Cases for Finals and Beyond: Nervous System 1 st October 2012 Alastair Brown ST1 Neurosurgery.

Cases for Finals and Beyond: Nervous System

1st October 2012

Alastair Brown ST1 Neurosurgery

Objectives

Describe 3 common clinical scenarios Understand the relevant signs and symptoms of

common neurological conditions. Understand how to decribe gait patterns in

common neurological conditions Understand the investigations and management Be aware of common sequelae of certain

neurological conditions and their management.

Case 1

FY1 covering the COTE Ward on Night Asked to see Mr Williams

84 year old manHas had a fall on the ward Is confusedNot sure if he has injured himself

On the Phone

What things are you going to ask the nurse to do while you are on your way?Get patient back to bed safelyGet a set of observations (inc neuro

observations)Find notes and drug chartConsider asking for and ECG

On the Ward

What are your three priorities with this patient?

1) Identify any injuries2) Identify cause of the fall3) Try to prevent/limit impact of further falls

What are you going to do next? Take a history Examine patient (General, MSK and Neuro)

On the Ward

Drug chart is in pharmacy Nurse looking after the patient is a bank

nurse and does not know much about him. Thinks he is normally confused Fall was unwitnessed Patient just says don’t know to all

questions.

Examination

General and MSK examination unremarkable with no evidence of external injury.

CNS Cranial nerves unremarkable. PEARL Following commands appropriately

PNS - Inspection:

PNS: Inspection

Describe the face of the patient you saw.ExpressionlessMasked

Describe the movement of the hand you saw.Resting tremor of the left hand Improves following purposeful movement

PNS Tone

PNS: Tone

Describe what you saw Intermittent resistance to passive flexion of the upper limbs.

What is this pattern of rigidity called? Cog wheel rigidity

What condition is this pattern of rigidity associated with? Parkinson’s disease

Can you name another pattern of rigidity seen in the same condition? Lead-pipe rigidity

PNS: Gait

PNS: Gait

Describe the person’s gait No aids Slow Stooped Slow turning Small steps Shuffling Tremor in hands Festinating Would also like to see them stand and sit

What condition is the gait pattern typical of? Parkinson’s disease

Parkinson’s Disease: Features

What are the main pathological features in Parkinson’s disease? Loss of Dopaminergic neurons in the substantia nigra Formation of Lewy bodies.

What are the three cardinal features of Parkinsons disease? Tremor Rigidity Bradykinesia

Parkinson’s Disease: Diagnosis

What investigations are used to diagnose PD? Generally a clinical diagnosis MRI and SPECT can be used but this is rare Trial of treatment often helps to make diagnosis.

Can you name three differential diagnoses for PD Lewy Body dementia Drug – induced parkinsonism Vascular dementia Wilson’s disease in young patients

Parkinson’s disease: Treatment

What is the main treatment of Parkinson’s disease? Levodopa treatment Coupled with Carbidopa to reduce peripheral release

and achieve higher CNS concentration with fewer systemic side effects.

Are you aware of any emerging treatments? Deep brain stimulation (normally of Subthalamic

nucleus)

Parkinson’s: Prognosis and Complications What is the course of Parkinson’s disease?

Progressive condition

What later complications are commonly seen? Postural imbalance Dementia Swallowing difficulties Autonomic dysfunction

Case 2

You are an FY2 in A+E Asked to go to resus to see a patient who

has been brought in with seizures.Name: Ethel O’DonohueFive minute seizure terminated after some PR

Diazepam72 year old femalePMH: Unknown

How are you going to approach this patient? A – Patent and protected B – Sats 100% on 15L Chest clear C – HR 110 reg CRT < 2 secs BP155/60 D – E3V2M4 BM 14.1 Pupils equal and

reactive. Not moving left side. E – Ulcers on left leg, Median sternotomy

scar, no evidence of any external injury.

What investigations are you going to arrange? Bloods

FBC, U+E, , LFTs, CRP, Mg, Clotting ABG

Bedside Tests ECG Urine Dip

Radiology ? CXR ? CT head

Results

Bloods CRP – 54 Otherwise unremarkable ABG:

pH – 7.29 pO2: 54.3, pCO2: 4.9 BE: -12.4 Lactate: 6.4 What does this show?

Metabolic acidosis What is the likely cause?

Seizure

While you are waiting…

Patient starts to have another seizure. First you notice shaking of the left arm and leg Patient then stops responding Then starts to have full tonic-clonic seizure.

What are three steps in the seizure described. Partial seizure Initially simple then becomes complex Secondary generalisation.

Cont…

What is the definition of status epilepticus? One seizure > 30 minutes or multiple seizures without

regaining consciousness for over 30 minutes. What is the emergency management of status?

