Neurology – a whistle stop tour to finals!!

1. Neurology – a whistle stop tour to finals!! Katie Baxter & Hannah Baird

2. Warning: This is not an all you need to neurology session! – It is a guide the “definitely need to know” for OSCE’s, (and also FY1) you can do the “maybe need to knows” at home!!! Because we forgot them the day we finished finals exams!

3. Examining the Cranial Nerves -Intro … Your name, your purpose - check the patient -Observations – In a neuro exam this will tell you loads immediately. Are they walking? Require walking aids? Any obvious wasting or weakness Speech is it normal? Tremor/ dyskinesis

4. CN 1 – Olfactory - have you noticed any change in your sense of smell ?? (it is unlikey but there maybe smelling salts for you to use!) CN2 – Optic – 1. Visual acuity (use snellen chart/ or reading a book or simple sentence.) 2. Visual fields – any loss? 3. Examination of blind spot – any central scotoma? 4. Accomodation – “look at the wall behind me and then the pin” 5. Pupils (Afferent CN2, efferent CN3) – a)direct b) Consensual c) Swinging - any relevant afferent pupillary defect? 6. Fundoscopy

5. CN3 – Occulomotor – Elevates, depresses and abducts the eye. (innervates inferior oblique, superior, inferior and medial rectus muscles.) - Palsy: Eye will be down and out. CN4 – Trochlear – moves the eyeball down and medially. (innervates the superiror oblique) Palsy: Failure to look inferiorly during adduction . RARE!! CN6 – Abducens – abducts the eye (lateral gaze) (innervates the lateral rectus) Palsy: inability to abduct the eye CN5 - Trigeminal: - Sensory: Test over three areas with cotton wool - Motor: Any temporalis wasting? Clench teeth, open jaw against resistance. - jaw jerk!

6. CN7 – Facial (Temporal, zygomatic, Buccal, Mandibular, cervical Motor: 5 areas: Close your eyes Puff out your cheeks Smile Frown CN8 – Vestibular Cochlear : gross test of hearing (whisper numbers in their ear) - Webbers - tuning fork on to the forhead. Is the vibration heard loudest in one ear or the other? Heard loudest in the ear with hearing loss = conduction deafness Heard loudest in normal hearing ear = sensorineural deafness - Rinne’s – If bone conduction is greater than air = conduction deafness. So do Webber’s first, then in the ear with the loudest noise, do Rinne’s to confirm which type of deafness!!

7. CN9 – Glossophargneal CN10 – Vagus Asses 9&10 together: 1. Swallow 2. Speech – “British constitution”, “baby hippopatmus” If speech is satacarto and slurred – ataxic speech (cerebellar) Nasal speech – Bulbar palsy (LMN sign) Spastic speech (hot potato speech) – psudeo-bulbar palsy (UMN sign) 3. Gag reflex (DON’T DO IT!) CN11 – Accessory – Turn your head to my hand, resist me pushing - Shrug your shoulders..resist me! CN12 – Hypoglossal – tongue out – any deviation? - put tongue inside your cheek – don’t let me push you away To complete my examination……… Full history Full neuro exam (upper &lower limb) Full SALT assessment if any stroke concerns Relevant tests/ imaging - CT head/ EMG/ MRI

8. Most likely thing you would get in an OSCE facial palsy: Causes: Bell’s – LMN sign Post acoustic Neuroma operation – LMN sign Stroke – UMN sign Q: How would you tell the difference between an Upper motor neuron facial palsy and a lower motor neuron palsy??

9. The Neuro Exam • Know your dermatomes! • Light touch • Pain • Proprioception • Temperature • Vibration Sensory

10. Motor Fasiculations Scars Wasting Abnormal positioning • Inspection • Tone Increased/ decreased Clonus

11. Power- MRC grading out of 5 • Reflexes- Same as the myotomes • Co-ordination- Finger to nose, dysdiadokokinesis, rebound, heel-shin

12. Watch this case....1.Picture it is your OSCE, below is Wilf your patient!2. What would you do?3. What order would you do stuff in?4. Do you know enough to answer the examiners questions??

