Neurology String of Pearls

The department

Quiz

Cases from a clinic

What you need to know about Epilepsy: Alan Whone and Sue Higgins

What you need to know about PD: Mark Silva and Ann Gilbert

What you need to know about MS: Roswell Martin and Richard Warner

The Department4 Consultants (Fuller, Silva, Martin, Morrish), 1 Reg, 1 SHO4 Specialist nurses (2 MS, 1 Epilepsy, 1 PD)2 GP assistants Secretaries at GRH and CGHOP’s every day except Wednesday in CGH and GRH Neurology beds at GRHErmin House (neuro disability unit) at GRHNeurophysiology at GRHSpecial interests: Silva, Morrish: PD, Movement Disorders, Fuller: EpilepsyMartin: White matter disease, CADASIL

What do we do?

Clinics (new and special interest)

Ward cover – inpatients (approx 10-16) and referrals (3 -4 per day)

Supervising nurse specialists, junior medical staff

Paperwork

Teaching

Research

Other interests

Referrals Received

0

50

100

150

200

250

300

350

400

450

Other 106 118 126 120 98 76 112 98 72 97 95 117 88 100 99 75 89 94 93 96 73 113 74 109

GP referred 255 229 237 248 246 237 218 252 191 215 234 238 243 281 241 243 232 235 266 242 166 245 210 244

Apr-05

May-05

Jun-05

Jul-05

Aug-05

Sep-05

Oct-05

Nov-05

Dec-05

Jan-06

Feb-06

Mar-06

Apr-06

May-06

Jun-06

Jul-06

Aug-06

Sep-06

Oct-06

Nov-06

Dec-06

Jan-07

Feb-07

Mar-07

Total of referrals 3951 (06-07). No significant change over preceding year. 72% from GP’s.

3477 new attendances: 5802 follow-ups

Neurology

100

200

300

400

500

600

Num

bers

wai

ting

as a

t en

d of

mon

th

13+ wks 9-13 wks 5-8 wks 0-4 wks 2005/06 total

0-4 wks 197 239 244 209 220 191 211 229 212 162 205 197 204

5-8 wks 120 125 147 148 119 154 103 102 118 136 84 100 70

9-13 wks 29 42 53 42 50 56 58 40 44 43 40 16 5

13+ wks

2005/06 total 432 491 513 520 529 560 540 456 444 402 360 398 346

previous yr end

Apr May June July Aug Sept Oct Nov Dec Jan Feb Mar

Waiting list

800 GP referrals (70% of total)1 Consultant1 GP assistantPopulation served 520,000

2848 GP referrals per year (72% of total)4 Consultants2 GP assistants3 nurse specialistsPopulation served 585,000

1984

2006

How things change……..

From “Workload of an English Neurologist” DL Stevens*

*other observations: GP’s managing bulk of neurology. Referrals rising, will it plateau?

Neurology Out-Patients: What do we actually do?

Geraint Fuller 2006

Gloucestershire Royal Hospital

Initiatives affecting neurology

New appointments: Maximum waiting lists

NICE guidelines MS, Epilepsy, PD

NSFFollow up appointments:

Limitations of the Study

Reflects local practice Local consultants Local GPs Local Population

Diagnoses are presentation diagnoses and not final diagnoses

12 week study

Results

  Doctors Nurses

Doctors and Nurses

New 587 43 630

New/old 74 56 130

Follow up 1058 273 1331

    Total 2091

new:old ratio 1.6 2.8 1.8

New Patients by Diagnosis

Epilepsy

Migraine

Headaches

Movement disorders otherthan Parkinson's disease

Dizziness and giddiness

Stroke and TIA

Peripheral neuropathies

MS

Faints and blackouts

Cranial nerve disease

Peripheral nerve palsies

 

 This series Stevens Wiles UK

Disorders of consciousness 17.1 17.3 17.7 17.6

Headaches, migraine and face pain 22.8 15.5 18.0 18.8

Movement disorders 8.1 7.1 3.5 2.7

Nerve, root syndromes and neuropathies 11.0 11.2 12.7 13.0

MS 3.9 6.1 10.0 5.9

Stroke and TIA 4.8 6.5 3.0 10.3

Cranial nerve syndromes 3.1 7.1 3.8 2.3

Dizziness 5.3 3.2 5.0 2.7

Sub-total of these diagnostic categories 76.1 74.0 73.7 73.3 

New Patients

What did we do?

010

2030

4050

6070

8090

100

New Follow up Nurses

Review

Examination

Tests

Explainresults/Diagnosis

What did we do?

