Ictal Asystole Research Articles

Clinical cues for detecting ictal asystole

The occurrence of asystole during an epileptic seizure is the most dramatic manifestation of ictal bradycardia. Recognition of ictal asystole is important as treatment with both antiepileptic drugs and cardiac pacing may be necessary. The purpose of this study was to identify clinical cues to aid in the detection of ictal asystole. We analyzed the clinical and electrophysiologic features of all recorded seizures in consecutive patients diagnosed with ictal bradycardia and asystole on prolonged video-EEG/ECG monitoring over a 14 year period. Twenty-nine seizures with ictal bradycardia were identified in 13 patients. Of these, 11 seizures in seven patients were associated with asystole. Bilateral transient limb movements consisting of asymmetric posturing or jerking occurred during eight episodes of ictal asystole, and loss of muscle tone occurred during four. In contrast, neither bilateral limb movement nor loss of muscle tone was observed in any of the non-asystolic seizures, whether ictal bradycardia was present or not. All patients with ictal asystole reported a history of seizure-related falls and brief body and limb jerking. The presence of loss of muscle tone or bilateral asymmetric jerky limb movements during a seizure suggests the possibility of ictal asystole. Video-EEG/ECG monitoring should be considered in patients with epilepsy demonstrating these clinical features to determine if ictal asystole is present.

Asystole induced by electrical stimulation of the left cingulate gyrus

The cortical control of the autonomic system may account for the clinical phenomenon of ictal asystole which, in turn, has been speculated to be a potential mechanism for sudden unexpected death in epilepsy (SUDEP). We report an 18-year-old patient with frontal lobe epilepsy who had intracranial electrode placement showing bifrontal seizure-onset. This patient received electrical stimulation to the left cingulate gyrus and developed cardiac asystole within 3 seconds of electrical stimulation. Intracranial monitoring showed epileptiform discharges in the left frontal polar, frontal lateral and interhemispheric electrodes. We suggest that the left cingulate gyrus, as part of the central autonomic network, may mediate bradyarrhythmia through the vagal pathway. There remains the possibility that other brain regions were also involved due to the time lag between asystole and epileptiform discharges, and the lack of intracranial exploration in the mesial temporal and insular regions. [Published with video sequences].

Cerebral arrhythmia influencing cardiac rhythm: A case of ictal bradycardia

Partial seizures of temporal origin can be associated with clinically significant tachycardia or bradycardia. Ictal bradycardia and asystole has been implicated in the etiology of sudden unexpected death in epileptic patients (SUDEP). Although symptomatic ictal bradycardia has been relatively well described in the literature; information on asymptomatic ictal bradycardia is scarce. We report a case of asymptomatic ictal bradycardia diagnosed during video EEG telemetry that was subsequently implanted with a cardiac pacemaker.

Sudden unexpected death in epilepsy: from mechanisms to prevention

To discuss the pathophysiology and potential prevention of sudden unexpected death in epilepsy. Long-term electrocardiogram monitoring over several months has detected ictal asystole in three out of 20 (15%) patients with refractory epilepsy, suggesting that high-risk ictal arrhythmias occur in a greater proportion of patients with refractory epilepsy than previously thought. In case-control studies, sudden unexpected death in epilepsy was found to be associated with frequent generalized tonic-clonic seizures and greater ictal maximal heart rate, especially during nocturnal attacks. Conversely, supervision at night was associated with a lower risk of occurrence. The impact of epilepsy surgery on the risk of death and sudden unexpected death in epilepsy remains unclear, with comparable long-term survival in an epilepsy surgery cohort compared with a matched population of patients with refractory epilepsy who did not undergo surgery. Previous results may have been partly confounded by the association observed between preoperative decreased heart rate variability and poor postoperative seizure outcome. Ictal arrhythmias may represent a more prevalent cause of sudden unexpected death in epilepsy than previously thought. No clear recommendations have emerged from the literature regarding the most appropriate therapeutic strategies to prevent the event, apart from the supervision at night of patients with refractory epilepsy.

Platform Session B: Clinical Neurophysiology/Clinical Epilepsy 3:00 p.m.–6:00 p.m.

Platform Session B: Clinical Neurophysiology/Clinical Epilepsy 3:00 p.m.–6:00 p.m.

Clinical Neurophysiology: EEG–Video Monitoring

Clinical Neurophysiology: EEG–Video Monitoring

THE CINGULAR GYRUS: AREA 24

THE CINGULAR GYRUS: AREA 24