Brainstem and special senses Flashcards
How does the incidence of TLOC change depending on age?
More common as you age
Which cause of syncope has the worse outcome? Cardiac related cause or neurological cause?
Cardiac related cause
What are the main challenges we face with TLOC episodes?
- main witness is unconscious
- eye witness account is essential and can be unreliable
- unpredictable so they are difficult to record
- driving restriction and health and safety concerns
- initial diagnosis is often inaccurate
Differential diagnosis for TLOC?
- Syncope
- Vasovagal - situational and provoked
- Situational - provoked
- Orthostatic hypotension can be caused by medication
- Cardiac causes
- Seizures
- Non-epileptic attack disorder
What are important features to ask about in the history taking in someone presenting with TLOC?
Triggers
Prodrome: before attack any warning, aura, associated symptoms
What happened during the attack? - duration of attack, change in complexion, limb jerking or twitching, injuries, pulse, tongue biting or incontinence
What was the recovery like? - rapid or prolonged, confusion or sleepiness, duration, muscle pain
Frequency of attacks
Differences between vasovagal syncope and cardiac syncope?
Vasovagal - 3 P’s
- posture (upright)
- provocation
- prodromal (pale, sweaty, vision blurred, hearing muffled)
- brief duration, reduced muscle tone and rapid recovery
Cardiac syncope
- temporary but sudden reduction in blood supply
- vasodilation, hypotension, arrhythmia
- onset is rapid and recovery from LOC is spontaneous, complete and usually prompt.
Use ECG readings - any long QT syndrome, any heart block?
Signs which would suggest epilepsy instead of TLOC?
Epilepsy
- Description of an aura, deja vu
- Brief attack (30-180s)
- Prolonged post-ictal confusion
- Head turning or posturing of body
- Stiffening of body and myoclonic kerking
- Abnormal behaviour or which patients do not remeber
- Severe tongue biting
Are focal seizures limited to 1 hemisphere or both?
1 hemisphere
Where do generalised seizures occur in the brain?
- Originate at some point within and rapidly engage bilaterally distributed networks
- They can include cortical and subcortical structures but not necessarily the entire cortex
Differentiating TLOC from NEAD?
- NEAD is common and we are more likely to witness NEAD than epileptic seizure
- There is a gradual onset, undulating motor activity with pauses
- Sinusoidal and asynchronous arm and leg movements - they do not follow a pattern
- Prolonged atonia, rhythmic pelvic movements or thrusting and side to side head movements
- Post-ictal crying, high anxiety in carers - patient carer is continiously asking for help is a clue to NEAD
- Prolonged attack with prolonged or unexpected sudden recovery
- In NEAD there may be different types of seizures every time
- History of somatoform or MUS in patients with NEAD is common
Investigations we should carry out for TLOC?
ECG!
EEG: only used to determine the type of epilepsy
MRI: only for focal epilepsy
