Cardiac asystole in epilepsy: Clinical and neurophysiologic features

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Rocamora R, Kurthen M, Lickfett L, Von Oertzen J, and Elger CE (2003) Cardiac asystole in epilepsy: Clinical and neurophysiologic features. Epilepsia 44:2 179–85.

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Abstract: PURPOSE: Cardiac asystole provoked by epileptic seizures is a rare but important complication in epilepsy and is supposed to be relevant to the pathogenesis of sudden unexplained death in epilepsy (SUDEP). We sought to determine the frequency of this complication in a population of patients with medically intractable epilepsy and to analyze the correlation between EEG, electrocardiogram (ECG), and clinical features obtained from long-term video-EEG monitoring. METHODS: Retrospective analysis of the clinical records of hospitalized patients from May 1992 to June 2001 who underwent long-term video-/EEG monitoring. RESULTS: Of a total of 1,244 patients, five patients had cardiac asystole in the course of ictal events. In these patients, 11 asystolic events, between 4 and 60 s long in a total of 19 seizures, were registered. All seizures had a focal origin with simple partial seizures (n = 13), complex partial seizures (n = 4), and secondarily generalized seizures (n = 2). One patient showed the longest asystole ever reported (60 s) because of a seizure. Cardiac asystole occurred in two patients with left-sided temporal lobe epilepsy (TLE) and in three patients with frontal lobe epilepsy (FLE; two left-sided, one bifrontal). Two patients reported previous cardiac disease, but only one had a pathologic ECG by the time of admission. Two patients had a simultaneous central ictal apnea during the asystole. None of the patients had ongoing deficits due to the asystole. CONCLUSIONS: These findings confirm that seizure-induced asystole is a rare complication. The event appeared only in focal epilepsies (frontal and temporal) with a lateralization to the left side. A newly diagnosed or known cardiac disorder could be a risk factor for ictal asystole. Abnormally long postictal periods with altered consciousness might point to reduced cerebral perfusion during the event because of ictal asystole. Central ictal apnea could be a frequent associated phenomenon.

Keywords: ECG, EEG, Asystole

Context

  • Retrospective study of data from EEG video monitoring unit over 10 year period. Among > 1,200 patients, 5 were found to have ictal asystole, with asystole lasting up to 60 s. Simple partial, complex partial, and secondarily generalized seizures were all seen in conjunction with asystole. Two patients also had central apnea during asystole. Two patients had temporal lobe epilepsy and 3 had frontal lobe epilepsy; of these, 4 were lateralized to the left. All 5 patients were taking AED (1 to 4 medications). 2 patients had histories of cardiac disease. 4 of the 5 EKG abnormalities were bradycardia, and asystole began 5-100 s after seizure onset. 2 patients also experienced respiratory difficulties, and one who remained conscious described his inability to breathe. The authors point out in the discussion that epileptiform activity on EEG preceded asystole in all of the cases they describe, but in cases where the differential diagnosis includes ictal arrhythmia and convulsive syncope, the latter is “never” accompanied by ictal activity on EEG, a fact that may facilitate diagnosis in some cases.

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