Doctor, why do I faint when I turn my head to the left? is it epilepsy or syncope?/ Doktor, neden sola donunce bayiliyorum? epilepsi mi senkop mu?
Though syncope is a common problem in the community, if important key questions were not addressed during the initial evaluation, differentiating it from other non-syncopal conditions associated with real or apparent transient loss of consciousness might be challenging, and influences the subsequent diagnostic strategy.
The pressure on carotid sinus baroreceptors, which are located just cephalad to the bifurcation of the common carotid artery, results in bradycardia, hypotension, or combination of both. A sinus pause longer than 3 s and a decrease in systolic blood pressure greater than 50 mmHg is accepted abnormal and is defined as carotid sinus hypersensitivity (1). Syncope due to carotid sinus hypersensitivity occurs in the setting of shaving, a tight collar, or turning the head to one side, as well as in cases of carotid occlusion, neck tumors and after radiotherapy.
The patient was a 35-year-old gentleman who had had total laryngectomy and left radical neck dissection for T2N2M0 squamous cell hypopharyngeal carcinoma, followed by radiotherapy (5000 Rad) and chemotherapy one year ago and chemotherapy in 2005. In September 2006, after three episodes of transient loss of consciousness, falls and myoclonic jerks of his legs he had been taken to hospital. After assessments including cranial magnetic resonance imaging (performed to rule out intracranial metastasis and which was negative) and electroencephalography (reported to be normal) he had been started on valproic acid and discharged with a diagnosis of epilepsy. Since his complaints had not improved after the commencement of the medication, the patient was referred to our hospital. The patient's complaints were the same with an important detail in the history that he was experiencing these episodes whenever he turned his head to the left, and before his falls he experienced blurring of vision, a prickle on his head and sweating. His wife acknowledged that after he lost consciousness he had 1-3 myoclonic jerks only of his legs. He had no eye movements, vocalizations or righting movements, neither before nor during the attacks. He also had no spontaneous jerks. The episodes were lasting at most several seconds and there was no postictal confusion. Neurological examination revealed left Horner's syndrome and was otherwise normal. His blood count, biochemistry and urine analysis were normal on laboratory work-up. Blood glucose levels were normal (between 95-110 mg/dl) during all syncopal episodes. Routine electrocardiogram showed sinus rhythm with no arrhythmia. A routine and sleep deprived electroencephalographic recording showed no abnormality. During a syncopal episode, he was found to have marked bradycardia (30 beats/min) and hypotension (60/40 mmHg). Atropine 0.5 mg relieved the bradycardia and hypotension. On requested cardiology (based only on physical examination) and ear-nose-and-throat consultations, no recommendation that would help the differential diagnosis was mentioned. The patient was directly monitored. During all subsequent episodes, he had marked hypotension (systolic blood pressure dropping from 110-120 mmHg to 50-60/ 30-40 mmHg) and bradycardia (heart rate dropping from 85-90 beats/min to 25-30 beats/min) and during one of them, he had sinus arrest up to 4-5 seconds in duration. A tender carotid massage performed for 5 seconds in the supine position yielded the same changes. A further investigation using neck computerized tomography revealed a mass in the left prevertebral area, with dimensions of 50 x 35 x 25 mm, pushing the carotid artery forward and compressing the left internal carotid artery, with peripheral contrast enhancement which was assumed to be a recurrence of the primary lesion (Figure 1). The patient was referred to oncology service, where he commenced chemotherapy with cisplatine, docetaxel and 5-flourouracil. After this chemotherapy regimen, he experienced no more syncope episodes.
[FIGURE 1 OMITTED]
In spite of distinct underlying pathophysiological processes, syncope and seizure share some clinical characteristics which may lead to diagnostic confusion. Both may occur suddenly without warning, both may result in injury and convulsive jerks may occur in both (2). According to the literature, the problem is rather one of misdiagnosing eepileptic fits and missing a syncope, it is the other way around (3,4), as was the case in our patient in whom we speculate that epilepsy diagnosis was thought because of the presence of myoclonic jerks, probably the most misleading symptom. Though sometimes it is difficult to differentiate epilepsy from syncope, the symptoms surrounding the loss of consciousness may be useful in clinical practice (1,5,6). The occurrence of almost all episodes just after turning the head to one side, and the symptoms patient described before the falls, raised the suspicion of syncope and the diagnosis of carotid sinus syncope was confirmed by performing carotid massage.
