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Published on : Mar 14, 2014
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Slide 1 - Transient Global Amnesia Allan B. Wolfson, MD University of Pittsburgh Department of Emergency Medicine
Slide 2 - Presentation of TGA
Slide 3 - Clinical features Sudden onset Anterograde amnesia Repetitive questioning Retrograde amnesia (variable, often spotty) Normal alertness, behavior, & cognition Non-focal neuro exam Resolution within 24 hrs
Slide 4 - Reported triggers Emotional upset Sexual activity Vigorous exercise Valsalva
Slide 5 - Differential Diagnosis Head injury Toxic / metabolic Vascular / TIA – posterior circulation Non-convulsive seizure Post-ictal state Migraine Tumor Encephalitis AV fistula Functional
Slide 6 - Epidemiology of TGA Age group usually over 50, but seen in kids too Family history ?2% Incidence 5 - 30 per 100,000 Recurrence 5 - 8% per year Apparent triggering factors in 33 - 50%
Slide 7 - TGA -- Criteria for Dx Witnessed onset Antegrade amnesia No clouding of consciousness or loss of personal identity No cognitive impairment No focal findings No epileptic features No recent head trauma, no sz within 2 yrs Resolution within 24 hrs
Slide 8 - Anatomy of Memory What structures subsume memory? Medial temporal lobes (hippocampus) Thalamus “Diencephalon” Frontal / pre-frontal “Deep cortical structures”
Slide 9 - Physiology of Memory Memory acquisition Memory storage or consolidation Memory retrieval 3-compartment model? immediate, recent, remote
Slide 10 - Emergency Dept Evaluation History Neuro exam “Basic labs”? Head CT EEG MRI
Slide 11 - Bedside evaluation of episodic memory Orientation? Remember 3 things for 3 minutes? Remember what happened yesterday?
Slide 12 - Other types of memory to check on Semantic memory Procedural memory Biographical memory Topographic memory Meta-memory
Slide 13 - Etiology of TGA? Vascular Seizure Migraine Venous hypertension (Valsalva, paradoxical embolism)
Slide 14 - Etiology of TGA? Case-control studies show no association with stroke or TIA Sub-group with epilepsy excluded by definition Nonconvulsive status epilepticus? Association with migraine Reported precipitating factors
Slide 15 - Differentiating features Repetitive questioning Complex acts and instructions Memory gap for the event Severity of retrograde amnesia Rapid onset Duration
Slide 16 - Transient epileptic amnesia Short attacks, multiple attacks No repetitive questioning Anterograde amnesia may be only partial Altered behavior Alteration in consciousness Other features of epilepsy (eg, automatisms, other seizures, EEG, response to anticonvulsants)
Slide 17 - Functional Amnesia Severe retrograde amnesia Absence of anterograde amnesia Duration often weeks or longer
Slide 18 - Fancy Diagnostic Studies EEG CT scanning SPECT scanning, PET scanning MRI, DW-MRI, PW-MRI
Slide 19 - SPECT scanning Some studies have shown decreased perfusion in medial temporal lobes, thalamus, or frontal lobes Usually returns to normal after attack Reflection of abnormality or cause?
Slide 20 - Diffusion-weighted MRI Inconsistent findings Sometimes shows abnormalities (esp in left hippocampus) Sensitive for ischemia (decreased diffusibility of water) But also consistent with “spreading depression” (rapid resolution, unlike ischemia)
Slide 21 - Diffusion-weighted MRI Sensitive for ischemia (decreased diffusibility of water) But also consistent with “spreading depression” (rapid resolution, unlike ischemia)
Slide 22 - What is “spreading depression”? Wave of depolarization progressing across cortex at 3-5 mm/min Associated with aura of migraine
Slide 23 - Diffusion-weighted MRIin TGA Inconsistent findings Sometimes shows abnormalities, especially in left hippocampus Bilateral or left-sided only Sometimes no changes May be time-dependent
Slide 24 - Treatment None necessary Migraine therapy?
Slide 25 - Prognosis Essentially benign Subclinical persistent memory deficits? Associated conditions?
Slide 26 - Disposition from the ED Theoretically: after amnesia resolves, can discharge with neurology follow-up and no immediate testing Actually: admission, MRI, EEG
Slide 27 - Unanswered questions Etiology? Spectrum of causes? True role of precipitating factors? Acute treatment? Physiology of memory?
Slide 28 - QUESTIONS ???