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Objective: Considering that diagnostic decisions about mTBI are often predicated on clinical symptom criteria, it is imperative to determine which initial presentation features of mTBI have prognostic significance for identifying those at high risk for long-term functional impairment., Setting: Zoom interview Participants: Male, former NCAA Division I, and professional-level National Football League (NFL) athletes ( n  = 177) between the ages of 27 and 85 ( M  = 54.1, SD = 14.7)., Design: Cross-sectional case-control. Main Measures: History of mild TBI, history of loss of consciousness (LOC), depression symptoms, insomnia, neurobehavioral symptoms., Results: Number of mTBI exposures did not predict neurobehavioral symptoms (B = 0.21, SE = 0.18, p  = 0.23), but number of mTBI + LOC events did (B = 2.27, SE = 0.64, p  = <.001). Further analysis revealed that the number of mTBI + LOC events predicted neurobehavioral symptoms indirectly through both depression (B = 0.85, 95% CI = [0.27, 1.52) and insomnia (B = 0.81, 95% CI = [0.3, 1.4]). Further, the direct effect of mTBI + LOC events on neurobehavioral symptoms became non-significant when depression and insomnia were added to the model (B = 0.78, SE = 0.45, p  = 0.08)., Conclusions: Findings support LOC at time of injury as an important predictor of long-term outcomes. Additionally, results suggest depression and insomnia as potential mediators in the association between mTBI + LOC and neurobehavioral symptoms. These findings provide justification for early depression and insomnia symptom monitoring following mTBI + LOC.

Stroke warning syndromes manifest as brief, recurring episodes of focal neurological deficits that precede definitive brain ischaemia. Although the mechanisms remain unclear, intermittent hypoperfusion in specific vascular territories may explain these phenomena. A man in his 60s with vascular risk factors experienced recurrent episodes of sudden loss of consciousness. Initial imaging and tests were normal, excluding other potential causes. MRI revealed bilateral thalamic infarction and the presence of an artery of the Percheron variant. We propose 'thalamic warning syndrome' as a new term for this clinical presentation, characterised by recurrent transient loss of consciousness and a high risk of subsequent thalamic infarction. Early recognition of this syndrome can aid in the initial management and prognosis of similar cases, potentially preventing more severe neurological impairments., Competing Interests: Competing interests: None declared., (© BMJ Publishing Group Limited 2024. No commercial re-use. See rights and permissions. Published by BMJ.)

Background: Metastatic brain abscesses caused by Klebsiella pneumoniae are extremely rare but life-threatening conditions. To depict a unique case of the middle-aged hypertensive man with an unusual presentation of metastatic brain abscesses originating from a pleural abscess caused by Klebsiella pneumoniae and subsequently leading to loss of consciousness (LOC)., Case Report: A 52-year-old Iranian man with a history of hypertension presented to the emergency department with a five-day history of worsening cough, high-grade fever, shortness of breath, chest pain, fatigue, and a productive cough. Laboratory tests revealed leukocytosis, elevated C-reactive protein, and respiratory alkalosis. A chest computed tomography scan confirmed pneumonia, and a brain scan revealed multiple hypodense lesions. Despite antibiotic therapy, the patient's condition worsened, leading to confusion, disorientation, and loss of consciousness. Magnetic resonance imaging revealed multiple ring-enhancing lesions, suggesting an abscess formation. Bronchial washings and BAL samples confirmed a lower respiratory tract infection. Cultures from the bronchial washings grew Klebsiella pneumoniae., Conclusions: Metastatic brain abscesses caused by Klebsiella pneumoniae are exceedingly rare but life-threatening conditions. Timely diagnosis and effective antimicrobial treatment are critical for patient outcomes. This case underscores the significance of recognizing atypical presentations of bacterial infections, as early detection and appropriate management can significantly impact patient outcomes., (© 2024. The Author(s).)

Background: Tuberculous meningitis (TBM) accounts for about 1% of all tuberculosis cases and about 5% of extrapulmonary tuberculosis cases. However, it poses major importance because approximately half of those affected die or become severely disabled. Herein, the successful treatment of an 11-month-old boy with progressive limb weakness, fever, developmental retardation, and loss of consciousness due to tuberculosis, was reported., Case Presentation: An 11-month-old (Iranian Turk) boy was referred to Loghman Hakim hospital for progressive limb weakness and loss of previously attained developmental milestones for the past 2 months. He also had persistent fever and loss of consciousness for about 14 to 21 days. Before being referred to our center, the patient had been diagnosed with hydrocephalus at another center due to possible acute bacterial meningitis based on a CT scan and MRI imaging. On physical examination, anterior fontanel bulging and neck stiffness were observed on the admission. His body temperature and heart rate were 38.1 C and 86 beats per minute (bpm), respectively. He had left 6 cranial nerve palsy and spastic quadriparesis with a power of grade 3/5. Other systemic examinations were normal. Endoscopic third ventriculostomy (ETV) (and leptomeningeal biopsy) revealed diffuse thickening of the floor and lateral walls of the 3rd ventricle and also a cobblestone appearance in the form of multiple white patchy lesions was detected on the floor of the 3rd ventricle. CSF analysis and polymerase chain reaction confirmed the TB meningitis. During hospitalization, a temporary EVD (external ventricular drain) was initially inserted. Eventually, defervescence was denoted 5-6 days after initiation of anti-TB medications, and a permanent ventriculoperitoneal shunt was inserted due to hydrocephalus. Gradually his truncal and limb tone and motor function improved, as did his emotional responses to his parents and ability to eat. The patient can walk without help in the 15th month following the operation and resolved hydrocephalus demonstrated on follow-up imaging., Conclusion: Over half of treated TB meningitis patients die or suffer severe neurological sequelae, mainly due to late diagnosis. Hence, early diagnosis and prompt initiation of TB treatment offer the best chance of a good neurological outcome., (© 2024. The Author(s).)

