Syncope differential diagnosis: Difference between revisions

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__NOTOC__
__NOTOC__
{{Syncope}}
[[Image:Home_logo1.png|right|250px|link=https://www.wikidoc.org/index.php/Syncope]]
{{CMG}} {{AE}} {{KGH}}
{{CMG}} {{AE}} {{KGH}} {{Sahar}}
 
==Overview==
==Overview==
 
Syncope should be differentiated from other [[conditions]] causing partial or complete [[loss of consciousness]]. These [[disorders]] may include, [[coma]], [[dizziness]], [[seizure]], and [[vertigo]]. There are [[conditions]] that may mistakenly be diagnosed as syncope. These [[conditions]] include [[epilepsy]], [[hypoglycemia]], [[intoxication]], [[cataplexy]], and [[transient ischemic attacks]].
Syncope's differential diagnosis can be seen in the context of transient loss of consciousness. European Task Force created an algorithm to define whether or not there has been loss of consciousness, and from there, there could be different possible diagnosis. <ref name="pmid19713422">{{cite journal| author=Task Force for the Diagnosis and Management of Syncope. European Society of Cardiology (ESC). European Heart Rhythm Association (EHRA). Heart Failure Association (HFA). Heart Rhythm Society (HRS). Moya A et al.| title=Guidelines for the diagnosis and management of syncope (version 2009). | journal=Eur Heart J | year= 2009 | volume= 30 | issue= 21 | pages= 2631-71 | pmid=19713422 | doi=10.1093/eurheartj/ehp298 | pmc=PMC3295536 | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=19713422  }} </ref>
 
