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Neurology

Neurology. NEUROLOGY. CHAPTER 24. Symptoms: Headache (HA). Acute: Age > 50 years. Rapid onset and severe intensity. Fever. Trauma. Vision changes. Past medical history of hypertension or HIV infection. Hypertension.

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Neurology

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  1. Neurology

  2. NEUROLOGY CHAPTER 24

  3. Symptoms: Headache (HA) • Acute: • Age > 50 years. • Rapid onset and severe intensity. • Fever. • Trauma. • Vision changes. • Past medical history of hypertension or HIV infection. • Hypertension. • Neurologic findings (mental status changes, motor or sensory deficits).

  4. Headches • Chronic: • Migraine (pulsating or throbbing), • Tension (tightness or pressure ), or • Depression • Tumor, head injury, cervical spondylosis, dental or ocular disease, TM joint dysfunction, sinusitis, hypertension

  5. Headaches • Sharp and lancinating – neuralgic • Ocular/periorbital-icepick like pain- migraine/cluster headaches • Dull and steady- tumor • Cough aggravated in brain tumors • Severe headache in a previously well patient: rule out- sub arachnoid hemorrhage/ meningitis

  6. Headaches • Cranial MRI or CT scan required if: • New onset in middle or later life • Progressive • Disturb the sleep/related to exertion • Associated with neurological deficit

  7. Tension Headaches • Poor concentration • Vague non specific symptoms • Vise-like, worse on emotional stress/noise/ glare and occurs almost daily • Intense around back of the neck & head • May respond to Tylenol/ or migraine medicine • Relaxation therapy/Massage/Hot baths/ Biofeedback/?Botox

  8. Depression HA • Worse on waking up • Associated depressive symptoms • Antidepressants/Psychiatric help

  9. Migraine HA • Headache, usually pulsatile/dull/throbbing. • Nausea, vomiting, photophobia, and phonophobia are common • Transient neurologic symptoms (commonly visual) preceding headache of classic migraine. • No preceding aura is common.

  10. Migraine • Related to serotonin (5-HT) • Trigeminal trigger • Episodic lateralized throbbing headache • Late teen/early adult onset • Anorexia/Nausea/Vomiting • Visual/Auditory disturbances- gradual build up, last several hours • External Carotid artery system dilation/pulsation • Focal neurological signs/symptoms due to initial constriction of ICA

  11. Migraine • Visual: common- • field defects • luminous visual hallucinations such as stars, sparks, unformed light flashes, geometric patterns, or zigzags of light • Aphasia/numbness/tingling/clumsiness

  12. Migraine • FH+ • Factors- emotional stress, lack/excess sleep, missed meals, specific food items (chocolate, alcohol), menses, pill • ‘Basilar artery’ migraine- blindness/visual field defects initially and later- tinnitus/perioral tingling and transient loss of consciousness/ confusion followed by throbbing occipital HA, nausea/vomiting

  13. Migraine: Treatment • AVOID! Factors • Prophylactic treatment: aspirin/brufen/allieve • Ergot + caffeine (vasoconstrictor) • Serotonin blocker- Sumatriptan/Zolimtriptan

  14. Cluster Headache (Migrainous Neuralgia) • Predominantly middle-aged men • ?Vascular/?serotonin • No FH+ • Unilateral periorbital pain with- • ipsilateral nasal congestion, • rhinorrhea, • lacrimation, • redness of the eye, and • Horner's syndrome

  15. Horner syndrome • Results from an interruption of the sympathetic nerve supply to the eye, and is characterized by the classic triad: • 1 Miosis (ie, constricted pupil) • 2 Partial ptosis and • 3 Loss of hemifacial sweating (ie, anhidrosis)

  16. Cluster Headache (Migrainous Neuralgia) • AT night (wakeup) • Lasts <2hrs • Spontaneous remission • ?alcohol trigger/ glare/food

  17. THERAPY • Oxygen (acute attack) • Oxygen (8 L/min for 10 min or 100% by mask) may abort the headache if used early. • Mechanism of action is unknown. • Sumatriptan • Most studied of the triptans in cluster headache. • Subcutaneous injections can be effective, in large part, due to the rapidity of onset. • No evidence suggests that they are effective orally. • Dihydroergotamine • Can be abortive agent • IV/IM; self-injections

  18. Posttraumatic Headache • Closed head injury • Worsen over the ensuing weeks, and then gradually subsides • Disequilibrium, enhanced by postural change or head movement • Impaired memory, poor concentration, emotional instability, and increased irritability • Tests not helpful, Treatment difficult

  19. ?

