J Clin Med Res

Journal of Clinical Medicine Research, ISSN 1918-3003 print, 1918-3011 online, Open Access

Article copyright, the authors; Journal compilation copyright, J Clin Med Res and Elmer Press Inc

Journal website http://www.jocmr.org

Case Report

Volume 8, Number 8, August 2016, pages 610-615

Convulsive Syncope Induced by Ventricular Arrhythmia Masquerading as Epileptic Seizures: Case Report and Literature Review

Figure 1. Copy of AICD interrogation showing the occurrence of V-tach/vib. The verical dash line indicates the shock. The trace shows the V-fib episode on the day of admission, which was promptly terminated by ICD.

Figure 2. Blood pressure changes after admission. The heart function continued to worsen during this period as shown by the hypotensive episodes. Patient subsequently stabilized with appropriate medical treatment.

**Table 1.** Laboratory Findings on Presentation
	Result	Normal range
CK: creatinine phospho-kinase; BNP: brain natriuretic peptide; GFR-AA: estimated glomerular filtration rate for African American.
Sodium	131	136 - 146 mEq/L
Potassium	3.0	3.5 - 5.0 mEq/L
Chloride	90	3.5 - 5.0 mEq/L
Bicarbonate	30	23 - 29 mEq/L
Blood urea nitrogen	50	7 - 18 mg/dL
Creatinine	2.29	0.5 - 1.2 mg/dL
Glucose	120	70 - 105 mg/dL
GFR-AA	36	≥ 60 mL/min/1.73 m²
Hemoglobin	13.6	M: 13.5 - 17.5 g/dL
Hematocrit	43.7	M: 41-53%
Troponin I	0.07 → 0.06 → 0.04	< 0.4 ng/mL
CPK	58 → 55 → 44	38 - 120 ng/mL
BNP	196	< 100 pg/mL

Table 1. Laboratory Findings on Presentation

Result

Normal range

CK: creatinine phospho-kinase; BNP: brain natriuretic peptide; GFR-AA: estimated glomerular filtration rate for African American.

Sodium

131

136 - 146 mEq/L

Potassium

3.0

3.5 - 5.0 mEq/L

Chloride

3.5 - 5.0 mEq/L

Bicarbonate

23 - 29 mEq/L

Blood urea nitrogen

7 - 18 mg/dL

Creatinine

2.29

0.5 - 1.2 mg/dL

Glucose

120

70 - 105 mg/dL

GFR-AA

≥ 60 mL/min/1.73 m²

Hemoglobin

13.6

M: 13.5 - 17.5 g/dL

Hematocrit

43.7

M: 41-53%

Troponin I

0.07 → 0.06 → 0.04

< 0.4 ng/mL

CPK

58 → 55 → 44

38 - 120 ng/mL

BNP

196

< 100 pg/mL

**Table 2.** Characteristics of Syncope Versus Seizures (Adapted From [13, 15, 30, 31, 34, 37, 38])
	Syncope	Seizures
*In the presence of convulsion, postictal drowsiness may not differ between patients with or without syncope [37]. GTCS: generalized tonic-clonic seizure; SGTCS: secondarily generalized tonic-clonic seizure; HTN: hypertension; CAD: coronary artery disease; N/V: nausea/vomiting; CK: creatinine kinase.
Before spells
Precipitants	Frequent, prolonged standing/sitting, violent coughing, pain, micturation, defecation, warn/hot environment, exertion, antihypertensive drugs, blood loss, venipuncture, alcohol, HTN, CAD	Rare, stress
Prodrome	Gradual evolution, especially in young patients: N/V, abdominal discomfort, heat/cold, sweating, chest pain, dyspnea, light-headedness, headache, blurred vision, amaurosis, tinnitus, weakness	Deja vu, preoccupation, hallucination, mood changes, somatosensory auras, trembling
Position	Usually standing or sitting	Any
Blanks	“Fading away” in young, or abrupt loss in elderly patients	Abrupt loss
During spells
Falls	Slow, flaccid	Fast, tonic
Skin	Pale	Blue face, sometimes acrocyanosis
Convulsion	Common, start after LOC, prolonged, arrhythmic, asynchronous, small	Typical, coincide with LOC, short, rhythmic, synchronous, coarse
Automatism	Rare, short, solitary	Common
Tongue biting	Uncommon, tip of tongue	Common, side of tongue
Eye deviation	Transient lateral or upward	Sustained lateral
Incontinence	Common	Common
Duration	3 - 30 s	GTCS: 30 s - 5 m SGTCS: 16 - 108 s
After spells
Postictal state*	Short, mostly last < 30 s	Prolonged confusion, 2 - 20 m
Physical findings	Bradycardia, hypotension	Focal neurological abnormalities
Laboratory	Normal CK, prolactin	Increased CK, prolactin
Cardiac arrhythmia	Common	Rare, except sinus tachycardia
EEG	Slow, flat waves	Focal or general spike activity

