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Phase 3B Ellie Tanqueray & Becky Marlor

Neurology. Phase 3B Ellie Tanqueray & Becky Marlor. The Peer Teaching Society is not liable for false or misleading information…. Aims:. To revise relevant clinical neuroanatomy To be able to diagnose neurological conditions and understand their basic management: Stroke / TIA Seizures MS

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Phase 3B Ellie Tanqueray & Becky Marlor

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  1. Neurology Phase 3B Ellie Tanqueray & Becky Marlor The Peer Teaching Society is not liable for false or misleading information…

  2. Aims: • To revise relevant clinical neuroanatomy • To be able to diagnose neurological conditions and understand their basic management: • Stroke / TIA • Seizures • MS • Headache The Peer Teaching Society is not liable for false or misleading information…

  3. HEADACHE • RED FLAGS • Thunderclap headache • First and worst headache • Unilateral headache • Headache worse on coughing/in morning/on bending forwards • Persisting headache and scalp tenderness in >50s • Fever/neck stiffness accompanying headache • Change in pattern of usual headaches • Decreased level of consciousness The Peer Teaching Society is not liable for false or misleading information…

  4. Causes The Peer Teaching Society is not liable for false or misleading information…

  5. Tension Headache • TIGHT BAND across forehead • Bilateral • Pressure/tightness • Mild/moderate intensity • Rx: • Reassurance that it is nothing serious • Avoiding triggers • Physical Rx – ice packs, massage, relaxation • NSAIDs first line – ibuprofen, diclofenac • Paracetamol if intolerant to NSAIDs The Peer Teaching Society is not liable for false or misleading information…

  6. Migraine • Thought to be caused by dilatation of intracerebral vessels and oedema • Triggers: CHOCOLATE: CHeese, Oral contraceptives, Caffeine(or its withdrawal), alcohOL, Anxiety, Travel, Exercise Triggers found in 50% The Peer Teaching Society is not liable for false or misleading information…

  7. Migraine • Prodrome – hours to days before • Altered mood – depression/euphoria • Irritability • Fatigue • Muscle stiffness • Aura • 5mins to an hour before headache onset • Transient visual, sensory, motor, speech disturbances • Typically flickering lights, spots, zigzag lines, blind spots The Peer Teaching Society is not liable for false or misleading information…

  8. Migraine • Pain phase • Throbbing/pulsatile headache, usually unilateral • Moderate/severe pain • Worse on movement/physical activity • N&V • Photophobia & Phonophobia • Postdrome • May persist for some days • Sore feeling, impaired thinking • Tiredness, ‘hangover’ feeling The Peer Teaching Society is not liable for false or misleading information…

  9. Migraine: Management • Headache diary – to identify possible triggers • Acute treatment • Simple analgesia e.g. NSAID • 5HT agonists: triptan (e.g. sumatriptan) • +/- anti-emetic if nausea/vomiting • Preventative treatment (if recurrent debilitating attacks) • Topiramate or Propanolol The Peer Teaching Society is not liable for false or misleading information…

  10. Causes The Peer Teaching Society is not liable for false or misleading information…

  11. Meningitis • Neisseria meningitides (meningococcal) • Streptococcus pneumoniae (pneumococcal) • Fever • Neck stiffness • Photophobia • Rash (indicates meningococcal) • Kernig’s sign, Brudzinski’s sign The Peer Teaching Society is not liable for false or misleading information…

  12. Meningitis • Patient may present in shock • ABC • 999 • While waiting for ambulance, give • IM Benzylpenicillin • If allergic to penicillin, give Cefotaxime The Peer Teaching Society is not liable for false or misleading information…

  13. Meningitis: Investigations • Bloods: FBC, U&E, LFT, CRP, lactate, blood glucose, clotting • Microbiology: blood culture, throat swab • LP – ONLY IF NO ICP • What do we look for on LP? The Peer Teaching Society is not liable for false or misleading information…

  14. Meningitis The Peer Teaching Society is not liable for false or misleading information…

  15. Meningitis: Management • Antibiotics – IV Cefotaxime/Ceftriaxone • Amend on basis of microbiology results • Dexamethasone – reduces oedema. Must ensure on right Abx first. • Isolate pt for 1st 24 hrs • Notify HPA • Prophylaxis of household contacts – Rifampicin and meningococcal vaccine The Peer Teaching Society is not liable for false or misleading information…

  16. Causes The Peer Teaching Society is not liable for false or misleading information…

  17. Layers covering brain… Bleeding can occur between all layers… The Peer Teaching Society is not liable for false or misleading information…

