ACUTE NEUROLOGY A-Z

1. ACUTE NEUROLOGYA-Z Charles Hillier Poole Hospital Thank you. As you can see that when I gave this title, I had no idea what I was going to talk about. I have decided to take you on a virtual post take ward round, where, by chance all the patients have a neurological disease!Thank you. As you can see that when I gave this title, I had no idea what I was going to talk about. I have decided to take you on a virtual post take ward round, where, by chance all the patients have a neurological disease!

2. A is for........ MR A had a single seizure investigated by neurology services 3 months ago. Admitted on your take with a further generalised seizure � witnessed, tongue biting, post ictal amnesic. You want to start a drug....which one?MR A had a single seizure investigated by neurology services 3 months ago. Admitted on your take with a further generalised seizure � witnessed, tongue biting, post ictal amnesic. You want to start a drug....which one?

3. Available anticonvulsants Acetazolamide (1952) Benzodiazepines (1950�s) Carbamazepine (1964) Ethosuximide (1958) Felbamate (USA � 1980�s) Gabapentin (1990�s) Lacosamide (2008) Lamotrigine (1990�s) Levetiracetam (2000) Oxcarbazepine (1980�s; UK 2000) Phenobarbital (1912) Phenytoin (1952) Piracetam (1967; myoclonus 1978) Rufinamide (2008) Stiripentol (2007) Tiagabine (1990�s) Topiramate (1990�s) Valproate (late 1960�s) Vigabatrin (1990�s) Zonisamide (Japan 1970�s) You have a choice, to much of a choice.You have a choice, to much of a choice.

4. Bells treatment 50mg per day for 10 days A randomised controlled trial of the use of aciclovir and / or prednisolone for the early treatment of Bells palsy: the BELLS study Health Tecnol assess. 2009 13 1-130 (n = 496) BMJ research paper of the year. 4 arms, steroids alone, steroids and acyclovir, acyclovir alone or placebo. 9/12 recovery 96%, 92%, 85% and 78% respectively. PUBLISHED NEJM 0ct 2007BMJ research paper of the year. 4 arms, steroids alone, steroids and acyclovir, acyclovir alone or placebo. 9/12 recovery 96%, 92%, 85% and 78% respectively. PUBLISHED NEJM 0ct 2007

5. C ........is for out of hospital cardiac arrest What is the percentage of �good� outcome A 0% B 6% C 15% D 25% Off to ITU, Mr C 55 YEAR OLD MAN COLLAPSES OUT JOGGING. A BYSTANDER FINDS HIM UNCONSCIOUS and WITHOUT PULSE. CPR commenced. 24 HOURS LATER YOU ARE ASKED ABOUT PROGNOSIS (THEY NEED THE BED) WHAT CLINICAL AND LAB POINTERS HELP INFORM YOU? Off to ITU, Mr C 55 YEAR OLD MAN COLLAPSES OUT JOGGING. A BYSTANDER FINDS HIM UNCONSCIOUS and WITHOUT PULSE. CPR commenced. 24 HOURS LATER YOU ARE ASKED ABOUT PROGNOSIS (THEY NEED THE BED) WHAT CLINICAL AND LAB POINTERS HELP INFORM YOU?

6. Prognosis in anoxic ischaemic brain injury (brain stem death) Myoclonic status epilepticus at anytime Absent corneal or pupil responses 3/ 7 Absent motor responses at 3 / 7 Absent SSEP cortical responses Increased serum neuron specific enolase at any time (all other predictors have FPR) Outcome of coma is determined by underlying cause. In the current situation we are at outcome after anoxic-ischaemic brain injury (Confounders removed) Wijdicks and colleagues reviewed the literature from 1966 � 2006 and found five prognostic indicators for poor outcome. Poor outcome defined as no better than nursing home dependence at 6 months. Myoclonic status epilepiticus at any time MSE defined as spontaneous, repetitive, unrelenting, generalised multifocal myoclonus involving the face, limbs and axial musculature on comatose patients Absent corneal or pupil reflexes at 3 days Absent motor response at 3 days Absent sensory evoked potential cortical responses Increased serum specific enolase at any time.Outcome of coma is determined by underlying cause. In the current situation we are at outcome after anoxic-ischaemic brain injury (Confounders removed) Wijdicks and colleagues reviewed the literature from 1966 � 2006 and found five prognostic indicators for poor outcome. Poor outcome defined as no better than nursing home dependence at 6 months. Myoclonic status epilepiticus at any time MSE defined as spontaneous, repetitive, unrelenting, generalised multifocal myoclonus involving the face, limbs and axial musculature on comatose patients Absent corneal or pupil reflexes at 3 days Absent motor response at 3 days Absent sensory evoked potential cortical responses Increased serum specific enolase at any time.

7. D is for................... Miss D, presents with left sided neck and peri orbital pain. She has this clinical finding.Miss D, presents with left sided neck and peri orbital pain. She has this clinical finding.

8. Q: How would you treat cervical artery dissection? A aspirin B anticoagulation C stenting D thrombolysis CADISS cervical artery dissection in stroke study, UK SGH and RBH centres only 80 recruited so far. Jury out. I give aspirin and do not re-scan!CADISS cervical artery dissection in stroke study, UK SGH and RBH centres only 80 recruited so far. Jury out. I give aspirin and do not re-scan!

