Transitory Loss Of Consciousness Research Articles

Acute Paraparesis Syndrome after a Ruptured Aneurysm of the Azygos Anterior Cerebral Artery (P12-5.016)

<h3>Objective:</h3> To describe a rare case of acute paraparesis syndrome (APS) after a ruptured aneurysm of the azygos anterior cerebral artery (ACA). <h3>Background:</h3> The incidence of APS within 24 hours after subarachnoid hemorrhage is very rare. Additionally, the pathophysiology of this syndrome remains poorly defined. Nonetheless, the literature suggests it could emerge from a bilateral ACA vasospasm, acute hydrocephalus, or global cerebral edema and can be associated with poor clinical status. The azygos ACA is a rare variant whose unique anatomy intensifies the hemodynamic stress on the arterial wall, making aneurysm formation closely associated with this anomaly. <h3>Design/Methods:</h3> A 72-year-old man with a past medical history of hypertension presented to the hospital with the complaint of acute paraparesis after a thunderclap headache and transitory loss of consciousness. The physical exam showed paraparesis with brisk patellar and Achilles reflexes and a neutral response to bilateral plantar stimulation. No abnormalities were noticed on the cranial nerves, coordination, and sensory examination. <h3>Results:</h3> Routine laboratory studies were normal. Brain computed tomography revealed an acute punctate hemorrhage of an aneurysm located in the frontal interhemispheric fissure. Magnetic Resonance Imaging (MRI) of the spine was unremarkable. Brain MRI showed unspecific white matter abnormalities, and an MR angiography showed a 4.3 mm saccular aneurysm in the right ACA A3 segment in the bifurcation of an azygos ACA. The patient underwent coiling of the aneurysm and was able to walk unassisted nine weeks after the procedure. <h3>Conclusions:</h3> Acute paraparesis syndrome is a rare manifestation of a ruptured anterior communicating artery or anterior cerebral artery aneurysm. Here, we present an atypical etiology of APS caused by a ruptured aneurysm of the azygos ACA. To the best of our knowledge, this is the first description of an APS after a ruptured aneurysm of the azygos ACA. <b>Disclosure:</b> Dr. Moreno-Zambrano has nothing to disclose. Dr. Jimenez Zambrano has nothing to disclose. Jose Francisco Ortega Tola, MD has nothing to disclose. Dr. Yepez has nothing to disclose. Wilson Cueva has nothing to disclose.

\u201cDecision tree analysis for assessing the risk of post-traumatic haemorrhage after mild traumatic brain injury in patients on oral anticoagulant therapy\u201d

BackgroundThe presence of oral anticoagulant therapy (OAT) alone, regardless of patient condition, is an indication for CT imaging in patients with mild traumatic brain injury (MTBI). Currently, no specific clinical decision rules are available for OAT patients. The aim of the study was to identify which clinical risk factors easily identifiable at first ED evaluation may be associated with an increased risk of post-traumatic intracranial haemorrhage (ICH) in OAT patients who suffered an MTBI.MethodsThree thousand fifty-four patients in OAT with MTBI from four Italian centers were retrospectively considered. A decision tree analysis using the classification and regression tree (CART) method was conducted to evaluate both the pre- and post-traumatic clinical risk factors most associated with the presence of post-traumatic ICH after MTBI and their possible role in determining the patient’s risk. The decision tree analysis used all clinical risk factors identified at the first ED evaluation as input predictor variables.ResultsICH following MTBI was present in 9.5% of patients (290/3054). The CART model created a decision tree using 5 risk factors, post-traumatic amnesia, post-traumatic transitory loss of consciousness, greater trauma dynamic, GCS less than 15, evidence of trauma above the clavicles, capable of stratifying patients into different increasing levels of ICH risk (from 2.5 to 61.4%). The absence of concussion and neurological alteration at admission appears to significantly reduce the possible presence of ICH.ConclusionsThe machine-learning-based CART model identified distinct prognostic groups of patients with distinct outcomes according to on clinical risk factors. Decision trees can be useful as guidance in patient selection and risk stratification of patients in OAT with MTBI.