13. Parkinson’s Examination • Introduction.....you know the drill • Inspection – This is the most important bit of this station. • note the age of the patient • Posture (stooped, hands over hernia’s) • Expression – blank expression (facial hypomimia) • Speech – quiet, and slow • Any pill rolling tremor? • Any food down the front of their clothes (Q: What would this mean??) Then you know you can focus your examination... (Remember..these patients will have been treated, and some may have taken their medications..so the obvious features maybe less pronounced!)

14. 3. Assess for rigidity. - Shake the patients hand..move the arm and the wrist and elbow. -Is it stiff? (Cogwheel rigidity) -It is stiff but then gives way? (Clasp knife) If unsure you can extenuate it, by asking the patient to tap their knee with there other hand. 4. Assess for Bradykinesia (slowing down) • Thumb to fingers test ( it will slow down eventually). *At this point I would also ask the patient to do the finger nose test to check that the tremor is not an intention tremor (that would be where the tremor gets worse on an action.)

15. 5. Then move up to the face. -Eye movements – look for loss of vertical gaze. (Progressive Supranuclear palsy) - Gabellar tap – loss of attenuation (warn the patient!) 6. Asses the Gait • Festinatant • Reduced arm swing • Difficulty turning • You can also do Rhomberg’s to demonstrate unsteadiness 7.Asses Function - Ask them to write – evidence of micrographia. - Ask them to undo and re-do a button

16. To complete my examination... • Take a full history from the patient ( including testing their memory, and asking about any problems sleeping and their mood) • Check their medications • Lying/ Standing BP - Q: Why would you ask this? As Parkinson’s is a clinical diagnosis I would not expect any investigations... Although you could do a DAT scan – a dopamine update scan which would show reduced uptake in the substaniaNigra. )

17. The Parkinson Plus Syndromes • Progressive Supranuclear palsy – (also known as Steele Richardson Syndrome) • Opthamalpegia in addition to Parkinson’s disease. • Loss of vertical gaze • Patients can often miss their mouths when eating ....hence sloppy tie syndrome!! • Same treatment as Parkinson’s!!

18. Shy Dragers Syndrome • Autonomic Failure with Parkinson’s • Postural Hypotension • Loss of bladder control • Erectile dysfunction • You do not need to know much about this..but asking the questions on it, casually in a history or examination will make you look slick and know what your talking about.

19. Treatment of Parkinson’s 1. L dopa plus dopa-decarboxylase inhibitor – (replacement plus anti-dopamine break down drug)main medication in Parkinson’s, first line in very elderly patients. -SE: Dyskinesias • Efficency tends to decrease after around 5 years. (End of dose effect) 2. Dopamine agonists – stimulate the dopamine receptors in the brain. • Less effective • Used in younger patients to delay the need for L dopa 3. Catechol-o-methyltransferase (COMT) – prevent peripheral breakdown of dopamine. - Usually an add on therapy!

20. Multiple sclerosis • A relapsing and remitting autoimmune condition • T-cell mediated immune response targeting myelin • Prolonged demyelination leads to axonal loss and progression of symptoms • Women are three times more likely to be affected than men • Mean age of onset is 30 • Prevalence is much higher in countries further from the equator

21. Vitamin D in early years

22. Presentation • Unilateral optic neuritis (pain on eye movement, decline in central vision, optic disc swelling) • Sensory symptoms • Motor symptoms- weakness, transverse myelitis • Cerebellar or brainstem- ataxia, diplopia

23. Diagnosis • Clinical!! • 2 lesions disseminate in time and place • A careful history may release previous episodes

24. Treatment • Acute attacks- short course high dose steroids shorten relapses (no more than 2x a year) • Interferons- must have had two attacks in the last 3 years, followed by reasonable recovery. • This drug helps to reduce the relapse rate (by about 30%)and reduce the occurrence of plaques on MRI. • Does not alter the accumulation of disability • Others- glatiramer, natalizumab.

