Death in Epilepsy: Ictogenic Vs. Cardiogenic Mechanisms and Immunoassays in Postmortem Interval Estimation – Case Report

Background: Epilepsy may cause sudden death.More scenarios are possible: sudden unexpected death in epilepsy (SUDEP), cardiac and non-cardiac mechanisms of death.This study presents the case history of a 57-year-old person known for epilepsy who experienced a final tonic-clonic seizures with ictal cardiorespiratory arrest shortly after hospital admission.The present study aimed to determine 1) the cause of death and possible mechanisms; and 2) reference values for immunoassays at 36.8-hour postmortem interval. Materials and methods:A full medico-legal autopsy was performed.Postmortem findings and a large panel of investigations are provided: anatomic pathology, pericardial chemistry investigations, forensic serology and toxicology.Immunoassays including sodium dodecyl sulfate-polyacrylamide gel electrophoresis (SDS-PAGE) with Western blotting for vinculin and enzyme-linked immunosorbent for cardiac TnT, vinculin and desmin were used to assess the postmortem interval.Results: Cause of death, mechanisms and medico-legal causality are debated.Autopsy findings and relevant investigations did not reveal a single identifiable cause of death incompatible with life.Even more, SUDEP appears improbable and status epilepticus not documented.An ictogenic cause of death with autogenous and cardiac mechanisms involvement, enhanced by concomitant conditioning factors, a severe metabolic acidosis, respiratory failure with impaired ventilation and extensive myocardial fibrosis appears more probable.SDS-PAGE with Western Blot was able to detect the native molecular band 117 kD of vinculin and three molecular products of degradation at 90 kD, 87 kD, 84 kD at 36,8-hour postmortem interval and 2026; 21(1): 226-236 ABBREVIATIONS SUDEP: sudden unexpected death in epilepsy PMI: postmortem interval GTCS: generalized tonic-clonic seizure SCD: sudden cardiac death SUCD: sudden unexpected cardiac death SUDS: sudden unexpected death syndrome PMIc: postmortem interval calculated SDS-PAGE: Sodium dodecyl sulfate-polyacrylamide gel electrophoresis ELISA: enzyme-linked immunosorbent assay cTnT: cardiac troponin T GCS: Glasgow coma scale HR: heart rate RR: respiratory rate ECG: electrocardiogram C9: complement 9 H&E: hematoxylin-eosin CK-MB: creatine kinase-MB ABG: arterial blood gas AGMA: anion-gap metabolic acidosis NAGMA: non-anion-gap metabolic acidosis Death in epilepsy anD postmortem interval therefore confirmed the postmortem interval, while ELISA detected cardiac TnT (178.85 pg/mL), vinculin (570.96pg/mL) and desmin (565.77pg/mL) in the skeletal muscle.Conclusions: This case highlights the important role played by medico-legal autopsy in death investigation in epilepsy.If for legal purpose causality is required, causes of death and conditioning factors are to be extensively investigated and connected.ELISA delivered benchmarks references at 36.8-hour postmortem interval and provided to be a valuable immunoassay method in estimation of postmortem interval.