Çocuklarda Senkop Etiyolojisi, Nörolojik ve Kardiyolojik İncelemelerin Tanıdaki Değeri

Abstract

Amaç: Çocuklarda en sık nörokardiyojenik senkop görülmekle birlikte, altta yatan pek çok kardiyak ve nörolojik hastalık senkopa yol açabilir. Buna karşın nedene yönelik yapılan incelemelerin tanısal değeri oldukça düşüktür. Bu çalışmada, senkop nedeniyle başvuran hastaların klinik özellikleri, etiyolojisi ve yapılan incelemelerin tanısal değerinin belirlenmesi amaçlandı.Gereç ve Yöntemler: Temmuz 2011 ile Aralık 2013 tarihleri arasında çocuk nöroloji bölümüne senkop nedeniyle yönlendirilen 169 (%70.1) kız, 72 erkek (%29.9) toplam 241 hastanın dosyası retrospektif olarak incelendi. Senkop etiyolojisi ve tanı amaçlı yapılan testlerin tanıya ulaşmadaki değeri belirlendi.Bulgular: Olguların 146’sında (%60.6) nörokardiyojenik senkop, 30’unda (%12.4) postural ortostatik taşikardi sendromu (POTS), 22’sinde (%9.1) epilepsi, 6’sında (%2.5) kardiyak senkop, 23’ünde (%9.5) psikojenik psödosenkop, 4’ünde (%1.7) refleks senkop, 1’inde (%0.4) hidrosefali saptanırken, 9 (%3.7) hastada etiyoloji belirlenemedi. Yüz elli yedi (%65.1) olguya elektroensefalografi incelemesi yapıldı ve bunların 25’inde (%15.8) epileptik aktivite görüldü. Nörogörüntüleme yapılan 95 (%39.4) hastanın 1’inde (%1.1) mezial temporal skleroz, 1’inde (%1.1) akuaduktus Sylvii stenozu görülürken, 12 (%13.0) hastada rastlantısal nonspesifik beyaz cevher lezyonları izlendi. Olguların tamamına yapılan elektrokardiyografinin, 3’ünde (%1.3) tam atrio-ventriküler blok, 1’inde (%0.4) 2. derece atrio-ventriküler blok (Mobitz Tip II), 1 (%0.4) tanesinde ise kısa PR aralığı ve delta dalgası saptandı. Ekokardiyografik incelemede, olguların 11’inde (%4.6) mitral kapak prolapsusu, 3’ünde (%1.7) mitral yetersizlik saptanırken, 1 (%0.4) hastada ağır valvüler aort stenozu görüldü. Tilt testi yapılan 93 (%38.6) hastanın 34’ünde (%36.5) POTS saptanırken 14’ünde (%15.0) vazodepresör yanıt gözlendi. Holter testi yapılan 21 (%8.7) hastanın sadece 1’inde (%4.7) anormal kayıt bulundu. Hiçbir hastada senkop nedeni olarak anemi, elektrolit imbalansı ya da hipoglisemi saptanmadı.Sonuç: Pek çok nörolojik ve kardiyak hastalık senkop nedeni olabilir. Ayrıntılı öykü, fizik muayene ve EKG ile hastaların çoğuna tanı konulabilir. Elektroensefalografi, nörogörüntüleme, ekokardiyografi, tilt testi, holter testi ve rutin kan testlerinin tanıya katkısı oldukça sınırlıdır.

Keywords

• Çocuk, Kardiyak senkop, Nörokardiyojenik senkop

Etiology of Syncope in Children and the Value of Neurologic and Cardiologic Investigations in Diagnosis

