Pearls & Oy-sters: Severe Case of Ictal Asystole in Temporal Lobe Epilepsy

Ictal asystole is a rare condition associated primarily with temporal lobe epilepsy that can cause syncope, falls and head trauma. It is also associated with increased rates of sudden unexplained death in epilepsy (SUDEP). We present a case of a 33-year-old woman with a history of childhood epilepsy who presented with 3 years of recurrent syncope. Video-EEG revealed temporal lobe seizures with ictal asystole. EKG showed stepwise progression of bradycardia, asystole, and tachycardia. MRI showed focal cortical thickening at the right insular cortex with blurring of the grey-white matter interface, consistent with insular focal cortical dysplasia. The patient was transitioned from lacosamide to clobazam due to concern for PR interval prolongation and was referred to cardiology for pacemaker placement. Ictal asystole should be considered as a rare but serious cause of unexplained recurrent syncope, particularly in patients with a history of seizures. Management includes antiepileptic drug regimen optimization, consideration of epilepsy surgery, and referral for cardiac pacing when asystole lasts greater than 6 seconds.