Abstracts

Rationale: Seizure-induced cardiac asystole is a very rare condition than can threaten life of epilepsy patients and able to become a cause of SUDEP. It is usually preceded by sinus bradycardia and it appears in the context of an ongoing epileptic seizure. It usually originates from the left temporal lobe but frontal lobe may also be the cause. Left structures are more often implied in vagal symptoms while right structures are usually in relation with tachycardia and hypertension phenomena. Appropriate control relies on treatment for both epileptic and cardiac phenomena, with antiepileptic drugs or evaluation for epilepsy surgery in refractory epilepsy and pacemaker in cases of prolonged asystole and/or faints with falls. We present a case of ictal asystole arising from the right orbitofrontal area.Methods: Our patient is a 59-year-old epileptic woman monitorized in the videoEEG room for episodes of loss of consciousness and absence of muscle tone in the context of a typical complex partial epileptic seizure (CPS) with loss of awareness, staring and manual automatisms. She associated episodes of CPS and syncopes alone. No previous heart illnesses were reported and interictal electrocardiogram was normal. No risk factors for epilepsy were found in the anamnesis. A videoEEG monitoring and a magnetic resonance imaging were performed.Results: During the videoEEG with ECG electrodes, five episodes of ictal asystole were recorded. All but one were preceded by a paroxysmal discharge of spikes and spike and wave complexes arising from the right fronto-temporal area. This activity was accompanied by cardiac bradycardia leading to asystole which was responsible for syncopal episodes with movement artifact in the EEG recording and followed by slow generalized activity. A bicameral peacemaker was implanted and new seizures were registered, with clinical manifestations of CPS accompanied by bradycardia and posterior activation of the heart pacemaker with absence of clinical syncopes. A magnetic resonance with epilepsy protocol showed a right frontal lobe porencephalic lesion locating in the orbitofrontal area with hypointense signal in T1-weighted images and hyperintense appearance in T2-weighted signals. After the implantation of the pacemaker our patient did not suffer any other syncopal episodes and no more falls were referred. Conclusions: Ictal asystole is a rare feature found in patients with focal epilepsy. We present a very uncommon case originating in the right orbitofrontal area, supported by electric and structural findings, with no previous published cases in this location to our awareness. The diagnosis requires the recording of a representative clinical event during simultaneous registration of EEG and ECG activity.