==Differentiating Syncope from other Diseases==
==Differentiating Syncope from other Diseases==
Similar symptoms may be seen in other diseases such as:
A quick algorithm to differentiate syncope from other [[causes]] of altered mental status is demonstrated below:{{familytree/start}}
{{familytree/start}}
{{familytree | | | | | | | | | | A01 | | | | | |A01='''Clinical presentation'''}}
{{familytree | | | | | | | | | | |!| | | | | | | | }}
{{familytree | | | | | | | | | | B01 | | | | | |B01=Loss of conscoiusness}}
{{familytree | | | |,|-|-|-|-|-|-|^|-|-|-|-|-|-|.|}}
{{familytree | | | C01 | | | | | | | | | | | | C02 |C01=No|C02=Yes}}
{{familytree | | | |!| | | | | | | | | | | | | |!| | | | | | | | | | | }}
{{familytree | | | |!| | | | | | | | | | | | | D02 |D02=• Transient?<br>• Rapid onset?<br>• Short duration?<br>• Spontaneous recovery?}}
{{familytree | |,|-|^|-|.| | | | | |,|-|-|-|-|-|^|-|-|-|-|-|.|}}
{{familytree | F04 | | F05 | | | | G04 | | | | | | | | | | G05 |F04=Falls|F05=Altered consciousnes|G04=Yes|G05=No}}
{{familytree | | | | | | | | | | | |!| | | | | | | |,|-|-|-|+|-|-|-|.|}}
{{familytree | | | | | | | | | | | |!| | | | | | | E02 | | E03 | | E04 |E02=[[Coma]]|E03=Aborted SCD|E04=Others}}
{{familytree | | | | | | | | | | | D01 | | | | | | | | | | | | | |D01=T-LOC}}
{{familytree | | | | | | | | | |,|-|^|-|.| | | | | | | | | | | | |}}
{{familytree | | | | | | | | | D02 | | D03 | | | | | | | | | | | |D02=Non-Traumatic|D03=Traumatic}}
{{familytree | |,|-|-|-|-|v|-|-|^|-|-|v|-|-|-|-|.| | | | | | | | | |}}
{{familytree | D04 | | | D05 | | | | D06 | | | D07| |D04=Syncope|D05=Epileptic seizure|D06=Psychogenic|D07=Rare causes}}
{{familytree | |!| | | | |!| | | | | |!| | | | | | | | | | | | | | |}}
{{familytree | B04 | | | B05 | | | | B06 | | | | | | | | | | | | |B04=• Reflex syncope<br>• [[Orthostatic hypotension]]<br>• [[Cardiac]] syncope|B05=• Tonic<br>• Clonic<br>• Tonic-clonic<br>• Atonic|B06=• Pseudo-epileptic<br>• Pseudo-syncopal}}
{{familytree/end}}
<small><small>
'''Abbreviations:''' '''SCD''': Sudden cardiac death;'''T-LOC''': Transient-Loss of consciousness.
</small></small>
{|
! colspan="2" style="background:#DCDCDC;" align="center" + |The above algorithm adopted from ESC guideline <ref name="MoyaSutton2009">{{cite journal|last1=Moya|first1=A.|last2=Sutton|first2=R.|last3=Ammirati|first3=F.|last4=Blanc|first4=J.-J.|last5=Brignole|first5=M.|last6=Dahm|first6=J. B.|last7=Deharo|first7=J.-C.|last8=Gajek|first8=J.|last9=Gjesdal|first9=K.|last10=Krahn|first10=A.|last11=Massin|first11=M.|last12=Pepi|first12=M.|last13=Pezawas|first13=T.|last14=Granell|first14=R. R.|last15=Sarasin|first15=F.|last16=Ungar|first16=A.|last17=van Dijk|first17=J. G.|last18=Walma|first18=E. P.