DOCSLIB.ORG

Syncope Classification

Total Page：16

File Type：pdf, Size：1020Kb

Download full-text PDF Read full-text
Syncope Classification PROGRESS IN CARDIOVASCULAR DISEASES 55 (2013) 345– 356 Available online at www.sciencedirect.com www.onlinepcd.com Pathophysiological Basis of Syncope and Neurological Conditions that Mimic Syncope J. Gert van Dijka,⁎, Wouter Wielingb aDepartment of Neurology, Leiden University Medical Center, Leiden, The Netherlands bDepartment of Internal Medicine, Academic Medical Center, University of Amsterdam, The Netherlands ARTICLE INFO ABSTRACT Keywords: The definition of syncope has clinical and pathophysiological parts. The clinical part is that Syncope syncope is a form of transient loss of consciousness (TLOC), while the pathophysiological Transient loss of consciousness element is that syncope differs from other forms of TLOC by virtue of the basis of true Pathophysiology syncope – specifically cerebral hypoperfusion. As such, the signs and symptoms of syncope Hypoperfusion rely on three steps, starting with the cause of syncope and including the response of the systemic circulation and neurological effects. The causes of syncope all result in low blood pressure through low peripheral resistance and/or low cardiac output. The next step is the cerebral circulation, which is a large-volume and low-resistance system, characterized by relatively high diastolic flow. The cerebral circulation is usually protected against swings in arterial pressure by cerebral autoregulation, but in abrupt syncope, autoregulation acts too slowly to have much effect. In syncope, diastolic flow velocity is more impaired than systolic flow velocity, probably because closing vascular forces then opposes flow. The third step concerns neurological signs and symptoms; the cerebral cortex first responds by disruption of normal activity, followed by a complete cessation of activity when hypoperfusion deepens. The latter is likely when there is asystole or marked bradycardia. The neurological signs and symptoms suggest different principles: a loss of normal cortical activity, abnormal cortical activity and activity due to disinhibition of brainstem activity. © 2013 Elsevier Inc. All rights reserved. The importance of pathophysiology in understanding synco- Consequently, while it may seem counterproductive to use a pe is emphasized by its inclusion in the definition as the one pathophysiological criterion to define a clinical entity, it is item that sets syncope apart from all other forms of transient essential to do so in this case for at least two reasons. The first loss of consciousness (TLOC). In essence, syncope is TLOC due is that there is no practical way to define clinical criteria that to transient global cerebral hypoperfusion, characterized by encompass all expressions of syncope and also exclude rapid onset, short duration and spontaneous complete epileptic seizures and psychogenic TLOC. For example, the 1 recovery (Fig 1). following items can be present or absent in syncope: pallor, Except for cerebral hypoperfusion, the clinical features nausea, opening of the eyes, incontinence and myoclonic associated with syncope are shared by all three major TLOC jerks. The second is that without a criterion specific to groups: syncope, epileptic seizures and psychogenic TLOC. syncope it becomes impossible to distinguish it from other Statement of Conflict of Interest: see page 354. ⁎ Address reprint requests to J. Gert van Dijk, MD, PhD, Professor of Clinical Neurophysiology, Department of Neurology, Leiden University Medical Center, PO Box 9600, 2300 RC Leiden, The Netherlands. E-mail address: [email protected] (J.G. van Dijk). 0033-0620/$ – see front matter © 2013 Elsevier Inc. All rights reserved. http://dx.doi.org/10.1016/j.pcad.2012.10.016 346 PROGRESS IN CARDIOVASCULAR DISEASES 55 (2013) 345– 356 Abbreviations and Acronyms forms of TLOC and briefly touches upon the pathophysiology of epileptic sei- thereby develop ap- zures and psychogenic TLOC. CBF = cerebral blood flow propriate treatment EEG = electroencephalogram options.2 Pathophysiological Key factors in cerebral perfusion ESC = European Society of knowledge helps cli- Cardiology nicians understand The human brain is an expensive organ; even at rest it requires 15 MAP = mean arterial pressure the nature of signs to 20% of cardiac output, although at 1400 grams it constitutes and symptoms in syn- only about 2% of an adult's mass.3 In children of around two years PNES = psychogenic non- 4 epileptic seizures cope, which in turn of age, no less than 50% of cardiac output subserves the brain. It is helps them infer the also a ‘spoiled’ organ with an extremely small metabolic reserve PPS = psychogenic cause of a particular capacity. In fact, loss of consciousness starts only about eight pseudosyncope spell. For instance, seconds after the heart stops.5 The arterial system still pumps SFS = slow-flat-slow syncope beginning some blood through the body after the heart has stopped, so this while supine suggests short period does not reflect the pure metabolic reserve of the TCD = trans-cranial Doppler that gravity does not brain. Early experiments abolished that arterial pump effect by ultrasound play a role. Inasmuch occluding all neck arteries instantly with a cuff around the neck. TLOC = transient loss of as a prime task of Unconsciousness then started six to seven seconds after cuff 6 consciousness blood pressure regula- inflation. This latter finding vividly illustrates how little reserve tion is countering the capacity the brain has, and also suggests that the arterial pump TSLB = time since last beat effects of gravity in does not appreciably prevent loss of consciousness after cardiac the upright position, standstill. In the end, apart from cardiac output, cerebral perfusion supine syncope is not likely to be due to a primary failure of depends on the baroreflex system to maintain systemic blood blood pressure regulation. Instead, a low cardiac output, for pressure, and cerebral autoregulation maintains cerebral blood instance as a result of arrhythmia, is much more likely to be flow in the face of changes in arterial pressure. the basis for supine syncope, as it causes the circulation to come to a halt regardless of body position. The baroreflex system This paper focuses on the pathophysiology of the systemic and cerebral circulation and the neurological The baroreflex sensors are located in the carotid sinus and in consequences of cerebral hypoperfusion in syncope, and the aorta; those in the carotid sinus are located where the Fig 1 – Forms of transient loss of consciousness (TLOC). Traumatic TLOC concerns concussions that usually do not pose diagnostic confusion. The three major groups that do cause confusion are syncope, epileptic seizures and psychogenic TLOC. The ‘rare and mimics’ group is not discussed in this paper. For further discussion, see Refs. 1 and.24 PROGRESS IN CARDIOVASCULAR DISEASES 55 (2013) 345– 356 347 common carotid artery splits into the internal and external but this simplification ignores several factors that can play a role carotid arteries. As the arterial system has no valves, in syncope (Fig 2). A more detailed view holds that cerebral blood hydrostatic factors affect actual blood pressure depending flow (CBF) firstly depends on a pressure difference between on the height of the artery in question. In the upright position, arterial pressure and venous pressures; without that, there is no a distance of 30 cm between the aorta and the brain at eye flow. The second consideration is whether blood vessels are level means that arterial pressure at eye level is 22 mmHg less closed by forces opposing the pressure in their lumen that keeps than at the level of the heart and upper arm where blood them open: the closing forces are vessel wall tension and tissue pressure is conventionally measured. In the supine position pressure.3,10 All elements in this equation can affect the result. the upper arm, heart and brain are at the same height. If blood Tissue pressure, which for the brain means intracranial pres- pressure at the heart stays the same, lying down will sure, is normally very low. The exception occurs when the therefore increase arterial pressure at brain level by about volume of the content of the skull increases, through brain 22 mmHg. This simple effect partly explains the beneficial swelling or bleeding. As the rigid skull prohibits any significant effects of lying down when blood pressure is low; another changes of the volume of its contents, intracranial pressure will effect is that the change in posture often allows blood increase quickly. This increase of pressure diminishes cerebral pressure at heart level to increase. blood flow. When pressure rises sufficiently high that it exceeds The baroreflex arc involves afferent fibers running from the the arterial pressure, cerebral blood flow stops entirely. This carotid sinus baroreceptors through the glossopharyngeal