Diapositiva 1
annuncio pubblicitario
LA VALUTAZIONE NEUROLOGICA E PSICHIATRICA Differenziare la sincope dalle altre forme di perdita transitoria di coscienza di natura neurologica Giuseppe Micieli UO Neurologia d’Urgenza e Stroke Unit IRCCS Istituto Clinico Humanitas Rozzano (MI) Quadri clinici di maggior frequenza in P.S. Progetto NEU, 2003 Che cosa non è sincope ¾ Perdita di coscienza dovuta a trauma ¾ Perdita di coscienza non transitoria e non a regressione spontanea ¾ Perdita di coscienza transitoria e a regressione spontanea non dovuta ad ipoafflusso cerebrale ¾ Situazioni in cui non vi è una reale perdita di coscienza ¾ Concussione ¾ Coma, disturbi metabolici, intossicazione, “aborted sudden death” ¾ Epilessia ¾ Cadute, drop attack, disturbi psichiatrici, cataplessia, vertigini, presincope Causes of syncope in an outpatient cohort (structural heart disease excluded) Strano S et al. JNNP 2005;76:1597-1600 Sincope e Ipoperfusione Cerebrale MTT map 35 mL/100 g/min 20 mL/100 g/min Coutts SB et al, Neurology 2003 Wiebers et al, 1997 Subclavean steal syndrome Filis K et al. J Med Case Report 2008;2:392 Sincope da compressione estrinseca dell’arteria vertebrale sinistra nel suo tratto extracranico Sakaguchi M et al, Neurology 2003 Sincope e malattia cerebrovascolare: compressione estrinseca dell’arteria carotide interna di sinistra secondaria a tumore del glomo carotideo Misdiagnosis Syncope Epilepsy “Hardly anyone with epilepsy will come to any harm from a delay in diagnosis whereas a false positive diagnosis is gravely damaging”. “Improper pacemaker implantation in patients with fits and falls of neurological origin” The co-existence in the same subjects seems to be rare Misdiagnosis of epilepsy in three population-based and three cohort studies of patients with presumed seizure disorder Bergfeldt L. Heart 2003;89:353–358 Question Points (if yes) At times do you wake with a cut tongue after your spells? 2 At times do you have a sense of deja vu or jamais vu before your spells 1 At times is emotional stress associated with losing consciousness? 1 Has anyone ever noted your head turning during spell? 1 Has anyone never noted that you are unresponsive, have unusual posturing or have jerking limbs during your splells or have no memory of your spells afterwards? 1 Has anyone ever noted that you are confused after a spell? 1 Have you ever had lightheaded spells? -2 At times do you sweat before your spells? -2 Is prolonged sitting or standing associated with your spells? -2 Seizures: score >1; Syncope: score<1 Sheldon et al,J Am Coll Cardiol 2002 CAUSES OF SYNCOPE Neurally-mediated reflex syncopal syndromes Vasovagal Faint (common faint) Carotid sinus syncope Situational Faint Acute haemorrage Cough, Sneeze Gastrointestinal stimulation Micturition Post-exercise Others Glossopharyngeal and trigeminal neuralgia Task Force on Syncope, ESC 2004 Cough Syncope CAUSES OF SYNCOPE Orthostatic Autonomic Failure Primary Autonomic Failure syndrome (e.g. Pure Autonomic Failure, Multiple System Atrophy, Parkinson’s Disease with Autonomic Failure) Secondary Autonomic Failure syndromes (e.g. Diabetic Neuropathy, Amyloid Neuropathy) Drug and Alcohol Volume Depletion Task Force on Syncope, ESC 2004 Baroreflex arc Influencing factors • Origin and strenght of stimulus • Set point of the reflex • Input from higher centres • Responsiveness of cardiovascular receptors and organs • Neurohumoral and vasoactive substances • Interactions of the aortocarotid with chemoreflex arc +- AVP - NTS VLM MSA Arterial Blood Pressure PAF PD IML SG a NE Multiple System Atrophy This disorder encompasses: • Olivoponto-cerebellar atrophy (OPCA) – Sporadic late onset predominantly cerebellar syndrome (but with additional parkinsonism and dysautonomia).Dejerine and Thomas (1900) • Shy-Drager syndrome (SDS) – Neurogenic central autonomic failure in patients who also had parkinsonism and cerebellar signs. Shy and Drager (1960) • Striato-nigral degeneration (SND) – Rapidly progressive parkinsonism (but also cerebellar signs and dysautonomia). Adams et al. (1961) Graham and Oppenheimer (1969) Autonomic Failure in PD • Constipation • Urinary incontinence • Orthostatic or post-prandial light-headedness • Heat or cold Intolerance • Decreased bowel sounds • Orthostatic hypotension SYNCOPE AND FALLS 30% cognitively normal elderly people are unable to recall documented falls three months later 50% a withness account for syncopal events unavailable 40% of patients with an attributable diagnosis of carotid sinus syndrome, the only presenting symptoms were falls alone or falls with dizzines (syncope was denied) 20% Amnesia for loss of consciounsness demonstrated in patients with a diagnosis of carotid sinus syndrome FE Shaw and RA Kenny, 1997 Diagnostic algorithm in patients with suspected NES Muller T et al. Seizure 2002;11:85-89 Alsaadi TM, Vinter Marquez A. Am Fam Physician 2005;72:849-856 Features suggesting a diagnosis of psychogenic nonepileptic seizures Alsaadi TM, Vinter Marquez A. Am Fam Physician 2005;72:849-856 Point of care: accident and emergency department Petkar S et al. Postgrad Med J 2006;82:630-641 False negative & False positive diagnoses MOULIN T et al, 2003 Discharge diagnosis MOULIN T et al, 2003 Emergency Room SYNCOPE Cardiologist Neurologist Syncope Unit GP