Rationale: Unconsciousness is a nonfocal symptom of transient ischemic attack (TIA) that is frequently observed in patients with vertebrobasilar artery stenosis or occlusion. Conversely, loss of consciousness due to anterior circulation involvement (e.g., middle cerebral artery [MCA]) is a rare occurrence in TIA., Patient Concerns: This report describes a rare case in a 59-year-old woman who experienced recurrent episodes of altered consciousness because of the occlusion or stenosis of her MCAs., Diagnoses: The diagnosis of the case was updated from TIA to acute cerebral infarction, finally. Following initial loss of consciousness, cranial magnetic resonance imaging (MRI) did not reveal any evidence of acute cerebral infarction. However, following the second and third episodes of unconsciousness, the MRI revealed multiple new acute cerebral infarcts affecting both the cerebral hemispheres. Further evaluation through digital subtraction angiography disclosed complete occlusion of the left MCA and severe stenosis of the right MCA., Interventions: Early in her illness, the patient was treated with vasodilators, aspirin and atorvastatin. Finally, 2 stents in her right and left MCAs were placed respectively, followed by treatment with aspirin, clopidogrel, and double-dosed atorvastatin calcium. Meanwhile, the patient focused on avoiding conditions which may lead to dehydration in her daily life routine., Outcomes: The episodes of unconsciousness of this patient were completely resolved. During the 1-year postoperative follow-up, the patient remained clinically stable without any symptoms of unconsciousness, limb numbness or weakness, or dizziness., Lessons: These findings suggested that hypoperfusion in the bilateral cerebral hemispheres played a pivotal role in precipitating the patient episodes of unconsciousness. This case underscores the possibility that occlusion or severe stenosis in both MCAs can contribute to recurrent episodes of unconsciousness due to hypoperfusion. Moreover, it emphasizes the association between these episodes of unconsciousness and an increased risk of subsequent ischemic stroke., Competing Interests: The authors have no conflicts of interest to disclose., (Copyright © 2024 the Author(s). Published by Wolters Kluwer Health, Inc.)

INTRODUCTION: Gravity-induced loss of consciousness (G-LOC) is a major threat to fighter pilots and may result in fatal accidents. The brain has a period of 5-6 s from the onset of high +G z exposure, called the functional buffer period, during which transient ischemia is tolerated without loss of consciousness. We tried to establish a method for predicting G-LOC within the functional buffer period by using machine learning. We used a support vector machine (SVM), which is a popular classification algorithm in machine learning. METHODS: The subjects were 124 flight course students. We used a linear soft-margin SVM, a nonlinear SVM Gaussian kernel function (GSVM), and a polynomial kernel function, for each of which 10 classifiers were built every 0.5 s from the onset of high +G z exposure (Classifiers 0.5-5.0) to predict G-LOC. Explanatory variables used for each SVM were age, height, weight, with/without anti-G suit, +G z level, cerebral oxyhemoglobin concentration, and deoxyhemoglobin concentration. RESULTS: The performance of GSVM was better than that of other SVMs. The accuracy of each classifier of GSVM was as follows: Classifier 0.5, 58.1%; 1.0, 54.8%; 1.5, 57.3%; 2.0, 58.1%; 2.5, 64.5%; 3.0, 63.7%; 3.5, 65.3%; 4.0, 64.5%; 4.5, 64.5%; and 5.0, 64.5%. CONCLUSION: We could predict G-LOC with an accuracy rate of approximately 65% from 2.5 s after the onset of high +G z exposure by using GSVM. Analysis of a larger number of cases and factors to enhance accuracy may be needed to apply those classifiers in centrifuge training and actual flight. Ohrui N, Iino Y, Kuramoto K, Kikukawa A, Okano K, Takada K, Tsujimoto T. G-induced loss of consciousness prediction using a support vector machine . Aerosp Med Hum Perform. 2024; 95(1):29-36.

This paper aims to improve the diagnosis of syncope and transient loss of consciousness (TLOC) in children. Diagnostic problems stem, first, from some causes spanning various disciplines, e.g. cardiology, neurology and psychiatry, while the most common cause, vasovagal syncope, is not embraced by any specialty. Second, clinical variability is huge with overlapping signs and symptoms. Third, the approach to TLOC/syncope of the European Society of Cardiology (ESC) is underused in childcare. We explain the ESC guidelines using an additional paediatric literature review. Classification of TLOC and syncope is hierarchic and based on history taking. Loss of consciousness (LOC) is defined using three features: abnormal motor control including falling, reduced responsiveness and amnesia. Adding a < 5 min duration and spontaneous recovery defines TLOC. TLOC simplifies diagnosis by excluding long LOC (e.g. some trauma, intoxications and hypoglycaemia) and focussing on syncope, tonic-clonic seizures and functional TLOC. Syncope, i.e. TLOC due to cerebral hypoperfusion, is divided into reflex syncope (mostly vasovagal), orthostatic hypotension (mostly initial orthostatic hypotension in adolescents) and cardiac syncope (arrhythmias and structural cardiac disorders). The initial investigation comprises history taking, physical examination and ECG; the value of orthostatic blood pressure measurement is unproven in children but probably low. When this fails to yield a diagnosis, cardiac risk factors are assessed; important clues are supine syncope, syncope during exercise, early death in relatives and ECG abnormalities.  Conclusions: In adults, the application of the ESC guidelines reduced the number of absent diagnoses and costs; we hope this also holds for children. What is Known: • Syncope and its mimics are very common in childhood, as they are at other ages. • Syncope and its mimics provide considerable diagnostic challenges. What is New: • Application of the hierarchic framework of transient loss of consciousness (TLOC) simplifies diagnosis. • The framework stresses history-taking to diagnose common conditions while keeping an eye on cardiac danger signs., (© 2023. The Author(s).)

