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Phase 2 Kaveesha Rajapaksa Ryad Chebbout The Peer Teaching Society is not liable for false or misleading information…

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Presentation on theme: "Phase 2 Kaveesha Rajapaksa Ryad Chebbout The Peer Teaching Society is not liable for false or misleading information…"— Presentation transcript:

1 Phase 2 Kaveesha Rajapaksa Ryad Chebbout The Peer Teaching Society is not liable for false or misleading information…

2 Pathology, Aetiology, Clinical Symptoms and Signs, Investigations and Management of: Epilepsy Multiple Sclerosis Guillain-Barre Syndrome Motor Neuron Disease Parkinson's Disease Dementia The Peer Teaching Society is not liable for false or misleading information… Aims

3 Definition Recurrent tendency to have spontaneous, intermittent and abnormal electrical activity in a part of the brain or generalised across the brain. Leading to seizures. The Peer Teaching Society is not liable for false or misleading information… Epilepsy

4 Aetiology 1.Idopathic (2/3rds) 2.Structural (Trauma, SOL, Developmental, Stroke) 3.Metabolic (hypoglycaemia, hypocalcemia, hyponatraemia) The Peer Teaching Society is not liable for false or misleading information… Epilepsy

5 Partial = focal onset (localising features!) Generalised = no localising features! Simple = aware Complex = impaired awareness The Peer Teaching Society is not liable for false or misleading information… Epilepsy

6 Partial Seizures Commonly caused by structural pathology. Simple Partial (Jacksonian March) Complex Partial = classically temporal lobe! Partial + Secondary Generalisation The Peer Teaching Society is not liable for false or misleading information… Epilepsy

7 Generalised Seizures Commonly idiopathic. Absence = jerk, post-ictal confusion + drowsiness Myoclonic = sudden limb/face/trunk jerk Atonic = loss of tone->fall, no LOC The Peer Teaching Society is not liable for false or misleading information… Epilepsy

8 Prodrome – Aura – Ictal – Post-Ictal Prodrome Mood/Behaviour Change The Peer Teaching Society is not liable for false or misleading information… Epilepsy

9 Aura Strange Smell, Flashing Lights, Déjà vu/Jamais vu Post-Ictal Headache, Confusion, Myalgia, Sore Tongue, Todds Palsy (hemiplegia), Dysphasia The Peer Teaching Society is not liable for false or misleading information… Epilepsy

10 Ictal – Localising Features Temporal Lobe: Automatisms (lip smacking/fiddling), Visceral Aura (abdominal rising sensation), Dysphasia, Déjà vu/Jamais Vu, Hallucinations Frontal Lobe: Jacksonian March (tingling/muscle contractions from fingers to ipsilateral face), Todds Palsy The Peer Teaching Society is not liable for false or misleading information… Epilepsy

11 Parietal Lobe: Tingling Numbness Occipital: Visual Phenomena (spots/lines/flashes) The Peer Teaching Society is not liable for false or misleading information… Epilepsy

12 Investigations EEG (classification) MRI (structural lesions) MEG/PET/SPECT ictal (localise epileptogenic focus for surgery) The Peer Teaching Society is not liable for false or misleading information… Epilepsy

13 Management Partial = Carbamazepine Generalised = Sodium Valproate OR Lamotrigine Neurosurgical Resection The Peer Teaching Society is not liable for false or misleading information… Epilepsy

14 Management Counselling – employment, insurance, driving (1yr seizure free) Contraception and pregnancy Epilepsy Nurse Specialist The Peer Teaching Society is not liable for false or misleading information… Epilepsy

15 Complications Sudden Unexpected Death in Epilepsy (SUDEP) Status Epilepticus The Peer Teaching Society is not liable for false or misleading information… Epilepsy

16 Discrete Plaques of Demyelination in Central Nervous System T-cell Mediated The Peer Teaching Society is not liable for false or misleading information… Multiple Sclerosis

17 The Peer Teaching Society is not liable for false or misleading information… Multiple Sclerosis Risk Factors = Women, Temperate Areas ~30yrs

18 Demyelination Plaque (commonly periventricular, cervical spine, brain stem) Heals Incompletely Prolonged Demyelination Axonal Loss Clinically Progressive Symptoms The Peer Teaching Society is not liable for false or misleading information… Multiple Sclerosis

19 Clinical Courses Benign Relapsing Remitting Secondary Progressive Primary Progressive The Peer Teaching Society is not liable for false or misleading information… Multiple Sclerosis

