lmcc preparation back to basics
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LMCC Preparation Back to Basics. Neurology Dr. C.R. Skinner 17 April 2008. Major Topics. Neurology Made Simple Review Headache Trauma Infections Cerebrovascular Disease Demyelination Seizures Degenerative Diseases Sleep Disorders. Neurology Made Simple Questions. - PowerPoint PPT PresentationTRANSCRIPT
LMCC PreparationLMCC PreparationBack to BasicsBack to Basics
NeurologyNeurology
Dr. C.R. SkinnerDr. C.R. Skinner
17 April 200817 April 2008
Major Topics
• Neurology Made Simple Review• Headache• Trauma• Infections• Cerebrovascular Disease• Demyelination• Seizures• Degenerative Diseases• Sleep Disorders
Neurology Made SimpleNeurology Made SimpleQuestionsQuestions
• Is the Problem Neurological?Is the Problem Neurological?
• If So , Where Is It in the Nervous If So , Where Is It in the Nervous System ?System ?
• What Is the Most Likely Cause ?What Is the Most Likely Cause ?
• Is This Problem Serious Enough toIs This Problem Serious Enough to Require Urgent Referral ? Require Urgent Referral ?
• How to Stabilize the Patient DuringHow to Stabilize the Patient During Transport Transport
NEUROLOGY MADE NEUROLOGY MADE SIMPLESIMPLE
IS THE PROBLEM NEUROLOGICAL?IS THE PROBLEM NEUROLOGICAL?
Are there hard organic features ?Are there hard organic features ?
Is the behaviour bizarre ?Is the behaviour bizarre ?
Is there a history of seizures, drugIs there a history of seizures, drugaddiction or of psychiatric illness ?addiction or of psychiatric illness ?
Do the signs and symptoms make sense ?Do the signs and symptoms make sense ?
NEUROLOGY MADE NEUROLOGY MADE SIMPLESIMPLE
INTRODUCTIONINTRODUCTION
NEUROLOGICAL PROBLEMNEUROLOGICAL PROBLEM
WHERE IS THE LESIONWHERE IS THE LESION
WHAT IS THE CAUSEWHAT IS THE CAUSE
INVESTIGATIONINVESTIGATION
TREATMENTTREATMENT
PROGNOSISPROGNOSIS
MuscleNeuromuscular Junction
Peripheral nerve
Spinal Cord
Brain Stem
Deep White Matter/Basal Ganglia/Thalamus Cortex Cerebellum
Mental Status
Cranial Nerves
Motor
Reflexes
Sensory
Coordination
Gait
Localization Matrix
NEUROLOGY MADE NEUROLOGY MADE SIMPLESIMPLE
INTRODUCTIONINTRODUCTION
NEUROLOGICAL PROBLEMNEUROLOGICAL PROBLEM
WHERE IS THE LESIONWHERE IS THE LESION
WHAT IS THE CAUSEWHAT IS THE CAUSE
INVESTIGATIONINVESTIGATION
TREATMENTTREATMENT
PROGNOSISPROGNOSIS
Drugs Inflammatory Metabolic Vascular Electrical Trauma Neoplastic Degenerative Genetic
Acute
Subacute
Chronic
Etiology Matrix
NEUROLOGYNEUROLOGY MADE SIMPLEINVESTIGATIONS
History
Physical
According to presumed localizationand etiology
Metabolic systemic CSF
Structural
Neurophysiological
Time Sequence
• When was the person last neurologically normal?• What was the speed of onset of the symptoms?• What was the state of the patient’s health in the
last few days, weeks, months?• What medications is the patient taking and has
there been any recent changes?• Are there any significant other medical or surgical
problems?
HeadacheHeadache
Loss Of ConsciousnessLoss Of Consciousness
WeaknessWeakness
Difficulty With Vision , Hearing , Difficulty With Vision , Hearing , TasteTaste
NumbnessNumbness
WeaknessWeakness
DizzinessDizziness
Lightheadedness , Vertigo, Off Lightheadedness , Vertigo, Off balancebalance
FatigueFatigue
Loss Of BalanceLoss Of Balance
Loss Of CoordinationLoss Of Coordination
Difficulty Swallowing, ChewingDifficulty Swallowing, Chewing
Urinary And Stool IncontinenceUrinary And Stool Incontinence
Sexual DysfunctionSexual Dysfunction
Sleep DifficultiesSleep Difficulties
ESSENTIAL HISTORICALHISTORICAL FEATURESHISTORY OF PRESENT ILLNESS
Drugs Inflammatory Metabolic Vascular Electrical Trauma Neoplastic Degenerative Genetic
Acute
Subacute
Chronic
Etiology Matrix
NEUROLOGY MADE SIMPLESIMPLELOCALIZATION ANALYSIS
MuscleMuscle
Neuromuscular junctionNeuromuscular junction
Peripheral nervePeripheral nerve
Spinal cordSpinal cord
Brain stemBrain stem
Thalamus or basal gangliaThalamus or basal ganglia
CortexCortex
CerebellumCerebellum
MuscleNeuromuscular Junction
Peripheral nerve
Spinal Cord
Brain Stem
Deep White Matter/Basal Ganglia/Thalamus Cortex Cerebellum
Mental Status
Cranial Nerves
Motor
Reflexes
Sensory
Coordination
Gait
Localization Matrix
Muscle
Neuromuscular Junction
Peripheral Nerves
Lateral Medullary SyndromeLateral Medullary Syndrome• IpsilateralIpsilateral
– Pain numbness, impaired Pain numbness, impaired sensation over half of facesensation over half of face
– Ataxia of limbs with Ataxia of limbs with falling towards side of falling towards side of lesionlesion
– Vertigo, nausea, vomitingVertigo, nausea, vomiting– Horner’s syndromeHorner’s syndrome
• ContralateralContralateral– Impaired pain and Impaired pain and
temperature sensation temperature sensation over half of the body and over half of the body and some of the facesome of the face
Lateral Pontine SyndromeLateral Pontine Syndrome• IpsilateralIpsilateral
– Horizontal, vertical Horizontal, vertical nystagmus vertigo, nausea, nystagmus vertigo, nausea, vomiting, oscillopsiavomiting, oscillopsia
– Facial paralysisFacial paralysis
– Paralysis of conjugate gaze Paralysis of conjugate gaze to side of lesionto side of lesion
– Deafness, tinnitusDeafness, tinnitus
– AtaxiaAtaxia
– Impaired sensation over faceImpaired sensation over face
• ContralateralContralateral
– Impaired pain and thermal Impaired pain and thermal sense over half of bodysense over half of body
Ventral Midbrain SyndromeVentral Midbrain SyndromeWeber’s SyndromeWeber’s Syndrome
• IpsilateralIpsilateral
• Diplopia, dilated Diplopia, dilated pupilpupil
• AtaxiaAtaxia
• ContralateralContralateral
• Hemiplegia, Hemiplegia, mainly upper mainly upper limb and facelimb and face
CORRELATIVE FACTORSCORRELATIVE FACTORSCAPSULE, THALAMUS AND BASAL GANGLIACAPSULE, THALAMUS AND BASAL GANGLIA
• Hemi-sensory or motor signsHemi-sensory or motor signs
• Sensory signs of primary modalitiesSensory signs of primary modalities
• Sensory involvement of the trunkSensory involvement of the trunk
• Lack of cortical signsLack of cortical signs
• Uniform motor signs in arm ,Uniform motor signs in arm ,leg and faceleg and face
• Hypertension risk factorHypertension risk factor
CORRELATIVE FACTORSCORRELATIVE FACTORSCORTICALCORTICAL
• Aphasia and right sided weaknessAphasia and right sided weaknessfluent, non - fluent, paraphasiafluent, non - fluent, paraphasia
• Weakness - arm and face more than legWeakness - arm and face more than leg
• Visual field defectsVisual field defects
• Cortical sensory disturbanceCortical sensory disturbanceinattentioninattentionleft-rightleft-rightacalculiaacalculiaagnosiaagnosiaapraxiaapraxia
CerebellumBasal Ganglia
•Modulating structuresModulating structures
•Rule out other systems firstRule out other systems first
•Ipsilateral Rule for pure Ipsilateral Rule for pure cerebellar lesionscerebellar lesions
FINAL CHECKLISTTHINGS NOT TO MISS
MUSCLEPOLYMYOSITIS, POLYMYALGIA RHEUMATICA
NEUROMUSCULARMYASTHENIA
PERIPHERAL NERVEGUILLAIN - BARRE SYNDROME
SPINAL CORDACUTE SPINAL CORD COMPRESSION
FINAL CHECKLISTCHECKLISTTHINGS NOT TO MISS
BRAIN STEMBRAIN STEM
STROKE, MULTIPLE SCLEROSISSTROKE, MULTIPLE SCLEROSIS
MENINGITISMENINGITISLISERIA, TBLISERIA, TB
GUILLAIN - BARRE - FISHER VARIANTGUILLAIN - BARRE - FISHER VARIANT
TUMORSTUMORS
FINAL CHECKLIST
THINGS NOT TO MISS
CORTEX
STROKE
HERPES ENCEPHALTIS
SEIZURES
TUMORS
SUBARACHNOID HEMORRHAGE
Circulation du LCRCirculation of CSF
This 20 year old man presents with This 20 year old man presents with a three day history of abnormal a three day history of abnormal behaviour consisting of hallucinations, behaviour consisting of hallucinations, delusions of grandeur and memory delusions of grandeur and memory loss for recent events.loss for recent events.
