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KEEPING PACE: A CASE OF ICTAL ASYSTOLE
2301 JACC March 21, 2017 Volume 69, Issue 11
FIT Clinical Decision Making KEEPING PACE: A CASE OF ICTAL ASYSTOLE Poster Contributions Poster Hall, Hall C Saturday, March 18, 2017, 9:45 a.m.-10:30 a.m. Session Title: FIT Clinical Decision‐Making: Arrhythmias and Electrophysiology Abstract Category: Arrhythmias and Clinical EP Presentation Number: 1206-389 Authors: Rola Khedraki, Hiro Kawata, Shuktika Nandkeolyar, Teferi Mitiku, University of California, Irvine, Orange, CA, USA
Background: Ictal asystole is a rare condition for which there are no management guidelines. Pacemaker implantation should be considered for these patients especially if they are not candidates for curative epilepsy surgery.
Case: This is a 43 year old female with history of medication refractory epilepsy. She had convulsive seizures twice per year as well as partial seizures of unknown frequency. Therefore, she was admitted to the neurology service for long-term video EEG monitoring while off of anti-epileptic medication to guide medical versus surgical options. The patient was otherwise healthy and had no risk factors for epilepsy except positive family history. On admission, Lamotrigine and Topiramate were held. ECG and video EEG monitoring revealed subclinical seizures originating from the right posterior temporal region associated with periods of asystole lasting 5-40 seconds during sleep. Due to profound bradycardia following these episodes, the patient was transferred to the CCU for dopamine drip and consideration for pacemaker implantation. Decision‐Making: The patient was restarted on her anticonvulsant medications. Given the long duration of asystole and high risk for seizure recurrence not amenable to surgical intervention, our team decided to proceed with pacemaker implantation. At a one month follow up visit, the patient had no recurrence of seizure and pacemaker interrogation revealed no ventricular pacing.
Conclusions: This case is unique in capturing concomitant EEG and EKG evidence of ictal asystole in a patient with subclinical seizures, which would have been impossible to diagnose otherwise. To our knowledge this is the longest ictal asystole reported. Even in high-volume neurology centers, ictal-induced arrhythmias are documented in <0.5% of patients undergoing video EEG recording. Of note, sudden death in epilepsy (SUDEP) refers to the unexpected death in an epilepsy patient in the absence of status epilepticus or other identifiable cause. It is unclear if arrythmias contribute to sudden death in these cases. The mechanism of ictal asystole is unclear, although previously it has been proposed to perhaps confer a protective advantage with self-termination mechanism.
FIT Clinical Decision Making KEEPING PACE: A CASE OF ICTAL ASYSTOLE Poster Contributions Poster Hall, Hall C Saturday, March 18, 2017, 9:45 a.m.-10:30 a.m. Session Title: FIT Clinical Decision‐Making: Arrhythmias and Electrophysiology Abstract Category: Arrhythmias and Clinical EP Presentation Number: 1206-389 Authors: Rola Khedraki, Hiro Kawata, Shuktika Nandkeolyar, Teferi Mitiku, University of California, Irvine, Orange, CA, USA
Background: Ictal asystole is a rare condition for which there are no management guidelines. Pacemaker implantation should be considered for these patients especially if they are not candidates for curative epilepsy surgery.
Case: This is a 43 year old female with history of medication refractory epilepsy. She had convulsive seizures twice per year as well as partial seizures of unknown frequency. Therefore, she was admitted to the neurology service for long-term video EEG monitoring while off of anti-epileptic medication to guide medical versus surgical options. The patient was otherwise healthy and had no risk factors for epilepsy except positive family history. On admission, Lamotrigine and Topiramate were held. ECG and video EEG monitoring revealed subclinical seizures originating from the right posterior temporal region associated with periods of asystole lasting 5-40 seconds during sleep. Due to profound bradycardia following these episodes, the patient was transferred to the CCU for dopamine drip and consideration for pacemaker implantation. Decision‐Making: The patient was restarted on her anticonvulsant medications. Given the long duration of asystole and high risk for seizure recurrence not amenable to surgical intervention, our team decided to proceed with pacemaker implantation. At a one month follow up visit, the patient had no recurrence of seizure and pacemaker interrogation revealed no ventricular pacing.
Conclusions: This case is unique in capturing concomitant EEG and EKG evidence of ictal asystole in a patient with subclinical seizures, which would have been impossible to diagnose otherwise. To our knowledge this is the longest ictal asystole reported. Even in high-volume neurology centers, ictal-induced arrhythmias are documented in <0.5% of patients undergoing video EEG recording. Of note, sudden death in epilepsy (SUDEP) refers to the unexpected death in an epilepsy patient in the absence of status epilepticus or other identifiable cause. It is unclear if arrythmias contribute to sudden death in these cases. The mechanism of ictal asystole is unclear, although previously it has been proposed to perhaps confer a protective advantage with self-termination mechanism.