Neurology

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Neurology

• Adam Couves
• 0606330c_at_student.gla.ac.uk

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Today we will cover

• The two big uns
• Stroke
• Parkinsons Disease

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Aims

• Past paper questions
• Definitions
• Aetiology
• Clinical pictures
• Differential diagnoses
• Management
• Complications

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Stroke

• Acute neurological deficit (usually focal) of
  cerebrovascular origin lasting gt24 hours
• lt24 hours TIA
• Two types
• Ischaemic
• Haemorrhagic

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Pathophysiology

• Usually thrombotic embolus
• Origins
• Heart (AF, MI)
• Carotids (atherosclerosis)
• Lodges distally occluding blood supply and hence
  ?O2 delivery to cerebral tissue

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Ischaemic Cascade

• Failure of ATP dependant Na/K pump
  depolarisation
• Glutamate toxicity
• Ca2 influx into cells
• Initiating wide spread destructive effects
• Progressive infarction

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Risk Factors

• Atherosclerosis
• Smoking
• Diabetes
• Hypercholesterolaemia
• Age
• SE Asian heritage
• Thrombosis
• Oral Contraceptive Pill
• Polycythaemia
• Thrombophilia
• Vasculitis

• Cardiac
• MI
• AF
• Valvular heart disease
• Cheeky extra
• Previous Stroke / TIA

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Clinical Picture

• Related to neuroanatomy

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Total Anterior Circulation Syndrome

• Usually proximal MCA or ICA occlusion
• Hemiparesis
• Higher Cortical Dysfunction
• Dysphasia
• Visuospatial neglect
• Homonymous Hemianopia

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Homonymous Hemianopia

• Optic radiation runs along MCA territory

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Partial Anterior Circulation Syndrome

• Usually branch MCA occlusion
• Any 2 out of 3
• Hemiparesis
• Higher Cortical Dysfunction
• Dysphasia
• Visuospatial neglect
• Homonymous Hemianopia

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POsterior Circulation Syndrome

• Vertebral, Basilar, Cerebellar or PCA vessels
• Isolated Hemianopia (PCA)
• Brainstem Syndromes
• Cerebellar Syndromes

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LACunar Syndrome

• Basal Ganglia - supplied by end arteries
  (lenticulostriate arteries)
• Pure Motor Stroke ? Internal Capsule
• Pure Sensory Stroke ? Thalamus
• Sensorimotor Stroke
• Ataxic Hemiparesis
• Clumsy Hand Dysarthria

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Differential Diagnosis

• Todds Paresis (post ictal)
• Bells Palsy / VII CN HSV infection
• Cerebral Tumour
• Brain Abscess
• Hypoglycaemia
• Encephalitis
• Subdural Haematoma
• Traumatic Brain Injury

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ACUTE MANAGEMENT

• Airway
• Protected
• Swallowing?
• Breathing
• Adequate on air?
• Circulation
• Fluid replacement if BP ?
• Do not routinely treat hypertension
• Disablility
• GCS
• Pupils
• Exposure
• Sustained other injuries with fall?
• Concomitant pathologies?
• GLUCOSE!

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Investigations

• CT Scan
• Rule out HAEMORRHAGE
• Exclude tumour
• Evidence of early ischaemic changes
• Bloods FBC, UE, Glucose, Coagulation, ESR
• Cardiac
• ECG
• Echo
• Carotid doppler US
• CXR heart size, lung pathology, tumours

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Thrombolysis

• Administered lt4.5hrs of symptom onset
• Recombinant tissue Plasminogen Activator (rtPA)
  alteplase
• Binds to fibrin and activates plasminogen ?
  cleaves fibrin ? degrades thrombus
• Also give Aspirin 300mg

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Contraindications

• Extremes of age (gt80 or lt18)
• NIHSS gt 25 or NIHSS lt4
• Previous severe disability / terminal illness
• Hx ICH / neoplasm or AV malformation
• Stroke / prev head trauma (3/12)
• Platelets ?or INR gt 1.5
• Pregnancy / Recent Childbirth (2 weeks)
• Recent MI (1 month)
• Active Bleeding / Acute Trauma
• Major Surgery (2 weeks)

