Neurological Dilemmas in Primary Care

Transcription

1 Neurological Dilemmas in Primary Care David Clark, DO When to test? How to test? Pitfalls in testing? When to treat? How to treat? How long to treat?

2 Neurological Dilemmas Seizure When to treat When to consider discontinuing treatment Clinical features suggestive of psychogenic nonepileptic seizures Headache When to image? Secondary headaches with normal imaging Primary Headache treatments Medication Overuse Headaches

3 21M College Student 4 year history of recurrent déjà vu 2 months ago, lost consciousness. Awoke on the floor an undetermined time later. Did not seek medical attention This AM, sitting in class, felt profound déjà vu followed by loss of consciousness Onlookers describe a fall and generalized shaking movement lasting 60 seconds Followed by confusion lasting minutes What do you want to do?

4 Seizure When to treat When to consider discontinuing treatment Clinical features suggestive of psychogenic nonepileptic seizures

5 Seizure-when to treat 2 unprovoked seizures 1 seizure with high risk of recurrence No seizure with high risk of having one

6 Those with 1 seizure who are at high risk for recurrence

7 Those with 0 seizures who are at high risk for seizure

8 When to stop the seizure medication Lower risk of seizure recurrence Idiopathic etiology Normal mentation Normal neurologic exam Seizure free interval >2 years Normalized EEG at 2 years Higher risk of seizure recurrence Symptomatic etiology Abnormal neurologic exam JME EEG abnormalities

9 Psychogenic Nonepileptic Seizures Features suggestive of nonepileptic seizures Resistance to antiepileptic medications Stress as a trigger More likely to occur with an audience Side-to-side shaking Bilateral asynchronous movements Weeping or stuttering Arching the back No post ictal confusion

10 Seizure When to treat When to consider discontinuing treatment Clinical features suggestive of psychogenic nonepileptic seizures

11 Headache When to image? Secondary headaches with normal imaging Migraine Headache Treatment When is abortive treatment okay When is preventative treatment considered Medication Overuse Headaches Prevention Treatment

12 When to image a headache Postgrad Med May;101(5):46-50, 55-6, 62-4.

13 Brain parenchymal imaging CT Pros Quick and accessible Good for blood and bone Cons Radiation Lower parenchymal resolution MRI Pros Better parenchymal resolution No radiation Cons Claustrophobia Table weight limit Access may be limited in some communities

14 Angiography/Venography MRA/MRV CTA/CTV Catheter angiography/venography

15 68F headache began three months ago, gradually worsening

16 68F headache began three months ago, gradually worsening

17 23M thunderclap headache following a basketball game

18 23M thunderclap headache following a basketball game

19 69M abrupt headache, diplopia and then left eye vision loss

20 69M abrupt headache, diplopia and then left eye vision loss

21 Headache with normal imaging?

22 38F neck/head pain for 10 days, then recurrent ataxia 44M with 7 days of neck pain, then recurrent transient speech difficulty

23 38F neck/head pain for 10 days, then recurrent ataxia 44M with 7 days of neck pain, then recurrent transient speech difficulty

24 Double Lumen Cervical Artery Dissection

25 Cervical Artery Dissection Carotid Artery Pain, neck or face Horners Syndrome Ischemia Retinal Hemispheric Hemisensory Hemiparesis Vertebral Artery Pain, neck or head Ischemia Ataxia Diplopia Hemisensory Hiccups Horners

26 21M with recurrent thunderclap headaches Using marijuana, triptan Initial MRI normal

27 21M with recurrent thunderclap headaches Using marijuana, triptan Reversible Cerebral Vasoconstriction Syndrome HA (thunderclap) Nausea/vomiting Confusion Blur Risk for SAH and focal ischemia DDx vasculitis

28 33F two weeks post partum Severe holocephalic headache Left facial numbness Normal MRI brain

29 Cerebral Venous Sinus Thrombosis F>M Peripartum Hormonal contraceptives Tobacco Smoker Hypercoagulable

30 68F Headaches 4 weeks of: Jaw claudication Scalp tenderness Fever Myalgias Weight Loss Night sweats Labs ESR 97 (Normal <30) CRP 12 (Normal <0.5) Platelets 550,000

31 68F Headaches Temporal Arteritis (Giant Cell Arteritis)

32 32F three months of daily headaches BMI 39 Transient visual obscurations Pulse Synchronous Tinnitus Postural Headache, worse supine Photopsia

33 Idiopathic Intracranial Hypertension Pseudotumor Cerebri

34 MRI negative secondary headaches Consider angiography or venography Consider fundus evaluation Consider checking inflammatory markers (ESR, CRP)

35 Migraine-Preventative strategies Lifestyle Trigger avoidance Foods Bright light Strong odors Regular exercise Stress management Sleep quality Hydration

36 Migraine As needed Abortive Therapy 2 days/week Triptans Sumatriptan, Rizatriptan, etc NSAIDs Anti-emetics No more than 2-3 days/week Daily Preventative Therapy When headaches are 2 days/week Antiepileptics (topiramate) Antidepressants (amitriptyline) β blockers (propranolol) CCB (verapamil) OTC (magnesium, Vitamin B2) Abortive Therapy Preventative Therapy Two headache days/week

37 Medication Overuse Headache HA 15 days/month Regular medication overuse for 3 months HA developed or markedly worsened during medication overuse Overuse 3 days/week for at least 3 months

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39 Summary Seizure When to treat When to consider discontinuing treatment Clinical features suggestive of psychogenic nonepileptic seizures Headache When to image? Secondary headaches with normal imaging Primary Headache treatments Medication Overuse Headaches