Vague Neurological Conditions

Transcription

1 Vague Neurological Conditions Dr. John Lefebre, MD, FRCPC Chief Regional Medical Director Europe, India, South Africa, Middle East and Turkey

2 Canada

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5 Agenda Dr. John Lefebre, M.D., FRCPC 1. TIA s 2. Complicated migraine 3. Multiple Sclerosis 4. Incidental Findings on MRI

6 Understand the different symptoms of: Transient Ischemic Attacks i.e. TIAs Migraine Headaches Multiple Sclerosis Learning Objectives New TIA definition will lead to an increase in the number of strokes being diagnosed The occurrence of a TIA, often indicates the presence of significant vascular disease Migraine headache with aura is a recurrent, young persons disease 6

7 Silent strokes predict an increased risk, for the rapid development morbidity and mortality White matter lesions may predict an increased risk of stroke, mild cognitive impairment, dementia and death Radiographic WML and the following, significantly increase a persons morbidity and mortality Hypertension Lacunar strokes CVAs Learning Objectives cont. Atrophy of the temporal lobe/corpus callosum 7

8 How many years have you worked in insurance? 1. < 1 year years years years 5. > 15 years 0% 0% 0% 0% 0%

9 Dr. John Lefebre, M.D., FRCPC #1 TIA s

10 Dr. John Lefebre, M.D., FRCPC Definition of TIA

11 Previous Time Based TIA Definition Sudden focal Last less then 24 hrs Vascular origin New Tissue Based TIA Definition Neurologic dysfunction Focal brain or retinal ischemia No evidence of infarction 11

12 Potential Impact of New TIA Definition 30% - 50% of TIA s will have a related brain infarct Tissue vs. Time based definition: Reduce annual incidence of TIA by 28% Increase annual incidence of stroke by 8.1% Furie, Karen L et al. UpToDate. Feb 2012 Mullen, Michael T et al. Stroke. 2011;42: Ovbiagele B et al, Stroke Apr; 34(4):

13 Were Those Symptoms a TIA? Dr. John Lefebre, M.D., FRCPC

14 The occurrence of a TIA predicts/increases a persons future risk of? 1. Myocardial infarction 2. Stroke 3. Another TIA 4. All of the above 5. None of the above 0% 0% 0% 0% 0%

15 The occurrence of a TIA predicts/increases a persons future risk of? 1. Myocardial infarction:1.2% 2. Stroke: 1% within 90 days, but imaging positive is 14% 3. Another TIA: 8.1% 4. All of the above 5. None of the above Lancet 2005; 366: Abort M et al. Cerebrovascular Diseases. 2011;32:62 15

16 Risk Factors for TIA/Stroke Vascular risk factors >60 yrs. of age BP >140/90 * Atrial fibrillation Family history Smoker Diabetes Younger Ages yrs: 15/100,000/yr. =.00015/yr. <35 yrs: <10/100,000/yr. = <.00010/yr. 16

17 1. Progresses slowly in severity over time 2. Develop slowly over seconds to minutes 3. Are maximal at onset 4. 2 and 3 above The symptoms of a TIA? 0% 0% 0% 0%

18 1. Progresses slowly in severity over time 2. Develop slowly over seconds to minutes 3. Are maximal at onset 4. 2 and 3 above The symptoms of a TIA? 18

19 Sudden Onset of Vascular Events Sudden Without warning Maximal at onset Body parts affected simultaneously 19

20 What symptoms are not associated with a TIA? 1. Headache 2. Syncope 3. Memory loss 4. 1, 2 and 3 above 5. None of the above 0% 0% 0% 0% 0%

21 What symptoms are not associated with a TIA? 1. Headache: No mechanism 2. Syncope: Cardiac 3. Memory loss: No mechanism 4. 1, 2 and 3 above 5. None of the above 21

22 What symptoms are associated with a TIA? 1. Blurred vision 2. Focal symptoms 3. Sudden onset 4. 2 and 3 above 5. None of the above 0% 0% 0% 0% 0%

23 What symptoms are associated with a TIA? 1. Blurred vision: Loss or diplopia 2. Focal symptoms 3. Sudden onset 4. 2 and 3 above 5. None of the above 23

24 Symptoms/Factors Not Associated with TIA Recurrent stereotyped episodes No vascular risk factors Lack of single artery symptoms: Generalized symptoms Gradual or hazy onset Weak" and Dizzies negative workup Not Focal 24

25 An example of a focal neurological symptom would be? 1. Unilateral weakness 2. Speech impairment 3. Numbness of a specific limb 4. All of the above 5. None of the above 0% 0% 0% 0% 0%

26 An example of a focal neurological symptom would be? 1. Unilateral weakness 2. Speech impairment 3. Numbness of a specific limb 4. All of the above 5. None of the above 26

27 I would be concerned about a vascular event i.e. stroke or TIA if the event lasted? minutes minutes 3. < 10 minutes 4. 1 and 2 5. None of the above 0% 0% 0% 0% 0%

28 I would be concerned about a vascular event i.e. stroke or TIA if the event lasted? minutes minutes 3. < 10 minutes: Not significant 4. 1 and 2 5. None of the above 28

29 Would isolated vertigo with no other neurological symptoms usually be caused by a TIA? 1. Yes 2. Not usually 3. Not sure 0% 0% 0%

30 Would isolated vertigo with no other neurological symptoms usually be caused by a TIA? 1. Yes 2. No: Very small 3. Not sure 30

31 Symptoms and TIA s Sudden onset Weakness face/arm/leg Slurred speech Able to walk Dizziness Seizure LOC Confusion Stroke 2006; 37: Lancet 2005; 4: MIMIC OR TIA/STROKE 31

