We report a patient with ictal asystole in which the diagnosis took a long time to be confirmed despite early suspicion and investigation. Clinical features leading to suspicion and implications of this diagnosis are discussed. A 59-year-old man was referred following several episodes of sudden collapse & an episode of confusion & automatisms without collapse. There was witnessed history of loss of postural tone, fall from height, pallor & rigidity. Clinical examination was unremarkable. Investigations including CT Brain, EEG and 24 h ECG were unremarkable. A diagnosis of complex partial seizures with generalisation was made but the patient was poorly concordant & after a trial of 2 AEDs he elected to stop medication. In NewZeland he collapsed on a cycling holiday and was found to be bradycardic with ventricular pauses and a permanent pacemaker was implanted. Episodes of gestural automatism & disorientation continued but sudden collapses stopped. During a further admission, continuous bedside EEG & ECG recording showed slowing & spikes from a left temporal origin with secondary generalisation. Corresponding ECG showed ventricular slowing & pacemaker activation after the initial complex partial phase of the seizure with subsequent return of sinus rhythm after the seizure. Ictal asystole is rare & under recognised. Simultaneous EEG& ECG are key in diagnosis. It might be a cause of SUDEP & successful treatment is based on antepileptics along with Pacemaker.
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