This document discusses various causes of falls, including syncope (transient loss of consciousness) and non-syncopal causes. It covers topics such as neurocardiogenic, cardiac, and neurological causes of syncope including seizures, progressive supranuclear palsy, third ventricular cysts, and more. Investigations discussed include Holter monitoring, loop recorders, tilt table testing, and imaging. Differential diagnosis and management are also covered.
2. A Symptom…. Not A Diagnosis
“Human beings are falliable / fallable”-quote
Falling is not an abnormal phenomenon nor a recent
phenomenon
Owsei Temkin quoted the reasons of falling in his book “THE
FALLING SICKNESS”-a history of epilepsy from the Greek era
We aim to discuss the etiology and d/d and approach to various
causes of falling
FALL is a sudden unintentional change in position causing a
individual to land on a lower level object or ground.
7. SYNCOPE
Term syncope(greek:- synkope)literally syn means ‘with’
and koptein means ‘cessation’ or ‘cutting short’ or ‘pause
DEFINITION OF SYNCOPE:-sudden transient loss of
consciousness and postural tone with spontaneous
recovery
Cessation of cerebral blood supply for 6-8 sec or decrease
of systolic BP <60 mmhg or>20% drop in cerebral blood
supply is sufficient.
Syncope accounts for 3% to 5% of emergency room visits
and 1% to 3% of hospital admissions
8. CLINICAL FEATURES OF SYNCOPE
Sense of giddiness, lightheadedness, apprehension, may
sway, headache(sometimes) Vision may dim or close in
concentrically ,tinnitus may be +nt
Patients with neuro-cardiogenic syncope experience a
typical sense of warmth associated with sweating and a
sense of `greying out`. Cardiogenic syncope may be ppt by
arrthymias or chest pain
A hurtful fall is exceptional in the young
Patient is motionless. Skeletal muscles are fully relaxed .
Sphincter control is usually maintained . Body appears pale
9. CLINICAL FEATURES contd…
After syncope:-Retrograde amnesia esp in the elderly
,muscle ache fatigue with short lasting confusion(<5min)
Convulsive syncope:-mild asynchronous clonic jerk of
limbs and trunk with face twitching , occ. flexor jerking,
rarely tongue bite and urinary incontinence
EEG shows b/l synchronous delta and theta waves esp in
frontal lobes .Flattening may occur in prolonged cardiac
arrest (>15 sec).Epileptiform activity is not seen.
11. SEIZURES
Seizures are the most common neurogenic causes of drop
attacks.
GTCS , CPS , atonic seizures and negative myoclonus and may be
causes of sudden falls
A specific aura may precede
Incontinence , hurtful falls , tongue bite , post-ictal confusion(>
5 min) and motor manifestations are imp distinguishing
features
Atonic seizures are defined as epileptic attacks chr. by a sudden
loss or diminution of muscle tone, which may be fragmentary,
confined to a segment (limb, jaw, head), or massive, leading to a
slumping to the ground
12. Negative myoclonus is defined as an interruption of tonic muscular
activity (50 to 400 msec in duration), causing “instability” or, more
often, dropping of objects from the hands, head nodding, or falls
Epileptiform EEG in the inter ictal period is diagnostic
Biochemical parameters:-Serum prolactin , serum creatine kinase ,
serum ACTH(or cortisol), serum pH, body temperature
MRI can be used to identify seizure foci.
Response to anti-convulsants can also be used for differentiation
14. OTHER NEUROLOGICAL CAUSES OF
DROP ATTACKS
cerebrovascular disoders
drop attacks
cataplexy
third ventricular cyst (colloid cyst)
otolithic crises
progressive supranuclear palsy
basilar migraine
arnold chiari malfofmation
psychogenic syncope
creudzfeldt jacob disease(variant type)
corticobasal degeneration
intermittent spinal ischemia
Hyperexplexia(`jumping frenchman of maine`)
Frontal lobe ataxia
15. FALLS IN CEREBROVASCULAR DISORDERS
Very rare manifestation
Multiple occlusions of large arteries like in Takayasu`s
disease involving carotid and vertebral arteries
Subclavian steal syndrome
Subarachnoid hemorrhage:-raised ICT causes
momentary cessation of cerebral blood
supply(equalisation of pressure),usually associated
with severe headache and neck stiffness
16. Vertebrobasilar TIA or ischemia usually associated with
other signs of brainstem dysfunction
Does not occur in ischemia confined to carotid territory.
Cervical spine abnormalities like Klippel Feil`s syndrome
and cervical spondylosis
Acute lesions of the parieto- insular vestibular cortex due
to embolisation of middle cerebral artery can cause
imbalance of vestibular stimuli and can present as falls
without hemiparesis.