Video surveillance has almost universally been employed by professional sports to identify signs of concussion during competition. This study examined associations between video-identified possible loss of consciousness (LOC), acute concussion evaluation findings, and recovery time in concussed professional rugby league players. Medical personnel and sideline video operators identified head impact events sustained during three seasons of National Rugby League (NRL) matches to determine the need for further medical evaluation. If a concussion was suspected, players were removed from play and underwent a Head Injury Assessment, including the Sports Concussion Assessment Tool, Fifth Edition (SCAT5). Video footage was later examined to identify signs of possible LOC (i.e., observed LOC, no protective action in the fall, and unresponsiveness or lying motionless). Possible LOC was identified in 99 of the 1706 head impact events (5.8%). The median duration of apparent unresponsiveness was 4.2 sec (M = 7.4, standard deviation [SD] = 12.8, interquartile range [IQR] = 2.5-6.6). In the 661 athletes for whom SCAT5 data were available, those with possible LOC endorsed more SCAT5 symptoms and performed worse on Maddocks questions, Standardized Assessment of Concussion (SAC) total scores, orientation, immediate recall, concentration, and delayed recall. For the 255 players with medically diagnosed concussions, SCAT5 data were available for 245. Concussed players with possible LOC performed significantly worse on Maddocks questions. However, there were no group differences in SCAT5 symptom endorsement, SAC total scores, orientation, immediate recall, concentration, delayed recall, or the modified version of the Balance Error Scoring System (mBESS) total errors. Further, the presence or absence of possible LOC was not associated with number of games missed or time to medical clearance for match play. The duration of possible LOC was not associated with the number of games missed or time to medical clearance for match play. According to video review in NRL players, brief LOC might be more common than previously thought. The present study reveals possible LOC is not predictive of missed games or time to recover following concussion.

Introduction: Little is known about how electrical current passes through the human body except that it follows the physical rule of least resistance. Whether organs remote from the shortest route of the current can be affected is unknown, as different types of tissue vary in resistance. This may explain why some people exposed to electrical injury report symptoms from the central nervous system (CNS). In this study, we examined the association between exposure to cross-body electrical current and immediate CNS symptoms., Material and Methods: In a prospective cohort study, we followed 6960 members of the Danish Union of Electricians for 26 weeks using weekly questionnaires. We identified 2356 electrical shocks, and for each shock we asked whether the exposure was cross-body or same-side. We excluded those who reported exposure to the head as well as those who could not report the entry and exit points of the current. We examined two outcomes: becoming unconscious or having amnesia of the event. We use percentages to describe the data and logistic regression to analyze the results., Results: We found that unconsciousness and amnesia following electric shocks were rare events (0.6% and 2.2%, respectively). We found an increased risk of reporting unconsciousness and amnesia in those exposed to cross-body electrical shock exposure compared to those with same-side exposure (Odds Ratio 2.60[0.62 to 10.96] and Odds Ratio 2.18[0.87 to 5.48])., Conclusion: Although the outcomes investigated are rare, we cannot rule out a possible effect on the CNS when persons are exposed to cross-body electrical current even though it does not pass through the head., Competing Interests: The authors have declared that no competing interests exist., (Copyright: © 2023 Biering et al. This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.)

A 30-year-old woman who presented loss of consciousness was diagnosed as having large anterior mediastinal tumor. Computed tomography (CT) showed a 17.0×13.0×7.3 cm cystic mass with internal calcification in the anterior mediastinum that was markedly compressing the heart, great vessels, trachea and bronchi. A mature cystic teratoma was suspected, and the mediastinal tumor was resected through a median sternotomy. At the induction of anesthesia to prevent the development of the respiratory and circulatory collapse, the patient was consciously intubated under the right lateral decubitus position while preparing for percutaneous cardiopulmonary support by cardiac surgeons, and the surgery was safely performed. The tumor was pathologically diagnosed as a mature cystic teratoma, and symptoms such as loss of consciousness have disappeared.

Background: Traumatic brain injury (TBI) patients with unconsciousness and normal initial head computed tomography (CT) present a clinical dilemma for physicians and neurosurgeons in the emergency department (ED). We recorded how long it took for patients to regain consciousness and evaluated the patients' characteristics., Methods: From 2018 to 2020, TBI patients with unconsciousness and normal initial head CT [Glasgow coma scale (GCS) score < 13, negative CT scan and normal laboratory test results] were evaluated. Patients who regained consciousness were analyzed. Multivariate logistic regression (MLR) analyses were used to evaluate independent factors for regaining consciousness., Results: A total of 77 patients were included in this study. Fifty-eight (75.3%) patients regained consciousness, most within one day (43.1%). Nineteen (24.7%) patients never regained consciousness. MLR analysis showed that initial GCS score (odds 1.85, p = 0.017), early airway protection in ED (odds 25.02, p = 0.018) and 72-h GCS score improvement by two points (odds 0.02, p = 0.001) were independent factors for regaining consciousness. Overall, 94.1% of patients who received early airway protection and improved 2 points in 72-h GCS score regained consciousness. The association between days to M5 status and days to M6 status (consciousness) was highly significant. Fewer days to M5 status were highly associated with needing fewer days to regain consciousness., Conclusions: For TBI patients with unconsciousness and normal initial head CT, a higher probability of regaining consciousness was observed in those who underwent early airway protection and who improved 2 points in 72-h GCS score. Regaining consciousness within a short period could be expected in patients with M5 status., (© 2022. The Author(s) under exclusive licence to Société Internationale de Chirurgie.)

