TLOC

Nota:

• if not tonic clonic seiz or syncope rare: cataplexy, narcolepsy, atypical seizures (abscence) or mimicking condits falls, funct disorders, drug/alc intox trauma- concussion NB- TIAs rarely cause TLOC

1. Collapse
   1. cardiac
      1. MI + cardiac arrhythmias
   2. blood pressure
      1. Shock

         Nota:

         • cardiac, hypovolemia incl hemorrhagic incl ectopic preg, septic incl peritonitis, adrenal insufficiency
      2. Syncope
         1. 4 subtypes
            1. arrhythmia related
               1. transient comp of CO
            2. cardiac
               1. due to structural heart disease (or acute PE or aortic dissect)
            3. orthostatic
               1. b/c fail to maintain BP on assuming upright posture (can be caused by drugs)
            4. reflex
               1. vasodilat and/or bradycard in response to trigger (eg vasovagal or carotid sinus syncope)
         2. result from global cerebral hypoperfusion; typically assoc w/a BP <60mmHg for >6sec
         3. clin feats
            1. preced by chest pain, palpit, dyspnea, light headed, or typical 'pre-syncopal' prodrome
            2. LOC after stand up, prolonged standing, during exert, following unpleasant sight/pain, venepunt, micturition, cough, large meal
            3. brief duration <1min
            4. rapid return of clear-headedness
         4. investigs: 24 hr EEG (so can catch); implantable loop recorder ; supine + erect carotid sinus massage (to check hypersens)
   3. neuro
      1. Stroke
      2. seizure
         1. Epilepsy
            1. tendency to have recurrent seizures

               Nota:

               • convulsions = the motor signs of electrical discharges
            2. phases
               1. prodrome (rare) hrs-days. Change in behaviour
               2. aura- part of seizure. pt aware. may be funny gut feeling, deja vu, strange smells, flashing lights
                  1. Implies partial seizure from temproal lobe
               3. post-ictal: may be headache, confusion, myalgia, sore tongue, temporary weakness after focal seizure in motor ctx (Todd's palsy), temporary dysphasia after focal seizure in temporal lobe
            3. causes
               1. 2/3 idopathic
                  1. often FH
               2. structural

                  Nota:

                  • cortical scarring (eg prev head inj), developmental, SOL, stroke, hippocampal sclerosis, vasc malforms
               3. other

                  Nota:

                  • tuberous sclerosis, sarcoid, SLE, PAN
            4. diagnosis

               Nota:

               • 1. are they really seizures? -get witness account -chee/tongue bit + slow recovery v suggestive -try not to diag incorrectly- syncope can have convulsions too 2. what type of seizure is it? -partial or generalized? ONSET KEY- if it begins w/focal, is partial however rapidly it generalizes 3. what triggers? -flicker lights, alch? can this be avoided? (TV induced seizures rarely req drugs) Also if 1st - really the 1st? -ask about prior odd behaviour -was it provoked (see non-epileptic cause) -admiss for 24h may be indicated
               1. witness account
                  1. ?really seizures
               2. partial or gen? onset key
               3. what triggers
            5. seizure classific
               1. PARTIAL

                  Nota:

                  • focal onset, feats referable to a part of one hemisphere -often seen w/underlying structural disease
                  1. simple partial

                     Nota:

                     • awareness unimparied (focal motor, sens, autonomc or psychiatric symps)
                     1. awareness UNimpaired
                     2. focal symps
                     3. no post-icatl symps
                     4. like responsive kid w/twitchy mouth
                  2. complex partial
                     1. awareness IMpaired
                     2. may have AURA or impaired aware at onset
                     3. most commonly temporal lobe
                     4. post -ictal confusion (temporal); rapid recovery (frontal)
                  3. partial seizure w/secondary generalization

                     Nota:

                     • 2/3 of pts w/partials
                     1. starts focally, -> spreads -> generalized seizure which is typically convulsive
                     2. most common, onset teens/early 20s or later in life w/stroke (can be hippocamp or temporal lobe damage)
               2. PRIMARY GENERALIZED

                  Nota:

                  • simultaneous onset of elect discharge throughout ctx (no localiz feats referable to only one hemis)
                  1. Absence
                     1. brief (<10s pauses); presents in childhood

                        Nota:

                        • eg suddenly stops talking mid-sentence, then carries on where left off
                  2. Tonic -clonic
                     1. loss of consc, TONIC limbs stiffen + musc contract ; then CLONIC jerk

                        Nota:

                        • may have one without the other
                     2. post ictal confusion + drowsiness
                  3. Myoclonic
                     1. sudden jerk of limb, face, or trunk

                        Nota:

                        • pt may be thrown suddenly to ground or have disobedient limb
                  4. Atonic (akinetic)
                     1. sudden loss of musc tone causing a fall
                     2. no loss of consc
                  5. Infantile spasms
                     1. commonly assoc w/tuberous sclerosis
               3. localizing features * (read note)

                  Nota:

