Postgraduate Medicine

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Transient global amnesia
Gilbert J. Toffol DO & Michael Swiontoniowski MD
To cite this article: Gilbert J. Toffol DO & Michael Swiontoniowski MD (1990) Transient global
amnesia, Postgraduate Medicine, 88:2, 217-219, DOI: 10.1080/00325481.1990.11704711
To link to this article: http://dx.doi.org/10.1080/00325481.1990.11704711

Published online: 17 May 2016.

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Date: 02 July 2016, At: 18:25

Transient global amnesia

Gilbert J. Toffol, DO

Michael Swiontoniowski, MD

Downloaded by [Monash University Library] at 18:25 02 July 2016

Preview
Although transient global amnesia tends to occur only once in a
patient and is usually benign, such an episode can be alarming.
The authors describe a typical case and discuss the characteristics, possible causes, prognosis, and treatment of transient
global amnesia.

A 63-year-old woman was admitted
to Mesa General Hospital, Mesa,
Arizona, because of transient confusion that had been noted by her husband. She had suddenly become
disoriented after having an orgasm
during sexual intercourse. She had a
mild, throbbing headache that had
begun at onset of her confusion, and
she continually repeated questions as
to her whereabouts and the time. An
emergency department nurse noted
that "the patient doesn't remember
what you talked about a few minutes
earlier."
On physical examination, the patient was oriented only to her name.
Recent and remote memory for the
past several months was absent. She
was unable to retain new information for more than 30 seconds. The
patient was normotensive, and the
remainder of the physical examination was unremarkable. Results of
noninvasive carotid studies, electrocardiogram, echocardiogram, elec-

troencephalogram, magnetic resonance imaging, and thyroid function
studies were normal. Within 4 hours
the patient's memory deficits resolved, except for permanent amnesia of the events that occurred between onset of the transient global
amnesia and recovery.

Discussion
Amnesic syndromes (table 1) are
disorders of cognitive function in
which memory is impaired out of
proportion to other components of
mentation and behavior. 1 Transient
global amnesia is characterized by
sudden onset of retrograde amnesia
(impaired ability to recall previously
well-established information), an-

'?
•
A PERPLEXING CASE

terograde amnesia (inability to form
new memories), and repetitive
queries. No other neurologic signs
and symptoms are present, and personal identity is preserved.
The term "transient global amnesia'' was first used by Fisher and
AdaJns2 in 19S8. Two years earlier,
the condition had been described by
Bender as a "syndrome of isolated
episode of confusion with amnesia."
A typical attack is characterized by

VOL88/NO 2/AUGUST 1990/PQSTGRADUATE MEDICINE • TRAIIIIBn' QLOIIAL A-..A

sudden onset of profound amnesia
without loss of consciousness. Retrograde amnesia can extend for several
hours to years but recedes spontaneously as the attack subsides. The
patient is unable to recall events that
occur during the attack, which usually lasts 4 to 8 hours but can last up
to 24 hours before slowly resolving.
The exact cause and incidence of
transient global amnesia in the general population are uncertain.
A unique characteristic of transient global amnesia is the repetition
of questions during an attack. In one
study,4 64 of71 patients repeated a
series of questions or statements. Although this may indicate confusion,
neuropsychological testing during an
attack has shown only impairment
of memory with no other cognitive
dysfunctions. 5 Patients are able to
perform complex motor skills, such
as dressing, preparing food, typing,
or driving. They indicate an awareness of their predicament by repeating questions such as "Where am I?"
or "Why am I here?" and stating
that something is wrong.
Transient global amnesia occurs
mainly in the middle-aged and elderly. In Rollinson's review of 213
cases from the literarure,6 the age
range was 34 to 92 years, with a
mean age of SS years. Attacks tended
to be singular, with only 34 (16%)
of the 213 patients having one or
more recurrences. There was a 4:3
male-female ratio. Precipitating factors included coitus, bathing in cold
water, pain, migraine, and emotional
experiences. One repon of transient
continued
217

PERPLEXING CASE CONTINUED

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Table 1. Disorders characterized
by an amnesic syndrome

Transient global amnesia
Thiamine deficiency
Tumors
Trauma
Subarachnoid bleeding
Central nervous system infections
Paraneoplastic syndromes (eg,
limbic encephalitis)
Cerebral infarction
Migraine
Seizure (postictal)

global amnesia in four brothers7 suggests a familial occurrence.
Croft and associat~ found that
persons with transient global amnesia formed the largest group (62%)
of patients referred to neurologic
clinics for evaluation of transient
amnesia. Differential diagnostic considerations include the following:
• Epilepsy. Epileptic seizures usually
are brief, and automatism and depersonalization may be present.
• Psychogenic disturbance. Patients
with a psychogenic disturbance often have a history of stress, anxiety,
depression, or histrionic personality
Gilbert J. Toffol, DO
Mlchael Swlontonlowskl, MD
Or Toffol is clinical assistant professor of
neurology, College of Osteopathic Medicine
of the Pacific, Pomona, California. He is also
in the private practice of neurology in
Phoenix.
Or Swiontoniowski is clinical instructor in
stroke and attending physician, department
of neurology, Michael Reese Hospital and
Medical Canter, Chicago.

