Ictal bradycardia and atrioventricular block: a cardiac manifestation of epilepsy

Abstract

We describe a case of a patient with recurrent syncopal episodes that ultimately was discovered to be due to ictal bradycardia caused by temporal lobe epilepsy. A diagnostic dilemma was presented by a 55-year-old male who had recurrent syncopal events despite having an atrial pacemaker. The patient was noted to have automatisms and was diagnosed via electrocardiogram/electroencephalogram (EEG/ECG) co-registration to have ictal bradycardia and atrioventricular (AV) block leading to syncope. He was successfully managed with seizure control with the use of levetiracetam. Ictal bradycardia and AV block are uncommon manifestations of epilepsy and can progress to complete heart block and asystole. Diagnosis is best performed with simultaneous ECG and EEG recordings. Definitive management is seizure control with the use of antiepileptic drugs, with the question of pacemaker placement still up for debate.

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

“…As noted above, ictal semiology provided by witnesses before referral to an EMU in all patients was consistent with isolated ictal syncope and absent epileptic auras or other prodromal clinical symptoms [11] , [12] , [13] , [14] , [15] , [16] , [17] . Patients' postictal symptoms included variable confusion, weakness, chest pain, decreased responsiveness, nausea or vomiting, diaphoresis, and visual disturbances [11] , [12] , [13] , [14] , [15] , [16] , [17] . Three patients had been receiving anti-seizure drugs prior to referral for diagnostic EEG.…”

“…Twenty-three patients met the inclusion criteria of having seizures with asystole and syncope accompanied by various abnormal movements (7 patients) or experiencing prodromal sensations (16 patients). Eight patients had recurrent isolated loss of consciousness and falls prior to the admission for continuous EEG [11] , [12] , [13] , [14] , [15] , [16] , [17] . The ictal semiology of isolated ictal asystole-syncope was reproduced in 4 patients during the recording of seizures in the EMU [13] , [14] .…”

“…With the focus on isolated ictal syncope, we identified reports involving 8 patients with syncope who failed to demonstrate any typical seizure signs during the habitual spells prior to admission for EEG monitoring. Those included 4 patients who later had confirmed isolated ictal asystole-syncope during video-EEG monitoring [12] , [13] , [14] and 4 patients who demonstrated other semiological signs consistent with temporal lobe seizures [11] , [12] , [13] , [14] , [15] , [16] , [17] . The average duration of asystole in the patients identified in the present review was 15 s which was strongly associated with syncope in previous studies [20] .…”

Ictal heart rate changes and the effects of vagus nerve stimulation for patients with refractory epilepsy

“…Findings from previous research support the idea that epileptic stimulation may affect the heart via direct neural pathways. 13 Analysis of TRE etiology shows that patients with neuronal migration disorders tend to have a poorer response to VNS (mean reduction: 44.5%) compared to patients with other etiologies. 1 Importantly, decreased efficacy has not been noted in patients with IT, an indication that IT can potentially be detected prior to the EEG and onset of the clinical seizure.…”

“…These manifestations include changes in HRV, IT, IB, atrioventricular block, and asystole. 13 The latest research has shown that patients with IT during seizures demonstrate good responses to VNS therapy, 9 – 11 yet, its mechanism of action in treating epileptic seizures remains unclear.…”