0

10

20

30

40

50

60

70

New Old Nurses

Start medication

Review medication

Change medication

Arrange othertreatment

New and New/old

New and discharge

New, investigateanticipate dischargeInvestigation cycle

Chronic: review tillresolvedChronic: intermittentFUChronic: long term FU

Previous studies

This study See and discharge 38%; investigate/anticipate

discharge 22%; investigation cycle 21%; chronic disease 16%.

ABN survey (1993): 69% discharged; 29% followed up; 10% admitted

Wiles (1996) 38% discharged; 34% discharged with investigations;

23% investigated or admitted Hopkins (1985)

33% discharged; 49% expected to be seen once more; 18% seen on continuing basis

Follow up diagnoses (%)

Epilepsy 37.3

MS 16.6

Parkinson’s disease 9.6

Focal dystonia 3.5

Other movement disorders 3.5

Headaches 3.2

subtotal 73.7

Over view of Out-patients

Chronic diseases

Part of investigation cycle

Anticipate discharge

See and discharge

DNA and discharge

DNA and further appontmentDNA and furtherappontment

DNA andfurtherappontment

Chronic diseases

New 1 2 3 4 5 to 8 9 or more

644 253 150 106 96 182 415Total =1,846

0

20

40

60

80

100%

Type of Patient

Number of Prior Appointments

Conclusions

Neurology OPD provides 2 intertwined services Consultation service for new symptoms Chronic disease management service

Consultation service

For patients with headaches, migraine, giddiness and dizziness, strokes and TIAs, faints and blackouts, focal peripheral neuropathies, cervical and lumbosacral disease, cranial nerve disorders.

Most seen once, few seen up to 4 times.Service capacity determined by incidence

of these conditions

Chronic Disease Service

Predominantly for patients with Epilepsy, MS and Movement disorders. Significant number of patients with rarer diseases.

Half patients may be discharged if problem resolves

Half long term follow up Service capacity determined by

prevalence of these conditions

Two Services

Consultation service 68% of doctors time

Chronic disease management 32% of doctors time 100% of nurses time

To whom to refer what?

NeurologyElderly care

Acute Medicine

Eg: Parkinson’s, Weak legs, Dizzy turns, TIA

ENT

Radiology

Neurophysiology

Medical Genetics

Does it matter? Variables include urgency, personnel, geography, experience

Opthalmology

How we think:

Where is the lesion? What is the lesion? What can we do about it?

1. A 78 year old left handed man has suddenly lost his ability to express speech and attends urgently. What neurological signs might you look for/expect?

a. L homonymous hemianopia?

b. R LMN facial weakness?

c. R triceps weakness?

d. Constructional apraxia?

e. R plantar extensor?

A warm-up quiz

There are no other signs.

How would you classify this event and what is the prognosis?

PACI TACI LACI POCI

The Major Stroke Syndromes

TACI = Total anterior circulation infarct

PACI = Partial anterior circulation infarct

POCI = Posterior circulation infarct

LACI = Lacunar infarct

Arterial Territories

Anterior Cerebral

Posterior Cerebral

Middle Cerebral

Anterior Circulation

Posterior Circulation

Total Anterior Circulation (TACI)

Hemiplegia contralateral to the lesionHemianopia contralateral to the lesionHigher cortical dysfunction eg dysphasia, dyspraxia

CT MRI

Partial Anterior Circulation (PACI)

Isolated higher cortical dysfunction ORAny 2 of hemiparesis, higher cortical dysfunction & hemianopia

CT MRI

Posterior Circulation (POCI)

Isolated hemianopia OR Brainstem syndrome

CT MRI

Lacunar Infarct (LACI)

Pure motor stroke OR Pure sensory stroke OR

Sensorimotor stroke

By occlusion of single deep perforating artery

CT MRI

Prognostic Value30 Day Outcome

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

TACI PACI POCI LACI

Dead

Dependent

Independent

It resolves in two hours. What do you do?

Admit (?where) Refer to TIA clinic (?how) Manage at home

ABCD score (risk of CVA in 48 hours)

Age >60 1

BP>/=140/90 1

Unilateral weakness 2

Speech impaired, no weakness 1

Duration>1 hour 2

Duration 10 mins to 1 hour 1

Diabetes 1

Score 6-7: 8.1%Score 4-5:4.1%Score 3 or below:1.0%

You decide to manage at home. What tests are urgent?

FBC U&E ECG CXR CT head U/S carotids Echocardiogram

NNT – How many to treat to prevent 1 stroke per year?