He had been " up north " fishing just He had been " up north " fishing just prior to the onset of these symptoms.prior to the onset of these symptoms.
Case Case
•Physical ExamPhysical Exam
•Fever 38.0 CFever 38.0 C
•InattentiveInattentive
•Poor short term memoryPoor short term memory
•Left upper quadrantopsiaLeft upper quadrantopsia
•Hyperflexia Left upper and Hyperflexia Left upper and lower limblower limb
Case Case
Case 1Case 1
• Where is the lesion?Where is the lesion?– why?why?
• What is the cause?What is the cause?
• What are the immediate treatment What are the immediate treatment priorities?priorities?
Herpes Simplex Encephalitis
• Any time of year, any age, any sex
• Selective infection of temporal lobes
• New onset seizures or behaviour disturbance
• Treat if you suspect - Acyclovir 30 mgm/kg-day
Herpes SimplexHerpes SimplexTreatmentTreatment
• Acyclovir IVAcyclovir IV
• Management of ICP (max at 8 – 10 Days)Management of ICP (max at 8 – 10 Days)– Head upHead up– HyperventilationHyperventilation– MannitolMannitol– Hypertonic SalineHypertonic Saline
• Seizure treatmentSeizure treatment
CASE 2
This 24 year old soldier was doing his This 24 year old soldier was doing his early morning run with his regimental early morning run with his regimental company. He developed an acute severe company. He developed an acute severe headache which caused him to stop and fall headache which caused him to stop and fall to the ground. to the ground.
On examination, he was alert, oriented, On examination, he was alert, oriented, moving all four limbs with a normal moving all four limbs with a normal neurological examination.neurological examination.
Where is the lesion ?Where is the lesion ?
CT Scan
without contrast
Subarachoid Hemorrhage
CT ScanSubarachnoid
Blood
Subarachnoid HemorrhageSubarachnoid Hemorrhage
• Worse headache of lifeWorse headache of life• Sudden onset, often with activitySudden onset, often with activity• Signs of meningeal irritationSigns of meningeal irritation
– Kernig, BrudzinskiKernig, Brudzinski
• Focal signsFocal signs• Signs of comaSigns of coma• Positive CT scanPositive CT scan• Positive LPPositive LP
Subarachnoid Hemorrhage
• Blood in subarachnoid space
• Require urgent referral for angiogram
• Use acetaminophen not ASA for headache
Subarachnoid HemorrhageInvestigations
• CT Scan - 90 - 95% sensitive• LP - nearly 100% sensitive
– rbc in CSF– xanthochromic in CSF after 12 – 18 hours
• Angiogram• Treatment
– surgical clipping– coiling
Subarachnoid HemorrhageTreatment
• Clipping
• Coiling
Giant Aneurysm
GDC Coil
Headache in the Emergency Headache in the Emergency RoomRoom
1. Distinguish ominous from benign 1. Distinguish ominous from benign headacheheadache
2. Treat effectively the benign headaches2. Treat effectively the benign headaches
Assessment ApproachAssessment ApproachAirwayAirway
BreathingBreathing
CirculationCirculation
DrugsDrugs
EvaluationEvaluation
Assess, secure Assess, secure Not a problem unless obtundedNot a problem unless obtunded
Assess, assistAssess, assist
Not a problem unless obtundedNot a problem unless obtunded
O2 not necessaryO2 not necessary
IV line with crystalloid to restore volumeIV line with crystalloid to restore volume
No drugs until diagnosed, unless required to No drugs until diagnosed, unless required to stablize circulationstablize circulation
In particular, no analgesics until diagnosedIn particular, no analgesics until diagnosed
Rapid neurological assessmentRapid neurological assessment
Investigations as necessaryInvestigations as necessary
The Spectrum of Ominous The Spectrum of Ominous HeadachesHeadaches
• Subarachnoid hemorrhageSubarachnoid hemorrhage
• meningitismeningitis
• increased intracranial pressureincreased intracranial pressure
Danger SignalsDanger Signals
• the worse headache everthe worse headache ever
• onset with exertiononset with exertion
• decreased level of consciousnessdecreased level of consciousness
• meningeal irritationmeningeal irritation
• abnormal physical signs (including abnormal physical signs (including feverfever))
• worseningworsening
All Clear SignalsAll Clear Signals
• previous identical headachesprevious identical headaches
• patient bright and alertpatient bright and alert
• neck suppleneck supple– Kernig, Brudzinski’s signsKernig, Brudzinski’s signs
• normal examinationnormal examination
• improving without analgesicsimproving without analgesics
CT ScanCT Scan
• detects most conditions causing increased detects most conditions causing increased ICPICP
• misses 10 - 15 % of subarachnoid misses 10 - 15 % of subarachnoid hemorrhagehemorrhage
• misses nearly all cases of meningitismisses nearly all cases of meningitis
Modified HIS Diagnostic Modified HIS Diagnostic Criteria for MigraineCriteria for Migraine
• multiple previous attacksmultiple previous attacks
• duration of attacks a few hours to a few daysduration of attacks a few hours to a few days
• headaches have at least two of:headaches have at least two of:
• hemicranialhemicranial
• severesevere
• pulsatingpulsating
• worse with activityworse with activity
• headaches accompanied by at least one of:headaches accompanied by at least one of:
• nausea and or vomitingnausea and or vomiting
• aversion to light or noiseaversion to light or noise
• no evidence of ominous disease in history or examinationno evidence of ominous disease in history or examination
Classification of Primary Classification of Primary HeadachesHeadaches
• MigraineMigraine– with aura, without aurawith aura, without aura
– Ophthalmoplegic, retinalOphthalmoplegic, retinal
• Tension HeadacheTension Headache
• Cluster HeadacheCluster Headache
• Miscellaneous without structural Miscellaneous without structural lesionlesion
Treating Migraine in the ERTreating Migraine in the ER
1. Restore intravascular volume1. Restore intravascular volume
2. Identify contraindications2. Identify contraindications
3. Choose appropriate medication3. Choose appropriate medication
Narcotic - AntinauseantNarcotic - Antinauseant
• Meperidine 75 - 100 mg plusMeperidine 75 - 100 mg plus
• Prochlorperazine 5-10 mgProchlorperazine 5-10 mg
• IV slow pushIV slow push
DHE - AntinauseantDHE - Antinauseant
• Metoclopramide 10 mg IV, followed in 10 Metoclopramide 10 mg IV, followed in 10 minutes byminutes by
• DHE 0.5 - 1.0 mg IV by slow pushDHE 0.5 - 1.0 mg IV by slow push
ChlorpromazineChlorpromazine• Ensure patient is normovolemicEnsure patient is normovolemic
– 250 - 500 cc crystalloid250 - 500 cc crystalloid
• Prepare CPZ for injectionPrepare CPZ for injection– 25 mg (1ml) CPZ diluted to 5 ml by adding 4 ml of 25 mg (1ml) CPZ diluted to 5 ml by adding 4 ml of
crystalloidcrystalloid
– each ml contains 5 mg CPZeach ml contains 5 mg CPZ
• Inject into IV tubing 5 mg CPZ every 10 - 15 Inject into IV tubing 5 mg CPZ every 10 - 15 minutes, stopping when minutes, stopping when – improvement clearly occurring, orimprovement clearly occurring, or
– 25 mg given25 mg given
– Watch for hypotension and sedationWatch for hypotension and sedation
Nasal SpraysNasal Sprays
• DHEDHE
• SumatriptanSumatriptan
SumatriptanSumatriptan
1 mg SC if:1 mg SC if:• no ergot or DHE in past 24 hoursno ergot or DHE in past 24 hours• no contraindicationno contraindication
Patient Instructions:Patient Instructions:GuidelinesGuidelines
• Do not drive a car or operate machineryDo not drive a car or operate machinery
• Do not drink alcohol or take Do not drink alcohol or take tranquillizers, antihistamines, or other tranquillizers, antihistamines, or other drugs that affect the CNSdrugs that affect the CNS
• Store in child-resistant containersStore in child-resistant containers
• Neurological followup if frequent or Neurological followup if frequent or incapacitatingincapacitating
Cluster HeadacheCluster Headache
• 1/10 as common as migraine1/10 as common as migraine
• Not genetically determinedNot genetically determined
• M:F 6:1M:F 6:1
• Later OnsetLater Onset
• RhythmicityRhythmicity
• Severe unilateral orbital, supraorbital Severe unilateral orbital, supraorbital and/or temporal painand/or temporal pain
