The wisdom of a broken heart is leading to the head: Seizure evoked autonomic dysregulation could lead to life threatening symptoms

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Background:
A seizure is a hypersynchronization of cerebral cortical neuronal networks. Of the neurological symptoms and signs, a less well-known consequence is autonomic dysregulation. This case report describes seizure-related autonomic dysregulation leading to an out of hospital cardiac arrest (OHCA).
Case report:
A 70-year-old patient, with no cardiac or neurologic history presented with episodes of collapses, eventually culminating in an OHCA due to asystole. After resuscitation and the placement of pacing wires, an extensive investigation of the cardiovascular system was conducted, but no cardiac causes were found.
It was however, noticed that a focal seizure preceded periods of bradycardia and asystole. Due to the short-lived nature of the phenomenon, no EEG could be recorded. An MRI was performed where a right-sided temporoparietal cerebral lesion was seen, leading to a working diagnosis of post-ictal asystole.
The lesion, a Low-Grade Glioma, was resected under a TIVA anesthetic. The procedure was uncomplicated. No seizures or autonomic disturbances were observed during the peri-operative period.
Discussion:
The pathophysiology of seizure elicited autonomic dysfunction is not well understood. The central autonomic network (CAN, figure 1) plays a pivotal role in the regulation of the autonomic nervous system. It is organized into the forebrain, the brain stem, and the spinal system(1). Its involvement in epilepsy impedes its normal functioning, eventually leading to overexpression of sympathetic and parasympathetic output centers (rostral ventrolateral medulla (RVLM) and nucleus ambiguous (nAmb)) respectively. This leads to autonomic dysfunction.
In this patient, parasympathetic overactivity, due to seizure evoked CAN dysfunction, resulted in extreme bradycardia leading to OHCA.
Learning points:
During the immediate care of a patient with a seizure, be aware of potentially serious autonomic dysregulation that can cause severe bradycardias or even asystole.
Originele taal-2English
TijdschriftEuropean Journal of Anaesthesiology
StatusUnpublished - dec-2021

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