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TCD 22 - Headaches zakariya.mouyer@student.manchester.ac.uk KostopoulopoulosAdmin Stuff - Checkyourjunkmail - Checktheemailaddressthatyouregisteredforthezoomwith-that’sthe oneit’llbesentto - Pleasedon’tdmmexxx - YouwilleventuallygettheslidesIpromise(ifyoufilledoutfeedback forms) - BEPATIENTWITHUS(PLEASEEEEE) - Don’tworryaboutthenittygrittystuff,justtryandabsorbasmuchasyou canFeeding back to your feedback - Wewilldomorepolls - Notheycan’tbelonger - Notheycan’tbeshorter - Wedon’tdothelecturebeforeyourTCDsessiononFridayssothatyou canreallymakethemostofit - Zakcan’tbeanyslower,he’salreadyprettyslow - Thoseofyouthatsaidnothing-youarecorrect<3:DContent - THESE ARE OUR ILOs TODAY OKAYY ● Headaches ○ Primary ○ Secondary ● Meningitis ● HeadacheHistory(+exampleHx) ● PotentialOSCEStations 11.10 Learning Objectives ● CoverTCDCase24content:noonedidthiscasesowejustgonnausevibestogetusthroughthis ○ LoCHx ○ DDxforLoC ○ Syncope ○ Seizures ○ Cases ○ ProgressQuestions-MAINFOCUSFOR2DAYHeadache Classification Primary Secondary:causedbyanunderlyingcondition - Tension - Haemorrhages - Migraine - Tumour - Cluster - Encephalitis - TikTokoveruse - IdiopathicIntracranialHypertension - TrigeminalNeuralgia - TemporalArteritis(GCA) - Meningitis(wewillcoverthis separately)Primary Headaches 11.15Primary Headache - Tension - Z - S:likeatightbandaroundtheirhead - O:veryvaried,lookforrecentchangesintheirlife(job/exams) - C:bilateral-nothrobbingorpulsatile - R:N/A - A: - symptoms:head-musclesoreness,NOvisualchanges Mx: - Noaura/nauseaandvomiting - Veryself-limiting - causes: stress,depression,alcohol,missedmeals,dehydration,sleep - lifestyle/eliminate deprivation triggers - T:minutestoevendays - Analgesia(overuseis - E:worsenedbystressesetc,relievedwithbasicanalgesia→but aworry) thinkabout‘overuseheadaches’! - Ifchronic - S:not-that-deeptomoderate - Amitriptyline (whatdis?) - Acupuncture Typicalpatient: Atypicalpatientwithclusterheadachesisa30-50year Primary Headache - Cluster - G oldmalesmokerpacingaroundwithhandoneye Mx: - S:unilateral,localisedaroundoneeye DuringAttacks - O:suddenonset,comeinintensesetsof ● Athome15L100%Oxygen(what’stheCI clusters here?)viaNon-rebreathemask(whodisand - C:stabbing howdoesthiswork? - R:N/A ● SubcutaneousorNasalTriptan(whodis?) - A:RedSwollenLacrimalEye,FacialSweat, (what’stheCIhere)?→riskofoveruse headache Miosis(whodis?),RunnyNose ● Nomorethan2xdoses/day - T: 15minsto3hrs,maybe2x/day,forabout1-3monthsand Prophylaxis mightdisappearforupto2yearsatatime - Prednisolone - E:(E)Avoidtriggers(smells,exercise, - (usedin2-3weeksatatimetobreak thecycleofclusters) alcohol),(R)somepeoplepacearounda - Verapamil room - Lithium - S:extraordinarilypainfulandtruly debilitating,oftentermedasthe‘suicide headache’NOTE: Triptans and Overuse Headaches - G ● Asmentionedpreviously,Triptans(e.g.Sumatriptan(SC/oral)orZolmitriptan(nasal/oral)are 5HT1-Agonistsandhencepowerful(cerebral/SMC)vasoconstrictors. ● TheyalsoinhibitCNSactivity(drowsiness) ● They’reusedinClusterHeadachesandMigraines→justindifferentRoutesofAdministration(we’ll gettothatdw) ● ContraindicatedinIHD,TIA/Strokes,MIs(butnotPVD) OveruseHeadache: ● Progressivelyhappensinpeoplewhotakethefollowingmedsalmostdaily