Abstracts

Rationale: Reflex Anoxic Seizures (RAS) occur when a stimulus leads to a temporary vagally mediated sinus arrest, causing cerebral hypoperfusion and convulsions. These episodes can be mistaken for epileptic seizures, resulting in mismanagement of patients. In this case report, we present an 18-year-old patient with needlestick-induced episodes of RAS. This case is presented to show the importance of clarification in diagnosis for patients presenting with seizure-like episodes. Additionally, the case demonstrates the use of intranasal midazolam as a preventative medication for RAS.

Methods: This is a case report with one patient. She presented with a history of seizure-like episodes. She described triggers including venipuncture, vaccinations, and accidental cuts. No anticonvulsant drugs had been tried. The patient was admitted to the epilepsy monitoring unit for evaluation, with continuous video EEG. MRI of the brain was done as well.

Results: MRI of the brain was non-lesional for seizures. Two typical episodes were recorded during the admission. Each episode was triggered by medical needlestick. The patient first developed pallor, followed by loss of consciousness and 30 seconds of tonic clonic movements. On monitoring, the patient was noted to become bradycardic, then asystolic for 30 seconds (see Figure 1 for asystole). EEG showed generalized delta slowing (see Figure 2). She was seen by cardiology and diagnosed with vagally mediated sinus arrest. This is consistent with RAS, with needlestick serving as the trigger to her sinus arrest, leading to anoxic seizures.

Needlestick phobia was considered as a contributing factor to the patient’s episodes. Thus, a trial was done using intranasal midazolam to target her anxiety. The medication was given one minute prior to needlestick, and it successfully prevented an episode. She was discharged home with instructions to use the medication prior to any planned needlesticks.

Conclusions: RAS is an important differential diagnosis when evaluating seizures. A complete history should be taken including potential triggers. Monitoring during an event may show bradycardia and then asystole, with generalized slowing on EEG.

In our patient’s case, administration of intranasal midazolam prior to needlestick prevented an episode. This medication should be considered for other similar patients, especially when there is a history suggesting anxiety or phobia.

Funding: Please list any funding that was received in support of this abstract.: none.