Sudden fall (with loss of consciousness and without it)

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

[1], [2], [3], [4], [5], [6], [7]

The main causes of a sudden fall (with loss of consciousness and without it):

1. Astatic epileptic seizure.
2. Vasovagal syncope.
3. Fainting with a cough, swallowing, nocturnal fainting.
4. Carotid sinus hypersensitivity syndrome.
5. Adams-Stokes Syndrome (atrioventricular block).
6. Drop-attack.
7. Cataplectic attack.
8. Psychogenic fit (pseudo-syncope).
9. Basilar migraine.
10. Parkinsonism.
11. Progressive supranuclear palsy.
12. Shay-Draeger Syndrome.
13. Normotensive hydrocephalus.
14. Idiopathic senile dysbasia.

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

Astatic epileptic fit

The age of the debut of astatic epipripeds is early childhood (from 2 to 4 years). A separate attack lasts only a few seconds. The child falls vertically, does not lose consciousness and is able to immediately rise to his feet. Attacks are grouped in a series, separated by light intervals of about an hour. Due to a large number of seizures, the child receives many bruises; some protect the head, wrapping it with a thick layer of tissue. 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 occurs for the first time in adolescence or adulthood, but the disease can persist for many years after this age period. At the initial stage, situations that provoke fainting and are the cause of orthostatic hypotension with sympathetic insufficiency and the predominance of parasympathetic innervation of the cardiovascular system are fairly easy to identify. Fainting occurs, for example, after a jump with a hard landing on the heels or with forced long, motionless standing in one place. Emotional tension predisposes to fainting. Over time, to provoke fainting, even minimal stress becomes sufficient, and psychological factors already come to the fore in the provocation of attacks.

Separate seizures gradually lose their characteristic features (darkening or blurred vision, dizziness, cold sweat, slow slipping to the ground). In severe fainting, the patient can suddenly fall, and at this moment it is possible to involuntarily urinate, get bruises, bite the tongue and lose consciousness for a long time - up to one hour. In such situations, it is not easy to clinically differentiate simple syncope and epileptic seizure if the physician was unable to personally observe the attack and see blanching rather than flushing of the face, closed eyes, not open, narrow rather than wide pupils that do not respond to light. With fainting, short-term tonic stretching of limbs is possible, even short-term clonic twitching of the limbs is possible, which is explained by the rapidly oncoming transient hypoxia of the brain, leading to simultaneous discharges of large populations of neurons.

If there is an opportunity to conduct an EEG study, then one can see normal results. EEG also remains normal after sleep deprivation and with prolonged monitoring.

Cough fainting, fainting on swallowing, nocturnal fainting

There are several specific situations that provoke fainting. It is coughing, swallowing and nighttime urination; each of these actions predisposes to a rapid transition to a state in which the tone of the parasympathetic autonomic nervous system predominates. It is noteworthy that in a particular patient, syncope never occurs in circumstances different from the characteristic provoking situations for this patient. Psychogenic factors are almost never detected.

Carotid sinus hypersensitivity syndrome

With carotid sinus hypersensitivity syndrome, there is also a relative lack of sympathetic effects on the heart and blood vessels. The general realizing mechanism is the same as with 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 tilting the head back (especially - when wearing a too tight collar), pressure on the sinus area. In these conditions, the carotid sinus has an external mechanical pressure, which, with a changed sensitivity of the receptors, provokes a drop in blood pressure and fainting. Attacks occur mainly in the elderly, who are showing signs of atherosclerosis.

The diagnosis is confirmed by pressing the carotid sinus during the recording of the electrocardiogram and the electrocephalogram. The sample should be performed with extreme caution in connection with the risk of developing a prolonged asystole. Moreover, by ultrasonic dopplerography it is necessary to make sure that the carotid artery is passable at the site of compression, otherwise there is a risk of tearing off the embolus from the local plaque or the risk of provoking an acute occlusion of the carotid artery in its subtotal stenosis, which in 50% of cases is accompanied by thromboembolism of the middle cerebral artery.

Adams-Stokes Syndrome

With Adams-Stokes syndrome, syncope develops as a result of a paroxysmal asystole lasting more than 10 seconds or, in very rare cases, with a paroxysmal tachycardia with a heart rate of more than 180-200 beats per minute. With extreme severity 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 the cardiac nature of syncope in the absence of abnormalities in the EEG. It is important to study the pulse during an attack, which often determines the diagnosis.

Drop-attack

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

The patient, who generally feels healthy, suddenly falls to the floor, landing on his knees. Situational conditioning (for example, the presentation of an unusually high load on the cardiovascular system) is not present. Patients, as a rule, do not lose consciousness and are able to immediately get up. They do not experience pre-patchy sensations (lightheadedness) or changes in the heartbeat. Patients describe the attack in the following way: "... As if suddenly the legs buckled." Frequent injuries of the knees and, sometimes, - the face.

Ultrasonic dopplerography of vertebral arteries rarely reveals significant abnormalities, such as the subclavian artery stasis syndrome or stenosis of both vertebral arteries. All other additional studies of pathology do not reveal. Droop attacks should be considered as an option for transient ischemic attacks in the vertebral-basilar vascular basin.

Differential diagnosis of drop-attacks is carried out primarily with epileptic seizure and cardiogenic syncope.

Ischemia in the region of the anterior cerebral artery can also lead to a similar syndrome with the fall of the patient. Drop-attacks are described in addition for tumors of the third ventricle and posterior cranial fossa (and other volumetric processes) and malformations of Arnold-Chiari.

Cataplectic attack

Cataplectic seizures are one of the rarest causes of a sudden fall. They are characteristic of narcolepsy and, therefore, are observed against the background of an unfolded or incomplete picture of narcolepsy.

Psychogenic fit (pseudo-syncope)

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

Basilar migraine

With migraine, in particular - with basilar migraine, sudden drop is one of the very rare symptoms; moreover, such falls do not occur in every migraine attack. As a rule, the patient pales, falls and for a few seconds loses consciousness. If these manifestations 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, the fall occurs when the unprepared movement begins. In idiopathic parkinsonism, gross postural disturbances and falls are not the first symptom of the disease and join in subsequent stages of its course, which facilitates the search for possible causes of the fall. A similar mechanism of falls is characteristic for progressive supranuclear palsy, Shay-Dryger syndrome and normotensive hydrocephalus (axial apraxia).

Certain postural changes are also characteristic for physiological aging (the slow, uncertain walk of the elderly). Minimal provoking factors (soil unevenness, sharp turns of the trunk, etc.) can easily provoke a fall (idiopathic senile dysbasia).

Such rare variants of dysbasia as idiopathic apraxia of walking and primary progressive walking with "freezing" ("freezing") can also cause spontaneous falls during walking.

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