|last19=Wieling|first19=W.|last20=Abe|first20=H.|last21=Benditt|first21=D. G.|last22=Decker|first22=W. W.|last23=Grubb|first23=B. P.|last24=Kaufmann|first24=H.|last25=Morillo|first25=C.|last26=Olshansky|first26=B.|last27=Parry|first27=S. W.|last28=Sheldon|first28=R.|last29=Shen|first29=W. K.|last30=Vahanian|first30=A.|last31=Auricchio|first31=A.|last32=Bax|first32=J.|last33=Ceconi|first33=C.|last34=Dean|first34=V.|last35=Filippatos|first35=G.|last36=Funck-Brentano|first36=C.|last37=Hobbs|first37=R.|last38=Kearney|first38=P.|last39=McDonagh|first39=T.|last40=McGregor|first40=K.|last41=Popescu|first41=B. A.|last42=Reiner|first42=Z.|last43=Sechtem|first43=U.|last44=Sirnes|first44=P. A.|last45=Tendera|first45=M.|last46=Vardas|first46=P.|last47=Widimsky|first47=P.|last48=Auricchio|first48=A.|last49=Acarturk|first49=E.|last50=Andreotti|first50=F.|last51=Asteggiano|first51=R.|last52=Bauersfeld|first52=U.|last53=Bellou|first53=A.|last54=Benetos|first54=A.|last55=Brandt|first55=J.|last56=Chung|first56=M. K.|last57=Cortelli|first57=P.|last58=Da Costa|first58=A.|last59=Extramiana|first59=F.|last60=Ferro|first60=J.|last61=Gorenek|first61=B.|last62=Hedman|first62=A.|last63=Hirsch|first63=R.|last64=Kaliska|first64=G.|last65=Kenny|first65=R. A.|last66=Kjeldsen|first66=K. P.|last67=Lampert|first67=R.|last68=Molgard|first68=H.|last69=Paju|first69=R.|last70=Puodziukynas|first70=A.|last71=Raviele|first71=A.|last72=Roman|first72=P.|last73=Scherer|first73=M.|last74=Schondorf|first74=R.|last75=Sicari|first75=R.|last76=Vanbrabant|first76=P.|last77=Wolpert|first77=C.|last78=Zamorano|first78=J. L.|title=Guidelines for the diagnosis and management of syncope (version 2009): The Task Force for the Diagnosis and Management of Syncope of the European Society of Cardiology (ESC)|journal=European Heart Journal|volume=30|issue=21|year=2009|pages=2631–2671|issn=0195-668X|doi=10.1093/eurheartj/ehp298}}</ref>
|-
|}
Syncope should be differentiated from other [[conditions]] causing partial or [[loss of consciousness]]. These [[disorders]] may include:<ref name="pmid19713422">{{cite journal| author=Task Force for the Diagnosis and Management of Syncope. European Society of Cardiology (ESC). European Heart Rhythm Association (EHRA). Heart Failure Association (HFA). Heart Rhythm Society (HRS). Moya A et al.| title=Guidelines for the diagnosis and management of syncope (version 2009). | journal=Eur Heart J | year= 2009 | volume= 30 | issue= 21 | pages= 2631-71 | pmid=19713422 | doi=10.1093/eurheartj/ehp298 | pmc=PMC3295536 | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=19713422  }} </ref>
:*[[Coma]]
:*[[Coma]]
:*[[Dizziness]]
:*[[Dizziness]]
Line 14: Line 39:
:*[[Shock]]
:*[[Shock]]
:*[[Vertigo]]
:*[[Vertigo]]
 
