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Drop attacks 11/08/14 17:53 Drop attacks Contributors Douglas J Lanska MD MS MSPH, contributing editor. Dr. Lanska of the Great Lakes VA Healthcare System at the VA Medical Center in Tomah, Wisconsin, has no relevant financial relationships to disclose. Publication dates Originally released December 28, 2004; last updated March 6, 2014; expires March 6, 2017 Folder Path Neurology > Neuro-otology > Drop attacks Quick Reference Sections of Summary - Historical note and nomenclature - Clinical manifestations - Clinical vignette - Localization - Pathophysiology - Differential diagnosis Key points • Drop attacks are sudden falls without loss of consciousness that are not precipitated by a specific stimulus, occur with abrupt onset and without warning, and are followed by a rapid return to baseline. • The term “drop attack” has subsequently been used to encompass a wide variety of sudden falls with or without existing conditions known to increase the risk of falls, with or without provocation by a specific stimulus, with or without loss of consciousness, and with or without significant baseline abnormalities. • A range of localizations for drop attacks is possible, but most commonly lower brainstem or spinal cord structures are implicated. • Drop attacks generally indicate transient impairment of bilateral central nervous system structures involved in maintenance of postural muscle tone and balance. • Tumarkin otolithic catastrophes (or crises) are drop attacks without associated autonomic or neurologic symptoms in patients with severe vestibular disease, usually due to Ménière disease. - Diagnostic workup - Prognosis and complications - Management Supplemental Content - Associated disorders - Related summaries - Differential diagnosis - Demographics References - References cited Web Resources Guidelines - AAN: Assessing Patients in a Neurology Practice for Risk of Falls - NICE: Epilepsy (U.K.) Historical note and nomenclature Drop attacks are sudden falls without loss of consciousness that are not precipitated by a specific stimulus, occur with abrupt onset and without warning, and are followed by a rapid return to baseline (Sheldon 1960). Initially these events were described in otherwise healthy elderly people (Sheldon 1960), but the term “drop attack” has subsequently been used to encompass a wide variety of sudden falls with or without existing conditions known to increase the risk of falls, with or without provocation by a specific stimulus, with or without loss of consciousness, and with or without significant baseline abnormalities. For the purposes of this chapter, drop attacks do not include so-called epileptic “drop attacks” or other seizure-related falls (Rathore et al 2007; Abd-El-Barr et al 2010), presyncope or syncope, stimulus-sensitive loss of muscular tone, or falls in patients with marked nonparoxysmal leg weakness, ataxia, postural instability (eg, Parkinson disease, progressive supranuclear palsy), or sensory loss. - AAN: Epilepsy Clinical Trials - NIH: Epilepsy Google Scholar - Other articles on this topic PubMed - Other articles on this topic About Links - About Web Resources Clinical manifestations Table 1. Clinical Criteria for Drop Attacks http://www.medlink.com/cip.asp?UID=mlt002in Página 1 de 13 Drop attacks 11/08/14 17:53 Sudden falls while standing or walking Onset • abrupt • no aura or warning • not provoked by specific stimulus Event • brief (seconds to a few minutes) • no loss of consciousness • no evidence of seizure (eg, tonic or clonic activity) • may be accompanied by transient neurologic signs and symptoms Post-event • fully alert • not confused • rapidly returns to baseline • may have transient difficulty standing Baseline • no severe leg weakness, ataxia, postural instability, or sensory loss Tumarkin's otolithic catastrophes (or crises) are drop attacks without associated autonomic or neurologic symptoms in patients with severe vestibular disease, usually due to Ménière disease (Tumarkin 1936; Black et al 1982; Janzen and Russell 1988; Odkvist and Bergenius 1988; Baloh et al 1990; Ishiyama et al 2001; 2003; Kentala et al 2001; Lee et al 2005; Timmer et al 2006; Ozeki et al 2008; Perez-Fernandez et al 2010; Huang and Young 2012). Rarely vestibular drop