                  • Localizing features of partial (focal) seizures Temporal lobe -automatisms (w/no recollection of) -dysphasia (ictal or post ictal) -abdo rising sens (or pain +/-vomit) -memory phenomena (deja vu or jamais vu) -hippocampal involve- (emotional disturb, religiosity) -uncal involve- (hallucincations of smell or taste or dream like state) -delusional behaviour -bizzare story.. (see pg 495) Frontal lobe -motor feats (posturing, eye moves, peddling moves of legs) -jacksonian march- (spreading focal motor seiz but retain awareness) -motor arest -subtle behaviour disturbs -dysphasia or speech arrest -post ictal Todd's palsy Parietal lboe -sensory disturbs (rare) -motor symps Occiptial lobe  -visual phenomena
            6. complics
               1. sudden unexpected death in epilepsy

                  Nota:

                  • more common in uncontrolled (maybe relat to nocturnal seizure-assoc apnea or asystole)
            7. investigs
               1. EEG

                  Nota:

                  • helps context for diag -&gt; don't do if likely syncope b/c false +ves only do emergency EEG if non-convulsive status epilepticus is the problem unprovoked inter-ictal EEG (ofte normal in ppl w/seizures; so often abnorm in ppl without) SO DO PROVOVOCATION (sleep depriv) + prolonged and /or video recording
               2. other

                  Nota:

                  • further options: neurological resection- if single focus eg hippocampal sclerosis, small tumor vagal nerve stimulation
                  1. MRI

                     Nota:

                     • structural lesions
                  2. serum drug lvls

                     Nota:

                     • are they taking tablets?
                  3. PET
                  4. cog assess
                  5. ictal SPECT
            8. management

               Nota:

               • involve pt!! essential for compliance
               1. counselling

                  Nota:

                  • -after a seizure advise agisnt possible dangers (eg swimming, driving, heights) until diag estab'd then individual counselling after diag -&gt; employment, insurance, conception  *driving- can't drive until seizure free &gt;1yr
               2. drugs

                  Nota:

                  • probably start treatment after 2nd fit discuss w/pt- if low freq eg 1fit/2yr, don't drive, may choose no treat treat w/one drug by one doc, build up over months
                  1. depends on type of seizure.
                     1. Generalized tonic clonic- sodium valproate or lamotrigine

                        Nota:

                        • 2nd line carbamazepine, topiramate
                     2. Absense: sodium valproate, lamotrigine, ethosuximide
                     3. tonic, atonic, myoclonic: sodium valproate or lamotrigine

                        Nota:

                        • avoid carbemazepine
                     4. parital seizures +/- secondary gneralization: carbemazepine

                        Nota:

                        • then sodium valproate, lamotrigine, oxcarbazepine, topiramate
         2. disordered electrical activity affected whole brain
            1. may be primary or secondary (resulting from focal that spreads)

               Nota:

               • if py doesnt' become secondary, partial seizures may cause altered consciousness without LOC
         3. triggers
            1. alcohol excess or withdrawal; recreational drug misuse
            2. sleep depriv, physical/mental exhaustion
            3. intercurrent infection
            4. metabolic disturbance (low Na, low Mg, low Ca, uremia, liver failure)
            5. non-compliance with meds, or drug interact
            6. flickering lights
         4. clin feats
            1. preced by aura (smell, rising sens in abo, deja vu)
            2. witness account of tonic-clinic limb moves
               1. coarse and rhythmic
               2. >30s (ask witness to demonstrate)
            3. tongue/cheek inj
            4. >5min confusion/drowsiness after
         5. causes
            1. epilep
            2. non epilep

               Nota:

               • trauma, storke, hemorrhage, rasie dICP, alcohol or benzo withdrawal, metabolic disturbance (hypoxia, hypo/hyper natremia, hypocalcemia, hypo/hyper glucose, uremia), liver disease, infection, raised temp, drugs (TCAs, cocaine, tramadol, theophylline), pseudoseizures, 
   4. other
      1. Diabetes (hypo or hyper)
         1. hypoglycemia
            1. may cause impari consc that resolves w/correction of blood glucose
            2. most cases iatrogenic 9insulin or sulphonylurea)
            3. other 'spontaneous' causes
               1. alcohol, liver failure, insulinoma, adrenal insufficiency
      2. PE
2. Dizziness, syncope and falls
   1. orthostatic hypotension
      1. any cause incl adverse drug reaction, cardioinhibitory syncope, autonomic neuropathy etc
   2. psychiatric
      1. anxiety
   3. neuro
      1. stroke, Parkinson's disease, myelopathy, MS
   4. vestibular disorders [any]
   5. metabolic
3. functional disorders (apparent TLOC)
   1. 'pseudosezizure'
   2. 'pseudosyncope'
   3. atypical feats that may suggest pseudo
      1. >5min episodes, eyes closed, numberous attacks/day, purposeful mves during, estab'd diag of other funct disorder
4. red flag
   1. TLOC during exertion
   2. severe heart disease
   3. FH cardiac sudden death
   4. previous or hi risk for ventric arryth
   5. tachycardia
   6. high risk ECG abnormality
5. history key!!!
   1. listen and clarify
   2. use witnesses
   3. circumstances, prodrome, episode, recovery