[Orthostatically induced epileptoid attack]

Area of Science:

• Neurology
• Cardiology
• Geriatrics

Background:

• A 72-year-old man with a six-year history of progressive autonomic failure and parkinsonism presented with recurrent episodes resembling epileptic seizures upon standing.
• The patient experienced severe orthostatic hypotension, syncope, and generalized convulsions, sometimes with urinary incontinence, upon assuming an upright position.

Observation:

• During tilt-table testing, the patient's blood pressure dropped significantly from 167/88 mmHg to 70/46 mmHg upon tilting to 50 degrees, leading to unconsciousness and generalized clonic seizure with jaw twitching.
• Electroencephalogram (EEG) during the seizure showed sharp waves and rhythmic spikes, while resting EEG was normal.
• Laboratory tests revealed diffuse autonomic dysfunction and mild cerebral atrophy on CT scan.

Findings:

• The patient's episodes were characterized as epileptoid seizures rather than convulsive syncope due to seizure semiology, spontaneous cessation even while standing, and partial response to diphenylhydantoin.
• The underlying mechanism is hypothesized to be transient cerebral hypoperfusion secondary to severe orthostatic hypotension.

Implications:

• This case underscores the importance of considering orthostatic hypotension as a potential trigger for seizure-like activity in elderly patients with autonomic dysfunction.
• It suggests that neurological symptoms previously attributed solely to epilepsy might, in some cases, stem from cardiovascular or autonomic dysregulation.
• Further investigation into the link between autonomic failure, cerebral hypoperfusion, and neurological events is warranted.