a b s t r a c t

Acute seizures represent 1% of all visits to emergency departments in the United States. While many acute sei- zures are correctly attributable to underlying epilepsy, approximately one-third of acute seizures are provoked by underlying and potentially life-threatening Acute conditions. Many clinical syndromes associated with Seizure-like activity are well-established and readily identified in the acute setting. cardiac dysrhythmias are known causes of acute seizure-like activity and, if transient and not captured by electrocardiogram tracings dur- ing acute episodes, may be incorrectly diagnosed as Epileptic seizures. We report a case of acute ST-segment el- evation myocardial infarction presenting with acute symptomatic seizure due to occult transient cardiac dysrhythmia.

(C) 2017

Introduction

Seizures, or acute convulsive disorders, are common occurrences in emergency department (ED), accounting for approximately 1% of all ED visits in the United States [1]. Seizures may be further defined as proximately unprovoked (e.g. epilepsy) or acutely provoked (e.g. acute symptomatic seizure, and acute convulsive syncope). The lifetime incidence of any acute seizure approaches 10%, of which approximately one-third is attributable to acute symptomatic (provoked) seizures [2]. While epileptic seizures are proximately unprovoked, they may occur following remote epileptogenic events, and are associated with a high likelihood of recurrence. In contrast, acute symptomatic seizures occur immediately after an acute systemic insult [3]. Acute symptomatic sei- zures are most commonly associated with head trauma, acute cerebro- vascular events, intracranial infections and withdrawal syndromes (most commonly alcohol withdrawal). Less frequently, metabolic insult consequent of electrolyte or osmolar aberrations, or following hypoxic events, may precipitate acute symptomatic seizures [4]. Cardiac dys- rhythmias are a rare, but known, precipitant of acute symptomatic sei- zures, presumably due to hypotension-induced cerebral hypoxic insult. Sabu et al. described a patient with ventricular tachycardia pre- senting with seizure [5]. Yin et al. reported a similar case of acute seizure

* Corresponding author at: Department of Emergency Medicine, George Washington University, Medical Center, 2120 L St., Washington, DC 20037, United States.

E-mail address: [email protected] (A. Pourmand).

following Polymorphic ventricular tachycardia [6]. While similar re- ports of acute symptomatic seizure have been described in cases of non-arrhythmic cardiogenic shock, no prior reports describe seizure as an associated symptom in acute coronary syndrome. We report a pa- tient with acute symptomatic seizure secondary to acute ST-segment el- evation myocardial infarction.

Case report

A fifty-eight-year-old male patient presented to the ED with a chief complaint of chest discomfort, dyspnea and diaphoresis, all of which began 2 h prior to arrival. He described his chest discomfort as severe, substernal chest pain, with associated defecation urgency. He reported no past medical history, denied medication use, and denied use of to- bacco products. His initial recorded heart rate and blood pressure were 76 bpm, and 140/80 mm Hg respectively. He was afebrile. An elec- trocardiogram was obtained, confirming sinus rhythm with anterolater- al and inferior ST-segment elevations, consistent with acute ST-segment elevation myocardial infarction . (Fig. 1) While providing con- sent for emergent percutaneous coronary intervention (PCI), the patient experienced acute, transient loss of consciousness (TLOC) with general- ized tonic-clonic seizure-like movements. The patient regained con- sciousness without alterations in arousal, motor function or sensation, within 30 s of seizure-onset. (Fig. 2) He was then emergently trans- ferred to the cardiac procedural suite. Coronary angiography revealed 100% occlusion of the right coronary artery , and 80% occlusion of the left anterior descending coronary artery , both of which were managed with PCI. He was discharged home following a two- day observation period in the cardiac care unit, without complication.

https://doi.org/10.1016/j.ajem.2017.10.013

0735-6757/(C) 2017

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Fig. 1. ECG displaying anterolateral and inferior acute ST-elevation myocardial infarction .

Discussion

Our case describes a patient with an acute symptomatic seizure oc- curring in the setting of an acute myocardial infarction complicated by ventricular fibrillation. In this case, the acute symptomatic seizure oc- curred immediately following a systemic provocation, thus differentiat- ing it from an unprovoked (e.g. epileptic) seizure. The significance of acute symptomatic seizures was demonstrated in a population study of all acute seizures diagnosed in both inpatient and outpatient settings in a single US city over a 50-year period. The authors reported acute symptomatic seizures represented roughly one-third of all acute seizures diagnosed during the study period [4]. While many acute symptomatic seizures occur in the setting of readily identifiable conditions (e.g. hypoglycemia, ethanol withdrawal, traumatic intracranial hemorrhage), our patient represents a case of transient ce- rebral hypoxia leading to seizure. Previously published case reports de- scribe acute symptomatic seizures following confirmed ventricular tachydysrhythmias [5,6]. A case published by Cunningham et al. de- scribed a patient who developed seizure in the setting of cardiac arrest in Takotsubo cardiomyopathy with ventricular fibrillation [7]. Still, others have suggested a high incidence of underlying cardiac disease precipitating seizure-like events. In a review of 50 patients referred for evaluation of possible epilepsy, 20% of all cases were found to have

cardiac dysrhythmias in association with seizure-like activity [8]. In an- other study of 12 patients who were previously diagnosed with epilep- sy, Linzer et al. reported that further evaluation revealed dysrhythmia- mediated syncope or reflex syncope associated with convulsive activity in all cases [9]. Some authors have questioned the diagnosis of acute sei- zure in cases of seizure-like activity associated with transient decreases in cardiac output, as occurs in acute cardiac dysrhythmias. They suggest such seizure-like activity may represent a distinct entity, more accurate- ly termed convulsive syncope [10,11]. Seizure-like convulsions follow- ing syncope of cardiac, reflex or orthostatic origin, they argue, are more often associated with electrocardiogram findings of generalized slowing rather than epileptiform discharges as can be seen in epilepsy [12]. However, while disagreement on terminology of acute provoked seizure-like events exists, the importance of identifying underlying causal associations is clear. Inappropriate attribution of acute symptom- atic seizures and convulsive syncope to a new diagnosis of epilepsy can have life-threatening consequences [13]. This case highlights the need to consider the diagnosis of acute provoked seizure secondary to poten- tially life-threatening underlying conditions in patients presenting with symptoms suggestive of epileptic seizures. This case further emphasizes the value of thorough History taking, and screening for coronary ische- mia and cardiac dysrhythmias, to differentiate acute symptomatic sei- zures from epilepsy in patients presenting with seizure-like activity.

Fig. 2. Ventricular fibrillation status post STEMI, presenting with Seizure like activity.

A. Pourmand et al. / American Journal of Emergency Medicine 36 (2018) 169.e1-169.e3 169.e3

Author disclosure statement

No competing financial interests exist.

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