To follow head or heart, an interesting case presentation

Background

The most important diagnostic problem in epileptology is to distinguish epileptic seizures from syncope. The diagnosis of episodic altered consciousness rests largely with the clinical history and neurophysiology.

We present an interesting case of a 12-year-old boy who was initially treated for epilepsy.

Objective

To review the timeline of events and how the diagnostic conclusion was made in association with the history of seizures.

Methods

Retrospective review of the patients` medical records.

Results

A 12-year-old boy was assessed in epilepsy clinic following a generalised tonic clonic seizure. He had possible recurrent seizures as a toddler and had been seizure free for 8 years. A clinical diagnosis of epilepsy was considered. ECG was normal; MRI showed an incidental sub-cortical right inferior frontal lobe cyst. During standard EEG, on photic stimulation, he had a generalised tonic clonic seizure; the ECG recording on the EEG was noted to have a progressive bradycardia leading to a 6 seconds pause preceding the seizure, with no epileptiform activity. The diagnosis of epilepsy was revised to a diagnosis of a possible dysrhythmia. A 72-hour ECG recording was performed; during an incidental venepuncture procedure he had an 8 second pause on his ECG, culminating with a tonic clonic seizure. A diagnosis of severe neurocardiogenic syncope was made and he was commenced on Atropine 500micrograms TDS. Due to the infrequency of seizures the patient will be followed up as an outpatient to make a decision on whether he will require pacemaker insertion.

Conclusion

Neurocardiogenic syncope can present as a seizure disorder and history alone may not be sufficient to make a confident diagnosis, which can be difficult. Careful interpretation of relevant investigations may aid in making the right diagnosis; our case demonstrates the importance of interpreting the simultaneous ECG on an EEG recording.