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Part 1: Parkinson’ s Disease Emma Ball 2440051B@student.gla.ac.ukILOS Parkinson’s disease. 1. describe the pathological changes seen in Parkinson’s disease; 2. describe the clinical features and differential diagnosis of Parkinson’s disease; 3. outline the principles of drug management of Parkinson’s disease; 4. describe the role of the multi-disciplinary team in management of Parkinson’s disease.Parkinson’s Disease ● Pathology: Degenerationof the dopaminergic neurons in thesubstantia nigra.Remaining neurones containLewy Bodies(an eosinophilic cytoplasmic inclusion made up of alpha synucleinprotein)Presentation ● 3 Features ○ Rigidity ○ Bradykinesia ○ Resting tremorPresentation ● 3 Features ○ Rigidity: ■ Cogwheel rigidity ○ Bradykinesia ■ Handwriting gets smaller and smaller ■ Shuffling gait ■ Difficultyinitiating movement ■ Hypomimia (facial masking) ○ Resting tremor ■ Unilateral tremor (can progressto bilateral tremor) ■ Pill rolling tremor ■ Worse at rest, improvement with movementOtherFeatures ● Depression ● REM sleep disturbance andinsomnia ● Anosmia ● Postural Instability ● Cognitive impairmentParkinson’s Plus Syndromes These arethe primary PD features(rigidity,bradykinesia and restingtremor) +other features. A question that might be asked:Apart from ParkinsonʼsDisease, state3 other causes ofParkinsonism? 1. Multi-System Atrophy 2. Dementia with Lewy Bodies 3. Progressive SupranuclearPalsy 4. Corticobasal DegenerationDiagnosis of Parkinson's Disease A clinicaldiagnosis… thatʼs itManagement Riskof neuropsychiatric Improving motor disability complications Riskof motor complicationsLevodopa Mechanism: dopaminecannot cross the blood brain barrier. Levodopacrosses theBBBandit convertedtodopamineand thus stimulates the dopaminergic pathways. Sideeffects -DYSKINESIASOCCUR WHENDOSE IS TOO HIGH ● Dystonia: excessive muscle contraction leads to abnormal posturesor exaggerated movement ● Chorea: abnormalinvoluntary movements ● Athetosis: involuntarytwistingor writhing movements,usually in finger,handsorfeet NOTE:co-prescriptionwith carbidopa(peripheral decarboxylase inhibitor)to stopperipheral conversionof levodopa to dopamine in peripheral tissue. NOTE:Symptoms arelesscontrolled overtime with Levodopatherefore reservedfor when other treatments donʼt worki.e. combined with dopamine agonists to allowlower dose of levodopa tobeused.Dopamine Agonists Examples:Pramipexole,Ropinirole(oral), Rotigotine (transdermal) Mechanism:mimicendogenous dopamine in the basal ganglia Use: canbe used as monotherapy but mainly used toreduce adverse effectsoflevodopa (fluctuating motorsymptoms).Allows areduced doseof Levodopa. Side Effects: ● Pulmonaryfibrosis ● Disinhibition e.g.hypersexuality, gambling ● Daytime drowsiness ● NauseaMonoamine-Oxidase-B Inhibitors (MAO-Bi) Example:selegiline Mechanism: blocks MAO-B,whichnormally breaksdown circulatingdopamine.This inhibitor maintains circulating dopamine levels Use: similar to dopamine agonist,used todelay the useof levodopaCOMT Inhibitors Examples:entacapone Mechanism: blocks theCOMTenzyme,which normallybreaks downlevodopain the brain and circulation. This willmaintain dopamine levels (and levelsoflevodopa) Uses:co-prescribed withlevodopa (anda dopa decarboxylase inhibitor) toslow breakdown of levodopa in the brain -extends effectivenessoflevodopa Carbidopa (dopa decarboxylase inhibitor):co-prescribed with levodopa to stop peripheral breakdown beforeit passesthe BBB. COMTi or MAOBi:block MAO/COMT to minimise dopamine/levodopa breakdown in the brain, maintainingdopaminelevels Levodopa:crosses the BBB, just like L-dopa, and is converted todopamineMCQ 1 Which of the following Parkinson’s Disease medications would risk loss of inhibition as a side effect? A Selegiline B Ropinirole C Levodopa D Carbamazepine E EntacaponeA MCQ 1 Which of the following Parkinson’s Disease medications would risk loss of inhibition as a side effect? A Selegiline B Ropinirole C Levodopa D Carbamazepine E Entacapone The dopamine agonist