Utilizing multimodal imaging to visualize potential mechanism for sudden death in epilepsy

•Multichannel recording platform allows simultaneous fast MRI scans and electrophysiology.•Multimodal data visualize esophageal reflux and cardio-respiratory changes.•Acid reflux can instigate laryngospasm, obstructive apnea, and sudden death in seizing animals.•Fatal cardio-respiratory distress initiates only after gastric acid reach larynx.•Results reveal potential mechanism for SUDEP in humans. Sudden death in epilepsy or SUDEP is a fatal condition that accounts for more than 4000 deaths each year. Limited clinical and preclinical data on sudden death suggest critical contributions from autonomic, cardiac, and respiratory pathways. A potential mechanism for such sudden and severe cardiorespiratory dysregulation may be linked to acid reflux-induced laryngospasm. Here, we expand on our previous investigations and utilize a novel multimodal approach to provide visual evidence of acid reflux-initiated cardiorespiratory distress and subsequent sudden death in seizing rats. We used systemic kainic acid to acutely induce seizure activity in Long Evans rats, under urethane anesthesia. We recorded electroencephalography (EEG), electrocardiography (ECG), chest plethysmography, and esophageal pH signals through a multimodal recording platform, during simultaneous fast MRI scans of the rat stomach and esophagus. MRI images, in correlation with electrophysiology data were used to identify seizure progression, stomach acid movement up the esophagus, cardiorespiratory changes, and sudden death. In all cases of sudden death, esophageal pH recordings alongside MRI images visualized stomach acid movement up the esophagus. Severe cardiac (ST segment elevation), respiratory (intermittent apnea) and brain activity (EEG narrowing due to hypoxia) changes were observed only after acid reached larynx, which strongly suggested onset of laryngospasm following acid reflux. The complementary information coming from electrophysiology and fast MRI scans provided insight into the mechanism of esophageal reflux, laryngospasm, obstructive apnea, and subsequent sudden death in seizing animals. The results carry clinical significance as it outlines a potential mechanism that may be relevant to SUDEP in humans.