Neurology Flashcards
what are degenerative brain diseases
- slowly progressive diseases which stop proper neurological function
what are some examples of degenerative brain disease
- Multiple sclerosis
- Motor neurone disease
- Parkinson’s disease
what is the most common CNS disorder fo the young
- multiple sclerosis
- 80:100,000
how does multiple sclerosis happen
- Demyelination of axons
- Happens because of changes to myelin sheath around the nerve axons connecting different parts of the brain
- Demyelination happens due to inflammatory change which can be seen on MRI scans as red changes
- Typical of multiple sclerosis where the areas of the body affected change from time to time but enivitably the permanent changes which happen in the CNS lead to deficit in neurological knowledge and function
- Affect any part of the body where nerves are involved
what patients have most severe MS
- women with 4th decade onset
what is the aetiology MS
• Cause remains a mystery
• Susceptibility acquired during childhood
• Possible altered host reaction ot an infective agent
• Background genetic/immune factors
• More common in identical twins
• Certain genetic component
• Not clear if it an infective or environmental trigger
• Incidence increases the further from equator you are
- Led to suggestion that sunlight is involved and possibly the lack of vitamin D
• Symptoms can vary a lot from patient to patient
- Some more critical that others
what are the symptoms of MS
- Muscle weakness
- Visual disturbance
- Paraethesia
- Autonomic dysfunction
- Dysarthria
- Pain
- Balance/hearing loss
what are the signs of MS
• Muscle weakenss • Spasticity • Altered reflexes • Tremor – intention • Optic atrophy • Proprioceptive loss - Sudden loss of facial feeling must be considered as MS • Loss of touch
what is spasticity
• Muscle spasticity happens where there is an upper motor neuron lesion meaning damage to nerve is not in the nerve going from the spinal cord to muscle but in the spinal cord itself
what is optic atrophy
- Optic nerve speed of conduction can be affected
- If light shone onto the eye it can take a finite amount of time for that stimulation to reach occipital lobe in the brain
- If patient has had inflammatory MS changes in the optic nerve, this conduction will be slowed and there will be a delay in receiving the signal
- This can be measured and is a common test when assessing MS
what investigations are done for MS
- history and examination
- magnetic resonance and imaging
- CSF analysis
- visual evoked potentials
- MRI useful to show areas of plaque in the brain
what will a patient with MS CSF be like
- reduced lymphocytes
- increased IgG protein
what are the 3 different outcomes of MS
- relapsing and remitting type
- primary progressive type
- symptomatic management
what is the relapsing and remitting type of MS like
- Acute exacerbations and periods of respite
- Damage builds up with each episode
- Many will eventually develop progressive form – secondary progressive
- Patient has episodes where there is active disease and loss of function, then after a few weeks it will settle and patient will enter period of stability
- But the damage from these episodes builds and eventually the patient will become disabled from loss of function due to the collective damage within the CSF
what is the primary progressive type of MS like
- Slow steady progressive deterioration
* Cumulative neurological damage
what is the symptomatic management for MS
- Management at the time of an acute attack has to be symptomatic
- Antibiotics, antispasmodics, analgesia, steroids
- Physiotherapy and occupational therapy
what therapy is done for MS
- physiotherapy and occupational therapy have a role with function loss
what therapy can be done for relapsing and remitting type of MS
- disease modifying therapies
- cladribine, siponomod, ocrelizumab
- drugs don’t help the damage but slow down the rate at which new lesions occur
how does a stem cell tranplstn help MS
- ‘reboot’ the immune system
- Effectively if the problem is an unhelpful inflammatory response to an environmental stimulus, then the immune system recognition of this can be changed by changing immune system
- Not without their own risks however
- Any existing disability will not be reversed from this however
what are the dental aspects of MS
• Limited mobility and psychological disorders
• Difficulty accessing care but also for oral hygiene reasons
• Treat under LA
• Orofacial motor and sensory disturbance
- Suspect in younger patients?
