Neurology revision Neurology revision
11 March 201411 March 2014
Antony ThomasAntony Thomas
Consultant NeurologistConsultant Neurologist
HistoryHistory
General ApproachGeneral Approach– Is this neurological?Is this neurological?– If so where in the neuroaxis: central or If so where in the neuroaxis: central or
peripheral?peripheral?– Above or below foramen magnum?Above or below foramen magnum?– Above or below the tentorium?Above or below the tentorium?– What might be the nature of the problem?What might be the nature of the problem?– Differential diagnosisDifferential diagnosis– Handedness Handedness
History TakingVital importanceGood listenerFocused Lateral thinkingAnatomical and Pathological Diagnosis Age / Occupation / HandednessTemporal features of a symptom : 1.Onset 2.Progression 3.Duration 4.Recovery 5.FrequencyWeakness of one side of the bodyNumbness of hands and legs
Direct QuestionsPain
Headache
Facial, neck, back and limb pain
Disturbance of consciousness
Blackouts, faints, fits
Altered sleep pattern
Cognitive & affective dysfunction
Memory, language
Depression, irritability
Direct QuestionsCranial Nerve symptoms
Loss of vision, blurring, diplopia
Hearing, sense of taste and smell
Facial muscle weakness
Vertigo, dizziness, giddiness
Bulbar muscles ( swallowing , articulation of speech)
QuestionsLimb symptoms
Difficulty lifting , gripping, fine finger movements, clumsiness
Gait disorder, leg weakness, stiffness, balance problems
Loss of sensation, altered sensation, numbness
Involuntary movements, incordination
Bladder, bowel, sexual dysfunction
Initial ImpressionGait
Facial Expression
Handshake
Speech
Arm swinging
Positive symptom and negative symptom
HistoryHistory
Speed of onsetSpeed of onset– InstantaneousInstantaneous– MinutesMinutes– HoursHours– DaysDays– Weeks/MonthsWeeks/Months– Months/YearsMonths/Years
Anatomically lesions localised to Where is the lesion?
Meninges (Venus Sinus) Spinal fluidCortexSubcortex (Basal Ganglia, Thalamus, Hypothalamus)Brain Stem (Midbrain, Pons & Medulla oblongata)CerebellumForamen magnum (Craniocervical Junction)Cranial NervesSpinal Cord (ends at Lower border L1)Anterior Horn Cell DisorderNerve root (Dorsal & Ventral)PlexusPeripheral Nerve Neuromuscular JunctionMuscle
HistoryHistory
InstantaneousInstantaneous– ““Electrical events”Electrical events”
EpilepsyEpilepsy
Myoclonic jerksMyoclonic jerks
Neuralgic painNeuralgic pain
– Vascular eventsVascular eventsSubarachnoid H’age (SAH)Subarachnoid H’age (SAH)
Intracerebral H’ageIntracerebral H’age
HistoryHistory
Maximal over minutesMaximal over minutesVascular eventsVascular events
Migranous eventsMigranous events
Maximal over HoursMaximal over HoursInfective eventsInfective events
Inflammatory: GBS, MyelitisInflammatory: GBS, Myelitis
Vascular: strokeVascular: stroke
Vasculitic:GCA, Mononeuritis multiplexVasculitic:GCA, Mononeuritis multiplex
HistoryHistory
Maximal over DaysMaximal over Days
Intoxication: IatrogenicIntoxication: Iatrogenic
Infection: HSV encephalitis, Infection: HSV encephalitis, MeningitisMeningitis
Inflammation: MS, GBSInflammation: MS, GBS
HistoryHistory
Maximal over weeks/monthsMaximal over weeks/months
Brain tumoursBrain tumours
Expanding unruptured aneurysmsExpanding unruptured aneurysms
Degenerative: CJDDegenerative: CJD
Some polyneuropathiesSome polyneuropathies
Some myopathies: Steriod inducedSome myopathies: Steriod induced
HistoryHistory
Maximal over months/years Maximal over months/years – NeurodegenerativeNeurodegenerative
Parkinson’s (PD)Parkinson’s (PD)
Alzheimer’sAlzheimer’s
Cerebellar ataxiasCerebellar ataxias
Motor Neurone Disease (MND)Motor Neurone Disease (MND)
Most NeuropathiesMost Neuropathies
Most myopathiesMost myopathies
Single or multipleSingle or multiple
MigraineMigraine
EpilepsyEpilepsy
TIATIA
SyncopeSyncope
Trigeminal NeuralgiaTrigeminal Neuralgia
Multiple Sclerosis (Relapsing Remitting) Multiple Sclerosis (Relapsing Remitting)
Documenting HxDocumenting Hx
No different in NeurologyNo different in Neurology Presenting complaint (PC)Presenting complaint (PC) Hx of the PCHx of the PC Past Medical: Injuries, Psychiatric, Op, Past Medical: Injuries, Psychiatric, Op,
