Ictal Asystole and Ictal Syncope

Abstract

Background Ictal asystole is a rare, serious, and often treatable cause of syncope. There are currently limited data to guide management. Characterization of ictal syncope predictors may aid in the selection of high-risk patients for treatments such as pacemakers. Methods and Results We searched our epilepsy monitoring unit database from October 2003 through July 2013 for all patients with ictal asystole events. Clinical, EEG, and ECG data for each of their seizures were examined for their relationships with ictal syncope events. In 10 patients with ictal asystole, we observed 76 clinical seizures with 26 ictal asystole episodes, 15 of which led to syncope. No seizure with asystole duration ≤6 seconds led to syncope, while 94% (15/16) of seizures with asystole duration >6 seconds led to syncope (P=0.02). During ictal asystole events, 4 patients had left temporal seizure onset, 4 patients had right temporal seizure onset, and 2 patients had both. Syncope was more common with left temporal (40%) than right temporal seizures (10%; P=0.002). Treatment options included anti-epileptic drug changes, epilepsy surgery, and/or pacemaker implantation. Eight patients received pacemakers. During follow-up of 72±95 months, all patients remained syncope-free. Conclusions Ictal asystole >6 seconds is strongly associated with ictal syncope. Ictal syncope is more common in left than right temporal seizures. A permanent pacemaker should be considered in patients with ictal syncope if they are not considered good candidates for epilepsy surgery.

Ictal asystole with isolated syncope: A case report and literature review

“…The association of ictal syncope with cardiac arrhythmia was recognized a decade ago following a report of sudden falls in three patients with drug-resistant epilepsy at the time of presurgical evaluation including both video-EEG and cardiac monitoring [18] . Subsequently, large retrospective studies confirmed that ictal asystole occurs in 0.002% - 0.4% of all monitored patients [7] , [19] , [20] , [21] and when prolonged, may cause syncope [7] , [21] . In these studies, the constellation of sudden atonia and the corresponding slowing or attenuation of the background EEG rhythm was strongly associated with prolonged cardiac arrest [7] , [20] , [22] .…”

Recurrence risk of ictal asystole in epilepsy

“…Second, we included studies with different definitions of IA or studies that lacked one ( table 1 ). 2 – 4 , 6 , 16 Because information on the duration of IA was missing, we could not verify in all reported IA which definition was used. However, the summary data showed that most IA lasted longer than 4 seconds and thus met all definition criteria for IA ( table 2 and figure 3B ).…”

Keeping pace: A 38-second ictal asystole revealed during simultaneous electroencephalogram and electrocardiogram monitoring

“…Other small retrospective studies have shown that in patients who received a pacemaker, there was no recurrence of syncope despite seizure recurrence. 12 …”

“… 14 Studies have demonstrated that appropriate control of epileptic seizures prevents ictal asystole; however, cardiac implantation may be a management option for those who have refractory or uncontrolled epilepsy. 11 , 12 We chose to implant a pacemaker, as the patient continued to have medication-refractory epilepsy despite trials of multiple antiepileptics. Furthermore, the longest period of asystole occurred when the patient was asleep and could not report any symptoms.…”