Neurology on the MAU Geraint Fuller
Conflicts of Interest Clinical neurologist No drug company links Past President of Association of British Neurologists Co-Editor of Practical Neurology Receive Royalties from Neurological examination made easy 5 th ed Neurology a colour illustrated text 3 rd ed Neurology and Neurosurgery illustrated 5 th ed
Common Neurological Emergencies Headache Weakness Blackouts Coma Confusion Dizziness Double vision Incoordination Stroke Epilepsy Subarachnoid Meningitis Encephalitis Myaesthenia Guillain-Barre Cord compression
Ms SA 34 year old woman normally fit and well Developed sudden and severe headache at work 1 hour before Vomited On citalopram 40mg/day; microgynon 155/90 In pain Normal neurological examination
Thunderclap Headache BMJ 2012;345:e8557 Instantaneous onset - 1 minute at most 43/100,000/year Single or recurrent Spontaneous or triggered
Thunderclap Headache BMJ 2012;345:e8557 Subarachnoid haemorrhage 11-25% CT Brain If CT negative LP (with spectrophotometry)
#asah
Quality of Care in Secondary Care Figure 3.6 8
Lumbar Puncture 5.4% Unable to perform LP 25% Unable to perform LP 24/7 75% had no guidance as to who should perform LP 9
Delayed or Overlooked Diagnosis (Advisors Form) Primary Care 17.6% of patients saw GP Delayed or overlooked in 32/75 Outcome affected in 23/32 Secondary Care Delay or overlooked in 12% Outcome affected in 10/49 Table 3.18 10
Quality of Care in Secondary Care Table 3.43 18% had NO neurological examination documented 11
Subarachnoid Haemorrhage Common problem Protocols Document examination Sort out LP Do simple things well
Thunderclap Headache BMJ 2012;345:e8557 Subarachnoid haemorrhage. CT Brain Other structural causes hydrocephalus; tumours If CT negative => LP (with spectrophotometry) meningitis If CT and CSF negative what then? Not SAH is NOT a diagnosis
Retake the history Really thunderclap? Prior history of headache? Thunderclap Headache Negative CT and CSF Previous investigations? Reexamine Horner s
Ms SA 34 year old woman normally fit and well Developed sudden and severe headache at work 1 hour before Vomited On citalopram 40mg/day; microgynon 155/90 In pain Normal neurological examination CT Brain normal CSF normal
You see what you are looking for
Thunderclap Headache Negative CT and CSF Cerebral venous sinus thrombosis Cervical artery dissection Spontaneous intracranial hypotension
Cerebral venous sinus thrombosis Up to 16% present with thunderclap headache CSF pressure may be elevated Post-partum Risk factors for thrombosis dehydration; COC; UC Alternative presentation Progressive headache with papilloedema Focal cortical deficits Seizures D-dimer negative in 25% with isolated headache Stroke. 2005;36:1716-1719 CT brain Treatment with anticoagulation
Hyperattenuation sign Sensitivity 65-95% Specificity 95% http://www.ajnr.org/ content/34/8/1568
Spontaneous Intracranial Hypotension Spontaneous leak of CSF similar to pneumothorax Develops into postural headache 15% have prominent onset CSF finds (if successful) low pressure, sometimes raised protein MRI venous engorgement (meningeal enhancement) Rx Blood patch
Ms SA 34 year old woman normally fit and well Developed sudden and severe headache at work 1 hour before Vomited On citalopram 40mg/day; microgynon 155/90 In pain Normal neurological examination CT brain normal CSF normal Called to see her Further severe headache when went to the toilet Screaming in pain BP surged to 160/110
Reversible Cerebral Vasoconstriction Syndrome Lancet Neurol 2012;11:906-17 Thunderclap headache Severe and recurrent Often triggered Sex; Valsalva Precipitants Vasoactive drugs Cannabis, cocaine, SSRIs, SRNIs, ephedrine, others ++ Post-partum
