The semiology of tilt-induced reflex syncope in relation to electroencephalographic changes
Abstract
Syncope is defined as transient loss of consciousness as a result of cerebral hypoperfusion. Electroencephalography during syncope shows either a 'slow-flat-slow' or a 'slow' pattern. The first is believed to denote more severe hypoperfusion. Although the diagnosis of vasovagal syncope relies primarily on history taking, there is limited evidence regarding the relative importance of various clinical features, and none that relate them to the severity of electroencephalographic changes. The aim of this investigation was to study symptoms, signs and electroencephalographic changes with a 1 s resolution using electroencephalography and video data in 69 cases of tilt-induced vasovagal syncope. The main finding was that flattening of the electroencephalograph indicated more profound circulatory changes: the 'slow-flat-slow' group had a lower minimum blood pressure, longer maximum RR-interval, contained more cases with asystole and had a longer duration of loss of consciousness than the 'slow' group. Second, we describe a range of signs, including some that have rarely been reported in syncope, e.g. oral automatisms. Third, signs occurred at different rates depending on electroencephalographic flattening, suggesting a classification of syncopal signs. Type A signs (e.g. loss of consciousness, eye opening and general stiffening) develop during the first slow phase, stay present during flattening and stop in the second slow phase. Type B (particularly myoclonic jerks) occur when the electroencephalograph is slow but not flat: their abolition with electroencephalographic flattening suggests dependence on cortical activity. Type C signs (making sounds, roving eye movements and stertorous breathing) occur only in the flat phase, whereas type D (dropping the jaw and snoring) may occur either in slow or flat phases. In conclusion, our findings provide a detailed assessment of clinical symptoms in relation to electroencephalographic (EEG) changes during tilt-induced syncope.
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A sudden cessation of cerebral blood flow for as short as 6-8 s can cause complete LOC.
“A sudden cessation of cerebral blood flow for as short as 6-8 s can cause complete LOC.”
From 2018 ESC Guidelines for the diagnosis and management of syncope (2018) · cites this paper as [9]
The Introduction (page unavailable) defines syncope as loss of consciousness due to cerebral hypoperfusion. The Patterns of selected events section reports when loss of consciousness began relative to EEG slowing, but the paper does not establish that a complete cessation of cerebral blood flow for 6–8 seconds causes it. (LLM, conf=0.86)
Experimental — accuracy not yet measuredA systolic BP of 50-60 mmHg at heart level (30-45 mmHg at brain level in the upright position) will cause LOC.
“A systolic BP of 50-60 mmHg at heart level, i.e. 30-45 mmHg at brain level in the upright position, will cause LOC. 8,9”
From 2018 ESC Guidelines for the diagnosis and management of syncope (2018) · cites this paper as [9]
The Introduction describes syncope as loss of consciousness due to cerebral hypoperfusion associated with low blood pressure, and the Heart rate and blood pressure section measures pressure during syncope. But the paper reports smoothed mean arterial pressure, not a systolic threshold of 50–60 mmHg at heart level or 30–45 mmHg at brain level; those figures are not supported by our copy. (LLM, conf=0.82)
Experimental — accuracy not yet measuredPPS and PNES differ pathophysiologically from the TLOC forms that they resemble: in PPS, BP and HR are normal or high rather than low, and the EEG is normal instead of showing the slowing or flattening typical of syncope; in contrast to epileptic seizures, the EEG in PNES shows no epileptiform brain activity during an attack.
“PPS and PNES differ pathophysiologically from the TLOC forms that they resemble: in PPS, BP and HR are normal or high rather than low, and the EEG is normal instead of showing the slowing or flattening typical of syncope; in contrast to epileptic seizures, the EEG in PNES shows no epileptiform brain activity during an attack.”
From 2018 ESC Guidelines for the diagnosis and management of syncope (2018) · cites this paper as [9]
Split into 2 atoms — 0 confirmed, 1 partially supported, 0 disputed, 0 misattributed, 1 unverifiable. Expand the claim to see per-atom verdicts.
Experimental — accuracy not yet measuredThis approach has revealed new pathophysiological insights in syncope.
“This approach has revealed new pathophysiological insights in syncope. 9”
From 2018 ESC Guidelines for the diagnosis and management of syncope (2018) · cites this paper as [9]
Attaching the camera to the tilt table allows detailed study of the face and head, which is useful when assessing the start and end of LOC.
“Attaching the camera to the tilt table allows detailed study of the face and head, which is useful when assessing the start and end of LOC. 9,205”
From 2018 ESC Guidelines for the diagnosis and management of syncope (2018) · cites this paper as [9]
There are two types of psychogenic TLOC: PPS and PNES.
“There are two types: PPS and PNES.”
