Impaired Consciousness Dr Nin Bajaj Consultant Neurologist QMC

Impaired Consciousness Dr Nin Bajaj Consultant Neurologist QMC & DRI

Assessment • • • Glasgow Coma Scale Eye opening-(E) Spontaneous-4 To speech-3 To pain-2 None-1

GCS • • Best Motor Response- (M) Obeys-6 Localises-5 Withdraws-4 Abnoraml flexion-3 Abnormal extension-2 None-1

GCS • • • Verbal Response(V) Orientated-5 Confused conversation-4 Inappropriate words-4 Incomprehensible sounds-3 None-1

History • Acute • Subacute • Chronic

Acute- quick recovery • Syncope- vasovagal, cough, micturition, carotid hypersensitivity, circulating volume • Apnoea- hyperventilation, sleep • Cardiac- arrythmia

Acute impairment- no previous hx • Usually implies a vascular event • Hemispheric bleed or thrombo-embolic stroke • Subarachnoid haemorrhage • Brain-stem event • Bleed into a tumour?

Acute impairment- previous hx • Might be post-ictal

Subacute impairment • Hours-Days • Implies systemic or CSF process • Possibly raised ICP

Subacute-systemic • Electrolyte imbalance- uraemia, hyperammonaemia, hypo/hypernatraemic • Endocrine- hypothyroid, Addisonian • Infection + with reduced cognitive reserve

Subacute- CSF process • Meningitis/Encephalitis • Neoplastic • Inflammatory- ADEM, MS, Vasculitic, Sarcoid

Subacute- raised ICP • Usually a rapidly growing tumour • Consider cerebral venous thrombosis • Might end up coning

Chronic • Neurodegenerative- Lewy Body, Prion, AD • Chronic Vascular • Drug induced- e. g. Anti-cholinergics, dopaminergic agents • Sleep attacks e. g. narcolepsy, synuclein deposition

Is it a stroke? • Hemispheric- should be localising neurology • Bleeds tend to be worse than embolic • Big MCA infarcts worse • Can be raised ICP complicating picture

Is it a stroke? • Needs urgent CT brain • Outside UK, might thrombolyse • For big MCA, consider skull vault removal or dexamathasone/mannitol/over-breathing

Thrombolysis for Stroke. Inclusion Criteria • Ischaemic stroke • Measurable deficit on NIH stroke scale • No evidence of intracranial bleed on CT brain • 180 minutes or less from time of symptom onset to intiation of IV rt-PA • IV rt-PA 0. 9 mg/kg, 10% as bolus, 90% as infusion over 60 min

Have they had a SAH? • Sudden onset • Worse headache ever, like “someone hitting me over the head” • Often nausea, vomiting, diplopia, neck stiffness, photophobia • Time to peak pain seconds-minutes • Pain can last hours, less often days

Have they had a SAH? • Not to be confused with thunderclap headache or sex-associated headache • Sentinel bleed can occur • Need Urgent CT brain (remains abnormal for up to 6 -10 days) • If negative, need LP after 12 hours and before 2 weeks (range 12 -33 days) for xanthochromia

Have they had a SAH? • If confirms dx, need nimodipine 60 mg/4 hr PO, and fluids (>3 l) • Consider urgent or elective clipping or neuroradiological coiling following formal angiography • Endovascular approaches generally best unless wide-necked aneursym

Have they had a fit? • • Classification Generalised or partial Grand mal or Petit mal (3 Hz spike & wave) Simple partial or Complex

Have they had a fit? • Markers • Short, minutes only • Tongue biting, urinary incontinence, sterotyped movements • GTCS or CPS localising features • Drowsy and confused afterwards

Causes • Usually primary- ? related to cellular migration defects or channelopathy • Secondary causes include SOL, drugs, stroke, alcohol

Management • ABC • First fit- conservative, CT brain, refer to a neurologist • Known epileptic- review drug management

Established Epilepsy- Drugs • • Epilim for GTCS but not females Lamotrigine GTCS in females Tegretol for CPS or Lamotrigine if female Phenytoin- status only

Status Epilepticus • Definition: • “generalised convulsive status epilepticus in adults and older children (>5) refers to more than 5 minutes (USED to be 30 min) of (a) continuous seizures or (b) two or more discrete seizures between which there is incomplete recovery of consciousness”

Status Epilepticus • • • Continuing seizure activity for >30 min Diazepam 10 -20 mg Lorazepam 4 mg IV ABC Phenytoin, 15 -18 mg/kg as IV over 20 -30 min, cardiac monitor • Transfer to ITU, phenobarbitone and propofol, CFM

Syncope and Seizure • • • Postural only? Feel hot, clammy- “cold sweat” Vision dark around edges LOC seconds only No tb, ui, drowsiness, confusion ? arrythmia, pale as a sheet micturition, cough, emotional trigger Hyperventilation, migraine Carotid sinus- e. g. stiff collar

Investigating Syncope • • ECG- look for WPW, long QT syndromes If abnormal, 24 hr ECG or loop monitor Postural BP Tilt table with CSM

Management • Emotional or specific trigger- avoid stimulus • Neurogenic with positive tilt table- salt and fluids, orthostatic training, fludrocortisone, midodrine • Cardiac- pacemaker