Syncope differential diagnosis
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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1] Associate Editor(s)-in-Chief: Karol Gema Hernandez, M.D. [2] Sahar Memar Montazerin, M.D.[3]
Overview
Syncope should be differentiated from other conditions causing partial or complete loss of consciousness. These disorders may include, coma, dizziness, seizure, and vertigo. There are conditions that may mistakenly be diagnosed as syncope. These conditions include epilepsy, hypoglycemia, intoxication, cataplexy, and transient ischemic attacks.
Differentiating Syncope from other Diseases
A quick algorithm to differentiate syncope from other causes of altered mental status is demonstrated below:
| Clinical presentation | |||||||||||||||||||||||||||||||||||||||||||||||||||||||||
| Loss of conscoiusness | |||||||||||||||||||||||||||||||||||||||||||||||||||||||||
| No | Yes | ||||||||||||||||||||||||||||||||||||||||||||||||||||||||
| • Transient? • Rapid onset? • Short duration? • Spontaneous recovery? | |||||||||||||||||||||||||||||||||||||||||||||||||||||||||
| Falls | Altered consciousnes | Yes | No | ||||||||||||||||||||||||||||||||||||||||||||||||||||||
| Coma | Aborted SCD | Others | |||||||||||||||||||||||||||||||||||||||||||||||||||||||
| T-LOC | |||||||||||||||||||||||||||||||||||||||||||||||||||||||||
| Non-Traumatic | Traumatic | ||||||||||||||||||||||||||||||||||||||||||||||||||||||||
| Syncope | Epileptic seizure | Psychogenic | Rare causes | ||||||||||||||||||||||||||||||||||||||||||||||||||||||
| • Reflex syncope • Orthostatic hypotension • Cardiac syncope | • Tonic • Clonic • Tonic-clonic • Atonic | • Pseudo-epileptic • Pseudo-syncopal | |||||||||||||||||||||||||||||||||||||||||||||||||||||||
Abbreviations: SCD: Sudden cardiac death;T-LOC: Transient-Loss of consciousness.
| The above algorithm adopted from ESC guideline [1] |
|---|
Syncope should be differentiated from other conditions causing partial or loss of consciousness. These disorders may include:[2]
| Conditions Incorrectly Diagnosed as Syncope |
|---|
| Disorders with partial or complete loss of consciousness |
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| Conditions without loss of consciousness |
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| The above table adopted from ESC guideline [1] |
|---|
Syncope, must be differentiated from other diseases that may cause, altered mental status, motor and or somatosensory deficits. The table below, summarizes the neurologic differential diagnosis for syncope:
| Diseases | History | Symptoms | Physical Examination | Diagnostic tests | Other Findings | |||||||||
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| Headache | ↓ LOC | Motor weakness | Abnormal sensory | Motor Deficit | Sensory deficit | Speech difficulty | Gait abnormality | Cranial nerves | CT/MRI | CSF | Gold standard test | |||
| Wernicke’s encephalopathy [3] |
|
– | + | – | – | – | + | + | + | + | – | NA | Clinical assesment and lab findings | |
| Drug toxicity [4][5][6][7] | Medication history of | – | + | – | + | + | + | – | + | – | – | NA | Drug screen test | |
