Brainstem Disinhibition Destabilizes Breathing in Dravet Syndrome, Leading to Sudden Unexpected Death in Epilepsy (SUDEP)

Developmental Progression of Respiratory Dysfunction in a Mouse Model of Dravet Syndrome Milla BM, da Silva EN, Sobrinho CR, Strain ML, Mulkey DK. JCI Insight , 2025 Oct;10(20). https://doi.org/10.1172/jci.insight.184231 Dravet syndrome (DS) is an early-onset epilepsy caused by loss-of-function mutations in the SCN1A gene, which encodes Nav1.1 channels that preferentially regulate activity of inhibitory neurons early in development. DS is associated with a high incidence of sudden unexpected death in epilepsy (SUDEP) by a mechanism that may involve respiratory failure. Evidence also shows that loss of Scn1a impaired activity of neurons in the retrotrapezoid nucleus (RTN) that regulate breathing in response to CO2/H+, suggesting breathing problems precede seizures and serve as a biomarker of SUDEP. Consistent with this, we showed that Scn1a+/- mice exhibited a blunted ventilatory response to CO2/H+ prior to overt seizure activity that worsened with disease progression. Later in development, some Scn1a+/- mice also showed a blunted ventilatory response to hypoxia. Importantly, the severity of respiratory problems correlated with mortality. We also found that pharmacological activation of Nav1.1 rescued activity deficits of RTN neurons in Scn1a+/- mice. We conclude that disordered breathing may be an early biomarker of SUDEP in DS, and at the cellular level, loss of Scn1a disrupts RTN neurons by mechanisms involving disinhibition and pharmacological activation of Nav1.1 to reestablish inhibitory control of RTN neurons rescues activity deficits.