Embed Size (px)
Citation preview
Neurology Review
MKSAP
Dementia
• Acquired chronic impairment of memory and other aspects of cognition that impair daily function.
• MCI = Mild Cognitive Impairment
• MCI does not impair daily function
• Degenerative or vascular disease that causes widespread or multifocal brain abnormalities.
Dementia
• Alzheimer’s Disease most prevalent • Non-AD ~1/3+ of Dementias• Different clinical presentations and
different Rx• FTD – presents with executive function
impairment and personality change vs Memory problems of AD
• Cholinergic Rx does not help FTD• Relieve FTD patients of responsibilies
DSM-IV criteria for Dementia
• A. Development of multiple cognitive deficits with both:– 1. Memory impairment– 2. One or more of the following
• a. Aphasia• b. Apraxia• c. Agnosia• d. Impair executive functions (planning, organizing, sequencing,
abstracting)
• B. A1 and A2 cause significant impairment in social or occupational functioning and represents a decline from prior functions
• C. Deficits do not occur exclusively as part of a delerium
Pathology of Alzheimer’s Diseasse
• Deposition of insoluble beta-amyloid protein in extracellular parenchymal plaques
• Amyloid Plaques surrounded by dystrophic tau-positive neurites and activated microglia
• Neurofibrillary tangles are microtubule-associated tau-protein; hyperphosphorylated and abnormally conformed.
• Number of tangles correlates with severity of dementia• Beta-Amyloid neurotoxicity is most likely key feature.• Early degeneration of Basal Forebrain (Nucleus basalis of Meynert)
results in Cholinergic deficit.• Mesial Temporal lobe degeneration results in memory impairment• Association area involvment in inferior temporal lobes, prefrontal,
and parietal areas are other features• Relative sparing of subcortical and primary motor and sensory
cortex.
Beta-Amyloid
• 1 – 42 fragment is cleaved by abnormal cleavage of larger Amyloid Precursor Protein.
• Alpha-secretase cleavage produces soluble product.
• Cleavage by beta or gamma-secretase produces toxic, insoluble 1-42 fragment.
• Cascade or inflammatory and toxic events initiated.
APP cleaving
APP processing
Epidemiology of AD
• Risk factors: advanced age, genetic predisposition, cardiovascular conditions, post-menopausal state.
• Prevalence* 1.5% for age 65- 69– Doubles every 5yrs to 85– Increases 10% every 5 yrs age 85 to 100– 45% at age 100
Genetics etc of AD• ~5% of cases are Mendelian• Dementia <65 some caused by Autosomal Dominant mutations in presenilin
1, presenilin 2, or APP• ~25% of genetic cases are presenilin 1 mutations. Most common familial
AD.• Genetic test available• Good genetic counseling required.
• For late onset, no known one gene mutations known, but FH is risk factor.• RR ~2.5 if affected relative• High risk of AD in Trisomy 21. APP is on #21• Apolipoprotein e4 is risk factor; onset about 10yrs earlier• Hypertension is risk factor• Estrogen replacement controversy• ? Benefit of Statin Rx• ?NSAIDs
Mild Cognitive Impairment (MCI)
• MCI is conceptually the intermediate stage between presymptomatic disease and Dementia
• MCI – memory impairment without other cognitive problems and without impairment in functional independence
• Progression from MCI to AD is about 10 -15% per year. In one study ~80% had AD at 6 yr follow-up.
Progression of AD
• Steadily progressive deterioration over 8 – 10 yrs.
• MMSE 20 – 26 = mild dementia with mild functional dependency needing some assistance (ex. Financial)
• MMSE 10 – 20 = moderate dementia. More impairment and help needed. Unable to drive.
• MMSE <10 = severe dementia with total dependency and constant supervision.
Diagnosis of Alzheimer’s Disease
• Clinical diagnosis supported by imaging and tests.• Typically normal neuro exam except for cognition• No pathognomonic features or reliable biomarkers.• Diagnostic Crieteria – next slide• Not very specific. ~70% accuracy
• Think other Dementias or dx when early symptoms are: impaired social behavior, gait disturbance, aphasia, hallucinations, delusions; or not insidious or chronic
NINCDS-ADRDA criteria
• 1. Dementia established by clinical examination and standardized brief mental status test and confirmed by neuropsychologic tests
• 2. Deficits in two or more areas of cognition• 3. Progressive worsening of memory and other
cognitive functions• 4. No disturbance of consciousness• 5. Onset between 40 – 90 years old• 6. Absence of other systemic or neurologic
disorder sufficient to account for the progressive cognitive defects
R/O secondary causes of Dementia
• 5 – 15% of dementias are at least partially reversible• Depression, medication induced encephalopathy and
metabolic disorders most likely.• D/C unnecessary Rx, especially sedatives and
anticholinergic agents.• Screen for depression, B12, hypothyroidism.• Syphilis screening if risk factors• CT or MRI to exclude structural pathology and eval for
strokes or hydrocephalus• Formal Neuropsych testing may be needed if atypical, ?
depression, medico-legal decisions such as competency.
Additional evaluation options
• EEG and/or LP if fluctuating ecephalopathy or subacute progressive dementia
• Functional imaging may help distinguish between FTD and AD.
• Biomarkers in CSF not yet ready for primetime
• Genetic testing not routinely needed.
