Download Brain Tumor is a Rare Cause of both Bradycardia and Seizure

CASE REPORT
ISSN 1738-5520
ⓒ 2007, The Korean Society of Circulation
Korean Circulation J 2007;37:449-452
Brain Tumor is a Rare Cause of both Bradycardia and Seizure
Ki-Hoon Park, MD, Sung-Ho Her, MD, Jong-Min Lee, MD, Hee-Jeoung Yoon, MD,
Jung-Yeon Chin, MD, Jun-Han Jeon, MD, Ye-Lee Park, MD,
Kyong-Rock Do, MD, Yun-Hwa Jung, MD and Seung-Won Jin, MD
Division of Cardiology, College of Medicine The Catholic University of Korea, Daejeon, Korea
ABSTRACT
The association between brain tumors and cardiac asystole has rarely been reported in the medical literature. This
potentially life-threatening symptom has usually been observed to arise from left temporal lobe brain tumors. Yet previously published papers have shown that cardiac asystole and bradycardia, as manifestations of epilepsy, originate
from the frontal lobe of the brain. Although syncope is a common presenting symptom of a brain tumor, bradycardia
and complete atrioventricular (AV) block, as the first signs of a brain tumor, have been only sporadically documented
in the literature. We report here on a patient with recurrent complete AV blocks that were followed by syncope as an
expression of seizures that may have arose from a brain tumor; this tumor was most likely a meningioma in the right
frontal lobe. The patient required the subsequent placement of a permanent pacemaker. In conclusion, cardiac asystole may be a potentially life-threatening symptom of frontal lobe lesion of the brain. The frontal lobe may play a role
in the autonomic regulation of cardiovascular responses. (Korean Circulation J 2007;37:449-452)
KEY WORDS：Brain tumor；Heart block；Seizures.
Introduction
sient complete AV blocks that were followed by syncope as an expression of seizures, and these seizures may
have arose from a brain tumor in the right frontal lobe.
A patient with a brain tumor can present with a diversity of symptoms or signs, including seizures, headache, nausea, vomiting, focal neurological deficit and
an altered mental function.1) It is often difficult to differentiate between the cardiac and neurological etiologies of syncope. To complicate matters, primary cardiac
abnormalities can cause secondary neurological signs
and vice versa. The causes of syncope range from benign
to lethal conditions. The distribution of the causes of
syncope in the population of the Framingham heart
study(7814 participants) was cardiac causes 9.7%, seizure
disorders 5.0%, vasovagal causes 21.2%, orthostatic causes 9.3%, medication 6.7%, unknown causes 36.3%
and other causes 11.8%.2) Bradycardia and cardiac asystole sometimes lead to life-threatening syncope for which implanting a demand pacemaker may be useful.3-6)
We report here on a patient with recurrent and tran-
Case
A 78-year-old right-handed man, who was without
any relevant medical history and he was not taking any
medication except aspirin, was admitted to the emergency
room of our hospital with loss of consciousness. He’d
had brief paroxysmal episodes that were characterized by
behavioral arrest with loss of consciousness during eating
breakfast.
On arrival at the hospital, the patient had an alert
mentality, a blood pressure of 170/100 mmHg and a regular pulse rate of 71 bpm. The cardiovascular and pulmonary examinations did not reveal any abnormalities.
Further neurological examination revealed no abnormality
of the cranial nerves. The initial electrocardiography
(ECG) showed a normal sinus rhythm and no prolonged
QT interval(0.414 second). A chest X-ray demonstrated
no abnormality. Blood analysis showed no abnormalities,
including the electrolytes and the CK-MB and Troponin
-T levels. The thyroid function tests were also within normal limits. Contrast computed tomography(CT) of the
brain showed a 1.4×2.0 cm sized brain mass in the right
Received：May 23, 2007
Revision Received：June 22, 2007
Accepted：July 4, 2007
Correspondence：Sung-Ho Her, MD, Division of Cardiology, College of
Medicine The Catholic University of Korea, 520-2 Daeheung-dong,
Jung-gu, Daejeon 301-723, Korea
Tel: 82-42-253-9505, Fax: 82-42-220-9504
E-mail: [email protected]
449
450·Korean Circulation J 2007;37:449-452
Fig. 1. Brain MRI revealed a 1.4×2.0 cm sized slight high signal mass
(white arrow) in the right frontal lobe on T2-weighted axial image.
