Long-term mortality of patients with West syndrome

Abstract

Objective
To study long‐term survival and mortality among patients with West syndrome.

Methods
The study population included all children born in 1960–1976 and treated for West syndrome in three tertiary care hospitals in Helsinki, Finland. The participants were prospectively followed for five decades for survival. Death data were derived from the National Causes of Death Register of the Population Register Center of Statistics Finland.

Results
During follow‐up, 102 (49%) of 207 patients had died at the mean age of 19 years. The mean overall annual mortality rate was 15.3 per 1,000 patient‐years. The rates ranged from 18.2 per 1,000 after 10 years to 17.2 per 1,000 after 20 years and 15.4 per 1,000 patient‐years after 40 years of follow‐up. One fourth (25%) had died by 17.2 (95% CI 11.8–22.7) years and 50% by 48.6 (95% CI 38.5–NA) years of follow‐up. Etiology at onset was symptomatic in 87% patients and cryptogenic in 13%; 6 of the latter 26 patients later turned out to be symptomatic. The mean annual mortality rate was 3.7 per 1,000 for 4 patients with cryptogenic etiology and 17.6 per 1,000 for those with symptomatic etiology. The hazard of death was fivefold in patients with symptomatic etiology versus cryptogenic etiology. The overall autopsy rate was 73%. Pneumonia was the most frequent cause of death (46%). All patients who died of pneumonia had symptomatic etiology. SUDEP occurred in 10 patients and was the most common epilepsy‐related cause of death (10%).

Significance
Risk of excess death of participants with West syndrome is not limited to early age but continues into adulthood, particularly in those with symptomatic etiology, and leads to death in half the cases at around 50 years of age. Measures should be directed to prevent pneumonia, the most common overall cause, and SUDEP, the most frequent seizure‐related cause, of death.

Full text

Long-term mortality of patients with West syndrome
*Matti Sillanp€
a€
a, †Raili Riikonen, *Maiju M. Saarinen, and ‡Dieter Schmidt
Epilepsia Open, **(*):1–6, 2016
doi: 10.1002/epi4.12008
Matti Sillanp€
a€
ais
former Professor of
Child Neurology and
present Senior
Research Scientist,
University of Turku,
Turku, Finland.
SUMMARY
Objective: To study long-term survival and mortality among patients with West
syndrome.
Methods: The study population included all children born in 1960–1976 and treated for
West syndrome in three tertiary care hospitals in Helsinki, Finland. The participants
were prospectively followed for five decades for survival. Death data were derived
from the National Causes of Death Register of the Population Register Center of
Statistics Finland.
Results: During follow-up, 102 (49%) of 207 patients had died at the mean age of
19 years. The mean overall annual mortality rate was 15.3 per 1,000 patient-years.
The rates ranged from 18.2 per 1,000 after 10 years to 17.2 per 1,000 after 20 years
and 15.4 per 1,000 patient-years after 40 years of follow-up. One fourth (25%) had died
by 17.2 (95% CI 11.8–22.7) years and 50% by 48.6 (95% CI 38.5–NA) years of follow-up.
Etiology at onset was symptomatic in 87% patients and cryptogenic in 13%; 6 of the lat-
ter 26 patients later turned out to be symptomatic. The mean annual mortality rate
was 3.7 per 1,000 for 4 patients with cryptogenic etiology and 17.6 per 1,000 for those
with symptomatic etiology. The hazard of death was fivefold in patients with symp-
tomatic etiology versus cryptogenic etiology. The overall autopsy rate was 73%. Pneu-
monia was the most frequent cause of death (46%). All patients who died of
pneumonia had symptomatic etiology. SUDEP occurred in 10 patients and was the
most common epilepsy-related cause of death (10%).
Significance: Risk of excess death of participants with West syndrome is not limited to
early age but continues into adulthood, particularly in those with symptomatic etiol-
ogy, and leads to death in half the cases at around 50 years of age. Measures should be
directed to prevent pneumonia, the most common overall cause, and SUDEP, the
most frequent seizure-related cause, of death.
KEY WORDS: Infantile spasms, Long-term follow-up, Mortality in West syndrome,
Outcome of West syndrome, Population study of epilepsy.
Whereas children with uncomplicated epilepsy are not
at higher risk of death than the general population, the
mortality risk is many-fold higher in complicated epi-
lepsy.
1
Among the childhood-onset epilepsies, West syn-
drome belongs to the high-mortality category. According
to the literature,
2,3
the mortality varied widely between 3%
and 30%, largely driven by the duration of follow-up. A
retrospective hospital-based study of 385 patients of child-
hood-onset epilepsy in Japan followed for 10 years or
more (no further data given) found a mortality rate of 41%
in infantile spasms.
4
Two retrospective chart reviews with
a follow-up of 16 and 17 years, respectively, reported a
lower mortality rate of 22% each,
5,6
and another paper
from Nova Scotia a rate of 25%, based on 20-year follow-
up of 692 children with generalized epilepsies.
7
One large
prospective cohort study of children with West syndrome,
Accepted June 16, 2016.
*Departments of Child Neurology and Public Health, University of
Turku, Turku, Finland; †Department of Pediatrics, University of Eastern
Finland and Kuopio University Hospital, Kuopio, Finland; and ‡Epilepsy
Research Group, Berlin, Germany
Address correspondence to Matti Sillanp€
a€
a, Department of Public
Health, University of Turku, 20014 Turku, Finland. E-mail: matti.sillan-
paa@utu.fi
©2016 The Authors. Epilepsia Open published by Wiley Periodicals Inc.
on behalf of International League Against Epilepsy.
This is an open access article under the terms of the Creative Commons
Attribution-NonCommercial-NoDerivs License, which permits use and dis-
tribution in any medium, provided the original work is properly cited, the
use is non-commercial and no modifications or adaptations are made.
1
FULL-LENGTH ORIGINAL RESEARCH