{| class="wikitable"
First step to determine if we are in the presence of syncope is to identify if there has been a complete loss of consciousness. If the answer to this question is no we can therefore think in falls or in altered consciousness. If there was complete loss of consciousness, then it has to meet four features. These features being:
|+
 
! style="background: #4479BA; color: #FFFFFF |'''Conditions Incorrectly Diagnosed as Syncope'''
*Transient
|-
 
|'''[[Disorders]] with partial or complete [[loss of consciousness]]'''
*Rapid onset
|-
 
|
*Short duration
 
*Spontaneous recovery
If the four features are met, we are in the presence of transient loss of consciousness (T-LOC). From there, one of the diagnostic possibilities is syncope. Another differential diagnosis are:
*[[Epilepsy]]
*[[Epilepsy]]
*Psychogenic pseudosyncope
|-
*Rare miscellaneous causes
|
**[[Cataplexy]]
*[[Metabolic disorders]]:
**Excessive daytime sleepiness
**[[Hypoglycemia]]
 
**[[Hypoxia]]
There are some conditions incorrectly diagnosed as syncope, that can also be differential diagnosis. Those conditions can be divided on whether to not there was loss of consciousness. The conditions with loss of consciousness but without cerebral hypoperfusion are:
** Hyperventilation with hypocapnia
*Metabolic disturbances:
|-
**[[hypoglycemia]]
|
**[[hypoxia]]
*[[Intoxication]]
**hyperventilation with [[hypercapnia]]
|-
*Intoxication
|
*Vertebrobasilar [[TIA]]
* Vertebrobasilar TIA
Conditions without complete loss of consciousness are:
|-
|'''[[Conditions]] without [[loss of consciousness]]'''
|-
|
*[[Cataplexy]]
|-
|
*[[Falls]]
|-
|
*Functional (pseudoscope)
|-
|
*
*Drop attacks
|-
|
*[[TIA]] of carotid origin
*[[TIA]] of carotid origin
*Falls
|}
*Drop attacks
{|
In the cases where there has not been loss of consciousness, the differential diagnosis is more evident, and syncope is unlikely. However, it may be more confusing when there is no knowledge of the patient's history. <ref name="pmid19713422">{{cite journal| author=Task Force for the Diagnosis and Management of Syncope. European Society of Cardiology (ESC). European Heart Rhythm Association (EHRA). Heart Failure Association (HFA). Heart Rhythm Society (HRS). Moya A et al.| title=Guidelines for the diagnosis and management of syncope (version 2009). | journal=Eur Heart J | year= 2009 | volume= 30 | issue= 21 | pages= 2631-71 | pmid=19713422 | doi=10.1093/eurheartj/ehp298 | pmc=PMC3295536 | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=19713422  }} </ref>
! colspan="2" style="background:#DCDCDC;" align="center" + |The above table adopted from ESC guideline <ref name="MoyaSutton2009">{{cite journal|last1=Moya|first1=A.|last2=Sutton|first2=R.|last3=Ammirati|first3=F.|last4=Blanc|first4=J.-J.|last5=Brignole|first5=M.|last6=Dahm|first6=J. B.|last7=Deharo|first7=J.-C.|last8=Gajek|first8=J.|last9=Gjesdal|first9=K.|last10=Krahn|first10=A.|last11=Massin|first11=M.|last12=Pepi|first12=M.|last13=Pezawas|first13=T.|last14=Granell|first14=R. R.|last15=Sarasin|first15=F.|last16=Ungar|first16=A.|last17=van Dijk|first17=J. G.|last18=Walma|first18=E. P.|last19=Wieling|first19=W.|last20=Abe|first20=H.|last21=Benditt|first21=D. G.|last22=Decker|first22=W. W.|last23=Grubb|first23=B. P.|last24=Kaufmann|first24=H.|last25=Morillo|first25=C.|last26=Olshansky|first26=B.|last27=Parry|first27=S. W.|last28=Sheldon|first28=R.|last29=Shen|first29=W. K.|last30=Vahanian|first30=A.|last31=Auricchio|first31=A.|last32=Bax|first32=J.|last33=Ceconi|first33=C.|last34=Dean|first34=V.|last35=Filippatos|first35=G.|last36=Funck-Brentano|first36=C.|last37=Hobbs|first37=R.|last38=Kearney|first38=P.|last39=McDonagh|first39=T.|last40=McGregor|first40=K.|last41=Popescu|first41=B. A.|last42=Reiner|first42=Z.|last43=Sechtem|first43=U.|last44=Sirnes|first44=P. A.|last45=Tendera|first45=M.|last46=Vardas|first46=P.|last47=Widimsky|first47=P.|last48=Auricchio|first48=A.|last49=Acarturk|first49=E.|last50=Andreotti|first50=F.|last51=Asteggiano|first51=R.|last52=Bauersfeld|first52=U.|last53=Bellou|first53=A.|last54=Benetos|first54=A.|last55=Brandt|first55=J.|last56=Chung|first56=M. K.|last57=Cortelli|first57=P.|last58=Da Costa|first58=A.|last59=Extramiana|first59=F.|last60=Ferro|first60=J.|last61=Gorenek|first61=B.|last62=Hedman|first62=A.|last63=Hirsch|first63=R.|last64=Kaliska|first64=G.|last65=Kenny|first65=R. A.|last66=Kjeldsen|first66=K. P.|last67=Lampert|first67=R.|last68=Molgard|first68=H.|last69=Paju|first69=R.|last70=Puodziukynas|first70=A.|last71=Raviele|first71=A.|last72=Roman|first72=P.|last73=Scherer|first73=M.|last74=Schondorf|first74=R.|last75=Sicari|first75=R.|last76=Vanbrabant|first76=P.|last77=Wolpert|first77=C.|last78=Zamorano|first78=J. L.|title=Guidelines for the diagnosis and management of syncope (version 2009): The Task Force for the Diagnosis and Management of Syncope of the European Society of Cardiology (ESC)|journal=European Heart Journal|volume=30|issue=21|year=2009|pages=2631–2671|issn=0195-668X|doi=10.1093/eurheartj/ehp298}}</ref>
 
