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Navin agrawal syncope presentation

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diagnosis and management of syncope:-neurological aspect

diagnosis and management of syncope:-neurological aspect

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  • 1. GUIDE:-DR.APOORVA PAURANIK CANDIDATE:-DR.NAVIN AGRAWAL
  • 2. A Symptom…. Not A Diagnosis  “Human beings are falliable / fallable”-quote  Falling is not an abnormal phenomenon nor a recent phenomenon  Owsei Temkin quoted the reasons of falling in his book “THE FALLING SICKNESS”-a history of epilepsy from the Greek era  We aim to discuss the etiology and d/d and approach to various causes of falling  FALL is a sudden unintentional change in position causing a individual to land on a lower level object or ground.
  • 3. SYNCOPAL CAUSES OF FALLS
  • 4. NON SYNCOPAL CAUSES OF FALLS
  • 5. SYNCOPE  Term syncope(greek:- synkope)literally syn means ‘with’ and koptein means ‘cessation’ or ‘cutting short’ or ‘pause  DEFINITION OF SYNCOPE:-sudden transient loss of consciousness and postural tone with spontaneous recovery  Cessation of cerebral blood supply for 6-8 sec or decrease of systolic BP <60 mmhg or>20% drop in cerebral blood supply is sufficient.  Syncope accounts for 3% to 5% of emergency room visits and 1% to 3% of hospital admissions
  • 6. CLINICAL FEATURES OF SYNCOPE  Sense of giddiness, lightheadedness, apprehension, may sway, headache(sometimes) Vision may dim or close in concentrically ,tinnitus may be +nt  Patients with neuro-cardiogenic syncope experience a typical sense of warmth associated with sweating and a sense of `greying out`. Cardiogenic syncope may be ppt by arrthymias or chest pain  A hurtful fall is exceptional in the young  Patient is motionless. Skeletal muscles are fully relaxed . Sphincter control is usually maintained . Body appears pale
  • 7. CLINICAL FEATURES contd…  After syncope:-Retrograde amnesia esp in the elderly ,muscle ache fatigue with short lasting confusion(<5min)  Convulsive syncope:-mild asynchronous clonic jerk of limbs and trunk with face twitching , occ. flexor jerking, rarely tongue bite and urinary incontinence  EEG shows b/l synchronous delta and theta waves esp in frontal lobes .Flattening may occur in prolonged cardiac arrest (>15 sec).Epileptiform activity is not seen.
  • 8. HISTORY
  • 9. SEIZURES  Seizures are the most common neurogenic causes of drop attacks.  GTCS , CPS , atonic seizures and negative myoclonus and may be causes of sudden falls  A specific aura may precede  Incontinence , hurtful falls , tongue bite , post-ictal confusion(> 5 min) and motor manifestations are imp distinguishing features  Atonic seizures are defined as epileptic attacks chr. by a sudden loss or diminution of muscle tone, which may be fragmentary, confined to a segment (limb, jaw, head), or massive, leading to a slumping to the ground
  • 10.  Negative myoclonus is defined as an interruption of tonic muscular activity (50 to 400 msec in duration), causing “instability” or, more often, dropping of objects from the hands, head nodding, or falls  Epileptiform EEG in the inter ictal period is diagnostic  Biochemical parameters:-Serum prolactin , serum creatine kinase , serum ACTH(or cortisol), serum pH, body temperature  MRI can be used to identify seizure foci.  Response to anti-convulsants can also be used for differentiation
  • 11. SEIZURE V/S SYNCOPE
  • 12. OTHER NEUROLOGICAL CAUSES OF DROP ATTACKS               cerebrovascular disoders drop attacks cataplexy third ventricular cyst (colloid cyst) otolithic crises progressive supranuclear palsy basilar migraine arnold chiari malfofmation psychogenic syncope creudzfeldt jacob disease(variant type) corticobasal degeneration intermittent spinal ischemia Hyperexplexia(`jumping frenchman of maine`) Frontal lobe ataxia
  • 13. FALLS IN CEREBROVASCULAR DISORDERS  Very rare manifestation  Multiple occlusions of large arteries like in Takayasu`s disease involving carotid and vertebral arteries  Subclavian steal syndrome  Subarachnoid hemorrhage:-raised ICT causes momentary cessation of cerebral blood supply(equalisation of pressure),usually associated with severe headache and neck stiffness
  • 14.  Vertebrobasilar TIA or ischemia usually associated with other signs of brainstem dysfunction  Does not occur in ischemia confined to carotid territory.  Cervical spine abnormalities like Klippel Feil`s syndrome and cervical spondylosis  Acute lesions of the parieto- insular vestibular cortex due to embolisation of middle cerebral artery can cause imbalance of vestibular stimuli and can present as falls without hemiparesis.
