Morganyi-Adams-Stokes's syndrome

Description:

Blinking — Adams — Stokes a syndrome (O.V. of Morgagni, the ital. doctor and the anatomist, 1682 — 1771; R. Adams, Irish doctor, 1791 — 1875; W. Stokes, the Irish doctor, 1804 — 1878) — an attack of the loss of consciousness which is followed by sharp pallor and cyanosis, disturbances of breath and spasms owing to the acute hypoxia of a brain caused by sudden falling of cordial emission.

Symptoms of the Syndrome of Morganyi-Adams-Stokes:

The attack comes suddenly. The patient has a sharp dizziness, blackout, weakness; he turns pale and in several seconds faints. Approximately in half-minute generalized epileptiform spasms develop, quite often there are an involuntary urination and defecation. About half-minute more later usually there comes the apnoea what the respiratory arrhythmia can precede to, and the expressed cyanosis develops. Pulse during an attack usually is not defined or it extremely rare, soft and empty. It is not possible to measure the ABP. Extremely frequent cardiac sounds are sometimes listened very rare or, on the contrary. If the attack is connected with fibrillation of ventricles, over a xiphoidal shoot of a breast peculiar "hum" (Goering's symptom) is in certain cases listened. Along with approach of cyanosis pupils sharply extend. After recovery of pumping function of heart of the patient quickly recovers consciousness, at the same time most often he does not remember an attack and feelings (retrograde amnesia) preceding it.
Rate of development of an attack, its weight and symptomatology can be very various. At very small duration the attack quite often has the reduced character, being limited to short-term dizziness, weakness, a short-term vision disorder. The syncopal state sometimes proceeds several seconds and is not followed by development of spasms or other displays of the developed attack. Sometimes the loss of consciousness does not come even at very big heart rate (about 300 blows in 1 min.), the symptomatology at the same time is limited to sharp weakness and block. Similar attacks are more often observed at persons of young age with good contractility of a myocardium and intact vessels of a brain. In case of the expressed diffusion (usually atherosclerotic) defeat of brain vessels the symptomatology, on the contrary, develops promptly.
The diagnosis in typical cases is not difficult, but sometimes represents a certain complexity since abortally proceeding attacks which are shown only dizziness, weakness, blackout, short-term stupefaction and pallor quite often meet at various morbid conditions, including at such rasprostraneyny as chronic cerebrovascular insufficiency. At the developed picture of a syndrome of Morganyi — Adams — Stokes the differential diagnosis most often will be seen off with epilepsy, is more rare with hysteria. At an epileptic seizure the face of the patient is hyperemic, tonic spasms are replaced clonic, the attack is often preceded by aura, pulse during an attack is usually intense and speeded a little up, is often raised the ABP. At the hysterics proceeding with spasms a little speeded up and intense full pulse, the ABP is also defined it is slightly raised; cyanosis is not characteristic even at a prolonged attack. In doubtful cases, especially if necessary to carry out the differential diagnosis between Morganyi-Adams-Stokes and chronic cerebrovascular insufficiency, long continuous monitoring of an ECG is shown. For identification of the erased epilepsy forms (including diencephalic) also long monitoring of the electroencephalogram is desirable.

Reasons of the Syndrome of Morganyi-Adams-Stokes:

