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Phase 3a - Neurology > Transient Loss of Consciousness : The History ; Lecture Flashcards > Flashcards

Transient Loss of Consciousness : The History ; Lecture Flashcards

1
Q

Define transient loss of consciousness (TLOC).

A

TLOC is a spontaneous loss of consciousness with complete recovery. It is also referred to as blackout or syncope. (NICE guidelines 2010, revised 2014).

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2
Q

TLOC is defined as a _________ loss of consciousness with complete _________.

A

spontaneous; recovery.

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3
Q

True/False: Sudden death due to cardiac arrhythmias is the most common killer in the US and causes 350,000 deaths annually.

A

True.

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4
Q

List two reasons why diagnosing TLOC can be challenging.

A

The main witness (the patient) is unconscious during the event, and eyewitness accounts are often unreliable but essential.

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5
Q

Driving restrictions and health & safety are key concerns for patients experiencing _________.

A

TLOC

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6
Q

Name one potential fatal outcome that TLOC might indicate.

A

TLOC can be the first symptom of a fatal arrhythmia.

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7
Q

True/False: Syncope is responsible for 3-5% of emergency room visits and 1-3% of hospital admissions in the UK.

A

True.

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8
Q

What are three categories of syncope in the differential diagnosis of TLOC?

A

Neurally mediated (e.g., vasovagal syncope)
Cardiac syncope
Neurological conditions (e.g., epilepsy).

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9
Q

_________ syncope includes cough, micturition, and carotid sinus hypersensitivity as provoking factors.

A

Situational.

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10
Q

What are key aspects to ask about before a TLOC episode?

A

Warning signs (e.g., aura or pre-syncopal symptoms).
Provoking features or associated symptoms.
Circumstances of the event.

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11
Q

During a TLOC episode, changes in _________, verbal/tactile responsiveness, and _________ jerking are key diagnostic clues.

A

complexion; limb.

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12
Q

What symptom distinguishes vasovagal syncope from epilepsy?

A

Lack of post-ictal confusion and the ability to hear people before responding.

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13
Q

Convulsive movements during syncope are _________.

A

common

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14
Q

What is a distinguishing feature of micturition syncope?

A

It involves relaxation rather than straining, except in cases of prostate enlargement or stricture.

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15
Q

What are the three main causes of reduced blood supply leading to cardiac syncope?

A

Vasodilation, hypotension, and arrhythmias.

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16
Q

Name one feature of TLOC that may suggest epilepsy rather than syncope.

A

Prolonged post-ictal confusion, head turning, or severe tongue biting.

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17
Q

What are two clinical features that help distinguish Non-Epileptic Attack Disorder (NEAD) from epilepsy?

A

Gradual onset with undulating motor activity.
Post-ictal crying and prolonged attacks.

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18
Q

True/False: EEG is a reliable diagnostic tool for distinguishing NEAD from epilepsy.

A

False

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19
Q

What is the most useful investigation for evaluating TLOC?

A

ECG

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20
Q

_________ imaging is not routinely used to distinguish epilepsy from other forms of TLOC.

A

Neuro

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21
Q

What is the most critical aspect of diagnosing and managing TLOC?

A

A detailed History

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22
Q

True/False: Non-specific findings on EEG or neuroimaging are common and can lead to misdiagnosis of TLOC.

A

True.

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23
Q

What are potential causes of transient ischemic attack (TIA) in young individuals?

A

Blood vessel abnormalities.
Cardiac causes.
Coagulation disorders.
Drug-related causes.

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24
Q

What are the key diagnostic tests for patients presenting with neurological symptoms?

A

MRI (with DWI/ADC images for ischemia).
ECG and prolonged cardiac monitoring for AF.
Echocardiography.
Blood tests for coagulation disorders.

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25
Q

What is the medical definition of a blackout?

A

A transient loss of consciousness (TLoC) with complete recovery and no residual neurological deficit.

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26
Q

How common is TLoC?

A

Accounts for 3% of A&E presentations.
Responsible for 1% of hospital admissions.

