www.peerteaching.co.uk

www.peerteaching.co.uk

Neurology Phase 3a Ameena Majed & Ayesha Javed The Peer Teaching Society is not liable for false or misleading information. Aims To cover Headache

Epilepsy CVA Bleeds PD Alzheimers disease Huntingtons disease - Myasthenia Gravis LEMS MS Cord compression Dermatomes The Peer Teaching Society is not liable for false or misleading information.

Headache red flags The Peer Teaching Society is not liable for false or misleading information. Headache red flags Subarachnoid haemorrhage is t i g n i n

e M The Peer Teaching Society is not liable for false or misleading information. Headache red flags The Peer Teaching Society is not liable for false or misleading information. Headache red flags d e s i a R

P C I The Peer Teaching Society is not liable for false or misleading information. Headache red flags The Peer Teaching Society is not liable for false or misleading information. Headache red flags Giant Cell Arteritis The Peer Teaching Society is not liable for false or misleading information. Neuro

Signs Migraine I R T ? S R E GG The Peer Teaching Society is not liable for false or misleading information.

Migraine CHOCOLATE TRIGGERS Cheese Oral contraceptive pill (combined) Diagnosis: Caffeine - Aura AlcohOL - if no aura: >5 headaches lasting 2-72h with either N&V Anxiety or photophobia and 2 of: Unilateral Travel Pulsating Interferes with normal life

Exercise Worsened by routine activity The Peer Teaching Society is not liable for false or misleading information. Migraine Classification: - Migraine with aura: o Visual most common (flashing lights, zigzags); o Somatosensory (paraesthesia spreading from fingers to face); o Motor (dysarthria, ataxia, opthalmoplegia, hemiparesis may resemble stroke) o Speech (dysphasia): - 15-30min then within 1h get unilateral, throbbing headache

- Isolated aura with no headache - Migraine without aura: unilateral, pulsating headache (4hdays), often premenstrual, N&V, photophobia The Peer Teaching Society is not liable for false or misleading information. Migraine management Most common way an attack resolves is through sleep! Acute: NSAIDs (ketoprofen) Triptans (sumitriptan) = 5HT agonists, Anti-emetic metoclopramide Prophylaxis: if >2 ep a month Propanolol Amitryptiline The Peer Teaching Society is not liable for false or misleading information.

Cluster headache M > F, peak age onset: 20-50yrs, commoner in smokers Symptoms: - Unilateral, rapid onset severe pain around one eye, - Lacrimation + redness of eye, rhinorrhoea - Partial Horners, FACIAL FLUSHING, - Lasts 1-2hrs, often nocturnal. - Clusters last 4-12 wks then followed by pain-free periods Treatment - Acute attack: 100% O2, SC/nasal triptans (Sumitriptan) - Preventatives: Verapamil, topiramate The Peer Teaching Society is not liable for false or misleading information. Giant Cell Arteritis (GCA) Symptoms: Headache

Scalp tenderness worse on combing hair Jaw claudication pain on eating Tender Thickened Pulseless Temporal artery Amaurosis fugax Blindness = EMERGENCY Common in >50s Associated: Polymyalgia Rheumatica50% Investigations Temporal artery biopsy SKIP LESIONS RAIED ESR/CRP Treatment Prednisolone 40-60mg 2 year course Start before biopsy results

The Peer Teaching Society is not liable for false or misleading information. Raised ICP Vomiting, papilloedema, SEIZURES; Headache worse on waking, lying down/bending forward/with coughing. Pupil changes: constriction at first then dilatation Exclude SOL by CT; LP CI until after imaging (can get coning) Acute Treatment: ABCDE, correct hypotension, maintain MAP >90, Elevate head of bed to 30-40 IV Mannitol, dexamethasone for reducing cerebral oedema Definitive Rx: craniotomy, burr holes, ICP monitor bolt The Peer Teaching Society is not liable for false or misleading information.

Trigeminal Neuralgia - Unknown cause, seen in old age (>50) - 20 causes: compression of trigeminal root, intracranial vessels/tumour, chronic meningeal inflam, MS - Test: MRI to exclude 20 causes The Peer Teaching Society is not liable for false or misleading information.

