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Seizures &Syncope

8

CONTENTS

Episodic loss of conscious- ness, 264

Approach o dia!nosis, 264

Seizures, 26"

Eiolo!y, 26"

Classi#caion & clinical #nd- in!s, 26$

%ia!nosis, 26

Selecion of herapy, 2$'

Co(plicaions of epilepsy & anicon)ulsan herapy, 2$"

*ro!nosis, 2$6

*seudoseizures, 2$$

Syncope, 2$8 +aso)a!al syncope si(ple fains, 2$8

Cardio)ascular syncope, 2$ Cere.ro)ascular syncope, 28' /iscellaneous causes of syn- cope, 282

0E1 CONCE*TS

O.ainin! a horou!h hisoryespecially

re!ardin! he presence or a.sence of prodro(alsy(po(s, he paien3s posiion hen heepisodes occur, and heher episodes are fol-loed .y periods of confusionis criical in e)al-uain! episodic loss of consciousness5 herefore,i is i(poran no o ne!lec he hisory and pro-ceed oo rapidly o he physical ea(inaion andla.oraory in)esi!aion7

*rodro(al li!h-headedness .efore conscious-ness is los su!!ess syncope fro( .rain hypoper-fusion, usually due o )aso)a!al ree, orhosa-

ic hypoension, or cardiac dysfuncion7

Syncope ha occurs in he recu(.en posiioneli(inaes orhosaic hypoension and )aso)a-!al ree as causes, and (a9es a cardiac disur-.ance or seizure (ore li9ely7

Eercise-induced syncope su!!ess a cardiac

cause7

Confusion afer he spell sron!ly su!!essseizure7

:er9in! .ody (o)e(ens and urinary inconi-nence are no necessarily indicai)e of seizure,and can occur durin! )aso)a!al and oher caus-es of syncope as ell7

*rolon!ed seizures ;ury and are hus a (edical e(er!ency7

?hen reain! seizure disorders, focus on heclinical responseseizure conrolraher hanon achie)in! paricular .lood anicon)ulsanle)els7

26

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E*SO%C DOSSO CONSCOFSNESS

Consciousness is los hen he funcion of .oh cere-.ral he(ispheres or of he .rainse( reicularaci)a-in! syse( is co(pro(ised7 Episodic dysfuncion ofhese anao(ic re!ions produces ransien, and ofenrecurren, loss of consciousness7 There are o (a>orcauses of episodic loss of consciousness7

H )u sensaions areco((onlyassociaed ih seizures ori!inain! in he e(plo.e7 47 *ro!ressi)e li!h-headedness, di((in! of )

and fainness, hich indicae diIuse cenral nersyse( dysfuncion, are associaed ih decreacere-.ral .lood o fro( any cause si(ple fains, carrhyh(ias, orhosaic hypoension7E)ens %urin! he Spell

'7 Jeneralized onic-clonic !rand (al, or (a>(oor seizures are characerized .y loss ofconscious-ness, acco(panied iniially .y onic siIenin! asu.seKuenly .y clonic >er9in! (o)e(ens of ere(iies7 27 Cere.ral hypoperfusion usually produces aunresponsi)eness7 er9in! (o)e(ens, especially if hypoperisenhanced .ecause he paien is pre)ened fro(fallin!or oherise assu(in! a recu(.en posure7 Suculaory e)ens are self-li(ied and do no reKuani-con)ulsan rea(en7 Doss of consciousness fropoperfusion rarely lass (ore han '" seconds ano folloed .y posical confusion unless prolo

.rain ische(ia has occurred7

Seizures

Seizures are disorders characerized .y ecessi)e oro)er-synchronized dischar!es of cere.ral neurons7

Syncope

Syncope is loss of consciousness due o a reducedsup-ply of .lood o he cere.ral he(ispheres or.rainse(7 can resul fro( pancere.ral hypoperfusion caused.y)aso)a!al reees, orhosaic hypoension, ordecreasedcardiac oupu or fro( seleci)e hypoperfusion of he.rainse( resulin! fro( )ere.ro.asilar ische(ia7 isi(poran o disin!uish seizures fro( syncope.ecausehey ha)e diIeren causes, dia!nosic approaches,andrea(en7

