LA VALUTAZIONE NEUROLOGICA E PSICHIATRICADifferenziare la sincope dalle altre forme di perdita

transitoria di coscienza di natura neurologica

Giuseppe MicieliUO Neurologia d’Urgenza e Stroke Unit

IRCCS Istituto Clinico HumanitasRozzano (MI)

Quadri clinici di maggior frequenza in P.S.

Progetto NEU, 2003

Che cosa non è sincope

Perdita di coscienza dovuta a traumaPerdita di coscienza non transitoria e non a regressione spontaneaPerdita di coscienza transitoria e a regressione spontanea non dovuta ad ipoafflusso cerebraleSituazioni in cui non vi è una reale perdita di coscienza

Concussione

Coma, disturbi metabolici, intossicazione, “aborted sudden death”

Epilessia

Cadute, drop attack, disturbi psichiatrici, cataplessia, vertigini, presincope

Causes of syncope in an outpatient cohort(structural heart disease excluded)

Strano S et al. JNNP 2005;76:1597-1600

20 mL/100 g/min

35 mL/100 g/min

MTT map

Sincope e Ipoperfusione Cerebrale

Coutts SB et al, Neurology 2003

Wiebers et al, 1997

Subclavean steal syndrome

Filis K et al. J Med Case Report 2008;2:392

Sincope da compressione

estrinseca dell’arteria

vertebrale sinistra nel suo tratto extracranico

Sakaguchi M et al, Neurology 2003

Sincope e malattia cerebrovascolare:

compressione estrinseca dell’arteria

carotide interna di sinistra secondaria a tumore del glomo

carotideo

Misdiagnosis

Syncope Epilepsy

“Hardly anyone with epilepsy will come to any harmfrom a delay in diagnosis whereas a false positive diagnosis is gravely damaging”.

“Improper pacemaker implantation in patients with fits and falls of neurological origin”

The co-existence in the same subjects seems to be rare

Bergfeldt L. Heart 2003;89:353–358

Misdiagnosis of epilepsy in three population-basedand three cohort studies of patients with presumed

seizure disorder

Question Points (if yes)

At times do you wake with a cut tongue after your spells? 2

At times do you have a sense of deja vu or jamais vu before your spells

1

At times is emotional stress associated with losing consciousness?

1

Has anyone ever noted your head turning during spell? 1

Has anyone never noted that you are unresponsive, have unusual posturing or have jerking limbs during your splells or have no memory of your spells afterwards?

1

Has anyone ever noted that you are confused after a spell? 1

Have you ever had lightheaded spells? -2

At times do you sweat before your spells? -2

Is prolonged sitting or standing associated with your spells? -2

Seizures: score >1; Syncope: score<1 Sheldon et al,J Am Coll Cardiol 2002

CAUSES OF SYNCOPENeurally-mediated reflex syncopal syndromes

Vasovagal Faint (common faint)Carotid sinus syncopeSituational Faint

Acute haemorrageCough, SneezeGastrointestinal stimulationMicturitionPost-exerciseOthers

Glossopharyngeal and trigeminal neuralgia

Task Force on Syncope, ESC 2004

Cough Syncope

CAUSES OF SYNCOPE

Orthostatic

Autonomic FailurePrimary Autonomic Failure syndrome

(e.g. Pure Autonomic Failure, Multiple System Atrophy, Parkinson’s Disease with Autonomic Failure)

Secondary Autonomic Failure syndromes(e.g. Diabetic Neuropathy, Amyloid Neuropathy)

Drug and AlcoholVolume Depletion

Task Force on Syncope, ESC 2004

-

-

+

AVPNTS

VLM

NE

Arterial Blood Pressure

IML SG

a

Baroreflex arcInfluencing factors

• Origin and strenght of stimulus• Set point of the reflex• Input from higher centres• Responsiveness of cardiovascular

receptors and organs• Neurohumoral and vasoactive

substances• Interactions of the aortocarotid

with chemoreflex arc

MSA

PD PAF

Multiple System Atrophy

This disorder encompasses:

• Olivoponto-cerebellar atrophy (OPCA)– Sporadic late onset predominantly cerebellar syndrome (but

with additional parkinsonism and dysautonomia).Dejerine and Thomas (1900)

• Shy-Drager syndrome (SDS)– Neurogenic central autonomic failure in patients who also had

parkinsonism and cerebellar signs. Shy and Drager (1960)

• Striato-nigral degeneration (SND)– Rapidly progressive parkinsonism (but also cerebellar signs and

dysautonomia). Adams et al. (1961)

Graham and Oppenheimer (1969)

Autonomic Failure in PD

• Constipation• Urinary incontinence• Orthostatic or post-prandial

light-headedness• Heat or cold Intolerance• Decreased bowel sounds• Orthostatic hypotension

SYNCOPE AND FALLS

30% cognitively normal elderly people are unable torecall documented falls three months later

50% a withness account for syncopal events unavailable

40% of patients with an attributable diagnosis of carotidsinus syndrome, the only presenting symptoms werefalls alone or falls with dizzines (syncope was denied)

20% Amnesia for loss of consciounsness demonstrated in patients with a diagnosis of carotid sinus syndrome

FE Shaw and RA Kenny, 1997

Diagnostic algorithm in patients withsuspected NES

Muller T et al. Seizure 2002;11:85-89

Alsaadi TM, Vinter Marquez A. Am Fam Physician 2005;72:849-856

Features suggesting a diagnosis ofpsychogenic nonepileptic seizures

Alsaadi TM, Vinter Marquez A. Am Fam Physician 2005;72:849-856

Point of care:accident and emergency department

Petkar S et al. Postgrad Med J 2006;82:630-641

False negative &

False positive diagnoses

MOULIN T et al, 2003

Dischargediagnosis

MOULIN T et al, 2003

Emergency Room

SYNCOPE Cardiologist Neurologist

GP

Syncope Unit