some three million Americans and 50 million people worldwide have epilepsy. About a third of Americans with epilepsy have uncontrolled seizures, said Dr. Daniel Friedman, an epilepsy researcher at New York University. That means about a million Americans could be at high risk of sudden death…

Ms. Pearson’s son was having at least 24 seizures a year despite anti-seizure medication. She could not bear to tell him about the sudden death risk. But he found out anyway three months later. He was meeting with an epilepsy support group meeting near their home in Galveston County in Texas and overheard people discussing it.

Ms. Pearson and her son were not alone in finding out about sudden death in epilepsy by accident. Despite the urging of professional organizations like the American Epilepsy Society and leading researchers to give patients the full picture, neurologists shy from a discussion of this phenomenon. The problem is that, at least for now, risk estimates are uncertain, and there are no proven ways to prevent it.

A national study of neurologists found that very few always told people with epilepsy about sudden death. That prompted Dr. William Gaillard, the director of the epilepsy program at the Children’s National Health System, to survey the children’s neurologists in his program. Most said they usually did not mention it to families.

“Many of my colleagues, myself included, are paternalistic creatures,” Dr. Gaillard said in an interview. “Many don’t talk about it because it is a low risk, and there is nothing you can do about it. They’ve made that decision for their patients.”

But Dr. Gaillard and others say families have a right to know. In addition, said Dr. Orrin Devinsky, the director of the epilepsy center at NYU Langone Medical Center, knowing about it could provide an impetus for patients to work with doctors to get their seizures under control, as death occurs just after a seizure.

Dr. Walter Koroshetz, the director of the National Institute of Neurological Disorders and Stroke, faced the disclosure question in his own family. In 1990, his father, who developed epilepsy late in life, walked to his refrigerator one day to get something to eat. He had a seizure, fell and died. Five years earlier, an uncle on his father’s side had died as a result of Sudep after developing late-life epilepsy. But Dr. Koroshetz, who as a neurologist knew about sudden death in epilepsy, had not mentioned it to his father.

“I did not think it would help him,” Dr. Koroshetz said.

Three years later, another of his father’s brothers developed epilepsy. This time, Dr. Koroshetz said, he had a long discussion about the risk of death with that uncle. He is still alive and doing well.

Dr. Koroshetz says there is not much adults can do to protect themselves except to take anti-seizure medications religiously, because the sudden death risk is associated mainly with uncontrolled seizures…

John Popovich lost his son John Paul to sudden death in epilepsy. A 19-year-old freshman at the University of Virginia, he had come home to celebrate the holidays last year. His father found him lying face down on his bed one morning, dead. He had had only three seizures in his entire life.

The death certificate did not mention sudden death in epilepsy, and Mr. Popovich and his family, who live in Northern Virginia, had never heard of Sudep until his brother told him about it several weeks after his son’s funeral. Mr. Popovich could not understand doctors’ reluctance to bring it up.

“As a parent who lost a child, I can say that the medical community is not doing anyone a favor,” he said.

The toxicology report after his son’s death indicated that he had not taken his seizure medication for at least a day — the drug was not in his system. If he had known about the risk of sudden death, he would never have missed a dose, his father said.

Courtesy of Doximity


1 comment:

  1. Epilepsy, however disabling it may be, is usually not considered to be a fatal condition.

    A common perception of parents first witnessing a generalized tonic-clonic seizure is that their child almost died, and a common fear is that their child might die if another seizure occurs. If the initial seizure or a subsequent seizure is nocturnal, parents may begin sleeping with the child, may alter the sleeping arrangements in the house, or may install a monitor in the child’s room. Fear of the consequences of seizure recurrence may result in parental overprotectiveness and undue limitations on the child’s activities. In view of such misplaced anxiety and common misperception, a focus on the mortality of epilepsy in newly diagnosed patients or in patients whose epilepsy is readily treated would be inappropriate. On the other hand, the question of whether a child can die during a seizure deserves an honest answer.

    An organization in the United Kingdom, “Epilepsy Bereaved?,” represents a large group of families who know from experience that people do die suddenly from epilepsy. The “Epilepsy Bereaved?” booklet, Epilepsy and the Young Adult states, “It is recognized that people do die from epilepsy. Some deaths are due to accidents and a small portion to suicide but the most significant cause of death is as the result of a seizure. Out of 350,000 people who have epilepsy in this country, there are about 900 epilepsy-related deaths each year. Taking your medications regularly should reduce the number of seizures and therefore the risk”. Patients with epilepsy, in addition to their families, have the same right to know the mortality risks associated with epilepsy as a patient suffering from another chronic condition with an increased risk for premature death. Understanding that epilepsy, like asthma or diabetes, is potentially fatal may improve patients’ treatment cooperation. Furthermore, parents, partners, and friends might monitor the patient and ensure that antiepileptic medications are taken regularly. Achieving complete seizure control with epilepsy surgery in refractory patients, who are good surgical candidates, reduces the risk of death to a level indistinguishable from that of the general population. This may encourage refractory patients to pursue surgical treatment. Once intelligent teenagers or adults know and accept the risks, they should be able to decide for themselves what precautions to take. If the increased risk of premature death were common knowledge, and if the worst happens, the death might be easier for the survivors to understand.

    Breningstall GN. Mortality in pediatric epilepsy. Pediatr Neurol. 2001 Jul;25(1):9-16.