Cases for Finals and Beyond Nervous System 1

Cases for Finals and Beyond: Nervous System 1 st October 2012 Alastair Brown ST 1 Neurosurgery

Objectives n n n Describe 3 common clinical scenarios Understand the relevant signs and symptoms of common neurological conditions. Understand how to decribe gait patterns in common neurological conditions Understand the investigations and management Be aware of common sequelae of certain neurological conditions and their management.

Case 1 FY 1 covering the COTE Ward on Night n Asked to see Mr Williams n ¨ 84 year old man ¨ Has had a fall on the ward ¨ Is confused ¨ Not sure if he has injured himself

On the Phone n What things are you going to ask the nurse to do while you are on your way? ¨ Get patient back to bed safely ¨ Get a set of observations (inc neuro observations) ¨ Find notes and drug chart ¨ Consider asking for and ECG

On the Ward n What are your three priorities with this patient? Identify any injuries 2) Identify cause of the fall 3) Try to prevent/limit impact of further falls 1) n What are you going to do next? Take a history ¨ Examine patient (General, MSK and Neuro) ¨

On the Ward Drug chart is in pharmacy n Nurse looking after the patient is a bank nurse and does not know much about him. n Thinks he is normally confused n Fall was unwitnessed n Patient just says don’t know to all questions. n

Examination General and MSK examination unremarkable with no evidence of external injury. CNS n Cranial nerves unremarkable. n PEARL n Following commands appropriately n

PNS - Inspection:

PNS: Inspection n Describe the face of the patient you saw. ¨ Expressionless ¨ Masked n Describe the movement of the hand you saw. ¨ Resting tremor of the left hand ¨ Improves following purposeful movement

PNS Tone

PNS: Tone n Describe what you saw ¨ n What is this pattern of rigidity called? ¨ n Cog wheel rigidity What condition is this pattern of rigidity associated with? ¨ n Intermittent resistance to passive flexion of the upper limbs. Parkinson’s disease Can you name another pattern of rigidity seen in the same condition? ¨ Lead-pipe rigidity

PNS: Gait

PNS: Gait n Describe the person’s gait ¨ ¨ ¨ ¨ ¨ n No aids Slow Stooped Slow turning Small steps Shuffling Tremor in hands Festinating Would also like to see them stand sit What condition is the gait pattern typical of? ¨ Parkinson’s disease

Parkinson’s Disease: Features n What are the main pathological features in Parkinson’s disease? ¨ Loss of Dopaminergic neurons in the substantia nigra ¨ Formation of Lewy bodies. n What are three cardinal features of Parkinsons disease? ¨ Tremor ¨ Rigidity ¨ Bradykinesia

Parkinson’s Disease: Diagnosis n What investigations are used to diagnose PD? ¨ Generally a clinical diagnosis ¨ MRI and SPECT can be used but this is rare ¨ Trial of treatment often helps to make diagnosis. n Can you name three differential diagnoses for PD ¨ Lewy Body dementia ¨ Drug – induced parkinsonism ¨ Vascular dementia ¨ Wilson’s disease in young patients

Parkinson’s disease: Treatment n What is the main treatment of Parkinson’s disease? ¨ Levodopa treatment ¨ Coupled with Carbidopa to reduce peripheral release and achieve higher CNS concentration with fewer systemic side effects. n Are you aware of any emerging treatments? ¨ Deep brain stimulation (normally of Subthalamic nucleus)

Parkinson’s: Prognosis and Complications n What is the course of Parkinson’s disease? ¨ Progressive n condition What later complications are commonly seen? ¨ Postural imbalance ¨ Dementia ¨ Swallowing difficulties ¨ Autonomic dysfunction

Case 2 You are an FY 2 in A+E n Asked to go to resus to see a patient who has been brought in with seizures. n ¨ Name: Ethel O’Donohue ¨ Five minute seizure terminated after some PR Diazepam ¨ 72 year old female ¨ PMH: Unknown

How are you going to approach this patient? A – Patent and protected n B – Sats 100% on 15 L Chest clear n C – HR 110 reg CRT < 2 secs BP 155/60 n D – E 3 V 2 M 4 BM 14. 1 Pupils equal and reactive. Not moving left side. n E – Ulcers on left leg, Median sternotomy scar, no evidence of any external injury. n

What investigations are you going to arrange? n Bloods ¨ FBC, U+E, , LFTs, CRP, Mg, Clotting ¨ ABG n Bedside Tests ¨ ECG ¨ Urine n Dip Radiology ¨? CXR ¨ ? CT head

Results n Bloods ¨ CRP – 54 ¨ Otherwise unremarkable ¨ ABG: n n p. H – 7. 29 p. O 2: 54. 3, p. CO 2: 4. 9 BE: -12. 4 Lactate: 6. 4 What does this show? ¨ n Metabolic acidosis What is the likely cause? ¨ Seizure

While you are waiting… n Patient starts to have another seizure. ¨ First you notice shaking of the left arm and leg ¨ Patient then stops responding ¨ Then starts to have full tonic-clonic seizure. n What are three steps in the seizure described. ¨ Partial seizure ¨ Initially simple then becomes complex ¨ Secondary generalisation.

Cont… n What is the definition of status epilepticus? ¨ One seizure > 30 minutes or multiple seizures without regaining consciousness for over 30 minutes. n What is the emergency management of status? ¨ A, B, C ¨ Call for Help ¨ IV Lorazepam ¨ Phenytoin infusion ¨ Sedation ¨ Barbituate coma

CXR Can you describe this radigraph? Adequate technical film Normal lung appearances.

