Neurogenic syncope (syncope) - Treatment

All treatment measures for syncopal (fainting) conditions are divided into two parts: those carried out during an attack and those carried out outside of attacks of loss of consciousness, with the latter option being encountered much more often in the practice of neurologists.

Treatment of syncopal (fainting) paroxysm is often limited to placing the patient in a horizontal position, especially in conditions where this is difficult - in a crowd, in a telephone booth, etc. (even fatal cases from simple fainting have been described due to the inability of the patient to fall or assume a horizontal position). It is necessary to provide access to fresh air or take the patient out of a room with severely polluted air, maintaining a horizontal position; it is necessary to unbutton the patient's collar, belt or remove other obstacles that impede free breathing and blood circulation, and perform a light general massage of the body. Reflex action on the respiratory and cardiovascular regulation centers is also used: inhalation of ammonia vapors, splashing the face with cold water.

The lack of effect from the above measures requires a number of urgent measures. In case of a sharp drop in blood pressure, sympathicotonic agents are administered: 1% mesaton solution, 5% ephedrine solution. Indirect cardiac massage, administration of 0.1% atropine sulfate solution are used in case of a pronounced hyperparasympathetic component in the structure of fainting with a slowdown or even cardiac arrest. If we are talking about a disturbance of the heart rhythm in cardiogenic fainting (atrial fibrillation), antiarrhythmic agents are administered.

Treatment of patients with syncopal (fainting) states in the interictal period is a frequent and usual situation in neurological practice. Of paramount importance for the effectiveness of treatment is accurate diagnostics with the clarification of those specific pathogenetic mechanisms that underlie certain syncopes.

Therapy aimed at reducing the degree of neurovascular excitability and reactivity, increasing mental and vegetative stability, and increasing the overall tone of the body serves as an undifferentiated treatment for almost all neurogenic syncopal states. In this regard, correction of the psychovegetative syndrome of varying severity, which is obligatory for all types of fainting states, seems important and necessary. For simple (vasodepressor) fainting, such correction is essentially pathogenetic therapy.

The means used for the treatment of vegetative paroxysms are reflected in the corresponding section of the manual. Here we will only list them.

Correction of mental disorders is carried out by means of psychotherapy aimed at explaining to the patient the connection between his fainting spells and the presence of emotional and vegetative dysfunction; measures are also taken to solve psychological problems of the individual, reduce the level of anxiety, etc. Psychotropic therapy includes the prescription of drugs depending on the structure of the existing syndromes of mental (most often neurotic) disorders. Correction of anxiety disorders requires the prescription of tranquilizers - seduxen, relanium, phenazepam, elenium, grandaxin, etc. Antelepsin has proven itself especially well recently (1 mg 3-4 times a day for 1-1.5 months). Antidepressants (amitriptyline, pyrazidol, azafen, inkazan) are indicated in the presence of distinct and hidden depressive disorders in patients, most often combined with anxiety manifestations. In case of pronounced anxiety-hypochondriacal disorders, neuroleptics (sonapax, frenolon, eglonil) are prescribed. The doses of the indicated psychotropic drugs depend on the severity of affective disorders. The duration of administration is usually 2-3 months.

Of great importance is the correction of increased neuromuscular excitability (tetanic syndrome), which occurs in 80% of patients with various forms of syncopal conditions.

As general tonics, B vitamins, vascular drugs and nootropics are prescribed.

Vegetative correction is achieved in two ways.

The first is to perform special breathing exercises to increase vegetative stability. Such exercises are indicated not only for hyperventilation disorders, but also in all cases where vegetative dysfunction plays an important role in the genesis of syncopal states.

The second method of correcting vegetative disorders is the administration of vegetative drugs. Most often, these are drugs such as belloid (bellaspon, bellataminal), beta-blockers (anaprilin, obzidan) in small doses (10 mg 2-3 times a day) in the absence of pronounced vagal disorders, combined alpha- and beta-blockers (pyrroxan), etc. With a decrease in the activity of the sympathoadrenal system and the predominance of parasympathetic reactions, such drugs as sidnocarb, caffeine, ascorbic acid, belladonna preparations can be used. An important "regulator" of vegetative functions is a certain, adjusted lifestyle of the patient: a sufficient proportion of his physical activity is necessary (gymnastics, swimming and other hydrotherapy procedures, walks, running, skiing, etc.).

In addition to psychovegetative correction, the treatment of a number of background and accompanying syncope manifestations is of great importance: vestibular dysfunction, allergic disposition, cerebral vascular dysfunction, neuroendocrine (hypothalamic) disorders, residual neurological manifestations, spinal osteochondrosis, somatic and other diseases.

Therapy of syncopal states in patients with hyperventilation manifestations largely depends on identifying the leading pathogenetic link. Correction of hyperventilation disorders is discussed in detail in the relevant section.

Treatment of syncopal conditions in patients with hypersensitivity of the carotid sinus consists of prescribing cholinolytics and sympatholytics, conducting a sinus block with electrophoresis with novocaine, X-ray therapy, surgical measures (sinus deprivation, periarterial dissection, etc.). In the practice of cardiac surgery, with the cardiac form of carotid sinus syndrome, implantation of pacemakers is used in patients.

In the treatment of cough syncope, along with the treatment of the underlying somatic disease, it is of great importance to eliminate the causes that directly cause the cough (for example, smoking), prescribe antitussives, etc. Normalization of the patient's body weight plays a role if it is excessive.

Treatment of syncopal conditions that occur during swallowing consists of therapeutic measures aimed at eliminating esophageal pathology and prescribing atropine drugs. Prescribing vegetotropic agents is also indicated.

In case of nocturic syncope, it is necessary to identify the leading pathogenetic mechanism, taking into account their polyfactorial pathogenesis. In case of increased vagal tendencies, drugs that increase sympathetic tone are used.

Treatment of glossopharyngeal neuralgia combined with syncope consists of prescribing anticonvulsants (carbamazepine, pycnolepsin, suxilene, trimetin, sodium valproate and their combinations). In case of pharmacological resistance, surgical intervention is indicated - cutting the nerve in the neck or in the posterior cranial fossa.

In hypoglycemic syncopal states, treatment is aimed at the underlying disease that causes hypoglycemia. In the case of pronounced signs of psychovegetative syndrome, appropriate correction is carried out to reduce it.

Syncopal states of hysterical nature require clarification of the leading link of pathogenesis: is the disturbance of consciousness an expression of hysterical pseudosyncope or is it the result of complicated conversion. Clarification of this issue will allow for more targeted therapy, the structure of which, in addition to the necessary massive psychotherapy, should include respiratory regulation techniques, the prescription of psychotropic and vegetotropic drugs.

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