What are drop attacks, also known as sudden loss of postural tone?

From the Guidelines

Drop attacks are sudden falls without clear warning signs or symptoms and without an obvious external cause, which should be classified as unexplained or non-accidental falls rather than drop attacks. According to the 2018 ESC guidelines for the diagnosis and management of syncope 1, the term 'drop attacks' may be used as a description of sudden falls, but it does not imply any specific cause and does not constitute a diagnosis.

Key Characteristics of Drop Attacks

• Sudden falls without warning or loss of consciousness
• No awareness of loss of consciousness (LOC)
• No obvious external cause such as stumbling over an object
• May be used to describe atonic seizures in epilepsy, sudden falls without vertigo in Ménière's disease, or a specific syndrome of unknown origin in middle-aged and elderly women

Diagnosis and Treatment

• Diagnosis involves a thorough medical history, physical examination, and tests to determine the underlying cause
• Treatment depends on the specific cause and may include medications, cardiac interventions, physical therapy, or surgical options
• Safety measures like removing tripping hazards, using assistive devices, and avoiding activities that could be dangerous during an episode are important preventive strategies to prevent serious injuries from falls, as noted in the context of the 2018 ESC guidelines 1.

Important Considerations

• The term 'unexplained' or 'non-accidental falls' is preferred over 'drop attacks' in the context of falls
• Drop attacks can be caused by various conditions, including vestibular disorders, cardiovascular problems, neurological conditions, and mechanical issues
• A thorough evaluation is necessary to determine the underlying cause and develop an effective treatment plan, as suggested by the guidelines 1.

From the Research

Definition and Causes of Drop Attacks

• Drop attacks encompass both falls and transient loss of consciousness, but the term is not clearly defined 2
• The most common causes of drop attacks are cardiovascular, with cardioinhibitory carotid sinus syndrome (CSS) or mixed CSS being common diagnoses in elderly patients 3
• Vestibular dysfunction is also a common cause of collapses, sometimes without typical vertigo, and may coexist with cardiovascular conditions, especially in the elderly 2
• Other potential causes of drop attacks include epilepsy, functional neurological disorder, cataplexy, and hydrocephalic attacks 2

Clinical Presentation and Diagnosis

• Drop attacks are defined as a sudden loss of postural tone without loss of consciousness, but the mechanism is often unknown 3
• A diagnosis of drop attacks can be established through clinical and electrographic criteria, and may require investigation for underlying arrhythmia or other serious cardiac disorders 2
• In elderly patients, a history of syncope may be unreliable, and routine investigation for hemodynamic changes during carotid massage and standing may be necessary 3

Management and Treatment

• Treatment of drop attacks depends on the underlying cause, and may involve management of cardiovascular conditions, vestibular rehabilitation, or treatment of underlying neurological disorders 2
• In cases of epilepsy, treatment with anticonvulsant medications such as carbamazepine may be necessary, but requires careful monitoring for potential adverse effects 4, 5, 6