ArteriopathArteriopath Medication: Recreational useMedication: Recreational use Social/Employment: Driver, Smoker / AlcoholSocial/Employment: Driver, Smoker / Alcohol Family Hx: Stroke, MND, PD, Dementias, Family Hx: Stroke, MND, PD, Dementias,
Tremors, DM, MSTremors, DM, MS
Common presenting complaints in Common presenting complaints in NeurologyNeurology
Funny turnsFunny turnsSeizures and LOCSeizures and LOCHeadachesHeadachesDizziness & VertigoDizziness & VertigoConfusionConfusionWeakness of arms / legsWeakness of arms / legsAbnormal movementsAbnormal movementsLoss of balanceLoss of balanceWalking difficultiesWalking difficultiesNumbness and tingling, pins and needlesNumbness and tingling, pins and needlesVisual failure, diplopiaVisual failure, diplopia
HPCHPC
As much detail as possibleAs much detail as possible
When and whereWhen and where
Previous episodesPrevious episodes
Witness accountsWitness accounts
Exacerbating and relieving factorsExacerbating and relieving factors
Treatments and changes to RxTreatments and changes to Rx
Associated symptomsAssociated symptoms
Recurrent attacks of LOCRecurrent attacks of LOC
Postures and manoeuvresPostures and manoeuvres
Drugs/AlcoholDrugs/Alcohol
PalpitationsPalpitations
Prodromal featuresProdromal features
Post-ictal confusional statesPost-ictal confusional states
Eye witness accountEye witness account
TreatmentsTreatments
ExaminationExamination
Higher Mental FunctionsHigher Mental FunctionsCranial NervesCranial NervesMotorMotorSensorySensoryCerebellarCerebellarGaitGaitSphinctersSphinctersSkull and SpineSkull and SpineNeck stiffnessNeck stiffnessNeurocutaneous markersNeurocutaneous markersGeneral examinationGeneral examinationOther systemsOther systems
Higher Mental FunctionsHigher Mental Functions
Appearance and behaviourAppearance and behaviourMood and AffectMood and AffectThought form and contentThought form and contentSensorium (GCS) and CognitionSensorium (GCS) and Cognition– AwarenessAwareness– SleepSleep– DrowsinessDrowsiness– StuporStupor– ComaComa
Perceptual disturbances: HallucinationsPerceptual disturbances: HallucinationsMMSEMMSESpeech and LanguageSpeech and Language
Cranial nervesCranial nerves1. Olfactory1. Olfactory
2. Optic2. Optic
3. Occulomotor3. Occulomotor
4. Trochlear4. Trochlear
5. Trigeminal5. Trigeminal
6. Abducens6. Abducens
SmellSmell
VisionVision
Elevate, depress and Elevate, depress and adduct, pup: constrictadduct, pup: constrict
Depression, adduction, Depression, adduction, intorsionintorsion
Face sensation, muscles Face sensation, muscles of masticationof mastication
AbductionAbduction
Cranial NervesCranial Nerves
7. Facial7. Facial
8. Vestibulocochlear8. Vestibulocochlear9. Glossopharyngeal9. Glossopharyngeal
10. Vagus10. Vagus
11. Spinal Accessory 11. Spinal Accessory
12. Hypoglossal12. Hypoglossal
Muscles of facial expression, Muscles of facial expression, Anterior 2/3 tongue tasteAnterior 2/3 tongue tasteHearing and balanceHearing and balanceTaste posterior 1/3 tongue, gag Taste posterior 1/3 tongue, gag reflexreflexGag reflex, motor to soft palate, Gag reflex, motor to soft palate, pharynx, larynx. Autonomic fibres pharynx, larynx. Autonomic fibres to oesophagus, stomach, small to oesophagus, stomach, small intestine, heart, trachea, visceraintestine, heart, trachea, viscera
Sternocleidomastoid, TrapeziusSternocleidomastoid, Trapezius
Motor control tongueMotor control tongue
Motor SystemMotor System
Bulk and nutritionBulk and nutrition
WastingWasting
ToneTone
PowerPower
ReflexesReflexes
Babinski Babinski
DTRDTR
00 AbsentAbsent
+/- Present with reinforcement+/- Present with reinforcement
+ Reduced+ Reduced
2+ Normal2+ Normal
3+ Increased Brisk Exaggerated3+ Increased Brisk Exaggerated
4+ Pathologically brisk with clonus4+ Pathologically brisk with clonus
Sensory SystemSensory System
Side to sideSide to sideProximal to distalProximal to distalPin prickPin prickTouchTouchVibrationVibrationJoint position senseJoint position senseRomberg’sRomberg’sCortical sensationCortical sensation
Cerebellar signsCerebellar signs
Intention TremorsIntention TremorsTitubationTitubationAtaxiaAtaxiaTruncal ataxiaTruncal ataxiaDysdiachokinesis Dysdiachokinesis Slurred speech and dysarthria Slurred speech and dysarthria Hypotonia Hypotonia Past pointing DysmetriaPast pointing DysmetriaNystagmus Nystagmus Tandem walking heel-toe walkingTandem walking heel-toe walkingRebound phenomenonRebound phenomenonPendular knee jerkPendular knee jerkHyporeflexiaHyporeflexiaFinger nose / Heel shin co-ordination (watch out for weakness)Finger nose / Heel shin co-ordination (watch out for weakness)