followed for 25.6 years (mean, range 20–35), showed an
overall mortality of 31%.
8
In contrast, the present study
has a substantially longer follow-up period, up to middle
age, a higher autopsy rate, and examines the etiology of
spasms and the immediate circumstances of death. In sum-
mary, the previous studies have variable designs, are
mostly retrospective, and often are small. These facts
prompted us to investigate the occurrence, profile, and
covariates of increased mortality, based on death certifi-
cates, in a population cohort during a long prospective fol-
low-up of five decades.
Methods
The study cohort consisted of all children who were born
in 1960–1976 and treated for West syndrome in the Chil-
dren’s Hospital of the University of Helsinki (Finland), the
Aurora Hospital in Helsinki, and the Children’s Castle
Hospital, Helsinki. The inclusion criteria of the original
study
9
were <2 years of age at onset; typical clinical flexion
or extension spasms; and hypsarrhythmia or a variant of
hypsarrhythmia on interictal electroencephalogram (EEG).
The total, prospectively collected original cohort numbered
214 infants, 107 of whom were from the county of Uusimaa
and the remaining 107 from other parts of Finland. For 7
patients, detailed data of death were not available. Thus, the
present analyses are based on 207 patients. The study design
was described in detail and follow-up studies were reported
previously.
9–11
Cases of death were identified from the National
Causes of Death Register of the Population Register Cen-
ter of Statistics Finland (http://www.tilastokeskus.fi/til/
vaerak/index_en.html), which covers all citizens and per-
manent residents in Finland. The Finnish death register
has been shown to be valid and reliable for epidemiolog-
ical research.
12
The information is based on statutory noti-
fications from public authorities and private individuals,
including death data. Adrenocorticotropic hormone
(ACTH) was standard primary therapy for all patients.
Antiepileptic drugs were administered to patients in whom
ACTH was contraindicated. Similarly, some severely men-
tally handicapped patients had other antiepileptic drug
therapy. Etiology was defined as cryptogenic if the
premorbid neurodevelopment was normal and no abnor-
malities in clinical status or neuroradiological studies
were detected at presentation.
11
If such abnormalities
were diagnosed before or after onset of spasms, the etiol-
ogy was considered as being symptomatic. Although the
classification of etiology of spasms might have been
revised either by clinical course or new neuroimaging
studies during follow-up, for this analysis, the original
classification was used. Sudden unexplained death in epi-
lepsy (SUDEP) was defined according to the Annegers
criteria.
13,14
Single seizures of longer duration than
30 min and multiple seizures without recovery in between
were considered episodes of status epilepticus. Terminal
remission was defined as seizure freedom for 1 year or
more.
All patients (n =107) with West syndrome from the
county of Uusimaa were treated in one of the aforemen-
tioned three hospitals; thus, they represent a population-
based cohort.
9
To check the external validity of the results
of the present study, we compared the mortality of patients
from the cohort from Uusimaa to that of the patients from
other parts of the country (n =107). For the present study,
we had the data of 103 (96%) of 107 from the county and
104 (97%) of 107 from outside the county. Of the patients
from the county, 45 (44%) and, of those from outside the
county, 54 (52%) had died. The difference was not signifi-
cant (p =0.267, Fisher’s exact test). Accordingly, the risk
for death did not relevantly differ according to place of
birth, and the results of the study can be considered repre-
sentative of the Finnish population for the risk of death for
West syndrome.
Ethics
For the original study, the design was approved by the
ethics committee of the University of Helsinki. The study
participants or relatives of study participants or the insti-
tutions of the deceased participants were not contacted
for the present study. According to Finnish legislation
(Personal Data Act 523/1999), approval by an ethical
committee or informed consent by study participants is
not required for studies based on the register data,
including death certificate data that are provided for sci-
entific research purposes.
Statistical analysis
The data are given as n (%), mean (SD), median, and
range, or mean mortality rate per 1,000 patient-years. For
comparisons of categorical variables, Fisher’s exact test
was used. Median survival ages with 95% confidence inter-
vals (CIs) were obtained from life tables. Hazard ratios
9HRs) with 95% CI were calculated from both univariate
and multivariate Cox regression models. A p-value of <0.05
was considered statistically significant. Statistical computa-
tions were done using SAS System for Windows, release
9.3 (SAS Institute, Cary, NC, U.S.A.).
Key Points
Mortality in West syndrome is high, with 50% of
cases of death at around 50 years of age
Mortality remains high throughout life
Symptomatic etiology is fivefold as common a risk
factor as cryptogenic etiology
Pneumonia is the leading overall cause of death, and
SUDEP is the most common seizure-related cause
Epilepsia Open, **(*):1–6, 2016
doi: 10.1002/epi4.12008
2
M. Sillanp€
a€
a et al.

