• Philippe Ryvlin, Lina Nashef, Samden D Lhatoo, Lisa M Bateman, Jonathan Bird, Andrew Bleasel, Paul Boon, Arielle Crespel, Barbara A Dworetzky, Hans Høgenhaven, Holger Lerche, Louis Maillard, Michael P Malter, Cecile Marchal, Jagarlapudi M K Murthy, Michael Nitsche, Ekaterina Pataraia, Terje Rabben, Sylvain Rheims, Bernard Sadzot, Andreas Schulze-Bonhage, Masud Seyal, Elson L So, Mark Spitz, Anna Szucs, Meng Tan, James X Tao, and Torbjörn Tomson.
• Hospices Civils de Lyon and CRNL, INSERM U1028, CNRS 5292, Lyon, France. Electronic address: philippe.ryvlin@chu-lyon.fr.
• Lancet Neurol. 2013 Oct 1; 12 (10): 966-77.

BackgroundSudden 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.MethodsBetween 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.Findings147 (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.InterpretationSUDEP 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.FundingCommission of European Affairs of the International League Against Epilepsy.Copyright © 2013 Elsevier Ltd. All rights reserved.

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