Emergency Lecture Series Syncope vs Seizure RALUCA PANA

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Emergency Lecture Series Syncope vs. Seizure RALUCA PANA PGY-2 ADULT NEUROLOGY JULY 17 TH

Emergency Lecture Series Syncope vs. Seizure RALUCA PANA PGY-2 ADULT NEUROLOGY JULY 17 TH 2013

Introduction Evaluating patients with transient loss of consciousness (TLOC) remains a challenge These patients

Introduction Evaluating patients with transient loss of consciousness (TLOC) remains a challenge These patients fall into 2 main groups: those with seizures and those with syncope 15% of transient loss of consciousness are due to seizures Reflex syncope remains most common etiology with 58%

Case 22 -year-old woman with a diagnosis of epilepsy since childhood presented to the

Case 22 -year-old woman with a diagnosis of epilepsy since childhood presented to the ER after passing out during a blood draw. She recalled feeling anxious and nauseous, having a racing heartbeat, experiencing graying of vision, and then losing consciousness. Her boyfriend reported that her eyes rolled upward and her body became limp before stiffening and shaking for approximately 20 seconds. Afterward, she returned to baseline within a few minutes. She had been diagnosed with epilepsy because of similar loss-ofconsciousness events occurring since she was 4 years old. She had a total of 10 such events, and half were associated with medical procedures or orthostatic stress. She had been on anticonvulsant medications for many years. The examination was normal, although she was pale and sweaty

Seizures OR Syncope?

Seizures OR Syncope?

Definitions Seizure Defined as stereotyped spells caused by abnormal electrical brain activity and can

Definitions Seizure Defined as stereotyped spells caused by abnormal electrical brain activity and can be provoked by a variety of conditions or occur spontaneously without an identifiable cause Manifestions depend on underlying neuroanatomic substrate (spells article)

DDX of Seizure

DDX of Seizure

Types of Seizures resembling syncope

Types of Seizures resembling syncope

Definitions Syncope defined as an abrupt and transient loss of consciousness associated with inability

Definitions Syncope defined as an abrupt and transient loss of consciousness associated with inability to maintain postural tone, often due to cerebral hypoperfusion

DDx of Syncope

DDx of Syncope

Classification of Syncope

Classification of Syncope

Examples of types of syncope Neurocardiogenic Lack of sympathetic vasoconstriction or vagal bradycardia Remains

Examples of types of syncope Neurocardiogenic Lack of sympathetic vasoconstriction or vagal bradycardia Remains most common cause, look for a trigger (pain, fear) Includes situational syncope : during straining, coughing etc Carotid Sinus hypersensitivity Common in Elderly, syncope on neck turning Can reproduce with carotid sinus massage

Grey Areas Psychogenic Presenting as seizure or apparent syncope Can account for up to

Grey Areas Psychogenic Presenting as seizure or apparent syncope Can account for up to 30% of refractory seizures Usually PMHx of psychiatric disorders, trauma, abuse May sometimes document during formal video EEG or tilt table Convulsive Syncope Myoclonic jerks during a syncope estimated to occur between 12 -46%, some reports 90% in blood donors

Clinical Approach to TLOC In 50% of cases, it is estimated to arrive at

Clinical Approach to TLOC In 50% of cases, it is estimated to arrive at a diagnosis by history and physical exam alone Thorough History taking often in the presence of reliable informant/by standers Should focus on two main elements: -Patient characteristics and past medical history -Extremely Detailed description of the episode of loss of consciousness

Specific Distinguishing Features Clinical Setting: Seizures are usually unprovoked Syncope occurs in settings of

Specific Distinguishing Features Clinical Setting: Seizures are usually unprovoked Syncope occurs in settings of strong emotional/painful stimuli recent prolonged standing or sitting, or being able to clearly remember the loss of consciousness. Startle : can point to hereditary long QT syndromes Aura/prodrome: pre-syncopal symtoms graying of vision, light-headedness, muffling of sounds, sitting preceding warmth or diaphoresis, palpitation, dyspnea, chest pain Typical Auras: rising epigastric sensation, automatisms, head turning, purpuseless movements, macropsia , dysphasia

