Central Nervous System Problems (CNS) Brain and spinal cord
STROKE

Stroke is a term pertaining to a brain infarct (brain damage due to starvation of bloodflow/oxygen otherwise known as ischemia).

A stroke is similar to a heart attack but only in a different organ (the brain and not the heart).

Strokes generally cause an abrupt (acute) loss of the ability to speak, unilateral paralysis, or vision loss. The paralysis may be partial or complete. Numbness may also occur but usually in conjunction with other symptoms mentioned above.

If the paralysis is transient or episodic (comes and goes) it is called a Transient Ischemic Attack (TIA). A TIA is similar to angina as a patient with coronary artery disease may experience before or during a heart attack. A TIA is a "stroke trying to happen" and medical/neurologic evaluation is most important here, to PREVENT a STROKE.

Once strokes occur, the brain damage is permanent and rehabilitation is often required. Only one drug intervention is now currently available for the treatment of acute stroke. It is called tPA and is known in lay press as "the clot buster". It can only be given intravenously IF the patient is taken to the hospital immediately (less than 3 hours from the onset of symptoms). It is associated with a risk of brain hemorrhage (bleeding into the brain) and thus is usually given only if the stroke seems large and/or disabling. A CAT scan is usually done prior to the administration of tPA to ensure that the stroke is not a hemorrhagic one to begin with. Intrarterial therapies such as thrombectomy are also now available at LGMC.

The following steps should be taken to prevent strokes:
1. Screening for hypertension (high blood pressure) is vital and proper blood pressure control is necessary.

2. Screening for diabetes (Type II diabetes or adult onset "sugar diabetes") should be done if one has a family history, if they are overweight, or if they have symptoms of increased thirst, urinary frequency, or transient lethargy (tiredness). This is done with a simple blood test. From a neurologist's standpoint, "borderline" diabetes means a stroke risk factor and should be addressed aggressively to avoid eventual complications.

3. Screening for hyperlipidemia/hypercholesterolemia is important as there are several new safe medications which can have a profound effect on lowering cholesterol. Of course, dietary modification must occur as well.

4. An irregular heart rhythm (a heart beat or "pulse" that skips or is very fast) may indicate a condition called atrial fibrillation (non-contracting of the top chambers of the heart). Most medical literature suggests that patients be placed on anticoagulation (warfarin/Coumadin) which decreases the risk of embolic stroke (a blood clot from the heart going up to the brain causing a stroke).

5. Smoking cessation is a must; some recent success has been shown with certain medications if a person has decided to quit.

6. Exercise helps to prevent and/or control the effects of diabetes, hypertension, and hyperlipidemia .

7. Screening for and treating sleep apnea


SEIZURES

Seizures are the clinical manifestation of abnormal electrical discharges in the brain. Like an EKG of the heart (electrocardiogram/electroKardiogram), an EEG (electroencephalogram) of the brain demonstrates elctrical activity in the brain.

Epilepsy is the clinical syndrome of recurrent unprovoked seizures. (Unprovoked seizures are ones that occur in the absence of metabolic derangements such as low blood sugar, alcohol intoxication, acute brain injury, or infection/inflammation of the brain.) If seizures occur after these events they are called "symptomatic" seizures.

Much of epilepsy is idiopathic (unknown primary reason for the condition). Many new and safe anti-epileptic drugs (AEDs) have been introduced in the last few years, making the treatment of epilepsy much more rewarding for neurologists [and much less burdensome to our epileptic patients].

People with epilepsy in general have normal intelligence and conduct normal lives. Special issues arise in pregnancy and in older people on multiple medications and such people such be followed by a neurologist at least periodically, especially if seizures are ongoing.

Most states have laws which restrict driving if the patient has had frequent seizures for reasons of public safety, obviously. However, if a person is seizure-free or if seizures are exclusively nocturnal (at night) or if only involve certain symptoms which do not interfer with driving, then exceptions can be made.


PARKINSON'S DISEASE

Parkinson's disease is a neurodegenerative disease which results in slow movements, a tremor (shaking), stiffness, and walking problems. Other symptoms include urinary dysfunction (resembling prostate problems) and erectile dysfunction (impotence). Depression is often under-recognized and can be significant. Not all features need be present for the diagnosis to be made, especially if a patient responds to medication (see below).