|-
 
|}
Syncope, must be [[Differentiate|differentiated]] from other [[diseases]] that may cause, [[altered mental status]], motor and or somatosensory deficits. The table below, summarizes the [[neurologic]] [[differential diagnosis]] for syncope:
{|
! rowspan="2" style="background: #4479BA; color: #FFFFFF; text-align: center;" |Diseases
! rowspan="2" style="background: #4479BA; color: #FFFFFF; text-align: center;" |History
! colspan="4" style="background: #4479BA; color: #FFFFFF; text-align: center;" |Symptoms
! colspan="5" style="background: #4479BA; color: #FFFFFF; text-align: center;" |Physical Examination
! colspan="3" style="background: #4479BA; color: #FFFFFF; text-align: center;" |Diagnostic tests
! rowspan="2" style="background: #4479BA; color: #FFFFFF; text-align: center;" |Other Findings
|-
! style="background: #4479BA; color: #FFFFFF; text-align: center;" |Headache
! style="background: #4479BA; color: #FFFFFF; text-align: center;" |↓ LOC
! style="background: #4479BA; color: #FFFFFF; text-align: center;" |Motor weakness
! style="background: #4479BA; color: #FFFFFF; text-align: center;" |Abnormal sensory
! style="background: #4479BA; color: #FFFFFF; text-align: center;" |Motor Deficit
! style="background: #4479BA; color: #FFFFFF; text-align: center;" |Sensory deficit
! style="background: #4479BA; color: #FFFFFF; text-align: center;" |Speech difficulty
! style="background: #4479BA; color: #FFFFFF; text-align: center;" |Gait abnormality
! style="background: #4479BA; color: #FFFFFF; text-align: center;" |Cranial nerves
! style="background: #4479BA; color: #FFFFFF; text-align: center;" |CT/MRI
! style="background: #4479BA; color: #FFFFFF; text-align: center;" |CSF
! style="background: #4479BA; color: #FFFFFF; text-align: center;" |Gold standard test
|-
! style="background: #DCDCDC; padding: 5px; text-align: center;" |[[Wernicke's encephalopathy|Wernicke’s encephalopathy]] <ref name="ThomsonMarshall2006">{{cite journal|last1=Thomson|first1=Allan D.|last2=Marshall|first2=E. Jane|title=THE NATURAL HISTORY AND PATHOPHYSIOLOGY OF WERNICKE'S ENCEPHALOPATHY AND KORSAKOFF'S PSYCHOSIS|journal=Alcohol and Alcoholism|volume=41|issue=2|year=2006|pages=151–158|issn=1464-3502|doi=10.1093/alcalc/agh249}}</ref>
| align="left" style="background:#F5F5F5;" |
*History of [[alcohol abuse]]
| align="center" style="background:#F5F5F5;" |–
| align="center" style="background:#F5F5F5;" |  +
| align="center" style="background:#F5F5F5;" |–
| align="center" style="background:#F5F5F5;" |–
| align="center" style="background:#F5F5F5;" |–
| align="center" style="background:#F5F5F5;" |  +
| align="center" style="background:#F5F5F5;" |  +
| align="center" style="background:#F5F5F5;" |  +
| align="center" style="background:#F5F5F5;" |  +
| align="center" style="background:#F5F5F5;" |–
| align="center" style="background:#F5F5F5;" |NA
| align="center" style="background:#F5F5F5;" |Clinical assesment and lab findings
| align="left" style="background:#F5F5F5;" |
*[[Ophthalmoplegia]]
*[[Confusion]]
|-
! style="background: #DCDCDC; padding: 5px; text-align: center;" |[[Drug toxicity]] <ref name="pmid29763168">{{cite journal |vauthors=Hedya SA, Avula A, Swoboda HD |title= |journal= |volume= |issue= |pages= |date= |pmid=29763168 |doi= |url=}}</ref><ref name="pmid29494051">{{cite journal |vauthors=Iorga A, Horowitz BZ |title= |journal= |volume= |issue= |pages= |date= |pmid=29494051 |doi= |url=}}</ref><ref name="Hamed2017">{{cite journal|last1=Hamed|first1=Sherifa A|title=The auditory and vestibular toxicities induced by antiepileptic drugs|journal=Expert Opinion on Drug Safety|volume=16|issue=11|year=2017|pages=1281–1294|issn=1474-0338|doi=10.1080/14740338.2017.1372420}}</ref><ref name="BrostoffBirns2008">{{cite journal|last1=Brostoff|first1=J. M.|last2=Birns|first2=J.|last3=McCrea|first3=D.|title=Phenytoin toxicity: an easily missed cause of cerebellar syndrome|journal=Journal of Clinical Pharmacy and Therapeutics|volume=33|issue=2|year=2008|pages=211–214|issn=0269-4727|doi=10.1111/j.1365-2710.2008.00903.x}}</ref>
| align="left" style="background:#F5F5F5;" |[[Medication]] history of