A**BOAC TO %AJNOSS

The iniial sep in e)aluain! a paien ho hassuIereda lapse of consciousness is o deer(ine heher hesein! in hich he e)en occurredor associaedsy(po(s or si!nssu!!ess ha i as a direcresulof a disease reKuirin! pro(p aenion, such ashypo-!lyce(ia, (enin!iis, head rau(a, cardiacarrhyh(ia,or acue pul(onary e(.olis(7 The nu(.er of spellsand heir si(ilariy or dissi(ilariy should .e esa.-

lished7 f all spells are idenical, hen a sin!le paho-physiolo!ic process can .e assu(ed, and hefolloin!(a>or diIerenial feaures should .e ascerained7

*osure ?hen Doss

of Consciousness Occurs Orhosaic hypoension and si(ple fains cur in he upri!h or siin! posiion7 Episo also or only occurrin! in he lyin! posiiosu!!es seizure or cardiac arrhyh(ia as a li9elycause,alhou!h syncope induced .y sron! e(oionalsi(uli(ay .e responsi.le e!, phelo.oo(y7Belaionship o *hysical Eerion

Syncope associaed ih eerion is usual o cardiac ouo o.srucion e!, aoric s

sis, o.sruci)e hyperrophic cardio(yopaarial (yo(a or arrhyh(ias7*heno(ena a Onse of Spell

A deailed inKuiry should alays .e (adea.ou prodro(al and iniial sy(po(s7 The ofen .rief, sereoyped pre(oniory sy(po(sauraa he onse of so(e seizures (ay localize he cenralner)ous syse( a.nor(aliy responsi.le for heseizures7 '7 An una(.i!uous descripion of a sudden onseofunconsciousness ihou prodro(al feaures is hi!hlysu!!esi)e of seizure7

27 ocal sensory or (oor pheno(ena e!, in)olun-ary >er9in! of one hand, he(ifacial pareshesias,forced

*heno(ena olloin! he Spell

'7 A period of confusion, disorienaion, or a!ion posical sae follos a !eneralized onicseizure7 The period of confusion is usually .riefin! only (inues7 Alhou!h such .eha)ior is ofesri9in!ly e)iden o inesses, i (ay no .e re.yhe paien7 27 *rolon!ed aleraion of consciousnessprolon!edposical sae (ay follo saus epilepicus7 l f i l i i i ih

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srucural cere.ral disease e!, de(enia, (enalrear-daion, or encephaliis or (ea.olic encephalopahy7

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fe.rile con)ulsions are usually self-li(ied, rea(enisofen unnecessary5 prolon!ed con)ulsions '"(inuescan .e reaed ih diazepa(, =7< (!@9! orally, inra-(uscularly, or inra)enously or =76 (!@9! recally7Suchrea(en (ay decrease he ris9 of recurrence7 Thepro.-a.iliy of de)elopin! a chronic seizure disorder is 2M6Pand is hi!hes in paiens ih persisen neurolo!ica.-nor(aliies5 prolon!ed, focal, or (uliple seizures5 orafa(ily hisory of nonfe.rile seizures7 Don!-er(ad(inis-raion of pheno.ar.ial o reduce he ris9 ofsu.seKuenafe.rile seizures is no indicaed, since he ef#cacy ofsuch prophylacic herapy is dispued, and co!nii)ei(-pair(en is a co((on side eIec of rea(en7 27 diopahic epilepsy for hich no speci#c cause

can .e esa.lished accouns for (ore han $"P ofseizure disorders7 diopahic epilepsy usually .e!ins.e-een he a!es of " and 2" years, ih (ore han$"Pof paiens ha)in! heir #rs seizure .efore a!e '8years7Dess freKuenly, idiopahic epilepsy .e!ins in laerlife,alhou!h in his a!e !roup seizures are alsoco((onlyassociaed ih sro9es, u(ors, rau(a, and

syse(icor (ea.olic disorders see i!ure 8M'7 No allpaiensih a sin!le idiopahic seizure !o on o de)eloprecur-ren seizuresQ recurrence raes )ary fro( a.ou uries are ofen reaed

67 /enin!iis or encephaliis caused .y .acere!, ae(ophilus inuenzae, u.erculous, )iraherpes si(ple, fun!al, or parasiic e!,cysicercosisinfecions can also cause seizures see ChaperSeizures in paiens ih A%S are (os ofen as

aed ih A%S de(enia co(ple, .u also ihplas(osis or crypococcal (enin!iis7 $7 Corical dys!enesis and neuronal (i!raionorders predispose o epilepsy7

