Chapter 54: Faints, fits and funny turns

When patients present with the complaint of a ‘funny turn’ it is usually possible to determine that they have one of the more recognisable presenting problems, such as fainting, ‘blackouts’, lightheadedness, weakness, palpitations, vertigo or migraine. However, there are patients who do present with confusing problems that warrant the label of ‘funny turn’. The most common problem with funny turns is that of misdiagnosis, so a proper and adequate history-taking is of great importance.

It is important to remember that seemingly ‘funny turns’ may be the subjective interpretation of cultural and linguistic communication barriers, especially in an emotional and frustrated patient.¹ Various causes of faints, fits and funny turns are presented in TABLE 54.1. A useful simple classification is to consider them as:

• syncope

• seizures

• sleep disorders—sleep apnoea/narcolepsy/cataplexy

• labyrinthine

A summary of the diagnostic strategy model is presented in TABLE 54.2.

History

The clinical history is of paramount importance in unravelling the problem. A reliable eye-witness account of the ‘turn’ is invaluable, as is the setting or circumstances in which the ‘episode’ occurred.

It is essential at first to determine exactly what the patient means by ‘funny turn’. In the process of questioning it is appropriate to evaluate the mental state and personal and social factors of the patient. It may be appropriate to confront the patient about feelings of depression, anxiety or detachment from reality.

It is important to break up the history into three components. First is the lead-up to the episode; second is an adequate description of what took place during the episode; third are the events that took place after the episode.

Apart from the events, note the patient’s feelings, symptoms, circumstances and provocative factors. Search for possible secondary gain.

Onset

A sudden onset may be due to cardiovascular causes, especially arrhythmias, which may include the more common supraventricular tachycardias in addition to the less common but more dramatic arrhythmias that may cause unconsciousness. Other causes of a sudden onset include the various epilepsies, vasovagal attacks and TIAs.

Precipitating factors²

Enquire about precipitating factors such as emotion, stress, pain, heat, fright, exertion, suddenly standing up, coughing, head movement or hypersomnolence:

• emotion and stress suggest hyperventilation

• fright, pain → vasovagal attack

• standing up → postural hypotension

• exertion → aortic stenosis

• head movement → cervical spondylosis with vertebrobasilar insufficiency

• hypersomnolence → narcolepsy

Associated symptoms²

Certain associated symptoms give an indication of the underlying disorder:

• breathing problems and hyperventilation suggest an anxiety state

• tingling in extremities or tightening of the hand → anxiety/hyperventilation

• visual problems → migraine or TIA

• fear or panic → anxiety or complex partial seizure

• hallucinations (taste/smell/visual) → complex partial seizure

• speech problems → TIA or anxiety

• sweating, hunger feelings → hypoglycaemia

• related to food → migraine

• first thing in morning → consider ‘hangover’

Drug history

This requires careful analysis and includes alcohol intake and illicit drugs such as marijuana, cocaine and amphetamines. Prescribed drugs that can cause lightheadedness or unconsciousness are listed in TABLE 54.3 and those causing seizures in TABLE 54.4.

Sudden cessation of certain drugs such as phenothiazines can also be responsible for ‘funny turns’.

Past history

The past history may give an indication of the cause of the ‘turn’. Such conditions include hypertension, migraine, epilepsy, rheumatic heart disease, diabetes, atherosclerosis (e.g. angina, vascular claudication), alcohol or other substance abuse and psychiatric disorders.

Diary of events

If the diagnosis is elusive it may help to get the patient to keep a diary of circumstances in which events take place, keeping in mind the importance of the time period prior, during and post episode.

Examination

Important focal points of the physical examination include:

• evaluation of the mental state, especially for anxiety

• looking for evidence of anaemia, alcohol abuse and infection

• cerebrovascular examination: carotid arteries, ocular fundi, bruits

• cardiovascular examination: pulses, BP, heart (the BP should be taken lying, sitting and standing)

• the cervical spine

Various manoeuvres

Subject the patient to a number of manoeuvres to try to induce various sensations in order to identify the one that affects them. These should include sudden assumption of the erect posture from a squat, spinning the patient and then a sudden stop, head positioning with either ear down (see FIG. 46.3, CHAPTER 46), Valsalva manoeuvre, and hyperventilation for 60 seconds. Children can spin a showbag ‘windmill’ while hyperventilating (blowing). Ask ‘Which one mimics your complaint?’

