Neurology presentation 17 Nov 11 - Croydon Health Services NHS ...

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Neurology presentation 17 Nov 11 - Croydon Health Services NHS ...

23/11/201

1

Neurology

17 November 2011

Practical simple and interesting –I hope

Fred Schon


Headaches

99.9999% benign

0.0001% life threatening

Need wisdom of Solomon sometimes


Life threatening

Meningitis-nothing really new

SAH-

1.Non invasive diagnosis

MRA and CTA

2. Coiling

3. Screening


Benign headaches

1. Chronic daily headaches? Tension

2. Migraine

3. Analgesic overuse


Tension headaches

1. Very satisfying –please please get

interested

2. Continuous, no red flag symptoms

3. Do not muddle poor sleep with early

morning headaches


Tension headaches

4. Treatments- physical

drugs please use adequate dose of tricyclic

agent

psychological


CT brain scans

“ no brainer”

Part of reassurance


Psychological issues-

Take a typical day

Find strategies.


Migraine theory

PET data

Blood flow data

Trigemino vascular hypothesis

Aura v TIA


Aura

15-45 ins

Positive phenomena

Moves

Spreading depression


Migraine-vomiting

Symptomatic treatment

Vomiting-yes please please please don’t give tablets

Buccastem 3mg

Domperidone supps

Tryptan sprays


Migraine

Symptomatic treatment

NSAIDs

Antiemetic

Short acting tyrptan


Migraine

Very rarely more than 1/week

Very little role for prophylaxis

Think of other headache types

Analgesic overuse

Plus tension headaches

Remember tryptan overuse


Migraine don’t if you can avoid it

Prophylaxis

Propranolol,pizotifen,tricyclics,topiramate.


More than 1 type of headache common need to

sort out

Migraine

Tension headache

Analgesic overuse-extremely common

Including trytans –limit to 2/week say


1. TMJ pain

2. Occipital neuralgia


Sexual intercourse headaches

Cough headaches

Post LP headaches


Cluster headaches

Describe

Verapamil

Evidence for hypothalamic involvement


Temporal arteritis.


BIH now IIH

Idiopathic intracranial hypertension

-venous stenting


How to manage demand???

1. Ring me anytime if you need advice

2. Come and do clinics with me

3. How are we going to manage-need 3 rd

neurologist-help please


How to examine headache patients

I doubt you need to use an ophthalmoscope but do not tell anyone I said so.


How to examine in general


Long term conditions

But 1 st what do you want to chat about

Epilepsy

TIAs/stroke

Bell’s palsy

Carpal tunnel syndrome

Dizzyness

Tremor /PD

Whatever you like –your meeting


Long term conditions-acute unit joining with

community-opportunities?

CNRT excellent

Stroke

MS

PD

MND

Head injuries

Brain tumours

Rarities add up like dystrophies


Need better integration between

primary and secondary care.


MS – real progress on edge of

hopefully real changes for patients.


Started with MRI 25 years ago.

1. Diagnosis.

2. Single attacks plus new MRI lesions

3. Prognosis- lesion load at diagnosis.

4. Disability -related to atrophy.


1 st attack-clinically isolated syndrome

Optic neuritis,brain stem,cord.

Change towards telling patients

Discussing new treatments


MS new evidence

Genome wide analysis

All immunological very important


MS

Family risk


Multiple sclerosis-2 phases

Relapses –inflammation

Progressive-axonal damage –degeneration

When you get to certain stage of disability may progress

inexorably

May be 1 st leads to 2 nd –hence need to prevent

relapses?

Primary progressive MS enigma.


MS

Disease modifying drugs

Beta interferon

Glatiramer


Beta interferon and glatiramer

Weak drugs

Short trials

Antibodies to beta interferon

Reduce attacks but for how long

Do they reduce disability long term –probably not


MS

Disease modifying drugs-newer

agents

Natalizumab (tysabri)-PML, JC

virus

Campath (alantuzimab)-

Autoimmune

Oral agents-fingolimod others


Change from major concern being

mobility/cord

Realisation that behavioural and cognitive

problems very important/brain

With work and relationships.


MS

New era

Try to stop relapses

Diagnosis early-tell patients

MRI new lesions

Clinically isolated syndromes

Treatment early

Not quite there yet but nearly


MS what’s new now for us

Practical

Bladderanticholinergics

DDAVP

Intermittant self catheterisation

Intravesical botox


MS

Nichola Riding-nurse (Role?)refer

through neurology.

Spasticty very disappointing

Drugs –baclofen and clonazepam

Physio

Botox

Baclofen pumps


Pain

Very disaapointing

Nothing new

Tricyclics

Gabapentin

Progabloin

NO naltrexone

NO sativex-cannabis


NMO- Devices

New disease

Aquaporin 4

Optico spinal

May be worse outlook in afrocaribeans.

MRI long cord lesions

Trials needed

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