MRI: magnetic resonance imaging.
frontal lobe. Magnetic resonance imaging(MRI) of the
brain revealed a 1.4×2.0 cm sized, slightly high signalintensity mass that was most likely a meningioma in the
right frontal lobe(Fig. 1). The patient was admitted to the
Department of Neurosurgery for further evaluation.
The EEG recordings revealed no definite epileptic discharges. On the 7th hospital day, he had a seizure and
then lost consciousness again. During the syncope event,
the ECG showed a progressive decrease of the heart rate
to 28 bpm and complete AV block(Fig. 2A), and the blood pressure decreased to 60/30 mmHg. Cardiac massage was initiated and some minutes later patient recovered an alert mentality with a normal sinus rhythm of
78 bpm(Fig. 2B) and a blood pressure of 90/60 mmHg.
Some 6 hours later, he had another seizure and then he
experienced complete AV block(Fig. 2C) with a blood pressure of 60/50 mmHg, but he did not lose consciousness.
Some minutes later, the patient completely recovered spontaneously with a normal sinus rhythm and blood pressure. The patient was transferred to the Department of
Cardiology for the further evaluation. Transthoracic echocardiography revealed good regional wall motion with
A
B
C
D
Fig. 2. The ECG showed a complete AV block during the first syncope event in the hospital (A), recovered the normal sinus rhythm after the first
syncope (B), redeveloped a complete AV block (C) and setted ventricular rate over 60 bpm by permanent pacemaker (D). ECG: electrocardiography, AV:
atrioventricular, bpm: beats per minute.
Ki -Hoon Park et al：Brain Tumor that Caused Bradycardia and Seizure·451
a left ventricular ejection fraction of 67%. A Holter test
revealed frequent APCs and rare VPCs, but it didn’t
reveal complete AV block. The coronary angiogram showed no definite abnormality. We still noted intermittent
seizures with complete AV block for 5-10 seconds until
the 12th hospital day. Thus, we decided to implant a
permanent pacemaker. During the following days after
permanent pacemaker implantation(the VVI type), we
set the ventricular rate over 60 bpm, and this resulted in
no bradycardia and no complete AV block or seizure(Fig.
2D). The patient did not experience any seizure and syncope attacks during the 20 days after implantation of the
permanent pacemaker.
Discussion
Many previously published papers have shown that
cardiac asystole and bradycardia, as manifestations of syncope or seizure, originate from the temporal lobe.7-9) Several studies have suggested a frontal lobe influence on the
autonomic cardiovascular regulation.10-13)
We report here on a patient with a complete AV block
that was followed by syncope as the first sign of a right
frontal brain tumor. Although we didn’t perform simultaneous ECG/EEG recordings during a period of
bradycardia, we believe that the origin of the bradycardia
was a brain tumor in the frontal lobe. Electrical stimulation of the cingulated gyrus and orbitofrontal cortex
has produced changes in the heart rate, and cases of ictal
bradycardia related to orbitofrontal lobe seizures have
been reported on.14-16) The insular cortex, the central nucleus of the amygdala and some structures of the hypothalamic(paraventricular nucleus, the lateral hypothalamic
area and dorsomedial nucleus) belong to the central autonomic network, which controls the pre-ganglionic sympathetic and parasympathetic visceromotor outputs. The
mesial, temporal and frontal areas are interconnected to
the central autonomic network so that ictal discharges arising from or spreading to these regions are more likely to
induce autonomic changes.11)17)
Many different regions of the nervous system are involved in the cardiovascular control(brain stem, thalamus,
hypothalamus, amygdale and insular cortex). Pathology
in these regions can give rise to various types of cardiac
dysfunction. For instance, cortical stimulation studies in
humans have shown depressor responses and bradycardia
upon stimulation of the left insular cortex, whereas the
converse applied for the right insular cortex.18) In humans
undergoing temporal lobectomy with amygdalo-hippocampectomy for epilepsy, bradycardia and hypotension
have occurred during manipulation of the amygdale and
hippocampus.19)
Critchley et al.20) conducted functional MRI experiments, and they reported changes in the heart rate for
both cognitive and motor performance that was related
to the strength of activation in the anterior cingulated
cortex. In particular, the activity observed in the anterior
cingulated cortex was related to sympathetic modulation
of the heart rate, and this was dissociable from cognitive
and motor-related activity.
In conclusion, our case confirms that cardiac asystole
may be a potentially life-threatening symptom during the
partial seizures that were caused by right frontal brain
tumor. We can also hypothesize that seizures originating
in the fronto-mesial structures may disrupt a complex
neural system involving the fronto-temporal-insular regions, and these regions have been implicated in the autonomic regulation of the cardiovascular responses.
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