attacks may be the presenting sign of Ménière disease (Baloh et al 1990). Patients frequently report the sensation of being pushed, thrown, or knocked to the ground (Tumarkin 1936; Baloh et al 1990; Ishiyama et al 2003). Many have a subjective tilt of the environment concurrently with the fall (Ishiyama et al 2003). Although occurring in patients with Ménière disease, vestibular drop attacks are not generally associated with the simultaneous occurrence of symptoms of typical attacks of Ménière disease (ie, aural fullness, tinnitus, fluctuating hearing loss, or vertigo) (Tumarkin 1936). Patients with vestibular drop attacks can stand up immediately after a fall, whereas patients with drop attacks from other causes may require several minutes to stand independently. Similar events may occur in patients without Ménière syndrome, but with a personal and family history of migraine and with typical migraine triggers for their drop attacks (eg, alcohol, lack of sleep, emotional stress, and menses) (Lee et al 2000; Ishiyama et al 2003). Patients with Ménière disease who develop Tumarkin attacks are more disabled, have more severely impaired hearing in the asymptomatic ear, especially at low frequencies, and experience autonomic symptoms that are more severe and more frequent than those without Tumarkin attacks (Perez-Fernandez et al 2010). Clinical vignette A 70-year-old man presented with drop attacks (Ishiyama et al 2001). The events occurred without warning and were characterized by a feeling of being pushed to the left with sudden loss of postural tone and abrupt falls, but no loss of consciousness, no associated focal neurologic findings, and no residual http://www.medlink.com/cip.asp?UID=mlt002in Página 2 de 13 Drop attacks 11/08/14 17:53 weakness. He had 4 falls over the previous year. He had a 2-year history of recurrent vertigo several times a week, lasting from 10 minutes to several hours, but without meeting criteria for Ménière syndrome (ie, no aural fullness, change in tinnitus, or fluctuation in hearing loss accompanying the vertigo). He also had a history of (sudden?) profound right-sided hearing loss 8 years previously. Neurologic examination, MRI with gadolinium, carotid ultrasound, and electroencephalography were unrevealing. A presumptive diagnosis of atonic seizures was made, but there was no improvement after treatment with phenytoin. Audiograms demonstrated a profound right-sided sensorineural hearing loss, and caloric testing demonstrated a complete right caloric paresis. A presumptive diagnosis of “vestibular Ménière disease” was apparently made and he was treated with a low-salt diet and diuretics without benefit. He ultimately underwent a right transmastoid labyrinthectomy and was able to walk unassisted by 3 weeks after surgery. He remained free of vertigo and drop attacks 3 years after surgery. Localization A range of localizations for drop attacks is possible, but most commonly lower brainstem or spinal cord structures are implicated. In patients with Ménière disease, vestibular drop attacks (Tumarkin's “otolithic catastrophes”) probably result from mechanical deformation of the otolithic membrane of the utricle or saccule (Tumarkin 1936; Baloh et al 1990; Timmer et al 2006; Huang and Young 2012). Less commonly, hemispheric motor outflow tracts (eg, acute hydrocephalus with third ventricular cysts, or bilateral anterior cerebral artery ischemia) have been implicated. Transient dysfunction of these areas can disrupt muscle tone bilaterally without affecting consciousness. Pathophysiology Drop attacks generally indicate transient impairment of bilateral central nervous system structures involved in maintenance of postural muscle tone and balance. In patients with cryptogenic drop attacks, a delay in long-loop (transcortical) reflexes may produce inadequately rapid adjustments in postural tone to maintain the erect posture under certain circumstances (Greenwood and Hopkins 1982). Differential diagnosis Conditions that may cause drop attacks include cervical cord compression, including foramen magnum lesions (Maurice-Williams 1974; Straus et al 2009); vertebrobasilar ischemia (Kameyama 1965; Brust et al 1979; Welsh et al 2004); inner ear disorders (eg, Ménière disease and likely migrainous vertigo) (Tumarkin 1936; Black et al 