Neurology I: Demyelination, Facial Pain and Cerebrovascular Disease

• What is neurology?


  The branch of medicine or biology that deals with the anatomy, functions, and organic disorders of nerves and the nervous system
• What do the different parts of the brain control?

  Frontal Lobe:Motor control, concentration, planning, problem solving, speech, smell.

  Parietal Lobe:Touch and Pressure, taste, body awareness, language

  Temporal Lobe:Hearing, facial recognition

  Occipital lobe:Vision

  Cerebellum:Coordination

  
• What do we mean when we say the cranial & spinal nerves all

  decussate?Right side of the body is controlled by the left side of the brain vice versa

  
  

  because the nerves cross and intersect with each other
• What is tested in a neurological examination?

  Tone– resistance to passive movement of a joint

  Power– power is tested by comparing the patient's strength against your own

  Reflex– involuntary and nearly instantaneous movement in response to a stimulus e.g using hammer

  Co-ordination– voluntary/purposeful movements

  Sensation– conscious experience resulting from stimulation
• How can you measure a patient's consciousness levels?

  AVPU/GCS

  AVPU:A-alert (can answer questions sensibly)V-responds to verbal commandsP-responds to a pressure or pain stimulusU-unresponsive to any stimulus

  GCS: see attached image

  
• What is a stroke?

  A focal neurological deficit which lasts longer than 24 hours resulting from a vascular lesion.

  Can have eitherIschaemicstroke(blood supply is blocked and cut off to a particular area of the brain)orHaemorrhagicstroke(you end up bleeding into a particular area of the brain or skull due to weakened vessel walls and that causes the stroke)

  80% of all stroke events are ischaemic

  
• How can you identify a stroke?

  FAST:Face- asymmetry of the face, unilateral palsyArms- weakness in the armsSpeech- slurring of speech (dysarthria)Time- phone for help
• What are some symptoms of strokes?

  Sudden numbness or weakness in the face, arm, or leg, especially on one side of the body

  
  

  Sudden severe headache with no known cause

  
  

  Confusion, trouble speaking, or difficulty understanding speech (aphasia)

  
  

  Sudden trouble seeing in one or both eyes (visual field defects)

  
  

  Ataxia- sudden trouble walking (gait disturbance), dizziness, loss of balance, or lack of coordination
• What is a transientischaemic attack (TIA)?


  A focal neurological deficit which lasts less than 24 hours resulting from a vascular lesion; the deficit fully resolves

  
  

  Temporary in nature

  
  

  Requires active preventative treatment and investigation, indicates a stroke coming.
• What are the risk factors for a stroke?

  Diabetes

  Cigarettes

  Obesity

  Oestrogen OCP

  Excess EtOH

  Polycythaemia (Raised haemoglobin)

  Atheroma (hypercholesterol/lipid aemia)

  Hereditable nature (family history of stroke)

  Hypertension
• How can someone be affected by a stroke depending on which side was damaged?

  
• What are the common lesions and outcomes of a stroke?

  
• What should you do in case of an acute stroke?

  Thrombolysis (Within 4 hours)- not for haemorrhagic stroke

  Clot retrieval

  Maintain BP

  ECG

  Nil by mouth- till SALT assessment
• What should you do in case of a chronic stroke?

  Support- Stroke unit; rehab/physio/skin care

  
  

  NG feeding/laryngeal introitus care; hydration

  
  

  Aids/chairs lifts/OT input/GDP OH adaptations

  
  

  Look for second risk factors

  
  

  Carotid atheroma (MRA/Doppler angio-flow); clotting screens (clotting syndromes/medications); hypertension

  
  

  Medication- anti-platelets/anticoagulants
• What is a subarachnoid haemorrhage?

  Uncommon type of stroke caused by bleeding into the brain - arterial
• What are the classic signs and symptoms of a subarachnoid haemorrhage stroke?

  Classic "thunderclap headache"with neck stiffness(caused by Circle of Willis Berry aneurysm,ballooning in blood vessel, rupture)

  Sudden LOC(loss of consciousness- shortly after event)

  Signs ofmeningism(e.g. photophobic)
• Why do you have to act rapidly in cases of subarachnoid haemorrhage?