  18. Haemorrhage • Intracerebral – stroke • Subarachnoid • Subdural • Extradural The Peer Teaching Society is not liable for false or misleading information…

  19. Subarachnoid Haemorrhage • Spontaneous arterial bleeding into subarachnoid space • Causes • Berry aneurysm rupture 85% • Non-aneurysmal haemorrhage 10% • Other 5% due to vascular anomalies e.g. AVM The Peer Teaching Society is not liable for false or misleading information…

  20. Subarachnoid Haemorrhage: Risk Factors • Hypertension • Smoking • Excessive alcohol intake • Family History – younger age of SAH • Berry aneurysms associations: with: • PKD • Coarctation of aorta • Ehlers-Danlos syndrome The Peer Teaching Society is not liable for false or misleading information…

  21. Subarachnoid Haemorrhage: Signs and Symptoms Symptoms • THUNDERCLAP HEADACHE • Sudden onset (secs-mins) • Severe • Often occipital – ‘like being hit in back of head with baseball bat’ • Vomiting • Seizures • Visual loss/double vision Signs • Kernig’s +ve • Papilloedema • Decreased GCS • Coma • High bp – reacting to blood loss • Focal neurological signs e.g. CN III Palsy if Pcom aneurysm The Peer Teaching Society is not liable for false or misleading information…

  22. Subarachnoid Haemorrhage: Investigations and Management Investigations • CT – immediately • LP if CT -ve – best done 12 hrs to 2 weeks after onset • Xanthochromia – yellow discolouration of CSF, due to bilirubin from Hb breakdown • CT/MR angiogram to visualise all cerebral arteries Management • Coiling/clipping of aneurysms • Nimodipine (CCB) to reduce vasospasm & hypoxia The Peer Teaching Society is not liable for false or misleading information…

  23. Subarachnoid Haemorrhage: Complications High mortality – 50% dead by time reach hospital, another 10-20% within weeks (re-bleed) • Rebleed • Ischaemia • Hydrocephalus • Epilepsy • Hyponatraemia The Peer Teaching Society is not liable for false or misleading information…

  24. Subdural Haematoma • Accumulation of blood in subdural space, putting pressure on the brain • Due to head injury (often trivial)  rupture of vein • May be acute/subacute/chronic • Acute – active bleeding at time of injury • Subacute 3-7 days after initial injury • Chronic 2-3 weeks after initial injury The Peer Teaching Society is not liable for false or misleading information…

  25. Subdural Haematoma: Risk Factors • Age – cerebral atrophy  tension on veins  more easily injured • Alcohol abuse  low platelets  ↑ risk of fall/head injury  cerebral atrophy • Anticoagulants – aspirin, warfarin therapy The Peer Teaching Society is not liable for false or misleading information…

  26. Subdural Haematoma: Acute • Usually presents soon after moderate/severe head injury • +/- loss of consciousness The Peer Teaching Society is not liable for false or misleading information…

  27. Subdural Haematoma: Chronic • Presents 2-3 weeks after trauma – often trivial injury • Gradually progressive symptoms over days/weeks • Gradually evolving neurological deficit • Limb weakness • Speech difficulty • Drowsiness/confusion • Personality changes • Gradually progressive headache The Peer Teaching Society is not liable for false or misleading information…

  28. Subdural Haematoma: Inv and Management Investigations • CT – crescent-shaped • Blood tests • FBC, U&E, LFTs • Coagulation screen Management • Refer – may need surgery • May resolve spontaneously The Peer Teaching Society is not liable for false or misleading information…

  29. Extradural Haematoma • Collection of blood in space between dura and bone (potential space) • Significant head injury – esp # temporal/parietal bone  damage to middle meningeal artery/vein  headache due to stripping of dura away from bone • Associated N&V, seizures, focal neurological deficit • Gradual loss of consciousness – decreasing GCS, after initial lucid period The Peer Teaching Society is not liable for false or misleading information…

  30. Extradural Haematoma: Investigations and Management Investigations: • CT – bi-convex shaped well-demarcated lesion of hyperdensity • X-ray of skull and cervical spine to show # Management: • ABC, stabilisept • Treatment may be conservative (monitoring) or interventional (burr holes) The Peer Teaching Society is not liable for false or misleading information…

  31. Causes The Peer Teaching Society is not liable for false or misleading information…

  32. Giant Cell Arteritis • Aka Temporal Arteritis • Immune-mediated systemic vasculitis affecting medium and large arteries • Associated with polymyalgia rheumatica (PMR) – shoulder girdle pain, muscle aches, proximal weakness • Typically occurs in over 50’s The Peer Teaching Society is not liable for false or misleading information…

