Long-Term Follow-Up of Ictal Asystole in Temporal Lobe Epilepsy: Is Permanent Pacemaker Therapy Needed?

Background: Ictal asystole (IA) is an infrequent complication of temporal lobe epilepsy (TLE), but one that may cause transient loss of consciousness (T-LOC) similar to reflex syncope (particularly the vasovagal faint). Although IA-triggered T-LOC is relatively rare, its recognition is therapeutically important. However, while the need for anti-epileptic drugs (AeDs) is broadly accepted, cardiac pacing in IA is controversial. This study aimed to evaluate the need for cardiac pacing in the follow-up of IA patients being treated with AeDs. Methods and Results: Six patients (2 men, mean age of 66 ± 16 years), with documented prolonged asystole on electrocardiogram (ECG) in association with TLE, were followed for an average of 19.7 (range, 2–37) years; a pacemaker had been implanted in 4 of 6 patients, whereas 2 patients underwent long-term ECG monitoring with an implantable loop recorder (ILR). The longest documented IA pause lasted 12.6 ± 6.2 (range: 3.5–20) seconds. All patients were treated with AeDs. During follow-up, after optimization of AeD dosing, none of the patients had T-LOC spells or detected epileptic seizure episodes. During regular device interrogation, there was no evidence of pacing interventions (cumulative ventricular pacing, 0%) in the 4 pacemaker patients, and no symptomatic bradyarrhythmias in the 2 ILR patients. Conclusions: AeD therapy was effective to prevent IA in this cohort of TLE patients with prior IA. Consequently, pacemaker implantation is not immediately indicated for IA prevention, but should be reserved for those cases in which there is documented failure of AeD therapy.