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Finishing Neuro with Seizures

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SeizuresSeizure disorders

Things you should know

  • Epileptic Seizures – abnormal brain activity (affects 5-10% of people)
  • Epilepsy – recurrent seizures (affects 1% of people)
  • Causes
    • Hyponatremia
    • Hypoglycemia
    • Stroke or transient ischemic attack (TIA)
    • Dementia, such as Alzheimer disease
    • Traumatic brain injury
    • Infections, including brain abscess, meningitis, encephalitis, and HIV/AIDS
    • Congenital brain defect
    • Metabolic disorder present at birth ( e.g. phenylketonuria)
    • Brain tumor
    • Abnormal blood vessels in the brain
    • Other illness that damages or destroys brain tissue
  • Types of Seizures
    • Generalized Seizure – involve the entire brain
      • Grand Mal or generalized
      • Absence
      • Clonic
      • Myoclonic
      • Tonic
      • Atonic
    • Partial Seizure – Involve a small area of the brain
      • Simple – awareness is retained
        • Simple Motor
        • Simple Sensory
        • Simple Psychological
      • Complex – impairment of awareness
      • Partial seizure with secondary generalization

I came in to see my physician assistant today because of…

  • Generalized Seizure
    • Grand Mal Seizure
      • Unconsciousness
      • Convulsions
      • Muscle rigidity
    • Absence Seizure
      • Brief loss of consciousness
    • Clonic Seizure
      • Repetitive jerking movements
    • Myoclonic Seizure
      • Sporadic jerking movements
    • Tonic Seizure
      • Muscle stiffness
      • Rigidity
    • Atonic Seizure
      • Loss of muscle tone
  • Partial Seizure
    • Preservation of consciousness and evolves into loss of consciousness and convulsions
    • Jacksonian march – Seizure spreads from distal limb to ipsilateral face.
    • Simple Seizure
      • Jerking, muscle rigidity, spasms, head-turning
      • Unusual sensations affecting vision, hearing, smell, taste or touch
    • Complex
      • Lip smacking, chewing fidgeting, walking and other repetitive, involuntary but coordinated movements
      • An aurora is often present
      • Involves the temporal lobe

Labs, Studies and Physical Exam Findings

  • Electroencephalogram –helps determine the type of seizure
    • Generalized seizures – generalized spikes and slow waves
    • Simple partial seizure – focal rhythmic discharges may be present
    • Complex partial seizure – interictal spikes with slow waves
  • MRI / CT – to rule out other diagnosis
  • Laboratory tests
    • Blood tests
      • Blood Glucose
      • Electrolyte levels (including calcium, magnesium and sodium)
      • Complete blood count
      • Renal and liver function tests
      • Toxicologic screening and anticonvulsant drug levels
      • Arterial blood gas results
      • Blood culture
      • Urinalysis
      • CSF analysis
    • Urine biochemistry (phenylketonuria)
  • Electroencephalogram (ECG) – to rule out heart conditions
  • Lumbar puncture – to diagnose a CNS infection

Treatment

  • First Aid
    • Place in recovery position or roll to one side
  • Treat underlying cause if you can find one
  • In most cases a first time seizure should not be treated medically.
  • Medications – one medication should be used per patient however no one medication is best for every patient.
    • Anticonvulsants
      • Midazolam
      • Phenytoin
      • Carbamazepine
      • Valproate
      • Phenobarbital
  • Surgery in patients who are not controlled with medications and have partial seizures surgery may be an option.
    • Resection of the offending area of the brain

Status epilepticus

Things you should know

  • A life-threatening neurologic disorder defined as 5 minutes or more of a continuous seizure activity or several clinical seizures without return to baseline in between
  • Seizure
  • Causes:
    • Stroke / Hemorrhage
    • Intoxicants or adverse reactions to drugs
    • Insufficient dosage of a medication already prescribed
    • Sudden withdrawal from a seizure medication
    • Consumption of alcoholic beverages while on an anticonvulsant, or alcohol withdrawal
    • Dieting/fasting while on an anticonvulsant
    • Starting on a new medication that reduces the effectiveness of the anticonvulsant or changes drug metabolism
    • Developing a resistance to an anticonvulsant already being used
    • Gastroenteritis while on an anticonvulsant
    • Developing a new, unrelated condition in which seizures are coincidentally also a symptom, but are not controlled by an anticonvulsant already used
    • Metabolic disturbances

Labs, Studies and Physical Exam Findings

  • Physical and Neurologic Exam
  • Laboratory Tests
    • Blood Glucose
    • Electrolyte levels (including calcium, magnesium)
    • Complete blood count
    • Renal and liver function tests
    • Toxicologic screening and anticonvulsant drug levels
    • Arterial blood gas results
    • Blood culture
    • Urinalysis
    • CSF analysis
  • Electroencephalogram (EEG) – Continuous seizure activity
  • CT Scan or MRI

Treatment

  • Medications
    • Benzodiazepines are first line- Diazepam, Lorazepam, Midazolam
    • Anticonvulsant agents – Phenytoin, Fosphenytoin
    • Barbiturates – Phenobarbital
    • Anesthetics – Propofol
  • Supportive Therapy

