Subclinical Tonic-Clonic Epileptic Seizure Detected by an Implantable Loop Recorder

Abstract

SummaryA 73-year old man received an implantable loop recorder (ILR) for the evaluation of transient loss of consciousness (TLOC) spells. His medical history was without any epileptic convulsions or automatism. ILR recording during a spontaneous episode revealed the presence of a regular, narrow QRS complex tachycardia associated with low-amplitude, high-frequency, continuous or discontinuous artifacts, consistent with myopotentials. During the event, the regular, lowamplitude continuous signals gradually became discontinuous, with a prolongation of the inter-signal cycle length, until their disappearance after manual activation of the ILR. The patient was diagnosed as experiencing subclinical tonic-clonic epileptic seizures. Antiepileptic drug treatment was initiated, and the patient has remained free of TLOC symptoms during 13 months follow-up. (Int Heart J 2013; 54: 289-291) Key words: Epilepsy, Syncope, Loss of consciousness T he implantable loop recorder (ILR) is a useful instrument for detection of heart rhythm disturbances in patients with transient loss of consciousness (TLOC) spells of unknown origin. For the most part ILRs have proven to be of greatest value in determining an arrhythmic basis for syncope, 1,2) and on occasion have been helpful in demonstrating that certain patients believed to be suffering from epilepsy, but whose symptoms are 'drug-refractory', may in fact be suffering from syncope.3) However, the ability of an ILR to unmask a seizure disorder in patients in whom the cause of TLOC is undetermined despite the usual investigations has been largely overlooked.Previous reports of ILR use in recurrent transient loss of consciousness (TLOC) in drug refractory epileptic patients have been published, and an association between ILR recorded myopotentials and clinically documented convulsive symptoms have been observed. 4,5) The present case describes a patient presenting with TLOC in the absence of apparent convulsions, in whom ILR monitoring detected myopotentials consistent with a subclinical epileptic seizure. Case ReportA 73-year-old man with a history of prior remote myocardial infarction and a 4-month-old hemorrhagic cerebral infarction was referred for evaluation of TLOC. The episode was characterized by sudden skin pallor followed by an abrupt fall onto the floor from a seating position in absence of convulsion. The episode lasted approximately 30 to 60 sec, and the patient regained consciousness immediately but sustained facial injuries from the fall. He denied having experienced palpitations or chest pain before or after the spell. His wife, who witnessed the episode, reported that the patient suddenly became pale and unresponsive to verbal stimuli; however, she did not observe any evidence of automatism or tonic-clonic movements. There was no report of epilepsy in the patient's family history.Blood pressure on admission was 114/82 mmHg and heart rate was 72 bpm and regular. A general physical examination and detailed neurologic assessment, including orthostatic vital signs, were ...

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