Results
The 207 patients were followed for 32.5 years (mean, SD
17.0, median 39.5, range 24–54). Because the onset of West
syndrome was before the age of 1 year in all patients, the
follow-up period is virtually the same as the age in years.
Until the end of follow-up, 102 (49%) of 207 patients had
died at the mean age of 19 years (Table 1). Seven patients
died during the first year of life (Fig. 1).
The overall mean annual mortality rate was 15.3/1,000
patient-years. The risk of death remained high during the
follow-up. Of the 102 deaths, 34 occurred during the first
10 years of follow-up, 25 during years 11–20, and the
remaining 43 after 20 years of follow-up, with the mortality
rates ranging from 18.2/1,000 after 10 years to 17.2/1,000
after 20 years and 15.4/1,000 patient-years after 40 years of
follow-up. During the total follow-up period, 25% of the
patients had died by 17.2 (95% CI 11.8–22.7) years and
50% by 48.6 (95% CI 38.5–NA) years (NA: upper limit for
confidence interval not applicable).
Etiology was symptomatic in 181 (87%) patients and
cryptogenic in 26 (13%); 6 of the latter later turned out to be
symptomatic. Eight (3.9%) of all patients had tuberous scle-
rosis. Of the 102 patients who died, only four were of cryp-
togenic etiology, with mean annual mortality rate 3.7/1,000,
whereas it was 17.6/1,000 for those with symptomatic etiol-
ogy. Within the prenatal symptomatic group, congenital
brain malformation and metabolic disorder and familial dis-
ease were most common. In addition, both perinatal and
postnatal infections were marked risk factors (Table 2).
Of 95 (95%) of 100 patients who had died and whose
intelligence level was known, 85 had an IQ of 80 or lower,
and the remaining 10 had an IQ higher than 80. So, 95%
needed some kind of assistance in activities of daily living.
Table 1. Duration of follow-up and age at death (years) in long-term followed participants with West syndrome
Characteristic
Follow-up time Age at death
N Mean (SD) Md Range N (%) Mean (SD) Md Range
All 207 32.5 (17.0) 39.5 0.24–53.7 102 (49) 19.1 (14.3) 17.0 0.2–51.5
Etiology
Cryptogenic 26 42.1 (13.4) 48.5 7.6–53.7 4 (15) 21.9 (20.0) 14.8 7.6–50.6
Symptomatic 181 31.1 (17.0) 38.6 0.2–53.1 98 (54) 19.0 (14.1) 17.0 0.2–51.5
Sex
Male 126 31.7 (17.2) 38.9 0.2–53.7 65 (52) 18.5 (13.6) 16.1 0.2–50.4
Female 81 33.8 (16.7) 40.7 0.4–53.0 37 (46) 20.2 (15.5) 19.4 0.4–51.5
ACTH treatment
Yes 161 33.7 (16.6) 40.2 0.2–53.7 74 (46) 19.3 (14.4) 17.2 0.2–50.6
No 46 28.4 (18.0) 27.7 1.0–53.3 28 (61) 18.7 (14.2) 15.8 1.0–51.5
ACTH, adrenocorticotropic hormone; Md, median; SD, standard deviation.
Figure 1.
Survival of 207 patients with West syndrome during the 54-year follow-up period. The hazard of death is almost fivefold for patients with
symptomatic etiology (blue line) compared with those with cryptogenic etiology (red line), p =0.003. Crypt, cryptogenic; Sympt,
symptomatic.
Epilepsia Open ILAE
Epilepsia Open, **(*):1–6, 2016
doi: 10.1002/epi4.12008
3
Long-Term Mortality in West Syndrome

