Ictal bradycardia and atrioventricular block: a cardiac manifestation of epilepsy

We describe a case of a patient with recurrent syncopal episodes that ultimately was discovered to be due to ictal bradycardia caused by temporal lobe epilepsy. A diagnostic dilemma was presented by a 55-year-old male who had recurrent syncopal events despite having an atrial pacemaker. The patient was noted to have automatisms and was diagnosed via electrocardiogram/electroencephalogram (EEG/ECG) co-registration to have ictal bradycardia and atrioventricular (AV) block leading to syncope. He was successfully managed with seizure control with the use of levetiracetam. Ictal bradycardia and AV block are uncommon manifestations of epilepsy and can progress to complete heart block and asystole. Diagnosis is best performed with simultaneous ECG and EEG recordings. Definitive management is seizure control with the use of antiepileptic drugs, with the question of pacemaker placement still up for debate.