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So welcome everyone um to the next installment of the Concha final series. Um This week we have Remya and Haya, Remya and Han Remya and Hannah who are going to be um covering neurology for us. Um It's a finals um focused session um but it can be appropriate for um those in sort of third year and fourth year that are also covering neurology. Any questions at any point, pop them in the chat and one of the three of us will try and answer. Um Please do engage with like the polls and any questions from our speakers because it's gonna help you get the most out of it. Um But any questions um just pop them in the chat and we'll help. Ok. Ok. Hi, everyone. I'm Remer, I'm one of the FT S working in Conquest. So I'm gonna start off with part one of neurology. So I am going to cover meningitis, MS and vein bleeds and then Hannah will be covering neuropathies, Parkinson's stroke. Um So let's get into it. Um Yeah, so I'm gonna do mine as kind of like a CSF interpret interpretation session. Um So we're gonna go straight into I'm gonna give you some polls to just start off with and interpret these CSF findings. So the first patient presents with a headache appearance of the CSF is clear white blood cells are normal. Um s ever so slightly raised but mostly lymphocytes, uh protein is mildly elevated and CSF is showing oligoclonal bands. So looking at the pole, I'm not quite sure how to open the bowl. So Hannah, could you help me with that? Oh, I can see that. I see that. Yeah. If, if you guys can decide what you think the pole answer is. Do you think it's a bacterial meningitis B viral meningitis, C, multiple sclerosis or D subarachnoid hemorrhage. I'm not seeing any answers come in. Uh Tess Hannah, can you see anything? I'm just seeing one answer so far. Can everyone see the polls? I can see 12. 0 You can see 12. It's not loading our end. OK. Hannah's in charge. Cool 16% for B and 83% for C. So we said 16% for B and 83% for C. Yeah, perfect. OK. So the answer here is C. So most of you got it right. Um The main giveaway here is the oligoclonal bands. You would only find that in multiple sclerosis and the protein being slightly elevated. Also show suggests that as well and we will go over this in a bit more detail and go over MS as we go along. But I'm gonna go to the next CSF interpretation. So now we've got a different patient also presenting with a headache. This patient comes uh the CSF is clear, the white blood cells mildly raised and primarily lymphocytes protein is slightly raised as well. Oh, is this the same, please? Oh, no, it's not CSF is not present and xanthochromia is negative. Um So if we put another pole up again, do we have any answers in Hannah? Just six at the moment? OK. To make it a bit easier, I'll highlight the key um findings here. So the fact that the protein is raised is significant and the fact that the white belt red cell is mildly raised and that it's mainly lymphocytes is also significant and the fact that the CSF is clear is also uh significant if that helps at all any more answers. No, until just sex. OK. What, what are we, what's the main answer we're getting? So 83% would be um 16% for a perfect. So yes, it is viral meningitis. So we can firstly rule out the last two. So we can rule out multiple sclerosis because there are no oligo oligoclonal bands present and we can rule out subarachnoid because Xanthochromia is negative. So we're looking at either bacterial or viral here and there's a few things that would suggest bacterial or viral. One of the main giveaways is the fact that the appearance is clear when you have bacterial. It would be a bit more cloudy whereas viral is completely clear, the white blood cells as well. Um It's raised but not overly raised and it's mostly lymphocytes and it's the protein that gives it away as well. So, yeah, viral meningitis is correct for this one. And obviously, when we're looking at the meningitis CSF is kind of the main giveaway for looking at whether it's bacterial or viral alongside your blood cultures. Ok. So next question again, your patient presents with a headache. This time, the CSF is cloudy, white blood cells are significantly raised this time and the glucose is low and the protein is normal. Everything else is negative. What do you think this patient is presented with? Again? Another pole. Yeah, we've got 11 responses and 100% for a perfect Yeah. So that's the correct answer. And the main giveaway here is the fact that it's cloudy on appearance and the fact that the white blood cells are so raised. Um and the glucose being low as well. So those are the key findings for bacterial. Ok. And this is the final one. Again, your patient has a headache this time, the CSF is kind of yellowish and white blood cells are normal. You find that there's um red cells in the CSF glucose and protein are on the whole normal no oligoclonal bands and the Xanthochromia is positive. What is the answer this time? Do we have many answers? I can only see two I but 100% for D for D Yeah. Perfect. Yeah. So this is subarachnoid hemorrhage. And we know this mainly because of the xanthochromia, you wouldn't get it positive in any other conditions. Um And the fact that the red cell count is raised. So in C Arachnoid, you have blood pooling out into various areas within the brain and then also then