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The Intersection of Cardiovascular Pathology and Neuro-Oncology: An unusual case of syncope
Session:
Sessão Melhores Casos Clínicos
Speaker:
Isabel Maria Martins Moreira
Congress:
CPC 2024
Topic:
P. Other
Theme:
37. Miscellanea
Subtheme:
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Session Type:
Prémios, Registos e Sessões Especiais
FP Number:
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Authors:
Isabel Martins Moreira; Catarina Ribeiro Carvalho; Marta Catarina Bernardo; Luís Sousa Azevedo; Isabel Nóbrega Fernandes; Pedro Rocha Carvalho; José Pedro Guimarães; Inês Silveira; Ilídio Moreira
Abstract
<p style="text-align:justify"><span style="font-size:11pt"><span style="font-family:Calibri,sans-serif">A 56-year-old man with medical history of arterial hypertension, dyslipidemia, and diabetes mellitus, presented to the emergency department after experiencing an episode of pre-syncope. On physical examination, the only notable finding was sinus bradycardia of 55/min, leading to his discharge.</span></span></p> <p style="text-align:justify"><span style="font-size:11pt"><span style="font-family:Calibri,sans-serif">He returned 4 months later, after experiencing 3 similar episodes, the latest resulting in syncope after vertigo, nausea, and a migraine with aura. ECG exhibited sinus bradycardia of 58/min, poor progression of precordial R waves, and inverted T waves in the lateral leads. Cerebral CT scan showed no abnormalities and pulmonary embolism was ruled out. Carotid sinus massage was negative, and echocardiogram revealed a mild increase in septal wall thickness (11mm), with no other abnormalities. While in the emergency department, a transient episode of sinus bradycardia of 27/min was registered, and the patient was admitted for cardiac monitoring. During hospital stay, two sinus pauses were documented (22 seconds and 40 seconds) and a temporary pacemaker was implanted via the right femoral vein. The tilt test could not be conducted due to temporary pacemaker and, considering the previous recurrent syncopal episodes and the documentation of spontaneous sinus pauses, a permanent DDDR pacemaker was implanted.</span></span></p> <p style="text-align:justify"><span style="font-size:11pt"><span style="font-family:Calibri,sans-serif">After 2 weeks, the patient experienced syncope recurrence with preceding vertigo, nausea, aura, and metallic taste. Pacemaker parameters were normal, and no events were registered. </span></span><span style="font-size:11pt"><span style="font-family:Calibri,sans-serif">Considering a possible hypotensive contribution, the Sudden Brady Response (SBR) algorithm<strong> </strong>was turned ON to respond to a sudden drop in heart rate that can occur with neurocardiogenic syncope, by pacing at an elevated heart rate.</span></span></p> <p style="text-align:justify"><span style="font-size:11pt"><span style="font-family:Calibri,sans-serif">The patient's symptoms persisted despite pacemaker optimization, leading to several visits to the emergency department. In the last visit, a focal seizure with an impaired awareness episode was witnessed, preceded by complaints of a metallic taste in mouth and auditory hallucinations. A diagnosis of epilepsy was made, and the patient was referred to the neurology clinic. Electroencephalogram (under antiepileptic drugs) showed no abnormalities. Cerebral magnetic resonance imaging was performed for better characterization and revealed an extensive lesion in the left frontotemporal region with characteristics consistent with glioblastoma multiforme with cystic-necrotic transformation.</span></span></p> <p style="text-align:justify"><span style="font-size:11pt"><span style="font-family:Calibri,sans-serif">Ictal bradyarrhythmias can be difficult to recognize since their clinical manifestations might be mistaken for the seizure itself and differential diagnosis with neurally mediated reflex syncope can be challenging. This unexpected neuro-oncological diagnosis underscores the importance of considering secondary etiologies in cases of atypical presentations, demonstrating the intricate intersection between cardiovascular pathology and neuro-oncology.</span></span></p>
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