Management and long-term outcome in patients presenting with ictal asystole or bradycardia

Abstract

Summary Purpose: Ictal asystole (IA) and ictal bradycardia (IB) are rare autonomic symptoms during epileptic seizures and may be potentially life‐threatening. Guidelines for the care of these patients are missing. The aim of this multicenter study was to evaluate the management and long‐term outcome in patients with IA and IB. Patients and Methods: All patients with IA and IB were included from four epilepsy centers (Bielefeld, Kork, Marburg, and Zürich) from 2002 until 2009. Using a standardized assessment form, clinical data, treatment decisions, and outcomes were extracted from patient charts and simultaneous electroencephalography/electrocardiography (EEG/ECG) recordings. Key Findings: Seizures with IA or IB were identified in 16 patients. In all patients an associated temporal seizure pattern was recorded and in 15 patients, sudden falls, fainting, or trauma was previously reported or recorded during the monitoring. In three patients (18.8%) diagnosis of focal epilepsy was newly established and anticonvulsive treatment was initiated. Two patients with refractory epilepsy underwent epilepsy surgery. In seven patients (43.8%) a cardiac pacemaker was implanted. In 14 of 16 treated patients, seizure freedom (n = 5) or absence of sudden falls, fainting, or trauma (n = 9) could be achieved. Two patients denied epilepsy surgery as well as a pacemaker and continue to have frequent falls and trauma. Significance: Our study demonstrates that epilepsy surgery and antiepileptic drugs may lead to sustained freedom of seizures as well as ictal syncope. In drug‐resistant patients not suitable for epilepsy surgery, implantation of a cardiac pacemaker may prevent sudden falls as well as trauma. Based on our results and previously reported cases we propose a treatment algorithm.

Ictal Asystole and Ictal Syncope

“…Four large retrospective studies in EEG/ECG-monitored epilepsy patients have similarly found the prevalence of ictal asystole to be 0.25%–0.40% in over 11,000 epilepsy patients, although these retrospective analyses likely underestimate the true prevalence. 5–8 Longer term monitoring may lead to increased detection of ictal asystole. In a study of 19 patients with refractory partial seizures who underwent ILR implantation, 7 had ictal bradyarrhythmia.…”

Cardiac arrhythmias during or after epileptic seizures

“…11 If this fails and there is documented recurrence of asystolic episodes, cardiac pacemaker implantation should be considered. Observational studies suggest that pacemakers can reduce falls and injuries due to seizure-induced syncope.…”

“…5 6 The mean prevalence of ictal asystole in all people with refractory focal epilepsy admitted for a vEEG recording was 0.318% (95% CI 0.316% to 0.320%). [7][8][9][10][11] Ictal asystole was only reported in people with focal epilepsy (table 1). Most of the ictal asystoles occurred during the course of a focal dyscognitive seizure (formally known as a complex partial seizure), on average starting 30 s after seizure onset.…”

Pearls & Oy-sters: Ictal syncope in a patient with temporal lobe epilepsy

“…2,3 However, ictal bradycardia (IB) and IA are rare occurrences, with IA reportedly occurring in 0.27%-0.4% of monitored epilepsy patients. 4 Seizures in patients with IB and IA have been primarily associated with temporal lobe onset. 5 However, lateralization of such events has not been consistent.…”