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The ictal bradycardia syndrome occurs when epileptic discharges disrupt normal cardiac rhythms leading to a reduction of heart rate that is more than 10 beats/min below the baseline. Mostly documented ictal bradycardias are accompanied by complex partial seizures of temporal lobe origin. Sudden unexpected death in epilepsy is often assumed to be associated with a concomitant seizure, but it is almost impossible to prove conclusively. Here, we report the case of a 52-year-old female patient admitted with the complaints of two episodes of generalized tonic–clonic seizures and vomiting followed by presyncope and syncope. The patient was admitted in a drowsy disoriented state with hypotension and electrocardiogram (ECG) illustrating sinus tachycardia. Later during admission, the patient developed complex focal seizures with secondary generalization and cardiac arrest. During video electroencephalogram/ECG, she had another similar episode and cardiac arrest. ECG showed rapid progression to asystole and ventricular pause of 25 s followed by complete heart block with ventricular escape rhythm of 17 beats/min. She was implanted with a temporary pacemaker but later during the hospitalization, sudden unexpected death in epilepsy occurred in spite of cardiac pacing and optimum antiepileptic medication. Most documented pauses are of nonlife-threatening duration (range 3–20 s) with longer pauses being observed. Cardiac pacing may help to reduce the risk of falls, but in the absence of official practice guidelines, cardiac pacing should only be considered for patients in whom conventional antiepileptic therapy has failed to prevent ictal asystole. Early diagnosis, interventions, and optimum antiepileptic dose escalation with occasional epilepsy surgery are the mainstay to prevent mortality and severe prognosis of the ictal bradycardia syndrome.

Background: Moyamoya disease (MMD) is a chronic, progressive occlusion of the circle of Willis arteries usually affects bilateral carotid arteries than unilateral that leads to the development of characteristic collateral vessels seen on imaging, particularly cerebral angiography. Once the occlusion process begins, tends to continue despite any known medical management unless treated with revascularization surgery Report of the case: A 28 year female gravida four in 34th week of gestation presented with features suggestive of acute meningoencephalitis and CSF examination suggested 75% polymorphs of 300 total leukocytes. After 7 days of optimum management, complaints of headache aggravated so patient was subjected to MRI Brain which reported as early subacute intraparenchymal haemorrhage left frontal lobe in periventricular region with mild surrounding perifocal edema and intraventricular extension. On further MR angiogram, patient was diagnosed as MMD. Patient was asymptomatic in her previous 3 pregnancies and presently underwent planned preterm high risk caesarean section after a week. However condition of patient deteriorated over 2 weeks post delivery, did not remain fit for any neurosurgical intervention and unfortunately succumbed to death. Conclusion: Antenatal patient presenting as acute meningoencephalitis with persistent headache refractory to medical therapy, should be subjected to CT/MR brain imaging for rare possibility of MMD and early neurosurgical interventions in view of its grave prognosis.

Background: CAD in the young require special attention as the clinical profile, risk factors and prognosis are different from that in older patients. Method: The present study is an attempt to evaluate acute myocardial infarction in young individuals (<40 years of age) undergoing coronary angiography (CAG). A total of 290 patients aged 40 years or younger who underwent CAG in the Department of Cardiology, Coimbatore medical college hospital between December 2019 to February 2021 were included in this study. Demographic characteristics, risk factor profile, laboratory test results, ECG and echocardiographic findings, CAG findings, and in-hospital mortality were as­sessed. All subjects completed the Hospital Anxiety and Depression Scale (HADS) to assess anxiety levels or presence of depressive symptoms as a potential risk factor among young patients. Results: The mean patient age was 35.6 ± 4.4 years. Men made up 87.2% of the study sample. STEMI was present in 84 % of acute MI while remaining had NSTEMI. CHF (Killip class II or III) was present at hospital admission 14.4% patients. Angiographically normal coronary arteries were found in 4% of patients with the diagnosis of ACS. The most common location of significant atherosclerotic coronary lesions was the left anterior descending artery (60.1%) followed by the right coronary artery (32.4%). The most prevalent were conventional cardiovascular risk factors followed by anxiety/depression, a family his­tory of CAD. The findings showed that 32% of the respondents had anxiety caseness and 40% had depression caseness. Conclusion: Significant risk of CHF on presentation and STEMI most common cases. Modifiable risk factors constitute primary etiology with less commonly evaluated cause as anxiety and depression need to be monitored regularly, provide regular counselling services. 4.0% revealing normal coronaries suggesting microvascular dysfunction important process other than atherosclerosis. Keywords: [young MI, nonconventional risk factors, STEMI, coronary angiogram]

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