AD
Tangles and Plaques
Treatment of AD
• Cholinergic augmentation recommended for all mild to moderate AD.
• Improves cognition and global functions
• Effect lasts for about a year
• Does not altered overall progression
• Not shown to delay nursing home placement or death.
Anticholinesterase agents• Donepezil (Aricept).
– Start at 5mg qd. Increase to 10mg qd in 4 – 6 weeks. Side effects: Nausea, diarrhea, Abdo pain, sleep disturbances
• Rivastigmine(Exelon). – Start 1.5mg bid, titrate up to 3 – 6mg bid over 6 weeks. SE: N/V,
anorexia, dizzines• Galantamine (Reminyl).
– Start at 4mg/d, titrate up to 12mg bid over months. SE: N/V, anorexia, weight loss, diarrhea
• Tacrine (Cognex) – not used anymore
• These agents may be helpful in Lewy Body dementia and vascular dementia, but not in Fronto-temporal dementia
NMDA glutamate antagonist Rx
• Memantine (Nemenda) – shown to be helpful for moderate to severe Alzheimer’s Disease.
• Start at 5mg/d, increase up 10mg bid with weekly changes. – SE: hallucinations, confusion, restlessness,
anxiety, dizziness, h/a, fatigue, constipation.
• Can be combined with Anticholinesterase inhibitor.
Other Rx’s
• ?Ginkgo biloba– Not proved. ?dose. ?standardization. ?effects
on other medications
• ?Vit E. 1000 IU twice daily was shown to benefit. But other studies with increased mortality. So ?
Treatment of Psychiatric Symptoms
• More likely to lead to institutionalization• Behavioral approaches: predictable routines, repetition,
patient redirection.• AChE inhibitors help:
– apathy, hallucinations, psychosis, depression,anxiety.
• Trazadone or atypical neuroleptics* may help delusional or agitated behaviors.– Resperidone, olanazapine, quetiapine– * increased risk of death shown in meta-analysis. Risk vs benefit.
• Remember the care givers may need care.• Elder abuse or neglect
Preventive Strategies
• Nothing as of yet.– Goal: slow amyloid deposition in brain
• Amyloid vaccines– Encephalitis
• Bad-Secretase inhibitors
• Good –Secretase enhancers
AD – Keypoint and recent advancs
• Normal Neuro exam except for memory and other cognitive domain impairments
• MCI is likely a predemential stage• Cholinergic augmentation is standard therapy• AChE inhibitors modesty improve cognition,
global function, and psychiatric symptoms• Memantine in moderate to severe AD improves
function better than AChE inhibitors• ?Vit E• Antipsychotic therapy has Black Box warning.
Non-Alzheimer’s Dementias
• Vascular dementia, Dementia with Lewy Bodies, Fronto-temporal Dementia – most common of the non-AD Dementias.
• Often superimposed on AD
• Prion Disease and other degenerative diseases (CBD) much less likely.
Vascular Dementia
• Multiple or strategically placed large-vessel occlusions
• Multiple small vessel occlusions***
• Primary hemorrhagic process
• *** likely most common
Vascular dementia
• ~25% of stroke patients meet criteria for dementia at 3 months
• ~1/3 of dementias a/w proximate stroke
• RR for dementia is 5.5 -8.4% per year in 4 years post stroke vs 1.3% per year
• Vascular disease and AD synergism.– Why?
Vascular dementia
Dx of vascular dementia
• H/o Stroke or risk factors• Neuro-imaging• Abrupt onset or step-wise progression• Poor sensitivity – most have insidious onset and
gradual decline.• Many have no signs of stroke or h/o stroke• Often mixed• MMSE not sensitivity. Typically cognitive
slowing, apathy, poor problem solving. “Subcortical dementia”.
• Formal neuropsych testing may help
RX Vascular Dementia
• Treat systolic hypertension – primary prevention. Secondary prevention – evidence of benefit not proved.
• ASA
• Acetyl Cholinesterase inhibitors
Fronto-temporal dementia (FTD)
• Early, insidiously progressive impairment of personality and executive functions – decision making, prioritizing, planning.
• Consensus Criteria for FTD:– Insidious onset and gradual decline– Early decline in social interpersonal conduct– Early impairment in regulation of personal conduct– Early emotional blunting– Early loss of insight
• Apathy• Usually noticed by family not by patient• Memory impairment may be relatively mild
FTD
• Disproportionate atrophy of frontal lobes and anterior temporal lobes
• Pick’s Disease
• Many have tau-positive inclusions in affected neurons. Cause not known
• RF: age and family history
• ~40% familial. Tau gene mutation in many.
Pick’s Disease
Dx of FTD
• History from family
• Poor 1 minute fluency test– List words from category in 1 minute.– 10,14,18
• Visuo-spatial functions preserved (cf AD)
• Formal neuropsych testing
• Neuro-imaging
Rx of FTD
• Medicationss can help irritability, agitation, depressive symptoms, eating disorders– Trazadone, SSRIs, Modafinil etc
• Not helpful for cognitition• AChE inhibitors don’t help.• Remove from responsibilites
– No driving– Decision making: financial, medical etc– Neuropsych testing have help here.
