Ten adult patients with 30 documented epileptic seizures during video-EEG recording and who later died of SUDEP were compared with 30 matched live controls with 92 epileptic seizures from the same video-telemetry database at Case Medical Center, Cleveland, OH, and Frenchay Hospital, Bristol, UK. Postictal generalized EEG suppression (PGES) was seen in 15/30 (50%) case and 35/92 (38%) control seizures. PGES was significantly longer in the generalized motor seizures of the SUDEP group (P<0.001). Odds of SUDEP occurring were elevated with PGES durations of >50 sees (P<0.05); the odds were quadrupled beyond 80 secs. For each 1 sec increase in duration of PGES, the odds of SUDEP increased by 1.7% (P<0.005). Refractory epilepsy patients at risk of SUDEP have prolonged PGES (>50 secs), and risk of SUDEP is correlated with duration of PGES. The authors propose that a profound postictal cerebral dysfunction leading to central apnea may be a pathogenic mechanism for SUDEP. 
COMMENT. The prognostic value of video-EEG monitoring and estimation of risk of SUDEP in patients with refractory generalized seizures is demonstrated in this study. Patients at risk should receive more aggressive medical and possibly surgical therapy as well as close postictal observation and stimulation to minimize the occurrence of central inhibition, apnea and SUDEP. Dr LJ Hirsch, Neurological Institute, New York, NY, in an editorial, recommends the use of multimodal ambulatory monitoring (respiration, oxygen saturation, C02, EKG, and EEG) in epilepsy patients at risk of SUDEP. He cites a prospective, international study in Europe and Australia, using cardio-respiratory and EEG monitoring in 16 cases of SUDEP, reporting central shutdown and respiratory arrest as the primary mechanism of death. (Findings presented at recent European Congress of Epileptology). The quality of life of patients with epilepsy needs protection, but the increasing interest in SUDEP indicates the need for closer monitoring of patients at risk.