1982; Janzen and Russell 1988; Odkvist and Bergenius 1988; Baloh et al 1990; Lee et al 2000; 2005; Ishiyama et al 2001; 2003; Kentala et al 2001; Brantberg et al 2005; Huang and Young 2012); hydrocephalus and intraventricular tumors (Criscuolo and Symon 1986; Pollack et al 1995; Kumar et al 2010); posterior fossa lesions (Lee et al 1994); subclavian steal syndrome (Osiro et al 2012); and reportedly myxedema (Kramer and Achiron 1993). In elderly patients with sudden falls and presumed drop attacks, the absence of a history of loss of consciousness is unreliable (Dey et al 1997). More than two thirds of such patients are in fact found to have forms of cardiovascular syncope, http://www.medlink.com/cip.asp?UID=mlt002in Página 3 de 13 Drop attacks 11/08/14 17:53 including carotid sinus syndrome, orthostatic hypotension, and vasovagal syncope (Dey et al 1997). Other causes in elderly patients include vestibular disorders (Lee et al 2005) and cerebrovascular disorders. Drop attacks due to vertebrobasilar insufficiency are typically accompanied by other event-related neurologic manifestations (eg, visual loss, diplopia, vertigo, numbness, etc.) in addition to the sudden loss of postural tone in the legs, but rarely cases of sudden unexpected falls without associated clinical manifestations are attributable to vertebrobasilar insufficiency (Brust et al 1979). Drop attacks have often been attributed to vertebrobasilar insufficiency without sufficient clinical support, making some authorities question the role of vertebrobasilar insufficiency as a common cause of drop attacks; however, a large proportion of older individuals with drop attacks have multiple areas of arterial occlusion, stenosis, or hypoplasia in the regional hindbrain circulation (Welsh et al 2004). Cryptogenic drop attacks are relatively common, represent a large proportion of drop attacks in case series, and mainly affect women (Stevens and Matthews 1973). Some of these cases may be due to autoimmune disorders. Drop attacks have been reported in 2 women with facio-brachio-crural dystonic episodes associated with antibodies to leucine-rich glioma-inactivated 1, presumably an autoimmune encephalitis (Maramattom et al 2013). In both cases, prolonged EEG monitoring and brain MRI studies were normal, and neither responded to conventional anticonvulsants. One case apparently responded to corticosteroid treatment with intravenous methylprednisolone, whereas the other improved spontaneously over 6 months. Drop attacks can be confused with the falls caused by atonic seizures (Obeid and Mikati 2007), cataplexy and other stimulus-induced drop episodes, movement disorders (eg, asterixis, chorea, myoclonus) (Massey et al 1988), and syncope. In children and young adults, it is important to distinguish spontaneous drop attacks with preserved consciousness from atonic seizures (with transient loss of consciousness) and stimulus-induced drop episodes. In older adults, it is particularly important to distinguish spontaneous drop attacks from syncope (for which the loss of consciousness may be transient and unrecognized). The term “epileptic drop attacks” is actually a misnomer as these events are actually generalized seizures with brief loss of consciousness. So-called epileptic “drop attacks” occur with myoclonic-atonic seizures (also called astatic or myoclonic-astatic seizures), Lennox-Gastaut syndrome, or other symptomatic generalized epilepsies associated with brief rapidly generalized seizures manifesting transient loss of consciousness and sudden atonic falls without protective reflexes (Pazzaglia et al 1985; Fukushima et al 1993; Oguni et al 1993; 1997; Gambardella et al 1994; Lin et al 1995; Guerrini et al 1998; Tinuper et al 1998; Maehara and Shimizu 2001; Rathore et al 2007). The loss of muscle tone is brief and may include head drop, jaw droop, dropping of a limb, or loss of all muscle tone and a fall (often with resulting head and facial injuries). Epileptic “drop attacks” occur most commonly in young children but may begin in adolescence and rarely in adults. Such epileptic falls are physically dangerous and are often refractory to medical and surgical therapy. Interictal electroencephalograms are usually abnormal and may include slow spike-wave complexes, rhythmic slow activity, polyspike