Dementia with Lewy Bodies (DLB)
• Dementia with intraneuronal inclusions in cortex
• Visual hallucinations, fluctuating cognition, parkinsonism
• Can co-occur with AD
Criteria for probable DLB• 1. Persistent memory impairment may not occur early but is usually evident with
progression. Deficits of attention, frontal-subcortical skills, and visuospatial ability may be particularly prominent
• 2. Two of the following core features– a. Fluctuating cognition with pronounced variation in attention and alertness– b. Recurrent visual hallucinations that are typically well formed and detailed.– c. Spontaneous motor features of parkinsonism
• 3. Supportive features include repeated falls, syncope, neuroleptic sensitivity, delusions, hallucinations in other modalities, REM behavior disorder.
• 80 - 90% specificity but only 50 - 60% sensitivity
• “Fluctuating cognition”– Daytime drowsiness and lethargy despite normal sleep– Falling asleep for > hours during the day– Staring into space for long periods– Episodes of disorganized speech marked by real words linked in a disjointed manner.
Treatment of DLB
• AChE inhibitors first– Can help behavior symptoms, hallucinations
and delusions
• “standard neuroleptics” can be associated with neuroleptic malignant syndrome.
• “Black box” warning of atypical neuroleptics
• Sinemet etc
Creutzfeldt-Jakob Disease (CJD)
• CJD is most common Prior disease• ~1 per million.• Degenerative disease that may be transmissible• Transformation of prion protein into insoluble
conformation• Spongioform changes in brain• ~85% are sporadic• Familial forms with mutation of prion protein• Prion protein is normal constituent of CNS• New variant CJD (vCJD) in younger patients a/w
consumption of meat affected with bovine spongiform encephalopathy
Dx of CJD
• Rapidly progressive disease a/w myoclonus
• Death usually in 3 – 6 months
• DDX includes: primary angiitis of CNS and Hashimoto’s encephalitis– Hashimoto’s: antithyroglobulin antibodies– Seizures, dementia, myoclonus, ataxia
• Brain Bx may be needed
Clinical criteria for probable CJD
• 1. Rapidly progressive dementia• 2. Electroencephalogram with periodic sharp waves or
elevated levels of 14-3-3 protein on CSF analysis– 14-3-3 is non-specific neuronal marker.
• limitations
• Two of the following– Myoclonus– Visual or cerebellar signs– Pyramidal or extrapyramidal motor signs– Akinetic mutism
• 65% sensitivity, 95% specificity
• EEG normal in vCJD
EEG in sCJD
CJD
CJD pathology
Key Points for non-AD dementias
• Most common are Vascular dementia, DLB, FTD• Clinical Dx of VD: h/o or risk factors for stroke, a stroke-
like course, and/or findings on imaging• DLB characterized by parkinsonism reponsive to
dopaminergic Rx, visual hallucinations, and fluctuating cognition
• Cholinergic augmentation may help psychiatric symptoms of DLB
• FTD presents with early executive and personality changes, and pronounced or asymmetric atrophy of frontal lobes on imaging
• CJD suspected if dementia with myoclonus that progressives of weeks to months
Headache and Facial Pain
• Significant advances in the past 20 years• Migraine alone: 10% of people
– 18% of women and 6% of men– 75% have moderate to severe headaches
• Distinguish Primary from Secondary Headache• Primary: Migraine, Tension-type, Chronic
Daily/rebound/medication overuse, Cluster.• Secondary: SAH, meningitis, PTC, Cerebral
mass lesions, GCA
Migraine
• Nausea, photophobia, phonophobia, throbbing pain. May worsen with movement and limit daily activities
• Pathophysiology: begins in the brainstem and higher brain structures; distention and inflammation of meningeal vessels is FINAL manifestation.
• Trigeminal vascular system: triggered to release of inflammatory peptides on blood vessels.
• Autonomic and chemoreceptor systems triggered: nausea, pallor, flushing, tearing, rhinorhea, sinus congestion.
• Sinus headache: fever, discolored nasal discharge and air-fluid level on CT.
Migraine cont’d• Prodrome in many, up to 24 hrs prior to attack: euphoria,
depression, food cravings, fatigue, hypomania, cognitive slowing, dizziness, asthenia.
• Auras in 15% - 20% - with hour of or during headache: visual loss or changes (ex. scintillating scotoma), hallucinations, numbness, tingling, weakness, confusion. Spreads. Caused by Spreading Cortical Depression = wave of neuronal depolarization. Auras last few minutes to up to an hour. ( Acephalgic migraine – aura without the headache.)
• Complicated migraine. Rare. Aura persists over 24 hours. May result in infarction – from profound metabolic disturbance. Risk increased by OCPs and smoking.
• Late life migraine accompaniments: patients over 50yrs. 20 – 60 minutes typically. (c/w TIA which usually lasts 10 -15 minutes.) May be repetative and not worsen in severity. (c/w TIA). ~50% a/w mild headache.
Migraine treatment• Acute Rx with triptans or ergots: bind directly to trigeminal nerve endings and blood
vessel. Decreased release of inflammatory substances – stabilized nerve endings and blood vessel swelling. Best for patients with moderate to severe headaches.
• Milder, infrequent migraines can be treated with NSAIDs or Acetominophen.• Triptan orally, intranasally, injection.• Faster but more SEs with shot: chest discomfort, nausea, dizziness, numbness,
flushing• Longer half-life triptans have less side effects, but slower action and ?less effective.