nerve, latter termination of flow is the major mechanism in brain and from the aortic arch through the vagal nerve, to the nucleus death. A temporary increase in intracanial pressure probably tractus solitarii in the medulla oblongata, where integration with also explains the temporary self-limiting loss of consciousness other incoming inputs takes place. The efferent signals course that can occur in subarachnoid hemorrhage (luckily, other through sympathetic nerves running to peripheral blood vessels features in its presentation make diagnostic confusion with and to the heart, and parasympathetic (vagal) nerve branches to syncope very unlikely). the heart. The fibers to the heart control heart
Load more

Recommended publications
  • Forensic Medicine
    YEREVAN STATE MEDICAL UNIVERSITY AFTER M. HERATSI DEPARTMENT OF Sh. Vardanyan K. Avagyan S. Hakobyan FORENSIC MEDICINE Handout for foreign students YEREVAN 2007 This handbook is adopted by the Methodical Council of Foreign Students of the University DEATH AND ITS CAUSES Thanatology deals with death in all its aspects. Death is of two types: (1) somatic, systemic or clinical, and (2) molecular or cellular. Somatic Death: It is the complete and irreversible stoppage of the circulation, respiration and brain functions, but there is no legal definition of death. THE MOMENT OF DEATH: Historically (medically and legally), the concept of death was that of "heart and respiration death", i.e. stoppage of spontaneous heart and breathing functions. Heart-lung bypass machines, mechanical respirators, and other devices, however have changed this medically in favor of a new concept "brain death", that is, irreversible loss of Cerebral function. Brain death is of three types: (1) Cortical or cerebral death with an intact brain stem. This produces a vegetative state in which respiration continues, but there is total loss of power of perception by the senses. This state of deep coma can be produced by cerebral hypoxia, toxic conditions or widespread brain injury. (2) Brain stem death, where the cerebrum may be intact, though cut off functionally by the stem lesion. The loss of the vital centers that control respiration, and of the ascending reticular activating system that sustains consciousness, cause the victim to be irreversibly comatose and incapable of spontaneous breathing. This can be produced by raised intracranial pressure, cerebral oedema, intracranial haemorrhage, etc.(3) Whole brain death (combination of 1 and 2).
    [Show full text]
  • IAEM Syncope
    IAEM Clinical Guideline Management of syncope in the emergency department Version 1 April, 2019 Authors: Dr Áine Mitchell, in collaboration with Dr Rosa McNamara, Professor Rose Anne Kenny and the IAEM Guideline Development Committee. DISCLAIMER IAEM recognises that patients, their situations, Emergency Departments and staff all vary. These guidelines cannot cover all clinical scenarios. The ultimate responsibility for the interpretation and application of these guidelines, the use of current information and a patient's overall care and wellbeing resides with the treating clinician. GLOSSARY OF TERMS AAA: Abdominal aortic aneurysm AFib: Atrial fibrillation ARVC: Arrythmogenic right ventricular cardiomyopathy AV: Atrioventricular βHCG: Beta human chorionic gonadotropin BP: Blood pressure BSL: Blood sugar level CCF: Congestive cardiac failure CM: Cardiomyopathy ECG: Electrocardiogram ED: Emergency Department EF: Ejection fraction ESC: European Society of Cardiology FHx: Family history GI: Gastrointestinal GP: General practitioner HCT: Haematocrit HOCM: Hypertrophic obstructive cardiomyopathy Hx: History IAEM: Irish Association for Emergency Medicine ICD: Implanted cardioverter defibrillator IHD: Ischaemic heart disease MI: Myocardial Infarction OPD: Out-patient department PCM: Physical counter-pressure manoeuvres PE: Pulmonary embolus PMHx: Past Medical History PPM: Permanent pacemaker RSA: Road safety authority SAH: Sub-arachnoid haemorrhage SBP: Systolic blood pressure SCD: Sudden cardiac death SVT: Supra-ventricular tachycardia TIA: Transient ischaemic attack T-LOC: Transient loss of consciousness VT: Ventricular tachycardia WPW: Wolff-Parkinson-White 2 IAEM CG: Management of syncope in the emergency department Version 1 April 2019 INTRODUCTION Syncope is defined as a transient loss of consciousness (T-LOC) due to cerebral hypoperfusion. It is characterised by a rapid onset, short duration and spontaneous complete recovery.
