EEG findings during tilt-table induced asystole: a case report (original) (raw)
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Syncope and seizures of psychogenic origin: Identification with head-upright tilt table testing
Clinical Cardiology, 1992
Psychogenic seizures and psychogenic syncope are common disorders but are difficult to identify. Head-upright tilt table testing has emerged as a promising means of evaluating vasovagally mediated syncope and convulsive syncope. Of a total of 42 patients evaluated by head-up tilt for recurrent syncope and 10 evaluated for recurrent idiopathic seizures, a total of 5 patients experienced syncope and 3 had tonic-clonic seizure activity unaccompanied by any significant changes in blood pressure, heart rate, transcranial Doppler cerebral blood flow velocity, and electroencephalographic monitoring. Psychiatric evaluation revealed that seven patients suffered from conversion reactions and one from probable malingering. We conclude that patients who pass out or convulse during head-upright tilt without any change in physiologic parameters can be presumed psychogenic in origin and may be referred for psychiatric evaluation without further expensive diagnostic studies.
Background: Patients with loss of consciousness and convulsion often have the diagnosis of epilepsy despite normal electroencephalograms (EEGs). Objective: To evaluate the proportion of patients referred to neurologists with presumed epilepsy and normal EEGs who have an alternative cause of syncope. Methods: It was a cross-sectional study of 55 consecutive patients aged 6-85 (41 ± 24) years presenting with faints, falls, convulsions, and normal EEGs, who were referred to neurologists before going to cardiologists. All patients underwent clinical examination, electrocardiogram, and echocardiogram. Head-up tilt table testing (HUT), 24-hour-Holter, and carotid sinus massage was offered as needed. Electrophysiological studies were undertaken in patients with structural heart disease or severe palpitations. Results: Anticonvulsant agents had been prescribed to 35 patients (64%) before entering the study. Vasovagal syncope was found in 22 (40%) patients, life-threatening arrhythmias in seven (13%), carotid sinus hypersensitivity in six (11%), orthostatic hypotension in three (5%), and aortic stenosis in one (2%). Etiology of syncope could not be found in 16 (29%) patients. Arrhythmias comprised two complete atrioventricular blocks, one sustained monomorphic ventricular tachycardia, one ventricular fibrillation, one atrial tachycardia, and two atrioventricular node reentrant tachycardias. Two patients developed a prolonged asystole during HUT. Presumptive diagnosis of syncope was found in 39 patients (71%). Patients on or off anticonvulsant drugs had 64% and 84% diagnosis of syncope, respectively (odds ratio = 0.33; 95% confidence interval 0.08-1.36; P = 0.13).
Variable Cerebral Dysfunction During Tilt Induced Vasovagal Syncope
Pacing and Clinical Electrophysiology, 1998
AMMIRATI, F., ET AL.: Variable Cerebral Dysfunction During Tilt Induced Vasovagal Syncope. Electroencephalographic (EEG) monitoring was performed during head-up tilt testing (HUT) in a group of 63 consecutive patients (27 males, 36 females, mean age 41.5 years) with a history of recurrent syncope of unknown origin despite extensive clinical and laboratory evaluation. Syncope occurred in 27/63 patients (42.8%) during HUT and was cardioinhibitory in 11/27 (40.7%) and vasodepressor in 16/27 (59.3%). All patients with a negative response to HUT had no significant EEG modifications. In patients with vasodepressor syncope a generalized high amplitude 4-5 Hz (theta range) slowing of EEG activity appeared at the onset of syncope, followed by an increase in brain wave amplitude with a reduction of frequency at 1.5-3 Hz (delta range). The return to the supine position was associated with brain wave amplitude reduction and frequency increase to 4-5 Hz, followed by restoration of a normal EEG pattern and arousal (mean total duration of syncope 23.2 s). In patients with cardioinhibitory syncope, a generalized high amplitude EEG slowing in the theta range was noted at the onset of syncope, followed by a brain wave amplitude increase and slowing in the delta range. A sudden reduction of brain wave amplitude ensued leading to the disappearance of electroencephalographic activity ("flat" EEG). The return to the supine position was not followed by immediate resolution of EEG abnormalities or consciousness recovery, both occurring after a longer time interval (mean total duration of syncope 41.4 s). EEG monitoring during HUT allowed the recording and systematic description of electroencephalographic abnormalities developing in the course of tilt induced vasovagal syncope. (PACE 1998; 2l[Pt. II):2420-2425
Clinical Neurophysiology, 2018
h i g h l i g h t s Simultaneous EEG recording during tilt table studies does not have significant clinical impact. Not all patients with syncope have EEG changes at the time of the syncope. EEG changes are not seen in other symptomatic orthostatic syndromes. a b s t r a c t Objective: To assess electroencephalography (EEG) changes during tilt table testing in syncope and other orthostatic syndromes. Methods: We retrospectively reviewed consecutive tilt table studies with simultaneous EEG from April 2014 to May 2016 at our center. All patients had video EEG during tilt table. All patients had at least 10 min of head up tilt unless they had syncope or did not tolerate the study. Video EEG was interpreted by epileptologists. Results: Eighty-seven patients met the inclusion criteria. Mean age was 45 years, and 55 were women. Seven patients (8%) had syncope during tilt table, 11 patients (12%) had significant neurogenic orthostatic hypotension and a separate group of 11 patients (12%) had significant orthostatic tachycardia. Valsalva responses were abnormal in 7 of the 11 patients with orthostatic hypotension, suggesting an underlying neurogenic orthostatic hypotension. Visually discernable EEG changes were seen in only 3 patients (43%) who had syncope and in 1 patient (9%) with orthostatic tachycardia. Conclusions: Qualitative EEG analysis based on visual inspection during tilt table study revealed abnormalities in less than half the patients with syncope and a very small fraction with orthostatic tachycardia. Significance: Routine qualitative EEG recording might not be clinically useful during tilt table studies.
