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MedReg+1 Rohrer Neuro
A 54-year-old man presents with difficulty walking and tingling in his legs that has progressed to involve both lower legs over 3 days. He also has difficulty passing urine. On examination he has decreased tone and weakness in his lower limbs with reduced sensation and absent reflexes. The document discusses evaluating him for Guillain-Barré syndrome versus transverse myelitis, with the next step being to perform a lumbar puncture and MRI to help distinguish between the two.
MedReg+1 Rohrer Neuro
- 1. Developing people forhealth and healthcare Neurology Dr Jonathan Rohrer
- 2. Developing people for healthand healthcare • Epilepsy • Management of convulsive status epilepticus • Focal and nonconvulsive status epilepticus • Headaches • Headache history • Evaluation of sudden, severe headache • Weakness • Evaluation of acute weakness • GBS and transverse myelitis Overview
- 3. Developing people for healthand healthcare • A 65-year-old man presents to A+E. He had been found unconscious at home by his wife who called an ambulance. He had come round by the time the ambulance arrived but was confused. • On his way to hospital he had a tonic-clonic seizure, and this had been going on for 3 or 4 minutes when he is brought in to resus. • What are you going to do first? Epilepsy case 1
- 4. Developing people for healthand healthcare • Despite your treatment he continues to have an ongoing seizure – this has now been going on for 11 or 12 minutes. • What are you going to do next? Epilepsy case 1
- 5. Developing people for healthand healthcare STEP 1: benzodiazepine; give if fitting for > 5 minutes STEP 2: if no response to step 1 WITHIN 10 minutes, give stage 2 agent and inform ICU/anaesthetics STEP 3: if no response to step 2 within 30 minutes of onset, anaesthesia and ICU admission Management of convulsive status epilepticus For the full protocol see: A protocol for the inhospital emergency drug management of convulsive status epilepticus in adults. Jones et al. Practical Neurology 2014l 14: 194-197. 1. IV lorazepam – usual dose 2 to 4mg (max 2mg/min); if necessary repeat up to a max dose of 0.1mg/kg 2. or IV diazepam – usual dose 5-10mg, up to 20mg if necessary; do not give too fast to avoid respiratory depression (max 5mg /min) 1. IV phenytoin – 18mg/kg; max rate 50mg/min; into large or central vein with ECG/blood pressure monitoring 2. Ensure ICU/anaesthetics aware of patient GENERAL MEASURES in parallel 1. Secure airway and resuscitate 2. Administer oxygen 3. Assess cardiorespiratory function 4. Establish IV access 5. Measure CBG and correct hypoglycaemia 6. Check temperature 7. Check blood gases 8. If poor nutrition/alcohol abuse suspected give Pabrinex 9. Take blood for FBC, U+Es, LFTs, clotting, glucose, Ca, Mg, CK, AED levels, tox screen
- 6. Developing people for healthand healthcare • He has now been intubated and ventilated and is being taken to ITU. • What are you going to do next? Epilepsy case 1
- 7. Developing people for healthand healthcare • Pre-existing epilepsy – concurrent illness, not taking AEDs etc. • Metabolic disturbance – electrolyte abnormalities, hypoglycaemia, renal failure • CNS infection – meningitis, encephalitis • Stroke • Head trauma • Drugs or alcohol • Hypoxia/cardiac arrest • Brain tumour or other SOL • Hypertensive encephalopathy/PRES • Autoimmune encephalitis e.g. anti-VGKC, anti-NMDA antibodies Epilepsy case 1 – why is this person in SE?
- 8. Developing people for healthand healthcare • 36 year old man with known Sturge-Weber syndrome attends A+E. He has known epilepsy and is on carbamazepine 300mg BD. • He has had continuous seizures for the last 30 minutes which are focal, affecting the right arm and leg only and in full consciousness. • He has been given 4mg of lorazepam and loaded with phenytoin but they are still ongoing – what would you do? Epilepsy case 2
- 9. Developing people for healthand healthcare • Continuous focal motor seizures (epilepsia partialis continua) can be difficult to treat • Avoid sedative and anaesthetic agents if possible • Next steps – options include: • IV levetiracetam 30mg/kg over 10 minutes • IV valproate 30mg/kg over 5 minutes Epilepsy case 2
- 10. Developing people for healthand healthcare • A 32-year-old woman presents to A+E with a sudden, severe headache. It started 4 hours ago and her family say she has been a bit confused since. She says that she feels nauseous. • What will you ask her and what would you do next? Headache case 1
- 11. Developing people for healthand healthcare • History of the headache itself including time to peak intensity and duration. Are they someone who has headaches usually? How many a month/year usually? • Meningitis (if acute): neck stiffness, fever, rash, photophobia • Migraine: unilateral or bilateral; nausea/vomiting, photophobia, phonophobia, osmophobia, movement sensitivity, aura • Trigeminal autonomic cephalgias (SUNCT 5s-4m – paroxysmal hemicrania 2-30m – cluster headache 15m-3h): unilateral; red eye, tearing, rhinorrhoea, nasal congestion, ptosis, miosis, restlessness • Pressure-related headache: time of day, effect of posture, effect of Valsalva manoeuvres, visual obscurations • Temporal arteritis: jaw claudication, scalp tenderness/sensitivity • Focal neurological symptoms The headache history
- 12. Developing people for healthand healthcare • Usually fit and well. Not on any medication apart from OCP. • On examination she has a normal exam with no focal neurology. She knows where she is and what day it is. • She has a normal CT head and goes on to have a lumbar puncture. This shows an opening pressure of 32cmH2O with a normal white cell count, normal protein and normal glucose. • What would you do next? Headache case 1
- 13. Developing people for healthand healthcare What causes acute severe headache?