pools into the CSF. So you'll get red cell count. Ok. So we'll go um It's a very quick point. We're just gonna do if and just using the message, the chat function or if you are able to speak out loud and name any contradict contraindications for doing a lumbar puncture. Yep. Thank you raised ICP. Any other ones? Purpuric rash. Yep, hemor crenelations, hemorrhage. Yeah. Oh How this, thank you for interacting. And so there's quite a few, so local skin infection. If you think there's a chance that you're gonna give them a CSF infection yourself, then you shouldn't go ahead with that. If there's any coagulation abnormalities. And this does depend on what presentation you have. But if it's a lumbar puncture, that's more elective, then you should wait for them to be off aspirin or whatever anticoagulant they're on um for a certain amount of time before continuing with the lumbar puncture. If they're hemodynamically unstable, you wanna stabilize them first before doing this procedure. If the signs of a spinal cord concussion and then as um a few of you have said raised ICP, um most likely due to a space occupying mass, then you wouldn't want to do that because of risk of coning. Um And the way you would know about raised ICP is if there's fluctuating consciousness or reduced consciousness, if there's signs of shock, if there's focal neurological signs, um unreactive or dilated pupils or papilledema and adults eye movements. So when you turn the head really quickly, the eyes go in the other direction fine. So we're gonna go through some cases. So you've got a 19 year old male who presents to A&E with a three day history of fever, headache, neck stiffness and photophobia. Koenig's and fins signs are positive. Does is anyone happy to have a go in the chat to describe what they are? Ok. I'll answer. So this is when you have the patient supine on the couch or the um bed and when you extend and bend their knees, it causes pain or stiffness along their back. Uh That's kni um and then Zinsky is when you bend the patient's neck forward and bend in, then they have pain. So those two signs are positive, the ops for this patient are stable based on the above and again, the chart. Can anyone name the main differential? Perfect. Thank you quite a few of you saying meningitis is perfect. Yeah, so we'll talk about other signs in a second and other investigations. So in terms of other signs. Um We'll come to that. So this is suspected meningitis. So this is inflammation of the meninges covering the brain or the spinal cord. And that's specifically um more so the Du and the Arachnoid um viral meningitis is more common, but you should treat it as bacterial until proven otherwise because you're more likely to die from bacterial meningitis than viral. And there are a few risk factors so young age and there are specific signs that you see in your neonatal young group, um including the bulging fontanels. And then if the patient is immunocompromised, uh if there's overcrowding. So for example, university students and actually the only time I've seen meningitis is in university students, I haven't seen it too many times thankfully. Um But yeah, that's mainly when I've seen it in university students, ok, in terms of clinical features, um in the earlier stage, you have kind of typ typically vague and nonspecific signs of fever, headache, nausea, and vomiting. Um things that can just be the flu as well, which is why you should also do a flu swab when you have suspected meningitis as it progresses, then you have other more specific symptoms, the ones that we kinda advertise more. So your non blanching rash, um the Koenigs and the Binkys, the stiff neck stiffness, the bulging f to now. So you have a lot of signs that can come along um and kind of help you determine how severe it is at this moment in terms of investigations. So you wanna do bloods, obviously, your FP CS and cop looking for infection using these as well, looking for other causes that could be causing the symptoms, coagulation screen. Because if you are going to do a lumbar puncture, you need to know that they're not gonna bleed out. And then you might do meningeal PCR as well doing blood cultures as well trying to identify the causative organ organism. So you can uh guide your antibiotic choice, the blood gas as well. And then a CT is only done if you're querying focal neurological signs. If you think there's a space occupying lesion, or if you think there's a specific cause for this uh meningitis, such such as mastoiditis. But the main investigation for this patient will be a lumbar puncture. And ideally, you should do that within an hour. And the only time you wouldn't do it within an hour is obviously they haven't arrived within an hour. Or if you think that doing the lumbar puncture would delay giving antibiotics because that's the main thing for this patient. Ok. So as we said before, we did the C CSF uh bacterial meningitis will show a cloudy appearance with very raised white blood cell count and glucose. Whereas viral will usually be clear, we have kind of elevated white blood cells but not as much as bacteria will and um protein will be elevated and viral. Fine. So this patient has bacterial meningitis. How would you manage the patient? What is the main antibiotic of choice? Yes, there's a few answers there. So, ok, so we said the patient has