Central poststroke pain

We explore the clinical characterstics, typical lesions (mostly spinothalamic, rarely lemniscal, capsular or cortical), diagnostics and treatment.

References

  • a 2009 article from the Lancet Neurology
  • Boivie’s wonderful chapter 48 in the Handbook of Clinical Neurology (vol 81 Pain)
  • As an addition this original current article in Pain 2011 shows that – contrary to what I expected (and practice) – Pregabalin helps not a bit.
  • My favorite orphans can come into play but as usual without much evidence: Ketamine, Disoprivan and THC. At least the former is widely practiced in pain clinics, so one can try the recommendations of this article.

Here are my take home message (or rather more fittingly, my take-to-work messages):

  • It happens more often than we think.
  • There is no way to avoid it
  • It is best treated by a specialist drawing on both medical on non-medical tools
  • As for drugs: standard is Amitryptiline and either LTG or CBZ. Probably other NASRIs (or however they are abbreviated nowadays) should be able to substitute Amitryptiline (here we often use Mirtazapin, Duloxetine or Venlafaxine) and other anticonvulsants might help just as well as LTG, but hey, these two have at least scant evidence.┬áLyrica doesn’t seem to work
  • TMS is easy and cheap (well, the device is not, talk about regulations) and effective, in contrast to many drugs
  • DBS is difficult and expensive, probably effective
  • TENS has some theory behind it, but there is no proof of effectiveness
  • Think about other non-standard stuff: hypnosis, accupuncture, Yoga (there, I said the 3 bad words), Ketamine and THC

MELAS

Inspired by a case on our wards where MELAS was contemplated as a cause for repeated seizures and psychosis over 15 years, I read up on MELAS and am going to discuss the relevant clinical and (in particular) imaging findings, using

Autoimmune myopathies

Using a case of Statin-triggered necrotizing myositis we approach the classical autoimmune myopathies from the point of view of an ambulatory care workup.

References:

  • Mammen. Autoimmune myopathies: autoantibodies, phenotypes and pathogenesis. Nature reviews nephrology 2011 – available via Medscape’s Neurology CME section
  • The autoimmune myopathies chapter of the Handbook of Neurology Vol 86
  • The chapter “Idiopathic inflammatory myopathies” of Pourmand’s book on Immune-mediated neuromuscular disorders

The Huntington case of the AAN ethics curriculum

As you might know, the professionalism movement has hardly reached the german medical world, let alone hospitals. Personally I find a lot of the material developed in this field quite helpful. Tomorrow, we will work through the “Huntington case” of the American Academy of Neurology’s ethics curriculum. As far as I know the information in the text is still up to date, i.e., conforms to the recommendations of the International Huntington Association & the World Federation of Neurology. At least that’s what our german guidelines say.
Since our Assistenten won’t bother reading material in advance (I do not even know the number of participants beforehand), we will work through the case online and just do the discussion part. This should lead to the realization that you need some structure for such ethical discussions – and I will hand out the particular example of the text to them.

As for literature on Huntingtons, there is nothing better than a current review in the Lancet Neurology. With regards to the ethical problem of presymptomatic genetic testing in Huntington’s: You will find a chapter on this classical topic in any good genetics book and similarly in every good ethics book.

Gyri and Sulci of the lateral view of the brain

One of the most obvious core qualifications of a Neurologists is neuroanatomy knowledge. We are going to recap gyri, sulci and lobes. First we are filling in all annotations on the medical color book page, then compare it to the Sobotta atlas and finally (most importantly) try to identify the gyri on axial T1 images.

Added after the fact: It is easy to locate the frontal gyri on the mri once you identified the frontal end (which is not identical to the frontal pole!). For the temporal gyri start with the central sulcus (a problem in itself, but we covered this in a previous session), extend it into the temporal operculum, then take the highest gyrus there as the superior temporal gyrus. The most difficult one is the inferior parietal gyrus, since the intraparietal sulcus is hard to identify.

Neurosyphilis

Yesterday we talked about a pt with strange white matter lesions. The resident had – of course – done a spinal tap, discovered oligoclonal bands. When discussing various microbiology tests we were still missing, it dawned on me: she hadn’t even done a syphilis serology. What used to be routine on all neuro pts has gotten kicked so far back that we tend to forget this great chameleon of all neurological complaints.

So first of all: the HBL rule – allways do HIV, Borreliosis, Lues (aka Syphilis) whenever thinking about infectious diseases in Neuro.

Here is a list of contexts, in which to think of Syphilis:

– Stroke in the (relatively) young
– “Viral meningitis” perhaps with elevated CSF pressure
– Gradual vision loss
– Vertigo with non-typical presentation
– (pre-)dementia
– Psychosis, particularly mania, not only because general paresis can look like BPD, but also b/c the sexual generosity of mania can certainly to STDs.
– Ataxia (of course)
– Myelitis
– Any other neuro complaint

Tomorrow we will be covering Neurosyphilis, using standard textbook chapters (Adams), the current AWMF guideline and the article

The changing face of neurosyphilis.Chahine LM, Khoriaty RN, Tomford WJ, Hussain MS.
Int J Stroke. 2011 Apr;6(2):136-43. doi: 10.1111/j.1747-4949.2010.00568.x. Epub 2011 Jan 10.

While surfing on the Syphilis wave, I came across a book title, that should find it’s way into my shelf: Deborah Hayden, POX (here‘s a review in the BMJ).