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Neurology at Sutter Neuroscience Institute

NeuroTips

NeuroTip #1 - Headaches

Frequent/daily headache is commonly a benign condition. Physicians should ensure there are no systemic findings (fever, hypertension, weight loss, visual problems, papilledema, nuchal rigidity, focal findings). In their absence, rebound headache or cervicogenic headache is likely. In most patients, rebound is more likely in the younger (<40y/o) population; cervicogenic headache in the older population. The first treatment for the rebound patient should be medication withdrawal. Physical therapy should be initiated in the cervicogenic headache patient.

NeuroTip #2 - Tremors

Tremor is a movement that is usually regular, rhythmical, and oscillatory. Describe whether the movement occurs at rest, with sustained posture, or with action. Note the body parts involved and whether the tremor is symmetrical. Don’t assume that a tremor is due to Parkinson’s disease. Look for possible causative agents, such as caffeine or medications. Essential tremor is the most common adult-onset movement disorder. It is usually causes a postural and action tremor, primarily affecting the upper extremities. It may also affect the head, voice, or legs. This is in contrast to the rest-predominant tremor seen in Parkinson’s disease. Many individuals with essential tremor report improvement with small amounts of alcohol, and worsening with stress. There may also be a family history of essential tremor. Question patients how essential tremor has affected their daily activities. Many individuals report social isolation due to embarrassment. Treatment options include: 1) stress reduction, 2) medication, and 3) surgical treatment for medically refractory tremor. Surgical options include permanent lesions by surgery or focused radiation (Gamma Knife), or temporary lesions (deep brain stimulation).

NeuroTip #3 - Multiple Myeloma

In evaluation of patients with vertebral fractures and underlying: osteopenia/osteoporosis, refractory pain or hx of cancer; r/o pathologic fracture.

Multiple myeloma is the most common primary neoplasm of the skeletal system. Multiple myeloma is a diffuse disease of the bone marrow. Almost 90% of patients with myeloma have osseous involvement. There are four distinct radiographic patterns of involvement seen:

  1. normal bone mineralization without a discrete lytic lesion
  2. diffuse demineralization and no lytic lesion
  3. a single lesion (plasmacytoma)
  4. widespread lytic lesions

In summary, consider and workup as indicated for:

  1. traumatic fracture
  2. osteoporotic compression fracture
  3. fracture secondary to primary neoplasm
  4. fracture secondary to metastatic disease

NeuroTip #4 - Treatment of Agitation in Alzheimer's Disease

Agitation is a frequent behavioral problem encountered in Alzheimer's Disease and other dementia syndromes. Always look for a potential inciting cause such as pain, infection (especially UTI), sleep disturbance, or change in routine.

Behavior modification is the first step with education of the caregiver of how to deal with the agitated behavior and avoid the triggers.

Cholinesterase inhibitors and memantine can be helpful in decreasing agitation. If already on these agents, low dose Depakote can be very helpful, starting at 125 mg bid and titrating, watching for excessive drowsiness. Antidepressants, esp. SSRI's may be helpful as well. Lastly, consider atypical antipsychotic agents such as Seroquel, Risperdal, and Zyprexa

NeuroTip #5 - Intermittent Hand Numbness

Bilateral intermittent hand numbness localizes the upper extremity peripheral nerves or to the cervical spine. It is most commonly carpal tunnel syndrome, less commonly Ulnar nerve entrapment or cervical sensory radiculopathy. Fingertip symptoms suggest CTS; Ulnar hand symptoms, the Ulnar nerve. Forearm symptoms, the cervical root. Try CTS splint first, both diagnostically and therapeutically. Persistent symptoms should lead to a NCS (more cost effective than MRI). MRI the cervical spine if NCS are normal or if patient has long tract signs or symptoms (lower extremity problems or bowel/bladder problems).

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