Transient Loss of Consciousness A Clinical Approach

Transcription

1 A Clinical Approach Dr. Hany. M. Zaki-eldine, MD Ass Prof Neurology and Interventional Neurology Ain Shams Univ Member of the World Federation of Therapeutic and Interventional Neuroradiology

2 Syncope Epilepsy Cerebral ischemia Migraine Metabolic disorder Sudden ICP DD: Breath-holding spells, drop attacks Psychogenic seizures, Anxiety, panic attacks and malingering

3 History patient observer Examination Investigation

4 Syncope Epilepsy Cerebral ischemia Migraine Metabolic disorder Sudden ICP DD: Breath-holding spells, drop attacks Psychogenic seizures, Anxiety, panic attacks and malingering

5 Etiology of Syncope Neurally mediated reflex syncope Vaso-vagal syncope (commonest) Carotid sinus syncope Glossopharyngeal neuralgia Situational: cough, micturition, defecation, swallowing, diving, valsalva maneuver Orthostatic Hypotension Dysautonomia, hypoadrenalism Drugs Hypovolemic Cardiac: Arrhythmias (tachy, brady) Decreased cardiac output (in & outflow obstruct, cardiomyopathy) Cerebrovascular disease Metabolic Hypoglycemia Hypoxia Anemia Hyperventilation-induced alkalosis

6 Vasovagal Syncope Precipitating factors: Unpleasant sights or pain, prolonged standing, heat, hunger, dehydration, alcohol. Posture dependent Onset gradual Aura: long initial warmth & dry mouth, desire for fresh air or water Nausea & deep sighing respiration Blurring with spots, loss of vision noise & vertigo depersonalization pallor, sweating Collapse (standing) flaccid, mb rigid +/- clonic movements (convulsive syncope) EEG: generalized slowing, NO epileptic activity Recovery: loss conscious is brief, recovery at site of collapse nausea, tremulous, pallor, sweating

7 Glossopharyngeal Neuralgia: paroxysmal intense pain in throat and neck bradycardia or asystole, hypotension if prolonged, seizure ppt by swallowing, chewing, speaking, laughing, coughing, sneezing, yawing Vagal irritation: Esophageal diverticulosis, tumor or aneurysm of the carotid sinus, mediastinal masses, gall bladder disease

8 Situational Syncope Cough syncope obese male, smoker with ch bronchitis sudden onset, brief (sec) flushed face then pallor +/- diaphoresis & hypotonia Mech: decreased venous return Micturition (defecation uncommon) male, middle of night, erect position Mech: periph vasodilatation due to release of intravesicular pressure bradychardia swallowing diving valsalva maneuver Sexual intercourse: neurocardiogenic, coronary artery disease, erectile dysfunction medications Exercise syncope: cardiac (arrhythmias, low CO..) anemia, hypoxia, hypoglycemia cerebrovascular situational syncope, autonomic dysfunction

9 Cerebrovascular Ischemia Occasional (non-hemispheric hemodynamic TIA), other neurologic symptoms are common exercise, orthostatic & head movement induced extensive occlusive disease (carotid or vertebrobasilar) Atherosclerotic, subclavian steal (upper limb exercise) giant-cell arteritis (eg.takayasu arteritis, pulseless) exercise & head movement induced Mechanical: elderly, severe cervical spondylosis head movements (hyper-extension or lat rotation) several sec after correction of head movements vertebrobasilar symptoms are common (vertigo, drop attacks) Vasospasm (esp in posterior circulation) basilar migraine child or young adult brain-stem symptoms & headache gradual loss of conscious & confusional state for hours subarachnoid hemmorrhage

10 Metabolic Disorders Usually only lightheadedness and dizziness Hypoglycemia: gradual onset, preceded by sense of hunger, pallor, sweating aggravated by exercise rapid correction with ingestion of food Hypoxia lack of oxygen or vasodepressor syncope Anemia aggravated by exercise Hyperventilation Psychogenic Gradual onset Parasthesia, buzzing sensation in head, lightheadedness, blurring of vision, dryness of mouth, tetany Tachycardia but normal blood pressure

11 Investigation for Syncope Depend on initial DD CBC, blood glucose Suspected cardiac syncope Chest X-ray Echocardiography, radionuclide scan ECG, Holter ECG Exercise tests Electrophysiologic studies & tilt table test Suspected cerebrovascular syncope MRI brain Vascular assessment intracranial arteries: CTA, MRA with Gd, TCD extracranial arteries: carotid duplex, CTA, MRA with Gd Suspected epileptic loss of consciousness EEG Epilepsy is a clinical diagnosis, normal EEG do not exclude the diagnosis Some pts with clinically documented seizures show no abnormalities even after serial EEG with provocation techniques, sleep EEG

