Download Seizure, syncope and drop attacks

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.
b.
c.
Simple partial
Complex partial
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
Fabry’s disease
Drug & Toxin
Antihypertensive medications
L-dopa
Degenerative
Idiopathic orthostatic hypotension
Multisystem atrophy
Parkinson’s 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
– Takayasu’s 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 pt’s 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 EEG’s 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 Neurology’s 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
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Adams and Victor’s 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.