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Clinical Review

First seizures in adults

BMJ 2014; 348 doi: (Published 15 April 2014) Cite this as: BMJ 2014;348:g2470

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Re: First seizures in adults

It is correct to highlight the importance of identifying cardiac arrhythmias, and of an ECG in all patients with transient loss of consciousness. There was a typographical error in the First Seizure article which has now been corrected.(1) Electrocardiography (not electroencephalography) is indeed mandatory for the identification of potentially fatal arrhythmias in all patients with transient loss of consciousness. At our institution we have identified an important minority of patients with unsuspected arrhythmias in the ECG strip of EEGs, which records for twenty minutes or more, and on occasions may capture an arrhythmia not seen on the briefer recording of a routine ECG. This is particularly the case for Brugada syndrome, as the ECG changes fluctuate and may even disappear on occasions.(2,3)

The author points out that Brugada syndrome is not classically associated with long QT interval. The initial description was of aborted arrhythmic sudden death with ventricular tachycardia, with ECG changes of right bundle branch block, and persistent ST segment elevation in right precordial leads not explicible by electrolyte disturbances, ischemia or structural heart disease.(4) The differential diagnosis of Brugada syndrome includes physiological changes in athletes; acute disturbance such as ischaemia, pulmonary embolus and pericarditis; structural anomalies; metabolic disturbance and Duchenne’s muscular dystrophy.(5) Recently, three patterns of ECG change have been delineated In Brugada syndrome, with prolonged QT in some patients and some families, often with variable ECG changes.(6,7) Patients may have sodium channel mutations with autosomal dominant transmission and variable penetrance. However autopsy and biopsy demonstrations of structural abnormalities such as myocarditis and fibrosis suggest that the aetiology may be multi-factorial.(3) Diagnosis and management of Brugada syndrome is complex and evolving, and requires specialist cardiological evaluation. This is considerably beyond the scope of primary care or neurology, but we all need to have a high index of suspicion for cardiac causes of syncope.

1. Angus-Leppan H. First seizures in adults. BMJ. 2014;348:g2470.
2. Veltmann C, Schimpf R, Echternach C, Eckardt L, Kuschyk J, Streitner F, et al. A prospective study on spontaneous fluctuations between diagnostic and non-diagnostic ECGs in Brugada syndrome: implications for correct phenotyping and risk stratification. European Heart Journal. 2006;27(21):2544-52.
3. Hoogendijk MG, Opthof T, Postema PG, Wilde AA, de Bakker JM, Coronel R. The Brugada ECG pattern: a marker of channelopathy, structural heart disease, or neither? Toward a unifying mechanism of the Brugada syndrome. Circulation. 2010;3(3):283-90.
4. Brugada P, Brugada J. Right bundle branch block, persistent ST segment elevation and sudden cardiac death: a distinct clinical and electrocardiographic syndrome. A multicenter report. J Am Coll Cardiol. 1992;20(6):1391-6.
5. Antzelevitch C, Brugada P, Borggrefe M, Brugada J, Brugada R, Corrado D, et al. Brugada syndrome: report of the second consensus conference endorsed by the Heart Rhythm Society and the European Heart Rhythm Association. Circulation. 2005;111(5):659-70.
6. Bayes de Luna A, Garcia-Niebla J, Baranchuk A. New electrocardiographic features in Brugada syndrome. Curr Cardiol Rev. 2014. Epub ahead of print.
7. Wilde AA, Antzelevitch C, Borggrefe M, Brugada J, Brugada R, Brugada P, et al. Proposed diagnostic criteria for the Brugada syndrome consensus report. Circulation. 2002;106(19):2514-9.

Competing interests: No competing interests

18 May 2014
Heather Angus-Leppan
Consultant Neurologist and Epilepsy Lead
Royal Free Hospital
Pond St, London NW3 2QG