Neurology Revision Dr Jordi M Morell - PowerPoint Presentation

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Neurology Revision

Dr Jordi M MorellManchester Royal Infirmary16th December 2016Slide2

Neurology Revision

The BasicsExamination tipsCommon ConditionsQuestion TimeSlide3

Neurology Basics

Where is the lesion?Central vs. PeripheralWhich lobe?Spinal cord tractsDetermine the levelUpper or lower motor neurone (or both)Slide4

Examination Tips

PracticePractice some moreSystematic approachLook like this isn’t your first timeSay what you seeDon’t forget to assess/ask about functionSlide5

Headache

ChronicTension headacheMigraineCluster headacheRaised intracranial pressureAcuteMeningitisSubarachnoid haemorrhageSlide6

Intracerebral haemorrhage 1

Subarachnoid HaemorrhageSpontaneous rather than traumatic usually10% of cerebrovascular diseasemean age 50yrs

70% - saccular berry aneurysm usually involving circle of Willis

 SymptomsAneurysm - usually asymptomatic until rupture, 3rd nerve palsy

Rupture - Severe headache, Nausea and Vomiting, sometimes loss of consciousness.Meningeal irritation - neck stiffness, +ve Kernigs sign

Focal neurological signsSubhyloid haemorrhages

Papilloedema

Investigations

CT

- 90% within 24hrs

Lumbar puncture

- xanthochromia

Surgical Intervention

Management

Bed rest, supportive (lower BP)

Nimodipine (Ca channel blocker)

Surgery - Burr hole - Craniotomy and clipping of aneurysm

Prognosis

- 50% die suddenly soon after haemorrhageSlide7

Intracerebral

haemorrhage 2Subdural HaematomaBlood accumulating in subdural space after rupture of vein running from hemisphere to sagittal sinusDue to head injury (often minor)Latent interval (weeks, months)

Susceptible - alcoholics, elderly 

Symptoms - headache, drowsiness, confusion (fluctuate)

 CT diagnosis

Treatment

- surgical removal

Extradural Haemorrhage

Damage to temporal bone - rupture of middle meningeal artery

Clinical picture

- Head injury

- loss of consciousness, followed by recovery, then sudden deterioration with focal neurological signs and reduced consciousness

Treatment

- surgical drainageSlide8

Weakness

Stroke

Peripheral neuropathy

Cord syndrome

Multifocal CNS lesion (MS)Slide9

Stroke

Sudden, focal neurological deficit > 24hrsVascular in origin (infarct or haemorrhage)(TIA - <24hrs to complete recovery)

85% Cerebral Infarct

thrombosis

Emboli (from carotid vertebral artery, heart in AF etc.) rarely severe hypotension

15% Cerebral Haemorrhage

rupture of intracranial

microaneurysm

Hypertensive

Risk factors

Hypertension,

Hyperlipidaemia,

Smoking,

Diabetes Mellitus

Atrial Fibrillation

Investigations

- differentiate between haemorrhage and infarct (CT or MRI)

FBC

- polycythaemia

ESR

-

polyarteritis

(syphilis serology)

Glucose

- DM

Cholesterol

- Hyperlipidaemia

ECG

Carotid Doppler

Angiography

Immediate Management

Consideration of

hyperacute

treatment

Admit to Acute Stroke Unit

Secondary Prevention

Aspirin

Anticoagulation (if AF)

Treat carotid artery stenosis

Control hypertension

Modify risk factors

RehabilitationMDT (Physio, OT, Social services, GP etc.) PrognosisDepends on severityTACS – 90% dead or dependent at 1 yearSlide10

Multiple Sclerosis

Demyelination with the brain and spinal cordNo single group of signs or symptoms is entirely diagnostic of MSTwo principal patterns: relapsing and remitting MS with lesions occurring in different parts of the CNS at different times chronic progressive MS (some 30% of cases)

Optic Neuropathy

Brainstem demyelinationSpinal cord lesion

Investigations

Imaging (MRI)CSF examinationElectrophysiology (VER)

Management

Steroids

Immunosuppression

Beta-Interferon

Disease modifying drugs

PhysiotherapySlide11

Acquired condition

Characterized by weakness and fatiguability of proximal limb, ocular and bulbar muscles.  CLINICAL FEATURES

Fatiguability

The proximal limb muscles, the

extraocular muscles, and the muscles of mastication, speech and facial expression

commonly affected in the early stages. Respiratory difficulties may occur.

Complex

extraocular

palsies, ptosis and a typical fluctuating proximal weakness

The reflexes are initially preserved but may be

fatiguable

.

Muscle wasting - late sign

INVESTIGATIONS

Tensilon

(

edrophonium

) test

Serum acetylcholine receptor

Nerve stimulation

COURSE AND MANAGEMENT

Severity fluctuates but most cases have a protracted course.

Important to recognize respiratory impairment, dysphagia and nasal regurgitation;

Emergency assisted ventilation may be required in

myasthenic

crises.

Exacerbations are usually unpredictable and unprovoked but may be brought on by infections, by aminoglycosides or other drugs.

Enemas (magnesium sulphate) may provoke severe weakness.

TREATMENT

Oral

anticholinesterases

Pyridostigmine

(60 mg tablet) (most widely used drug).

