Neurology in practice

4 cases

Think about the cases

Think about what might go wrong

Revise simple examination

Case 1Mr ECRetired jump jockey72 years of age Sunday morning –

walks to the paper shop and then feels dizzy and unable to walk

Ambulance called and taken to Addenbrooke’s

In hospital

CT head – acute infarction R MCA artery territory and Right corpus callosum, also demarcated area of low density involving the right posterior cerebellum

Case 1 QuestionsWhat clinical signs might

you expect to find in this man?

What is the possible management options when he gets to hospital

What are the risk factors?

What are the two most likely pathological processes that have cause this finding on CT?

Right sided Stroke - signs

Upper motor neurone signs on left

Facial weaknessPronator driftIncreased toneClonusWeaknessNo wastingBrisk reflexes

Back at home – case 1 questionsHe is seen at home and

is able to walk with a stick but keeps bumping into things on his left

He is no longer able to dress and puts both legs into his right pyjama trouser leg

He only eats half of his dinner

Can you explain this……..?

Visual field defect

Homonomous hemianopia

Sensory or visual inattentionNon dominant parietal lobe syndrome

Sensory inattentionMay mix up left and right Ignores one half of body

Visual inattentionSees both sides when tested

independently Ignores one side when

presented together

Causes of Stroke

80% Ischaemic

20% Haemorrhagic

Secondary prevention

What does he need to improve his quality of life?

What does his GP need to do and follow up?

Case 2Mr Brown 72 years of ageWoke up this morning

and noticed a sudden blurring of his vision like a curtain coming down

Then was noted to have problems with his speech

2 hours later completely better

Seen in surgery

BP 140/102P 70 regularHeart sounds

normalNo abnormal

neurological signsBruit over left

carotid artery

Case 2 questions ?

How can his symptoms be explained?

What is the chance of this happening again?

What can be done to investigate this?

How should he be managed?

EpidemiologyEpidemiology AetiologyAetiology

The incidence is 42 per 100,000 population and it is commoner with increasing age.

It is rare under the age of 60. The incidence is decreasing,1

perhaps as hypertension is better controlled.

It affects men more than women and black races are at greater risk.

About 15% of first stroke victims have had a preceding TIA.

Usually Thromboembolism: 80% carotid area in about 80% 20%. Vertebrobasilar . Commonest source of emboli is the

carotids, usually at the bifurcation. They can originate in the heart

with atrial fibrillation particularly, with mitral valve disease, or aortic valve disease, or from a mural thrombus forming on a myocardial infarct or a cardiac tumour, usually atrial myxoma.

The vertebrobasilar arteries may be a source.

TIA

Case 3A 26 year old

woman comes to see you

She has a history of migraine

Usually worse when she is due a period

Seems to have improved since taking the oral contraceptive pill

She is on a combined oestrogen and progesterone pill

She smokes 20 cigarettes a day

Should she continue the pill?

3 months later

She comes back saying the migraines have changed

She gets a warningHer boyfriend says that she goes blank before

her migraine and smacks her lips togetherShe then recovers but after 10-15 minutesHe is worried

Case 3 questions

What might be going on now?

Should she remain on the pills?

Can she still drive to work?

What does her GP need to do?

Focal Migraine with aura – avoid Oestrogen containing pills

Absence seizures

• Most common in children• seizure involves a brief

disruption of consciousness—lasting from a few seconds to about half a minute.

• Typically, this seizure starts suddenly; the person stops what they are doing and stares blankly.

• Eyes may roll upwards briefly before this event disappears as quickly as it came

• In the past, these seizures were known as "petit mal" attacks.

• These seizures can include eyelid movement, drooping or drawing back of the head, smacking of lips, or sweating.

http://www.dft.gov.uk/dvla/medical/ataglance.aspx

Case 4

Mr Perugia68 year old

caretaker for Catholic Church

3 weeks ago slipped whilst polishing floor – fell and banged his head

Quickly recovered

Case 4

Complains of headache

Worse when he wakes and when he bends down

When examined he is found to have mild right sided weakness

Case 4 - questionsWhat features about a

headache alert a clinician to a serious cause?

His right arm and leg are weak and have brisk reflexes – what does this suggest?

What does the clinician need to worry about and what does this man need doing ?

A subdural haematoma may be:

An acute subdural haematoma - the blood collects quickly after a head injury; symptoms can occur immediately or within hours.

A chronic subdural haematoma - the blood collects more slowly after a head injury; symptoms can occur 2-3 weeks after the initial injury.