La valutazione neurologica e La valutazione neurologica e psichiatrica nel paziente con psichiatrica nel paziente con

perdita di coscienzaperdita di coscienza

Giuseppe MicieliDip Neurologia d’Urgenza

IRCCS Fondazione Ist Neurologico Nazionale C. MondinoPavia

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

Che cosa non è sincopeChe 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

20 mL/100 g/min

35 mL/100 g/min

MTT map

Sincope e Ipoperfusione Sincope e Ipoperfusione CerebraleCerebrale

Coutts SB et al, Neurology 2003

Subclavean steal syndromeSubclavean steal syndrome

Filis K et al. J Med Case Report 2008;2:392

Sincope da Sincope da compressione compressione

estrinseca estrinseca dell’arteria dell’arteria vertebrale vertebrale

sinistra nel suo sinistra nel suo tratto tratto

extracranicoextracranico

Sakaguchi M et al, Neurology 2003

Sincope da Sincope da compressione compressione

estrinseca della estrinseca della CI sin CI sin

secondaria a secondaria a tumore del tumore del

glomo carotideoglomo carotideo

Bergfeldt L. Heart 2003;89:353–358

Misdiagnosis of epilepsy in three Misdiagnosis of epilepsy in three population-based and three cohort studies population-based and three cohort studies of patients with presumed seizure disorderof patients with presumed seizure disorder

The value of history for The value of history for distinguishing seizure from distinguishing seizure from

syncopesyncope

mod from: Hoefnagels WA et al. J Neurol 1991;238:39-43mod from: Hoefnagels WA et al. J Neurol 1991;238:39-43

Classification of syncopeClassification of syncope

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

Cough SyncopeCough Syncope

Classification of syncopeClassification of syncope

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

Clinical classification of primary Clinical classification of primary chronic autonomic failurechronic autonomic failure

Goldstein DS, Lancet Neurology, 2003

-

-

+

AVPNTS

VLM

NE

Arterial Blood Pressure

IML

SG

a

Baroreflex arcBaroreflex arcInfluencing fInfluencing factorsactors

• 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

MSA

PD PAF

Syncope & FallsSyncope & 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 Features suggesting a diagnosis of psychogenic nonepileptic of psychogenic nonepileptic

seizuresseizures

Alsaadi TM, Vinter Marquez A. Am Fam Physician 2005;72:849-856

NeurologicNeurologicalal

and and PsychiatricPsychiatric and and PsychiatricPsychiatric

evaluationevaluationevaluationevaluation

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

SYNCOPSYNCOPEE

Cardiologist

Neurologist

GP

Syncope Unit