La valutazione neurologica e psichiatrica nel paziente con perdita di coscienza Giuseppe Micieli Dip...
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Transcript of La valutazione neurologica e psichiatrica nel paziente con perdita di coscienza Giuseppe Micieli Dip...
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
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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