From brain to heart: a single-centre study of ictal and post-ictal asystole in epilepsy

The objective of this study is to explore ictal asystole (IA), a neurocardiogenic phenomenon occurring during epileptic seizures, and its implications in patients with epilepsy. The study aims to describe the clinical presentations, diagnostic challenges and management approaches of IA to contribute to the existing knowledge and improve patient care.

A retrospective analysis was conducted on 15 578 patients undergoing prolonged video-electroencephalogram monitoring over a period of 115 months. Clinical features, electrophysiology, neuroimaging, interventions and outcomes were assessed.

Eight patients (0.05%) exhibited IA (six females; mean age: 36.5 years; range: 26-45 years). The mean age at seizure onset was 20.5±11.73 years and mean disease duration from seizure onset was 16±10.66 years. Six patients gave a history of hypomotor features (75%), one exhibited automotor features (12.5%) and one exhibited sensorimotor features (12.5%). Of the 127 ictal events analysed, 47 (37%) progressed to asystole and 80 (63%) had bradycardia without asystole. Bradycardia preceded 95.7% of asystolic events. A significant direct correlation was observed between average duration of IA and average seizure duration (p=0.015). IA was predominantly observed in temporal lobe epilepsy. Falls and myoclonus were observed during asystolic events. All patients survived without requiring resuscitation. Six patients underwent surgical intervention for epilepsy, with varying degrees of success. One patient underwent permanent pacemaker implantation.

Clinicians should consider IA in patients with epilepsy presenting with unexplained syncope or sudden falls, especially when associated with recent changes in seizure semiology. A high index of suspicion is essential to enable timely diagnosis and prevent injury.