Neurology 1 - Demyelination, Facial Pain And Cerebrovascular Flashcards
Look at m recap
What is a stroke?
What are the 2 types?
What are the stroke common symptoms?
A focal neurological deficit which lasts longer than 24 hours resulting from a vascular lesion.
- Ischaemic
- Haemorrhagic
Face – Asymmetry of the face – Unilateral palsy
Arms – Weakness in the arms
Speech - Slurring of speech - (Dysarthria)
Time – Phone for help
Stroke symptoms?
Sudden numbness or weakness in the face, arm, or leg, especially on one side of the body.
Palsy is paralysis.
Sudden severe headache with no known cause. (Haemorrhagic)
Confusion, trouble speaking, or difficulty understanding speech.
Aphasia is an impairment of language, affecting the production or comprehension of speech and the ability to read or write.
Sudden trouble seeing in one or both eyes. (Visual Field Defects)
Ataxia - Sudden trouble walking (gait disturbance), dizziness, loss of balance, or lack of coordination.
Ischaemic stroke?
How do you treat it?
Area of the brain deprived of blood
Obstruction blocks the flow to part of the brain
Thrombus (Atheroma, Vegetations – IE) Atheroma / atherosclerotic plaques Severe hypoteinsion
80% of all stroke events
Treatment with thrombolysis in acute phase (Alteplase)
Haemorrhagic stroke?
Area of bleeding
Weakened vessel walls rupturing causing bleeding into the brain
Aneurysm
20% of all stroke events
What is a Transient Ischemic Attack ?
A focal neurological deficit which lasts less than 24 hours resulting from a vascular lesion. The deficit fully resolves
Temporary in nature
Requires active preventative treatment and investigation
Risk factors of a stroke?
Diabetes
Cigarettes
Obesity
Oestrogen OCP
Excess EtOH
Polycythaemia (Raised haemaglobin)
Atheroma (hypercholesterol / lipid aemia)
Hereditable nature
Hypertension
Is left side is damaged what side of body paralysed?
Lesions and outcomes of a stroke
What is the treatment and risk reduction of a stroke?
Nil by mouth = no food, drink or mouth medication (until salt therapy - language and speech assessment)
What can be given to prevent a TIA?
Carotid endarterectomy
Tia = warning shot / mini stroke
What is Subarachnoid Haemorrhage ?
Uncommon type of stroke caused by bleeding into the brain. - Arterial
Classic “Thunderclap headache” with neck stiffness
Circle of Willis Berry Aneurysm rupture
Sudden LOC – shortly after event
Menginism
High pressure so fast onset
MRI
Often Neuro surgery clip & Tie bleeder if not stopped spontaneously
What is extradural haematoma?
Young patient
Involved in a head strike (either during sport or a result of a motor vehicle accident) may or may not lose consciousness transiently.
Following the injury they regain a normal level of consciousness (lucid interval).
Usually have an ongoing and often severe headache.
Over the next few hours they gradually lose consciousness.
Arterial Middle meningeal artery damage CT/MRI - convex blood mass
What is subdural haematoma?
“Below the dura”
Slower onset – venous
Collection between the dura and the brain
Blood collection causes ”mass effect”
Typically after fall (anti- coagulants)
What are the different types of brain haemorrhage?
(4)
1) epidural haematoma
2) subdural haematoma
3) subarachnoid haemorrhage
4) inter-cerebral haemorrhage
What is epilepsy?
What are the types of epilepsy?
Does epilepsy always have seizures?
A neurological disorder marked by sudden recurrent episodes of sensory disturbance, loss of consciousness, or convulsions, associated with abnormal electrical activity in the brain.
Various types of epilepsy – General, Focal (simple partial)
Not all have seizures
Temporary bursts of electrical activity in the brain that affects how the brain works.
When does epilepsy start?
How long does epilepsy last?
How is epilepsy managed?
Can start at any age, but usually in childhood or over 60
Can be secondary to other neurological pathologies – tumors / strokes
Life-long condition
Managed with anti-convulsants
What is a tonic clonic seizure? (Grand mal)
Muscle Contractions
Stiff, Jerking muscular movements
Unable to communicate – blank stare / aphasic
Vomiting or loss of bladder/bowels
Cheek and tongue biting
Breathing difficulties
Loss of consciousness
Recovery – Variable but 5 minute duration not unusual
“Feels like I ran a marathon”
What are simple partial seizures?