Investigations

Depending on the clinical findings, investigations can be selected from the following tests:

• full blood count: ? anaemia ? polycythaemia

• blood sugar: ? diabetes ? hypoglycaemia

• metabolic studies: urea and electrolytes, calcium, magnesium

• ECG: ? ischaemia ? arrhythmia

• 24-hour ambulatory cardiac (Holter) monitor: ? arrhythmia

• radiology/imaging and neuroimaging:

  • – cervical X-ray

  • – chest X-ray

  • – carotid duplex Doppler scan: ? carotid artery stenosis

  • – CT scan

  • – MRI scan

• EEG or video EEG; include those recorded with sleep deprivation, hyperventilation or photic stimulation

• positron emission tomography (PET) or single photon emission computerised tomography (SPECT) may show localised brain dysfunction when others are negative

The various forms of seizures are also encountered in childhood, when most patients with epilepsy are diagnosed. They can be categorised as subtle (staring, eye deviation, abnormal sucking or lip smacking) or tonic and clonic. Benign sleep myoclonus occurs in infants normally only during sleep and usually resolves by 2 months of age. There is a concern, supported by evidence, that children are being misdiagnosed. It is appropriate to take a visual recording of the attack.³

Neonatal seizures are dangerous and require specialised care to identify the cause and quickly stop the seizure. Pyridoxine may be used.

The following are special age-related epilepsy syndromes seen in children.^4,5 (See CHAPTER 84.)

Febrile seizures

Tonic–clonic seizures occur in 2–5% of children usually aged 3 months to 6 years who have a high fever generally caused by a viral infection. The long-term prognosis is good. For seizures lasting more than 5 minutes, use midazolam or diazepam.

Salaam attacks or infantile spasms

Also known as West syndrome, these are generalised tonic seizures with sudden flexion of the arms, forward flexion of the trunk and extension of the legs, lasting only a few seconds, with the usual age of onset between 4 and 12 months. They are usually restricted to the first 3 years of life and are replaced by other forms of attacks. ECG shows typical hypsarrhythmias. Prognosis for cognitive development is also unfavourable. The most effective therapy is corticotrophin (ACTH), e.g. tetracosactin IM injection. Otherwise, oral prednisolone, vigabatrin, benzodiazepines or sodium valproate can be used.

Lennox–Gastaut syndrome (myoclonic epilepsy of infancy)

This uncommon syndrome refers to a triad of severe difficult-to-control seizures (usually tonic with drop attack), mental retardation and characteristic EEG. The seizures usually begin between the ages of 1 and 6 years, with a peak onset at 3–5 years. Prognosis is poor. Sodium valproate is the therapy of choice.

Benign focal childhood epilepsy with centrotemporal spikes

This disorder usually begins in children aged 2–13 years, with a peak age of 5–8 years. It is the most common form of childhood focal epilepsy, and there is a strong family history of epilepsy. The main feature is a simple partial motor or somatosensory seizure involving the face and mouth during sleep, producing a typical ‘glugging’ sound. The child usually wakes from sleep, goes to the parents and is unable to speak and has hemifacial contortions. It may progress to a tonic–clonic seizure. There is a characteristic EEG pattern. The prognosis is excellent as remission usually occurs around puberty. Carbamazepine is the therapy of choice.

Childhood and juvenile absence epilepsy

These children present with frequent absence seizures (formerly ‘petit mal’), often over a hundred daily. Peak age of onset is 4–9 years. The absence seizures can be very subtle. Signs include alteration of awareness (usually in the classroom), sudden onset, facial and other automatisms. Juvenile absence epilepsy presents later (10–15 years). First-line treatment is ethosuximide (best tolerated) or sodium valproate.

