Abstracts

Rationale: Epileptic seizures can affect the heart rate leading to arrhythmia. The most common arrhythmia associated with epilepsy is ictal tachycardia (~80% of all seizures). Ictal bradycardia occurs in fewer than 6% of seizures. Ictal asystole is a rare phenomenon, which is defined as the absence of ventricular complexes for more than 4 s, accompanied by electrographic seizure onset. Ictal asystole is found in 0.27–0.4% of patients undergoing video-EEG. Its occurrence may complicate the clinical presentation or delay diagnosis, and it is a life-threatening complication of epilepsy, with increased risk of sudden unexpected death in epilepsy (SUDEP).

Methods: We report a case of a 33-year-old male person with epilepsy who suffered ictal asystole. Clinical presentation, brain imaging, EEG data, and treatment outcome were analyzed.

Results: 33-year-old right-handed man with history of seizures (staring spells) since childhood. He started to experience different types of seizures for about 2 years, described as tonic and atonic seizures (drop attack). During one of his atonic seizure, he fell backwards and hit head which resulted in a traumatic brain injury—left subdural hematoma and skull fracture. During another event, he was found pulseless cardiac arrest. Thorough workup did not reveal cardiac etiology. He was vEEG monitored. During one of his typical events, the patient was noted behavioral frozen and starring; then he was noted hand fussing/finger. His body was then noted dropped back to bed, and head turning to left with mild limb non-rhythmic shaking. He lost consciousness followed with body myoclonus jerking. Reviewing EEG, at the onset of the event, diffuse irregular delta slow was note. Such diffuse slow persisting till the patient was note HR asystole for 13 seconds. EEG showed diffuse low voltage attenuation when asystole. The patient had another few events when bradycardia, and HR pauses for a few seconds. The onset of bradycardia and HR pauses were noted about 20 seconds after the clinical onsets. Based on such observation, the patient underwent emergent pacemaker implantation. While remonitoring, temporal onset seizures were recorded. The EKG RR interval was analyzed, and the RR prolongation noted ~20 seconds after the seizure onset. The patient was followed for two years thereafter, no recurrent tonic or atonic seizure.

Conclusions: Epileptic seizures can present with cardiac arrhythmias. Ictal bradycardia and asystole may lead to falling and/or sudden unexpected death. Simultaneous EEG and ECG are essential for the diagnosis. A cardiac pacemaker can be lifesaving for such patients, as it can decrease the morbidity and probably the mortality.

Funding: Please list any funding that was received in support of this abstract.: none.