Warning signs of an impending stroke

I want to lay stress on the warning signs of a stroke. We all need to be aware of these as a stroke can strike anyone anywhere and with stroke time is brain. The sooner the stroke is recognized and help is sought the better is the outcome.

So let us get to the heart of the topic. The following are some of the warning signs of an impending stroke/ stroke in evolution:

1) Sudden onset of speech difficulty. Either unable to speak or unable to comprehend speech (the patient can speak but cannot understand, so whatever he speaks makes no sense. We call this jargon speech). At times the problem with language can be more subtle: unable to name things (we call this nominal aphasia or anomia), the speech is slurred (we call this dysarthia).

2) Sudden onset of weakness in one arm or leg usually of the same side. For example weakness in right arm and right leg or in the left arm and left leg. This weakness may be prominent and the patient may not be able to move the arm and leg at all or it may be more subtle.

3) Sudden onset of numbness in one arm or leg usually of the same side. Numbness is hard to define and patients may use words like “weakness”, “tightness”, “dead feeling” or “my one side feels as if I slept on it”.

4) Sudden onset of facial weakness. One side of the face usually starts to sag, the smile is crooked when the patient attempts to smile and the patient may drool from the angle of the mouth.

5) Sudden onset of gait problems: the patient is unsteady and falls when attempting to walk. The balance is off. Patient is clumpsy and appears “drunk”.

6) Sudden onset of visual problems: patient may have an episode of transient loss of vision in one eye ( I felt as if a curtain decended in front of my eye). We call this transient monocular blindness and this is a TIA (transient ischemic attack). Patients may also complain of a field cut (unable to see one part of the visual field).

7) Acute loss of hearing in one ear especially in the elderly (this is a rare sign of a stroke).

Nitin Sethi, MD

Diabetic neuropathy: how to deal with it

In this post lets discuss about diabetic neuropathy. Diabetes is one of the most common causes of neuropathy. Neuropathy is a general term which refers to any condition which involves the nerves of the body. Diabetes involves the peripheral nerves of the body and can also involve the cranial nerves. The damage to the peripheral nerves is thought to be mediated by the increased levels of glucose and other metabolic factors in diabetic patients.

As I have stated in my earlier posts (see by my website http://braindiseases.info) neuropathies can be of different types. One may have a motor neuropathy in which only the motor nerves of the body are involved (hence patients present with weakness), one may have a predominantly sensory neuropathy in which the sensory nerves of the body are involved ( patients present with sensory complaints of numbness, tingling, pins and needles sensation) or one have a mixed sensory motor neuropathy (patients have a combination of motor and sensory findings in varying proportion).

Diabetes usually causes a mixed sensory motor neuropathy.

Clinical presentation: So how do patients with diabetic neuropathy present clinically? Well most patients seek medical help when they are bothered by dysesthesias (dysesthesias refers to uncomfortable sensations like feeling a part of the body usually the feet and hands are numb or “dead”, patients may also complain of feeling pins and needles sensation, tingling, burning etc). Patients with diabetic neuropathy have allodynia ( a condition in which a non-painful stimulus feels painful. Let me explain with an example. Suppose I touch your feet with a feather, you are not going to feel that as a painful stimulus. Now if I do the same to a patient with diabetic neuropathy, he may perceive that as a painful stimulus). They also have hyperpathia ( a condition in which the patient experiences a greatly exaggerated pain sensation to painful stimuli. Let me explain this with an  example. I touch the same diabetic patient’s leg with a sharp pin. Now any healthy person shall perceive this as a painful stimuli but to a patient with diabetic neuropathy, the pain may be so intense that it might be unbearable).

We sometimes divide these sensations experienced by patients with neuropathy into positive and negative symptoms.

Postitive symptoms include sensations of burning, pins and needles, pain etc while negative symptoms include sensations of feeling a part is numb or “dead”. It is easier to treat and control the positive symptoms while negative symptoms are more hard to treat.

The neuropathy in diabetes is length dependent (by that I mean, the longest nerves are the first to get involved). Hence symptoms first start in the feet (numbness in the toes etc and then proceed upwards. As the neuropathy progresses patients complain of numbness in the feet, then ankles, then shin, finger tips and so on).

Diagnosis of diabetic neuropathy: so now we come to the question of how do we diagnose diabetic neuropathy. The diagnosis of neuropathy is mostly clinical. If you are a diabetic patient presenting to a neurologist with compliants of numbness and tingling in the hands and feet, the diagnosis is readily apparent. Your doctor may test with with a tuning fork (to dtermine how well you perceive vibration), a disposable pin (pain sensation) and shall be able to determine if you clinically have an evidence of neuropathy or not. If the diagnosis is not apparent, he may order other tests like a Nerve Conduction Velocity test (we call this a NCV). During a NCV study, we check for the conduction of a nerve and whether it is delayed or not (this is done by giving a short electrical stimulus and then recording the response as it travels down the length of the nerve. As we are applying a short electrical current as stimulus, patients at times are not very comfortable during the test. The NCV study also helps in grading the severity of the neuropathy and helps in following the response to treatment.