  • 15. CAUSES OF VASCULAR ORIGIN  Most common cause of syncope,>33%  Types:- 1.ORTHOSTATIC HYPOTENSION: Definition  Cause:-autonomic dysfunction , hypovolemia , drug     ,vasovagal Symptoms Worse early in the morning and after meals or exercise Most common cause:-drugs like diuretics ,vasodilators ,alpha blockers ,ace inhibitors , tranquilizers Primary autonomic failure syndromes
  • 16.  Secondary neurogenic causes like aging ,diabetes, alcoholism , renal failure ,GBS ,multiple sclerosis ,wernicke`s encephalopathy ,HIV , metabolic disorders
  • 17. 2.REFLEX MEDIATED FALLS: Vascular effects of neural signals come from nucleus tractus solitarius Types:Neurally mediated hypotension:-triggers include sight of blood ,pain ,prolonged standing , warm environment ,stressful condition , physical injury particularly to viscera (like testicles and gut)
  • 18. -Carotid sinus hypersensitivity: Definition:- sinus pause>3 sec , systolic BP fall of >50 mm hg  Initiated on turning head to one side while wearing a Tight collar or while shaving  usually in standing position.
  • 19. CARDIAC CAUSES OF FALLS  Second most common cause ,10-20%  VT is the most common tachyarrhythmia causing syncope  Structural heart diseases like aortic stenosis, myocardial ischemia , mitral stenosis ,atrial myxoma
  • 20. ECG FEATURES SUGGESTIVE OF ARRYTHMOGENIC SYNCOPE  Bifascicular block (defined as either left bundle branch block or right bundle branch block combined with left anterior or left posterior fascicular block)  Other intraventricular conduction abnormalities (QRS duration >0.12 seconds)  Mobitz I OR type 2 second degree atrioventricular block or complete heart block  Asymptomatic sinus bradycardia (<50 beats/min), sinoatrial block, or sinus pause >3 seconds in the absence of negatively chronotropic medications  Pre-excited QRS complexes  Prolonged QT intervals  Right bundle branch block pattern with ST-elevation in leads V1-V3 (Brugada syndrome)  Negative T waves in right precordial leads, epsilon waves and ventricular late potentials suggestive of arrhythmogenic right ventricular dysplasia  Q waves suggesting myocardial infarction
  • 21. CATAPLEXY  Narcolepsy/Cataplexy syndrome is chr. by  excessive daytime sleepiness  cataplexy  hypnagogic hallucinations  sleep paralysis  sudden fall associated with loss of body tone precipitated by emotional change like anger or laughter  Part of syndrome associated with narcolepsy  The cataplexy associated with narcolepsy can be managed with tricyclic antidepressants.  The excessive sleepiness is managed with stimulants, OR newer agents, such as modafinil,
  • 22. PROGRESSIVE SUPRANUCLEAR PALSY  Also known as Steele-Richardson-Olszewski syndrome, is a neurodegenerative disease that affects cognition, eye movements, and posture  Characteristics include supranuclear, primarily vertical, gaze dysfunction accompanied by extrapyramidal symptoms and cognitive dysfunction  The disease usually develops after the sixth decade of life, and the diagnosis is purely clinical.  Currently, no therapy is proven to be effective.
