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