Idiosyncratic responses of pateints. Long half-life triptans may be useful for prophylaxis of menstrual migraine.
• Low risk of cardiac side effects, but contraindicated in patients with significant coronary risk factors. Chest pain may be side effect >>> diagnostic confusion.
• IV dihydroergotamine ofr status migrainosus. SEs: nausea and akasthisia. Given with anti-nausea rx. Intranasal DHE = triptans
• Earlier use = better response. Rx not perfect• Central sensitization – brain hypersensitive to all stimuli – light, sound, smell, touch.
Treatment less effective once Central sensitization has occurred. • No class effect for triptans. Therefore try many to find the best.• Recurrence of headache – repeat dose.
Acute Migraine Rx
• 1 mg IV DHE– With antiemetic. Pregnancy X
• 1mg DHE nasal spray. (Pregnancy X)
• Triptans– Sumatriptan (Imitrex)– Rizatriptan (Maxalt)– Zolmitriptan (Zomig)– Frovatriptan (Frova) – longest half life
Migraine rescue Rx
• For those who are resistent to triptan Rx or Rx ineffective.
• Beware using opioids more than a few times per year. Beware medication over use and rebound.
• Releive headache and cause sedation: cautions.• Home vs clinic/ED• IV medicaions: Haldol and Ativan together; lidocaine,
MgSO4, Valproate, Solumedrol, hydroxyzine, Promethazine, Prochlorperazine, Metachopramide
• Oral: Olanzapine, Quetiapine, Tizanidine, Hydroxyzine
Migraine Prophylaxis
• Consider in patients with 2 or more migraines per week. If less, consider the severity and level of disability.
• Antidepressants (tricyclics mostly), anticonvulsants, beta-blockers (Inderal FDA approved).
• AEDs: decrease neuronal irritability.– Depakote and Topamax FDA approved for migraine prophylaxis
• Start low, go slow. Titrate up over 1 - 2 months. Asses effect for couple months. If controlled for 3 -6 months, can consider tapering off
• Botox: may be useful. May prevent release of inflammatory peptides peripherally
Prophylactic Medications• Inderal LA – up to 160mg• Verapamil – may need big doses• Depakote ER – 1000mg qhs.
– Pregnancy D. Take Folate supplement– Check LFTs after 1 and 3 months– Weight gain
• Topamax – start at 25mg qhs up to 200mg– Weight loss, carbonic anhydrase effect, cognitive SEs
• Neurontin – up to 4800mg in 3 divided doses• Keppra – start 500mg bid• Other AEDs• Elavil or Pamelor – start at 10mg or 25mg qhs.• SNRIs – Duloxetine etc• Methysergide – now not available in the US• Cyproheptadine• CoEnzyme Q10• Riboflavin• Magnesium Oxide
Non-pharmacologic Rx
• Behavioral modications, meditation, counseling, hypnosis, acupuncture, PT, biofeedback, diet modification, sleep hygiene.
• Coping strategies, reducing effect of environmental stressors and triggers
• Dietary triggers (~20%): tyramines, nitrates, dairy products,xanthines
• Sleep: 7 – 8 hours for adults >25. 8 -10 hours for <25. Restful sleep decreases brain irritability.
Menstrual Migraine
• 60% of women with migraine• Triggered by decrease in estrogen. Can
also happen around ovulation.• Prophylaxis: estrogen rx instead of empty
pill during menses, oral magnesium.• Beware estrogen in smokers or h/o
hypercoagulability – increased stroke risk.• Preemptive therapy: NSAIDs or longer
acting triptans – Frova or Amerge.
Key Points: Migraine• Migraine originates in the brainstam and higher brain structures that cause
pain coming from inflamed cerebral blood vessels.• Acute migraine Rx includes specific therapy with triptans or ergot derivatives• Triptans are contraindicated in patients with significant coronary risk factors
or a history of coronary disease.• Treatment should be administered as early as possible in the attack to
ensure the greatest efficacy using the lowest dose of therapy.• Prophylactic therapy is indicated in patients who experience more than two
days with h/a per week.• Proper sleep hygiene may be the most effective migraine prophylaxis.• Consumption of foods containing tyramine, nitrates, dairy products, and
xanthines may trigger migraine in some patients.• Menstrual migraine prophylaxis includes administration of low-dose
estrogen therapy during menstruation, continuous estrogen therapy during menses, or oral magnesium.
Tension-type Headache
• Most prevalent• Mild migraine vs unique disorder?• Squeezing/pressure, bilaterally• May have light or sound sensitivity – not both• Minutes to days, constant, no nausea• Alone or with migraine• Low level of disability• If interfere with activities, Rx as migraine• Mild headaches: rx with NSAIDs or muscle
relaxants
Medication overuse Headaches• 4 - 5% of Americans have >15 headache days per month!• ~75% due to medication overuse• Acute Rx more than 2 days per week >>> risk for rebound
headache• Pain on or soon after waking. Pain like migraine or tension-
type• Medication response poor – vicious cycle• ~25% have secondary headache – r/o mass lesions, infection,
inflammatory disorders, sleep disorders, cervical pathology• Rx: complete withdrawal of offending agent(s), migraine
prophylactic Rx, breakthrough rx with NSAIDs, IV DHE, or steroids
• 2 -12 weeks of therapy• Caffeine withdrawal
Cluster Headache
• One of the most painful H/A syndromes• Pain + autonomic features• Episode lasts 15 minutes to 3 hours. (Migraine 4 hours
to 3 days)• Unilateral and periorbital/temporal• Associated with at least one on same side as Headache:
conjuctival irritation, lacrimation, rhinorrhea, nasal congestion, eyelid edema, facial sweating, miosis/ptosis.