for>3monthsatatime ● Theorysuggeststhatthereisadown-regulationofthepainreceptorssothetheoreticalpotencythresholdofthedrug isreduced ● Triptans,NSAIDs,Paracetamol,Weakopioids Mx: ● Weanoffmedication,theheadacheswillinitiallygetworsebutwithtimedisappearandgetbetter ● TheBestProphylaxisforthisistoadvisethatthepatientisnotusingtheirheadachemedsfor>15days/month Mmm...Chocolate: - Menstruation - Chocolate - Hangovers Primary Headache - Migraine - Z - Orgas(yuteasingmeunaughtynaughty) - OralcontraceptivesredMeats/redwine - S: Mostcommonlyunilateral - Lie-ins/Lackofsleep - Alcohol(iykykgettingwastedoffthat j20atamuzzyhalaalsesh) - O: Randomoridentifiabletriggers - Travel - Exercise(iykykChloeTingdoingsbitsforus💅) - C: painfullythrobbing - R: TheAuramayincludeparesthesiafromarmstoface - A: - Phonophobia,photophobia andN/V(whyarethesetwoparticular importanttoaskabout?) - Aurasymptoms:Visual zigzags,dots,sparksorblurriness,pinsandneedlestoarmsandfaceordysphasia/ataxia/reducedGCS - T: 4to72hours - E: Resting/lyingdowninadarkquietroom(i.e.sleeping),vomitingcanstopthemigraine - S: severeandagainanotherdebilitatingformofheadache Mx: - Nextslidekings/queens Talktomeaboutmetoclopramide: PROGRESS ● JustaquicknoteonDxMigraines: - Antiemetic(novomit) - Ithasantidopaminergiceffectssoooo: ○ Historyiskey. - Cancauseparkinsonian dystoniaanddyskinesia ○ Aurahelpstoconfirmthediagnosis. - CancauseOculogyricCrisis ○ Otherwise,thefollowingcriteriaisrequired: - CancauseTrismus/lockedjaw - CancauseTorticollis ■ atleast5headacheslasting4-72hours ■ withnausea/vomitingorphoto/phonophobia ■ AND2of:unilateralheadache,pulsatingcharacter,impairedorworsenedbydailyactivities. ● Management : ○ Oftenpatientsdeveloptheirownways(sleeping/darkroometc) ○ 1stlineisOral/Nasal(preferred-Whydat?)Triptain+/-NSAIDs(dispersibleaspirin-whydat?)/Paracetamol ○ Metoclopramide(whatdidwesayaboutthislasttime,SE,CI?-whywegiveithere?) ○ Prophylaxis-setupaheadachediaryandstrictlyavoidtriggers NB:whendoingaHeadacheHx,alwaysask ■ Propranolol(CIwhat?) ■ Topiramate(whodis?)(CIwhat?) womenabouttheCOCP.ItisCIwith ■ Amitriptyline Migrainesasthereisanincreasedriskof TIA/Stroke(thoughPOPonlyiscalm) ■ Acupuncture ■ Riboflavin(whodis?)mayhelpreduceseverity/frequencyandinduceremission ■ ProphylacticTriptan/NSAIDusepre-menstruationPrimary Headache - Trigeminal Neuralgia - G - S:Trigeminalsensorydistributionon - TNis80%causedbyvascularcompression/SoL atrootentryponsofCNV.TypicalSCA.DoNo face,normallyunilateralbutcanbe Harm? both (whichiswhere?) - 20%isfromMS(youare20xmorelikelytoget - O:varied,triggerdependant(wind, TNifyouhaveMS).Thereisalsodemyelination atrootentry. cold,chewing,spice,caffeine,citrous, - Sarcoid,LymeandPost-Herpeticareallalso lighttouch) causes - C:stabbing/electricallyshooting - Dx-alwaysclinical+/-MRI - Mx-Carbamazepine(whodis?)ordifferent - R:dependsonitscausetbh surgeries... - A:dependsonitscausetbh - T:secondstohours(thisisvvpeak) - E:treatingittbh - S:indescribablypainful(tasertothe RFs: facewhilebeingstabbed) - MS - Age - FemaleSecondary Headaches 11.45Headache Classification PrimaryDONEEEEEEEBABY Secondary:causedbyanunderlyingcondition - Tension - Haemorrhages - Migraine - Tumour - Cluster - Encephalitis - TikTokoveruse - Whenshegoesfromsaying - TrigeminalNeuralgia LMFFAAAOOOtolmaowithinthe spaceofaweek - IdiopathicIntracranialHypertension - TemporalArteritis(GCA) - Meningitis(wewillcoverthis separately)GCA/T emporal Arteritis - Z 11.45Secondary Headache - TemporalArteritis (GCA) - LargeVesselVasculitiscondition(inflammationofbloodvessels) - Sight-threateningandlife-threateningcondition - MUSTBERULEDOUTINANYOVER-50(mostlywomen) COMPLAININGOFHEADACHE - Symptoms - Temporalunilateralheadache - Thickenedtemporalartery+/-pulseless artery - AmaurosisFugax(whodis?)-VSERIOUS - UnilateralScalptenderness - normalintension,butwithcontextof>50y/o,youmustcompletelyruleoutGCA - Jawand/orTongueclaudicationoneating→THISISPATHOGNOMONIC (wotdatmeanbruh?) - SystemicFeatures: - Youmustaskaboutgeneralisedneck,shoulder,hip jointpains andsymmetricalproximalmuscle weakness(whydatzeek?) - PMR(whodatzeek?) - Polymyalgiarheumatica-betterwithmovementandworsewithinactivity - Lifethreatening: - Permanentmonocularblindness InDURTAYMCQsthey’llusethisforGCA: - Stroke - “anelderlyfemalehasaheadache andnoticespainwhenevershe brushesherhair…”Secondary Headache - TemporalArteritis (GCA) - Dx: - GOLDSTANDARD:TemporalArteryBiopsy - Histopathshowsgranulomatous/multinucleationofgiantcells - Diseasepathologyispatchy(skiplesions,wototherdiseasehasthis?) - Toavoidthistakeat3-5cmbiopsy,if-vetakecontralateralbiopsy - ConsiderCT/MRofAorticArch(why??) - Hx - FBC:normochormicnormoctyicanaemia,maybeleukocytosisandthrombocytosis - CRP( CReactiveProtei):elevated - ESR(ErythrocyteSedimentati):>50mm/hr,if>100mm/hrlikelypositivetemporalbiopsy - Zeekwegottaaproblem,GCAisanemergency,butaTAB/ESR/CRP/FBCcantake days-weekstoorganise/do-denwottfwefinnadobih? - TreatitSTAT-that’swhytheHxandclinicalDxare soimportantSecondary Headache - TemporalArteritis (GCA) - InitialMx: - ImmediateHighdoseOralPrednisoloneOD(60mg) - Stopsblindnessandstroke - NB:Iftheyexhibitfocalvisual/neurosigns - Give1gIVMethylprednisoloneviapulsetherapy foroptimalprognosis - Aspirincanbegivenas2ndarypreventionofstroke - Giveprophylaxisforprolongedsteroiduse - Infection - ThinkofCandidiasis(oral/esophageal)orHerpesZosterreactivation(shingley shingles) - ThinkHZVreactivationifthereisocularinvolvement-goodoldHutchinson! - BonesandTummyMoans - ThinkbisphosphonatesandPPIs!!Haemorrhages - G 11.45Secondary Headache - Haemorrhages - Extradural - Between the skull and dura - often visible trauma - Commonly caused by trauma to the pterion (who dat?), damage to middle meningeal artery - Patients present with acute severe headache, contralateral hemiplegia, and a deterioration in GCS following a lucid period. - On CT, a biconcave haematoma is diagnostic (lemon). - Bleed can’t expand into suture of skull, causing the bleed to expand towards the brain - Neurosurgical intervention is usually needed.well rounded shape - Subdural - Betweenduraandarachnoid-strictlyvenousbleed - Canbeacute,sub-acuteorchronic→brainparenchymashrinkswithage,sobridgingveinsstretchandaremoreliabletorupture→ mortalityrangingfrom50%-85%(earlydetectionisKEY) - Smalltrauma(hittingheadontable/yeetingittoohard)issufficienttocauseableedintheelderly - RFs:age,HxofHeadTrauma,Alcoholism,Anticoagulation - OnCT,crescent-shapeanddelineated (banana)asthebleedcanspreadfurtheraround anddeeperintothesulci - Symptomsfluctuatedependingon‘osmoticsize’ofhaematoma:personalitychangesandreducedGCS - Neurosurgicalinterventionisalmostalwaysneeded - Subarachnoid - NextfewslidesSecondary Headache - Haemorrhages - PrincipleofIntracranialHaemorrhageManagement: - ABCDE+GCS - ImmediateCTheadtoestablishthediagnosis - CheckFBCandclotting - Admittoaspecialiststrokeunit - Discusswithaspecialistneurosurgicalcentretoconsidersurgicaltreatment - Considerintubation,ventilationandICUcareiftheyhavereducedconsciousness - Correctanyclottingabnormality - CorrectseverehypertensionbutavoidhypotensionNTK GTK Secondary Headache - HaemorrhagesSecondary Headache - Subarachnoid Haemorrhage ● Haemorrhageunderarachnoidlayer-thereforecanenterdirectlysulcianddeeper cerebralstructures/tissues ● Thunderclap(occipital)headache-worstheadacheinentirelife ● Stiffneck(whoelsehasdis?) ● Coma,ReducedGCS,Seizures(end-stage) ● TraumaticorSpontaneous(berryaneurysmofCoW) ● fthereissuspicion-urgentCT(candetectalmostallSAH) ● Ifdelayedpresentation→MRIisafarbetterdiagnostictechnique ● IfCTdonewithin6hoursandnormal:noLP ● IfCTdoneafter6hoursandnormal:LPwithin12hrofonset ● WearelookingforbloodintheCSF→butwhataboutatraumatictap? ● ThenwelookforXanthachromia(whodathoe?) ● YellowColour RFs: ● BrokendownRBCsintheSAspace - HTN(aneurysm) ● Mx: ■ CCBtostopvasospasm - CTD(aneurysm) ■ Neurosurgeryw/interventionalradiology(cerebralangiograp-yiPKD(linktoaneurysm)ndlocate aneurysm)+/-endovascularcoiling/clipping - AVmalformations(rare)Secondary Headache - CerebralVenous Sinus Thrombosis - Basicallyabigclotinthecerebralduralsinuses(lolripsem3) - MostcommonlyaffectSSS - RarelyaffectsCavernousSinus(OTOMCAT) - typicallycausedbyspreadingsinusinfectionandpresentswithchemosis, exophthalmos,andperi-orbitalswelling - Presentation:vvaried RiskFactors:anythingthatincreaseschancesof - Headache venousthromboembolismtbh: - N+V - Hormones(CCP(butwhythozeek?, Preg) - LowGCS - Pro-thrombicconditions - Visualchanges - Sepsis - Dehydration - Seizures - Localinfection - CranialNervepalsies - Skullabnormalities - Papilloedema - Dx - CTvenogramw/contrast(wotisissuehere?????)lookingforthe‘emptydeltasign’ - Mx - LMWHandaddressRFsSOL/Tumour/ICP - Z 11.45Secondary Headache - SoL/Brain Tumours - Fascinatingyetdreadfultopic,let’sdothis( ﷲمﺳﺑ) - Mosttumoursaresilenttillitstoolate - Whentheydopresent-itswithfocalneurologicalsymptomsdependingonlesion location - Personalitychange?-typicalMCQ - AtypicalpresentationisduetoraisedICP-duetotheSoLdisruptingCSFflowasitoccupiescerebralspace - RaisedICP/SoL - Causes:Tumour,ICHaemorrhage,IIH,Abscess/Infection - Initiallyheadache+/N/V - Constant,Nocturnal,WakingWorse,Coughing,Straining,Lying/Bending,Vomiting - Seizures - LoweredGCS - Papilloedema(howwefinnainvestigatethisopp?) - VisualChanges(BTH-wotdaproblemhere?) - IIIrdnervepalsy(Horner+Ptosis) - VIthnervepalsys(howdisjawnpresent?)Secondary Headache - SoL/Brain Tumours Blurringoftheopticdiscmargin Elevatedopticdisc Lossofvenouspulsation Engorgedretinalveins Haemorrhagesaroundopticdisc Paton’slineswhicharecreasesintheretinaaroundtheopticdiscSecondary Headache - SoL/Brain Tumours - TypesofBrainTumour: - 2ndarymets:lung,breast,CRC,Prostate - Gliomas(smh) - Meningiomas - Pituitary(ChiasmicBTH) - Hypopit - Hyperpit - Acromegaly,Hyperprolactin,Cushings’Disease,Thyrotoxicosis - AcousticNeuroma - Tinnitus - HearingLoss - Balanceissues - Mx - Neurosurgery(mazzalini)aphat Lhere) - Pituitary(transphenoidal)+treatrelevanthormoneissues(SSTanalogueforGH/Bromocriptine forprolactin)Secondary Headache - Idiopathic Intracranial Hypertension - Thisisadiagnosisofexclusion,andusuallyoccursinobesewomenintheagerangeof 20-40. - Signs: - headache, - Papilloedema - signsofraisedICP(WHICHAREWOT?) - Mx: - Treatthemwithdiureticsandadviceonlosingweight. - Asit'sadiagnosisofexclusion,thereareafewthingsweneedtoruleout,canwename any?Secondary Headache - Encephalitis - FundamentallyhistologicalDxwithinflamofthecerebralparenchyma(lolsem3histo=bigbigL) - ClinicalfeaturescaneludetoDx,lookfor: - Alteredmentalstatus,headache,fever+/-prodromalcoryzal simp toms,seizures,motor/sensorydeficits,rash - MostlyViralAetiology:50%ofcasesareofunknownaetiology - HSV1(mostcommon),HSV-2,cytomegalovirus,EBV,varicellazostervirusb - Canbebacterial&TB:meningioencephalitis - OrevenAI(anti-NMDAab) - Encephalitisshouldbesuspectedinanypatientwithsuddenonsetbehaviouralchange,new seizuresandunexplainedacuteheadachewithmeningism. - Dx: - Difficultbutweusuallyliketocoverbases: - FBC,LFTs,BloodSmear(Y?),bloodcultures,CXR,Throatswab,MRI(T2),CSFculture/serology/PCR - Mx:aswithmostthingsviralgiveacyclovir - Maybegivebroadspecabxcovertoo(somethinglike2gIVceftriaxoneBD) - +/-anticonvulsant(phenytoinetc) - ConsiderICUadmission - SE:lookoutfornewneurodeficits,hepatorenalfailure,rash,photosensitivity RiskFactors: x<1/x>65,immunodeficiency,viral infections,bodyfluidexposure,organ transplantation,animalorinsectbites, location,andseason.Meningitis - Z 11.45 - Homestraightheresquad, - wedone6recons, - finnagetthatdubiAonfirmed, Secondary Headache - Meningitis - Meningitis-inflamofmeningeswithinfectiveornon-infectivecause - Infectivecauses: - Bacterial: streptococcuspneumoniae(pneumococcus),neisseriameningitidis(meningococcus),haemophilus influenzae,andlisteriamonocytogenes(beworriedforthese) - Viral:Enteroviruses(Echo,Polio,CoxasckieA/B)+1,000,000others(HSV1/2,Measles,Rubella etc) - Parasitic:Trainspotting→ HIV→MEOWMEOW→YEET→Toxoplasmagondii - Fungal:rare(immunocomptbh) - TB:seeninimmunocomp,lookforendemiccountries,slowdiseaseprogresswithtypicalB symptoms??,TreatasnormalTB→RIPE - (Rifampin,Isoniazid,Pyrazinamide,Ethambutol) - Non-infectivecauses: - Haematologicalmalignancies,Drugs(NSAIDs,Trimeth),Sarcoid,SLESecondary Headache - Meningitis - Presentation/Simptoms: - Headache,Fever,NeckStiffness,Photophobia,N/V,FocalNeuro,Seizures - Andoneother(onlywithBACTERIALMENINGICOCOUSonly)??? - Non-blanching?? - Petechial?? - Rash→cuptest - Kernig’sandBrudzinki’s(whothey?) - NB:lookfor - Elderly,children,unistudents,immunosuppressed(asplenic) - Whymightsomeonebeasplenic??? Whichsymptomhereissharedbetweenmeningitis Nicetoknow:non-blanchingredspotsdueto andSAH? bleedingundertheskinareeither: - petechiae(capillary<3mm), - purpura(macule/papulefrom DIC,HUS,Scurvy,MeningococcalSepteciaemia bleedingvessel3-10mm), - orechymoses(flat,non-traumatic