Primary spinal cord glioblastoma is a rare and aggressive malignant tumor seen in only 1-5% of all glioblastoma and 1.5% of all spinal cord tumors with average length of survival of 15 months. Neurologic deficits are common while cardiac symptoms are less common and often overlooked. 

A 26-year-old male was admitted for episodes of transient head and arm twitching followed by unresponsiveness. Medical history was significant for paraplegia secondary to spinal cord glioblastoma involving cervical, thoracic, and lumbar spine, with progression to caudal brainstem despite aggressive chemotherapy and radiation. These episodes were strictly positional and occurred only in upright position and resolved when reclining or lying flat. Bedside electroencephalography did not show any seizure activities during these episodes. He was diagnosed with convulsive syncope related to autonomic dysfunction. His hospital course was complicated by profound bradycardia and hypotension, treated with midodrine and fludrocortisone without remission. During one of the episodes, patient suffered asystole cardiac arrest requiring cardiopulmonary resuscitation and ultimately permanent pacemaker placement.  

Ventrolateral medulla provides major control for maintaining cardiovascular stability. The fibers descend in dorsolateral funiculus, synapse with spinal sympathetic preganglionic neurons and exit between T1-T4. Disruption of sympathetic pathway between brainstem to spinal cord due to spinal cord injury or infiltrating lesion, like glioblastoma, can result in reduced sympathetic tone. This can lead to unopposed parasympathetic activity on the sinus node, causing bradycardia, hypotension, and cardiac arrest as the most devastating consequence. 

Patients with spinal cord glioblastoma are at risk for autonomic dysfunction due to disruption of central sympathetic pathway. Early recognition and prompt treatment of autonomic dysfunction are essential to prevent mortality.