Fazila Aseem1, Fatemeh Sadeghifar1, Boyi Li2, Nicole Silva2, Benjamin Cho3, Yasmeen Rauf1, Clio Rubinos1, Albert Hinn1
1Neurology, 2Neurosurgery, 3Pathology, University of North Carolina at Chapel Hill
Objective:
To report electrographic seizures (ESs) and recurrent syncopal episodes due to ictal asystole (IA) in a patient with multifocal glioblastoma (mGBM).
Background:
IA is the absence of ventricular complexes for ≥ 4 seconds, coinciding with ESs. This cardio-neural phenomenon is observed in up to 0.4% of patients undergoing continuous electroencephalography (cEEG). To our knowledge, this is the first case of IA in a mGBM patient with multifocal ESs.
Results:
A 71-year-old man with history of obstructive sleep apnea and chronic sinus bradycardia was hospitalized for unresponsiveness at home and transient receptive aphasia with right superior quadrantanopia upon presentation. During hospitalization, he had several bradycardic and asystole events for which atropine was administered with uncertain efficacy. MRI brain showed mass lesions in the left temporal, parietal, and occipital lobes with cortical enhancement in the left temporal lobe. Serum studies, serial cerebrospinal fluid analyses, and cardiac workup were unremarkable. Continuous cardiac and EEG monitoring identified an ES over the left frontal region, associated with 23-seconds of asystole, establishing the diagnosis of IA. The patient was started on levetiracetam. Four days later, valproic acid was added for left occipital ESs without cardiac telemetry changes. The patient underwent left craniotomy for occipital biopsy and resection, with a confirmed diagnosis of GBM on pathology. He was started on chemo- and radiation therapies with improvement of his lesions. Over the last ten months, the patient has been on anti-seizure medications and has not experienced any bradycardic or syncopal episodes, eliminating the need for a pacemaker.
Conclusions:
IA is a rare and fatal cause of unexplained recurrent syncope. Capturing syncopal events on cardiac telemetry and cEEG is essential for diagnosis, especially for patients with multifocal ictuses for seizures. Neurologists and cardiologists should be aware of this phenomenon as timely and accurate diagnosis is critical for optimal management.