Sudden fall (with or without loss of consciousness)

A sudden fall as an isolated symptom is rarely observed. As a rule, falls are repeated, and by the time of the medical examination the patient can quite clearly describe various circumstances or situations in which the attack developed, or - such information is provided by his relatives. Diagnosis is largely based on a thorough collection of anamnesis.

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The main reasons for a sudden fall (with or without loss of consciousness):

1. Astatic epileptic seizure.
2. Vasovagal syncope.
3. Fainting when coughing, when swallowing, nocturic nocturnal fainting.
4. Carotid sinus hypersensitivity syndrome.
5. Adams-Stokes syndrome (atrioventricular block).
6. Drop attack.
7. Cataplectic attack.
8. Psychogenic seizure (pseudosyncope).
9. Basilar migraine.
10. Parkinsonism.
11. Progressive supranuclear palsy.
12. Shy-Drager syndrome.
13. Normal pressure hydrocephalus.
14. Idiopathic senile dysbasia.

Falls are also promoted by (risk factors): paresis (myopathy, polyneuropathy, some neuropathies, myelopathy), vestibular disorders, ataxia, dementia, depression, visual impairment, orthopedic diseases, severe somatic diseases, old age.

Astatic epileptic seizure

The age of onset of astatic epileptic seizures is early childhood (2 to 4 years). A single seizure lasts only a few seconds. The child falls vertically, does not lose consciousness and is able to immediately rise to his feet. The seizures are grouped into series, separated by light intervals lasting about an hour. Due to the large number of seizures, the child receives many bruises; some protect their head by wrapping it with a thick layer of cloth. There is a delay in mental development, various behavioral deviations are possible.

Diagnosis: pathological changes are always detected on the EEG in the form of irregular high-amplitude slow-wave activity with the presence of sharp waves.

Vasovagal syncope

Fainting usually first occurs in adolescence or young adulthood, but the disease may persist for many years after this age period. At the initial stage, situations that provoke fainting and cause orthostatic hypotension with sympathetic insufficiency and parasympathetic predominance of the cardiovascular system are quite easy to identify. Fainting occurs, for example, after a jump with a hard landing on the heels or when forced to stand motionless in one place for a long time. Emotional stress predisposes to the development of fainting. Over time, even minimal stress becomes sufficient to provoke fainting, and psychological factors come to the forefront in provoking attacks.

Individual attacks gradually lose their characteristic features (darkening or veil before the eyes, dizziness, cold sweat, slow sliding to the ground). In severe fainting, the patient may fall suddenly, and at this moment involuntary urination, bruises, tongue biting and loss of consciousness for a fairly long time - up to one hour - are possible. In such situations, clinically differentiating between simple fainting and an epileptic seizure may be difficult if the doctor has not had the opportunity to personally observe the attack and see pallor rather than hyperemia of the face, closed rather than open eyes, narrow rather than wide pupils that do not react to light. In fainting, short-term tonic extension of the limbs is possible, even short-term clonic twitching of the limbs is possible, which is explained by the rapidly developing transient hypoxia of the brain, leading to simultaneous discharges of large populations of neurons.

If it is possible to conduct an EEG study, then normal results can be seen. EEG also remains normal after sleep deprivation and with long-term monitoring.

Cough syncope, swallowing syncope, nocturic syncope

There are several specific situations that provoke syncope. These are coughing, swallowing, and nocturnal urination; each of these actions predisposes to a rapid transition to a state in which the tone of the parasympathetic vegetative nervous system predominates. It is noteworthy that in a given patient, syncope never occurs under circumstances other than the characteristic provoking situations for this particular patient. Psychogenic factors are almost never identified.

Carotid sinus hypersensitivity syndrome

In carotid sinus hypersensitivity syndrome, there is also a relative insufficiency of sympathetic influences on the heart and blood vessels. The general implementing mechanism is the same as in fainting, namely, hypoxia of the cortex and brainstem, leading to a drop in muscle tone, sometimes to fainting, and, rarely, to several short convulsive twitches. Attacks are provoked by turning the head to the side or throwing the head back (especially when wearing a too-tight collar), pressure on the sinus area. Under these conditions, external mechanical pressure is exerted on the carotid sinus, which, with altered receptor sensitivity, provokes a drop in blood pressure and fainting. Attacks occur mainly in elderly people who show signs of atherosclerosis.

