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NEUROLOGICAL
DISORDERS
Neurological disorders
 Nerve and muscle
 Multiple sclerosis
 Parkinson’s disease
 Stroke
 Epilepsy
 Headache and fa...
Nerve and muscle
 Neuropathy
 Myaesthenia gravis
 Muscular dystrophy
 Myopathy
Neuropathy
 Mononeuropathy
 damage by trauma eg pressure
 Diabetics – nerves sensitive to pressure
 damage to blood su...
Diabetic neuropathy
 30 – 40% of diabetic patients in UK will develop
significant nerve damage during their lives due to ...
Diabetic neuropathy
 Acute painful neuropathies, radiculopathies and
mononeuropathies
 Constant burning, parasthesiae, s...
Nerve compression
 Median nerve compression
 in carpal tunnel syndrome occurs in up to 10% patients
 Diagnosis difficul...
Guillain-Barre syndrome
 Acute peripheral neuropathy affecting motor more than
sensory nerves
 Usually follows infection...
Myaesthenia gravis
 Autoimmune disorder
 Most patients have antibodies to acetylcholine receptors
at neuromuscular junct...
Myaesthenia gravis
Myopathy
 Weakness of trunk and proximal limb muscles
 May be weakness of neck flexion and/or
extension and muscles of f...
Inflammatory myopathies
 Polymyositis
 May occur in association with autoimmune connective tissue
disorders
 Dermatomyo...
Dermatomyositis
Spinal root disease (radiculopathy)
 Cervical radiculopathy
 Prolapse of intervertebral disc may compress cervical nerve...
Spinal cord disease
 Inherited
 Hereditary spastic paraplegia
 Congenital
 Arnold-Chiari (develop syringomyelia)
 Tra...
Multiple sclerosis
 Most common chronic neurological disorder affecting
young people
 In most typical form is characteri...
Multiple sclerosis
 Pathophysiology
 Affects white matter of brain and spinal cord
 Inflammatory cells present and myel...
Multiple sclerosis
 Presentation
 Visual disturbance
 Optic neuritis caused by inflammatory demyelination of one optic
...
Multiple sclerosis
 Course
 Relapsing-remitting
 After episode may be complete or near-complete
resolution of symptoms ...
Multiple sclerosis
Multiple sclerosis
 Management
 If relapse severe enough to limit function – treat
with steroids
 Symptom control
 Spa...
Parkinson’s disease
 Degenerative condition affecting extrapyramidal pathways
(neurotransmitter dopamine)
 Affects dopam...
Parkinson’s disease
 Gait
 Flexed/stooped posture
 Difficulty defending balance
 Difficulty initiating walking (‘freez...
Posture
Parkinson’s disease
 Treatment
 Medical
 Levodopa (often in combination with DOPA decarboxylase inhibitor)
 Dopamine r...
Other movement disorders
 Chorea
 Randomly distributed, irregular timed muscle jerks
 Athetosis
 Inability to sustain ...
Stroke
 Third most common cause of death in developed world
(annual incidence 2 per 1000 population)
 Rapidly developing...
Vascular territories
Stroke
 Cerebral arteries
 Anterior
 Middle
 posterior
 Clinical features
 Anterior circulation infarct
 Hemiplegia...
Stroke
 Complications
 Pneumonia
 Deep venous thrombosis and pulmonary embolism
 Myocardial infarction
 10% of patien...
Stroke
 Treatment
 If no haemorrhage start aspirin (+/- dipyridamole)
 Clopidogrel can be used in patients intolerant o...
Subarachnoid haemorrhage
 Causes
 Rupture of aneurysm
 Arteriovenous malformation
 Trauma
 Blood vessels weakened by ...
Intracerebral haemorrhage
 10% of all strokes
 Large haematomas have poor prognosis (>50%
mortality) – risk of hydroceph...
Epilepsy
 1% of population suffer from epilepsy (recurring
tendency to have seizures)
 Definition
 ‘ paroxysmal disorde...
Partial seizures
 Simple partial seizure
 Arise in one cortical area (most commonly temporal lobes)
 Usually brief
 Di...
Generalised seizures
 Absence
 Myoclonic
 Clonic
 Tonic
 Tonic-clonic
 Atonic
Tonic-clonic seizures
 May have prodrome or no warning
 Tonic phase – rigidity
 Often cyanosed
 Clonic phase – jerking...
