Neurology for the Medical Practitioner. Department of Neurology School of Medicine John Doyle MD
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1 Neurology for the Medical Practitioner Department of Neurology School of Medicine John Doyle MD
2 The Spectrum of Diabetic Neuropathy Department of Neurology School of Medicine
3 Diabetic Neuropathy Acknowledge debt to Continuum, Smith and Singleton
4 Diabetic Neuropathy Distal Sensory Neuropathy(DSP) 50% of patients at some point 20% patients have DSP at time of diagnosis 20% DSP severe pain Leading risk factor for foot ulceration and limb amputation
5 Diabetic Neuropathy DSP characterized by paresthesias and numbness distally in lowers Some have sharp shooting pains Generally stocking and glove reduction in touch, pain, temperature Reduction in joint position sense and vibration threshold Absent Achilles Refex and Patellar Reflex as it progesses
6 Diabetic Neuropathy Motor Weakness unusual unless prolonged and severe Frequently accompanied by diabetic autonomic neuropathy (DAN) Diagnosis depends on demonstration of typical distal neuropathy in a diabetic with no other cause being found NCV supportive but not specific
7 Diabetic Neuropathy Small Fiber Neuropathy Distal burning, aching Vibration, joint position sense spared Intact Achilles Reflex Reduced pin stocking/glove NCV normal Dx via QSART, QST, autonomic testing depend on small fibers Skin bx diagnostic (fiber counting)
8 Diabetic Neuropathy Pain management American Academy of Neurology Position Statement: Treatment of Painful Diabetic Neuropathy A evidence : pregabalin mg/day B evidence: gabapentin /day Valproate /day Venlafaxine /day
9 Diabetic Neuropathy Duloxetine mg/day Amitriptyline 25-75m/day
10 What s new Factors other than hyperglycemia may play a role in pathophysiology of DSP Obesity, dyslipidemia, hypertension, smoking, and serum triglycerides independent risk factors for neuropathy Aggressive glycemic control reduces neuropathy risk in type I diabetes Data less impressive for type II
11 What s new Aggregate literature suggests modest improvement in neuropathy with aggressive management (Type II) Reinforces notion that risk factors at play other than hyperglycemia
12 What s new Classification A. Chronic (DSP, Autonomic Neuropathy B. Acute( Diabetic Amyotrophy, Mononeuropathies, Treatment Related) Classification II Focal, Multifocal, Generalized and symmetrical Classification III DSP and all others
13 Diabetic Autonomic Neuropathy Common; increases risk of cardiac death Orthostatic hypotension, Erectile dysfunction, gastroparesis, bladder dysfunction Many asymptomatic Prolonged diabetes, poor glycemic control, DSP are suspect Usually coexists with DSP rarely seen in isolation
14 Cardiovascular Dysautonomia Inputs from carotid baroceptors disrupted Frequent orthostatic hypotension Lightheadedness common-but many have other sx like neck pain, blue lights, visual blurring Exercise intolerance altered BP regulation Initially nighttime hypertension from decreased parasympathetic tone (lengthdependent vagal involvement)
15 Cardiovascular Dysautonomia Progression BP liability Frequently do not report angina with ischemia or infarction Two to five-fold risk of increased mortality; sudden death, MI, malignant arrhythmias more common European study dysautonomia single biggest risk factor for death during 7 year follow up period. ( Type I)
16 Testing Cardiovascular Autonomic Function Paced deep breathing with R-R variability Expiration (bradycardia)/inspiration(tachycardia) ratio of RR interval Standing from supine max tachycardia 15 seconds with slowest bradycardia 30 seconds R-R interval to Valsalva Diabetes Care 26: , 2003
17 Other dysautonomia Vasomotor alterations in distal extremities blue or red discoloration Cool extremities with reduced sweating QSART (Quantitative Sudomotor Axon Reflex Testing) sweat response to topically applied acetylcholine early sensitive test but false positives can be problematic
18 Other Dysautonomia Bladder dysfunction common from motor and sensory abnormalities Abnormalities in bladder distention and volume urgency Urodynamics and post void residual can evaluate Straight cath needed if no urgency with cc
19 Gastroparesis Retained food in stomach 8 hours after a meal Parasympathetic deficiency Nausea, early satiety, anorexia, vomiting typical symptoms Can cause labile glucose control and hypoglycemia since absorption retarded
20 ERECTILE DYSFUNCTION % TYPE 2 DM Linked to duration and HgbA1c Potent marker for vascular disease 3-4 fold ncreased risk for MI and other cardiovascular events Presence of ED should prompt cardiac evaluation
21 Treatment-Related Neuropathy Usually poorly controlled diabetes with new program of glycemic control (insulin) Profound weight loss can precipitate Type I and II diabetes Severe pain, distal or generalized Patients who withhold insulin to achieve weight loss at particular risk Will improve over months Related to Diabetic Neuropathic Cachexia
22 Diabetic Lumbar Plexus Diabetic Amyotrophy Neuropathy Most common acute diabetic neuropathy Acute onset thigh pain Then, atrophy and weakness of iliopsoas, quadriceps, and frequently distal muscles Loss of patellar reflex Progression over months, then gradual recovery Territorial extension to opposite leg common
23 Diabetic Lumbar Plexus Neuropathy Not related to glycemic control or duration of diabetes Many ascribe to autoimmune vasculitis but no role for immune treatments has been demonstrated Variants: symmetric lower extremity weakness with little pain Arm symptoms, independent or occurring with lower extremity symptoms
24 Acute Cranial Neuropathies Diabetic III n. palsy most common Usually pupil sparing, but search for aneurysm usually undertaken Improves over months Diabetes less commonly associated with CN IV, VI or VII palsy Most commonly seen in Type II DM
25 Diabetic Thoracic Radiculopathy (Truncal Neuropathy) Acute pain in thoracic dermatome(s);xan present with acute abdominal pain Usually burning sunburn Do not like bedclothes touching Can be bilateral or spread to opposite side Ultimately resolves
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