Abstract
Background
A 72 y/o male presented after a MVA
The differential, of syncope versus seizure, required cardiac examinations (including Electrophysiological Studies, and Sleep-Deprived EEG).
Two later episodes occurred: being found collapsed behind his parked vehicle and, later, behavioral arrest and head ‘collapsed’ on his chest
He volunteered ‘head drop’ recently when being driven
Preceding his collapse behind his vehicle, he had suddenly extended his neck.
Method
Review of relevant literature on syncope, DHS, orthostatic hypotension, neurodegenerative disorders
Outcomes
Neuro-degeneration is a slowly progressive disorder that may be suspected during life.
Pathologically, advanced cases reveal widespread changes throughout the cerebrum and brainstem.
Current, strict diagnostic criteria, pick up those with relatively late, well-developed disease - long after any interventions may be trialled.
Phenotypes of neuro-degeneration continue to expand (possibly due to longevity).
Both syncope in the seated position and DHS are rare: full cardiac assessment is mandatory, particularly for excluded drivers.
All neuro-degenerative conditions may be accompanied by autonomic failure and orthostatic hypotension
Structural and functional causes – orthopedic, neurologic, neuro-muscular junction, myopathy – structural or genetic – need exclusion, before consideration is given to a neuro-degenerative process.
Conclusions
Unexplained syncope occurs in 30% of all cases (depending on age).
Clues in this patient were syncope in the seated position and (intermittent) head drop.
DHS is a specific entity and an explanation should always be sought – it may be an initial symptom of neuro-degeneration.
