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Neurology Clinical > Collapse > Flashcards

Collapse Flashcards

1
Q

Differential Diagnosis of Collapse

A 
1- Epilepsy 
2- Syncope 
3- Psychogenic Attacks 
4- TIA / stroke 
5- Migraine 
6- narcolepsy 
7- Hypoglycaemia 
8- Hypersomnolence/OSA 
9- Infection 
10- Inner ear Pathology / BPPV
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2
Q

What are the 3 types of Syncope

A

1- Neurally mediated reflex

  • vasovagal : tunnel vision / lightheaded , brief
  • carotid sinus syncope: stimulated baroreceptors causing bradycardia& decrease BP
  • situational syncope : cough or micturition , giving blood
  • Valsalva : causes drop in bP

2- Cardiac

  • arrhythmias : heart block , tachycardia , decrease in CO
  • Valvular disease
  • Cardiomyopathies
  • Shunts

3- Perfusion

  • Orthostatic Hypertension
  • Hypovolaemia
  • Autonomic Failure
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3
Q

What types of Psychogenic attacks can cause collapse

A

1- Panic attacks / hyperventilation
2- night terrors
3- breath holding
4- Non-epileptical dissociative/functional event

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4
Q

How to Diagnose Blackouts

A

1- History
- any witnesses before , during or after ( usually get good history for before and after )

2- Examination

  • CVS : HR , BP
  • General
  • Neurological

3- Investigations

  • ECG / Holter monitor
  • Carotid sinus massage
  • tilt table
  • ECHO
  • MRI head
  • EEG
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5
Q

61 yr man , active went to gym in the morning.

  • briefly light headed
  • woke in casualty dazed , injured face , bitten side of tongue , not incontinent of urine
  • admitted ; sore but oriented

PMH : Hypertension 5 years (enalapril) , uncomplicated anteroseptal MI 2 years ago

Examination normal

ECG : Prolongation of PR interval , right bundle branch block , left anterior fascicular block = Trifasicular block

What is the likely Diagnosis ?
What is the treatment ?

A

Cardiac Syncope

Treatment : Pace maker

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6
Q

What has to be done for all unexplained blackouts

A

ECG to rule out Cardiac syncope

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7
Q

When to consider Cardiac Syncope

A

1- Treatment resistant epilepsy
2- Sleep-related seizures
3- normal EEG

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8
Q

Vasovagal vs Cardiac syncope presentation

A 
Vasovagal 
Trigger : Common 
prodrome: common ( nausea) 
onset: gradual 
Fatigue : minutes to hours 
Cardiac 
Trigger: uncommon 
prodrome : uncommon or brief 
Onset: sudden
Fatigue : none
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9
Q

What are hints it could be Cardiac syncope ( risk factors )

A

Syncope with heart disease

  • previous MI
  • congestive heart failure
  • abnormal ECG
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10
Q

16 year old girl collapsed while swimming

Prolonged QT interval

What is the diagnosis?
What is the treatment

A

Prolonged QT is a risk factor for Torsades de pointes

Treatment : Magnesium sulphate

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11
Q

Young female collapsed while swimming is usually due to what ?

A

Long QT syndrome due to torsades de pointes

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12
Q

27 yr man with nocturnal seizures

  • assaulted 2019 with metal pipe to front of head & lost consciousness
  • episodes for years but worse after injury
  • going and coming out of sleep
  • unable to move
  • sense of dread or nearby presence
  • breathing becomes shallow
  • tired next day and has headache

Girlfriend states

  • man is moaning
  • jerks a bit
  • Lucid and can recall seizures
  • not much snoring
  • heavy alcohol past and occasional smoker

FMH : similar problems

What is the likely diagnosis

a) Dissociative/non-epileptic attack
b) Frontal lobe epilepsy with nocturnal seizures
c) Narcolepsy
d) obstructive sleep apnoea
e) sleep paralysis

A

Sleep paralysis

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13
Q

What is sleep paralysis

A

Period of inability to voluntarily move either Hypnagogic ( at sleep onset ) or Hypnapompic ( upon waking up or in morning )

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14
Q

Sleep paralysis could be associated with what conditions

A

Nacrolepsy or Cataplexy syndrome

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15
Q

What exacerbates Sleep paralysis

A

Stress, excessive sleepiness , irregular sleep/wake cycle , jet lag

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16
Q

Presentation of Sleep paralysis

A

1- Isolated or frequent episodes
2- Associated with hallucinatory experiences
- sense presence
- pressure on chest with SOB or suffocation
- Floating or Flying out of body experience

17
Q

What is the cause of Sleep Paralysis

A

Dissociated manifesto of REM sleep

When Asleep during REM stage the body is paralyzed with exception of eye muscles. If suddenly aroused while in middle of REM , REM atonia ( sleep paralysis ) could happen before it’s switched off and you are awake

18
Q

What diseases can cause REM disorders

A

Parkinson’s disease

19
Q

15 yr girl with marked hypersomnolence after H1N1 vaccination

  • previously fit and well
  • Seasonal flu and swine vaccination 2015
  • Following spring, loses awareness multiple times during the day , nocturnal sleep not disrupted, legs giving away and occasionally dropping objects
  • Emotionally distraught , devastating affect on day to day function
  • no medication

