La valutazione neurologica e psichiatrica nel paziente con perdita di coscienza Giuseppe Micieli Dip Neurologia d’Urgenza IRCCS Fondazione Ist Neurologico Nazionale C. Mondino Pavia

ESC syncope guidelines, Eur Heart J 2009;30:2631-2671

Che cosa non è sincope Perdita di coscienza dovuta a trauma Perdita di coscienza non transitoria e non a regressione spontanea Perdita di coscienza transitoria e a regressione spontanea non dovuta ad ipoafflusso cerebrale Situazioni in cui non vi è una reale perdita di coscienza Concussione Coma, disturbi metabolici, intossicazione, “aborted sudden death” Epilessia Cadute, drop attack, disturbi psichiatrici, cataplessia, vertigini, presincope

Wiebers et al, 1997

Sincope e Ipoperfusione Cerebrale MTT map 35 mL/100 g/min Donna di 87 aa, episodi sincopali multipli che comparivano solo in ortostatismo. Trombosi carotidea destra + ipotensione in ortostatismo. Studio in TC perfusion. La mappa del flusso ematico cerebrale mostra una severa riduzione di flusso nell’emisfero destro circa 20 mL/100 g/min 20 mL/100 g/min Coutts SB et al, Neurology 2003 5

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 Uomo di 56 aa con sintomatologia prelipotimica (annebbiamento visivo) durante la rotazione del capo. Al TCD si osserva una marcata riduzione della velocità di flusso durante la rotazione. All’esame angiografico una compressione estrinseca dell’arteria vertebrale di sinistra a livello di C1-C2. Alla SPECT normale distribuzione del flusso ematico cerebrale in posizione neutrale del capo con marcato decremento a livello della corteccia occipitale, cervelletto e tronco dell’encefalo durante rotazione submassimale del collo. Sakaguchi M et al, Neurology 2003 7

Sincope da compressione estrinseca della CI sin secondaria a tumore del glomo carotideo

Misdiagnosis of epilepsy in three population-based and three cohort studies of patients with presumed seizure disorder Misdiagnosis of epilepsy in three population based and three cohort studies of patients with presumed seizure disorder. The third column states the number of re-evaluated cases, and the fourth in how many cases the initial diagnosis was considered wrong. Various clinical explanations emerged on re-evaluation; the number of cases with syncope and the confirmed cardiovascular mechanisms are presented in the right hand column. number of cases with syncope and the confirmed Bergfeldt L. Heart 2003;89:353–358 9

The value of history for distinguishing seizure from syncope mod from: Hoefnagels WA et al. J Neurol 1991;238:39-43

Classification of syncope ESC syncope guidelines, Eur Heart J 2009;30:2631-2671

Cough Syncope

Classification of syncope ESC syncope guidelines, Eur Heart J 2009;30:2631-2671

Clinical classification of primary chronic autonomic failure Clinical classification of primary chronic autonomic failure. Pure autonomic failure (PAF) features autonomic failure without evidence of central neurodegeneration. Multiple system atrophy (MSA) has parkinsonian, cerebellar, and mixed forms. PD with autonomic failure (PD–AF) can be difficult to distinguish clinically from the parkinsonian form of MSA. Goldstein DS, Lancet Neurology, 2003 15

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 PD PAF a NE IML SG

Syncope & 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

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

Neurological and Psychiatric evaluation ESC syncope guidelines, Eur Heart J 2009;30:2631-2671

Point of care: accident and emergency department Petkar S et al. Postgrad Med J 2006;82: 630-641

Emergency Room SYNCOPE Cardiologist Neurologist Syncope Unit GP