Diagnostic evaluation

ESC CardioMed ◽  
2018 ◽  
pp. 2021-2023
Author(s):  
Frederik J. de Lange ◽  
J. Gert van Dijk
Keyword(s):  
Cardiovascular Events ◽  
Epileptic Seizures ◽  
Loss Of Consciousness ◽  
Pressure Measurements ◽  
History Taking ◽  
Ambulance Personnel ◽  
Major Cardiovascular Events ◽  
Cardiac Syncope ◽  
Transient Loss ◽  
Standing Blood Pressure

When a patient presents with transient loss of consciousness (T-LOC), the history, usually initially derived from a general practitioner or ambulance personnel, is most important to determine whether it is indeed T-LOC. If so, more history taking is of paramount importance to differentiate between the different forms of T-LOC: syncope, epileptic seizures, or psychogenic attacks. When T-LOC is syncope and epileptic seizures and psychogenic attacks are less likely, the initial syncope evaluation should address the different forms of syncope: reflex syncope, orthostatic hypotension, or cardiac syncope. The initial syncope evaluation consists of (1) more detailed and careful history taking, (2) a physical examination, including supine and standing blood pressure measurements, and (3) an electrocardiogram. When the initial syncope evaluation does not yield either a certain or a highly likely diagnosis, the next step is to perform risk stratification of major cardiovascular events including sudden death. The subsequent evaluation will be determined by the causal risk.

Definition, epidemiology, classification, and pathophysiology

ESC CardioMed ◽  
2018 ◽  
pp. 2017-2021
Author(s):  
J. Gert van Dijk ◽  
Roland D. Thijs
Keyword(s):  
Cardiac Output ◽  
Orthostatic Hypotension ◽  
Epileptic Seizures ◽  
Cerebral Hypoperfusion ◽  
Loss Of Consciousness ◽  
Low Cardiac Output ◽  
Transient Loss Of Consciousness ◽  
Reflex Syncope ◽  
Cardiac Syncope ◽  
Transient Loss

Syncope can closely resemble other disorders with which it shares an apparent short-lived transient loss of consciousness. Together, these disorders are labelled as ‘transient loss of consciousness (T-LOC)’. Syncope is the form of T-LOC caused by cerebral hypoperfusion; the other main T-LOC forms are several types of epileptic seizures and the psychogenic conditions that resemble either syncope or epileptic seizures. The main forms of syncope are reflex syncope, syncope due to orthostatic hypotension, and cardiac syncope, also comprising cardiopulmonary causes and disorders of the great vessels. All forms of syncope share cerebral hypoperfusion and arterial hypotension as a final common pathway. They differ in the mechanism of hypotension: cardiac syncope is largely due to a low cardiac output, but in orthostatic hypotension and reflex syncope both low peripheral resistance and low cardiac output contribute to syncope. The clinical expression of the main forms is tightly linked to their pathophysiology, which is therefore important for differential diagnosis.

Definition, epidemiology, classification, and pathophysiology

ESC CardioMed ◽  
2018 ◽  
pp. 2017-2021
Author(s):  
J. Gert van Dijk ◽  
Roland D. Thijs
Keyword(s):  
Cardiac Output ◽  
Orthostatic Hypotension ◽  
Epileptic Seizures ◽  
Cerebral Hypoperfusion ◽  
Loss Of Consciousness ◽  
Low Cardiac Output ◽  
Transient Loss Of Consciousness ◽  
Reflex Syncope ◽  
Cardiac Syncope ◽  
Transient Loss

Syncope can closely resemble other disorders with which it shares an apparent short-lived transient loss of consciousness. Together, these disorders are labelled as ‘transient loss of consciousness (T-LOC)’. Syncope is the form of T-LOC caused by cerebral hypoperfusion; the other main T-LOC forms are several types of epileptic seizures and the psychogenic conditions that resemble either syncope or epileptic seizures. The main forms of syncope are reflex syncope, syncope due to orthostatic hypotension, and cardiac syncope, also comprising cardiopulmonary causes and disorders of the great vessels. All forms of syncope share cerebral hypoperfusion and arterial hypotension as a final common pathway. They differ in the mechanism of hypotension: cardiac syncope is largely due to a low cardiac output, but both low peripheral resistance and low cardiac output contribute to syncope due to orthostatic hypotension and reflex syncope. The clinical expression of the main forms is tightly linked to their pathophysiology, which is therefore important for differential diagnosis.

