Cardiac manifestations of central nervous system (CNS) abnormalities are well known. We describe a patient in nonconvulsive status epilepticus who had confusion and global T-wave changes.

A 78-year-old woman presented to the emergency department for evaluation of 3 days of mental status changes. She had sustained an inferolateral myocardial infarction (MI) 3 years before presentation. Epilepsy with complex partial seizures, diagnosed 6 years previously, was controlled with phenytoin.

The patient was oriented to person, place, and date but was confused and had general malaise. Physical examination results were normal; neurologic examination was without focal findings. Mini-Mental Status Examination score was 21 of 30. Serum electrolytes, aminotransferases, creatine phosphokinase, and lactate dehydrogenase were normal. The phenytoin level was 2.7 µg/mL. Serum toxicology was negative for neurotropic agents. Electrocardiography showed global deep T-wave inversions of up to 9 mm, markedly prolonged QTc (715 ms), and ventricular premature complexes (Figure 1, top). Accordingly, the patient was admitted to the cardiology service.

View larger version (107K): [in this window] [in a new window]   Figure 1. Complex partial status epilepticus-induced electrocardiographic changes. Top. Admission electrocardiogram obtained while patient was in complex partial status epilepticus. Bottom. Electrocardiogram recorded 9 days after admission and treatment for complex partial status epilepticus.

Computed tomography of the head and cerebrospinal fluid analysis were normal. Electroencephalography revealed continuous rhythmic right frontal and bilateral sharp and slow wave activity at 1 to 2 Hz, indicating complex partial status epilepticus. Seizure activity resolved over 24 hours in response to intravenous phenytoin; mental status returned to baseline over several days. Acute MI was excluded by measurements of serum creatine phosphokinase and lactate dehydrogenase isoenzymes and by echocardiography.

Daily electrocardiograms revealed decreasing amplitude of T-wave inversions and shortening of QTc. At discharge 5 days after admission, the maximum T-wave inversion was 3 mm and the QTc was 486 ms. Nine days after presentation, electrocardiography showed only nonspecific ST-segment abnormalities (Figure 1, bottom).

Cardiac arrhythmias often accompany seizure activity, but significant repolarization abnormalities are unusual [1]. In contrast, nonseizure CNS pathologies, such as stroke, often affect repolarization [2].

Global T-wave inversion has not previously been reported as an accompaniment to seizures. In one series, its most common causes were acute MI and CNS disorders other than seizure [3]. Global T-wave inversion is also seen in other cardiac disorders, metabolic and endocrine abnormalities, vascular disease, substance abuse [3], emotional distress [4], and pulmonary embolism [5].

As often occurs when acute electrocardiographic changes accompany CNS disease, this patient's initial diagnostic workup addressed the cardiovascular system. Thus, this case provides further impetus for clinicians to consider a CNS cause for electrocardiographic changes.