Among the most urgent of medical concerns is stroke. Since the brain does not “hurt”, or have the capacity to sense feels anything, the way you know something is wrong is usually neurologic “deficit”, where function of something is lost. In stroke, when arterial blood supply is interrupted, the brain tissue it supplies almost immediately stops functioning.
There are two basic ways this happens. One is where a clot is formed elsewhere in the body like in the heart or the carotid arteries, and travels to the brain circulation where it hits a small enough blood vessel and can’t go further, and causes the injury. These are called embolic (to travel), and are relatively small injuries that are generally complete when you see such a patient, and the hunt begins for the source. The other is where a big blood vessel has developed a large cholesterol buildup, which for some reason pops open like a piece of popcorn, aggregates blood to it, and a large area of brain tissue dies because it has lost its arterial supply. This is called “thrombotic” (a thrombus is a clot within a blood vessel. It is these latter big strokes that often give the warning spell we call the TIA.
TIA stands for transient ischemic attack, and “ischemic (i-SCHEME-ic is the pronunciation). It’s real simple. We think these cholesterol plaques grow very slowly but at some point rupture, and blood begins to stick to them. This may cause what looks like a stroke to last only about 20 or 30 minutes, and then there is a return to normal. And while it’s good to return to normal, one must definitely go to the hospital and be evaluated.
Embolic strokes are often minor and recovery nearly complete. Thrombotic strokes are big and usually bad, and while there is always some improvement as the brain recruits new tissue to do the work of the injured tissue (called “plasticity”), it’s not like the factory model. Consequently we do all we can to prevent them, and we have tricks to reverse them when we can. So, if there are signs of stroke, there is a big push to get people to the hospital, and for hospitals to recognize these patients at the door, and get them medication if they are candidates.
If you wake up with stroke symptoms, which is often the case, we usually cannot argue to give clot dissolvers, which are dangerous, because the three hour window is not known. But it’s always good to go to the hospital if you have symptoms like that, because a whole lot of things could be wrong,
Of course, preventing strokes is important. It starts with having aspirin in your diet, where even just a regular old 325 mg over the counter aspirin will reduce your chance of heart attack and stroke both by over 50%. Cholesterol-lowering drugs also reduce the likelihood of both of these terrible medical conditions. Know your family history, and properly treat blood pressure problems, and diabetic conditions. But, bang for the buck, taker that aspirin every day.
Other neurologic conditions
Dizziness is a common complaint in ERs and primary care offices. We separate them into three distinct categories: “True dizziness”, where there is a balance problem bad enough to have to hold on to something, “vertigo”, where there is room spinning and motion sickness, and “lightheadedness”, which is everything else when there is no imbalance and no room spinning. These are all very common reasons people go to a hospital.
True dizziness is what we’re looking for, because there is usually something wrong. A simple test is to see how one does with their eyes closed (Romberg’s test). A lot of times the eyes and the ability to fixate on something can cover some amount of imbalance, and it’s not hard to tell when someone is off balance. Scans and further studies are generally recommended, and it is often a functional problem where nothing is seen on a scan. And good luck fixing the dizzy patient.
In vertigo, the problem is eye movement related. Do you recognize that the eyes are on opposite sides of the head, and where one moves out, the other must move in to follow it. This coordination is done in the brain, and is assisted by a canal system in the inner ear called “the labyrinth”. As you move or turn your head, the fluid in this tiny canal system moves, and moves the nerves in there, and the brain directs the eyes to move conjugately. In motion like in a car or on an amusement park ride, this can set off a search pattern, and as the eyes dance back and forth the room appears to spin. It is a big symptom that can be incapacitating, and is surprisingly common. Being real drunken also does this, and the dancing eye pattern is something a cop will look for when he pulls you over and is suspicious of DUI.
The most common cause of vertigo in the general population is infection of this inner ear canal system with virus, like when an intestinal virus is going around, and respiratory viruses do it as well. Most of the time people aren’t otherwise sick, but they wake up one morning and when the sit up or turn their head, the room “spins” and they develop nausea. We see this every year when certain epidemics come through town, so some germs are much better at it than others. The spells generally calm down after a few days, but can happen intermittently for 3 weeks, with days of being normal in between. The treatment involves any nerve quieting medications, like antihistamines (meclizine, or “Antivert” is the most common Rx), and benadryl would work. In bad cases we use a famous brain slower called “Valium”, from psychiatry. The condition can be so bad that people can’t walk or can’t open their eyes.
And then there is everything else, “lightheadedness”. The brain is exquisitely sensitive to everything in the blood stream, so anything that’s out of balance, the brain knows it. There is no frank imbalance like in true dizziness, and no vertigo symptoms which are so peculiar. Just, swimmy-headed feeling. You can take a bunch of deep breaths and hyperventilate yourself, and get very lightheaded and numb all over, and even pass out, because by blowing off so much carbon dioxide you can change the chemistry of the blood stream enough to affect the brain’s function, because it’s an electrical organ. Hyperventilation, subtly, from too much adrenaline and stress and nervousness is by far the most common cause of being lightheaded. Things like blood sugar (low or high), and medications, and being dehydrated are other examples.
Numbness is a common complaint, and if it’s from nervousness it should be symmetric on both sides of the body, and start in the periphery, like in the hands and feet and face. If numbness is more one sided, it gets a little more interesting. If it involves several areas of the body and there fore several nerve distributions, we figure it’s a brain symptom. But in the absence of movement problems, trouble talking or walking, or visual complaints, it’s usually the brain malfunctioning from stress, adrenaline, or behavioral difficulties. If numbness is in an extremity, and follows a single nerve supply distribution, it is probably entrapped somewhere. And with all lacerations, we have to wonder if you may have cut a nerve somewhere, and there are ways of telling.
