The patient’s symptoms suggest Brown-Séquard syndrome, which is caused by a hemisection of the spinal cord. This results in ipsilateral pyramidal weakness and loss of joint position/vibration sense, along with contralateral loss of pain/temperature sensation. The patient’s lesion is located in the left mid-thoracic cord. A lesion in the left lumbosacral plexus would only affect the left lower limb. A cervical cord lesion would affect the upper limbs. A central lesion would produce bilateral symmetrical defects, which is not the case here. A right mid-thoracic cord lesion would produce similar symptoms, but on the right side instead. Other spinal cord syndromes include complete cord transection, anterior cord syndrome, subacute combined degeneration of the cord, syringomyelia, and cauda equina syndrome. Each of these has a distinct set of symptoms and affected areas.

The Royal College of Physicians (RCP) and NICE have published guidelines on the diagnosis and management of patients following a stroke. The management of acute stroke includes maintaining normal levels of blood glucose, hydration, oxygen saturation, and temperature. Blood pressure should not be lowered in the acute phase unless there are complications. Aspirin should be given as soon as possible if a haemorrhagic stroke has been excluded. Anticoagulants should not be started until brain imaging has excluded haemorrhage. Thrombolysis with alteplase should only be given if administered within 4.5 hours of onset of stroke symptoms and haemorrhage has been definitively excluded. Mechanical thrombectomy is a new treatment option for patients with an acute ischaemic stroke. NICE recommends thrombectomy for people who have acute ischaemic stroke and confirmed occlusion of the proximal anterior circulation demonstrated by computed tomographic angiography or magnetic resonance angiography. Secondary prevention includes the use of clopidogrel and dipyridamole. Carotid artery endarterectomy should only be considered if carotid stenosis is greater than 70% according to ECST criteria or greater than 50% according to NASCET criteria.

Bulbar onset motor neuron disease can be identified by the presence of tongue fasciculations.

While benign fasciculation syndrome can also cause tongue fasciculations, the overall clinical picture suggests a more serious underlying condition. Other factors may be misleading in making a diagnosis.

Understanding Motor Neuron Disease: Signs and Diagnosis

Motor neuron disease is a neurological condition that affects both upper and lower motor neurons. It is a rare condition that usually presents after the age of 40 and can manifest in different patterns such as amyotrophic lateral sclerosis, progressive muscular atrophy, and bulbar palsy. The diagnosis of motor neuron disease is based on clinical features, including the presence of fasciculations, the absence of sensory signs, and the combination of upper and lower motor neuron signs. Wasting of the small hand muscles and tibialis anterior is also common.

Other features that can help diagnose motor neuron disease include the absence of external ocular muscle involvement, the absence of cerebellar signs, and preserved abdominal reflexes. Sphincter dysfunction, if present, is usually a late feature. While vague sensory symptoms may occur early in the disease, sensory signs are typically absent.

Nerve conduction studies can help exclude a neuropathy, while electromyography shows a reduced number of action potentials with increased amplitude. MRI is usually performed to exclude other conditions such as cervical cord compression and myelopathy. Understanding the signs and diagnosis of motor neuron disease is crucial for early detection and management of the condition.

Myotonic dystrophy is a genetic disorder that causes muscle stiffness and wasting. It is inherited in an autosomal dominant pattern and typically presents between the ages of 15 and 40. The disease progresses slowly and can lead to cataracts, hypogonadism, frontal balding, and cardiac issues. Patients may experience weakness, wasting, and myotonia in affected muscles, particularly in the face and limbs. Other symptoms include hollowing of the cheeks, swan neck appearance, and difficulty releasing a handshake. This patient’s presentation is consistent with myotonic dystrophy and likely inherited from her father.

Myasthenia gravis is an autoimmune disorder that causes weakness, particularly in the periocular, facial, bulbar, and girdle muscles. Fatigue is a hallmark symptom, and dysphagia may occur in advanced cases. Temporalis atrophy is not a feature.

Motor neurone disease is a rare condition that typically presents with mixed upper and lower motor neuron signs in the same limb. Symptoms may include weakness, wasting, cramps, stiffness, and problems with speech and swallowing. Dysphagia and speech problems become more common as the disease progresses. MND is unlikely in a woman of this age, and there is typically no familial link.

