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Seizure syncope

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Seizure syncope & drop attacks. Mark Keezer. R5 Neurology. ELS . July 13, 2011. Seizure versus syncope!? All of the above? – PowerPoint PPT presentation

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Title: Seizure syncope


1
Seizure syncope drop attacks
Seizure versus syncope!?
All of the above?
  • Mark Keezer
  • R5 Neurology
  • ELS
  • July 13, 2011

2
Outline
  • Brief overview of epileptic seizures
  • Syncope an organized approach
  • Seizure versus syncope
  • An approach to the patient
  • Further differentials diagnoses for your
    consideration.

3
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4
  • What is an epileptic seizure?
  • What is epilepsy?

5
  • Epilepsy
  • Etymology epilepsia (Gk) to seize upon
  • Hughlings Jackson circa 1870
  • an excessive and disorderly discharge of
    cerebral nervous tissue on muscles

6
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

7
1981 ILAE Seizure Classification
  • Focal onset
  • Simple partial
  • Complex partial
  • Partial seizures evolving to secondarily
    generalized
  • Generalized Onset
  • Absence
  • Myoclonic
  • Clonic
  • Tonic
  • Tonic-clonic
  • Atonic

8
  • What does a GTC actually look like?

9
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.

10
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.

11
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.

12
Video
13
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14
  • What is syncope?

15
  • 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.

16
Video
17
  • How frequent is convulsive syncope?

18
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!

19
Convulsive syncope
  • Intermittent posturing of brainstem origin
  • Dis-inhibition in the context of cortical
    hypo-activity due to transient cerebral hypoxia

What are the presumed levels of these lesions?
20
  • What are the causes of syncope?
  • Do you have an organized approach?

21
Mechanistic classification of syncope
  • Neurally mediated
  • Orthostatic hypotension
  • Cardiopulmonary disease
  • CNS syncope

22
Neurally mediated (1/4)
  • Vasovagal syncope
  • Carotid sinus syncope
  • Situational syncope
  • Atypical causes
  • Glossopharyngeal neuralgia.

23
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.

24
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?

25
Situational syncope
  • Diminished venous return
  • Cough
  • Swallow
  • Micturition
  • Defecation
  • Weight-lifting
  • Hairbrushing
  • Stretch.

26
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!

27
Orthostatic hypotension (2/4)
Vascular  
  Prolonged bedrest
  Hypothalamic lesions (including NMO)
Trauma  
  Spinal cord trauma (or any severe myelopathy)
Autoimmune Inflammatory  
  Guillain Barre syndrome
  CIDP
  Pure pandysautonomia
  Amyloidosis neuropathy
  LEMS
Metabolic Endocrine  
  Diabetes mellitus
Inherited  
  Fabrys disease
Drug Toxin  
  Antihypertensive medications
  L-dopa
Degenerative  
  Idiopathic orthostatic hypotension
  Multisystem atrophy
  Parkinsons disease
  • Primary
  • Secondary
  • Including shock
  • Dehydration
  • Hemorrhage
  • Sepsis
  • dysautonomia

28
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.

29
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.

30
Seizure vs Syncope
Often not present in cardiopulmonary syncope!
31
  • 539 patients diagnosed with seizure or syncope
  • Completed a 108 item questionnaire
  • Score 1 is 94 sensitive and specific for
    seizures

32
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33
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.

34
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?

35
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36
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37
EEG insensitivity
  • In those with new onset seizures
  • 50 of routine EEGs reveal epileptiform
    abnormalities.

38
  • 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!)

39
Transient atonia orloss of consciousness
  • Differential diagnosis
  • Seizure
  • Syncope
  • Psychogenic functional disorder
  • Basilar migraine
  • Vertebrobasilar TIA
  • Vertiginous attack
  • Otolithic catastrophe of Tumarkin
  • Cataplexy
  • Paroxysmal dyskinesia
  • Hyperekplexia.

40
Summary
Bad Emerg consults bring it on!
  • 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.

41
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
    20098370-81.
  • Fisher RS, et al. Epileptic seizures and
    epilepsy Definitions proposed by the ILAE and
    IBE. Epilepsia 200546470-2.
  • Krumholz A et al. Practice parameter evaluating
    an apparent unprovoked first seizures in adults
    (an evidence-based review). Neurology
    2007691996-2007.
  • Lempert T, et al. Syncope a videometric analysis
    of 56 episodes of transient cerebral hypoxia. Ann
    Neurol 199436233-7.
  • McKeon A, et al. Syncope versus seizure. Lancet
    Neurol 20065171-80.
  • Sheldon R, et al. Historical criteria that
    distinguish syncope from seizures. J Am Coll
    Cardiol 200240142-8.
  • Proposal for revised clinical and
    electroencephalographic classification of
    epileptic seizures. Epilepsia 198122489-501.
  • Soteriades ES, et al. Incidence and prognosis of
    syncope. NEJM 2002347878-85.
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