Javed%20Mahmood

Page 1

FUNNY TURNS – A NEUROLOGY PERSPECTIVE

Dr Javed Mahmood Consultant Neurologist

Funny Turns

Generally means a sudden, short lived episode when someone becomes

dizzy, wobbly on the feet, confused or perhaps blacks out altogether  Clinical history is critical!  basis of making the diagnosis

in most patients  Eye witness account invaluable

Differential Diagnosis 

  

 

NEUROLOGICAL (Main presenting symptoms)  Seizures  Migraine  TIA  Transient Global Amnesia (TGA)  Paroxysmal Dyskinesias  Narcolepsy/Cataplexy CARDIOLOGICAL DIZZINESS/VERTIGO SLEEP SYNDROMES  Night terrors  Myoclonus  REM sleep disorder  Hallucinations  Paralysis Metabolic/toxic disorders/CNS infections - hypoglycemia PSYCHOLOGICAL  Hyperventilation  Panic attacks  Non Epileptic Attack Disorder (NEAD)

NEUROLOGICAL

Migraine

Migraine

Seizure

Duration

15 to 60 min

Brief (<1 min)

Occurs in isolation?

Acephalgic migraine

Simple partial seizure

Common symptoms

Visual: most common Sensory: parasthesia Motor: unilateral weakness

Limbic: abd. sensation, fear Sensory: parasthesia Motor: twitching

Visual symptoms: migraine vs seizure

Migraine

Seizure

Colour

B&W (may be coloured)

Coloured

Positive symptoms

Linear or flash, zigzag

Circular, spherical

Localisation

Begins at centre

Hemifield, same spatial localisation

Scotoma

Common

Uncommon

Fortification spectra

Common

Unusual

Formed visual hallucinations

Rare, only in familial hemiplegic migraine

Unusual

Duration

Prolonged

Brief

Visual symptoms: migraine vs seizure

Migraine

Seizure

Colour

B&W (may be coloured)

Coloured

Positive symptoms

Linear or flash, zigzag

Circular, spherical

Localisation

Begins at centre

Hemifield, same spatial localisation

Scotoma

Common

Uncommon

Fortification spectra

Common

Unusual

Formed visual hallucinations

Rare, only in familial hemiplegic migraine

Unusual

Duration

Prolonged

Brief

TIA  A clinical syndrome characterized by an acute loss of focal cerebral

or monocular function with symptoms lasting less than 24 hrs. and which is thought to be due to inadequate cerebral or ocular blood supply as a result of low blood flow, arterial thrombosis or embolism associated with disease of the arteries, heart or blood (adapted from Hankey & Warlow 1994)  Negative symptoms (weakness, numbness)  No spreading of symptoms

TGA (diagnotsic criteria)

 Attacks witnessed by observer  Acute onset of anterograde amnesia  No change of consciousness or loss of self-awareness  No recent head trauma or seizures  Duration of symptoms 1-24 hours

 No neurological symptoms bar dizziness, vertigo or headache

Hodges and Warlow, Journal of Neurology, Neurosurgery and Psychiatry, 1990

Paroxysmal dyskinesias  Paroxysmal Kinesigenic Dyskinesia    

Sudden attacks of involuntary movement Standing up quickly or startled Lasts <1 min Rx with Carbamazepine

 Paroxysmal Non-kinesigenic Dyskinesia    

Usually spontaneous Occ by emotional stress, fatigue, alcohol/caffeine Lasts minutes to 4 hrs Difficult, Clonazepam, CBZ

Cataplexy  With narcolepsy/cataplexy syndrome  Loss of postural tone  No LOC

 Triggered by emotional stimuli

Tics

 Vs focal motor seizure  Key in story

 Aware of need to move  Internal tension  Can defer movement

DIZZINESS/VERTIGO

Recurrent vertigo  Migrainous vertigo  Meniere’s Disease  Vertebrobasilar TIA

 Paroxysmal recurrent vertigo  Perilymph fistula  Orthostatic hypotension  Other rarer causes

Positional vertigo  Posterior canal BPPV (>80%)  Horizontal-canal BPPV  Migrainous vertigo

 Central positional vertigo  Other causes

Posterior canal BPPV  Brief attacks of vertigo (<30 sec)  Provoked by turning in bed, lying down, sitting up from lying, head

extension or bending over  Dix-Hallpike positional testing  Epley’s or Semont’s manouvre

Hallpike’s manouvre

Video

Epley’s manouvre

Video

SLEEP SYNDROMES

REM sleep disorder  Vs frontal lobe seizure  Middle aged/elderly  Middle 3rd of night /early morning

 Aggressive behaviour/vivid dreams  Can recall parts  Degn disorder like PD

PSYCHOGENIC

Hyperventilation and Panic attacks  Periods of stress in susceptible persons  Dizziness, occ altered awareness/LOC  Chest pain, dyspnoea, blurred vision, paraesthesia, ms cramps,

fatigue

Non Epileptic Attack Disorder (NEAD) : incidence reported to range from 3 to 5 per 100 000 people.  A prevalence up to 20% in epileptic patients was reported.  Risks factors :  female gender  late teens or early 20s  history of medically unexplained symptoms  depression or personality disorders  poor coping strategies  sexual and physical abuse

NEAD

GTCS

NEAD

Precipitating factors

Sleep loss, alcohol withdrawal, flashing lights

Emotion

Head movement

To one side or none

Side to side

Biting

Tongue – lateral side

Lips, arms, other people

Eyes

Open

Closed, resistant to opening

Awareness

Lost

Generally preserved

Sequence of symptoms

Stereotyped

Variable

Usual duration

1-5 minutes

5-60 minutes

Post ictal

Tired, confused, sleeps

Alert, emotional outbursts

SEIZURES

Epileptic seizure - definition Transient occurrence of signs and/or symptoms due to an abnormal excessive or asyncronous neuronal activity in the brain. Epilepsy is an enduring predisposition to generate epileptic seizures.

ILAE Classification  Partial (focal) 

Simple:    

 

Motor sensory autonomic psychic

Complex: impairment of consciousness and automatism Secondary generalised

 Generalised (convulsive & non-convulsive)      

Absence Myoclonic Clonic Tonic Tonic-clonic Atonic

 Unclassified

Diagnosis  Three classes of information can be diagnostically useful :

1. Background

2. Pattern of attacks 3. Clinical features of attack

1. Background  Syncope : teenage, environment, on hypotensive drugs  Cardiac syncope : extreme of age, cardiac history, family history  Seizure : history of potential cause

 Pseudoseizures : female, history of abuse  Hypoglycaemia : Diabetes  TIA : elderly, risk factors

2. Pattern and triggers  Syncope : triggering, fright/pain, upright position only  Cardiac syncope : exercise  Seizure : catamenial, clustering

 Pseudoseizure : frequent from start, social triggering  Hyperventilation : emotion /stress  Positional vertigo : specific head movements

3. Clinical features of attacks

Onset

LOC/awareness

Motor phenomenon

Skin colour

Eyes

Incontinence

Tongue biting

Post ictal

Duration

History 

Beware - Frontal lobe seizures : bizarre behaviour rapid recovery

minimal post ictal confusion

QUESTIONS?

Turn static files into dynamic content formats.

Create a flipbook
Issuu converts static files into: digital portfolios, online yearbooks, online catalogs, digital photo albums and more. Sign up and create your flipbook.