[Seizure by asystole or asystoleby seizure?]

A 75 years old man is suffering from recurrent seizures since several years. The seizures start with vegetative symptoms including tingling sensations, followed by a deep feeling of eternity and happiness. In one third of the cases he looses consciousness completely. Several workups have failed to reveal a diagnosis. An ECG loop recorder was implanted which finally revealed an asystole of 15 seconds duration. It was thought that this caused cerebral hypoxia which was triggering focal seizures. A pacemaker was inserted. The attacks of unconsciousness disappeared; however, the spells of vegetative sensations persisted. After antiepileptic treatment was initiated the symptoms improved, however it was not possible to achieve complete control. Is this patient primarily suffering from recurrent asystole or from epilepsy which causes complex seizures with disturbance of cardiac rhythm? The latter phenomenon in its most extreme presentation is better known as sudden unexplained death in epilepsy (SUDEP). The diagnostic approach and therapy of both diseases are discussed.