title: Sudden neurologic death masquerading as out-of-hospital sudden cardiac death.
abstract: OBJECTIVE
  To characterize the frequency of and risk factors for out-of-hospital sudden neurologic deaths.
  
  
  METHODS
  During the initial 25 months (February 1, 2011-March 1, 2013) of the San Francisco Postmortem Systematic Investigation of Sudden Cardiac Death Study, we captured incident WHO criteria sudden cardiac deaths (SCDs) through active surveillance of consecutive out-of-hospital deaths, which must be reported to the medical examiner by law. All cases were referred for full autopsy with detailed examination of the heart and cranial vault, toxicology, and histology. A multidisciplinary committee adjudicated a final cause of death.
  
  
  RESULTS
  Of 352 incident SCDs, 335 (95%) underwent systematic evaluation including full autopsy. Of these 335 cases, 18 (5.4%) were sudden neurologic deaths (mean age 60.6 years [SD 17.6, range 27-87]; 67.7% female), which accounted for 14.9% of the 121 noncardiac sudden deaths. The risk of sudden neurologic death compared to non-neurologic SCD was lower in male and white participants (p < 0.01). Neurologic causes included intracranial hemorrhage (8), sudden unexpected death in epilepsy (6, including 2 with juvenile myoclonic epilepsy), aneurysmal subarachnoid hemorrhage (2), acute ischemic stroke (1), and aspiration from Huntington disease (1). Most deaths were unwitnessed (16; 89%) with asystole at presentation (17; 94%). Prior stroke/TIA was not associated with risk of stroke (odds ratio [OR] 1.4 [95% confidence interval (CI) 0.18-11.8], p = 0.73), but antithrombotic medication use was (OR 3.9 [95% 1.01-15.5], p = 0.05).
  
  
  CONCLUSIONS
  Sudden neurologic death is an important cause of out-of-hospital apparent SCDs. Low prevailing autopsy rates may result in systematic misclassification of apparent SCDs and underestimation of the incidence of sudden neurologic death.
authors.affiliation: From the Department of Neurology (A.S.K.), San Francisco Office of the Chief Medical Examiner (E.M.), Department of Pathology (P.C.U.), and Department of Medicine, Division of Cardiology (J.O.), Cardiac Electrophysiology Section (Z.H.T.), University of California, San Francisco; and Department of Neurology (O.D.), New York University, New York.
authors.forename: Anthony S
authors.initials: AS
authors.lastname: Kim
authors.affiliation: From the Department of Neurology (A.S.K.), San Francisco Office of the Chief Medical Examiner (E.M.), Department of Pathology (P.C.U.), and Department of Medicine, Division of Cardiology (J.O.), Cardiac Electrophysiology Section (Z.H.T.), University of California, San Francisco; and Department of Neurology (O.D.), New York University, New York.
authors.forename: Ellen
authors.initials: E
authors.lastname: Moffatt
authors.affiliation: From the Department of Neurology (A.S.K.), San Francisco Office of the Chief Medical Examiner (E.M.), Department of Pathology (P.C.U.), and Department of Medicine, Division of Cardiology (J.O.), Cardiac Electrophysiology Section (Z.H.T.), University of California, San Francisco; and Department of Neurology (O.D.), New York University, New York.
authors.forename: Philip C
authors.initials: PC
authors.lastname: Ursell
authors.affiliation: From the Department of Neurology (A.S.K.), San Francisco Office of the Chief Medical Examiner (E.M.), Department of Pathology (P.C.U.), and Department of Medicine, Division of Cardiology (J.O.), Cardiac Electrophysiology Section (Z.H.T.), University of California, San Francisco; and Department of Neurology (O.D.), New York University, New York.
authors.forename: Orrin
authors.initials: O
authors.lastname: Devinsky
authors.affiliation: From the Department of Neurology (A.S.K.), San Francisco Office of the Chief Medical Examiner (E.M.), Department of Pathology (P.C.U.), and Department of Medicine, Division of Cardiology (J.O.), Cardiac Electrophysiology Section (Z.H.T.), University of California, San Francisco; and Department of Neurology (O.D.), New York University, New York.
authors.forename: Jeffrey
authors.initials: J
authors.lastname: Olgin
authors.affiliation: From the Department of Neurology (A.S.K.), San Francisco Office of the Chief Medical Examiner (E.M.), Department of Pathology (P.C.U.), and Department of Medicine, Division of Cardiology (J.O.), Cardiac Electrophysiology Section (Z.H.T.), University of California, San Francisco; and Department of Neurology (O.D.), New York University, New York. zhtseng@medicine.ucsf.edu.
authors.forename: Zian H
authors.initials: ZH
authors.lastname: Tseng
mesh_terms: D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D003645:Death, Sudden / Q000453:epidemiology* / Q000209:etiology*; D005260:Female; D006801:Humans; D008297:Male; D008875:Middle Aged; D009422:Nervous System Diseases / Q000401:mortality*; D012307:Risk Factors