Sîrbu Journal of Medical Case Reports 2011, 5:441 http://www.jmedicalcasereports.com/content/5/1/441 that a morphopathological examination would have helped to confirm the diagnosis, although this may sometimes be irrelevant. Treatment for DNT is surgical resection; however, there is no cohort of untreated control patients. The relationship of DNT to the epileptogenic foci can be determined by extensive interictal and ictal EEG record- ings. Noninvasive recording and careful mapping show that a structural lesion is not the source of epileptic activity. There is little correlation between the lesion site and epileptogenic foci of the ictal onset zone as well as the irritative zone. Seizure control after surgery is good with 80-90% seizure free. Other authors show that seizure outcome is not always favorable. Although the majority of children remain seizure free after surgical excision of DNTs, a considerable number have recurrent seizures. Short-term outcome is influenced by older age at surgery and longer duration of epilepsy. Residual tumor is a significant risk factor for poor seizure out- come [5]. DNTs have a benign course, but there are some reports with malignant transformation. Our patient was found by her mother in a prone position at the time of death. At the time she was on topiramate 400 mg/day in two divided doses, without seizure con- trol. Our patient meets the criteria used in most SUDEP studies: she had recurrent unprovoked seizures, died unexpectedly and suddenly while in a reasonable state of health, during normal and benign circumstances, and the death was not the direct result of a seizure or status epilepticus. The probable SUDEP is given because of lack of autopsy. In 60% of cases, the event was related to sleep, which might indicate involvement of a sleep- related event. Our patient was not assessed for any sleep disorders which may predispose to SUDEP. The seizures are known to cause central apnea by direct propagation of the electrical discharge to the respiratory center. Cardiac dysrhythmias during the interictal state is another potentially fatal condition because of chronic autonomic dysfunction, effects of antiepileptic medication and a common genetic suscept- ibility [6,7]. Asystole might underlie many of the deaths. Clinical characteristics of patients with periictal cardiac abnormalities are very similar to those at greatest risk of SUDEP. Cardiac arrest can cause secondary cardiopul- monary arrest [8]. Asphyxiation secondary to an obstructive cause has been postulated to play a role in the deaths of patients who were found in a prone posi- tion at the time of death [9]. Human and animal data suggest that specific genetic factors might play a role in some cases. Serotonin might affect respiratory mechan- isms and may be involved [10]. Prolonged postictal gen- eralized electroencephalographic suppression, greater than 50 seconds, appears to identify refractory epilepsy patients who are at risk of SUDEP [11]. There are some Page 4 of 5 data suggesting that having an extratemporal focus or lesion is the main correlate of SUDEP [12]. Our patient presented several risk factors: generalized seizures, lower age of onset of seizures, duration of sei- zures longer than 10 years, age between 20 and 40 years and a poorly controlled disorder. SUDEP incidence rates vary from 0.35 per 1000 person-years of follow-up in population based studies to 9.3 per 1000 person-years in patients with refractory epilepsy [13]. Estimated SUDEP rates in patients receiving the new anticonvulsant drugs lamotrigine, gabapentin, topiramate, tiagabine, and zoni- samide were found to be similar to those in patients receiving standard anticonvulsant drugs, suggesting that SUDEP rates reflect population rates and not a specific drug effect. The Food and Drug Administration require warning labels on the risk of SUDEP in association with the use of each of the above-mentioned drugs [14]. Elimination of seizures after surgery reduces mortality rates in individuals with epilepsy to a level indistinguish- able from that of the general population [15]. The pub- lished National Institute for Clinical Excellence guidelines state that “individuals with epilepsy and their families and/or carers should be given and have access to information on SUDEP”. Conclusion DNTs are now known to be more frequent in children and young adults than was previously believed. Early and complete surgery, with functional studies before and during the surgery, leads to a good control of sei- zures, avoiding complications such as hemorrhage, malignant transformation and neuropsychological changes, as in our case. Unfortunately, all the studies, (especially the case series) published so far mention only the medium term seizure control but do not refer to the neurological disabilities caused by the surgery. Patients with refractory epilepsy should have complete sleep dis- order and cardiology assessments including electrocar- diogram evaluation of cardiac rhythm disturbances, which could be performed at the same time as the EEG. Consent Written informed consent for publication from the patient¹s next of kin could not be obtained despite all reasonable attempts. The case is important to public health and every effort has been made to protect the identity of our patient. There is no reason to believe that our patient’s next of kin would object to publication. Acknowledgements I would like to thank all those who helped me investigate the case: Professor Dumitru Constantin, MD, PhD; psychologist Diana Bălan from the Clinic of Neurology, Professor Ioan Codorean, MD, PhD; Maria Gălăman, MD;