Abstract

Objective: Although neurocardiogenic syncope is the most common type of syncope in children, a wide variety of neurologic and cardiologic disorders may present with syncope. However, the diagnostic yield for most tests commonly used in the evaluation of children with syncope is low. We aimed to document the clinical characteristics, etiology, and the value of neurologic and cardiologic investigations in the diagnosis of syncope in children.Material and Methods: Hospital charts of 241 children (169 female and 72 male) who were referred to the pediatric neurology department due to syncope between July 2011 and December 2013 were retrospectively reviewed. Outcome variables were etiology and yield of diagnostic tests performed.Results: The etiology was neurocardiogenic syncope in 146 (60.6%), postural ortostatic tachycardia syndrome (POTS) in 30 (12.4%), epilepsy in 22 (9.1%), cardiac causes in 6 (2.5%), psychogenic pseudosyncope in 23 (9.5%), reflex syncope in 4 (1.7%), unspecified syncope in 9 (3.7%) patients and hydrocephalus in 1 (0.4%) patient. Electroencephalography was performed in 157 (65.1%) patients and revealed epileptic discharges in 25 (15.8%) of them. Neuroimaging studies were performed in 95 (39.4%) patients and revealed incidental white-matter lesions in 12 (13%) patients and mesial temporal sclerosis and aqueductus Sylvii stenosis in 1 patient (%1.1) each. Electrocardiography was performed in all patients and revealed complete atrioventricular block in 3 (1.3%) patients and 2nd degree atrio-ventricular block (Mobitz type II) and short PR interval with a delta wave in 1 (0.4%) patient each. Echocardiography was performed in all patients and revealed mitral valve prolapsus in 11 (4.6%), mitral regurgitation in 3 (1.2%) patients and severe aortic stenosis in 1 patient (0.4%). Tilt testing was performed in 93 (38.6%) patients and revealed POTS in 34 (36.5%) and vasodepressor response in 14 (15.0%) patients. The Holter test was performed in 21 (8.7%) patients and was abnormal in 1 (4.7%) of them. Anemia, hypoglycemia or electrolyte imbalance was not found to be the cause of syncope in any of the patients.Conclusion: A wide variety of neurologic or cardiac disorders can present with syncope in children. A focused history and a thorough clinical examination along with electrocardiography can reveal the cause of syncope in the majority of cases. The yield of electroencephalography, neuroimaging, echocardiography, tilt test, Holter test, and routine blood tests is very low

Keywords

• Child, Cardiac syncope, Neurocardiogenic syncope

References

1. Feit LR. Syncope in the pediatric patient: Diagnosis, pathophysio- logy, and treatment. Adv Pediatr 1996;43:469-94.
2. Fischer JWJ, Cho CS. Pediatric syncope: Cases from the emergency department. Emerg Med Clin North Am 2010;28: 501-16.
3. Anderson JB, Czosek RJ, Cnota J, Meganathan K, Knilans TK, Heaton PC. Pediatric syncope: National hospital ambulatory medical care survey results. J Emerg Med 2012;43:575-83.
4. Driscoll DJ, Jacobsen SJ, Porter CJ, Wollan PC. Syncope in children and adolescents. J Am Coll Cardiol 1997;29:1039-45.
5. Ganzeboom KS, Colman N, Reitsma JB, Shen WK, Wieling W. Prevalence and triggers of syncope in medical students. Am J Cardiol 2003;91:1006–8.
6. Kapoor WN. Syncope. N Engl J Med 2000;343:1856–62.
7. Massin MM, Bourguignont A, Coremans C, Comté L, Lepage P, Gérard P. Syncope in pediatric patients presenting to an emer- gency department. J Pediatr 2004;145:223–8.
8. Brignole M, Alboni P, Benditt DG, Bergfeldt L, Blanc JJ, Thomsen PEB, et al. Guidelines on management (diagnosis and treatment) of syncope-update 2004. Executive Summary. Eur Heart J 2004;25:2054–72.

9. Hegazy RA, Lotfy WN. The value of Holter monitoring in the assessment of pediatric patients. Indian Pacing Electrophysiol J 2007;7:204–14.
10. Prodinger RJ, Reisdorff EJ. Syncope in children. Emerg Med Clin North Am 1998;16:617–26.
11. Landau WM, Nelson DA. Clinical neuromythology XV. Feinting science: Neurocardiogenic syncope and collateral vasovagal confusion. Neurology 1996;46:609–18.
12. Syncope or seizure? The diagnostic value of synchronous tilt testing and video-EEG monitoring in children with transient loss of consciousness. Epilepsy Behav 2012;24:93–6.