9. E is for....... Encephalitis: once you have considered the diagnosis then cranial imaging, preferably MRI, CSF examination for cells, protein, glucose cells, matched serum and CSF glucose, PCR for HSV, then acyclovir at appropriate IV dose. Then you have room to think. Remember Autoimmune encephalitis ie NMDA raise awarenessEncephalitis: once you have considered the diagnosis then cranial imaging, preferably MRI, CSF examination for cells, protein, glucose cells, matched serum and CSF glucose, PCR for HSV, then acyclovir at appropriate IV dose. Then you have room to think. Remember Autoimmune encephalitis ie NMDA raise awareness

11. F is for faint Q: what percentage of people who faint have myoclonus? A 0% B 20% C 60% D 90%

12. syncope: a videometric analysis healthy German medical students n = 56 (42) induced transient cerebral hypoxia video of outcome myoclonic activity observed in 90% Lempert et al Ann Neurol 1994 ;36: 233-7

13. conclusions �we observed syncopal myoclonus in 90% suggesting that it represents the rule rather than the exception in the brain�s response to hypoxia� incontinence occurs if bladder full recovery may be prolonged in the elderly

14. G is GBS�.. Can present with back pain often severe If asymmetric think again Cardiac monitoring whilst deteriorating Thromboembolic prevention IVIg if off legs in first 2 weeks Let ITU know even if you�re not that worried Loss of reflexes, no real need for early CSF or nerve conduction studies as normal early on. Start IVIg 0.4 grams per KiloLoss of reflexes, no real need for early CSF or nerve conduction studies as normal early on. Start IVIg 0.4 grams per Kilo

15. H is for Headache�.. Headaches that catch physicians out. How many can you spot?Headaches that catch physicians out. How many can you spot?

17. J is�.. J is for joint position sense, beware the deaffrented hand, may look functional. J is for joint position sense, beware the deaffrented hand, may look functional.

19. L is for�.. L is for Lisa. Out in August, few drinks, fall, few bruises, 72 hours later severe postural head and neck pain, with in a week diplopia. Examination on the round bilateral VIth nerve palsies. Low pressure syndrome:L is for Lisa. Out in August, few drinks, fall, few bruises, 72 hours later severe postural head and neck pain, with in a week diplopia. Examination on the round bilateral VIth nerve palsies. Low pressure syndrome:

20. M is for meningitis Q: when would you add dexamethasone A viral B pneumococcal C meningococcal D septic shock www.meningitis.org It is my view and the view of our microbiologists' here that we should give 10mg dexamethasone with or before the first dose of antibiotics. GANS + co, took 300 patients RCCT. Bottom line reduced poor outcome from 25% to 15%. Cochrane review 2008 agreed. It is my view and the view of our microbiologists' here that we should give 10mg dexamethasone with or before the first dose of antibiotics. GANS + co, took 300 patients RCCT. Bottom line reduced poor outcome from 25% to 15%. Cochrane review 2008 agreed.

21. N is for..... www.neurosymptoms.org ? Good video of NEAD use of EEG in this situation? Good video of NEAD use of EEG in this situation

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23. P is for�� PRES: post renal transplant 6 weeks, admitted c/o visual axial FLAIR vasogenic oedemaPRES: post renal transplant 6 weeks, admitted c/o visual axial FLAIR vasogenic oedema

24. R is for..... Remember acute angle glaucoma can rarely be bilateral � needs eye opinion same dayRemember acute angle glaucoma can rarely be bilateral � needs eye opinion same day

26. U is for uveitis..... Quick spot: bottle of wine What unifies ulcers, uveitis and cerebral venous thrombosis (CVT)? BehcetsQuick spot: bottle of wine What unifies ulcers, uveitis and cerebral venous thrombosis (CVT)? Behcets

27. dVla First unprovoked epileptic seizure = 6/12 LOC / awareness no clinical pointers = 6/12 Google �dvla at a glance� More than one seizure in 24 hours regarded by dvla regarded as one eventMore than one seizure in 24 hours regarded by dvla regarded as one event

28. WIJDICKS and colleagues reviewed the literature 1966 to 2006 and put together an algorithm. Published neurology 2006. Time is the ultimate diagnostic tool BUT IF your dead your dead. Here �poor outcome � means full nursing care at best. DAY 1 Myoclonus status epilepticus defined as spontaneous, repetitive, unrelenting, generalised multifocal myoclonus involving the face, limbs and axial musculature on comatose patients DAY 1-3 SSEPs + NSE (neuron specific enolase) DAY 3...... All other predictors have False Positive Rates and cannot be relied upon. One comment: age >70 do not do well in rehabWIJDICKS and colleagues reviewed the literature 1966 to 2006 and put together an algorithm. Published neurology 2006. Time is the ultimate diagnostic tool BUT IF your dead your dead. Here �poor outcome � means full nursing care at best. DAY 1 Myoclonus status epilepticus defined as spontaneous, repetitive, unrelenting, generalised multifocal myoclonus involving the face, limbs and axial musculature on comatose patients DAY 1-3 SSEPs + NSE (neuron specific enolase) DAY 3...... All other predictors have False Positive Rates and cannot be relied upon. One comment: age >70 do not do well in rehab