Neuroloigcal Dieases Flashcards
What is a stroke
A stroke is an acute focal neurological deficit resulting from cerebrovascular disease and lasting more than 24 hours or causing earlier death
What happens to the tissue in a stroke
There is death of brain tissue from hypoxia, there is no local cerebral blood flow and haemorrhage into the brain tissue
What is a transient ischaemic attack?
This is when there is rapid loss of function but rapid recovery within 24hrs.
Following this attack this raises the patients chance of having a stoke in the future
What does the acronym FAST stand for with regards to a stroke?
F- facial drooping
A- arm weakness
S- speech difficultly
T - Time ( how long has this been happening for)
What is thought to be the cause of a tia?
Thought that these happen because of platelet emboli within the vessels in the head
These platelets block blood flow causing ischaemia but are rapidly removed by the circulation and blood flow is restored before any permanent damage occurs
What figure diastolic blood pressure reading would puta patient 15x more at risk of a stroke than a patient with diastolic pressure of <80mm Hg
> 110mm Hg
Why is AF a risk factor for stroke
This is because emboli from abnormally contracting atria passing though ventricle up into the cerebral circulation causing ischamia
Name three other risk factors for stoke
( Not including AF and hypertension)
Smoking/alcohol
Ischaemic heart diease
Diabetes
When are three instances that an embolic stroke may occur
Embolism from left side of the heart
- Recent MI
- Heart valve diease
-Atrial. Fibrillation
What kind of aneurysm may be seen at weakpoints in an angiogram
Berry aneurysm
Can be a familial link
An infarction in a stroke is much more difficult to see, what kind of scan would you order
MRI
Shows more clearly than a CT the inflammatory change
What are three risk factors that should be reduced in order to aid in stroke prevention
Smoking, diabetes control and controlling hypertension
Surgery can be an option for prevention of stroke in which situations and what happens in the surgery?
Surgery can be an option when the coronary artery is heavily involved.
Carotid Endarterectomy
In these cases there is a large amount of atherosclerosis around the carotid furcation.
- in some cases complete excision happens taking the full artery away
- collateral blood supply of the head and neck is good and cope
In other occasions the surgeon will instead try to remove the plaque and make the area more patent
When ordering investigations for a stroke and haemorrhage why do you need to differentiate infarct, bleed or a haemorrhage
For a haemorrhage a CT should be ordered
Bleed - angiogram
Infarct - MRI
Name some complications of a stroke
Motor function - cranial nerve or somatic ( opposite side)
Sensory loss - ‘’. ‘’
Swallowing may be affected - can be an aspiration risk for patients, which can subsequently lead to pneumonia and death
There are two phases of stroke management, what are they
Acute phase - limit damage and reduce future risk
Chronic phase - rehab and reduce future risk
Why is it so important that there is normoglycaemia during the acute phase of treatment for a stroke
Brain is dependant on glucose for energy stores so if this is not available the patient will exaggerated damage from the stroke
What kind of drugs would be prescribed in the acute phase of stroke Treatment
Calcium channel blockers such as nimodipine are prescribed to act as anti-hypertensive medication
How do we prevent future risk of a stroke in the acute phase of stroke treatment
Aspirin 300mg daily
Anti-coagulation if indicated
- AF
- left ventricular thrombosis
What does the chronic phase of the stroke treatment include
This is about nursing and rehabilitation for the patient
Immobilty support, speech and language therapy and occupational therapy
What is ‘stroke pain’
Damage to the brain can change the way the brain understands its environment and can report pain but it is centrally herniated within the CNS and not actually due to peripheral stimulation
Partietns that have had a stroke may struggle with their sensory information, why may this be a problem in dentistry
This may mean that it is difficult for them to adapt to new oral environments e.g. dentures
What happens in epilespy
Epilespy is associated with reduced GABA levels in the brain.
This leads to abnormal cell-cell propagation
- meaning that it takes less stimulation for a neuron to fire and pass the message to another cell.
This causes an abnormal chain reaction to be set up causing an abnormal discharge of that’s of neurons either in one area or throughout the brain leading to the changes that we see.