Cluster HeadacheCluster Headache
• IpspilateralIpspilateral– conjunctival injectionconjunctival injection– nasal congestionnasal congestion– forehead and facial swellingforehead and facial swelling– miosismiosis– ptosisptosis– eyelid edemaeyelid edema
• Every 2 - 8 times per dayEvery 2 - 8 times per day
Cluster HeadacheCluster Headache
• TriggerTrigger– alcoholalcohol
• PathophysiologyPathophysiology– Role of proximal internal carotid arteryRole of proximal internal carotid artery– Role of histamineRole of histamine
• TreatmentTreatment
• Acute attackAcute attack– ergotamineergotamine
Cluster HeadacheCluster Headache
• ProphylaxisProphylaxis– SansertSansert
– SteroidsSteroids
– LithiumLithium
– Calcium channel blockersCalcium channel blockers
– CombinationsCombinations
Inflammatory HeadachesInflammatory Headaches
• Most people who think they have sinus Most people who think they have sinus headaches usually have migraine or headaches usually have migraine or muscle contraction headachemuscle contraction headache
• Diagnosis requires acute sinusitisDiagnosis requires acute sinusitis
• Nasal congestion, post nasal drip, fever, Nasal congestion, post nasal drip, fever, pain over the involved sinusespain over the involved sinuses
• Tender on percussionTender on percussion
• Sinus xray confirmsSinus xray confirms
• TreatmentTreatment– Antibiotics or drainage Antibiotics or drainage
Temporal ArteritisTemporal Arteritis
• Progressively obliterative granulomatous Progressively obliterative granulomatous arteritisarteritis
• Temporal or occipitalTemporal or occipital
• Can involve cerebral and ophthalmic Can involve cerebral and ophthalmic arteriesarteries
• 50% will go blind and have a stroke50% will go blind and have a stroke
• Greater than > yearsGreater than > years
Temporal ArteritisTemporal Arteritis
• Usually temporal headacheUsually temporal headache• Malaise, anorexia, night sweats, myalgia, Malaise, anorexia, night sweats, myalgia,
+/- fever, jaw claudication+/- fever, jaw claudication• ESR > 50ESR > 50• DiagnosisDiagnosis
– Superficial temporal artery biopsySuperficial temporal artery biopsy
• TreatmentTreatment– Prednisone 60 -100 mgm dailyPrednisone 60 -100 mgm daily
Meningeal IrritiationMeningeal Irritiation
• Meningitis and subarachnoid Meningitis and subarachnoid hemorrhagehemorrhage
• Occurs due to inflammation and Occurs due to inflammation and intracranial pain sensitiveintracranial pain sensitive
• structures.structures.• Subarachnoid hemorrhage - sudden Subarachnoid hemorrhage - sudden
onset meningitisonset meningitis• Meningitis - more gradual.Meningitis - more gradual.
Meningeal IrritiationMeningeal Irritiation
• Occipital and nuchal pain.Occipital and nuchal pain.• Interscapular and low back pain.Interscapular and low back pain.• Aggravated by movementsAggravated by movements• Photophobia, vomitingPhotophobia, vomiting• FeverFever• DiagnosisDiagnosis• History and physicalHistory and physical• CT LPCT LP
Headache and Headache and Brain tumorBrain tumor
• Traction on intracranial pain sensitive Traction on intracranial pain sensitive structures.structures.
• Progressively worsening headache.Progressively worsening headache.
• Morning headaches.Morning headaches.
• Worsen in head down position.Worsen in head down position.
• Worsen with cough and strainingWorsen with cough and straining
• May be localized (constant).May be localized (constant).
• Focal neurologic signs.Focal neurologic signs.
Benign Headaches Hierarchy of Treatment
• Acute Treatment– Low tech first– Prevention– Acetaminophen alternate with NSAID– Adequate doses and timing according to body
weight– Avoid codeine
Hierarchy of Treatment
Acetaminophen/NSAIDSAcetaminophen/NSAIDS
Muscle Relaxants/Topiramate/ValproateMuscle Relaxants/Topiramate/Valproate
Narcotics/Steroids/OxygenNarcotics/Steroids/Oxygen
Triptans/ChlorpromazineTriptans/Chlorpromazine
Hierarchy of Prevention
Risk Factors – Headache DiaryRisk Factors – Headache Diary
Alcohol/Foods/Sleep deprivation/Meals/Stress management/Repetitive Stress Alcohol/Foods/Sleep deprivation/Meals/Stress management/Repetitive Stress injuryinjury
Amitriptyline/Beta blockers/pizotyline/SingulairAmitriptyline/Beta blockers/pizotyline/Singulair
Lithium/DBSLithium/DBS
Valproate/ChlorpromazineValproate/Chlorpromazine
Case Case
• 22 year old man develops double vision 22 year old man develops double vision especially when looking up or to either sideespecially when looking up or to either side• He has noted some increased fatiguability of his He has noted some increased fatiguability of his musclesmuscles• EOM shown in videoEOM shown in video• Exam otherwise normalExam otherwise normal
Case Case
• He is then given 10 mgm of IV Tensilon He is then given 10 mgm of IV Tensilon (Edrophonium)(Edrophonium)
• His extra ocular movements are then His extra ocular movements are then reexaminedreexamined
Case Case
• Where is the lesion?Where is the lesion?
• What other tests might be used?What other tests might be used?
• What is the commonest treatment?What is the commonest treatment?
• What are the long term risks of the disease?What are the long term risks of the disease?
Myasthenia GravisDefinition
* Autoimmune disease with destruction Of neuromuscular junctions
* Symptoms
- Progressive fatigibility over time
Myasthenia GravisSymptoms
* Progressive fatigibility over time
* Double vision
* Drooping of eyelid(s)
* Difficulty swallowing
* Change in voice
* Difficulty breathing
Myasthenia GravisSigns
* Weakness of eyes movements
* Weakness of facial muscles
* Weakness of swallowing, cough
Or gag
* Weakness of limbs
* No sensory loss
Myasthenia Gravis
Myasthenia GravisInvestigations
• Tensilon Test
• EMG
• Anti-acetylcholine receptor antibodies
Myasthenia GravisTreatment
• Mestinon (pyridostigmine)
• Steroids
• IV IgG
• Plasma exchange
• Thymectomy
CASE
This 65 year old man present with acute This 65 year old man present with acute aphasia and right sided weakness.aphasia and right sided weakness.
On examination, he has a right facial droop, On examination, he has a right facial droop, weakness of the right arm greater than the leg weakness of the right arm greater than the leg and global aphasia.and global aphasia.
Where is the lesion ?Where is the lesion ?
What is the etiology ?What is the etiology ?
CT Scans
Left ACA and MCA Territory Infarction
CT Scans
Left Carotid StenosisLeft Carotid Stenosis
AngiogramAngiogram PathologyPathology
StrokeStroke
• 50,000 new cases per year50,000 new cases per year
• #3 cause of death#3 cause of death
Risk FactorsRisk Factors
• age - doubles every decade after 55 yearsage - doubles every decade after 55 years• sex - males 25% greater than femalessex - males 25% greater than females• blood pressure - 5 timesblood pressure - 5 times• CholesterolCholesterol• Sleep apnea – 3 –4 timesSleep apnea – 3 –4 times• smoking - 4 timessmoking - 4 times• alcohol abuse - 3 timesalcohol abuse - 3 times• diabetes - 3 timesdiabetes - 3 times• homocysteinhomocystein
DefinitionDefinition
• Transient ischemic attackTransient ischemic attack– Focal cerebral ischemic event resolving Focal cerebral ischemic event resolving
within 24 hourswithin 24 hours
• Completed StrokeCompleted Stroke– No resolution of symptomsNo resolution of symptoms
Causes of StrokeCauses of Stroke
• 85% infarct -85% infarct -– 60% cerebral atherosclerosis60% cerebral atherosclerosis– 20% lacunar20% lacunar– 15 cardiogenic emboli15 cardiogenic emboli
• 15% hemorrhage – 15% hemorrhage – – intracerebralintracerebral– subarachnoid hemorrhagesubarachnoid hemorrhage
Cerebral Circulation 2 Vertebral Arteries Basilar• 2 Carotid Arteries• Circle of Willis
CT Angiogram
Vascular DistributionVascular Distribution
LacuneLacune
• Fibrinoid degeneration of penetrating Fibrinoid degeneration of penetrating arteriesarteries
• Most commonly due to hypertensionMost commonly due to hypertension
• Involves deep white matter pens and Involves deep white matter pens and basal gangliabasal ganglia
Cardiogenic EmholiCardiogenic Emholi
• NVAF -45%.NVAF -45%.
