Drop attacks

Douglas J Lanska MD FAAN MS MSPH (Dr. Lanska of the Great Lakes VA Healthcare System and the University of Wisconsin School of Medicine and Public Health has no relevant financial relationships to disclose.)
Originally released December 28, 2004; last updated January 29, 2017; expires January 29, 2020

This article includes discussion of drop attacks, otolithic catastrophe, otolithic crisis of Tumarkin, and Tumarkin falls. The foregoing terms may include synonyms, similar disorders, variations in usage, and abbreviations.

Overview

Drop attacks are sudden falls without loss of consciousness that are not precipitated by a specific stimulus, occur with abrupt onset and without warning, and are followed by a rapid return to baseline. The author explains the clinical presentation, pathophysiology, diagnostic work-up, and management of drop attacks.

Key points

 

• Drop attacks are sudden falls without loss of consciousness that are not precipitated by a specific stimulus, occur with abrupt onset and without warning, and are followed by a rapid return to baseline.

 

• The term “drop attack” has subsequently been used to encompass a wide variety of sudden falls with or without existing conditions known to increase the risk of falls, with or without provocation by a specific stimulus, with or without loss of consciousness, and with or without significant baseline abnormalities.

 

• A range of localizations for drop attacks is possible, but most commonly lower brainstem or spinal cord structures are implicated.

 

• Drop attacks generally indicate transient impairment of bilateral central nervous system structures involved in maintenance of postural muscle tone and balance.

 

• Tumarkin otolithic catastrophes (or crises) are drop attacks without associated autonomic or neurologic symptoms in patients with severe vestibular disease, usually due to Ménière disease.

Historical note and terminology

Drop attacks are sudden falls without loss of consciousness that are not precipitated by a specific stimulus, occur with abrupt onset and without warning, and are followed by a rapid return to baseline (Sheldon 1960). Initially these events were described in otherwise healthy elderly people (Sheldon 1960), but the term “drop attack” has subsequently been used to encompass a wide variety of sudden falls with or without existing conditions known to increase the risk of falls, with or without provocation by a specific stimulus, with or without loss of consciousness, and with or without significant baseline abnormalities.

For the purposes of this chapter, drop attacks do not include so-called epileptic “drop attacks” or other seizure-related falls (Rathore et al 2007; Abd-El-Barr et al 2010; Ito et al 2015; Kagawa et al 2016), presyncope or syncope, stimulus-sensitive loss of muscular tone, or falls in patients with marked nonparoxysmal leg weakness, ataxia, postural instability (eg, Parkinson disease, progressive supranuclear palsy), or sensory loss.

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