Reversible Cerebral Vasoconstriction Syndrome Lancet Neurol 2012;11:906-17 Surges of BP with pain in 30% Transient focal neurological deficits 10% Small convexity subarachnoid haemorrhage 10% Resolves after 4 weeks
What is reversible cerebral vasoconstriction syndrome? A clinical and radiological diagnosis: Diagnostic criteria for RCVS Acute/severe headache(s) Uniphasic course; no new symptoms >1/12 after onset Cerebral arterial vasoconstriction on angiography No evidence of aneurysmal SAH Normal/nearly normal CSF (prot <1g/L, WCC <15) Complete/substantial normalisation of arteries on angiography at 12/52 International Headache Society 2004 and Calabrese et al 2007
CT angiogram
CT angiogram
Follow up MRI angiogram
String and Beads Chen et al, 2010
RCVS Management Avoid triggers Stop precipitants (citalopram) Treat BP Analgesia Nimodipine, verapamil or Mg suggested Low risk of recurrence
Thunderclap Headache Think subarachnoid haemorrhage Remember not SAH is not a diagnosis Revisit the history Think about scan and CSF negative conditions Cerebral venous thrombosis Reversible cerebral vasoconstriction syndrome Cervical artery dissection Low CSF pressure headache
Mr AV 50 year old man with hypertension Developed vertigo with nausea and vomiting 10 hours earlier No hearing problem, pain or other symptoms Horizontal nystagmus to the left Very unsteady on walking
Differential Diagnosis Acute peripheral vestibular syndrome vestibular neuritis Acute central vestibular syndrome Cerebellar stroke Other brain stem strokes PICA AICA
Differential Diagnosis Acute peripheral vestibular syndrome vestibular neuritis Acute central vestibular syndrome Cerebellar stroke Other brain stem strokes PICA AICA
Does my dizzy patient have a stroke? CMAJ 2011;183:571-591 Gradual onset => neuritis (?) Sudden onset => stroke (?) Pain => stroke (+ve likelihood ratio 3) Diplopia & other symptoms => stroke (strong) < 50 => neuritis (weak) Vascular risk factors => stroke (weak)
Does my dizzy patient have a stroke? CMAJ 2011;183:571-591 Conventional neurological examination normal => neuritis (OR 0.36) Neurological signs present => stroke (probably strong) Normal head thrust test => stroke (positive likelihood ratio 18) No dangerous signs on HINTS bedside testing => Negative likelihood ratio 0.02)
HINTS to diagnose stroke in the acute vestibular syndrome: 3-step bedside test more sensitive than MRI Kattah et al Stroke 2009;40: 3504-10 Dangerous signs Head impulse test - Normal Nystagmus direction changing Skew deviation present Any one of these indicated stroke Sensitivity 100% Specificity 91%
Case 1 differential diagnosis Bronstein; Dizziness Cambridge Clinical Guides 2007
HINTS to diagnose stroke in the acute vestibular syndrome: 3-step bedside test more sensitive than MRI Kattah et al Stroke 2009;40: 3504-10 Dangerous signs Head impulse test - Normal Nystagmus direction changing Skew deviation present Any one of these indicated stroke Sensitivity 100% Specificity 91%
Mr AV: Treatment Vestibular neuritis Cerebellar stroke Short term vestibular sedatives Vestibular rehabilitation Admission Monitoring for complications
TOS Study Study Nicholl et al JRCPE 2012;42;306-10 Patients referred to neurology for opinion were asked if they recalled being examined using a: Stethoscope 96% Tendon hammer 67% Ophthalmoscope 52% Why?
A Patient 55 year old man presents to A&E Woke with blurred vision PERLA 6/5 bilaterally Fields normal Discs normal
Fields techniques Face Finger counting Red comparison Static finger wiggle Kinetic finger wiggle Kinetic 5 mm red pin Too much choice..
