Abstracts

Rationale: The mechanism of SUDEP is unclear; cardiac and pulmonary mechanisms have been implicated. Ictal asystole is a well described event occurring with temporal lobe seizures. We describe our experience with near death in temporal lobe seizures and the neurologic and cardiac prognosis. Methods: A forty year old female was monitored in the intensive care unit when she developed ictal bradycardia, asystole requiring resuscitation, and prolonged status epilepticus. Results: A forty year old female with hypertension presented with a week long history of episodic chest pain, clamminess, and pre-syncope. She experienced a "burning" odor and a "funny feeling" with these episodes. She was found in a confusional state by family and taken to a local hospital. She had multiple generalized convulsions associated with bradycardia. She was loaded with phenytoin and transferred to our institution. During transfer the patient had a staring episode, after which she became asystolic and subsequently had a generalized convulsion. She was unresponsive and required atropine, after which she recovered. Upon arrival at our institution, she had an unremarkable neurologic and cardiac examination, a normal EKG, and a normal EEG. She had another asystolic episode that required CPR for one minute and atropine injection. About thirty minutes after the return of spontaneous circulation, her neurologic exam was normal except for mild confusion. A temporary transvenous pacemaker was placed. She remained confused, and continuous EEG monitoring was initiated. Multiple seizures were recorded, originating independently from both temporal lobes. Both right and left sided temporal seizures led to pacemaker activation. She was treated with lorazepam and levetiracetam. She was intubated and started on a continuous infusion of propofol. She had multiple seizures per hour over the next two days, requiring the addition of midazolam and oxcarbazepine. Lumbar puncture and MRI were unremarkable. The pacemaker was deactivated for MRI, and afterward the patient had recurrent seizures but no recurrent cardiac events. Burst-suppression was achieved with the addition of pentobarbital. Over the next three weeks, attempts to wean any of the continuous infusions were unsuccessful, until topiramate, lacosamide, and felbamate were added. Seizures did not recur after the fortieth day of hospitalization. Due to complications with urinary and pulmonary infections, a permanent pacemaker was not placed. Eventually the patient awoke, was weaned from the ventilator, and underwent intense rehabilitation. She currently lives at home with her family and is not able to work due to cognitive dysfunction. One year later, the patient and her family continue to decline pacemaker placement. Currently she does have one seizure every three months, without cardiac events, and she is maintained on phenytoin, phenobarbital, levetiracetam, and felbamate. Conclusions: Ictal asystole associated with temporal lobe seizures may play a role in SUDEP. The natural history, recurrence, and prognosis of ictal asystole remain unclear and require further study.