Neurology revision
11 March 2014
Antony Thomas
Consultant Neurologist
History
General Approach
– Is this neurological?
– If so where in the neuroaxis: central or
peripheral?
– Above or below foramen magnum?
– Above or below the tentorium?
– What might be the nature of the problem?
– Differential diagnosis
– Handedness
History Taking
Vital importance
Good listener
Focused
Lateral thinking
Anatomical and Pathological Diagnosis
Age / Occupation / Handedness
Temporal features of a symptom :
1.Onset 2.Progression 3.Duration
4.Recovery 5.Frequency
Weakness of one side of the body
Numbness of hands and legs
Direct Questions
Pain
Headache
Facial, neck, back and limb pain
Disturbance of consciousness
Blackouts, faints, fits
Altered sleep pattern
Cognitive & affective dysfunction
Memory, language
Depression, irritability
Direct Questions
Cranial 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)
Questions
Limb 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 Impression
Gait
Facial Expression
Handshake
Speech
Arm swinging
Positive symptom and negative symptom
History
Speed of onset
– Instantaneous
– Minutes
– Hours
– Days
– Weeks/Months
– Months/Years
Anatomically lesions localised to
Where is the lesion?
Meninges (Venus Sinus) Spinal fluid
Cortex
Subcortex (Basal Ganglia, Thalamus, Hypothalamus)
Brain Stem (Midbrain, Pons & Medulla oblongata)
Cerebellum
Foramen magnum (Craniocervical Junction)
Cranial Nerves
Spinal Cord (ends at Lower border L1)
Anterior Horn Cell Disorder
Nerve root (Dorsal & Ventral)
Plexus
Peripheral Nerve
Neuromuscular Junction
Muscle
History
Instantaneous
– “Electrical events”
Epilepsy
Myoclonic jerks
Neuralgic pain
– Vascular events
Subarachnoid H’age (SAH)
Intracerebral H’age
History
Maximal over minutes
Vascular events
Migranous events
Maximal over Hours
Infective events
Inflammatory: GBS, Myelitis
Vascular: stroke
Vasculitic:GCA, Mononeuritis multiplex
History
Maximal over Days
Intoxication: Iatrogenic
Infection: HSV encephalitis,
Meningitis
Inflammation: MS, GBS
History
Maximal over weeks/months
Brain tumours
Expanding unruptured aneurysms
Degenerative: CJD
Some polyneuropathies
Some myopathies: Steriod induced
History
Maximal over months/years
– Neurodegenerative
Parkinson’s (PD)
Alzheimer’s
Cerebellar ataxias
Motor Neurone Disease (MND)
Most Neuropathies
Most myopathies
Single or multiple
Migraine
Epilepsy
TIA
Syncope
Trigeminal Neuralgia
Multiple Sclerosis (Relapsing Remitting)
Documenting Hx
No different in Neurology
 Presenting complaint (PC)
 Hx of the PC
 Past Medical: Injuries, Psychiatric, Op,
Arteriopath
 Medication: Recreational use
 Social/Employment: Driver, Smoker / Alcohol
 Family Hx: Stroke, MND, PD, Dementias,
Tremors, DM, MS
Common presenting complaints in
Neurology
Funny turns
Seizures and LOC
Headaches
Dizziness & Vertigo
Confusion
Weakness of arms / legs
Abnormal movements
Loss of balance
Walking difficulties
Numbness and tingling, pins and needles
Visual failure, diplopia
HPC
As much detail as possible
When and where
Previous episodes
Witness accounts
Exacerbating and relieving factors
Treatments and changes to Rx
Associated symptoms
Recurrent attacks of LOC
Postures and manoeuvres
Drugs/Alcohol
Palpitations
Prodromal features
Post-ictal confusional states
Eye witness account
Treatments
Examination
