Multiple Sclerosis

What are the two main types of MS?

Which one is more common in females?

Which common is more common in young (<40y/o) pts?

Relapsing-Remitting (RR-MS)** young, female

Primary-Progressive (PP-MS)

what is a classic early finding on MRI in a pt with MS that manifests clinically as a monocular visual impairment, local eye pain, scotomas, and relative afferent pupillary defect (Marcus Gunn Pupil)?

When will the funduscopic exam be normal in a pt with these symptoms?

Optic Neuritis

funduscopic exam may be normal with retrobulbar neuritis

#1  Fatigue

#2  Parasthesias of hands and arms

#3  Optic Neuritis or retrobulbar neuritis

Lhermitte's sign (what is this?), paresthesias/anesthesias, and decrease in vibration and proprioception sense are common early signs of what disease?

What are the 2 other sinal cord findings associated with this disease?

Multiple Sclerosis

Lhermitte's sign:  transient electric shock-like pain down back and into extremities with passive neck flexion

additional spinal cord-related symtoms:

Bladder dysfunction (incontinence)

Spastic paraparesis or tetraparesis (tonic spasms, hyperreflexia & + Babinski)

Pregnancy

Infection

Emotinal Stress

Injury

Hx of > 2 exacerbations/remissions separated in time or progressive course

and

Evidence of lesions in >2 sites of central white matter

What test is used to evaluate MS that is sensitive (95%) but not specific?

What test may show increase in IgG and oligoclonal bands?

MRI (brain and spinal cord)

Lumbar puncture

what is Uhtoff's phenomenon?

what pt's should be aware of this and why?

Uhtoff's phenomenon:  ↓ in nerve condution with ↑ in temperature

MS pts should be careful in hot tubs, saunas, etc. b/c the heat may trigger their symptoms.

Alzheimer's Disease

5th leading cause of death in the US

5.3 million cases

33-40% >85 y/o

memory impairment (new learning, recall)

apraxia

agnosia

executive funtioning disturbance (planning, organizing sequencing, abstracting)

manifestations of what?

Dementia of Alzheimer's Type (DAT) 

AD/DAT

Cholinesterase inhibitors are the 1st line tx of what disease?

Name 3

Alzheimer's Disease

Donepezil (Aricept)

Rivastigmine (Excelon)

Galantamine hydrobromide (Reminyl)

Donepezil (Aricept)

Rivastigmine (Excelon)

Galantamine hydrobromide (Reminyl)

class of drug?

Tx?

Cholinesterase inhibitors (increase ACH in brain)

tx of AD

Parkinson's Disease and Movement Disorders

neuroleptics**

metoclopramide

heavy metals

MPTP (steet drug)

associated with causing what disease?

Parkinsonism

due to permanent decrease in dopamine

Pathology of Parkinson's Disease:

Loss of __________ containing and secreting neurons in the _____________and locus ceruleus (_______) with depigmentation, lewy bodies, and decreased dopamine at nerve endings in the _____________.

Diminished dopamine in the basal ganglia and related nuclei cause _______________ symptoms.

Imbalance between dopamine and _________.

Pathology of Parkinson's Disease:

Loss of dopamine containing and secreting neurons in the substantia nirga and locus ceruleus (medulla) with depigmentation, lewy bodies, and decreased dopamine at nerve endings in the basal ganglia.

Diminished dopamine in the basal ganglia and related nuclei cause extraphyramidal symptoms.

Imbalance between dopamine and ACH

what findings on the PE motor exam are consitent with Parkinson's Disease?

(2)

Asymmetrical rest tremor (palms up, hands on lap and held out)

Cogwheel rigidity on Passive ROM (Froment's Maneuver)

stooped gait, festinating, retropropulsion, and slow RAMs

Cerebellar/Balance PE findings of what disease?

Akinesia or bradykinesia:  inability to initiate movement/slow movement

Rigidity:  cogwheel** or lead pipe

Tremor:  rest at arms/hands with pill-rolling, unilateral

**Most common symptom**

Gait disturbances and postural instability

decrease arm swing, postural reflex impairment, festinating, stooped posture, retropulsion

Rest tremor*

Rigidity*

Bradykinesia*

Impaired posural reflexes

*asymmetrical

_____________:  tremor that gets worse with action, intention.

Benign essential (central) tremor:  tremor that gets worse with action, intention.

**most common type of movement disorder**

bimodal (peaks in 20s and 60s)

genetic predisposition

What diagnostic studies would you order to r/o other conditions when diagnosing Parkinsons?

(2)

CT or MRI

Thyroid Function Tests (TSH, FT4)

what is the pharm tx for Parkinson's Disease? (older)

important s/e?

Carbidopa/levodopa

Levodopa:  DA precursor that crosses the BBB and is convere to DA

Carbidopa:  inhibits peripheral dopa enzymes to increase levodopa in CNS

s/e:

decreased efficacy >2 yrs tx

dyskinesias (chorea, dystonia) after 5yrs ts

Pramipexole (Mirapex)

Ropinirole (ReQuip)

good 1st line drugs for tx of what?

MOA?

ADRs?

Parkinson's

MOA:  dopamine receptor agonists

ADRs:  N/V, sedation, sleep attacks, decreased impulse control

Trihexyphenidyl (Artane) is the most common __________ used to tx Parkinsons

useful in early disease to treat ________

Trihexyphenidyl (Artane) is the most common Anti-ACH used to tx Parkinsons

useful in early disease to treat termor

Rasagiline (Axilect) is a MAO-B Inhibitor used in the tx of what disease?

Why?

Parkinsons's

neuroprotective

slows progression

AVOID SSRIs (serotonin crisis)

propranolol

primidone (Mysoline)

Gabapentin

Topiramate (Topamax)

first line pharm tx of what?

Essential Tremor

will decrease Sx by up to 70-80%

Neurological Testing

what are you looking for on an AP Cervical spine film?  (quantitative/qualitative, not diagnostic)

7 cervical vertebrae

alignment of vertebral bodies & spinous processes

what dx tool is used in the primary evaluation of trauma to the head/neck/back?

**head trauma < neck and back **

Plain Films (X-ray)

head trauma is CT (x-ray won't pick up bleed)

Pregnancy (1st trimester especially)

conrast allergy (CT w/ contrast)

Pt presents with a hip fracture.

what dx study do you order?

CT SCAN

look for fragments

CT scan w/ contrast

RARELY USED IN CASES OF TRAUMA

contrast helps to characterize the brain or spinal cord lesion by causing enhancement or better delineation of the lesion

decreased image quality for brain/spine tissue and CSF spaces

decreased image for deep brain structures (palatine fossa, craniocervical junction)

decreased ablity to detect acute ischemic or infarct changes (stroke)

disadvantages of what type of imaging?

Coagulopathy

Papilledema

Non-communicating Hydrocephalus

contraindications for what procedure?

interspace between L3-4

[image]

What are you assessing with Lumbar Puncture?  (not diagnostically speaking)

(5)

Color/Clarity

Protein

Glucose

Glucose ratio (CSF: Plasma)

Opening Pressure

Myelogram

[image]

A myelogram uses a special dye (contrast material) and X-rays (fluoroscopy) to make pictures of the bones and the fluid-filled space (subarachnoid space) between the bones in your spine (spinal canal). A myelogram may be done to find a tumor, an infection, problems with the spine such as a herniated disc, or narrowing of the spinal canal caused by arthritis.

EMG

eletromyography