Sudden cardiac arrest with super-refractory seizures in a patient with bilateral temporal lobe meningioma and end-stage renal disease
Linda Dharmaraj*
Clinical Pharmacist, Kauvery Hospital, Alwarpet, Chennai, Tamil Nadu
*Correspondence
Abstract
Sudden cardiac arrest accompanied by super-refractory seizures is a rare and complex clinical scenario, particularly in elderly patients with multiple comorbidities such as brain tumors and end-stage renal disease. Meningioma located in the temporal lobe can predispose patients to seizure disorders and neurological complications.
Case Presentation: This case report describes a 79-year-old female admitted to the Hospital following sudden desaturation and unresponsiveness leading to cardiac arrest. Cardiopulmonary resuscitation was performed and return of spontaneous circulation was achieved after three cycles. Neuroimaging revealed bilateral temporal lobe meningioma. Electroencephalography demonstrated epileptiform activity suggestive of seizure susceptibility. The patient also had multiple comorbidities including heart failure with reduced ejection fraction, chronic kidney disease stage V on hemodialysis, hypertension, and type 2 diabetes mellitus. During hospitalization, the patient developed gastric erosions with palatal bleeding and required endoscopic evaluation and blood transfusion. Multidisciplinary management including ventilator support, antiepileptic therapy, antibiotics, and supportive care resulted in clinical stabilization.
Conclusion: This case highlights the complexity of managing elderly patients with cardiac, neurological, and renal comorbidities. Early recognition, prompt resuscitation, and multidisciplinary care are essential for improved outcomes in such patients.
Keywords: Sudden cardiac arrest; Super-refractory seizure; Meningioma; Chronic kidney disease; Heart failure; Elderly patient
Introduction
Sudden cardiac arrest is a life-threatening condition characterized by abrupt cessation of cardiac activity leading to hemodynamic collapse. Neurological conditions such as brain tumors may predispose patients to seizure disorders that can complicate the clinical course. Meningioma’s are among the most common primary intracranial tumors and are frequently present with seizures when located in the temporal lobe. In elderly patients with multiple comorbidities such as chronic kidney disease and cardiovascular disease, management becomes particularly challenging. This case report describes the successful management of a geriatric patient presenting with cardiac arrest and super-refractory seizures secondary to bilateral temporal lobe meningioma along with multiple systemic comorbidities.
Case Presentation
A 79-year-old female was admitted to the emergency department with complaints of sudden desaturation and unresponsiveness. Cardiopulmonary resuscitation was initiated immediately and return of spontaneous circulation was achieved after three cycles of resuscitation. The patient was intubated and placed on mechanical ventilation. She was initially evaluated at another hospital and diagnosed with super-refractory seizures associated with intracranial pathology. She was subsequently transferred for further management. The patient had a history of Super refractory seizure disorder, Bilateral temporal lobe meningioma, chronic kidney disease stage V (on hemodialysis), Type 2 diabetes mellitus, Systemic hypertension, S/P Cholecystectomy (2015).On examination, the patient was conscious and oriented after stabilization. Vital signs were as follows: Pulse: 75 beats/min, Blood pressure: 190/80 mmHg, Respiratory rate: 18 breaths/min, Oxygen saturation: 100% on room air, Glasgow Coma Scale: 15/15. Systemic examination was unremarkable except for cardiovascular findings consistent with left ventricular dysfunction.
Investigations
Electrocardiography revealed normal sinus rhythm with evidence of left ventricular hypertrophy. Echocardiography demonstrated mildly dilated left atrium and global hypokinesia of the left ventricle with an ejection fraction of approximately 35%, indicating moderate left ventricular systolic dysfunction. Mild mitral and tricuspid regurgitation were also noted.
Magnetic resonance imaging of the brain revealed large Dural-based enhancing extra-axial lesions in the right temporal region and left temporal convexity, consistent with bilateral temporal lobe meningioma. Magnetic resonance angiography showed reduced flow in both middle cerebral arteries. Electroencephalography demonstrated occasional sharp and wave discharges in the fronto-temporal regions bilaterally, suggesting seizure predisposition. Upper gastrointestinal endoscopy revealed gastric erosions and palatal oozing, indicating upper gastrointestinal bleeding. Laboratory investigations showed mild anemia, elevated blood urea and creatinine levels consistent with advanced renal failure, and mild electrolyte abnormalities.
Clinical Course
The patient was admitted to the intensive care unit and managed with ventilator support. Gradual clinical improvement allowed weaning from mechanical ventilation. During hospitalization, a pseudomonas infection was identified in the endotracheal tube culture and was treated with intravenous Meropenem. The patient subsequently developed upper gastrointestinal bleeding, and endoscopic evaluation revealed gastric erosions and palatal bleeding. One unit of packed red blood cells was transfused. The patient continued maintenance hemodialysis three times per week. Antiepileptic medications were administered for seizure control, while cardiovascular medications were used to manage heart failure and hypertension. Proton pump inhibitors and supportive therapy were also initiated. Following multidisciplinary management involving cardiology, neurology, nephrology, gastroenterology, and ENT specialists, the patient showed significant clinical improvement and was discharged in stable condition. At discharge, the patient was prescribed with Dual antiplatelet therapy, Calcium Channel blockers, Statins, Antihypertensives, Anticonvulsants, Hematinics/Hematopoietic agent (ESA) and Antidiabetic drugs.
Discussion
This case highlights the complex interaction between neurological, cardiovascular, and renal disorders in an elderly patient. Sudden cardiac arrest in elderly patients with multiple comorbidities represents a complex medical emergency associated with high morbidity and mortality. The present case highlights the coexistence of neurological, cardiovascular, and renal disorders that complicated clinical management and required a multidisciplinary approach. Meningiomas are among the most common primary intracranial tumors, accounting for approximately 30–40% of all central nervous system tumors. They arise from arachnoid cap cells and are typically slow-growing and benign. However, their location can significantly influence clinical manifestations. Temporal lobe meningiomas are frequently associated with seizures because of their proximity to cortical neuronal networks responsible for epileptogenic activity.
