Neurology Part 2 Phase 2 Kaveesha Rajapaksa Ryad
- Slides: 55
Neurology – Part 2 Phase 2 Kaveesha Rajapaksa Ryad Chebbout The Peer Teaching Society is not liable for false or misleading information…
Aims Pathology, Aetiology, Clinical Symptoms and Signs, Investigations and Management of: • Epilepsy • Multiple Sclerosis • Guillain-Barre Syndrome • Motor Neuron Disease • Parkinson's Disease • Dementia The Peer Teaching Society is not liable for false or misleading information…
Epilepsy Definition Recurrent tendency to have spontaneous, intermittent and abnormal electrical activity in a part of the brain or generalised across the brain. Leading to seizures. The Peer Teaching Society is not liable for false or misleading information…
Epilepsy Aetiology 1. Idopathic (2/3 rds) 2. Structural (Trauma, SOL, Developmental, Stroke) 3. Metabolic (hypoglycaemia, hypocalcemia, hyponatraemia) The Peer Teaching Society is not liable for false or misleading information…
Epilepsy Partial = focal onset (localising features!) Generalised = no localising features! Simple = aware Complex = impaired awareness The Peer Teaching Society is not liable for false or misleading information…
Epilepsy Partial Seizures Commonly caused by structural pathology. Simple Partial (Jacksonian March) Complex Partial = classically temporal lobe! Partial + Secondary Generalisation The Peer Teaching Society is not liable for false or misleading information…
Epilepsy Generalised Seizures Commonly idiopathic. Absence = </ 10 sec, childhood Tonic-Clonic = complex, stiff->jerk, post-ictal confusion + drowsiness Myoclonic = sudden limb/face/trunk jerk Atonic = loss of tone->fall, no LOC The Peer Teaching Society is not liable for false or misleading information…
Epilepsy Prodrome – Aura – Ictal – Post-Ictal Prodrome Mood/Behaviour Change The Peer Teaching Society is not liable for false or misleading information…
Epilepsy Aura Strange Smell, Flashing Lights, Déjà vu/Jamais vu Post-Ictal Headache, Confusion, Myalgia, Sore Tongue, Todds Palsy (hemiplegia), Dysphasia The Peer Teaching Society is not liable for false or misleading information…
Epilepsy Ictal – Localising Features Temporal Lobe: Automatisms (lip smacking/fiddling), Visceral Aura (abdominal rising sensation), Dysphasia, Déjà vu/Jamais Vu, Hallucinations Frontal Lobe: Jacksonian March (tingling/muscle contractions from fingers to ipsilateral face), Todds Palsy The Peer Teaching Society is not liable for false or misleading information…
Epilepsy Parietal Lobe: Tingling Numbness Occipital: Visual Phenomena (spots/lines/flashes) The Peer Teaching Society is not liable for false or misleading information…
Epilepsy Investigations EEG (classification) MRI (structural lesions) MEG/PET/SPECT ictal (localise epileptogenic focus for surgery) The Peer Teaching Society is not liable for false or misleading information…
Epilepsy Management Partial = Carbamazepine Generalised = Sodium Valproate OR Lamotrigine Neurosurgical Resection The Peer Teaching Society is not liable for false or misleading information…
Epilepsy Management Counselling – employment, insurance, driving (1 yr seizure free) Contraception and pregnancy Epilepsy Nurse Specialist The Peer Teaching Society is not liable for false or misleading information…
Epilepsy Complications Sudden Unexpected Death in Epilepsy (SUDEP) Status Epilepticus The Peer Teaching Society is not liable for false or misleading information…
Multiple Sclerosis Discrete Plaques of Demyelination in Central Nervous System T-cell Mediated The Peer Teaching Society is not liable for false or misleading information…
Multiple Sclerosis Risk Factors = Women, Temperate Areas ~30 yrs The Peer Teaching Society is not liable for false or misleading information…
Multiple Sclerosis Demyelination Plaque (commonly periventricular, cervical spine, brain stem) Heals Incompletely Prolonged Demyelination Axonal Loss Clinically Progressive Symptoms The Peer Teaching Society is not liable for false or misleading information…
Multiple Sclerosis Clinical Courses • Benign • Relapsing Remitting • Secondary Progressive • Primary Progressive The Peer Teaching Society is not liable for false or misleading information…
Multiple Sclerosis The Peer Teaching Society is not liable for false or misleading information…
