Epileptic falling seizures associated with seizure-induced cardiac asystole in drug-resistant temporal lobe epilepsy

Clinical history: A 52-year-old gentleman with positive family history for epilepsy. At 1 year of age he suffered from prolonged febrile seizures. At 29 years, he started to present brief episodes of loss of contact, staring and psychomotor arrest, paleness, oro-alimentary and right-hand gestural automatisms; the episodes occurred usually once or twice per month. At 49 years, the episodes increased in frequency and about 50% of them started to be complicated by abrupt and sudden falls to the ground. Despite several antiepileptic treatments, his seizures were never completely controlled. The patient was admitted to undergo long-term video–EEG monitoring for presurgical evaluation. General history: Arterial hypertension; duodenal ulcer; chronic HVB hepatitis; deep venous thrombosis with pulmonary embolism; thrombophilia (heterozygous factor V Leiden mutation). Examination: Unremarkable. Right-handed (Oldfield score: +1). Brain MRI: Right mesial temporal sclerosis (Fig. 1). Interictal EEG: Sporadic theta activities occasionally associated with spikes during sleep in the right temporal leads. Long-term video-EEG monitoring: Three stereotyped seizures were recorded during a 10-day computerized video-EEG monitoring. All of them occurred while the patient was sitting, and displayed stereotyped electroclinical features: the clinical onset was characterized by psychomotor arrest, oscillations of the trunk, and then backward fall in two seizures, frontward in the third episode; then oro-alimentary and right-hand automatisms were observed. A very brief postictal state followed. Ictal EEG showed a brief flattening in the right fronto-temporal leads, followed by a rhythmic theta-delta discharge with phase reversal in F8-T4; then delta activity mainly confined to the right temporal leads appeared. The EKG lead showed periods of asystole whose durations ranged from 5 to 8 seconds, associated with the right temporal rhythmic theta activity (Fig. 2), then the heart rate progressively resumed to baseline. The fall of the patient occurred few seconds after the end of the asystole, when the heart rate was starting to recover.