Recurrent syncope with seizure-like features:
the role of emergency monitoring in revealing
intermittent AV block

Recurrent syncope with seizure-like features:
the role of emergency monitoring in revealing
intermittent AV block

Recurrent syncope, Atrioventricular block, Intermittent complete heart block, Adams–Stokes syndrome,
Emergency monitoring, Seizure-like activity, Post-syncopal hypertension

Abstract
Background Recurrent syncope with seizure-like stiffening may mimic epilepsy or neurological disorders, and when
routine tests are repeatedly normal, intermittent arrhythmia can be easily overlooked.
Case presentation We report a case of a 65-year-old man with hypertension, hyperuricaemia, dyslipidaemia,
and asthma who experienced recurrent syncopal episodes over one month. He presented several times to
emergency departments and tertiary hospitals. Neurological and cardiovascular investigations—including brain
MRI, echocardiography, coronary angiography, laboratory tests, and a previous Holter ECG—were consistently
unremarkable. The initial diagnosis was hypertensive crisis based on marked post-event blood pressure surges, which
was later recognized as a secondary phenomena rather than the primary cause of syncope. On the index admission,
continuous emergency monitoring captured a sinus arrest of ~ 17 s with absent arterial pulse waveform, followed by
bradyarrhythmia. Post-event blood pressure spiked to 220/110 mmHg. A repeat Holter ECG confirmed intermittent
Mobitz II and complete AV block with asystole up to 18.6 s. EEG, performed during this admission to exclude epilepsy,
was normal. A dual-chamber permanent pacemaker was implanted with complete resolution of symptoms (Shen et
al, Circulation 136(5):e60-e122, 2017; Kusumoto et al, Circulation 140(8): e382-e482, 2019; Brignole et al, Eur Heart J
39(21):1883-1948, 2018).
Conclusion This case demonstrates how intermittent AV block may masquerade as seizure or hypertensive crisis,
underlining the critical role of emergency department monitoring and prolonged ECG recording in recurrent
unexplained syncope.
Keywords Recurrent syncope, Atrioventricular block, Intermittent complete heart block, Adams–Stokes syndrome,
Emergency monitoring, Seizure-like activity, Post-syncopal hypertension

Huong Thi Thanh Le1* , Ninh Xuan Nguyen1

, Ngoc Tien Pham1

, Quoc Viet Tran1

, Hang Ngoc Thuy Tran1
and

Nhat Hong Tran2

https://doi.org/10.1186/s12245-025-01113-w

2026

peri irawan

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