• IHD - acute MI -15%IHD - acute MI -15%
• - ventricular aneurysm -10%- ventricular aneurysm -10%
• RHD -10%RHD -10%
• Prosthetic valve -10%Prosthetic valve -10%
• Other -10%.Other -10%.
Stroke SyndromesStroke SyndromesCarotid CirculationCarotid Circulation
Internal Cerebral ArteryInternal Cerebral Artery
• HemiplegiaHemiplegia
• Hemisensory lossHemisensory loss
• Aphasia (L)Aphasia (L)
• Neglect (R)Neglect (R)
Anterior Cerebral arteryAnterior Cerebral artery
• Contralateral lower limb paresis and Contralateral lower limb paresis and hyperreflexiahyperreflexia
• upper limb relatively sparedupper limb relatively spared
PCA Infarct
Vertebrobasilar CirculationVertebrobasilar Circulation
• Multiple stroke syndromes depending on Multiple stroke syndromes depending on vessels in sitevessels in site
• DysarthriaDysarthria
• AtaxiaAtaxia
• Bilateral weaknessBilateral weakness
• Bilateral sensory complaintsBilateral sensory complaints
• Bilateral visual complaintsBilateral visual complaints
Pontine InfarctPontine InfarctLocked-In SyndromeLocked-In Syndrome
Lacunar InfarctLacunar Infarct
• Multiple stroke syndromes but in general Multiple stroke syndromes but in general produces pure motor or pure sensory produces pure motor or pure sensory strokestroke
Isolated Symptoms Rarely due Isolated Symptoms Rarely due to Stroke or TIAto Stroke or TIA
• Vertigo. dizzinessVertigo. dizziness
• DiplopiaDiplopia
• Loss of consciousnessLoss of consciousness
• ConfusionConfusion
Differential DiagnosisDifferential Diagnosis
• Transient Ischemic attackTransient Ischemic attack
• Focal seizureFocal seizure
• HypoglycemiaHypoglycemia
• Carpal tunnel syndromeCarpal tunnel syndrome
• MigraineMigraine
• HysteriaHysteria
Ddx Vertebrobasilar TIADdx Vertebrobasilar TIA
• SyncopeSyncope
• LabyrinthitisLabyrinthitis
• Myasthenia gravisMyasthenia gravis
• Meniere's diseaseMeniere's disease
InvestigationInvestigation
• CT, CTA, CT perfusion CT, CTA, CT perfusion
• MRI/MR angiogram MRI/MR angiogram
• CBC. differential and plateletsCBC. differential and platelets
• INR, PTTINR, PTT
• Cholesterol, triglycerideCholesterol, triglyceride
• DopplerDoppler
• EchocardiogramEchocardiogram
Vertebrobasilar CirculationVertebrobasilar Circulation
• As above but no DopplerAs above but no Doppler
• TreatmentTreatment
• Prevention:Prevention:
• Controlled risk factorsControlled risk factors
Carotid CirculationCarotid Circulation
• If no severe carotid stenosis or cardiac embolusIf no severe carotid stenosis or cardiac embolus• antiplatelet agents. specifically aspirin, Plavix antiplatelet agents. specifically aspirin, Plavix
or Ticlid.or Ticlid.• Cardiac embolus is treated with CoumadinCardiac embolus is treated with Coumadin• Carotid stenosis severe than 70% is treated Carotid stenosis severe than 70% is treated
with carotid endarterectomy or angioplasty with carotid endarterectomy or angioplasty and stentingand stenting
• Risk factor managementRisk factor management
Acute ThrombolysisAcute Thrombolysis
PrePre
PostPost
Treatment of Acute Stroke
• NINDS protocol– < 3 hours since onset– < 1/3 of MCA territory– No recent bleeding or surgery– IV r-tpa and/or intraarterial tpa angioplasty,
stent
Brain AttackDistribution of Hemorrhages
Case History
• 22 yr old male assaulted in a bar at 2400 hrs
• Had been drinking
• Loss of consciousness ??
• Vomited twice
• Brought to ED by car at 0100
• “Alert and oriented” x3 @ RN
Case cont’d
• Seen by EP at 0230:– ambulatory; not distressed– GCS 15– amnesia x 5 min before injury– object recall 3/3– forehead contusion but no signs of open or
basilar #
Case cont’d
What would you do?
a) observe overnight
b) do CT scan immediately
c) do CT scan in a.m.
d) discharge home with head injury sheet
Case cont’d
• Discharged home with friends
• Returned 36 hrs later c/o headache and dizziness
• Ambulatory; not distressed
• GCS 15
• Neurologically intact
• CT ordered
Skull fracture
epiduralWhat would be the symptoms and signs? What would be the treatment?
ACUTE EPIDURAL HEMATOMA • Note the biconvex
hyperdense area (arrows). The blood collection is between the skull and dura.
• It crosses dural attachments, but not sutures. The etiology is secondary to a lacerated meningeal artery or dural sinus.
• The Subdural windows may help to discern extra-axial collections such as blood in this case.
ACUTE SUBDURAL HEMATOMA WITH SUBFALCINE HERNIATION
• The arrow heads point to the presence of subfalcine herniation (midline shift). This is secondary to the mass effect caused by the moderate sized acute subdural hematoma (arrow) overlying the right fronto-temporal convexity.
Acu
te o
n c
hro
nic
SD
H What would be the symptoms and signs? What would be the treatment?
RIGHT FRONTAL PETECHIAL HEMORRHAGIC CONTUSION
• Contusions may be hemorrhagic or nonhemorrhagic. They are part of the spectrum of cranio-cerebral trauma. Although there is no obvious mass effect, and there may not be neurologic deficits solely due to the presence of this particular lesion, there are usually areas of associated brain injury known as diffuse axonal injury (DAI) which may account for more severe neurologic deficits.
• An MRI will demonstrate more subtle anomalies which cannot be demonstrated on CT scan examination.
Subdural hematomaSubdural hematoma
• Drowsiness. headacheDrowsiness. headache
• Evolves over days to weeksEvolves over days to weeks
• History of head trauma not always History of head trauma not always presentpresent
Subdural HematomaSubdural Hematoma
Case
• 24 year old woman presents with decreased vision in right eye
• No history of recent febrile illness
• Exam shows decreased colour vision in right eye and bilateral hyperreflexia
• Where is the lesion?
Multiple SclerosisMultiple SclerosisMRIMRI
Demyelinating DiseaseDemyelinating DiseaseClassificationClassification
• Multiple sclerosis.Multiple sclerosis.
• Diffuse cerebral sclerosis.Diffuse cerebral sclerosis.
• Post viral or post vaccinial disseminated Post viral or post vaccinial disseminated encephalomyelitis.encephalomyelitis.
• Necrotizing hemorrhagic encephalomyelitis.Necrotizing hemorrhagic encephalomyelitis.