There is also something we call “pseudoneurological” symptoms, where psychiatry is the problem. This is perhaps the dramatic and weird patient with “the weak and dizzies”, or a sense of numbness or neurologic-sounding symptoms, often limited to sensation but not showing the hard core “deficits” we find on neurologic examination. They’re the hard work of the job.
One more thing. If you can close your eyes and jump up and down on one foot, you’re probably OK. To do this maneuver you must first hear the common, understand it, understand that you are to follow it, and have enough strength and coordination to do it physically.
Seizures: The brain is an electrical organ, and if one area of the brain goes wild and generates a lot of electricity, it can cause the whole brain to “turn on”, and this is seizure. All of the muscles contract, and while the flexors and extensors fight it out, there is a mixture of tonic contraction, and back and fotth movement we call clonus. So a true, full-blown seizure is this unconscious, fall to the ground, chew your tongue experience with “tonic and clonic” movements lasting 2-5 minutes, and in some cases longer. There is some amount of air movement that goes on, so people don’t die of them, unless they are unwitnessed and go on one after the next (status epilepticus). When it’s over a person generally wakes up a few minutes later with no recollection of the incident. It is followed ny 2-6 hours of being groggy and out of it, and people usually sleep. A seizure is called “ictus”, and the recovery “post ictus”, or being “post-ictal”.
Some people just have a seizure every once in a while, and this is epilepsy. Brain injuries like previous trauma or stroke or brain infection can leave injured tissue that can ‘spark” these spells every so often. In all these cases there are medications that prevent them or reduce them significantly.
Our main concern in an ER is two things: was it really a seizure or not, or was it just a pass out spell. And if it was real, then we must inform patients that it is illegal to drive a care for 3 months until you are seizure-free under the care of a neurologist.
But you can’t believe how many phony seizures there are out there (“pseudoseizure”), and many of the mind confabulations are are in people with actual seizure disorders. But when witnessed by people who have ever seen seizures, they just don’t look right, or involve too much symmetrical bouncing around like an athletic act would be, or lots of eyelid fluttering, a famous sign of behavioral conditions, and also crying is a dead giveaway. Often there are months of increasing spells of apparent seizure activity, medications have not helped, and diagnostic studies are normal. And so often, there is the accomplice, the very concerned family member or loved one for whom the performance is being executed, from the subconscious mind of the sufferer. There is no fun for anyone involved. Look for histories of sexual abuse, identity maldevelopment, a history of psychiatric intervention, or other dysfunction.
Passing Out (Syncope)
In school I embarrassed myself by pronouncing the word syncope as it appears, or “sin-cope”. It’s “SIN-ko-pee”. Or being syncopal, or having a syncopal episode. You wouldn’t believe how much of it we see. They say half of people pass out once in their life, and there are some that do it recurrently. There is sudden, often instantaneous loss of consciousness with a fall to the floor, and return to noral alertness happens in anywhere from a few seconds to a few minutes. Usually people around thought you were dying. And people of all ages do it. So we sort through them a lot.
The most common and famous cause of syncope is abrupt imbalance of the automatic parts of the nervous system that control heart rate and blood distribution. You take for granted that the two systems that do this are in a balance, and when they go out of balance even briefly down you go. The two systems in a tug of war for blood supply are the adrenaline side, wanting blood to flow to the muscles and for the heart to race in order to assist this, and a vegetative side that holds blood to the core, especially around an impressive latticework of blood vessels around the digestive system. When you eat, this latticework engorges, and nutrients are absorbed and sent up to the liver for management and packaging. In simple syncope, this system goes off, slows the heart, and engorges the vessels of the digestive system. With the brain at the top of the body requiring a steady flood of blood for proper function, this “perfusion pressure” drops, and the thing winks out, and down you go. Once flat, blood will re-flow, and you wake up. During this time blood pressure is barely noticeable, in the 50s or 60s. Soon, the adrenaline receptors in the circulation will notice what’s happened, and a big adrenaline surge will follow. So, often no only do people wake up, but will be nervous and shaky and pale, and this will all take a half an hour or so to play out. And of course that’s an eternity.
Again the question: what happened? Was it a seizure? Was it an abnormal heart rhythm? Did you pass out” Ultimately, what we’re looking for, as far as danger is concerned, is, is there any reason to think your heart was in a potentially fatal rhythm? This is very hard to say, and very unusual. Was it during exercise? Was there any chest pain? Is this the third time in a week in someone who’s never passed out before? Were you exercising? In anything weird, we’re recommending a monitoring device which most hospitals offer for home use, and cardiologists have tests they do.
A typical pass out spell goes like this. Usually a person can feel their abdominal vessels engorge, and describe a “queasy” feeling. They recognize that they need to sit down before they fall down, and then ultimately end up on the floor. The triggers are many. Usually people haven’t eaten or drank all day. The sight of blood and the smell of food can trigger it. Coughing can trigger them, as can laughing really hard. Breath holding can do it. Squeezing your eyeballs can do it. A very big cause is going to the bathroom, especially bearing down as if the have a baby or pass stool or urine (Valsalva’s maneuver), and I’m amazed at how often this happens.
After a period of observation in an ER, often with an EKG check or lab studies, and cardiac monitoring, we send most people home with apparent simple syncope. It is a spell often named after the big nerves of the torso that come directly from the brain, the “Vagus” nerves, that manage the blood flow to the bowels mentioned above, and they send a nerve to the heart and cause it to slow. So terms like “vagal spells”, or vaso (blood vessel) vagal syncope is a term, as is vagaling down also.