This document discusses various causes of falls, including syncope (transient loss of consciousness) and non-syncopal causes. It covers topics such as neurocardiogenic, cardiac, and neurological causes of syncope including seizures, progressive supranuclear palsy, third ventricular cysts, and more. Investigations discussed include Holter monitoring, loop recorders, tilt table testing, and imaging. Differential diagnosis and management are also covered.

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.

4. SYNCOPAL CAUSES OF FALLS

5. NON SYNCOPAL CAUSES OF FALLS

7. 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

8. 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

9. 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.

10. HISTORY

11. 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

12.  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

13. SEIZURE V/S SYNCOPE

14. OTHER NEUROLOGICAL CAUSES OF
DROP ATTACKS
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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

15. 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

16.  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.

17. CAUSES OF VASCULAR ORIGIN
 Most common cause of syncope,>33%
 Types:-
1.ORTHOSTATIC HYPOTENSION: Definition
 Cause:-autonomic dysfunction , hypovolemia , drug
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,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

18.  Secondary neurogenic causes like aging ,diabetes,
alcoholism , renal failure ,GBS ,multiple sclerosis
,wernicke`s encephalopathy ,HIV , metabolic disorders

19. 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)

20. -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.

21. 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

22. 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

24. 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,

25. 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.

26. 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.

27. 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

28. 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

29. 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

30. `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

31. 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

32. 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.

33. 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

34. DIFFERENTIAL DIAGNOSIS
 anxiety attacks and hyperventilation syndrome
 hypoglycemia
 concussion
 sudden vascular collapse like ruptured aortic aneurysm ,
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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

35. CLINICAL FEATURES SUGGESTIVE
OF SPECIFIC ETIOLOGY

38. 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

39.  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

40. LOOP RECORDERS

41. INSERTABLE LOOP RECORDERS

42. 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

43. 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.
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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.
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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.
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Type 3 vasodepressor. Heart rate does not fall more than 10% from its peak at the time o f
syncope.
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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).

45. 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

46.  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

47. THANK YOU
IF BY NOW YOU`RE TIRED AND FEEL LIKE FAINTING THIS FOR
YOU IS THE CARVED ANCIENT VICTORIAN FAINTING COUCH

48. PHYSICAL EXAMINATION
 GENERAL EXAMINATION FOR
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PALLOR,WEAKNESS,GENERAL HEALTH
POSTURAL BLOOD PRESSURE
DETAILED CARDIAC EXAMINATION
PULSE RATE,VOLUME,REGULARITY
SYSTEMIC EXAMINATION FOR SPECIFIC DISEASES

49. CAUSES AND THEIR RELATIVE FREQUENCY