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A 51 year old man, with a previous history of 15 years of hypertension treated with β blockers, complained of nocturnal and early morning seizures. One year ago, he had a syncope thought to be caused by bradycardia. β Blockers were reduced in a first step, and then discontinued. Serial neurological investigations were normal. Therapeutic challenges using sodium valproate or phenytoin did not had any favourable influence. Glucose metabolism was normal.
Cardiac investigations including carotid sinus massage, recording of late potentials, repetitive 24 hour Holter monitoring, and tilt table testing were normal. At electrophysiological testing, AH interval was 80 ms, and HV interval was 42 ms. Sinus node function and anterograde atrioventricular conduction were normal. Programmed atrial and ventricular stimulation did not induce any sustained arrhythmia. The ajmaline test was negative.
A Reveal Plus implantable loop recorder (Medtronic) was implanted. One month later, at the follow up visit, the downloading of the recorded ECGs showed an asymptomatic nocturnal pause of 35 seconds. An antibradycardia pacemaker was implanted in 1999, and during three years of follow up the patient has remained completely asymptomatic.
The originality of the present case report is the length of the documented asymptomatic sinus pause. The asymptomatic three year follow up confirms the relation between the sinus pauses and the symptoms. One may thus be concerned about the length of symptomatic sinus pauses.
The present case also suggests that in patients with convulsive syncope, but no clear diagnosis of epilepsy, an implantable loop recorder may provide useful complementary diagnostic information.