Dr M.Jalali neurologist syncope Dr M.Jalali neurologist

Rapid onset Short duration Spontaneous complete recovery Transient loss of con ciousness due to transient global cerebral hypoperfusion characterized by: Rapid onset Short duration Spontaneous complete recovery

Conditions incorrectly diagnosed as syncope: Disorders with partial or complete LOC but without cerebral hypoperfusion: Epilepsy metabolic disorders including hypoglycemia, hypocapnia Intoxication Vertebrobasilar TIA Disorders without impairment of conciousness Drop attack psychogenic

Classification of syncope -reflex(neurally mediated) syncope -orthostatic hypotention mediated syncope -cardiac syncope

Reflex syncope(neurally mediated syncope): -Vasovagal: Mediated by emotional:fear,pain,blood phobia Mediated by orthostatic stress -Situational: Cough ,valsava,micturation -Carotid sinus syncope

Syncope due to orthostatic hypotension: Primary autonomic failure:PD,lewy body dementia Secondary autonomic failure:DM,amyloidosis,spinal cord injury Drug induced:vasodilator Volume depletion:hemorrhage,diarrhea

Cardiac syncope -Arrhythmia -Structural disease:pulmonary emboli,valvular heart disease,cardiac mass,tamponade,aortic dissection,MI

Careful hx Physical exam (orthostatic hypotension) ECG Initial evaluation of a patient presenting with transient loss of conciousness: Careful hx Physical exam (orthostatic hypotension) ECG

Initial evaluation should answer three key questions: Is it a syncopal episode or not? Has the etiological diagnosis been determined? Are there data suggestive of a high risk of cardiovascular events or death?

history Position:supine,sitting,standing Activity:rest,exercise,cough,micturtion,swallowing Predisposing factor:prolonged standing,hot weather Stimulating factors:fear,severe pain,neck movement Symptoms prior syncope:N/V,dizziness,sweating,aura,blurred vision Attack:skin color,LOC duration ,respiration,abnormal movement,tongue bitting,urinary incontinency post attack myalgia and headache,injury Medical history:medication,heart dx,DM,family hx of sudden death

Clinical clue Reflex syncope: After pain or fear,prolonged standing,N/V,after eating,pressure on carotid,hot weather during or after micturation,cough,defication,swallowing Orthostatic hypotension: Postural change,hx of autonomic neuropathy or parkinsonism,anti hypertensive drugs Cardiac syncope: heart dx,palpitation,sudden death family hx,supine position,on exercise Situational

Differentiation between syncope and convulsion Seizure syncope Relation to posture no common Time of day diurnal or nocturnal diurnal Aura or premonitory symptoms brief long Convulsion rare injury urinary incontinency Tongue biting Postictal confusion Postictal headache Focal neurological signs Cardiovascular signs