Case Report Ventricular Tachycardia
Pseudoseizure with
Pseudo-ventricular Tachycardia
Ozlem Karabulut, Ozcan Ozeke, Ilke Erbay, Ertan Ekici, Serkan Cay, Firat Ozcan, Serkan Topaloglu and Dursun Aras
Health Sciences University, Turkiye Yuksek Ihtisas Training and Research Hospital, Department of Cardiology, Ankara, Turkey
DOI: https://doi.org/10.17925/EJAE.2018.04.01.28
P
sychogenic nonepileptic seizures (PNES), or pseudoseizures, are paroxysmal episodes that resemble, and are often misdiagnosed
as, epileptic seizures; however, they are psychological (i.e., emotional, stress-related) in origin. Unlike epileptic seizures, PNES do not
result from an abnormal electrical discharge from the brain; they are a physical manifestation of a psychological disturbance. We
present an interesting case of PNES with pseudo-ventricular tachycardia due to body movement related artefacts. A careful analysis of the
whole 12-lead electrocardiogram is required to rule out an artefact-related appearance of ventricular tachycardia. Correct interpretation of
electrocardiograms and their co-relation to clinical history and presentation is key.
Keywords
Pseudo-ventricular tachycardia, pseudoseizure,
psychogenic nonepileptic seizures
Disclosure: Ozlem Karabulut, Ozcan Ozeke,
Ilke Erbay, Ertan Ekici, Serkan Cay, Firat Ozcan,
Serkan Topaloglu and Dursun Aras have nothing
to declare in relation to this article.
Review Process: Double-blind peer review.
Compliance with Ethics: All procedures were followed
in accordance with the responsible committee on human
experimentation and with the Helsinki Declaration of
1975 and subsequent revisions, and informed consent
was received from the patient involved in this case study.
Authorship: All named authors meet the International
Committee of Medical Journal Editors (ICMJE) criteria
for authorship of this manuscript, take responsibility
for the integrity of the work as a whole, and have
given final approval to the version to be published.
Open Access: This article is published under the
Creative Commons Attribution Noncommercial License,
which permits any non-commercial use, distribution,
adaptation and reproduction provided the original
author(s) and source are given appropriate credit.
© The Authors 2018.
Received: 5 December 2017
Accepted: 4 January 2018
Citation: European Journal of Arrhythmia
& Electrophysiology. 2018;4(1):28–30
Corresponding Author: Ozcan Ozeke, Türkiye
∙
Yüksek Ihtisas Hastanesi Kardiyoloji Klinigi, Ankara,
06100, Turkey. E: ozcanozeke@gmail.com
Support: No funding was received in the publication of
this article.
Psychogenic nonepileptic seizures (PNES), or pseudoseizures, are paroxysmal episodes that
resemble, and often misdiagnosed as, epileptic seizures; however, they are psychological
(i.e., emotional, stress-related) in origin. Unlike epileptic seizures, PNES do not result from an
abnormal electrical discharge from the brain; they are a physical manifestation of a psychological
disturbance.1 PNES may be thought of as a type of conversion disorder. Misdiagnosis of epilepsy
is common and occurs in approximately 25% of patients with a previous diagnosis of epilepsy
that does not respond to drugs. Most cases of misdiagnosed epilepsy are eventually shown to be
PNES or, more rarely, syncope. Accurately distinguishing pseudoseizures from epilepsy and other
illnesses is difficult because of the breadth and overlap of symptoms seen in each condition and
because of the frequent co-occurrence of pseudoseizures and epilepsy. Moreover, despite the
ambulatory electrocardiographic monitoring system used, which is used in clinical practice as a
means of detecting cardiac arrhythmias during daily activities,2 a number of artifacts could lead
to misdiagnosis.3
Case report
A 28-year-old woman with a prediagnosis of ventricular tachycardia (VT) captured by Holter
recording, was referred to our clinic for further investigation. She had a history of PNES and anxiety.
The electrocardiography (ECG) and echocardiography were nondiagnostic. Although at first glance
the appearance of the recording resembled polymorphic VT (Figure 1), an accurate analysis of the
trace revealed an underlying normal heart rhythm and the continued presence of normal QRS
complexes (the ‘notches’ sign) at the cycle length of baseline rhythm within the apparent wide
complexes (marked by stars in Figure 2). This resulted in the recognition that the wide complexes
were electrocardiographic artefacts. We ordered a tilt testing to investigate the cause of her
fainting episodes. On the tilt testing, the patient experienced drowsiness and light-headedness
without any arrhythmic or haemodynamic compromise. Based on the aforementioned analysis
of the Holter tracing and Tilt testing result, we decided not to conduct any further cardiological
diagnostic testing.
