La valutazione neurologica e psichiatrica nel paziente con perdita di coscienza Giuseppe Micieli

1. La valutazione neurologica e psichiatrica nel paziente con perdita di coscienza Giuseppe Micieli Dip Neurologia d’Urgenza IRCCS Fondazione Ist Neurologico Nazionale C. Mondino Pavia

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

3. Che 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

4. Wiebers et al, 1997

5. Sincope e Ipoperfusione Cerebrale MTT map 35 mL/100 g/min 20 mL/100 g/min Coutts SB et al, Neurology 2003

6. Subclavean steal syndrome Filis K et al. J Med Case Report 2008;2:392

7. Sincope da compressione estrinseca dell’arteria vertebrale sinistra nel suo tratto extracranico Sakaguchi M et al, Neurology 2003

8. Sincope da compressione estrinseca della CI sin secondaria a tumore del glomo carotideo

9. Misdiagnosis of epilepsy in three population-based and three cohort studies of patients with presumed seizure disorder Bergfeldt L. Heart 2003;89:353–358

10. The value of history for distinguishing seizure from syncope mod from: Hoefnagels WA et al. J Neurol 1991;238:39-43

11. Classification of syncope ESC syncope guidelines, Eur Heart J 2009;30:2631-2671

13. Cough Syncope

14. Classification of syncope ESC syncope guidelines, Eur Heart J 2009;30:2631-2671

15. Clinical classification of primary chronic autonomic failure Goldstein DS, Lancet Neurology, 2003

16. Baroreflex arc Influencing factors • 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 - + AVP NTS - VLM MSA Arterial Blood Pressure PAF PD a NE IML SG

17. Syncope & 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

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

19. Features suggesting a diagnosis of psychogenic nonepileptic seizures Alsaadi TM, Vinter Marquez A. Am Fam Physician 2005;72:849-856

20. Neurological and Psychiatric evaluation ESC syncope guidelines, Eur Heart J 2009;30:2631-2671

21. Point of care:accident and emergency department Petkar S et al. Postgrad Med J 2006;82: 630-641

23. Emergency Room SYNCOPE Cardiologist Neurologist Syncope Unit GP