Ictal Asystole During Focal Impaired Awareness Seizures: A Case Report
Abstract number :
3.167
Submission category :
18. Case Studies
Year :
2024
Submission ID :
323
Source :
www.aesnet.org
Presentation date :
12/9/2024 12:00:00 AM
Published date :
Authors :
Presenting Author: Loren Marino, BS – University of Virginia School of Medicine
Sonia Gill, MD – Inova Fairfax Hospital, Department of Neurology
Peter Sumner, DO – Inova Fairfax Hospital, Department of Neurology
Rationale: Ictal asystole is a relatively rare occurrence and refers to an RR interval of over 3 seconds recorded on ECG during a seizure. It is more strongly associated with temporal lobe onset seizures, and in adults with long-standing epilepsy. Implanted pacemakers have been recommended to reduce the risk of falls and trauma associated with ictal asystole and resulting syncope. However, recommendations for concurrent optimal medical management of these seizures are still lacking, given that some antiseizure medications can promote arrhythmias, including bradyarrhythmias, and the role of underlying bradycardia in ictal asystole is unclear.
Methods: We present a case report of a 45 year-old man with a history of bradycardia, presenting with a new onset of focal impaired awareness seizures with secondary generalization. He was admitted for video EEG monitoring and neuroimaging to further characterize his seizures and determine appropriate medical management.
Results: During EEG monitoring, the patient was found to have three seizures originating in the left anterior to mid temporal lobe. Two were followed by periods of EEG attenuation that corresponded with prolonged pauses on ECG, followed by secondary generalization. Echocardiogram at that time was unremarkable. He was initially treated with levetiracetam, with three breakthrough seizures. Lacosamide was then added, with one breakthrough seizure. The patient subsequently had a leadless pacemaker placed, as his loop recorder continued to show continuous bradycardia with pauses of 5-10 seconds. Since pacemaker placement, he continues to have asymptomatic bradycardia and remains seizure free thus far.
Conclusions: Ictal asystole has been managed thus far with antiepileptic medications and pacemakers to minimize morbidity. In terms of the significance of these findings, this case report demonstrates that patients with ictal asystole require close monitoring with both neurology and cardiology, and that guidelines for optimal medical management after pacemaker placement are needed to reduce seizure recurrence without exacerbating the risk of asystole.
Funding: No funding received.
Case Studies