- 14. Developing people for healthand healthcare Primary headaches • Migraine • Cluster headache and other trigeminal autonomic cephalalgias • Others e.g. primary thunderclap headache Secondary headaches • Head or neck trauma • Cranial or cervical vascular disorder: SAH, ICH, ischaemic stroke, dissection, venous sinus thrombosis • Nonvascular intracranial disorder: raised or low intracranial pressure, tumour, pituitary apoplexy • Due to a substance or its withdrawal • Infection: intracranial or systemic • Due to problems in the head, neck and cranial structures: acute glaucoma What causes acute severe headache?
- 15. Developing people for healthand healthcare If meningitis suspected, investigate and treat accordingly Ask, is time to peak intensity <5 minutes and headache duration >1 hour If yes, strongly consider SAH and organise CT head. If normal then perform LP >12 hours after onset with OP, cell count, glucose, protein, spectrophotometry If no, but warning features present (see below) then CT head/discuss with neurology team Emergency evaluation of sudden, severe headache MAIN WARNING FEATURES • New onset or change in headache in people over 50 • Time to peak intensity of <5 minutes • Focal neurological symptoms • Non-focal neurological symptoms e.g. seizure or cognitive disturbance • Change in headache frequency, characteristics or associated symptoms • Abnormal neurological exam ADDITIONAL WARNING FEATURES • Headaches that change with posture • Headaches waking the patient up, or precipitated by Valsalva manoeuvres • Risk factors for cerebral venous thrombosis • Jaw claudication or visual disturbance • Neck stiffness • Fever and rash • New onset headache in patient with HIV • New onset headache in patient with cancer
- 16. Developing people for healthand healthcare Weakness
- 17. Developing people for healthand healthcare UMN LMN NM J Muscl e
- 18. Developing people for healthand healthcare UMN LMN NM J Muscl e NM J Muscl e Brain Brainste m Spine AHC BrainRoot Plexu s Nerve Nerve s
- 19. Developing people for healthand healthcare UMN LMN NM J Muscl e NM J Muscl e Brain Brainste m Spine AHC BrainRoot Plexu s Nerve Nerve s Where? (Anatomy)
- 20. Developing people for healthand healthcare UMN LMN NM J Muscl e NM J Muscl e Brain Brainste m Spine AHC BrainRoot Plexu s Nerve Nerve s Where? (Anatomy) What? (Pathology)
- 21. Developing people for healthand healthcare UMN Brain Brainste m Spine Brain In the UMN Question 1 Is it a hemiparesis, quadraparesis or paraparesis? HEMIPARESI S QUADRA- PARESIS PARAPARES IS
- 22. Developing people for healthand healthcare UMN Brain Brainste m Spine Brain In the UMN Question 2 What are the sensory features? HEMIPARESI S QUADRA- PARESIS PARAPARES IS
- 23. Developing people for healthand healthcare UMN Brain Brainste m Spine Brain In the UMN Question 3 Are there any cranial nerve signs? HEMIPARESI S QUADRA- PARESIS PARAPARES IS
- 24. Developing people for healthand healthcare LMN NM J Muscl e NM J Muscl e AHC BrainRoot Plexu s Nerve Nerve s Beyond the UMN Question 1 Is weakness symmetrical or asymmetrical? Asymmetrical/unilateral Symmetrical
- 25. Developing people for healthand healthcare LMN NM J Muscl e NM J Muscl e AHC BrainRoot Plexu s Nerve Nerve s Beyond the UMN Question 2 If symmetrical, is it distal or proximal? DISTAL PROXIMAL PROXIMAL Symmetrical
- 26. Developing people for healthand healthcare LMN NM J Muscl e NM J Muscl e AHC BrainRoot Plexu s Nerve Nerve s Beyond the UMN Question 3 If asymmetrical, what is sensory impairment? Asymmetrical/unilateral NORMAL DERMATOMA L DERMATOMA L NERVE
- 27. Developing people for healthand healthcare DERMATOMAL NERVE
- 28. Developing people for healthand healthcare LMN NM J Muscl e NM J Muscl e AHC BrainRoot Plexu s Nerve Nerve s Beyond the UMN The example of foot drop NORMAL DERMATOMA L DERMATOMA L NERVE MND Normal sensation
- 29. Developing people for healthand healthcare LMN NM J Muscl e NM J Muscl e AHC BrainRoot Plexu s Nerve Nerve s Beyond the UMN The example of foot drop NORMAL DERMATOMA L DERMATOMA L NERVE L5 radiculopath y