    [Show full text]
  • Coma Stimulation: Suggested Activities
    Coma stimulation: suggested activities Headway’s publications are all available to freely download from the information library on the charity’s website, while individuals and families can request hard copies of the booklets via the helpline. As a charity, we rely on donations from people like you to continue providing free information to people affected by brain injury. Donate today: www.headway.org.uk/donate. Introduction It is quite common for family members to feel ‘useless’ when a relative is in a coma, and to be desperate to do something to help. A coma stimulation programme (sometimes called a coma arousal programme) is an approach based on stimulating the unconscious person’s senses of hearing, touch, smell, taste and vision individually in order to help their recovery. There is still controversy over how effective it is to try to stimulate a person in coma. However, most would say that such programmes have some beneficial effect, even if only to provide something constructive for the family to do. It is very important that the activities used would have been enjoyable for the patient before the injury. For example, only play music they like and talk to them about subjects they are interested in. Try not to do anything for too long in order to avoid tiring the person out. A stimulation programme must only be started after discussion with the clinical staff, who will advise you what might be appropriate at any particular stage in the recovery process. Activity suggestions Here are some examples of activities that could form part of a coma stimulation programme: • Make sure that a few friends and family members visit regularly, rather than in large groups at a time.
    [Show full text]
  • Single Family Residence Design Guidelines
    ADOPTED BY SANTA BARBARA CITY COUNCIL IN 2007 Available at the Community Development Department, 630 Garden Street, Santa Barbara, California, (805) 564-5470 or www.SantaBarbaraCA.gov 2007 CITY COUNCIL, 2007 ARCHITECTURAL BOARD OF REVIEW, 2007 Marty Blum, Mayor Iya Falcone Mark Wienke Randall Mudge Brian Barnwell Grant House Chris Manson-Hing Dawn Sherry Das Williams Roger Horton Jim Blakeley Clay Aurell Helene Schneider Gary Mosel SINGLE FAMILY DESIGN BOARD, 2010 UPDATE PLANNING COMMISSION, 2007 Paul R. Zink Berni Bernstein Charmaine Jacobs Bruce Bartlett Glen Deisler Erin Carroll George C. Myers Addison Thompson William Mahan Denise Woolery John C. Jostes Harwood A. White, Jr. Gary Mosel Stella Larson PROJECT STAFF STEERING COMMITTEE Paul Casey, Community Development Director Allied Neighborhood Association: Bettie Weiss, City Planner Dianne Channing, Chair & Joe Guzzardi Jaime Limón, Design Review Supervising Planner City Council: Helene Schneider & Brian Barnwell Heather Baker, Project Planner Planning Commission: Charmaine Jacobs & Bill Mahan Jason Smart, Planning Technician Architectural Board of Review: Richard Six & Bruce Bartlett Tony Boughman, Planning Technician (2009 Update) Historic Landmarks Commission: Vadim Hsu GRAPHIC DESIGN, PHOTOS & ILLUSTRATIONS HISTORIC LANDMARKS COMMISSION, 2007 Alison Grube & Erin Dixon, Graphic Design William R. La Voie Susette Naylor Paul Poirier & Michael David Architects, Illustrations Louise Boucher H. Alexander Pujo Bill Mahan, Illustrations Steve Hausz Robert Adams Linda Jaquez & Kodiak Greenwood,
    [Show full text]
  • Evaluation and Management in an Urgent Care Setting
    Syncope Evaluation and Management in an Urgent Care Setting Urgent message: When a patient presents to urgent care after a syncopal event, the clinician’s charge is to determine whether the episode was of benign or potentially life-threatening etiology and whether the patient should be transferred for further evaluation. Kenneth V. Iserson, MD, MBA, FACEP, FAAEM, Professor of Emergency Medicine, The University of Arizona, Tucson, AZ Introduction yncope is a sudden, transient loss of consciousness with a loss of postural tone (typically, falling). It results from an abrupt, transient, and diffuse cerebral Smalfunction and is quickly followed by sponta- neous recovery. The term syncope excludes seizures, coma, shock, or other states of altered consciousness. Many patients will ascribe their syncopal episode to a sit- uationally mediated vasovagal episode. Despite this, the goals in the urgent care setting include the following: Ⅲ Determining whether the patient’s episode was actually a syncopal or presyncopal event, and if it could have a life-threatening etiology Ⅲ Stabilizing the patient Ⅲ Transferring those patients who need further diag- nostic studies or therapeutic interventions © John Bolesky, Artville © John Bolesky, Epidemiology Syncope accounts for up to 3% of emergency depart- common in young adults, while cardiac syncope ment (ED) visits and up to 6% of hospital admissions becomes increasingly more frequent with advancing each year in the United States.1,2 At some time in their age.4 The chance of having at least one syncopal episode lives, up to about half the population (12% to 48%) of in childhood is between 15% and 50%.5 Though a people may experience syncope.3 benign cause is usually found, syncope in children war- Syncope occurs in all age groups, but it is most com- rants prompt detailed evaluation.6 mon in adults.