Syse(ic %isorders

/ea.olic and oher syse(ic disorders, includidru!-o)erdose and dru!-ihdraal syndro(es.eassociaed ih seizures ha a.ae ih correche underlyin! a.nor(aliy7 n hese cases, hepaienis no considered o ha)e epilepsy7 '7 ypo!lyce(ia can produce seizures, espec

ih seru( !lucose le)els of 2=M

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Ta.le 8M27 /a>or cae!ories of dru!s reporedo cause seizures7

Anicholineserases or!anophosphaes, physosi!(ineAnidepressans ricyclic, (onocyclic, heerocyclicAnihisa(ines

Anipsychoics phenohiazines, .uyrophenones,clozapine recepor .loc9ers propranolol, oprenololChe(oherapeuics eoposide, ifosfa(ide, cisplainu(Cyclosporine, 0 "=6ypo!lyce(ic a!ens includin! insulinypoos(olar pareneral soluionssoniazidDocal anesheics .upi)acaine, lidocaine, procaine, eidocaine/ehylanhines heophylline, a(inophyllineNarcoic anal!esics fenanyl, (eperidine, penazocine, propoyphene*enicillins*hencyclidineSy(paho(i(eics a(phea(ines, cocaine, ephedrine, /%/A' Recsasy, phenylpropanola(ine, er.ualine

' /ehylenedioy(eha(phea(ine7

7 %ru! ihdraal, especially ihdraal fro(

ehanol or sedai)e dru!s, (ay .e acco(panied .yoneor (ore !eneralized onic-clonic seizures ha usuallyresol)e sponaneously7 Alcohol ihdraal seizuresoc-cur ihin 48 hours afer cessaion or reducion ofehanol ina9e in =P of cases, and are characerized.y .rief urries of one o si aac9s ha resol)eihin'2 hours7 Acue a.sinence fro( sedai)e dru!s canalso produce seizures in paiens ha.iuaed o (orehan 6==M8== (!@d of seco.ar.ial or eKui)alen

dosesof oher shor-acin! sedai)es7 Seizures fro(sedai)edru! ihdraal ypically occur 2M4 days afer a.si-nence .u (ay .e delayed for up o ' ee97 ocalseizures are rarely due o alcohol or sedai)e dru!ih-draal alone5 hey su!!es an addiional focalcere.rallesion ha reKuires e)aluaion7 '=7 Jlo.al cere.ral ische(ia fro( cardiac arres,cardiac arrhyh(ias, or hypoension (ay produce, a

onse, a fe onic or onic-clonic (o)e(ens ha re-se(.le seizures, .u hey pro.a.ly reec a.nor(al.rainse( aci)iy insead7 Jlo.al ische(ia (ay also.eassociaed ih sponaneous (yoclonus see Chaper$or, afer consciousness reurns, ih (yoclonusprecipi-aed .y (o)e(en acion (yoclonus7 *arial or!en-eralized onic-clonic seizures also occur5 hese (ay.e

(anifesed only .y (inor (o)e(ens of he face oreyes and (us .e reaed7 Noneheless, isolaedseizures

''7 yperensi)e encephalopahy, hich (ayacco(panied .y !eneralized onic-clonic or parseizures, is considered in Chaper '7 '27 Ecla(psia refers o he occurrence of seizorco(a in a pre!nan o(an ih hyperension,

proein-uria, and ede(a preecla(psia7 As in hyperenen-cephalopahy in nonpre!nan paiens, cere.raede(a,ische(ia, and he(orrha!e (ay conri.ue o nelo!ic co(plicaions7 /a!nesiu( sulfae has .eeidely used o rea ecla(pic seizures, and (asu-perior for his purpose o anicon)ulsans such phenyoin7 '

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268 @ CA*TEB 8

i!ure 8M27 Tonic conracion of he (uscles of respi-raion (ay produce an epiraion-induced)ocalizaioncry or (oan and cyanosis, and conracion of (asi-caory (uscles (ay cause on!ue rau(a7 Thepaien

falls o he !round and (ay .e in>ured7 27 Clonic phaseThe onic phase is folloed .y aclonic alernain! (uscle conracion and relaaionphase of sy((eric li(. >er9in! ha persiss for anad-diional er9in! .eco(es less freKuen, unil #-nally all (o)e(ens cease and he (uscles areaccid7Sphinceric relaaion or derusor (uscle conracion

(ay produce urinary inconinence7

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is (ade7 The spells are characerisically induci.le .yhyper)enilaion7 The elecroencephalo!ra( EEJshos a characerisic