• Chronic orofacial pain possible
• Enhanced trigeminal neuralgia risk
- Suspect in younger patients!
why do we not do GA for MS patients
- if did under GA it has been suggested to cause damage n the brain
what is motor neurone disease (MND)
- degeneration of the motor nerves in the spinal cord
- corticospinal tracts/anterior horns
- bulbar motor nuclei can also be affected - in the brainstem
what age are patients with MND
- 30-60 years
what is the prognosis of MND
- 3 years within diagnosis
who is more likely to get MND
- males
- 2.5:1 female
what happens in MND
- progressive loss of motor function
- limbs
- intercostal
- diaphragm = impair ventilation
- motor cranial nerves = VII-XII
what is death due to in MND
- ventilation failure = leading to hypoxia
- aspiration pneumonia
what will the patient notice in MND
- weakness in ankle or leg
- slurred speech, develop into difficulty swallowing food
- a weak grip
- muscle cramps and twitches
- weight loss
- emotional lability = crying or laughing in appropriate situations
what is the treatment for MND
- none effective
- physiotherapy and occupational therapy
- riluozole = some get 6-9 months life extension
- PEG tube feed to prevent aspiration pneumonia
- reduce salivation
what are the dental aspects of MND
- difficulty in acceptance of dental care = muscle weakness of head and neck
- realistic treatment planning = be sensible, shorter life expectancy so we give treatment to help self-image, not complicated treatment
- drooling and swallowing difficulties = give anticholinergics and botox injections into saliva glands
what is Parkinson’s
- quite common
- disabling
- progressive
- due to a lack of a neurotransmitter dopamine int eh substantia nigra of brain
who is most likely to get Parkisons
- older people
- mostly affects over 50’s
what happens as Parkinson’s progresses
- marker for dopamine is gradually lost
what is the cause of Parkinson’s
- unknown
- repeated head trauma
- degeneration of dopaminergic neurones in the basal ganglia of the brain
- shortage of dopamine results in difficulty of message passaging from ‘thinking’ to ‘doing’ brain = from cortex to cerebellum
what are some clinical signs of Parkinson’s
- bradykinesia = slow movement
- rigidity = increased muscle tone, more stiff
- tremor = slow amplitude, resting tremor (key features of Parkinson’s)
what is the effect of Parkinson’s
- can lead to problems with posture and also communication and cognition
what are clinical observations of Parkinson’s
- impaired gait and falls = walking is unsteady
- impaired use of upper limbs
- mask-like face
- swallowing problems
- dementia, psychosis
what are the treatment options for Parkinson’s
- physical support
- medical
- surgery
what physical support is offered for Parkinson’s
- physiotherapy and occupational therapy
- work to maintain function at as a high level for as long as possible
what medical treatment is given for Parkinson’s
- dopamine = levodopa
- dopamine analogues
what is the problem with levodopa for Parkinson’s
- very effective treatment initially but the dose needs to be continually increased to keep the benefit and therefore the consequences of the side effects eventually becomes intolerable
what are the different types of dopamine analogues for Parkinson’s
- Mimic the effect of dopamine
- Tablets - promipexole, selegiline
- Injection - apomorphine – subcutaneous
- Infusion - duodopa – directly into the gut
what surgery is offered for Parkinson’s
- stereotactic surgery = becoming more common
- stem cell transplant to produce dopamine = not majorly used yet
how is stereotactic surgery done
- Deep brain stimulation
- Using 3-dimensional technique to locate electrode in part of the brain and this deep brain stimulation can help some patients return to a much more normal function so that the medical dose they require is much lower
what are the dental aspects of Parkinson’s
specialist area
- difficulty accepting treatment = tremor (but should go away when open mouth)
- dry mouth from anticholinergic drugs
- drug interactions
what is a stroke?
acute focal neurological deficit resulting from cerebrovascular disease and lasting more than 24 hours or causing earlier death
- death of brain tissue from hypoxia
what can lead to a stroke
- no local cerebral blood flow
- infarction of tissue
- haemorrhage into the brain tissue
what is a TIA
- transient ismchaemic attack
- rapid loss of function but also rapid recovery
- suggests a worse stroke will occur later on