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Complications

• Dysphagia
• Malnutrition / Medications
• Aspiration pneumonia
• Immobility
• Muscle wasting and contractures
• Pressure sores ? ulceration ? infection
• Falls
• Osteoporosis
• Incontinence
• Skin integrity
• Retention of Urine
• Catheterisation ? UTI
• Epilepsy
• Depression
• Death

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Secondary Prevention

• Antiplatelet
• Aspirin 300mg (2/52) then 75mg
• Dipyridamole 200mg
• Statin
• BP (aggressive if DM)
• Carotid Endarterectomy
• Lifestyle

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Parkinsons Disease
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Parkinsonism

• Triad of Symptoms
• Tremor
• Unilateral
• 4-6 Hz
• Pin - rolling
• Worse at rest
• Rigidity
• Lead pipe
• Cog-wheeling
• Bradykinesia
• Serpentine Stare (Hypomimia)
• Reduced arm swing
• Reduced frequency and amplitude of repetitive
  movements
• Worse with co-stimulation
• Loss of Postural reflexes

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Idiopathic Parkinsons Disease

• Progressive degeneration of dopaminergic neurons
  of nigrostriatal pathway (Subtantia Nigra ?
  Lentiform Nucleus)
• Disrupting complex feedback mechanisms involved
  in initiating and maintaining movement
• Symptoms arise when 60-80 of neurons are lost

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Non-motor Symptoms

• Sensory
• Anosmia!!
• Psychological
• Depression
• Obsessive and Impulsive behaviours
• Dementia
• Hallucinations
• Sleep Disorders
• Urinary Incontinence
• Dysphagia and Gastro-Oesophageal reflux
• Sweating and pale cool skin
• Erectile dysfunction

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Management
L-DOPA
L-DOPA

• Levodopa
• Combined with Carbidopa (Sinemet)
• Improve pharmaco-kinetic profile
• Reduce side effects
• Postural hypotension
• Nausea
• Hallucinations

DOPA
Dopamine
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Dopamine Agonists

• E.g. Ropinirole, Apomorphine

Agonise dopamine receptors
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MAOI Selegine
DOPA
Dopamine
3-MT
MAOI
HVA
3-4-DPA
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COMT-I - Entacapone
3-OMD
DOPA
Dopamine
3-MT
COMT-I
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Considerations for L-DOPA?

• Age of patient
• Disease severity
• Dysphagia / Gut motility
• Preparation
• Protein
• Side effects

On / Off syndrome
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Differentials - Parkinsonism
Disease Key Features
Essential Tremor Tremor alone, episodic Improves with alcohol Family history
Drug induced DA agonists- antipsychotics e.g. haliperidol Antiemetics e.g. metaclopramide prochlorperazide
Vascular Parksinsonism Stepwise progression Other neuro deficit CV risk factors
Multi Systems Atrophy Autonomic features postural hypotension, erectile dysfunction, sphincter disturbances
Progressive Supranuclear Palsy Loss of vertical gaze Extreme axial rigidity Fixed facial expression
Any cerebellar disease Drugs e.g. Lithium, Phenytoin Intention tremor Other cerebellar signs (DANISH)
Wilsons Disease Young age LFTs deranged High serum copper
Post-encephalitic Parkinsonism Hx of encephalitis (obvs)
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Akinetic Rigid Syndromes
Disease Key Features
Essential Tremor Tremor alone, episodic Improves with alcohol Family history
Drug induced DA agonists- antipsychotics e.g. haliperidol Antiemetics e.g. metaclopramide prochlorperazide
Vascular Parksinsonism Stepwise progression Other neuro deficit CV risk factors
Multi Systems Atrophy Autonomic features postural hypotension, erectile dysfunction, sphincter disturbances Hot cross bun sign on CT
Progressive Supranuclear Palsy Loss of vertical gaze Extreme axial rigidity Fixed facial expression
Any cerebellar disease Drugs e.g. Lithium, Phenytoin Intention tremor Other cerebellar signs (DANISH)
Wilsons Disease Young age LFTs deranged High serum copper
Post-encephalitic Parkinsonism Hx of encephalitis (obvs)