Neurology symposium Flashcards
Epilepsy vs NEAD
Stand back and observe: -Shaking? Amplitude, frequency, evolution -Eyes? -incontinence? -O2 Zats an other other obs -Unpleasant bites? -Resonsiveness? -Estimated duration? -Speed of recovery? (spells seizures)
Less reliable signs for epilepsy vs NEAD
Injuries
Pelvic thrusting
Incontinence
Twiching
TLOC signs
Episodes of daydreaming since teens
Always clumsy and dropping things in mornings
Worse when tired??**
TLOC differential
Epilepsy
Syncope
NEAD
Epilepsy signs
Perinatal trauma
Febrile convulsions
Family history
CNS infections
Syncope signs
Preceding symptoms
Postural
Negative signs
CV rheumatoid factors
NEAD signs
Psychosocial substrate
Contextual
Awareness
Fluctuant
Emergency management of generalised tonic-clonic seizures
Most self-limiting
If prolonged, iv lorazepam 2-4mg, repeat if necessary
If not settling, iv phenytoin 1g over 20mins with cardiac monitor
If still fitting, need anaesthetic help
(In dentist’s chair): 999, document what you see
Epilepsy syndrome classification
Idiopathic generalised epilepsy JME -photosensitivity -sleep deprivation -alcohol Localisation-related epilepsy -aura -focal neurology -age -PMH
Is a brain MRI likely to show a brain tumour?
False
**
Does a pt require treatment after a single tonic-clonic fit?
Yes if:
- previous myoclonic seizures or absences
- congenital neurological deficit
- unequivocal epileptiform changes on EEG
- risk of recurrence unacceptable to pt
Tonic/ clonic/ tonic-clonic seizures
Tonic seizures involve sudden stiffening & contraction of muscles
Clonic seizures involve rhythmic twitching or jerking of one or several muscles
Tonic-clonic seizures are a combination of these two types in a specific pattern
-type of generalized seizure
What is the best anticonvulsant
Valproate in a young man with JME or IGE Lamotrigine in women with IGE Levetiracetam??? Localisation related epilepsy: -lamotrigine -carbamezapine -levetirecetam
Electroencephalograms
Only 30% sensitive
Epileptiform activities seen in 0.5% healthy adults and much higher in learning disabled
–>do an ECG
What to do if someone fits in your chair
Watch carefully, document what you saw Protect from injury, O2, recovery position If not self limiting, lorazepam Refer to first fit clinic ECG, listen to heart Driving advice Treatment: consider syndrome and sex
Trigeminal neuralgia symptoms
Localised to one side of face Sudden onset Electric/ sharp character Radiates around face/ mouth No associations Paroxysmal (suddenly intensely recurs) Exacerbated by touch, cold, wind, E&D??? Excruciating
Likeliest cause of trigeminal neuralgia
Cerebellopontine angle tumour Demyelination -this is her reason but why? Nasopharyngeal carcinoma Vascular loop Viral infection Pontine tumour
Vascular loops?
??
MRI brain
Diagnosis of MS
Clinical evidence of 2 attacks Previous episodes, objective lesions MRI can now be used to demonstrate dissemination in time and space after 1 attack (CSF) (VEP - visual evoked potential)
Treatment of MS
2 relapses in 2 years Interferons and glatiramer Natalizumab Fingolimod (Fumarate, alemtuzumab)
Treatment of trigeminal neuralgia
Carbamazepine- Start low, uptitrate
SE’s: Dizziness, diplopia, rash, deranged LFT’s
Oxcarbazepine- Lower SE profile
Phenytoin- Particularly effective as push
LMTG/Gabapentin
Microvascular Decompression
Stereotactic Radiosurgery, Nerve Blocks etc.
Need to eat and drink!
Symptoms of stroke
Face
Arm
Speech
Time
Priority if someone has a stroke
Transfer to hospital as soon as possible
***
Appropriate next step if stroke pt does not get better after arrival to hospital
- FBC, ESR, U/Es, LFTs, glucose and clotting are normal
- cholesterol is 3.4mmol/L
- brain CT performed an hour after onset
Consider for thrombolysis
After considering for thrombolysis, what are the next important questions?
Age/persistent/CT
Is he taking warfarin?
End stage illness/surgery/gi bleed/ trauma 3/52?
Retinopathy/pericarditis/pancreatitis/childbirth/CPR/recent stroke?
Blood pressure >185/100?
Are bloods normal (Plats, LFTs)?
Parkinson’s diagnosis
Clinical Idiopathic Triad of features- Tremor, Rigidity, Bradykinesia Other symptoms Parkinson’s plus
Management of Parkinson’s Disease
L-dopa (dyskinesias, wearing off) Dopamine agonists (neuropsychiatric side effects) Amantadine MAO-B inhibitors (Selegiline) COMT inhibitor (Entacapone) Apomorphine pump, Duodopa Surgery
Long-term complications of Parkinson’s
Wearing off Dyskinesias Off and on freezing Falls Constipation Neuropsychiatric
Motor neuron disease
Slurred speech and swallowing problems
Slow tongue movements
Jaw jerk is brisk
Parksinson’s pt freezes and can’t get out of chair.
- pt takes Sinemet, Rotigine, Madopar
- O/E cogwheeling, resting tremor, bradykinesia and some dyskinesia
Try giving Madopar dispersible 62.5mg
Most important diagnostic test for MND
Electromyography
-records electrical activity produced by skeletal muscles
Diagnosis of MND
El-Escorial criteria -progressive -mixed UMN and LMN signs -regions involved -exclude other causes -definite/ probable/ possible Sensory signs Eyes Sphincters
Bulbar onset MND
Bulbar onset motor neurone disease occurs in about 20% of those affected. The first sign is usually slurring of the speech, caused by impaired tongue movement, which may be accompanied by obvious wasting and fasciculation of the tongue
Prognosis is not better
Treatment for MND
Riluzole is indicated
-amyotrophic lateral sclerosis
-delays onset of ventilator-dependence or tracheostomy in selected pts
-may > survival by approximately 2-3 months
Other meds are available***