Posttraumatic stress disorder (PTSD) is prevalent and associated with significant morbidity. Mild traumatic brain injury (mTBI) concurrent with psychiatric trauma may be associated with PTSD. Prior studies of PTSD-related structural brain alterations have focused on military populations. The current study examined correlations between PTSD, acute mTBI, and structural brain alterations longitudinally in civilian patients (N = 504) who experienced a recent Criterion A traumatic event. Participants who reported loss of consciousness (LOC) were characterized as having mTBI; all others were included in the control group. PTSD symptoms were assessed at enrollment and over the following year; a subset of participants (n = 89) underwent volumetric brain MRI (M = 53 days posttrauma). Classes of PTSD symptom trajectories were modeled using latent growth mixture modeling. Associations between PTSD symptom trajectories and cortical thicknesses or subcortical volumes were assessed using a moderator-based regression. mTBI with LOC during trauma was positively correlated with the likelihood of developing a chronic PTSD symptom trajectory. mTBI showed significant interactions with cortical thickness in the rostral anterior cingulate cortex (rACC) in predicting PTSD symptoms, r = .461-.463. Bilateral rACC thickness positively predicted PTSD symptoms but only among participants who endorsed LOC, p < .001. The results demonstrate positive correlations between mTBI with LOC and PTSD symptom trajectories, and findings related to mTBI with LOC and rACC thickness interactions in predicting subsequent chronic PTSD symptoms suggest the importance of further understanding the role of mTBI in the context of PTSD to inform intervention and risk stratification., (© 2022 International Society for Traumatic Stress Studies.)

Competing Interests: Disclosure The authors report no conflicts of interest in this work.

Tubercular meningitis is a devastating presentation of extra pulmonary tuberculosis, with fatality in each case without treatment. A 39 years male, a regular consumer of alcohol and a known case of major depressive disorder, presented with the alleged history of using an electric heater in a closed room, and presented to emergency with unconsciousness and cardiac arrest. As his neurological status didn't improve over 72 hrs, a magnetic resonance imaging brain was done which was non-conclusive. Electroencephalogram revealed diffuse right fronto-parietal seizure activity ceasing with midazolam injection, hence levetiracetam was started. Lumbar puncture revealed increased adenosine deaminase and nil white blood cells. Repeat lumbar puncture showed lymphocytic-predominant pleocytosis, elevated protein and low glucose. The patient was started on anti-tubercular therapy and an injection of dexamethasone was added. Repeat electroencephalogram didn't show any seizure-like activity. It is important to be aware of variety of presentations of tubercular meningitis. Delay in treatment leads to irreversible neurological damage and even death., Keywords: cardiac arrest; case report; tubercular meningitis; unconsciousness.

Aims: The role of triage for patients admitted to the emergency department (ED) for a syncopal transitory loss of consciousness (TLOC) has not been debated, and no comparisons with the recent European Society of Cardiology (ESC) guidelines are currently available. To verify the ability of triage to correctly prioritize patients with syncopal TLOC., Methods and Results: All patients who received a triage assessment at the ED of the Merano Hospital (Italy) between 1 January 2017 and 30 June 2019 for a syncope were considered. All syncope were reclassified according to the aetiology reported in the ESC guidelines. The baseline characteristics of the patients were recorded and divided according to the severity code provided during triage into two study groups: high priority (red/orange) and low priority (yellow/green/blue). The outcome of the study was the presence of a diagnosed cardiac cause within 30 days after the admission. A total of 2066 patients were enrolled (14.3% high priority vs. 85.7% low priority). Cardiac syncope was present in 7.5% of patients. Nurse triage showed a sensitivity for cardiac syncope of 44.8%, a specificity of 88.1%, and an accuracy of 84.9%. The observed discriminatory ability presented an area under the receiver operating characteristic curve of 0.685 (95% confidence interval 0.638-0.732). The possible identification of the aetiology of the syncopal TLOC by the nurse showed good agreement with the medical diagnosis (Cohen's kappa 0.857, P < 0.001)., Conclusions: In cases of syncopal TLOC, nurse triage had a fair specificity but suboptimal sensitivity for cardiac causes. Specific nursing assessments following triage (e.g. precise scores or electrocardiogram) could improve the triage performance., (Published on behalf of the European Society of Cardiology. All rights reserved. © The Author(s) 2021. For permissions, please email: journals.permissions@oup.com.)

Although transient loss of consciousness (TLOC) is a common problem, hospital care for patients with TLOC is characterised by high rates of no diagnosis and misdiagnosis, accompanied by unnecessary hospital admissions and tests. We attribute these problems to increasing specialisation as well as to a blind spot for vasovagal syncope, a condition not claimed by any specialty. We suggest that all doctors seeing patients with TLOC, both in primary and secondary care, should be familiar with the presentations of the relatively harmless vasovagal syncope and the alarm symptoms of potentially life-threatening cardiac syncope. In this article we present some practical pointers to recognise these conditions and answer some frequently-asked questions regarding the diagnosis and treatment of TLOC.

Introduction: Loss of consciousness (LOC) is used as a diagnostic feature of mild traumatic brain injury (MTBI). However, only 10% of concussions result in LOC. There are only a limited number of in-vivo studies dealing with unconsciousness and structural and functional integrity of the brainstem in patients with MTBI. The aim of our pilot study was to assess the sensitivity of proton magnetic resonance spectroscopy ( 1 H-MRS) to detect metabolic changes in the brainstem in patients after MTBI with unconscioussness., Methods: Twenty-four patients (12 with LOC, and 12 without LOC) within 3 days of MTBI and 19 healthy controls were examined. All subjects underwent single-voxel 1 H-MRS examination of the upper brainstem. Spectra were evaluated using LCModel software. Ratios of total N-acetylaspartate (tNAA), total choline-containing compounds (tCho) and glutamate plus glutamine (Glx) to total creatine (tCre) were used for calculations., Results: We found a significant decrease in tNAA/tCre and tCho/tCre ratios in the patient group with LOC when compared with the control group of healthy volunteers (P=0.002 and P=0.041, respectively), and a significant decrease in the tNAA/tCre ratio in the LOC group when compared with patients without LOC (P=0.04). Other metabolite ratios in the brainstem did not show any significant group differences., Conclusion: Our findings indicate that decrease of tNAA/tCre ratio in the upper brainstem using single-voxel 1 H-MRS may provide a potential biomarker for MTBI associated with LOC.