Thymectomy

Immunosuppressant drugs

Plasmapheresis

and immunoglobulin

Myasthenia GravisSlide12

Motor Neurone Disease

Progressive degeneration of upper and lower motor neuronesThree patterns…Progressive muscular atropthyAmyotrophic lateral sclerosisProgressive bulbar palsySame condition

Diagnosis

No diagnostic testEMG/NCSManagement

RiluzoleSupportive treatmentPalliative careSlide13

Faints, fits and funny turns

Syncope

Cardiogenic

Vasogenic

EpilepsyNon-epileptic attack disorderSlide14

Epilepsy 1

CLASSIFICATION A. Idiopathic Generalised Epilepsies 

1. Tonic-

clonic (Grand mal) fitsTonic phase

Clonic phase

Post-ictal 

2. Absence Attacks (Petit Mal)

3. Myoclonic Epilepsy

B. Localisation-Related Epilepsy

1. Focal Motor Attacks

2. Focal Sensory Attacks

3. Temporal Lobe Epilepsy

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Epilepsy 2

CausesIdiopathicMetabolic (Hypoxia, Hyperglycaemia, Hypoglycaemia, Uraemia, Alcoholism, Hyponatraemia

, Hypernatraemia, Liver failure, Pyridoxine deficiency)

Drugs and toxins

Trauma and surgery

Space occupying lesionsCerebral infarction

Organic (SLE, PAN, Sarcoidosis, Vascular malformations)

Infections (Encephalitis, Syphilis, HIV)

Degenerative brain disorders (Alzheimer's disease,

Creutzfeld

-Jacob disease)

EPILEPSY INVESTIGATIONS

Single seizure not pursued unless:

- Incomplete recovery

- Two or more seizures within 1 year

History

,

Examination

Blood tests

(FBC, U+E's, Serum Calcium, LFT's, and Glucose)

CXR

,

ECG

EEG

- 10-15% of population may have an 'abnormal' EEG

- ~15% of epileptics never have specific

epileptiform

discharges

CT/MRI

- frequency of abnormalities in epilepsy vary. Indicated in late-onset epilepsy with focal seizures (tumour)

TREATMENT

Aim - to prevent seizures and avoid side effects

80% on one drug, remainder requires a second drug.

Differential Diagnosis

Syncope

Drop Attacks

Hypoglycaemia

Narcolepsy

Cataplexy

Micturition, Defecation and Cough Syncope

Carotid sinus syncope

Postural Hypotension

TIA's esp. Posterior cerebral circulation

Cardiac arrhythmias

Psychogenic (Hysterical fits)

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Movement Disorders

Parkinson’s DiseaseThe Shaking Palsy

Tremor, rigidity and

akinesiaCommonly asymmetrical

Response to Levodopa

Side effects of treatment‘Wearing off’

Psychiatric aspects

Drug Induced/Vascular Parkinsonism

Essential Tremor

Chorea

Hemiballismus

Myoclonus

Tic disorder

Torsion

dystoniasSlide17

Case

135yr old man presents with sudden onset of headachePain is on the left side just above his ear He woke up this morning with the pain this morning. Worse on coughing, sneezing and stooping down. He has experienced some blurred and double vision today.

He is currently feeling quite nauseous but has not vomited.

He has a temperature since yesterday evening when he began to feel unwell.

 His wife reports that he had a fit in bed this morning and again before coming into hospital. He has no memory of these events. He is worried it may be epilepsy.

 Past Medical History

Ear infection on return from holiday in Greece

Nil else

Medication

3 days worth of Amoxycillin for infection.

Nothing currently

No family history, non-smoker, unemployed

On Examination

Pyrexial

Pain localising to Left side above ear

Papilloedema and diplopia

Signs of ear infectionSlide18

Case 2

22yr old women presents with weakness in Left arm She noticed this when she dropped a cup of tea. This has never happened before. She has no related symptoms 

When questioned she says she experienced blurred vision in both eyes a few weeks ago. This lasted a few minutes and was related to exercise/

 On flexing her neck she experiences parasthesiae in legs and an 'electric shock' sensation down her back

 PMH

None 

Medication

None

Family History

Mother has Multiple Sclerosis

Investigations

CSF - Pleocytosis, raised protein, IgGSlide19

Case 3

80 yr old man presents with weakness in left arm and problems with speech.He woke up yesterday morning with weakness and has so far noticed no improvement.He is right handed 

PMH

TIA'sHigh BP

Type II Diabetic for 20yrs, well controlledMI - 10yrs ago

 SHSmoker

Non-drinker

Family History

Ischaemic heart disease

On Examination

Aphasia

Right sided hemianopia

Left arm - reduced power, tone and reflexes

No change in sensation

Left leg unaffected

Other limbs - Normal power, tone and reflexes

GI, Lungs and Heart - all normalSlide20

Case 4

40yr old male. Attending GP at request of his wife - he doesn't think anything is wrong. Collateral History from wifeHe has 'funny turns' when he doesn't respond to her and appears to walk round in a dreamy state but continues with normal activities.

On careful questioning the man admits to experiencing some strange things, there is often a smell, like sewerage, just before his wife notices these episodes. He also experiences Déjà vu frequently.

His wife reports that he sometimes responds to voices which she cannot hear when he is having one of these 'funny turns'. 

No PMH 

No Family HistorySlide21
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Merry Christmas!