neurology update: a few selected topics edward wong auckland city & middlemore hospitals 28...

NEUROLOGY UPDATE:A Few Selected TopicsEdward Wong

Auckland City & Middlemore Hospitals

28 June, 2014

OVERVIEW

• TIA and Stroke

• Epilepsy• Carbamazepine in Chinese

• Headaches/Migraine

• Parkinson’s disease and Tremor

• Carpal tunnel syndrome

• Vertigo

STROKE MORTALITY IN AUCKLAND

• In Auckland Chinese • Age-standardised mortality rate (per 100,000)

• Stroke 19• Coronary artery disease 11

STROKES IN CHINA

• In China• Major cause of death• Greater proportion of haemorrhagic stroke than in the West• ?Greater proportion of ischaemic strokes are due to small vessel

disease (“lacunar” strokes)

• Applies to Chinese in NZ?

STROKE AND TIA

• “New” Definition of TIA/Stroke (2009)• a transient episode of neurological dysfunction caused by focal brain, spinal

cord, or retinal ischemia, without acute infarction• Neuro-imaging important, especially MRI/DWI • 39% of “TIAs” (time-based definition) have DWI +ve lesions

• In practice, until you have brain imaging (MRI?), use the old time-based definition

TIA MIMICS

• The history is key• Abrupt onset• Focal deficit• “Negative” phenomena (“loss of….”) Int Med J 2013; :353-60

STROKE RISK AFTER TIA

2 days 7 days

ABCD2 SCORE

• Score between 0 and 7

• Do not use ABCD2 if “crescendo TIAs”, AF or known ipsilateral carotid artery disease

Sensory not included

ABCD2 SCORE

ABCD2 <4Low Risk

Refer to TIA Clinic

ABCD2 >4High Risk Admit

STROKE AND TIA 2O PREVENTION: Antiplatelets

• Stroke Guidelines:• Aspirin (any dose >75mg od) + Dipyridamole SR 150 mg bid, OR• Clopidogrel 75 mg od• (loading dose? 300mg of each)

• Aspirin alone, is not unreasonable

• Start before brain imaging?

• YES

STROKE AND TIA: CHANCE STUDY

• High-risk TIA ABCD2 >4

or minor stroke (NIHSS <3)

ASA group ASA + C groupDay 1 ASA 75-300 mg ASA 75-300 mg

Clopidogrel 300mgDay 2 -21 ASA 75 mg ASA 75 mg +

Clopidogrel 75 mgDay 22-90 ASA 75 mg Clopidogrel 75 mg

STROKE AND TIA: CHANCE STUDY

At 90 days

STROKE AND TIA 2O PREVENTION: Statin

• 16% relative risk reduction over 5 years

• 2.2% ARR

STROKE AND TIA 2O PREVENTION: BP Lowering

• 28% relative risk reduction over 4 years

• 4% ARR

• Any class of drug

• A prolonged decline of 12 mmHg in usual SBP and 5 mmHg in usual DBP would be expected to reduce the risk of secondary stroke by about one-third

STROKE AND TIA

• Anticoagulation for AF• Superior to Aspirin and other anticoagulants (66% relative risk reduction, vs 20%)• NOACs, as good as or superior to Warfarin, and as safe as or safer than

Warfarin• Direct thrombin inhibitors

• Dabigatran (RELY 2009): 150 mg superior/110mg non-inferiority to warfarin in AF, similar/less haemorrhages

• Factor Xa inhibitors• Apixaban (ARISTOTLE 2011): superior, less haemorrhages• Rivaroxaban (ROCKET AF 2011): non-inferior, fewer ICH• Edoxaban (ENGAGE-AF 2014): non-inferior, less haemorrhages

CHA2DS2VASC SCORE

“TIME IS BRAIN”

• 2 RCTs showing benefit up to 4.5 hours of stroke onset• Some controversy

• Consensus statement in NZMJ (2014;127:113-4)• “Time is brain” – Ongoing symptoms or signs → Ambulance to Hospital

(Stroke. 2006;37:263-266.)

STROKE IV THROMBOLYSIS

STROKE: SUNDRY

• IV thrombolysis and Clot retrieval + IA thrombolysis• Not superior to IV Thrombolysis

• PFO Closure• Not superior to medical therapy

• Carotid stenting• No better than carotid endarterectomy

• Possibly greater risk of stroke

• Decompressive Hemicraniectomy• Life-saving procedure• Reduces disability

EPILEPSY: Seizure vs syncope

• Careful history-taking• Detailed account of the circumstances and behaviour before, during and after

the episode• Patients have limited recall of events during a seizure, a witness account is

essential.

EPILEPSY: Seizure vs syncope

• Generalised seizure• Usually has no warning, no preceding aura and no focal features. • Motor activity is generalised from the outset in generalised tonic–clonic seizures.

• Psychogenic non-epileptic seizures (if in doubt, treat as seizure)• Often last longer than epileptic seizures• Eyes are often closed (sometimes this is forced)• Motor behaviour may be asynchronous, large-amplitude, waxing and waning, and

movements such as side-to-side rolling, head turning, back arching, thrashing of limbs and pelvic thrusting may be involved

• Resolution of consciousness may be rapid without postictal confusion• May coexist with epileptic seizures• An underlying psychiatric illness or history of psychological distress is not always present

EPILEPSY: Seizure vs syncope

• Syncope should always be considered• Specific precipitant, particularly pain

• Also, anxiety, rising from the supine position, coughing and prolonged standing• Prodromal symptoms

• Nausea, lightheadedness, or tunnel or blurred vision• Onset is generally rapid, pallor and diaphoresis• Brief convulsive motor activity and urinary incontinence can occur