20 The Peer Teaching Society is not liable for false or misleading information… Multiple Sclerosis

21 The Peer Teaching Society is not liable for false or misleading information… Multiple Sclerosis Symptoms Monosymptomatic! Disseminated in Time and Space

22 The Peer Teaching Society is not liable for false or misleading information… Multiple Sclerosis Optic Neuritis: Decreased Visual Acuity, Pain on Eye Movement, Dyschromatopsia Sensory: Lhermittes Sign, Limb Numbness/Tingling Motor: Transverse Myelitis, UMN Weakness, Uhthoff’s Phenomenon

23 The Peer Teaching Society is not liable for false or misleading information… Multiple Sclerosis Other: Ataxia, Erectile Dysfunction, Urinary retention

24 The Peer Teaching Society is not liable for false or misleading information… Multiple Sclerosis Investigation Dissemination in Time and Space! Clinically (attacks + clinical lesions, 2:2, 2:1, 1:1) +/- Aid of MRI CSF (Oligoclonal Bands) Evoked Potentials

25 The Peer Teaching Society is not liable for false or misleading information… Multiple Sclerosis Management Acute: Methylprednisolone IV Chronic: Interferon/Glatiramer, Natalizumab

26 The Peer Teaching Society is not liable for false or misleading information… Guillain-Barre Syndrome Acute AUI Inflammatory Demyelinating Polyneuropathy Triggers: Campylobacter jejuni, CMV, Mycoplasma

27 The Peer Teaching Society is not liable for false or misleading information… Guillain-Barre Syndrome Symptoms 4 wk peak! Weakness – Leg, Trunk, Respiratory. Proximal, Distal. Symmetrical. Back/Limb Pain Autonomic Features: seating, tachycardia, arrhythmia’s.

28 The Peer Teaching Society is not liable for false or misleading information… Guillain-Barre Syndrome Signs Areflexia!

29 The Peer Teaching Society is not liable for false or misleading information… Guillain-Barre Syndrome Investigations Nerve Conduction Studies – slow conduction Regular FVC

30 The Peer Teaching Society is not liable for false or misleading information… Guillain-Barre Syndrome Management IV Immunoglobin or Plasma Exchange

31 The Peer Teaching Society is not liable for false or misleading information… Motor Neuron Disease Selective loss of motor neurons in: Motor Cortex (UMN), Cranial Nerve Nuclei (UMN/LMN) and Anterior Horn Cells (LMN). >40yrs.

32 The Peer Teaching Society is not liable for false or misleading information… Motor Neuron Disease Key Features UMN + LMN Signs No Sensory Loss/Sphincter Disturbance No Eye Involvement

33 The Peer Teaching Society is not liable for false or misleading information… Motor Neuron Disease Clinical Patterns Amyotrophic Lateral Sclerosis Progressive Bulbar Signs – CN IX-XII, bulbar/pseudobulbar palsy Progressive Muscular Atrophy – no UMN signs Primary Lateral Sclerosis – mainly UMN

34 The Peer Teaching Society is not liable for false or misleading information… Motor Neuron Disease Associations Fronto-Temporal Dementia (10-35%)!

35 The Peer Teaching Society is not liable for false or misleading information… Motor Neuron Disease Signs Stumbling Spastic Gait Foot Drop +/- Proximal Myopathy Weak Grip Spasticity/Hypereflexia/Upwards Plantars + Wasting/Fasciculations

36 The Peer Teaching Society is not liable for false or misleading information… Motor Neuron Disease Investigations MRI/LP/Neurophysiology – exclude other causes Management Riluzole – prolong life by ~ 3months Symptomatic + MDT (Ventilation, PEG)

37 The Peer Teaching Society is not liable for false or misleading information… Parkinson's Disease Decreased Dopaminergic Neurons in Substantia Nigra (Pars Compacta) Decreased Striatum Dopamine Levels Decreased Basal Ganglia – Cortex Communication Decreased Movement

38 The Peer Teaching Society is not liable for false or misleading information… Parkinson's Disease ~65yrs. Associated with Lewy Bodies

39 The Peer Teaching Society is not liable for false or misleading information… Parkinson's Disease Classic Triad Tremor – resting, pill-rolling Rigidity – increased tone, cogwheel rigidity, leadpipe rigidity Bradykinesia – slowness of movement initiation -Expressionless Face, Monotonous Hypophonic Speech, Micrographia -Gait: Festinant, Reduced Arm Swing