Can triage correctly stratify cardiogenic syncope in patients admitted to the emergency department for a transitory loss of consciousness?

Abstract Background The Manchester Triage System (MTS) is the most popular validated triage system in Europe. It allows the stratification of the large volume of patients admitted to the emergency department (ED) into five increasing risk categories, assigning higher priority to the most serious patients [1]. Purpose To evaluate the effectiveness of the MTS in stratifying patients admitted to the ED for syncopal transitory loss of consciousness (TLOC) and correctly identifying cardiogenic syncope. Methods All patients consecutively evaluated in the ED between 1 January 2017 and 1 July 2019 for a TLOC episode were retrospectively considered. TLOCs were retrospectively classified according to the guidelines of the European Society of Cardiology (ESC) [2]. Syncopal TLOCs were separated from non-syncopal TLOCs. Demographic and baseline characteristics of all patients were recorded. Patients were divided into two groups for comparison according to the MTS code assigned at triage: blue/green/yellow (low priority) versus orange/red (high priority). Considering only syncopal TLOCs, the primary study outcome was the presence of cardiogenic syncope as defined in the ESC guidelines. The performance of the MTS was evaluated using a 2x2 table, deriving sensitivity, specificity and accuracy, and through analysing receiver operating characteristic curves. Sensitivity analyses were also performed on patient subgroups. Results A total of 2,291 patients with TLOC were considered (83% low priority versus 17% high priority). Of these, 90.2% (2,066/2,291) presented syncopal TLOC. Among the patients with syncopal TLOC, 85.7% (1,770/2,066) were assigned a low priority code, while 14.3% (296/2,066) were given high priority. Patients with a high priority code were older (median age 66 versus 77 years; p&amp;lt;0.001), presented more altered vital signs (p&amp;lt;0.001), presented more associated symptoms (p&amp;lt;0.001) and presented more cardiac comorbidities (p&amp;lt;0.001). Overall, cardiogenic syncope was present in 7.5% (154/2,066) of patients with syncopal TLOC. Of these, 55.2% (85/154) were stratified with a low priority code, while 44.8% (69/154) were stratified with a high priority code (p&amp;lt;0.001). The MTS presented a sensitivity of 44.8%, a specificity of 88.1% and an accuracy of 84.9%. The area under the receiver operating characteristic curve for the prioritisation of cardiogenic syncope through MTS codes was 0.683. Sensitivity analyses on specific subgroups of patients, such as those with or without other associated symptoms in triage or major cardiac comorbidities, revealed comparable performance. Conclusions Syncopal TLOC is an insidious clinical condition. Currently, limited information is available about triage systems and the correct prioritisation of syncope. Although the MTS has demonstrated good performance for other cardiac symptoms, its performance is not acceptable for syncopal TLOC [3]. Improvements are needed to optimise triage systems for syncopal TLOC. Funding Acknowledgement Type of funding sources: None.

Nurse triage accuracy in the evaluation of syncope according to European Society of Cardiology guidelines.

The role of triage for patients admitted to the emergency department (ED) for a syncopal transitory loss of consciousness (TLOC) has not been debated, and no comparisons with the recent European Society of Cardiology (ESC) guidelines are currently available. To verify the ability of triage to correctly prioritize patients with syncopal TLOC. All patients who received a triage assessment at the ED of the Merano Hospital (Italy) between 1 January 2017 and 30 June 2019 for a syncope were considered. All syncope were reclassified according to the aetiology reported in the ESC guidelines. The baseline characteristics of the patients were recorded and divided according to the severity code provided during triage into two study groups: high priority (red/orange) and low priority (yellow/green/blue). The outcome of the study was the presence of a diagnosed cardiac cause within 30 days after the admission. A total of 2066 patients were enrolled (14.3% high priority vs. 85.7% low priority). Cardiac syncope was present in 7.5% of patients. Nurse triage showed a sensitivity for cardiac syncope of 44.8%, a specificity of 88.1%, and an accuracy of 84.9%. The observed discriminatory ability presented an area under the receiver operating characteristic curve of 0.685 (95% confidence interval 0.638-0.732). The possible identification of the aetiology of the syncopal TLOC by the nurse showed good agreement with the medical diagnosis (Cohen's kappa 0.857, P < 0.001). In cases of syncopal TLOC, nurse triage had a fair specificity but suboptimal sensitivity for cardiac causes. Specific nursing assessments following triage (e.g. precise scores or electrocardiogram) could improve the triage performance.