    [Show full text]
  • Acute Stress Disorder
    Trauma and Stress-Related Disorders: Developments for ICD-11 Andreas Maercker, MD PhD Professor of Psychopathology, University of Zurich and materials prepared and provided by Geoffrey Reed, PhD, WHO Department of Mental Health and Substance Abuse Connuing Medical Educaon Commercial Disclosure Requirement • I, Andreas Maercker, have the following commercial relaonships to disclose: – Aardorf Private Psychiatric Hospital, Switzerland, advisory board – Springer, book royales Members of the Working Group • Christopher Brewin (UK) Organizational representatives • Richard Bryant (AU) • Mark van Ommeren (WHO) • Marylene Cloitre (US) • Augusto E. Llosa (Médecins Sans Frontières) • Asma Humayun (PA) • Renato Olivero Souza (ICRC) • Lynne Myfanwy Jones (UK/KE) • Inka Weissbecker (Intern. Medical Corps) • Ashraf Kagee (ZA) • Andreas Maercker (chair) (CH) • Cecile Rousseau (CA) WHO scientists and consultant • Dayanandan Somasundaram (LK) • Geoffrey Reed • Yuriko Suzuki (JP) • Mark van Ommeren • Simon Wessely (UK) • Michael B. First WHO Constuencies 1. Member Countries – Required to report health stascs to WHO according to ICD – ICD categories used as basis for eligibility and payment of health care, social, and disability benefits and services 2. Health Workers – Mulple mental health professions – ICD must be useful for front-line providers of care in idenfying and treang mental disorders 3. Service Users – ‘Nothing about us without us!’ – Must provide opportunies for substanve, early, and connuing input ICD Revision Orienting Principles 1. Highest goal is to help WHO member countries reduce disease burden of mental and behavioural disorders: relevance of ICD to public health 2. Focus on clinical utility: facilitate identification and treatment by global front-line health workers 3. Must be undertaken in collaboration with stakeholders: countries, health professionals, service users/consumers and families 4.
    [Show full text]
  • Best Practices Single-Family Residences
    SITE PLANNING best practices single-family residences for aesthetic review by the city of coral gables board of architects 2018 1 SINGLE-FAMILY RESIDENCE BEST PRACTICES July 2018 table of contents 1. Purpose & Uses 2. Site Planning 3. Architecture 4. Checklist Purpose & Uses The purpose of the City of Coral Gables, Florida Zoning Code is to implement the Comprehensive Plan (CP) of the City pursuant to Chapter 163, Florida Statutes for the protection and promotion of the safety, health, comfort, morals, convenience, peace, prosperity, appearance and general welfare of the City and its inhabitants. ~ Zoning Code Section 1-103 Purpose of the City of Coral Gables Zoning Code PURPOSE & USE Single-Family Residential (SFR) District The Single-Family Residential (SFR) District is intended to accommodate low density, single-family dwelling units with adequate yards and open space that characterize the residential neighborhoods of the city. The city is unique not only in South Florida but in the country for its historic and archi- tectural treasures, its leafy canopy, and its well-defined and livable neighborhoods. These residential areas, with tree-lined streets and architecture of harmonious proportion and human scale, provide an oasis of charm and tranquility in the midst of an increasingly built-up metropolitan environment. The intent of the Single-Family Residential code is to protect the distinctive character of the city, while encouraging excellent architectural design that is responsible and responsive to the individual context of the city’s diverse neighborhoods. The single-family regulations, as well as the design and performance standards in the Zoning Code, seek to ensure that the renovation of residences as well as the building of residences is in accord with the civic pride and sense of stewardship felt by the citizens of Coral Gables.