32 Questions? 32

33 Complicated Migraine vs. TIA Dr. John Lefebre, M.D., FRCPC

34 Migraine Headache ± Aura Headache 4-72 hours Unilateral and throbbing 75%: Headache and no Aura 38%: Aura without headache and aura with headache 4%: Aura and no headache Aura 25% Visual disturbances Sensory or Verbal Motor Spread and intensify 5-20 min Gradually fade < 60 min 34

35 The incidence of migraine headache, with a aura, in a person over the age of 60 is? 1. 5% 2. 10% 3. 15% 4. 20% 0% 0% 0% 0%

36 Incidence of Migraine

37 Key Points Re. Migraine Headaches Recurrent Young persons Complicated migraine if > 60 yrs. of age Not Likely 37

38 Questions? 38

39 2. Is a Multiple Sclerosis Exclusion Required? Dr. John Lefebre, M.D., FRCPC

40 Multiple Sclerosis Is a white matter disease Disseminated in time: Two separate attacks separated by some amount of time Disseminated in space: Two separate places in the nervous system Differential Diagnosis of Multiple Sclerosis Examples: Balo concentric sclerosis Schilder disease Marburg disease ect 40

41 Which disease is most commonly confused with MS? 1. Psychiatric disease 2. Migraine headaches 3. Benign/normal sensory symptoms 4. Stroke/TIA 5. Peripheral neuropathy 6. Vertigo 7. Cervical stenosis =with Time?? 0% 0% 0% 0% 0% 0% 0%

42 Which disease is most commonly confused with MS? 1. Psychiatric disease: 27-76% 2. Migraine headaches: =with 3-21% Time?? 3. Benign/normal sensory symptoms: 11-22% 4. Stroke/TIA: 3-6% 5. Peripheral neuropathy: 1-6% 6. Vertigo: 6% 7. Cervical stenosis: 1-3% 42

43 Psychiatric conditions that can mimic MS Somatization Hypochondriasis Malingering Depression Anxiety 43

44 Classic MS Symptoms Clear anatomical locations Ex. Optic nerve and spinal cord Finite time course Occur abruptly Evolve over minutes to days Resolve 44

45 Is weakness all over a symptom of MS? 1. Yes 2. No 3. Maybe 4. Don t know =with Time?? 0% 0% 0% 0%

46 Symptoms That Are Not MS Diffuse and difficult to explain Tingling both hands and feet Numbness over the entire face Feeling weak all over Benign sensory symptoms Brief i.e. last seconds to minutes Psychiatric symptoms Multiple symptoms Come and go or never go 46

47 The average person with MS has 1 distinct neurological episode every months and then is free of symptoms till their next relapse? 1. True 2. False 3. Don t know =with Time?? 0% 0% 0%

48 The average person with MS has 1 distinct neurological episode every months and then is free of symptoms till their next relapse? 1. True: Remitting and relapsing 2. False =with Time?? 3. Don t know 48

49 Questions 49

50 3. Incidental Findings on MRI Dr. John Lefebre, M.D., FRCPC

51 You may not be as Normal as you thought! Mean age 63.3 years old 7.2% brain infarct 1.6% benign tumors 1.8% cerebral aneurysm Vernooij MW et al, N Engl J Med Nov 1;357(18):

52 Silent strokes in general are much more common than symptomatic strokes? 1. False 2. True 3. Don t know 0% 0% 0%

53 Silent strokes in general are much more common than a symptomatic stroke? 1. False 2. True: 5 times greater, women with high blood pressure 3. Don t know 53

54 Silent vs. Symptomatic Strokes Vermeer SE et al, Stroke Jan;33(1):

55 Natural History of Silent Strokes Rotterdam Study > 1000 elderly, yrs Baseline infarcts: 5x stroke 3x stroke with risk control Steeper cognitive decline 2x dementia Vermeer et al, NEJM,

56 In the previous study how long do you think it took to see the increased risk of recurrent stroke, cognitive decline and the development of dementia? 1. 4 years 2. 8 years years 4. Don t know 0% 0% 0% 0%

57 Questions 57

58 Do You Know

59 Radiographic White Matter Lesions Leukoaraiosis on MRI 59

60 Questions 60

61 Understand the different symptoms of: Transient Ischemic Attacks i.e. TIA Migraine Headache Multiple Sclerosis Learning Objectives New TIA definition will lead to an increase in the number of strokes being diagnosed The occurrence of a TIA, often indicates the presence of significant vascular disease Migraine headache with aura is a recurrent, young persons disease 61

62 Silent strokes predict an increased risk, for the rapid development morbidity and mortality White matter lesions may predict an increased risk of stroke, mild cognitive impairment, dementia and death Radiographic WML and the following, significantly increase a persons morbidity and mortality Hypertension Lacunar strokes CVAs Learning Objectives cont. Atrophy of the temporal lobe/corpus callosum 62

63 Thank you for your attention. 63

64 References/Additional Slides 64

65 MRI vs. CT for Acute Ischemic Stroke 65

66 False Negative Rate of MRI Ischemic stroke is 17% Brain stem location Few hard neurological signs Lancet 2007 January 2007 (369)(9558):

67 Fazekas Scale for WML 67

68 The clinical importance of white matter lesions on brain magnetic resonance imaging 46 prospective studies from Male and yrs High risk and general population Data on white matter lesions: Stroke Dementia Death 68

69 WML and Stroke Risk Debette S et al BMJ 2010:341:bmjc

70 WML and Risk of Incident Dementia 70 Debette S et al BMJ 2010:341:bmjc3666

71 WML and Mortality Risk 71 Debette S et al BMJ 2010:341:bmjc3666