Background: Sudden neurological death (SND) remains underdiagnosed compared with sudden cardiac death. In Tunisia, cerebrovascular diseases ranked second among the leading causes of death in 2020. This study aimed to describe the epidemiological and post-mortem characteristics of SND in the Sousse region and to analyse its aetiological distribution.

Methods: We conducted a retrospective descriptive study of all medico-legal post-mortem examinations performed for SND at the Department of Forensic Medicine, Farhat Hached University Hospital, Sousse, Tunisia, over a 21-year period (January 2002 to December 2022). Statistical analyses were performed using SPSS version 25.0. Chi-square tests were used to assess associations between categorical variables. Statistical significance was set at p < 0.05.

Results: A total of 106 cases of SND were identified, accounting for 1.3% of all medico-legal post-mortem examinations and 11.1% of all sudden deaths. The mean age was 48.44 ± 22.82 years, with a male predominance (male-to-female ratio, 1.46). Haemorrhagic stroke predominated (66.0%), with spontaneous meningeal haemorrhage (32.0%) and aneurysmal rupture (13.2%) being the most frequent subtypes. Cardiovascular risk factors were significantly associated with a vascular cause of death (p = 0.009). A significant circadian peak was observed between 12:00 and 18:00 (p = 0.030). Haemorrhagic stroke was significantly more frequent than ischaemic stroke (p = 0.011). The distribution of brain tumours differed significantly across age groups (p = 0.045).

Conclusion: This first Tunisian autopsy-based series dedicated to SND highlights the predominance of vascular causes. The significant association between cardiovascular risk factors and vascular aetiology underscores the importance of primary prevention. Standardised autopsy protocols, including systematic histopathological and toxicological investigations, are essential to improve diagnostic accuracy.