Syncope

Things you should know

  • Global cerebral hypoperfusion
  • Causes
    • Cardiac
      • Arrhythmias
      • Abnormalities of the heart valves
      • Hypertension
      • Aortic Dissection
      • Cardiomyopathy
    • Non-cardiac
      • Postural hypotension
      • Dehydration
      • High altitude
      • TIA
      • Migraine
      • Situational syncope (blood drawing, micturition, defecation, swallowing, coughing)
  • Differential diagnosis
    • Central nervous systems ischemia
    • Vasovagal Syncope
    • Deglutition Syncope
    • Blood pressure

I came in to see my physician assistant today because of…

  • Partial or complete loss of consciousness
  • Skin paleness
  • Lightheadedness
  • Tunnel vision
  • Nausea
  • Cold, clammy skin
  • Blurring of vision

Labs, Studies and Physical Exam Findings

  • Neurologic Exam
  • CT or MRI scan – if with seizure and abnormalities in neurologic exam
  • Carotid ultrasonography – to identify carotid artery disease
  • Hemoglobin count – to identify anemia or blood loss
  • ECG
  • Holter monitoring
  • Tilt table test – to elicit orthostatic syncope secondary to autonomic dysfunction

Treatment

  • Positioning
    • In the event of syncope, position the patient on the ground, with the legs slightly elevated or leaning forward, head between the knees for 10 to 15 minutes
  • Intravenous access
  • Oxygen administration
  • Advanced airway techniques
  • Glucose administration
  • Pharmacologic circulatory support
  • Pharmacologic or mechanical restraints
  • Defibrillation or temporary pacing

Tourette disorder

Things you should know

  • Motor and vocal tics – sudden brief intermittent movements
  • Coprolalia – involuntary swearing
  • Occurs between 2 and 15 years old
  • Causes
    • Genetics – Likely an inherited disorder
    • Brain abnormalities

I came in to see my physician assistant today because of…

  • Motor Tics
    • Eye blinking
    • Head jerking
    • Shoulder shrugging
    • Eye darting
    • Finger flexing
    • Sticking the tongue out
    • Touching the nose
    • Touching other people
    • Smelling objects
    • Obscene gesturing
    • Flapping the arms
    • Hopping
  • Vocal Tics
    • Hiccupping
    • Yelling
    • Throat clearing
    • Barking
    • Using different tones of voice
    • Repeating one’s word or phrases
    • Using vulgar, obscene swear words

Labs, Studies and Physical Exam Findings

  • Physical Exam – Maybe normal or show repetitive movements
  • To rule out other conditions and secondary causes:
    • EEG – if tics and seizure activity exists
    • MRI – to rule out brain abnormalities
    • TSH levels – to rule out hypothyroidism, that cause tics
    • Urine drug screen
    • Serum Copper – to rule out Wilson’s disease

Treatment

  • Deep brain stimulation
  • Behavioral therapy
    • Habit reversal
    • Exposure and response prevention
  • Medication once behavior is interfering with social interactions or activities of daily living
    • Dopamine antagonists – fluphenazine, or pimozide
    • Haloperidol is historically the drug of choice

Study Tip

Parkinson’s law - “work expands, so as to fill the time available for its completion”.

Key Terms and Ideas

  • Which type of seizure is associated with generalized spikes and slow waves?
    • Generalized seizure
  • Does the term tonic refer to jerking movements or muscle stiffness?
    • Muscle stiffness
  • What is the age range for the onset of Tourette syndrome?
    • 2-15 years old
  • What is the first line treatment for a patient in status epilepticus?
    • Barbiturates – Diazepam

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MS, Myasthenia Gravis, Guillain Barre and so much more

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Multiple sclerosisGuillain-Barré syndrome

Things you should know

  • Autoimmune disease, triggered by an antigen and resulting in an attack on the peripheral nervous system
    • Campylobacter jejuni
    • Cytomegalovirus
    • Influenza
  • Ascending paralysis - weakness of the feet and hands going upward, towards the trunk

I came in to see my physician assistant today because of…

  • Bilateral ascending paralysis – begins in the lower limbs and rapidly moves up.
    • Difficulty walking with rubbery legs or legs that buckle.
  • Tingling or numbness
  • Muscle tenderness or cramp-like pain
  • Orthostatic hypotension
  • Abnormal heart rate – Palpitations can occur
  • Blurred vision and double vision
  • Difficulty moving facial muscles

Emergency symptoms:

  • Breathing temporarily stops
  • Difficulty breathing
  • Difficulty swallowing
  • Drooling
  • Fainting
  • Feeling light-headed when standing

Labs, Studies and Physical Exam Findings

  • Physical Examination
    • Presence of muscle weakness
    • Loss of tendon reflexes in the arms and legs – Areflexia
    • Loss of proprioception
    • Loss of autonomic function
      • Orthostatic hypotension
      • Changes in rate and rhythm
      • Labile blood pressure
    • Decreased breathing – caused by gradual respiratory paralysis
  • Lumbar puncture –  presence of albuminocytological dissociation, an elevated protein level, but with no increased cell count
  • EMG ( electromyography) and Nerve conduction velocity test – show prolonged distal latencies, conduction slowing, conduction block, and temporal dispersion of compound action potential in demyelinating cases
  • ECG – may show arrhythmias
  • Pulmonary function tests

Treatment

  • Supportive care is the primary treatment.  About 30% of patients will require breathing support
  • Plasmapheresis – in an effort to filter the antibodies
  • Gammaglobulin (IVIG)
  • Rehabilitation – 60- 80% of patients recover completely within a year.