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27
Q

What are the primary causes of TLoC?

A

Fits, faints, and “funny do’s” (e.g., panic attacks, head injuries, trauma, metabolic/toxic causes)

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28
Q

What are the triggers and features of syncope?

A

Triggers: Posture, exertion, metabolic changes.
Pre-ictal: Pale, clammy, palpitations, chest pain, going dark.
Ictal: Floppy, seconds long, eyes closed, maybe jerks.
Post-ictal: Rapid recovery, usually within seconds.

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29
Q

What are the triggers and features of epileptic seizures?

A

Triggers: Alcohol, lack of sleep, illness, strobe lights, or no triggers.
Pre-ictal: Aura, staring/vacant episodes, vocalisation, posturing.
Ictal: Tonic-clonic movements, symmetrical jerks, eyes open, tongue bite, incontinence.
Post-ictal: Slow recovery, confusion, drowsiness, sleepiness.

30
Q

What are the features of NEAD?

A

Triggers: Stress, panic, heightened emotion, subconscious triggers.
Ictal: Thrashing, asymmetric violent movements, waxing/waning symptoms, back arching, crying.
Post-ictal: Rapid recovery, emotional, possible amnesia.

31
Q

What are the key components of the history for TLoC?

A

Witness account (video recordings if possible).
Circumstances of the event.
Posture immediately before the event.
Prodromal symptoms (e.g., sweating, feeling hot).
Appearance during the event (e.g., eyes open or shut, skin color).
Movement during the event (e.g., limb jerking).
Tongue-biting (tip vs. side).
Duration of the event.
Recovery period symptoms (e.g., confusion, weakness).

32
Q

What past medical history is relevant for TLoC?

A

Premature birth, febrile seizures, CNS infections, significant head injuries, psychological comorbidities.

33
Q

What social history should be considered?

A

Alcohol, recreational drugs, driving eligibility, psychological comorbidities.

34
Q

Define epilepsy.

A

A condition characterized by recurrent unprovoked seizures due to abnormal and excessive cerebral neuronal discharge.

35
Q

What are the classifications of seizures?

A

Focal onset: Simple partial, complex partial, secondary generalised tonic-clonic.
Generalized onset: Tonic-clonic, myoclonic, absences.

36
Q

What is the hallmark EEG finding in absence seizures?

A

3/second spike and wave pattern.

37
Q

What causes syncope?

A

Reflex (neurally mediated): Vasovagal, situational, carotid sinus hypersensitivity.
Cardiogenic: Tachyarrhythmias, bradyarrhythmias, cardiac ischemia, structural heart disease.
Orthostatic hypotension: Drugs, autonomic failure.

38
Q

What are red flag features of cardiogenic syncope?

A

Occurs during exertion.
Family history of sudden cardiac death (<40 years).
New or unexplained breathlessness.
Heart murmur.
ECG abnormalities.

39
Q

What is the most important investigation for a first seizure?

A

ECG

40
Q

What imaging is indicated in TLoC?

A

CT: Useful in acute seizure assessment but not indicated in syncope unless hydrocephalus is suspected.

MRI: Investigation of choice in epilepsy unless genetic generalised epilepsy is diagnosed.

41
Q

What is the role of EEG in epilepsy?

A

Useful for diagnosis and classification but does not exclude epilepsy if normal.

42
Q

What is PNES?

A

Episodes resembling seizures but without ictal cerebral discharges, often linked to psychological distress or trauma (e.g., childhood sexual abuse).

43
Q

How are PNES episodes diagnosed?

A

History and video evidence.
Video EEG monitoring if attacks are frequent.

44
Q

What are the most important points to remember when evaluating TLoC?

A

Take a comprehensive history, including events before and after the blackout.
Perform an ECG in all cases.
A blackout during exercise is cardiogenic until proven otherwise.
Not all jerking is epilepsy; consider other causes.
Address social and occupational concerns, such as driving eligibility.

45
Q

What driving advice is given to patients with TLoC?