bacterial meningitis. Um Management depends on where you are seeing the patient. So if it's in the community, if you have time, if you think it's um appropriate, you can give im or intravenous benzopin if they're not allergic and then arrange urgent transfer to the hospital. If it's within the hospital itself, it's IV cefTRIAXone for Children above three months in adults. Um you can consider for Children under three months. So the babies er cefotaxime because you're covering for listeria, you might also consider steroids or dexamethasone because there is a chance of is um in um raised intracranial pressure as well. And then most of it is supportive care if it's viral meningitis and this is more common but less deadly. You can give acyclovir if it's herpes simplex, but otherwise it's supportive care and it, it does usually resolve within 10 days fine. Now we have another patient, almost the same patient. 19 year old presents with a three day history of fever, headache, neck stiffness and photophobia. The signs are positive again. But this time his abs are, he's um tachycardic and hypertensive and he's now got this rash and a non blanching. PPAR rash is present and the patient says that it's been spreading. What is the diagnosis now? Yeah. Yeah. Perfect. Fine. So we've got meningococcal septicemia. So, what is the difference here? So meningitis simply means the inflammation of meninges and that can be infectious or noninfectious. If it's infectious, it can be bacterial, viral or fungal. If it's noninfectious, it's usually autoimmune or medication related. Um And the three symptoms here are fever, headache, neck stiffness, photophobia. The kind of more earlier stage that we mentioned and you would do CSF meningococcal disease refers to any of these diseases caused specifically by the bacterium Naia meningitis. And so that can include meningococcal meningitis. So that's simply the meninges are inflamed by this bacteria or meningococcal septicemia. So that means the blood is infected by this organism and this is when you would get your purpuric rash, uh you'd get go into shock, you might have D IC and this is a bit more serious, a bit more dangerous. Um So at this point, you should avoid LP if the patient is hemodynamically insta unstable, if there's a risk of bleeding. So if they have D IC, they have that risk of bleeding. And this actually doesn't give much diagnostic value. Anyway, if you do a lumbar puncture because you've already got the rash, that's um quite key towards meningoseptica. So the management there is supportive care and immediate antibiotics. Any questions or men meningitis, I'm gonna take that as a no. OK. Going on to case three, we have a 28 year old female who presents to the neuro clinic with a three week history of visual problems in the right eye. She reports her vision has become progressively blurry with accompanying eye pain when moving the eye on further questioning. She also reports roughly a year and a half ago, she had an episode of tingling and pins and needles in the left arm lasting one week. However, this self result. So she didn't go to the GP at the time. Past medical history includes type one diabetes and she is also a smoker. What is the likely diagnosis? Oh, yeah, I see how the same MS any other takers, MS? Yeah. And you're thinking specifically about what, um, what presentation they're coming with with uveitis. Yeah. And what investigations would you do if you, if you're querying MS? Yeah. Optic neuritis is correct. Noncontrast Mr MRI MRI with contrast. Ok. So, yeah, we'll go into this in a second. Ok. Let's go on. So it is multiple sclerosis most likely. I mean, obviously we need to do more investigations and MS is a chronic progressive demy of, um, the C NS characterized by lesions disseminated in both time and space. So these symptoms are spread off across years, months and they were in different parts of the body. You kind of have four types and it seems that there are four types of change since I was a med student. Not that that was long ago, it used to be on the left hand side. You have the relapsing, remitting the primary progressive, secondary progressive and progressive relapsing, but it seems like they're trying to move forward towards the clinically isolated syndrome or uh radiologically isolated syndrome and then relapsing, remitting secondary progressive and primary progressive. So, risk factors for MS include genetics being female, the E BV virus, low Vitamin D smoking, obesity and autoimmune diseases. And uh typically, in terms of initial presentation, people present with optic issues. So, like you guys have said optic neuritis or the UTIs or limb numbness, tingling, that kind of feeling or weakness and sometimes cerebellar symptoms. Um So these are quite vague, these can be assigned to many other things and Hannah will go over later about neuropathies as well. So these can come under different things. So it goes back to the whole disseminated in time and space and having um more than one episode really to be able to diagnose and there are some phenomena that are characteristic of MS. So, um I'm not gonna say the name but the first one where it's worse in a warm environment. So if you're in a bath or a shower or in a hot country, and then the last one where you have a lightning sharp pain down the spine on flexion of the neck, right. So