Table 2. Characteristics of Syncope Versus Seizures (Adapted From [13, 15, 30, 31, 34, 37, 38])

Syncope

Seizures

*In the presence of convulsion, postictal drowsiness may not differ between patients with or without syncope [37]. GTCS: generalized tonic-clonic seizure; SGTCS: secondarily generalized tonic-clonic seizure; HTN: hypertension; CAD: coronary artery disease; N/V: nausea/vomiting; CK: creatinine kinase.

Before spells

Precipitants

Frequent, prolonged standing/sitting, violent coughing, pain, micturation, defecation, warn/hot environment, exertion, antihypertensive drugs, blood loss, venipuncture, alcohol, HTN, CAD

Rare, stress

Prodrome

Gradual evolution, especially in young patients: N/V, abdominal discomfort, heat/cold, sweating, chest pain, dyspnea, light-headedness, headache, blurred vision, amaurosis, tinnitus, weakness

Deja vu, preoccupation, hallucination, mood changes, somatosensory auras, trembling

Position

Usually standing or sitting

Any

Blanks

“Fading away” in young, or abrupt loss in elderly patients

Abrupt loss

During spells

Falls

Slow, flaccid

Fast, tonic

Skin

Pale

Blue face, sometimes acrocyanosis

Convulsion

Common, start after LOC, prolonged, arrhythmic, asynchronous, small

Typical, coincide with LOC, short, rhythmic, synchronous, coarse

Automatism

Rare, short, solitary

Common

Tongue biting

Uncommon, tip of tongue

Common, side of tongue

Eye deviation

Transient lateral or upward

Sustained lateral

Incontinence

Common

Duration

3 - 30 s

GTCS: 30 s - 5 m
SGTCS: 16 - 108 s

After spells

Postictal state*

Short, mostly last < 30 s

Prolonged confusion, 2 - 20 m

Physical findings

Bradycardia, hypotension

Focal neurological abnormalities

Laboratory

Normal CK, prolactin

Increased CK, prolactin

Cardiac arrhythmia

Common

Rare, except sinus tachycardia

EEG

Slow, flat waves

Focal or general spike activity

**Table 3.** Questions Help to Distinguish Syncope From Seizure (Adapted From [32])
Questions	Points if yes
Seizure if total score ≥ 1; syncope if < 1.
Tongue biting?	2
Sense of deja vu or jamais vu before spells?	1
Emotional stress associated with LOC?	1
Witnessed head turning during spells?	1
Witnessed unresponsiveness? Unusual posturing? Jerking limbs? No memory of spells afterwards? (score for any positive response)	1
Witnessed confusion after spells?	1
Lightheaded spells?	-2
Sweating before spells?	-2
Prolonged sitting or standing associated with spells?	-2

Table 3. Questions Help to Distinguish Syncope From Seizure (Adapted From [32])

Questions

Points if yes

Seizure if total score ≥ 1; syncope if < 1.

Tongue biting?

Sense of deja vu or jamais vu before spells?

Emotional stress associated with LOC?

Witnessed head turning during spells?

Witnessed unresponsiveness? Unusual posturing? Jerking limbs? No memory of spells afterwards? (score for any positive response)

Witnessed confusion after spells?

Lightheaded spells?

-2

Sweating before spells?

-2

Prolonged sitting or standing associated with spells?

-2