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i!ure 8M47 EEJ of a paien ih idiopahic pri(ary !eneralized epilepsy7 A .urs of !eneralized epilepifoaci)iy cener is seen on a relai)ely nor(al .ac9!round7These #ndin!s, o.ained a a i(e hen he paieasno eperiencin! seizures, suppor he clinical dia!nosis of epilepsy7 Odd-nu(.ered leads indicae elecrodeplace-(ens o)er he lef side of he head5 e)en nu(.ers, hose o)er he ri!h side7

con)ulsan herapy should .e .ased on hepro.a.iliyof recurrence7 olloin! a sin!le !eneralized onic-clonic seizure, recurrence can .e epeced ihin

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Ta.le 8M47 Su((ary of anicon)ulsan dru! herapy7

Seru( alf-DifeNor(al Benal and epaic uncion%ru!

*henyoin %ilanin

Fsual*reparaion

'==-(! capsule7Also

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SELFBES & S1NCO*E @ 2$aundice occur7 Da(ori!ine has a 'Q'=== incideSe)ens-:ohnson syndro(e in he #rs 8 ee9s7 /os anicon)ulsan dru!s especially .ar.iuaIec co!nii)e funcion o so(e de!ree, e)en

hera-peuic doses7

conseKuences of saus epilepicus are relaed o in-creased (oor aci)iy and hi!h le)els of circulain!ca-echola(ines5 hey include hyperher(ia o 42M4

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Ta.le 8M67 %ru! rea(en of saus epilepicus in aduls7

%ru!

Dorazepa( or

diazepa( ordiazepa( !el

%osa!e@Boue

=7' (!@9! +' a rae no !reaer han2 (!@(in

'= (! + o)er 2 (inues=72 (!@9! recally

Ad)ana!es@%isad)ana!es@Co(plicaions

as acin!7 EIeci)e half-life '" (inues for diazepa( a'4

hours for lorazepa(7 A.rup respiraory depression orhypoension in "P, especially hen !i)en in co(.inaioihoher sedai)es7 Seizure recurrence in "=P of paiens5herefore(us add (ainenance dru! phenyoin or pheno.ar.ia

*BOCEE% //E%ATED1 TO OS*EN1TON OB*EN1TON

osphenyoin or

phenyoin

'===M'"== (! 2= (!@9! + a '"=(!@(in in saline or derose soluion'===M'"== (! 2= (!@9! sloly arae no !reaer han "= (!@(incanno .e !i)en in derosesoluion

*ea9 seru( concenraion '=M2= (inues folloin! +infusion7Dile or no respiraory depression%ru! le)els in he .rain are herapeuic a co(pleion ofinfusion7EIeci)e as (ainenance dru!7 ypoension and cardiacarrhyh(ias can occur7

SELFBES *EBSST, ANOTEB '= (!@9! O OS*EN1TON OB *EN1TON CAN E A%/NSTEBE%5

SELFBES STDD CONTNFE, *BOCEE% //E%ATED1 TO *ENOABTAD, *BO*OOD, *ENTOABTAD, OB /%ALOD*heno.ar.ial '===M'"== (! 2= (!@9! + sloly

"= (!@(in*ea9 .rain le)els ihin

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Ta.le 8M$7 Side eIecs of anicon)ulsan dru!s7

%ru!

*henyoin

%ose Belaed

%iplopiaAaiaJin!i)al hyperplasiairsuis(Coarse facial feaures*olyneuropahyOseo(alacia/e!alo.lasic ane(ia

%iplopiaAaiaJasroinesinal disressSedaion

diosyncraic

S9in rashe)erDy(phoid hyperplasiaepaic dysfuncionlood dyscrasiaSe)ens-:ohnson syndro(e

S9in rashlood dyscrasiaepaic dysfuncionSe)ens-:ohnson syndro(eSA%

S9in rash

S9in rashSe)ens-:ohnson syndro(e

%ru!

Clonazepa(

%ose Belaed

Sedaion%iplopiaAaiaeha)ioral disur.anceypersali)aion

%rosinessai!ue%ru!!ed sensaionDoss of li.ido

%izzinessAaia

diosyncraic

Ja.apenin

Car.a(azepine

Da(ori!ine

Ocar.azepine

*heno.ar.ial

yponare(ia

Sedaionnso(niaeha)ioral disur.ance%iplopiaAaia

S9in rash in 'M2PfreKuency increase.y conco(ian )alproic acid herapyand reduced .y !ra

ual .uild-up of doseSe)ens-:ohnsonsyndro(e

*eripheral )isualconsricionirre)ersi.le

Benal sonesJlauco(a

Bash

+i!a.arin Sedaion+eri!o*sychosis

AaiaConfusion

%izzinessSedaionNausea

%rosinessAaiaAnoreiaeadache

+alproic acid Jasroinesinal disress epaic dysfuncionTre(or*eripheral ede(aSedaion*ancreaiis?ei!h !ainair loss