Syncope may be caused by a number of different etiologies. The most frequent causes are vasovagal, cardiac and orthostatic (1,7). The cause of syncope remains obscure even after extensive evaluation. We reported this case to emphasize some points. First, the clinicians confronted with patients with sudden loss of consciousness should avoid limiting the scope of diagnostic thinking before evaluating all probable causes, and before postulating some diagnoses and treatment according to the postulated one, some underrecognized causes as carotid sinus syncope should be searched. In the setting of head or neck cancer, the physician should have a high index of suspicion, because syncope may arise due to carotid sinus hypersensitivity (secondary to mechanical compression of the carotid sinus) and glossopharyngeal neuralgia (from tumour-induced irritation of the glossopharyngeal nerve), examples of which have been previously reported (8-10). A meticulous evaluation of the features in the patient's history may decrease the misdiagnosis, as well as the unnecessary investigations and medications.
(1.) The Task Force on Syncope, European Society of Cardiology. Guidelines on management (diagnosis and treatment) of syncope--update 2004. Europace 2004; 6:467-537. [Abstract] / [Full Text] / [PDF]
(2.) Britton JW. Syncope and seizures: differential diagnosis and evaluation. Clin Auton Res 2004; 14:148-59. [Abstract] / [PDF]
(3.) Bergfeldt L. Differential diagnosis of cardiogenic syncope and seizure disorders. Heart 2003; 89:353-8. [Abstract] / [Full Text] / [PDF]
(4.) Zaidi A, Clough P, Cooper P et al. Misdiagnosis of epilepsy: many seizure like attacks have a cardiovascular cause. J Am Coll Cardiol 2000; 36:181-4. [Abstract] / [PDF]
(5.) Kapoor WN. Current evaluation and management of syncope. Circulation 2002; 106:1606-9. [Abstract] / [Full Text] / [PDF]
(6.) Sheldon R, Rose S, Ritchie D et al. Historical criteria that distinguish syncope from seizures. J Am Coll Cardiol 2002; 40:142-8. [Abstract] / [PDF]
(7.) Soteriades ES, Evans JC, Larson MG et al. Incidence and prognosis of syncope. N Eng J Med 2002; 347:878-85. [Abstract] / [Full Text] / [PDF]
(8.) Chen-Scarabelli C, Kaza AR, Scarabelli T. Syncope due to nasopharyngeal carcinoma. Lancet Oncol 2005; 6:347-9. [Full Text] / [PDF]
(9.) Lin RH, Teng MM, Wang SJ et al. Syncope as the presenting symptom of nasopharyngeal carcinoma. Clin Neurol Neurosurg 1994; 96:152-5. [Abstract] / [PDF]
(10.) Rentmeester T, van Zile J, van Hal M et al. Vasodepressor carotid sinus syncope. Br Med J 1984;289:720. [Abstract] / [Full Text]
Serpil DEMIRCI, Ersin CENGIZHAN, Ahmet TUFEKCI
Suleyman Demirel Universitesi Tip Fakultesi, Noroloji Anabilim Dali, Isparta- Turkiye
Address for Correspondence/Yazisma Adresi: Dr. Serpil Demirci, Suleyman Demirel Universitesi Tip Fakultesi, Noroloji Anabilim Dali, Isparta, Turkiye Tel.: +90 246 211 25 12 E-mail: firstname.lastname@example.org Received/Gelis tarihi: 05.01.2010 Accepted/Kabul tarihi: 05.03.2010
|Printer friendly Cite/link Email Feedback|
|Title Annotation:||Case Report/Olgu Sunumu|
|Author:||Demirci, Serpil; Cengizhan, Ersin; Tufekci, Ahmet|
|Publication:||Archives of Neuropsychiatry|
|Date:||Dec 1, 2010|
|Previous Article:||Bilateral temporomandibular joint dislocation associated with use of anti-psychotic drug/Antipsikotik kullanimina bagli bilateral temporomandibuler...|
|Next Article:||Three neuroacanthocytosis cases representing different psychiatric aspects/Farkli psikiyatrik gorunumler sergileyen uc noroakantositoz olgusu.|