title: Significant postictal hypotension: expanding the spectrum of seizure-induced autonomic dysregulation.
abstract: Periictal autonomic dysregulation is best studied using a "polygraphic" approach: electroencephalography ([EEG]), 3-channel electrocardiography [ECG], pulse oximetry, respiration, and continuous noninvasive blood pressure [BP]), which may help elucidate agonal pathophysiologic mechanisms leading to sudden unexpected death in epilepsy (SUDEP). A number of autonomic phenomena have been described in generalized tonic-clonic seizures (GTCS), the most common seizure type associated with SUDEP, including decreased heart rate variability, cardiac arrhythmias, and changes in skin conductance. Postictal generalized EEG suppression (PGES) has been identified as a potential risk marker of SUDEP, and PGES has been found to correlate with post-GTCS autonomic dysregulation in some patients. Herein, we describe a patient with a GTCS in whom polygraphic measurements were obtained, including continuous noninvasive blood pressure recordings. Significant postictal hypotension lasting >60 s was found, which closely correlated with PGES duration. Similar EEG changes are well described in hypotensive patients with vasovagal syncope and a similar vasodepressor phenomenon, and consequent cerebral hypoperfusion may account for the PGES observed in some patients after a GTCS. This further raises the possibility that profound, prolonged, and irrecoverable hypotension may comprise one potential SUDEP mechanism.
authors.affiliation: Epilepsy Center, Neurological Institute, University Hospitals Case Medical Center, Cleveland, Ohio 44106, USA.
authors.forename: Alireza
authors.initials: A
authors.lastname: Bozorgi
authors.forename: Stephanie
authors.initials: S
authors.lastname: Chung
authors.forename: Farhad
authors.initials: F
authors.lastname: Kaffashi
authors.forename: Kenneth A
authors.initials: KA
authors.lastname: Loparo
authors.forename: Satya
authors.initials: S
authors.lastname: Sahoo
authors.forename: G Q
authors.initials: GQ
authors.lastname: Zhang
authors.forename: Kitti
authors.initials: K
authors.lastname: Kaiboriboon
authors.forename: Samden D
authors.initials: SD
authors.lastname: Lhatoo
mesh_terms: D000293:Adolescent; D001341:Autonomic Nervous System / Q000503:physiopathology*; D003645:Death, Sudden / Q000209:etiology*; D004562:Electrocardiography; D004569:Electroencephalography / Q000379:methods; D005260:Female; D006801:Humans; D007022:Hypotension / Q000150:complications / Q000503:physiopathology*; D012640:Seizures / Q000150:complications / Q000503:physiopathology*; D019462:Syncope, Vasovagal / Q000150:complications / Q000503:physiopathology
keywords: Autonomic dysregulation; Postictal hypotension; Seizure polygraphy; Sudden unexpected death in epilepsy