From 2018 ESC Guidelines for the diagnosis and management of syncope (2018) · cites this paper as [9]
The Conclusion mentions psychogenic attacks when discussing eye closure, but does not classify psychogenic transient loss of consciousness. Searches for PPS, PNES, psychogenic pseudosyncope, and a two-type classification found no passage stating that the two types are PPS and PNES; the paper’s classification instead concerns signs of syncope in relation to EEG changes. (LLM, conf=0.76)
Experimental — accuracy not yet measuredIn PPS movements are absent, so PPS resembles syncope or longer-lasting LOC, whereas in PNES impressive limb movements mean the attacks resemble epileptic seizures.
“In PPS movements are absent, so PPS resembles syncope or longer-lasting LOC, whereas in PNES impressive limb movements mean the attacks resemble epileptic seizures.”
From 2018 ESC Guidelines for the diagnosis and management of syncope (2018) · cites this paper as [9]
The Conclusion discusses eye closure in psychogenic attacks, but not whether movements are absent in PPS or prominent in PNES. The Introduction and syncope results describe movements during syncope, not the claimed comparison between PPS, PNES, syncope and epileptic seizures. Searches for PPS, PNES and those movement comparisons found no passage that addresses the claim. (LLM, conf=0.74)
Experimental — accuracy not yet measuredIn psychogenic TLOC there is no gross somatic brain dysfunction, but the attacks fulfil the criteria for TLOC.
“In psychogenic TLOC there is no gross somatic brain dysfunction, but the attacks fulfil the criteria for TLOC (see section 3.1).”
From 2018 ESC Guidelines for the diagnosis and management of syncope (2018) · cites this paper as [9]
The Conclusion distinguishes psychogenic attacks from syncope and seizures by noting that the eyes are commonly closed in psychogenic attacks. It does not say whether those attacks involve gross somatic brain dysfunction or fulfil criteria for transient loss of consciousness; searches for those points found no supporting passage in our copy. (LLM, conf=0.72)
Experimental — accuracy not yet measuredEpilepsy and syncope may evoke one another on rare occasions, resulting in epileptic seizures triggering syncope as well as syncope triggering an epileptic seizure.
“Epilepsy and syncope may evoke one another on rare occasions, resulting in epileptic seizures triggering syncope as well as syncope triggering an epileptic seizure.”
From 2018 ESC Guidelines for the diagnosis and management of syncope (2018) · cites this paper as [9]
The Introduction (page unavailable) discusses syncope and epileptic seizures as causes of transient loss of consciousness, but does not say either can trigger the other. Searches for bidirectional triggering and for seizure-related syncope or hypoperfusion-induced seizures found no passage addressing that claim. (LLM, conf=0.74)
Experimental — accuracy not yet measured
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Self-citation
- Authors
- van Dijk, J. G., Thijs, R. D., van Zwet, E., Tannemaat, M. R., van Niekerk, J., Benditt, D. G., & Wieling, W.
- Affiliations
- Leiden University Medical Center (NL)
- Netherlands Institute for Neuroscience (NL)
- University of Minnesota (US)
- Amsterdam UMC Location University of Amsterdam (NL)
- Venue
- Brain
- Publisher
- Oxford University Press (OUP)
- Published
- 2013-12-16
- Volume
- 137
- Issue
- 2
- Pages
- 576-585
- ISSN
- 0006-8950 (ISSN-L)
- 1460-2156
- OpenAlex
- W2128227714
- Cited by
- 160
- References
- 33
- Citations by year
- 2026: 9 · 2025: 6 · 2024: 8 · 2023: 11 · 2022: 7 · 2021: 15 · 2020: 19 · 2019: 12 · 2018: 16 · 2017: 22 · 2016: 14 · 2015: 11 · 2014: 10
- FWCI
- 11.49
- Type
- journal article
- Language
- en
- Open access
- closed
- Locations
- Brain (publishedVersion)
- PubMed (publishedVersion)
- Pure Amsterdam UMC (publishedVersion)
- KNAW research portal (Royal Academy of Art and Sciences (KNAW)) (publishedVersion)
- Data Archiving and Networked Services (DANS) (submittedVersion)
- Leiden Repository (Leiden University) (submittedVersion)
- KNAW Research Portal (The Royal Netherlands Academy of Arts and Sciences) (submittedVersion)
- Topics
- Health Sciences › Medicine › Surgery › Cardiovascular Syncope and Autonomic Disorders
- Life Sciences › Neuroscience › Neurology › Vestibular and auditory disorders
- Health Sciences › Medicine › Cardiology and Cardiovascular Medicine › Heart Rate Variability and Autonomic Control
- Keywords
- vasovagal syncope, cerebral hypoperfusion, myoclonic jerks, asystole, blood pressure, loss of consciousness, video-EEG monitoring
- MeSH terms
- Adolescent, Adult, Aged, Aged, 80 and over, Blood Pressure, Child, Electroencephalography, Female, Humans, Male, Middle Aged, Reflex, Syncope, Tilt-Table Test, Young Adult
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