Hypophosphatemia compared to classical biomarkers of tonic clonic seizures

BackgroundHypophosphatemia was recently reported as a potential marker of tonic-clonic (TC) seizures among patients with transitory loss of consciousness (TLOC). Its value compared to classical markers (creatine kinase [CK] and lactate) is however unknown. AimCompare the diagnostic performance of hypophosphatemia, plasma CK, and lactate levels for distinguishing TC seizures from other TLOCs, alone or in combination. Methods128 patients aged 18−90, consecutively admitted to our hospital emergency department for TLOC were included. Diagnostic accuracy of plasma phosphate, CK, and lactate levels were compared with ROC curves. ResultsWe found significantly higher CK (median 154 U/l, range 38–5608; vs 115.5, 37–2340 U/l; p = 0.037) and lower phosphatemia (median 0.79 mmol/l, 0.34–1.37; vs 0.93, 0.52–1.89 mmol/l, p = 0.007) in TC seizures compared to other TLOCs; lactatemia was not different, although using a smaller sample (n = 72). Hypophosphatemia was the only independent predictor of TC seizures, even in later samples (>2 h). Comparing ROC curves, Combining hypophosphatemia and hyperCKemia had higher diagnostic accuracy for TC seizures than hyper-CKemia alone (AUC 0.68, 95 % CI 0.571−0.783 vs. 0.59, 95 % CI 0.475−0.706; p = 0.018), but the combination was only marginally better than hypophosphatemia alone (AUC 0.67, 95 % CI 0.559−0.778). ConclusionHypophosphatemia seems to be more useful than CK levels for diagnosing TC seizures in patients assessed in an emergency setting for TLOC. Combining both parameters together does not significantly increase the diagnostic yield. No conclusion could be drawn regarding the comparison with lactate. A prospective study is needed.

Resting Tremor after Mild Head Injury: Case Report

AbstractOver the past few decades, it has been recognized that traumatic brain injury (TBI) may result in various movement disorders. However, moderate or mild TBI only rarely causes persistent post-traumatic movement disorders. In the present report, we describe a case of secondary tremor due to a mild head injury with a transitory loss of consciousness. A 26-year-old man developed an isolated rest tremor of the hands and legs without other neurologic signs. The interval between the head trauma and the onset of the symptoms was 4 months. Neuroimaging studies reveled gliosis in the lentiform nucleus. Haloperidol administration resulted in tremor reduction. A rest tremor, similar to essential tremor, can be a rare complication of head trauma. Haloperidol may be an effective and safe treatment modality for post-traumatic tremor. Further studies are needed to clarify the optimal drug for the treatment of post-traumatic tremor.