Discussion
Cardiovascular disorders may cause loss of consciousness complicated by abnormal
movements due to generalised cerebral hypoxia, leading to the initial impression of epileptic
seizure.4,5 Indeed, epilepsy and seizures can have a dramatic effect on the autonomic nervous
system by involvement of the central autonomic control centers.6 Epileptic discharges directly
influence areas of the central autonomic network, thus regulating heart rate and rhythm. In
addition, epilepsy is frequently associated with epileptic ictal tachycardia or bradycardia, which
sometimes precedes the onset of seizures.6 Epileptic ictal tachycardia is sometimes associated
with electrocardiographic morphologic changes and epileptic ictal bradycardia often progresses
to asystole. Such cardiac manifestations of seizures have been hypothesised as possible causes
for sudden unexplained death in epilepsy.7 The diagnosis of epilepsy is often made on the basis of
clinical grounds, but the clinical criteria for epilepsy may not be sufficiently specific to differentiate
28
Print Publication Date: 27 February 2018
TOUC H ME D ICA L ME D IA
Pseudoseizure with Pseudo-ventricular Tachycardia
between epileptic and non-epileptic seizures. Occasionally, but more
often than has been reported, true epileptic seizures are triggered by
non-epileptic syncopes. This combination of syncope and epileptic
seizure has been called an reflex anoxic-epileptic seizure. Syncope
may be an under-recognised trigger for convulsive acute symptomatic
seizures. Avoidance of syncope may be more effective than anti-seizure
medications in preventing reflex anoxic seizures.8,9 Moreover, PNES
continue to represent a serious diagnostic challenge for neurologists.1
The PNES, or pseudoseizures, are paroxysmal episodes that resemble,
and are often misdiagnosed as, epileptic seizures; however, PNES are
psychological (i.e., emotional, stress-related) in origin. Patients with
episodes of collapse are frequently referred to either cardiological or
neurological services and the correct diagnosis is often elusive.
Since some cardiovascular arrhythmias, such as asystole or VT, may
cause loss of consciousness complicated by abnormal movements
due to generalised cerebral hypoxia, leading to the initial impression of
seizure, cardiac issues should be systematically considered in patients
with a diagnosis of epilepsy remaining uncertain.10 Moreover, even under
the supervision of board-certified cardiologists or electrophysiologists,
artefacts on electrocardiograms could be misinterpreted as ventricular
tachycardia and cause inappropriate resuscitation, cardioversion or
device implantation. The difficulty in reaching a correct diagnosis, even
for experienced physicians, was further highlighted by a large study of
766 doctors conducted in the US.7 This revealed that 58% of cardiologists
and 38% of electrophysiologists failed correctly to recognise ECG artefact
resembling a wide complex tachycardia, and the majority of them
recommended subsequent invasive procedures for further evaluation or
therapy.11 Artefacts are defined as ECG abnormalities that may be due to
sources other than the electrical activity of the heart. By far, body tremor
is the most common cause, resulting in electrocardiographic artefact in
clinical practice, and could be misdiagnosed as VT.12–15 In addition to the
tremors, other factors such as clonic jerking, loose leads, etc. may play a
role. Incorrect interpretation of these artefacts can lead to unnecessary
and potentially harmful procedures, such cardioversion or drugs,
invasive electrophysiological testing, or implantation of cardioverter
defibrillators.2,11,16 However, there has been no electrocardiographic
algorithm effectively differentiating pseudo-VT. Huang et al. suggested
an electrocardiographic algorithm for differentiation of tremor-induced
pseudo-VT. In this study, three electrocardiographic ‘signs’ were identified:
‘sinus’ sign, ‘spike’ sign, and ‘notch’ sign, an electrocardiographic
algorithm was created.17 Artefact can often be differentiated from
VT when normal or discrete components of the QRS complexes (the
‘notches’ sign) are visible at intervals that correspond to multiples of
the baseline rhythm RR interval.18 To confirm the presence of artefact,
one need only establish that the notch-to-notch intervals correspond to
the sinus RR intervals, as can easily be done in each of these recordings.
The notches sign is especially useful in cases in which the native QRS
complexes are not readily recognisable within the apparent instance
of rapid, wide-complex tachycardia.18 Additional findings that support a
diagnosis of artefact include: the absence of haemodynamic compromise;
an unstable baseline on the electrocardiogram; a pseudo-premature
ventricular contraction occurring within the absolute refractory period of
the native QRS complex without the corresponding compensatory pause
(RR interval not modified); and the relation of the arrhythmia to patient
1.
2.
3.
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electrocardiographic artifacts mimicking arrhythmias in
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Nikitas G, Maniotis C, Manolis G, et al. Pseudo-polymorphic
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5.
E UROPEA N JOU RN A L O F AR RH YT H MIA & E LE CT RO PH YS IO LO G Y
Figure 1: Holter recording showing pseudo-ventricular
tachycardia
Figure 2: Holter recording showing pseudo-ventricular
tachycardia with ‘notches’ sign
movement (in this case, tremor). In order to prevent artefacts during
a Holter recording, the integrity of the electrodes must be evaluated
and the patient advised to avoid intense body movements or exercise.
In addition, physicians must be experienced and able to recognise
such artefacts to avoid an erroneous diagnosis and should include
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Stephenson J, Breningstall G, Steer C, et al. Anoxic-epileptic
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Case Report Ventricular Tachycardia
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EUR OP EAN J OUR N AL OF AR R HY T HM I A & EL EC T ROPH YSIOLOG Y