Distinguishing Features Associated Signs and Symptoms: -Pallor and diaphoresis strongly suggest syncope -In syncope,

Distinguishing Features Associated Signs and Symptoms: -Pallor and diaphoresis strongly suggest syncope -In syncope, fall is flaccid usually, eyes are open and gaze is upward or straight -Tongue biting: unusual but if occurs, location is at tip of tongue. Lateral Tongue biting is associated with epileptic seizures -Urinary incontinence can occur in both seizures and syncope.

Specific Distinguishing Features Motor Activity: -brief motor activity, including tonic extension of the trunk

Specific Distinguishing Features Motor Activity: -brief motor activity, including tonic extension of the trunk and limbs or several clonic jerks can occur in both conditions -Syncopal jerks are NOT rhythmic or synchronous, small amplitude, occur after LOC, last around 15 seconds -Seizure : synchronous, large amplitude , long lasting , clearly unilateral and can occur prior to loss of consciousness. Clearly unilateral points to seizure

Specific Distinguishing Features • Recovery Time: -Unconsciousness lasts less than 20 sec in syncope

Specific Distinguishing Features • Recovery Time: -Unconsciousness lasts less than 20 sec in syncope unless patients are kept upright -Recovery is spontaneous and typically prompt -Post-ictal phase can last for hours, especially in children. -Behavior and orientation usually return after 30 sec 1 min -Retrograde amnesia in the elderly has been described

Clues in the history

Clues in the history

Events during an Attack

Events during an Attack

Events after an Attack

Events after an Attack

Patient caracteristics

Patient caracteristics

Validated Discriminating Features

Validated Discriminating Features

What about tongue biting? Meta-analysis by Brigo et al. In 2012 looked at clinical

What about tongue biting? Meta-analysis by Brigo et al. In 2012 looked at clinical relevance of tongue biting in seizures and Psychogenic non epileptic events and evaluated Likelihood ratio of this physical finding Showed a statistically significant difference in Tongue biting prevalence between epilepsy and PNEEs More Tongue biting in Epilepsy group, even higher if it was lateral tongue biting

Studies Included

Studies Included

Meta-Analysis for Tongue Bite in Epilepsy

Meta-Analysis for Tongue Bite in Epilepsy

Normogram: LR for Lateral TB vs TB no precise localization

Normogram: LR for Lateral TB vs TB no precise localization

Clinical Approach Another useful tool to help distinguish syncope from seizures Bedside questionnaire developed

Clinical Approach Another useful tool to help distinguish syncope from seizures Bedside questionnaire developed by Sheldon et al in 2002 that is validated to identify seizures in 94% of cases

Validated Historical Criteria Prospectively analyzed data from 617 patients with loss of consciouness who

Validated Historical Criteria Prospectively analyzed data from 617 patients with loss of consciouness who completed a 118 item questionnaire Developped Diagnostic criteria by correlating these historic features with their final diagnosis They then tested the decision rule on 268 patients Overall accuracy in test sample was 94% with a sensitivity of 94% for seizures The presence of negative criteria solves the diagnostic problem of convulsive syncope

Bedside Questionnaire

Bedside Questionnaire

Physical Exam Vital signs: orthostatic VS, irregular HR Performing a carotid massage to identify

Physical Exam Vital signs: orthostatic VS, irregular HR Performing a carotid massage to identify carotid sinus hypersensitivity can be useful Cardiovascular examination: look for murmurs suggestive of aortic stenosis, increased size and altered location of PMI , Pericardial rub (restrictive pericarditis), etc

Physical exam Thorough Neurological exam: - VS : febrile for seizures, meningitis/encephalitis - ENT:

Physical exam Thorough Neurological exam: - VS : febrile for seizures, meningitis/encephalitis - ENT: Tongue lacerations - Altered mental status, post-ictal confusion - Looks for focal neuro signs - Previous scars (Neurosurgical) - Signs of Neuro dx associated with Autonomic dysfunction (PD, MSA)

To summarize. . .