PREVALENCE AND CAUSES OF TRANSITORY LOSS OF CONSCIOUSNESS IN GENERAL POPULATION (BY THE DATA FROM ЭССЕ-RF TRIAL)

Aim. To study prevalence of transitory loss of consciousness (TLC) in general population of the city Samara and to suggest its genesis according to anamnestic data. Material and methods. The material for the study was provided by a simple randomized selection of persons from general population in Samara city, performed during the multicentre observational trial "Epidemiology of Cardio-Vascular Diseases in the Regions of Russian Federation — ЭССЕ-RF". Total volume of the selection was 1796 persons (more than 80% responded to the call). Average age of the studied persons was 45,8±11,9 y., women — 1256 (69,9%), men — 540 (30,1%). In questionnaire module respondents analysed: 1) are there any cases of sudden death in family anamnesis at the age less than 45 y. and linked or suspicious to be linked to heart disease; 2) any complaints on palpitation; 3) presence of palpitations and their main characteristics; 4) episodes of TLC in anamnesis and their characteristics; and 14 questions more, than make it to suspect neuromediatory mechanism of TLC. Results. The prevalence of TLC in analysed population was 23%, maximum at the age of 40-49 y., reaching 28%. TLC were 2 times more prevalent in women than in men (27,5% and 13,5% resp., p&lt;0,01). Median of the age of first episode was 16 (11; 23) y. o., taken that in 333 (&lt;85%) respondents at the age &lt;30 y. o. Almost in the half of cases (53% men, 46% women) the first TLC occurred at the age between 10 and 19 y. o., and with increasing of age probability of TLC decreased to the minimum of 1% in women of 60-69 y.o. The average length of anamnesis was 27,7 (12; 47) y. Most respondents (83,5%) had no any background somatic pathology. About the episodes of sudden death of immediate family members in younger age reported 27 persons (6,5%). Conclusion. In more than a half of patients, we found the signs showing a neuromediatory genesis of TLC (56%). These were the main cause for TLC in all age groups (50%-66%) as in men (60%) and women (55%). Th second cause was arrhythmic, having 6% of cases. In 35% the main cause for TLC by the method of questionnaire was not revealed.

Value of Ambulatory Electrocardiographic Monitoring in Syncope

Implantable loop recorders (ILRs) continuously monitor electrocardiographic signals and perform real-time analysis of heart rhythm for up to 36 months. ILRs are used to evaluate transitory loss of consciousness from possible arrhythmic origin, particularly unexplained syncope, and to evaluate difficult cases of epilepsy and unexplained falls, although current indications for their application in these areas are less clearly defined. This article analyzes the current indications for ILRs according the European Society of Cardiology guidelines on the management of syncope and the European Heart Rhythm Association guidelines on the use of implantable and external electrocardiogram loop recorders, and their limitations.

Accuracy of the S100β protein as a marker of brain damage in traumatic brain injury

Introduction: This study tested the hypothesis that S100β is a useful screening tool for detecting intracranial lesion (IL) in patients with a normal level of consciousness after traumatic brain injury (TBI).Methods: One hundred and forty-three post-TBI patients without a decrease in consciousness (GCS = 15) and with at least one neurological symptom (e.g. transitory loss of consciousness, amnesia, headache, dizziness or vomiting) were prospectively included. A blood sample was drawn at 6-hours post-TBI. A routine CT scan was obtained within 24 hours post-injury. Diagnostic properties of S100β for IL prediction in CT scan findings were tested using ROC-analysis.Results: A total of 15 patients (10.5%) had IL. Serum levels were significantly higher in these patients. Significant differences were found between S100β levels and CT scan findings (p = 0.007). ROC-analysis showed that S100β is a useful tool for detecting the presence of IL in CT scans (p = 0.007). In this series, the best cut-off for S100β is 0.130 µg L−1, with 100% sensitivity and 32.81% specificity.Conclusion: Within the first 6 hours post-TBI, serum S100β seems to be an effective biochemical indicator of IL in patients without a decrease in consciousness. These results indicate that higher S100β cut-off values substantially improve the clinical relevance of this protein.