The main problem leading to Parkinson's disease is the loss of the chemical Dopamine in certain parts of the brain, or lower part of the brain called the brainstem, specifically the substantia nigra. This loss occurs because cells which produce this neurochemical die. This cell death occurs in all of us and some experts believe that if humans lived to age 140 or more that wed all have Parkinsons disease.

Parkinson's disease is often slowly progressive (runs a benign course) and usually does not decrease a persons life expectancy. Another positive feature is that it is easily treated in most cases with medication. If youve seen the movie, "Awakenings", then you are familiar with how the discovery of dopamine changed peoples lives. Luckily, in the last decade, there have been several newer medications introduced which give added ammunition against the disease, and help us to avoid the complications you may remember seeing in the movie.

The mainstay of Parkinson's disease treatment is to replace whats missing with Levodopa (also referred to as L-dopa or Sinemet, or the long acting Sinemet CR). However, for young persons or persons with milder disease, other agents may be used first. Side effects of L-dopa and other anti- Parkinsonian medications include nausea or abdominal discomfort. Confusion or hallucinations may occur but usually with high dosages or with underlying dementia.

Dementia (like Alzheimers) co-occurs with Parkinsons disease in ultimately about half of Parkinsons disease patients. And, of course, the risk of this increases with age as well.

For younger people with severe, disabling Parkinson's disease, there are surgeries that can be done to help with movements and/or help prevent medication side effects.

Anti-depressants are often helpful for depression as well as other neuropsychiatric complications of Parkinson's disease. Dementia can be safely treated with appropriate medications. There are safe antipsychotics which can be used if patients have hallucinatory side effects from the medication.

Parkinsonism

Sometimes people look like they have Parkinson's disease but their symptoms can be attributed to another disease process (such as multiple strokes) or medications (antipsychotics). This is referred to as Parkinsonism and not idiopathic Parkinson's disease. Often times medications are not as helpful as in true Parkinson's disease.


Tests for Parkinson's Disease

No simple diagnostic test exists to confirm the diagnosis of idiopathic Parkinson's disease however the dopamine transporter scan or DAT scan can help distinguish essential tremor and Parkinson's. Screening tests are often done to look for secondary causes of Parkinsonism, including brain imaging (CT or MRI) to look for a multi-infarct state (multiple strokes which could have occurred without the patients knowledge). Other more rare diseases such as Wilsons disease may be screened for with blood tests and/or an ophthalmologic exam (eye exam by an ophthalmologist).


Diffuse Lewy Body Disease

This disease is also an idiopathic neurodegenerative disease which strongly resemebles Parkinsons disease but usually has no tremor. Patients often experience severe medication side effects, suggesting the diagnosis. Dementia is more common with this than with idiopathic Parkinsons disease. Fluctuating mental status (episodes of confusion or agitation) are also common.

Unfortunately, the Parkinsons medications usually are not as effective. The dementia medications may be particularly effective, however. Again, there is no diagnostic blood test or imaging study.






HEADACHE

Headaches can be divided into two main groups for the most part. Migraine is the syndrome most publicized. Migraine is a syndrome of unknown etiology or cause. Migraine headaches are typically severe, unilateral, may be pounding (with the heart beat), and could be associated with nausea or vomiting, or visual disturbances. Lights or noise may cause the headache to worsen and the pain interferes with the ability to work or enjoy hobbies.

For persons who smoke or take birth control pills or have other stroke risk factors, migraines can sometimes cause stroke. There are several safe medications that have been shown to help prevent migraines. There are also newer medications which effectively end a migraine once it has begun. These medications (any pain medications) should be taken as soon as the migraine symptoms develop. Some medications are not safe for people who have hypertension or heart disease or a history of stroke.

Tension type headaches are more common. They tend to be bilateral (both temples or the back of the head), are often associated with neck pain, and should not have associated nausea or visual symptoms. The severity can also be severe, and the condition can be chronic.


Chronic daily headache is the classification used when headaches occur daily for greater than 15 days each month. They can evolve from either a tension or migraine condition. They are often a result of chronic analgesic or pain medication use. This phenomenon of "rebound headaches" or "withdrawal headaches" refers to the recurrence of headaches when the levels of pain medications wear off or become low. These are particularly difficult to treat and often require multimodality approach (counseling/psychologist or psychiatrist, medication tapering; hands on therapy such as massage, accupunture, chiropractic, etc.)