• Metabolic toxicMetabolic toxic
• postanoxic encephalopathypostanoxic encephalopathy
• CPMCPM
Dvsmvelinating DisordersDvsmvelinating Disorders
• ALDALD
• MLDMLD
• Krabbe'sKrabbe's
• Canavan'sCanavan's
• Chediak HigashiChediak Higashi
• Neuraxonal dystrophyNeuraxonal dystrophy
• Pelazeus MerzbacherPelazeus Merzbacher
Multiple SclerosisMultiple Sclerosis
• Dissemination of lesions in time and spaceDissemination of lesions in time and space
• MacDonald CriteriaMacDonald Criteria
• EDSS or Kurtze ScaleEDSS or Kurtze Scale
• Prevalence 0.1%Prevalence 0.1%
• Female:male = 3:2Female:male = 3:2
• 20 to 40 years old (peak age 28 years)20 to 40 years old (peak age 28 years)
The Expanded Disability Status Scale (EDSS), or Kurtzke scale, gauges the extent of a person's disability by measuring the level of neurologic impairment. Following is a breakdown
of the EDSS:
• 0 – 1 No disability, minimal signs on one FS* (functional system)• 1 – 2 Minimal disability in 1 FS• 2 – 3 Moderate disability in 1 FS or mild disability in 3-4 FS, though fully
ambulatory• 3 – 4 Fully ambulatory without aid, up and about 12 hours/day, despite
relatively severe disability; able to walk without aid for 500 meters• 4 – 5 Ambulatory without aid for about 200 meters; disability impairs full
daily activities• 5 – 6 Intermittent or unilateral constant assistance required to walk 100
meters with or without resting• 6 – 7 Unable to walk beyond 5 meters even with aid, essentially restricted
to wheelchair, wheels self, transfers alone• 7 – 8 Essentially restricted to bed or chair or perambulated in wheelchair,
but may be out of bed much of day; retains self-care functions, generally effective use of arms
• 8 – 9 Helpless bed patient, can communicate and eat• 9 - 9.5 Unable to communicate effectively or eat/swallow• 10 Death due to multiple sclerosis
Practical use of MRI in the diagnosis and management of patients with
MS
Key Features for the Diagnosis of MS
• Dissemination in time and space of lesions typical of MS
• Exclusion of other better explanations for the clinical features
Lesions in Space
• Clinical evidence must be an objective sign
• MRI evidence should meet 3 out of 4 Barkhof criteria
(minimum of 2 to 9 lesions depending on use of gadolinium and location of lesions), or
2 lesions and abnormal CSF
Lesions in TimeClinical attacks should be: • >24 hours duration and separated by > 30 days• Consistent with demyelination• Not a pseudoattack • Requires an objective finding
MRI attacks can be: • A new gadolinium enhancing lesion or • A new T2 lesion • Separated by > 3 months from clinical event
Paraclinical TestsMRI
Most sensitive and specific
Visual evoked potentials Can be used as objective clinical evidence Delayed with preserved wave form
CSF required for:Equivocal MRIPPMS diagnosisUnusual clinical picture
What is a Positive MRI (Barkhof Criteria)?
3 out of 4 of the following:• 9 T2 lesions or 1 Gad-enhancing lesion• 1 infratentorial lesion• 1 juxtacortical lesion• 3 periventricular lesion
Minimum lesions required 5 (2 if Gad used)
Note: 1 spinal cord lesion = 1 brain lesion
What is MRI Evidence for Dissemination in Time?
At least 3 months after the clinical attack:1 Gad-enhancing lesion
At least 3 months after the last MRI scan:1 new T2 lesion or 1 Gad-enhancing lesion
Definite MS (DMS) Requirements:
2 Clinical attacks2 objective signs
1 objective sign
0–1 MRI required None ― but recommended
(Caution if MRI and CSF are normal)
3 of 4 Barkhof criteria
or 2 MRI lesions and abnormal CSF
1 Clinical attack2 objective signs
1 objective sign
1–3 MRIs required Gd lesion > 3 months after clinical attack
orNew T2 or Gd lesion > 3 months after 1st MRI
2–3 MRIs required Positive 1st MRI AND Gd lesion > 3 months
after clinical attack
TreatmentTreatment• Acute AttacksAcute Attacks• Steroids.Steroids.
– SolumedrolSolumedrol– Prednisone not for optic neuritisPrednisone not for optic neuritis
• ProphylaxisProphylaxis– Beta interferonBeta interferon– CopolymerCopolymer– MitoxandroneMitoxandrone– NatalizumabNatalizumab
• SymptomaticSymptomatic• SpasticitySpasticity
– BaclofenBaclofen– DantriumDantrium– BenzodiazepinesBenzodiazepines
TreatmentTreatment
• Paroxysmal DisordersParoxysmal Disorders– TegretolTegretol– DilantinDilantin
• Bladder DysfunctionBladder Dysfunction– Anticholinergic drugs eg. (Ditropan)Anticholinergic drugs eg. (Ditropan)– Antibiotic treatmentAntibiotic treatment
• DepressionDepression– Tricyclic antidepressantsTricyclic antidepressants
• FatigueFatigue– AmantidineAmantidine
Seizures
• Seizures originate from the cortex
• Case
Simple Partial Seizures.Simple Partial Seizures.
1. motor1. motor
2. somatosensory or special sensory2. somatosensory or special sensory
3. autonomic3. autonomic
4. psychic4. psychic
Complex Partial SeizuresComplex Partial Seizures
• Partial seizure with altered awarenessPartial seizure with altered awareness
• SP -CPSP -CP
• CPCP
• + automatisms.+ automatisms.
Partial SeizuresPartial Seizures - to secondary generalization - to secondary generalization
• SP-GTCSP-GTC
• CP - GTCCP - GTC
• SP -CP-GTCSP -CP-GTC
Generalized Seizures Generalized Seizures (convulsive and non convulsive)(convulsive and non convulsive)• AbsenceAbsence
– TypicalTypical
– AtypicalAtypical
• MyoclonicMyoclonic• ClonicClonic• TonicTonic• Tonic-clonicTonic-clonic• Atonic.Atonic.
HistoryHistory• How did the seizure startHow did the seizure start
– staringstaring
– eye deviationeye deviation
– jerking or one limbjerking or one limb
• Patient's description of auraPatient's description of aura• Post ictal statePost ictal state• Age of onsetAge of onset• Family historyFamily history• Past historyPast history• Alcohol or drug abuseAlcohol or drug abuse
Physical ExamPhysical Exam
• Todds paralysisTodds paralysis
• Eye deviationEye deviation
• Cranial bruitCranial bruit
• HyperventilationHyperventilation
• Skin examinationSkin examination
• IncontinenceIncontinence
InvestigationInvestigation
• Glucose. BUN, Calcium. SodiumGlucose. BUN, Calcium. Sodium
• CT, MRICT, MRI
• EEGEEG
TreatmentTreatmentPartial SeizuresPartial Seizures
• CarbamazepineCarbamazepine
• PhenytoinPhenytoin
• PrimidonePrimidone
• PhenobarbitalPhenobarbital
• Valproic AcidValproic Acid
Tonic ClonicTonic Clonic
• Valproic acidValproic acid
• CarbamazepineCarbamazepine
• PhenytoinPhenytoin
• PhenobarbitalPhenobarbital
• PrimidonePrimidone
AbsenceAbsence
• ValproateValproate
• EthosuximideEthosuximide
MvoclonicMvoclonic
• ValproateValproate
• ClonazepamClonazepam
• NitrazepamNitrazepam
Add On Meds
• Gabapentin
• Lamictal
• Vigabatrin
• Topiramate
CASE
• This 23 year gay man has had progressive This 23 year gay man has had progressive cognitive impairment in the last 3 months cognitive impairment in the last 3 months which has been complicated by PCP which has been complicated by PCP pneumonia from which he is recovering.pneumonia from which he is recovering.
• On examination, he has general mental On examination, he has general mental slowing with some tremor in the left upper slowing with some tremor in the left upper limb. limb.
• Where is the lesion ?Where is the lesion ?
CT ScanCT Scan
DementiaDementia• A loss of intellectual ability of sufficient A loss of intellectual ability of sufficient
severity to interfere with social or occupational severity to interfere with social or occupational functioning.functioning.
• Memory impairment.Memory impairment.• At least one of:At least one of:
– impaired abstract thinkingimpaired abstract thinking
– Impaired judgementImpaired judgement
– Other disturbances of higher cortical functioning -Other disturbances of higher cortical functioning -
– aphasia. apraxia, agnosia. constructional difficultyaphasia. apraxia, agnosia. constructional difficulty
– Personality changePersonality change
IrreversibleIrreversible
• Alzheimer’s Disease, Frontotemporal Dementia Alzheimer’s Disease, Frontotemporal Dementia (tauopathies)(tauopathies)
• MSA, PD, CBD, Lewy Body (synucleinopathies)MSA, PD, CBD, Lewy Body (synucleinopathies)• HIVHIV• MIDMID• PrionopathiesPrionopathies
– CJDCJD
– CJDvCJDv
– Gerstmann-Straussler-SkenkerGerstmann-Straussler-Skenker
– Fatal Familial InsomniaFatal Familial Insomnia
Reversible• Drugs
– Alcohol, alcohol, alcohol
• Metabolic– B12– T4
• Infectious– Syphilis
• SOL– Subdural– Meningioma
• NPH• Sleep Apnea• Pseudodementia
Alzheimer's DiseaseAlzheimer's Disease
• 50 to 60% of cases of dementia.50 to 60% of cases of dementia.
