MedReg+1 Rohrer Neuro
Transcript of MedReg+1 Rohrer Neuro
Developing people for health and healthcare
Neurology
Dr Jonathan Rohrer
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•Epilepsy
• Management of convulsive status epilepticus
• Focal and nonconvulsive status epilepticus
•Headaches
• Headache history
• Evaluation of sudden, severe headache
•Weakness
• Evaluation of acute weakness
• GBS and transverse myelitis
Overview
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• A 65-year-old man presents to A+E. He had been found unconscious at
home by his wife who called an ambulance. He had come round by the
time the ambulance arrived but was confused.
• On his way to hospital he had a tonic-clonic seizure, and this had been
going on for 3 or 4 minutes when he is brought in to resus.
• What are you going to do first?
Epilepsy case 1
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• Despite your treatment he continues to have an ongoing seizure – this
has now been going on for 11 or 12 minutes.
• What are you going to do next?
Epilepsy case 1
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STEP 1: benzodiazepine;
give if fitting for > 5
minutes
STEP 2: if no
response to step
1 WITHIN 10
minutes, give
stage 2 agent
and inform
ICU/anaesthetics
STEP 3: if no
response to step
2 within 30
minutes of
onset,
anaesthesia and
ICU admission
Management of convulsive status epilepticus
For the full protocol see: A protocol for the inhospital emergency drug management of convulsive status epilepticus in adults. Jones et al. Practical Neurology 2014l 14: 194-197.
1. IV lorazepam – usual dose
2 to 4mg (max 2mg/min); if
necessary repeat up to a
max dose of 0.1mg/kg
2. or IV diazepam – usual
dose 5-10mg, up to 20mg if
necessary; do not give too
fast to avoid respiratory
depression (max 5mg /min)
1. IV phenytoin – 18mg/kg;
max rate 50mg/min; into
large or central vein with
ECG/blood pressure
monitoring
2. Ensure ICU/anaesthetics
aware of patient
GENERAL MEASURES in parallel
1. Secure airway and resuscitate
2. Administer oxygen
3. Assess cardiorespiratory function
4. Establish IV access
5. Measure CBG and correct hypoglycaemia
6. Check temperature
7. Check blood gases
8. If poor nutrition/alcohol abuse suspected
give Pabrinex
9. Take blood for FBC, U+Es, LFTs, clotting,
glucose, Ca, Mg, CK, AED levels, tox screen
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• He has now been intubated and ventilated and is being taken to ITU.
• What are you going to do next?
Epilepsy case 1
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• Pre-existing epilepsy – concurrent illness, not taking AEDs etc.
• Metabolic disturbance – electrolyte abnormalities, hypoglycaemia, renal
failure
• CNS infection – meningitis, encephalitis
• Stroke
• Head trauma
• Drugs or alcohol
• Hypoxia/cardiac arrest
• Brain tumour or other SOL
• Hypertensive encephalopathy/PRES
• Autoimmune encephalitis e.g. anti-VGKC, anti-NMDA antibodies
Epilepsy case 1 – why is this person in SE?
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• 36 year old man with known Sturge-Weber syndrome attends A+E. He
has known epilepsy and is on carbamazepine 300mg BD.
• He has had continuous seizures for the last 30 minutes which are focal,
affecting the right arm and leg only and in full consciousness.
• He has been given 4mg of lorazepam and loaded with phenytoin but
they are still ongoing – what would you do?
Epilepsy case 2
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• Continuous focal motor seizures (epilepsia partialis continua) can be
difficult to treat
• Avoid sedative and anaesthetic agents if possible
• Next steps – options include:
• IV levetiracetam 30mg/kg over 10 minutes
• IV valproate 30mg/kg over 5 minutes
Epilepsy case 2
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• A 32-year-old woman presents to A+E with a sudden, severe headache.
It started 4 hours ago and her family say she has been a bit confused
since. She says that she feels nauseous.
• What will you ask her and what would you do next?
Headache case 1
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• History of the headache itself including time to peak intensity and
duration. Are they someone who has headaches usually? How many a
month/year usually?
• Meningitis (if acute): neck stiffness, fever, rash, photophobia
• Migraine: unilateral or bilateral; nausea/vomiting, photophobia,
phonophobia, osmophobia, movement sensitivity, aura
• Trigeminal autonomic cephalgias (SUNCT 5s-4m – paroxysmal
hemicrania 2-30m – cluster headache 15m-3h): unilateral; red eye,
tearing, rhinorrhoea, nasal congestion, ptosis, miosis, restlessness
• Pressure-related headache: time of day, effect of posture, effect of
Valsalva manoeuvres, visual obscurations
• Temporal arteritis: jaw claudication, scalp tenderness/sensitivity
• Focal neurological symptoms
The headache history
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• Usually fit and well. Not on any medication apart from OCP.
