title: Incidence and mechanisms of cardiorespiratory arrests in epilepsy monitoring units (MORTEMUS): a retrospective study.
abstract: BACKGROUND
  Sudden unexpected death in epilepsy (SUDEP) is the leading cause of death in people with chronic refractory epilepsy. Very rarely, SUDEP occurs in epilepsy monitoring units, providing highly informative data for its still elusive pathophysiology. The MORTEMUS study expanded these data through comprehensive evaluation of cardiorespiratory arrests encountered in epilepsy monitoring units worldwide.
  
  
  METHODS
  Between Jan 1, 2008, and Dec 29, 2009, we did a systematic retrospective survey of epilepsy monitoring units located in Europe, Israel, Australia, and New Zealand, to retrieve data for all cardiorespiratory arrests recorded in these units and estimate their incidence. Epilepsy monitoring units from other regions were invited to report similar cases to further explore the mechanisms. An expert panel reviewed data, including video electroencephalogram (VEEG) and electrocardiogram material at the time of cardiorespiratory arrests whenever available.
  
  
  RESULTS
  147 (92%) of 160 units responded to the survey. 29 cardiorespiratory arrests, including 16 SUDEP (14 at night), nine near SUDEP, and four deaths from other causes, were reported. Cardiorespiratory data, available for ten cases of SUDEP, showed a consistent and previously unrecognised pattern whereby rapid breathing (18-50 breaths per min) developed after secondary generalised tonic-clonic seizure, followed within 3 min by transient or terminal cardiorespiratory dysfunction. Where transient, this dysfunction later recurred with terminal apnoea occurring within 11 min of the end of the seizure, followed by cardiac arrest. SUDEP incidence in adult epilepsy monitoring units was 5·1 (95% CI 2·6-9·2) per 1000 patient-years, with a risk of 1·2 (0·6-2·1) per 10,000 VEEG monitorings, probably aggravated by suboptimum supervision and possibly by antiepileptic drug withdrawal.
  
  
  CONCLUSIONS
  SUDEP in epilepsy monitoring units primarily follows an early postictal, centrally mediated, severe alteration of respiratory and cardiac function induced by generalised tonic-clonic seizure, leading to immediate death or a short period of partly restored cardiorespiratory function followed by terminal apnoea then cardiac arrest. Improved supervision is warranted in epilepsy monitoring units, in particular during night time.
  
  
  BACKGROUND
  Commission of European Affairs of the International League Against Epilepsy.
authors.affiliation: Hospices Civils de Lyon and CRNL, INSERM U1028, CNRS 5292, Lyon, France. Electronic address: philippe.ryvlin@chu-lyon.fr.
authors.forename: Philippe
authors.initials: P
authors.lastname: Ryvlin
authors.forename: Lina
authors.initials: L
authors.lastname: Nashef
authors.forename: Samden D
authors.initials: SD
authors.lastname: Lhatoo
authors.forename: Lisa M
authors.initials: LM
authors.lastname: Bateman
authors.forename: Jonathan
authors.initials: J
authors.lastname: Bird
authors.forename: Andrew
authors.initials: A
authors.lastname: Bleasel
authors.forename: Paul
authors.initials: P
authors.lastname: Boon
authors.forename: Arielle
authors.initials: A
authors.lastname: Crespel
authors.forename: Barbara A
authors.initials: BA
authors.lastname: Dworetzky
authors.forename: Hans
authors.initials: H
authors.lastname: Høgenhaven
authors.forename: Holger
authors.initials: H
authors.lastname: Lerche
authors.forename: Louis
authors.initials: L
authors.lastname: Maillard
authors.forename: Michael P
authors.initials: MP
authors.lastname: Malter
authors.forename: Cecile
authors.initials: C
authors.lastname: Marchal
authors.forename: Jagarlapudi M K
authors.initials: JM
authors.lastname: Murthy
authors.forename: Michael
authors.initials: M
authors.lastname: Nitsche
authors.forename: Ekaterina
authors.initials: E
authors.lastname: Pataraia
authors.forename: Terje
authors.initials: T
authors.lastname: Rabben
authors.forename: Sylvain
authors.initials: S
authors.lastname: Rheims
authors.forename: Bernard
authors.initials: B
authors.lastname: Sadzot
authors.forename: Andreas
authors.initials: A
authors.lastname: Schulze-Bonhage
authors.forename: Masud
authors.initials: M
authors.lastname: Seyal
authors.forename: Elson L
authors.initials: EL
authors.lastname: So
authors.forename: Mark
authors.initials: M
authors.lastname: Spitz
authors.forename: Anna
authors.initials: A
authors.lastname: Szucs
authors.forename: Meng
authors.initials: M
authors.lastname: Tan
authors.forename: James X
authors.initials: JX
authors.lastname: Tao
authors.forename: Torbjörn
authors.initials: T
authors.lastname: Tomson
mesh_terms: D000328:Adult; D001315:Australia / Q000453:epidemiology; D002648:Child; D016757:Death, Sudden, Cardiac / Q000453:epidemiology / Q000209:etiology*; D004827:Epilepsy / Q000150:complications* / Q000453:epidemiology / Q000503:physiopathology; D005060:Europe / Q000453:epidemiology; D005260:Female; D006323:Heart Arrest / Q000453:epidemiology / Q000503:physiopathology*; D006757:Hospital Units / Q000706:statistics & numerical data; D006801:Humans; D015994:Incidence; D007557:Israel / Q000453:epidemiology; D008297:Male; D008875:Middle Aged; D009520:New Zealand / Q000453:epidemiology; D012189:Retrospective Studies; D012640:Seizures / Q000453:epidemiology / Q000503:physiopathology; D055815:Young Adult