Blackouts, Funny Turns and Dizziness

Question 1

What are blackouts?

Answer 1

-Episodes of loss of consciousness
=Consciousness is not a simply localised brain function
=Blackouts results from something that affects the brain GLOBALLY

Question 2

What are the general causes of blackouts?

Answer 2

-Syncope
-Epileptic seizure
=Then dissociative attack

Question 3

What is syncope?

Answer 3

-Loss of consciousness due to hypoperfusion of the brain

Question 4

Types of syncope

Answer 4

• Vaso-vagal (reflex)
• Postural hypotension (failure of autonomic NS)
• Cardiac (dysthymic/ structural)

Question 5

What are epileptic seizure blackouts?

Answer 5

-Consciousness lost due to abnormal electrical discharges in the brain

Question 6

Types of epileptic seizure

Answer 6

• Generalised epileptic seizures

- Complex partial seizures

Question 7

Clinical information needed to diagnose blackouts

Answer 7

• Clinical background
• Immediate context
• Onset of attack
• During attack (eye witness)
• Recovery from attack

Question 8

Clinical background for diagnosing blackouts

Answer 8

• Age
• PMH (brain injury)
• FH (inherited condition for epilepsy)
• Drug history

Question 9

Differentiating between epilepsy and syncope

Answer 9

-Favours epilepsy:
=long duration, post-event confusion (long recovery), cyanosis, sever biting of sides of tongue
-Both:
=Pallor, jerking, warning and stiffness

Question 10

What are the other causes of blackouts?

Answer 10

• Functional blackouts
• Non-epileptic attack disorder
• Dissociative attacks
• Hypoglycaemia (diabetes on treatment)

Question 11

Investigations for blackouts

Answer 11

• Depending on context, none
• ECG (conduction abnormality)

-In certain syncope cases
=Ambulatory ECG
=Tilt table testing

-In selected epilepsy cases:
=Routine EEG (limited utility confirming epilepsy, useful for classification type)
=Video-telemetry ECG (difficult cases)
=Cerebral imaging (cause of epilepsy)

Question 12

What are funny turns?

Answer 12

• Discrete episode(s)
• Due to some sort of brain event
• Deliberately vague/ inclusive definition unusual to patient
• Tend to reflect localised brain dysfunction
• Affecting a particularly focal brain area

Question 13

General causes of funny turns

Answer 13

• TIA
• Epileptic seizure
• Migraine

Question 14

What questions are used to differentiate funny turns?

Answer 14

-Onset/course
=Sudden onset/ simultaneous (multiple features)
=Sudden (occur at once) or spreading (develop)
-Sequential (multiple events)

-Nature
=Negative (loss of function)
=Positive
=Mixed

Question 15

TIA as funny turn

Answer 15

-Dysphagia and loss of limb power

=Sudden and simultaneous, negative

Question 16

Migraine as funny turn

Answer 16

• Tingling in arm, spreading over 15 minutes, followed by dysphagia (positive, spreading, sequential)
• Spreading, coloured pattern in vision with visual loss (spreading mixed)

Question 17

Epilepsy as funny turn

Answer 17

-Twitching fingers, spreading up arm, to whole arm twitching (positive, spreading and sequential)

Question 18

Other causes of funny turns

Answer 18

• Dissociation/ depersonalisation/ derealisation
• Anxiety/ panic attacks
• Hypoglycaemia
• Parasomnias

Question 19

Investigations of funny turns

Answer 19

• Clearly migraine= none

- TIA/ epilepsy= appropriate investigation

Question 20

What could a patient mean when describing dizziness?

Answer 20

• Imbalance (legs not head)
• Pre-syncope
• ‘Funny feeling’
• Vertigo

Question 21

What is vertigo?

Answer 21

-On or more:
=A distortion of static gravitational orientation
=An erroneous perception of movement of the sufferer
=An erroneous perception of movement of the environment
(not all vertigo is rotational vertigo)

Question 22

Main causes of vertigo

Answer 22

• Unusual stimulation of intact systems (motion sickness)

- Pathological dysfunction of those systems

Question 23

Three structural items dealing with static gravitational orientation and perception of motion

Answer 23

-Visual
-Vestibular (acceleration)
-Somatosensory
-Feed information to the vestibular nucleus in the brainstem
=motion perception and spatial orientation
=eye movements
=posture

=Mismatch= vertigo

Question 24

Components of vertigo syndrome

Answer 24

• Oculomotor: nystagmus, ocular deviation
• Autonomic: nausea, vomiting, sweating
• Postural: ataxia, falls
• Perceptual: vertigo, disorientation
• Secondary: anxiety, avoidance behaviour

-Peripheral (inner ear) vs central (brainstem)

Question 25

Classifying vertigo (time)

Answer 25

• Acute vertigo
• Recurrent, episodic
• Chronic

Question 26

Types of acute vertigo

Answer 26

• Isolated
• +deafness (peripheral/ ENT)
• +other neurological features (central/ neurology)

Question 27

What is vestibular neuronitis?

Answer 27

-Acute Unliteral Idiopathic Peripheral Vertigo (AUIPV)
=Vestibular nerve affected before joins cochlear nerve
=Inflammatory/ viral/ vascular
=NOT labyrinthitis (cochlear also damaged)

Question 28

Clinical presentation of AUIPV

Answer 28

• May come on over a few hours/ may awake with it
• Severe rotatory vertigo, accompanying vertigo disturbances (nausea), exacerbated by head movement (injured vestibular side stimulated)
• Often prostrate for around a week, gradual recovery with good prognosis
• Vertigo on sudden head movements may persist

-Recovery: resolution and central compensation

Question 29

What is Benign Paroxysm Positional Vertigo?

Answer 29

• BPPV
• Attacks of rotational vertigo
• Generally last 10-20 seconds, may be brief nausea
• Provoked by positional change

Question 30

What is BPPV caused by?

Answer 30

-Fragments of otoliths in semi-circular canals
=Preceding history of head trauma in some cases
=Good prognosis
=Positional exercises can help