![]() In a follow-up phone encounter five days after the convulsive syncope episode, the patient reported that his headache symptoms improved overall. The patient did not have any strict activity restrictions except for driving and lifting heavy objects. At discharge, the patient was advised to maintain adequate hydration and to report to the emergency department if he experienced recurrence of seizure-like episodes or other concerning symptoms including fever, abdominal distention concerning for hematoma, cool or clammy skin, and hematemesis or hematochezia. A computed tomography (CT) scan was obtained of the lumbar spine, which did not reveal any procedural-related complications. No abnormalities were found in serological studies including complete blood count and electrolytes. The patient was observed in the recovery unit for 2.5 hours and was then transferred to the emergency department for further workup and observation for another four hours. For these reasons, an electroencephalogram was not ordered. The neurology service was consulted, and this spell was diagnosed as a convulsive syncopal episode given gradually progressive prodromal symptoms that were vagal in nature, lack of rhythmic movements, and rapid recovery of mental status. Further history and medical chart review revealed no prior history of seizures, seizure disorder, or syncopal episodes. Physical exam revealed no focal neurologic deficits. The patient was transferred to the recovery unit for close observation, and no neurological symptoms, hypotension, or bradycardia was observed. No benzodiazepines or antiepileptic medications were administered. His bradycardia (heart rate in 40 beats/minute) and hypotension (systolic blood pressure in upper 80 beats/minute) resolved over the next 10 minutes. He was oriented and able to answer questions appropriately but did not recall the episode. The spell lasted 15 seconds, after which the patient spontaneously regained consciousness and appeared flushed and was warm to palpation. The procedure was immediately aborted however, the patient promptly lost consciousness, followed by nonrhythmic shaking of his upper extremities and sustained, nonrhythmic upward deviation of both eyes. When epidural injection of autologous blood was resumed, he complained of feeling worse after injection of another 3 mL. The procedure was paused for one minute, with symptomatic and hemodynamic resolution. He quickly became diaphoretic, lightheaded, and bradycardic (i.e., heart dropping from 80 to upper 40 beats/minute), and his systolic blood pressure dropped from 110 mmHg to 90 mmHg. After slow epidural injection of 13 mL of autologous blood, the patient complained of nausea. The patient was asymptomatic during blood draw from the left antecubital space. His international normalized ratio (INR) was 1.0 (normal range = 0.9–1.1), and the platelet count was 201×10 9/L (normal range = 150–450×10 9/L) thus, a repeat epidural blood patch was scheduled.Īfter subcutaneous infiltration with 3 mL of 1% lidocaine, the epidural space was accessed at the L4-L5 interspace on the first pass, with placement confirmed by contrast injection. An epidural blood patch had been performed 10 days previously, utilizing a right paramedian interlaminar approach at the L4-L5 interspace, resulting in 30% pain reduction in his frontal orthostatic headache. Case PresentationĪ 37-year-old male with a history of chronic headaches from hemicrania continua, congenital scoliosis status-post extensive hardware instrumentation, and an undifferentiated familial connective tissue disorder status-post aortic root and aortic valve replacement on chronic anticoagulation presented to the Pain Clinic for consideration of repeat lumbar epidural blood patch to ameliorate headache related to spontaneous cerebrospinal fluid (CSF) leak. The secondary objective is to review other reported cases of seizures and seizure-like episodes following epidural blood patch. The primary objectives of this case report are to describe a patient with a history of cardiac comorbidities who experienced convulsive syncope after an epidural blood patch and discuss the implications for management of periprocedural seizure-like episodes. Erroneously diagnosing convulsive syncope as a seizure disorder may have serious ramifications, as seizure treatment is not benign and syncope related to an unrecognized underlying cardiac condition has been associated with 30% mortality at one year. Although patients may experience convulsions secondary to a seizure, 12% of patients with syncope may also have seizure-like convulsions. ![]() Convulsive syncope may mimic seizures and can be clinically challenging to differentiate.
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