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PPALS Year4Neurology Teaching Adam Hussain+ Layan Alrazihi TABLEOFCONTENTS ● Epilepsy ● MyastheniaGravis ● Stroke ● MS ● GBS ● Migraines 1 Epilepsy 2 MyGravisia 3 StrokeFeaturesFeaturesFeatures Management of Stroke ● Maintain BM, hydration, O2 saturation, temperature ● ↓ BP except in hypertensive encephalopathy ● Exclude haemorrhagic stroke and give 300 mg aspirin oral/rectal ASAP ○ given 24 hrs after thrombolysis/thrombecty if indicated ○ if Cholestrol > 3.5mmol/l → :statin after 48 hours from stroke onset ● Alteplase ● Thrombectomy ● DVLA guidance ○ TIA / Stroke - 1 month off, no need to inform DVLA ○ Multiple TIA over short period of time - 3 months off, inform DVLA Guidelines - Alteplase ● Give within 4.5 hours of onset of symptoms+ haemorrhage excluded by imaging ● Consider patients with AIS + TKW >4.5 hours earlier if: ○ treatment can be started between 4.5 and 9 hours of known onset OR within 9 hours of the midpoint of sleep when they have woken with symptoms, AND ○ they have evidence from CT/MR perfusion (core-perfusion mismatch) or MRI (DWI-FLAIR mismatch) of the potential to salvage brain tissue ● this should be irrespective of whether they have a large artery occlusion and require mechanical thrombectomy.Guidelines - Thrombectomy Stroke - Thrombectomy guidelines ● mRS < 2 + NIH Stroke Scale > 5 ● OFFER if within 6 hours of symptoms onset + together with IV thrombolysis (if within 4.5 hours) + AIS + confirmed occlusion of proximal anterior circulation on CTA/MRA ● OFFER if LTKW between 6-24hrs (wake up strokes) + confirmed occlusion of proximal anterior circulation on CTA/MRA + potential to salvage brain tissue, as shown by imaging such as CT perfusion or diffusion-weighted MRI sequences showing limited infarct core volume ● CONSIDER if LTKW is <24 hours + together with IV thrombolysis (if within 4.5 hours) + AIS + confirmed occlusion of proximal posterior circulation (basilar /posterior cerebral artery) on CTA/MRA + potential to salvage brain tissue, as shown by imaging such as CT perfusion or diffusion-weighted MRI sequences showing limited infarct core volume ● Secondary prevention -Commence 2 weeks after stroke + haemorrhage excluded -1st-line → clopidogrel. -2nd-line → aspirin + MR dipyridamole. -3rd-line → MR dipyridamole. -Atorvastatin 20-80mg OD -BP control etc. -Carotid artery endarterectomy → -Carotid stenosis > 70%. -Carotid stenosis > 50% + symptoms. -Stroke/TIA in carotid territory + not severely disabled. Secondary prevention AF patients - CHADV ASC + ORBIT score - 1st line → DOAC - 2nd line → Warfarin4 MSWhat is MS + Features ● A chronic cell-mediated autoimmune disorder characterised by demyelination in the central nervous system ● Visual ● Motor ○ optic neuritis: common presenting ○ spastic weakness: most commonly feature seen in the legs ○ optic atrophy ○ Cerebellar ataxia: more often seen ○ Uhthoff's phenomenon: worsening of during an acute relapse than as a vision following rise in body presenting symptom temperature ○ tremor ○ internuclear ophthalmoplegia ● Others ● Sensory ○ urinary incontinence ○ pins/needles ○ sexual dysfunction ○ numbness ○ intellectual deterioration ○ trigeminal neuralgia ○ Lhermitte's syndrome: paraesthesiae in limbs on neck flexion MS - Investigations ● MRI ○ high signal T2 lesions ○ periventricular plaques ○ Dawson fingers: often seen on FLAIR images - hyperintense lesions perpendicular to the corpus callosum ● CSF ○ oligoclonal bands (and not in serum) ○ increased intrathecal synthesis of IgG ● Visual evoked potentials -> delayed, but well preserved waveform 5 GBS GBS - Features ● Guillain-Barre Syndrome is an immune-mediated demyelination of the peripheral nervous system often triggered by an infection (classically Campylobacter jejuni) ● History of gastroenteritis -> for exams!!! ● Initially back/leg pain -> progressive, symmetrical weakness of the limbs ○ weakness is