A case report of ictal bradycardia and asystole: An uncommon manifestation of epilepsy

Abstract

The ictal bradycardia syndrome occurs when epileptic discharges disrupt normal cardiac rhythms leading to a reduction of heart rate that is more than 10 beats/min below the baseline. Mostly documented ictal bradycardias are accompanied by complex partial seizures of temporal lobe origin. Sudden unexpected death in epilepsy is often assumed to be associated with a concomitant seizure, but it is almost impossible to prove conclusively. Here, we report the case of a 52-year-old female patient admitted with the complaints of two episodes of generalized tonic–clonic seizures and vomiting followed by presyncope and syncope. The patient was admitted in a drowsy disoriented state with hypotension and electrocardiogram (ECG) illustrating sinus tachycardia. Later during admission, the patient developed complex focal seizures with secondary generalization and cardiac arrest. During video electroencephalogram/ECG, she had another similar episode and cardiac arrest. ECG showed rapid progression to asystole and ventricular pause of 25 s followed by complete heart block with ventricular escape rhythm of 17 beats/min. She was implanted with a temporary pacemaker but later during the hospitalization, sudden unexpected death in epilepsy occurred in spite of cardiac pacing and optimum antiepileptic medication. Most documented pauses are of nonlife-threatening duration (range 3–20 s) with longer pauses being observed. Cardiac pacing may help to reduce the risk of falls, but in the absence of official practice guidelines, cardiac pacing should only be considered for patients in whom conventional antiepileptic therapy has failed to prevent ictal asystole. Early diagnosis, interventions, and optimum antiepileptic dose escalation with occasional epilepsy surgery are the mainstay to prevent mortality and severe prognosis of the ictal bradycardia syndrome.