Electroencephalographic Correlates of Vasovagal Syncope Induced by Head-Up Tilt Testing
2000
Background and Purpose— We sought to determine whether the introduction of EEG monitoring during head-up tilt testing could significantly improve the understanding of the cerebral events occurring during tilt-induced vasovagal syncope and the potential danger to the patient of this diagnostic procedure. Methods— EEG monitoring was performed during head-up tilt testing in a group of 63 consecutive patients (27 males
Convulsive syncope: a condition to be differentiated from epilepsy
Epileptic disorders : international epilepsy journal with videotape, 2009
The clinical presentation of epilepsy and syncope can be confusingly similar. We present a patient with reflex syncopal episodes that mimic seizures using video-EEG recordings. During the episodes, head/eye deviations, automatisms and dystonic movements, suggesting an epileptic seizure, were observed. The EEG revealed diffuse slow waves when the patient lost consciousness and complete cessation of the cerebral activity occurred when the dystonic movements started. On ECG recordings, bradycardia, followed by complete asystolia lasting for 40 seconds, was observed. We conclude that the differential diagnosis of epilepsy and syncope can be quite misleading and clinical features may not always be reliable. In cases where diagnosis is uncertain, circulatory and cardiac causes should always be kept in mind and video-EEG with simultaneous cardiac recordings are mandatory for accuracy of diagnosis.
Transient loss of consciousness: The value of the history for distinguishing seizure from syncope
Journal of Neurology, 1991
We studied 94 consecutive patients (age 15 or over) to investigate which aspects of the history and clinical findings help to distinguish seizures from synope and related conditions. Clonic movements or automatism observed by an eyewitness classified an event as a seizure. The seizure group consisted of 41 patients and the syncope group of 53 patients. The likelihood ratio was used to calculate the predictive power of single findings and logistic regression to analyse combinations of findings. The best discriminatory finding was orientation immediately after the event according to the eyewitness and the age of the patient in the absence of an eyewitness report (P < 0.001). We found a seizure five times more likely than syncope if the patient was disoriented after the event and three times more likely if the patient was less than 45 years of age. Nausea or sweating before the event were useful to exclude a seizure. Incontinence and trauma were not discriminative findings.
Asystolic Cardiac Arrest During Head-Up Tilt Test: Incidence and Therapeutic Implications
Pacing and Clinical Electrophysiology, 1997
Asystolic Cardiac Arrest during Head-Up Tilt Test: Incidence and Therapeutic Implications. Occasionally, the cardioinhibitory response may be profond during tilt induced syncope. Whether this response is associated with more severe symptoms or predicts a poor response to pharmacotherapy remains controversial. The aim of this study was to characterize patients with vasovagally mediated asystole occurring during head-up tilt test and to evaluate the respective interests of sequential pacing and ^-Mockers to treat them. We performed 60° tilt testing in 179 consecutive patients with unexplained syncope (91 women and 88 men, age 36.6 ± 20.1 years). Asystole was defined as a ventricular pause > 5 seconds. AH patients with tilt induced asystole received therapy with either ^-Mockers or sequential pacing, the efficacy of which was evaluated with serial tilt tests. Of 77 patients with positive tilt test, 10 developed syncope related to asystole (mean duration 11.9 ± 4.9 s), 2 with spontaneous recovery, and 8 with seizures needing a brief cardiopulmonary resuscitation. When compared with patients without asystole, asystolic patients had more severe symptoms (seizures: 6/10 vs 9/67, P = 0.05, injury: 9/10 vs 27/67, P = 0.0048). In the first six patients in whom cardiac pacing was considered, syncope or presyncope still occurred despite atrioventricular pacing at 45 beats/min. Five of these 6 patients, as well as the remaining 4 asystolic patients, were tilted with ji-biockers: 3 patients became tilt-negative; 3 were significantly improved; and 3 did not respond. During follow-up (mean 22.7 ± 11.7 months) with every patient taking (3-b!ockers and seven having a permanent pacemaker, no syncopal recurrence was observed. Tiltinduced asystole that may require resuscitative maneuvers occurs especially in patients with a history of seizures or injury. Therapy with (i-blockers is often effective to prevent induction of syncope as well as recurrences.
Journal of Neurology, Neurosurgery & Psychiatry, 1991
Syncope and related conditions where cerebral blood flow is impaired are usually distinguished from seizures on the history alone. The wide variety of epileptic manifestations and the clonic jerks that may be seen in fainting patients cause problems.' 2 When the diagnosis remains in doubt, other diagnostic tests are needed. The finding of epileptiform activityspikes, spike-waves, sharp waves-in the EEG must reinforce the diagnosis of a seizure,3-5 though the extent remains uncertain, as some patients with this finding never have seizures.6 Anxiety or hyperventilation attacks are mistaken for seizures.79 Many of the so-called pseudoseizures are actually hyperventilation attacks.'0 When associated with fainting the differentiation from epilepsy is particularly difficult." A hyperventilation test provoking characteristic symptoms (such as paresthesia, giddiness and dyspnoea) is used for the diagnosis. Does this test really help to distinguish seizure from (hyperventilation) syncope? Cardiac syncope may be mistaken for a seizure.'2 '3 An ECG cannot exclude cardiac syncope, but may suggest a cardiac disorder. We carried out a prospective study of patients with transient loss of consciousness to assess the diagnostic value of a single interictal EEG, of the hyperventilation test, of a standard ECG and of the routine laboratory examination. Methods