Chapter 2. Episodic Impairment of Consciousnes Flashcards
Question 2-1: A simple faint is provoked by which of the following? A. Prolonged standing B. Emotional stress C. Unpleasant visual stimuli D. Pain E. All of the above
Answer 2-1: E.
All of these can precipitate the hypotension
which is responsible for the simple faint. All
of these have autonomic consequences which
predispose to hypotension, cerebral
hypoperfusion, and loss of consciousness.
(PI I)
Question 2-2:
Which feature suggests that the cause for an episode of loss of consciousness was a seizure rather than cardiac or vasovagal syncope?
A. Precipitation by emotional stress
B. Confusion upon awakening
C. Twitching of the arms during the blackout
D. Weakness upon awakening
E. All of the above
Answer 2-2: B.
Confusion upon awakening is more likely in a
patient with seizure rather than cerebral hypoperfusion. Twitching is common with seizure and with hypotension, though the appearance would usually differ between etiologies; this may not be able to be determined if a spell is not observed by the examiner. Weakness upon awakening can be
seen with either syncope or seizure, although focal deficits suggest seizure. Provocation by emotional stress is typical of syncope and unexpected with seizure. (p 12)
Question 2-3: Provocation by emotional stress. A. Cardiac arrhythmia B. Vasodepressor syncope C. Seizure D. None of these
Answer 2.-3: B.
Emotional stress is most likely to precipitate vasodepressor syncope. Although cardiac arrhythmia can be exacerbated by stress, this is not a common immediate inciting event. Seizure is not expected to be more likely in the presence of stress. unless it is a pseudoseizure.
Question 2-4: Palpitations or fluttering in the chest. A. Cardiac arrhythmia B. Vasodepressor syncope C. Seizure D. None of these
Answer 2-4: A.
Palpitations and fluttering in the chest strongly
suggest cardiac arrhythmia, especially if the
chest symptoms occur immediate prior to an
event. Arrhythmia is not always heralded by
chest symptoms, however, so the absence of
such symptoms does not eliminate arrhythmia
as a possibility. (P12)
Question 2-5: Patient with a blackout spell is found to have a mild left hemiparesis. A. Cardiac arrhythmia B. Vasodepressor syncope C. Seizure D. None of these
Answer 2-5: C.
Seizure is the only one of these potential diagnoses which would commonly be associated with focal findings on neurologic examination. The focal deficit suggests a structural abnormality which can be the focus of the seizure. Care should be exhibited with
examination immediately following a seizure, since recovery of function may be asymmetric. so subtle findings are not always associated with structural abnormalities. (P12)
Question 2-6:
A 74-year-old man presents with episodes of loss of consciousness associated with brief twitching during the unconsciousness. The syncope is recurrent and provoked by shaving, especially during shaving of the neck. Which is the most likely diagnosis?
A. Seizure
B. Paroxysmal supraventricular tachycardia
C. Carotid vascular disease
D. Reflex cardiac arrhythmia
Answer 2-6: D.
Syncope induced by physical stimulation of
the neck suggests reflex arrhythmia due to
carotid sinus hypersensitivity. The stimulation
results in loss of cerebral perfusion due to
cardiac arrhythmia such as sinus bradycardia,
sinus arrest, or A V block. Peripheral
vasodilatation can be a contributing factor.
Subtle twitching is common with any cause of
syncope and does not obligate a diagnosis of
seizure. Choice C - Carotid vascular disease
can also be associated with syncope with neck
massage, though other neurologic symptoms
are more likely and this effect is much less
likely than carotid sinus hypersensitivity.
(pI4)
Question 2-7:
Which of the following can be causes of syncope?
1. Basilar migraine
2. Cervical osteoarthritis
3. Subclavian steal
4. Carotid Occlusive Disease
Select: A = 1. B = 1,3. C = 2,4. D= 4 only. E = All
Answer 2-7: E.
Any of these can produce syncope with a
common vascular basis. Basilar migraine can
produce cerebral vasospasm which can cause
syncope. Cervical osteoarthritis can produce
compression of the vertebral arteries, resulting
in vertebro-basilar insufficiency, although this
is rare. Subclavian steal commooly produces
decreased basilar perfusion especially with
exercise of the ann. Carotid occlusive disease
is unlikely to produce syncope, but can if
embolic disease results in cerebral
hypoperfusion. Also, fixed carotid occlusive
disease can produce syncope if anastomotic
vessels or perfusion pressure are even mildly
compromised. (PIS-16)
Question 2-8:
Which of the following statements are true regarding micturition syncope?