To summarize. . .

Investigations Should not be guided by the specialty under which the patient is admitted

Investigations Should not be guided by the specialty under which the patient is admitted Rather should be guided by elements gathered in history taking Recent review by Krahn et. al looked at evidence supporting different investigation modalities in patients with “collapse”. In general it is recommended to start with EKG in all patients (can give prognostic information if underlying structural cardiac disease)

Investigations Standard blood test CBC, chem 7, trops +/- toxicology depending on clinical history

Investigations Standard blood test CBC, chem 7, trops +/- toxicology depending on clinical history Dx yield is about 2 -3% Prolactin levels are not useful CK levels are usually elevated in seizure patients, but not always EEG in undifferentiated patients with TLOC yield of 1. 5% similar to general population

Investigations EEG: interictal EEG useful when there is a clinical suspicion of epilepsy (focal

Investigations EEG: interictal EEG useful when there is a clinical suspicion of epilepsy (focal neuro findings or hx suggestive of epilepsy) Timing of EEG is crucial: 50 % of patients who present after generalized convulsion have abnormlities on EEG within 24 hours. Within 48 hrs, only 21 -34% have epileptiform activity Younger patients have higher yield Sleep deprived EEG may increase dx yield by 30%

Investigations Tilt table to detect neuro-cardiogenic syncope Mainly in atypical stories Holter diagnostic yield

Investigations Tilt table to detect neuro-cardiogenic syncope Mainly in atypical stories Holter diagnostic yield of about 10% when worn for 24 hrs Electrophysiologic studies

Investigations Imaging (CT, MRI) Diagnostic yield is about 5% for CT scan in undifferentiated

Investigations Imaging (CT, MRI) Diagnostic yield is about 5% for CT scan in undifferentiated patients with collapse should be done if there is a trauma In the presence of focal neurological deficits High suspicion of first seizure

What about our case. . . This case illustrates several prototypical features of reflex

What about our case. . . This case illustrates several prototypical features of reflex syncope, including the temporal association with a painful event, the characteristic prodromal symptoms, and the rapid return to baseline. The association of the event with abnormal movements is not inconsistent with the diagnosis of convulsive syncope, and the association of her prior losses of consciousness with medical procedures suggests that these events might also be due to convulsive syncope. The patient underwent video-EEG monitoring, and one of her typical events was elicited by venipuncture and associated with a prolonged (40 -second) asystolic pause, consistent with malignant reflex syncope . ECG, cardiac telemetry, and echocardiography were normal, and the patient underwent pacemaker placement to prevent further prolonged asystoles. While the diagnosis of epilepsy could not be completely excluded, the patient has since been able to gradually wean antiepileptic medications and has remained seizure free.

In Summary

In Summary

References Mc. Keon, Vaughan, Delanty. Seizures versus Syncope. 2006, Lancet 5; 171 -80 Dijk,

References Mc. Keon, Vaughan, Delanty. Seizures versus Syncope. 2006, Lancet 5; 171 -80 Dijk, Thijs, Benditt et Wieling. A guide to Transient loss of consciouness van. Nat. Rev. Neurol. 5, 438– 448 (2009) Thijs, Dijk and Bloem. Falls, Faints, Fits and funny Turns (2009) J Neurol (2009) 256: 155– 167 Kaplan, Nguyen, Non epileptic Paroxysmal disorders in Adults and Adolescents (2012). Uptodate. com Krahn, Andrew et Dewell, Selecting Appropriate diagnostic Tools for Evaluating the patient with Syncope/collapse 2013, Progress in Cardiovascular Diseases 402 -409.