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Brain Advance Access originally published online on July 8, 2009
Brain 2009 132(10):2630-2642; doi:10.1093/brain/awp179
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© The Author (2009). Published by Oxford University Press on behalf of the Guarantors of Brain. All rights reserved. For Permissions, please email: journals.permissions@oxfordjournals.org

Review Article

Symptoms and signs of syncope: a review of the link between physiology and clinical clues

Wouter Wieling1, Roland D. Thijs2,3, N. van Dijk4, Arthur A. M. Wilde5, David G. Benditt6 and J. Gert van Dijk2

1 Department of Internal Medicine, Academic Medical Centre, University of Amsterdam, Amsterdam, The Netherlands 2 Department of Neurology and Clinical Neurophysiology, Leiden University Medical Centre, Leiden, The Netherlands 3 Epilepsy Institute in the Netherlands SEIN, Heemstede, The Netherlands 4 Department of Clinical Epidemiology, Biostatistics and Bioinformatics, Academic Medical Centre, Amsterdam, The Netherlands 5 Department of Cardiology, Academic Medical Centre, University of Amsterdam, Amsterdam, The Netherlands 6 Cardiac Arrhythmia Center, Department of Medicine, University of Minnesota Medical School, Minneapolis, MN, USA

Correspondence to: W. Wieling, MD, PhD, Department of Internal Medicine, Academic Medical Centre/University of Amsterdam, Room-F4 221, PO Box 22700, 1100 DE Amsterdam, The Netherlands E-mail: w.wieling{at}amc.uva.nl

Detailed history taking is of paramount importance to establish a reliable diagnosis in patients with transient loss of consciousness. In this article the clinical symptoms and signs of the successive phases of a syncopal episode are reviewed. A failure of the systemic circulation to perfuse the brain sufficiently results in a stereotyped progression of neurological symptoms and signs culminating in loss of consciousness; when transient, this is syncope. Prior to loss of consciousness the affected individual tends to exhibit unclear thinking, followed by fixation of the eyes in the midline and a ‘frozen’ appearance. Narrowing of the field of vision with loss of colour vision (‘greying’ out) and finally a complete loss of vision (hence ‘blacking’ out) occurs. Hearing loss may occur following loss of vision. This process may take as little as ~7 s in cases of sudden complete circulatory arrest (e.g. abrupt asystole), but in other circumstances it may take longer depending on the rate and depth of cerebral hypoperfusion. Complete loss of consciousness occurs with the ‘turning up’ of the eyeballs. Profound cerebral hypoperfusion may be accompanied by myoclonic jerks.

Key Words: blood pressure; cerebral blood flow; syncope; reflex; vasovagal

Abbreviations: TLOC, transient loss of consciousness; EEG, electroencephalogram

Received February 3, 2009. Revised May 29, 2009. Accepted June 2, 2009.


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