Conditions that mimic epilepsy
 Syncope
 Lasts <30 secs, pale, little/no confusion after event
 Cardiac
 arrhythmia, o...
Headache and facial pain
 Headache
 Primary (uncertain cause)
 Migraine
 Cluster headache
 Tension-type headache
 Se...
Migraine
 Unilateral headache
 Associated with nausea, vomiting, visual disturbance
 Typical onset teens and twenties
...
Other headaches
 Cluster headache
 Unilateral headache
 Severe attacks pain around one eye
 Lasts 20 – 120 mins
 Usua...
Facial pain
 Trigeminal neuralgia
 Compression of trigeminal sensory root
 Unilateral facial pain with trigger areas
 ...
Neurological infections
 Bacterial
 Meningitis
 Neisseria meningitidis, Haemophilus influenza, Streptococcus
pneumoniae...
Neurological infections
 Viral infections
 Viral meningitis
 Mumps, enterovirus
 Viral encephalitis
 Commonest cause ...
Head injury
 Damage at impact
 Contusion and laceration
 Diffuse axonal injury
 Secondary complications
 Haematoma
 ...
Brain tumour
 Intracranial neoplasms:
 Benign
 Usually extra-axial (eg. Meninges, cranial nerves)
 Compress brain
 Ma...
Glioma
Brain tumour - management
 Surgery
 Benign tumours
 Complete excision may be possible -cure
 Malignant
 Histology
 S...
Congenital disorders
 Cerebral palsy
 Spinal dysraphism
 Infantile hydrocephalus
 Cerebral structural disorders
 Intr...
Cerebral palsy
 Pre- or peri-natal insult
 Fetal hypoxia or infection
 Prematurity
 Traumatic delivery (intracranial h...
Spinal dysraphism (spina bifida)
 Failure of closure of neural tube during development
 Defect of overlying skin
 Abnor...
Congenital disorders (continued)
 Infantile hydrocephalus
 Enlargement of head
 Delayed development, learning difficult...
Neurogenetics
 Huntington’s disease
 Wilson’s disease
 Friedreich’s ataxia
 Hereditary spastic paraplegia
 Leber’s he...
Friedreich’s ataxia
 Autosomal recessive
 Trinucleotide repeat (GAA)
 Progressive ataxia, areflexia, extensor
plantars
...
Pes cavus
Muscular dystrophy
 Dystrophinopathies (mutations of X-linked gene for
muscle protein dystrophin)
 Duchenne muscular dys...
Muscular dystrophy
 Myotonic dystrophy
 Autosomal dominant
 Abnormally sustained muscle contraction (myotonia)
 Bilate...
Hereditary motor and sensory
neuropathy (HMSN)
 Inherited neuropathies
 Genetic defects discovered
 Incidence 1:2500
 ...
Dementia
 Inherited
 Familial Alzheimer’s disease, Huntington’s disease
 Trauma
 Infection
 Syphilis, AIDS-related,
...
Neurorehabilitation
 Aim ‘to restore patients to maximum capability and
independence within limits set by their disabilit...
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Neurological Disorders

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Neurological Disorders

  1. 1. NEUROLOGICAL DISORDERS
  2. 2. Neurological disorders  Nerve and muscle  Multiple sclerosis  Parkinson’s disease  Stroke  Epilepsy  Headache and facial pain  Neurological infections  Head injury and tumour  Spinal conditions  Congenital disorders  Dementia
  3. 3. Nerve and muscle  Neuropathy  Myaesthenia gravis  Muscular dystrophy  Myopathy
  4. 4. Neuropathy  Mononeuropathy  damage by trauma eg pressure  Diabetics – nerves sensitive to pressure  damage to blood supply (vasa nervorum)  Vasculitic diseases  Polyneuropathy  Multiple peripheral nerves  Distal, symmetrical pattern  Lower limbs before upper limbs  Causes -  Inflammatory  Metabolic  toxic
  5. 5. Diabetic neuropathy  30 – 40% of diabetic patients in UK will develop significant nerve damage during their lives due to sub- optimal control  Small fibre neuropathy  Autonomic neuropathy  Motor neuropathy  Large fibre neuropathy  Complications  Callus and plantar neuropathic ulcers  Infection
  6. 6. Diabetic neuropathy  Acute painful neuropathies, radiculopathies and mononeuropathies  Constant burning, parasthesiae, shooting pains  Either symmetrical sensory stocking distribution (both feet) or single or adjacent nerve roots affecting:  feet and/or legs or one or both thighs  Often wasting  May be weakness leading to falls  ‘diabetic amyotrophy’/ proximal motor neuropathy due to radiculopathy or femoral neuropathy  Contact discomfort (eg. clothes)  Insomnia