*[[Lithium]]
*[[Sedatives]]
*[[Phenytoin]]
*[[Carbamazepine]]
| align="center" style="background:#F5F5F5;" |–
| align="center" style="background:#F5F5F5;" |  +
| align="center" style="background:#F5F5F5;" |–
| align="center" style="background:#F5F5F5;" |  +
| align="center" style="background:#F5F5F5;" |  +
| align="center" style="background:#F5F5F5;" |  +
| align="center" style="background:#F5F5F5;" |–
| align="center" style="background:#F5F5F5;" |  +
| align="center" style="background:#F5F5F5;" |–
| align="center" style="background:#F5F5F5;" |–
| align="center" style="background:#F5F5F5;" |NA
| align="center" style="background:#F5F5F5;" |Drug screen test
| align="center" style="background:#F5F5F5;" |
*[[Confusion]]
|-
! style="background: #DCDCDC; padding: 5px; text-align: center;" |Metabolic disturbances ([[electrolyte imbalance]], [[hypoglycemia]]) <ref name="GiulianiPeri2014">{{cite journal|last1=Giuliani|first1=Corinna|last2=Peri|first2=Alessandro|title=Effects of Hyponatremia on the Brain|journal=Journal of Clinical Medicine|volume=3|issue=4|year=2014|pages=1163–1177|issn=2077-0383|doi=10.3390/jcm3041163}}</ref><ref name="WitschNeugebauer2012">{{cite journal|last1=Witsch|first1=Jens|last2=Neugebauer|first2=Hermann|last3=Flechsenhar|first3=Julia|last4=Jüttler|first4=Eric|title=Hypoglycemic encephalopathy: a case series and literature review on outcome determination|journal=Journal of Neurology|volume=259|issue=10|year=2012|pages=2172–2181|issn=0340-5354|doi=10.1007/s00415-012-6480-z}}</ref>
| align="center" style="background:#F5F5F5;" |–
| align="center" style="background:#F5F5F5;" |–
| align="center" style="background:#F5F5F5;" |  +
| align="center" style="background:#F5F5F5;" |  +
| align="center" style="background:#F5F5F5;" |  +
| align="center" style="background:#F5F5F5;" |  +
| align="center" style="background:#F5F5F5;" |  +
| align="center" style="background:#F5F5F5;" |–
| align="center" style="background:#F5F5F5;" |–
| align="center" style="background:#F5F5F5;" |  +
| align="center" style="background:#F5F5F5;" |–
| align="center" style="background:#F5F5F5;" |[[Hypoglycemia]], [[hyponatremia]], [[hypernatremia]], [[hypokalemia]], and [[hyperkalemia]]
| align="center" style="background:#F5F5F5;" |Depends on the cause
| align="left" style="background:#F5F5F5;" |
*[[Confusion]]
*[[Seizure]]
*[[Palpitation]]
*[[Sweating]]
*[[Dizziness]]
*[[Hypoglycemia]]
|-
! style="background: #DCDCDC; padding: 5px; text-align: center;" |[[Meningitis]] or [[encephalitis]]
| align="left" style="background:#F5F5F5;" |
*History of [[fever]] and [[malaise]]
| align="center" style="background:#F5F5F5;" | +
| align="center" style="background:#F5F5F5;" |–
| align="center" style="background:#F5F5F5;" |–
| align="center" style="background:#F5F5F5;" |–
| align="center" style="background:#F5F5F5;" |–
| align="center" style="background:#F5F5F5;" | +
| align="center" style="background:#F5F5F5;" | +
| align="center" style="background:#F5F5F5;" |–
| align="center" style="background:#F5F5F5;" |–
| align="center" style="background:#F5F5F5;" |–
| align="center" style="background:#F5F5F5;" |↑ [[Leukocytes]], ↑ [[protein]], ↓ [[glucose]]
| align="center" style="background:#F5F5F5;" |[[CSF analysis]]
| align="left" style="background:#F5F5F5;" |
*[[Fever]]
*[[Neck rigidity]]
*[[Confusion]]
|}
==References==
==References==
{{reflist|2}}
{{reflist|2}}