GaitGait
NormalNormalHemiplegic / CircumductionHemiplegic / CircumductionParkinsonianParkinsonianCerebellarCerebellarHigh stepping/ steppage or stampingHigh stepping/ steppage or stampingWaddling / TrendelenburgWaddling / TrendelenburgSpasticSpasticScissor gaitScissor gaitAntalgicAntalgicFunctionalFunctional
Diagnostic testsDiagnostic tests
CSF analysis (LP)CSF analysis (LP)EEGEEGEvoked PotentialsEvoked PotentialsEMGEMGNCSNCSCTCTMRMRDATDATSPECTSPECTBloodsBloods
Typical Cerebrospinal Fluid Findings in Various Types of Meningitis Typical Cerebrospinal Fluid Findings in Various Types of Meningitis
Test Test Bacterial Bacterial Viral Viral Fungal Fungal TubercularTubercular
Opening pressureOpening pressure Elevated Elevated Usually normal Usually normal Variable Variable Variable Variable
WBCWBC ≥≥1,000 per mm3 1,000 per mm3 <100 per mm3 <100 per mm3 Variable Variable Variable Variable
Cell differentialCell differential Predominance of Predominance of Predominance of Predominance of Predominance Predominance Predominance Predominance
PMNs* PMNs* lymphocyteslymphocytes†† of lymphocytes of lymphocytes of lymphocytes of lymphocytes
Protein Protein Mild to marked Mild to marked Normal to elevated Normal to elevated Elevated Elevated Elevated Elevated elevation elevation
CSF-to-serum glucoseCSF-to-serum glucose Normal to marked Normal to marked Usually normal Usually normal Low Low Low Low
ratio decreaseratio decrease
CSF = cerebrospinal fluid; PMNs = polymorphonucleocytes.CSF = cerebrospinal fluid; PMNs = polymorphonucleocytes. *—Lymphocytosis present 10 percent of the time.*—Lymphocytosis present 10 percent of the time. †—†—PMNs may predominate early in the course. PMNs may predominate early in the course.
EEGEEG
EncephalitisEncephalitis
Seizure DisorderSeizure Disorder
EncephalopathyEncephalopathy
Anoxic brain injuryAnoxic brain injury
Degenerative conditions (CJD)Degenerative conditions (CJD)
Trimodality EPsTrimodality EPs
Visual Evoked ResponsesVisual Evoked Responses
Brain Stem Auditory Evoked ResponseBrain Stem Auditory Evoked Response
Somatosensory EPSomatosensory EP
EMG/NCSEMG/NCS
Muscle vs Motor NeuronMuscle vs Motor Neuron
Demyelinative vs AxonalDemyelinative vs Axonal
Nerve root vs PlexopathyNerve root vs Plexopathy
Localisation of mononeuropathyLocalisation of mononeuropathy
NMJ disorders: MG, LEMSNMJ disorders: MG, LEMS
Entrapment NeuropathyEntrapment Neuropathy
NeuropathyNeuropathy
DemyelinatingDemyelinating– Slowed conductionSlowed conduction– Preserved amplitudePreserved amplitude
AxonalAxonal– Reduced amplitudeReduced amplitude– Normal NCVNormal NCV
NeuroradiologyNeuroradiology
CT Head +/- contrastCT Head +/- contrast
MRI (MRA, MRV)MRI (MRA, MRV)
DWI (acute stroke)DWI (acute stroke)
PWIPWI
FLAIRFLAIR
MR AngiogramMR Angiogram
PET/SPECTPET/SPECT
CortexCortex
Cortical AreasCortical Areas
Brain blood supplyBrain blood supply
CirculationCirculation
Brainstem supplyBrainstem supply
Spinal cordSpinal cord
Cord blood supplyCord blood supply
Neurological EmergenciesNeurological Emergencies
Status EpilepticusStatus EpilepticusComaComaTraumatic Brain Injury (TBI)Traumatic Brain Injury (TBI)Acute StrokeAcute StrokeInfections (Meningitis)Infections (Meningitis)Subarachnoid HaemorrhageSubarachnoid HaemorrhageRaised intracranial pressure Raised intracranial pressure Herniation HerniationAcute Spinal cord compressionAcute Spinal cord compressionAcute Neuromuscular respiratory paralysisAcute Neuromuscular respiratory paralysisAcute Visual lossAcute Visual lossDeliriumDelirium
Clinical scenarioClinical scenario
35 years old lady35 years old lady
2/7 ago started with pins and needles in 2/7 ago started with pins and needles in feet followed by difficulty walking then in feet followed by difficulty walking then in the last 24 hours unable to hold a cup in the last 24 hours unable to hold a cup in her hands and could not get out of the bedher hands and could not get out of the bed
Past: Had diarrhoeal illness2 weeks ago.Past: Had diarrhoeal illness2 weeks ago.