  7. 7. Nerve compression  Median nerve compression  in carpal tunnel syndrome occurs in up to 10% patients  Diagnosis difficult if severe neuropathy involving hands  Requires nerve conduction studies  Surgical decompression  Ulnar nerve compression  Usually at elbow (groove of medial epicondyle)  Pain and paraesthesia along medial aspect of forearm and numbness in little and ring fingers  May be wasting and weakness of ulnar-innervated small muscles of hand  Common peroneal nerve neuropathy  Nerve runs around head of fibula  Presents with foot drop and may have wasting of tibialis anterior (weak foot dorsiflexion, toe extension and foot eversion)
  8. 8. Guillain-Barre syndrome  Acute peripheral neuropathy affecting motor more than sensory nerves  Usually follows infection  Clinical features  Symptoms over days/weeks  Bilateral flaccid weakness  Loss of tendon reflexes  May affect muscles of respiration  Burning pains and numbness
  9. 9. Myaesthenia gravis  Autoimmune disorder  Most patients have antibodies to acetylcholine receptors at neuromuscular junction  Rare (annual incidence 0.4 in 100000)  Clinical features  Fatiguable ptosis  Diplopia with limitation of eye movements  Facial weakness  Dysphagia  Dysarthria  Neck and limb muscle weakness (fatiguable)  Can involve respiratory muscles
  10. 10. Myaesthenia gravis
  11. 11. Myopathy  Weakness of trunk and proximal limb muscles  May be weakness of neck flexion and/or extension and muscles of facial expression  Gait waddling
  12. 12. Inflammatory myopathies  Polymyositis  May occur in association with autoimmune connective tissue disorders  Dermatomyositis  Rash affects face and knuckles  In minority of cases may have associated malignancy  Inclusion body myositis  Selective involvement of finger flexors and quadriceps
  13. 13. Dermatomyositis
  14. 14. Spinal root disease (radiculopathy)  Cervical radiculopathy  Prolapse of intervertebral disc may compress cervical nerve as exits  Neck pain, muscle weakness, loss of tendon reflex, sensory impairment  Drugs, physiotherapy, may need surgery  Prolapsed lumbar intervertebral disc  S1 root  Low back pain and tenderness  Pain down leg from buttock to ankle (sciatica)  Wasting and weakness of gastrocnemius and soleus)  S1 sensory loss  Depressed ankle reflex  L5 root  Sciatic pain  Foot drop (weakness extensor hallucis longus)  L5 dermatomal sensory impairment
  15. 15. Spinal cord disease  Inherited  Hereditary spastic paraplegia  Congenital  Arnold-Chiari (develop syringomyelia)  Trauma  Disc protrusions, vertebral fracture  Infection  Epidural abscess  Inflammation  Post-viral transverse myelitis  Neoplasm  Vetebral metastases, cord tumour  Vascular  Spinal cord infarct, epidural haematoma  Metabolic  Subacute combined degeneration of the cord  Degenerative  Cord – motor neurone disease  Spine – spondylosis with cord compression
  16. 16. Multiple sclerosis  Most common chronic neurological disorder affecting young people  In most typical form is characterised by lesions separated in time and space in central nervous system  More common in temperate than tropical climate  More common in females (M:F 1.5:1)  Usual age of presentation is between ages of 20 – 40  Prevalence in UK of 1 in 1000
  17. 17. Multiple sclerosis  Pathophysiology  Affects white matter of brain and spinal cord  Inflammatory cells present and myelin damaged  Foci of inflammation and demyelination known as plaques  Initially inflammation and oedema, followed by loss of myelin and then gliosis (scar tissue)  Leads to reduction in conduction velocity  Thought that environmental agent (eg. virus) triggers condition in genetically susceptible individual
  18. 18. Multiple sclerosis  Presentation  Visual disturbance  Optic neuritis caused by inflammatory demyelination of one optic nerve  Pain around one eye especially on eye movement  Blurred vision which may progress to monocular blindness over days or weeks  Loss of colour vision  Limb weakness and sensory disturbance  Lesion in spinal cord or cerebral hemispheres  May have tingling sensation down back +/or limbs on neck flexion  Symptoms may be worse after hot bath
