Blackouts, Dizziness & Vertigo
New-onset blackouts with features suggestive of a seizure require urgent referral to neurology.1 In most areas there is a dedicated `first fit’ clinic.
It is not necessary to routinely refer adults with blackouts if there are clear features of a vasovagal syncope, even if associated with limb jerks.
In dizzy patients, think about hypoglycaemia, benign paroxysmal positional vertigo (BPPV) and postural hypotension as causes. If these do not account for it, be suspicious of a posterior circulation stroke.
Dizziness alone is unlikely to indicate a serious neurological pathology except when accompanied by a focal neurological deficit, altered gait or deafness.
Consider using the Hallpike manoeuvre in those with a transient rotational vertigo on head movement, and the Epley manoeuvre if BPPV is diagnosed.
The head-impulse, nystagmus, test-of-skew (HINTS) manoeuvre is used in those with sudden-onset acute vestibular syndrome (vertigo, nausea or vomiting and gait unsteadiness). A negative HINTS makes the diagnosis of stroke very unlikely. Refer immediately if HINTS testing suggests a stroke.
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Facial pain with persistent numbness, facial weakness or abnormal eye movement requires an urgent referral to exclude a space-occupying lesion. Trigeminal neuralgia refractory to treatment in primary care requires a referral.
Note that a normal ESR does not always exclude the presence of giant cell arteritis where there is clinical suspicion.2 It is very rare in those under the age of 50, however if clinically suspected, refer urgently for consideration of temporal artery biopsy.
A sudden-onset unsteady gait may suggest a stroke.
An unsteady gait that progresses rapidly (over days to weeks) requires an urgent referral for neurological assessment as it could indicate a brain tumour, an autoimmune condition, an atypical infection such as herpes zoster or legionella or even a paraneoplastic presentation of an ovarian, lung or breast cancer.
In those with gradually progressive unsteady gait, in addition to a usual history-take and work-up, consider serological testing for gluten sensitivity to eliminate coeliac disease.3 True gait ataxia can be caused by a cerebellar or proprioceptive sensory lesion due to peripheral neuropathy or spinal cord (dorsal column) pathology.
An inflammatory neuropathy will usually present with distal or proximal weakness and depressed tendon reflexes as well as ataxia. Gait apraxia (difficulty initiating or coordinating their walking) needs referral to neurology or elderly care in order to exclude normal pressure hydrocephalus.
more info Rheumatology 2010: 49; 8, 1594-1597.
Handwriting may be something we are unlikely to ask about, but the NICE guideline committee noted that sudden handwriting difficulty may raise the possibility of stroke.1
Where adults are having difficulty with handwriting, and a musculoskeletal cause is not obvious, consider the following.
Does the issue lie with generating language rather than hand function? If so, refer for neurological assessment.
If their writing is small and slow, consider Parkinson’s disease.
If the difficulty is only related to handwriting and neuromuscular examination is otherwise normal, consider referral for a possible focal dystonia.
Data on deaths between 2011 and 2015 from the Primary Care Mortality Database show that on average, the number of deaths, where the primary diagnosis was a neurological condition (excluding injuries), have increased over time, from 270 deaths in 2011 to 393 in 2015. Numbers of deaths for those under 40 are very small (≤ 5 per year)
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We should try to distinguish memory loss from difficulty concentrating, as poor concentration is seen in those with conditions including anxiety, depression, ME, and fibromyalgia. Recurrent episodes require referral and may herald epileptic amnesia.
Transient global amnesia is a single episode of dense amnesia.
Suspect cervical dystonia in adults who have persistent abnormalities of head or neck posture, with or without head tremor, especially if the symptom improves when the person touches their chin with their hand.’
Dystonias can affect any part of the body. Refer to neurology or a movement disorders clinic for assessment and treatment. Exclude iatrogenic causes including medication (such as anti-emetics and antipsychotics)
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