Transient loss of consciousness (TLOC) is a common emergent neurological issue, which can be attributed to syncope, epileptic seizures, and psychogenic nonepileptic seizures. The purpose of this article is to outline an approach to diagnosing the most common etiologies of TLOC by focusing on the importance of the history and physical examination, as well as targeted diagnostic tests., Competing Interests: M.B-O. reports grants from NeuroPace and UCB, outside the submitted work., (Thieme. All rights reserved.)

Objectives: We investigated rates of cognitive decline at 3-year follow-up from initial examination in people reporting mild traumatic brain injury (mTBI) with loss of consciousness (LOC) more than a year prior to initial examination. We examined the role of social support as predictor of preserved cognitive function in this sample., Method: Analyses were conducted on 440 participants who had self-reported LOC of <1 min, 350 with LOC of 1-20 min, and 10,712 healthy controls, taken from the Canadian Longitudinal Study on Aging (CLSA), a nationwide study on health and aging., Results: People who reported at baseline that they had experienced mTBI with LOC of 1-20 min more than a year prior were 60% more likely to have experienced global cognitive decline than controls at three-year follow-up. Cognitive decline was most apparent on measures of executive functioning. Logistic regression identified increased social support as predictors of relatively preserved cognitive function., Discussion: mTBI with longer time spent unconscious (i.e., LOC 1-20 min) is associated with greater cognitive decline years after the head injury. Perceived social support, particularly emotional support, may help buffer against this cognitive decline., (© The Author(s) 2020. Published by Oxford University Press on behalf of The Gerontological Society of America. All rights reserved. For permissions, please e-mail: journals.permissions@oup.com.)

Editor's note: This is the next installment in a series on electrocardiogram (ECG) interpretation. Nurses in all settings should know the basics, as medications and physiological changes can cause cardiac arrhythmias. Each article will start with a brief case scenario and an ECG strip and then take you step by step through analyzing the heart rhythm., (Copyright © 2021 Wolters Kluwer Health, Inc. All rights reserved.)

Background and Aims: An electrocardiogram (ECG) is a mandatory test for anyone presenting with loss of consciousness. Many referrals to the first seizure clinic (FSC) are caused by syncope. We assessed the sensitivity of neurologists' ECG reporting in detecting rhythm abnormalities including some potentially life-threatening cardiac conditions., Methods: We audited patients referred to a FSC in Glasgow over 4 years. All ECGs were interpreted by the attending neurologist as standard practice. Subsequently, two cardiologists reviewed the ECGs independently., Results: Of 160 consecutive patients, 92 patients (58%) were diagnosed as having seizures, 43 (27%) as syncope, and 25 (16%) were unclassified. Twenty eight ECGs thought to be normal by the neurologist were considered abnormal by the cardiologist, including three with long corrected QT interval. The proportion of abnormal ECGs and disparity in reporting between neurologists and cardiologists persisted independent of the underlying diagnosis., Conclusion: Reporting of ECGs by non-cardiologists may not be adequately sensitive in picking up potentially life threatening cardiac conditions. Cardiologist input into FSCs is recommended to enhance the diagnostic yield., (© 2021. The Author(s).)

Background: Recommendations for a head computed tomography (CT) scan in elderly patients without a loss of consciousness after a traumatic brain injury and without neurological findings on admission and who are not taking oral anticoagulant therapy, are discordant., Objectives: To determine variables associated with intracranial hemorrhage (ICH) and the need for neurosurgery in elderly patients after low velocity head trauma., Methods: In a regional hospital, we retrospectively selected 206 consecutive patients aged ≥ 65 years with head CT scans ordered in the emergency department because of low velocity head trauma. Outcome variables were an ICH and neurological surgery. Independent variables included age, sex, disability, neurological findings, facial fractures, mental status, headache, head sutures, loss of consciousness, and anticoagulation therapy., Results: Fourteen patients presented with ICH (6.8%, 3.8-11.1%) and three (1.5%, 0.3-4.2%) with a neurosurgical procedure. One patient with a coma (0.5, 0.0-2.7) died 2 hours after presentation. All patients who required surgery or died had neurological findings. Reducing head CT scans by 97.1% (93.8-98.9%) would not have missed any patient with possible surgical utility. Twelve of the 14 patients (85.7%) with an ICH had neurological findings, post-trauma loss of consciousness or a facial fracture were not present in 83.5% (95% confidence interval 77.7-88.3) of the cohort., Conclusions: None of our patients with neurological findings required neurosurgery. Careful palpation of the facial bones to identify facial fractures might aid in the decision whether to perform a head CT scan.

Suspension torture is one of the most common and widespread methods of torture. The objective of the study is to conduct a systematic literature review and produce an overview of suspension torture and its health implications, thus improving the diagnosis of suspension torture victims and documentation of their injuries. The review includes the prevalence, geographical distribution and description of variations of suspension torture. Physical sequelae like nerve injuries, e.g. brachial plexus injuries, scars, joint dislocation and possible causes of death will be described in detail. The results of the review are discussed resulting in recommendations on torture identification and documentation practices and possible future research questions., (Copyright © 2021 Elsevier Ltd and Faculty of Forensic and Legal Medicine. All rights reserved.)