[[Category:Emergency medicine]]
[[Category:Emergency medicine]]
[[Category:Cardiology]]
[[Category:Cardiology]]
[[Category:Neurology]]
[[Category:Neurology]]
[[Category:Nutrition]]
[[Category:Metabolic disorders]]
[[Category:Primary care]]
[[Category:Needs overview]]
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Latest revision as of 16:20, 20 January 2021

Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1] Associate Editor(s)-in-Chief: Karol Gema Hernandez, M.D. [2] Sahar Memar Montazerin, M.D.[3]

Overview

Syncope should be differentiated from other conditions causing partial or complete loss of consciousness. These disorders may include, coma, dizziness, seizure, and vertigo. There are conditions that may mistakenly be diagnosed as syncope. These conditions include epilepsy, hypoglycemia, intoxication, cataplexy, and transient ischemic attacks.

Differentiating Syncope from other Diseases

A quick algorithm to differentiate syncope from other causes of altered mental status is demonstrated below:

 
 
 
 
 
 
 
 
 
Clinical presentation
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Loss of conscoiusness
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
No
 
 
 
 
 
 
 
 
 
 
 
Yes
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
• Transient?
• Rapid onset?
• Short duration?
• Spontaneous recovery?
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Falls
 
Altered consciousnes
 
 
 
Yes
 
 
 
 
 
 
 
 
 
No
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Coma
 
Aborted SCD
 
Others
 
 
 
 
 
 
 
 
 
 
T-LOC
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Non-Traumatic
 
Traumatic
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Syncope
 
 
Epileptic seizure
 
 
 
Psychogenic
 
 
Rare causes
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
• Reflex syncope
• Orthostatic hypotension
• Cardiac syncope
 
 
• Tonic
• Clonic
• Tonic-clonic
• Atonic
 
 
 
• Pseudo-epileptic
• Pseudo-syncopal
 
 
 
 
 
 
 
 
 
 
 
 

Abbreviations: SCD: Sudden cardiac death;T-LOC: Transient-Loss of consciousness.

The above algorithm adopted from ESC guideline [1]

Syncope should be differentiated from other conditions causing partial or loss of consciousness. These disorders may include:[2]

Conditions Incorrectly Diagnosed as Syncope
Disorders with partial or complete loss of consciousness
  • Vertebrobasilar TIA
Conditions without loss of consciousness
  • Functional (pseudoscope)
  • Drop attacks
  • TIA of carotid origin
The above table adopted from ESC guideline [1]

Syncope, must be differentiated from other diseases that may cause, altered mental status, motor and or somatosensory deficits. The table below, summarizes the neurologic differential diagnosis for syncope:

Diseases History Symptoms Physical Examination Diagnostic tests Other Findings
Headache ↓ LOC Motor weakness Abnormal sensory Motor Deficit Sensory deficit Speech difficulty Gait abnormality Cranial nerves CT/MRI CSF Gold standard test
Wernicke’s encephalopathy [3] – + – – – + + + + – NA Clinical assesment and lab findings
Drug toxicity [4][5][6][7] Medication history of – + – + + + – + – – NA Drug screen test
Metabolic disturbances (electrolyte imbalance, hypoglycemia) [8][9] – – + + + + + – – + – Hypoglycemia, hyponatremia, hypernatremia, hypokalemia, and hyperkalemia Depends on the cause
Meningitis or encephalitis + – – – – + + – – – ↑ Leukocytes, ↑ protein, ↓ glucose CSF analysis