Unusual association of seronegative, nonparaneoplastic limbic encephalitis and relapsing polychondritis in a patient with history of thymectomy for myasthenia: a case study

Limbic encephalitis (LE) associated with other autoimmune disorders is relatively rare. There is an evidence of LE with relapsing polychondritis [1, 2] or Sjogren’s syndrome [3], and also with myasthenia gravis [6]. We present a case of LE with an unusual association of different autoimmune conditions. A 73-year-old man developed headache and fever over 2 weeks and a transitory loss of consciousness. His wife reported episodes of confusion over the previous 2 months. He had a medical history of seropositive myasthenia gravis in 1996 requiring artificial ventilation, plasmapheresis, immunotherapy and thymectomy. Removed thymus showed atrophy without histopathological finding of thymoma or thymic hyperplasia. After 2 years, the patient was asymptomatic and decided to stop all treatment and follow up. His medical history also included acute myocarditis in 1972, asthma, gastric ulcer. He was followed up for bladder carcinoma without signs of activity since the operation in 1994 and recent biopsy revealed prostatic microcarcinoma. On admission, he was disoriented in place and person and was confabulating. He had painful erythema of his right auricle, which he had experienced in the past. Neurological examination was unremarkable except for slight gait instability. Laboratory results showed mild inflammatory changes (hyperleucocytosis, higher erythrocyte sedimentation rate 20 mm/h, and raised C reactive protein 20.3 mg/l). Thyroid function was normal. Serum auto-antibodies ANA, ANCA, GBMi and dsDNA were negative; only anti-striatal muscle antibodies were slightly positive. Cerebrospinal fluid analysis showed mild protein-cytological association (hyperproteinorachia 0.657 g/l and 89 mononuclear cells). Serology for HIV, Borrelia, HSV1,2, CMV, EBV, VZV and neurosyphilis was negative. Onconeural antibodies anti-Yo, Hu, Ri, anti-VGKC antibodies, anti-GAD, antiamphiphysin and anti-NMDA receptor antibodies were negative in serum and cerebrospinal fluid. MRI showed FLAIR and T2 hippocampal temporal hyperintensities, vascular white matter lesions and moderate atrophy (Fig. 1). EEG repeatedly showed slow waves in the temporal regions. Whole body PET scan was negative. Progressively, myoclonic jerks, cerebellar signs, aphasia and hallucinations appeared with worsening of cognitive impairment. Bilateral auricle swelling occurred with softening and loss of cartilage contour. Biopsy revealed nonspecific cartilage inflammation without signs of an acute vasculitis (Fig. 2b), compatible with criteria for relapsing chondritis. Parenteral bolus of methylprednisolone 1,500 mg over 3 days led to partial and transitory improvement, therefore a month later bolus of 3,500 mg was repeated followed by permanent treatment with oral methylprednisolone 24 mg daily. Painful swelling extended to elbows and knees, and partial complex seizures with orofacial automatisms developed. A third bolus of 1,500 mg methylprednisolone was administered and four cycles of plasmapheresis were performed with only limited effect, moreover, massive eruptions of herpes labialis required intravenous acyclovir. Finally, IVIG was added. The patient’s condition worsened K. Storey (&) R. Rusina Department of Neurology, Thomayer Teaching Hospital and Institute for Postgraduate Education in Medicine, Videňska 800, 14059 Prague 4, Czech Republic e-mail: katerina.storey@gmail.com

Routine electrocardiogram and medical history in syncope: a simple approach can identify most high-risk patients

Syncope accounts for 3–5% Emergency Department visits and for 1–6% of urgent hospital admissions each year.1 In the USA, between 1 and 2 million patients are evaluated annually for syncope. Despite the updated clinical guidelines and the development of diagnostic algorithms over recent years, the cost associated with hospitalization and clinical management of syncope is still overwhelming. One of the problems is that syncope is not a disease per se , but a symptom related to an extensive range of differential diagnoses, which could span from cardiac to neurological to psychiatric conditions. Furthermore, up to 47% of patients presenting with syncope may be discharged without the diagnosis1 and, even if their outcome is generally benign, the 1-year mortality rate in syncope of cardiac origin could reach 18–33%.2 Overall, these data point towards the importance of identifying which are the most useful clinical tools that physicians could use in their practice to correctly differentiate between syncopal events with benign vs. those with serious outcome. When analysis of the substrate of transitory loss of consciousness is narrowed to a population of children or young adults, the importance in selecting which episodes are associated with a malignant prognosis becomes even more evident. As a matter of fact, most of these episodes may be situational or vasovagal syncope, therefore benign events. However, syncope is the main symptom also in inherited channelopathies, such as long QT syndrome (LQTS), Brugada … *Corresponding author. Tel: +39 0382 592040, Fax: +39 0382 592094, Email: silvia.priori{at}fsm.it