Thro(.ocyopenia

Jasroinesinal disress S9in rashSedaionlood dyscrasiaAaiaeadache

Topira(ae

Tia!a.ine

Ehosui(ideLonisa(ide Nephrolihiasis

S9in rash

epilepsy7 f a second seizure occurs, hoe)er, herecur-rence rae approaches $"P and anicon)ulsans

here-fore should .e sared7 ?ih appropriaeanicon)ulsandru! rea(en, seizures can .e ell conrolled, al-hou!h no alays eli(inaed, in (os epilepic pa-iens7 A he onse of rea(en paiens should .eseene)ery fe (onhs o (onior seizure freKuency and(a9e dose ad>us(ens7*SEF%OSELFBES

Aac9s ha rese(.le seizures psycho!enic seizures,or pseudoseizures (ay .e (anifesaions of apsychi-aric disur.ance such as con)ersion disorder, so(ai-zaion disorder, faciious disorder ih physical

sy(po(s, or (alin!erin!7 n con)ersion or so(ion disorder, he paien is unaare of he psy-cho!enic naure of sy(po(s and he (oi)aio

heir producion7 n faciious disorder, he paiereco!nizes ha he spells are self-induced, .u hereason for doin! so7 n (alin!erin!, here is conaareness of .oh he producion of sy(po(s he underlyin! (oi)aion7 *seudoseizures usually can .e disin!uished clinically and .y he EEJ #ndin!s7 n paiens pseudoseizures rese(.lin! onic-clonic aac9s(ay .e arnin! and preparaion .efore he aahere is usually no onic phase, and he clonic pconsiss of ild hrashin! (o)e(ens durin! hhepaien rarely co(es o har( or is inconinen7 so(ei h . l f l

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Ta.le 8M87 So(e (a>or anicon)ulsan dru!ineracions7

%ru!

*henyoin

De)elsncreased .y

enzodiazepinesChlora(phenicol%isul#ra(Ehanolsoniazid*henyl.uazoneSulfona(ides

Topira(aeTri(ehopri(?arfarinLonisa(ide

Eryhro(ycin

el.a(ae'soniazid*ropoyphene+alproic acid

*ri(idone+alproic acid

De)els%ecreased .y

Car.a(azepine*heno.ar.ial*yridoine+i!a.arin

he aac97 The EEJ recorded durin! he episodno sho or!anized seizure aci)iy, and posicslo-in! does no occur7 The diIerenial dia!nosis shinclude fronal lo.e seizures, hich (ay .e (ar.y

unusual (idline (o)e(ens pel)ic hrusin!, .clin! and .y )ery .rief posical saes7 cal EEnor(aliies (ay escape deecion as ell7 is i(poran o appreciae ha so(e paienihpseudoseizures also ha)e !enuine epilepic aahareKuire anicon)ulsan (edicaions, .u hese s.e prescri.ed a an e(pirically appropriae doschiaric referral (ay .e helpful7S1NCO*E

*heno.ar.ial

*henyoinOcar.azapineLonisa(ide

Car.a(azepine Syncope is episodic loss of consciousness assoc

ih loss of posural one7 The pahophysiolo!yinc fro( ha of seizures and in)ol)es !lo.alhypoper-fusion of he .rain or .rainse(7 The (os co((causes of syncope are !i)en in Ta.le 8M7*heno.ar.ial

+alproic acid

+ASO+AJAD S1NCO*E S/*DE ANTS

Topira(aeTia!a.rinDa(ori!ine*henyoinCar.a(azepine

Car.a(azepine*heno.ar.ial*henyoin

Car.a(azepine*henyoin+alproic acid

Car.a(azepine*henyoin*heno.ar.ial

Car.a(azepine*henyoin

Ehosui(ide

Clonazepa(

Ja.apenin

Da(ori!ine

+alproic acid

+alproic acid

+i!a.arin

Topira(ae

Tia!a.ine

Lonisa(ide

'

Da(ori!ine

De)els of he paren co(pound are di(inished, .u le)elsof aci)e (ea.olie increase7

shouin! or o.scene uerances durin! apparen lossofconsciousness or !oal-direced .eha)ior7 There is noposical confusion or a.nor(al clinical si!nsf ll i

