Neurology in practice. 4 cases Think about the cases Think about what might go wrong Revise simple...
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Transcript of Neurology in practice. 4 cases Think about the cases Think about what might go wrong Revise simple...
Neurology in practice
4 cases
Think about the cases
Think about what might go wrong
Revise simple examination
Case 1Mr ECRetired jump jockey72 years of age Sunday morning –
walks to the paper shop and then feels dizzy and unable to walk
Ambulance called and taken to Addenbrooke’s
In hospital
CT head – acute infarction R MCA artery territory and Right corpus callosum, also demarcated area of low density involving the right posterior cerebellum
Case 1 QuestionsWhat clinical signs might
you expect to find in this man?
What is the possible management options when he gets to hospital
What are the risk factors?
What are the two most likely pathological processes that have cause this finding on CT?
Right sided Stroke - signs
Upper motor neurone signs on left
Facial weaknessPronator driftIncreased toneClonusWeaknessNo wastingBrisk reflexes
Back at home – case 1 questionsHe is seen at home and
is able to walk with a stick but keeps bumping into things on his left
He is no longer able to dress and puts both legs into his right pyjama trouser leg
He only eats half of his dinner
Can you explain this……..?
Visual field defect
Homonomous hemianopia
Sensory or visual inattentionNon dominant parietal lobe syndrome
Sensory inattentionMay mix up left and right Ignores one half of body
Visual inattentionSees both sides when tested
independently Ignores one side when
presented together
Causes of Stroke
80% Ischaemic
20% Haemorrhagic
Secondary prevention
What does he need to improve his quality of life?
What does his GP need to do and follow up?
Case 2Mr Brown 72 years of ageWoke up this morning
and noticed a sudden blurring of his vision like a curtain coming down
Then was noted to have problems with his speech
2 hours later completely better
Seen in surgery
BP 140/102P 70 regularHeart sounds
normalNo abnormal
neurological signsBruit over left
carotid artery
Case 2 questions ?
How can his symptoms be explained?
What is the chance of this happening again?
What can be done to investigate this?
How should he be managed?
EpidemiologyEpidemiology AetiologyAetiology
The incidence is 42 per 100,000 population and it is commoner with increasing age.
It is rare under the age of 60. The incidence is decreasing,1
perhaps as hypertension is better controlled.
It affects men more than women and black races are at greater risk.
About 15% of first stroke victims have had a preceding TIA.
Usually Thromboembolism: 80% carotid area in about 80% 20%. Vertebrobasilar . Commonest source of emboli is the
carotids, usually at the bifurcation. They can originate in the heart
with atrial fibrillation particularly, with mitral valve disease, or aortic valve disease, or from a mural thrombus forming on a myocardial infarct or a cardiac tumour, usually atrial myxoma.
The vertebrobasilar arteries may be a source.
TIA
Case 3A 26 year old
woman comes to see you
She has a history of migraine
Usually worse when she is due a period
Seems to have improved since taking the oral contraceptive pill
She is on a combined oestrogen and progesterone pill
She smokes 20 cigarettes a day
Should she continue the pill?
3 months later
She comes back saying the migraines have changed
She gets a warningHer boyfriend says that she goes blank before
her migraine and smacks her lips togetherShe then recovers but after 10-15 minutesHe is worried
Case 3 questions
What might be going on now?
Should she remain on the pills?
Can she still drive to work?
What does her GP need to do?
Focal Migraine with aura – avoid Oestrogen containing pills
Absence seizures
• Most common in children• seizure involves a brief
disruption of consciousness—lasting from a few seconds to about half a minute.
• Typically, this seizure starts suddenly; the person stops what they are doing and stares blankly.
• Eyes may roll upwards briefly before this event disappears as quickly as it came
• In the past, these seizures were known as "petit mal" attacks.
• These seizures can include eyelid movement, drooping or drawing back of the head, smacking of lips, or sweating.
http://www.dft.gov.uk/dvla/medical/ataglance.aspx
Case 4
Mr Perugia68 year old
caretaker for Catholic Church
3 weeks ago slipped whilst polishing floor – fell and banged his head
Quickly recovered
Case 4
Complains of headache
Worse when he wakes and when he bends down
When examined he is found to have mild right sided weakness
Case 4 - questionsWhat features about a
headache alert a clinician to a serious cause?
His right arm and leg are weak and have brisk reflexes – what does this suggest?
What does the clinician need to worry about and what does this man need doing ?
A subdural haematoma may be:
An acute subdural haematoma - the blood collects quickly after a head injury; symptoms can occur immediately or within hours.
A chronic subdural haematoma - the blood collects more slowly after a head injury; symptoms can occur 2-3 weeks after the initial injury.