Management of diabetic neuropathy: the management of diabetic neuropathy is twofold. One is the treatment of the underlying disease process (in this case the diabetes which is the cause of the neuropathy in the first case) and the other is the treatment of the neuropathy itself (how to control its symptoms so patients are not bothered by the sensations of numbness, tingling etc).

First and foremost in the managment of diabetic neuropathy, one should ensure good control of the blood sugar. Studies have shown that neuropathy develops in those diabetics who have uncontrolled or poorly controlled blood sugars. Hence aiming for euglycemia is essential (euglycemia means normal or near normal blood sugars). There are oral medications as well as insulin which can be used to achieve euglycemia and your doctor shall guide you in this. It is also essential to follow the blood sugars on a periodic basis so that one is sure that the blood sugar is well controlled.

There are many medications available to treat neuropathic symptoms. Some anti-depressants and anti-convulsants group of drugs are used for this purpose. The role of complimentary therapies like acupuncture, acupressure is not clearly determined as there are not many scientific studies to determine whether these are truly beneficial.

Patients should be advised about the importance of skin and foot care. Patients with diabetic neuropathy are prone to ulcers and infections in the foot, hence the feet should be kept clean and dry, avoid wearing ill fitting shoes and always always do wear clean pair of socks.

I hope this is useful to some of you.

Personal Regards,

Nitin Sethi, MD

Neuropathy presenting features

Neuropathy presenting features

So what are the signs and symptoms of someone with a neuropathic condition:

Sensory neuropathies present with the following signs and symptoms:

1) Numbness in the arms or legs ( a clue to neuropathy is that the signs and symptoms are usually symmetrical and start distally. For example the patient may complain of numbness in both legs or hands initially in the toes and the fingertips. As the disease progresses this numbness also moves more proximally reaching to the ankles, shin and the arms).

The patient may not complain of numbess rather may use words like ” my legs feel dead” or “my hands burn” to describe his symtoms.

2) Pins and needles sensation in the arms and legs: people with neuropathy have what doctors call paresthesias or abnormal sensations.  They may complain of feeling pins and needles , electric shocks or at times as if their skin is been touched with a feather.

They have allodynia (a non-noxious stimuli feels noxious meaning that if I touch you with a feather you may feel as if I am boring a sharp pin into your skin) and hyperalgesia (meaning that they have an increased sensitivity to pain).

3) Patients with neuropathy may present with skin changes. This is most commonly noted on the skin overlying the shin and feet. The skin is shiny and atrophic, the overlying hair are sparse or completely lost. At times people may develop non-healing ulcers of the feet which may get infected and even gangrenous. This condition is commonly seen in diabetic patients with severe neuropathy (diabetic foot).

4) If a patient has a large fiber neuropathy, he may complain of difficulty with balance especially at night or when his eyes are closed. They feel as if they are walking on cotton wool.

5) Patients may present with ulcers or burns in their hands: this is because as they are not able to detect the sensations of heat etc they may touch something hot like a gas stove and get burnt.



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In this section we shall discuss neuropathies. This is a vast topic and I shall try to make it simple. First lets start with the basics. What is neuropathy? Neuropathy refers to disease and dysfunction of the nerves.  There are different types of nerves in the human body: some nerves supply the muscles of the head, face and neck example the facial nerve supplies the muscles of the face ( it is this nerve which helps you to smile or frown).  Another  example is the auditory nerve which helps you to hear. These nerves which supply the muscles of the head and face are referred to as Cranial Nerves.

Apart from the cranial nerves there are other nerves which supply the muscles of the arms and legs and carry sensations of pain, temperature, pressure, joint sense, vibration and light touch. As these nerves supply the muscles in the periphery of the body they are referred to as peripheral nerves. Peripheral nerves are of three types:

1) Motor nerves : nerves which carry out motor functions example closing and unclosing your fist , walking etc

2) Sensory nerves: nerves which carry sensation of pain, temperature, touch, joint sense, vibration and position sense from the periphery back to the brain.

3) Mixed nerves: nerves which carry out both the above functions.

Neuropathies can thus be of different types based on which type of nerve is involved by the disease process. So you can have a motor neuropathy, a sensory neuropathy and a mixed motor-sensory neuropathy.

Another way to classify neuropathies is on the basis of the size of the nerve fibers involved. Pain, temperature and crude touch is carried by small sized nerve fibers and hence neuropathy of the small sized sensory nerves is referred to as small fiber neuropathy. Vibration, position sense and joint sense are carried by larger diameter nerve fibers and hence neuropathy of larger diameter nerve fibers is referred to as large fiber neuropathy.

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