Ictal Bradycardia and Asystole Associated With Intractable Epilepsy
Ictal bradycardia/asystole is a poorly recognised cause of collapse late in the course of a typical complex partial seizure. Its recognition is important as it might potentially lead to sudden unexpected death in epilepsy (SUDEP). We present five patients with intractable complex partial seizures who had associated ictal bradycardia/asystole. All the patients underwent cardiac pacing to potentially prevent SUDEP. It is important to recognise and treat ictal asystole early, and to achieve this there is need for both an increase in epilepsy monitoring beds and a recognition of the potential role of implantable loop recorders in the evaluation of patients with epilepsy who clinically appear to be at increased risk for ictal asystole.
Heart rhythm changes are common during seizures, even those seizures not associated with convulsive activity. Most studies report tachycardia, a heart rate increase of more than 10 beats per minute above the baseline, as the most common rhythm abnormality occurring in 64–100% of temporal lobe seizures. By contrast, ictal bradycardia has been reported in less than 6% of patients with complex partial seizures. The ictal bradycardia syndrome occurs in those with established epilepsy when epileptic discharges disrupt normal cardiac rhythm leading to a decrease in heart rate of more than 10 beats per minute below the baseline. The majority of patients with ictal bradycardia have temporal lobe seizures. It is believed that abnormal neuronal activity during a seizure can affect central autonomic regulatory centres in the brain leading to cardiac rhythm changes. It is important to identify ictal bradycardia as a potential harbinger of lethal rhythms, such as asystole, as this may be one important mechanism leading to sudden unexpected death in epilepsy (SUDEP). Ictal bradycardia/asystole may be unrecognised until documented during video-electroencephalograph (EEG)–electrocardiogram (ECG) monitoring in those with refractory epilepsy, often in the context of pre-surgical evaluation. Here we present five patients with intractable complex partial seizures associated with ictal bradycardia or asystole. All the patients underwent cardiac pacing to potentially prevent SUDEP.
Abstract and Introduction
Abstract
Ictal bradycardia/asystole is a poorly recognised cause of collapse late in the course of a typical complex partial seizure. Its recognition is important as it might potentially lead to sudden unexpected death in epilepsy (SUDEP). We present five patients with intractable complex partial seizures who had associated ictal bradycardia/asystole. All the patients underwent cardiac pacing to potentially prevent SUDEP. It is important to recognise and treat ictal asystole early, and to achieve this there is need for both an increase in epilepsy monitoring beds and a recognition of the potential role of implantable loop recorders in the evaluation of patients with epilepsy who clinically appear to be at increased risk for ictal asystole.
Introduction
Heart rhythm changes are common during seizures, even those seizures not associated with convulsive activity. Most studies report tachycardia, a heart rate increase of more than 10 beats per minute above the baseline, as the most common rhythm abnormality occurring in 64–100% of temporal lobe seizures. By contrast, ictal bradycardia has been reported in less than 6% of patients with complex partial seizures. The ictal bradycardia syndrome occurs in those with established epilepsy when epileptic discharges disrupt normal cardiac rhythm leading to a decrease in heart rate of more than 10 beats per minute below the baseline. The majority of patients with ictal bradycardia have temporal lobe seizures. It is believed that abnormal neuronal activity during a seizure can affect central autonomic regulatory centres in the brain leading to cardiac rhythm changes. It is important to identify ictal bradycardia as a potential harbinger of lethal rhythms, such as asystole, as this may be one important mechanism leading to sudden unexpected death in epilepsy (SUDEP). Ictal bradycardia/asystole may be unrecognised until documented during video-electroencephalograph (EEG)–electrocardiogram (ECG) monitoring in those with refractory epilepsy, often in the context of pre-surgical evaluation. Here we present five patients with intractable complex partial seizures associated with ictal bradycardia or asystole. All the patients underwent cardiac pacing to potentially prevent SUDEP.
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