MULTIPLE SCLEROSIS

Multiple Sclerosis (MS) is a disease of the brain and spinal cord. The destruction of myelin, an insulating material around nerve cell processes, characterizes the disease. The areas of destruction are referred to as MS plaques. They are easily seen with MRI but not CT scan. They can occur in any part of the brain and spinal cord. MS is not usually inherited but some cases do occur morecommonly in some families.

National Institute for Neurologic Disease and StrokeAmerican Academy of NeurologyAmerican Headache Society Epilepsy Foundation of America


Peripheral Nervous System Problems (Nerve and Muscle)
Peripheral Neuropathies


Diabetes is the leading cause of neuropathy in the United States. Patients with this condition often have numbness and tingling in the feet which sometimes progresses to a burning type pain in the legs. The numbness can cause significant balance problems and falls. Diabetic patients can have serious penetrating injuries to the feet without realizing it, until infection threatens their limbs. Thus, it is very important that all diabetics briefly check their feet daily.

Entrapment Neuropathies

Carpal Tunnel Syndrome (CTS), also known as median nerve entrapment at the wrist, is by far the most common entrapment neuropathy. It may cause hand numbness, pain, and weakness. It is a chronic condition, often diagnosed after months to years of being present. Some medical conditions increase the risk of having CTS (diabetes, thyroid conditions), but most cases are of unknown cause/idiopathic.


Radiculopathies

This term refers to an impingement of a nerve root. A nerve root is the first part of a nerve as it exits the spinal cord. It is here where a herniated disc can cause problems. It is important to know, however, that most back pain is not caused from disc disease. And having a herniated disc and back pain does not necessarily imply a cause and effect relationship.

Many asymptomatic (normal) middle age individuals will be found to have abnormal intervertebral disc problems by MRI.


Neuromuscular junction (NMJ) diseases

Myasthenia Gravis (myasthenia) is the most common NMJ disease. This is a rare autoimmune disease which affects nerve to muscle transmission, thus causing weakness. Patients who have eyelid droopiness and double vision may have myasthenia. Patients with prominent fatigue and or shortness of breath may also have the disorder. It is best diagnosed with a combination of physical exam, blood tests, and sometimes EMG/NCV.

Myopathies

This term refers to disorders of the muscle itself. Myopathies can be inflammatory or metabolic. Muscular dystrophies are closely related to myopathies, but are usually congenital (inherited and present at an earlier age). Some myopathies are treatable and/or slowly progressive.

Sleep Disorders

Sleep Apnea describes a condition in which a person stops breathing for about ten seconds repeatedly during sleep because their airway collapses and prevents air from getting into their lungs and interrupts restorative sleep - a potentially life-altering and life-threatening condition.

Obstructive sleep apnea is a disorder in which breathing is briefly and repeatedly interrupted during sleep. Apnea is defined as a cessation of breath that lasts at least ten seconds. Obstructive apneas occur when the muscles in the back of the throat are not able to keep the throat open, despite efforts to breathe. This causes blockages in the airway and breathing interruptions, or apneas. Obstructive apneas can result in two problems: fragmented sleep and lowered levels of oxygen in the blood. The combination of sleep disturbance and oxygen starvation can result in multiple problems, including automobile accidents, hypertension, heart disease, and mood and memory problems. Sleep apnea can be life-threatening and you should consult your doctor immediately if you feel you may suffer from it.

Narcolepsy is a chronic neurological disorder that involves your body's central nervous system. The central nervous system is the "highway" of nerves that carries messages from your brain to other parts of your body. For people with narcolepsy, the messages about when to sleep and when to be awake sometimes hit roadblocks or detours and arrive in the wrong place at the wrong time. This is why someone who has narcolepsy, not managed by medications, may fall asleep while eating dinner or engaged in social activities - or at times when he or she wants to be awake.

It affects both men and women of any age, but its symptoms are usually noticed after puberty begins. For the majority of persons with narcolepsy, their first symptoms appear between the ages of 15 and 30.

