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