at this point, you would wanna do bloods. Um The main ones here are thinking about vitamin deficiencies or hormone deficiencies that can also be causing these issues. Uh And then you would wanna do MRI brain and spinal cord and we will come to contrast or not to contrast in a second. You can do lumbar puncture as well and there is a mcdonald criteria that you guys can look up if you wanna know more about diagnosing MS. So next poll, what MRI findings would most support diagnosis of MS and there's a few options here. So I'll give you a second to read it over. OK. Um Hannah, could you open the pole again, please? Thank you. OK, I see it. Oh, let's jump to 14 responses now. So I'll go on with it. Um So obviously, the first question is contrast or not contrast. So yes, we do do contrast question is which contrast. So we would do ga ga gadolinium contrast and you would expect to see at two hyperintense uh lesions. So as you can see here, the white blobs that are brighter than the rest of the and the brain, that's what unfortunately, it's one of those things that you just have to learn and remember there's no, as far as I'm aware, there's no way of just remembering. Um OK, fine. In terms of lumbar puncture, um you should pursue all the other noninvasive tests first before trying to do a lumbar puncture in the case of MS. But if you do the main finding will be oligoclonal glands, as we said earlier, in terms of management for MS, in terms of an acute management more everything needs to have a medical intervention. Sometimes the symptoms just resolve on their own, but you can consider high dose steroid therapy. Um and there is also plasmapheresis if steroids is not an option in terms of long term, unfortunately, there's no cure. It is a progressive disease, but you can consider other agents to help slow down the disease progression. So beta interferons or your um disease modifying therapies. And but one of the main managements is an MDT approach. Thinking about your occupational therapist, your physiotherapist, seeing how you can make life more manageable with MS. OK. That is MS any questions for MS did, did uh does the contrast make sense? Ok. I'll assume no questions. OK. Case four, you have a 54 year old lady presenting to A&E with sudden onset, severe headache, reaching max intensity within seconds, described as worst headache of her life starting 30 minutes prior to a viral and it particularly worse at the back of her head. She's got associated neck stiffness, nausea and photophobia. What is the likely diagnosis? Cool. I can see people saying subarachnoid hemorrhage. So it's perfect. So, subarachnoid hemorrhage was suspected in this case can be either traumatic. So for example, a secondary to road traffic accident and most subarachnoid are due to this or it can be spontaneous. Um and in terms of spontaneous subarachnoid, 70% is due to intracranial aneurysms. So, in terms of risk factors and this is more. So for your uh spontaneous hypertension, smoking, family history, um polycystic kidney disease, age over 50 female sex. It more so female sex postmenopausal because when you have a drop in estrogen that causes more vascular issues. In terms of your findings, it's, it's that thunderclap headache, that severe onset max maximum intensity within seconds, you get nausea and vomiting and photophobia as well. Um So obviously, with the nausea and vomiting and photophobia, it's, you have to consider also things like meningitis or migraines. Um in terms of clinical findings, you might have reduced level of consciousness, you might have neck stiffness and you might have the chronic sign again that we saw in meningitis. So in terms of bloods, you do some bloods to get baseline and also coagulation studies in case you want to do lumbar puncture or you need to do surgery, you do CT and in terms of CT findings, you'd find that there's pooling of the blood. So it kind of just looks like everything's smushed together. And so you can see that you can't really see the stents, you can't see the gaps as well as you could in other CT S, you might do a CT angiogram as well. And lumbar puncture is only done in specific criteria. So if, if the CT was performed more than six hours after symptom onset, and it's not very helpful and you have to wait 12 hours after the onset of symptoms before performing a lumbar puncture. Uh And as we went through in the beginning, the main findings is xanthochromia and a bloody CSF. So you, you might be bloody or cloudy and has red cell count in terms of management. So you do your at e assessment, make sure your patient stabilized and an urgent neurosurgical referral. And then they will decide whether they want to ob uh obliterate the ruptured aneurysm or if they want to do balloon angioplasty or if they want to train um for cases of secondary hydrocephalus. Ok. Let's go into case five. So we have a 74 year old man who has brought in by ambulance after sleeping on the sidewalk two hours ago, he's accompanied by his partner, he hit his head on the pavement and now in A&E he does not remember the incident and he's complaining of right sided headache. He's vomited once he is confused with the G CS of 14, what would you like to do next for this man? Well, not nece, not necessarily next. What do you wanna do for this man in general? What investigations do you want? Yeah. So we