A 77-year old man presented following two episodes of altered awareness, with facial and hand automatisms. He had been seizure-free for 23 years, taking phenytoin following excision of a meningioma.
A diagnosis of symptomatic temporal lobe focal seizures was made and phenytoin substituted with carbamazepine. A 12-lead electrocardiogram (ECG) revealed prolonged PR interval of 288 milliseconds. MR imaging revealed a residual right temporal lobe cystic lesion with focal enhancement. Following discussion at the epilepsy-cardiology multidisciplinary meeting (MDT) and anticipating a neurosurgical/anaesthetic work-up, a 24-hour ECG was performed, which demonstrated high grade atrioventricular block with 6.5 seconds of ventricular standstill.
He was admitted as an emergency, during which he collapsed with further ventricular standstill. He underwent pacemaker insertion, remaining seizure-free.
This case illustrates the challenges of epilepsy consultations and management in the elderly with dual pathology. The urgency here was not the potential re-occurrence of the brain lesion, but the conduction abnormality which unmasked serious cardiac pathology. Careful evaluation of the ECG is vital in all patients presenting with episodes of altered consciousness however the pursuit of a recognised benign cardiac conduction abnormality may in the elderly just prove life-saving. The value of a dedicated epilepsy-cardiology MDT therefore cannot be underestimated.