• On examination she has a normal exam with no focal neurology. She
knows where she is and what day it is.
• She has a normal CT head and goes on to have a lumbar puncture.
This shows an opening pressure of 32cmH2O with a normal white cell
count, normal protein and normal glucose.
• What would you do next?
Headache case 1
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What causes acute severe headache?
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Primary headaches
• Migraine
• Cluster headache and other trigeminal autonomic cephalalgias
• Others e.g. primary thunderclap headache
Secondary headaches
• Head or neck trauma
• Cranial or cervical vascular disorder: SAH, ICH, ischaemic stroke, dissection,
venous sinus thrombosis
• Nonvascular intracranial disorder: raised or low intracranial pressure, tumour,
pituitary apoplexy
• Due to a substance or its withdrawal
• Infection: intracranial or systemic
• Due to problems in the head, neck and cranial structures: acute glaucoma
What causes acute severe headache?
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If meningitis suspected,
investigate and treat
accordingly
Ask, is time to peak intensity
<5 minutes and headache
duration >1 hour
If yes, strongly
consider SAH and
organise CT head.
If normal then
perform LP >12
hours after onset
with OP, cell count,
glucose, protein,
spectrophotometry
If no, but warning
features present
(see below) then
CT head/discuss
with neurology
team
Emergency evaluation of sudden, severe headache
MAIN WARNING FEATURES
• New onset or change in headache in people
over 50
• Time to peak intensity of <5 minutes
• Focal neurological symptoms
• Non-focal neurological symptoms e.g. seizure
or cognitive disturbance
• Change in headache frequency, characteristics
or associated symptoms
• Abnormal neurological exam
ADDITIONAL WARNING FEATURES
• Headaches that change with posture
• Headaches waking the patient up, or
precipitated by Valsalva manoeuvres
• Risk factors for cerebral venous thrombosis
• Jaw claudication or visual disturbance
• Neck stiffness
• Fever and rash
• New onset headache in patient with HIV
• New onset headache in patient with cancer
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Weakness
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UMN LMN NM
J
Muscl
e
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UMN LMN NM
J
Muscl
e
NM
J
Muscl
eBrain Brainste
m
Spine AHC BrainRoot Plexu
s
Nerve Nerve
s
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UMN LMN NM
J
Muscl
e
NM
J
Muscl
eBrain Brainste
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Spine AHC BrainRoot Plexu
s
Nerve Nerve
s
Where? (Anatomy)
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UMN LMN NM
J
Muscl
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NM
J
Muscl
eBrain Brainste
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Spine AHC BrainRoot Plexu
s
Nerve Nerve
s
Where? (Anatomy)
What? (Pathology)
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UMN
Brain Brainste
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Spine Brain
In
the
UMN
Question 1
Is it a
hemiparesis,
quadraparesis
or
paraparesis?
HE
MIP
AR
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I
S
QU
AD
RA
-
PA
RE
SIS
PA
RA
PA
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IS
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UMN
Brain Brainste
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Spine Brain
In
the
UMN
Question 2
What are the
sensory
features?HE
MIP
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QU
AD
RA
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PA
RE
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PA
RA
PA
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UMN
Brain Brainste
m
Spine Brain
In
the
UMN
Question 3
Are there any
cranial nerve
signs?HE
MIP
AR
ES
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QU
AD
RA
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PA
RE
SIS
PA
RA
PA
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LMN NM
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NM
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eAHC BrainRoot Plexu
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Nerve Nerve
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Beyond
the
UMN
Question 1
Is weakness
symmetrical or
asymmetrical?
Asymmetrical/unilateral Symmetrical
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LMN NM
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Question 2
If symmetrical,
is it distal or
proximal?
DIS
TA
L
PR
OX
IMA
L
PR
OX
IMA
L
Symmetrical
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LMN NM
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Nerve Nerve
s
Beyond
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UMN
Question 3
If
asymmetrical,
what is
sensory
impairment?