1. Most common in men
2. Exacerbated by ethanol use
3. Usually nocturnal
4. Associated with supraventricular tachycardia
Select: A = 1. B = 1,3. C = 2,4. D= 4 only. E = All
Answer 2-8: A.
Micturition syncope is most common in men,
who pass out during micturition when arising
during the nigh!. Reduction in inlravesicular
pressure causes reflex bradycardia rather than
tachycardia. Ethanol use prior to bed makes
micturition more likely. (p16)
Question 2-9:
A 24-year-old female presents with syncope preceded by lightheadedness. She has loss of consciousness without any motor acthity. Which studies are indicated for evaluation?
1. CBC
2. ECG
3. Echocardiogram
4. EEG
Select: A = 1. B = 1,3. C = 2,4. D= 4 only. E = All
Answer 2-9: ACRC
evaluates for anemia which can
predispose to syncope at any age. ECG and
Holter monitoring evaluate the possibility of
arrhythmia. Echocardiogram can evaluate for
contractile dysfunction or, at this age, valvular
dysfunction. EEG is indicated mainly for
patients with seizure activity, so if their
history suggests cardiovascular causes, EEG is
not needed. (p 17)
Question 2-10: 24-year-old man with episodes of loss of consciousness without loss of posture, followed by several minutes of confusion. A. Absence seize B. Complex partial seizure C. Both D. Neither
Answer 2-10: B.
Complex partial epilepsy may resemble
absence epilepsy, but there is commonly a
period of postictal confusion. (p 19)
Question 2-11: 16-year-old female with episodes of loss of responsiveness for a few seconds without loss of posture. Normal function immediately following the episode. A. Absence seize B. Complex partial seizure C. Both D. Neither
Answer 2-11: A.
Absence epilepsy typically presents with
episodes of unresponsiveness without loss of
posture. There is no postictal confusion. (p 19)
Question 2-12: Automatisms are present during the seizure. A. Absence seize B. Complex partial seizure C. Both D. Neither
Answer 2-12: C.
Both absence and complex partial seizures can be associated with automatisms. Absence epilepsy is associated with simple automatisms such as lip smacking, whereas complex partial epilepsy is associated with more complex stereotypic automatisms. (P19)
Question 2-13:
Which of the following features suggests pseudoseizure (nonepileptic seizure).
1. Occur solely or exclusively in sleep
2. Pelvic thrusting is common
3. Urinary incontinence is common
4. May be precipitated by photic stimulation or hyperventilation
Select: A = 1. B = 1,3. C = 2,4. D= 4 only. E = All
Answer 2-13: C.
Pseudoseizures are commonly characterized by pelvic thrusting, while this is uncommon in patients with real seizures. Both real seizures and pseudoseizures may be precipitated by photic stimulation or hyperventilation. and the spectrum of what stimuli evoke seizures is more extensive in patients with pseudoseizures. Pseudoseizures do not occur during sleep. and urinary incontinence is rare though not unheard of. (P19)
Question 2-14:
Breath-holding spells are differentiated from seizures by which of the following features?
A. Breath-holding spells occur several times per day whereas seizures are usually less common.
B. Clonic activity is seen only with epilepsy and not with breath- holding pells
C. Breath-holding spells occur without provocation, whereas epilepsy is frequently startle-induced
D. D. Incontinence is only seen with epilepsy and not with breath-holding spells
E. E. All of the above
Answer 2-14: A.
Breath-holding spells often occur several times per day. While this can be true of epilepsy, this high frequency is unusual. Clonic activity and incontinence are seen in both epilepsy and breath-holding spells, making differentiation difficult; nonneurologists often fall into the trap of assuming that all that shakes is seizure activity, whereas these episodes in children and clonic syncope in adults is not epilepsy. Provocation is the best differentiating clinical feature between epilepsy and breath-holding spells. (P20)
Question 2-15: Which ofthe following can cause episodic loss of consciousness? A. Aqueductal stenosis B. Colloid cyst ofthe third ventricle C. Chiari malformation D. Increased intracranial pressure E. All of the above
Answer 2-15: E.
All of these can be associated with syncope. Aqueductal stenosis and colloid cyst of the third ventricle can produce intermittent obstruction ofCSF flow, thereby elevating intracranial pressure. Increased CSF pressure decreases cerebral perfusion pressure. Chiari malformation can produce syncope in both children and adults. (P20-2l).
