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

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

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