Blackout

Question 1

What are the reflex causes of syncope?

Answer 1

Vasovagal
Carotid sinus hypersensitivity
Situational syncope

Question 2

What are the cardiac causes of syncope?

Answer 2

Arrythmias
Structural cardiac pathology causing outflow
Massive PE

Question 3

What are the orthostatic causes of syncope?

Answer 3

Dehydration
Drugs
Autonomic instability
Baroreceptor dysfunction

Question 4

What are the cerebrovascular causes of syncope?

Answer 4

Vertebrobasilar insufficiency
Subclavian steal
Aortic dissection

Question 5

What are the non-syncopal causes of transient loss of consciousness?

Answer 5

Intoxication
Head trauma
Metabolic
Non-epileptic seizures
Epileptic seizures
Nacrolepsy

Question 6

What are the main causes of loss of consciousness in patients aged 25?

Answer 6

Vasovagal

Question 7

What are the main causes of loss of consciousness in patients aged 55?

Answer 7

Vasovagal syncope and cardiac arrythmias

Question 8

What is the main causes of loss of consciousness in patients aged 85?

Answer 8

Orthostatic hypotension caused by medications

Eg diuretics, ACE-I, Beta-blockers, alpha-blockers

Question 9

What should ask about before an episodes of loss of consciousness?

Answer 9

Warning? - No warning is most likely cardiac arrhythmias

Precipitating factors?

Trauma?

Question 10

What should you ask about the patient about their experience during their loss of consciousness?

Answer 10

How long for? Seconds or minutes? - Vasovagal/arrhythmia are short-lived, lasting seconds

Did they bite their tongue, move their limbs or were they incontinent? - Tongue biting = epilepsy, twitching and incontinence can be vasovagal

Question 11

What should you ask about the patient about their experience after their loss of consciousness?

Answer 11

Recover spontaneously?

Confused after recovery?

Question 12

What are the most important features of PMH with regards to loss of consciousness?

Answer 12

Diabetes
Cardiac illness
Peripheral vascular disease
Epilepsy
Anaemia
Psychiatric illnesses

Question 13

Mrs Maxwell is a 37-year-old housewife who has been referred to neurology outpatients by her GP after several episodes of loss of consciousness. The GP wonders if she has epilepsy. The GP’s letter adds that Mrs Maxwell is an anxious lady with a history of depression. She has come to outpatients with her husband.
You ask her about the attacks. She describes a series of different events. On one occasion, she says
she was having an argument with her 8-year-old son and then woke up on the floor. On another occasion, she was out shopping with her husband and son and collapsed. She also says she has ended up
on the floor at home without knowing how she got there. Her husband corroborates a number of these episodes. There never appears to be any warning or precipitant.
Her husband tells you the episodes typically last a few minutes. He says that sometimes she twitches,
but not always. Afterwards she appears fine apart from sometimes a headache. She tells you that she frequently suffers with headaches.

Given the history, what is the most likely diagnosis?

Answer 13

Non-epileptic seizures

Question 14

Mr Woodward is a 69-year-old gentleman who is brought to his GP by a friend after fainting in the street.
Mr Woodward has been visiting family for the past couple of days and has been complaining of ‘dizzy
spells’, although this is the first time he has lost consciousness. When asked what he means by ‘dizzy spells’, he confirms that he means light-headedness rather than vertigo (i.e. there is no rotational component
to the sensation). He says this occurs on standing and only started about a month ago. On the occasion on which he lost consciousness, his friend says he came round a few seconds later. He
says he wasn’t particularly confused afterwards, other than wondering why it happened. His medical
history includes hypertension, angina, and benign prostatic hyperplasia for which he takes aspirin, bendroflumethiazide, atenolol, and doxazosin. He has been taking these for several years, except the
doxazosin which he started a month ago.

Answer 14

Orthostatic hypotension

Question 15

Mr O’Brien is a 42-year-old estate agent who presents to his GP after several episodes of loss of consciousness
over the last 2 months. The episodes occurred whilst he was running or rushing, e.g. for the
bus. Each was immediately preceded by sweating. He does not recall any palpitations, nausea, chest
pain, or shortness of breath. He tells you that some of these episodes were witnessed and he was told that he was only unconscious for a few seconds. He has not bitten his tongue or been incontinent at any time. He says he recovers rapidly and is able to carry on as normal, although he has been taking it a bit easier.
He has no known history of cardiovascular disease, epilepsy, or diabetes, and takes no medications.
His pulse rate is 72 bpm and regular. There is a slow-rising carotid pulse. His apex beat is undisplaced and
there are no heaves or thrills. Heart sounds I and II are both audible and there is a loud ejection systolic
murmur which radiates to the carotids. His examination is otherwise unremarkable. His blood glucose, ECG, and U&Es are normal. In light of his heart murmur, you order an echocardiogram

Answer 15

Aortic stenosis

Question 16

Miss Gokhale is a 15-year-old school student who has come to neurology outpatients with her mother following three suspected seizures in the past 4 months. The first occurred during break time at school, after which she was brought to hospital by ambulance. Two subsequent attacks have taken place, one at home and another at school. Miss Gokhale has no recollection of the episodes, although
she knows that she is confused for some time after they occur. Her mother, who spoke to witnesses at school, says that during each attack she ‘goes tense and shakes vigorously’. She has not bitten her tongue or been incontinent. The attacks last 5–10 minutes, after which her daughter is confused for around 30 minutes.

Answer 16

Epileptic seizures

Question 17

What is a Stoke-Adams attacks?

Answer 17

A sudden transient loss of consciousness induced by a slow or absent and subsequent loss of cardiac loss of cardiac output

Underlying problem is either complete heart block or sinoatrial disease

Question 18

What is a tilt table test?

Answer 18

A tilt table test is sometimes used to help determine whether there is a vasovagal cause for blackouts. The patient is placed on a ‘tilt table’ that swings them from a supine position through 90° to upright. The patient is
connected to continuous ECG and blood pressure monitoring and asked to report their symptoms every 3–5 minutes. A baseline is established by monitoring the patient supine for 5 minutes. The patient is then tilted
(head up) to between 60° and 90° for between 10 and 60 minutes (a variety of different protocols are used).
The test is considered positive if:

• the patient experiences loss of consciousness with a significant fall in blood pressure or heart rate, in
which case they are returned to a supine position; or

• symptoms develop.