12 Syncope Epilepsy Cerebral ischemia Migraine Metabolic disorder Sudden ICP DD: Breath-holding spells, drop attacks Psychogenic seizures, Anxiety, panic attacks and malingering

13 Seizures Altered consciousness occur in both generalized seizures (absence and tonic-clonic) complex partial seizures Temporal lobe syncope: drop attacks in pt with CPS (rare) Atonic seizures children drop attacks with extremely brief loss of consciousness

14 Features Relation to posture Syncope (Vaso-vagal & orthostatic) Seizure No Precipitating factors Emotion, injury, crowd. Sleep loss, drug withdrawel Onset Aura convulsion Skin colour Autonomic changes Diaphoresis Respiration/circulation Injury Sphincter Incontinence Duration Rate of recovery Post-ictal confusion Post-ictal headache Focal Neurol Signs Gradual Long Rare (myoclonic jerks if prolonged) Pallor (not orthost) (not orthost) shallow breathing low Bl Pr, slow weak pulse (not ortho) Rare Rare Brief (seconds) Rapid Rare No No (general weakness) Abrupt brief Cyanosis or normal GTC (CPS aura) Diaphoresis, mydriasis, piloerect Apnea or stertorous resp High bl p & HR Longer Slower May occur

15 Features Arrhythmic Syncope Seizure Precipitating factors +/- exertion +/- Sleep loss, drug withdrawal Onset Aura convulsion Skin colour/coldness Autonomic changes Diaphoresis Respiration/circulation Injury Sphincter Incontinence Duration Rate of recovery Post-ictal confusion Post-ictal headache/body aches Focal Neurol Signs History of palpitations Cardiovasular signs Abrupt No Rare (myoclonic jerks if prolonged) Pallor/periph coldness No shallow breathing Pulse abnormal, low Bl Pr possible Uncommon (if prolonged) Brief (sec-min) Rapid (? Arrhythmias, cerebral ischemia; prolonged confusion) Rare No No May occur Abrupt Mb Cyanosis or normal GTC (CPS aura) Diaphoresis, mydriasis, piloerect Apnea or stertorous resp High bl p & HR Longer Slower (GTC, CPS) May occur, path reflex No No

16 Syncope Epilepsy Cerebral ischemia Migraine Metabolic disorder Sudden ICP DD: Breath-holding spells, drop attacks Psychogenic seizures, Anxiety, panic attacks and malingering

17 Sudden ICP (impairment of cerebral perfusion) Periodic obstruction of CSF circulation (ex. Aqueductal stenosis or colloid cyst of 3 rd ventricle) Sudden severe headache followed by loss of consciousness, occasionally opithotonus and clonic movements Tinnitus is common spontaneous or ppt by postural change or valsalva maneuver

18 Syncope Epilepsy Cerebral ischemia Migraine Metabolic disorder Sudden ICP DD: Breath-holding spells, drop attacks Psychogenic seizures, Anxiety, panic attacks and malingering

19 Breath-holding spells Age: onset: 6months-2y disappear by 5-6 y Mb several time /day Cyanotic: Ppt: injury, fright, anger Crying vigorously then holding breath in expiration, cyanosis then loss of consciousness Occasional stiffeness, few clonic movements and urinary incontenence EEG normal Pallid: Ppt: mild injury or startle Crying then pallor then loss of consciousness Occasional stiffeness, few clonic movements and urinary incontenence Mech: excessive vagal tone (as vasovagal attacks) Drop attacks Narcolepsy with cataplexy (second or third decade)

20 Psychogenic or pseudo-seizures Episodes of altered behavior that resemble epileptic seizure Mostly they superficially resemble tonic-clonic fits Complex partial seizures of frontal lobe may be difficult to be distinguished

21 Attack Feature Precipitating factors Presence of others Diurnal variation Onset Stereotypy of attacks Autonomic: pupil Ictal eye closure Resistance to eye opening or passive limb movements cyanosis Injury Sphincter Incontinence Motor activity Consciousness Duration Postictal confusion Reproduction of attacks by suggestion Secondary Gain & Psychiatric disturbances Ictal EEG Post-Ictal EEG (seizure with impaired consciousness) Psychogenic Seizure Emotional disturbances common Daytime Mb gradual Mb variable Normal common common No Rare rare Prolonged, uncoordinated; pelvic thrust, flailing, rolling. Retained in prolonged attack prolonged Rare sometimes common Normal Normal Epileptic Seizure Sleep loss, drug withdrawal Not essential Nocturnal or daytime sudden Usually stereotypical Dilated Rare unusual common Mb Frequent Coordinated tonic-clonic activity or automatism Very rare Brief common No uncommon Abnormal (except in some CPS & simple partial) Usually abnormal

22 Thank You