Sincope
Definizione
La sincope fa parte delle “perdite transitorie di coscienza” (PdCT).
Di perdite transitorie di coscienza ce ne sono diverse ma non
tutte sono associate alla sincope, perché diverso può essere il motivo per cui la coscienza va via temporaneamente:
- Attacchi epilettici;
- Febbre: a chi non è mai capitato di sentirti un po’ tra le nuvole durante una febbre, soprattutto se alta;
- Attacco narcolettico; crisi di sonno, usualmente incoercibili, di durata variabile in media 15-20 minuti e ricorrenti pluriquotidianamente, facilitati da situazioni a basso stimolo e seguite da una netta sensazione di ristoro psico-fisico.
- TIA ( attacco ischemico transitorio): non induce PdCT se è interessato il distretto carotideo, mentre può indurla, seppure molto raramente, qualora sia interessato il distretto vertebro-basilare.
In tal caso sono presenti sintomi neurologici focali quali paresi,
atassia, diplopia, parestesie; queste ultime, tuttavia, possono essere presente anche nella sincope neuromediata; - Traumi cranici.
Condizioni metaboliche: l’ipoglicemia per esempio induce generalmente una perdita della coscienza di lunga durata (coma); se invece quest’ultima è di breve durata la causa ipoglicemica deve essere sospettata in soggetti in trattamento antidiabetico, in particolare se la PdCT è preceduta da sudorazione e tremori intensi. Ma la perdita di coscienza dell’ipoglicemia potrebbe anche non avere nessun sintomo premonitore perché, come la neurologia ci insegna, il paziente diabetico potrebbe avere anche una neuropatia automatica.
L’ipossiemia acuta transitoria (intossicazione da CO, esposizione a basse concentrazioni di ossigeno) ecc.e poi ci sono pure condizioni che possono simulare una transitoria perdita di coscienza, ma in cui in realtà la coscienza è integra;
Drop attac: è caratterizzato da una caduta a terra improvvisa, spesso sulle ginocchia, tanto che alcuni autori la definiscono “sindrome delle ginocchia blu”, ma non vi è perdita della coscienza. In soggetti anziani può essere tuttavia coinvolta nella diagnosi differenziale con la sincope. La cosa caratteristica è che il paziente dopo il drop attac non ricorda come stare in piedi, per cui bisogna restituirlo facendogli appoggiare la pianta dei piedi.
Inoltre è perso il tono ma il paziente non è paralizzato.
Attacco cataplettico: il paziente cade a terra lentamente senza farsi male, vi è una perdita del tono muscolare che simula una paralisi, ma il soggetto è vigile pur non rispondendo alle domande; per tale motivo la cataplessia può simulare una sincope. Ad innescare la perdita del tono muscolare è generalmente una risata che, può rappresentare il trigger anche di una sincope neuromediata.
Crisi isterica e forme psicogene in genere: intanto c’è sempre un pubblico, e poi se noi siamo nei paraggi e vediamo un tizio con perdita di coscienza e gli alziamo il braccio e lo lasciamo di colpo quando è sulla sua testa: se il braccio resta alzato non è una perdita di coscienza. Anche alcuni elementi lo possono far capire ad es. nella sincope il paziente non ricorda nulla essendo svenuto, se invece il tizio riferisce che quando ero svenuto sentiva la moglie ma non riusciva a parlare questo non convince, oppure anche se svenuto sentiva le persone intorno a lui ma con una sensazione strana. Altra cosa è che in un paziente con crisi isterica se si tenta di aprire gli occhi oppone resistenza, mentre il paziente con sincope lascia sollevare la palpebra senza porre resistenza.
Causa accidentale nell’anziano: è caduto perché ha avuto un mancamento o semplicemente perché ha inciampato?
Diagnosi
La valutazione iniziale del paziente che ha accusato una perdita
di coscienza transitoria (PdCT) include anamnesi, unitamente all’interrogazione di eventuali testimoni, l’esame obiettivo, compresa la misurazione della pressione arteriosa in clino ed ortostatismo, e elettrocardiogramma (ECG) a 12 derivazioni. La valutazione iniziale consente la diagnosi della causa di sincope nel 35% dei casi. Gli esami di laboratorio non sono indicati di routine, ma soltanto quando si sospetta una causa metabolica della PdCT (es. ipoglicemia) oppure una riduzione del volume circolante da emorragia interna o disidratazione. L’anamnesi deve essere finalizzata a definire tutte le circostanze nel contesto delle quali si è verificata la PdCT: posizione: era in piedi? Era seduto e si è alzato?
Attività del paziente: che stava facendo? Ad esempio ci sono le sincopi degli atleti durante attività muscolare intensa, si può avere la perdita di coscienza con vario meccanismo quale può essere disidratazione per sudorazione e altro (la manovra di valvasa), durante o dopo minzione (sono spesso soggetti che si alzano di notte vanno in bagno ad urinare e hanno la sincope in questo caso
si associa a quella ortostatica quella minzionale), deglutizione, tosse.
Predisponenti: luoghi caldi e affollati (succedono al cinema o altri ambienti, a proposito delle forme finte psicogene queste hanno bisogno di pubblico, quindi accadono solo se ci sono persone presenti perché la sincope deve essere dimostrata e non può mai avvenire da solo) prolungato ortostatismo, periodo postprandiale.
Sintomi accusati sia prima che dopo la PdCT: dolore, nausea, sensazione di freddo, sudorazione, dolori addominali, aura (si riferisce alla crisi epilettica di tipo grande male che può essere preceduta da aura che non è l’aura emicranica in cui vi sono segni focali, ma l’aura nella crisi epilettica di grande male è una sensazione che dura pochi secondi, parte dall’epigastrio e va in alto con sensazione di qualcosa che sale, improvvisamente compare la crisi epilettica, l’aura dura pochissimi secondi quindi la crisi non ha prodromi, il paziente non ha neanche la possibilità di capire che gli sta venendo la crisi perché l’aura dura 1-2 secondi) però se il paziente la cita e dice che poi non ricorda altro allora potremmo orientarci per una crisi epilettica.
Dolori al collo, alle spalle fa parte della presincope e può essere prodromo della sincope per ischemia dei muscoli del collo e delle spalle che fa parte dell’ ipoafflusso nelle parti alte del corpo, e questo può dare dolore muscolare, talora una situazione di questo tipo non evolve in sincope ma rimane allo stato di presincope e può essere un campanello d’allarme in pazienti che potrebbero andare in sincope se la situazione peggiora, visione scura offuscata.
Osservazione rilevati da testimoni: come è caduto? Se improvvisamente o lentamente, nella sincope e nell’epilessia la caduta è improvvisa, il paziente si può far male perché può sbattere; (Nella sincope nel giro di 30 sec- 1 min passa, il paziente si riprende, nella crisi epilettica può durare non più di tanto la crisi quanto lo stato post-critico mentre nella crisi funzionale può durare anche mezz’ora) presenza di movimenti muscolari tonici-clonici, o minime mioclonie che possono comparire nella sincope per ipoafflusso cerebrale.
Dovrebbe essere ricercata la presenza di precedenti malattie inclusa quella a carattere familiare e raccolta un’attenta anamnesi dell’ eventuale terapia farmacologica in atto.
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