Authors :
Presenting Author: Fawad Khan, MD – International Center for Epilepsy at Ochsner, Ochsner Health System, New Orleans, LA
Fawad A Khan - International Center for Epilepsy at Ochsner, Ochsner Health System, New Orleans, LA; The University of Queensland School of Medicine, Ochsner Clinical School, New Orleans, LA; Tulane University School of Medicine, New Orleans, LA; Masoud Yeganegi - International Center for Epilepsy at Ochsner, Ochsner Health System, New Orleans, LA; Marika Antimisiaris - International Center for Epilepsy at Ochsner, Ochsner Health System, New Orleans, LA; Nadia Siddiqui - The University of Washington School of Medicine; Syed I Hussaini - Department of Medicine, Insight Hospital and Medical Center Chicago, Chicago, IL; Saher Taj Shiza - Department of Medicine, Lincoln Medical Center, Bronx, NY; Samuel L. Carter - Neurocritical Care Division, Ochsner Health System, New Orleans, LA
Rationale:
Cardiac rhythm abnormalities are among the autonomic changes that can occur during focal seizures. Atrial fibrillation (AFib) and atrial flutter following epileptic seizures has only rarely been reported in the literature. The study aims to explore the relationship between the propagation of focal seizures observed during phase II evaluation with SEEG and the development of AFib in a patient with no prior history of cardiac rhythm abnormalities.
Methods:
We describe a case of a 21-year-old male with treatment resistant focal epilepsy since the age of 12 and no prior history of cardiac disease. Past medical history included obesity. His seizures were characterized by painful somatosensory aura followed by tonic stiffening of the right lower extremity with preserved awareness. Infrequently they progressed to generalized tonic-clonic seizures. After phase 1 evaluation, the hypothesis suggested a parietal lobe versus insular epilepsy in the left hemisphere. At the time of phase II evaluation with SEEG (9 intracranial leads - 8 left and 1 right), he was taking Levetiracetam, Lacosamide, and Oxcarbazepine. Oxcarbazepine and Levetiracetam were discontinued. Results:
SEEG captured four seizures with electrographic onset involving the electrode sampling of the postcentral gyrus in the topographic distribution of the leg within a span of four hours. During the first seizure, propagation to the posterior insular cortex with observed 4-8 hz evolving spike and wave activity was associated with tachyarrhythmia. This evolved to AFib with RVR (HR > 200). During the subsequent three seizures there was no improvement in the ongoing tachyarrhythmia despite two treatments of lorazepam and four treatments of metoprolol 5 mg. The AFib was subsequently treated successfully with continuous intravenous diltiazem infusion resulting in return of sinus rhythm (HR 60-80). Antiseizure medications were resumed at original doses. Two additional seizures were not associated with rhythm abnormalities. Cortical stimulation identified eloquent function in the seizure onset zone. Patient is planned to undergo implantation of responsive neurostimulator.
Conclusions:
This observation raises concerns about the morbidity and mortality of cardiac events associated with seizures. Growing evidence suggests the role of cardiac arrythmias in the mechanisms for SUDEP. Furthermore, patients with focal epilepsy have a higher risk of sudden cardiac death. Our observations actively contribute to this perilous situation by urging clinicians to assess for AFib, as in many cases it may remain asymptomatic, as it significantly elevates the risk of stroke.
Funding: None