Seizure, syncope and drop attacks - McGill University

Seizure, syncope and drop attacks - McGill University

All of the above? Seizure versus syncope!? Seizure syncope

& drop attacks Mark Keezer R5 Neurology ELS July 13, 2011 Outline Brief overview of epileptic seizures Syncope: an organized approach

Seizure versus syncope An approach to the patient Further differentials diagnoses for your consideration. What is an epileptic seizure? What is epilepsy? Epilepsy:

Etymology: epilepsia (Gk): to seize upon Hughlings Jackson circa 1870 an excessive and disorderly discharge of cerebral nervous tissue on muscles ILAE definitions Epileptic seizure: transient occurrence of signs and/or symptoms due to abnormal excessive or synchronous neuronal activity in the brain

Epilepsy: Disorder of the brain characterized by an enduring predisposition to generate epileptic seizures and by the neurobiologic, cognitive, psychological and social consequences of the this condition. The definition of epilepsy requires the occurrence of at least one epileptic seizure 1981 ILAE Seizure Classification Focal onset

a. Simple partial b. Complex partial c. Partial seizures evolving to secondarily generalized Generalized Onset a. b. c. d. e.

f. Absence Myoclonic Clonic Tonic Tonic-clonic Atonic What does a GTC actually look like?

Generalized Tonic Clonic Seizure the seizure strikes "out of the blue," beginning with a sudden loss of consciousness and a fall to the ground. The initial motor signs are a brief flexion of the trunk, an opening of the mouth and eyelids, and upward deviation of the eyes. The arms are elevated and abducted, the elbows semiflexed, and the hands pronated. These are followed by a more protracted extension phase, involving first the back and neck, then the arms and legs.

There may be a piercing cry as the whole musculature is seized in a spasm and air is forcibly emitted through the closed vocal cords This is the tonic phase and lasts for 10 to 20 seconds. Generalized Tonic Clonic Seizure there is a mild generalized tremor, which is, in effect, a repetitive relaxation of the tonic contraction. begins at a rate of 8 per second and coarsens to 4 per second; then it rapidly gives way to brief, violent

flexor spasms that come in rhythmic salvos and agitate the entire body. Autonomic signs are prominent: the pulse is rapid, blood pressure is elevated, pupils are dilated, and salivation and sweating are prominent; bladder pressure may increase six-fold during this phase. Generalized Tonic Clonic Seizure The clonic jerks decrease in amplitude and frequency over a period of about 30 seconds. The patient remains

apneic until the end of the clonic phase In the terminal phase of the seizure, all movements have ended and the patient lies still and limp in a deep coma Breathing may be quiet or stertorous. This state persists for several minutes, after which the patient opens his eyes, begins to look about, and is obviously bewildered and confused and may be quite agitated. Video

What is syncope? Syncope: Etymology: synkoptein (Gk): to cut off Abrupt, transient, and self-limiting loss of consciousness associated with loss of postural tone, caused by a sudden fall in cerebral perfusion.

Video How frequent is convulsive syncope? Convulsive syncope Lempert et al. studied 42 patients with syncope Induced by hyperventillation, orthostasis and valsalva 90% with myoclonus Multifocal arrythmic jerks in proximal and distal muscles

Generalized myoclonus 79% with head version, oral automatisms and righting movements 60% reported visual and auditory hallucinations 1 lateral tongue bite! Convulsive syncope Intermittent posturing of brainstem origin Dis-inhibition in the context of cortical hypoactivity due to transient cerebral hypoxia

What are the presumed levels of these lesions? What are the causes of syncope? Do you have an organized approach? Mechanistic classification of syncope

1. Neurally mediated 2. Orthostatic hypotension 3. Cardiopulmonary disease 4. CNS syncope Neurally mediated (1/4)

Vasovagal syncope Carotid sinus syncope Situational syncope Atypical causes Glossopharyngeal neuralgia. Vasovagal Syncope Aka vasodepressor syncope Loss of sympathetic vascular tone coupled with heightened vagal activity on

the heart. Vasodilate while bradycardic Transient but excessive sympathetic activity may paradoxically vasodilate in intramuscular and splanchnic vessels? Neurocardiogenic component? Initial vigorous ventricular contractions lead to deficient filling therefore prompting the empty-heart syndrome Younger individuals, women, migraineurs?