CT Head Can you describe the CT scan? -Hypo-intense area in the right hemisphere seen on multiple slices of CT no evidence of midline shift What is the most likely cause for these findings? -Stroke What vascular territory has been affected? Right MCA

PNS: Inspection n What comments can you make about this gentleman’s posture? ¨ ¨ n What is the posture typical of? ¨ n Spastic paralysis Would this be typical of an acute stroke? ¨ n Flexed elbows Flexed wrist Flexed digits Inversion of left foot No, spasticity develop over weeks to months. What would you expect to find examining his reflexes? ¨ Hyperreflexic

PNS: Tone

PNS: Tone n What is the pattern of rigidity seen? ¨ Clasp n knife rigidity. What conditions is this pattern of rigidity seen in? ¨ Upper motor neurone lesions

PNS: Gait

PNS: Gait n Can you describe this person’s gait? ¨ No aids ¨ Reasonable speech ¨ Spastic posture ¨ Hip hitching of right leg ¨ Circumduction of right leg n What is this pattern of Gait called? ¨ Hemiplegic gait.

CNS and Remaining PNS n n Sensation – normal Power 1/5 on left and 5/5 on right CNS unremarkable. How do you grade power? 0 – No movement 1 – Flicker of movement 2 – Can move a joint with gravity eliminated 3 – Can move a joint against gravity 4 – Reduced from normal power 5 – Normal power

Stroke n How would you define stroke? ¨ Sudden loss of circulation to an area of brain resulting in a corresponding neurological deficit that persists for more than 24 hours. n What would your differentials include? ¨ Todd’s paresis ¨ Intracranial haemorrhage ¨ SOL ¨ Previous neurosurgery

Stroke: Investigation and Diagnosis n What risk factors are you aware of for stroke? ¨ ¨ n Vascular risk factors (smoking, diabetes, hypertension, age) Previous stroke AF Thrombophilias How would you investigate someone you believed may have had a stroke? ¨ ¨ ¨ History and examination CT/MRI ECHO ECG Carotid dopplers

Stroke: Management n What treatments can be given in acute stroke? ¨ ¨ n What other treatments can be given in the longer term to reduce the risk ¨ ¨ ¨ n Aspirin Thrombolysis (currently within 3 hours of onset) Modification of vascular risk factors (Statin, smoking cessation, etc) Warfarin if patient has AF Carotid endarterectomy. What are the other components of stroke patient management? ¨ ¨ PT/OT- rehabilitation SALT to assess swallowing

Case 3 n n n You are an FY 1 in acute medicine 27 year old female Presents with vision problems for last 3 days Complaining of blurry and double vision and pain on looking around Mother has noticed has been quite clumsy Normally fit and well.

CN II n n Visual acuity L Eye 6/4. 5 R Eye 6/12 Which eye has better vision? ¨ n b) What is the abnormality seen in a) ¨ n L eye Which fundus is normal? ¨ n a) Swollen optic disc What is the likely diagnosis? ¨ Optic neuritis b)

CNS: III, IV, VI n What eye disorder is shown here? ¨ n n Internuclear opthalmoplegia Which eye is affected? ¨ Left Right eye Which neurological structure is involved? ¨ Right Medial longitudinal fasciculus Convergence

PNS: Coordination

PNS: Coordination n What sign is being demonstrated in this patients left arm? ¨ n Which hemisphere of which part of the brain is not working ¨ n Intention tremor L cerebellar hemisphere What other signs would you test for in this patient? Dysdiadochokineses ¨ Past pointing ¨ Romberg’s test. ¨

PNS: Gait

PNS: Gait n Describe this patient’s gait. ¨ ¨ ¨ n What is the name for this gait pattern? ¨ n No aids Normal walking speed Poor balance Broad based gait Unsteady Ataxic gait What dysfunction is this gait pattern normally due to? ¨ Cerebellar dysfunction

Case 3 Cont … n What is the likely diagnosis? ¨ Multiple n sclerosis What would be your differential diagnosis? ¨ Space occupying lesion ¨ Other inflammatory CNS conditions (vasculitis, sarcoidosis etc. ) ¨ Clinically isolated syndrome

Multiple sclerosis: Background n What is your understanding of Multiple sclerosis? ¨ Immuno-mediated demyelinating disease of the central nervous system. n What patterns of disease are you aware of? ¨ Relapsing-remitting ¨ Primary progressive ¨ Secondary progressive

MS: Diagnosis and Investigation n How would you investigate this patient? ¨ Bloods n n Routine Auto-antibodies Infectious serology (Lyme, VDRL) Vitamin B 12 ¨ MRI ¨ CSF – Oligoclonal bands and Ig. G ¨ Visual and Somatosensory evoked potentials

MRI – Of Patient with MS

MS: Treatment n What treatments are used in the acute treatment of MS? ¨ Methylprednisolone ¨ Plasma n exchange What treatments are used in the long-term management of MS: ¨ Interferon ¨ Other immunomodulatory drugs

Objectives n n n Describe 3 common clinical scenarios Understand the relevant signs and symptoms of common neurological conditions. Understand how to decribe gait patterns in common neurological conditions Understand the investigations and management Be aware of common sequelae of certain neurological conditions and their management.

Any questions? alastairjwbrown@gmail. com