• Greater than 65 years old - Greater than 65 years old - – prevalence 1-6%.prevalence 1-6%.
• 4th most common cause of death4th most common cause of death
Diagnostic CriteriaDiagnostic Criteria"Probable (clinically ascertained) "Probable (clinically ascertained)
A.D.A.D.• DementiaDementia
• Onset 40 to 90 yearsOnset 40 to 90 years
• Deficits present in greater than 2 Deficits present in greater than 2 cognitive spherescognitive spheres
• Progressive deterioration.Progressive deterioration.
• No disturbance of consciousness.No disturbance of consciousness.
• No other illness to account for symptoms.No other illness to account for symptoms.
"Definite" (pathologicallv confirmed) "Definite" (pathologicallv confirmed) ADAD
• Clinical criteria.Clinical criteria.
• Histopathological evidence.Histopathological evidence.– neurofibrillary tanglesneurofibrillary tangles– neuritic plaquesneuritic plaques– granulovacular degenerationgranulovacular degeneration– Hirano bodiesHirano bodies
Alzheimer’s DiseaseAlzheimer’s DiseasePathophysiologyPathophysiology
• Acetylcholine (memory)Acetylcholine (memory)– Nucleus Basalis of MeynertNucleus Basalis of Meynert– diagonal band of Brocadiagonal band of Broca– medial septal nucleimedial septal nuclei
Multi-Infarct DementiaMulti-Infarct Dementia
• Greater than 50-100% of cerebral Greater than 50-100% of cerebral hemisphere destroyedhemisphere destroyed
• Multiple strokes involving both Multiple strokes involving both hemisphereshemispheres
• Bilateral pyramidal signsBilateral pyramidal signs
• Pseudobulbar signsPseudobulbar signs
Vitamin B12 DeficiencyVitamin B12 Deficiency
• Insidious onsetInsidious onset
• May have normal smear and normal May have normal smear and normal neurologic exam except for dementianeurologic exam except for dementia
• Look for paresthesias plus signs of dorsal Look for paresthesias plus signs of dorsal column and corticospinal tract column and corticospinal tract involvement.involvement.
Normal Pressure Normal Pressure HydrocephalusHydrocephalus
• TriadTriad– AtaxiaAtaxia– IncontinenceIncontinence– DementiaDementia
• 6-12 months• usually idiopathic• CSF Pressure Measurements• CT and RISA• Rx - VP shunt
DepressionDepression" Pseudodementia"" Pseudodementia"
• Commonly have history of previous Commonly have history of previous psychiatric disorder.psychiatric disorder.
• Brief duration.Brief duration.• Complaint of cognitive deficit but make Complaint of cognitive deficit but make
little effort to performlittle effort to perform• even with simple tasks.even with simple tasks.• Frequent "don't know" answers.Frequent "don't know" answers.• Associated features of depression.Associated features of depression.
Creutzfeldt-Jacob DiseaseCreutzfeldt-Jacob Disease
• Onset to death usually months.Onset to death usually months.
• Dementia. myoclonus. UMN. basal Dementia. myoclonus. UMN. basal ganglia.ganglia.
• Characteristic EEG - periodic discharge Characteristic EEG - periodic discharge 1/sec,1/sec,
• Caused by prionsCaused by prions
Environmental FactorsEnvironmental Factors
• Head traumaHead trauma
• Infectious agentsInfectious agents
• NeurotoxinsNeurotoxins
• AlcoholAlcohol
Down's Syndrome and ADDown's Syndrome and AD
• Neuropathologic similaritiesNeuropathologic similarities
• Role of chromosome 21Role of chromosome 21
InvestigationInvestigation
• CT, MRICT, MRI
• EEGEEG
• B12. folateB12. folate
• CBC, differential. plateletsCBC, differential. platelets
• VDRLVDRL
• Thyroid function testsThyroid function tests
• BUN. creatinine.BUN. creatinine.
InvestigationInvestigation
• AST. ALTAST. ALT
• LytesLytes
• ESRESR
• CXRCXR
• Neuropsychological testingNeuropsychological testing
• Lumbar punctureLumbar puncture
Case 6
• This 28 year old man presented with a three week history of a headache and weakness on the left side
• The day of admission he suffered a generalized seizure which was characterized by initial twitching to the left side of the face
Case 20Case 20
• Neuro exam showsNeuro exam shows• InattentiveInattentive• Left facial weaknessLeft facial weakness• Mild left upper and lower limb weakness Mild left upper and lower limb weakness
and hyperreflexiaand hyperreflexia• Normal sensationNormal sensation• Decreased RAM of left upper and lower Decreased RAM of left upper and lower
limbslimbs
Where is the lesion?Where is the lesion?
CT ScanCT Scan
Brain TumorsBrain TumorsGBMGBM
Meningioma
Brain TumorsBrain TumorsMedulloblastomaMedulloblastoma
TumorTumor
• Often in frontal lobe.Often in frontal lobe.
• Grasp, suck. snout reflexesGrasp, suck. snout reflexes
• "slowness" in carrying out tasks"slowness" in carrying out tasks
• Impaired smellImpaired smell
• Tumors obstructing 3rd or 4th ventriclesTumors obstructing 3rd or 4th ventricles
Case 19Case 19
• This 70 year old lady noted a 9 month This 70 year old lady noted a 9 month history of tremors and clumsiness in both history of tremors and clumsiness in both her hands and feether hands and feet
• Physical examPhysical exam– See videoSee video
Parkinson’s DiseaseParkinson’s Disease
• 70 to 80 years old70 to 80 years old
• rarely less than 40 years oldrarely less than 40 years old
• 1/1.0001/1.000
Cardinal FeaturesCardinal Features
• a. tremor.a. tremor.
• b. rigidityb. rigidity
• c. bradykinesiac. bradykinesia
• d. postural instabilityd. postural instability
TremorTremor
• resting tremorresting tremor
• "pill rolling""pill rolling"
• 5 to 6 Hz5 to 6 Hz
• unilateral earlyunilateral early
• increases with stressincreases with stress
• decreases with movementdecreases with movement
RigidityRigidity
• "lead pipe""lead pipe"– bilateralbilateral– 1 side greater than the other1 side greater than the other
BradykinesiaBradykinesia
• masked faciesmasked facies
• decreased blink frequencydecreased blink frequency
• decreased rapid alternating movementsdecreased rapid alternating movements
• decreased extraocular movementsdecreased extraocular movements
• hypophonia, palilalia. aprosodyhypophonia, palilalia. aprosody
• sialorrheasialorrhea
• micrographiamicrographia
BradykinesiaBradykinesia
• decreased spontaneous movementdecreased spontaneous movement• difficulty rising from chair or rolling difficulty rising from chair or rolling
over in bedover in bed• slow ADLslow ADL• characteristic stooped gait with small characteristic stooped gait with small
stepssteps• and decreased arm swingand decreased arm swing• "freezing"freezing
Postural instabilityPostural instability
• retropulsionretropulsion
• festinationfestination
• sit "en bloc"sit "en bloc"
• fallingfalling
Clinical StagesClinical StagesStage IStage I
• Mild unilateral tremor or rigidity with or Mild unilateral tremor or rigidity with or without bradykinesiawithout bradykinesia
Stage IIStage II
• Moderate bilateral tremor or rigidity and Moderate bilateral tremor or rigidity and bradykinesia.bradykinesia.
Stage IIIStage III
• Significant tremor. rigidity and or Significant tremor. rigidity and or bradykinesia plus impairedbradykinesia plus impaired
• postural reflexespostural reflexes
• gait disturbance, mild daily fluctuations gait disturbance, mild daily fluctuations +- dementia+- dementia
Stage IVStage IV
• Severely disabled but still mobile and Severely disabled but still mobile and able to functionable to function
• independently - with or without daily independently - with or without daily periods of completeperiods of complete
• immobility; +- dementiaimmobility; +- dementia
Stage VStage V
• Loss of ability to function independentlyLoss of ability to function independently
Autonomic dysfunctionAutonomic dysfunction
• constipationconstipation
• dysphagiadysphagia
• neurogenic bladderneurogenic bladder
• droolingdrooling
• orthostatic hypotensionorthostatic hypotension
• diaphoresisdiaphoresis
Primary sensory symptomsPrimary sensory symptoms
• vague parasthesiavague parasthesia
EtiologyEtiology
• Abnormal processing of synuclein Abnormal processing of synuclein proteinprotein
• ToxinsToxins
• Infectious agentsInfectious agents
• Immunological factorsImmunological factors
• Genetic factorsGenetic factors
• MPTPMPTP
PathophysiologyPathophysiology
• Progressive loss of presynaptic Progressive loss of presynaptic dopaminergic neurons in the substantia dopaminergic neurons in the substantia nigranigra
• cortical pathological changes like AD in cortical pathological changes like AD in 50%.50%.
