Age-specific periictal electroclinical features of generalized tonic–clonic seizures and potential risk of sudden unexpected death in epilepsy (SUDEP)

• Sudden unexpected death in epilepsy (SUDEP), which is strongly associated with Treatment-refractory generalized tonic–clonic seizures, is ten times less common in children.
• Prolonged postictal generalized EEG suppression may be a risk marker of SUDEP.
• The tonic phase of the generalized tonic–clonic seizure and postictal generalized EEG suppression are significantly shorter in children.
• Long tonic phases and prolonged postictal generalized EEG suppression in children may identify those at particular risk of SUDEP.

Generalized tonic–clonic seizure (GTCS) is the commonest seizure type associated with sudden unexpected death in epilepsy (SUDEP). This study examined the semiological and electroencephalographic differences (EEG) in the GTCSs of adults as compared with those of children. The rationale lies on epidemiological observations that have noted a tenfold higher incidence of SUDEP in adults. We analyzed the video-EEG data of 105 GTCS events in 61 consecutive patients (12 children, 23 seizure events and 49 adults, 82 seizure events) recruited from the Epilepsy Monitoring Unit. Semiological, EEG, and 3-channel EKG features were studied. Periictal seizure phase durations were analyzed including tonic, clonic, total seizure, postictal EEG suppression (PGES), and recovery phases. Heart rate variability (HRV) measures including RMSSD (root mean square successive difference of RR intervals), SDNN (standard deviation of NN intervals), and SDSD (standard deviation of differences) were analyzed (including low frequency/high frequency power ratios) during preictal baseline and ictal and postictal phases. Generalized estimating equations (GEEs) were used to find associations between electroclinical features. Separate subgroup analyses were carried out on adult and pediatric age groups as well as medication groups (no antiepileptic medication cessation versus unchanged or reduced medication) during admission. Major differences were seen in adult and pediatric seizures with total seizure duration, tonic phase, PGES, and recovery phases being significantly shorter in children (p < 0.01). Generalized estimating equation analysis, using tonic phase duration as the dependent variable, found age to correlate significantly (p < 0.001), and this remained significant during subgroup analysis (adults and children) such that each 0.12-second increase in tonic phase duration correlated with a 1-second increase in PGES duration. Postictal EEG suppression durations were on average 28 s shorter in children. With cessation of medication, total seizure duration was significantly increased by a mean value of 8 s in children and 11 s in adults (p < 0.05). Tonic phase duration also significantly increased with medication cessation, and although PGES durations increased, this was not significant. Root mean square successive difference was negatively correlated with PGES duration (longer PGES durations were associated with decreased vagally mediated heart rate variability; p < 0.05) but not with tonic phase duration. This study clearly points out identifiable electroclinical differences between adult and pediatric GTCSs that may be relevant in explaining lower SUDEP risk in children. The findings suggest that some prolonged seizure phases and prolonged PGES duration may be electroclinical markers of SUDEP risk and merit further study.