Synkope, epileptischer oder psychogener Anfall? Der Weg zur richtigen Diagnose

2019 ◽  
Vol 144 (12) ◽  
pp. 835-841
Author(s):  
Tobias Baumgartner ◽  
Rainer Surges
Keyword(s):  
Emergency Room ◽  
Daily Life ◽  
Epileptic Seizures ◽  
Loss Of Consciousness ◽  
Transient Loss Of Consciousness ◽  
Daily Life Activities ◽  
Transient Loss ◽  
Impact On Treatment ◽  
Key Features ◽  
The Impact

AbstractTransient loss of consciousness (TLOC) is a frequent cause of referral to an emergency room. In view of the impact on treatment and the patients’ daily life activities (e. g. profession, driving license), an accurate and timely diagnosis is of uttermost importance. This article provides key features and suggests a practical step-by-step approach of how to differentiate syncope, epileptic and psychogenic non-epileptic seizures as the commonest causes of nontraumatic TLOC.

#3079 Investigating the feasibility of automating the differential diagnosis of transient loss of consciousness

2021 ◽  
Vol 92 (8) ◽  
pp. A7.1-A7
Author(s):  
Nathan Pevy ◽  
Heidi Christensen ◽  
Traci Walker ◽  
Markus Reuber
Keyword(s):  
Differential Diagnosis ◽  
Random Forest ◽  
Epileptic Seizures ◽  
The Other ◽  
Future Research ◽  
Loss Of Consciousness ◽  
Transient Loss Of Consciousness ◽  
Audio Recordings ◽  
Transient Loss ◽  
Nonepileptic Seizures

BackgroundThere are three common causes of Transient Loss of Consciousness (TLOC), syncope, epileptic and psychogenic nonepileptic seizures (PNES). Many individuals who have experienced TLOC initially receive an incorrect diagnosis and inappropriate treatment. Whereas syncope can be distinguished from the other two causes relatively easily with a small number of yes/no questions, the differentiation of the other two causes of TLOC is more challenging. Previous qualitative research based on the methodology of Conversation Analysis has demonstrated that epileptic and nonepileptic seizures are described differently when patients talk to clinicians about their TLOC experiences. One particularly prominent difference is that epileptic seizure descriptions are characterised by more formulation effort than accounts of nonepileptic seizures.AimThis research investigates whether features likely to reflect the level of formulation effort can be automatically elicited from audio recordings and transcripts of speech and used to differentiate between epileptic and nonepileptic seizures.MethodVerbatim transcripts of conversations between patients and neurologists were manually produced from video and audio recordings of interactions with 45 patients (21 epilepsy and24 PNES). The subsection of each transcript containing the patients account of their first seizure was manually extracted for the analysis. Seven automatically detectable features were designed as markers of formulation effort. These features were used to train a Random Forest machine learning classifier.ResultsThere were significantly more hesitations and repetitions in descriptions of first epileptic than nonepileptic seizures. Using a nested leave-one-out cross validation approach, 71% of seizures were correctly classified by the Random Forest classifier.ConclusionsThis pilot study provides proof of principle that linguistic features that have been automatically extracted from audio recordings and transcripts could be used to distinguish between epileptic seizures and PNES and thereby contribute to the differential diagnosis of TLOC. Future research should explore whether additional observations can be incorporated into a diagnostic stratification tool. Moreover, future research should explore the performance of these features when they have been extracted from transcripts produced by automatic speech recognition and when they are combined with additional information provided by patients and witnesses about seizure manifestations and medical history.

