Tuesday, 25 March 2008

Tweedledum and Tweedledee

I had a revelation! Not quite on the Pauline level but one of many stations on the way to some unknown terminus. Enough of the paschal references, although death and resurrection is pretty close to many of us.

Anybody who has read some of the other posts will know that I have been investigating the possibility of not having epilepsy and hence the possibilities it opens up – if that is the right phrase. Now, an epileptologist is a neurologist who has specializes in epilepsy. Simple enough, but if the diagnosis of epilepsy is thrown into doubt then one can be thrown into ping-pong game of going from neurologist to cardiologist, then possibly back again, then back again. Labelling my condition as 'syncope' does not fool me as that is just a fancy word for fainting – from the Greek meaning “to cut short” - one of a galaxy of medical terms that merely describes the phenomenon rather than the cause.

I have finally found a really good website with full articles on syncopes; not more descriptions of symptoms but the most recent thoughts on the neurocardiological mechanisms that kick in when we feel we're being kicked into touch. If you are having doubts about your own diagnosis of epilepsy then have a look at the National Dysautonomia Research Foundation and especially the research abstracts.

Having read some of these excellent articles it strikes me that the reason many of us are passed from neuro to cardio and back again is because the mechanism of syncopes is a synthesis of both specializations. I am not sure whether they should be called neurocardiologists or cardioneurologists, Tweedledum or Tweedledee, so long as someone is there to pick up those patients who fall between these two stools. As Alice said, “I do believe they live in the same house!” But looks like she was wrong.

Anybody who knows of hospitals that have these dual specialists then post it here. For the rest of us, it looks like the cardiology department has the larger budget.

Coming back to syncopes, although I was being flippant above, I was also being serious – looks like much of the confusion is also in the heads of doctors who are just a bit lax in their use of their own terminology. OK, let's try.

Syncope is a symptom defined as a transient spontaneous loss of consciousness with a rapid onset, and self-limited, complete, and usually prompt recovery the underlying mechanism of which is a transient global cerebral hypoperfusion. This last bit just means a loss of blood in the brain.

An epileptic syncope is all the above apart from the cerebral hypoperfusion, which is replaced by epileptiform waves on an EEG.

So the problem is really that the words are defined by the causes of the loss of consciousness, which can only be established after testing for a whole range of things under the broad banner of transient loss of consciousness (TLOC). Both syncope and epilepsy are subcategories of TLOC, slightly complicated by the fact that on rare occasions one can have epileptic and non-epileptic seizures at the same time (I'm not going to go into this now!) What I am going to look into are the mechanisms of syncopes, so back to the neurocardiology department!

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