Objective: An expert working group was set up at the initiative of the French Ministry of Sports with the objective of harmonising the management of sport related concussion (SRC) in France, starting with its definition and diagnosis criteria., Results: Definition: A clinical definition in 4 points have been established as follows: Concussion is a brain injury: 1) caused by a direct or indirect transmission of kinetic energy to the head; 2) resulting in an immediate and transient dysfunction of the brain characterised by at least one of the following disorders: a) Loss of consciousness, b) loss of memory, c) altered mental status, d) neurological signs; 3) possibly followed by one or more functional complaints (concussion syndrome); 4) the signs and symptoms are not explained by another cause. Diagnosis criteria: In the context of the direct or indirect transmission of kinetic energy to the head, the diagnosis of concussion may be asserted if at least one of the following signs or symptoms, observed or reported, is present within the first 24hours and not explained by another cause: 1) loss of consciousness; 2) convulsions, tonic posturing; 3) ataxia; 4) visual trouble; 5) neurological deficit; 6) confusion; 7) disorientation; 8) unusual behaviour; 9) amnesia; 10) headaches; 11) dizziness; 12) fatigue, low energy; 13) feeling slowed down, drowsiness; 14) nausea; 15) sensitivity to light/noise; 16) not feeling right, in a fog; 17) difficulty concentrating., Conclusion: Sharing the same definition and the same clinical diagnostic criteria for concussion is the prerequisite for common rules of management for all sports and should allow the pooling of results to improve our knowledge of this pathology., (Copyright © 2020 Elsevier Masson SAS. All rights reserved.)

Objective: To assess associations between head injury (HI) with loss of consciousness (LOC), ageing and markers of later-life cerebral pathology; and to explore whether those effects may help explain subtle cognitive deficits in dementia-free individuals., Methods: Participants (n = 502, age = 69-71) from the 1946 British Birth Cohort underwent cognitive testing (subtests of Preclinical Alzheimer Cognitive Composite), 18 F-florbetapir Aβ-PET and MR imaging. Measures include Aβ-PET status, brain, hippocampal and white matter hyperintensity (WMH) volumes, normal appearing white matter (NAWM) microstructure, Alzheimer's disease (AD)-related cortical thickness, and serum neurofilament light chain (NFL). LOC HI metrics include HI occurring: (i) >15 years prior to the scan (ii) anytime up to age 71., Results: Compared to those with no evidence of an LOC HI, only those reporting an LOC HI>15 years prior (16%, n = 80) performed worse on cognitive tests at age 69-71, taking into account premorbid cognition, particularly on the digit-symbol substitution test (DSST). Smaller brain volume (BV) and adverse NAWM microstructural integrity explained 30% and 16% of the relationship between HI and DSST, respectively. We found no evidence that LOC HI was associated with Aβ load, hippocampal volume, WMH volume, AD-related cortical thickness or NFL (all p > 0.01)., Interpretation: Having a LOC HI aged 50's and younger was linked with lower later-life cognitive function at age ~70 than expected. This may reflect a damaging but small impact of HI; explained in part by smaller BV and different microstructure pathways but not via pathology related to AD (amyloid, hippocampal volume, AD cortical thickness) or ongoing neurodegeneration (serum NFL)., (© 2021 The Authors. Annals of Clinical and Translational Neurology published by Wiley Periodicals LLC on behalf of American Neurological Association.)

Background: There is growing awareness internationally around the prevalence and dangerousness of non-fatal strangulation (NFS). The aim of this study was to: (i) identify the prevalence of NFS in patients presenting to the Saint Mary's Sexual Assault Referral Centre (SARC), Manchester, UK for an acute forensic medical examination (FME) after a report of rape or sexual assault, (ii) explore the characteristics of patients reporting NFS compared to those who did not and (iii) explore the prevalence of various symptoms and signs associated with NFS., Method: Data from case files of all patients attending in a three year period, January 1, 2017 to December 31, 2019, were analysed. There was not any age or gender related exclusion criteria. In the NFS cases the Saint Mary's SARC NFS pro-forma used as part of the contemporaneous medical notes was also reviewed., Results: A total of 2196 adults (≥18 years old) attended Saint Mary's SARC for an acute FME during the three year study period. This comprised 1994 (90.7%) non-NFS cases and 204 (9.28%) NFS cases. The prevalence of NFS was 18.9% where the alleged perpetrator was a partner or ex-partner. For NFS cases, 96.6% (n = 197) of the patients were female and the alleged perpetrator was male in 98% (n = 200) of the NFS cases. 40% of the NFS cases had been strangled in their own homes and in 33% of cases children lived in that home. In 27% (n = 55) of the NFS cases the patient said that the alleged perpetrator had also strangled them on a previous occasion. 46.6% had an injury to the neck or above attributable to the NFS. 15.7% (n = 32) of the NFS cases reported loss of consciousness, 8.8% (n = 18) were incontinent of urine and 2% (n = 4) incontinent of faeces as a result of the NFS. Over a third of the patients (36.6%) thought that they were going to die during the NFS., Conclusion: The study shows that NFS in sexual assault is a gendered crime, with most victims female and most assailants male. NFS is prevalent and this prevalence increases where the alleged perpetrator is a partner or ex-partner. Many are assaulted in their own homes, homes frequently shared with children. Visible NFS injuries are not the norm yet fear of death is not uncommon. Over 1 in 6 (15.7%) reported loss of consciousness suggesting that they were victims of a near lethal assault. That 27% had previously been a victim of NFS by the same alleged perpetrator indicates that there are considerable numbers potentially living in fear and at risk. Awareness of the risk of NFS, and an enhanced response to it, is required by those looking after victims and all those in the criminal justice system., (Copyright © 2021 Elsevier Ltd and Faculty of Forensic and Legal Medicine. All rights reserved.)

Acute cerebral infarction due to occlusion of the artery of Percheron (AOP) is rare and poses a diagnostic challenge due to unspecific clinical symptoms. A prompt diagnosis and treatment is vital due to a potentially very serious outcome. Here we represent a healthy young woman who developed sudden headache and loss of consciousness. At admission she was unconscious with GCS of 4, pupils were unevenly dilated and poorly reactive and the plantar reflex was upward bilaterally. She had seizure like movements in all limbs. CT of brain and CT angiography were normal but acute MRI showed bilateral paramedian thalamic diffusion restriction. The patient was treated with i.v. thrombolysis (tPA) 70 minutes after hospital arrival and recovered fully.

