neurology update
Download
Skip this Video
Download Presentation
Neurology Update

Loading in 2 Seconds...

play fullscreen
1 / 42

Neurology Update - PowerPoint PPT Presentation


  • 146 Views
  • Uploaded on

Neurology Update. Paul Hart Neurologist Epsom + St Helier AMNU @ St George’s Royal Marsden Hospital. Neurology Update. Diseases Parkinsons disease Multiple Sclerosis Epilepsy Stroke Dementia Headache ……. Neurology Update. Diseases Parkinsons disease Multiple Sclerosis Epilepsy

loader
I am the owner, or an agent authorized to act on behalf of the owner, of the copyrighted work described.
capcha
Download Presentation

PowerPoint Slideshow about ' Neurology Update' - blaze


An Image/Link below is provided (as is) to download presentation

Download Policy: Content on the Website is provided to you AS IS for your information and personal use and may not be sold / licensed / shared on other websites without getting consent from its author.While downloading, if for some reason you are not able to download a presentation, the publisher may have deleted the file from their server.


- - - - - - - - - - - - - - - - - - - - - - - - - - E N D - - - - - - - - - - - - - - - - - - - - - - - - - -
Presentation Transcript
neurology update

Neurology Update

Paul Hart

Neurologist

Epsom + St Helier

AMNU @ St George’s

Royal Marsden Hospital

neurology update1
Neurology Update
  • Diseases
    • Parkinsons disease
    • Multiple Sclerosis
    • Epilepsy
    • Stroke
    • Dementia
    • Headache
    • ……..
neurology update2
Neurology Update
  • Diseases
    • Parkinsons disease
    • Multiple Sclerosis
    • Epilepsy
    • Stroke
    • Dementia
    • Headache
    • …….. Germline mosaicism of MPZ gene in Dejerine-Sottas syndrome (HMSN III) associated with hereditary stomatocytosis

Neuromuscul Disord. 1999 Jun;9(4):232-8

neurology update3
Neurology Update
  • Diseases
    • Parkinsons disease
    • Multiple Sclerosis
    • Epilepsy
    • Stroke
    • Dementia
    • Headache
    • …….. Germline mosaicism of MPZ gene in Dejerine-Sottas syndrome (HMSN III) associated with hereditary stomatocytosis

Neuromuscul Disord. 1999 Jun;9(4):232-8

  • Neurology Top 10 Tips
  • Services
    • TWRs
    • Direct access investigations
    • Local provision
    • How to get the most out of your neurologist
update parkinsons disease
Update - Parkinsons disease
  • Suspected PD
  • Unsuspected PD – making the penny drop
  • PD review
  • Common
  • Increasing prevalence
    • Predicted to treble over the next 50 years
    • Age 50 – 10:100,000
    • Age 80 – 200:100,000
  • < 80% confirmed at post-mortem !?
classification of movement disorders
Akinetic

Idiopathic Parkinsons Disease

Parkinsons plus

MSA

PSP

DLB

CBD

Secondary Parkinsonism

Hyperkinetic

Chorea

Ballism

Tremors

Myoclonus

Wilsons disease

Dystonia

Tics + Tourettes

Sleep related movement disorders

Ataxia

Dyskinesias

Psychogenic

Classification of Movement Disorders
slide7

Definition of idiopathic PD

  • Pathological diagnosis
  • depigmentation + neuronal loss in substantia nigra
  • Intraneuronal inclusions- Lewy bodies
slide9
Tremor

UL>LL

Asymmetric

Rest tremor

Tongue lips chin

Rigidity

Akinesia

Postural instability

Gait

micrographia

Facial Hypomimia

Speech

Non-motor manifestations

Constipation

EDS

Anosmia

REM behaviour disorder

Depression

Dementia

Pain

Postural stability

Skin

Autonomic

….

Clinical Features

slide10

Sleep

  • 75-90% PD sleep dysfunction
  • Insomnia
  • Sleep fragmentation
  • Sleep akinesia
  • Nocturia
  • Nocturnal panic attacks
  • RLS
  • Excesssive daytime somnolence
  • Drug induced psychosis 10-30%
  • reduce parkinson meds
  • monitor response
  • neuroleptic trial quetiapine / clozapine / olanzapine
  • Mirtazapine
  • RIvastigmine

Neuropsychiatric problems

Depression and Dementia

a clinical diagnosis
A Clinical Diagnosis

Investigations: Exclude Wilsons -young with tremor

MRI

DaT scan

Research

SPECT

PET

pd is it something else
Essential Tremor

Kinetic +/- postural tremor

4-12 Hz

UL, head, voice, LL, trunk, tongue

>90% undiagnosed

73% report significant disability

Treatment: medical, botox, surgical

Parkinsons plus

MSA

PSP

LBD

CBD

Drug induced Parkinsonism

12% of 328 patients referred to secondary care

Prochloperazine 32%

Typical antipsychotics 42%

atypical antipsychotics 18%

Metoclopramide 11%

Amiodarone 8%

Lithium 8%

Antihistamines 8%

Promethazine and cinnarazine

Valproate 5%

PD - Is it something else ?
pd treatment what when and how
PD Treatment – what when and how?
  • 1817 James Parkinson
    • Blood letting
    • Iatrogenic pus formation
  • 2011 Dopaminergic
  • Non dopaminergic
  • Symptomatic
  • Neuroprotective
  • Surgery – Ablation – DBS – Brain Grafting
  • Preventative
levo dopa
Levo Dopa

