Navin agrawal syncope presentation

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DROP ATTACKS GUIDE:-DR.APOORVA PAURANIK CANDIDATE:-DR.NAVIN AGRAWAL

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diagnosis and management of syncope:-neurological aspect

Transcript of Navin agrawal syncope presentation

  • 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 recentphenomenon Owsei Temkin quoted the reasons of falling in his book THEFALLING SICKNESS-a history of epilepsy from the Greek era We aim to discuss the etiology and d/d and approach to variouscauses of falling FALL is a sudden unintentional change in position causing aindividual 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 withand koptein means cessation or cutting short or pause DEFINITION OF SYNCOPE:-sudden transient loss ofconsciousness and postural tone with spontaneous recovery Cessation of cerebral blood supply for 6-8 sec or decreaseof systolic BP 20% drop in cerebral blood supply is sufficient. Syncope accounts for 3% to 5% of emergency room visitsand 1% to 3% of hospital admissions 6. CLINICAL FEATURES OF SYNCOPE Sense of giddiness, lightheadedness, apprehension, maysway, headache(sometimes) Vision may dim or close in concentrically ,tinnitus may be +nt Patients with neuro-cardiogenic syncope experience atypical 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(15 sec).Epileptiform activity is not seen. 8. HISTORY 9. SEIZURES Seizures are the most common neurogenic causes of dropattacks. GTCS , CPS , atonic seizures and negative myoclonus and may becauses 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 suddenloss 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 muscularactivity (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`sdisease involving carotid and vertebral arteries Subclavian steal syndrome Subarachnoid hemorrhage:-raised ICT causesmomentary cessation of cerebral blood supply(equalisation of pressure),usually associated with severe headache and neck stiffness 14. Vertebrobasilar TIA or ischemia usually associated withother signs of brainstem dysfunction Does not occur in ischemia confined to carotid territory. Cervical spine abnormalities like Klippel Feil`s syndromeand cervical spondylosis Acute lesions of the parieto- insular vestibular cortex dueto 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 aTight 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 causingsyncope 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 (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 byemotional change like anger or laughter Part of syndrome associated with narcolepsy The cataplexy associated with narcolepsy can be managed with tricyclicantidepressants. 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 aneurodegenerative 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 obstructivehydrocephalus with paroxysmal headache associated with changing head position Sudden weakness in the lower limbs associated withfalls 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 andweakness 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 forsudden onset vertigo 26. HYPEREXPLEXIA An autosomal dominant trait(Chromosome 5) disorder in whichbabies have an exaggerated startle reflex Hypertonia (stiffness), exaggerated startle response in somecases, epilepsy Acute generalized Hypertonia (sudden stiffness) causing theperson 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 congenitaldislocation of the hip. Good response to clonazepam , valproate and phenobarbitone 27. `JUMPING FRENCHMAN OF MAINE` Genetic mutation that prevents "exciting" signals in the nervoussystem 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 findthe reaction amusing, and trigger it repeatedly. Curiously patient has an automatic reflex to obey any order thatis 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 aspecific 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 cardiovascularillness Evident lack of change in pulse , blood pressure , or color ofthe skin Outward display of anxiety General personality and behavioral characteristics ofhysteria. 30. SUBACUTE SCLEROSING PAN-ENCEPHALITIS A rare chronic, progressive encephalitis Chr by a h/o of primary measles infection before the age of 2years, f/b several asymptomatic years (615 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 highvoltage 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 recorderof 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