  There's a fast onset and it's a high pressure bleed because it's arterial so you have to act quickly
• How do you treat subarachnoid haemorrhage?

  First MRI scan and then often neurosurgery

  
  

  Clip & tie bleeder if not stopped spontaneously - this is when blood vessel is clipped and tied off
• Who is typically affected by subarachnoid haemorrhages?


  Older women
• Who is typically affected by an

  extraduralhaemorrhage?Young patients, usually involved in a head strike (either during sport or a result of a motor vehicle accident) and they may/may not lose consciousness transiently
• What happens to people with extradural haemorrhage following the injury?

  Following the injury they regain a normal level of consciousness(lucid interval)

  Usually have an ongoing and often severe headache

  Over the next few hours they gradually lose consciousness
• What type of bleed is an extradural haemorrhage?

  Arterial bleed, usually middle meningeal artery damage
• How does an extradural haemorrhage present in a CT/MRI?

  As a convex blood mass
• What is a


  subdural haematomaand where is it located?It's a collection of blood between the dura and the brain which has a slower onset and is a venous bleed

  
  

  Located 'below the dura
• When does a subdural haematoma typically occur?

  Typically after a fall or if they're on anti-coagulants
• Where do the different brain haemorrhages happen?

  
• What is epilepsy?

  A neurological disorder marked by sudden recurrent episodes of sensory disturbance, loss of consciousness, or convulsions, associated with abnormal electrical activity in the brain

  
  

  Generally it's a lifelong condition
• What are the different types of epilepsy?

  General, focal (simple partial)
• Do all types of epilepsy involve having seizures?

  No
• When can you start having epilepsy?

  Can start at any age, but usually in childhood or over 60

  
  

  But if onset is at >60yrs, it is likely to be secondary to other neurological pathologies- tumours/strokes
• What is epilepsy managed with?

  Anti-convulsants
• Describe the characteristics of a tonic-clonic (grand mal) seizure.

  Muscle Contractions

  Stiff, jerking muscular movements

  Unable to communicate- blank stare/aphasic

  Vomiting or loss of bladder/bowels

  Cheek and tongue biting

  Breathing difficulties

  Loss of consciousness

  Recovery- variable but 5 minute duration not unusual

  "Feels like I ran a marathon"
• What are some characteristics of a simple partial seizure?

  A general strange feeling that's hard to describe

  
  

  A feeling that events have happened before (déjà vu)

  
  

  A sinking feeling in your abdomen- like when on a fairground ride

  
  

  Unusual smells or tastes; tingling in your arms and legs;

  
  

  stiffness or twitching in part of your body, such as an arm or hand but you remain awake and aware while this happens Considered as "warnings" or "auras" as they can be a herald of another type of seizure
• What happens to you during a complex partial seizure?

  You lose your sense of awareness and make random body movements

  
  

  Patient won't be able to respond to anyone during seizure & won't have any memory of it
• What are the characteristics of a complex partial seizure?

  Smacking of lips

  
  

  Rubbing of hands

  
  

  Making random noises

  
  

  Moving arms around

  
  

  Picking at clothes or fiddling with objects

  
  

  Chewing or swallowing
• What is an absence (petit mal) seizure?

  An absence seizure, is where you lose awareness of your surroundings for a short time

  
  

  Mainly affects children, but can happen at any age
• What might a person do during an absence seizure?

  Stare blankly into space

  
  

  Look like they're "daydreaming"

  
  

  Flutter their eyes

  
  

  Make slight jerking movements of their body or limbs

  
  

  The seizures usually only last up to 15 seconds and you won't be able to remember them

  
  

  They can happen several times a day
• What are the other types of epileptic seizures?

  Status epilepticus : name of any seizure that lasts a long time or a series of seizures when the person doesn't regain consciousness in between.

  
  

  Medical emergency and needs to be treated ASAP

  
• What are triggers for seizures?

  Stress

  Fatigue

  Lights (Photosensitive 3%)

  Alcohol

  Missing medication

  Coffee

  Nicotine
• What investigations do you do for epilepsy?

  CT scan- first seizure

  MRI

  EEG- electroencephalogram

  Blood tests- to investigate underlying electrolyte cause e.g. low glucose (hypoglycaemia), low sodium (hyponatraemia)