Paper # 002

Abnormalities of the cardiac conduction system and fibrous skeleton in an epyleptic patient with sudden death

M.Paz Suarez-Mier (1), Soledad Sanchez de León (1), Milagros Arbella (2), Carlos Gamallo (3).

(1) Instituto de Toxicología de Madrid; (2) Instituto Anatómico Forense de Bilbao; (3) Hospital La Paz de Madrid.

Instituto de Toxicología de Madrid. C/ Luis Cabrera, 9
28002 Madrid. España

[Introduction] [Materials and Methods] [Results] [Pictures] [Discussion] [Bibliography] [Comments]

Summary

Epileptic seizures resulting in sudden death, associated to alcohol withdrawall in chronic drinkers, are well known. The mechanisms involved in sudden unexplained death in epileptic patients, regardless its etiology, are: sympathetic autonomically induced irreversible cardiac arrhythmias; parasympathetic (vagal) induced cardiac bradycardias; respiratory failure and irreversible apnea; combination of cardiac arrhythmia and apnea; and "neurogenic" pulmonary edema with cardiac failure. As far as we know, no cardiac conduction system studies have been done in these cases.

We present a 30 years old man, with a history of alcoholism and epileptic seizures, who was on Phenobarbital and died suddenly in the street. The toxicological analysis only showed 0.25 g/l alcohol in blood and 0.52 g/l in vitreous humor. The gross and microscopic examination showed hepatomegaly with hepatic fatty change, heart weight of 368 g, permeable coronary arteries, normal myocardium, mitral valve myxoid degeneration, and meaningful abnormalities in the cardiac fibrous skeleton and conduction system: the upper part of the central fibrous body was incomplete, the AV node artery was placed under de skeleton, the AV node was divided in three portions, there was an atriohisian connection and a nodule of the central fibrous body compressed the bifurcation.

We think the meaningful structural abnormalities observed in the cardiac fibrous skeleton and conduction system in this case, were the morphologic ground over which functional factors, originating a fatal arrhythmia, took place.

This case shows the need of studying the cardiac conduction system in epileptic patients dying suddenly, because in some of them there could be morphologic abnormalities responsable of death.

Drs. María Paz Suárez-Mier and Soledad Sanchez de León work at the Histopathological section of the Instituto de Toxicología de Madrid.

Dr. Milagros Arbella is forensic physician in Bilbao.

Dr. Carlos Gamallo is the head of section at the Pathology Department of the Hospital La Paz in Madrid.

The Instituto Nacional de Toxicología (National Institute of Toxicology) is a Forensic Sciences center that belongs to the Ministry of Justice in Spain. It is divides in the following sections: Histopathology, General chemistry, Drugs, Forensic biology forense, Criminology, Toxicologic experimentation and the Toxicologic Information Service. The Histopathology section of the Department in Madrid carries out the anatomopathlogical study of more than 1,400 judicial autopsies during the each year.

Key Words: Sudden death, Epilepsy, cardiac conduction system.