Rosalind W.Picard, Professor, Massachusetts Institute of Technologypicard@media.mit.edu
M Migliorini, C Caborni, F Onorati, G Regalia, D Friedman, O Devinsky
Submitted January 03, 2018
We appreciate the comments from Dr. Stewart on our article, [1] and agree that obstructive
apnea and laryngospasm are potentially relevant factors in some SUDEP cases. We also agree
that laryngospasm can occur during seizures. Well-documented cases have been rarely
reported in witnessed SUDEPs.
Our understanding of the normal response to obstructive apnea is to change
position; the movement data measured by the Embrace smartwatch did not show a change of
position. [1] Prior studies showed large electrodermal responses (EDRs) during or
following tonic-clonic seizures without observed obstructive apnea, with the size of the
EDR correlated with the duration of postictal generalized EEG suppression. [2,3] Further,
in our unpublished studies of obstructive sleep apnea, EDRs following apneas were much
smaller than in this published SUDEP case and those observed following tonic-clonic
seizures. An unusually severe suppression of brain activity, arousal or respiratory
function (or some combination thereof), is likely the critical factor in such cases.
Therefore, if there was airway obstruction due to laryngospasm in this case of SUDEP, it
is unlikely to be the sole mechanism of death.
1. Picard RW, Migliorini M, Caborni C, et al. Wrist sensor reveals sympathetic
hyperactivity and hypoventilation before probable SUDEP. Neurology 2017;89:633-635.
2. Poh MZ, Loddenkemper T, Reinsberger C, et al. Autonomic changes with seizures
correlate with postictal EEG suppression. Neurology 2012;78:1868-1876.
3. Sarkis RA, Thome-Souza S, Poh MZ, et al. Autonomic changes following
generalized tonic clonic seizures: An analysis of adult and pediatric patients with
epilepsy. Epilepsy Res 2015;115:113-118.
For disclosures, please contact the editorial office at journal@neurology.org.
We appreciate the comments from Dr. Stewart on our article, [1] and agree that obstructive apnea and laryngospasm are potentially relevant factors in some SUDEP cases. We also agree that laryngospasm can occur during seizures. Well-documented cases have been rarely reported in witnessed SUDEPs.
Our understanding of the normal response to obstructive apnea is to change position; the movement data measured by the Embrace smartwatch did not show a change of position. [1] Prior studies showed large electrodermal responses (EDRs) during or following tonic-clonic seizures without observed obstructive apnea, with the size of the EDR correlated with the duration of postictal generalized EEG suppression. [2,3] Further, in our unpublished studies of obstructive sleep apnea, EDRs following apneas were much smaller than in this published SUDEP case and those observed following tonic-clonic seizures. An unusually severe suppression of brain activity, arousal or respiratory function (or some combination thereof), is likely the critical factor in such cases. Therefore, if there was airway obstruction due to laryngospasm in this case of SUDEP, it is unlikely to be the sole mechanism of death.
1. Picard RW, Migliorini M, Caborni C, et al. Wrist sensor reveals sympathetic hyperactivity and hypoventilation before probable SUDEP. Neurology 2017;89:633-635.
2. Poh MZ, Loddenkemper T, Reinsberger C, et al. Autonomic changes with seizures correlate with postictal EEG suppression. Neurology 2012;78:1868-1876.
3. Sarkis RA, Thome-Souza S, Poh MZ, et al. Autonomic changes following generalized tonic clonic seizures: An analysis of adult and pediatric patients with epilepsy. Epilepsy Res 2015;115:113-118.
For disclosures, please contact the editorial office at journal@neurology.org.