• Patient aggitated, can’t stay still. May touch head to help alleviate pain (c/w migraine).
• May recur several times per day at the same time. No pain between episodes.
• Clusters typically last 3 – 6 weeks.
Cluster Pathophysiology
• Probably similar to migraine except trigger may be in the hypothalamus– Periodicity– Autonomic symptms– PET scan evidence
• Increase levels of histamine
• Sensitivity to histominogenic triggers
Rx of Cluster
• Oral Steroid Rx for 2 – 4 weeks with taper over 2 - 4 weeks
• Anticonvulsants
• Calcium Channel Blockers
• (Lithium – not mentioned in MKSAP)
• Fast acting triptan (injection), IV DHE, high flow Oxygen
• Exclude primary sleep disorder
“Jabs and Jolts”
• H/As with Autonomic manifestations• Paroxysmal hemicrania• Short-lasting unilateral neuralgiform
headache with conjunctival injection and tearing (SUNCT)
• Shorter duration, more frequent pains that Cluster. Many per day. Seconds to minutes.
• Indomethacin
Other primary headaches
• Benign thunderclap headache• Headache upon awakening• Headache a/w sexual activity• Exercise induced headache• Benign cough headache• ?pathophysiology• R/O secondary causes• Rx triptans or NSAIDs (Indomethacin)
Secondary Headaches• Low threshold for imaging (and Neuro consult)
– “CT of head is like CXR of the CNS”• DDX: AVM, TIA/Stroke, dissection, vasculitis, Venous
thrombosis, tumor, seizure, acute HTN, pituitary apoplexy, acute HC, infection.
• CT less sensitive for posterior fossa lesions and may miss up to 10% of SAH.
• +/- MRI is less emergent situations• MRI for significant change in pattern and for focal neurologic
sx/sx.• If SAH suspected and CT negative >>> LP
– R/o mass lesion or obstructive HC prior to LP– Get Opening pressure along with labs
• LP if fever, seizures, meningeal signs with headache.
Exam!
Giant Cell Arteritis (temporal arteritis)
• Patients >50• Progressive worsening of headaches often with swollen tender scalp vasculature• Jaw claudication• Polymyalgia rheumatica• Visual blurring• Amaurosis fugax• Systemic disease affecting medium and large arteries. Predilection for cranial arteries• ESR elevated in >95% (above 50, usually 80 -100)• CRP• Rx with 60mg/d prednisone to prevent visual loss from AAION (inflamation of short
posterior ciliary arteries) AAION = Arteritic Anterior Ischemic Optic Neuropathy.• Ophthalmology eval for Temporal Artery Bx• May need to Bx both sides• High-dose Steroids indicated for Dx• Long term (1 -2+ years) steroid Rx may be needed if Dx proved by Bx• Monitor response to Rx by Sx and ESR• Blindness possible if not treated
GCA
Idiopathic Intracranial Hypertension (Pseudotumor Cerebri)
• Increased intracranial pressure without evidence of intracranial disease.• R/o mass lesions, hydrocephalus, Venous sinus thrombosis.• Pathophysiology: ?decreased CSF reabsorption. (narrowed cerebral venous
drainage pathways.• Mostly in obese women of childbearing age.• Also a/w Tetracycline Rx, OCPs, and hypervitaminosis A• Daily non-throbbing headache worsens with cough/sneeze or lying down.
+/- diplopia, TVOs, pulsative tinnitus• Papilledema, enlarge blind spot or VF changes, +/- sixth nerve palsy.
Maybe get Optic nerve damage with visual loss.• Eval: MRI with MRV, LP with OP and labs.• Rx: weight loss. Diamox (carbonic anhydrase inhibitor) reduces CSF
production• Optic nerve sheath fenestration. Consider CSF shunting (second choice).• Ophthalmology follow-up to monitor vision.
PTC
MRV
Normal CSF flow
Chiari Malformation
Chiari
Syringomyelia
Trigeminal Neuralgia• Paroxysms of pain in one or more divisions of CN V• Sharp, stabbing pains lasting seconds to a few minutes• Touching face can trigger pain• Exam typically normal. If sensory loss, this suggests secondary
cause• Get MRI to exclude secondary cause in everyone• Etiology sometimes compression by vascular loop.• RX: AEDs +/- Baclofen
– Tegretol– Neurontin– Trileptal– Others
• Microvascular decompression in some patients,– or Gamma-knife radiotherapy – directed at the trigeminal ganglion >>>
sensory loss, dry eye, anesthesia dolorosa
Trigeminal Neuralgia
Carotid Dissection
• May follow head or neck trauma, but may be spontaneous
• Ipsilateral head, neck, or eye pain– Sudden or gradual onset
• Possible Horner’s syndrome
• +/- contralateral weakness or numbness
• +/- ipsilateral visual symptoms
• MRA, carotid duplex
Guess what’s next?
