Acute Neurological Problems

Transcription

1 The International Convention Centre (ICC), Birmingham September 2017 Acute Neurological Problems David Nicholl Consultant Neurologist, SWBH & UHB NHS Trusts, Birmingham; Hon Sec to the

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3 Acute Neurological Problems- the scale of the problem (in 30 mins). ABN Acute Neurology report- March 2017 (#AcuteNeurology)

4 An overview of this talk If you come away with 4 things I will have succeeded Neurology is easy if you actively listen if you examine the patient if you actively consider a differential diagnosis if you are curious Neurology rapidly becomes VERY VERY hard if you do NOT do these 4 things!

5 Urgent neurology assessment is low tech!

6 1. Actively listen..

7 49y old man who had a fit in Rackham s OE No neurology deficit Compound skull# with contracoup injury in R frontal region Which came first?

8 Assessing a blackout Making a clinical diagnosis is the key step to determining investigations/ management/ treatment. Mis-diagnosis is common. Mis-diagnosing a seizure/ cardiac syncope may have consequences Diagnosing a seizure, when a faint occurred has consequences- Inappropriate drug treatment, removal of driving privileges- 10 year for HGV, loss of employment etc.

9 The differential diagnosis of a blackout - a sudden collapse Faint (vasovagal syncope) very common Seizure Cardiac syncope Cataplexy Hypoglycaemic attacks. (very rare)

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11 First suspected seizurecauses Seizure Syncope Psychogenic ABC DEFG

12 What is a faint? (vasovagal syncope) COMMONLY misdiagnosed as seizure Syncope refers to a sudden impairment of consciousness with loss of tone Caused by reduced blood/oxygen to the brain There is often a provoking factor- blood, pain, dehydration etc. Presyncopal symptoms include light-headedness, warm, dizzy builds in intensity, then maybe loss of vision, hearing before LOC. Usually come round where they fell- not in an ambulance Stiffening and jerking is common Urinary and faecal incontinence may occur.

13 Video Differential diagnosis syncope- self induced fainting in German medical students Remember- these patients were expecting to faint in real situations stress, failure to fall flat may cause more prolonged LOC with more florid motor activity. U-tube- search for faints lots to see

14 Was it a seizure? Unhelpful features- these are often mistakenly thought to indicate seizure but occur frequently in syncope Brief twitching and jerking Incontinence (reflects a full bladder at the time of the event). Pallor Bitten tongue tip Post event fatigue Helpful features- these indicate a likely seizure. Post event confusion of longer than 2 minutes Deeply bitten lateral border of the tongue Prolonged tonic then clonic movement lasting greater than 1 minute Deep cyanosis Further Reading Lempert T. Recognising syncope: pitfalls and surprises. Journal of the royal society of medicine 1996;89: NICE Guidelines. The diagnosis and management of the epilepsies in adults and children in primary and secondary car. Appendix A-The differential diagnosis of epilepsy and appendix E- Key clinical questions.

15 2. Examine the patient

16 2. Examine the patient Google Brief Neuro >300,000 views since shown at SAMBelfast if you don t know what is happening by the time you get to the feet you are in real trouble -Jerome Posner in Nicholl & Appleton (2014)

17 Headaches Headache is a common presenting complaint in ED, ~2% of all visits. Subarachnoid haemorrhage accounts for only 1-3% of these headaches Its (nearly) ALL in the history! Don t forget fundi + blood pressure! Jeffrey J Perry et al. BMJ 2010;341:bmj.c5204

18 Fig 2 Example of recursive partitioning analysis with rule 1: age 40, complaint of neck pain or stiffness, witnessed loss of consciousness, onset of pain during exertion. CT head CSF exam (+ spectrophotometry) Jeffrey J Perry et al. BMJ 2010;341:bmj.c by British Medical Journal Publishing Group

19 Thunderclap headache (BMJ 2012;345:e8557) -instant (<1min max) 43/100,000/yr CT + CSF negative: RETAKE THE HISTORY! CSF hypotension Venous sinus thrombosis Carotid dissection Reversible cerebral vasoconstriction syndrome Lancet Neurol 2012;11:906-17

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21 3. Actively consider a differential diagnosis

22 Don t assume the experts are correct- do it yourself 47y old referred from Eye Hospital with headaches & bilateral papilloedema & bp 210/120 CT/CTV normal

23 . How similar is this to the Honey Rose case? 41y died October 2014 Admitted to A&E 4am with headaches & vomiting. Working diagnosis- gastroenteritis & dehydration. Consultant review-scan not required. Surgical ward- reviewed by Cons Physician next day. (noon) Scan not required, psych review. Reviewed by Cons Physician (14:30), extensor plantar noted, urgent CT Worsened++ 17:00. CT head under anaesthetic.- acute hydrocephalus from colloid cyst

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28 Mollan, Spitzer & Nicholl (submitted)

29 2 Examine the patient- 32y old woman w/ 4/7 Hx of flu like symptoms. Mild headache, myalgia, pins and needles R arm, mouth & thighs. normal neurology examination ALT mildly raised. Presumed viral infection.

30 Day 3..readmitted 10/52 post-partum Generalised pins & needles, weakness all 4 limbs, unable to walk. OE flaccid quadriparesis. Diagnosed Guillain Barre syndrome (CMV) Day 4- intubated ITU for 6/52 Discharged 3/12 later; Independently mobile at 1 year

31 Lessons from this case neurology normal.did anyone see the patient walk?..the differential diagnosis?..how curious were the Team?

32 43y taxi driver C6/C7 disc prolapse with localised myelomalacia Whiplash injury 3/12 before Discharged from A&E OE Obese++ Mobility not so good Midthoracic low back pain + numbness L hand Cranials & upperlimbs normal Lower limbs-?increase in tone, L BJ difficult to elicit, both KJ brisk. Plantars withdrawal. Gait antalgic

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34 3. Actively consider a differential diagnosis 64y old man Lethargic & confused; Took 2 extra Metformin in error PMH bp, type 2 diabetes 4/4 orientated in time & place Headache GCS 15/15 Lactate 6.7 mmol/l ; 6.0 then 3.9 ABG- normal (ph 7.42; pco2 5.59; po2 11.4) Lactic acidosis secondary to metformin Day 2- swallowing difficulty?urti Day 3- Examined by FY1; Nystagmus in all directions

35 Bilateral cerebellar infarctions

36 3. Actively consider a differential diagnosis 61y Jehovah s witness Poorly compliant with antibp Rx Admitted with acute vertigo & nausea Unilateral nystagmus No skew Catch-up saccade on HIT Vestibular neuronitis NOT stroke

37 4. Be curious 21y 2/7 Hx of amnesia & confusion, admitted with a seizure MH of MDMA/cannabis use but when? OE, Restless, orientated in person/place but not time DIAGNOSIS-?drug induced seizures MRI/CSF normal, EEG mild slow activity, Rx Levericetam Transferred Day 5 to Psych ward Day 6- dysphasic, perseverating

38 References: 1. Nicholl DJ, Appleton JP. Clinical neurology: why this still matters in the 21st century. J Neurol Neurosurg Psychiatry 2014;0: Nicholl DJ. Are the skills of neurological assessment in need of resuscitation? Acute Med 2014;13(4): ) 3. Google Brief Neuro

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