Objective: The study explored the therapeutic value of standard trauma craniectomy (STC) for the treatment of traumatic multiple intracranial hematoma., Methods: Clinical data of traumatic multiple intracranial hematoma patients who underwent surgical treatment in 2014 and 2015 were collected. The STC group and a control group according to the surgical mode, 48 and 30 cases were randomly selected from each group, respectively. Statistical analysis was performed on the change in the Glasgow coma scale (GCS) score from before the operation to 1 day, 1 week and 1 month postoperatively through repeated analysis of variance and Wilcoxon rank-sum analysis., Results: Significant differences in the GCS were observed at different time points for the two operative modes (P < .01), and an interaction was observed between time and treatment groups (P < .05). The rates of change of the GCS score for the two surgical modes were most obviously different at 3 days and 1 week postoperatively (P ≤ .001, P < .01). No statistically significant differences were observed in the rates of change of the GCS at 1 month postoperatively (P > .05)., Conclusions: Compared to conventional craniotomy, STC has obvious effects on the recovery after disturbance of consciousness at 1 week postoperatively but does not result in a significant improvement in recovery at 1 month postoperatively., Competing Interests: The authors have no conflicts of interest to disclose., (Copyright © 2021 the Author(s). Published by Wolters Kluwer Health, Inc.)

Objective: The purpose of this study was to evaluate whether loss of consciousness (LOC), retrograde amnesia (RA), and anterograde amnesia (AA) independently influence a particular aspect of post-concussion cognitive functioning-across-test intra-individual variability (IIV), or cognitive dispersion., Method: Concussed athletes (N = 111) were evaluated, on average, 6.04 days post-injury (SD = 5.90; Mdn = 4 days; Range = 1-26 days) via clinical interview and neuropsychological assessment. Primary outcomes of interest included two measures of IIV-an intra-individual standard deviation (ISD) score and a maximum discrepancy (MD) score-computed from 18 norm-referenced variables., Results: Analyses of covariance (ANCOVAs) adjusting for time since injury and sex revealed a significant effect of LOC on the ISD (p = .018, ηp2 = .051) and MD (p = .034, ηp2 = .041) scores, such that athletes with LOC displayed significantly greater IIV than athletes without LOC. In contrast, measures of IIV did not significantly differ between athletes who did and did not experience RA or AA (all p > .05)., Conclusions: LOC, but not RA or AA, was associated with greater variability, or inconsistencies, in cognitive performance acutely following concussion. Though future studies are needed to verify the clinical significance of these findings, our results suggest that LOC may contribute to post-concussion cognitive dysfunction and may be a risk factor for less efficient cognitive functioning.

In the very young child (less than eight years of age), transient loss of consciousness represents a diagnostic and management dilemma for clinicians. While most commonly benign, syncope may be due to cardiac dysfunction which can be life-threatening. It can be secondary to an underlying ion channelopathy, cardiac inflammation, cardiac ischemia, congenital heart disease, cardiomyopathy, or pulmonary hypertension. Patients with genetic disorders require careful evaluation for a cardiac cause of syncope. Among the noncardiac causes, vasovagal syncope is the most common etiology. Breath-holding spells are commonly seen in this age group. Other causes of transient loss of consciousness include seizures, neurovascular pathology, head trauma, psychogenic pseudosyncope, and factitious disorder imposed on another and other forms of child abuse. A detailed social, present, past medical, and family medical history is important when evaluating loss of consciousness in the very young. Concerning characteristics of syncope include lack of prodromal symptoms, no preceding postural changes or occurring in a supine position, after exertion or a loud noise. A family history of sudden unexplained death, ion channelopathy, cardiomyopathy, or congenital deafness merits further evaluation. Due to inherent challenges in diagnosis at this age, often there is a lower threshold for referral to a specialist.

In order to understand general anaesthesia and certain seizures, a fundamental understanding of the neurobiology of unconsciousness is needed. This review article explores similarities in neuronal and network changes during general anaesthesia and seizure-induced unconsciousness. Both seizures and anaesthetics cause disruption in similar anatomical structures that presumably lead to impaired consciousness. Despite differences in behaviour and mechanisms, both of these conditions are associated with disruption of the functionality of subcortical structures that mediate neuronal activity in the frontoparietal cortex. These areas are all likely to be involved in maintaining normal consciousness. An assessment of the similarities in the brain network disruptions with certain seizures and general anaesthesia might provide fresh insights into the mechanisms of the alterations of consciousness seen in these particular unconscious states, allowing for innovative therapies for seizures and the development of anaesthetic approaches targeting specific networks., (Copyright © 2020 British Journal of Anaesthesia. Published by Elsevier Ltd. All rights reserved.)

Objective: To investigate the association between reported traumatic brain injury plus loss of consciousness (TBI + LOC) and a range of demographic, military, and physical and mental health factors among a sample of UK veterans seeking support for mental health difficulties., Design: The present study was a cross-sectional study., Participants: Clinical records were used to identify a sample of treatment-seeking UK veterans (N = 3335), of which a total of 403 took part., Main Measures: Information on demographic characteristics, military experiences, and a range of physical and mental health difficulties was collected., Results: Almost half of the sample (48%) reported a TBI + LOC, which was most strongly associated with drug use and childhood adversity. More modest associations also emerged with earlier service termination, likelihood of unemployment, as well as chronic pain and poor mobility., Conclusion: The findings suggested that TBI + LOC may not specifically be associated with symptoms of posttraumatic stress in a sample of treatment-seeking veterans. The demonstrated links between TBI + LOC and adverse childhood, drug use, physical health, and employment may be useful in improving the assessment and rehabilitation of veterans with TBI + LOC., Competing Interests: The authors declare no conflicts of interest., (Copyright © 2020 Wolters Kluwer Health, Inc. All rights reserved.)

