Episodes that involve transient alteration in the level of consciousness can be particularly a challenging problem faced by the practicing neurohospitalist. Getting a good history is key in neurology, but often challenging given patient factors and the hospital environment. It is the experience of the authors that many times an initial evaluation ensues that is primarily focused on “ruling out” vascular or epileptic etiologies. It is worth noting, however, that while all vascular events and seizures are spells, not all spells are seizures or transient ischemic attacks. The challenge for the neurohospitalist comes when the clinical picture remains unclear. This chapter will focus on spells not of vascular, epileptic, or psychogenic origin. In particular, there will be an emphasis on conditions that may evade the standard diagnostic workup. These spells may occur in otherwise healthy patients with no (known) prior neurological history. Patients may present with unexplained collapse, or with symptoms that are not immediately suggestive of a neurological cause such as nausea and malaise. In the following review we offer diagnoses to also think of when the standard medical workup does not reveal a cause.
CASE 24-1
Ms. K. S., an 18-year-old, is brought to the hospital emergency department by her parents for evaluation of several passing-out spells in the last several months. She has been seen in three other hospital emergency departments (EDs) for this as well. The parents are extremely concerned. The patient has recently also been having some headaches. Today, she suddenly passed out again, she rolled her eyes, fell to the ground “like a sack of potatoes,” and looked dead for a second. She did have a pulse. She came around after 10 seconds and had a headache, but no confusion. She is also having her menstrual period. She had an electroencephalogram (EEG) and computed tomography (CT) head at the ER, and three times before at other facilities. All those were described as normal.
Number of similar episodes
What was the patient doing at that time?
Prodrome—any palpitations, diaphoresis? What other associated symptoms?
Characteristics of onset (sudden and intense?)
The symptoms according to the patient, and ideally description of the event by collateral
Triggers, exacerbating factors, and relieving factors
Family history (eg, where relevant; familial hypokalemic periodic paralysis)
Postictal period
History of illicit substance use
As a rule, seizures present in stereotypical ways and, if affecting both sides of the body, involve loss of consciousness and have a postictal period.
Also if any focal neurological symptoms, then rule out strokes. Details of this in a different chapter.
Most common causes are syncope and presyncope.
Reflex syncope are situational spells of loss of consciousness, such as fainting when seeing blood. A reflex syncope seen surprisingly often as a cause for hospital admission is the micturition syncope. These spells are often seen at night, when baseline blood pressures are lower to begin with. Patients fall on their way to the toilet, or from the toilet. Upon their night time arrival to the hospital, a clear cause is not usually found and patients are often admitted for observation.
