Abstracts

Rationale: Patients admitted to Epilepsy Monitoring Units (EMUs) for diagnosis of paroxysmal spells are often diagnosed with physiologic events instead. Many studies describe cardiac abnormalities secondary to epileptic seizures, but only one published case study to our knowledge describes a case of cardiac asystole masquerading as seizures.   Methods: We present a case series of six patients who underwent prolonged video electroencephalogram (EEG) monitoring for spells and were found to have primary cardiac asystole based on concurrent electrocardiogram (ECG). Results: 1A 57 year old woman was admitted for evaluation of spells present since age five. During monitoring, she had a typical event of left facial twitching, then several minutes of unresponsiveness. She regained consciousness with brief myoclonic activity. During the event, the ECG showed 37 seconds of asystole, while the EEG slowed, becoming suppressed for 30 seconds. The patient underwent pacemaker insertion and was spell-free five months later.2A 69 year old man with a history of syncope was admitted for evaluation of new musicogenic spells. Twice, music had resulted in accidents while driving. During monitoring, the patient had a music-induced event, involving unresponsiveness and apnea for 32 seconds, followed by generalized myoclonus. There was one minute of postictal confusion. During the event, the ECG showed 27 seconds of asystole, while the EEG showed diffuse suppression. The patient underwent pacemaker placement. Postoperatively, he enjoyed music without spells.3An 85 year old man was admitted after having multiple spells in a day, each with postictal memory impairment. During monitoring, his convulsive events were associated with up to 40 seconds of asystole and associated EEG slowing then suppression. He underwent a cardiac pacemaker and did not return for follow up.4A 42 year old woman with a history of neonatal anoxia, traumatic brain injury, and parahippocampal glioma was admitted with various spell types. After IV placement, she had 3 minutes of unresponsiveness followed by a myoclonic jerk. She remained minimally interactive and slept for several hours. During the event, the ECG showed 71 seconds of asystole followed by return of an irregular heart rhythm. The EEG was attenuated, which gradually returned to normal. She underwent pacemaker placement, followed by a psychogenic event.5A 25 year old male gunshot wound victim was being treated for a T2 spinal cord injury and paroxysmal spells. He developed sinus pauses of up to 5 seconds on cardiac monitoring, which increased in duration, eventually with brief generalized tonic clonic activity. He underwent placement of a temporary transvenous pacemaker. His need for pacing gradually improved, and the pacemaker was removed before discharge.6A 19 year old man with spells of loss of consciousness was admitted after he had a spell that caused a motor vehicle accident resulting in a subdural hematoma and one witnessed seizure. Two events were captured during monitoring. He became limp and lost consciousness with quick return to baseline. Each event was associated with 10 seconds of asystole, while the EEG showed diffuse slowing. Conclusions: Most centers utilize continuous single-channel ECG monitoring, but this modality often is insufficient for prompt response and for differentiating between various arrhythmias.Given the possible fatality associated with cardiac events such as asystole, it is surprising that continuous cardiac telemetry (CCT) is not more commonly utilized in EMUs nationwide. We recommend that EMUs employ the use of CCT on all patients. Funding: none