- 30. Developing people for healthand healthcare LMN NM J Muscl e NM J Muscl e AHC BrainRoot Plexu s Nerve Nerve s Beyond the UMN The example of foot drop NORMAL DERMATOMA L DERMATOMA L NERVE Lumbar plexopath y
- 31. Developing people for healthand healthcare LMN NM J Muscl e NM J Muscl e AHC BrainRoot Plexu s Nerve Nerve s Beyond the UMN The example of foot drop NORMAL DERMATOMA L DERMATOMA L NERVE Sciatic nerve
- 32. Developing people for healthand healthcare LMN NM J Muscl e NM J Muscl e AHC BrainRoot Plexu s Nerve Nerve s Beyond the UMN The example of foot drop NORMAL DERMATOMA L DERMATOMA L NERVE Peronea l nerve
- 33. Developing people for healthand healthcare • A 54-year-old man presented to A+E with a three day history of difficulty walking and tingling in his legs. This initially started in his feet but had now progressed to affect the whole of both lower legs. He had come today as he had also developed difficulty passing urine and hadn’t been for six hours. He had not long got back from a holiday in India. • On examination he had a normal cranial nerve territory and upper limb examination but in the lower limb he had decreased tone with weakness in the hip flexors and the ankle dorsiflexors bilaterally. Reflexes were present and symmetrical with downgoing plantars. Sensation was decreased to pinprick throughout the legs. • What would you do next? Weakness case 1
- 34. Developing people for healthand healthcare GBS vs transverse myelitis Motor Sensory Autonomic CN Ix Ascending weakness; become areflexic but can be intact initially Transverse myelitis May be minimal on exam but can be ascending Cardiovascular > bladder/bowel early May have facial or EOM weakness CSF: elevated protein but not WCC EMG/NCS: demyelination GBS Para or quadraparesis; reflexes usually brisk Spinal cord level usually Early loss of bladder/bowel control None CSF: may have increased WCC/protein MRI: usually abnormal
- 35. Developing people for healthand healthcare Please email me if any questions or you want any references: j.rohrer@ucl.ac.uk
- 36. Developing people for healthand healthcare Some brainstem anatomy MIDBRAIN PONS MEDULLA
- 37. Developing people for healthand healthcare Some brainstem anatomy 1. Rule of 4 MIDBRAIN PONS MEDULLA
- 38. Developing people for healthand healthcare Some brainstem anatomy 1. Rule of 4 MIDBRAIN PONS MEDULLA 3 4
- 39. Developing people for healthand healthcare Some brainstem anatomy 1. Rule of 4 MIDBRAIN PONS MEDULLA 3 4 6 5 7 8
- 40. Developing people for healthand healthcare Some brainstem anatomy 1. Rule of 4 MIDBRAIN PONS MEDULLA 3 4 6 12 5 7 8 9 10 11
- 41. Developing people for healthand healthcare Some brainstem anatomy 1. Rule of 4 1 proviso MIDBRAIN PONS MEDULLA 3 4 6 12 5 7 8 9 10 11
- 42. Developing people for healthand healthcare Some brainstem anatomy 1. Rule of 4 1 proviso 2. Rule of 12 MIDBRAIN PONS MEDULLA 3 4 6 12 5 7 8 9 10 11 LATERAL MEDIAL
- 43. Developing people for healthand healthcare Some brainstem anatomy 1. Rule of 4 1 proviso 2. Rule of 12 3. Rule of S+M Lateral = sensory and sympathetic Medial = motor MIDBRAIN PONS MEDULLA 3 4 6 12 5 7 8 9 10 11 LATERAL MEDIAL
- 44. Developing people for healthand healthcare Where is the brainstem syndrome? • Left facial sensation loss, left face weakness, left hearing loss and right arm and leg sensory loss
- 45. Developing people for healthand healthcare Where is the brainstem syndrome? • Left facial sensation loss, left face weakness, left hearing loss and right arm and leg sensory loss • Left lateral pons
- 46. Developing people for healthand healthcare Where is the brainstem syndrome? • Left facial sensation loss, left face weakness, left hearing loss and right arm and leg sensory loss • Left lateral pons • Tongue deviation to the right and left hemiparesis
- 47. Developing people for healthand healthcare Where is the brainstem syndrome? • Left facial sensation loss, left face weakness, left hearing loss and right arm and leg sensory loss • Left lateral pons • Tongue deviation to the right and left hemiparesis • Right medial medulla