Simple partial (focal) seizures or “auras” can cause:
A simple partial seizure a general strange feeling that’s hard to describe
A feeling that events have happened before (déjà vu)
A sinking feeling in your abdomen – like when on a fairground ride
Unusual smells or tastes / tingling in your arms and legs stiffness or twitching in part of your body, such as an arm or hand
You remain awake and aware while this happens.
Considered as “warnings” or “auras” as they can be a herald of another type of seizure
What are complex partial seizures?
During a complex partial seizure, you lose your sense of awareness and make random body movements, such as:
Smacking of lips
Rubbing of hands
Making random noises
Moving arms around
Picking at clothes or fiddling with objects
Chewing or swallowing
Patient won’t be able to respond to anyone during seizure and won’t have any memory of it.
What is Absences (Petit-mal) ?
Absence Seizure
An absence seizure, is where you lose awareness of your surroundings for a short time. Mainly affect children, but can happen at any age.
During an absence seizure, a person may:
Stare blankly into space
Look like they’re “daydreaming”
Flutter their eyes
Make slight jerking movements of their body or limbs
The seizures usually only last up to 15 seconds and you won’t be able to remember them.
They can happen several times a day.
Other types of seizures?
Seizure - triggers
What are the triggers for a seizure?
Stress
Fatigue
Lights (Photosensitive 3%)
Alcohol
Missing medication
Coffee
Nicotine
What are the investigations for a seizure?
CT Scan - First Seizure
MRI
EEG – electroencephalogram
Blood tests – to investigate underlying electrolyte cause
low glucose (hypoglycaemia) low sodium (hyponatraemia)
What are the treatments for a seizure?
Treatment aims :- minimize or stop seizures completely
Treatments include:
Anti-epileptic drugs -the main treatment
Surgery to remove a small part of the brain that are causing the seizures (Rarely)
A procedure to put a small electrical device inside the body that can help control seizures – (Vegus nerve or deep brain stimulation)
A special diet (ketogenic diet) that can help control seizures
If triggers are known & can be avoided, treatment may be avoided
Some people need treatment for life but some might be able to stop treatment if your seizures disappear over time.
What are anti epileptic drugs? (AED)
Do they cure epilepsy?
How often do you use them?
Examples?
AEDs are the most commonly used treatment for epilepsy. They help control seizures in about 70% of people.
AEDs work by changing the levels of chemicals in your brain. They don’t cure epilepsy, but can stop seizures happening.
Must be used EVERY day- sudden cessation can provoke a seizure – cessation is slow withdrawal.
• Phenytoin
• Sodium valproate
• Carbamazepine
• Lamotrigine
• Levetiracetam
• Oxcarbazepine
• Ethosuximide
• Topiramate
AED’s have a significant teratogenic profile (cause deformities in foetus in pregnant mum is taking it)
AEDs - dental relevance?
Trauma
Broken restorations
Diet
Oral Hygiene Compliance
Drug Side Effects
Phenytoin induced gingival hyperplasia !!!!!
Multiple sclerosis
What is it ?
Affects more males or females?
Cause?
Common Neurological Condition (1:1000)
Characterised by areas of demyelination in CNS
Higher female prevalence
Geographic variance in prevalence
Unknown cause - ?Viral / Autoimmune mechanism
More common in family members, but no known inheritance pattern
Multiple sclerosis Pathology?
What doesn’t it involve?
Predilection for?
Peri-venular plaques of demyelination
Predilection for:
Optic nerves - (First presentation can be optic neuritis)
Periventricular white matter
Brainstem & cerebellar connections
Cervical spinal cord – corticospinal and dorsal columns
MS Does not involve the peripheral nerves.
N.B – Guillan Barre Syndrome (Locked in) does affect the peripheral nerves and results in peripheral demyelination)
Multiple sclerosis symptoms?
Highly Variable
Any symptom starts rapidly before evolving over a few days – peak intensity
Symptoms then resolves partially / fully after a few weeks
Typically associated with periods of chronic fatigue
Axonal blockade -> slowing / ceasing of neuro-conduction
“Recovery”
Whole / partial regression of perineural oedema & partial re- myelination
Multiple sclerosis investigations?