  20. TRIGEMINAL NERVE

  21. Trigeminal Neuralgia • Brief episodes of stabbing facial pain. • Pain is in the territory of the second and third division of the trigeminal nerve. • Pain exacerbated by touch • Middle and later life (F>M)

  22. Trigeminal Neuralgia • Sudden lancinating facial pain occur • commonly arise near one side of the mouth and shoot toward the ear, eye, or nostril on that side • Trigger-touch, movement, drafts, and eating • Pain become more frequent, remissions become shorter and less common, and a dull ache may persist between the episodes of stabbing pain • Confined to the distribution of the trigeminal nerve (usually the second or third division

  23. Trigeminal Neuralgia • Young patient presenting with trigeminal neuralgia, multiple sclerosis • Tests-evoked potential testing and examination of cerebrospinal fluid may be corroborative • Treatment- carbamazepine (Tegretol)/ Baclofen/ Gabapentin • Nerve ablation • Structural cause for the neuralgia (despite normal findings on CT scans, MRI, or arteriograms) -surgery

  24. Etiology & Pathology: Exterior –WIND-COLD Invasion Interior – LV/ST FIRE Interior – YIN DEFICIENCY w/empty fire rising Differentiation: Wind-Cold Invasion Signs & Symptoms: Acute onset, severe pain for a few seconds to a few minutes several times/day Exterior signs, runny nose, tearing Tongue: Thin white coat Pulse: Tight, floating LV/ST Fire Signs & Symptoms: Severe pain w/irritability Internal heat signs, thirst, constipation Tongue:Yellow, dry coat Pulse: Wiry Yin Deficiency w/empty heat rising Signs & Symptoms: Pain is more insidious, gradual, comes and goes, malar flush, soreness in lumbar area Tongue: Red w/no coat Pulse: Thin, fast TCM Diagnoses and Acupuncture Treatments

  25. Treatment Points • For pain in the supraorbital region: • Local: Taiyang • GB14/ UB2 • Distal: TH5 / LI4 • For pain in the maxillary region: • Local: ST2 / SI 18 / LI 20 • Distal: LI4 • For pain in the mandibular region: • Local: ST6 / ST 7 • Extra point 1 cun lateral to CV24 • Distal: LI4 • Wind-Cold : Add GB 20 • LV/ST Fire: Add LV3, possibly LV2, ST44 • Yin Deficiency : Add KD6, SP6

  26. Glossopharyngeal Neuralgia • Occurs in the throat, about the tonsillar fossa, and sometimes deep in the ear and at the back of the tongue • Precipitated by swallowing, chewing, talking, or yawning

  27. Postherpetic Neuralgia • 15% of patients who develop shingles suffer from postherpetic neuralgia • High risk: elderly and involvement of Ophthalmic (I) division • Incidence of postherpetic neuralgia may be reduced by the treatment of shingles with oral acyclovir or famciclovir (?) • Corticosteroids do not help (?) • Zoster vaccine for elderly (?) • ZOSTAVAX® [Zoster Vaccine Live (Oka/Merck)] • Carbamazepine/TCA/Lidocaine (local)

  28. Epilepsy • Recurrent seizures. • Characteristic electroencephalographic changes accompany seizures. • Mental status abnormalities or focal neurologic symptoms may persist for hours postictally • Seizure is a transient disturbance of cerebral function