Multiple sclerosis is a more common condition in women that typically presents with transient episodes of optic neuritis or limb weakness/paraesthesiae. Only a small percentage of sufferers have a family history of MS.

Polymyositis is a connective tissue disease that causes proximal muscle weakness and tenderness. Atrophy is a late feature, and patients may have difficulty rising from chairs. Dysphagia may occur in advanced cases, but ptosis and temporalis wasting are not features. Polymyositis is not typically inherited.

NICE Guidelines for Investigating Head Injuries in Adults

Head injuries can be serious and require prompt medical attention. The National Institute for Health and Care Excellence (NICE) has provided clear guidelines for healthcare professionals to determine which adult patients need further investigation with a CT head scan. Patients who require immediate CT head scans include those with a Glasgow Coma Scale (GCS) score of less than 13 on initial assessment, suspected open or depressed skull fractures, signs of basal skull fractures, post-traumatic seizures, focal neurological deficits, and more than one episode of vomiting.

For patients with any loss of consciousness or amnesia since the injury, a CT head scan within 8 hours is recommended for those who are 65 years or older, have a history of bleeding or clotting disorders, experienced a dangerous mechanism of injury, or have more than 30 minutes of retrograde amnesia of events immediately before the head injury. Additionally, patients on warfarin who have sustained a head injury with no other indications for a CT head scan should also receive a scan within 8 hours of the injury.

It is important for healthcare professionals to follow these guidelines to ensure that patients receive appropriate and timely care for their head injuries. By identifying those who require further investigation, healthcare professionals can provide the necessary treatment and support to prevent further complications and improve patient outcomes.

Differentiating Neurodegenerative Disorders: A Comparison of Parkinson’s Disease, Alzheimer’s Dementia, Frontotemporal Dementia, Huntington’s Disease, and Vascular Dementia

Neurodegenerative disorders can be difficult to differentiate due to overlapping symptoms. Parkinson’s disease, for example, involves the death of neurones in the substantia nigra and is often confirmed through the use of DaTscan, which visualises dopamine transporter levels in the brain. Dementia is a common complication of Parkinson’s disease, affecting 20-40% of patients and causing cognitive, mood, and behavioural changes.

Alzheimer’s dementia, on the other hand, is characterised by cortical atrophy visible on CT and MRI scans and is not typically associated with movement disorders. Frontotemporal dementia primarily affects behaviour and language and is also not typically associated with movement disorders.

Huntington’s disease is another basal ganglia disorder, but it primarily involves cell loss in the striatum, leading to chorea – uncontrollable limb movements. CT and MRI scans can show loss of striatal volume in moderate-to-severe cases, but early scans may appear normal.

Vascular dementia, the second most common cause of dementia after Alzheimer’s, often has a history of cerebral vascular disease and is not typically associated with movement disorders. Understanding the unique characteristics of each neurodegenerative disorder is crucial for accurate diagnosis and treatment.

The common peroneal nerve is a branch of the sciatic nerve that provides motor and sensory innervation to the lateral and anterior compartments of the leg, as well as the dorsum of the foot. Damage to this nerve, often caused by fibular neck fracture, results in footdrop and sensory loss in the affected areas.

The sciatic nerve, which originates from the lumbosacral plexus, innervates the posterior compartment of the thigh and indirectly innervates the posterior leg/calf muscles and some intrinsic muscles of the feet. It also provides sensory innervation to the posterolateral leg, lateral foot, and sole of the foot. Sciatica, a common condition that causes pain radiating down the leg, is often caused by irritation of the sciatic nerve root.

The posterior tibial nerve, another branch of the sciatic nerve, supplies motor innervation to the posterior compartment of the leg and sensory innervation to the posterolateral leg, lateral foot, and sole of the foot. Damage to this nerve, often caused by compression or trauma, results in ankle and sole of foot paraesthesiae.

The L5 root innervates muscles responsible for ankle and great toe dorsiflexion, hip abduction, and sensory innervation to the buttocks, posterolateral thigh, and lateral calf. L5 radiculopathy, which causes pain radiating from the lower back to the foot, is a common condition associated with damage to this root.

