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INTRODUCTION

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Episodes that involve transient alteration in the level of consciousness can be particularly a challenging problem faced by the practicing neurohospitalist. Getting a good history is key in neurology, but often challenging given patient factors and the hospital environment. It is the experience of the authors that many times an initial evaluation ensues that is primarily focused on “ruling out” vascular or epileptic etiologies. It is worth noting, however, that while all vascular events and seizures are spells, not all spells are seizures or transient ischemic attacks. The challenge for the neurohospitalist comes when the clinical picture remains unclear. This chapter will focus on spells not of vascular, epileptic, or psychogenic origin. In particular, there will be an emphasis on conditions that may evade the standard diagnostic workup. These spells may occur in otherwise healthy patients with no (known) prior neurological history. Patients may present with unexplained collapse, or with symptoms that are not immediately suggestive of a neurological cause such as nausea and malaise. In the following review we offer diagnoses to also think of when the standard medical workup does not reveal a cause.

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CASE 24-1

Ms. K. S., an 18-year-old, is brought to the hospital emergency department by her parents for evaluation of several passing-out spells in the last several months. She has been seen in three other hospital emergency departments (EDs) for this as well. The parents are extremely concerned. The patient has recently also been having some headaches. Today, she suddenly passed out again, she rolled her eyes, fell to the ground “like a sack of potatoes,” and looked dead for a second. She did have a pulse. She came around after 10 seconds and had a headache, but no confusion. She is also having her menstrual period. She had an electroencephalogram (EEG) and computed tomography (CT) head at the ER, and three times before at other facilities. All those were described as normal.

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WHAT IS A SPELL?

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Recurrent or paroxysmal events that involve transient alteration in the level of consciousness. Often, the episodes are discreet, re-occur, and share similar characteristics to one another.

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WHAT ARE THE ELEMENTS OF HISTORY THAT NEED TO BE ELICITED IN THIS PATIENT?

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  • Number of similar episodes

  • What was the patient doing at that time?

  • Prodrome—any palpitations, diaphoresis? What other associated symptoms?

  • Characteristics of onset (sudden and intense?)

  • The symptoms according to the patient, and ideally description of the event by collateral

  • Triggers, exacerbating factors, and relieving factors

  • Family history (eg, where relevant; familial hypokalemic periodic paralysis)

  • Postictal period

  • History of illicit substance use

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HOW WOULD YOU EXAMINE THIS PATIENT?

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  • Detailed neurological examination looking for focal deficits

  • Orthostatic vitals

  • General examination including abdomen and cardiac

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WHAT ARE THE COMMON CAUSES OF SPELLS?

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  • As a rule, seizures present in stereotypical ways and, ...

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