What is reduced in epilespy
Epilepsy is associated with reduced GABA levels in the brain
What is GABA
It it an inhibitory neurotransmitter
If a patient is having a febrile seizure, they demonstrate the same symptoms as a tonic clonic seizure, how can you tell the difference
Febrile seizures are largely in children and they are only when a child has a FEVER.
This does not mean that the child is epileptic - just that they are prone to febrile seizures
Children above 38 degrees are at risk of febrile seizure, how can you cool hot children down?
Paracetamol and ibuprofen should be given
Remove the child’s clothing
Cool sponging and bath
There are two types of epileptic focus what are they
Central and partial
What is central focus in epilepsy
This sends signals out to all parts of the Cortex so are parts of the body are involved in the seizure
What is partial focus in epilepsy
The primary area will be affected by the seizure and this can be any modality in the body.
this can affect motor or perception/sensation
hear, smell,see, taste something that is generated in the brain by epileptic focus not present in their environment.
Must be wary of this when patients are presenting with symptoms with no obvious cause
What is a tonic clonic seizure?
In these seizures the patient is aware of the change in their brain function.
They experince an initial TONIC (stiff) - where all the joints contract together putting a huge strain on the spine.
there is then the CLONIC (contraction/relaxation) - intermittent contraction, patient seeming to jerk/spasm
A patient experiencing a tonic clonic seizure will experince, prodromal aura. What is this?
The patient has an awareness in the change in their brain function, they may not be able to report it to you but they have a change in the awareness of their actions
What is status epilepticus?
A seizure that lasts longer than 5 minutes, or having more than 1 seizure within a 5 minutes period, without returning to a normal level of consciousness between episodes is called status epilepticus. This is a medical emergency that may lead to permanent brain damage or death.
If this continues to happen it can be vary dangerous a normal breathing muscles cannot operate and the patient will become hypoxic
What is a petit mal( absence) seizure?
These are short levied episodes - sometimes only lasting 5-15 seconds, there can be multiple attacks in a single day
It is a loss of awareness.
It usually happens in childhood
What are some symptoms of someone having a petit mal seizure?
Loss of awareness
- eyelids flutter
- vacant stare
-stops activity
- loss of response
Medically how can you help someone having a tonic clonic seizure?
Protect them from INJURY
- help to guide fall if possible
- remove things from mouth if possible
Asphyxia
- use supplemental 02
-suction any secretions
How may aspiration lead to sudden death in epilepsy patients
Ther can be aspiration of the gastric contents which have refluxed leading to acute lung damage
Sodium valproate can often be used to treat tonic clonic seizures, in what situation should we be careful with this medication as it can be harmful
This drug can be harmful in pregnancy
Tonic clonic seizures are most often idiopathic - however what are some precipitating factors?
Poor compliance or withdrawn of medication - patients often do not like the side affects or stop medicine before staring on a new one
Mentrustion
Fatigue/stres
Infection
Antidepressants and some GA agents
What is a Jacksonian seizure?
This happens in a partial focus seizure
The paietnt will start with a small tremor at extremity of upper limb and it will aggressively move up towards the neck
What symptoms might a patient get during a partial seizure?
Tends to be sensory
- visual or auditory hallucinations
- can have a taste in thier mouth
- strong smell
What happens during a complex partial seizure?
This is when different areas of the brai are affected which produce connected Movements.
This leads to repeated purposeless movement
E.g.lip smacking, grimacing - both which require a variety of muscles
Name some common preventative anticonvulsant medications prescribed for epileptic patients. With tonic clonic seizures
Valproate, carbamazepine and phenytoin
Gabapentin
What may levitiracetam be used to treat
Absence seizures
How does valproate work
This drug is a gaba transaminase inhibitor
When would surgery be used in epilepsy treatment
This can be used to removal focal neurological lesions - such as a brain tumour ( begin)
It can also be used when there is an identifiable point of origin within the brain that isn’t well controlled by medication - focal seizures
When treating an epileptic patient what are some questions you might ask to determine the patients risk level
When did the last three fits take place?