and wave activity, temporal or frontal spikes, and bilateral synchronous spike activity during sleep. Stimulus-induced sudden loss of muscular tone occurs most commonly as cataplexy in patients with narcolepsy (OMIM #161400, #605841, and #609039), but can also occur as a mono-symptomatic familial disorder (Gelardi and Brown 1967), and in certain degenerative conditions, such as Niemann-Pick type C disease (Turpin et al 1991; Zafeiriou et al 2003) and Coffin-Lowry syndrome http://www.medlink.com/cip.asp?UID=mlt002in Página 4 de 13 Drop attacks 11/08/14 17:53 (Fryns and Smeets 1998; Nakamura et al 1998; Freesia et al 2002;Grau et al 2003; Nelson and Hahn 2003; Vankova et al 2003), and in certain uncommon stimulus-sensitive reflex syncopes, such as stretch syncope (Sarrigiannis et al 2011). Cataplexy is often triggered by laughter, but can be triggered by surprise, anger, or other emotional stimuli. Consciousness is retained but the patient loses muscular tone with somewhat variable motor manifestations ranging from complete postural collapse with a fall to relatively mild weakness with head droop, jaw drop, and buckling of the knees. The duration of hypotonia in cataplexy ranges from several seconds to several minutes, and recovery is complete. In patients with narcolepsy, cataplexy occurs as part of a constellation of manifestations that include excess sleepiness, sleep attacks, hypnagogic and hypnopompic hallucinations, and sleep paralysis. Although not all of the classic features of narcolepsy may be present in all patients, cataplexy rarely precedes the onset of hypersomnolence. About two thirds of patients with narcolepsy as associated with cataplexy. Niemann-Pick type C disease (OMIM #257220 and #607625) is an autosomal recessive disorder with highly variable clinical manifestations and age of onset. Onset of neurologic signs may be from infancy through adulthood, but is rare after the age of 30 (Lanska and Lanska 1993). Clinical features may include cataplexy as well as abnormal behavior, developmental delay, dementia, psychosis, seizures, vertical gaze palsy, dysarthria, dysphagia, dystonia, myoclonus, spasticity, ataxia, and hepatosplenomegaly (Grau et al 2003; Vankova et al 2003; Zafeiriou et al 2003). Cataplexy occurs most commonly in the juvenile forms, but may also occur in adults (Turpin et al 1991). Bone marrow examination shows sea-blue histiocytes and may show foam cells, which contain polymorphic cytoplasmic inclusions. Cholesterol esterification studies show accumulation of unesterified cholesterol in lysosomes and low intracellular esterification of exogenously supplied lipoprotein-derived cholesterol in cultured fibroblasts (Lanska and Lanska 1993). Niemann-Pick type C disease should be considered when progressive neurologic symptoms develop with either organomegaly or a history of nontraumatic splenectomy (Lanska and Lanska 1993). Coffin-Lowry syndrome (OMIM #303600) is characterized by mental retardation, small stature, facial dysmorphism, skeletal deformities, and tapering digits (Coffin et al 1966; Lowry et al 1971; Temtamy et al 1975; Fryns and Smeets 1998; Nakamura et al 1998; Fryssira et al 2002; Nelson and Hahn 2003). In patients with Coffin-Lowry syndrome, “stimulus-induced drop episodes” are characterized by sudden loss of muscular tone induced by sensory stimuli, such as loud noises, visual threat, or unexpected light tactile stimulation (Fryns and Smeets 1998; Nakamura et al 1998; Freesia et al 2002;Nelson and Hahn 2003). Consciousness is retained, and recovery is immediate. These episodes are not associated with epileptiform activity on electroencephalography. During spells, tonic electromyographic activity may be lost (as in cataplexy) or increased (as in hyperekplexia), even in the same patient (Nelson and Hahn 2003). Stretch syncope may be difficult to distinguish from epilepsy (Sarrigiannis et al 2011). Episodes are initiated with stretching associated with neck torsion and breath holding, which may be followed by loss of consciousness and in more prolonged episodes by asymmetric, recurrent facial and upper limb jerks. Stretching may be associated with sinus tachycardia, followed by rhythmic generalized slow wave abnormalities on EEG in attacks with associated impairment of consciousness. Transcranial