25. Other treatment • Treat infections promptly, especially UTIs • Spasticity- baclofen, diazepam • Incontinence- oxubutynin, intermittent self-catheterisation • Physio and OT input • Counselling

26. End stage symptoms: Dementia Incontinence Ataxia Brainstem signs

27. Neuro Exam • So what could you be given as part of your normal Neuro exam: • Mononeuropathy * – one nerve affected • Mononeuritis multiplex – 1+ nerves affected in a non symetrical pattern • Polyneuropathy * • Autonomic Neuropathy

28. Mononeuropathy Upper limb: 3 major nerves affected. 4 things to know for each: Copy out the title and then match up the clinical signs

29. Median Nerve ( Carpal Tunnel syndrome) • Compression at the carpal tunnel • More likely in women, Diabetics, pregnant women. • Classically hurts people at night, but pain relieved by dropping hand over the side of the bed. Sensory pattern: Loss over 1st, 2nd and half of the third finger. Motor: Weak abductor pollicis brevis Special Test: • Tinnel’s: tap over the carpal tunnel area- if positive this will replicate the tingling. • Phalen’s: Make the prayer sign with both hands, this should replicate the tingling in the fingers. Treatment: Carpal Tunnel release – small incision in to the wrist, to cut/loosen the palmar apperneurosis. - Very succsessful surgery.

30. Radial Nerve • Compression at the biceps head or under arm pit (Saturday night palsy!!) • Motor: Wrist drop (no wrist extension) • Sensory: Loss of sensation over anatomical snuffbox • Test: Extension of the wrist against resistance • Treatment: Usually resolves by itself

31. Ulnar Nerve • Compression at the medial condyle Occurs in Supracondylar fractures! • Motor: - loss of adduction of the thumb – no pincer grip! - wasting of the first dorsal interossi • Sensory: Loss over half of 3rd and 4th finger • Special tests: Fromet’s: Take a piece of paper and tell the patient to hold it between their fingers and thumb. Then pull the paper away.. The thumb will bend if positive, to compensate for the lack of pincer grip. (thumb adduction).

32. Polyneuropathy – motor, sensory or both… • Motor: -Wasting of muscles - Can have diminished reflexes - Muscle Weakness - Foot Drop (unilateral often nerve compression – most commonly common peroneal) *Examine as you would for a lower limb neuro …remember to say you would look at the shoes. Why?

33. Sensory neuropathy • Sensory: - Loss of joint position sense - Burning or tingling sensation in the legs/arms - Classic glove and stocking distribution of sensory loss - Decreased sensation over all modalities: - Pain and temperature (spinothalmic) is an early sign - Loss of vibration is a late sign (Dorsal Column)

34. Causes of peripheral Neuropathy • Alcohol - small fibre neuropathy. • B12 deficiency - large fibre neuropathy • Chronic Renal failure • Diabetes – mix of small and large fibre neuropathy • Every Vasculitis • Lyme disease • Malignancy • Charcot Marie Tooth * Get ready to be able to quote 5 off without thinking!

35. *Charcot Marie Tooth • Autosomal dominant • Ch 17 • Motor and Sensory neuropathy • Appearance: • Bilateral peroneal muscle wasting (Inverted Champagne bottle legs!) • Pes Cavus (flat feet) • Claw toes • Multiple scars from surgery • Charcot joint (swollen joint, with fusion of the joint – loss of mobility, loss of sensation.)