  19. 19. Multiple sclerosis  Course  Relapsing-remitting  After episode may be complete or near-complete resolution of symptoms (80% patients)  After further episodes may be some residual disability  Secondary progressive  Steady progression without resolution  Primary progressive  10% patients have this form of disease with no clear relapses and remissions
  20. 20. Multiple sclerosis
  21. 21. Multiple sclerosis  Management  If relapse severe enough to limit function – treat with steroids  Symptom control  Spasticity, fatigue, bladder disturbance, depression, pain  Disease modifying therapy  Interferon beta and glatiramer acetate
  22. 22. Parkinson’s disease  Degenerative condition affecting extrapyramidal pathways (neurotransmitter dopamine)  Affects dopaminergic neurones in substantia nigra of midbrain projecting to striatum of basal ganglia  Symptoms occur when 60-80% nigrostriate neurones lost  Mean age of onset 60 years  Positive family history unusual but some gene mutations identified  Clinical triad:  Akinesia  Rigidity  Tremor
  23. 23. Parkinson’s disease  Gait  Flexed/stooped posture  Difficulty defending balance  Difficulty initiating walking (‘freezing’)  Steps small and shuffling  Festinant  Normal arm swing lost  Risk of falls
  24. 24. Posture
  25. 25. Parkinson’s disease  Treatment  Medical  Levodopa (often in combination with DOPA decarboxylase inhibitor)  Dopamine receptor agonists  Selegiline (monoamine oxidase inhibitor type B)  Entacapone (catechol-O-methyltransferase inhibitor)  Amantadine  Surgical  Stereotactic thalamotomy (severe tremor)  Pallidotomy (drug-induced dyskinesias)
  26. 26. Other movement disorders  Chorea  Randomly distributed, irregular timed muscle jerks  Athetosis  Inability to sustain body part in one position (eg fingers)  Tremor  Dystonia  Tics  Drug-induced  Restless legs syndrome  Stiff person syndrome
  27. 27. Stroke  Third most common cause of death in developed world (annual incidence 2 per 1000 population)  Rapidly developing symptoms or signs  If resolve within 24 hours – transient ischaemic attack  Mechanism  Infarction  thrombotic (thrombosis of arteries in CNS – degenerative, inflammatory, trauma)  Embolic (cardiac valve disease, AF, recent MI)  Haemorrhage
  28. 28. Vascular territories
  29. 29. Stroke  Cerebral arteries  Anterior  Middle  posterior  Clinical features  Anterior circulation infarct  Hemiplegia  Hemianopia  Cortical deficits (dysphasia, visuospatial loss)  Lacunar infarct  Pure motor stroke  Pure sensory stroke  Ataxic hemiparesis  Posterior circulation infarct  Brainstem lesion  Homonymous hemianopia
  30. 30. Stroke  Complications  Pneumonia  Deep venous thrombosis and pulmonary embolism  Myocardial infarction  10% of patients with cerebral infarction die in first 30 days post- stroke  50% remain dependent  Long-term disability  Pressure sores, seizures, falls, spasticity, depression
  31. 31. Stroke  Treatment  If no haemorrhage start aspirin (+/- dipyridamole)  Clopidogrel can be used in patients intolerant of aspirin  Thrombolysis  iv tissue plasminogen activator (alteplase)  Within 3 hours of stroke onset  Prevention  Modify risk factors  Smoking  Diet (inc lower cholesterol)  Blood pressure  Diabetic control
  32. 32. Subarachnoid haemorrhage  Causes  Rupture of aneurysm  Arteriovenous malformation  Trauma  Blood vessels weakened by infection (v rare)  Features  Sudden severe headache with photophobia, vomiting, neck stiffness  Management  30-40% die within few days of onset  Signif risk of rebleeding in 6 weeks after onset  Nimodipine  Aneurysm clipped or coiled
  33. 33. Intracerebral haemorrhage  10% of all strokes  Large haematomas have poor prognosis (>50% mortality) – risk of hydrocephalus and coning  Causes  Hypertension  Bleeding into tumours  Trauma  Blood disorders  Blood vessel disorders