Trigeminal Neuralgia con Features: - Unilateral, severe spasms of knife-like Triggers: washing, shaving, talking, eating. stabbing pain in one/more sensory divisions of 5th CN (rarely ophthalmic division), lasting seconds. Treatment: 1. Anticonvulsant Carbamazepine 100mg/12h 2. Thermocoagulation of trigeminal ganglion or section of sensory division 3. Microvascular decompression Differentials: similar pain in structural lesions of 5th CN, but will have

physical signs like depressed corneal reflex The Peer Teaching Society is not liable for false or misleading information. Epilepsy Seizure = abnormal + excessive excitability of neurones of cerebral hemisphere. Epilepsy: tendency to recurrent ( 2), unprovoked seizures Causes: - 2/3rd idiopathic (often familial) - Structural - cortical scarring (head injury yrs before onset), SOL, stroke,

hippocampal sclerosis, vascular malformation - Others: Tuberous sclerosis, sarcoid, SLE, - Non-epileptic causes: - Trauma, stroke, bleed, raised ICP, alcohol/benzo withdrawal - Metabolic: hypoxia, hypocalcaemia, hypo/hyper Na & glucose, uraemia - Liver disease, meningitis, encephalitis, HIV, pyrexia The Peer Teaching Society is not liable for false or misleading information. Epilepsy Classification

Partial: focal, Sx referable to 1 part of brain Simple unimpaired consciousness Complex impaired consciousness AURA mostly temporal lobe Generalised: bilateral motor manifestation + impaired consciousness Tonic clonic Absence - childhood Myoclonic

Atonic Infantile spasms Post-ictal: confusion, headache, sore tongue (from biting), temporary weakness The Peer Teaching Society is not liable for false or misleading information. Epilepsy con Management: During seizure ABC Prolonged seizure: diazepam Anti-epileptics: Generalised: sodium valproate / lamotrigine

Partial: carbamazepine Absence: valproate / lamotrigine Tests: EEG, CT/MRI (SOL), ECG Bloods: FBC, glucose, U&E, Ca, drug screen What advice would you give to your patient? The Peer Teaching Society is not liable for false or misleading information. Epilepsy con Management: During seizure ABC Prolonged seizure: diazepam

Anti-epileptics: Generalised: sodium valproate / lamotrigine Partial: carbamazepine Absence: valproate / lamotrigine Tests: EEG, CT/MRI (SOL), ECG Bloods: FBC, glucose, U&E, Ca, drug screen What advice would you give to your patient? Epilepsy nurse specialist Avoid dangers like climbing, swimming until diagnosis confirmed DVLA pt informs. Must be seizure free for >1yr to drive

The Peer Teaching Society is not liable for false or misleading information. CVA RF: hypertension, smoking, hyperlipidaemia, AF, IHD, previous TIA/Stroke, COCP, alcoholism, clotting abnormality

Ischaemic 85% Atherothromboembolism Cardiac mural thrombi (left atrium in AF) Haemorrhage 15% Intracranial haemorrhage SAH (berry aneurysm rupture) Young adults carotid/vertebral artery dissection ACA infarct: weakness + sensory loss - contralateral leg/foot MCA infarct: weakness + sensory loss contralateral arm/face + contralateral homonymous hemianopia PCA infarct: contralateral loss of pain + temp + contralateral homonymous hemianopia The Peer Teaching Society is not liable for false or misleading information.