Diagnostic accuracy of confrontation visual field tests Neurology 2010;74:1184-1190 Sensitivity Specificity Face 40 100 Finger counting 48 100 Red comparison 86 26 Static finger wiggle 55 96 Kinetic finger wiggle 59 98 Kinetic 5 mm red pin 91 96
Diagnostic accuracy of confrontation visual field tests Neurology 2010;74:1184-1190 Combination Static finger wiggle PLUS kinetic red pin => Sensitivity 79% => Specificity 90%
A Patient 55 year old man presents to A&E Woke with blurred vision PERLA 6/5 bilaterally Fields NOT normal Discs normal
Patient GH A 57 year old man got onto a plane feeling fine. During the 1 hour flight his legs became numb and on landing he could not get out of his seat. He taken to A and E. Cranial nerves and arms normal. Reduced tone both legs. HF 3 3; HE 3 3; KF 3 3; KE 3 3; FDF 4 4; PF 4 4 Knee reflex and right ankle reflex absent; left ankle reflex present. Plantars unresponsive. Loss of sensation to upper thigh Catheterised
Patient GH What is the diagnosis? A) Guillain Barre syndrome B) Multiple sclerosis C) Spinal cord compression D) Stroke
Wrong question!
Neurology and Detective Writing Kempster and Lees, Practical Neurology Dec 2013
Neurology and the Underground
Stopping at all the stations of the diagnostic process Weak legs Multiple sclerosis Symptoms and signs Synthesis Syndrome Diagnosis
Neurology and the Underground Missing stops Makes you Go too far
Stopping at all the stations of the diagnostic process Weak legs Localisation of lesion(s) + time course + tests Multiple sclerosis Symptoms and signs Synthesis Syndrome Diagnosis
Patient GH A 57 year old man got onto a plane feeling fine. During the 1 hour flight his legs became numb and on landing he could not get out of his seat. He taken to A and E. Cranial nerves and arms normal. Reduced tone both legs. HF 3 3; HE 3 3; KF 3 3; KE 3 3; FDF 4 4; PF 4 4 Knee reflex and right ankle reflex absent; left ankle reflex present. Plantars unresponsive. Loss of sensation to upper thigh Catheterised Type of weakness? Upper or lower motor? Distribution of weakness? Spinal cord? Cauda equina? Peripheral nerve? Distribution of sensory loss? Autonomic involvement? Spinal cord? Cauda equina?
MRCP and Cases all the information Real world Information correct? All information you need? What is missing?
Patient GH A 57 year old man got onto a plane feeling fine. During the 1 hour flight his legs became numb and on landing he could not get out of his seat. He taken to A and E. Cranial nerves and arms normal. Reduced tone both legs. HF 3 3; HE 3 3; KF 3 3; KE 3 3; FDF 4 4; PF 4 4 Knee reflex and right ankle reflex absent; left ankle reflex present. Plantars unresponsive. Loss of sensation to upper thigh Catheterised
Patient GH Is anything missing? Modalities of sensation: Vibration sense Joint position sense Temperature Pin prick Could there be a level?
Dissociated sensory loss Sensory level to umbilicus
Spinal Cord
Weakness and reflex loss above L1 Loss of spinothalamic sensation; preserved posterior column sensation Loss of bladder function => Where is the lesion? Anterior spinal cord syndrome at T12 or above => What is the lesion? Anterior spinal artery stroke Patient GH
Missing Information Uncritical examination of sensory system Failure to examine the sensation on the trunk
Sensory Examination Made Easy. Vibration Sense Temperature
Sensory Examination Made Easy Vibration Sense Temperature Joint position sense Pin prick (light touch..) Distal to proximal Abnormal to normal Delineate edge of normal Look for level if you think there might be one
Think about the sensory distribution in all 4 modalities Missing information Remember to look for a level on trunk Missing information Imagine you are shading in a drawing
Myotomes and Dermatomes
Common Neurological Emergencies Headache Weakness Blackouts Coma Confusion Dizziness Double vision Incoordination Stroke Epilepsy Subarachnoid Meningitis Encephalitis Myaesthenia Guillain-Barre Cord compression
Neurological Emergencies Thunderclap headaches Think SAH Not SAH is not a diagnosis Vertigo Clinical examination can distinguish central from peripheral lesions Weakness Think about missing data Critical and systematic sensory examination
Thank you