"Neurally mediated syncope" is the most common cause of syncope in all age groups, and includes various overlapping entities, such as neurocardiogenic syncope, vasovagal syncope, and vasodepressor syncope. These are distinctly different from orthostatic hypotension and seizures. 

A careful history is the most important “test” to diagnose neurally mediated syncope. It is frequently preceded by a characteristic prodrome with symptoms such as nausea, dizziness, feelings of warmth or coldness, visual dimming or blurring, clammy skin, facial pallor, general weakness, decreased hearing, or fecal urgency. Symptoms last 30 seconds to several minutes prior to syncope. 

Differentiating syncope from seizures:

Brief, multifocal,arrhythmic, myoclonic jerks are observed in up to 90% of patients at the time of syncope. These are caused by brainstem hypoperfusion and may be mistaken for seizures. The jerks follow the LOC (rather than immediate) and the eyes deviate upward (rather than lateral). If tongue biting occurs, it’s the tip (rather than the side, which is what occurs with seizures).

 

Cheshire WP. Syncope. Continuum 2017;23(2):335–358.

• Vasogenic cerebral edema is most commonly seen with brain tumors and cerebral abscesses.
• It mainly involves the white matter.
• Gray-white differentiation is maintained, so the edema has a finger-like pattern on CT (see Figure).
• It is caused by disruption of the blood-brain-barrier, thus responds to treatment with steroids.

Case image courtesy of Dr David Cuete, Radiopaedia.org, rID: 23178

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Simplified GCS vs. Full GCS?  Which One To Use?

Chou R, Totten AM, Carney N, et al. Predictive Utility of the Total Glasgow Coma Scale Versus the Motor Component of the Glasgow Coma Scale for Identification of Patients with Serious Traumatic Injuries. Ann Emerg Med. 2017 Jan 11. [Epub ahead of print].

 

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Majerisk JJ. Inherited and Uncommon Causes of Stroke. Continuum 2017;23(1):211–237.

 

IV Fluids for Headache?

• Headache is the 4th most common ED visit in the US.
• Clinical experience suggests that IV fluids (IVF) are commonly used as adjunctive treatment for headaches, however, the efficacy is unknown.
• A retrospective study using the National Hospital Ambulatory Medical Care Survey (NHAMCS) found that ED length of stay was significantly greater in patients who received IVF than in those who did not (202 min vs. 131 min, p<0.001) even after adjusting for initial pain score, sex, age, and mode of arrival. 
• A post-hoc analysis of data collected from 4 ED-based migraine trials found that IVF was not associated with improvement of pain score or sustained headache freedom.
• There is no current evidence to suggest a direct analgesic effect of IVF in the treatment of headaches.

• Jones CW, et al. Epidemiology of intravenous fluid use for headache treatment: Findings from the National Hospital Ambulatory Medical Care Survey. Am J Emerg Med. 2017. [Epub ahead of print]
• Balbin JEB, et al. Intravenous fluids for migraine: a post hoc analysis of clinical trial data. Am J Emerg Med. 2016;34:713-6.

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• 15% of all cases of ischemic strokes occur in patients less than 45 years old.
• To put things into perspective, incidence of stroke in this age group is twice that of multiple sclerosis.
• Delayed diagnosis is due to several factors:
• • The relative rarity of the diagnosis in comparison to stroke mimics at this age, the 3 most common being: migraines, seizures, and Bell's palsy. 
  • Atypical presentations, such as acute vestibular syndrome. 
  • Although “typical" risk factors (such as smoking, diabetes and hypertension) are present in young patients with strokes, other factors to be considered are high-risk alcohol consumption, cocaine use (especially smoked), physical inactivity, sleep 6 hours or less a night, and known thrombophilia. 

 

Back to the Basics: Aphasia

• Aphasia is an impairment of language
• 3 important assessments in an aphasic patient are fluency, comprehension, and repetition (see attached figure)
• Patients with fluent speech are able to generate speech spontaneously, though the content of their speech may have errors
• Patients with non-fluent speech have difficulty initiating speech
• Patients who have fluent speech but are unable to repeat have a problem with comprehension or a disconnect between the sensory and motor components of language
  • In Wernicke’s aphasia, patients cannot comprehend what they read and hear 
  • In conduction aphasia, patients can comprehend what they read and hear

Types of aphasia [Online image]. Retrieved February 8, 2017 from https://www.aphasia.org/

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Nicolle MW. Myasthenia Gravis and Lambert-Eaton Myasthenic Syndrome. Continuum. 2016;22(6):1978–2005

 

Driving after concussion: Is it safe to drive after symptoms resolve?

• Limited data is available to guide when individuals should return to driving after a concussion.
• Cognitive impairments in reaction time, executive function, and attention can persist even after symptoms of a concussion resolve.
• Schmidt et al. compared driving performance between individuals within 48 hours following symptom resolution after a concussion with matched controls using simulated driving.
• They found that concussed individuals had poorer driving performance despite being asymptomatic.
• This study is limited by a small sample size (n=28), however, it raises interesting questions regarding whether driving should be restricted following concussions and how should readiness to return to driving be determined.

