Wake-up Call for SUDEP: Unveiling Sleep Biomarkers

Sleep EEG and Respiratory Biomarkers of Sudden Unexpected Death in Epilepsy (SUDEP): A Case–Control Study. Magana-Tellez O, Maganti R, Hupp NJ, Luo X, Rani S, Hampson JP, Ochoa-Urrea M, Tallavajhula SS, Sainju RK, Friedman D, Nei M, Gehlbach BK, Schuele S, Harper RM, Diehl B, Bateman LM, Devinsky O, Richerson GB, Lhatoo SD, Lacuey N. Lancet Neurol . 2025;24(10):840–849. https://www.thelancet.com/journals/laneur/article/PIIS1474-4422(25)00273-X/abstract Background: Sudden unexpected death in epilepsy (SUDEP) is the most common category of epilepsy-related mortality. Centrally mediated respiratory dysfunction has been observed to lead to death in the majority of cases of SUDEP. SUDEP also mainly occurs during nighttime sleep. This study seeks to identify sleep EEG and sleep-related respiratory biomarkers of SUDEP risk. Methods: In this case–control study, we compared demographic, clinical, EEG, and respiratory data from people with epilepsy who later died of SUDEP (the SUDEP group) with data from age and sex-matched living people with epilepsy, classified as high risk of SUDEP (with ≥1 generalised tonic–clonic seizure [GTCS] per year), low risk of SUDEP (no history of GTCS), and non-epilepsy controls. These data were prospectively collected as part of a multicentre National Institutes of Health study. We analysed sleep macroarchitecture and microarchitecture features and measured sleep homeostasis by calculating overnight change in slow wave activity (SWA; 0.5–4.0 Hz) in non-rapid eye movement (NREM) sleep during seizure-free nights using linear regression models. We also analysed sleep respiratory metrics, including inter-breath interval variability. We used receiver operating characteristic analysis to assess the individual discriminative performance of demographic, clinical, sleep EEG, and sleep-related respiratory features to predict the risk of SUDEP. Findings: Between Sept 1, 2011, and Oct 15, 2022, 41 participants who later died of SUDEP and 123 matched controls (41 people living with epilepsy at high risk of SUDEP, 41 people living with epilepsy at low risk of SUDEP, and 41 non-epilepsy controls) were enrolled. The SUDEP group showed an abnormal lack of overnight decline and an increase in the slope of SWA power compared with the other groups (SUDEP group mean 0.005, standardized error of the mean [SEM] 0.003; high-SUDEP risk group −0.005, 0.002; low-SUDEP risk group −0.003, 0.002; non-epilepsy controls −0.007, 0.003; p = 0.017). The overnight increase in the SWA slope was more pronounced in males compared with females (males mean 0.012, SEM 0.001; females 0.001, 0.002; p = 0.005). The variability of the inter-breath interval was significantly higher in the SUDEP (coefficient of variation mean 0.15, SD 0.09; SD mean 0.54 s, SD 0.35 s) and high-SUDEP risk groups (0.11, 0.03; 0.46 s, 0.19 s) compared with low- SUDEP risk group (0.08, 0.03; 0.30 s, 0.14 s) and non-epilepsy controls (0.08, 0.02; 0.31 s, 0.11 s; p < 0.0001). The coefficient of variation of inter-breath interval had the greatest predictive power of SUDEP risk (between-group point estimate difference 0.30, AUC 0.80; 95% CI 0.70–0.90; p < 0.0001). Interpretation: This study identifies impaired sleep homeostasis in the form of altered SWA progression during NREM sleep overnight in people with epilepsy who later died of SUDEP, and an increase in respiratory variability during NREM sleep in people with epilepsy who later died of SUDEP and in people with epilepsy at high risk of SUDEP. Multiday polysomnography studies are needed to validate sleep homeostasis and respiratory variability during sleep as potential biomarkers of SUDEP risk. Further studies are required to explore possible sleep interventions that could mitigate SUDEP risk.