Approach to Loss of Consciousness: Distinguishing Epileptic Seizures, Psychogenic Nonepileptic Seizures, and Syncope

2021 ◽  
Vol 41 (06) ◽  
pp. 667-672
Author(s):  
Ima Ebong ◽  
Zahra Haghighat ◽  
Meriem Bensalem-Owen
Keyword(s):  
Physical Examination ◽  
Diagnostic Tests ◽  
Epileptic Seizures ◽  
Loss Of Consciousness ◽  
Transient Loss Of Consciousness ◽  
Psychogenic Nonepileptic Seizures ◽  
Transient Loss ◽  
Nonepileptic Seizures

AbstractTransient loss of consciousness (TLOC) is a common emergent neurological issue, which can be attributed to syncope, epileptic seizures, and psychogenic nonepileptic seizures. The purpose of this article is to outline an approach to diagnosing the most common etiologies of TLOC by focusing on the importance of the history and physical examination, as well as targeted diagnostic tests.

Emergency department prioritization of transient loss of consciousness due to epileptic seizures

2021 ◽  
Vol 429 ◽  
pp. 117688
Author(s):  
Bruna Nucera ◽  
Fabrizio Rinaldi ◽  
Arian Zaboli ◽  
Norbert Pfeifer ◽  
Gianni Turcato ◽  
...  
Keyword(s):  
Emergency Department ◽  
Epileptic Seizures ◽  
Loss Of Consciousness ◽  
Transient Loss Of Consciousness ◽  
Transient Loss

280 A screening questionnaire for transient loss of consciousness

2018 ◽  
Vol 89 (10) ◽  
pp. A41.3-A42
Author(s):  
Wardrope Alistair ◽  
Jamnadas-Khoda Jenny ◽  
Broadhurst Mark ◽  
Grünewald Richard A ◽  
Howell Stephen J ◽  
...  
Keyword(s):  
Feature Selection ◽  
Delayed Diagnosis ◽  
Epileptic Seizures ◽  
Feature Model ◽  
Loss Of Consciousness ◽  
Transient Loss Of Consciousness ◽  
Associated Symptoms ◽  
Uncertain Significance ◽  
Transient Loss ◽  
Test Probability

BackgroundTransient loss of consciousness (TLOC) is a common primary care presentation. 90% are due to syncope (S), epilepsy (E), or psychogenic non-epileptic seizures (PNES). Misdiagnosis and delayed diagnosis is common. We explore symptoms and witness observations that can classify patients with likely diagnoses of E, S, or PNES.MethodsPatients with objectively-documented diagnoses of E, S, or PNES, and an attack witness, were invited to complete a questionnaire (capturing medical history, 86 peri-episodal experiences, and 31 witness observations). Iterative feature selection identified questions strongly predictive of diagnosis; a random forest trained on these classified patients into likely diagnoses of E, S, or PNES.Results249 patients (86 E, 79 s, 84 PNES) were randomly assigned to training or validation in a 2:1 ratio. Feature selection identified 36 highly-predictive questionnaire items. The classifier correctly diagnosed 86% of patients in validation. 100% of S were correctly diagnosed, 85.7% E and 75% PNES. A simpler 12-feature model correctly classified 76.7% of cases (E: 75%; S: 92.3%; PNES: 65.6%).ConclusionsTLOC-associated symptoms and manifestations can contribute to a decision rule for primary/emergency care, assisting triage and referral. Determining a diagnostic pre-test probability from TLOC features can aid interpretation of investigation abnormalities of uncertain significance.

Neurologist, 7 years’ experience, Kenya

2020 ◽  
pp. 300-304
Author(s):  
Markus Reuber ◽  
Gregg H. Rawlings ◽  
Steven C. Schachter
Keyword(s):  
Epileptic Seizure ◽  
Epileptic Seizures ◽  
Clinical History ◽  
Sub Saharan Africa ◽  
Loss Of Consciousness ◽  
Tertiary Referral Center ◽  
Resource Limited ◽  
Transient Loss ◽  
Sub Saharan ◽  
Convulsive Syncope

This chapter looks at the experience of a Neurologist who has had the privilege to be trained by internationally renowned specialists in epilepsy and Psychogenic Non-Epileptic Seizures (PNES). The diagnosis and management of PNES became more challenging, however, when the Neurologist moved countries to practice as a general Neurologist in a resource-limited regional tertiary referral center in Kenya. There, Neurology remains a poorly taught topic and “neurophobia” is strife; healthcare professionals therefore seem to label everything that falls and shakes as an epileptic seizure or, annoyingly, “unexplained seizure disorder.” Indeed, PNES in sub-Saharan Africa is not very well described in the published literature, and therefore the Neurologist’s introduction of terms such as PNES, transient loss of consciousness, and convulsive syncope were initially met with disbelief. The Neurologist realized early on that all staff, including the trainee doctors, had to be retrained and reminded of the importance of the clinical history and the witness account to make the diagnosis.

