Abstracts

Bradycardia and asystole occurring during seizures are thought to be possible risk factors for SUDEP in patients with epilepsy. Pacemaker implantation has been carried out in most patients because of concerns of potential cardiac morbidity and mortality. Literature review of patients reported to have ictal asystole and pacemakers implanted show them to have a long history of seizures and better control of seizures following diagnosis and change in treatment resulting in lack of pacemaker activation. We report a patient with ictal asystole on VEEG who failed prior montherapy that was subsequently treated with Levetiracetam (LEV) and did not undergo pacemaker implantation. The case is a 27 year old female with a 4 year history of spells consisting of an aura of deja vu and fear followed by loss of consciousness for less than 30 seconds. She was also described as becoming limp with tongue biting and incontinence but no tonic clonic activity. Due to lack of response to Topiramate and need to characterize spells, she underwent VEEG monitoring. VEEG recording of 2 events were done. The two events were preceded by tachycardia which was up to 200 beats per minute(bpm) followed by asystole for 20 seconds in one and tachycardia of 120 bpms followed by bradycardia of 30 seconds in the other. (VEEG will be shown at meeting).There was brief right temporal theta seziure activity seen preceding the second event. SPECT injection was normal. The patient was placed on LEV and underwent a Reveal Loop recorder implantation for continuous EKG recording. The patient has been seizure free for 6 months with no cardiac arrhythmias detected. Ictal asystole has not been associated with increased mortality from epilepsy. The occurrence of asystole during seizures in patients with longstanding epilepsy and reports that seizures may respond to antiepileptic medication supports this concept. Patterns of heart rate change leading to ictal asystole appear unique and will be discussed. Further studies looking at larger numbers of patients with comprehensive cardiac evaluation are needed to further understand the concept of SUDEP rather than single aspects such as bradyarrhythmias. This case suggests that ictal asystole may not necessitate pacemaker implantation.