Altered Consciousness and Epilepsy Overview

Altered Consciousness

• Consciousness is the state of awareness of self and surroundings.
• Altered consciousness and impaired mental functions are different categories of dysfunction. Localizable deficits, dementia/Alzheimer's disease and other conditions fall under impaired mental functions.
• Consciousness levels range from alert and aware (conscious) to confused (disoriented, impaired judgment, needing cues) to lethargic (stupor, needing strong stimuli to respond) to unconscious (syncope, coma).
• Sleep is NOT considered unconsciousness.
• Consciousness levels are measured using scales, like the Glasgow Coma Scale.

Epilepsy

• Epilepsy is characterized by recurrent seizures, arising from abnormal, synchronous neuronal firing in the central nervous system (hyperexcitability and hypersynchronisation).
• Seizures are usually brief (1-2 minutes) and self-limiting, often followed by a period of post-ictal depression.
• Common causes/risk factors include idiopathic cases (75%), congenital defects, genetic factors (channelopathies), drugs/alcohol, sympathomimetics, antidepressants, antipsychotics, arteriovenous malformations, head trauma, infections, vascular disease, neoplasms, and degenerative diseases.
• Symptoms may include altered consciousness, clonic movements (rhythmic jerking), tonic positions (rigid postures), and other variable neurologic deficits.

Types of Seizures

• Partial Seizures: Begin in one hemisphere.
  • Simple: no change in consciousness.
  • Complex: alteration in consciousness. Jacksonian march (clonic movement following homunculus) is indicative of structural brain disease.
• Generalized Seizures: Begin in both hemispheres simultaneously.
  • Common types include absence (petit mal) seizures (often in children) and grand mal (tonic-clonic) seizures, which can include loss of consciousness and bowel/bladder control.

Stages of a Seizure

• Prodrome: Mood/behavior changes before the seizure.
• Aura: Immediate sensations or symptoms preceding the seizure, often indicating the seizure's origin (e.g., temporal lobe aura with epigastric sensation or psychic aura).
• Ictus: The seizure itself.
• Postictal Period: Occurs after the seizure, with symptoms of numbness, headache, fatigue, drowsiness, partial paralysis, confusion, agitation, loss of consciousness/unresponsiveness, and loss of bowel/bladder control.

Treatment and Management

• Treatment typically involves anticonvulsant medications to reduce neuronal excitability (e.g., Phenytoin, Carbamazepine) or enhance GABAergic inhibition (e.g., Phenobarbital, benzodiazepines, Vigabatrin, Tiagabine).
• NICE Guideline CG137 is a resource for diagnosis and management.
• First aid for seizures involves protecting the person from injury, noting the duration, looking for epilepsy identification, placing them in the recovery position after the seizure, staying with the person and reassuring them. Do NOT restrain them, put anything in their mouth, move them unless in danger, or give them anything to eat or drink until fully recovered.

Differential Diagnosis

• Syncope (vasovagal attack)
• Cardiac arrhythmias
• Migraine
• Hypoglycemia
• Panic attacks

Vasovagal Syncope

• Vasovagal syncope (or attack) is a short-term reduction in blood pressure and flow to the brain, causing a transient loss of consciousness.
• It's common, particularly in younger people.
• Triggers include extreme emotions, pain, prolonged standing/heat exposure, and phobias.
• Symptoms include light-headedness, sweating, pallor, tunnel vision, feelings of heat or cold. During the episode, there is a loss of consciousness with spontaneous return in usually less than a minute
• Physical exam should quickly return to normal.
• Referrals are appropriate for first-time occurrences, tongue-biting (suggesting an epileptic seizure), prolonged pallor (suggesting anemia), or other atypical findings.

Hypoglycemia

• Hypoglycemia is more common than hyperglycemia.
• Diabetic individuals can experience rapid drops in blood glucose due to skipped meals, exercise, illness, or insulin overdoses.
• Signs include unusual behavior/aggression, confusion, pallor, shakiness, sweating, rapid breathing, fast pulse, and potential seizures.
• Immediate treatment involves giving sugary foods/drinks; if improvement occurs, continue until full recovery in ~10 minutes. Medical checkup is still necessary, as blood sugar levels can further drop. If hypoglycemia is not resolving or worsens, call an ambulance.

Traumatic Brain Injury (TBI)

• TBI involves brain damage resulting from impact, penetration or rapid skull movement.
• It's a leading cause of death in young adults.
• Severity is determined by Glasgow Coma Scale.
• Injuries are divided into primary (trauma) and secondary (chemical cascades).
• Primary Injuries: direct damage.
• Secondary Injuries: damage that develops in the hours or days following the initial trauma. This can lead to additional neuronal loss.
• Common focal injuries: coup contusion/laceration, contrecoup contusion, intracranial hematoma, infection (e.g., meningitis/abscess).
• Common diffuse/primary injuries: axonal shearing.

Head Trauma – Concussion

• A brief alteration of brain function from a blow to the head.
• Symptoms include dazedness, disorientation, diplopia, headache, tinnitus, nausea, dizziness, difficulty sleeping, photophobia, memory loss, changes in taste/smell. Medical evaluation is essential.

Head Trauma – Hematomas

Epidural Hematoma

• Artery tear, causing rapid bleeding with brain tissue compression.
• Life-threatening within hours to 48 hours, requiring immediate medical attention.
• Symptoms may include transient loss of consciousness (typically 5 minutes), regaining consciousness, and continuing activity, followed by progressive lethargy/weakness/altered consciousness.

Subdural Hematoma

• Vein tear, causing slower leakage and less compression.
• Chronic subdural hematomas (less acute) may not manifest for months or years, with symptoms developing gradually.
• Symptoms can include a headache, nausea, focal symptoms (e.g., ataxia, motor weakness, sensory loss).

Chronic Traumatic Encephalopathy (CTE)

• CTE results from repeated brain trauma (e.g., boxers, football players).
• Progressive, degenerative changes, with symptoms appearing months to decades after the last trauma.
• Tissue changes include atrophy of cerebral hemispheres, medial temporal lobe, thalamus, mammillary bodies, and brainstem. Symptoms include memory loss, confusion, impaired judgment, aggression, explosive anger, depression, and progressive dementia.

Assessment for Head Injury

• Call an ambulance for unconsciousness, abnormal breathing, serious wounds/suspected skull fractures, bleeding/fluid discharge from nose/ear/mouth, lack of coordination, speech/vision disturbances, unequal pupils, weakness/paralysis, dizziness, neck pain/stiffness, fits, or vomiting.

This quiz explores key concepts of altered consciousness and epilepsy. It covers definitions, levels of consciousness, and seizure characteristics related to epilepsy, including causes and risk factors. Test your understanding of these essential topics in neurological function.