Syncope differential diagnosis: Difference between revisions

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! 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>
! 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 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;" |[[Subdural hematoma|Subdural hemorrhage]]<ref name="pmid216947552">{{cite journal| author=Birenbaum D, Bancroft LW, Felsberg GJ| title=Imaging in acute stroke. | journal=West J Emerg Med | year= 2011 | volume= 12 | issue= 1 | pages= 67-76 | pmid=21694755 | doi= | pmc=3088377 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=21694755  }}</ref><ref name="pmid218073452">{{cite journal| author=DeLaPaz RL, Wippold FJ, Cornelius RS, Amin-Hanjani S, Angtuaco EJ, Broderick DF et al.| title=ACR Appropriateness Criteria® on cerebrovascular disease. | journal=J Am Coll Radiol | year= 2011 | volume= 8 | issue= 8 | pages= 532-8 | pmid=21807345 | doi=10.1016/j.jacr.2011.05.010 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=21807345  }}</ref>
| align="left" style="background:#F5F5F5;" |
*[[Trauma]]
*Fall
| 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;" |[[Xanthochromia]]
| align="center" style="background:#F5F5F5;" |CT scan without contrast
| align="left" style="background:#F5F5F5;" |
*[[Confusion]]
*[[Dizziness]]
*[[Nausea and vomiting]]
|-
! style="background: #DCDCDC; padding: 5px; text-align: center;" |[[Neurosyphilis]]
| align="left" style="background:#F5F5F5;" |
*[[Sexually transmitted disease]]
| 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]] and [[protein]]
| align="center" style="background:#F5F5F5;" |Specific: CSF [[VDRL]]
Sensitive: CSF FTA-Ab
| align="left" style="background:#F5F5F5;" |
*[[Blindness]]
*[[Confusion]]
*[[Depression]]
*Abnormal [[gait]]
|-
! style="background: #DCDCDC; padding: 5px; text-align: center;" |[[Hypertensive encephalopathy]]
| align="left" style="background:#F5F5F5;" |
*[[Hypertension]]
| 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
| align="left" style="background:#F5F5F5;" |
*[[Delirium]]
*Cortical [[blindness]]
*[[Cerebral edema]]
*[[Seizure]]
|-
! style="background: #DCDCDC; padding: 5px; text-align: center;" |[[Wernicke's encephalopathy|Wernicke’s encephalopathy]]
| align="left" style="background:#F5F5F5;" |
*History of alcohal 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]]
| 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]])
| 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]]
|-
! style="background: #DCDCDC; padding: 5px; text-align: center;" |[[Seizure]]
| align="left" style="background:#F5F5F5;" |
*Previous history of [[seizures]]
| 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;" |Mass lesion
| align="center" style="background:#F5F5F5;" |Clinical assesment and [[EEG]]
| align="left" style="background:#F5F5F5;" |
*[[Confusion]]
*[[Apathy]]
*[[Irritability]]
|}
|}
==References==
==References==

Revision as of 17:37, 26 April 2020

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

Overview

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. [1]

Differentiating Syncope from other Diseases

Similar symptoms may be seen in other diseases such as:

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:

  • Transient
  • 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
  • Psychogenic pseudosyncope
  • Rare miscellaneous causes

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:

Conditions without complete loss of consciousness are:

  • 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. [1]

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 [2]

References

  1. ↑ 1.0 1.1 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.
  2. ↑ 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.


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