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Sudden, abrupt falls to the ground during focal seizures, without any associated major motor manifestations, are a well-known although poorly investigated phenomenon.1 Pathophysiologic mechanisms may include bitemporal or frontal involvement with subsequent bilateral spread of the epileptic discharge.2,3 Seizure-related cardiac arrhythmias (i.e., bradycardia or asystole4,5) may result in syncope but may not always be considered in the etiology of ictal sudden falls. We describe three patients with drug-resistant focal epilepsy undergoing presurgical evaluation in whom sudden falls during focal seizures resulted from seizure-related cardiac asystole.
Case reports.
Case 1.
Since age 29 years, this 52-year-old man had had seizures with loss of contact, paleness, and oroalimentary automatisms. At 49 years, seizure frequency increased, in spite of several antiepileptic treatments, and about 50% of episodes were associated with abrupt falls to the ground. Brain MRI demonstrated right mesial temporal sclerosis. During long-term video-polygraphic monitoring three stereotypical seizures were collected, characterized by psychomotor arrest and fall, followed by oroalimentary and right hand automatisms (figure, and video 1 on the Neurology® Web site at www.neurology.org). Ictal EEG-EKG recording showed a right temporal rhythmic theta discharge associated with 7 to 8 seconds asystole; the fall of the patient occurred at the end of the asystole (figure). After right anteromesial temporal lobectomy (follow-up 19 months), neither focal seizures nor sudden fall …
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