ICTAL ASYSTOLE: RETURN TO THE HISTORY

In these two adult cases of transient loss of consciousness (TLoC), careful history-taking revealed a stereotyped prodrome of deja vu suggestive of focal seizures. One patient had an implantable cardiac monitor fitted, the other a 48 hour Holter monitor. Each patient subsequently had a typical event of deja vu followed by TLoC with rapid recovery and for both, the monitor showed cardiac asystole corresponding with this event. A permanent pacemaker (PPM) was inserted in both patients. This abolished TLoC. In its absence, deja vu became more frequent, intense, and prolonged for one patient, resolving with levetiracetam. The other patient had a post-PPM episode of deja vu followed by a generalised tonic-clonic seizure. It transpired that their lamotrigine had been withdrawn following PPM insertion. Seizure-freedom was achieved by restarting lamotrigine. Ictal asystole, a rare complication of focal epilepsy, has a mean ventricular standstill duration of 20 s. This can be benign or progress to post-ictal asystole −fatal in 54% of cases. Careful attention should be paid to prodromal symptoms suggestive of focal seizures (including ‘auras’) in patients presenting with what might otherwise sound like syncope. These patients may have epilepsy presenting with ictal asystole and require antiepileptic drugs alongside their cardiac investigations/interventions.