wanna do a CT head because he's got a head injury. Um, so first off, we wanna do at e do a secondary service. If there's any other uh, injuries that we need to look out for, take a history and a collateral because he cant can't really remember what happened. We wanna do some bedside investigations. We want bedside may need to figure out why is he falling? So we wanna do his ECG, is there a cardiac cause blind standing BP and blood sugars and urine dip as well? Is there a uti and then in terms of bloods, we're doing EP ce mostly for um, baseline also checking if there's any infections going on group and say with, in case we do want to send him to surgery and a clotting as well. Again, if we want a lumbar puncture or surgery and then the CT head. So having a look at this um, CT head, er, Hannah, can we get one more pull up? But there's not five options, there's only three options. Um, but what do you guys think it is? Ok. So there's quite an even split here between A and Z and thank you to whoever chose D when it's not even an option. Um ok, so between A and C one and three is correct. So we obviously know it's not subarachnoid. We've already seen the CT for that. Um, in this particular example, it is a subdural hemorrhage and the kind of pneumonic to remember that is the B stands for banana and it's more of a banana shape than epidural, which would be more of a lemon shape. Your subdural is also more common in elderly people. Um, so it's your classic old man or woman who's fallen down. Um, yeah, whereas your epidural it's more typically your man in your twenties. So that's that. Um And here are some, hopefully we'll send out the slides later. So you can look at the differences between the two. Yeah, in terms of management. So if you have a person coming in with uh with subdural hematoma, um you'd correct the coagulation so often with elderly patients, they will be on anticoagulants. Um So you'd want to stop that or stop aspirin, consider reversal agents if need be. And if they have other natural co coagulopathies, then you'd want to discuss with him. The main thing here is a neurosurgical referral. Um And then they will decide whether conservative management so kind of letting it ride out itself. Um If there's no immediate concerns and there's minimal mass effect or they might consider a trauma craniotomy. Uh And that's more in acute subdural where there's significant mass effect or if it's a chronic SDH, then they might consider bur hole craniotomy. So that's subdual. I think that's all my slides. Any questions based on that, it's quite a very quick go through to everything cool. If not, then I'll pass over to Hannah. I hate it all out. Um OK, so we'll just go straight into it. So starting with a case here. So a 33 year old female presents to A&E with worsening leg weakness. Now unable to walk, started four days ago with back pain and tingling in her feet. She's got a past medical history of diabetes and reports an episode of gastroenteritis four weeks ago, she got reduced tone bilaterally. Zero out of five power in an, in her ankles, er, knee flexing extensions. One out of five, no, sorry, zero out of five in knee flexion extension and one out of five in hip extension and flexion. And you can't say reflexes. So, based on what you think the diagnosis is, what would be the Gold Standard investigation, we start the whole. OK. So I can see you've got a bit of a spread of answers before we go to the answer. Does anyone want to put in the chat? What they think the diagnosis is here? Yeah, Guillain Barre. So we've got a young lady with worsening leg weakness that based on the examination findings, we can see is ascending weakness. She got a history of gastroenteritis four weeks ago, which can be the trigger. So the Gold Standard investigation for Guillain Barre is actually nerve conduction studies. Um You can do lumbar punches and on lumbar puncture, you might see raised protein, but the gold standard would be nerve conduction, MRI spine, MRI spine would be more if you're thinking called a equina. Um and electromography looks more at sort of muscle response to nerve impulses. So in terms of neuropathies, I felt find I found them quite confusing when I was a med student, but I thought this diagram was quite helpful. So you have radiculopathies which is where you get damage to a nerve root. So you'll tend to have a more der dermatomal distribution. So, this will be caused by things like disc herniation or spinal canal stenosis plexopathy is when you've got damage to the nerve plexus, like a brachial plexa plexopathy, mononeuropathy, that's when you've just got damage to one peripheral nerve. So for example, uh carpal tunnel syndrome, you might just have um neuropathy in the median nerve distribution. Myitis multiplex is when you get damage to multiple m multiple nerves in different distributions. And then poly neop withy is when you get opathy of multiple nerves. Um and they tend to be, they can be like a glove and stocking distribution. So for polyneuropathy, you can split it into two sort of mechanisms to have axonal or demyelinating. And these will show you um on nerve conduction will help you distinguish between them. So, axonal polyneuropathy on a nerve conduction study will show decreased amplitude and then demyelinating where you've got damage to the, the myelin sheath, it will have