    [Show full text]
  • ICD-11 Diagnostic Guidelines Stress Disorders 2020 07 21
    Pre-Publication Draft; not for citation or distribution 1 ICD-11 DIAGNOSTIC GUIDELINES Disorders Specifically Associated with Stress Note: This document contains a pre-publication version of the ICD-11 diagnostic guidelines for Disorders Specifically Associated with Stress. There may be further edits to these guidelines prior to their publication. Table of Contents DISORDERS SPECIFICALLY ASSOCIATED WITH STRESS ...................................... 2 6B40 Post-Traumatic Stress Disorder ............................................................................ 3 6B41 Complex Post-Traumatic Stress Disorder ............................................................. 8 6B42 Prolonged Grief Disorder .................................................................................... 12 6B43 Adjustment Disorder ........................................................................................... 15 6B44 Reactive Attachment Disorder ............................................................................ 17 6B45 Disinhibited Social Engagement Disorder .......................................................... 20 6B4Y Other Specified Disorders Specifically Associated with Stress ......................... 22 QE84 Acute Stress Reaction ......................................................................................... 23 © WHO Department of Mental Health and Substance Abuse 2020 Pre-Publication Draft; not for citation or distribution 2 DISORDERS SPECIFICALLY ASSOCIATED WITH STRESS Disorders Specifically Associated with Stress
    [Show full text]
  • Neurocardiogenic Syncope and Associated Conditions: Insight Into Autonomic Nervous System Dysfunction
    Türk Kardiyol Dern Arş - Arch Turk Soc Cardiol 2013;41(1):75-83 doi: 10.5543/tkda.2013.44420 75 Neurocardiogenic syncope and associated conditions: insight into autonomic nervous system dysfunction Nörokardiyojenik senkop ve ilişkili durumlar: Otonomik sinir sistemi işlev bozukluğuna bir bakış Antoine Kossaify, M.D., Kamal Kallab, M.D. Department of Syncope and Electrophysiology, ND Secours/USEK University Hospital, Byblos, Lebanon Summary– Neurocardiogenic syncope is known to be asso- Özet– Nörokardiyojenik senkopun mekanizması hala tam ola- ciated with autonomic nervous system dysfunction, although rak aydınlatılamamasına ragmen otonom sinir sistemi işlev the mechanism has not been entirely elucidated. In this study, bozukluğu ile ilişkili olduğu bilinmektedir. Bu yazıda nörokardi- we sought to highlight the pathogenic role of the autonomic yojenik senkop patogenezinde otonom sinir sisteminin rolünü nervous system in neurocardiogenic syncope and to review destekleyen en göze çarpıcı konuları araştırırken, temelinde the associated co-morbidities known to have a dysautonomic otonom sinir sistemi bozukluğunun olduğu bilinen komorbid basis. Herein we discuss migraine, orthostatic hypotension, durumları da gözden geçidik. Bu amaçla otonom sinir siste- postural orthostatic tachycardia syndrome, endothelial dys- minin patogenezdeki rolü ve klinik çıkarımları üzerine odak- function, chronic fatigue syndrome, and carotid sinus hyper- lanarak migren, ortostatik hipotansiyon, postüral ortostatik sensitivity with a focus on the pathogenic role of the autonom- taşikardi sendromu, endotel işlev bozukluğu, kronik yorgunluk ic nervous system and any consecutive clinical implications. sendromu ve karotis sinüs hipersensitivitesi tartışıldı. Tilt testi Other conditions, such as pre-syncopal heart rate acceleration sırasında ortaya çıkabilen senkop öncesi kalp atımlarında hız- and/or instability and pre-syncopal breathing instability, which lanma ve/veya instabilite ve senkop öncesi instabil solunum occur during a tilt test, are discussed in the same perspective.