Furthermore, many patients had a severe spastic tetraplegia
and kyphoscoliosis requiring even more assistance.
The underlying condition was mostly a structural brain
abnormality of prenatal or perinatal origin (Table 2). A vast
majority lived in either an institution for people with mental
retardation or a residential care home. Of the 5 (5%) patients
with an IQ higher than 80, 4 were in remission and socially
competent. The cause of death for each of these 4 patients
was SUDEP, acute myeloid leukemia, multiple gliomata, or
purulent meningitis. One patient was not in remission and
died of pneumonia.
Sufficient data on remission status at death were avail-
able for 82 (80%) of 102 patients. During the preceding
year, one or more seizures were found in 47 (57%)
patients, including 4 with status epilepticus (>30 min), 2
with an eye-witnessed seizure (≤30 min), and still
another likely (but not eye-witnessed) case of seizure of
<30 min as the primary cause of death (Table 3).
SUDEP (n =10) was the most common epilepsy-related
cause of death (Table 3). The mean age at SUDEP was
27.4 years (SD 9.9, median 25, range 9–42). One patient
was 9 years of age, while the remaining were adults 21–
42 years of age at death. None of the participants who
died of SUDEP had witnessed seizures at death. All had
mental retardation, except for one who had IQ >80 and
was socially competent (male, age at death 21 years).
The overall autopsy rate was 73% (74 of 102) of patients.
Death was classified as natural in 97 (95%), caused by acci-
dent in 4 (4%), and unclear in 1 (1%). In 83%, the immedi-
ate cause of death was unrelated to epilepsy. Pneumonia
was the most frequent cause of death noted in 47 (46%) of
all known causes of death. All 47 patients had symptomatic
etiology. Of them, 46 (98%) had mental retardation (severe
in 45, and mild in 1). Forty (85%) of 46 patients had struc-
tural brain abnormalities, including congenital cerebral mal-
formations (n =15), microcephaly or cerebral atrophy (13),
progressive encephalopathy (5), tuberous sclerosis (3), and
isolated cases of other abnormalities (4). Furthermore, 8 of
the 40 patients were recorded as cases of combined mental
retardation and spastic tetraplegia but without any other
congenital disorders. Kyphoscoliosis was often associated.
In Cox regression models, the hazard of death was five-
fold in patients with symptomatic etiology compared with
those with cryptogenic etiology. The result remained in
multivariable analysis adjusted for sex and ACTH treat-
ment. The mortality rate was slightly higher among men
than among women, and men died at a somewhat younger
age, but the differences were nonsignificant (Table 4).
In Cox regression models adjusted for sex and ACTH
treatment, the hazard of death was five times as high among
patients with symptomatic etiology as among those with
cryptogenic etiology. The mortality rate was nonsignifi-
cantly higher among men than among women (Table 4).
Discussion
The strength of this study is that it involves a cohort of
patients with West syndrome that was prospectively fol-
lowed for more than 50 years, with full ascertainment of
death and autopsy-confirmed causes of death in the vast
majority of cases. With markedly longer follow-up than that
reported in the literature, the overall mortality is much
higher than previously reported (49% vs. 22–31%; see
Introductory text). Symptomatic etiology of West syndrome
was associated with a fivefold risk of death versus crypto-
genic etiology. This compares with a fourfold risk in the
Table 2. Etiological classification of patients with West syndrome with regard to term and death
Etiology All Surviving Dead
Symptomatic 181 82 (45) 98 (55)
Prenatal 103 41 (40) 62 (60)
Congenital brain malformation, tuberous sclerosis, Down syndrome 38 9 (24) 29 (76)
Other familial disease or metabolic disorder
a
23 9 (39) 14 (61)
Two or more causal comorbidities 7 4 (57) 3 (43)
Unknown prenatal/(perinatal) lesion 13 6 (46) 7 (54)
Unknown prenatal 23 14 (61) 9 (39)
Perinatal 59 32 (54) 27 (46)
Hypoxic-ischemic insult: birth injury 21 11 (52) 10 (48)
Neonatal hypoglycemia (tested or not tested) 28 19 (68) 9 (32)
Early infection 10 2 (20) 8 (80)
Postnatal 18 9 (50) 9 (50)
Infection 12 4 (33) 8 (67)
Intracranial hemorrhage, anoxia due to aspiration 5 4 (80) 1 (20)
Brain tumor 1 1 0
Cryptogenic 26 22 (85) 4 (15)
Total 207 105 (51) 102 (49)
a
Includes deceased participants with inborn error of metabolism NAS (n =4); PEHO (progressive encephalopathy with edema, hypsarrhythmia, and optic atro-
phy) (n =2); Cornelia de Lange syndrome (n =2); progressive encephalopathy of unknown origin (n =2); progressive mitochondrial encephalopathy (n =1);
Prader-Willi syndrome (n =1); chromosomal anomaly with excessive marker chromosome (n =1); nonketotic hypergl ycinemia (n =1).
Epilepsia Open, **(*):1–6, 2016
doi: 10.1002/epi4.12008
4
M. Sillanp€
a€
a et al.