Examination normal
MRI brain normal
Overnight SaO2 normal
EEG shows slowing during wakefulness and increased fast activity during REM sleep

What is likely diagnosis

a) Dissociative/non-epileptic attack
b) Frontal love epilepsy
c) Kleine-Levin syndrome
d) Narcolepsy
e) OSA
f) REM sleep behavioural disorder

A

d) Narcolepsy

20
Q

What is Narcolepsy & what is the Cause ( Different types )

A

One of the primary hypersomnia syndromes.
excessive sleepiness associated with cataplexy and other REM sleep phenomena ( sleep paralysis , hypnagogic hallucinations )

Cause:
Type 1 : hypocretin deficiency , always associated with cataplexy
Type 2 : 2+ SOREMPS on multiple sleep latency tests
Idiopathic hypersomnia : less than 2 SOREMPS

21
Q

What is hypersomnolence

A

excessive sleepiness

22
Q

What is cataplexy

A

sudden loss of muscle tone , causing weakness

23
Q

What is SOREMPS

A

Sleep onset REM periods, REM periods that occur within 15 minutes of sleep onset

24
Q

What is Klein-Levin Syndrome, presentation , onset , treatment , common in who?

A

Rare , usually in teenage years and more in males

Presents :

  • persistent episodic hypersomnia
  • cognitive or mood changes
  • hyrerphagia
  • hyper sexuality

Recurrent episodes > 10 years , individual episodes last from 1 week to 1 month

Symptoms spontaneously resolve

Onset usually follow viral infection

25
Q

What is Obstructive Sleep Apnoea , presentation , risk factors and associated risk of developing conditions ?

A

Excessive daytime somnolence - falls asleep a lot

Present :

  • wakes up gasping , choking or with sore/dry throat
  • poor memory and concentration
  • headaches
  • nocturne

Associated with increased risk of of hypertension , stroke and CVS disease

Risk factors : Age, obesity , Males, retrognathia

26
Q

What is retrognathia

A

Small chin

27
Q

33 yr left-handed women with shaking episodes since age of 24

  • up to 3 times a week
  • occurs when falling asleep , especially if stressed
  • left head, arm and leg aching , stiff, shaking for 10-30s
  • appears awake but not fully , chewing side of mouth
  • few minutes to recover

MRI brain normal
Inter-ictal EEG normal
ECG normal

Major events

  • every 2-3 months
  • especially if stressed , loss of consciousness and awareness
  • feels head turn to one side
  • wake up with people over her
  • tongue bitten in middle
  • incontinent of urine

What is the likely diagnosis

a) cardiac syncope
b) dissociative/functional disorder
c) epileptic seizure
d) panic disorder
e) vasovagal syncope

A

C) epileptic seizure

28
Q

33 yr left-handed women with shaking episodes since age of 24

  • up to 3 times a week
  • occurs when falling asleep , especially if stressed
  • left head, arm and leg aching , stiff, shaking for 10-30s
  • eyes closed
  • few minutes to recover

MRI brain normal
Inter-ictal EEG normal
ECG normal

Major events 
 - every 2-3 months 
- especially if stressed , loss of consciousness and awareness 
- head shakes from side to side 
- back arching 
shout out 
- wake up with people over her 
- tongue bitten on tip 
- incontinent of urine 
- injured in past 
- on lamotrigine trial but no changes

What is the likely diagnosis

a) cardiac syncope
b) dissociative/functional disorder
c) epileptic seizure
d) panic disorder
e) vasovagal syncope

A

B) dissociate / functional disorder

29
Q

Epileptic seizure Vs Psychogenic non-epileptic

A

Epileptic

  • Onset : rarely situational or gradual
  • stimuli : rarely
  • purposeful movement : rarely
  • Opisthotonus: very rare
  • Bite tongue tip : rare
  • Bite tongue middle : common
  • Prolonged octal atonia : very rare
  • Vocalization : very rare
  • Reactivity: very rare
  • Fluctuating in motor activity: very rare
  • Asynchronous limb -movement : common
  • eyelids commonly open
  • mouth usually closed
  • uncommon for convulsion to be > 2 minutes
  • Cyanosis common
  • incontinence may happen
Psychogenic 
-Onset : Situational and -gradual common 
-stimuli : occasionally 
-purposeful movement : occasionally 
-Opisthotonus : occasionally 
-Bite tongue tip : Occasional 
-Bite tongue middle : very rare
-Prolonged octal atonia : occasional
-Vocalization: occasional 
-Reactivity: occasional 
-Fluctuating in motor activity: common 
-Asynchronous limb movement : rare 
-Suttering /crying/ whispering  : common 
closed eyelids & mouth 
-Convulsion > 2 minutes common 
- incontinence may happen
30
Q

what is Opisthotonus

A

Back arching

31
Q

What can mimic NEAD ( non epileptic attack disorder ) and give presentation & how to differentiate

A

Frontal lobe epilepsy

  • patient remains conscious and have strange behaviour
  • eye lids open
  • Ictal grasping feature
  • pelvic thrusting
  • vocalization common
  • Arise from sleep, brief
  • quick tonic posturing
  • can be hyper motor but less dramatic and disorganized than NEAD

Differentiate : Video EEG
- Normal octal EEG is common in FLE so Video EEG is needed

Neurology Clinical (14 decks)

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