Neurology Topics. Ian Rosemergy

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1 Neurology Topics Ian Rosemergy

2 Plan An unusual presentation of a not so unusual problem Some seizure cases

3 49 year old female Patient 1 Hit on back and neck by swinging car door o Severe neck and shoulder pain o One week later developed left arm weakness Biceps curls, shoulder abduction Difficulty hanging out washing No sensory symptoms

4 Clinical findings No muscle wasting Weak muscles in left arm only o Biceps, brachioradialis (mild) o Infraspinatus (severe) o Shoulder abduction (severe) Reduced reflexes

5 Patient 2 Referred from respiratory OPC with elevated hemi diaphragm o Pre op CXR (Jul 12) NAD o Mild orthopnoea, repeat CXR (Oct 12) abnormal No preceding illness, no neck or shoulder pain MRI cervical spine o Nerve sheath tumour

6 Weak FPL only Clinical findings Other motor and sensory findings normal

7 Subsequent Testing Patient 1 o Widespread patchy denervation in left arm only Patient 2 o Isolated denervation in FPL

8 Brachial plexopathy Idiopathic form o Parsonage Turner syndrome o Radiculo-plexo-neuropathy Other nerves away from brachial plexus affected o Anterior interosseous n. o Musculocutaneous n. Upper trunk commonly affected o Suprascapular nerve o Axillary and long thoracic nerves

9 Provoking event o Viral infection (25%) o Immunization (15%) Comments o Remote injury, surgery, post exercise Maybe bilateral (33%) Clinical course usually self limiting o Recovery may be incomplete Treatment o Pain management (Prednisone)

10 Infiltrative Traumatic Post radiation Compressive

11 Commonly affected components

12 Scapula winging unlikely to be caused by radiculopathy

14 Useful pointers Upper plexus innervates shoulder Middle plexus innervates elbow Lower plexus innervates hand

15 Comments Patchy motor and sensory changes in an arm Shoulder pain (patchy) absent reflexes Cervical imaging often necessary Brachial plexus imaging in the setting of cancer/compression EMG after some weeks

16 An illustrative case

17 Details Maori male Mid 50 s Smoker

18 Known seizure disorder Has been seen by neurology in the past - abnormal EEG, normal CT head and MRI Previously taking epilim but says it makes him feel drowsy and stupid, so he has stopped it within the last 2-3 months Had a seizure last month Last night had 2 seizures, approx 2 hours apart No incontinence but did bite tongue Initially GCS 14, slightly confused C/O headache post seizure as well No recent unwellness Has been under a bit of stress recently as was laid off from his job due to seizures at work Says he is managing ok though

19 O/E: Initially very hypertensive but settling Otherwise vitals ok GCS 15, alert and orientated PERL, FROEM Normal peripheral strength, tone and reflexes Gait normal

20 Next Loaded with phenytoin 800mg IV Please see your GP to discuss starting a new antiseizure medication to prevent seizures

21 Issues raised 1. Acute seizure treatment 2. Discharge planning 3. AED choice

22 Issues raised Patient is not convulsing o No necessity to use IV preparation o What would you do if a GP called with that same patient? o IV phenytoin is dangerous

23 Earnest et al. Complications of Intravenous Phenytoin for Acute Treatment of Seizures JAMA. 1983;249(6): Intravenous (IV) phenytoin in ED for the treatment of convulsions in 200 patients. 72 complications developed in 51 patients. o Burning pain at the IV site (29) o Drug intoxication (36) o Cardiovascular complications (7) Both the IV and cardiovascular complications promptly resolved when the IV rate was slowed or temporarily stopped.

24 From April 8, 1982, through June 1984, 11 patients in a single hospital experienced 17 episodes of limb edema and discoloration after the intravenous (IV) administration of phenytoin sodium (Dilantin). One patient required a below-the-elbow amputation; all other patients recovered. Patients with reactions were more often female and elderly and had underlying cardiovascular disease. Affected patients received phenytoin through an IV catheter smaller than 20 gauge (50% vs 6%), at a rate greater than 25 mg/min (63% vs 19%). Arch Intern Med 1988;148:

25 Review of all seizure presentations to Auckland City Hospital (adult) ED between Jun 2009 and Dec 2009 IMJ Vol 42:(9),

26 Phenytoin Use (all seizure types) No existing AED Other AED Existing PHT use PHT in ED Discharge on PHT (iv) (oral) 12 Most patients receiving IV phenytoin are not in status epilepticus and are not discharged on that drug

27 Comments If patient is conscious and treatment is required, consider oral loading o PHT 300mg tds for 24 hours Try to predict on going treatment o Young woman o Focal seizures o Presumed idiopathic epilepsy avoid valproate lamotrigine valproate, levetiracetam Having to change drugs in 3 months has implications o Driving, swapping drugs

28 Seen yesterday 18 year old female Heavy K2 use for 6 weeks 2 x GTC seizures in 2 days No seizure history

29 Commenced phenytoin (500mg/day) for seizures (awaits neuro OP assessment) 2/7 ago developed itchy rash which has become widespread. O/E Blanching maculopapular rash affecting limbs, trunk and neck. Sparing the face. Nil breathing problems. D/W Medical registrar who has advised withdraw phenytoin and introduce valproate Valproate commenced at 300mg BD as per NZF.

30 Paroxysmal Kinesigenic Choreoathetosis Can be associated with primary generalised epilepsy but is not epilepsy Responded very well to low dose CBZ

31 Ictal Bradyarrhythmia Focal epilepsies o Majority in temporal lobe epilepsy o not seen in generalised epilepsy May have role in SUDEP

Nerve Conduction Studies and EMG

Nerve Conduction Studies and EMG Limitations of other methods of investigations of the neuromuscular system - Dr Rob Henderson, Neurologist Assessment of Weakness Thanks Peter Silburn PERIPHERAL NEUROPATHY