| Metabolic disturbances (electrolyte imbalance, hypoglycemia) [8][9] | – | – | + | + | + | + | + | – | – | + | – | Hypoglycemia, hyponatremia, hypernatremia, hypokalemia, and hyperkalemia | Depends on the cause | |
| Meningitis or encephalitis | + | – | – | – | – | + | + | – | – | – | ↑ Leukocytes, ↑ protein, ↓ glucose | CSF analysis | ||
References
- ↑ 1.0 1.1 Moya, A.; Sutton, R.; Ammirati, F.; Blanc, J.-J.; Brignole, M.; Dahm, J. B.; Deharo, J.-C.; Gajek, J.; Gjesdal, K.; Krahn, A.; Massin, M.; Pepi, M.; Pezawas, T.; Granell, R. R.; Sarasin, F.; Ungar, A.; van Dijk, J. G.; Walma, E. P.; Wieling, W.; Abe, H.; Benditt, D. G.; Decker, W. W.; Grubb, B. P.; Kaufmann, H.; Morillo, C.; Olshansky, B.; Parry, S. W.; Sheldon, R.; Shen, W. K.; Vahanian, A.; Auricchio, A.; Bax, J.; Ceconi, C.; Dean, V.; Filippatos, G.; Funck-Brentano, C.; Hobbs, R.; Kearney, P.; McDonagh, T.; McGregor, K.; Popescu, B. A.; Reiner, Z.; Sechtem, U.; Sirnes, P. A.; Tendera, M.; Vardas, P.; Widimsky, P.; Auricchio, A.; Acarturk, E.; Andreotti, F.; Asteggiano, R.; Bauersfeld, U.; Bellou, A.; Benetos, A.; Brandt, J.; Chung, M. K.; Cortelli, P.; Da Costa, A.; Extramiana, F.; Ferro, J.; Gorenek, B.; Hedman, A.; Hirsch, R.; Kaliska, G.; Kenny, R. A.; Kjeldsen, K. P.; Lampert, R.; Molgard, H.; Paju, R.; Puodziukynas, A.; Raviele, A.; Roman, P.; Scherer, M.; Schondorf, R.; Sicari, R.; Vanbrabant, P.; Wolpert, C.; Zamorano, J. L. (2009). "Guidelines for the diagnosis and management of syncope (version 2009): The Task Force for the Diagnosis and Management of Syncope of the European Society of Cardiology (ESC)". European Heart Journal. 30 (21): 2631–2671. doi:10.1093/eurheartj/ehp298. ISSN 0195-668X.
- ↑ Task Force for the Diagnosis and Management of Syncope. European Society of Cardiology (ESC). European Heart Rhythm Association (EHRA). Heart Failure Association (HFA). Heart Rhythm Society (HRS). Moya A; et al. (2009). "Guidelines for the diagnosis and management of syncope (version 2009)". Eur Heart J. 30 (21): 2631–71. doi:10.1093/eurheartj/ehp298. PMC 3295536. PMID 19713422.
- ↑ Thomson, Allan D.; Marshall, E. Jane (2006). "THE NATURAL HISTORY AND PATHOPHYSIOLOGY OF WERNICKE'S ENCEPHALOPATHY AND KORSAKOFF'S PSYCHOSIS". Alcohol and Alcoholism. 41 (2): 151–158. doi:10.1093/alcalc/agh249. ISSN 1464-3502.
- ↑ Hedya SA, Avula A, Swoboda HD. PMID 29763168. Missing or empty
|title=(help) - ↑ Iorga A, Horowitz BZ. PMID 29494051. Missing or empty
|title=(help) - ↑ Hamed, Sherifa A (2017). "The auditory and vestibular toxicities induced by antiepileptic drugs". Expert Opinion on Drug Safety. 16 (11): 1281–1294. doi:10.1080/14740338.2017.1372420. ISSN 1474-0338.
- ↑ Brostoff, J. M.; Birns, J.; McCrea, D. (2008). "Phenytoin toxicity: an easily missed cause of cerebellar syndrome". Journal of Clinical Pharmacy and Therapeutics. 33 (2): 211–214. doi:10.1111/j.1365-2710.2008.00903.x. ISSN 0269-4727.
- ↑ Giuliani, Corinna; Peri, Alessandro (2014). "Effects of Hyponatremia on the Brain". Journal of Clinical Medicine. 3 (4): 1163–1177. doi:10.3390/jcm3041163. ISSN 2077-0383.
- ↑ Witsch, Jens; Neugebauer, Hermann; Flechsenhar, Julia; Jüttler, Eric (2012). "Hypoglycemic encephalopathy: a case series and literature review on outcome determination". Journal of Neurology. 259 (10): 2172–2181. doi:10.1007/s00415-012-6480-z. ISSN 0340-5354.