Clarification of origins of a syndrome is connected with development of electrocardiographic and especially cardiomonitor researches. Most often it is caused by various forms of atrioventricular blockade. The attack can arise at the time of transition of an incomplete atrioventricular block in full, and also at the time of emergence against the background of a sinoatrial rate or supraventricular arrhythmias of a total atrioventricular block. In similar cases development of an attack is connected with delay of emergence of ventricular automatism (a long preautomatic pause). At total cross block the attack arises in case of a sharp urezheniye of the impulses proceeding from the heart of the geterotopny center of automatism located in a ventricle, in particular at development of so-called blockade of an exit of impulses from this center. Sometimes lead an incomplete atrioventricular block of high degree with carrying out on ventricles of every of the third, fourth to sudden sharp decrease in cordial emission or the subsequent atrial impulses, and also a long preautomatic pause which precedes emergence of a ventricular rhythm at sudden development of sinuatrial blockade of high degrees or full suppression of activity (stop) of a sinus node. In most cases the attack arises if heart rate becomes less than 30 blows in 1 min. though some patients keep consciousness even at much smaller heart rate (12 — 20 in 1 min.) and, on the contrary, the loss of consciousness at the patient with diffusion defeats of vessels of a brain can develop at rather frequent reductions of heart (35 — 40 blows in 1 min.). Not only excessively rare, but also excessively frequent rate of reductions of ventricles of heart can serve as the reason of an attack (usually more than 200 blows in 1 min.) that is observed at an atrial flutter with carrying out on ventricles of each impulse arising in auricles (an atrial flutter 1:1) and at a takhisistolichesky form of a ciliary arrhythmia. Arrhythmias with such high heart rate arise, as a rule, in the presence at the patient of additional conduction paths between auricles and ventricles. At last, sometimes full loss of sokratitelny function of ventricles of heart owing to their fibrillation or an asystolia leads to development of an attack.

Treatment of the Syndrome of Morganyi-Adams-Stokes:

Treatment of patients with a syndrome of Morganyi — Adams — Stokes consists of the actions directed to stopping of an attack, and actions which purpose is the prevention of repeated attacks. At for the first time the revealed syndrome even if this diagnosis has presumable character, hospitalization in medical institution of a cardiological profile for specification of the diagnosis and the choice of therapy is shown.

    During the developed attack the patient on site is given the same immediate help, as well as at a cardiac standstill since directly the attack reason, as a rule, does not manage to be established at once. The attempt to recover cardiac performance is begun with sharp blow with the hand compressed in a fist on the lower third of a breast of the patient. In the absence of effect at once begin an indirect cardiac massage, and in case of an apnoea — an artificial respiration of companies in a mouth. Whenever possible resuscitation events are held in wider volume. So, if elektrokardiografichesk fibrillation of ventricles is revealed, make a defibrillation electric discharge of high voltage. In case of detection of an asystolia outside, transesophageal or transvenous electric cardiac activation, introduction to cardial cavities of solutions of adrenaline, Calcii chloridum are shown. All these actions continue before the termination of an attack or emergence of signs of biological death. Waiting tactics is inadmissible: though the attack can pass and without treatment, it is never impossible to be sure that it will not end with the death of the patient.

    Medicinal prevention of attacks is possible only if they are caused by paroxysms of tachycardia or a tachyarrhythmia; appoint constant reception of various antiarrhythmic means. At all forms of an atrioventricular block attacks of a syndrome of Morganyi — Adams — Stokes serve as the absolute indication to surgical treatment — implantation of electric pacemakers. The model of a stimulator is chosen depending on a blockade form. So, at a total atrioventricular block implant fixed permanent rate pulse generators. If the critical urezheniye of a heart rhythm against the background of an incomplete atrioventricular block occurs periodically, implant the pacemakers joining "on demand" (demand mode). The electrode of the implanted pacemaker is usually entered on a vein into a cavity of a right ventricle of heart where by means of these or those devices it is fixed in intertrabecular space. Less often (at the expressed sinoauricular block or a periodic stop of a sinus node) fix an electrode in a wall of the right auricle. The stimulator case usually have in a vagina of a direct muscle of a stomach, at women — in retromammary space. On open heart practically refused the implantation of electrodes applied earlier because of injury of operation. Terms of work of electric pacemakers are defined by the capacity of their power supplies and parameters of the impulses generated by the device. Operability of stimulators is controlled 1 time in 3 — 4 months by means of special extracorporal devices. Separate successful attempts of implantation of the stimulators generating programmed (the "steam rooms" "linked", etc.) the impulses allowing to stop a tachycardia attack and also tiny defibrillators which working electrode can be implanted in a myocardium of auricles or ventricles are described. These devices are supplied with systems for the automatic analysis of electrocardiographic information and work at emergence of certain disturbances of a cordial rhythm. In some cases destruction (cryosurgical, laser, chemical or mechanical) additional atrioventricular conduction paths, for example Kent bunch at patients with the syndrome of premature excitement of ventricles of heart complicated by a ciliary arrhythmia is shown.