References

  1. ↑ 1.0 1.1 Moya, A.; Sutton, R.; Ammirati, F.; Blanc, J.-J.; Brignole, M.; Dahm, J. B.; Deharo, J.-C.; Gajek, J.; Gjesdal, K.; Krahn, A.; Massin, M.; Pepi, M.; Pezawas, T.; Granell, R. R.; Sarasin, F.; Ungar, A.; van Dijk, J. G.; Walma, E. P.; Wieling, W.; Abe, H.; Benditt, D. G.; Decker, W. W.; Grubb, B. P.; Kaufmann, H.; Morillo, C.; Olshansky, B.; Parry, S. W.; Sheldon, R.; Shen, W. K.; Vahanian, A.; Auricchio, A.; Bax, J.; Ceconi, C.; Dean, V.; Filippatos, G.; Funck-Brentano, C.; Hobbs, R.; Kearney, P.; McDonagh, T.; McGregor, K.; Popescu, B. A.; Reiner, Z.; Sechtem, U.; Sirnes, P. A.; Tendera, M.; Vardas, P.; Widimsky, P.; Auricchio, A.; Acarturk, E.; Andreotti, F.; Asteggiano, R.; Bauersfeld, U.; Bellou, A.; Benetos, A.; Brandt, J.; Chung, M. K.; Cortelli, P.; Da Costa, A.; Extramiana, F.; Ferro, J.; Gorenek, B.; Hedman, A.; Hirsch, R.; Kaliska, G.; Kenny, R. A.; Kjeldsen, K. P.; Lampert, R.; Molgard, H.; Paju, R.; Puodziukynas, A.; Raviele, A.; Roman, P.; Scherer, M.; Schondorf, R.; Sicari, R.; Vanbrabant, P.; Wolpert, C.; Zamorano, J. L. (2009). "Guidelines for the diagnosis and management of syncope (version 2009): The Task Force for the Diagnosis and Management of Syncope of the European Society of Cardiology (ESC)". European Heart Journal. 30 (21): 2631–2671. doi:10.1093/eurheartj/ehp298. ISSN 0195-668X.
  2. ↑ Task Force for the Diagnosis and Management of Syncope. European Society of Cardiology (ESC). European Heart Rhythm Association (EHRA). Heart Failure Association (HFA). Heart Rhythm Society (HRS). Moya A; et al. (2009). "Guidelines for the diagnosis and management of syncope (version 2009)". Eur Heart J. 30 (21): 2631–71. doi:10.1093/eurheartj/ehp298. PMC 3295536. PMID 19713422.
  3. ↑ Thomson, Allan D.; Marshall, E. Jane (2006). "THE NATURAL HISTORY AND PATHOPHYSIOLOGY OF WERNICKE'S ENCEPHALOPATHY AND KORSAKOFF'S PSYCHOSIS". Alcohol and Alcoholism. 41 (2): 151–158. doi:10.1093/alcalc/agh249. ISSN 1464-3502.
  4. ↑ Hedya SA, Avula A, Swoboda HD. PMID 29763168. Missing or empty |title= (help)
  5. ↑ Iorga A, Horowitz BZ. PMID 29494051. Missing or empty |title= (help)
  6. ↑ Hamed, Sherifa A (2017). "The auditory and vestibular toxicities induced by antiepileptic drugs". Expert Opinion on Drug Safety. 16 (11): 1281–1294. doi:10.1080/14740338.2017.1372420. ISSN 1474-0338.
  7. ↑ Brostoff, J. M.; Birns, J.; McCrea, D. (2008). "Phenytoin toxicity: an easily missed cause of cerebellar syndrome". Journal of Clinical Pharmacy and Therapeutics. 33 (2): 211–214. doi:10.1111/j.1365-2710.2008.00903.x. ISSN 0269-4727.
  8. ↑ Giuliani, Corinna; Peri, Alessandro (2014). "Effects of Hyponatremia on the Brain". Journal of Clinical Medicine. 3 (4): 1163–1177. doi:10.3390/jcm3041163. ISSN 2077-0383.
  9. ↑ Witsch, Jens; Neugebauer, Hermann; Flechsenhar, Julia; Jüttler, Eric (2012). "Hypoglycemic encephalopathy: a case series and literature review on outcome determination". Journal of Neurology. 259 (10): 2172–2181. doi:10.1007/s00415-012-6480-z. ISSN 0340-5354.
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