O/E:-O/E:-
O/EO/E
HypotoniaHypotonia
Faccid weaknessFaccid weakness
AreflexiaAreflexia
Bilateral Bell’s palsyBilateral Bell’s palsy
No UMN signsNo UMN signs
Glove and stocking sensory disturbanceGlove and stocking sensory disturbance
Diagnosis ??Diagnosis ??
GBSGBS
HistoryHistoryExaminationExamination– Flaccid weaknessFlaccid weakness– HypotoniaHypotonia– HyporeflexiaHyporeflexia– Cranial nerves involvementCranial nerves involvement– Respiratory muscle involvementRespiratory muscle involvement– Autonomic involvementAutonomic involvement– Sensory disturbanceSensory disturbance– No UMN signsNo UMN signs
GBSGBS
Mortality rate 3 to 5 %Mortality rate 3 to 5 %Symmetric rapidly progressive, ascending, flaccid Symmetric rapidly progressive, ascending, flaccid paralysis from a demyelinating poly radiculoneuropathyparalysis from a demyelinating poly radiculoneuropathyPost infective, post inflammatoryPost infective, post inflammatory10% starts in ULs10% starts in ULsProgresses over the initial days up to 4 weeksProgresses over the initial days up to 4 weeksPlateaux and then improves afterwardsPlateaux and then improves afterwardsProximal weaknessProximal weaknessBells palsy in 50%Bells palsy in 50%Prior infection GIT/RespPrior infection GIT/Resp
Diagnosis of GBSDiagnosis of GBS
Classical history & findingsClassical history & findingsNeurophysiology: Slowing of nerve conductionNeurophysiology: Slowing of nerve conductionSerology: Campylobactor, CMV, EBV, HSV, Serology: Campylobactor, CMV, EBV, HSV, MycoplasmaMycoplasmaAntibodies: Anti GM1, Anti GQ1bAntibodies: Anti GM1, Anti GQ1bCSF analysis: High protein with normal cells CSF analysis: High protein with normal cells (Albumino-cytological dissociation)(Albumino-cytological dissociation)(? Neuro-imaging)(? Neuro-imaging)Papilledema in GBSPapilledema in GBS
TreatmentTreatment
Admit and observe Admit and observe HDU/ITU HDU/ITU
Monitor FVCMonitor FVC
Artificial ventilation in 23% patientsArtificial ventilation in 23% patients
Mortality from cardiac causes and Mortality from cardiac causes and respiratory infectionsrespiratory infections
IVIGIVIG
Plasma exchangePlasma exchange
GBS - IVIGGBS - IVIG
Easy administrationEasy administration
Safety profileSafety profile
0.4 g/kg/day for 5 days0.4 g/kg/day for 5 days
IVIG vs PlasmapheresisIVIG vs Plasmapheresis
Studies showed equal efficacyStudies showed equal efficacy
IVIG alone, Plasmapheresis alone and IVIG alone, Plasmapheresis alone and Plasmapheresis followed by IVIG : - have Plasmapheresis followed by IVIG : - have equal outcome.equal outcome.
Clinical ScenarioClinical Scenario
70 years old male70 years old maleH/o difficulty chewing foodH/o difficulty chewing foodChoking and coughing on foodChoking and coughing on foodCT normal, MR scan normalCT normal, MR scan normalSent home ? StrokeSent home ? StrokeSymptoms continued with good days and Symptoms continued with good days and
bad daysbad daysDiagnosis ??Diagnosis ??