A,B,C Call for Help IV Lorazepam Phenytoin infusion Sedation Barbituate coma

CXRCan you describe this radigraph?

Adequate technical film

Normal lung appearances.

CT HeadCan you describe the CT scan?

-Hypo-intense area in the right hemisphere seen on multiple slices of CT no evidence of midline shift

What is the most likely cause for these findings?

-Stroke

What vascular territory has been affected?

Right MCA

PNS: Inspection

What comments can you make about this gentleman’s posture? Flexed elbows Flexed wrist Flexed digits Inversion of left foot

What is the posture typical of? Spastic paralysis

Would this be typical of an acute stroke? No, spasticity develop over weeks

to months. What would you expect to find

examining his reflexes? Hyperreflexic

PNS: Tone

PNS: Tone

What is the pattern of rigidity seen?Clasp knife rigidity.

What conditions is this pattern of rigidity seen in?Upper motor neurone lesions

PNS: Gait

PNS: Gait

Can you describe this person’s gait?No aidsReasonable speechSpastic postureHip hitching of right legCircumduction of right leg

What is this pattern of Gait called?Hemiplegic gait.

CNS and Remaining PNS

Sensation – normal Power 1/5 on left and 5/5 on right CNS unremarkable. How do you grade power?

0 – No movement1 – Flicker of movement2 – Can move a joint with gravity eliminated3 – Can move a joint against gravity4 – Reduced from normal power5 – Normal power

Stroke

How would you define stroke? Sudden loss of circulation to an area of brain resulting

in a corresponding neurological deficit that persists for more than 24 hours.

What would your differentials include? Todd’s paresis Intracranial haemorrhage SOL Previous neurosurgery

Stroke: Investigation and Diagnosis

What risk factors are you aware of for stroke? Vascular risk factors (smoking, diabetes, hypertension, age) Previous stroke AF Thrombophilias

How would you investigate someone you believed may have had a stroke? History and examination CT/MRI ECHO ECG Carotid dopplers

Stroke: Management

What treatments can be given in acute stroke? Aspirin Thrombolysis (currently within 3 hours of onset)

What other treatments can be given in the longer term to reduce the risk Modification of vascular risk factors (Statin, smoking cessation, etc) Warfarin if patient has AF Carotid endarterectomy.

What are the other components of stroke patient management? PT/OT- rehabilitation SALT to assess swallowing

Case 3

You are an FY1 in acute medicine 27 year old female Presents with vision problems for last 3 days Complaining of blurry and double vision and pain

on looking around Mother has noticed has been quite clumsy Normally fit and well.

CN II

Visual acuity L Eye 6/4.5 R Eye 6/12

Which eye has better vision? L eye

Which fundus is normal? b)

What is the abnormality seen in a) Swollen optic disc

What is the likely diagnosis? Optic neuritis

a)

b)

CNS: III,IV,VI

What eye disorder is shown here? Internuclear

opthalmoplegia Which eye is

affected? Right eye

Which neurological structure is involved? Medial longitudinal

fasciculus

Right

Left

Convergence

PNS: Coordination

PNS: Coordination

What sign is being demonstrated in this patients left arm? Intention tremor

Which hemisphere of which part of the brain is not working L cerebellar hemisphere

What other signs would you test for in this patient? Dysdiadochokineses Past pointing Romberg’s test.

PNS: Gait

PNS: Gait

Describe this patient’s gait. No aids Normal walking speed Poor balance Broad based gait Unsteady

What is the name for this gait pattern? Ataxic gait

What dysfunction is this gait pattern normally due to? Cerebellar dysfunction

Case 3 Cont …

What is the likely diagnosis?Multiple sclerosis

What would be your differential diagnosis?Space occupying lesionOther inflammatory CNS conditions

(vasculitis, sarcoidosis etc.)Clinically isolated syndrome

Multiple sclerosis: Background

What is your understanding of Multiple sclerosis? Immuno-mediated demyelinating disease of the

central nervous system.

What patterns of disease are you aware of? Relapsing-remitting Primary progressive Secondary progressive

MS: Diagnosis and Investigation

How would you investigate this patient? Bloods

Routine Auto-antibodies Infectious serology (Lyme, VDRL) Vitamin B12

MRI CSF – Oligoclonal bands and IgG Visual and Somatosensory evoked potentials

MRI – Of Patient with MS

MS: Treatment

What treatments are used in the acute treatment of MS?MethylprednisolonePlasma exchange

What treatments are used in the long-term management of MS: InterferonOther immunomodulatory drugs

Objectives

Describe 3 common clinical scenarios Understand the relevant signs and symptoms of

common neurological conditions. Understand how to decribe gait patterns in

common neurological conditions Understand the investigations and management Be aware of common sequelae of certain

neurological conditions and their management.

Any questions?

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