![]() ![]() Afterward he underwent dual chamber pacemaker placement and over a ten-month follow-up has had no further convulsive events.Ī 41-year-old woman was referred for evaluation of recurrent convulsive episodes. The download of the ILR showed the patient had experienced > 20 seconds of cardiac systole coincident with the episode (Figure (Figure1). An ILR (Medtronic Reveal XT) was inserted in the patient and one month later, the patient experienced a witnessed “mild” convulsive episode while sitting at the table. ![]() External event recorders were unable to capture an episode. He was tried on multiple seizure medications to no avail. A head upright tilt table test was normal as was an exercise stress test. The patients' electrocardiogram, echocardiogram, baseline and sleep deprived electroencephalogram (EEG), and magnetic resonance imaging (MRI) scan of the brain were all normal (each having been repeated multiple times). The patient had undergone extensive neurologic and cardiovascular evaluation at the several major medical centers in the US, yet an etiology for these events could not be found. The patient would experience between five and seven major episodes each year, as well as less severe episodes every one to two months. He would often be incontinent of urine and have a postictal period of confusion and disorientation lasting from ten to twenty minutes, followed by severe confusion and fatigue that would persist for the remainder of the day. During these episodes the patient would suddenly turn pale then abruptly fall to the floor followed by convulsive activity that would last anywhere from 30 seconds to one minute. It was only following prolonged cardiac rhythm monitoring with an implantable loop recorder (ILR) that a cardiac rhythm abnormality was identified as the cause of their recurrent convulsive events.Ī 10 year-old young man who had suffered from recurrent idiopathic “seizures” since he was one year of age was referred for evaluation. Due to the recurrent nature of their convulsive events, lack of a response to anti-seizure medications, and normal cardiac evaluations patients were referred to our center for further evaluation. We report on three patients who were initially diagnosed with recurrent seizures due to epilepsy. Currently, the majority of patients suffering from “seizure like” episodes are diagnosed as having epilepsy purely on clinical grounds, often without extensive cardiovascular investigations and without corroborating electroencephalographic (EEG) evidence 9, 10. Schott et al 8 found that 20% of patients diagnosed with idiopathic epilepsy actually had a cardiac arrhythmia as a cause of their convulsive events. Gastaut et al 7 has estimated that as many as one third of patients initially diagnosed with epilepsy actually had a cardiovascular cause of their convulsive episodes. The exact frequency at which patients with non-epileptic convulsive disorders are misdiagnosed as having epilepsy is unclear 3, 4, 5, 6. Indeed, the difficulty in distinguishing epileptic seizures from other conditions that can cause convulsive activity has been long recognized 3, 4. A variety of cardiac rhythm disturbances will create a state of cerebral hypoxia that can be manifested by convulsive activity that may be difficult to distinguish from epileptic seizure activity. However recent studies have suggested that as many as 20% to 30% of these individuals have an occult cardiovascular cause of their convulsive events. It has been estimated that up to three percent of the US population suffers from recurrent convulsive episodes that are usually thought to be seizures due to epilepsy 1, 2. In all patients their convulsive episodes were eliminated by permanent pacemaker implantation.Ĭonclusion: In patients with refractory “seizure' like episodes of convulsive activity of unknown etiology a potential cardiac rhythm disturbance should be considered and can be easily evaluated by ILR placement. In each patient placement of an implantable loop recorder (ILR) demonstrated that their convulsive episodes were due to prolonged periods of cardiac asystole and/or complete heart block. ![]() Although each patient had undergone extensive evaluation, no other potential cause of his or her seizure like episodes had been uncovered. Methods: We report on three patients who suffered from recurrent convulsive episodes, thought to be epileptic in origin, who were refractory to antiseizure therapy. Failure to identify these patients delays the provision of adequate therapy while at the same time exposes the individual to the risk of injury or death. Introduction: Not all convulsive episodes are due to epilepsy and a number of these have a cardiovascular cause. ![]()
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