(DATATOP trial n=352; F/U 20 months +/- 9)

  • Wearing off 50%
  • Dyskinesias 33%
  • Severe on-off 10%
  • Hedonistic homeostatic dysregulation
  • Pros: effective
  • Cons: side effects
    • Early side effects – N+V, HR, BP
    • Late SE
  • motor fluctuations
  • dyskinesias
  • neuropsychiatric
  • Symptoms unresponsive to L-Dopa
    • postural instability
    • freezing phenomena
    • speech
    • sialorrhoea
    • depression and dementia
    • ANS - sweating, urinary frequency, constipation
    • sensory symptoms + pain
    • Tremor
    • REM sleep behaviour disorder
levodopa therapeutic manoeuvres
Levodopa therapeutic manoeuvres
  • On with dyskinesia vs Off without dyskinesia
    • CR preparations
    • Hyperfractionate dosing schedule
    • COMT inhibitors - entacapone, tolcapone
      • Stalevo
        • Levodopa carbidopa entacapone
          • 50 / 12.5 / 200
          • Stalevo “50” “75” “100” “125” “150” “200”
    • MAO inhibitors - selegeline, rasagiline
    • Amantadine
    • Dopamine Agonists
    • Duo-dopa
    • Apomorphine pump
agonists
No dyskinesia

potentially neuroprotective

delays use of levodopa

longer half life

no absorption delay/dietary effects

no metabolic conversion

Apomorphine

Pergolide

Cabergoline

Pramipexole

Ropinirole

Rotigitone

Side effects

Ankle oedema

Gambling

Sexual appetite

Agonists
pd whats new
PD – whats new
  • Genetics
  • Drugs
  • NSAIDs
    • Ibuprofen protective but not other NSIADs
    • N=136,474
  • Stem cells
pd whats new genetics
PD – whats new - Genetics
  • 15% PD patients have an affected 1st degree relative
  • 5% due to mutation in one of several specific genes
    • alpha-synuclein (SNCA)
    • ubiquitin carboxy-terminal hydrolase L1 (UCH-L1)
    • parkin (PRKN)
    • leucine-rich repeat kinase 2 (LRRK2 or dardarin)
    • PTEN-induced putative kinase 1 (PINK1)
    • DJ-1
    • ATP13A2
  • In most cases, people with these mutations will develop PD.
  • All rare except LRRK2
    • 10% familial PD
    • 3% sporadic PD
  • Genome wide association studies
    • Complex late onset sporadic degenerative
    • 15 confirmed genes
  • Mutations in genes including SNCA, LRRK2 and glucocerebrosidase (GBA) have been found to be risk factors for sporadic PD.
    • Mutations in GBA are known to cause Gaucher\'s disease
  • All identified risks account for 2.5-3x risk
update multiple sclerosis1
Update – Multiple Sclerosis
  • Disease modifying therapies
  • CCSVI
  • Lifestyle effects
  • Sativex
  • NMO antibodies
update multiple sclerosis2
Refresher

Demyelination

Inflammation

Clinically isolated syndrome

Optic neuritis

Transverse myelitis

Brain stem

motor

Sensory

McDonald criteria 2001 2005 2010

Update – Multiple Sclerosis
mcdonald criteria
McDonald criteria

Clinical presentationAdditional data needed for MS diagnosis

  • Two or more attacks

objective clinical evidence of two or more lesions None

  • Two or more attacks

objective clinical evidence of one lesion Dissemination in space shown on MRIor Up to two MRI detected lesions typical of MS plus positive CSF*or Await a further relapse suggestive of dissemination in space (ie affecting another part of the body)

  • One attack

objective clinical evidence of two or more lesions Dissemination in time demonstrated by MRIor Second clinical attack (relapse)

  • One attack

objective clinical evidence of one lesion

(known as \'clinically isolated syndrome\') Dissemination in space demonstrated by MRIor Up to two MRI detected lesions typical of MS plus positive CSF

AND dissemination in time demonstrated by MRIor Dissemination in time demonstrated by MRI (ie new lesion seen on MRI at least 3 months after the original scan)or Second clinical attack (relapse)

  • Insidious neurological progression suggestive

of multiple sclerosis (typical for primary progressive MS) Positive cerebrospinal fluid*

AND

dissemination in space, shown on MRI

or Abnormal visual evoked potential plus abnormal MRI

AND

dissemination in time demonstrated by MRI or Continued progression for one year (determined retrospectively or by ongoing observation)

update multiple sclerosis3
Treatment of MS

Relapses

Treatment

Oral methyprednisilone 500mg od - 5days

Prevention

DMTs

Treatment of symptoms

Fatigue

Amantadine

Modafinil

Depression

Spasticity

Baclofen

Tizanidine

Sativex

Bladder

Etc….