  34. 34. Epilepsy  1% of population suffer from epilepsy (recurring tendency to have seizures)  Definition  ‘ paroxysmal disorder in which cerebral cortical neuronal discharges result in intermittent, stereotyped attacks of altered consciousness, motor or sensory function, behaviour or emotion’  Classification  Partial (simple or complex)  Generalised (absence, myoclonic, tonic-clonic, tonic, atonic)
  35. 35. Partial seizures  Simple partial seizure  Arise in one cortical area (most commonly temporal lobes)  Usually brief  Discharge remains localised (eg focal motor, sensory or psychic symptoms)  No loss of awareness  Complex partial seizure  Impairment of awareness during attack  Frequently altered or ‘autonomic’ behaviour  Reactive automatisms – may be able to do simple task  Partial onset with secondary generalisation  Epileptic discharge spreads to both cerebral hemispheres
  36. 36. Generalised seizures  Absence  Myoclonic  Clonic  Tonic  Tonic-clonic  Atonic
  37. 37. Tonic-clonic seizures  May have prodrome or no warning  Tonic phase – rigidity  Often cyanosed  Clonic phase – jerking (about 2 mins)  May be incontinent or bite cheek/tongue  Post-ictal confusion and tiredness
  38. 38. Conditions that mimic epilepsy  Syncope  Lasts <30 secs, pale, little/no confusion after event  Cardiac  arrhythmia, outflow obstruction  Transient ischaemic attacks  Usually last longer, rarely LOC  Narcolepsy, cataplexy  Metabolic disturbance  Non-epileptic attacks
  39. 39. Headache and facial pain  Headache  Primary (uncertain cause)  Migraine  Cluster headache  Tension-type headache  Secondary (known cause)  Raised intracranial pressure  Idiopathic intracranial hypertension  Meningeal irritation  Giant cell arteritis  Metabolic disturbances  Facial pain  Trigeminal neualgia  Post-herpetic neuralgia
  40. 40. Migraine  Unilateral headache  Associated with nausea, vomiting, visual disturbance  Typical onset teens and twenties  Aura may be phase of vasoconstriction  Then vasodilatation of extracerebral vessels may cause headache  Treatment  simple analgesia initially  triptan (5HT1 R agonist)  Prophylactic agents  Propranolol  pizotifen
  41. 41. Other headaches  Cluster headache  Unilateral headache  Severe attacks pain around one eye  Lasts 20 – 120 mins  Usually recurs several times a day  Pattern continues for days, weeks or months  Then symptom-free for weeks-months  Treatment  Steroids initially, then methysergide, verapamil or pizotifen  Tension-type headache/ chronic daily headache  May be due to neck muscle contraction  Amitriptyline may help
  42. 42. Facial pain  Trigeminal neuralgia  Compression of trigeminal sensory root  Unilateral facial pain with trigger areas  Treat with carbamazepine initially  May require surgery  Post-herpetic neuralgia  Post-shingles of a branch of trigeminal nerve  Persistent facial pain after rash healed  May respond to amitriptyline, carbamazepine
  43. 43. Neurological infections  Bacterial  Meningitis  Neisseria meningitidis, Haemophilus influenza, Streptococcus pneumoniae  Brain abscess  May complicate otitis media  Raised intracranial pressure, focal signs, seizures  Parameningeal infections  Pus in epidural space  Tuberculosis  Syphilis  Lyme disease  Leprosy
  44. 44. Neurological infections  Viral infections  Viral meningitis  Mumps, enterovirus  Viral encephalitis  Commonest cause Herpes simplex  Headache, fever, reduced LOC, may have seizures  Herpes zoster  Dormant in dorsal root ganglion after chickenpox  May reactivate as shingles  Pain and itching of single or adjacent dermatomes, following by vesicular rash  Retroviral infections  Meningitic illness may occur at seroconversion  Slowly progressive dementia  Risks of immunocompromise (infection, tumour)
  45. 45. Head injury  Damage at impact  Contusion and laceration  Diffuse axonal injury  Secondary complications  Haematoma  Cerebral oedema  Cerebral ischaemia  Coning  Infection  Post-traumatic epilepsy
  46. 46. Brain tumour  Intracranial neoplasms:  Benign  Usually extra-axial (eg. Meninges, cranial nerves)  Compress brain  Malignant  Usually intra-axial (ie. brain parenchyma)  Primary (>50% adult intracranial neoplasms)  gliomas  Secondary (15-20% adult intracranial neoplasms)  metastases