classically ascending ○ reflexes -> reduced/absent ○ sensory sx are mild (some paraesthesia) ● respiratory muscle weakness ● cranial nerve involvement ○ diplopia ○ bilateral facial nerve palsy ○ oropharyngeal weakness is common ● autonomic involvement ○ urinary retention ○ diarrhoeaGBS - Investigations + Management Investigations: ● lumbar puncture -> rise in protein with a normal white blood cell count ● nerve conduction studies may be performed ○ decreased motor nerve conduction velocity (due to demyelination) ○ prolonged distal motor latency ○ increased F wave latency Management; ● IV Immunoglobulins/Plasmapheresis + Supportive Mx ○ Respiratory Depression -> O2 + Intubation + Ventilation ○ VTE prophylaxis ○ Pain -> Gabapentin/TCAs ● Rehabilitation Miller-Fisher Syndrome ● Variant of GBS ● associated with ophthalmoplegia, areflexia and ataxia. The eye muscles are typically affected first ● usually presents as a descending paralysis rather than ascending as seen in other forms of Guillain-Barre syndrome ● anti-GQ1b antibodies are present in 90% of cases 6 Migraine Migraine - Features + Triggers Features: ● a severe, unilateral, throbbing headache ● associated with nausea, photophobia and phonophobia ● attacks may last up to 72 hours ● patients characteristically go to a darkened, quiet room during an attack ● 'classic' migraine attacks are precipitated by an aura: ○ these occur in around one-third of migraine patients ○ typical aura are visual, progressive, last 5-60 minutes and are characterised by transient hemianopic disturbance or a spreading scintillating scotoma ● Hemiplegic Migraine -> Associated Motor Weakness occurs as part of aura Triggers: ● tiredness, stress ● alcohol ● COCP ● lack of food or dehydration ● cheese, chocolate, red wines, citrus fruits ● menstruation ● bright lights Migraine - Diagnosis ● International Headache Society Criteria ● NICE criteria notes the following: ○ NICE suggests migraines may be unilateral or bilateral ○ NICE also give more detail about typical auras: ■ Auras may occur with or without headache and ■ are fully reversible ■ develop over at least 5 minutes ■ last 5-60 minutes Migraine - Management Acute Management: ● first-line: offer combination therapy with ○ an oral triptan and an NSAID, or ○ an oral triptan and paracetamol ● If age 12-17 -> Nasal Triptan is preferred ● If ineffective: non-oral preparation of metoclopramide or prochlorperazine and consider adding a non-oral NSAID or triptan Prophylaxis: ● Given if: 'Migraine attacks are having a significant impact on quality of life and daily function, for example they occur frequently (more than once a week on average) or are prolonged and severe despite optimal acute treatment' ● propranolol ● topiramate: should be avoided in women of childbearing age as it may be teratogenic and it can reduce the effectiveness of hormonal contraceptives ● amitriptyline ● if these measures fail NICE recommends 'a course of up to 10 sessions of acupuncture over 5-8 weeks' ● NICE recommend: 'Advise people with migraine that riboflavin (400 mg once a day) may be effective in reducing migraine frequency and intensity for some people' Migraine - Pregnancy, Menstruation + COCP Migraines during pregnancy ● paracetamol 1g is first-line ● NSAIDs can be used second-line in the first and second trimester ● avoid aspirin and opioids such as codeine during pregnancy Migraines during menstruation: ● for women with predictable menstrual migraine treatment NICE recommend either frovatriptan (2.5 mg twice a day) or zolmitriptan (2.5 mg twice or three times a day) as a type of 'mini-prophylaxis' ● SIGN recommends that women are treated with mefanamic acid or a combination of aspirin, paracetamol and caffeine Migraine and the COCP ● if patients have migraine with aura then the COCP is absolutely contraindicated due to an increased risk of strokeTHANK YOU PleaseCompletetheFeedbackForm ALayan.alrazihi@student.manchester.ac.uk