17. CAUSES OF VASCULAR ORIGIN
Most common cause of syncope,>33%
Types:-
1.ORTHOSTATIC HYPOTENSION: Definition
Cause:-autonomic dysfunction , hypovolemia , drug
,vasovagal
Symptoms
Worse early in the morning and after meals or exercise
Most common cause:-drugs like diuretics ,vasodilators ,alpha
blockers ,ace inhibitors , tranquilizers
Primary autonomic failure syndromes
19. 2.REFLEX MEDIATED FALLS: Vascular effects of neural signals come from nucleus
tractus solitarius
Types:Neurally mediated hypotension:-triggers include sight of
blood ,pain ,prolonged standing , warm environment
,stressful condition , physical injury particularly to
viscera (like testicles and gut)
20. -Carotid sinus hypersensitivity: Definition:- sinus pause>3 sec , systolic BP fall of >50
mm hg
Initiated on turning head to one side while wearing a
Tight collar or while shaving
usually in standing position.
21. CARDIAC CAUSES OF FALLS
Second most common cause ,10-20%
VT is the most common tachyarrhythmia causing
syncope
Structural heart diseases like aortic stenosis,
myocardial ischemia , mitral stenosis ,atrial myxoma
22. ECG FEATURES SUGGESTIVE OF
ARRYTHMOGENIC SYNCOPE
Bifascicular block (defined as either left bundle branch block or right bundle branch block
combined with left anterior or left posterior fascicular block)
Other intraventricular conduction abnormalities (QRS duration >0.12 seconds)
Mobitz I OR type 2 second degree atrioventricular block or complete heart block
Asymptomatic sinus bradycardia (<50 beats/min), sinoatrial block, or sinus pause >3 seconds
in the absence of negatively chronotropic medications
Pre-excited QRS complexes
Prolonged QT intervals
Right bundle branch block pattern with ST-elevation in leads V1-V3 (Brugada syndrome)
Negative T waves in right precordial leads, epsilon waves and ventricular late potentials
suggestive of arrhythmogenic right ventricular dysplasia
Q waves suggesting myocardial infarction
23.
24. CATAPLEXY
Narcolepsy/Cataplexy syndrome is chr. by
excessive daytime sleepiness
cataplexy
hypnagogic hallucinations
sleep paralysis
sudden fall associated with loss of body tone precipitated by
emotional change like anger or laughter
Part of syndrome associated with narcolepsy
The cataplexy associated with narcolepsy can be managed with tricyclic
antidepressants.
The excessive sleepiness is managed with stimulants, OR newer agents,
such as modafinil,
25. PROGRESSIVE SUPRANUCLEAR PALSY
Also known as Steele-Richardson-Olszewski syndrome, is a
neurodegenerative disease that affects cognition, eye
movements, and posture
Characteristics include supranuclear, primarily vertical,
gaze dysfunction accompanied by extrapyramidal
symptoms and cognitive dysfunction
The disease usually develops after the sixth decade of life,
and the diagnosis is purely clinical.
Currently, no therapy is proven to be effective.
26. THIRD VENTRICULAR CYST
Colloid cysts are nonmalignant tumors
Almost always found in the third ventricle
Classic symptoms of intermittent obstructive
hydrocephalus with paroxysmal headache associated
with changing head position
Sudden weakness in the lower limbs associated with
falls without loss of consciousness has been reported.
27. DROP ATTACKS
Also known as ‘maladie des genoux bleus’.
usually occurs in elderly women
Usually there is sudden onset loss of body tone and
weakness of legs . people drop on their knees .no
associated symptoms.
No loss of consciousness occurs
Vision, hearing ,speech remain intact
28. OTOLITHIC CRISIS
Also known as Tumarkin`s attacks.
It occurs without warning, vertigo, nausea or vomiting,
sweating, disequilibrium, loss of consciousness, numbness
or paralysis
the feeling of being pushed to the ground
There is no loss of consciousness
Sudden increase in labyrinthine pressure is responsible for
sudden onset vertigo
29. HYPEREXPLEXIA
An autosomal dominant trait(Chromosome 5) disorder in which
babies have an exaggerated startle reflex
Hypertonia (stiffness), exaggerated startle response in some
cases, epilepsy
Acute generalized Hypertonia (sudden stiffness) causing the
person to fall like a log to the ground
Startles can be elicited by lightly touching the person's nose,
clapping or making other noises, or suddenly jolting the person's
chair.
Tendency to umbilical and inguinal hernias and congenital
dislocation of the hip.
Good response to clonazepam , valproate and phenobarbitone
30. `JUMPING FRENCHMAN OF MAINE`
Genetic mutation that prevents "exciting" signals in the nervous
system from being regulated
type of hyperexplexia
An extended, grossly exaggerated startle response from a
"jumper," including crying out, flailing limbs, twitching, and
sometimes convulsions.
sufferers are sometimes teased mercilessly by people who find
the reaction amusing, and trigger it repeatedly.
Curiously patient has an automatic reflex to obey any order that
is delivered suddenly, echolalia is present
31. IDIOPATHIC SYNCOPE
Almost one third of all syncopal attacks
Positive tilt table test suggests neuro-cardiogenic cause
Repetitive and erratically spaced syncope without a
specific predisposing factor suggests an arrthymogenic
cause and Holter and EPS study must be done
32. HYSTERICAL FAINTING
Occurs in dramatic circumstances
Esp. in young females without evidence of cardiovascular
illness
Evident lack of change in pulse , blood pressure , or color of
the skin
Outward display of anxiety
General personality and behavioral characteristics of
hysteria.
