Management and outcome in patients with ictal bradycardia and asystole

Purpose: Ictal bradycardia and asystole are rare autonomic symptoms during epileptic seizures and are potentially life-threatening. The pathop-hysiological mechanisms are poorly understood and a potential contribution to SUDEP remains speculative. Guidelines for the care of patients with ictal arrhythmias are missing. However, in order to prevent life-threatening cardiac arrest, syncope and trauma, such patients should be treated actively and individually, once the diagnosis is established. We report on management and outcome of four patients in whom simultaneous EEG/ECG recording showed ictal bradycardia or asystole.

Patients and Methods: Using a standardized assessment form, information on epilepsy syndrome, seizure localization, anticonvulsive treatment, clinical management and outcome was extracted from patient records and systematically reported.

Results: In four patients an ictal asystole or bradycardia could be recorded on simultaneous EEG/ECG recording. In all patients a right temporal seizure pattern was associated with bradycardia and asystole. Patient #1 was a 28-year-old female with medically refractory temporal lobe epilepsy with right hippocampal sclerosis. The patient underwent a right sided selective amygdalohippocampectomy two weeks after the recorded asystole. Following surgery the patient remained seizure free and reported no further episode of syncope during 6 months follow-up. Patient #2 was a 66-year-old woman with history of recurrent loss of consciousness associated with epigastric auras for 5 years without anticonvulsive treatment. VPA 900mg per day was recommended, and a permanent pacemaker was implanted five days after the recorded asystole. During the follow-up of one year, no seizure with unconsciousness recurred. However, the typical epigastric aura still occurred twice per week followed by the sensation, that the pacemaker sets in for a minute or so. The patient had discontinued VPA and refused to take AEDs. Patient #3 was a 41 year-old male with history of epilepsy since the age of 32 with frequent falls and severe traumatic injuries for the past few years. High resolution magnetic resonance imaging showed no epileptogenic intracerebral lesions. A cardiac pacemaker was implanted two days after the recorded asystole. Currently at one-year follow-up the patient reported neither overt seizures nor syncopes or traumatic falls.

Patient #4 was a 75-year-old woman with arterial hypertension treated with captopril, hydrochlorothiazide and metoprolol who was admitted for recurrent loss of consciousness initially once four months ago and three times on the day of admission. The patients was started on VPA monotherapy of 1500mg. Also, metoprolol was discontinued, because we felt it may have worsened the ictal bradycardia. A cardiac pacemaker was not implanted at this point, however, this will be recommended should the syncopal episodes recur.

Discussion: Our case series uniquely demonstrates that epilepsy surgery as well as implantation of a cardiac pacemaker while continuing AEDs may result in long-term freedom of syncopes and traumatic falls. As guidelines are still missing a case-by-case assessment should be performed regarding treatment in ictal asystole and bradycardia.