title: Management and long-term outcome in patients presenting with ictal asystole or bradycardia.
abstract: OBJECTIVE
  Ictal asystole (IA) and ictal bradycardia (IB) are rare autonomic symptoms during epileptic seizures and may be potentially life-threatening. Guidelines for the care of these patients are missing. The aim of this multicenter study was to evaluate the management and long-term outcome in patients with IA and IB.
  
  
  METHODS
  All patients with IA and IB were included from four epilepsy centers (Bielefeld, Kork, Marburg, and Zürich) from 2002 until 2009. Using a standardized assessment form, clinical data, treatment decisions, and outcomes were extracted from patient charts and simultaneous electroencephalography/electrocardiography (EEG/ECG) recordings.
  
  
  RESULTS
  Seizures with IA or IB were identified in 16 patients. In all patients an associated temporal seizure pattern was recorded and in 15 patients, sudden falls, fainting, or trauma was previously reported or recorded during the monitoring. In three patients (18.8%) diagnosis of focal epilepsy was newly established and anticonvulsive treatment was initiated. Two patients with refractory epilepsy underwent epilepsy surgery. In seven patients (43.8%) a cardiac pacemaker was implanted. In 14 of 16 treated patients, seizure freedom (n = 5) or absence of sudden falls, fainting, or trauma (n = 9) could be achieved. Two patients denied epilepsy surgery as well as a pacemaker and continue to have frequent falls and trauma.
  
  
  CONCLUSIONS
  Our study demonstrates that epilepsy surgery and antiepileptic drugs may lead to sustained freedom of seizures as well as ictal syncope. In drug-resistant patients not suitable for epilepsy surgery, implantation of a cardiac pacemaker may prevent sudden falls as well as trauma. Based on our results and previously reported cases we propose a treatment algorithm.
authors.affiliation: Department of Neurology and Epilepsy Center, Marburg, Germany Swiss Epilepsy Centre, Zürich, Switzerland. adam.strzelczyk@med.uni-marburg.de
authors.forename: Adam
authors.initials: A
authors.lastname: Strzelczyk
authors.forename: Margarethe
authors.initials: M
authors.lastname: Cenusa
authors.forename: Sebastian
authors.initials: S
authors.lastname: Bauer
authors.forename: Hajo M
authors.initials: HM
authors.lastname: Hamer
authors.forename: Ian W
authors.initials: IW
authors.lastname: Mothersill
authors.forename: Thomas
authors.initials: T
authors.lastname: Grunwald
authors.forename: Barbara
authors.initials: B
authors.lastname: Hillenbrand
authors.forename: Alois
authors.initials: A
authors.lastname: Ebner
authors.forename: Bernhard J
authors.initials: BJ
authors.lastname: Steinhoff
authors.forename: Günter
authors.initials: G
authors.lastname: Krämer
authors.forename: Felix
authors.initials: F
authors.lastname: Rosenow
mesh_terms: D000328:Adult; D000368:Aged; D001919:Bradycardia / Q000150:complications / Q000175:diagnosis* / Q000628:therapy*; D019468:Disease Management; D004569:Electroencephalography / Q000379:methods; D004827:Epilepsy / Q000150:complications / Q000175:diagnosis* / Q000628:therapy*; D005260:Female; D006323:Heart Arrest / Q000150:complications / Q000175:diagnosis* / Q000628:therapy*; D006801:Humans; D008297:Male; D008875:Middle Aged; D013997:Time Factors; D016896:Treatment Outcome; D055815:Young Adult