Seizures occur in approximately 20–40% of patients with intracranial meningiomas, particularly when the tumor involves the temporal or frontal lobes. Cortical irritation, peritumoral edema, and altered neuronal excitability contribute to the development of seizure disorders. In some patients, seizures may become refractory or super-refractory, requiring aggressive antiepileptic therapy and intensive monitoring. Super-refractory seizures, defined as seizures that continue for more than 24 hours despite treatment with anesthetic agents, represent a neurological emergency. Management typically involves multiple antiepileptic drugs, sedation, and supportive intensive care. In the present case, electroencephalography demonstrated frontotemporal epileptiform discharges, indicating persistent seizure susceptibility.
Cardiovascular complications may occur secondary to prolonged seizures or underlying cardiac disease. The patient in this case had heart failure with reduced ejection fraction (LVEF 35%), which increases the risk of arrhythmias and sudden cardiac arrest. Reduced cardiac output and ventricular remodeling contribute to electrical instability, predisposing patients to life-threatening cardiac events. Chronic kidney disease further complicates the clinical picture by affecting drug pharmacokinetics and increasing susceptibility to electrolyte imbalance. End-stage renal disease patients undergoing hemodialysis require careful monitoring of medication dosing, fluid balance, and metabolic parameters. Many antiepileptic and cardiovascular drugs require dose adjustments in renal impairment to prevent toxicity. Another important complication observed in this case was upper gastrointestinal bleeding associated with gastric erosions and palatal bleeding. Critically ill patients are particularly vulnerable to stress-related mucosal disease, which can lead to gastrointestinal hemorrhage. The use of antiplatelet agents and anticoagulants may further increase bleeding risk, necessitating careful monitoring and prophylactic therapy with proton pump inhibitors.
In addition, infections are common among mechanically ventilated patients. Endotracheal tube colonization with pathogens such as Pseudomonas aeruginosa is frequently associated with ventilator-associated infections. Prompt identification and targeted antimicrobial therapy are crucial to prevent systemic complications. The successful management of this patient highlights the importance of early recognition, prompt resuscitation, and coordinated multidisciplinary care. Collaboration between cardiology, neurology, nephrology, gastroenterology, and critical care teams allowed comprehensive management of the patient’s complex medical conditions.
From a clinical pharmacist perspective, this case underscores the importance of medication optimization, prevention of drug-related problems, and monitoring for drug interactions in patients with multiple comorbidities and polypharmacy.
Clinical Pharmacist Interventions
Clinical pharmacists play a critical role in the management of complex hospitalized patients, particularly those with multiple comorbidities and extensive pharmacotherapy. Several potential interventions were identified in this case.
Medication Reconciliation
A comprehensive medication review was performed at admission and discharge to ensure continuity of care and prevent medication errors. Special attention was given to antiepileptics, cardiovascular medications, and renal-supportive therapies.
Renal Dose Adjustment
Because the patient had end-stage renal disease and on hemodialysis, medications were evaluated for renal dose modifications. Drugs requiring dose considerations included:
- Antiepileptic agents
- Antibiotics such as Meropenem
- Cardiovascular medications
- Vitamin supplements
Appropriate dose adjustments helped reduce the risk of accumulation and toxicity.
Monitoring for Drug Interactions
Drug–drug interactions were monitored. Important interactions assessed were included:
- Antiepileptic’s with cardiovascular medications
- Antiplatelet therapy with gastrointestinal bleeding risk
- Antibiotics with renal impairment
Monitoring helped minimize adverse drug reactions and optimize therapeutic outcomes.
Management of Antiplatelet Therapy
The patient was prescribed dual antiplatelet therapy despite gastrointestinal bleeding risk. The careful monitoring and concurrent use of gastro protective therapy played a crucial role in reducing Risk of bleeding complications.
Therapeutic Drug Monitoring
Antiepileptic therapy requires monitoring to maintain effective plasma concentrations and prevent toxicity. Regular monitoring of clinical response and potential adverse effects was advised.
Antibiotic Stewardship
The detection of Pseudomonas aeruginosa infection required targeted antimicrobial therapy. Clinical pharmacist ensured appropriate antibiotic selection, dosing, and duration to optimize treatment outcomes and prevent antimicrobial resistance.
Glycemic Monitoring
Insulin therapy with long-acting insulin glargine was initiated for diabetes management. The pharmacist ensured regular monitoring of fasting blood glucose levels and educated caregivers regarding hypoglycemia symptoms.
Anemia Management in CKD
The patient received erythropoiesis-stimulating therapy with Wepox (Recombinant Human Erythropoietin Alfa). Hemoglobin levels were monitored and appropriate dosing intervals were ensured to manage anemia associated with chronic kidney disease.
Patient and Caregiver Counseling
Education was provided regarding:
- Insulin administration
- Antiepileptic adherence
- Dietary restrictions (fluid, sodium, potassium)
- Hemodialysis schedule
- Recognition of warning signs such as seizures or cardiac symptoms
Prevention of Medication Errors
Due to multiple medications with varying dosing schedules, Clinical pharmacist continuously monitored the medication charts to improve adherence and reduce medication administration errors.
Conclusion
This case illustrates the successful management of sudden cardiac arrest and super-refractory seizures in an elderly patient with bilateral temporal lobe meningioma and end-stage renal disease. Early diagnosis, rapid resuscitation, and coordinated multidisciplinary management were critical in achieving a favorable clinical outcome.
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