Ictal asystole – Late manifestation of partial epilepsy and importance of cardiac pacemaker

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Zubair S, Arshad AB, Saeed B, Luqman S, and Oommen KJ (2009) Ictal asystole – Late manifestation of partial epilepsy and importance of cardiac pacemaker. Seizure 18:6 457–61.

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Abstract: Ictal asystole (IA) is a life-threatening complication of epilepsy and is a potential mechanism of sudden unexplained death in epilepsy (SUDEP). This entity has been proven by multiple case reports and small case series. The management of the patients with IA is still in early phase of discussion. We report a patient with medically intractable cryptogenic partial epilepsy for 27 years who presented with new onset drop attacks. During the epilepsy monitoring unit stay he was found to have a left fronto-temporal partial onset seizures which triggered brady-arrhythmia followed by asystole for 20s. A cardiac pacemaker was implanted and the patient was followed for 2 years. He continued to have simple and complex partial seizures but did not have drop attacks anymore. He still occasionally feels the activation of his pacemaker during simple partial phase of his seizures but the characteristic loss of muscle tone never happened again which made him highly satisfied. Our case demonstrates that IA can even happen decades after the onset of epilepsy. Cardiac pacemaker should be considered in all patients with IA as it prevents ictal falls and possibly SUDEP.

Keywords: Ictal asystole, Temporal lobe seizures, Cardiac pacemaker

Context

  • Single-case report of patient with new-onset interictal asystole after a long history of epilepsy. As in the case reported by Strzelczyk et al. (2008), implantation of a cardiac pacemaker prevented further drop attacks. The seizures, which preceded bradyarrhythmia and asystole, originated from a focus in the left fronto-temporal region. In monitoring simultaneous EEG and EKG from 81 patients, Zijlmans et al. (2011) report a single instance of asystole, which lasted 30 seconds.

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