S-100b as a screening marker of the severity of minor head trauma (MHT)--a pilot study.

Due to its neural tissue specificity S-100b is considered as a screening marker of cerebral injury in head trauma patients. However, the occurrence and relevance of an increased S-100b serum level in minor head trauma (MHT) is still debated. Therefore, the purpose of our study was to evaluate the diagnostic utility of S-100b measurements in a level I trauma center emergency room (ER). Eighty patients presenting with clinical symptoms of MHT (GCS score of 13-15, transitory loss of consciousness, amnesia, nausea) were prospectively recruited. Blood samples were drawn at 0 h, 6 h and 24 h after admission, and a cerebral computed tomography (CT) was performed. The reference group consisted of 10 patients with severe head injury (GCS score < 8), the control group of 20 healthy volunteers. Concentrations of S-100b in serum were determined by an immunoluminometric assay. The results were compared with the plasma levels of polymorphonuclear (PMN) elastase as an established general trauma marker. In the MHT group, the S-100b serum level revealed 1.26 +/- 0.57 ng/ml at study entry (73.46 +/- 47.53 min after trauma). In comparison, the S-100b concentration was significantly elevated in patients with severe head trauma (5.26 +/- 1.65 ng/ml, p = 0.009), but no significant difference became evident in relation to the control group (0.05 +/- 0.01 ng/ml). Starting values of PMN elastase in plasma amounted to 66.40 +/- 14.92 ng/ml in severe trauma, and to 60.52 +/- 10.75 ng/ml in MHT showing significant differences only in relation to the control group (23.36 +/- 1.53 ng/ml). When correlated with the severity of the later clinical course, the first S-100b measurements exhibited steadily increasing values as demonstrated in MHT outpatients (0.29 +/- 0.11 ng/ml), MHT in-hospital patients (0.70 +/- 0.19 ng/ml) and MHT intensive care unit patients (5.03 +/- 3.18 ng/ml). PMN elastase levels revealed no significant differences concerning the three MHT subgroups. Thus, in contrast to the general trauma marker PMN elastase, assessment of the specific neuroprotein S-100b early after traumatic insult appears to be a promising laboratory marker for the prognosis of the severity of brain injury in MHT patients. Nevertheless, further investigations are required to better understand its predictive value.

Unwelcome orgasms

A 44-year-old woman was referred to a neurology clinic in March, 1995, after a brief episode of loss of consciousness. For the previous 3 years, she had had recurrent episodes, approximately once every 2 weeks, in which she would suddenly become aware of an internal, ascending feeling indistinguishable from an orgasm, lasting up to a minute. She had not sought medical advice for these episodes. They had no definite triggers and were neither particularly pleasurable nor satisfying because they were out of her control. On several occasions she experienced an episode while driving and had to stop the car. There were no other symptoms, no associated loss of consciousness, and no reduced awareness until on one occasion, in the company of her sister, she had an episode while listening to a radio play. This was followed by jerking of her left hand and collapse to the ground with transitory loss of consciousness. She recovered completely within 2 minutes. Her medical history was unremarkable apart from an episode 2 years previously of a sudden, severe right-sided headache with subsequent nausea and confusion lasting several days. At the time, the episode was thought to be migrainous. General and neurological examination was normal. In particular, she was normotensive, and there were no visual-field defects or audible cranial bruits.