Juvenile myoclonic epilepsy (myoclonic epilepsy of Janz)

This is a triad of seizures: myoclonic jerks, tonic–clonic seizures and absences. Onset is around puberty but may occur earlier. The myoclonic jerks and tonic–clonic seizures usually occur in the early morning after waking. Mental development is usually as normal, but the disorder is generally lifelong and is well controlled with sodium valproate.

Medial temporal lobe epilepsy

This syndrome of complex partial seizures, which usually last 1–3 minutes, is seen in childhood. Transient postictal confusion and speech dysfunction is common. Those with medically intractable seizures respond well to surgery.

Dravet syndrome

Known as severe myoclonic epilepsy of infancy, it is a catastrophic form with a very poor prognosis. It is largely inherited. Early diagnosis and treatment are essential.

Many normal and abnormal behaviours seen in children resemble seizures but are unrelated to epilepsy. A careful history is very important. The following are examples:

• Postures of spasticity and movement disorders. These occur in children with neurological disorders such as cerebral palsy.

• Syncope. The child may describe a ‘sinking feeling’, or ‘everything getting louder’ prior to the loss of consciousness.

• Breath-holding. This often occurs after a crying spell and clonic movements may be seen at the end of the event.

• Masturbation. This behaviour leads to a tonic-like posture of the legs and preoccupation, especially in young girls.⁶

• Munchausen-by-proxy.⁷ This syndrome of fictitious epilepsy described by a parent is becoming more recognised.

• Psychogenic seizures (pseudo seizures). A diagnostic dilemma exists when these coexist with genuine seizures. These should be suspected when they occur in particular circumstances and the description of the ‘seizure’ is bizarre.

• Shuddering. Shuddering or shivering spells can resemble myoclonic jerks.

• Night terrors.⁸ These episodes, which usually affect children aged 2–4 and 6–9, generally develop within 2 hours of sleep onset and last 1–2 minutes (sometimes longer). They are alarming and the child usually cannot be reassured or settled. A 6-week trial of phenytoin or imipramine can be used for severe problems.

• Tics. Motor tics can be quite complex but are usually brief involuntary movements involving the face and upper limbs.

• Cardiac causes. For example, long QT syndrome.

The important causes of blackout include the various syncopes that are listed in TABLE 75.4 (see CHAPTER 75) and the various forms of epilepsy. The classic tonic–clonic seizure is described in CHAPTER 74, while descriptions of other seizures producing blackouts or funny turns now follow.

Important causes of convulsions (tonic–clonic seizures) are listed in TABLE 54.4. Refer also to CHAPTER 84.

Complex partial seizures

In complex partial seizures (known also as temporal lobe epilepsy) the symptomatology varies considerably from patient to patient and is often a diagnostic problem. It is the commonest type of focal epilepsy and the attacks vary in time from momentary to several minutes (usually 1–3 minutes).

Possible manifestations²

• Commonest: slight disturbance of perception and consciousness

• Hallucinations: visual, taste, smell, sounds

• Absence attacks or vertigo

• Illusions—objects/people shrink or expand

• Affective feelings—fear, anxiety, anger

• Dyscognitive effects: déjà vu (familiarity), jamais vu (unreality), waves emanating from epigastrium

• Objective signs: lip-smacking, swallowing/chewing/sucking, unresponsive to commands or questions, pacing around a room

• Postictal drowsiness

Unreal or detached feelings are common in complex partial seizures. There can be permanent short-term memory loss. The sensation of strange smells or tastes is more common than auditory or visual hallucinations.¹ They can progress to tonic–clonic seizures.

Diagnosis

• EEG is diagnostic in 50–60% of cases; a repeat EEG will increase rate to 60–80%

• EEG/video telemetry helpful with frequent attacks

• CT or MRI scan—to exclude tumour when diagnosis confirmed

Medication (see CHAPTER 84)

• carbamazepine (first choice):^5,9 children and adults

• or

• sodium valproate (second choice): not <2 years

• or (others)

• vigabatrin, phenytoin, phenobarbitone, tiagabine, benzodiazepines, ethosuximide, levetiracetam

Tonic–clonic seizures

The classic seizure sequence: aura—cry—fall—fit (clonic then tonic-incontinence).