reduced velocity on nerve conduction. In terms of causes of poly polyneuropathy, there are loads and loads of causes. So I find a good way to structure them would be to use your surgical sieve and here I put them into axonal and Demy. So axonal are in blue and Demy are in purple. So what out of all of these causes, what do you think is the most common cause of a polyneuropathy if anyone wants to put in the chat. Yeah, exactly. So, diabetes is the most common cause followed by alcohol. But you do have some other, very rare things, things like paraproteinemia, which would be things like myeloma. You can get some paraneoplastic presentations as well. But your most common ones are ge generally your metabolic ones. So, thinking about these causes, what investigations do you think would be helpful to differentiate between these causes? Yeah, definitely blood tests very good. So you can split this, especially when you're presenting in um your acies, it's good to have a structure. So, bedside bloods and imaging or in this case, just extra cos there's quite a few different things you can do. So the bedside, you need to do a full neurological examination and you can also check the capillary glucose as well for blood looking at full blood count CRP. Is there any evidence of infection? U LFT ST FT S looking for hypothyroidism, HBA1C looking at diabetes can do a tox screen, um B12 and folate and HIV. Again, these tests will be um you can pick and choose based on the sort of history um of the patient, an extra test you can do. So as we said earlier, you can do a lumbar puncture, but your best um test is gonna be a nerve conduction study. You can do biopsies and genetic testing. Maybe if you're considering things like Charcot Meri tooth and on examination of that, you might find some classic findings of that. So you might see a sort of champagne leg um and you might see the sort of classic shark foot. So treatment of poopy is mainly based just on the underlying cause. So, controlling diabetes, um stopping alcohol, vitamin replacement physio and at can be helpful for Guillain Barre IV IG is a very helpful um treatment. You also with Guillain Barre want to do lung function tests because it can affect the respiratory muscles. So very important to do lung function tests in Glib bar as well. C IDP, which is chronic inflammatory demyelinating opathy. That is a chronic form of Guillain barring and you can treat that with steroids IV IG and personal exchange. But it it's a chronic condition. So they may need to keep coming back to the hospital every couple of weeks or so for those infusions and pain specialists can also be helpful. Ok. Mm. Any questions about neuropathy? If not, we'll move on to case two. So here we have a, a 70 year old male brought in by ambulance with facial drooping, slurred speech and left arm weakness that came on suddenly two hours ago. He's got a past medical history of hypertension and hypercholesterolemia. What would be your next step? Yeah. Yeah, an hour. Ok. So I can see most people have gone for a which is the correct answer, but a couple for B and C. So we'll go through um why it's not B and C. So this guy is presenting with facial drooping, slurred speech and left arm weakness. So we're thinking, um, he's having a stroke. So our next step is we want to know, first of all, whether it's hemorrhagic or ischemic, the reason we need to know that is we can't, if someone's got a hemorrhagic stroke and you Folli them or give them aspirin, it's gonna make it um make it a lot worse. So we just need to check first of all, whether they have um an ischemic or hemorrhagic stroke. So act head is the first thing to do and also the stat dose of aspirin that you'd give would be 300 mg. Um but we'll come on to that in a second. So just another question about this case. So the same gentleman with facial drooping, slurred speech and left arm weakness, er which is a three out of five and mild leg weakness, which is four out of five. That again came on suddenly two hours ago on examination, he's got a forehead sparing, left facial palsy aphasia and a visual field defect as shown um above in the top, right. So what type of stroke is this according to the Bamford classification? And what arteries are likely affected? Thank you. Start the pole. Sorry. Yes. So I right. 67. OK. So I can see that most of you have gone for a which is the correct answer. So if we write down a question, so he's got left arm weakness and a mild left leg weakness. So he's got more arm weakness than leg weakness. He then has a forehead sparing, left facial nerve pulsing. So from that, we can tell that he's had a total anterior circulation stroke affected by the middle cerebral artery. And the reason why we'll come on to explain now. So the Bamford stroke classification. So this is a, a key thing to know. Um it is quite, it's just a sort of thing you have to learn. Unfortunately, there's not really an easy way of memorizing it that I'm aware of. Um but Gynix has a nice breakdown of it. So total anterior circulation strokes, these require you to have all three of unilateral weakness, ominous hemianopia and a high higher cerebral dysfunction. So things like dysphasia, aphasia, a partial anterior circulation stroke. Um just only needs two of those criteria. Lacuna syndromes just need one of the following. So it might be just pure