  47. 47. Glioma
  48. 48. Brain tumour - management  Surgery  Benign tumours  Complete excision may be possible -cure  Malignant  Histology  Symptomatic  Radiotherapy  Gliomas – direct towards tumour  Metastases – whole-brain radiation  Drug treatment  Anti-convulsants  Dexamethasone  Chemotherapy
  49. 49. Congenital disorders  Cerebral palsy  Spinal dysraphism  Infantile hydrocephalus  Cerebral structural disorders  Intrauterine infection
  50. 50. Cerebral palsy  Pre- or peri-natal insult  Fetal hypoxia or infection  Prematurity  Traumatic delivery (intracranial haemorrhage)  Clinical features:  Spastic diplegia  May have shortening and deformity of legs  Spastic hemiplegia  Associated with hemisensory deficits, learning difficulties and epilepsy  Athetoid cerebral palsy  Movement disorder develops in early childhood. Usually normal cognitive function
  51. 51. Spinal dysraphism (spina bifida)  Failure of closure of neural tube during development  Defect of overlying skin  Abnormal development of bony structures  Particularly affects lumbosacral region  Myelomeningocoele  Parts of spinal cord in meningeal sac  Paraplegia and incontinence  Spina bifida occulta  Mildest form  Failure of fusion of vertebral arches
  52. 52. Congenital disorders (continued)  Infantile hydrocephalus  Enlargement of head  Delayed development, learning difficulties, seizures, spastic paraparesis  Neurosurgery – eg. ventricular shunt  Cerebral structural disorders  May be incidental findings or may delay development  Intrauterine infection  Rubella  Cataracts, hearing loss, learning difficulties, congenital heart disease  Neurosyphilis  Adult disease plus deafness, keratitis, deformed teeth
  53. 53. Neurogenetics  Huntington’s disease  Wilson’s disease  Friedreich’s ataxia  Hereditary spastic paraplegia  Leber’s hereditary optic atrophy  Hereditary spinal muscular atrophies  Hereditary motor and sensory neuropathy (HMSN)  Muscular dystrophies
  54. 54. Friedreich’s ataxia  Autosomal recessive  Trinucleotide repeat (GAA)  Progressive ataxia, areflexia, extensor plantars  Kyphoscoliosis  Pes cavus  Cardiomyopathy
  55. 55. Pes cavus
  56. 56. Muscular dystrophy  Dystrophinopathies (mutations of X-linked gene for muscle protein dystrophin)  Duchenne muscular dystrophy  Boys develop proximal weakness in early childhood  Difficulty rising from squatting position (use hands to ‘climb’ up legs – Gowers’ sign)  Pseudohypertrophy of calf muscles (muscle replaced by fatty tissue)  Progressive disability  Becker muscular dystrophy  Presents in adolescence or adult life  Can have normal lifespan but progressive disability  Limb-girdle dystrophies
  57. 57. Muscular dystrophy  Myotonic dystrophy  Autosomal dominant  Abnormally sustained muscle contraction (myotonia)  Bilateral ptosis  Facial weakness  Wasting and weakness of sternomastoids  Cataracts  Endocrine associations (diabetes mellitus, frontal balding, testicular atrophy)  Facioscapulohumeral muscular dystrophy  Autosomal dominant  Bilateral facial weakness  Winging of scapulae  Weakness of spinal and pelvic muscles - waddling gait  Lumbar lordosis
  58. 58. Hereditary motor and sensory neuropathy (HMSN)  Inherited neuropathies  Genetic defects discovered  Incidence 1:2500  Clinical features:  Atrophy of muscles supplied by peroneal nerves (‘inverted champagne-bottle legs’)  Areflexia  Pes cavus  Claw toes  Distal sensory loss and/or paraesthesia
  59. 59. Dementia  Inherited  Familial Alzheimer’s disease, Huntington’s disease  Trauma  Infection  Syphilis, AIDS-related,  Inflammation  Multiple sclerosis  Neoplasm  Frontal tumours  Vascular  Multi-infarct dementia  Metabolic  hypothyroidism  Drugs/toxins  Barbiturates, alcohol  Degenerative  Alzheimer’s disease, Prion disease
  60. 60. Neurorehabilitation  Aim ‘to restore patients to maximum capability and independence within limits set by their disability and their needs’  Multidisciplinary teams  Physiotherapy  Occupational therapy  Speech therapy  Neuropsychology  Social work

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