NEUROLOGY PROBLEMS – DIAGNOSTIC CHALLENGES · LP – wbc
Transcript of NEUROLOGY PROBLEMS – DIAGNOSTIC CHALLENGES · LP – wbc
NEUROLOGY PROBLEMS – DIAGNOSTIC CHALLENGES
Dr Ben Turner Barts Health NHS Trust London Bridge Hospital
Thunderclap Headache
! Subarachnoid haemorrhage ! Other vascular events - AVM, mass lesion,
GCA, hypertension, dissection, cerebral venous thrombosis
! Pituitary apoplexy ! Meningitis ! Exertional headache (sex, gym) ! Migraine ! Idiopathic
Subarachnoid haemorrhage
Subarachnoid haemorrhage
! 6 / 100,000 - annual incidence ! 1 / 4 of sudden onset headache ! 1 / 8 of isolated sudden headache ! defining sudden onset - ‘hit by a sledge-hammer’ ! arising in seconds, within a few minutes lasting > 1 hour ! community study of sudden onset headache <1 minute and
lasting >1 hour 37 / 148 (25%) had SAH ! more likely with assoc features, nausea, vomiting, neck
stiffness, transient loss of consciousness, focal neurological features
Subarachnoid haemorrhage
! CT scan – 98% < 12 hours, 93% < 20 hours ! LP – xanthochromia develops after 12 hours ,
remains for ~ 2 weeks ! Spectrophotometry for bilirubin (only made in
vivo) and oxyhaemoglobin
CT scans in A&E: false reassurance
! Cerebrovascular - Subarachnoid haemorrhage (SAH) - arterial dissection - cerebral venous sinus thrombosis - CNS vasculitis (Temporal arteritis) ! Meningoencephalitis ! Tumours - posterior fossa, pituitary, leptomeningeal ! Low intracranial pressure
Case 1 – worse headache ever
! 56 year old female ! History of occasional migraine ! 2 day before presentation, nausea for 30 mins
then vomited, followed by abrupt (< 1 minute) onset severe headache, extended to neck, eased after 2 hours, then recurred today, then residual headache 6/10, throbbing, BP 160/90mmHg
! Had been using nasal decongestants last few weeks
! Subsequent 2 – 3 episodes of ‘thunderclap’ headaches
! Some nausea, no photophobia, mild neck stiffness
! No focal neurology or seizures
Case 1 – worse headache ever
! No fever, hypertension, no neurological signs ! Bloods normal, no raised inflammatory
markers ! CT brain – normal ! LP – wbc <1, RBC 702 / 486, protein 430mg/lL but raised bilirubin ! CT cerebral angiogram
Reversible Cerebral Vasoconstriction Syndrome (RCVS)
! Severe headaches with or without seizures or focal neurological deficits
! Transient disturbance in the control of cerebral vascular tone leading to multifocal arterial constrictions and dilatations
! Resolves in 1 -3 months ! 20% cortical SAH, 10% ischaemic or
haemorrhagic CVA
Reversible Cerebral Vasoconstriction Syndrome (RCVS)
! Incidence unknown ! Females > males, 13 -70yrs, mean 45 yrs ! 60% secondary; 1. postpartum, 1st week, 60% assoc with
vasoconstrctors 2. vasoactive substances, ergotamine to OTC
sympathomimetics (nasal decongestants) 3. SSRI 4. recreational drugs – cannabis, cocaine
Reversible Cerebral Vasoconstriction Syndrome (RCVS)
! Multiple ‘thunderclap’ headaches suggestive ! Usually over 7 days, then constant for 3 weeks ! haemorrhage early in first 7 days, infarction in
second week ! Triggers reported in majority, sex, coughing etc ! CT cerebral angiogram 80% sensitive, but may be
normal in first 4 days ! CSF may be abnormal with pleocytosis and ↑protein
! Treatment - nimodipine IV or 60mg 4 hourly
NEUROLOGY PROBLEMS – DIAGNOSTIC CHALLENGES
Dr Ben Turner Barts Health NHS Trust London Bridge Hospital
Case 2 Tingling and unsteady
! 21 year old female ! Gastrointestinal upset then.. ! 2 week history of paraesthesia hands and feet ! Vitamin B12 low normal – given replacement ! Continued progression with ascending
paraesthesia and unsteadiness ! Areflexia with loss of vibration and joint
position sense, Romberg’s positive, no weakness
Case 2 Tingling and unsteady
Differential Diagnosis ! Guillain Barre Syndrome ! Vitamin B12 deficiency ! myelitis (posterior) ! Compressive myelopathy ! Paraneoplastic syndrome ! Vitamin E deficiency
Case 2 Tingling and unsteady
Case 2 Tingling and unsteady
Case 2 Tingling and unsteady
Case 2 Tingling and unsteady
Nitrous Oxide Myeloneuropathy
Nitrous oxide is an inhaled anaesthetic drug which irreversibly oxidizes the cobalt ion of cobalamin (vitamin B12) from the (+) 1 to the (+) 3 valence state. Oxidation of the cobalt ion by nitrous oxide prevents methylcobalamin from acting as a coenzyme in the production of methionine and subsequently S-adenosylmethionine, which is necessary for methylation of myelin sheath phospholipids. The result is decreased myelin formation.
Nitrous Oxide Myeloneuropathy
Nitrous Oxide Myeloneuropathy
NO and Vitamin B12
! 15 % > 65 years are Vitamin B12 deficient ! Megablastic anaemia is inverse to neurology ! 20% of B12 is bound to transcobalamin
(active) ! Methylmalonic acid levels may be indirect but
superior marker of B12 status, homocysteine also but less specific
! Subacute combined degeneration of spinal cord (SACD) occurs typical 2 – 6 weeks after exposure from anaesthetic
NO and Vitamin B12
! Clinical Presentation ! Loss of posterior column modalities –
proprioception and vibration sense (a sensory ataxia), L’hermitte’s phenomenon, optic neuropathy
! Can progress to weakness, incontinence, pyramidal signs – extensor plantars
! Demyelination of posterior and lateral spinal columns and demyelinating / axonal neuropathy
! Treatment – parenteral hydroxocobalamin 1mg im alternate days, until improvement