Blackouts and funny dos

Blackouts are one of the most common presentations in neurology, accounting for 18% of new
neurological outpatients. The most common causes are seizures or syncope. While a list of possible causes
is long, the clinical history, particularly with an account from a witness, will usually define the nature of
the attack and direct investigations.
History
Blackout is a term that is usually used to mean episodes of loss of consciousness but some patients use it
to mean episodes of altered consciousness. Other patients can mean a range of other things including
dizzy feelings, memory loss or occasionally even episodes of weakness without impaired consciousness. It
is important to find out what they mean. To help you do this, the range of feelings most often included
within the term are discussed below. Other key aspects of the history include a detailed description of the
blackout what the patient was doing, any precipitating factors and the time course of the blackout,
including any prodromal symptoms, aura immediately before the blackout, features of the blackout (ictus)
itself and any post-ictal effects are all important in making the diagnosis. A witnessed account of what
happened is essential. The widespread availability of mobile phones makes tracking down the person who
saw the event easier.
Examination
The examination is usually normal in patients with blackouts of all causes. Examinations of the
cardiovascular system and the nervous system are particularly important look for pulse irregularity,
evidence of cardiac failure, murmurs, extracranial bruits, erect and supine blood pressures and any focal
neurological signs.
Types of blackouts and funny dos
Episodes with collapse
Tonic-clonic seizure
These may occur at any time and in any position (Fig. 1). The patient may have a warning (aura), such as a
smell or taste or simply a strange feeling (see below). The aura is usually brief (a few seconds). There may
be no warning. The patient may be observed to go blank or be lip smacking before losing consciousness.
The patient then goes stiff and lets out a grunt. The arms and legs go stiff for a period and the jaw is
clenched tight. This may be followed by a jerking of the limbs. This usually goes on for 23 min. The
patient usually goes into a deep sleep. On coming round, the patient is muddled. Patients frequently bite
their tongue and pass urine.


Time course of syncope and tonic-clonic seizure.
Syncope
Syncope results from a fall in blood pressure leading to cerebral hypoperfusion. Syncope is usually
preceded by a feeling of lightheadedness, dimming of vision, a sweaty feeling and a feeling of becoming
distant. This may be brief but usually lasts minutes. Some patients get no warning. The patient goes pale
and sweaty and slumps to the ground, occasionally falling more stiffly. They then lie still, or there are often
a few small twitching movements. The period of unconsciousness is usually brief, less than 30 s, and is
followed by a rapid recovery. Incontinence of urine occurs quite often. Tongue biting is very rare. Syncope
in older patients or those with known ischaemic heart disease, or occurring on exertion, suggests a
significant cardiac cause.
N.B. A patient who has a syncopal event but is kept upright or who has a prolonged cerebral hypotensive
episode for some other reason may go on to have a tonic-clonic seizure (see above). This is a provoked
reflex-anoxic seizure.

There may be factors in the situation of the blackout that suggest syncopal episodes:

If it occurred after prolonged standing, in a hot place or after some distress such as the sight of
blood. All these suggest a vasovagal syncope.
If it is preceded by a palpitation, occurs without any prodrome or occurs with exertion all suggest
cardiac syncope, e.g. due to an arrhythmia or obstructive cardiomyopathy.
If it occurred on prolonged standing suggesting postural hypotension.
If it occurred in particular situations, e.g. micturition (micturition syncope) or cough (cough
syncope).
Syncope can be physiologically induced, e.g. by hyperventilation or Valsalva manoeuvre. Patients
may be unaware that they are hyperventilating. In these patients there may be a sensation of
breathlessness and tingling in the arms and legs.
Syncope can occur recurrently, which may reflect carotid hypersensitivity or malignant vasovagal
syndrome.
Rarer causes of collapse
Subarachnoid haemorrhage
This may present with sudden severe headache followed by loss of consciousness.
Intermittent hydrocephalus
This may present with sudden loss of consciousness often without warning. This is a classical (meaning
very rare but everyone remembers it) presentation of the rare colloid cyst of the third ventricle.
Drop attack
In this condition the patient suddenly drops to the ground. Often it is not clear whether the patient has
lost consciousness. This may be a form of seizure, cardiac arrhythmia or may reflect structural brain
disease. Most commonly it is seen in older women and no cause is found.
Sleep disorders
These can enter the differential diagnosis of blackouts: a tendency to fall asleep suddenly and
unexpectedly is seen in narcolepsy and sometimes in obstructive sleep apnoea. Patients with narcolepsy
also may have episodes of loss of muscle tone at times of high emotion, such as laughter or tears:
cataplexy.
Hypoglycaemia
Hypoglycaemia presents with lightheadedness, sweating and often a feeling of fear. The patient becomes
dizzy. This usually presents no diagnostic problems in diabetics. However, if there is a coexistent
autonomic neuropathy, then prodromal symptoms are lost. Hypoglycaemia is also common in alcoholics
(poor dietary intake and reduced hepatic glycogen stores combined with the hypoglycaemic effect of
alcohol). Insulinomas are very rare causes.
Non-epileptic attacks, pseudo-seizures and psychogenic seizures
These present a common and difficult diagnostic problem. The attacks are usually different from epileptic
seizures: they are variable, longer lasting and fluctuate during the attack. Movements often seem more
purposeful or semi-purposeful and they more often resist those attending them: It took five people to hold
me down. There is no associated cyanosis or respiratory changes. The differential diagnosis is with frontal
seizures and rare intermittent movement disorders.
Episodes without collapse
Absences
Absences typically occur in children as a manifestation of primary generalized epilepsy. The child is still
and stares. The eyelids may flutter and there may be some mouth movement. They are usually very brief
but may last minutes. They occur frequently. An EEG shows 3 Hz spike and wave discharges.
Partial seizures and complex partial seizures
These are focal onset seizures either with (complex partial seizures) or without (partial seizures) loss of
consciousness. The prodromal sensations that occur are the same in either situation whether or not
consciousness is lost. The manifestations depend on the site of onset of the seizure. Either type of seizure
may go on to a secondary generalized seizure so these may constitute the aura of a generalized seizure.
Common patterns include:
all are brief (usually seconds or very occasionally minutes)
a smell or taste often associated with an unpleasant feeling in the stomach (temporal lobe onset)
a feeling of dj vu (temporal lobe onset)
a sensation of numbness or tingling (parietal lobe onset)
jerking of one limb or head turning, or occasionally more stereotyped movements, e.g. cycling
(frontal lobe onset)
a flash of light (occipital lobe onset).
A witness may describe a patient with complex partial seizures as going glassy eyed, changing colour,
making lip-smacking movements or other semi-purposeful movements with their hands. The patient is
often confused afterwards.
Transient ischaemic attacks
The sudden onset of loss of any function of the nervous system can arise from vascular causes. Only rarely
is consciousness lost.
Transient global amnesia
This is a moderately common condition in adults aged over 40 years. For a period of 26 h, there is almost
total failure to acquire new information and patients appear confused. They characteristically ask the
same question again and again, ignoring any answers. Otherwise they can do quite complicated things
such as driving. The recurrence rate is about 10%. The condition is associated with migraine, but not
epilepsy or cerebrovascular disease.
Migraine
Migraine may cause focal neurological symptoms of gradual onset over about 1530 min. Typically these
are visual symptoms, though numbness, tingling or speech disturbance can occur. The typical headache
usually follows, but may not, which may lead to consideration of other differential diagnoses (Table 1).

TABLE1 Pattern of sensory and other symptoms in different types of attack

Diagnosis Typical duration Symptoms
Partial seizure Seconds to 3 minutes Positive
Migraine 1030 minutes Positive and negative
Transient ischaemic attack Minutes to hours Negative
Investigation
This is directed by the history. All patients who faint should have an ECG. Although the yield is low, rare
arrhythmias such as long Q-T syndrome should be excluded. If the patient is thought to have had a
syncopal attack, the following investigations may be considered: fasting glucose, 24-h ECG,
echocardiogram or tilt table test. If the patient is thought to have had a seizure, the following
investigations could be considered (see p. 74 for discussion): MRI or CT brain scan, EEG, 24-h EEG or
calcium. If the diagnosis is uncertain, investigation should be directed towards both syncope and seizure,
concentrating particularly on treatable options.

Management
Management will depend on the cause. Patients who have had a blackout need to be advised about the
regulations relating to driving (Box 1) and common sense advice about lifestyle, to avoid any situation that
could put them or anyone else at risk, for example swimming; showering instead of taking a bath.




BOX 1Regulations in relation to driving

This is a summary of some of the driving regulations in the UK in relation to ordinary driving licences. It is the
doctors responsibility to make the patient aware of the regulations and to contact the Driving and Vehicle
Licensing Authority (DVLA). Special licences, such as those required to drive heavy goods vehicles, have more
stringent regulations.

Single seizure or blackout
with seizure markers
Licence revoked for 1 year; 6 months if ECG and scan
are normal
Single provoked seizure
Dealt with by DVLA on an individual basis Must inform
DVLA
Recurrent seizures Licence revoked until seizure free for 1 year
Seizures in sleep only
May drive despite continuing seizures, providing all
seizures have been in sleep for at least 3 years
Transient ischaemic attacks Usually can drive 1 month after a single episode
Transient global amnesia No effect on driving
Simple faint No effect on driving

Blackouts and funny dos

The diagnosis of blackouts depends almost entirely on the history.

The history from a witness is essential.

The cause of single unwitnessed blackouts is often uncertain.

The relevant driving regulations must be explained to the patient after they have had a blackout.