Objective: Electroacupuncture (EA) is used in the treatment of various diseases through the use of electrical stimulation. Reports of adverse events (AEs) associated with acupuncture are relatively consistent, but the safety of EA has been less well reported. In this systematic review, we provide a summary of the types of AEs related to EA in clinical practice., Methods: Twelve electronic databases, including those in English (PubMed, Ovid-EMBASE, CENTRAL), Korean (KMbase, KISS, NDSL, KISTI, OASIS), Chinese (CNKI, Wanfang, Weipu) and Japanese (J-STAGE), were systematically searched for single case studies and case series through April 2018. There were no language restrictions. We included clinical studies in which EA was used as a key intervention and in which AEs that may have been causally related to EA were reported., Results: Thirty-seven studies, including 27 single case studies and 10 case series, were evaluated. The most frequently reported AEs were pallor (eight cases), skin pigmentation (eight cases), vertigo (seven cases), chest tightness (six cases), vomiting (six cases) and unconsciousness (five cases). Thirty-one cases (62%) achieved full recovery and three cases (6%) achieved partial recovery. There were also three cases of death (6%)., Conclusion: AEs related to EA included acupuncture-related AEs and serious AEs induced by electrical stimulation. Currently, specific stimulation conditions associated with EA-specific AEs are not identifiable due to inappropriate reporting. However, skin pigmentation, syncope or spasm, implantable cardioverter-defibrillator shock, cardiac emergencies, electrical burns, and potential internal organ injury are potential EA-specific AEs regarding which physicians should be cautious in clinical practice.

Background: Transient loss of consciousness (TLOC) is common among children and adolescents. The aims of this study were to identify clinical differences between patients with vasovagal syncope and those with epileptic seizures, which account for a large proportion of TLOC cases, and to evaluate the effectiveness of various diagnostic tests., Methods: The medical records of 160 children and adolescents with TLOC were analyzed retrospectively, and age, sex, clinical symptoms, and trigger factors were recorded. The cardiological and neurological evaluations performed included electrocardiograms, computed tomography scanning, magnetic resonance imaging, electroencephalograms (EEGs), echocardiograms, and head-up tilt tests (HUTTs). Overall assessments of the 160 patients generated final diagnoses., Results: The mean age of patients was 14.6 years old and TLOC occurred more frequently among girls (59.4%). The most common final diagnosis was vasovagal syncope (n = 102, 63.4%), followed by undetermined (n = 21, 13.1%) and epileptic seizures (n = 17, 10.6%). There were many other diagnoses, including cardiogenic syncope (1.3%). Patients diagnosed with vasovagal syncope were much more likely to have dizziness or light-headedness and blurred vision as pre-symptoms (p < 0.05), whereas patients diagnosed with epileptic seizures were more likely to have convulsions as an accompanying sign (p < 0.05). In addition, standing up was the most significant trigger factor for TLOC among those diagnosed with vasovagal syncope (p < 0.05). The sensitivity, specificity, and accuracy of the HUTT for vasovagal syncope were 95.1%, 75.0%, and 91.8%, respectively. Similarly, the sensitivity, specificity, and accuracy of EEGs for epileptic seizures were 80.0%, 70.6%, and 80.0%, respectively., Conclusion: Vasovagal syncope and epileptic seizures should be considered as possible causes of most cases of TLOC in children and adolescents. An accurate case history and appropriate evaluation are essential for correct diagnoses., Competing Interests: Declaration of Competing Interest The authors declare that they have no conflicts of interest., (Copyright © 2020. Published by Elsevier B.V.)

Background: Sudden loss of consciousness (LOC) in the prehospital setting in the absence of cardiac arrest and seizure activity may be a challenge from a dispatcher's perspective: The aetiology is varied, with many causes being transient and mostly self-limiting, whereas other causes are potentially life threatening. In this study we aim to evaluate the dispatch of HEMS to patients with LOC of medical origin, by exploring to which patients with a LOC HEMS is dispatched, which interventions HEMS teams perform in these patients, and whether HEMS interventions can be predicted by patient characteristics., Methods: We performed retrospective cohort study of all patients with a reported unexplained LOC (e.g. not attributable to a circulatory arrest or seizures) attended by the Air Ambulance Kent, Surrey & Sussex (AAKSS), over a 4-year period (July 2013-December 2017). Primary outcome was defined as the number of HEMS-specific interventions performed in patients with unexplained LOC. Secondary outcome was the relation of clinical- and dispatch criteria with HEMS interventions being performed., Results: During the study period, 127 patients with unexplained LOC were attended by HEMS. HEMS was dispatched directly to 25.2% of the patients, but mostly (74.8%) on request of the ground ambulance crews. HEMS interventions were performed in 65% of the patients (Prehospital Emergency Anaesthesia 56%, hyperosmolar therapy 21%, antibiotic/antiviral therapy 8%, vasopressor therapy 6%) and HEMS conveyed most patients (77%) to hospital. Acute neurological pathology was a prevalent underlying cause of unexplained LOC: 38% had gross pathology on their CT-scan upon arrival in hospital. Both GCS (r = - 0.60, p < .001) and SBP (r = 0.31, p < .001) were related to HEMS interventions being performed on scene. A GCS < 13 predicted the need for HEMS interventions in our population with a sensitivity of 94.9% and a specificity 75% (AUC 0.85)., Conclusion: HEMS dispatchers and ambulance personnel are able to identify a cohort of patients with unexplained LOC of medical origin who suffer from potentially life threatening (mainly neurological) pathology, in whom HEMS specific intervention are frequently required. Presenting GCS can be used to inform the triage process of patients with LOC at an early stage.