The diagnosis is confirmed by pressing on the carotid sinus during recording of the electrocardiogram and electroecephalogram. The test should be carried out with extreme caution due to the risk of developing prolonged asystole. Moreover, it is necessary to use ultrasound Dopplerography to ensure the patency of the carotid artery at the site of compression, otherwise there is a risk of embolus detachment from the local plaque or a risk of provoking acute occlusion of the carotid artery with its subtotal stenosis, which in 50% of cases is accompanied by thromboembolism of the middle cerebral artery.

Adams-Stokes syndrome

In Adams-Stokes syndrome, syncope develops as a result of paroxysmal asystole lasting more than 10 seconds or, in very rare cases, paroxysmal tachycardia with a heart rate of more than 180-200 beats per minute. In extreme cases of tachycardia, cardiac output decreases so much that cerebral hypoxia develops. The diagnosis is made by a cardiologist. A general practitioner or neurologist should suspect a cardiac origin of syncope in the absence of abnormalities on the EEG. It is important to examine the pulse during the attack, which often determines the diagnosis.

Drop attack

Some authors describe drop attacks as one of the symptoms of vertebrobasilar insufficiency. Others believe that there is still no satisfactory understanding of the pathophysiological mechanisms of drop attacks, and they are probably right. Drop attacks are observed mainly in middle-aged women and reflect an acute failure of postural regulation at the level of the brainstem.

A patient who generally considers himself healthy suddenly falls to the floor, landing on his knees. There is no situational causation (e.g., an unusually high load on the cardiovascular system). Patients usually do not lose consciousness and are able to stand up immediately. They do not experience pre-fainting sensations (fainting) or changes in heart rate. Patients describe the attack as follows: "...as if my legs suddenly gave way." Knee injuries are common, and sometimes injuries to the face.

Ultrasound Dopplerography of the vertebral arteries rarely reveals significant abnormalities such as subclavian artery steal syndrome or stenosis of both vertebral arteries. All other additional studies do not reveal pathology. Drop attacks should be considered as a variant of transient ischemic attacks in the vertebrobasilar vascular basin.

The differential diagnosis of drop attacks is carried out primarily with epileptic seizures and cardiogenic syncope.

Ischemia in the anterior cerebral artery can also lead to a similar syndrome with the patient falling. Drop attacks have also been described in tumors of the third ventricle and posterior cranial fossa (and other space-occupying processes) and Arnold-Chiari malformation.

Cataplectic attack

Cataplectic seizures are one of the rarest causes of sudden falls. They are characteristic of narcolepsy and, therefore, are observed against the background of a full-blown or incomplete picture of narcolepsy.

Psychogenic seizure (pseudosyncope)

It should always be remembered that with certain personality traits, when there is a tendency to express themselves in the form of "conversion symptoms", a predisposition to fainting in the past can become a good basis for psychogenic seizures, because a sudden fall outwardly gives the impression of a very serious symptom. The fall itself looks like an arbitrary "throw" to the floor; the patient "lands" on his hands. When trying to open the patient's eyes, the doctor feels active resistance from the patient's eyelids. For some such patients (not only young ones), the help of a qualified psychiatrist is no less important than the help of a cardiologist to make a diagnosis.

Basilar migraine

In migraine, particularly in basilar migraine, a sudden fall is one of the very rare symptoms; moreover, such falls do not occur in every migraine attack. As a rule, the patient turns pale, falls, and loses consciousness for a few seconds. If these symptoms occur only in connection with migraine, there is nothing threatening in them.

Parkinsonism

Spontaneous falls in Parkinsonism are caused by postural disorders and axial apraxia. These falls are not accompanied by loss of consciousness. Often, a fall occurs at the moment of the beginning of an unprepared movement. In idiopathic Parkinsonism, gross postural disorders and falls are not the first symptom of the disease and join in at subsequent stages of its course, which facilitates the search for possible causes of the fall. A similar mechanism of falls is characteristic of progressive supranuclear palsy, Shy-Drager syndrome and normotensive hydrocephalus (axial apraxia).

Certain postural changes are also characteristic of physiological aging (slow, unsteady gait in the elderly). Minimal provoking factors (uneven ground, sharp turns of the body, etc.) can easily provoke a fall (idiopathic senile dysbasia).

Rare variants of dysbasia such as idiopathic apraxia of gait and primary progressive gait with “freezing” can also cause spontaneous falls while walking.

Also described are “cryptogenic falls in middle-aged women” (over 40 years old), in which the above-mentioned causes of falls are absent, and the neurological status does not reveal any pathology.