Warfarin if patient in AF Carotid surgery if >70% in symptomatic side Aspirin Statin (whatever the lipids) Stopping smoking

Intervention NNT

Warfarin in AF 12

Carotid surgery in >70% stenosis 6

Aspirin 100

Statin 20

Smoking 43

2. A 37 yr old lady presents with : R arm and R leg feel weak and odd, left leg feels numb, buzzing in neck on flexion; all coming on over 1 week. On examination she has:Normal cranial nerves and visual fields, UMN weakness in R arm and leg. R plantar goes up, Impaired JPS in R arm and R leg Impaired pinprick in L arm and L leg

What is the name of the syndrome? What is the buzzing? Where is the lesion? Give three possible diagnoses

Possible causes (B-S and Lhermitte’s)

Disc Demyelination Other SOL eg tumour, abscess B12 deficiency

Useful things to know 1:

Corticospinal tract

In brain on opposite side

In cord on the same side as arm/leg

Starts in the motor cortex,Runs through internal capsule,Crosses in the medulla

Brain

Spine

Useful things 2: Dorsal-columns

Vibratory and joint position sense. Their sensory neurones run on the same side of spinal cord and cross over in midbrain

(ie like motor nerves)

Brain

Spine

Useful things 3: Spino-thalamic

Convey pain and temperature

Sensory neurones cross to the opposite side of spinal cord soon after entering.

Brain

Spine

Useful things 4:The Visual Fields

“Homonymous” field defect = lesion behind the optic chiasm

“Monocular” defect = lesion in front of chiasm

3. A 36 year old lady is referred to you by optician (from routine eye test)

What is it called? What abnormalities of vision might you look for? Give three causes

4. A patient known to have PD (for 5 years) is brought in by his wife; she is complaining of his fidgety movements. What would you do/say?

Blood tests (which?) Stop tablets and reassess after 1 week Is he bothered? Add Pimozide/tetrabenazine/haloperidol Refer to whom?

5. A 27 year old man blacks out whilst walking from the toilet on an aeroplane. When he wakes (a few minutes later) the cabin crew tell him he has had a fit and that he needs to seek urgent medical attention. What things might help you work out what happened and what to do next?

What do you do next?

Tell him he mustn’t drive (till when?) Refer him for specialist opinion (which?) Request urgent EEG and CT Check ECG Tell him to avoid aeroplanes, lunch and toilets

6. A 24 year old girl with epilepsy for ten years wants to start a family and stop her medication. Give 5 things that she (and you) might want to discuss.

GP letter to neurology

“This girl wants to start a family. Please see and do the needful”

7. A 24 year old lady with one previous episode of optic neuritis and otherwise well has developed urinary frequency and urgency. What might you do?

Some suggestions

MSU Start oxybutinin Refer to urology for catheter Refer to MS nurse Treat suspected relapse with steroids (which?) Measure urinary residual Consider disease modifying treatment Pregnancy test MRI Head MRI Spine

What might we do?

1. Do same as usual in non-MS patient

ie MSU, ?pregnant

2. Add MS implications

Is diagnosis secure? Maybe re-investigate

Consider steroids if disabling relapse

Measure urinary residual ?SIC

Consider disease modifying treatment

8. A 36 year old man attends surgery 5 days after developing a headache during sex. What does he need?

Routine referral to neurology Urgent referral to neurology Urgent admission to AAU CT scan Lumbar puncture MRI/MRA A full history (what do you want to know?) Examination for meningism

Screening for aneurysm

Best test is angiography (1% risk) MRI/MRA less good- may show false pos/neg If positive, risk of neurosurgery/coiling 2-3% What is the risk of leaving an incidental aneurysm? Usually only screen if 2 first degree relatives, or PC kidneys

9. A 37 year old tax adviser is worried that her memory is failing her. What do you do?

Reassure : dementia unlikely in 37 year old Refer to neurology Blood tests (which) Test her memory (how?) Take a history (what do you want to know?) Examine her (what for?)

Some causes of dementia in the young

Alzheimer (usually familial) SOL New Variant CJD Untreated Complex Partial Seizures Myxoedema HIV

11. A 25 year old lady with recurrent headache has read (in the Daily Mail) that having her PFO sealed will cure her headache. What do you do?

Refer to cardiology for “starflex” closure Take history (what do you want to know?) Examine (what do you look for?) Prescribe analgesia (?which)

12. A 42 year old man attends with his wife. His sister died three months ago of a brain haemorrhage, he has headaches and he wants a scan. His BP is 160/100, he smokes 20/day and drinks 40 units per week. What do you do?

Direct request for CT Refer for urgent neuro opinion re headache and screening Reassure, and reassess in 1 month Counsel in respect of fags and beer Request urgent admission for ?SAH

Some Clinic Cases