A

Patients must stop driving unless TLoC is due to an uncomplicated faint.
Report TLoC to the DVLA after specialist assessment for orthostatic hypotension or other causes.

46
Q

What is the medical definition of transient loss of consciousness (TLoC)?

A

A temporary loss of consciousness with spontaneous recovery and no residual neurological deficit.

47
Q

What are the “Big Three” causes of TLoC?

A

Epileptic seizure
Syncope
Psychogenic non-epileptic seizures (PNES)

48
Q

What is an epileptic seizure?

A

A clinical manifestation of abnormal and excessive discharge of cerebral neurons.

49
Q

What are the classifications of seizures based on onset?

A

Focal onset: Simple partial, complex partial, secondary generalized tonic-clonic.
Generalized onset: Tonic-clonic, myoclonic jerks, absences.

50
Q

What EEG pattern is characteristic of absence seizures?

A

3/second spike-and-wave pattern.

51
Q

Seizures with a focal onset are often associated with a __________ cause, such as structural brain abnormalities.

A

structural

52
Q

True/False:
Q: Early morning seizures and seizures worsened by alcohol are typical of genetic epilepsy.

A

true

53
Q

What is the primary cause of syncope?

A

Transient global cerebral hypoperfusion.

54
Q

What are the types of syncope?

A

Reflex (neurally mediated): Vasovagal, situational, carotid sinus hypersensitivity.
Cardiogenic: Tachyarrhythmias, bradyarrhythmias, cardiac ischemia, structural heart disease.
Orthostatic hypotension: Drugs, autonomic failure.

55
Q

Syncope during exertion is __________ until proven otherwise.

A

cardiogenic

56
Q

What are red flags for cardiogenic syncope?

A

Occurs during exertion.
Family history of sudden cardiac death (<40 years).
Heart murmur.
ECG abnormalities.

57
Q

Which cardiac conditions are associated with syncope?

A

Aortic stenosis.
Hypertrophic cardiomyopathy.
Wolff-Parkinson-White syndrome.
Brugada syndrome.
Arrhythmogenic right ventricular dysplasia (ARVD).

58
Q

What is PNES?

A

Episodes resembling seizures but without ictal cerebral discharges, often linked to psychological distress or trauma.

59
Q

PNES is often associated with a history of __________ or other significant psychological trauma.

A

childhood sexual abuse

60
Q

True/False:
Q: In PNES, the eyes are usually closed during episodes.

A

true

61
Q

How are PNES diagnosed?

A

Through history, video evidence, or video EEG monitoring if attacks are frequent.

62
Q

What are the critical elements of a history for TLoC?

A

Circumstances of the event.
Prodromal symptoms (e.g., sweating, feeling hot).
Appearance during the event (e.g., stiffening, jerking, eyes open/closed).
Duration of the event.
Recovery period (e.g., confusion, rapid recovery).

63
Q

Why is a witness account essential in TLoC?

A

It provides details about the event that the patient may not recall, such as physical movements and duration.

64
Q

If you cannot make a diagnosis by the end of the history, what are the chances of diagnosing TLoC?

A

Very small.

65
Q

What is the most critical investigation in TLoC?

A

ECG.

66
Q

A blackout occurring during exercise is __________ until proven otherwise.

A

cardiogenic

67
Q

When is neuroimaging indicated in TLoC?

A

In acute seizure assessment.
In epilepsy unless a diagnosis of genetic generalized epilepsy is already made.

68
Q

True/False:
Q: EEG is highly specific and can always confirm epilepsy.

A

False. (EEG can have false positives and does not exclude epilepsy if normal.)

69
Q

What are common diagnostic mistakes in TLoC?

A

Incomplete history or lack of witness account.
Misinterpretation of syncope or myoclonic jerks.
Overinterpretation of EEG abnormalities.

70
Q

What are the consequences of misdiagnosing epilepsy?

A

Unnecessary anticonvulsant treatment.
Unemployment or driving restrictions.
Psychological and social impacts.

71
Q
A

Phase 3a - Neurology (18 decks)

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