    [Show full text]
  • Recovery from Disorders of Consciousness: Mechanisms, Prognosis and Emerging Therapies
    REVIEWS Recovery from disorders of consciousness: mechanisms, prognosis and emerging therapies Brian L. Edlow 1,2, Jan Claassen3, Nicholas D. Schiff4 and David M. Greer 5 ✉ Abstract | Substantial progress has been made over the past two decades in detecting, predicting and promoting recovery of consciousness in patients with disorders of consciousness (DoC) caused by severe brain injuries. Advanced neuroimaging and electrophysiological techniques have revealed new insights into the biological mechanisms underlying recovery of consciousness and have enabled the identification of preserved brain networks in patients who seem unresponsive, thus raising hope for more accurate diagnosis and prognosis. Emerging evidence suggests that covert consciousness, or cognitive motor dissociation (CMD), is present in up to 15–20% of patients with DoC and that detection of CMD in the intensive care unit can predict functional recovery at 1 year post injury. Although fundamental questions remain about which patients with DoC have the potential for recovery, novel pharmacological and electrophysiological therapies have shown the potential to reactivate injured neural networks and promote re-emergence of consciousness. In this Review, we focus on mechanisms of recovery from DoC in the acute and subacute-to-chronic stages, and we discuss recent progress in detecting and predicting recovery of consciousness. We also describe the developments in pharmacological and electro- physiological therapies that are creating new opportunities to improve the lives of patients with DoC. Disorders of consciousness (DoC) are characterized In this Review, we discuss mechanisms of recovery by alterations in arousal and/or awareness, and com- from DoC and prognostication of outcome, as well as 1Center for Neurotechnology mon causes of DoC include cardiac arrest, traumatic emerging treatments for patients along the entire tempo- and Neurorecovery, brain injury (TBI), intracerebral haemorrhage and ral continuum of DoC.
    [Show full text]
  • Syncope in Adults: Systematic Review and Proposal of a Diagnostic and Therapeutic Algorithm
    International Journal of Cardiology 162 (2013) 149–157 Contents lists available at SciVerse ScienceDirect International Journal of Cardiology journal homepage: www.elsevier.com/locate/ijcard Review Syncope in adults: Systematic review and proposal of a diagnostic and therapeutic algorithm Salvatore Rosanio a,⁎, Ernst R. Schwarz b, David L. Ware c, Antonio Vitarelli d a University of North Texas Health Science Center (UNTHSC) Department of Internal Medicine, Division of Cardiology 855 Montgomery Street 76107 Fort Worth, TX, United States b Cardiology Division, Cedars Sinai Medical Center, Los Angeles, CA, United States c Cardiology Division, University of Texas Medical Branch, Galveston, TX, United States d Cardio-Respiratory Department, La Sapienza University, Rome, Italy article info abstract Article history: This review aims to provide a practical and up-to-date description on the relevance and classification of syncope Received 19 June 2011 in adults as well as a guidance on the optimal evaluation, management and treatment of this very common clin- Received in revised form 28 October 2011 ical and socioeconomic medical problem. We have summarized recent active research and emphasized the value Accepted 24 November 2011 for physicians to adhere current guidelines. A modern management of syncope should take into account 1) use of Available online 20 December 2011 risk stratification algorithms and implementation of syncope management units to increase the diagnostic yield and reduce costs; 2) early implantable loop recorders rather than late in the evaluation of unexplained syncope; Keywords: fi Syncope and 3) isometric physical counter-pressure maneuvers as rst-line treatment for patients with neurally- Pacing mediated reflex syncope and prodromal symptoms.
    [Show full text]
  • The Vegetative State: Guidance on Diagnosis and Management
    n CLINICAL GUIDANCE The vegetative state: guidance on diagnosis and management A report of a working party of the Royal College of Physicians contrasts with sleep, a state of eye closure and motor Clin Med 1INTRODUCTION quiescence. There are degrees of wakefulness. 2003;3:249–54 Wakefulness is normally associated with conscious awareness, but the VS indicates that wakefulness and Background awareness can be dissociated. This can occur because 1.1 This guidance has been compiled to replace the brain systems controlling wakefulness, in the the recommendations published by the Royal College upper brainstem and thalamus, are largely distinct of Physicians in 1996, 1 in response to requests for from those which mediate awareness. 6 clarification from the Official Solicitor. The guidance applies primarily to adult patients and older children Awareness in whom it is possible to apply the criteria for diagnosis discussed below. 1.6 Awareness refers to the ability to have, and the having of, experience of any kind. We are typically aware of our surroundings and of bodily sensations, Wakefulness without awareness but the contents of awareness can also include our 1.2 Consciousness is an ambiguous term, encom- memories, thoughts, emotions and intentions. passing both wakefulness and awareness. This dis- Although understanding of the brain mechanisms of tinction is crucial to the concept of the vegetative awareness is incomplete, structures in the cerebral state, in which wakefulness recovers after brain hemispheres clearly play a key role. Awareness is not injury without recovery of awareness. 2–5 a single indivisible capacity: brain damage can selectively impair some aspects of awareness, leaving others intact.
    [Show full text]