The Magic of Spells
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“Those who suffer from frequent and strong faints, without any manifest cause die suddenly”
∼Hippocrates (460-373 BC)
Causes of Spells
Cerebral vascular accident
-low carbon dioxide (hyperventilation)
Differential Diagnosis of Seizures and Syncope
Prodrome (nausea, palpitations, dizziness, visual disturbances, flushing)
Event not recalled
Event may or may not be recalled
The incidence of seizures increases exponentially after 60 years of age (3). In older persons it can take up to 17 years to make the diagnosis. Seizures may be either generalized (toniclonic, absence, myoclonic or atonic) or partial, where they are unilateral and consciousness can be preserved. Complex partial and generalized tonic clonic seizures make up over half of seizures (4). Fyodor Dostyeski (1821–1880) was the prototypic example of complex partial seizures where he presented with ecstasy or anguish followed by convulsions. Complex partial seizures can present with hallucinations (visual, auditory or olfactory), psychomotor (dysphagia, chewing, taking off clothes) or temporal (dreamy state, memory problems, fear or déjà vu). Diagnostic clues include elevated prolactin for a 20 to 60-minute window following the seizure and, in some cases, elevated CPK or lactate (5, 6). The diagnosis of seizures is made by electroencephalogram. Artificial intelligent techniques are being developed to enhance the diagnosis (7).
Cardiogenic syncope - heart fails as a pump
Orthostatic syncope - reduced venous return
Abnormal arterial vasodilation - inappropriate arterial vasodilation
Common Causes of Syncope
Hypertrophic obstructive cardiac
Carotid sinus hypersensitivity
Rare Causes of Syncope (Black Swans and Zebras)
VIPoma (Verner-Morrison Syndrome)
Giant cell arteritis
Paraplegic induced cerebral syncope
Eagle syndrome (elongated styloid process)
Acupuncture induced syncope (“Yun-Cheng” phenomenon)
Orthostatic syncope occurs when there is greater than 20% of the blood volume pooling in the extremities on standing.
Management of Orthostasis
Elevate head of bed
Get up slowly
Exercise training for orth
Coffee in morning
-Midodrin (alpha-1 adrenegic antagonist)
-Nonsteroid anti-inflammatory drugs ‘e.g., Motrin
-3,4 di-threo-diphenoxyphenyl serine
-Droxidropa - prodrug to norepinephrine
Postprandial Hypotension (“Big Mac Attack”)
Thirty to 120 minutes following a meal blood pressure can drop fairly dramatically. This postprandial hypotension is variable and occurs more often in the morning (15). It occurs in about a quarter of older persons and results in falls, syncope, stroke, myocardial infarction and death. The fall in blood pressure is mainly due to carbohydrates in meals. The fall in blood pressure is due to the vasodilatory of calcitonin gene related peptide (16). Postprandial hypotension can be treated with coffee in the morning only, small meals, fiber with the meals and alpha-1 glucosidase inhibitors, e.g., acarbose and miglitol, which slow gastric emptying by increasing glucagon-like peptide 1.
With vertigo “the external world seems to revolve around the individual or the individual seems to revolve in space.” Like syncope there are multiple causes of dizziness (19). These include benign paroxysmal positional vertigo (BPPV), Meniere’s disease, labyrinthitis, vestibular neuronitis, acoustic neuroma, arteriosclerosis, ototoxicity and osteoarthritis.
BPPV occurs in the fifth to seventh decades of life and is responsible for 20% of all cases (20). It is bilateral in 10%. It can be treated with the Epley maneuver.
Meniere’s disease occurs when endolymph cannot be drained from the inner ear (21). It presents with episodes of dizziness and tinnitus. There is fluctuation in sensorineural hearing and a feeling of pressure in the ear. Table 6 lists possible treatments for Meniere’s disease.
Superior semicircular canal dehiscence occurs in 0.4% to 1.5% (22). It presents with disequilibrium that can be triggered by noise, gaze or pressure and can be associated with nystagmus. Treatment consists of a pressure equalization tube or surgical repair (23).
Finally, a number of exercises have been developed to treat dizziness (24). These include Brandt-Baroff Habituation exercise, the Sermont (Liberatory) Maneuver, Gaze Stabilization exercises and Crawthorne-Cooksey exercises. These exercises are variably effective.
Spells are very common in older persons. They result in falls, frailty, disability and death. The diagnosis is often difficult to make. With the exception of postprandial hypotension, treatment success is variable.
Disclosures: The authors declare there are no conflicts.
- 1.Mechanic OJ, Grossman SA. Syncope and related paroxysmal spells. StatPearls Publishing LLC; 2019, Apr 3 PMID: 29083598 [Epub]Google Scholar
- 3.Hauser WA, Annegers JF, Kurland LT. Incidence of epilepsy and unprovoked seizures I Rochester, Minnesota: 1935–1984.Google Scholar