Sudden, Unexpected Death in Epilepsy – Pathway to the Forensic Investigation

Abstract

Introduction: Sudden Unexpected Death in Epilepsy (SUDEP) is a recognized and often underreported cause of mortality in individuals with epilepsy. It can be defined as a sudden and unexpected death, whether witnessed or not, non-traumatic, in benign circumstances, with or without seizure activity but excluding status epilepticus, and with no toxicological or anatomical cause of death identified a thorough post-mortem examination.
From a forensic standpoint, SUDEP is a diagnosis of exclusion, established following comprehensive autopsy, with toxicology, pathological anatomy study and clinical history review. The pathophysiological mechanisms remain incompletely understood but are believed to involve a combination of cardiac arrhythmias, respiratory dysfunction, and autonomic instability. Risk factors include male sex, young adult age, early epilepsy onset, long epilepsy duration, subtherapeutic antiepileptic drug levels, and high seizure frequency.
Case presentation: We present the case of a 35 years-old male with a know history of epilepsy, treated with valproic acid. He had a prior suicide attempt four years before death and no history of alcohol or illicit drug intake.
The victim lived with his brother, who reported increased anxiety related to family issues but no other behavioral changes. The deceased was found unresponsive on the bedroom floor by his brother, with no suspicious signs in the body scene examination. The last time he was seen alive was the previous night.
A medico-legal autopsy was performed. External examination revealed marked cervicofacial congestion, and minor bruises and abrasions on the upper limbs. Internal examination showed hemorrhagic suffusions on the epicardium, left ventricular and interventricular septum hypertrophy, and diffuse pulmonary edema. Neither macroscopic brain abnormalities nor lethal traumatic injuries were observed. Toxicological analyses were negative for ethanol, medications (including antiepileptic drugs), drugs of abuse, and carbon monoxide. Histopathology revealed moderate subendocardial fibrosis without signs of acute ischemia and coronary atherosclerosis causing approximately 10% luminal stenosis.
The absence of lethal trauma or toxicological findings and the lack of an alternative anatomical cause of death, combined with the victim's clinical history and risk profile, support the diagnosis of SUDEP as the cause of death. This case illustrates the critical role of multidisciplinary forensic investigation in sudden deaths among epileptic patients.
Discussion and conclusions: Recognition of SUDEP in forensic practice is essential to avoid misclassification of cause of death and to provide clarity for legal, medical, and family contexts. Awareness of risk factors and thorough post-mortem investigation remain crucial in diagnosing SUDEP. This case underscores the importance of considering SUDEP in sudden, unexplained deaths in individuals with epilepsy, particularly when other causes are excluded.