36. Stroke • Rapid onset (seconds-minutes) of focal CNS signs and symptoms • Ischaemic (80-90%)- atherothromboembolism, cardiac emboli, thrombus • Haemorrhagic (10-20%) • 3rd commonest cause of death • At age 75 risk is 10/1000/year

38. O/E Ix • A- maintain airway • B- O2, breath sounds • C- BP, ?AF, ?murmurs,?carotid bruits • D- glucose, GCS, neuro • E • ECG • Bloods- FBC, ESR, clotting, cholesterol • CT (urgent)

39. Management • Monitor BP but do not correct • NBM and SALT assessment • Hydration • Stroke unit input- specialist nursing and physio • Antiplatelets- aspirin 300mg OD for 2/52, dipyridamole 200mg BD

40. Thrombolysis • Within 3hrs of onset of symptoms • Tissue plasminogen activator (alteplase) • Increased risk of haemorrhage- repeat CT 24hrs after

41. Prevention • Primary • Secondary- modification of risk factors Age Sex Family Hx Ethnicity Smoking Htn Lipid Diabetes Lifestyle • Carotid stenosis, cardiac source of embolism, vasculitis • Complications: depression, contractures, aspiration, pressure sores

42. TIA • Symptoms resolve in <24 hours • Treatment is crucial, they may precede a stroke/MI • Should be seen within 1/52 • Optimise RF, aspirin+dipyridamole, carotid endarterectomy, warfarin. • ABCD2- score 4 or greater should be seen within 24 hours.

43. Headaches Heaches are very common, the majority people do not consult the doctor about when they have a headache, but they can be a sign of something serious and life threatening. So what questions do we ask to answer this crucial question.. 1. Benign or malignant??? To help reach this answer we ask: 2. Acute or chronic? How acute? 3. Location? 4. Intensity? 5.An y visual signs: Photophobia, flashing lights? Floaters? 6. Triggers? 7. Relieving factors? 8. Associated factors? Nausea? Pain on brushing hair? Washing face? 9. Related to the time of day? 10. Any risk factors ?

44. 1. Subarachnoid haemorrhage • Sudden onset • Worst headache of their life • Usually occipital in location • Photophobia • Nausea or vomiting • Many have pappiloedmea on examination • CT scan, if negative LP with xathechromia • Medical emergency – If you have had such a history in an OSCE remember to say I would ask for senior help!! Recognising when your out of your depth is just as important.

45. 2. Meningitis • Fairly sudden onset headache – not thunderclap • Vomiting • Photophobia • Feeling lethargic and generally unwell • Stiff neck • Not necessarily a rash!!! • Any one in the family ill? • LP and treat accordingly. • Once suspicious of meningitis: In community IM benzylpencillin, in hospital Ceftriaxone. (Chloramphenicol in penicillin allergy.) • Rifampicin for relatives as prophylaxis

46. 3. Space Occupying lesion • Headache that has come on over weeks/months • Often occurs in the mornings • Associated with nausea or vomiting • Many have local signs relating to compression (i.e compression of the optic chiasm/ nerve) • +/- other signs of malignancy – weight loss etc.. • CT head is usually the best imaging for this.

47. 4. Benign Intercranial Hypertension • Worse in the mornings • Relieved by lying down • The syterotypical picture is female, high BMI • Nausea and vomiting • Pappiloedema • High opening pressure on LP • Treatment: Therapuetic tap

48. 5. Migrane Can come in many different shapes and sizes – each patient is different and will experience different symptoms. Classically: • Unilateral • Long lasting – can last for days • +/- aura – zigzagging lines, floaters • Photophobic • Better lying in dark room. • Triggers: Chocolate, Caffeine, COC, certain smells

49. 6. Temporal arthritis • >50 years • Fairly sudden onset • Temporal headache • Bilateral • ?history of polymalagia Rheumatica • Pain on hairbrushing • Do an ESR (will be raised) • Immetidate treatment with high dose Prednisolone –(around50mg.)

50. 7. Tension headache • Bialteral • Temporal • Feels like a band around the head • Can last for days This can be similar to medication overuse headache. Ask the patient how much pain relief they take and how long they have done this for?