Movement Disorders
• Hypokinetic (too little movement)– Ex) Parkinson’s Disease, Parkinsonian
Syndromes
• Hyperkinetic (too much movement)– Ex) Chorea, Dystonia, Essential Tremor
Parkinsonism Syndromes
• Primary Parkinsism– Idiopathic Parkinson’s Disease– Juvenile parkinsonism
• Secondary Parkinsonism– Medication induced– Hydrocephalus– Infectious– Metabolic – Calcium, parathyroid, Copper– Neoplastic– Toxin induced– Traumatic– Vascular– Psychogenic
Medication induced Parkinsonism
• Antipsychotics
• Antiemetics
• Tetrabenazine
• Reserpins
• Allpha-methydopa
• Calcium Channel Blockers
• Lithium
Infectious causes of Parkinsonism
• Lethargic encephalitis
• AIDS
• Fungal
• Syphilis
• SSPE
• Spongiform Encephalopathy
Toxin induced Parkinsonism
• MPTP– 1-methyl-4-phenyl-1,2,3,6-tetrapyridine
• CO• Manganese• CN• Carbon disulfide• Mercury• MeOH• EtOH
Basic idea of PD Rx
Parkinsonism-Plus Syndromes
• Corticobasal Ganglionic Degeneration• Dementia Syndromes
– AD– Dementia with Lewy Bodies– Frontotemporal Degeneration
• Multisystem Atrophy– Olivopontocerebellar Degeneration (OPCA)– Shy-Drager Syndrome
• Progressive Supranuclear Palsy (PSP)
Hereditary and Degenerative Parkinsonism
• Familial basal ganglionic degeneration
• FTD with parkinsonism– Linked to chormosome 17
• Huntington’s Disease
• Wilson’s Disease
• Fragile X premutation carriers
• Other rare disorders
Patho-physiology of PD
Loss of cells in Substantia Nigra
Lewy Bodies
Parkinson’s Disease
• James Parkinson, 1817 essay on the “shaking palsy”. Charcot coined the term “Parkinson’s Disease”.
Multiple Sclerosis
Multiple Sclerosis
• Most common cause of non-traumatic neurologic disability in young adults
• Signs/Symptoms• Diagnosis• Course• DDX
– Cervical spondylosis, myelopathies, DM, neurosarcoid, SLE, Sjogren’s, Vit B12 deficiency
• NMO
MS cont’d
• Rx exacerbations• Disease modifying Therapies
– Interferons– Glatiramer– Natalizumab (blocks migration of inflammatory
cells, a/w PML– Mitoxantrone– Other immunosuppressants
• Symptomatic Rx
MS keypoints• On MRI, the presence of ovoid lesions perpendicular to the lateral
ventricles and corpus callosum are characteristic of MS• Management of leg spaciticity a/w MS should involve PT for
stretching and pharmacologic Rx• The decision to treat an exacerbation of neurologic deficit with
corticosteroids is determined by whether the patient’s function is affected
• Plasma exchange may benefit patients with severe exacerbations of MS that are refractory to steroids
• PT, OT, ST may be appropriate after severe MS exacerbations• There is no therapy that convincingly slows degenerative processes
in MS or definitively provides neuroprotection.• Treatment of primary progressive MS is limited to symptomatic Rx
Peripheral Neuropathies
Peripheral Neuropathies
• Recent advance: Muscle-specific Kinase antibodies in Myasthenia Gravis
• Axonal vs Demyelinating• Acquired vs hereditary
– Charcot-Marie-Tooth disease is most common hereditary neuropathy
• Toxins
Neuropathies a/w pain
• Cryptogenic Sensorimotor neuropathy• Diabetic Neuropathy• Vasculitis• GBS• Radiculopathy/plexopathy• Alcoholic neuropathy• HIV sensorimotor Neuropathy• Syphilis• Heavy Metal toxicity• Amyloidosis• Fabry’s disease• Hereditary sensory/autonomic neuropathy
Peripheral Neuropathy eval• Standard:
– CBC, Chemistries, SPEP/IFE, B12, glucose assessment, RPR, TFTs• Optional:
– HIV, ESR, ANA, RF, SS-A, SS-B– Anti-Hu– Genetic studies– Lyme titre– Heavy metals – 24 hour urine– Phytanic acid
• LP if suspecting CIDP or AIDP• NCVs• Sensory nerve Bx
– If vasculitis suspected
Symptomatic Rx of Neuropathic pain
• TCAs
• AEDs
• Lidocaine Patch
• Capsaicin cream
• Acupuncture
• Transcutaneous nerve Stim
• Tramadol
Guillain-Barre
• Rapidily progressive, immune-mediated demyelinating polyneuropathy
• Up to 75% a/w preceding infection, immunization, or surgical procedure– EBV, CMV, Campylobacter, Lyme, Hepatitis, HIV
• Weakness, pain, paresthesias, autonomic symptoms, facial weakness, ophthalmoparesis, respiratory failure (25%)
• 2 – 4 weeks• Respiratory monitoring – FVCs etc• EMG• Rx: IVIG or Plasmapheresis
Polyneuropathy keypoints• Asymmetric involvement should raise suspicion for MND,
radiculopathies, plexopathies, compressive neuropathies, or mononeuritis multiplex
• Viral illness, immunization, or surgery may precede GBS• DDX of neuropathy with Mental Status change should include B12,
thiamine, or niacin deficiency• Immunosuppresive Rx indicated for CIDP• NCV may be helpful to determine Axonoal vs demyelinating process• Treatment of idiopathic polyneuropathy generally limited to pain Rx• Hospitalize and do frequent respiratory monitoring for suspected
GBS• Rx with IVIG or plasmapheresis GBS patients who are unable to
ambulate independently and have impaired respiratory functions or rapidly progressive weakness
• Oral immunosuppressive rx for CIDP; IVIG or plasmapheresis indicated for severe or refractory CIDP
Amyotrophic Lateral Sclerosis