40 The Peer Teaching Society is not liable for false or misleading information… Parkinson's Disease Other Symptoms Anosmia Depression Sleep disturbances Visual Hallucinations (animals, children) Dementia (late stage)

41 The Peer Teaching Society is not liable for false or misleading information… Parkinson's Disease Management L-Dopa + Dopa-Decarboxylase Inhibitor (e.g. Madopar) -Efficacy reduces with time = Increased Dose -Dyskinesia’s, Off Freezing, End-of-Dose Reduced Relapse

42 The Peer Teaching Society is not liable for false or misleading information… Parkinson's Disease Management Dopamine Agonist – Ropinirole/Pramipexole Apomorphine – potent DA agonist, acute Anticholinergics – tremor Deep brain stimulation

43 The Peer Teaching Society is not liable for false or misleading information… Dementia Syndrome of progressive deficits in 2 or more higher cognitive domains. (Memory, language, apraxia, agnosia, visuospatial function, personality) Interferes with social functioning. Occurs in clear consciousness. >80yrs=20%, >100yrs=70%

44 The Peer Teaching Society is not liable for false or misleading information… Dementia Types Alzheimer's Disease Vascular Dementia Lewry Body Dementia Fronto-Temperal Dementia

45 The Peer Teaching Society is not liable for false or misleading information… Alzheimer's Dementia Increased Beta-Amyloid Peptide = Progressive Neuronal Damage (hippocampus, amygdala, temporal neocortex) -Neurofibillary Tangles -Amyloid Plaques -Decreased Ach

46 The Peer Teaching Society is not liable for false or misleading information… Alzheimer's Dementia Risk Factors Family History, Downs Syndrome, Homzygosity for ApoE e4 Allele, DM/HTN/AF Protective Factors Smoking, Oestrogen

47 The Peer Teaching Society is not liable for false or misleading information… Alzheimer's Dementia Symptoms Progressive Global Cognitive Impairment Aphasia Anosognosia (lack of insight) Irritability Mood Disturbance – Depression, Euphoria Behavioural Change – Wandering, Aggression

48 The Peer Teaching Society is not liable for false or misleading information… Alzheimer's Dementia Investigations MMSE or Addenbrooks Cognitive Exam CT – temporal/parietal atrophy, ventricular enlargement MRI – hippocampus/amygdala/medial temporal lobe grey matter atrophy CSF – phosphorylated tau protein

49 The Peer Teaching Society is not liable for false or misleading information… Alzheimer's Dementia Management Acetylcholinesterase Inhibitors (Donepezil, Rivastigmine, Galantamine) – help lay down new memories Memantine (Antiglutamatergic) BP Control

50 The Peer Teaching Society is not liable for false or misleading information… Vascular Dementia Cumulative effect of many small strokes. Vascular RF’s – Stroke Hx, HTN Sudden Onset + Stepwise Deterioration -Emotional/Personality Changes -Cognitive Defecits -Depression/Labile Mood

51 The Peer Teaching Society is not liable for false or misleading information… Lewy Body Dementia Fluctuating Cognitive Impairment Visual Hallucinations (animals/children) +/- Parkinsonism Repeated Falls/Syncope CT/MRI – relative sparing of medial temporal lobe Histology – Lewy Bodies in Brainstem/Neocortex

52 The Peer Teaching Society is not liable for false or misleading information… Fronto-Temporal Dementia Frontal + Temporal Atrophy. AD Histology. Early, 45-65yrs Behavioural/Personality Change Disinhibition Change in Diet (sweets, overeating) Emotional Blunting Pick bodies on histology

53 The Peer Teaching Society is not liable for false or misleading information… Dementia Management Care Coordinator Capacity Develop Routines, Plan Ahead Challenging Behaviour – Lorazepam, Risperidone (not Lewy Body!) Depression - Citalopram

54 A 65 year old man with walking difficulties presented to his general practitioner. He complained of worsening tremor in the right arm with stiffness, which he said on occasion spread to his right leg. He said that the tremor was much worse when he was stressed, or in public. Examination revealed a man with a resting tremor, marked cogwheeling rigidity of the right side and an inability to perform repetitive tasks with the right arm. His gait was not normal and he had a reduced arm swing on the right.

55 A 36 year old male patient presents with increasing unsteadiness which started two days ago. Two years ago he had blurred vision in his left eye which improved considerably within a few weeks, but left him with some minor deficit. Eight years ago he had a 3 week episode of numbness in his left arm.


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