Remember: HOMUNCULUS The Peer Teaching Society is not liable for false or misleading information. Bamford/Oxford Classification TACS: MCA +ACA. Contralateral hemiplegia + homonymous hemianopia Higher cortical function dysfunction PACS: MCA or ACA. Deficits from same hemisphere Any 2 of Sx of TAC, but not all 3 together POCS: Cerebellum, occipital lobes homonymous hemianopia

DANISH cerebellar signs LACS: Pure motor/sensory Sx Occlusion of deep perforator arteries The Peer Teaching Society is not liable for false or misleading information. CVA management ABCDEFG O2, monitor blood glucose Urgent CT/MRI for: thrombolysis, head injury, ++ headache, on anticoag Rx, low GCS If non haemorrhagic: Thrombolysis: IV Altepase <4hrs Aspirin 300mg/2wks + dipyridamole/clopidogrel (dual antiplatelet therapy) DO NOT lower BP until 2 wks/pt stable Carotid endarterectomy if >70% stenosis Primary prevention: control RF: smoking, DM, HTN 20 prevention: aspirin + clopidogrel, ACE-I, statin **EQ: NBM until swallowing assessment! The Peer Teaching Society is not liable for false or misleading information. TIA

Sudden onset of focal neurological deficit due to temporary occlusion of part of cerebral circulation ABCD2 Resolves < 24hrs score 6 predicts stroke <2d Usually caused by emboli score>4 specialist assess within 24hrs Sx same as stroke + amaurosis fugax Treatment: 1. ABC 2. Dual antiplatelet therapy: aspirin 300mg/d + dipyridamole 3. Reverse RF 4. Change to warfarin for long term

if cardiac emboli / AF 5. Carotid endarterectomy if >70% stenosis Age 60 (1) BP 140/90 (1) Clinical features Unilateral weakness (2), Speech disturbance w/o weakness (1) Duration of Sx: 1h (2), 10-59mins (1) Diabetes (1) The Peer Teaching Society is not liable for false or misleading information. Do not drive for 1 month!

SAH Common sites for berry aneurysms rupture SAH Symptoms: Sudden bilateral thunderclap headache at at occiput. Feel like been kicked in back of head. Meningism neck stiffness, N&V, photophobia, kernig sign +ve. 3rd nerve palsy Tests: CT If no raised ICP LP after 12hrs

Xanthochromia confirms diagnosis (12hrs-2wks) Rx: surgically clip aneurysm Control RF: HTN, smoking, alcohol, bleeding disorder The Peer Teaching Society is not liable for false or misleading information. SDH and EDH Subdural Haematoma Minor injury causes slow bleeding to form haematoma and chronic subdural Sx develop wks later. 50% unable to recall injury as so minor. Atrophy of brain in elderly means more space for haematoma to expand Treatment: o May not need if not causing mass effect.

o Burr holes, craniotomy Extradural Haematoma Skull fracture tearing middle meningeal artery Traumatic head injury Symptoms produced within mins-hours Lucid intervals in 1/3 of cases Symptoms Headache Nausea Confusion consciousness Speech problems The Peer Teaching Society is not liable for false or misleading information.

Parkinsons disease Degeneration of dopaminergic neurons in the substantia nigra pars compacta, associated with lewy bodies Causes dopamine levels The Peer Teaching Society is not liable for false or misleading information. Parkinsons disease Epidemiology & Aetiology 1-2% of population, affecting mainly 60 years + M:F 1.35:1

Increase risk if FH, exposed to MPTP Reduced risk with cigarette smoking and caffeine Progressive and incurable The Peer Teaching Society is not liable for false or misleading information. Parkinsons clinical features Classical Triad 1. Tremor Resting, pillrolling 2. Bradykinesia slowness of initiating voluntary movement (inc. expressionless face, monotone hypophonic speech, micrographia) 3. Rigidity cogwheel,

increased tone Gait festinant, reduced arm swing Postural instability Unilateral onset, persistent asymmetry Progressive Anosmia Dementia Visual hallucinations Sleep disorder Depression The Peer Teaching Society is not liable for false or misleading information.

