epilepsy is associated with a two- to three - fold increase in mortality among patients compared with the general population .
sudden unexpected death in epilepsy ( sudep ) is one of the most frequent causes of death among patients with epilepsy .
there is strong evidence suggesting that sudden unexpected death in epilepsy ( sudep ) is a seizure - related phenomenon , , , .
the first description of this phenomenon was introduced by russell in 1906 . since then , several cases have been reported in the literature presenting with a drop in heart rate or asystole during the seizure .
bradycardia and asystole resulted from increased parasympathetic flow through the vagus nerve , which originates in the nucleus ambiguous and dorsal nucleus of the vagus in the medulla . on the basis of one study ,
the incidence of sudep ranges from 1:1000 and 1:2000  person - years to 1:200  person - years , . according to a recent revised definition ,
sudep consists of sudden , unexpected , witnessed or unwitnessed , nontraumatic and nondrowning death in patients with epilepsy , with or without evidence of a seizure , excluding documented status epilepticus ( seizure duration >  30  min or seizures without recovery in between ) and asphyxia ; if postmortem examination does not reveal a cause of death , the diagnosis is definite sudep , and if there is a preexisting condition before or after autopsy , which could have contributed to the death , it is classified as sudep plus .
strong risk factors for sudep include young age , early onset of seizures , the presence of generalized tonic  clonic seizures , male sex , and bedtime occurrence .
less significant risk factors for sudep include the prone position , one or more subtherapeutic blood levels , sleep occurrence , and a structural brain lesion .
the underlying pathophysiologic mechanisms for sudep are not completely understood , but autonomic dysfunction ; ictal arrhythmias , ictal bradyarrhythmia , and asystole , ; neurogenic pulmonary edema ; and ictal central or obstructive apnea , ,   were introduced in the literature . in this report , we describe two patients with seizure - associated asystole monitored by simultaneous video electroencephalography  electrocardiography .
a thirteen - year - old right - handed male with seizure disorder was admitted for a presurgical assessment . there was a history of neonatal hypoglycemia during an apparently normal vaginal delivery .
he was started on antiepileptic drugs , but the second seizure appeared six months later .
the seizures typically consisted of blurred vision and upward gaze followed by a loss of consciousness .
his mri showed near symmetrical signal abnormality at parietooccipital regions bilaterally ( parasagittal aspect ) accompanied by mild gliosis and volume loss ( fig . 
, there was bilateral rhythmic activity maximum to the left associated with right - side clonic jerk and head and eye deviation to the right that secondarily generalized and was followed by 16  s of asystole at the end of the seizure ( fig .  1 , fig .  2 , fig .  3 ) .
interictal abnormality consisted of bilateral spike - and - wave and bilateral slow activity maximum in the right posterior head region . at the end of monitoring , an anticonvulsant drug regimen of valproic acid and levetiracetam was started , and cardiology consultation was suggested .
a 42-year - old right - handed male with seizure disorder was admitted for presurgical assessment .
his epilepsy was due to penetrating head trauma in the left frontal lobe from a shell injury .
since then , he had been experiencing episodes of intense fear followed by generalized tonic  clonic movements .
neurologic examination included mild paresis in the right upper extremity and in the distal part of the right lower extremity in the range of 12/5 .
the very first clinical manifestation was after the initial eeg changes and consisted of a generalized tonic 
afterwards , the sa arrest took place and lasted about 1  min ( see fig .  5 , fig .  6 ,
the very first eeg change started with 5-hz spike  slow waves over the left parasagittal area with the maximum amplitude on c3 and f3 .
the interictal abnormality consisted of delta waves seen at p3 , c3 , and f3 . considering his cardiac arrest during the seizure
, a cardiac consultation was done , and a pacemaker was implanted . during 24  months of antiepileptic regimen , the frequency of seizures was reduced remarkably .
theoretically , these asystoles could have a role in the incidence of sudep , meaning that the presence of ictal bradycardia is a risk factor for sudep . furthermore , in cases of epileptic cardiac dysrhythmia , isolated eeg or ecg recording may prove insufficient , and prolonged simultaneous eeg / ecg monitoring may be required .
only simultaneous eeg and ecg recording will reveal a possible cerebral origin of arrhythmias in these patients who are , typically , young .
attaining the correct diagnosis is essential because appropriate treatment may prevent cardiogenic sudep , which is thought to be related to potentially lethal arrhythmias , such as asystole induced by epileptic seizures , and to prevent the cardiac side effects of specific antiepileptic drugs . in conclusion ,
cardiological investigation should be included in epilepsy management to search for abnormalities of hr or ischemic events .
in addition , it can provide an appropriate guideline in pharmacotherapy since certain types of drugs including carbamazepine , phenytoin , benzodiazepine , and barbiturates should only be used with caution by patients with epilepsy who have cardiac dysfunction . increasing knowledge about sudep risk factors can have a significant preventive role .
moreover , strategies such as taking a detailed cardiovascular history to get the comprehensive clinical picture including a detailed history of symptoms , risk factors , and prior cardiac findings should be undertaken .
 ictal asystole is a rare , probably underestimated manifestation of epileptic seizures whose pathophysiology is still debated . 
 this report describes two patients who had cardiac asystole at the end of their seizure . 
 the first patient was a 13-year - old boy with complex partial seizures .. 
 his mri showed symmetrical signal abnormality in the bilateral parietooccipital lobe accompanied by mild gliosis and volume loss . during a 3-day long - term video - eeg monitoring , he had cardiac arrest at the end of one of his seizures that was secondarily generalized . 
 the second one was a 42-year - old veteran with penetrating head trauma in the left frontal lobe due to shell injury . during long - term video - eeg monitoring , he had one generalized tonic  
 clonic seizure accompanied by bradycardia and cardiac asystole . 
 asystoles could have a role in the incidence of sudden unexpected death in epilepsy ( sudep ) , meaning that the presence of ictal bradycardia is a risk factor for sudep . in cases of epileptic cardiac dysrhythmia , 
 prolonged simultaneous eeg / ecg monitoring may be required . 
 cardiological investigation should be included in epilepsy management . 
Introduction
Case1
Case2
Discussion