Neurology

Vassilis Aggelis

Objectives
A vast subject Common cases seen in Finals Keywords and pattern recognition Crack a few bad jokes

So we will briefly cover

Stroke Subdural haematoma Delirium vs Dementia Parkisons disease Headache Meningitis Multiple sclerosis Epilepsy & status epilepticus

The Neurologists approach

History
Is there a lesion? Where is the lesion? Onset of symptoms? Progression of symptoms?

Examination
Central or peripheral?

Day 1 at ED

Case 1
79 year old man presents to ED escorted by ambulance. He seems to have difficulty making himself understood and is unable to give a clear history

Start of your day

Case 1
O/e Pulse of 120 bpm irregularly irregular pulse, BP 180/98, apyrexial, BM 6.4.
Son calls in: PMH : AF, mild mobility problems, recent fall. This morning he suddenly started not making sense

Differential diagnoses
Stroke
Elderly muddled Suddenly aphasia

?
recent fall

???

Acute confusional state

Subdural haematoma
Advanced dementia A

Elderly muddled

Stroke
Clinical syndrome consisting of rapidly developing clinical signs of focal (at times global) disturbance of cerebral function, lasting more than 24 h or leading to death with no apparent cause other than that of vascular origin. Ischaemic vs haemorrhagic

Clinical features
Focal deficits depending on which part of the brain is affected Initially flacid areflexic weakness followed by spastic tone, brisk reflexes, extensor plantars

Clinical features
Middle cerebral/internal carotid artery (internal capsule)
Hemiparesis (limbs and face) Aphasia Hemianopia Dysarthria
Dysphasia -Expressive ( Brocas area frontal lobe) -Receptive ( Wernickes are in temporo-parietal)

Posterior inferior cerebellar artery

Coma, altered consciousness Vertigo Dysphagia, choking Ataxia Contralateral loss of pain on face

Bamford Stroke classification

PAC LAC TAC POC

Investigations
Neurological assessment Imaging (CT HEAD/MRI/FLAIR) Baseline investigations :bloods (incl FBC, glucose, lipids, ESR), CXR, ECG Carotid Doppler scan

Treatment
Acute ischaemic BEWARE: Thrombolysis (if given within the first 4.5hrs) STROKE/TIA DO NOT CAUSE LOSS Antiplatelet treatment OF CONSCIOUSNESS UNLESS Admission to acute stroke unit VERTEBROBASILAR Physiotherapy INVOLVEMENT IS PRESENT
Warfarin 2-3 weeks later Neurosurgical decompression

Haemorrhagic

Subdural haematoma
Blood in subdural space following a rupture of a vein after head injury Most common in elderly, alcohol abuse,anticoagulant use, shaken baby syndrome, trauma Delayed Headache,drowsiness, confusion, focal deficits Tx: conservative or surgical drainage

Acute confusional state vs Dementia

Delirium
Impairment of consciousness associayed with abdnormalities of perception and mood
-Acute -Fluncuant -Worse at night -Visual hallucinations -More common in elderly

Dementia
Progressive decline of cognitive function in the absence of clouded consciousness -Progressive -Stable -Different types have different presentations

Causes of delirium
Infection (UTI, LRTI) Metabolic disturbances (electrolytes, renal, renal failure, hypoxia) Endocrine abnormalities (Hypoglycaemia) Intracranial (SAH, tumour) Drug intoxication (anticonvulsants, opiates) Drug/alcohol withdrawal Postoperative state Vitamin deficiency ( Thiamine, Vitamin B12, Nicotinic acid)

Dementia
Alzheimers disease (neurofibrillary tangles, senile plaques) Vascular dementia ( Hx of CVA/TIA) Lewy body dementia (visual hallucinations, delusions) Frontotemporal (change of behaviour, aggresion)
Huntingtons disease Parkinsons disease Normal pressure hydrocephalus

Case 2

Parkinsons disease
A combination of:
Tremor Rigidity Akinesia (or bradykinesia) Postural instability

Parkinsons disease
1 in 2 over 70 yrs old Aetiology: idiopathic Caused by cell degeneration in the substantia nigra with subsequent loss of dopamine

Parkisons disease
Clinical features:
4-7Hz (pill-rolling tremor) Cogwheel rigidity Micrographia Mask-like facies Reduced blinking Stooping, shuffling gait Poor arm swing Falls Monotonous speech

Parkinsons disease
Treatment
Levodopa plus dopa decarboxylase Dopaminergic agonists (e.g. bromocriptine) Monoamine oxidase B inhibitors (e.g. selegiline) - Invasive methods ( Neurosurgery, deep brain stimulations)