sensory, pure motor or maybe things like ataxic hemiparesis and a posterior circulation. Um strokes they can present with just sort of cranial nerve palsies, maybe um just a ga's palsy or some cerebellar dysfunction. So maybe they've got sort of sudden onset vertigo or ataxia then in terms of breaking down the arteries affected. So I find it's quite easy to, well, it makes it easier to visualize it based on the homunculus So using the um sort of areas of the brain affected by each artery. So here you can see the anterior um artery affects sort of this area which is mainly the leg. So, anterior um strokes are gonna affect the leg more than the arm, whereas the middle cerebral artery is this area. So that's more of the hand, the more of the hand and the arm are gonna be affected more than the leg. So if we go back to the question, we've got a unilateral weakness, got the left side, we've got a hormon hemianopia and we've got evidence of higher cerebral dysfunction with the aphasia. So that's enough for a total anterior circulation stroke. And we know it's more likely to be the middle cerebral artery than the anterior because the arm is more affected than the leg. If the leg was more affected than the arm, then it would be more likely to be the anterior cerebral artery. Mhm OK. Uh This again, this is from past med and I find it quite a good table sort of break down the more typical symptoms of each um each sort of artery and the strokes symptoms they would produce. And this is a good, I think you guys will get the slides. Um I hope so anyway, so this is quite good to go through. So things that we didn't mention there um Webers or Webers Syndrome. So that's a, that's when you get a stroke in the posterior cerebral artery, they might just have an ipsilateral cranial nerve three, pausing a stroke, affecting just the ophthalmic artery. You might get something called amaurosis fugax, which is where you essentially get, it feels like a curtain, like a black curtain coming down and you can get that as well in um oh, mine's come back. But the, the stroke, the stroke that um resolves within 24 hours. I'm sorry, my mind's gone completely back, begins with at it'll come back to me in a second. Ok. And then if it affects the basilar artery ti a thank you. Um And if it affects the basilar artery, you might get locked in syndrome. We are sort of aware of their surroundings, but they're not able to communicate with anyone. It's in management of stroke acutely, they need to be admitted to a hyperacute stroke unit. Um In this area, Eastbourne has one. Conquest does not. So any patients that are fast positive um brought in by ambulance won't be accepted by conquest. They'll need to go to Eastbourne, they'll need act scan first to find out whether it's ischemic or hemorrhagic. And then the treatment depends. So if it's an ischemic stroke, the treatment would be if it's been less than 4.5 hours since onset and there's evidence of brain tissue salvage on the scan, they can have throbs usually with um alter plays a less contraindicated. So, for example, if there's any evidence of bleeding if it's less than six hours and there's a confirmed occlusion in the anterior circulation. They can also have thrombectomy. And then the guidelines get a bit complicated um to do with wake up strokes on when they can have thrombolysis and thrombectomy. And there are guidelines on this, if you get the slides that this link will take you to them. Um but it's, it's, yeah, it gets very complicated and confusing about sort of what wake up strokes and then use sort of midpoint of sleep to time it. Um So it might be worth just having a look through that in your own time. Then um the next sort of step of management would be to start Aspirin 300 mg. Nice guideline says within 24 hours. However, in practice, it's usually delayed until 24 hours after thrombolysis all took place. And actually the B NF says that it should be started 24 hours as well. I only need that once daily for two weeks and then long term management. So once daily for two weeks, um if they have Dyspepsia, then they can have that with a PPI and then from day 14, they'll need secondary prevention. So that's usually clopidogrel, 75 mg once a day lifelong. Um But if they don't tolerate that, they can have aspirin um and a statin. But if they have af um they'll just need to be on a doac and a statin they won't need any clopidogrel. Other important secondary preventions is um sort of managing those risk factors. So, managing BP, um cholesterol, um alcohol exercise, those sort of things. And neuro neurorehabilitation is also a big part of stroke management. Um And like physio and ot as well. Ok. Last question. So 17 year old male comes into neurology clinic with his wife. You first noticed that he has a shuffling gait. Um One of the neurologists when I did my knee replacement told me that you can tell a lot about a patient in a neurology clinic before they even walk into the room. Like you can listen to their gait in the hallway. I don't know. I thought that was quite interesting. Um Anyway, he reports over the past couple of years that he's finding it increasingly difficult to do up his shirt buttons. His wife reports that his speech has changed and become a lot slower and slurred and he's also fallen over backwards multiple times. He said that his last doctor had