Parkinsons - management MDT physio, OT, social worker, PD nurses Treatment delayed till symptoms warrant GOLD STANDARD Levodopa (SE: N/V, anorexia) Dopa-decarboxylase inhib (Madopar) Efficacy reduces over time, increased dose needed Dopamine Agonists Ropinirole Anticholinergics helps tremor (SE) The Peer Teaching Society is not liable for false or misleading information. Alzheimers Disease - The leading cause of dementia - F>M, most common in >65years Accumulation of Beta-amyloid peptide results in progressive neuronal damage, neurofibrillary

tangles (tau and ubiquitin), increase of amyloid plaques and loss of Ach The Peer Teaching Society is not liable for false or misleading information. Alzheimers disease Symptoms RF - First degree relative, downs syndrome,

homozygosity for ApoE DM, AF, HTN- Enduring, progressive and global cognitive problems Visual spatial skills getting lost Memory, verbal abilities and executive function (planning) Anosognosia lack of insight Irritability/mood disturbances Behavioural change The Peer Teaching Society is not liable for false or misleading information. Alzheimers management No specific investigation. Do MMSE, score? AMT General dementia management (social

services) - Refer to specialist memory services - Acetylcholinesterase inhibitors (Rivastigmine, Donepezil) slow deterioration - Control BP The Peer Teaching Society is not liable for false or misleading information. Huntingtons disease RARE Autosomal dominant disorder, full penetrance Characterised by progressive chorea and dementia Caused by expansion of CAG repeats Onset 35-40years Death within 15 years The Peer Teaching Society is not liable for false or misleading information.

Huntingtons disease Signs are insidious then progressive Chorea -> irritability -> dementia -> +/- fits -> DEATH Pathology Cerebral atrophy with loss of corpus striatum GABA-nergic and cholinergic neurons - No treatment - Offer counselling to patient and family The Peer Teaching Society is not liable for false or misleading information. Myasthenia Gravis Autoimmune disorder Antibodies against acetylcholine receptors at NMJ (post-synaptic), interfering with transmission

Rare 1/10,000 prevalence Peaks at 3rd and 6th decade Associated with other autoimmune disorder (thymic hyperplasia and atrophy) The Peer Teaching Society is not liable for false or misleading information. Myasthenia Gravis Clinical features o Weakness and fatigue of ocular, bulbar and proximal limb muscles (affects in order - extra-ocular, bulbar, face, neck, limb, girdle, trunk) - ptosis, diplopia -Facial weakness (myasthenia snarl) -Bulbar dysphagia, dysarthria, difficulty

talking, chewing, resp difficulties The Peer Teaching Society is not liable for false or misleading information. Myasthenia Gravis Investigations o TENSILON test - +ve if edrophonium improves power within a min o Antibodies: Anti AChR (anti-muSK) o Neurophysiology reduced muscle response to repetitive nerve stimulation o TFT

Treatment o Anticholinesterase ie pyridostigmine. Provides sympotmatic relief o Corticosteroids ie prednisolone (if unresponsive) o Plasmapheresis and iv IG o Thymectomy The Peer Teaching Society is not liable for false or misleading information. CRISIS! Myasthenic crisis LIFE THREATENING CONDITION! Weakness of the respiratory

muscles, causing respiratory failure Monitor forced vital capacity, if low, need ventilator support Treat with plasmapharesis or IV Ig Cholinergic crisis Over-treatment with anticholinesterase Hypersalivation Lacrimation Increased sweating Vomiting Pupillary constriction

Muscle weakness and fasciculation The Peer Teaching Society is not liable for false or misleading information. Lambert-Eaton (LEMS) Autoimmune - Failure of Ach release at the NMJ (pre-synaptic) Neoplastic - associated with SCC of bronchus Symptoms Proximal muscle weakness (lower limb), aches and tenderness, reduced strength before eye symp Bulbar and resp muscles spared. Mild ocular symp Autonomic symptoms (constipation ,dry mouth, impotence) Reduced/absent reflexes TREAT IV Ig or 3,4 Less response to tensilon test diaminopyridine

Regular CXR The Peer Teaching Society is not liable for false or misleading information. Multiple Sclerosis Chronic autoimmune disorder of CNS (T cell response) Multiple plaques of demyelination Disseminated in time and space Relapsing and remitting Prolonged demyelination = axonal loss and clinically progressive symptoms The Peer Teaching Society is not liable for false or misleading information. -Mean age onset 30

yrs -F:M 3:1 Cause? Environmental agent in a genetically susceptible host Multiple Sclerosis Clinical features Usually monosymptomatic Optic neuritis (rapid decline in central vision) Numbness/tingling in limbs Leg weakness Brainstem/cerebella symp eg diplopia, ataxia