• Return to consciousness is usually rapid, but can be slower in older patients• Postictal confusion is not a feature, unless a significant head injury has

occurred• ECG

EPILEPSY ACUTE TREATMENT

• Prolonged (lasting >5 minutes) or repeated (>2 in an hour) convulsive seizures

• First-line treatment in the community• General protective measures, e.g. ensure the head is protected, release any constricting neck

wear, move away from a dangerous position.• Resuscitation as required: secure the airway and assess respiratory and cardiac function• Use buccal midazolam (5mg in adult) or rectal diazepam (10-20mg in adults)• If intravenous access is established and resuscitation facilities are available, administer

intravenous lorazepam (4mg over 2 minutes in adults)• Depending on response to treatment, the person's situation and any personalised care plan,

call an ambulance, particularly if: • The seizure is continuing 5 minutes after the emergency medication has been

administered.• The person has a history of frequent episodes of serial seizures or has convulsive status

epilepticus.• This is the first episode requiring emergency treatment.• There are concerns or difficulties monitoring the person's airway, breathing, circulation or

other vital signs.

CARBAMAZAPINE IN HAN CHINESE

• Stevens-Johnson syndrome (SJS) and Toxic epidemal necrolysis (TEN)• 5% risk in Asians (<0.06% risk with Europeans)• Up to 30% mortality• Spectrum SJS – overlap SJS/TEN – TEN• Erythematous or purpuric macules or flat atypical targets with <10% (SJS), 10-30%

(overlap SJS/TEN), and >30% (TEN) detachment of body surface area• Gastroinestinal and tracheobronchial epithelial involvement increases mortality

• Association between CBZ-induced SJS/TEN and HLA-B*1502 in Han Chinese• 100% of all 44 cases, 3% of CBZ-tolerant controls, and 8.6% of healthy controls• Odds ratio 2504

• 12 European patients with CBZ-induced SJS/TEN• 4/12 had HLA-B*1502, all of Asian ancestry• Not a universal marker of SJS/TEN but is ethnicity specific

CARBAMAZEPINE IN HAN CHINESE

• HLA-B*1502• Han Chinese 5-15%• Malays 12-15%• Thais 8-27%• Vietnamese >10%• Indonesians 16%• Indians 0-2%• Korean 0.4%• Japanese 0.2% (HLA-A*3101)

• Other AEDs(?)• Phenytoin, Lamotrigine

DRIVING

• After a seizure or TIA/stroke

• Medical aspects of fitness to drive

HEADACHES

• Primary Headaches (the headache is the disease process)• Migraine with or without aura• Tension-type headaches• Chronic daily headaches• Cluster headaches• Primary stabbing headaches• Trigeminal autonomic cephalgias

• Secondary Headaches (the headache is a symptom of an underlying pathlogical process)

• Is there are history of headaches in the past?

HEADACHE: RED FLAGS

• Abrupt onset of headache (thunderclap headache)

• New headache pattern, including new onset or change in existing headache pattern

• Waking from sleep with headache

• Neurologic signs or symptoms, including papilloedema

• Head or neck trauma

• Fever, weight loss, or history of systemic disease, esp HIV or known cancer

• Pregnancy

• Headaches triggered by exertion, sexual activity, cough, or Valsalva

• Postural headaches

• (Check ESR/CRP)

BRAIN TUMOURS

• Annual incidence of 0.01%

• 72% are >50 years

• 70% have headaches

MIGRAINE

• Headache • attacks lasting 4-72 hours (untreated or unsuccessfully treated)• unilateral• pulsating quality• moderate or severe pain intensity• aggravation by or causing avoidance of routine physical activity (eg, walking or climbing

stairs)

• During headache• nausea and/or vomiting• photophobia and phonophobia

• Aura• typical aura consisting of fully reversible visual and/or sensory and/or speech symptoms.

Gradual development (over >5min), duration no longer than one hour, a mix of positive and negative features and complete reversibility characterise the aura which is associated with a headache

CHRONIC/TRANSFORMED MIGRAINE

• 2.5% transform per year from episodic to chronic migraine

• 80% are women

• 80% depressed

• Consider analgesic overuse

• Other Risk factors: high caffeine, stressful life events, anxiety, baseline high attack rate, low educational and SE level, obesity, snoring, sleep apnoea, previously married

MIGRAINE: Prophylactic treatment

• “Analgesic” withdrawal

• Lifestyle changes

• Medications• Adequate dose• Adequate duration

MIGRAINE: Acute treatment

• Analgesics • Avoid Codeine, Tramadol • High dose• As soon as headache develops

• Triptans• As soon as headache develos

TREMOR: ET vs PD

ET• Postural (kinetic) tremor

• Arms, usually bilateral• Voluntary movements, e.g. writing,

pouring, eating• Can involve head/neck, voice

• Less frequently, trunk, legs, tongue, face

• Arms 95%• Head 34%• Trunk and legs 30%• Voice 12%• Face 5%

• Progressive – NOT “benign”• ¾ significant disability and decreased

quality of life• Check TSH, Trial of Propranolol

PD• Rest tremor

• Initially unilateral or asymmetric• Head usually spared but can have

jaw tremor

• May complain of “weakness”

• Other signs• Bradykinesia• Rigidity + cogwheeling• Loss of arm swing• Shuffling gait• Mask-like facies

SUMMARY

• History is important in neurology

• Stroke TIAs• Secondary prevention (an opportunity): “ABC”• If they have on-going symptoms and signs then treat as stroke• TIA Clinics

• Epilepsy• Caution with Carbamazepine

• Headache• “newer” secondary prevention drugs for migraine

• Tremor• Et is much more common than PD, consider a trial of Propranolol