218

disorder. A psychogenic attack may
end abruptly, in contrast to the gradual shortening of retrograde amnesia
in transient global amnesia.
• Encephalitis. A prodromal illness,
fever, and abnormal cerebrospinal
fluid and electroencephalographic
findings may be present.
• Trauma. Evidence of head injury
may be found on physical examination or on skull films of patients
with posttraurnatic amnesia.
• Tumors. Cerebral tumors usually
manifest with other neurologic findings. Symptoms are progressive, and
computed tomographic or magnetic
resonance imaging scans are abnormal.
• Migraine. An a~ o~ headache
may accompany nugrame.
• Alcohol abuse. An alcoholic patient may present with confabulation and loss of insight in addition to
the stigmata of alcohol abuse (eg,
malnutrition, neuropathy, ophthalmoplegia).
• Hypoglycemia. Hypoglycemic
episodes are shorter than attacks of
transient global amnesia, and laboratory results are abnormal.
Transient amnesia has also been
linked to allergic encephalopathy
due to antitetanus serum, cerebral
and coronary angiography, pituitary
rumor, polycythemia, myxomatous
degeneration of the mitral valve,
neurosyphilis, and intoxication with
digitalis, iodochlorhydroxyquin
(clioquinol) (Vioform), or diazepam
(Valium, Valrelease).6.&-to
The exact cause of transient glob-

al amnesia is uncertain. An attack is
usually solitary, unaccompanied by
other signs and symptoms, and followed by complete recovery, all of
which make it difficult to explain.
Fisher and Adarns4' 11 argue that
seizure is the cause, but this theory is
contradicted by the age at onset, low
recurrence rate, absence of clearly
recognizable attacks of epilepsy, and
infrequency of electroencephalographic abnormalities.
Another possible explanation is
transient ischemia in the posrerior
cerebral artery. Arguments favoring
this theory include the facts that amnesia is seen with occlusion of the
posterior cerebral artery, 12 other signs
and symptoms of vertebrobasilar insufficiency may be present, and risk
factors for cerebrovascular disease are
present in some patients with transient global amnesia. 13 Jensen and de
Fine Olivarius14 argue that there is a
clinical spectrum of ischemia: At one
end is transient global amnesia with
a single episode and no other findings; in the center, transient amnesia
with other transient symptoms of insufficient posterior cerebral circulation; and at the other end, more
widespread ischemia and infarction.
Caplan and associates15 agree that
a problem in the posterior cerebral
circulation explains transient global
amnesia, but they argue in favor of
migraine because it is a vascular disorder with bias for the posterior cerebral circulation. In addition, electroencephalographic abnormalities
have been described in transient

TRANIImfT GLOIIAL ~ • VOL 88/NO 2/AUGUST 1990/PQSTGRAOUATE MEDICINE

Downloaded by [Monash University Library] at 18:25 02 July 2016

global amnesia, 1s. 17 and these are also
consistent with migraine. 18
Follow-up studies reveal that transient global amnesia is usually benign. In one series of33 patients, 19 6
(18%) had recurring episodes and 2
(6%) progressed to stroke. In another repon,20 4 (12.5%) of32 patients
had recurring episodes and 1 (3%)
had transient ischemic attacks. Other investigators have fOund that the
oudook is not so benign. Of the 28
patients described by Jensen and de
Fine Olivarius, 14 9 (32%) had strokes
and 4 (14%) had recurring transient
ischemic attacks. Transient global
amnesia by itself still has a good
prognosis, but the presence of other
transient ischemic manifestations or
risk factors fur cerebrovascular disease increases the chance of funher
problems. Nevenhdess, fOllow-up
neuropsychological testing may reveal a persistence of deficit in verbal
IQ and impairment of verbal memory even in patients who have had a
single episode of transient global amnesia and have returned to work and
family life with no complaint of
memory loss or other mental difficulties.21
Providing reassurance to both patient and family and avoiding invasive investigation are the mainstays
of treatment of transient global amnesia.9 Patients with migraine and
risk factors for cerebrovascular disease need to be fOllowed closely.
Crowell and associater bdieve that
prophylaxis with antiplatdet therapy
may have value if migraine plays a

role in .some cases of transient global
amnesta.

risk factors fur stroke necessitates
dose patient monitoring. Antiplatelet therapy should be considered. RN

Summary
The authors wish to thank Ms Susan
Tapia for her hdp in the preparation of
this manuscript.

Transient global amnesia is often
attributed to a seizure, vascular
cause, or migraine, but the outcome is usually benign. The presence of migraine and important

Address for correspondence: Gilbert J.
TofiOl, DO, Valley Neurology Associates,
4244 N 19thAve, Phoenix, AZ 85015.

Rdm:nces
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