Worse with heat and exercise (see table in ox handbook!) Progression Early on, relapses may be followed by remission and full recovery With time, remission incomplete The Peer Teaching Society is not liable for false or misleading information. Multiple Sclerosis Diagnosis

Clinical History and examination MRI sensitive, not specific CSF oligoclonal bands of IgG om electropherisis Nerve conduction studies evoked potentials SEE MCDONALD CRITERIA! The Peer Teaching Society is not liable for false or misleading information. Multiple Sclerosis

Treatment Methylprednisolone short course 3d for relapse (2x yr) Beta-Interferon reduces relapses and lesion accumulation Natalizumab 2nd line Other- Azathioprine Physio and OT The Peer Teaching Society is not liable for false or misleading information. Cauda Equina Compression of nerves below L1 Medical emergency!! Needs urgent management/ decompression

RED FLAGs Incontinence Urinary retention Anal sphincter disturbance Saddle anesthesia Neurological deficit leg weakness, numbness, pain, sciatica Loss of reflexes Sudden The Peer Teaching Society is not liable for false or misleading information. Brown sequard Cord hemisection

Ipsilateral UMN weakness below lesion (Severed corticospinal tract) causing spastic paraparesis, brisk reflexes, extensor plantars Ipsilateral loss of proprioception and vibration (severed dorsal columns) Contrlateral loss of pain and temperature (severed spinothalamic ) The Peer Teaching Society is not liable for false or misleading information. Thanks for listening! The Peer Teaching Society is not liable for false or misleading information.

Recently Viewed Presentations

  • Splines Model for Prediction of House Prices

    Splines Model for Prediction of House Prices

    Splines Model for Prediction of House Prices David Boniface - UCL Aim To create a web-based facility for customers to enter address of a house and obtain graph showing trend of price of house since last sold, extrapolated to current...
  • Shaker&#x27;s Resident Educator Program

    Shaker's Resident Educator Program

    Program Overview & Timeline. Ohio's Resident Educator (RE) Program. Ohio's RE Program is the only one like it in the US. Created to combat teacher turnover within the first 5 years of their career.
  • Got Robots?

    Got Robots?

    Got Bots? Adding Robotics to Gifted Services By Debra Vogt McPherson Middle School
  • The Updated Statewide Transition Plan Spring 2017 Background

    The Updated Statewide Transition Plan Spring 2017 Background

    Statewide Transition Plan. All states were required to develop an HCBS transition plan, that provides a comprehensive assessment of potential gaps in compliance with the new regulation, as well as strategies, timelines, and milestones for becoming compliant with the rule's...
  • Vocabulary Words World Literature Week 12 Autonomy Our

    Vocabulary Words World Literature Week 12 Autonomy Our

    Vigilant Definition: adj.—alert, watchful, wary Synonym: cautious, observant, attentive Antonym: slack Pretext Jerry's unexpected visit to bring me a book I left at school was only a pretext for him to get a chance to play my new X-Box 360...
  • 21 Electromagnetic Induction Induction Experimental Magnetic Flux  B

    21 Electromagnetic Induction Induction Experimental Magnetic Flux B

    21 Electromagnetic Induction P40-Transformer P45-Magnetic Energy Voltmeter Construction d' V' If the V-meter required for maximum V' (full scale) then Ammeter Construction d' Ig College Physics: Motion along a Straight Line 17 Electric Charge and Electric Field Active Lecture Questions...
  • Highland Falls-Fort Montgomery Central School District

    Highland Falls-Fort Montgomery Central School District

    Highland Falls-Fort Montgomery Central School District. Superintendent's. Proposed Draft Annual Budget. 2011 - 2012. March 10, 2011 Board of Education Meeting
  • Chapter 9 - Neural Nets

    Chapter 9 - Neural Nets

    Chapter 11 - Neural Nets Data Mining for Business Intelligence Shmueli, Patel & Bruce © Galit Shmueli and Peter Bruce 2010 * * * * * * * * * * * * * * * * * * *...