17-year-old student with recurrent seizures

History: A 17-year-old female student presented in our emergency room after a seizure with motoric fits and enuresis. It was the second event of this kind within 3 weeks. Investigations: The resting ECG on admission showed sinus bradycardia at 45 bpm and a remarkable repolarisation with notched or bifurcated T waves in several leads. Further clinical investigations were unremarkable. Treatment and course: As an arrhythmogenic syncope (bradycardia or tachycardia related) was presumed, beta-blocker therapy was initiated and an implantable loop recorder (ILR) was inserted. Approximately one year after the index event, the student was brought to the emergency room by ambulance after another seizure. Interrogation of the ILR revealed torsade de pointes tachycardia with spontaneous termination after 1 min and 24 s. A dual-chamber ICD for secondary prophylaxis of sudden cardiac death was therefore implanted and the dose of beta-blocker was increased. Genetic analysis for long-QT-syndrome (LQTS) was negative with regards to the most frequent known gene loci. For 6 months the patient has been free of symptoms. Conclusion: Arrhythmogenic syncopes can clinically resemble epileptic seizures ("convulsive syncope"). During basic work-up of syncope, the 12 lead ECG may provide valuable clues indicating an arrhythmogenic cause of syncope, showing excitation as well as repolarisation abnormalities. If an arrhythmogenic cause of syncope is suspected but ECG documentation as a proof of diagnosis is missing, implantation of an ILR can be useful. In LQTS, multiple gene mutations are known but cover only a fraction of clinical LQTS.