Faints, fits and funny turns

Dr Dominic Heaney

Consultant neurologist and honorary senior lecturer

ULCH NHS Foundation Trust

National Hospital for Neurology and Neurosurgery

London

Emergency department at UCH

• 130,000 patients/year

• Separate from NHNN

• Inner city, varied

demographic

Clinical history

• Subjective account

– Before/during/after

• Witness account(s)

• Past medical history

• Risk factors

• …

Generalised tonic-clonic seizure

• loss of consciousness

• ‘epileptic cry’

• fall (injury)

• tonic phase then clonic jerking

• tongue biting, incontinence, cyanosis

• sudden onset, gradual recovery

• post-ictal confusion, sleep,

headache, muscle pain

• aura/partial features if SGS

1. Idiopathic generalised

epilepsies

2. Symptomatic generalised

epilepsies with wide range

underlying pathology

Generalised absence seizure

• blank stare

• loss of consciousness

• cessation of motor activity

• blinking, eye rolling, minor tone change

• sudden onset, rapid recovery

• brief, many attacks per day

• usually in IGE

• generalised spike and wave discharge

Simple partial seizures

• no alteration in consciousness

• no amnesia

• sudden onset and cessation

• focal symptoms or signs:

motor

sensory and special sensory

psychic (dysmnestic, cognitive, affective,

hallucinations, illusions)

• reflect anatomical origin of the seizure

• due to focal cortical pathology

Complex partial seizures

• Temporal lobe 60%

• Extra-temporal 40%

(mostly frontal lobe)

Temporal lobe seizure

• aura (as SPS: visceral, dysmnestic), brief

• altered consciousness

• amnesia

• automatism (oro-alimentary, gestural, verbal)

• sudden onset, gradual recovery

focal spikes

rhythmic ictal discharge

Frontal lobe CPS

• brief stereotyped seizures

• frequent attacks with clustering

• nocturnal +

• sudden onset and cessation

• complex bilateral motor automatisms

• secondary generalisation

• interictal and ictal EEG variable

Other extra-temporal partial seizures

Central Contralateral jerks (march)

Contralateral sensory

Posturing

EEG often normal

Parietal Somatosensory

Illusion of change in body size/shape

Vertigo

Gustatory

Occipital Elementary visual hallucinations

Visuo-spatial distortion

Amaurosis

Head turning (usually adversive)

Eyelid flutter, blinking, nystagmus

May propagate to adjacent

cortical regions

EEG : focal / non-localised /

anterior

Epilepsy epidemiology

Head injury

Clinical examination

• Height, joints

• Blood pressure (lying, standing), pulse

• Cranial nerves

• General neurological examination

Clinical examination

• Height, joints

Clinical examination

• Height, joints

• Blood pressure (lying, standing), pulse

• Cranial nerves

• General neurological examination

Investigations

• From ED?

– WCC, CK, FBC, Biochemistry

• 12 lead ECG

• (echocardiography)

• Blood testing

• EEG

• Neuro-imaging

EEG abnormalities

Patients seen

• Epileptic seizure

• Syncope

– Vaso-vagal

– cardiogenic

• Psychological (“non-epileptic”)

• Other

Syncope

• 25% first seizure clinics…

• The “new diagnoses”

– PoTS

– Hyper-mobile joints

Implications

• Driving

• Freedom Pass

• Holidays

• Diving

• Flying

Conclusion

• Faints fits and funny turns

• Cardiology trumps neurology

• Coping with diagnostic uncertainty