Parkinson Plus Syndromes

Multiple system atrophy Progressive supranuclear palsy Parkinsonism-dementia-amyotrophic lateral sclerosis complex Corticobasal ganglionic degeneration Diffuse Lewy body disease And dont forget drug induced parkisonisms ( atypical neuroleptics, methyldopa, prochlorperazine, metoclopramide)

Case 3
The 33 year old son of case 1 comes back to ED complaining of having the worst headache of his life. The pain is widespread and came over after todays stressful events with his father

Essential questions
ie Red flags:
New onset in over 50yrs old Sudden onset Associated neurological deficits Associated photophobia, rash and fever Worse in the morning Vision problems

Most common headaches

Tension headache (throbbing, tight band sensation, pressure behind eyes, stress related, analgesic overuse) Migraine (episodic unilateral headaches associated visual and GI disturbance- aura) Cluster headache (males, excruciating pain, conjuctival injection, lacrimation) Temporal arteritis ( elderly, jaw claudications, raised ESR, scalp tenderness)

Most common headaches

Tension headache (relaxation, simple analgesia) Migraine (avoid precipitating factors, paracetamol, antiemetics, triptans,ergotamine) Cluster headache (oxygen during attack,triptans Temporal arteritis (steroids) Medication overuse headache (stop them!)

So what if it was described as

Subarachnoid Haemorrhage
Spontaneous arterial bleeding into subarachnoid space Causes: Idiopathic, berry anurysms, AVM Sudden onset associated with vomiting, LOC, neck stiffness, Positive Kernigs sign Ix: CT scan, LP (xanthochromia) Tx: dexamethasone, nimodipine, bed rest with view of aneurysm clipping or coil insertion

Case 3
You decide to let him go home with simple analgesia and advice for relaxation and some time off work The same evening he returns complaining of neck stiffness and aversion to lights

Meningitis
Causes: Bacteria/Viruses/ Fungi/ chronic inflammatory conditions/Malignancy Clinical features: Headache, neck stiffness, fever, vommiting, photophobia, petechial purpuric rash, drowsiness, focal neurological deficit Ix CT brain, LP, Bld cultures, Bld glucose, CXR Immediate antibiotic treatment + steroids Aciclovir for ?viral meningitis Contact treatment

Quick Cases

Epilepsy
Tendency to suffer recurrent seizures Seizure: convulsion or transient event resulting from paroxysmal discharge of cerebral neurones 2% of the populations has two or more seizures

Classification of epileptic seizures

Partial seizures Simple (no loss of consciousness) Complex partial seizures: With impairment of consciousness at onset Partial seizures evolving to generalised tonic-clonic convulsions Primary generalised seizures (Convulsive or non-convulsive with bilateral discharges involving sub-cortical structures) Absence Myoclonic Clonic Tonic Tonic-clonic Atonic

Unclassified seizures (These usually occur when an adequate description is not available)

Treatment and side effects

Sodium Valproate Carbamazepine Phenytoin Ethosuximide Lamotrigine Vigabatrin Clobazam

Ataxia Nystagmus Dysarthria Gum hypertrophy Hypertrichosis Osteomalacia Folate deficiency

Status Epilepticus
More than 30 minutes of continuous seizure activity or two or more sequential seizures without full recovery of consciousness between seizures. Medical emergency ABCDE -> Lorazepam->Phenytoin infusion -> ITU input

Multiple Sclerosis
Multiple plaques of demyelination in the brain and spinal cord disseminated in time and space. Most common sites: Optic nerve, periventricular region, brainstem and cerebellar connections, cervical spinal, posterior columns Clinical features: relapsing/remiting, chronic progressive Ix: MRI brain spinal cord, CSF (oligoclonal bands, visual evoked responses) Tx: corticosteroids, beta-interferon, cannabinoids, new oral agents, OT, speech therapy

Extradural Haematoma
Lucid interval
Severe headache Vomiting Confusion fits CT LP contraindicated!

And a few key phrases

Ptosis, fatigue, slowness of speech as day goes by Inverted champagne bottle legs,pes cavus Ascending weakness 1-3/52 post infection
MYASTHENIA GRAVIS Charcot Marie tooth Guillain-Barre syndrome

A few more
Nystagmus, ataxia, opthalmoplegia, confusion Blistering rash affecting eye or ear canal Caf au lait spots, axillary freckling, lisch nodules
WernickeKorsakoff syndrome Herpes Zorster (Ramsay Hunt) Neurofibromatosi s

This presentation could go for another hour

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