Variants of tonic–clonic seizures are more common than realised. Some patients may simply stiffen or drop to the ground while others may have one or two jerks or shakes only:

• stiffen and fall = tonic

• floppy and fall = atonic

• shaking only = clonic

Refer to CHAPTER 75 and CHAPTER 84.

In simple partial seizures (Jacksonian epilepsy) there is no loss of consciousness. These include focal seizures, which may proceed to a generalised tonic–clonic seizure or to motor seizures.

Jacksonian (motor seizure)

Typically, jerking movements begin at the angle of the mouth or in the thumb and index finger and ‘march’ to involve the rest of the body (e.g. thumb → hand → limb → face ± leg on one side and then on to the contralateral side). A tonic–clonic or complex partial seizure may follow.

Medication

• carbamazepine (first choice)⁵: children and adults

• or

• sodium valproate (second choice) not <2 years

• or (others)

• phenytoin, vigabatrin, gabapentin

Absence seizure

This type of generalised epilepsy typically affects children from 4 years up to puberty:² (see CHAPTER 84).

• child ceases activity and stares suddenly

• child is motionless (may blink or nod)

• no warning

• sometimes clonic (jerky) movement of eyelids, face, fingers

• may be lip-smacking or chewing (called complex absence)

• only lasts few seconds—usually 5–10 seconds

• child then carries on as though nothing happened

• usually several per day (not just one or two)

• may lead to generalised seizures in adulthood

• two types—childhood and juvenile

Diagnosis

Best evoked in the consulting room by hyperventilation and ‘windmill’.

EEG:

• classic 3 Hz wave and spike

• may be normal

• always include hyperventilation

• easier with sleep deprivation

Medication

• ethosuximide (first choice)^5,10

• or

• sodium valproate (second choice)

• or (others) e.g. clonazepam, gabapentin

• childhood absence may not need pharmacotherapy

Note: Beware of hepatoxicity with sodium valproate, especially in those under 2 years.

The decision to treat the first seizure with medication is based on several factors. Since 50% of patients will never have another seizure, treatment is not usually recommended. However, if two or more seizures occur over more than 24 hours, patients are likely to experience more and require treatment. The risk is increased in specific types, such as partial (focal) seizures, those with ECG abnormalities and a lesion on neuroimaging.^5,12

Narcolepsy

Narcolepsy is characterised by brief spells of irresistible sleep during daytime hours, usually in inappropriate circumstances, even during activity. Its cause is unknown. Although patients are usually aware of their disorder, some may have no insight into the problem and present with the complaint of unusual turns. Narcolepsy can present as ‘attacks’ in which the patient may crumple and fall without losing consciousness. It can be part of a tetrad syndrome (daytime hypersomnolence, cataplexy, hypnogogic and hypnopompic hallucinations, sleep paralysis).

Other features:

• onset in teens or 20s

• can have several attacks per day

Refer to CHAPTER 71.

Diagnosis

• A clinical diagnosis

If doubtful:

• EEG monitoring

• sleep laboratory studies (sleep latency test)—rapid eye movement is a hallmark

Medication¹¹

• dexamphetamine (in slowly increasing doses to 60 mg daily)

• or

• methylphenidate (immediate release) up to 60 mg daily

• or

• modafinil 200–400 mg (o) daily

• or

• tricyclic antidepressants (e.g. clomipramine, imipramine, fluoxetine), for associated cataplexy

Amnesic episodes in which people cannot recall events or their own identity can be psychogenic (commonly), such as fugue states, conversion disorder, severe depression and factitious states. They may be related to an organic problem such as epilepsy, sleep apnoea, cerebrovascular disorder, post-trauma, Wernicke–Korsakoff syndromes and drugs (e.g. alcohol, cannabis and anaesthetic agents).

Transient global amnesia^5,13,14

This is a benign, self-limited profound amnesic episode of unknown aetiology tending to occur in middle-aged or elderly people. Proposed causation includes transient ischaemia or dysfunction of the temporal lobes, similar to temporal lobe epilepsy or a migraine variant.

Clinical features

• Typically last 4–8 hours (up to 24 hours)

• Identity and conscious state preserved

• Agitated, perplexed, anxious patient

• State of bewilderment (e.g. ‘where am I?’)