causedisinhibition, which canincludehypersexuality, for example.Carbamazepine is ananti-epileptic. Levodoparisksdyskinesias.MCQ 2: A 68 year old woman comes to the GP as she is worried about a tremor she has developed in her hands. She finds it particularly noticeable when she is holding a cup of tea but it disappears when she goes to take a drink. What is the cause of this tremor? A Parkinsonʼs Disease B Benign Essential Tremor C Dementia with Lewy Bodies D Multisystems Atrophy E Progressive Supranuclear PalsyA MCQ 2: A 68 year old woman comes to the GP as she is worried about a tremor she has developed in her hands. She finds it particularly noticeable when she is holding a cup of tea. What is the cause of this tremor? AParkinsonʼsDisease -thiswould causea resting tremor that typically improves with movement (this womanhasthe opposite).Also,in PD the tremor usually starts unilaterally andprogresses to a bilateral tremor. BBenignEssentialTremor -correct, she has a bilateral tremorthat is worsewith movement. CDementiawith Lewy Bodies - cancause a parkinsonian presentationwith additional features such as visualhallucinationandREM sleep behaviours (sleep vocalisation or acting out dreams) DMultisystemsAtrophy-usually presents as Parkinsonian features plusautonomicdysfunction (posturalhypotension,constipation, sexual dysfunction) EProgressive Supranuclear PalsyPart 2: EpilepsyILOS Lecture:Epilepsy 1. outline causes for loss of consciousness; 2. defineseizures and epilepsy; 3. briefly outline different typesof seizure; 4. discuss investigation of lossof consciousness;outlinelonger-term managementof epilepsy; describe management of status epilepticus;DDx - Syncope ● Seizure: auras, LOC possible, tongue biting, involuntaryurination,post-ictalfor hours ● Non-epileptic attack ● TIA:symptoms fully resolve within 24hours and thereisnot evidenceofinfarction on imaging ● Stroke: focal neurological deficit,sustainedreduced GCS,CT/MRI infarction ● Orthostatic Hypotension: strongpostural link,PMHParkinsonʼs Disease/MSA, elderly ● Cardiac syncope: ECG will I.D. cause ● Hypoglycaemia: BMmeasurement, PMHof DM ● Vasovagal syncope: prodrome of lightheadedness,feelingwarm/cold, palpitation, nausea, visual blurring,hearing changes, quickrecoveryDefinitions Seizure: a transient episode ofuncontrolledelectricalactivityin thebrain Epilepsy:a conditions wherethere is atendency tohaveseizures (spontaneous abnormal electrical activity inthe brain) Epilepsy -A person must have2or more unprovoked seizures,morethan24hours apart.Types of Seizure 1. Generalised (LOC always)-involves the wholebrain a. Atonic:these are “drop attacks” where a patient loses allmuscle tone. Last typically 3minutes. b. Tonic-Clonic:tonic (stiffening) followedby rhythmicjerking (clonic).Associatedwith tongue biting, incontinence and irregular breathing. Long postictal period. c. Myoclonic: sudden and brief contraction of muscles. Patient isAWAKEduring episode. d. Absence: a sudden cessation in whatsomeoneisdoing andstaring blanklyinto space followed by sudden return tonormal. Lats 10-20 seconds. >90% ofchildren willnot have seizureswhenolder. 2. Focal (Partial) - involves one part of the brain a. Complex (LOC) b. Simple (NoLOC)Focal Seizures Frontal Lobe:head/eyesturnto oneside, figure of4 posturing, Jacksonian March, pedalling,screaming Temporal Lobe: feeling of fear, deja vu,auditory hallucination, lip smacking,salivation, Automatisms (fidgeting, undressing,running) Parietal Lobe: somatosensory changes e.g. numbness, electricshock sensation, Occipital Lobe: flashing lights, vision loss, uncontrolledeye movements, repeated blinking Donʼtnecessarily need to knowthis but useful for understandingMCQ3: Which seizure type allows a patient to have retained awareness of their surroundings? A Simplepartial seizure B Atonicseizures C Absenceseizure D Complex partial seizure E Tonic-Clonic SeizureA MCQ3: Which seizure type allows a patient to have retained awareness of their surroundings? A Simple partial seizure B Atonicseizures C Absenceseizure D Complex partial seizure