Multi-disciplinary care

Update – Multiple Sclerosis
update multiple sclerosis dmts
Update – Multiple Sclerosis - DMTs
  • a group of compounds which alter the progression of MS
  • reduce the frequency and severity of relapses and slow the development of disability in some people.
  • Beta interferon 1a AVONEX im

REBIF sc

1b BETAFERON sc

Fingolimod po

  • Glatiramer acetate COPAXONE sc
    • Different mechanism, similar effect
  • Natalizumab TYSABRI
    • A recombinant humanised monoclonal antibody produced in murine myeloma cells.
    • The specific mechanism(s) not fully defined. However, inhibition of leucocyte transmigration out of the vascular space.
    • Progressive Multifocal Leukoencephalopathy*(PML) is an opportunistic infection caused by the JC virus that typically occurs in patients that are immunocomprimised.
  • Mitoxantrone
    • Cardiac toxicity
update multiple sclerosis dmts1
Update – Multiple Sclerosis - DMTs
  • CCSVI
    • Zamboni
  • Stem cells
  • Lifestyle effects
    • Vitamin D
    • tobacco
    • diet
  • NMO antibodies
    • Neuromyelitis optica (Devic’s disease)
    • Aquaporin antibodies
update multiple sclerosis dmts2
Update – Multiple Sclerosis - DMTs
  • CCSVI
    • Zamboni
  • Stem cells
  • Lifestyle effects
    • Vitamin D
    • tobacco
    • diet
  • NMO antibodies
    • Neuromyelitis optica (Devic’s disease)
    • Aquaporin antibodies
  • Other neurological antibodies
  • MUSK
  • VGKC
  • NMDA
update epilepsy
Update – Epilepsy
  • More New AEDs
    • Enhance slow activation of Na channels
      • Lacosamide
      • Rufinamide
    • Ca channel lockers + carbonic anhydrase inhibitor
      • Zonisamide
  • Sudden unexplained death in epilepsy
    • Epilepsy SMR 1.6-9.3
      • Underlying disorder / status / accidents / suicide / Rx related death / SUDEP
      • 8-17% of deaths
  • Memory
  • Psychosocial
update stroke
Update – Stroke
  • Risk of stroke after TIA
  • Thrombolysis
  • PFO
overview
Overview
  • Neurology - there’s a lot of it about
overview1
Overview
  • Neurology - there’s a lot of it about
  • Guidelines, QOFs, and more guidelines
overview2
Overview
  • Neurology - there’s a lot of it about
  • Guidelines, QOFs, and more guidelines
  • Do you suffer from Neurophobia ?
overview3
Overview
  • There’s a lot of it about
  • Guidelines, QOFs, and more guidelines
  • Neurophobia widespread
neurological disorders are common
Neurological disorders are common
  • WHO

“Neurological disorders – a public health challenge”

“one of the greatest threats to public health”

  • Mortality vs DALYs
  • Neurological disease accounts for 20% of admissions to general hospitals
  • More diagnoses than the rest of medicine put together
guidelines qofs etc
Guidelines, QOFs, etc…..
  • NICE – PD
  • NICE – epilepsy
  • SIGN – epilepsy
  • QOF – epilepsy
  • Stroke and TIA
  • Headache
  • MS
  • And all the others….
do you suffer from neurophobia
Do you suffer from Neurophobia ?
  • A fear of neurosciences and clinical neurology
    • Jozefowicz 1994
    • Schon Hart et al 2002
do you suffer from neurophobia1
Do you suffer from Neurophobia ?
  • A fear of neurosciences and clinical neurology
    • Jozefowicz 1994
    • Schon Hart et al 2002
  • Seeds Sown at medical school ?
we can cure it for you
We can cure it for you !
  • The Epsom and St Helier neurology Service
    • ~100% patients seen by Consultant grade
    • 4 Consultant Neurologists
    • 2 Consultant Neurophysiologists
    • 4 specialist nurses
    • Neuro PT, OT etc…
    • State of the art imaging facilities, EEG, EMG, PIU
    • 52 clinics per month
    • 94% of ward referrals seen on day of referral, 99% within 48 hrs
neurology top ten tips
Neurology – top ten tips
  • TIAs never cause isolated loss of consciousness
  • Numb tingling hands are rarely due to neck pathology
  • Beware of medication overuse headache
  • Essential hypertension, sinusitis and “eye strain do not cause chronic daily headache
  • Vertigo usually originates from the vestibular apparatus not the brain
  • Diplopia – monocular = ophthalmology, binocular = neurology
  • Know which headaches are worth worrying about
  • Beware of misdiagnosing tremor
  • Radiological imaging is rarely helpful in illuminating headache or back pain
  • The neurological examination is hugely overvalued in non-neurologists
slide41
Our ethos ?
  • Referral guidelines ?
  • Communication
    • Tel 0208 296 3355
    • Fax 0208 296 3356
neurology update4

Neurology Update

Paul Hart

Neurologist

Epsom + St Helier t 0208 296 3355

f 0208 296 3356

AMNU @ St George’s

Royal Marsden Hospital

ad