1. Impaired Consciousness Dr Nin Bajaj Consultant Neurologist QMC & DRI

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

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

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

5. History Acute Subacute Chronic

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

7. 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?

8. Acute impairment- previous hx Might be post-ictal

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

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

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

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

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

14. 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

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

16. 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

17. 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

18. 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

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

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

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

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

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

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

25. 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”

26. 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

27. 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

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

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