Teaching NeuroImages: Medically intractable epilepsy and ictal asystole treated with cardiac pacing

Summary

  • 43yo M
  • c/c
    • Bi periventricular nodular heterotopia
    • intractable multiforcal epilepsy
    • Sz-related falls
  • Ex
    • vEEG
      • Sz w/ ictal asystole
      • EEG attenuation
      • postural tone(–)
      • cerebral hypoperfusion
    • vEEG after pacemaker implantation
      • Sz w/ ictal cardiac pacing
      • w/o EEG attenuation

Further

Terminology

  • periventricular nodular heterotopia

Original

A 43-year-old man with bihemispheric periventricular nodular heterotopia had medically intractable multifocal epilepsy and seizure-related falls. Video-EEG recorded a seizure with ictal asystole, EEG attenuation, and loss of postural tone, reflective of cerebral hypoperfusion (figure 1). After pacemaker implantation, EEG recorded a seizure with ictal cardiac pacing, without EEG attenuation (figure 2). His falls resolved. Antiseizure medications and epilepsy surgery can control seizures and ictal asystole.1 For individuals with intractable epilepsy and ictal asystole who are poor surgical candidates, pacemaker implantation is indicated to prevent injury and any potential contribution of ictal asystole in sudden unexpected death in epilepsy.1,2

Figure 1

Figure.1

Right temporal onset seizure and ictal asystole
Right posterior temporal onset seizure with 24-second ictal asystole and associated generalized EEG attenuation with superimposed myogenic artifact. Longitudinal anatomic bipolar montage with subtemporal coverage.

Figure 2

Figure.2

Left temporal onset seizure and ictal cardiac pacing
Left posterior temporal onset seizure, with right temporal spread, loss of normal cardiac rhythm, and onset of paced cardiac rhythm lasting 17 seconds.

References
  1. Strzelczyk A, Cenusa M, Bauer S, et al. Management and long-term outcome in patients presenting with ictal asystole or bradycardia. Epilepsia 2011;52:1160–1167.
  2. Hampel KG, Thijs RD, Elger CE, Surges R. Recurrence risk of ictal asystole in epilepsy. Neurology 2017;89:785–791.