Autonomic dysfunction related to seizures may give rise to a broad spectrum of cardiovascular abnormalities. Among these, ictal bradycardia and conduction delays may be encountered. Failure to recognize these abnormalities may contribute to sudden, unexplained death in epilepsy patients. We report a case of a Haitian female with temporal lobe epilepsy associated with recurrent sinus pauses.
Epilepsies are known to alter autonomic function during the ictal, postictal, and interictal periods. Autonomic function at both sympathetic and parasympathetic levels may be affected. These effects may give rise to a broad spectrum of cardiovascular abnormalities. We report a case of a Haitian female with temporal lobe epilepsy associated with recurrent sinus pauses.
A 58-year-old Haitian female with known history of hypertension was admitted for severe bilateral lower extremity weakness. CT scan of the thoracolumbar spine revealed severe kyphosis of T10-T11 secondary to anterior collapse of the T11 vertebral body. She received intravenous steroids and was evaluated for surgical intervention. She eventually underwent T11 corpectomy, fusion of T10-T12, implantation of biomechanical device at T11, anterior instrumentation of T10-12, and posterolateral fusion of T8-L3. Bone biopsy revealed evidence of osteomyelitis. She was started on a 42-day course of antibiotics. After surgery, she was noted to be increasingly lethargic and confused. Rapid response was called when she developed a complex partial seizure with secondary generalization. The seizure was terminated upon administration of intravenous Ativan. She was given a 1500 mg loading dose of Keppra followed by 500 mg twice daily maintenance dose. EKG monitoring during the seizure episode revealed sinus bradycardia, which eventually progressed to a 10-second sinus pause, approximately 20 seconds after seizure onset (Figure
Telemetry tracing during the seizure episode, revealing sinus bradycardia, which eventually progressed to a 12-second pause.
EEG revealing evolution of seizure, beginning with right temporal periodic lateralized epileptiform discharges (PLEDs) and then right temporal rhythmic sharp waves (a), followed by more widespread epileptiform activity (b).
MRI of the brain showing a large area of gyral edema, sulcal effacement, and cortically based diffusion restriction involving the right occipital lobe and right posterior temporal and parietal lobes (indicated by RED arrow).
Epileptiform activity from the amygdala, anterior cingular cortex, and insula of the temporal lobe can produce cardiac rate and rhythm abnormalities [
Changes in heart rate are frequently observed during seizure episodes [
There is no absolute agreement on laterality of seizure onset and degree of cardiovascular dysfunction. Oppenheimer et al. [
EKG rhythm abnormalities may occur in 35% of generalized seizures [
Ictal bradycardia is seen primarily in seizures involving the temporal lobe but may occur particularly with bilateral spread of seizure activity [
Temporal lobe epilepsy is associated with autonomic and cardiovascular dysfunction. This may take the form of changes in cardiac rate and rhythm. While increases in heart rate are more common, ictal bradycardia should also be carefully detected and addressed, to prevent progression into cardiac asystole. Early suspicion and recognition of these events may aid the clinician in averting sudden, unexplained death in epilepsy.
The authors declare that there is no conflict of interests regarding the publication of this paper.