Dissociative (non-epileptic) seizures: tackling common challenges after the diagnosis

2019 ◽  
Vol 19 (4) ◽  
pp. 332-341 ◽  
Author(s):  
Markus Reuber
Keyword(s):  
Personal Experience ◽  
Epileptic Seizures ◽  
Loss Of Consciousness ◽  
Crucial Point ◽  
Transient Loss Of Consciousness ◽  
Transient Loss ◽  
Dissociative Seizures

Dissociative (non-epileptic) seizures are one of the three major causes of transient loss of consciousness. As such, their treatment cannot be left to superspecialised experts. In this article I draw on personal experience to suggest ways to tackle some challenges that commonly arise after diagnosing dissociative seizures, focusing on three issues: “I want to know what is wrong with me,” “I hear what you are saying but it doesn’t apply to me” and “What if I have a seizure?” The suggestions detail both actions and words that may help at a crucial point in the patient’s journey. If handled well, the process can leave the patient better equipped to understand their seizures and to engage in further treatment; if handled badly, patients may be left more traumatised, angry and with additional disability.

scholarly journals Machine learning as a diagnostic decision aid for patients with transient loss of consciousness

2019 ◽  
Vol 10 (2) ◽  
pp. 96-105 ◽  
Author(s):  
Alistair Wardrope ◽  
Jenny Jamnadas-Khoda ◽  
Mark Broadhurst ◽  
Richard A. Grünewald ◽  
Timothy J. Heaton ◽  
...  
Keyword(s):  
Machine Learning ◽  
Decision Rules ◽  
Epileptic Seizures ◽  
Analysis Data ◽  
Machine Learning Techniques ◽  
Loss Of Consciousness ◽  
Class Iii ◽  
Transient Loss Of Consciousness ◽  
Transient Loss ◽  
Female Responses

BackgroundTransient loss of consciousness (TLOC) is a common reason for presentation to primary/emergency care; over 90% are because of epilepsy, syncope, or psychogenic non-epileptic seizures (PNES). Misdiagnoses are common, and there are currently no validated decision rules to aid diagnosis and management. We seek to explore the utility of machine-learning techniques to develop a short diagnostic instrument by extracting features with optimal discriminatory values from responses to detailed questionnaires about TLOC manifestations and comorbidities (86 questions to patients, 31 to TLOC witnesses).MethodsMulti-center retrospective self- and witness-report questionnaire study in secondary care settings. Feature selection was performed by an iterative algorithm based on random forest analysis. Data were randomly divided in a 2:1 ratio into training and validation sets (163:86 for all data; 208:92 for analysis excluding witness reports).ResultsThree hundred patients with proven diagnoses (100 each: epilepsy, syncope and PNES) were recruited from epilepsy and syncope services. Two hundred forty-nine completed patient and witness questionnaires: 86 epilepsy (64 female), 84 PNES (61 female), and 79 syncope (59 female). Responses to 36 questions optimally predicted diagnoses. A classifier trained on these features classified 74/86 (86.0% [95% confidence interval 76.9%–92.6%]) of patients correctly in validation (100 [86.7%–100%] syncope, 85.7 [67.3%–96.0%] epilepsy, 75.0 [56.6%–88.5%] PNES). Excluding witness reports, 34 features provided optimal prediction (classifier accuracy of 72/92 [78.3 (68.4%–86.2%)] in validation, 83.8 [68.0%–93.8%] syncope, 81.5 [61.9%–93.7%] epilepsy, 67.9 [47.7%–84.1%] PNES).ConclusionsA tool based on patient symptoms/comorbidities and witness reports separates well between syncope and other common causes of TLOC. It can help to differentiate epilepsy and PNES. Validated decision rules may improve diagnostic processes and reduce misdiagnosis rates.Classification of evidenceThis study provides Class III evidence that for patients with TLOC, patient and witness questionnaires discriminate between syncope, epilepsy and PNES.

Sign in / Sign up

Export Citation Format

Share Document