The deep peroneal nerve, a branch of the common peroneal nerve, innervates the muscles responsible for foot dorsiflexion and provides sensory innervation to the area between the first and second toes. Damage to this nerve, often caused by conditions such as LMD or diabetes, results in footdrop with minimal sensory loss and preserved eversion.

Differentiating Types of Dementia: A Brief Overview

Dementia is a broad term used to describe a decline in cognitive function that interferes with daily activities. However, there are different types of dementia, each with unique characteristics. Here are some key features to help differentiate between frontotemporal dementia, Alzheimer’s disease, Huntington’s disease, normal-pressure hydrocephalus (NPH), and Parkinson’s disease.

Frontotemporal Dementia
This type of dementia is rare and typically affects individuals between the ages of 55 and 65. Early personality and behavior changes are core symptoms, while memory impairment is not typical. Other key features include a gradual progression, decline in social conduct, emotional blunting, and loss of insight.

Alzheimer’s Disease
Alzheimer’s disease is the most common form of dementia, affecting individuals over the age of 65. Memory loss is a key early symptom, followed by agitation and obsessive behavior later in the disease course.

Huntington’s Disease
Huntington’s disease is a neurodegenerative condition that is often inherited. Symptoms include memory impairment, depression, clumsiness, mood swings, and difficulty concentrating. However, this patient’s symptoms are more consistent with early frontotemporal dementia.

Normal-Pressure Hydrocephalus (NPH)
NPH is a reversible cause of dementia characterized by gait abnormality, memory impairment, and incontinence. It may be mistaken for Parkinson’s disease, but symptoms will not improve with levodopa.

Parkinson’s Disease
While dementia and hallucinations may develop during the course of Parkinson’s disease, it is primarily a movement disorder characterized by tremors, rigidity, and bradykinesia.

Focal aware seizures do not affect consciousness or awareness, and may involve automatic, repetitive actions such as lip smacking.

Epilepsy is classified based on three key features: where seizures begin in the brain, level of awareness during a seizure, and other features of seizures. Focal seizures, previously known as partial seizures, start in a specific area on one side of the brain. The level of awareness can vary in focal seizures, and they can be further classified as focal aware, focal impaired awareness, or awareness unknown. Focal seizures can also be motor, non-motor, or have other features such as aura. Generalized seizures involve networks on both sides of the brain at the onset, and consciousness is lost immediately. They can be further subdivided into motor and non-motor types. Unknown onset is used when the origin of the seizure is unknown. Focal to bilateral seizures start on one side of the brain in a specific area before spreading to both lobes and were previously known as secondary generalized seizures.

Managing Alzheimer’s Disease: Non-Pharmacological and Pharmacological Approaches

Alzheimer’s disease is a type of dementia that progressively affects the brain and is the most common form of dementia in the UK. To manage this condition, there are both non-pharmacological and pharmacological approaches available.

Non-pharmacological management involves offering a range of activities that promote wellbeing and are tailored to the patient’s preferences. Group cognitive stimulation therapy is recommended for patients with mild to moderate dementia, while group reminiscence therapy and cognitive rehabilitation are also options to consider.

Pharmacological management involves the use of medications. The three acetylcholinesterase inhibitors (donepezil, galantamine, and rivastigmine) are options for managing mild to moderate Alzheimer’s disease. Memantine, an NMDA receptor antagonist, is considered a second-line treatment and is recommended for patients with moderate Alzheimer’s who are intolerant of or have a contraindication to acetylcholinesterase inhibitors. It can also be used as an add-on drug to acetylcholinesterase inhibitors for patients with moderate or severe Alzheimer’s or as monotherapy in severe Alzheimer’s.

When managing non-cognitive symptoms, NICE does not recommend antidepressants for mild to moderate depression in patients with dementia. Antipsychotics should only be used for patients at risk of harming themselves or others or when the agitation, hallucinations, or delusions are causing them severe distress.

It is important to note that donepezil is relatively contraindicated in patients with bradycardia, and adverse effects may include insomnia. By utilizing both non-pharmacological and pharmacological approaches, patients with Alzheimer’s disease can receive comprehensive care and management.