Multiple Sclerosis Symptoms Monosymptomatic! Disseminated in Time and Space The Peer Teaching Society is not liable for false or misleading information…
Multiple Sclerosis Optic Neuritis: Decreased Visual Acuity, Pain on Eye Movement, Dyschromatopsia Sensory: Lhermittes Sign, Limb Numbness/Tingling Motor: Transverse Myelitis, UMN Weakness, Uhthoff’s Phenomenon The Peer Teaching Society is not liable for false or misleading information…
Multiple Sclerosis Other: Ataxia, Erectile Dysfunction, Urinary retention The Peer Teaching Society is not liable for false or misleading information…
Multiple Sclerosis Investigation Dissemination in Time and Space! Clinically (attacks + clinical lesions, 2: 2, 2: 1, 1: 1) +/- Aid of MRI CSF (Oligoclonal Bands) Evoked Potentials The Peer Teaching Society is not liable for false or misleading information…
Multiple Sclerosis Management Acute: Methylprednisolone IV Chronic: Interferon/Glatiramer, Natalizumab The Peer Teaching Society is not liable for false or misleading information…
Guillain-Barre Syndrome Acute AUI Inflammatory Demyelinating Polyneuropathy Triggers: Campylobacter jejuni, CMV, Mycoplasma The Peer Teaching Society is not liable for false or misleading information…
Guillain-Barre Syndrome Symptoms 4 wk peak! • Weakness – Leg, Trunk, Respiratory. Proximal, Distal. Symmetrical. • Back/Limb Pain • Autonomic Features: seating, tachycardia, arrhythmia’s. The Peer Teaching Society is not liable for false or misleading information…
Guillain-Barre Syndrome Signs Areflexia! The Peer Teaching Society is not liable for false or misleading information…
Guillain-Barre Syndrome Investigations Nerve Conduction Studies – slow conduction Regular FVC The Peer Teaching Society is not liable for false or misleading information…
Guillain-Barre Syndrome Management IV Immunoglobin or Plasma Exchange The Peer Teaching Society is not liable for false or misleading information…
Motor Neuron Disease Selective loss of motor neurons in: Motor Cortex (UMN), Cranial Nerve Nuclei (UMN/LMN) and Anterior Horn Cells (LMN). >40 yrs. </10% Familial. ~20% SOD 1 mutation. The Peer Teaching Society is not liable for false or misleading information…
Motor Neuron Disease Key Features UMN + LMN Signs No Sensory Loss/Sphincter Disturbance No Eye Involvement The Peer Teaching Society is not liable for false or misleading information…
Motor Neuron Disease Clinical Patterns Amyotrophic Lateral Sclerosis Progressive Bulbar Signs – CN IX-XII, bulbar/pseudobulbar palsy Progressive Muscular Atrophy – no UMN signs Primary Lateral Sclerosis – mainly UMN The Peer Teaching Society is not liable for false or misleading information…
Motor Neuron Disease Associations Fronto-Temporal Dementia (10 -35%)! The Peer Teaching Society is not liable for false or misleading information…
Motor Neuron Disease Signs Stumbling Spastic Gait Foot Drop +/- Proximal Myopathy Weak Grip Spasticity/Hypereflexia/Upwards Plantars + Wasting/Fasciculations The Peer Teaching Society is not liable for false or misleading information…
Motor Neuron Disease Investigations MRI/LP/Neurophysiology – exclude other causes Management Riluzole – prolong life by ~ 3 months Symptomatic + MDT (Ventilation, PEG) The Peer Teaching Society is not liable for false or misleading information…
Parkinson's Disease Decreased Dopaminergic Neurons in Substantia Nigra (Pars Compacta) Decreased Striatum Dopamine Levels Decreased Basal Ganglia – Cortex Communication Decreased Movement The Peer Teaching Society is not liable for false or misleading information…
Parkinson's Disease ~65 yrs. Associated with Lewy Bodies The Peer Teaching Society is not liable for false or misleading information…
Parkinson's Disease Classic Triad Tremor – resting, pill-rolling Rigidity – increased tone, cogwheel rigidity, leadpipe rigidity Bradykinesia – slowness of movement initiation -Expressionless Face, Monotonous Hypophonic Speech, Micrographia -Gait: Festinant, Reduced Arm Swing The Peer Teaching Society is not liable for false or misleading information…
Parkinson's Disease Other Symptoms Anosmia Depression Sleep disturbances Visual Hallucinations (animals, children) Dementia (late stage) The Peer Teaching Society is not liable for false or misleading information…
