S03. Ictal asystole - A rare presentation of focal epilepsy

Abstract

Introduction Ictal tachycardia has been frequently observed during temporal lobe seizures. However, Ictal severe bradycardia and asystole are less common and can be associated with serious consequences including risk of sudden death. We present a case of ictal syncope in a woman with recurrent episodes of loss of consciousness and fall. Methods A 69 year old right handed woman presented with one year history of recurrent episodes of loss of consciousness. The patient experienced a number of events when she suddenly develops a funny feeling in her head associated with visual disturbances and followed by loss of awareness and fall. She describes a quick recovery and return to baseline after these episodes. She also reported episodes of rising sensation in her stomach followed by loss of awareness and fall. She denied any prior history of convulsive seizures. She was treated with levetiracetam but continued to experience these episodes. Her brain MRI showed left inferior frontal cavernous angioma that has been seen on previous brain imaging. The patient was admitted to our epilepsy monitoring unit for evaluation of her recurrent spells. Her seizure medication was gradually withdrawn to capture typical events. Her interictal EEG showed bilateral independent temporal slowing and rhythmic delta activity (TIRDA). Results Video EEG evaluation was obtained at our epilepsy monitoring unit. The patient experienced multiple epileptic seizures emanating from the right temporal region and associated with significant bradycardia as well asystole that lasted up to 20 s. Her EEG demonstrated rhythmic right temporal slowing at the onset of her events concurrently associated with bradycardia. This was followed by diffuse severe suppression of background consistent with syncope that correlated with asystole on her EKG. She experienced one seizure that had an onset of right temporal theta seizure discharge and bradycardia and later appeared to have left hemifacial contraction, and then left upper extremity dystonic posturing, before generalization of her seizure. Her case was discussed with our cardiac electrophysiology consult team and she was transferred to the cardiac care unit for pacemaker implantation. Conclusion This case describes an uncommon presentation of recurrent syncope due to temporal lobe seizures that are associated with severe bradycardia and prolonged asystole.