Neurology in practice

4 cases Think about the cases Think about what might go wrong Revise simple examination

Case 1 Mr EC Retired jump jockey 72 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 Questions What 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 weakness Pronator drift Increased tone Clonus Weakness No wasting Brisk reflexes

Back at home – case 1 questions He 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 inattention Non dominant parietal lobe syndrome Sensory inattention May mix up left and right Ignores one half of body Visual inattention Sees 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 2 Mr Brown 72 years of age Woke 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 140/102 P 70 regular Heart sounds normal No abnormal neurological signs Bruit 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?

Epidemiology Aetiology 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. 1hypertension 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: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. mitral valve diseaseaortic valve diseaseatrial myxoma The vertebrobasilar arteries may be a source. TIA

Case 3 A 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 warning Her boyfriend says that she goes blank before her migraine and smacks her lips together She then recovers but after minutes He 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.

Case 4 Mr Perugia 68 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 - questions What 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.