bruise>1cm)Secondary Headache - Meningitis - Ix: - Bloods:FBC,U&E(metabollichypomazzainsepsis),Glucose(hyper/hypomazzainsepsis),coag screen(DIC→rash) - ABG/VBG(whytho?)WITHIN1HOUR - Bloodcultures(whytho?)WITHIN1HOUR - LUMBARPUNCTUREWITHIN1HOUR - CSFM-C-G-S - CSFPCRforpneumococcusandmeningococcus - CSFAppearance - CSFGlucose - CSFWCCandType - CSFProtein - CSFLactate - CSFOpeningPressuresNTK GTK Secondary Headache - Meningitis (LP) - Lumbarpuncture: - L3/4/5 - IliaccrestsalignwithL4spinousprocesses - Lateralrecumbent(whynotsittingup?) - Givemesome ✨contraindications✨ - RaisedICP,Thrombocytopenia,coagissues,delaytoabx!!! - GivemealowkeyadditionaltestthelabcanrunwithdatsaucyCSF - TestforXanthachromia(whodat?Utellmeking/queen)Secondary Headache - Meningitis Complications→goforitboys - Septicshock-SEPSISSEPSISSEPSIS(vworrying→mustruleoutandaddressSEPSIS 6statespeciallyifMeningococcus→alhamdulillahthere’savaccineforthistho) - DisseminatedIntravascularCoagulation - Coma - Subduraleffusions - Syndromeofinappropriateantidiuretichormonesecretion(SIADH) - Seizures - Delayed:Hearingloss,cranialnervedysfunction,hydrocephalus,intellectual deficits,ataxia,blindness - Death(cardiacarrestduetoSepticShock) - NB:anychildthatisfebrilewith(??????)is meningitisuntilprovenotherwise Secondary Headache - Meningitis - ?????=non-blanchingrash - 1.2gBenzylpenicillinSTATthenadmitpronto - Mx:revolvesaroundthepatient’spenicillin/cephalosporinallergystatus - Rememberwetreatveryquicklyso initiallywegobroadspec - Onceculturesandsensitivitiescomeback,tailortheAbxregimentotherelevantspecies - Oklet’sdothis: - ALLERGIC - NONALLERGIC - Chloramphenicol25mg/kgQDSIV - Cefotaxime2gQDS/Ceftriaxone2gBDIV - ANDDexamethasone10mgQDSIV - ANDDexamethasone10mgQDSIV - Ispatient>60? - Ispatient>60? - Yes→addco-trimoxazole10-20 - Yes→giveIVAmoxi2gIV mg/kg - Whatisco-trimoxazole?? - Areyoususofapenicillin-resistantpneumococci? - Yes→addVancomycin/RifampicinSecondary Headache - Meningitis - AnotherIMPORTANTperspectivetoMeningitisMx: - Aswithanyinfectiouspicture,wehavetoquerytheriskofSEPSISandapotentiallylethalsepticshock - Howdowebestmitigatethisrisk? - CheekySEPSIS6(rattletheseoffformekings/queens) - Whataresomesignsofanacutelysepticaemicshock?HOWDOWEASSESSTHIS? - GoodoldABCDE - PlummetingBP - Tachycardia - Delayedcaprefill - Ifsepticaemiaisasus→itisanEMERGENCY+++asopposedtonormalmeningitiswhichisanEMERGENCY + - AnotherIMPORTANTperspectivetoMeningitisMx: - RAISEDICP(whatwelookforhere?) - Papilloedema,Seizures,FocalNeuro,LowGCS(AVPU) - SUMMARY: - ifnosepsisriskand/ornoraisedICPriskgiveabx/dexa/LPwithin1hourofadmission - Ifeither/bothpresent→straighttoresus/ICU→thisnolongercanbemanagedbyjuniorstaffandneeds immediatestabilisation.LoC Hx - skip this these neeks have done their CCAs masha ’Allah <3LoC History ● Before: ○ Situation–ICE,sat/standing,warm,ill,alcohol,illicitdruguse ○ Pre-syncopalsx(aura,C/P,exercise,ringingears,lighthead,flashinglights/static,emotional) ○ Pre-seizuresx(cryingout,weirdsmells,weirdmemories,lipsmacking) ● During: ○ How?Video?Didyouhityourhead? ○ Didyouseize?Wasyourwholebodyshaking?Tonguebitten?Comebackincontient? ● After: ○ Post-ictal:wereyoudrowsy,tired,forgetful,groggy,confusedorachingthroughyourwhole