Often in the context of heat, hunger, pain, strong emotion. Carotid Sinus Syncope Nerve of Hering, branch of CN IX Vagal-mediated decrease in BP Episodes precipitated by Tight collar Turning of the head Shaving over the sinus

Older men Atherosclerosis? Situational syncope Diminished venous return Cough Swallow Micturition Defecation

Weight-lifting Hairbrushing Stretch. Glossopharyngeal Neuralgia Paroxysms of pain localized to the base of the tongue, pharynx, larynx or ear Beginning in the 6th decade 2% associated with syncope

Mediated by activation of the dorsal motor nucleus of the vagus by the nucleus solitarius Deglutitional syncope Syncope post forceful swallow! Orthostatic hypotension (2/4) Vascular Primary

Prolonged bedrest Hypothalamic lesions (including NMO) Trauma Spinal cord trauma (or any severe myelopathy) Secondary Autoimmune & Inflammatory

Guillain Barre syndrome CIDP Pure pandysautonomia Amyloidosis neuropathy LEMS Including shock Dehydration Hemorrhage Sepsis

& dysautonomia Metabolic & Endocrine Diabetes mellitus Inherited Fabrys disease Drug & Toxin Antihypertensive medications

L-dopa Degenerative Idiopathic orthostatic hypotension Multisystem atrophy Parkinsons disease Cardiopulmonary disease (3/4) Arrythmia AV block Long QT

Some degree of PEA Structural disease Valvular disease (AS) Acute MI Pericardial tamponade Pulmonary embolism Pulmonary hypertension. CNS syncope (4/4)

Ictal bradycardia Cingulate gyrus, insular cortex, amygala Potentially related to SUDEP Acute increase in ICP Colloid cyst of the 3rd ventricle Subclavian steal syndrome Atherosclerosis Cervical rib

Takayasus arteritis Hyperventilation. Seizure vs Syncope Often not present in cardiopulmonary syncope!

539 patients diagnosed with seizure or syncope Completed a 108 item questionnaire Score 1 is 94% sensitive and specific for seizures Examination

Vitals Orthostatic BP and HR Supine to standing 30mmHg at 3 mins, etc Carotid massage With pts neck extended & rotated away from you, massage below the angle of the jaw, lateral to the thyroid cartilage but no longer than 5 minutes To reproduce presyncope

Beware of any bruits Cardiac and neurologic examinations. Investigations CBC, SMA7, LFT Exclude anemia, infection, electrolyte disturbances, or renal and liver dysfunction. EKG, cardiac monitor

TTE? D dimer V/Q scan or PE study Suspected seizure, dysautonomia or CNS syncope? EEG insensitivity In those with new onset seizures 50% of routine EEGs reveal epileptiform abnormalities.

Retrospective study 517 EEGs, between 2003-2007 57 (11%) were abnormal No clear epileptiform abnormalities 5 EEGs resulted in further investigations 1 pt treated with PHT (despite Neurologys advice!) Transient atonia or loss of consciousness Differential diagnosis

Seizure Syncope Psychogenic functional disorder Basilar migraine Vertebrobasilar TIA Vertiginous attack Otolithic catastrophe of Tumarkin Cataplexy Paroxysmal dyskinesia

Hyperekplexia. Summary Brief overview of epileptic seizures An approach to syncope Neurally mediated Orthostatic hypotension Cardiopulmonary disease CNS syncope

Seizure versus syncope An approach to the patient Differential diagnosis. Bad Emerg consults bring it on! References

Adams and Victors Principle of Neurology 8th Edition. Crompton DE, et al. The borderland of epilepsy: clinical and molecular features of phenomena that mimic epileptic seizures. Lancet Neurol 2009;8:370-81. Fisher RS, et al. Epileptic seizures and epilepsy: Definitions proposed by the ILAE and IBE. Epilepsia 2005;46:470-2. Krumholz A et al. Practice parameter: evaluating an apparent unprovoked first seizures in adults (an evidence-based review). Neurology 2007;69:1996-2007. Lempert T, et al. Syncope: a videometric analysis of 56 episodes of transient cerebral hypoxia. Ann Neurol 1994;36:233-7. McKeon A, et al. Syncope versus seizure. Lancet Neurol 2006;5:171-80.

Sheldon R, et al. Historical criteria that distinguish syncope from seizures. J Am Coll Cardiol 2002;40:142-8. Proposal for revised clinical and electroencephalographic classification of epileptic seizures. Epilepsia 1981;22:489-501. Soteriades ES, et al. Incidence and prognosis of syncope. NEJM 2002;347:878-85.

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