put him on levodopa, but it doesn't seem to have any effect on examination. He's got limited vertical, up, gaze and down gaze. What do you think is the most likely diagnosis? Ok. So a bit of a split here between Parkinson's and progressive supranuclear palsy. So the answer is actually Dean. Um and then we'll go into why? So we've got um a patient with a shuffling gait, difficult to do up his shirt buttons, which could be because of a tremor and he's got slower and slurred speech. So those sort of features we're thinking sort of Parkinson's the falling over backwards can also be a feature of Parkinson's so postural instability. Um and also a feature of progressive supranuclear palsy, but it's the last two sort of things that are highlighted that point more towards a progressive supranuclear palsy than Parkinson's say, a key feature of progressive supranuclear palsy is the limited vertical, up gaze and down gaze. And what that eventually turns into over time is complete, sort of ophthalmoplegia and they unable to move their eyes. That's when it's very, very progressed. And also levodopa doesn't tend to have much of an effect in progressives pausing with. Um actually, I'll come on to that in a second. So Parkinson's is a chronic progressive neurological disorder and the main sort of triad of symptoms are bradykinesia, um which means sort of slow movements. So you might get that shuffling gait, they might have micrographia. Um This arthritis is slowing of the speech as well. They have a rest tremor, which is typically referred to as pill rolling and core rigidity. Other side they might have is a masked faces, which is where the sort of expression that um hypophonia so quietening of the voice, dysarthria, micrographia, um acute posture as well. And Parkinson's is a clinical diagnosis. So you'd only really do a scan if you were unsure of the diagnosis and wanted to draw all other things out. So a lot of the time, patients, particularly with progressive supranuclear palsy might originally present as for Parkinson's. Hence why maybe this patient was died on levodopa. Um and then more symptoms might come to light as the disease progresses, that points to a different diagnosis. So in management of Parkinson's, it's um there isn't a cure. So it's mainly about um treating symptoms. So for patients who have motor symptoms, affecting their quality of life, you can start them on a dopamine agonist. Cos Parkinson's um is due to sort of a reduction of dopa ic neurones. So you want to treat that with dopamine. So you'd give levodopa, but levodopa is um broken down before it can reach the brain. So you'd give it with a decarboxylase inhibitor um to stop it being broken down peripherally. So you'd give it as something like cowl dopa or Cobey dopa. And if the motor symptoms are not affecting their quality of life, you have a bit more um medications that you can use. Um So dopamine other dopamine agonists, things like ropinirole or Ticotin, um or monoamine oxidase B inhibitors like Rosaline or Rosline. And depending on the symptoms that are affecting the patient, um more you might lean towards some of those, more than others. So, Parkinson's plus disorders. So there are four really so progressive supranuclear palsy that presents with sort of Parkinsonian features. So it falls typically backwards, that supranuclear palsy, which causes a limited upgaze and downgaze, which as I said can lead to ophthalmoparesis um in sort of severe stages and typically has a poor response to levodopa multiple system atrophy again will have parkinsonian features but more prevalent would be things like autonomic dysfunction. So, abnormal sweating, um urogenital dysfunction, they might have cerebellar ataxia as well. And on MRI you can see a hot cross bun sign in the pons. I appreciate that, which is quite small. So it's a bit difficult to see. But there is, I don't know if you can see my mass either, but there is, if you look in the middle of the brain, there is a sort of cross in the middle of that area, other Parkinson's plus disorders. So things like corticobasal degeneration, which you'd get parkinsonian features, but they have something called alien hand syndrome where their hand um basically does movements and they're not in control of them. And interestingly, it will sort of try to copy someone else's movements if they were sort of opposite them. And they also have features of apraxia and aphasia and then Lewy body dementia. They may have features of Alzheimer's Parkinson's hallucinations. So typically animals um and ram sleep disorder, which is where people tend to sort of act out their dreams. And that can be one of the first symptoms that comes on like maybe years before um sort of Parkinsonian features appear. Oh, here we go. Here's a bigger picture so you can sort of see the hot cross bun sign there in the middle. OK. Any questions about anything? I was the person? Sure. If not, I think that's, that's everything. Yeah. Thank you so much. Both you Hannah and Reer um I found that really useful personally. Um If you guys can fill in the feedback form, that's really helpful for us to continue improving. Um and for the speakers to put it in their portfolios. Thank you everyone so much for coming um and engaging really well this week. Um Any questions, pop them in the chat, we'll hang around for a few minutes. Thank you.