bodyafter? ● RoS: ○ NS:focalweakness,lossofsensation,balancechanges,visualoraudiochanges ○ GIT/GUM:anytummypain,bowelchangesorwaterworkschanges ○ Constitutional:recentinfections,weightloss,nightsweatsetc ● PMHx:hasthiseverhappenedbefore?Epilepsy? ● FH:Epilepsy,suddendeaths,arrhythmias ● SH:smoke,drinking,ilictdrugs,whoisathome?Work?Stress?Syncope - Top G(eorge)Syncope DDxSyncope Presycnopal symptoms During After Vasovagal Syncope Provoking event Flaccid fall Lightheaded Flashing lights Most have loss of tone Vomiting Dehydration +/- Moaning and growling Brief confusion Emotional stress w/ hips and knees Well oriented immediately Dizzy extended Blurring of vision +/- Tonic clinic Ringing in the ears movements, but not rhythmic +/- Tongue biting and incontinence Lasts seconds Cardiogenic Syncope Collapse while exercising Twitching of limbs May not recognise people is common Lasts 1-2 mins aroundSyncopeSeizures/Epilepsy - Z (taught properly in year 4 dw)Note ● Seizure:developduetoanimbalancebetweeninhibitoryandexcitatory signalsinthebrain. ● >2unprovokedseizures,>24hoursapart ● Canbeduetoaninsultintermsof: ○ Genetics/FH ○ DevelopmentalProblems(>2febrileconvulsions) ○ Masseffect ○ Stroke ○ Feverinfection ○ Trauma ○ Hypoxia ○ DRUGS(andtheirwithdrawal) ○ Sleep ○ Metabolicdisturbances:hypoglycaemia,hyponatraemiaandhyperuraemia ● Epilepsy:chronicneurodisorderofRECURRENTseizuresEpilepsyvs Syncope Classifying Epilepsy Area of onset Focal: localised to a network of neurons in one hemisphere of the brain. Generalised: affecting both hemispheres of the brain and associated neuronal networks Focal to bilateral tonic-clonic: a focal seizure may spread to affect a wider network of neurons involving both hemispheres.Traditionally termed a secondary generalised seizure. Awareness Awareness: fully aware of themselves and their environment throughout seizure. Impaired awareness: any impairment of awareness during course of seizure. Complex partial seizures was the old term for focal onset impaired awareness seizures.Epileptic Presentations Epileptic Presentations Prodromal: ● sensation that occurs before the onset of a seizure. It only occurs in some patients and may present with features such as confusion, irritability or mood disturbances. Early-ictal ● An aura is the earliest sign of seizure activity and refers to subjective symptoms experienced by the patient. These can include sensory, cognitive, emotional or behaviour changes. ● An aura is suggestive of focal epilepsy (occurring in one part of the brain) and may progress to affect a wider area, or develop into a focal to bilateral tonic-clonic seizure. Ictal ● In layman terms, 'seizure' usually refers to a generalised tonic-clonic seizure. This is characterised by stiffening and subsequent rhythmic jerking of the limbs. It may be associated with urinary incontinence and tongue biting, and normally lasts 1-2 minutes. ● When a single seizure lasts > 30 minutes in duration, or two seizures occur without regaining consciousness after the first, it is termed status epilepticus or 'status'. Status is broadly divided into convulsive (i.e. movement) and non-convulsive (i.e. no movement). This is a medical emergency. Post-ictal ● This is the recovery period, and may be an extended recovery period, which is dependent on seizure type. During the period of recovery there may be altered consciousness, confusion, memory loss, drowsiness or general malaise. ● This period may last hours, particularly with tonic-clonic seizures.Epileptic DxEpileptic Dx NB: EEGs: ● Support a diagnosis of epilepsy ● Assess risk of seizure recurrence ● Determine seizure type of epilepsy syndrome ● It is not used as a sole diagnostic tool and cannot be used to exclude epilepsy, particularly if the clinical presentation supports a diagnosis of epilepsy. MRIs: ● Able to look for structural abnormalities that cause certain epilepsies. ● Look up Mesial Temporal Sclerosis ● MRI essential in patients who develop epilepsy before two years old, there is a suggestion of focal onset seizures or poor seizure control with anti-epileptics. MUST STOP DRIVING Epileptic Rx AND INFORM DVLA M● Management of epilepsy is broadly divided into acute control of seizures and long-term prevention of seizures with AEDs. ● The overall goal for managing a patient with epilepsy should be for no seizures and no side-effects from medications. This will not be possible in every patient due to the complexity of epilepsy. ● The key aspects of management are education and safety, treating acute seizures, role of the first fit clinic and long-term treatment with AEDs. MUST STOP DRIVING Epileptic Rx AND INFORM DVLA IF A PERSON HAS 1 SEIZURE AND COMES TO GP, DO NOT PRESCRIBE ANYTHING 1ST LINE MANAGEMENT FOR QUERY NON-ACUTE SELF-PRESENTING EPILEPSY IS WHAT? REFERRAL TO 1ST FIT CLINIC Epileptic Rx ● Common AEDs: ○ Sodium valproate: unclear mechanism. Teratogenic. Key side-effects: drug-induced liver injury, pancreatitis, increased suicide risk, weight gain plus many many more ○ Carbamazepine: sodium channel antagonist. Increased teratogenic risk. Key side-effects: agranulocytosis, SIADH, thrombocytopenia, aplastic anaemia. (worsens myoclonic/absence) ○ Lamotrigine: sodium channel antagonist. Increased teratogenic risk (but low). Key side-effects: severe skin reactions, ataxia, N/V, tremor ○ Levetiracetam: unclear mechanism. Not enough evidence re. teratogenicity. Key side-effects: CNS disturbance (somnolence, decreased energy, headache), neuropsychiatric disturbance. ○ Phenytoin: sodium channel antagonist. Teratogenic. Key side-effects: multiple. Arrhythmia with parenteral use. Classic cause of heart block, bradycardia (need ECG first), gum hypertrophy, cerebellar atrophy, hirsutism, acne.Epileptic Rx - what to give - guidelines just changed ahlie top quality content here at scrubbedup get your money up not your funny up foCaL abScEnce Complications of Epilepsy ● Status Epilepticus ● SUDEP ○ sudden unexpected death in epilepsy → most common cause of death in adults with epilepsy, mostly poorly controlled epilepsy and nocturnal variants ● Trauma ● Drowning ● RTC Status Epilepticus ● Status epilepticus is defined as a seizure lasting >5 minutes, or >/=2 seizures within 5 minutes with incomplete resolution. Do A-E then…Progressively Depressive Progress Questions 12.30Progress QuestionsThanks. Any Questions? By Zakariya Mouyer zakariya.mouyer@student.manchester.ac.uk