Multiple sclerosis

Things you should know

  • It is a demyelinating disease, however the cause is uncertain
    • Autoimmune destruction of myelin
    • Failure of myelinating cells
  • This is a progressive disease
  • Risk Factors?
    • Geography – more common to those who live farther from the equator and in the northern Europe regions.  People who move after age 15 retain the risk factor from their country of origin.
    • Some genetic variations may be at an increased risk
    • Infections?
    • Smoking
  • The course is usually relapsing and remitting

I came in to see my physician assistant today because of…

  • Symptoms are relapsing and remitting and often move from one area of the body to another during each exacerbation
  • Visual disturbances
    • Double vision, nystagmus, blindness, blurry vision
  • Focal weakness
  • Gait difficulties – Ataxia
  • Fatigue and weakness
  • Numbness or tingling
  • Dizziness and Vertigo
  • Pain
  • Emotional Changes
  • Bladder dysfunction
  • Tremor
  • Headache
  • Seizures

Labs, Studies and Physical Exam Findings

  • Physical Exam
  • Lumbar puncture – may show evidence of chronic inflammation in the CNS including mild protein elevation, mild increase in leukocytes
  • MRI with gadolinium shows areas of demyelination
  • Evoked Potential Tests – measure electrical signals sent by the brain in response to stimuli. It can be visual stimuli or electrical stimuli.  Lesions and nerve damage to the optic nerves, brainstem or spinal cord can be detected.
  • Blood tests – to rule out some infectious diseases that have similar symptoms with MS

Treatment

  • To Treat attacks
    • Corticosteroids high dose
      • oral prednisone
      • intravenous methylprednisolone (Solu-Medrol)
    • Plasmapheresis has been shown to be beneficial
  • To Slow progress of the disease
    • Beta interferons
    • Glatiramer acetate (Copaxone)
    • Fingolimod (Gilenya)
    • Natalizumab (Tysabri)
    • Mitoxantrone
    • Teriflunomide (Aubagio)
  • To Treat Symptoms
    • Physical therapy – will involve stretching and strengthening exercises and the use of devices that can make it easier to perform daily tasks.
    • Dalfampridine (Ampyra) an oral medication may improve walking speed
  • Baclofen and Tizanidine (Zanaflex) help with spasticity
  • Amantadine helps with fatigue
  • Medications also may be prescribed for depression, pain, and bladder or bowel control problems that may be associated with multiple sclerosis.

Myasthenia Gravis

Things you should know

  • An autoimmune disorder where acetylcholine receptors are blocked by antibodies
  • Acetylcholine normally causes an excitatory effect at the neuromuscular junctions

I came in to see my physician assistant today because of…

 

  • Fatigability – Increasing weakness which improves with rest

 

    • Ptosis (Droopy eyelids)
    • Diplopia (Double vision)
    • Difficulty chewing and swallowing
    • Change in the voice
    • Difficulty breathing, leading to respiratory failure (myasthenic crisis)

Labs, Studies and Physical Exam Findings

  • Physical and Neurologic Exam
    • Often Normal
    • Easy Fatigability, weakness improving after rest and worsening again on repeat exertion
    • Normal reflexes and feeling of sensation
  • Blood test
    • Acetylcholine receptor antibody test
  • Ice test – applying ice causes an increase in strength
  • Edrophonium is a short acting anticholinesterase which may aid in the diagnosis
  • CXR / CT / MRI – to identify a tumor or thymoma
  • Nerve Conduction Studies
  • Electromyography – results will present muscle fibers to be unresponsive to stimuli
  • Pulmonary function tests
  • Muscle biopsy

Treatment

  • Medication
    • Acetylcholinesterase inhibitors
      • Neostigmine and pyridostigmine – slows down the natural enzyme cholinesterase that degrades acetylcholine in the motor end plate.
    • Immunosuppressive drugs
      • Prednisone, cyclosporine, mycophenolate, and azathioprine
      • Use in combination with an acetylcholinesterase inhibitor.
  • Plasmapheresis and IVIG – in an emergency to remove antibodies
  • Surgery
    • Thymectomy

PANCE Tips

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Key Terms and Ideas

Matching section answer choices are MS, MG, GB.

  • Ascending paralysis                                                   GB
  • Easy fatigability which improves with rest          MG
  • Relapsing and remitting symptoms                       MS
  • Has an issue with acetylcholine receptors           MG  (I mistakenly say MS in the podcast)
  • Loss of tendon reflexes                                              GB

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