  29. Epilepsy • Usually begin between 5 and 20 • Congenital abnormalities and perinatal injuries • Alcohol withdrawal/hypo or hyper glycemia • Trauma (within 2 years following the injury) • Tumors-especially important cause of seizures in middle and later life , must be excluded by appropriate imaging studies in all patients with onset of seizures after 30 years of age

  30. RED FLAGS!Epilepsy • Epilepsy-Old age – • Vascular diseases • Alzheimer's disease • Infectious disease- • AIDS ∆bacterial meningitis or herpes encephalitis

  31. Tests • Imaging?- • new onset of seizures after the age of 20 years, • A chest radiograph should also be obtained in such patients, since the lungs are a common site for primary or secondary neoplasms.

  32. Tests • EEG • CBC • Blood glucose • BUN, Creatinine

  33. DD • TIAs • Rage attacks • Panic attacks • Syncope • Cardiac arrhythmias

  34. Treatment • goal of preventing further attacks and is usually continued until there have been no seizures for at least 3 years • report to the state department of public health any patients with seizures or other episodic disturbances of consciousness

  35. Generalized tonic-clonic (grand mal) or partial (focal) seizures • Phenytoin -Dilantin®, • Carbamazepine-Tegretol® • Valproic Acid, Depakene® • Gabapentin Neurontin® • Topiramate Topamax® • Ethosuximide Zarontin® • Clonazepam Klonopin®

  36. Monitoring serum drug levels has led to major advances in the management of seizure disorders • Surgical treatment • Vagal nerve stimulation • Status epilepticus is a medical emergency

  37. Sensory Disturbances • Peripheral Nerve • Nerve roots • One limb • One half of the body • Distal: • ‘glove & stocking’

  38. Weakness & Paralysis :1Upper/Lower motor neuron2Spinal roots3Plexus4Peripheral nerves

  39. Muscle groups involved Spasticity Brisk DTRs Babinski’s Sign present Muscle wasting Falccid weak muscle Loss of DTRs Babinski’s sign absent Fasciculations present UMN : LMN

  40. Transient Ischemic Attacks: TIAs • Focal neurologic deficit of acute onset. • Clinical deficit resolves completely within 24 hours. • Risk factors for vascular disease often present. • Increased in patients with hypertension or diabetes • Risk of stroke is highest in the month after a transient ischemic attack

  41. TIA: Causes • Emboli- from Carotids • Cardiac- atrial fibrillation, post infarction • Cervical spondylitis • Subclavian steal syndrome: bruit in the supraclavicular fossa, unequal radial pulses, and a difference of 20 mm Hg or more between the systolic blood pressures in the arms

  42. TIA symptoms: • Abrupt onset –within minutes • Rapid recovery • Carotid territory - Weakness and heaviness of the contralateral arm, leg, or face, singly or in any combination. Slowness of movement, dysphasia, or monocular visual loss in the eye contralateral to affected limbs.

  43. Vertebrobasilar ischemic attacks • Vertigo, ataxia, diplopia, dysarthria, dimness or blurring of vision, perioral numbness and paresthesias, and weakness or sensory complaints on one, both, or alternating sides of the body

  44. TIA risks: • Carotid ischemic attacks are more liable than vertebrobasilar ischemic attacks to be followed by stroke • Stroke risk is greater in patients older than 60 years, in diabetics, or after transient ischemic attacks that last longer than 10 minutes and with symptoms or signs of weakness, speech impairment, or gait disturbance.

  45. Imaging Tests • CT scans • Carotid duplex US • Aretirography • MRI angio less sensitive than conventional

  46. Lab Tests • Assessment for: hypertension, heart disease, hematologic disorders, diabetes mellitus, hyperlipidemia, and peripheral vascular disease • CBC/ Lipids, Cholesterol, Homocysteine/ ECG/ CXR/ Echo/ Holter

  47. Treatment • Carotid artery surgery • Preventive- Stop smoking/ treat underlying disease/ • If embolic- anticoagulants • ?antiplatelet drugs- aspirin 325 mg/ or Plavix ®75 mg (clopidogrel)

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