+aso)a!al syncope, hich is eceedin!ly co((oc-curs in all a!e !roups7 *recipiain! facors inclue(oional si(ulaion, pain, he si!h of .lood,fai!ue,(edical insru(enaion, .lood loss, or prolon!(o-

ionless sandin!7 +a!ally (ediaed decreases iarerial.lood pressure and hear rae co(.ine o producen-ral ner)ous syse( hypoperfusion and su.seKusyn-cope7 Cere.ral ische(ia resulin! in onic-clonic(o)e-(ens can occur7 +aso)a!al episodes !enerally .e!in hile hepaienis in a sandin! or siin! posiion and only rare

horizonal posiion e!, ih phle.oo(y or F% ion7 A prodro(e lasin! '= seconds o a fe (usually precedes syncope and can include lassili!h-headedness, nausea, pallor, diaphoresis,sali)aion,.lurred )ision, and achycardia7 The paien, hloses consciousness and falls o he !round, is panddiaphoreic and has dilaed pupils7 radycardiareplacesachycardia as consciousness is los7 %urin! uncsciousness, a.nor(al (o)e(ens (ay occur, p

larly if he paien re(ains relai)ely )erical5 hare(ainly onic or opishoonic, .u seizureli9e onclonic aci)iy is occasionally seen, hich can lea(isdia!nosis of epilepsy7 Frinary inconinence (also occur7 The paien reco)ers consciousness )ery rapsec-onds o a fe (inues afer assu(in! he horizposiion, .u residual ner)ousness, dizziness,headache,

nausea, pallor, diaphoresis, and an ur!e o defe(ay.e noed7 A posical confusional sae ih

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Ta.le 8M7 Co((on causes of syncope and heirpre)alences in )arious series7

*ercena!e of *aiens

Neurally (ediaed causes +aso)a!al Siuaional /icuriion %efecaion Sallo Cou!h Caroid sinus syncope

Orhosaic hypoension

%ecreased cardiac oupu O.srucion o o

Arrhyh(ias

Neurolo!ic and psychiaric diseases

Fn9non

8M4''M8

Ta.le 8M'=7 Causes of syncope fro(cardio)ascular disease7

Cardiac arresCardiac dysrhyh(ias Tachyarryh(ias

Supra)enricular *aroys(al arial achycardia Arial #ler Arial #.rillaion Acceleraed >uncional achycardia +enricular +enricular achycardia +enricular #.rillaion radyarrhyh(ias Sinus .radycardia Sinus arres Second- or hird-de!ree hear .loc9 (planed pace(a9er failure or (alfuncion /iral )al)e prolapse clic9-(ur(ur syndro(e *rolon!ed YT-iner)al syndro(es Sic9-sinus syndro(e achycardia-.radycardia synd %ru! oiciy especially di!ialis, Kuinidine,procaina(ide, propranolol, phenohiazines, ricyclic anidepressa poassiu(Cardiac ino o.srucion Def arial (yo(a or hro(.us Ti!h (iral senosis Consrici)e pericardiis or cardiac a(ponade Besrici)e cardio(yopahies Tension pneu(ohoraCardiac ouo o.srucion

Aoric senosis *ul(onary senosis yperrophic cardio(yopahy asy((eric sepal hyperrophy, idiopahic hyperrophic su.aoric se%issecin! aoric aneurys(Se)ere pul(onary-)ascular disease *ul(onary hyperension Acue pul(onary e(.olus

=74"

4M'=

'M8

4M

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28= @ CA*TEB 8

achycardia, arial uer, or arial #.rillaion (ay .eparoys(al or chronic7 ear raes faser han '6=M2==@(in reducecardiacoupu .y decreasin! he )enricular #llin! period orinducin! (yocardial ische(ia7 *rolon!ed achycardia

of '8=M2== .eas or (ore per (inue ill producesyn-cope in "=P of nor(al persons in he upri!h posure5in paiens ih underlyin! hear disease, a hear raeof'

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SELFBES & S1NCO*E @ 28'

cially folloin! eerion7 A he(odyna(ic processsi(i-lar o ha occurrin! in aoric senosis is responsi.le7"7 1*EBTBO*C CAB%O/1O*AT1yperrophic cardio(yopahy co(prises a !roup ofcon!enial cardio(yopahies inheried as auoso(aldo(inan disorders of )aria.le se)eriy7 Sy(po(susu-ally .e!in .eeen he second and fourh decades7%ys-pnea is he (os co((on presenin! co(plain, .usyncope occurs in