doppler studies showed a marked drop in middle cerebral artery perfusion during the episodes. http://www.medlink.com/cip.asp?UID=mlt002in Página 5 de 13 Drop attacks 11/08/14 17:53 Diagnostic workup A thorough history and examination are appropriate in patients with presumed drop attacks, with careful attention in the history to any warning or aura, precipitating factors (including emotional stimuli), loss of consciousness, or ictal manifestations. Observations from witnesses can be particularly helpful in clarifying the features of the episodes and in focusing the differential diagnosis. Prior cardiovascular disease, palpitations, strokes or transient ischemic attacks, movement disorders (including Parkinson disease, progressive supranuclear palsy, myoclonus, ataxia, and asterixis), presyncope or syncope, headaches, amaurosis, aural fullness, hearing loss, tinnitus, vertigo, cervical spondyloarthropathy, and any severe orthopedic problems or peripheral vascular disease involving the legs should be noted. Medications should be thoroughly reviewed, with particular attention to agents that may precipitate seizures, orthostatic hypotension, or sedation. Examination should identify any signs of raised intracranial pressure (including papilledema), evidence of previous strokes, movement disorders affecting postural tone or producing abnormal movements of the legs or trunk, myelopathy, ataxia, postural instability, leg weakness or spasticity, severe sensory loss in the legs, or mechanical/orthopedic leg dysfunction. Evaluation should include assessment or orthostatic pulse and blood pressure (ie, supine, standing, and standing after 3 minutes). Depending on the clinical circumstances, various studies may be necessary, including electrocardiography, Holter monitoring, cervical spine imaging, brain imaging, vascular imaging (eg, Doppler ultrasonography, magnetic resonance angiography, CT angiography, or traditional angiography), electroencephalography, audiograms, electronystagmography or video nystagmography, and vestibular evoked myogenic potential testing. Prognosis and complications Injuries are common with drop attacks, because the falls are unexpected, rapid, with inadequate opportunity for self-protective responses. Long-term prognosis depends on the underlying condition. Some previous studies of prognosis have included patients with cardiovascular syncope, epilepsy, and other conditions that would not meet criteria for true drop attacks. However, such patients are labeled, those with baseline significant neurologic findings, cardiac arrhythmias, and congestive heart failure have a worse prognosis (Meissner et al 1986). Patients with an isolated drop attack who have unrevealing medical and neurologic evaluations have a favorable long-term outcome (Meissner et al 1986). Management With a varied constellation of causes, no single therapy is appropriate for all drop attacks. Therapy is instead directed at treatment of the underlying cause. Treatment is not generally indicated for individuals with an isolated drop attack and unrevealing medical and neurologic evaluations (Meissner et al 1986). Some authorities advocate conservative management of otolithic crises, particularly given that many cases have a flurry of episodes followed by remission (Janzen and Russel 1988; Baloh et al 1990). However, the events can be associated with significant injuries and for some patients the attacks are so http://www.medlink.com/cip.asp?UID=mlt002in Página 6 de 13 Drop attacks 11/08/14 17:53 dangerous or intractable that surgery is indicated (Baloh et al 1990). Otolithic crises have been treated successfully with either surgical ablation (labyrinthectomy) or trans-tympanic gentamicin therapy in the absence of serviceable hearing, or middle fossa vestibular nerve section to preserve serviceable hearing (Black et al 1982; Odkvist and Bergenius 1988; Ishiyama et al 2001). Even older patients can be successfully treated with ablative surgery with excellent compensation and no vertigo or falls up to 10 years after surgery (Ishiyama et al 2001). Vestibular nerve section is usually recommended only for patients who have had symptoms for at least 5 years, unless the patient is severely incapacitated or is in danger of severe bodily harm because of otolithic crises (Black