Parkinson's Disease Management L-Dopa + Dopa-Decarboxylase Inhibitor (e. g. Madopar) -Efficacy reduces with time = Increased Dose -Dyskinesia’s, Off Freezing, End-of-Dose Reduced Relapse The Peer Teaching Society is not liable for false or misleading information…
Parkinson's Disease Management Dopamine Agonist – Ropinirole/Pramipexole Apomorphine – potent DA agonist, acute Anticholinergics – tremor Deep brain stimulation The Peer Teaching Society is not liable for false or misleading information…
Dementia Syndrome of progressive deficits in 2 or more higher cognitive domains. (Memory, language, apraxia, agnosia, visuospatial function, personality) Interferes with social functioning. Occurs in clear consciousness. >80 yrs=20%, >100 yrs=70% The Peer Teaching Society is not liable for false or misleading information…
Dementia Types Alzheimer's Disease Vascular Dementia Lewry Body Dementia Fronto-Temperal Dementia The Peer Teaching Society is not liable for false or misleading information…
Alzheimer's Dementia Increased Beta-Amyloid Peptide = Progressive Neuronal Damage (hippocampus, amygdala, temporal neocortex) - Neurofibillary Tangles - Amyloid Plaques - Decreased Ach The Peer Teaching Society is not liable for false or misleading information…
Alzheimer's Dementia Risk Factors Family History, Downs Syndrome, Homzygosity for Apo. E e 4 Allele, DM/HTN/AF Protective Factors Smoking, Oestrogen The Peer Teaching Society is not liable for false or misleading information…
Alzheimer's Dementia Symptoms Progressive Global Cognitive Impairment Aphasia Anosognosia (lack of insight) Irritability Mood Disturbance – Depression, Euphoria Behavioural Change – Wandering, Aggression The Peer Teaching Society is not liable for false or misleading information…
Alzheimer's Dementia Investigations MMSE or Addenbrooks Cognitive Exam CT – temporal/parietal atrophy, ventricular enlargement MRI – hippocampus/amygdala/medial temporal lobe grey matter atrophy CSF – phosphorylated tau protein The Peer Teaching Society is not liable for false or misleading information…
Alzheimer's Dementia Management Acetylcholinesterase Inhibitors (Donepezil, Rivastigmine, Galantamine) – help lay down new memories Memantine (Antiglutamatergic) BP Control The Peer Teaching Society is not liable for false or misleading information…
Vascular Dementia Cumulative effect of many small strokes. Vascular RF’s – Stroke Hx, HTN Sudden Onset + Stepwise Deterioration -Emotional/Personality Changes -Cognitive Defecits -Depression/Labile Mood The Peer Teaching Society is not liable for false or misleading information…
Lewy Body Dementia Fluctuating Cognitive Impairment Visual Hallucinations (animals/children) +/Parkinsonism Repeated Falls/Syncope CT/MRI – relative sparing of medial temporal lobe Histology – Lewy Bodies in Brainstem/Neocortex The Peer Teaching Society is not liable for false or misleading information…
Fronto-Temporal Dementia Frontal + Temporal Atrophy. AD Histology. Early, 45 -65 yrs Behavioural/Personality Change Disinhibition Change in Diet (sweets, overeating) Emotional Blunting Pick bodies on histology The Peer Teaching Society is not liable for false or misleading information…
Dementia Management Care Coordinator Capacity Develop Routines, Plan Ahead Challenging Behaviour – Lorazepam, Risperidone (not Lewy Body!) Depression - Citalopram The Peer Teaching Society is not liable for false or misleading information…
A 65 year old man with walking difficulties presented to his general practitioner. He complained of worsening tremor in the right arm with stiffness, which he said on occasion spread to his right leg. He said that the tremor was much worse when he was stressed, or in public. Examination revealed a man with a resting tremor, marked cogwheeling rigidity of the right side and an inability to perform repetitive tasks with the right arm. His gait was not normal and he had a reduced arm swing on the right.
A 36 year old male patient presents with increasing unsteadiness which started two days ago. Two years ago he had blurred vision in his left eye which improved considerably within a few weeks, but left him with some minor deficit. Eight years ago he had a 3 week episode of numbness in his left arm.
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