Seeing a Seizure? Look for Pulmonary Embolism

BALTIMORE – A seizure was initially the only presenting symptom in 1% of patients diagnosed with pulmonary embolism during a 5-year retrospective study of cases seen at an emergency department.

Although it is an unusual presentation, pulmonary embolism–related seizure does occur – and when it does, it’s a life-threatening emergency, Dr. Kimitoshi Kimura reported in a poster at the annual meeting of the American Epilepsy Society.

"With a seizure, clinical evaluation may be compromised by the postictal confusional state. Hypoxia, tachypnea, and tachycardia, which are important signs of PE, may be attributed to the seizure. This results in delayed diagnosis," said Dr. Kimura of the department of neurology at Kurashiki (Japan) Central Hospital.

He reported a retrospective study of 319 pulmonary embolism (PE) cases seen at the hospital over a 5-year period. The vast majority of these (282) did not involve any seizure activity. Most (165) had classic PE symptoms of chest pain, hypoxia, and impaired consciousness. In 75 cases, the only early symptom was swelling or tenderness in the leg, leading to a PE diagnosis. Another 42 cases were asymptomatic and were detected incidentally. No diagnostic details were available for 34 cases.

Only 1% (3 cases) initially presented as a seizure; none of these patients had a history of any seizure or cardiopulmonary disorders.

The first case was a 78-year-old man who "suddenly raised his hands over his head and stared at a fixed point for a substantial period of time," Dr. Kimura wrote. "On the next evening, he complained of increasing dyspnea and was taken to our hospital."

When he arrived, the patient was already in cardiopulmonary arrest. The embolism was diagnosed soon after, but the patient died the next day.

The second case was an 87-year-old woman who complained of chest discomfort while at home. The next morning, she experienced generalized tonic seizures with conjugated deviation; the seizures occurred intermittently for 4 hours. She was admitted to the hospital and received four 5-mg doses of diazepam. When the seizures stopped, the patient had persistent hypoxia and an elevated d-dimer of more than 10 mcg/mL (normal is less than 1.0 mcg/mL). Mild right ventricular overload and PE were detected.

"In this case, she was treated successfully with anticoagulation therapy," Dr. Kimura wrote.

The third patient was a 78-year-old woman admitted because of a 5-minute generalized tonic-clonic seizure and drowsiness. After the seizure, she also remained hypoxic and had a d-dimer value of 2.3 mcg/mL.

"At first, we suspected the cause of the seizure was a cerebral infarction because a small subacute infarction was detected, but intermittent oxygen desaturation persisted," Dr. Kimura noted. The embolism was diagnosed 2 days later. This patient was successfully treated with heparin.

Neither of the surviving patients required any antiepileptic drugs after discharge, he added.

Dr. Kimura reported that he had no financial conflicts.

BALTIMORE – A seizure was initially the only presenting symptom in 1% of patients diagnosed with pulmonary embolism during a 5-year retrospective study of cases seen at an emergency department.

Although it is an unusual presentation, pulmonary embolism–related seizure does occur – and when it does, it’s a life-threatening emergency, Dr. Kimitoshi Kimura reported in a poster at the annual meeting of the American Epilepsy Society.

"With a seizure, clinical evaluation may be compromised by the postictal confusional state. Hypoxia, tachypnea, and tachycardia, which are important signs of PE, may be attributed to the seizure. This results in delayed diagnosis," said Dr. Kimura of the department of neurology at Kurashiki (Japan) Central Hospital.

He reported a retrospective study of 319 pulmonary embolism (PE) cases seen at the hospital over a 5-year period. The vast majority of these (282) did not involve any seizure activity. Most (165) had classic PE symptoms of chest pain, hypoxia, and impaired consciousness. In 75 cases, the only early symptom was swelling or tenderness in the leg, leading to a PE diagnosis. Another 42 cases were asymptomatic and were detected incidentally. No diagnostic details were available for 34 cases.

Only 1% (3 cases) initially presented as a seizure; none of these patients had a history of any seizure or cardiopulmonary disorders.