• ALS – both UMN and LMN • Primary Lateral Sclerosis – UMN• Primary Bulbar palsy – Brain stem• Progressive muscular Atrophy – LMN
• ~2/100,000 incidence. • Slight male predominance• 95% sporadic• Mean survival 2 – 5yrs
Rx of ALS
• Riluzole is approved for ALS (very modest effect)
• PEG• Noninvasive PP ventilation with Bilevel
positive airway pressure may prolong survival and improve quality of life
• Symtomatic Rx for spasticity, emotional lability, muscle cramping, and drooling may maintain dignity and quality of life
Myasthenia Gravis
• Antibodies against the AChR• Characterized by fatigable weakness
– Ocular with diplopis, ptosis– Bulbar with dysarthria, dysphagia– Proximal extremity– Neck with head drop– Respiratory with dyspnea
• Dx: repetitive Nerve Stim, Tensilon (not availbable) or SF-EMG may help
• Rx: Mestinon, immune Rx– May initially get worse on Prednisone
Medications to avoid in MG
• Calcium channel blockers• Beta-blockers• Quinine• Quinidine• Procainamide• Lidocaine• Aminoglycosides• Polymyxin• Morphine• Barbiturates• Neuromuscular blocking agents• Magnesium
MG keypoints
• There is an increased incidence of thymic abnormalities and thyroid disease in patients with MG
• 85% of patients with generalized MG are AChR antibody positive
• Mild cases may be treated with acetylcholinesterase therapy (pyridostigmine 60mg tid or qid), whereas worse presentations may benefit from immunosuppresive Rx
• IVIG or Plasmapheresis may help severe weakness
Muscle Diseases
Neuro-oncology
Epilepsy
Epilepsy
Seizure or Syncope?
Pre-ictal features• Seizure
– Warning: may be preceded by aura
• Aura is actually part of seizure (Simple Partial)
– Provocation: Alcohol or medication withdrawal, CNS infections, Trauma
– Appearance: no change; may be staring
– Posture: Any
– Onset: Sudden
• Syncope– Warning: lightheadness,
feeling of faintness or “doom”.
– Provocation: Change of posture, pain, dehydration, anxiety, cough, micturition, etc
– Appearance: Pale, ashen, sweating
– Posture: Usually upright, may be sitting
– Onset: Gradual
Ictal features
• Seizure– Duration: Seconds to
minutes
– Incontinence: May be present
– Injuries: More Common
– Tonic/clonic movements: Generalized or focal
– Autonomic features: Tachycardia, increased blood pressure
• Syncope– Duration: Seconds
– Incontinence: None
– Injuries: Infrequent
– Tonic/clonic movements: Rare, usually bilateral
– Autonomic features: Bradycardia, Low BP, Dilated pupils
Post-ictal Features
• Seizure– Confusion/Disorientation:
Present for several minutes
– Speech: May be garbled
– Pain/muscle soreness: Present after a generalized tonic-clonic seizure
– Focal transient neurologic deficits: May be present
• Syncope– Confusion/Disorientation:
Usually rapid return to baseline
– Speech: Normal
– Pain/muscle soreness: Absent
– Focal transient neurologic deficits: None
Stroke• Sudden focal neurologic deficit caused by ischemia (80% - 85%) or
Hemorrhage (15% -20%).• TIA = sudden ischemic focal neurologic deficit that resolves
completely. 24 hours is current definition. (Good cause for 1 hour as cutoff.)
• Hemorrhagic Stokes: SAH (5% total) or intraparenchymal (10% - 15%)
• Leading cause of disability in US• Third leading cause of death in US• Incidence: 700,000+ per year. 20% recurrent• Risk increases exponentially with age.• Racial differences: higher in AA• Cost >$50,000,000,000 per year. About 50% hospital costs. Rehab
and long term care account for most of the rest.• Costs of lost productivity not accounted for.
Pathophysiology• Large vessel occlusions
– MCA: contralateral hemiparesis or hemisensory loss, visual field loss– Left: aphasia– Right: hemineglect
• Deep penetrating vessel occlusions• Lacunar syndromes
– Pure motor hemiparesis • Internal Capsule, Corona radiata, or basis pontis
– Pure sensory syndrome • VPL nucleus of Thalamus
– Clumsy hand – dysarthria syndrome • basis pontis
– Ataxic hemiparesis• Posterior limb of the internal capsule, basis pontis
• Spinal cord strokes can occur but rare• Ischemia and Hemorrhage may be indentical clinically• Clues for Hemorrhage: headache, n/v, Severe HTN
Artherosclerotic lesions
Cerebro-vascular Territories and Syndromes
• Anterior Cerebral Artery– Contralateral leg weakness
• Middle Cerebral Artery– Contralateral face/arm >leg weakness– Hemisensory Loss– Visual Field cut– Aphasia/Neglect
• Posterior Cerebral Artery– Contralateral Visual Field Cut
• Deep or “Lacunar”– Contralateral Motor or sensory loss with “cortical signs”
• Basilar Artery– Occulomotor deficits +/- ataxia with crossed motor/sensory deficits
• Vertebral Artery– Lower CN deficits +/- ataxia with Crossed sensory signs– Ex) Wallenberg Syndrome
Blood supply to base of brain
Emergency Stroke Evaluation
• Stroke is time-critical medical emergency
• Area of infarct – minutes to hours of ischemia leads to irreversible infarct
• Ischemic penumbra – area that could infarct if perfusion not restored quickly.
