Seizures, Takotsubo syndrome, and sudden unexpected death in epilepsy: A still puzzling triangle

I immensely enjoyed the contribution by Finsterer and Bersano [1], published in the September 2015 issue of the Journal, about seizures, Takotsubo syndrome (TTS), and sudden unexpected death in epilepsy (SUDEP). The authors carried out a review of the heretofore reported cases of TTS triggered by seizures, with particular intension of evaluating fatal outcome. Among the reported 74 patients (86% female) with seizure-triggered TTS, only 2 (3%) died. Seizures experienced by these patients included generalized tonic clonic seizures, generalized status epilepticus, and complex partial seizures, and the underlying plausible cause of the seizures was noted. The authors concluded that ‘‘fatalities are rare in patients experiencing seizure-triggered TTS’’, and that ‘‘seizure-triggered TTS does not seem to play a major role in the pathogenesis of SUDEP’’ [1]. I shall appreciate the response of the authors on the following: (1) Since seizures, after subarachnoid hemorrhage, are the most common central nervous system triggering TTS, is it possible that we are missing milder, atypical, subclinical forms of TTS? [2,3]. (2) It is conceivable that such milder forms of seizure-triggered TTS, that do not result in hospitalization, after control of the seizures, leave behind some electrocardiographic hallmarks, which could be detected by ‘‘smartphone’’-based technology monitoring, carried out by the patients themselves, or their relatives and other caregivers [3,4]. (3) How do we know that all or many of the victims of unexplainable SUDEP, had not suffered a seizure-triggering TTS, that led to an immediate or early demise, due to a ventricular arrhythmia (monomorphic or polymorphic ventricular tachycardria, degenerating in ventricular