Cases for Finals and
Beyond: Nervous
System
1st October 2012
Alastair Brown ST1
Neurosurgery
Objectives

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Describe 3 common clinical scenarios
Understand the relevant signs and symptoms of
common neurological conditions.
Understand how to decribe gait patterns in
common neurological conditions
Understand the investigations and management
Be aware of common sequelae of certain
neurological conditions and their management.
Case 1
FY1 covering the COTE Ward on Night
 Asked to see Mr Williams

 84
year old man
 Has had a fall on the ward
 Is confused
 Not sure if he has injured himself
On the Phone

What things are you going to ask the
nurse to do while you are on your way?
 Get
patient back to bed safely
 Get a set of observations (inc neuro
observations)
 Find notes and drug chart
 Consider asking for and ECG
On the Ward

What are your three priorities with this
patient?
Identify any injuries
2) Identify cause of the fall
3) Try to prevent/limit impact of further falls
1)

What are you going to do next?

Take a history
 Examine patient (General, MSK and Neuro)
On the Ward
Drug chart is in pharmacy
 Nurse looking after the patient is a bank
nurse and does not know much about him.
 Thinks he is normally confused
 Fall was unwitnessed
 Patient just says don’t know to all
questions.

Examination
General and MSK examination
unremarkable with no evidence of external
injury.
CNS
 Cranial nerves unremarkable.
 PEARL
 Following commands appropriately

PNS - Inspection:
PNS: Inspection

Describe the face of the patient you saw.
 Expressionless
 Masked

Describe the movement of the hand you
saw.
 Resting
tremor of the left hand
 Improves following purposeful movement
PNS Tone
PNS: Tone

Describe what you saw


What is this pattern of rigidity called?


Cog wheel rigidity
What condition is this pattern of rigidity associated with?


Intermittent resistance to passive flexion of the upper limbs.
Parkinson’s disease
Can you name another pattern of rigidity seen in the
same condition?

Lead-pipe rigidity
PNS: Gait
PNS: Gait

Describe the person’s gait










No aids
Slow
Stooped
Slow turning
Small steps
Shuffling
Tremor in hands
Festinating
Would also like to see them stand and sit
What condition is the gait pattern typical of?

Parkinson’s disease
Parkinson’s Disease: Features

What are the main pathological features in
Parkinson’s disease?
 Loss
of Dopaminergic neurons in the substantia nigra
 Formation of Lewy bodies.

What are the three cardinal features of
Parkinsons disease?
 Tremor
 Rigidity
 Bradykinesia
Parkinson’s Disease: Diagnosis

What investigations are used to diagnose PD?
 Generally a clinical diagnosis
 MRI and SPECT can be used but this is rare
 Trial of treatment often helps to make diagnosis.

Can you name three differential diagnoses for
PD
 Lewy Body dementia
 Drug – induced parkinsonism
 Vascular dementia
 Wilson’s
disease in young patients
Parkinson’s disease: Treatment

What is the main treatment of Parkinson’s
disease?
 Levodopa
treatment
 Coupled with Carbidopa to reduce peripheral release
and achieve higher CNS concentration with fewer
systemic side effects.

Are you aware of any emerging treatments?
 Deep
brain stimulation (normally of Subthalamic
nucleus)
Parkinson’s: Prognosis and
Complications

What is the course of Parkinson’s disease?
 Progressive

condition
What later complications are commonly seen?
 Postural
imbalance
 Dementia
 Swallowing difficulties
 Autonomic dysfunction
Case 2
You are an FY2 in A+E
 Asked to go to resus to see a patient who
has been brought in with seizures.

 Name:
Ethel O’Donohue
 Five minute seizure terminated after some PR
Diazepam
 72 year old female
 PMH: Unknown
How are you going to approach this
patient?
A – Patent and protected
 B – Sats 100% on 15L Chest clear
 C – HR 110 reg CRT < 2 secs BP155/60
 D – E3V2M4 BM 14.1 Pupils equal and
reactive. Not moving left side.
 E – Ulcers on left leg, Median sternotomy
scar, no evidence of any external injury.

What investigations are you going
to arrange?

Bloods
 FBC,
U+E, , LFTs, CRP, Mg, Clotting
 ABG

Bedside Tests
 ECG
 Urine

Dip
Radiology
?
CXR
 ? CT head
Results

Bloods
– 54
 Otherwise unremarkable
 ABG:
 CRP


pH – 7.29 pO2: 54.3, pCO2: 4.9 BE: -12.4 Lactate: 6.4
What does this show?


Metabolic acidosis
What is the likely cause?

Seizure
While you are waiting…

Patient starts to have another seizure.
 First
you notice shaking of the left arm and leg
 Patient then stops responding
 Then starts to have full tonic-clonic seizure.

What are three steps in the seizure described.
 Partial
seizure
 Initially simple then becomes complex
 Secondary generalisation.
Cont…

What is the definition of status epilepticus?
 One
seizure > 30 minutes or multiple seizures without
regaining consciousness for over 30 minutes.