population cohort of 688 10-year-old children with infantile
spasms and Lennox-Gastaut syndrome.
15
In our study, mental and neurologic disability following
congenital structural brain malformations, anomalies, infec-
tions, and genetic disorders strongly contributed to prema-
ture mortality in line with previous reports.
1,14,16–18
During
12-year follow-up of 120 Swedish children with epilepsy,
11 participants died, 8 (73%) of whom had “neurodeficit,”
that is, mental retardation and cerebral palsy, and none of
them were in remission.
16
According to a Dutch study, 9
(2%) of 472 children died during follow-up of 5 years or
until death. All 9 participants had symptomatic epilepsy.
17
During 4,733 person-years of follow-up, 13 of 613 children
with newly diagnosed epilepsy died. Ten of 13 deaths (77%)
were associated with underlying cause of the seizures, and
both symptomatic etiology and epileptic encephalopathy
were independently associated with mortality.
18
Among
2,239 participants followed for more than 300,000 person-
years, mortality was significantly higher in those with com-
plicated epilepsy, whereas participants with uncomplicated
epilepsy had no significant excess mortality compared with
the general population.
1
In a Finnish population study of
245 followed for 40 years,
14
60 participants died. Of them,
45 (75%) had symptomatic etiology and mental and/or neu-
rologic disability (IQ <50 in 39 and ≥50 in 6, and an addi-
tional cerebral palsy in 24).
In the vast majority of cases (83%), the immediate cause
of death was unrelated to epilepsy, with pneumonia as the
most frequent known cause of death. All patients who died
of pneumonia had symptomatic West syndrome. Our per-
centage of deaths due to pneumonia (47%) is well compara-
ble with 50% of Berg et al.
1
Most of those patients were bedridden and helpless
owing to severe mental retardation, spastic tetraplegia,
Table 3. Immediate cause of death among 102 patients with West syndrome related to symptomatic etiology of
epilepsy
Cause of death All
a
Autopsied
Etiology
Prenatal Perinatal Postnatal
Death related to epilepsy 17
SUDEP 10 9 (90) 6 (60) 2 (20) 2 (20)
Epileptic seizure
b
7 4 (57) 5 (71) 1 (14) 1 (14)
Death not related to epilepsy 85
a
Pneumonia 47 34 (72) 29 (62) 16 (34) 2 (4)
Other infection 9 7 (78) 5 (56) 4 (44) 0
Aspiration 5 3 5 0 0
Vascular 5 3 4 1 0
Cancer 3 2 2 0 1
Other 12 10 6 3 3
Total 102
a
74 62 27 9
SUDEP, sudden unexplained death in epilepsy.
a
Includes 4 patients with cryptogenic etiology who died of infection other than pneumonia (1), cancer (1), or other cause of death (2).
b
Includes 4 cases of status epilepticus, 2 eye-witnessed cases of seizures of <30 min, and 1 likely case of seizure.
Table 4. Proportions of dead and mean survival times in 207 patients with West syndrome. Hazard ratios from Cox
regression models, calculated for symptomatic versus cryptogenic etiology, male versus female sex, and not treated
versus treated with ACTH
Characteristic
Total Dead
Median survival time,
years
Cox regression
Univariate Multivariate
N N (%) Med 95% CI HR 95% CI HR 95% CI
All 207 102 (49) 48.6 38.5–NA –– ––
Etiology*
Symptomatic 181 98 (54) 40.4 31.3–51.5 4.7 1.8–12.9 4.6 1.7–12.6
Cryptogenic 26 4 (15) NA 50.6–NA
Sex
Male 126 65 (52) 43.2 30.3–NA 1.2 0.8–1.8 1.2 0.8–1.8
Female 81 37 (46) 50.6 38.8–NA
ACTH treatment
No 46 28 (61) 27.7 16.8–50.4 1.5 1.0–2.3 1.4 0.9–2.2
Yes 161 74 (46) 50.6 40.3–NA
ACTH, adrenocorticotropic hormone; CI, confidence interval; HR, hazard ratio; Med, median.
*
p=0.002 in univariate analysis, and p =0.003 in multivariate analysis.
Epilepsia Open, **(*):1–6, 2016
doi: 10.1002/epi4.12008
5
Long-Term Mortality in West Syndrome

