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Transient loss of consciousness Flashcards

1
Q

What are the ‘big three’ for a differential diagnosis of TLOC?

A
  1. Epileptic seizure
  2. Syncope
  3. Psychogenic nonepilpetic seziure
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2
Q

Define a seizure

A

Clinical manfestation of abnormal and excessive discharge of cerebral neurones

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3
Q

Causes of a seizure

A

May be due to epilepsy, may be the first seizure, may be an acute symptomatic seizure

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4
Q

Define epilepsy

A

a tendency to experience recurrent unprovoked epileptic seizures

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5
Q

two important factors which cause different clinical manifestations of a seizure

A

where the seizure arises from

where the seizure spreads to

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6
Q

What is a focal onset of an epileptic seizure?

A
  • Simple, partial seziure [aura]
  • Complex partial seziures
  • Secondary generalized tonic clonic seziures [GTCS]

Structural cause

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7
Q

Focal onset is one, what is the other type of onset for ES? How do they present?

A

Generalized tonic clonic seizures [GTCS]
Moyclonic jerks
Absences

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8
Q

Causes of generalized onset seizures

A

Idiopathic/genetic cause
family history
Early morning seizures, worse with sleep deprivation or alcohol, photosensitivity

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9
Q

What does an absence seizure look like on an EEG?

A

slides

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10
Q

When is the only time you should talk about ‘absence seizures’?

A

Only if you mean a clinical absence seizure associated with a 3 second spike and wave on the EEG.

Otherwise, use ‘loss of awareness’ or ‘vacant spell’.

Lots of seizures can cause somebody to briefly lose awareness, not just absence seizures.

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11
Q

What is the technical term for syncope?

A

Transient global cerebral hypoperfusion

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12
Q

Three main causes for a syncope

A

Reflex [nuerally mediated]:

  • VASOVAGAL
  • situational
  • carotid sinus hypersensitivity

Cardiogenic

Orthostatic hypotension
- drugs, autonomic failure

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13
Q

Cause for cardiac syncope

A
  1. Condiitons that predispose to transient tachyarrhythmias
  2. Bradyarhythmias
  3. Cardiac ischaemia
  4. Structural heart disease
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14
Q

What would a cardiac syncope look like on an ECG?

A

slides

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15
Q

What would Wolff-Parkinson-White look like on an ECG?

A

slides

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16
Q

What would Brugada syndrome look like on an ECG?

A

slides

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17
Q

What is Brugada syndrome?

A

look up

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18
Q

Arrythmogenic right ventricular dysplasia on ECG

A

slides

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19
Q

learning point 2: what do conditions that give rise to transient tachyarrhythmias look like on an ECG?

What can these conditions cause?

What should you ALWAYS do on a patient with TLOC?

A

Have an abnormal ECG between events

These conditions cause sudden death in young people

Do an ECG in pts with TLOC

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20
Q

Which type of heart block have a high risk of progression to asystole?

A

Complete [3rd degree] heart block

Moritz type II 2nd degree heart block

incomplete trifascicular block

  • RBBB
  • LAD
  • 1st degree heart block
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21
Q

how does acute ischaemia cause syncope?

A

Causes syncope due to arrhythmia, output failure or acute mitral regurgitation

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22
Q

What can previous MI cause to the heart?

A

Can cause scar related VT

23
Q

Which two conditions can cause cardiac syncope by cardiac outflow obstruction during exertion?

A

Aortic stenosis

Hypertrophic cardiomyopathy

24
Q

What can cardiac syncope look like?

25
Learning point 3: what is the most important Ix to do in the first seizure clinic? A blackout during exercise is what until proven otherwise?
ECG is the most important Ix in the first seizure clinic. A blackout occurring during exercise is cardiogenic until proven otherwise
26
What is PNES also known as?
Psychogenic non-epileptic seizure: - 'pseudo-seizures' - 'non-epileptic attack disorder' - 'dissociative seizures'
27
Define PNES
Episodes of movement, sensation or experience that resemble epileptic seizures, but without ictal cerebral discharges Physical manifestations of psychological distress Associated with comorbid psychopathology and with childhood sexual abuse
28
Differential Dx of TLOC
Rare but important: 1. Hypoglycaemia 2. Acute hydrocephalus
29
Should vascular causes be a DDx of TLOC? what about migraine? W
No, look up why. | Slides suggest it is to do with the reticulating activating system.
30
Learning point 4: should TIA be a DDx for TLOC?
[almost] never a DDx for TLOC
31
how do we make a Dx w/o a video of the event of syncope?
History is essential
32
Main important questions in the history from the patient's account
What were the circumstances of the event? What do they recall beforehand? What is the next thing they remember? Did the attack cause injury or incontinence?
33
What should you do if there was a witness?
Phone them up, then ask: - in what circumstances did the event occur? - what were the first signs of the attack? - what exactly happened during the attack? loss of consciousness/stiffening trunk/hands, eyes opened/closed, cyanosis/noisy breathing/vocalisation - how long did the event last? - what immediately happened after the event?
34
What are other useful history features?
slides
35
PMH questions
slides
36
DH questions
anti-depressants [psychological comorbid.], tramadol
37
SH questions
evidence of psychological comorbid alcohol and drugs driving
38
FH questions
seizures, sudden cardiac death, evidence of psychological comorbid.
39
Learning point 5: if you haven;t made a Dx end of history, are you likely to make one at all?
no, unlikely
40
Characteristics of a GTCS [circumstances, prodrome, wtiness, duration, post-ictal phase, other phenomena, other events, PMH, DH, SH, FH]
slides
41
Characteristics of a syncope
slides
42
Characteristics of PNS
slides
43
Important when to do generla and neuro examination?
In acute seizures
44
Why examination is important in the acute setting?
look up
45
most important ECG all pts with TLOC should have?
12 lead ECG!
46
When should neuroimaging be used?
Ct useful in acute assessment seizures CT not indicated in syncope [unless acute hydrocephlus suspected] Pts with epilepsy should have neuroimaging, unless they have a Dx of genetic generalized epilepsy MRI is the Ix of choice Abnormalities on imaging are found in about 30% of pts with epilepsy
47
When is an EEG useful?
Useful in the Dx and classification of epilepsy
48
When is a EEG not useful? [why it's known as one of the most abused Ix]
slides
49
how to record an event ECG?
slides
50
Percentage of pts referred to specialist epilepsy clinic with refractory seizures that don't have epilepsy
26.1%
51
Most commonly made mistakes when Dx epilepsy
Incomplete history, lack of witness account Misinterpretation of syncope, myoclonic jerks Misinterpretation of EEG-changes
52
What are the consequences of misdiagnoses?
100% treated with anticonvulsants 39% unemployed 41% barred from driving
53
Is all jerking epilepsy/
NO
54
Which circumsrtances should psychogenic seizures be thought of?
Setting pt with presumed status or refractory epilepsy

Neurology (13 decks)

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