What is the emergency management of status?
 A,B,C
 Call for Help
 IV Lorazepam
 Phenytoin infusion
 Sedation
 Barbituate coma
CXR
Can you describe this
radigraph?
Adequate technical film
Normal lung
appearances.
CT
Head
Can you describe the
CT scan?
-Hypo-intense area in
the right hemisphere
seen on multiple slices
of CT no evidence of
midline shift
What is the most likely
cause for these
findings?
-Stroke
What vascular
territory has been
affected?
Right MCA
PNS: Inspection

What comments can you make
about this gentleman’s posture?



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
What is the posture typical of?

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Spastic paralysis
Would this be typical of an acute
stroke?

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Flexed elbows
Flexed wrist
Flexed digits
Inversion of left foot
No, spasticity develop over weeks
to months.
What would you expect to find
examining his reflexes?

Hyperreflexic
PNS: Tone
PNS: Tone

What is the pattern of rigidity seen?
 Clasp

knife rigidity.
What conditions is this pattern of rigidity
seen in?
 Upper
motor neurone lesions
PNS: Gait
PNS: Gait

Can you describe this person’s gait?
 No
aids
 Reasonable speech
 Spastic posture
 Hip hitching of right leg
 Circumduction of right leg

What is this pattern of Gait called?
 Hemiplegic
gait.
CNS and Remaining PNS



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Sensation – normal
Power 1/5 on left and 5/5 on right
CNS unremarkable.
How do you grade power?
0 – No movement
1 – Flicker of movement
2 – Can move a joint with gravity eliminated
3 – Can move a joint against gravity
4 – Reduced from normal power
5 – Normal power
Stroke

How would you define stroke?
 Sudden
loss of circulation to an area of brain resulting
in a corresponding neurological deficit that persists for
more than 24 hours.

What would your differentials include?
 Todd’s
paresis
 Intracranial haemorrhage
 SOL
 Previous neurosurgery
Stroke: Investigation and Diagnosis

What risk factors are you aware of for stroke?


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Vascular risk factors (smoking, diabetes, hypertension, age)
Previous stroke
AF
Thrombophilias
How would you investigate someone you believed may
have had a stroke?
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History and examination
CT/MRI
ECHO
ECG
Carotid dopplers
Stroke: Management

What treatments can be given in acute stroke?

Aspirin
 Thrombolysis (currently within 3 hours of onset)

What other treatments can be given in the longer term to reduce the
risk

Modification of vascular risk factors (Statin, smoking cessation, etc)
 Warfarin if patient has AF
 Carotid endarterectomy.

What are the other components of stroke patient management?

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PT/OT- rehabilitation
SALT to assess swallowing
Case 3
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You are an FY1 in acute medicine
27 year old female
Presents with vision problems for last 3 days
Complaining of blurry and double vision and
pain on looking around
Mother has noticed has been quite clumsy
Normally fit and well.
CN II

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Visual acuity L Eye 6/4.5 R
Eye 6/12
Which eye has better vision?


b)
What is the abnormality seen
in a)


L eye
Which fundus is normal?


a)
Swollen optic disc
What is the likely diagnosis?

Optic neuritis
b)
CNS: III,IV,VI

What eye disorder is
shown here?



Internuclear
opthalmoplegia
Which eye is
affected?

Right
Left
Right eye
Which neurological
structure is involved?

Medial longitudinal
fasciculus
Convergence
PNS: Coordination
PNS: Coordination

What sign is being demonstrated in this patients left
arm?

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Which hemisphere of which part of the brain is not
working

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Intention tremor
L cerebellar hemisphere
What other signs would you test for in this patient?



Dysdiadochokineses
Past pointing
Romberg’s test.
PNS: Gait
PNS: Gait

Describe this patient’s gait.



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What is the name for this gait pattern?

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No aids
Normal walking speed
Poor balance
Broad based gait
Unsteady
Ataxic gait
What dysfunction is this gait pattern normally due to?

Cerebellar dysfunction
Case 3 Cont …

What is the likely diagnosis?
 Multiple

sclerosis
What would be your differential diagnosis?
 Space
occupying lesion
 Other inflammatory CNS conditions
(vasculitis, sarcoidosis etc.)
 Clinically isolated syndrome
Multiple sclerosis: Background

What is your understanding of Multiple
sclerosis?
 Immuno-mediated
demyelinating disease of the
central nervous system.

What patterns of disease are you aware of?
 Relapsing-remitting
 Primary
progressive
 Secondary progressive
MS: Diagnosis and Investigation

How would you investigate this patient?
 Bloods

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
Routine
Auto-antibodies
Infectious serology (Lyme, VDRL)
Vitamin B12
 MRI
– Oligoclonal bands and IgG
 Visual and Somatosensory evoked potentials
 CSF
MRI – Of Patient with MS
MS: Treatment

What treatments are used in the acute
treatment of MS?
 Methylprednisolone
 Plasma

exchange
What treatments are used in the long-term
management of MS:
 Interferon
 Other
immunomodulatory drugs
Objectives





Describe 3 common clinical scenarios
Understand the relevant signs and symptoms of
common neurological conditions.
Understand how to decribe gait patterns in
common neurological conditions
Understand the investigations and management
Be aware of common sequelae of certain
neurological conditions and their management.
Any questions?
alastairjwbrown@gmail.com