neurology for finals - · pdf fileheadache: secondary •neck trauma •vascular...

NEUROLOGY FOR

FINALSSean Davidson & Hannah Hayhurst

What we’ll cover

• History taking

• Core conditions

• MS

• PD

• MND

• Stroke

• Epilepsy

• MG

• GB

• Headache

What we won’t…

• Examination

• Dementia

• Neuropathy/myopathy

• SBAs

Presenting complaints

• Weakness

• Sensory loss

• Fits/faints/funny turns

• Fatigue

• Tremors/twitches

• Visual disturbance

• Headache

Kahoot.it

MS

• Autoimmune (T cell) inflammatory demyelination with axonal degeneration

• White matter

• Women, young adults

• Types• (Clinically isolated syndrome) – most get MS in next 20 years

• Relapsing-remitting

• Secondary progressive – 85% RRMS get

• Primary progressive 10-15%

• Progressive-relapsing 5%

MS

MS: Presentation

• Symptoms:

• Motor – weakness, spasms

• Sensory – pain, paresthesia, sensory loss

• Autonomic – bladder, bowel, sexual

• UMN signs

• Timescale: days-weeks, evolve, improve though not

always completely

MS: presentation

• Commonly:• Optic neuritis

• Transverse myelitis

• Worth knowing for MCQs:• Uhthoff’s – symptoms come on/worsen with heat

• Lhermitte’s – neck flexion, shooting pain down neck back and arms

• Internuclear ophthalmaplegia

MS: diagnosis

• Revised McDonald Criteria

• Dissemination in time and space

• Evidence: clinical, radiological (MRI, GAD enhanced), visual evoked potentials

• LP – increased protein, unmatched oligoclonalbands

MS: differential diagnosis

• SLE

• Vasculitis

• Sarcoidosis

• HIV/AIDS

• Neuromyelitis optica – TM and ON

• Acute disseminated encephalomyelitis – usually children and adolescents, single flare up

MS: managment

• Conservative MS nurse, PT, psychology, continence

services

• Medical

• Self-inection – interferon beta, glatiramer

• Oral – dimethylfumerate, fingolimod

• IV – natalizumab, alemtuzumab

• Surgical urology

• Challenges - fatigue, pain, spasticity, ataxia, visual

Parkinson’s disease

Parkinson’s disease

• A movement disorder caused by degeneration of

the dopaminergic pathways in the substantial

nigra

• Characterised by• Tremor

• Rigidity

• Bradykinesia

Parkinsonism: causes

Parkinsonism: causes

• Idiopathic PD

• Drugs - antipsychotics, antiemetics

• DLB

• Genetic

• Parkinson’s plus

Parkinson’s Disease: examination

findings

PD: investigations

• Clinical diagnosis!

• Bloods & CT/MRI to r/o other differentials

• DAT scan

PD: management

• Conservative

• Medical

• Surgical

PD: management

• Conservative: SALT, PT, OT, specialist nurses, MDT etc

• Medical

• Surgical: DBS

PD: medications

• Levodopa

• Dopamine agonists

• Apomorphine

• Glutamate antagonist

• Anticholinergics

• COMT inhibitors

• MAO-B inhibitors

PD: medications

• Levodopa - co-beneldopa/co-careldopa

• Dopamine agonists - bromocriptine

• Apomorphine

• Glutamate antagonist - amantadine

• Anticholinergics - procyclidine

• COMT inhibitors - entacapone

• MAO-B inhibitors - selegeline

PD: medications

• Levodopa - co-beneldopa/co-careldopa

• Dopamine agonists - bromocriptine

• Apomorphine

• Glutamate antagonist - amantadine

• Anticholinergics - procyclidine

• COMT inhibitors - entacapone

• MAO-B inhibitors - selegeline

*Weaning off*

*On/off fluctuations*

*Dyskinesias*

MND

MND

• Degeneration of the motor system (both leading to

weakness and wasting

• 4 types:

• Amyotrophic lateral sclerosis

• Progressive muscular atrophy

• Progressive bulbar palsy

• Primary lateral sclerosis

MND: presentation

• 50s-60s

• Weakness - dropping things, difficulty gripping

• Foot drop & gait disturbance

• Falls

• Fasciculations

• Wasting

• Rarely: speech/swallowing disturbance

MND: signs

• MIXED UMN

& LMN

PICTURE

UMN LMN

Weakness (arm

extensors, leg flexors)Weakness

Hypertonia Atrophy

Upgoing plantars Fasciculations

Hyper-reflexia Hyporeflexia

MND: investigations

• Bloods:

• Imaging:

• EMG:

MND: investigations

• Bloods: B12 & folate, CK, serum electrophoresis

• Imaging: CT & MRI to exclude other pathologies

• EMG: fibrillation & fasciculations

MND: management

• Conservative:

• Medical:

• Complications:

• End of life care!

