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after many minutes, seizures and coma The diagnosis depends largely on the history, the documentation of reduced blood glucose during an attack, and reproduction of the patient s spontaneous attacks by an injection of insulin or hypoglycemia-inducing drugs (or ingestion of a high-carbohydrate meal in the case of reactive hypoglycemia) Acute Blood Loss Acute hemorrhage, usually within the gastrointestinal tract, is a cause of weakness, faintness, or even unconsciousness when the patient stands suddenly The cause (gastric or duodenal ulcer is the most common) may remain obscure until the passage of black stools Transient Cerebral Ischemic Attacks The many symptoms comprised by these attacks in the carotid system are fully described in Chap 34, but syncope is not one of the clinical presentations In the case of attacks in the vertebrobasilar territory, an impairment of consciousness is a rare manifestation, but almost always in the context of additional signs of upper brainstem dysfunction The above described syncope of aortic arch occlusive (Takayasu) disease is, however, usually associated with TIAs, some elicited by effort or exercise Drop Attacks This term is generally applied to falling spells that occur without warning and without loss of consciousness or postictal symptoms The patient, usually elderly and more often female, suddenly falls down while walking or standing, rarely while stooping The knees inexplicably buckle There is no dizziness or impairment of consciousness, and the fall is usually forward, with scuf ng of the knees and sometimes the nose The patient, unless obese, is able to right herself and to rise immediately and go her way, quite embarrassed There may be several attacks during a period of a few weeks and none thereafter The interval EEGs and ECGs are normal One potential mechanism is a lapse of tone in leg muscles during the silent phase of an unnoticed myoclonic jerk Drop attacks also occur in hydrocephalics, and these patients, though conscious, may not be able to arise for several hours Drop attacks as de ned above are usually without an identi able mechanism, requiring no treatment if cardiologic studies are normal On uncertain grounds, they are often attributed to brainstem ischemia In only about one-quarter of such cases, according to Meissner and coworkers, can an association be made with cardiovascular or cerebrovascular disease, to which treatment should be directed Rare instances of Meniere disease, in which the patient is suddenly ` thrown to the ground ( otolithic catastrophe of Tumarkin, page 260) may be mistaken for a syncopal or drop attack, but only brie y, until vertigo becomes prominent Seizures and Syncope In the nal analysis, the loss of consciousness in the different types of syncope must be caused by impaired function of the neural elements in those parts of the brain subserving consciousness, ie, in the high brainstem and thalamic reticular activating system In this respect syncope and primary generalized (so-called centrencephalic) epilepsy have a common ground; yet there is, of course, a fundamental difference In epilepsy, whether major or minor, the arrest in consciousness is almost instantaneous, and, as revealed by the EEG, is accompanied by a paroxysm of electrical activity occurring simultaneously in all of the cerebral cortex and thalamus The EEG changes (mainly by way of diffuse slowing delta waves) in syncope appear later in the course of the attack The difference relates to the essential pathophysiology the rapid spread of an electrical discharge in epilepsy and a more gradual failure of cerebral circulation in syncope There are also a number of important clinical distinctions between epileptic and syncopal attacks The epileptic attack may oc-
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cur day or night, regardless of the position of the patient; syncope rarely appears when the patient is recumbent, the only common exception being the Stokes-Adams attack The patient s color usually does not change at the onset of an epileptic attack; pallor is an early and almost invariable nding in all types of syncope except those due to chronic orthostatic hypotension or hysteria, and it precedes unconsciousness An epileptic attack, as indicated above, is more sudden in onset; if an aura is present, it rarely lasts longer than a few seconds before consciousness is abolished The onset of syncope is usually more gradual, and the prodromal symptoms are quite distinctive and different from those of seizures In general, injury from falling is more frequent in epilepsy than in syncope, because protective re exes are instantaneously abolished in the former (Nevertheless, cardiogenic syncope is an important cause of hurtful falls, especially in the elderly) Tonic spasm of muscles with upturning of the eyes is a prominent and often initial feature of epilepsy, but this occurs only rarely and late in the course of a faint; however, twitching and a few clonic contractions of the limbs may occur several seconds after the patient has fainted (see above) Urinary incontinence is a frequent occurrence in epilepsy, but it need not occur during an epileptic attack and may occasionally occur with syncope, so that it cannot be used as a means of excluding entirely the latter disorder The return of consciousness is slow in epilepsy, prompt in syncope; mental confusion, headache, and drowsiness are common sequelae of seizures, and physical weakness with clear sensorium of syncope (a brief period of grogginess may follow vasodepressor syncope) Repeated spells of unconsciousness in a young person at a rate of several per day or month are much more suggestive of epilepsy than of syncope The EEG may be helpful in differentiating syncope from epilepsy In the interval between epileptic seizures, the EEG, particularly if repeated once or twice, shows some degree of abnormality in 50 to 75 percent of cases, whereas it should be normal between syncopal attacks Sometimes one must resort to continuous EEG monitoring by tape recording or telemetry to clarify the situation (this can be combined with continuous ECG recording) Another useful laboratory marker of a seizure, especially if unwitnessed, is an elevation of the serum creatine kinase (CK) concentration; such a nding occurs only infrequently in the rare case of syncope associated with extensive muscle trauma Elevated prolactin levels have not proved discriminating enough for routine use in separating seizure from syncope but remain useful in distinguishing both of these from other causes of loss of consciousness, particularly hysteria, in which such elevations do not occur No single one of these criteria will absolutely differentiate epilepsy from syncope, but taken as a group and supplemented by the EEG, they usually enable one to distinguish the two conditions
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