The first case was a 78-year-old man who "suddenly raised his hands over his head and stared at a fixed point for a substantial period of time," Dr. Kimura wrote. "On the next evening, he complained of increasing dyspnea and was taken to our hospital."

When he arrived, the patient was already in cardiopulmonary arrest. The embolism was diagnosed soon after, but the patient died the next day.

The second case was an 87-year-old woman who complained of chest discomfort while at home. The next morning, she experienced generalized tonic seizures with conjugated deviation; the seizures occurred intermittently for 4 hours. She was admitted to the hospital and received four 5-mg doses of diazepam. When the seizures stopped, the patient had persistent hypoxia and an elevated d-dimer of more than 10 mcg/mL (normal is less than 1.0 mcg/mL). Mild right ventricular overload and PE were detected.

"In this case, she was treated successfully with anticoagulation therapy," Dr. Kimura wrote.

The third patient was a 78-year-old woman admitted because of a 5-minute generalized tonic-clonic seizure and drowsiness. After the seizure, she also remained hypoxic and had a d-dimer value of 2.3 mcg/mL.

"At first, we suspected the cause of the seizure was a cerebral infarction because a small subacute infarction was detected, but intermittent oxygen desaturation persisted," Dr. Kimura noted. The embolism was diagnosed 2 days later. This patient was successfully treated with heparin.

Neither of the surviving patients required any antiepileptic drugs after discharge, he added.

Dr. Kimura reported that he had no financial conflicts.

BALTIMORE – A seizure was initially the only presenting symptom in 1% of patients diagnosed with pulmonary embolism during a 5-year retrospective study of cases seen at an emergency department.

Although it is an unusual presentation, pulmonary embolism–related seizure does occur – and when it does, it’s a life-threatening emergency, Dr. Kimitoshi Kimura reported in a poster at the annual meeting of the American Epilepsy Society.

"With a seizure, clinical evaluation may be compromised by the postictal confusional state. Hypoxia, tachypnea, and tachycardia, which are important signs of PE, may be attributed to the seizure. This results in delayed diagnosis," said Dr. Kimura of the department of neurology at Kurashiki (Japan) Central Hospital.

He reported a retrospective study of 319 pulmonary embolism (PE) cases seen at the hospital over a 5-year period. The vast majority of these (282) did not involve any seizure activity. Most (165) had classic PE symptoms of chest pain, hypoxia, and impaired consciousness. In 75 cases, the only early symptom was swelling or tenderness in the leg, leading to a PE diagnosis. Another 42 cases were asymptomatic and were detected incidentally. No diagnostic details were available for 34 cases.

Only 1% (3 cases) initially presented as a seizure; none of these patients had a history of any seizure or cardiopulmonary disorders.

The first case was a 78-year-old man who "suddenly raised his hands over his head and stared at a fixed point for a substantial period of time," Dr. Kimura wrote. "On the next evening, he complained of increasing dyspnea and was taken to our hospital."

When he arrived, the patient was already in cardiopulmonary arrest. The embolism was diagnosed soon after, but the patient died the next day.

The second case was an 87-year-old woman who complained of chest discomfort while at home. The next morning, she experienced generalized tonic seizures with conjugated deviation; the seizures occurred intermittently for 4 hours. She was admitted to the hospital and received four 5-mg doses of diazepam. When the seizures stopped, the patient had persistent hypoxia and an elevated d-dimer of more than 10 mcg/mL (normal is less than 1.0 mcg/mL). Mild right ventricular overload and PE were detected.

"In this case, she was treated successfully with anticoagulation therapy," Dr. Kimura wrote.

The third patient was a 78-year-old woman admitted because of a 5-minute generalized tonic-clonic seizure and drowsiness. After the seizure, she also remained hypoxic and had a d-dimer value of 2.3 mcg/mL.

"At first, we suspected the cause of the seizure was a cerebral infarction because a small subacute infarction was detected, but intermittent oxygen desaturation persisted," Dr. Kimura noted. The embolism was diagnosed 2 days later. This patient was successfully treated with heparin.

Neither of the surviving patients required any antiepileptic drugs after discharge, he added.

Dr. Kimura reported that he had no financial conflicts.