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282 @ CA*TEB 8

in an ae(p o dia!nose caroid sinus syncope inpa-iens ih caroid aheroscleroic disease enails aris9of disal e(.olizaion of ahero(aous (aerial7

causes of orhosaic hypoension deser)e speccon-sideraion7 diopahic orhosaic hypoension isciaed (ainly ih he de!eneraion of pos!ansy(paheic neurons ihou oher neuropahochan!es7 n Shy-%ra!er syndro(e, orhosaic h

poension appears o .e relaed o de!eneraiopre-!an!lionic sy(paheic neurons5 his occurs in cnaion ih par9insonian, pyra(idal, cere.ellar,loer (oor neuron si!ns7 The dia!nosis of orhosaic hypoension is elished .y de(onsrain! a drop in .lood pressuraleas ury ih paraple!ia Sur!ical sy(paheco(y Syrin!o(yelia@syrin!o.ul.ia Ta.es dorsalis ?ernic9e encephalopahyCardiac pu(p failure*rolon!ed .ed res

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SELFBES & S1NCO*E @ 28or senosis or occlusion of he su.cla)ian arery.efore i has !i)en rise o he )ere.ral arery canleado he su.cla)ian seal syndro(e, in hich .loodpasses fro( he )ere.ral arery ino he disalsu.cla-)ian arery ih physical aci)iy of he ipsilaeralar(7The syndro(e is a (anifesaion of !eneralizedahero-sclerosis and is no predici)e of sro9e in he )ere-.ro.asilar syse(7 *aiens are usually asy(po(aic,

and sro9e, hen i occurs, is ypically due ocoeisin!caroid lesions7

e!(enu( of he pons produces unilaeral oreral a.ducens + ner)e palsy5 horizonal eye ((ens are i(paired, .u )erical nysa!(us andocular.o..in! (ay .e presen7 The pupils are consricas aresul of he in)ol)e(en of descendin! sy(papupillodilaor #.ers in he pons, .u hey (ay rereaci)e7 e(iple!ia or Kuadriple!ia is usuallypresen,and co(a is co((on7 Alhou!h he syndro(e olar occlusion in unconscious paiens (ay .econfusedih ponine he(orrha!e, a CT or /B .rain scadiIereniae he o7 n so(e paiens ih .asilar occlusion, he )porion of he pons .asis ponis is infarced ane!(enu( is spared7 Such paiens re(ainconscious.u Kuadriple!ic7 The er( loc9ed-in syndro(e .een applied o his sae7 Doc9ed-in paiens (a.le o si!nify ha hey are conscious .y openiheireyes or (o)in! heir eyes )erically on co((an

oher cases, a con)enional elecroencephalo!rEEJ ih si(ulaion (ay .e needed o disinhe loc9ed-in sae in hich he EEJ is nor(alco(a see Chaper '=7 .7 E(.olis(E(.oli s(all enou!h o passhrou!h he )ere.ral areries ino he lar!er .aar-ery are usually arresed a he op of he .asilaarery,here i .ifurcaes ino he poserior cere.ral ai!ure M''C7 The resulin! reducion in .loodo he ascendin! reicular for(aion of he (id.

and hala(us produces i((ediae loss or i(paof consciousness7 Fnilaeral or .ilaeral oculo(o ner)e palsies are characerisic7 e(iple!iaKuadriple!ia ih decere.rae or decoricaeposurin!occurs .ecause of he in)ol)e(en of he cere.duncles in he (id.rain7 Thus, he op of he .asyndro(e (ay .e confused ih (id.rain failurcaused .y ransenorial uncal herniaion7 Dess (only, an e(.olus (ay lod!e (ore proi(ally ahero(aous narroed porion of he .asilar aproducin! a syndro(e indisin!uisha.le fro( .a

hro(.osis7 S(aller e(.oli (ay occlude he rosral .asilaareryransienly .efore fra!(enin! and passin! inoor.oh poserior cere.ral areries i!ure M''%7 suchcases, porions of he (id.rain, hala(us, ande(po-ral and occipial lo.es can .e infarced7 f conschese paiens display a )ariey of )isualho(ony(ous

he(ianopia, corical .lindness, )isuo(oor i(con)er!ence, paralysis of upard or donard diplopia, and .eha)ioral especially confusion