Schmidt JD, Hoffman NL, Ranchet M, et al. Driving after concussion: Is it safe to drive after symptoms resolve? J Neurotrauma. 2016 Dec 13. [Epub ahead of print]

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• This retrospective study compared the number of patients meeting goal door-to-needle (DTN) time of 60 minutes with and without an ED pharmacist participating on the stroke alert team.
• A higher proportion of patients with an ED pharmacist met goal DTN time of 60 minutes (71% vs. 39%, p=0.002, 95% CI 0.10-0.50).
• Patients with an ED pharmacist had an average 20-minute decrease in door-to-needle time (p=0.004, 95% CI 6.6-33.4).

Montgomery K, Hall AB, Keriazes G. Impact of an emergency medicine pharmacist on time to thrombolysis in acute ischemic stroke. Am J Emerg Med 2016;34:1997-9.

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• There is increased attenuation of the basal cisterns and subarachnoid space as well as diffuse cerebral edema.
• At first glance, it appears to be a subarachnoid hemorrhage.
• However, the Hounsfield unit of the density is lower than blood.
• This is a pseudosubarachnoid hemorrhage sign.  
• This can be seen in anoxic injury with cerebral edema, pyogenic meningitis, venous sinus thrombosis, bilateral large subdural hemorrhages.

Kim JM, Eom TH. The pseudosubarachnoid hemorrhage: clinical implications of subarachnoid hemorrhage misdiagnosis. Pediatr Emerg Care. 2016 May 12. [Epub ahead of print]

Singh K, Mechtler LL and Klein JP. Imaging of Spinal Cord Disorders. Continuum 2016;22(5):1595 1612

In Depth:

This is a retrospective study, with no control group.  However, it is the largest study to date that was specifically designed to answer this clinical question, including 37 patients over a 10-year period, with the following results:

- PCC was effective 90% of patients

- The median INR was 2.2 before, and 1.3 after (checked immediately after the infusion)

- The median time from starting the infusion and LP was 135 minutes.

- None of the patients had a spinal hemorrhage or allergic reaction.

- Some patients were started on vitamin K according to the physician’s discretion, with variable starting times of anticoagulation after the procedure (if at all).

Laible M, Beynon C, Sander P, et al. Treatment with Prothrombin Complex Concentrate to Enable Emergency Lumbar Puncture in Patients Receiving Vitamin K Antagonists. Ann Emerg Med. 2016 Sep;68(3):340-4

 

My patient won't open his/her eyes!

 

Ashizawa T and Xia G. Ataxia. Continuum 2016;22(4):1208-1226

Patient presents after a fall confused, not moving his right side, but moving his left side spontaneously.  What's the diagnosis?

 

• The patient has a right subdural hematoma (SDH) with midline shift and right uncal herniation. 
• The classic presentation of a cerebral lesion with uncal herniation is ipsilateral mydriasis, contralateral hemiparesis, and abnormal extensor posturing.
• In this patient’s case, there is compression of the contralateral cerebral peduncle of the midbrain by the edge of the tentorium cerebelli producing an ipsilateral hemiplegia (see attachment for Figure 2).
• This false localizing sign is named Kernohan’s notch syndrome, Kernohan’s notch phenomenon, or Kernohan’s sign.

Diagram modified from "Localised Neurological Disease and Its Management A Intracranial". clinicalgate.com/localised-neurological-disease-and-its-management-a-intracranial/. Accessed 10 Aug 2016.

 

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Over the past few years, there have been numerous studies discussing the "best" way to diagnose subarachnoid hemorrhage (SAH). These 2016 guidelines review the current evidence.

Classic approach: dry CT, and if negative perform the lumbar puncture (LP)

It is the most common approach, with the most robust evidence. Still considered "standard of care"

Dry CT alone: Sensitivity of a dry CT alone for SAH has increased with improved technology, and the sensitivity is highest when done within the first 6 hours of headache onset. Despite studies quoting a sensitivity of 100% within 6 hours, this evidence is still insufficient due to concerns for selection bias in the study, and the fact that the CTs in the study were read by neuroradiologists.

CT/CTA: CTA is very sensitive for aneurysmal SAH (98% for aneurysms >3mm). CTA would miss non-aneurysmal SAH, but would detect aneurysms that may or may not need to be treated before rupture. It is a reasonable strategy to exclude aneurysmal SAH in select patients, and in patients who refuse LPs or in whom the LP results are equivocal.

Bottom Line: CT/LP is still standard of care, with CT/CTA being an acceptable alternative if LP is equivocal or refused by the patient. CT alone is NOT enough to exclude SAH.

Clinical Guidelines for the Emergency Department Evaluation of Subarachnoid Hemorrhage. Meurer WJ, Walsh B, Vilke GM and Coyne CJ. JEM 2016; 50(4) 696-701

 

Screening Tool for Large Vessel Occlusion Strokes (LVOS)?

 

1. Powers WJ, Derdeyn CP, Biller J, et al. 2015 American Heart Association/American Stroke Association Focused Update of the 2013 Guidelines for the Early Management of Patients with Acute Ischemic Stroke Regarding Endovascular Treatment: A Guideline for Healthcare Professionals From the American Heart Association/American Stroke Association. Stroke. 2015;46(10):3020-35.
2. Lima FO, Silva GS, Furie KL, et al. Field Assessment Stroke Triage for Emergency Destination: A Simple and Accurate Prehospital Scale to Detect Large Vessel Occlusion Strokes. Stroke. 2016 Jun 30. [Epub ahead of print]

 

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