Convulsive syncope: a Stokes-Adams case

Síncope convulsivo: un caso de Stokes-Adams

A 26-year-old male with two-days prior cocaine consumption, presented with a 5-day history of new-onset focal nonmotor dyscognitive epileptic events. After three days of treatment with oral phenytoin (PHT) 100 mg t.i.d., a convulsive status epilepticus developed at the same time a third-degree atrioventricular block was registered (Figures 1 and 2).

Figure 1.
6 consecutive epochs (11:02:28 to 11:03:28) are shown. Montage: Bipolar, longitudinal, double-banana. HF: 70 Hz, LF: 1 Hz, NF: 60 Hz, Sens: 70 μV/cm; 13 seconds after a 10-second ventricular pause, 2‒3 Hz generalized polymorphous slow waves are registered with greater expression in the anterior regions. Following this, a new ventricular pause of 9 seconds appears, which will continue in the following figure.

Figure 2.
The last ventricular pause described in Fig. 1 continues for 17 more seconds (26 in total). Synchronous generalized slow waves are again registered. On the 24^th second, generalized electrodecrement with muscle artifact due to a generalized tonic seizure of 4 seconds of duration. This event ends with the recovery of the heart rhythm and subsequent slow waves in delta range before recovering its alpha rhythm.

As we know, cocaine consumption and PHT (specially in infusions >50 mg/min or previous heart disease) are both related with adverse cardiovascular effects, specially arrhythmias^1,2. Our case exemplifies the lethal combination of both, and the narrow neurological and cardiologic assessment of syncope versus epilepsy in patients with stereotypic paroxysmal episodes^3,4.

References

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  Phillips K, Luk A, Soor GS, Abraham JR, Leong S, Butany J. Cocaine cardiotoxicity: a review of the pathophysiology, pathology, and treatment options. Am J Cardiovasc Drugs. 2009;9(3):177-96. https://doi.org/10.2165/00129784-200909030-00005
  » https://doi.org/https://doi.org/10.2165/00129784-200909030-00005
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  Guldiken B, Rémi J, Noachtar S. Cardiovascular adverse effects of phenytoin. J Neurol. 2016;263:861-70. https://doi.org/10.1007/s00415-015-7967-1
  » https://doi.org/https://doi.org/10.1007/s00415-015-7967-1
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  Ozkara C, Metin B, Kucukoglu S. Convulsive syncope: a condition to be differentiated from epilepsy. Epileptic Disord. 2009 Dec;11(4):315-9. https://doi.org/10.1684/epd.2009.0281
  » https://doi.org/https://doi.org/10.1684/epd.2009.0281
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  Díaz-Castro O, Orizaola P, Vázquez S, Gonzáles-Rios C, Pardo M, Fernández-López JÁ, et al. “Stokes-Adams Epilepsy” Sometimes We Need the Electroencephalogram. Circulation. 2005;112(8):e101-2. https://doi.org/10.1161/CIRCULATIONAHA.104.503144
  » https://doi.org/https://doi.org/10.1161/CIRCULATIONAHA.104.503144

Publication Dates

• Publication in this collection
  29 June 2020
• Date of issue
  Aug 2020

History

• Reviewed
  14 Aug 2019
• Received
  21 Jan 2020
• Accepted
  12 Feb 2020