kyphoscoliosis, and tube feeding. Epilepsy or seizure-
related death, including SUDEP, was uncommon and noted
in a minority (17%) of patients. SUDEP was found in 10%
of all deceased participants or 2% of those who died before
age 16. Much lower percentages of SUDEP of all deaths
(<1%) have been presented.
1,19
The wide variation is proba-
bly a consequence of different definitions, inclusion criteria,
and duration of follow-up; the longer the follow-up of child-
hood-onset epilepsy, the higher the probability of SUDEPs.
Our study with substantially longer follow-up of childhood-
onset epilepsy supports previously reported percentages of
12–38%.
20,21
There is an ongoing debate about whether
SUDEP may occur despite seizure remission. In a long-term
followed population study,
14
18 died of SUDEP. Seven
(39%) of the 18 patients were in 1-year remission (unpub-
lished data) and among 11 (61%), seizures were “unlikely”
or “none witnessed”at death.
14
Among children, nearly all
of the mortality is related to an underlying neurologic disor-
der, not the seizures.
22
All but one of our cases of SUDEP
(90%) had an underlying neurologic disorder, but none of
our cases of SUDEP had witnessed seizures at death. In a
long-term followed study with 60 deaths of 245 participants
with childhood-onset epilepsy,
14
10 (43%) of SUDEPs
deceased without witnessed seizures at death. In conclusion,
the increased rate of death seen in our study of patients with
West syndrome was substantial and persisted into adult-
hood, dispelling the notion that the risk of death is largely
limited to childhood or early adulthood.
Although our study is useful because of the very long fol-
low-up of 50 years and a high autopsy rate of over 70%,
limitations exist. We could not assess the role of seizure
remission and the effect of drug treatment of West syn-
drome on mortality. Studies in the literature have shown in
general that seizure remission is lowering the risk of death
in childhood epilepsy.
23
Finally, our study does contribute
insight on how to prevent death in West syndrome in the
future. The highest mortality risk for people with West syn-
drome is developing pneumonia. Future efforts to lower the
mortality risk need to embrace measures to prevent pneu-
monia or to treat it more effectively, although entering sei-
zure remission will probably reduce the death rate as in any
childhood epilepsy syndrome.
In addition to prevention of pneumonia, epilepsy preven-
tion is an important public health issue.
24
Measures to
improve prevention of epilepsy need to include earlier con-
sideration of epilepsy surgery; better adherence to medica-
tion, possibly with increased nocturnal supervision and
more vigorous interaction of the patient postictally; earlier
use of rescue mediation; formal status protocols; and educa-
tion regarding proper positioning during a seizure. Like-
wise, drowning is a rare cause of seizure-related death,
14
and it is preventable, and persons with epilepsy should be
advised to shower rather than to bathe and should be closely
supervised when swimming or around water.
Disclosure
None of the authors has any conflict of interest to disclose. We confirm
that we have read the Journal’s position on issues involved in ethical publi-
cation and affirm that this report is consistent with those guidelines.
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