• Most damage in first 3 – 6 hours
• Penumbra is Target of Rx
Stroke Mimics
• Seizure with Todd’s Paresis• Intracranial mass• Migraine• Meningitis/encephalitis• Drug OD• Hyper or hypoglycemia• Unmasking of prior deficits due to acute illness• Cervical or head trauma• Post cardiac arrest ischemia• Hypertensive encephalopathy• Psychogenic
Emergent Eval and Rx
• Sudden neurologic dysfunction over minutes to hours probably = stroke
• Stroke mimics• Quick eval – NIH stroke scale
– GCS not very useful for stroke
• Full Neuro exam later• With TIA, risk for stroke increased with
– TIA >10 minutes, limb weakness, speech disturbance, >60 yo, DM
• Hospitalize TIAs – risk highest in first few days after TIA for major vascular event
• Neuro-immaging: ischemic vs Hemorrhage vs ?
Emergent CT scan
NIH Stroke Scale• LOC: (alert to coma)• LOC questions: month and age• LOC commands: close eyes, make fist• Best Gaze• Visual Fields• Facial palsy• Left Arm• Right Arm• Left Leg• Right Leg• Limb ataxia• Sensation to Pin• Best Language• Dysarthria• Extinction
Neuroimaging in acute Stroke• Noncon CT first study – r/o hemorrhage
– Relatively insensitive to acute stroke in first few hours– Subtle findings: Hyperdense vessels, loss of grey-white boundaries,
effacement of sulci. These findings are highly specific– Noncon CT: ~100% sensitive for intraparenchymal hemorrhage; ~90%
for SAH.– Xenon inhalation - map of cerebral blood flow – not widely available.
• MRI: More expensive, time consuming, less available; therefore not the standard of care.– DWI: sensitive to early cytotoxic edema. May slightly overestimate area
of infarction. Apparent Diffusion Coefficient (ADC) may be more accurate.
– PWI: area of decreased perfusion– PWI – DWI = ischemic penumbra area– Spectroscopy: biochemical marker identification.
• Vessel imaging: Conventional angiogram, CTA, MRA, Transcranial Doppler. (This info usually not critical for initial treatment decisions.
Neuro-imaging
Cerebral Angiogram
Acute Stroke Therapy
• IV t-PA (recombinant tissue plasminogen activator) is effective for acute ischemic stroke if given within 3 hours of onset, better if given earlier.
• Rigorous selection of right patients necessary to maximize efficacy and minimize risk.
• Knowing time of onset is crucial.– Awaken with stroke – time last seen normal = onset– Aphasic with no witness – onset time not known;
therefore contraindicated.
BP management in Acute Stroke
• BP may be up to maintain perfusion• Elevated BP increases risk of hemorrhage after t-PA.• BP should be under 185/110 for t-PA• Use Nitro paste or Labetalol acutely to get BP down if
necessary• Maintain BP below 185/105 after Rx with nicardipine,
labetalol, or nitroprusside.• t-PA dose is 0.9mg/kg to max of 90mg. 10% as one
minute bolus, other 90% infused over an hour.• No antiplatelet Rx for 24 hours.
rt-PA
t-PA eligibility criteria• Inclusion Criteria
– Age >18– Clinical Dx of ischemic Stroke– Onset within 3 hours of Treatment– CT without hemorrhage
• Exclusion Criteria – Historical– Stroke or head trauma within 3 months– History of intracranial Hemorrhage– GI or GU bleeding in previous 21 days– Major surgery or trauma within previous 14 days– Arterial puncture at noncompressible site or LP in previous 21 days– Pregnant or lactating
• Exclusion Criteria – Clinical– Rapidly improving stroke symptoms– Seizure at onset– Symptoms suggestive of SAH– Persistent BP > 185/110 or aggressive rx needed to control BP– Acute/subacute MI or pericarditis
• Exclusion Criteria – Radiographic– CT evidence of hemorrhage– CT sings of major early infarct *controversial
• Exclusion Criteria – Laboratory– Glucose <50 or >400 mg/dl– Platelet count <100,000– If on warfarin and PT >15secs– If on Heparin with 48 hours and PTT elevated
If worsening while on t-PA
• Stop infusion
• Stat CT
• Platelet count – treat if low
• PT/PTT/fibrogen – Rx with cryoprecipitate if necessary
• Neurosurgery consult
Effectiveness of t-PA
• Nearly doubles the odds of recovery to independent function at 3 months: 47% vs 27%.
• Symptomatic intracranial Hemorrhage risk is 6.4%
• No impact on mortality after stroke.
Antiplatelet therapy
