Neurology Symposium - neurology in dentists chair Flashcards
Epilepsy questions
What is epilepsy
Perinatal trauma, febrile convulsions, head injury, family history, CNS infections e.g meningitis or encephalitis
Tendency to have recurrent seizures
Umbrella term e.g juvenile myoclonic epilepsy
Syncope questions
Transient loss of consciousness, due to loss of cerebral perfusion
Preceding symptoms - dizziness, nausea, hot
Postural
Negative signs - absence of function e.g not clenching tongue
Cardiovascular RF
Non-epileptic attack disorder (NEAD)
Psychosocial substrate e.g childhood trauma, domestic or sexual abuse, response to
Contextual
Awareness - will appear unconscious but not
Fluctuant
Non-epileptic attack disorder (NEAD) questions
Psychosocial substrate Contextual Awareness Fluctuant Eyes tight and closed May be unresponsive
Is Case 1 typical of an NEA
No - it is epileptic
Checklist for NEAD vs Epilepsy
in NEA context
Shaking - amplitude can vary throughout frequency and evolution
Eyes - shut
Incontinence
O2 Zats and other observations - stay the same in NEA
Unpleasant bites - sides in epilepsy
Responsiveness - can sometimes respond
Estimated duration - longer than epilepsy
Speed of recovery - come round quickly
Less reliable signs of differentiation (NEAD)
Injuries
Pelvic thrusting
Incontinence
Twitching
True or False : If he is still shaking after 30 seconds, he requires intravenous lorazepam 4 mg
FALSE
Emergency management of GTC seizures
Which medications
Self limiting
2-4mg lorazepam if prolonged (repeat if needed) - min of 5 mins
IV phenytoin 1g over 20 mins with cardiac monitor if not settling
30mg/kg levitoracitan or valproate 30mg/kg
if in dentists chairs call 999
T or F: An MRI scan of case I is likely to show a brain tumour
False
Syndrome classification
2 types and triggers
Idiopathy generalised epilepsy juvenile myoclonic epilepsy - photosensitivity, sleep deprivation, alcohol
Localisation related epilepsy - aura, focal neurology, age, PMH
Indications for further treatment after single seizure
Previous myoclonic seizures or absences
Congenital neurological deficit
Unequivocal epileptiform changes on EEG
Risk of recurrence is unacceptable to pt
Choice of anticonvulsant
Men
Women
Localisation related epilepsy
Valproate - teratogenic in women
Lamotrigine
Lamotrigine, carbamazepine, levetiracetam
Summary
What to take into account with treatment
Watch carefully Protect from injury, O2 and recovery position ECG and listen to heart Treatment - syndrome and sex of pt Driving advice
Case 2
A 23yo lady comes in with right-sided toothache. It is worse when touching the right side of her face and when she brushes her teeth. There is no other PMH of note.
The teeth appear normal, but she insists you remove the right lower molars because the pain is excruciating. Neurological examination is normal.
What is the diagnosis?
Will teeth be removed as requested?
Site: Right lower face Onset: Sudden, Character: Electric/ Sharp Radiation: Around face/mouth Association: Nil Time: Paroxysmal Exacerbating: Touch, cold, wind, E+D Severity: Excruciating
Right trigeminal neuralgia
No
Likeliest cause
Cerebellopontine angle tumour Demyelination Nasopharyngeal carcinoma Vascular loop - pressure of a vessel onto nerve Viral infection Pontine tumour
Case 1
An 18yo man comes in for a tooth extraction. Half way through, he goes stiff, turns blue, his limbs starts shaking and he bites his tongue. His partner in the waiting room says he has had episodes of daydreaming since his teens. He sometimes becomes anxious in the car. He is always clumsy and dropping things in the mornings. He occasionally gets headaches. He has had a cough recently. Worse when tired.
Clumsiness may be myoclonic jerk –> random muscle spasm
Biting tongue - forced tonic contractions
First aid for fits
Clear area
Open airway
Don’t restrict head
Does case 1 require treatment after a single tonic-clonic fit
No
EEG significance
only 30% sensitive
Activities seen in 0.5% healthy adults
Do an ECG e.g to identify risk of heart blocks (sino
Diagnosis of MS
Clinical evidence of 2 attacks
Prev episodes
Demyelination of nerve in time and pace after 1 attack
Treatment of MS
2 relapses in 2 years
Natalizumab
Treatment of trigeminal neuralgia
Which drugs and details
Carbamazepine - hepatotoxic and may affect combined pill
Phenytoin
Microvascular decompression
Radio surgery and nerve blocks
Case 3 A 70yo man in the waiting room suddenly collapses. He is unable to speak and has dense weakness of the right side of his face, arm and leg
Left side paralysed
Speech centres affected
What is priority in case 3
give aspirin (if not haemorrhage stroke)
Take to hospital if haemorrhage
Thrombotic stroke can be given aspirin
Case 3 - On arrival in hospital, he is no better. FBC, ESR, U/Es, LFTs, glucose and clotting are normal. Cholesterol is 3.4mmol/L. An urgent CT brain is organised and performed an hour after onset.
CT shows nothing
MRI not necessary
Consider for THROMBOLYSIS - dissolve any clots already present and prevents further clots from forming for next hour
Important questions for 3
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)?
Dark shadow indicates clotting
Better treatment than thrombolysis?
Thrombectomy - removing clot
Case 4 A 70 year old man with a history of Parkinson’s disease attends for a routine check-up. At the end of the consultation, he “freezes” and is unable to get out of the chair. His usual medications are Sinemet 125mg five times a day, Rotigotine patch 8mg/day and Madopar dispersible prn. On examination, there is cogwheeling, resting tremor, bradykinesia and some dyskinesias.
What is parkinson’s
triad
Progressive Neurodegenerative disease involving loss of dopamine production
Sinemet and madopar - levopar
Rotigotine (dopamine agonist)
stiffness, rigidity, tremor
gait impairment
What to do about case 4
Give madopar dispersible 62.5mg
Parkinson’s disease - diagnosis
Clinical Idiopathic Triad of features- Tremor, Rigidity, Bradykinesia Other symptoms Parkinson’s plus
Management of PD
L-dopa (dyskinesias, wearing off) Dopamine agonists (neuropsychiatric side effects) Amantadine - anticholinergic MAO-B inhibitors (Selegiline) COMT inhibitor (Entacapone) Apomorphine pump, Duodopa Surgery
Long term complications
Wearing off Dyskinesias Off and on freezing Falls Constipation Neuropsychiatric - hallucinations
Case 5 A 45yo man comes for a check-up. He has noticed slurred speech and swallowing problems over the last two months.
Examination of his teeth is unremarkable but his tongue movements are very slow, the jaw jerk is brisk.
Dysphagia
Brisk jaw jerk via tendon hammer
Likely diagnosis of case 5
Motor neurone disease - bulbar onset disease is worse
Diagnostic test for MND
EMG
Criteria for diagnosis of motor neurone disease
UMN
LMN
Progressive
Mixed UMN and LMN signs
- spasticity and stiffness
LMN - muscle wastage Regions involved Exclude other causes Definite/probable/possible
Diagnosis
Sensory signs
Eyes
Sphincters
Shouldn’t be incontinent
Prognosis is better in BOD
False
Medication for BOD
Riluzole
Are there other treatments for MND
Non-invasive ventilation, BPAP
Carbamazepine is
Phenytoin long term use
an enzyme inducer - antibiotics
Gingival hyperplasia