• Anterograde and retrograde amnesia

• Frequent repetition of questions

• Able to perform complex motor skills (e.g. driving)

• Usually single episode (20% recurrence)

• Complete resolution: good prognosis

• No abnormal neurological signs

• All investigations unhelpful

Four diagnostic criteria (after Caplan)¹²

• Witnessed onset of attack (essential for diagnosis)

• Dysfunction during attack limited to amnesia and repetitive queries

• No other neurological features

• Memory loss should be transient, lasting no longer than 24 hours

Management

• Reassuring explanation/education

• Special investigations, including angiography, not needed if conform to above criteria

• No active treatment usually needed

Cerebrovascular disease is one of the major causes of mortality and morbidity in developed countries and can cause recurrent attacks of ischaemia in the carotid and vertebrobasilar systems (particularly vertebrobasilar insufficiency), which may present as ‘funny turns’. In particular, brain-stem ischaemia causes ‘funny turns’ such as impaired consciousness, including transient global amnesia, drop attacks and the ‘locked-in’ syndrome.

There are three main syndromes of autonomic instability with orthostatic intolerance leading to syncope

1. Reflex (vasovagal) syncope. This affects 30% of the population, has a strong family history and an onset in the young. There is a hypotensive response. The multiple precipitants include coughing, micturition, fright, standing, heat and defecation (straining). Although consciousness quickly returns, recovery can be delayed (e.g. malaise for 12–24 hours). See CHAPTER 75.

2. Postural orthostatic tachycardia syndrome (POTS).¹⁵ This is orthostatic intolerance with dysautonomia upon changing from the supine to the upright position or head up tilt. Tachycardia with decreased ventricular filling is a feature with hypotension and possibly syncope. There are myriad symptoms including dizziness, fatigue, blurred vision, chest pain and cognitive impairment. Some consider it a variety of chronic fatigue syndrome. It has an adolescent onset and a familial history. Referral to a ‘syncope’ unit is recommended for this complex and debilitating condition. One treatment option is fludrocortisone acetate. Another is the vasopressor/hypertensive agent midodrine to treat dysautonomia and orthostatic hypotension.

3. Autonomic failure. This is age related and can be primary (e.g. multiple system atrophy) or secondary (e.g. diabetes, amyloid). It leads to hypoperfusion syncope. Precipitants include orthostasis, meals and alcohol. Recovery from syncope is rapid.

Psychogenic causes have to be considered. ‘Hysterical fugue’ is one such manifestation. The problem can be a communication disorder, such as an emotional person trying to communicate a problem in a language foreign to them.

Patients with psychiatric disorders such as schizophrenia or depression may experience feelings of depersonalisation or unreality, which can be interpreted as a ‘turn’ or even temporal lobe epilepsy.

Patients who complain of vague and bizarre symptoms, such as ‘queer feelings in the head’, ‘swimming sensation’, ‘unreal feelings’ and ‘walking on air’ are likely to have an anxiety state.

Severe anxiety or panic attacks typically cause lightheadedness that presents as a ‘funny turn’. Other somatic symptoms include palpitations, sweating, inability to swallow, headache, breathlessness and manifestations of hyperventilation.

• The main pitfall associated with seizure disorders and epilepsy is misdiagnosis (not all seizures are generalised tonic–clonic in nature).

• Failing to place appropriate emphasis on the history in making the diagnosis.

• Misdiagnosing syncope with some involuntary movements for epilepsy.

• Overlooking cardiac arrhythmias as a cause of funny turns, including recurrent dizziness.

• Failing to consider the possibility of aortic stenosis with syncopal attacks.

• Misdiagnosing vertigo and syncope for TIA.

• Mistaking visual or sensory migraine equivalents in young adults for TIA.

• Overlooking drugs (including self-administered drugs) as a cause of lightheadedness.

• Transient ischaemic attacks, especially if the diagnosis is in doubt

• Clinical suspicion of or proven cardiac arrhythmias

• Evidence of aortic stenosis

• Seizures

• General uncertainty of the diagnosis

Hand-out sheets from Murtagh’s Patient Education 7th edition:

• Fainting (syncope)