Neurology symposium articles

Diagnosis and management of epilepsy in adults

26 Sep 2022Paid-up subscribers

According to the International League Against Epilepsy, epilepsy can be diagnosed if any of the following criteria are met: at least two unprovoked seizures occurring on separate days (seizures within 24 hours count as one event); one unprovoked seizure with at least a 60% risk of recurrence over the next ten years on the basis of associated clinical factors (such as a recent stroke or brain tumour); diagnosis of a specific epilepsy syndrome. Convulsive events should be described rather than given a label. The EEG can establish the diagnosis of epilepsy and distinguish between focal and primary generalised epilepsy. An MRI brain scan is usually mandatory.

GPs should be vigilant for Parkinson’s disease

25 Sep 2021Paid-up subscribers

Parkinson's disease is the second most common neurodegenerative disease. Parkinsonism is defined as bradykinesia in combination with at least one of rest tremor or rigidity. Parkinson's disease is a clinical diagnosis. Examination should include gait and posture, decreased blink rate and a lack of spontaneous facial movements. Speech will be hypophonic. Evidence of a resting tremor should be sought and the patient assessed for joint rigidity and bradykinesia. After initial assessment, prompt referral to a neurologist is important to confirm the diagnosis and discuss management.

History and examination pivotal in diagnosis of Bell’s palsy

24 Sep 2021Paid-up subscribers

Bell’s palsy is the most common cause of facial palsy and presents as a unilateral lower motor neurone facial weakness in association with sensory and parasympathetic dysfunction. Maximal facial weakness occurs within 72 hours and most cases recover over the following few weeks. It is essential to consider alternative causes of acute peripheral facial palsy including: infection, malignancy and autoimmune disease. Urgent referral to neurology or ENT, depending on local referral pathways, is warranted if there is uncertainty about the diagnosis or there are atypical features.

GPs should be vigilant for acute deterioration in myasthenia gravis

24 Sep 2020Paid-up subscribers

Myasthenia gravis is an autoimmune disorder of neuromuscular junction transmission. It is relatively rare, with an approximate annual incidence of 1 per 100,000 population, and prevalence of 15 per 100,000 population in the UK. An ocular presentation may include fatiguing ptosis or diplopia. Typically, symptoms ‘fatigue’ (the physical power of the muscle deteriorates rapidly with repeated activity) and become more noticeable as the day progresses. More generalised symptoms include fatiguing difficulty with speech or swallowing. There may be fatiguing weakness of the arms and legs. The diagnosis will usually be confirmed by referral to a neurologist. 

Detailed history the cornerstone of epilepsy diagnosis

24 Sep 2020Paid-up subscribers

The incidence of epilepsy in the UK is estimated to be 50 per 100,000 per year and up to 1% of the population have active epilepsy. The diagnosis of epilepsy will usually be made in a neurology clinic. A generalised seizure as part of a generalised epilepsy syndrome may occur without warning but may be preceded by blank spells or myoclonic jerks. A generalised seizure with focal onset may be preceded by an aura. Brain imaging is required in almost all cases where epilepsy is suspected, the only possible exception being people with generalised epilepsies proven on EEG. MRI is the imaging modality of choice.

Optimising the management of neuropathic pain

25 Sep 2019Paid-up subscribers

Neuropathic pain is defined as ‘pain that is caused by a lesion or disease of the somatosensory nervous system.’ The International Association for the Study of Pain (IASP) pain grading system is a simple way of determining the likelihood of a neuropathic component. If the history suggests a relevant neurological lesion or disease and the patient describes pain in an anatomically plausible distribution of a nerve, neuropathic pain is ‘possible’; it is ‘probable’ if there are corresponding examination findings in that same distribution and ‘definite’ if there is a confirmatory diagnostic test. 

Tackling medication overuse headache in primary care

24 Sep 2018Paid-up subscribers

Medication overuse headache (MOH) occurs as a complication of the management of primary headache disorders, mainly migraine and tension type headache. MOH does not occur in cluster headache unless there is associated migraine. MOH is defined as headache occurring on 15 or more days per month, that has evolved in association with the frequent use of acute medication over a period of more than 3 months. Any medication used for the acute treatment of headache can cause MOH.

Diagnosis and management of sleep-related epilepsy in adults

24 Sep 2018Paid-up subscribers

Nocturnal epilepsies account for 10-15% of all epilepsies, and 80% of nocturnal epilepsies in adults are focal. They present a diagnostic challenge as they can be difficult to differentiate from normal movements and behaviour during sleep and also from several non-epileptic, sleep-related, motor and behavioural disorders. More than 90% of the seizures in sleep-related hypermotor epilepsy (SHE) occur during sleep. Seizures in SHE are simple partial seizures which easily wake the patient so that they will usually be able to recall the seizures, often describing auras of somatic sensations or feeling unable to breathe. SHE seizures have a rapid onset and offset, a short duration (usually < 2 min), and a stereotyped motor pattern for that individual.

Diagnosis and management of complex regional pain syndrome

22 Sep 2017Paid-up subscribers

Complex regional pain syndrome (CRPS) is a chronic debilitating painful condition comprising unremitting pain, sensory, sudomotor, vasomotor and motor abnormalities in the affected extremity. It has a peak incidence in the 55-75 age group and there is an association with asthma and migraine. CRPS is three times more common in women than men. CRPS should be suspected in any patient presenting with persistent pain in an extremity beyond the expected period of tissue healing following an acute injury, sprain, fracture or surgical procedure. Severe pain in a glove or stocking distribution is the predominant symptom in > 90% of cases.