• Changes in post synaptic striatal dopamine Changes in post synaptic striatal dopamine receptorsreceptors
TreatmentTreatmentMild DisabilityMild Disability
• AnticholinergicAnticholinergic
• AmantadineAmantadine
• SelegilineSelegiline
Moderate DisabilityModerate Disability
• L-DopaL-Dopa
• RopineroleRopinerole• PramipexolePramipexole
Severe DisabilitySevere Disability
• Increased doses of L-Dopa and Increased doses of L-Dopa and Dopamine AgonistDopamine Agonist
• COMT InhibitorCOMT Inhibitor
Long Term Complications of Long Term Complications of Treatment with L-DopaTreatment with L-Dopa
• DyskinesiaDyskinesia
• Daily fluctuations in level of functionDaily fluctuations in level of function– End of dose deteriorationEnd of dose deterioration– freezing episodesfreezing episodes– "on-off" phenomenon"on-off" phenomenon
• Dementia and drug induced confusionDementia and drug induced confusion
• Progressive drug failure.Progressive drug failure.
Case StudyCase Study
• 34 year old woman with one year history of difficulties with voice and swallowing with weakness in right hand
Case Case ExamExam
• Cranial NervesCranial Nerves• DysarthriaDysarthria• Fasciculations of tongueFasciculations of tongue
• MotorMotor– Upper and lower limb weakness and wastingUpper and lower limb weakness and wasting– Upper and motor limb hyperreflexiaUpper and motor limb hyperreflexia
• SensorySensory– NormalNormal
Case Case
• Where is the lesion?Where is the lesion?
• What is the cause?What is the cause?
• What is the prognosis?What is the prognosis?
Amyotrophic Lateral Sclerosis (ALS)
Natural History * Progressive asymmetrical muscular Wasting and weakness
* Initially weakness begins in one or Two muscles
* Adjacent muscles intact and Compensating for weakness Of involved muscles
* Hyperexcitability of involved Muscles associated with Muscle cramps and fasciculation
Amyotrophic Lateral Sclerosis (ALS)
Natural History * PROGRESSIVE COURSE LEADING TO DEATH* PROGRESSIVE COURSE LEADING TO DEATH MONTHS TO YEARS UNTIL COMPLETEMONTHS TO YEARS UNTIL COMPLETE PARALYSISPARALYSIS
* RANGE 1 TO 15 YEARS* RANGE 1 TO 15 YEARS
* 50% DIE WITHIN 4 YEARS* 50% DIE WITHIN 4 YEARS
* 20% LIVE FOR FIVE YEARS* 20% LIVE FOR FIVE YEARS
* 10% LIVE FOR TEN YEARS* 10% LIVE FOR TEN YEARS
* AGE LESS THAN 65 AVERAGE* AGE LESS THAN 65 AVERAGE DURATION OF LIFE 3 YEARSDURATION OF LIFE 3 YEARS
* AGE GREATER THAN 65, AVERAGE* AGE GREATER THAN 65, AVERAGE DURATION OF LIFE 2 YEARSDURATION OF LIFE 2 YEARS
Amyotrophic Lateral SclerosisNatural History
* Apparent stabilization of the Disease may be compensation By other muscle groups
* Age of onset more than 50 years Median age of onset 55
* Rarely develops before age 30
* Median age seems to be increasing
ALS ALS SignsSigns
• In pseudobulbar group, disorders of pursuit movements are common
• Minor losses of sensory function
• Little involvement of autonomic system
• Dementia is uncommon, unless age or
• Premiered dementia cause co-existence of ALS and dementia
ALS ALS SignsSigns
* Atrophic weak limb with hyperreflexia
* Mixture of upper and lower Motor neuron signs, Characteristic of bulbar form
* Hyperactive jaw jerk with a sucking Reflex, common in bulbar form
* Pseudobulbar emotional incontinence
* Paralysis of extraocular movement or loss of bowel and bladder Continence
Amyotrophic Lateral SclerosisSymptoms
* No pattern to site of onset
* Fatiguability early complaint
* Hyperactive DTRs with spasticity
Amyotrophic Lateral SclerosisSymptoms
* Asymmetrical fatigue,cramping, Fasciculations, weakness And atrophy of muscles
* Atrophied and normal muscles may Be found adjacent in the same limb
* When disease begns in the muscles Of the tongue,lips and throat, Limb weakness is usually not present Initially but progresses later
* Early recognition of bulbar symptoms
ALS Signs
* Minor losses of sensory function
* Little involvement of autonomic system
* Dementia is uncommon,unless age or Premorbid dementia cause co-existence Of als and dementia
ALSTreatmen
t * Supportive
* Prevention of complications
* Respiratory - Pneumonia - Tracheostomy - Ventilation
* Nutrition - Feeding tube
* Musculoskeletal - Splints - Contractures
ALSTreatmen
t
* Social
- Acceptance of diagnosis - Early decisions re: trach and Ventilator - Support of dying patient
Case Study
• 30 year old male referred for evaluation• Fell asleep while driving causing an accident• Occurred in early afternoon• Snores at night, witnessed apneas in sleep• BMI 33.9• Normal - Neuro exam• Thick neck, redundant soft palate
Obstructive Sleep ApneaClinical Features
Middle Aged MalesExcessive Daytime Sleepiness (EDS)
Snoring - Loud, Gutteral, Inspiratory
Observed Respiratory Pauses in Sleep
Irresistable Sleep Attacks
Behavioral Automatisms With Amnesia
Marked Nocturnal Movement
Enuresis
Morning Headache
Late Cyanosis
Polycythemia
Edema
Dyspnea
Nocturnal Death
Pickwickian Syndrome
The Sleep Apnea Syndromes
• Apnea defined as cessation of airflow at the nostrils and mouth lasting ten seconds or more
• Obstructive secondary to sleep induced airway obstruction
• Central apnea due to decrease activity of muscles of respiration
• Mixed apnea from a combination of both
Sleep Apnea
• Nasal-CPAP improves EDS• Effect is objectively measurable with the multiple
sleep latency test (MSLT)• Epworth Score Increased • Adult prevalence of sleep apnea/hypopnea
syndromes is about 2-4%.• Bed partner best witness• Cofactors:BMI, use of alcohol,CNS depressants • PSG confirmation
Risk Factors
Obesity
Micrognathia
Enlarged Tonsils and Adenoids
Enlarged Thyroid
Acromegaly (enlarges tongue)
Nasal Septal Defects
Neuromuscular Disease
Miscellaneous:Assoc’d With Narcolepsy-cataplexy (“-20%)
Relation to Sudden Infant Death Syndrome
Management• Causal
– weight loss– removal of T and A– mandibular advancement surgery
• Relieve obstruction– continuous nasal positive pressure in sleep– uvolo-palato-pharyngoplasty– tracheostomy
• Drugs – medroxyprogesterone - (pure Pickwickians)
Abstinence from alcohol, hypnotics, sedatives
Driving Recommendations for Patients With Obstructive Sleep Apnea
• Patients with obstructive sleep apnea (documented by a sleep study), who are compliant with CPAP or have had successful UPPP treatments should be safe to drive any type of motor vehicle.
Case Study
• 30 year old tow truck driver with history of EDS
• Episodes of uncontrolled sleepiness with paralysis
• Episodes of loss of posture with extreme emotion
• No family history
Case Study
• Neuro Exam – Normal• HLA-DQB1*0602 – pending
• Patients receives Letter from MTO suspending licence – unable to work, no private insurance
• OSS and MSLT ordered
MSLT PretreatmentMSLT Pretreatment
MSLT Post treatmentMSLT Post treatment
Narcolepsy
Cardinal symptoms– Sleep attacks and EDS– Cataplexy– Sleep paralysis– Vivid hypnagogic hallucinations
Ancilliary symptoms– “Microsleeps”– Automatic behavior– Memory problems– Visual problems– Non-restorative night sleep– Nightmares
Narcolepsy
• Genetics
• HLA Linkage - DQB1*0602 – same HLA relationship has also been observed
for essential hypersomnia (EHS).