MRI
Brain & Spinal cord (CNS) 1st line Ix – demyelination plaques – white lesions –
Esp peri-ventricular & Brainstem - Rarely visible on CT
Electrophysiology
Visual evoked Potentials (light flash - record on optic cortex - ? slowed/ decr amplitude)
Auditory evoked Potentials (sound evoked version)
Somatosensory – touch smell etc
Types of multiple sclerosis
Multiple Sclerosis - Optic Neuritis
Facial pain different types
Allodynia
Hyperalgesia
Dysaesthesia
Hypoalgesia
Paraesthesia
Anaesthesia
Neuralgia
Neuropathic
Neuropathy
Facial pain: Allodynia?
Definition
pain from normally non- painful stimulus
Facial pain: Hyperalgesia?
Definition
increased response to normally painful stimulus
Facial pain : Dysaesthesia?
Definition
Unpleasant sensation spontaneous or evoked
Facial pain : Paraesthesia?
Definition
abnormal sensation – spontaneous / evoked – not unpleasant
Facial pain : Hypoalgesia?
Definition
diminished pain response to painful stimulus
Facial pain : Anaesthesia
Definition
no pain from painful stimulus
Facial pain : Neuralgia
Definition
nerve distribution pain
Facial pain : Neuropathic
Definition
nerve pathol / damage pain
Facial pain : Neuropathy
Definition
Nerve function / damage / pathology pain
Common neurological presentations of facial pain?
Dental pain
Trigeminal neuralgia
Trigeminal neuropathic pain
Trigeminal autonomic cephalgia
Post herpetic neuralgia
What could dental pain be in new case?
Acute/ chronic pulpitis
Dentine sensitivity
Perio / Perio-endo
What could dental pain be when undergoing treatment ?
High filling
Pulp exposure
Chemical / thermal irritation (curing lights)
Crack cusp?
Phoenix abscess
Perio-endo
Lateral canals??
What do we use to take a history of facial pain?
SOCRATES
Social history
Additional examinations and investigatioms
How does Trigeminal neuralgia present?
What are the causes and treatment of Trigeminal neuralgia?
Causes -
majority no cause identified
Some - vascular compression of Trigeminal nerve as it leaves skull base
Multiple sclerosis
Treatment -
Carbamazepine
Oxcarbaezpine
Lamotragine
• LA Injections (Temporary)
• Nerve ablation (Gamma knife, Thermo, Chemical)
• Vascular decompression
Glossopharyngeal Neuralgia
What is it?
What does it affect?
What are the triggers?
Paroxysmal pain in ear, base of tongue, tonsillar fossa or angle of jaw
Similar treatment modalities as trigeminal neuralgia.
Affects sensory areas of IX nerve
Triggers chewing, swallowing, talking, yawning and coughing
What is post herpetic neuralgia?
Occurs from shingles (herpes zoster)
In the elderly and immunosuppressed
Pain is steady and sustained
Persists for several months
Paroxysmal shooting pain
Erythema and typical herpetiform rash
Trigeminal Autonomic Cephalgias
TN like History
Localised to V1/2
Recurrent episodic headaches
Males – 20-50y/o
Peri-orbital pain
Fast onset
Often autonomic features
Red eye
Tearing
Trigeminal Neuropathic Pain
Pain caused by insult to the peripheral nerves.
Following removal of the painful stimulus, the pain or altered sensation persists.
Some patients report burning sensations.
Managed with anti-depressant therapy such as nortriptyline
Psychology
Self management
Persistent Idiopathic Facial Pain
Nagging dull throbbing / persecuting pain
Doesn’t conform to anatomical boundaries – typically crosses midline
Typically doesn’t disturb sleep – awake for diff reason then appreciate the pain
Relieved by relaxation / rest
Management techniques include pychology – CBT
Self management – meditation, stress and lifestyle modulation
Antidepressants Nortryptyline, Amitryptiline
Burning Mouth Syndrome
Idiopathic burning sensation on the tongue. Can also include unusual tastes.
Female predisposition
Age > 40
Must exclude low Ferritin, B12, Candida
Often subjective dry mouth
Stress and anxiety can modulate the level of burning
Psychology
Symptomatic relief (Difflam/lidocaine)
Anti-depressants