Identifying neurological causes of daytime sleepiness

22 Sep 2017Paid-up subscribers

The prevalence of sleep complaints in adults in a primary care setting is > 10%. The most frequently seen condition by far is that of primary insomnia, which affects 10% of adults on a chronic basis. In contrast to primary insomnia, in which most patients report tiredness and fatigue during the day but are unable to sleep during the day either, the second most frequent sleep disorder encountered, obstructive sleep apnoea, is typified by excessive daytime sleepiness. Patients with primary insomnia or fatigue syndromes typically will score low on the Epworth Sleepiness Scale (ESS < 3) whereas those with organic sleep pathologies or sleep restriction will score higher. A score > 10 is seen as 'pathological', with a mean ESS in the population of 5-6. 


Special reports

Early symptom recognition key in management of TIA and stroke

24 Nov 2020Registered users

In the UK, at least 100,000 people have an acute stroke each year. A first ever transient ischaemic attack (TIA) affects around 50 people per 100,000 per year and around 15% of people who have a first stroke have had a preceding TIA. Patients with a suspected TIA should be referred immediately for specialist assessment and investigation, to be seen within 24 hours of onset of symptoms. Patients with a suspected stroke should be admitted immediately to hospital, ideally to an acute stroke unit. Patients with a suspected TIA who have a bleeding disorder or are taking an anticoagulant should also be admitted to an acute stroke unit as haemorrhage must be excluded.

Prompt diagnosis can improve outcomes in multiple sclerosis

27 Oct 2020Registered users

Multiple sclerosis (MS) is the leading cause of non-traumatic neurological disability in young adults. Between 1990 and 2016, the UK prevalence increased by 28%, due to earlier diagnosis and increased survival. The female to male ratio is 2:1, and patients have a minimally reduced life expectancy. Diagnostic criteria require that clinical, radiological and laboratory signs of MS are disseminated in both time and space. Diagnosis is based on a combination of features (relapses and clinical progression), MRI findings, and CSF analysis.

Non-motor symptoms may herald Parkinson’s disease

20 Dec 2017Paid-up subscribers

While the three cardinal motor symptoms of Parkinson’s disease (PD), bradykinesia, rigidity and tremor, are key to the diagnosis of the condition, there is evidence that non-motor symptoms start long before motor features arise. Two of these in particular, REM sleep behaviour disorder and olfactory dysfunction, have been strongly associated with the development of PD. Non-motor symptoms are increasingly recognised as main features of PD with a high impact on quality of life. Their progression has been shown to be independent of motor deterioration. Sleep, GI and attention/memory problems become more prevalent over time, whereas psychiatric and cardiovascular problems become less prevalent.

Rapid diagnosis vital in thunderclap headache

25 Apr 2016Registered users

Thunderclap headache is a severe and acute headache that reaches maximum intensity in under one minute and lasts for more than five minutes. Thunderclap headaches may be associated with symptoms such as photophobia, nausea, vomiting, neck pain, focal neurological symptoms or loss of consciousness. Subarachnoid haemorrhage (SAH) accounts for 10-25% of all thunderclap headaches and, despite advances in medical technology, has a 90-day mortality of 30%. Up to a quarter of cases of SAH are misdiagnosed, often through failure to follow guidance.


Diagnosing non-parkinson’s movement disorders

24 Feb 2012Paid-up subscribers

Movement disorders are a common cause of neurological disability in older people. Idiopathic Parkinson’s disease (IPD), caused by degradation of dopaminergic neurones in the nigrostriatal pathways of the brain leading to a triad of tremor, rigidity and bradykinesia, is probably the most well known. This article focuses on the most common non-parkinson’s movement disorders seen in older people.

Early aggressive treatment improves prognosis in complex regional pain syndrome

23 Jan 2011Paid-up subscribers

The condition now named complex regional pain syndrome (CRPS) has been recognised for many years, and known by many terms, although the adoption of the current taxonomy is recent. The condition typically starts with an injury to an extremity, which is often seemingly trivial, followed by immobilisation, such as an ankle sprain or Colles' fracture. However, instead of the expected resolution of symptoms, persistent pain and dysfunction develop. recent attention to its key features by international authorities should allow the diagnosis to be made with greater confidence by non-specialists. Management should be based upon general principles of neuropathic pain treatment, combined with aggressive physical rehabilitation. Many cases will resolve spontaneously, or with simple measures. For severe or resistant cases, early specialist intervention is indicated.

Improving the management of neuropathic pain

21 Jul 2010Paid-up subscribers

Neuropathic pain is relatively common. One large European study found a prevalence of 6%. The diagnosis and treatment of long-term pain has received considerable attention recently. Long-term pain is pervasive and costly. There is an interrelationship with psychosocial problems and there are often difficulties in clarifying the diagnosis. Most treatment for long-term pain, including neuropathic pain, should be provided at the primary care level, with support as necessary from specialist services.

GPs have pivotal role in care of stroke patients

15 Feb 2010Paid-up subscribers

GPs play a key role in early recognition of stroke symptoms, thus ensuring that patients receive appropriate acute treatment, early initiation of secondary prevention, lifestyle advice and referral to exercise schemes. It is becoming increasingly recognised that stroke is a chronic disease. So GPs will also be central to managing ongoing risk of recurrent stroke and identifying and managing long-term post-stroke problems.