7 DONJ CBCF/EBENTAD +EBTEBOASDAB BANCES '7 Anao(yThe lon! circu(ferenial .ranch

arisin! fro( he )ere.ral and .asilar areries a

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Midbrain

)o"teriorcerebral artery

Superiorcerebellar artery

)on"Ba"ilar artery

Anterior inferior

cerebellar artery

/ertebralartery

)o"teriorinferior

cerebellarartery

')

M-

;

Ba"ilar artery

ST

III

)aramedian branch

A7 /id.rain

Medulla

Anterior

"pinal artery or"olateralbranch

Ba"al branch

)o"teriorcerebral artery

7 *ons

/I/III

/

/II

ST

M-

)aramedian

branch

or"olateral

branch

C7 /edulla

/III

B)

Ba"al

branch

Anterior inferior

cerebellar artery Ba"ilar

artery

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usify he ris9 of an!io!raphy or inhe ris9 is especially hi!h .ecause of coeisin!illness orhe lac9 of an!io!raphic eperise, he #ndin! o(al caroid .lood o or co(plee occlusion .y%oppler sudies can o.)iae he need foran!io!raphy7Transcranial doppler ulrasono!raphy is so(ei(used in he e)aluaion of suspeced senosis of racranial inernal caroid arery, (iddle cere.rarery,or .asilar arery and for deecin! and folloin!course of cere.ral )asospas( afer aneurys(alarachnoid he(orrha!e7

J7 ECOCAB%OJBA*1Echocardio!raphy (ay .e useful for de(onsrahecardiac lesions responsi.le for e(.olic sro9e iniens ih clinically e)iden cardiac disease, suarial #.rillaion7

7 EDECTBOENCE*ADOJBA/ EEJThe EEJ is rarely useful in e)aluain! sro9e7 hoe)er, help diIereniae .eeen a seizuredisorderand TAs or .eeen lacunar and corical infarche occasional paien in ho( hese possi.iliican-no oherise .e disin!uished7

%EBENTAD %AJNOSSn paiens presenin! ih focal cenral ner)ousyse(dysfuncion of sudden onse, ische(ic sro9e (disin!uished fro( srucural and (ea.olicprocesses

ha can (i(ic i7 An underlyin! process oher fo-cal cere.ral ische(ia should .e suspeced here-sulin! neurolo!ic de#ci does no confor( o hri.uion of any sin!le cere.ral arery7 n addiiosro9es do no ypically i(pair consciousness ina.-sence of profound focal de#cis, hereas ohercere.raldisorders (ay do so7 +ascular disorders (isa9en for ische(ic sro

clude inracere.ral he(orrha!e, su.dural or ephe(ao(a, and su.arachnoid he(orrha!e fro(ure of an aneurys( or )ascular (alfor(aion7 T

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STBO0E @ used o (ahe a*TT a a.ou '7" o 27" i(es he prerea()alue7 ?arfarin he usual (ainenance dose is "M'"orally can .e sared si(ulaneously ih hepaher-

apy7 A.ou 2 days afer he prohro(.in i(e *reaches rou!hly one and one-half i(es he prerea(en )alue ypically a.ou " days, heparcan .e disconinued7 The *T or inernaional noized raio NB should .e (easured a leas e)e2 ee9s and he dose of arfarin ad>used o(ainain*T \ '7" i(es conrol or NB \

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or co(plicaion of r-*A rea(en is orrha!e, hich (ay aIec he .rain or oher isThe lac9 of pro)en .ene# hen r-*A is !i)en a< hours, he ris9 of .leedin! co(plicaions, and

i(-porance of a correc dia!nosis hen rea(enenially dan!erous dicae ha r-*A no .e !i)cerain sein!s7 is i(poran ha he i(e of ofsy(po(s can .e esa.lished ih con#dence7 CTscan should no already sho e)idence of a lar!che(ic sro9e or of he(orrha!e7 *aiens hosecoa!u-laion funcion has .een co(pro(ised .y head(inis-

raion of arfarin or heparin or .y hro(.ocyoplaele coun 185 ((

! or diasolic .lood pressure >110 (( !7 To areain! TAs ha are already resol)in! or ohercondi-ions unli9ely o respond o r-*A, or for hich heceeds li9ely .ene#, paiens hose de#cis apro)in! rapidly and sponaneously, paiens iand isolaed de#cis, and hose ih .lood !lucocon-cenraions consisen ih a hypo- or hyper!lycori!in of sy(po(s X"= (!@dl or >400 (!@dl s

.e ecluded7 *aiens recei)in! r-*A for sro9e should .e (a!ed in faciliies in hich he capaciy eiss o

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