MND: management

• Conservative: MDT, specialist nurses, dieticians, PT,

communication aids, support groups

• Medical: riluzole, symptomatic management e.g. hyoscine,

baclofen, NIV, **treat depression**

• Complications: resp failure, aspiration pneumonia, HAP,

constipation, UTIs etc

• End of life care!

Stroke: presentation

• Oxford/Bamford classification

• TACS – large, cortical, anterior circulation

• PACS – smaller, cortical, anterior circulation

• LACS – subcortical, small vessel disease, lenticulostriatearteries

• POCS - cerebellum, brainstem or occipital, posterior circulation

ICA ->

ACA & MCA

Vertebrals

and basilar

Stroke: presentation

• Oxford/Bamford classification

• TACS – 1)weakness, 2)homonymous hemianopia, 3)dysphasia/inattention

• PACS – 2 of 3

• LACS – pure motor, pure sensory, sensory-motor, ataxic hemiparesis

• POCS – loss of consciousness, isolated homonymous hemianopia, brainstem syndromes, DANISH

ICA ->

ACA & MCA

Vertebrals

and basilar

Stroke: assessment and acute rx

ABCDon’t ever

forget glucose

Bloods including

ESR, TSH,

lipids, glucose

ECG – AF

CT head: bleed

or infarct?

(CTA,

MRI+DWI)

ICH – nuerosurgery not

interested, reverse

anticoag, observe, manage

BP, CTA/MRA ?aneurysm

Ischaemic <4.5 hours (<3)

THROMBOLYSIS

CI seizures, trauma, prev

ICH, INR >1.7, bleeding

risk

Ischaemic >4.5 hours/

uncertain

Aspirin 300mg

Stroke: causes/ further ix

• Young: vasculits, thrombophilia, SAH, venous sinus

thrombosis, carotid dissection

• Old:

• Cardioembolic – AF, PFO

• Large Vessel – carotid stenosis

• Small Vessel – smoking, high BP, high cholesterol

• Ix

• ECG, 24 hour tape – are they in AF?

• Carotid doppler – carotid artery stenosis

• Echo – valvular diasease, PFO?

Stroke: management (ischaemic)

• Conservative SALT, PT, OT, dietician, community stroke

team, smoking cessation, think about driving

• Medical

• Anti-platelet: aspirin 300mg 14/7, clopidogrel 75mg thereafter

• Anticoag if AF

• Lipids: atorvastatin 40-80mg

• Antihypertensives

• Management of DM

• VTE prophylaxis (IPCs, tinz after 4-7 days)

• Surgical endarterectomy if >50% stenosis

TIA

• <24 hours but most mins

• Abrupt sensory/motor/visual/speech deficit

• 300mg aspirin, stroke physician within 24 hours (7 days if

occurred >week ago)

• Age, BP, Clinical features, Duration, Diabetes - >4 high risk

• Rx – clopidogrel 75mg, atorvastatin, risk factors, driving

• Mimics: Todds paresis, complex migraine, functional,

labyrinthine, hypoglycaemia

Epilepsy

• Recurrent tendency towards seizures

• Seizure causes

• Vascular - ICH, SAH

• Infective - meningoencephalitis

• Toxin – alcohol withdrawal, drugs

• Traumatic – head injury

• Metabolic – ↓glucose, ↓ Ca, ↓ Mg, ↓/↑ Na, uraemia

• Structural – post-stroke, SOL

• Eclampsia

• Idiopathic/genetic

Mimics

• Syncope – reflex anoxic seizure

• Causes of LOC – OH, cardiac syncope, vasovagal

• Complex migraine

• Functional non-epileptic attacks

• Narcolepsy/cataplexy

Epilepsy: investigations

• ECG

• Bloods – glucose, electrolytes, renal function

• MRI – particularly older people, focal onset

• EEG – inter-epileptiform abnormalities

• Gold standard – video telemetry

Epilepsy: generalised

• Both hemispheres simultaneously

• Absence

• Tonic-clonic

• Tonic

• Atonic

• Myoclonic

• Secondary generalised

Epilepsy: focal

Occipital – visual hallucinations

Parietal – paraesthesia, pain,

distortion

Temporal – epigastric rising,

memory phenomena, auditory,

olfactory, gustatory, fear

Frontal – Jacksonian march, posturing,

peddling, screaming

Simple or complex/dyscognitive – originate in one

hemisphere

Status epilepticus

• ABCDon’t ever forget glucose

• Bloods, ECG, CXR, (CT)