  • 23. THIRD VENTRICULAR CYST  Colloid cysts are nonmalignant tumors  Almost always found in the third ventricle  Classic symptoms of intermittent obstructive hydrocephalus with paroxysmal headache associated with changing head position  Sudden weakness in the lower limbs associated with falls without loss of consciousness has been reported.
  • 24. DROP ATTACKS  Also known as ‘maladie des genoux bleus’.  usually occurs in elderly women  Usually there is sudden onset loss of body tone and weakness of legs . people drop on their knees .no associated symptoms.  No loss of consciousness occurs  Vision, hearing ,speech remain intact
  • 25. OTOLITHIC CRISIS  Also known as Tumarkin`s attacks.  It occurs without warning, vertigo, nausea or vomiting, sweating, disequilibrium, loss of consciousness, numbness or paralysis  the feeling of being pushed to the ground  There is no loss of consciousness  Sudden increase in labyrinthine pressure is responsible for sudden onset vertigo
  • 26. HYPEREXPLEXIA  An autosomal dominant trait(Chromosome 5) disorder in which babies have an exaggerated startle reflex  Hypertonia (stiffness), exaggerated startle response in some cases, epilepsy  Acute generalized Hypertonia (sudden stiffness) causing the person to fall like a log to the ground  Startles can be elicited by lightly touching the person's nose, clapping or making other noises, or suddenly jolting the person's chair.  Tendency to umbilical and inguinal hernias and congenital dislocation of the hip.  Good response to clonazepam , valproate and phenobarbitone
  • 27. `JUMPING FRENCHMAN OF MAINE`  Genetic mutation that prevents "exciting" signals in the nervous system from being regulated  type of hyperexplexia  An extended, grossly exaggerated startle response from a "jumper," including crying out, flailing limbs, twitching, and sometimes convulsions.  sufferers are sometimes teased mercilessly by people who find the reaction amusing, and trigger it repeatedly.  Curiously patient has an automatic reflex to obey any order that is delivered suddenly, echolalia is present
  • 28. IDIOPATHIC SYNCOPE  Almost one third of all syncopal attacks  Positive tilt table test suggests neuro-cardiogenic cause  Repetitive and erratically spaced syncope without a specific predisposing factor suggests an arrthymogenic cause and Holter and EPS study must be done
  • 29. HYSTERICAL FAINTING  Occurs in dramatic circumstances  Esp. in young females without evidence of cardiovascular illness  Evident lack of change in pulse , blood pressure , or color of the skin  Outward display of anxiety  General personality and behavioral characteristics of hysteria.