Excessive daytime sleepiness is usually the first symptom to appear, and often the most troubling. It is an overwhelming and recurring need to sleep at times when you want to be awake. In addition to sleepiness, key symptoms of narcolepsy can include regular episodes of:

  • cataplexy - a sudden loss of muscle control ranging from slight weakness (head droop, facial sagging, jaw drop, slurred speech, buckling of knees) to total collapse. It is commonly triggered by intense emotion (laughter, anger, surprise, fear) or strenuous athletic activity. Most persons with narcolepsy have some degree of cataplexy.
  • sleep paralysis - being unable to talk or move for a brief period when falling asleep or waking up. Many persons with narcolepsy suffer short-lasting partial or complete sleep paralysis.
  • hypnagogic hallucinations - vivid and often scary dreams and sounds reported when falling asleep. People without narcolepsy may experience hypnagogic hallucinations and sleep paralysis as well.
  • automatic behavior - familiar, routine or boring tasks performed without full awareness or later memory of them.

In addition to a medical history and physician examination, a diagnosis is made from polysomnogram tests in an overnight sleep laboratory to measure brain waves and body movements as well as nerve and muscle function. A diagnosis also includes the results of the Multiple Sleep Latency Test (MSLT), which measures the time it takes to fall asleep and to go into deep sleep while taking several naps over a period of time.

Restless Legs Syndrome (RLS) is a sleep disorder characterized by a deep creeping, or crawling sensation in the legs that tends to occur when an individual is not moving. There is an almost irresistible urge to move the legs; the sensations are relieved by movement. 

The sleep disturbances with RLS can range from mild to severe, but sleep problems are often the reason that people suffering from RLS seek a doctor's help.

If leg twitching or jerking is also present, a related disorder called periodic limb movements during sleep (PLMS) may be the cause. With PLMS, the leg movements may be severe enough to awaken you. In RLS, PLMS-like symptoms can sometimes occur during wakefulness, as well as in sleep.

The symptoms of RLS can range anywhere from bothersome to incapacitating. Fluctuations in severity are common, and occasionally the symptoms may disappear for periods of time. Anxiety as bedtime approaches, frustration with nighttime awakenings, moodiness and depression, difficulty concentrating and excessive daytime sleepiness have all been reported in association with RLS. It also can affect marital, family and social relations as well as having an adverse effect on school, work or other activities. Another effect can be increased drowsiness while driving or great difficulty performing overnight shift work.

The following clinical criteria are used for diagnosis of RLS:

  • A compelling urge to move the limbs.
  • Motor restlessness; for example, floor pacing, tossing and turning, and rubbing the legs.
  • The symptoms may be worse or exclusively present at rest, with variable and temporary relief by activity.
  • Symptoms are worse in the evening and at night.

Other associated features commonly found in RLS include:

  • Sleep disturbances and daytime fatigue.
  • Normal neurological exam in primary RLS.
  • Involuntary, repetitive, periodic, jerking limb movements, either in sleep or while awake and at rest.

Most RLS cases may be treated with pharmacological treatments.

Insomnia is the inability to fall asleep or remain asleep. Insomnia is also used to describe the condition of waking up not feeling restored or refreshed. Insomnia can be either acute, lasting one to several nights, or chronic, even lasting months to years. Insomnia can be a disorder in its own right, but often it is a symptom of some other disease or condition. Half of all those who have experienced insomnia blame the problem on stress and worry. Insomnia can also occur with jet lag, shift work and other major schedule changes.

If you have difficulty sleeping, it is essential to determine whether an underlying disease or condition is causing the problem. Sometimes insomnia is caused by pain, digestive problems or a sleep disorder. Insomnia may also signal depression or anxiety. Often times, insomnia exacerbates the underlying condition by leaving the patient fatigued and less able to cope and think clearly. For insomnia related to a medical condition or pain, ask your doctor about nighttime pain aids.

If your sleep trouble is confined to difficulty falling asleep, the time you are choosing to go to sleep may not be synchronized with your biological clock. The biological processes that initiate and maintain sleep in humans are active throughout the night. Opposing this sleep tendency, however, is the alerting action of the biological clock that is active throughout the day. When the biological clock is active at your scheduled bedtime, you will have sleep-onset insomnia.

The prevalence of insomnia is higher among older people and women. Women suffer loss of sleep in connection with menstruation, pregnancy, and menopause. Rates of insomnia increase as a function of age but most often the sleep disturbance is attributable to some other medical condition.

Some medications can lead to insomnia, including those taken for:

  • colds and allergies
  • high blood pressure
  • heart disease
  • thyroid disease
  • birth control
  • asthma
  • pain medications
  • depression (especially SSRI antidepressants)

Some common sleep disorders such as restless legs syndrome and sleep apnea can also lead to insomnia.