• Oxygen

• IV lorazepam, buccal midazolam if no access

• IV Phenytoin

Epilepsy: chronic managment

• Conservative seizure awareness/ recognition, driving

once seizure free for a year, safety advice re

baths/ladders/swimming etc

• Medical

• Focal 1st carbamazepine or lamotrigine

• Generalised tonic-clonic 1st sodium valproate

• Absence 1st line sodium valproate or ethosuximide

• Surgical vagus nerve stimulators, removal benign

tumours/AV malformations

Myasthenia Gravis

Myasthenia Gravis

• Disorder of neuromuscular transmission, resulting from

binding of autoantibodies to components of the

neuromuscular junction

MG: causes

• Autoimmune

• Role of the thymus gland??

MG: presentation

• Women <50, men >50

• Muscle fatigue

• Eyelid drooping

• Double vision

• Slurred speech

• Myasthenic crisis

Myasthenic crisis

• Worsening muscle weakness resulting in respiratory

failure

• Triggers: infection, surgery

• 20-30% of MG patients, usually within 1st year of illness

MG: investigations

• Bloods:

• Imaging:

• EMG:

MG: investigations

• Bloods: TFTs, ACh-R, serum MuSK

• Imaging: CXR/thymus CT

• EMG: repetitive nerve stimulation, single fibre

electromyography

MG: management

• Acute:

• Symptomatic:

• Immunosuppression:

• Surgery:

MG: management

• Acute: IVIG, steroids

• Symptomatic: acetylcholinesterase inhibitors e.g.

pyridostigmine

• Immunosuppression: steroids, azathioprine

• Surgery: thymectomy

Guillain-Barre

Guillain-Barre

• Disorder causing demyelination and axonal degeneration

• Acute, ascending and progressive neuropathy

Guillain-Barre - causes

• 75% preceded by infection

• Resp or GI infection 1-3 weeks before

• Campylobacter jejuni, EBV

• Malignancy & pregnancy also risk factors

Guillain-Barre - symptoms

• Symptoms starting in the legs and moving proximally

• Weakness

• Pain

• Sensory loss

• Autonomic symptoms: reduced sweating, heat intolerance

Guillain-Barre - signs

• Hypotonia

• Sensory disturbance

• Reduced/absent reflexes

Guillain-Barre - differentials

• Brain:

• Spinal cord:

• Peripheral nerve:

• NMJ:

• Muscle:

Guillain-Barre - differentials

• Brain: stroke, brainstem compression, encephalitis

• Spinal cord: cord compression, transverse myelitis

• Peripheral nerve: vasculitis

• NMJ: MG

• Muscle: hypokalaemia, polymyositis

Guillain-Barre - investigations

• Bedside: obs, urine dip etc (recent infection)

• Bloods: inflammatory markers, antibody screen

• Imaging: CT/MRI to exclude other pathologies

• Nerve conduction studies (abnormal in 85%)

• LP: raised proteins

Guillain-Barre - management

Acute Chronic

Plasma exchange PT

IVIG OT

Steroids SALT

Analgesia MDT

Headache: Secondary• Neck trauma

• Vascular

• SAH – thunderclap, neurology, seizures -> neurosurgery

• GCA - >50, scalp tenderness, jaw claudication -> ESR, pred

• Subdural haemorrhage -> neurosurgery v conservative

• ICH -> neurosurgery v conservative

• Raised intracranial pressure – SOL, IIH

• Meningitis – photophobia, meningism, fever, rash

• Encephalitis – flu-like illness, confusion, coma, seizures

• Facial pain– TG neuralgia, sinusitis, tooth/oral pain, eye pain including glaucoma

Headache: Primary

• Migraine

• Prophylaxis – avoid triggers, beta-blocker, amitriptyline

• Acute – NSAIDs + anti-emetics, triptans, ergotamine

• Cluster/ trigeminal autonomic cephalgias

• Prophylaxis – verapimil, pred, lithium

• Acute – triptans, oxygen

• Tension

• Medication overuse headache

• Exertional