  • 30. SUBACUTE SCLEROSING PAN-ENCEPHALITIS  A rare chronic, progressive encephalitis  Chr by a h/o of primary measles infection before the age of 2 years, f/b several asymptomatic years (6–15 on average),  gradual, progressive psycho neurological deterioration, seizures, myoclonus, ataxia, chorioretinitis , spasticity, and coma.  EEG shows periodic(every 5-8 sec) bursts of 2 to 3/sec high voltage waves f/b flat pattern  CSF shows increased protein esp. gamma globulin (IgG Ab)  Eosinophilic inclusions is the histopathological hallmark
  • 31. DIFFERENTIAL DIAGNOSIS  anxiety attacks and hyperventilation syndrome  hypoglycemia  concussion  sudden vascular collapse like ruptured aortic aneurysm ,      aortic dissection , pulmonary embolism , acute blood loss cerebellar ataxia vestibular neuronitis normal pressure hydrocephalus visual deficits induced collisions and mechanical falls sporting injury related falls
  • 32. CLINICAL FEATURES SUGGESTIVE OF SPECIFIC ETIOLOGY
  • 33. INVESTIGATIONS  Holter  Event monitor  Loop recorder of  Echo  Tilt table test  EP study (frequent syncope , suggestive ecg,0-4% yield) (infrequent events not with sudden LOC) (infrequent events in ambulatory patients, IOC in case bradyarrythmias) (orthostatic,YIELD <=60%) -50-80% yield with SHD -5-10% yield with no SHD -less useful for bradyarrythmias
  • 34.  EEG (for suspected epilepsy)  CT or MRI brain(for structural abnormalities and epileptic foci) and for hematomas.  MRI Angio for cerebrovascular diseases in cases of TIA  Carotid Doppler (for suspected TIA)  CT chest in case of suspicion of pulmonary embolus ,ruptured aneurysm and aortic dissection
  • 35. LOOP RECORDERS
  • 36. INSERTABLE LOOP RECORDERS
  • 37. HEAD UP TILT TABLE TEST  UNMASKS LATENT VASO VAGAL SYNCOPE  REPRODUCES THE PATIENT SYNCOPE  DEVELOPS BETTER PATIENT UNDERSTANDING OF HIS ILLNESS AND ITS SYMPTOMS  ALLOWS THE PHYSICIAN TO PROGNOSTICATE AND COUNSEL THE PATIENT  C/I SEVERE LVOT OBSTRUCTION,CRITICAL MITRAL STENOSIS,SEVERE CEREBROVASCULAR STENOSIS,PROXIMAL CORONARY ARTERY STENOSIS
  • 38. Classification of positive responses to tilt testing  Type 1 mixed. Heart rate falls at the time of syncope but the ventricular rate does not fall to less than 40 bpm or falls to less than 40 bpm for less than 10 s with or without asystole of less than 3 s. Blood pressure falls before the heart rate falls.  Type 2A cardio inhibition without asystole. Heart rate falls to a ventricular rate less than40 bpm for more than 10 s but asystole of more than 3 s does not occur. Blood pressure falls before the heart rate falls.  Type 2B cardio inhibition with asystole. Asystole occurs for more than 3 s. Blood pressure fall coincides with or occurs before the heart rate fall.  Type 3 vasodepressor. Heart rate does not fall more than 10% from its peak at the time o f syncope.  Exception 1. Chronotropic incompetence. No heart rate rise during tilt testing (i.e. less than10% from the pre tilt rate).  Exception 2. Excessive heart rate rise. An excessive heart rate rise both at the onset of the upright position and throughout its duration before syncope (i.e. greater than 130 bpm).
  • 39. TREATMENT  MANAGEMENT OF THE CAUSE  avoiding or precautions for provocative stimuli esp those for vasovagal syncope like prolonged standing , stress ,blood donation ,extreme emotions ,nausea ,vomiting ,micturation ,defecation  in case of syncope patient should be made to lie down with raising of legs ,tight clothing should be loosened, inciting stimuli if possible should be removed
  • 40.  Salt and fluid consumption may be increased ,offending drugs should be avoided  Drugs such as beta blockers ,midodrine ,fludrocortisone ,SSRI`s have been tried  Management of specific arrthymias with drugs or pacemakers  patient counseling regarding behavior and occupational rehabilitation  consideration of the psychological effects of the disease
  • 41. THANK YOU IF BY NOW YOU`RE TIRED AND FEEL LIKE FAINTING THIS FOR YOU IS THE CARVED ANCIENT VICTORIAN FAINTING COUCH
  • 42. PHYSICAL EXAMINATION  GENERAL EXAMINATION FOR     PALLOR,WEAKNESS,GENERAL HEALTH POSTURAL BLOOD PRESSURE DETAILED CARDIAC EXAMINATION PULSE RATE,VOLUME,REGULARITY SYSTEMIC EXAMINATION FOR SPECIFIC DISEASES
  • 43. CAUSES AND THEIR RELATIVE FREQUENCY

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