Drop attacks are sudden spontaneous falls while standing or walking, followed by a very swift recovery, within seconds or minutes. Drop attacks are typically seen in elderly patients, and the most common cause is carotid sinus hypersensitivity, resulting in either short periods of reversible asystole, or in marked drop in blood pressure in response to carotid sinus stimulation. Drop attacks are differnetiated from vaso-vagal and other causes of syncope due to the characteristic feature of drop attack that is a sudden feeling of being pulled or pushed towards the ground without any loss of consciousness.

Causes of drop attacks include:

1. Vascular – transient ischemic attack, cerebrovascular accident, dissection, occlusion and hemorrhage
   • Intracranial hemorrhage
   • Posterior circulation infarction, emboli and vasospasm
   • Bilateral anterior circulation occlusion
   • Migraine – develops over 1 hour, with associated paresthesia, Hypertonia arterialis
   • Basilar artery insufficiency – older patient with no loss of consciousness, transient loss of lower extremity tone
2. Epilepsy/paroxysmal:
   • Neurally mediated syncope – 75% of all causes
   • Myoclonic seizure
   • Myoclonic-astatic seizure
   • Petit mal syndrome
   • Lennox-Gastaut syndrome – atonic seizure, myoclonic seizure and generalized tonic-clonic seizure typically occurring in neurologically abnormal patients
   • Juvenile Myoclonic Epilepsy – fall with myoclonus
   • Laugh or cough triggered epilepsy
   • Cataplexy associated with narcolepsy
   • Periodic paralysis
   • Complex partial seizure
   • Breath-holding spells – associated pallor/cyanosis, emotion related
   • Pure autonomic failure (Riley-Day Syndrome, long standing diabetes mellitus)
   • Episodic ataxia
   • Panayiotopoulos syndrome
3. Degenerative disease:
   • Postural instability with Parkinsons
4. Structural:
   • Chronic odontoid instability
   • Spinal cord trauma with transient paraplegia
   • Brainstem mass
5. Metabolic:
   • Hypoglycemia
   • Hypocalcemia
   • Hypomagnesemia
   • Toxins, drugs – cocaine, sedatives, antihistamine and tricyclic antidepressants
6. Cardiac:
   • Prolonged QT
   • Tachycardia
   • Bradycardia
   • Sick sinus syndrome
   • arhythmia
   • Hypertrophic cardiomyopathy
   • Aortic stenosis
   • Hypovolemia
7. Psychologic:
   • Malingering
   • Conversion disorder
   • Panic attack
   • Anxiety

• Seizure
• Transient ischemic attack
• Cerebrovascular accident
• Basilar artery insufficiency
• Hypoglycemia
• Hypotension
• Cataplexy associated with narcolepsy
• Cardiac arrhythmia
• Sick sinus syndrome
• Migraine
• Aortic stenosis
• Conversion disorder

• Important in the presence of an inciting event (Neuroleptic malignant syndrome, breatholding, postural), any loss of consciousness and presence of post-ictal period
• Initial tests:

1. Glucose
2. EKG
3. Pregnancy test
4. Urine toxicology test
5. CT head
6. Electrolytes
7. Later consider: EEG, Echocardiogram, MRI and Tilt test

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