et al 1982). In a small series of 10 patients, surgical decompression of Chiari I malformation had a high success rate (70%) for clinical improvement in patients with drop attacks (Straus et al 2009). Tilt table testing had poor predictive value in judging the clinical response to surgical decompression and was useful in guiding surgical decision- making. A cardiac pacemaker has been anecdotally reported to resolve drop attacks associated with ictal asystole in a patient with partial complex seizures (Zubair et al 2009). Miglustat, a reversible inhibitor of the enzyme glucosylceramide synthase, has been anecdotally reported to resolve secondary cataplexy after 6 months of use in a patient with Niemann-Pick disease type C (Zarowski et al 2011). In patients with repeated falls, steps should be taken to minimize the risk of injury. Clinicians should discuss and address modifiable risk factors for fractures (as appropriate to the clinical situation): • Excess alcohol intake (more than 2 drinks a day) • Cigarette smoking • Frail body habitus (weight less than 127 pounds or body mass index less than 20) • Inadequate diet • Estrogen deficiency • Impaired eyesight • Medications that facilitate development of osteomalacia (eg, phenytoin) • Unsafe footwear (heels more than a quarter inch; loose heels; strap sandals; smooth, hard soles; etc.) • Sedentary lifestyle • Home safety concerns (loose rugs, uneven surfaces, inadequate grab rails in the bath tub, etc.) Older adults, particularly those with falls, should undergo assessment of bone mineral density by dual energy x-ray absorptiometry (DEXA) of the distal forearm, lumbar spine, and proximal femur. Screening DEXA scans of the heels can also be informative, but the results of heel DEXA studies do not correlate perfectly with DEXA studies of the areas most likely to be fractured with falls (ie, the wrist and femoral neck). According to World Health Organization criteria, Tscores above -1 are normal, T-scores between -1 and -2.5 indicate osteopenia and a moderately increased risk of fracture, and T-scores below -2.5 are indicative of osteoporosis (or severe osteomalacia) and a severely increased risk of fracture. Significantly abnormal values (ie, generally T-scores less than -1.5 in the presence of other risk factors for osteoporosis or falls with injury, or less than -2.0 in the absence of other risk factors) should generally be managed with calcium and vitamin D supplementation, and bisphosphonate therapy (eg, alendronate). http://www.medlink.com/cip.asp?UID=mlt002in Página 7 de 13 Drop attacks 11/08/14 17:53 Associated disorders None identified Related summaries Atonic seizures Lennox-Gastaut syndrome Neurocardiogenic syncope Syncope West syndrome Differential diagnosis cervical cord compression foramen magnum lesions vertebrobasilar ischemia inner ear disorders Ménière disease migrainous vertigo hydrocephalus intraventricular tumors posterior fossa lesions myxedema cardiovascular syncope carotid sinus syndrome orthostatic hypotension vasovagal syncope vertebrobasilar insufficiency visual loss diplopia vertigo vertebrobasilar insufficiency multiple areas of arterial occlusion stenosis hypoplasia in the regional hindbrain circulation falls caused by atonic seizures cataplexy other stimulus-induced drop episodes movement disorders asterixis chorea myoclonus preserved consciousness from atonic seizures (with transient loss of consciousness) stimulus-induced drop episodes syncope (for which the loss of consciousness may be transient and unrecognized) generalized seizures with brief loss of consciousness myoclonic-atonic seizures astatic or myoclonic-astatic seizures Lennox-Gastaut syndrome stimulus-induced sudden loss of muscular tone cataplexy mono-symptomatic familial disorder Niemann-Pick type C disease http://www.medlink.com/cip.asp?UID=mlt002in Página 8 de 13 Drop attacks 11/08/14 17:53 Coffin-Lowry syndrome narcolepsy excess sleepiness sleep attacks hypnagogic hypnopompic hallucinations sleep paralysis organomegaly nontraumatic splenectomy stimulus-induced drop episodes hyperekplexia Demographics For more specific demographic information, see the Epidemiology, Etiology, and Pathogenesis and pathophysiology sections of this clinical summary. 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