  33. Giant Cell Arteritis: Presentation • Temporal headache • Myalgia • Fever • Malaise • Scalp tenderness – pain on combing hair, resting head on pillow • Jaw/tongue claudication – pain on chewing • Visual symptoms e.g. diplopia The Peer Teaching Society is not liable for false or misleading information…

  34. Giant Cell Arteritis: Signs • Scalp tenderness • On palpation of temporal artery: • Absent pulse • Beaded • Tender • Enlarged The Peer Teaching Society is not liable for false or misleading information…

  35. Giant Cell Arteritis: Investigations • FBC – anaemia • ESR – significantly elevated >50 • Temporal artery biopsy: • Mononuclear cell or granulomatous inflammation • Multinucleated giant cells • But negative biopsy doesn’t mean no GCA – SKIP LESIONS The Peer Teaching Society is not liable for false or misleading information…

  36. Giant Cell Arteritis: Treatment • STEROIDS – high dose prednisolone • Low dose aspirin – reduces visual loss and stroke • If long-standing disease, immunosuppressants e.g. methotrexate The Peer Teaching Society is not liable for false or misleading information…

  37. Space-Occupying Lesion • What can occupy space? • Tumour • Primary • Mets • Abscess • From adjacent structures e.g. otitis media, dental infection, mastoiditis, sinusitis • Haematoma The Peer Teaching Society is not liable for false or misleading information…

  38. Space-Occupying Lesion: Presentation • Features of raised intracranial pressure • Vomiting • Posture-related headache • Headache wakes pt from sleep • Papilloedema • Seizure may be presenting sign • Localising signs The Peer Teaching Society is not liable for false or misleading information…

  39. Space-Occupying Lesion: Investigations and management Investigations: • CT/MRI • MR angiography • PET, CXR – looking for mets Management of brain tumour: • Dexamethasone – reduces oedema • Antiepileptics if seizures • Surgery • Radiotherapy The Peer Teaching Society is not liable for false or misleading information…

  40. Causes The Peer Teaching Society is not liable for false or misleading information…

  41. Trigeminal Neuralgia • Thought to be due to compression of V nerve by loop of artery/vein • Paroxysmal stabbing unilateral pain in branch distribution, like electric shock – sporadic, sudden • Secs-mins duration • May have triggers e.g. light touch to face, eating, cold wind, vibration • Do MRI to rule out other causes (MS/tumour/ cyst/aneurysm causing pressure) - Rx is difficult – pt support, carbamazepine 1st line, pain service referral The Peer Teaching Society is not liable for false or misleading information…

  42. Cluster Headache • Attacks of severe unilateral pain around eye, may wake pt • Associated symptoms: autonomic • Eye watering • Conjunctival redness • Rhinorrhoea • Most common in • Men • Smokers • Clusters (1-2 attacks daily) last 1-3months then remission • Acute Rx: 100% O2 and sumatriptan. Preventative Rx: verapamil The Peer Teaching Society is not liable for false or misleading information…

  43. Medication Overuse Headache • Frequent headaches • Caused by regular painkillers/triptans for headaches/migraine • Management: • Explain to pt • Stop painkillers  worse/more frequent headaches for around 1 week before improvement The Peer Teaching Society is not liable for false or misleading information…

  44. Causes The Peer Teaching Society is not liable for false or misleading information…

  45. Clinical Neuroanatomy: Dominant Hemisphere: Expressive/Receptive Dysphasia Non-Dominant Hemisphere: Apraxia, Sensory inattention The Peer Teaching Society is not liable for false or misleading information…

  46. Occulomotor (III) nerve

  47. The Peer Teaching Society is not liable for false or misleading information…

  48. Cerebrovascular Events: Deficit: Focal neurological Onset: Sudden Origin: Vascular TIA = reversible Stroke = >24hours, permanent or death Ischaemic or Haemorrhagic in origin Risk factors for ischaemic stroke? Risk factors for hemorrhagic stroke? The Peer Teaching Society is not liable for false or misleading information…

  49. Presentation: Symptoms: • Weakness • Numbness • Confusion/Dysphasia • Visual changes Signs: • Flaccid paralysis* • Diminished reflexes* • Hemiplegia • Hemianopia • Aphasia *Later develops a spastic paralysis, up-going plantar reflexesand hyperreflexia The Peer Teaching Society is not liable for false or misleading information…

  50. DDx Weakness: Cerebral infarction Cerebral haemorrhage Spinal infarction Subdural/Extradural haematoma Epilepsy (Todd’s Paralysis) MS Intracranial lesion – tumour or abscess !! RememberBells Palsy (Differences?) The Peer Teaching Society is not liable for false or misleading information…

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