E Tonic-Clonic Seizure The restALL cause a loss of consciousness.Long Term Epilepsy Management Mechanisms Sodium Valproate: Inhibits GABA transaminase, increasing the concentration of GABA Carbamazepine:increases refractory period of voltagegatedsodiumchannels Phenytoin:inhibitsvoltage gatedsodium channels Ethosuximide:blocks thalamic T-typecalcium channels Lamotrigine:blocks voltage gated sodium channelsandglutamatereceptors Levetiracetam:bindsto SV2A,impairing release ofglutamateSeizure Type 1st line 2nd line Focal Carbamazepine Levetiracetam Lamotrigine Sodium valproate Generalised Tonic Clonic Sodium Valproate Lamotrigine Myoclonic Sodium Valproate Levetiracetam Topiramate Absence Ethosuxamide Lamotrigine Sodium Valproate Atonic Sodium Valproate LamotrigineStatus Epilepticus Aseizure lasting >5 minutes or >3 seizuresin1 hour.Itis amedialemergency. Management 1. A-EAssessment 2. After5 mins IV lorazepam4mg (repeat after10minutesif seizurecontinues) Buccalmidazolam or rectal diazepam are alternatives 3. IV phenytoin/phenobarbital15-18mg/kgMCQ4 Which of the following anti-epileptic increases the concentration of GABA? APhenytoin B Carbamazepine C Sodium Valproate D Ethosuximide E KeppraA MCQ4 Which of the following anti-epileptic increases the concentration of GABA? A Phenytoin- Inhibits Na+ B Carbamazepine -Inhibits Na+ C Sodium Valproate - increasesGABA concentration by inhibiting GABA transaminase D Ethosuximide -blocks t-type Ca++channels E Keppra -or levetiracetam,inhibits SVA2 and thusblocksrelease ofGlutamate (excitatory neurotransmitter)MCQ5 A concerned parent brings their 4 year old son to the GP as they are concerned he is having seizures. He will just stop what he is doing and stare into space for up to 1 minute. What is the most likely diagnosis? A Absence seizure B Atonicseizures C Daydreaming DFocalimpaired awareness seizures ENon-epileptic AttackA MCQ5 A concerned parent brings their 4 year old son to the GP as they are concerned he is having seizures. He will just stop what he is doing and stare into space for up to 1 minute. What is the most likely diagnosis? A Absence seizure - theses wouldonly last 10-20 seconds B Atonicseizures - sudden lossesof muscle tone C Daydreaming DFocalimpaired awareness seizures EGeneralised Tonic Clonic SeizuresStrokeLecture:Stroke. 1. revisethe anatomy of thebloodsupply to brain; 2. discuss the epidemiology of stroke; 3. outline the pathophysiological processesthatcan resultinstroke; 4. describe the clinical presentationand managementof stroke/TIA;Causes ● Ischaemic Stroke (85%) Pathological Mechanisms ○ Carotid bruit ○ AF ● Thrombusformation ● Embolus ○ Previous TIA ● HemorrhagicStroke (15%) ● Atherosclerosis ○ Meningism ● Shock ○ Coma within hours ● Vasculitis ○ Severe headacheAnatomyAnterior Cerebral Artery ● Contralateral hemiparesis/sensorloss ● Lower limb > upper limb MiddleCerebral Artery ● Contralateral hemiparesis/sensory loss ● Upperlimb > lower limb ● Contralateral homonymous hemianopia ● Aphasia Posterior Cerebral Artery ● Contralateral homonymous hemianopia with macularsparing ● Visual agnosia Basilar artery - Locked In Syndrome OphthalmicArtery - AmaurosisFugaxTACS: Proximal MCA or InternalCarotidArtery PACS:Anterior Cerebral Artery orMiddleCerebralArtery POCS:Anything that is not the arteriesabove Lacunar: perforating branchesof the middle meningeal arteryTransient Ischemic Attack Transient neurologicaldeficitthatcompletely resolves within24 hours.Ischaemia withoutinfarction. Management:StartAspirin300mgdaily and referral tostroke specialist.Management 1. CT Head - RULE OUT HEMORRHAGIC 2. IfIschaemic Stroke confirmed: a. Aspirin 300mg b. If within 4.5 hours: Thrombolysiswith Alteplase c. If within 24 hours: Thrombectomy 3. IfHemorrhagic : a. Call neurosurgery b. Reverse anticoagulationOther points for Stroke/TIA: Secondary prevention ● Clopidogrel 75 mg oncedaily ● Atorvastatin 80 mg oncedaily (regardlessof cholesterol) ● Optimise modifiable risk factors Specialist Imaging ● Diffusion weighted MRIis theGold Standard forstrokeThank you