Etiology
• Genetic and Sporadic Cases– Abnormal hypocretin receptor– HLA DR 15 (DR2), DQB1*0602
Sporadic alone (60% of cases)– Precipitating Factors
Irregular Prior Sleep/Wake Patterns Flu-like Illnesses
• Symptomatic Cases (Rare)– Demyelinating Disease– Tumoral – Post-traumatic (all in hypothalamus)
Treatment• CNS Stimulants for EDS
– methylphenidate– Amphethamines
• CNS Alerting Drugs– Modafinil
• REM Suppressants– tricyclics – clomipramine – desipramine – Imipramine– SSRIs– MAO inhibitors
• Experimental Drugs– gamma-hydroxybutyrate– zimelidine– naloxone
Driving recommendations for narcoleptic patients:
• Patients with a diagnosis of narcolepsy supported by a sleep study and with uncontrolled episodes of cataplexy during the past 12 months (with or without treatment) should not drive any type of motor vehicle.
• Patients with a diagnosis of narcolepsy supported by a sleep study and with uncontrolled daytime sleep attacks or sleep paralysis in the past 12 months (with or without treatment) should not drive any type of motor vehicle.
Occupational RiskOccurrence
• Sudden incapacitation –
• Cognitive Decline
• Psychomotor Slowing
• Secondary Complications
Occupational Risk Groups • Low
– Operators of Private Motor Vehicles– Office workers– Physicians– Retail Workers
• Intermediate– Taxis, ambulances, buses– Surgeons, EMT– Mechanics, electricians
• High– Pilots, divers, Drivers Class A, B, C, D– Chemical, nuclear industry– Operators of weapons of mass destruction
Huntington’s DiseaseHuntington’s Disease
• Prevalence 5-10/100,000Prevalence 5-10/100,000• Motor. cognitive and behavioural Motor. cognitive and behavioural
manifestationsmanifestations• Mean age of onset 36 years.Mean age of onset 36 years.• Duration 19 years.Duration 19 years.• Autosomal dominant with complete Autosomal dominant with complete
penetrancepenetrance• 10-15% -juvenile onset10-15% -juvenile onset
Huntington’s DiseaseHuntington’s Disease
• Westphal variantWestphal variant
• 90% from affected father90% from affected father
• 10-15% - greater than 55 years old10-15% - greater than 55 years old
• slower declineslower decline
NeuropathologyNeuropathology
• Caudate and putamenCaudate and putamen
• Atrophy. neuronal depletion. gliosisAtrophy. neuronal depletion. gliosis
• Decreased GABA and acetylcholineDecreased GABA and acetylcholine
Gene DefectGene Defect
• Short arm of chromosome 4Short arm of chromosome 4
ComaComa
• A. AirwayA. Airway
• B. BreathingB. Breathing
• C. CirculationC. Circulation
• Neurological ExaminationNeurological Examination
• 1. Respiration1. Respiration
• 2. Pupils, oculomotor function2. Pupils, oculomotor function
• 3. Skeletal motor3. Skeletal motor
RespirationRespiration
• Bilateral encephalopathy - Cheyne StokesBilateral encephalopathy - Cheyne Stokes
• Upper pens - hyperventilationUpper pens - hyperventilation
• Pontine tegmentum - apneustic breathingPontine tegmentum - apneustic breathing
• Lower pons - cluster breathingLower pons - cluster breathing
• Meduila - ataxic breathingMeduila - ataxic breathing
PupilsPupils
• Bilateral hemisphere diencephalonBilateral hemisphere diencephalon– Small reactiveSmall reactive
• III nerve. III nerve. – Uncal mass with herniationUncal mass with herniation
• Tectal - large fixedTectal - large fixed
• Midbrain - mid position. regular fixedMidbrain - mid position. regular fixed
• Pons -Small pinpoint.Pons -Small pinpoint.
Extra-Ocular MovementsExtra-Ocular Movements
• conjugateconjugate
• deviateddeviated
• skewskew
• bobbing; nystagmusbobbing; nystagmus
Reflex eye movementsReflex eye movements
• Doll's eyesDoll's eyes
• Calorics (COWS) Calorics (COWS)
• Dysconjugate -MLFDysconjugate -MLF
• Lost - brainstem nucleiLost - brainstem nuclei
Motor ResponsesMotor Responses• HemisphereHemisphere
– appropriate ipsilateralappropriate ipsilateral– flexion contralateralflexion contralateral
• Hypothalamus and midbrainHypothalamus and midbrain– decorticatedecorticate
• Lower midbrain - Lower midbrain - – decerebratedecerebrate
• Medulla - Medulla - – Flexion of upper limbs.Flexion of upper limbs.– rudimentary flexion of lower limbs.rudimentary flexion of lower limbs.
Differential Diagnosis of ComaDifferential Diagnosis of Coma
• Supratentorial mass lesions.Supratentorial mass lesions.
• Midbrain or pontine destructive lesions.Midbrain or pontine destructive lesions.
• Intratentorial mass lesions.Intratentorial mass lesions.
• Diffuse multifocal disorders.Diffuse multifocal disorders.
• PseudocomaPseudocoma
InvestigationsInvestigations
• Glucose, BUN. creatinine, Glucose, BUN. creatinine,
• Gas. ASTGas. AST
• LytesLytes
• Toxic screenToxic screen
• CTCT
• EEGEEG
• LPLP
SeizuresSeizures
• alcohol withdrawal seizuresalcohol withdrawal seizures
• 12 to 48 hrs following cessation of alcohol 12 to 48 hrs following cessation of alcohol intakeintake
• generalized tonic clonic seizuresgeneralized tonic clonic seizures
• 2-3 seizures2-3 seizures
• risk of delerium tremensrisk of delerium tremens
Neurology of AlcoholismNeurology of Alcoholism
• RUM fitsRUM fits
• Seizure induced by alcoholSeizure induced by alcohol
Seizure Induced by AlcoholSeizure Induced by Alcohol
• usually focalusually focal
• reflect intrinsic CNS diseasereflect intrinsic CNS disease
• often post traumatic due to multiple fallsoften post traumatic due to multiple falls
• rule out subdural hematoma and rule out subdural hematoma and meningitismeningitis
Wernickes EncephalopathyWernickes EncephalopathyDue to Thiamine DeficiencyDue to Thiamine Deficiency
• Ocular changesOcular changes– nystagmusnystagmus– 6th nerve palsy6th nerve palsy– paralysis of conjugate gazeparalysis of conjugate gaze
• AtaxiaAtaxia
• ConfusionConfusion
Korsokoff's PsychosisKorsokoff's Psychosis
• extension of confusion of Wernickesextension of confusion of Wernickes
• permanent severe memory impairment permanent severe memory impairment with confabulationwith confabulation
TreatmentTreatment
• Thiamine 100 mg IVThiamine 100 mg IV
• Repeat daily until patient is back on normal Repeat daily until patient is back on normal diet.diet.
• Intravenous glucose - always give with Intravenous glucose - always give with thiaminethiamine
• - glucose depletes thiamine stores and- glucose depletes thiamine stores and
• can give rise to Wernickes encephalopathycan give rise to Wernickes encephalopathy
PolyneuropathyPolyneuropathy
• Nutritional and toxicNutritional and toxic
• Distal weakness and paresthesiaDistal weakness and paresthesia
• TreatmentTreatment– dietdiet– abstinence from alcoholabstinence from alcohol– multivitaminsmultivitamins
Cerebellar DegenerationCerebellar Degeneration
• males more than femalesmales more than females
• trunchal ataxia and lower limb dysmetriatrunchal ataxia and lower limb dysmetria
• TreatmentTreatment– diet and vitamins.diet and vitamins.– abstinence from alcoholabstinence from alcohol
Delerium TremensDelerium Tremens
• 72 to 96 hours72 to 96 hours
• Severe tremulousnessSevere tremulousness
• Hallucinations - visual and auditoryHallucinations - visual and auditory
• autonomic hyperactivity - hypertension. autonomic hyperactivity - hypertension. fever. dilatedfever. dilated
• pupils and diaphoresispupils and diaphoresis
• Can be fatalCan be fatal
TreatmentTreatment
• ThiamineThiamine
• FolateFolate
• Lorazepam, diazepamLorazepam, diazepam
Duchenne Muscular Dystrophy (DMD)
• Commonest lethal x-linked dystrophy• 1/4,000 live male births• Delayed motor development• 1/2 unable to walk by 18 months• Waddle• Lordosis• Problem running and climbing stairs• Toe walking• Frequent fall
Duchenne Muscular Dystrophy• Gower’s manoeuvre• Proximal weakness• Calf hypertrophy• Hyporeflexia• Wheelchair by 7 to 12 years• Contracture scoliosis• Obesity or cachexia• Death by teens or early 20’s from respiratory or cardiac• complications• Lower IQ with 1/3 mentally retarded• Cardiomyopathy