I read with interest the case report by Herskovitz and Schiller.1 The authors reported in total 5 cases in which atrial fibrillation or atrial flutter occurred in close proximity to a generalized tonic-clonic seizure. In all the reported cases, the disorder of cardiac rhythm was self-limited, with spontaneous conversion to sinus rhythm over a few hours. The authors concluded that atrial fibrillation occurred secondary to an epileptic seizure, leading to loss of consciousness. While this is certainly possible, the more likely explanation is that it was the cardiac arrhythmia that led to a generalized convulsion in patients inherently predisposed to a seizure disorder. Patient 1 likely possessed a latent primary generalized epilepsy trait as evidenced by the electroencephalogram findings, patient 2 had idiopathic generalized epilepsy since age 16 years, and patient 3 likely still harbored a right temporal seizure focus following right temporal cavernoma resection surgery. Patient 4 likely also harbored a primary generalized epilepsy trait taking his age and history into consideration, while the natural history of patient 5 still remains to be determined because it seems he suffered a single unprovoked convulsion. In the authors' reported series, the likely culprit is clinically latent heart disease presenting itself with convulsions and not vice versa.
Sethi NK. Atrial Fibrillation Associated With Epileptic Seizures. JAMA Neurol. 2013;70(2):273–274. doi:10.1001/jamaneurol.2013.1265
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