33. SUBACUTE SCLEROSING PAN-ENCEPHALITIS
A rare chronic, progressive encephalitis
Chr by a h/o of primary measles infection before the age of 2
years, f/b several asymptomatic years (6–15 on average),
gradual, progressive psycho neurological deterioration, seizures,
myoclonus, ataxia, chorioretinitis , spasticity, and coma.
EEG shows periodic(every 5-8 sec) bursts of 2 to 3/sec high
voltage waves f/b flat pattern
CSF shows increased protein esp. gamma globulin (IgG Ab)
Eosinophilic inclusions is the histopathological hallmark
34. DIFFERENTIAL DIAGNOSIS
anxiety attacks and hyperventilation syndrome
hypoglycemia
concussion
sudden vascular collapse like ruptured aortic aneurysm ,
aortic dissection , pulmonary embolism , acute blood loss
cerebellar ataxia
vestibular neuronitis
normal pressure hydrocephalus
visual deficits induced collisions and mechanical falls
sporting injury related falls
38. INVESTIGATIONS
Holter
Event monitor
Loop recorder
of
Echo
Tilt table test
EP study
(frequent syncope , suggestive
ecg,0-4% yield)
(infrequent events not with
sudden LOC)
(infrequent events in
ambulatory patients, IOC in case
bradyarrythmias)
(orthostatic,YIELD <=60%)
-50-80% yield with SHD
-5-10% yield with no SHD
-less useful for bradyarrythmias
39. EEG
(for suspected epilepsy)
CT or MRI brain(for structural abnormalities and epileptic
foci) and for hematomas.
MRI Angio for cerebrovascular diseases in cases of TIA
Carotid Doppler (for suspected TIA)
CT chest in case of suspicion of pulmonary embolus
,ruptured aneurysm and aortic dissection
42. HEAD UP TILT TABLE TEST
UNMASKS LATENT VASO VAGAL
SYNCOPE
REPRODUCES THE PATIENT
SYNCOPE
DEVELOPS BETTER PATIENT
UNDERSTANDING OF HIS ILLNESS
AND ITS SYMPTOMS
ALLOWS THE PHYSICIAN TO
PROGNOSTICATE AND COUNSEL THE
PATIENT
C/I SEVERE LVOT
OBSTRUCTION,CRITICAL MITRAL
STENOSIS,SEVERE
CEREBROVASCULAR
STENOSIS,PROXIMAL CORONARY
ARTERY STENOSIS
43. Classification of positive responses
to tilt testing
Type 1 mixed. Heart rate falls at the time of syncope but the ventricular rate does not fall
to less than 40 bpm or falls to less than 40 bpm for less than 10 s with or without asystole
of less than 3 s. Blood pressure falls before the heart rate falls.
Type 2A cardio inhibition without asystole. Heart rate falls to a ventricular rate less
than40 bpm for more than 10 s but asystole of more than 3 s does not occur. Blood
pressure falls before the heart rate falls.
Type 2B cardio inhibition with asystole. Asystole occurs for more than 3 s. Blood pressure
fall coincides with or occurs before the heart rate fall.
Type 3 vasodepressor. Heart rate does not fall more than 10% from its peak at the time o f
syncope.
Exception 1. Chronotropic incompetence. No heart rate rise during tilt testing (i.e. less
than10% from the pre tilt rate).
Exception 2. Excessive heart rate rise. An excessive heart rate rise both at the onset of the
upright position and throughout its duration before syncope (i.e. greater than 130 bpm).
44.
45. TREATMENT
MANAGEMENT OF THE CAUSE
avoiding or precautions for provocative stimuli esp those
for vasovagal syncope like prolonged standing , stress
,blood donation ,extreme emotions ,nausea ,vomiting
,micturation ,defecation
in case of syncope patient should be made to lie down
with raising of legs ,tight clothing should be loosened,
inciting stimuli if possible should be removed
46. Salt and fluid consumption may be increased ,offending drugs
should be avoided
Drugs such as beta blockers ,midodrine ,fludrocortisone ,SSRI`s
have been tried
Management of specific arrthymias with drugs or pacemakers
patient counseling regarding behavior and occupational
rehabilitation
consideration of the psychological effects of the disease
47. THANK YOU
IF BY NOW YOU`RE TIRED AND FEEL LIKE FAINTING THIS FOR
YOU IS THE CARVED ANCIENT VICTORIAN FAINTING COUCH
48. PHYSICAL EXAMINATION
GENERAL EXAMINATION FOR
PALLOR,WEAKNESS,GENERAL HEALTH
POSTURAL BLOOD PRESSURE
DETAILED CARDIAC EXAMINATION
PULSE RATE,VOLUME,REGULARITY
SYSTEMIC EXAMINATION FOR SPECIFIC DISEASES