Monté Carlos Paul, Monté Carlos Jules, Boon Paul, Arends Johan
Academic Centre for Epileptology Kempenhaeghe, Heeze, the Netherlands; Department of Neurology, St. Elisabeth Hospital, Zottegem, Belgium.
Department of Neurology, St. Elisabeth Hospital, Zottegem, Belgium.
Epilepsy Behav. 2019 Jan;90:168-171. doi: 10.1016/j.yebeh.2018.10.027. Epub 2018 Dec 19.
Heart rate decrease during epileptic seizures is rare and should be considered in patients with unusual or refractory episodes of syncope or in patients with a history suggestive of both epilepsy and syncope. We systematically reviewed the literature to better understand the clinical signs and risk factors of ictal heart rate decreases.
We performed a literature-search on "ictal bradycardia" and "ictal asystole" in Pubmed and added papers from the references and personal archives. Articles relating to animal studies, seizures without ictal decrease of heart rate, cases without simultaneous electroencephalography (EEG) and electrocardiography (ECG), convulsive syncopes, or cases with bradycardia before seizure onset and articles written in other languages than English, Dutch, German, French, or Spanish were excluded. Full texts of the remaining articles were screened for cases of ictal bradycardia or ictal asystole. Cases were selected on the basis of a self-designed quality score. The relationship of RR wave interval of at least 5 s, signs of syncope, and EEG signs of ischemia were analyzed with chi-square test and identifying 95% confidence intervals.
Ictal bradycardia and ictal asystole predominantly occurred during focal seizures with loss of awareness (proportion in the combined group of bradycardia and asystole (p1 + 2) = 0.85) in people with mainly left lateralized (p1 + 2 = 0.64; p = 0.001) temporal lobe seizures (p1 + 2 = 0.91). Seizures with ictal asystole typically started with a heart rate decrease. During ictal asystole in the majority of cases, not only the clinical signs of syncope occurred (change of proportion (Δp) = 0.67; 95% CI: 0.48-0.86; p < 0.0001), i.e., interrupting the seizure semiology, but also the characteristic EEG signs of ischemia (Δp = 0.50; 95% CI: 0.26-0.74; p < 0.001). We found a statistically significant relation between signs of syncope and EEG signs of ischemia (Δp = -0.37; 95% CI: (-0.64)-(-0.10); p < 0.01) but not between duration of asystole (5 s) and either signs of syncope (Δp = -0.36; 95% CI: (-0.77)-0.05; p = 0.03) or EEG signs of ischemia (Δp = -0.37; 95% CI: (-1.07)-0.33; p = 0.16).
In the ictal bradycardia syndrome, signs of syncope disrupt the semiology of ongoing seizures and are associated with EEG signs of brain ischemia and the duration of the cardiac arrhythmia.
癫痫发作期间心率下降较为罕见，对于晕厥发作异常或难治的患者，或有癫痫和晕厥病史的患者，应考虑这一情况。我们系统回顾了文献，以更好地了解发作期心率下降的临床体征和危险因素。
我们在PubMed上对“发作期心动过缓”和“发作期心搏停止”进行了文献检索，并补充了参考文献和个人存档中的论文。排除与动物研究、发作期心率未下降的癫痫、未同时进行脑电图（EEG）和心电图（ECG）检查的病例、惊厥性晕厥，或发作前出现心动过缓的病例，以及非英文、荷兰文、德文、法文或西班牙文撰写的文章。对其余文章的全文进行筛选，查找发作期心动过缓或发作期心搏停止的病例。根据自行设计的质量评分选择病例。采用卡方检验分析RR波间期至少5秒、晕厥体征和缺血性EEG体征之间的关系，并确定95%置信区间。
发作期心动过缓和发作期心搏停止主要发生在意识丧失的局灶性癫痫发作期间（心动过缓和心搏停止合并组中的比例（p1+2）=0.85），主要为左侧颞叶癫痫发作（p1+2=0.64；p=0.001）（p1+2=0.91）。发作期心搏停止的癫痫发作通常始于心率下降。在大多数发作期心搏停止病例中，不仅出现了晕厥的临床体征（比例变化（Δp）=0.67；95%CI：0.48-0.86；p<0.0001），即中断了癫痫发作症状学，还出现了缺血性EEG特征性体征（Δp=0.50；95%CI：0.26-0.74；p<0.001）。我们发现晕厥体征与缺血性EEG体征之间存在统计学显著关系（Δp=-0.37；95%CI：（-0.64）-（-0.10）；p<0.01），但心搏停止持续时间（5秒）与晕厥体征（Δp=-0.36；95%CI：（-0.77）-0.05；p=0.03）或缺血性EEG体征（Δp=-0.37；95%CI：（-1.07）-0.33；p=0.16）之间无此关系。
在发作期心动过缓综合征中，晕厥体征会干扰正在进行的癫痫发作症状学，并与脑缺血的EEG体征及心律失常持续时间相关。
