Abstracts

Rationale: Episodes of transient loss of consciousness are commonly due to syncope or epilepsy. The distinction between both entities can be challenging and is often impeded by similar clinical presentation. Ictal bradycardia and asystole are rare, but serious complications of epileptic seizures. We describe a rare case of prolonged ictal asystole lasting for 34 seconds in a patient with refractory temporal lobe epilepsy.Methods: A 43-year-old female with a history of epilepsy presented for evaluation of 1-year-history of recurrent syncope. She was diagnosed with temporal lobe epilepsy at age 16 with semiology of staring, hand automatism, difficulty getting words out, and unresponsiveness. The newly onset of syncope was described as sudden onset of falls and loss of consciousness without any prodrome, incontinence, tongue laceration or confusion after the event.Results: Workup of syncope included cardiac monitoring for one month without an event, negative tilt table, automonic tests and echocardiogram. 48-hour aEEG was unremarkable. She was admitted to the epilepsy monitoring unit. During the 2-day-vEEG monitoring, she had three events of bradycardia followed by asystole of 4 seconds, 6 seconds and 34 seconds duration. There were no obvious behavioral changes other than arousal from sleep preceding the events. During the longest asystole event, she had some tonic posturing and head deviation to the right side. EEG showed rhythmic theta activity over the left temporal region with subsequent spread to the contralateral side. Pacemaker is implanted the next day.Conclusions: Seizure-induced syncope is rare complication particularly involving insular, orbital frontal and anterior temporal epilepsy and may be suspected in patients with epilepsy who experience sudden onset of atonia, transient loss of consciousness and seizure-related falls. The implantation of a cardiac pacemaker may prevent seizure-related injury and sudden unexpected death in epilepsy (SUDEP) before full seizure-control is achieved.