Asymmetrical/unilateral
NO
RM
AL
DE
RM
AT
OM
A
L
DE
RM
AT
OM
A
L
NE
RV
E
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DERMATOMAL NERVE
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LMN NM
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NM
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eAHC BrainRoot Plexu
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Nerve Nerve
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Beyond
the
UMN
The
example of
foot drop
NO
RM
AL
DE
RM
AT
OM
A
L
DE
RM
AT
OM
A
L
NE
RV
E
MNDNormal
sensation
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LMN NM
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Muscl
eAHC BrainRoot Plexu
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Nerve Nerve
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Beyond
the
UMN
The
example of
foot drop
NO
RM
AL
DE
RM
AT
OM
A
L
DE
RM
AT
OM
A
L
NE
RV
E
L5 radiculopath
y
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LMN NM
J
Muscl
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NM
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Muscl
eAHC BrainRoot Plexu
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Nerve Nerve
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Beyond
the
UMN
The
example of
foot drop
NO
RM
AL
DE
RM
AT
OM
A
L
DE
RM
AT
OM
A
L
NE
RV
E
Lumbar
plexopath
y
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LMN NM
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Muscl
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NM
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Muscl
eAHC BrainRoot Plexu
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Nerve Nerve
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Beyond
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UMN
The
example of
foot drop
NO
RM
AL
DE
RM
AT
OM
A
L
DE
RM
AT
OM
A
L
NE
RV
E
Sciatic
nerve
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LMN NM
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Muscl
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Nerve Nerve
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Beyond
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UMN
The
example of
foot drop
NO
RM
AL
DE
RM
AT
OM
A
L
DE
RM
AT
OM
A
L
NE
RV
E
Peronea
l nerve
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• A 54-year-old man presented to A+E with a three day history of difficulty
walking and tingling in his legs. This initially started in his feet but had
now progressed to affect the whole of both lower legs. He had come
today as he had also developed difficulty passing urine and hadn’t been
for six hours. He had not long got back from a holiday in India.
• On examination he had a normal cranial nerve territory and upper limb
examination but in the lower limb he had decreased tone with weakness
in the hip flexors and the ankle dorsiflexors bilaterally. Reflexes were
present and symmetrical with downgoing plantars. Sensation was
decreased to pinprick throughout the legs.
• What would you do next?
Weakness case 1
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GBS vs transverse myelitis
Motor
Sensory
Autonomic
CN
Ix
Ascending weakness;
become areflexic but can be
intact initially
Transverse myelitis
May be minimal on exam
but can be ascending
Cardiovascular >
bladder/bowel early
May have facial or EOM
weakness
CSF: elevated protein but
not WCC
EMG/NCS: demyelination
GBS
Para or quadraparesis;
reflexes usually brisk
Spinal cord level usually
Early loss of bladder/bowel
control
None
CSF: may have increased
WCC/protein
MRI: usually abnormal
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Please email me if any questions or you want any references:
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Some brainstem anatomy
MIDBRAIN
PONS
MEDULLA
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Some brainstem anatomy
1. Rule of 4MIDBRAIN
PONS
MEDULLA
Developing people for
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Some brainstem anatomy
1. Rule of 4MIDBRAIN
PONS
MEDULLA
3
4
Developing people for
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Some brainstem anatomy
1. Rule of 4MIDBRAIN
PONS
MEDULLA
3
4
65
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8
Developing people for
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Some brainstem anatomy
1. Rule of 4MIDBRAIN
PONS
MEDULLA
3
4
6
12
5
7
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Developing people for
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Some brainstem anatomy
1. Rule of 4
1 provisoMIDBRAIN
PONS
MEDULLA
3
4
6
12
5
7
8
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10
11
Developing people for
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Some brainstem anatomy
1. Rule of 4
1 proviso
2. Rule of 12
MIDBRAIN
PONS
MEDULLA
3
4
6
12
5
7
8
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10
11
LATERAL MEDIAL
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Some brainstem anatomy
1. Rule of 4
1 proviso
2. Rule of 12
3. Rule of S+M
Lateral =
sensory and
sympathetic
Medial = motor
MIDBRAIN
PONS
MEDULLA
3
4
6
12
5
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LATERAL MEDIAL
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Where is the brainstem syndrome?
• Left facial sensation loss, left face weakness, left hearing lossand right arm and leg sensory loss
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Where is the brainstem syndrome?
• Left facial sensation loss, left face weakness, left hearing lossand right arm and leg sensory loss
• Left lateral pons
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Where is the brainstem syndrome?
• Left facial sensation loss, left face weakness, left hearing lossand right arm and leg sensory loss
• Left lateral pons
• Tongue deviation to the right and left hemiparesis
Developing people for
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Where is the brainstem syndrome?
• Left facial sensation loss, left face weakness, left hearing lossand right arm and leg sensory loss
• Left lateral pons
• Tongue deviation to the right and left hemiparesis
• Right medial medulla