- this gives a good indication of how likely they are to have one in the chair
- ask about compliance with medication
- ask about changes in medication
How may complications of fits affect the patients dental care
When they fall they may cause a dental injury/fracture or may cause an oral soft tissue injury
The medication can have dentally related side affects such as phenytoin - gingival hyperplasia
Valproate can lead to bleeding tendency
Multiple sclerosis, motor neurone disease and Parkinson’s diease
What do these three diseases ask have in common
They are slowly progressive diease which stop proper neurological function.
They can be quicker in some, slower in others but decline will occur
Why does multiple sclerosis happen
It happens due to the DEMYLINATION of axons, it happens due to inflammatory change
Progressive functional loss which leads to permanent neurological deficit causing loss of function
What symptoms may a patient complain of when suffering from multiple sclerosis
Muscle weakness
Visual disturbance
Paraesthesia - may present to dentist with sudden loss of facial feeling
Dysarthria - muscles weakness so cant talk properly
What signs might a clinician report in a patient with multiple sclerosis
Muscle weakness
Spasticity- happens in UMN lesion
Tremor
Optic atrophy - condution speed of nerve will be slower
Proprioception loss and loss of touch
In a CSF analysis of a patient of Multiple sclerosis, what might be the findings?
Reduced lymphocytes
Increased IgG proteins
Why does patient with multiple sclerosis unfortunately eventually end up disabled?
The damage to the CNS builds up with each episode and many will eventually develop progressive form ( secondary progressive)
What is the difference between the primary and secondary progressive types of MS
Primary - slow steady progress, cumulative damage. There is no exacerbation and remission just a slow detioration.
Relapsing and remitting type. - damage builds with each episode and this collective damage will eventually develop secondary progressive form
What are physiotherapy and occupational therapy aiming to do. While treating MS patients?
They are aiming to reduce function loss but they cannot reduced Madge
If a patient presents to you with sdden loss of facial motor function, what should you suspect and what investigation should be ordered
Suspect MS
Investigation should be an MRI
What happens in motor neurone disease?
There is degeneration in the spinal cord of the motor nerves in the anteior horns
The corticospinal tract
Why may patients with motor neurone disease experience hypoxia
Because there is progressive loss of motor function in this diease and this can affect the intercostal muscles and the diaphragm - impairing ventilation - leading to hypoxia
What are two main causes of death in motor neurone disease
Ventilation failure - type 2 respiratory failure
Aspiration pneumonia - patient is no longer able to use protective relflexes in pharynx to keep material out of lungs when eating
What might the patient notice, when they have motor neurone disease?
They may find that they have weakness in thier ankle/leg - which can cause them to trip and can eventually lead to them tripping.
They may experience slurred speech- eventually leading to swallowing difficulties.
A weak grip - droppping things, or finding it hard to open jars or do up buttons
What is the treatment for motor neurone dieSEASE?
There are no effective
Physiotherapy and occupational therapy
Aspiration prevention - PEG fed and reduce salivation
Why might someone with motor neurone diease have thier saliva reduced?
This is to prevent saliva containing oral bacteria being aspirated back into the lungs
What happens to the brain in Parkinson’s dieseae
Degeneration of dopaminergic neurones in the basal ganglia of the brain ( substantia nigra)
The underlying cause is unknown
In Parkinson’s one of the clinical signs can be bradykinesia, what is this
Slow movement and slow initiation of movement
A resting tremor is a key feature in which degenerative brain disease?
Parkinson’s
How may Parkinson’s manifest clinically
The. Patient may have impaired gait and falls
Impaired use of upper limbs
Swallowing issues
What is the aim of physical support in Parkinson’s
Physio and occupational therapy work to maintain function at a high level for as long as possible.
They try to Maximise living ability with that function
What is levodopa used to treat
and what is the problem with it
This is used to treat patients hat have Parkinson’s diease
It is a effective at the beginning however the dose needs to be continually increased to keep that benefit so then the side affect eventually become intolerable
Dopamine analogues can b used in patients with Parkinson’s to mimic the affect of dopamine ( promipexole and apomorphine ), however what can these drugs lead to
These medications can lead to compulsions and issues with gambling so the patients family must be made aware of this.
Why must a dentist be patient with someone who has Parkinson’s
These patients can often have difficulty accepting treatment due to access, movement and cooperation. The dentist must be aware that they may take some time to be compliant