Higher Mental Functions
Cranial Nerves
Motor
Sensory
Cerebellar
Gait
Sphincters
Skull and Spine
Neck stiffness
Neurocutaneous markers
General examination
Other systems
Higher Mental Functions
Appearance and behaviour
Mood and Affect
Thought form and content
Sensorium (GCS) and Cognition
–
–
–
–
–
Awareness
Sleep
Drowsiness
Stupor
Coma
Perceptual disturbances: Hallucinations
MMSE
Speech and Language
Cranial nerves
1. Olfactory
2. Optic
3. Occulomotor
4. Trochlear
5. Trigeminal
6. Abducens
Smell
Vision
Elevate, depress and
adduct, pup: constrict
Depression, adduction,
intorsion
Face sensation, muscles
of mastication
Abduction
Cranial Nerves
7. Facial
8. Vestibulocochlear
9. Glossopharyngeal
10. Vagus
Muscles of facial expression,
Anterior 2/3 tongue taste
Hearing and balance
Taste posterior 1/3 tongue, gag
reflex
Gag reflex, motor to soft palate,
pharynx, larynx. Autonomic fibres
to oesophagus, stomach, small
intestine, heart, trachea, viscera
11. Spinal Accessory
Sternocleidomastoid, Trapezius
12. Hypoglossal
Motor control tongue
Motor System
Bulk and nutrition
Wasting
Tone
Power
Reflexes
Babinski
DTR
0 Absent
+/- Present with reinforcement
+ Reduced
2+ Normal
3+ Increased Brisk Exaggerated
4+ Pathologically brisk with clonus
Sensory System
Side to side
Proximal to distal
Pin prick
Touch
Vibration
Joint position sense
Romberg’s
Cortical sensation
Cerebellar signs
Intention Tremors
Titubation
Ataxia
Truncal ataxia
Dysdiachokinesis
Slurred speech and dysarthria
Hypotonia
Past pointing Dysmetria
Nystagmus
Tandem walking heel-toe walking
Rebound phenomenon
Pendular knee jerk
Hyporeflexia
Finger nose / Heel shin co-ordination (watch out for weakness)
Gait
Normal
Hemiplegic / Circumduction
Parkinsonian
Cerebellar
High stepping/ steppage or stamping
Waddling / Trendelenburg
Spastic
Scissor gait
Antalgic
Functional
Diagnostic tests
CSF analysis (LP)
EEG
Evoked Potentials
EMG
NCS
CT
MR
DAT
SPECT
Bloods
Typical Cerebrospinal Fluid Findings in Various Types of Meningitis
Test
Bacterial
Opening pressure
Elevated
WBC
 1,000 per mm3
Cell differential
Protein
Fungal
Tubercular
Variable
Variable
<100 per mm3
Variable
Variable
Predominance of
Predominance of
Predominance
Predominance
PMNs*
lymphocytes†
of lymphocytes
of lymphocytes
Mild to marked
elevation
Normal to elevated
Elevated
Elevated
Usually normal
Low
Low
CSF-to-serum glucose Normal to marked
Viral
Usually normal
ratio decrease
CSF = cerebrospinal fluid; PMNs = polymorphonucleocytes.
*—Lymphocytosis present 10 percent of the time.
†—PMNs may predominate early in the course.
EEG
Encephalitis
Seizure Disorder
Encephalopathy
Anoxic brain injury
Degenerative conditions (CJD)
Trimodality EPs
Visual Evoked Responses
Brain Stem Auditory Evoked Response
Somatosensory EP
EMG/NCS
Muscle vs Motor Neuron
Demyelinative vs Axonal
Nerve root vs Plexopathy
Localisation of mononeuropathy
NMJ disorders: MG, LEMS
Entrapment Neuropathy
Neuropathy
Demyelinating
– Slowed conduction
– Preserved amplitude
Axonal
– Reduced amplitude
– Normal NCV
Neuroradiology
CT Head +/- contrast
MRI (MRA, MRV)
DWI (acute stroke)
PWI
FLAIR
MR Angiogram
PET/SPECT
Cortex
Cortical Areas
Brain blood supply
Circulation
Brainstem supply
Spinal cord
Cord blood supply
Neurological Emergencies
Status Epilepticus
Coma
Traumatic Brain Injury (TBI)
Acute Stroke
Infections (Meningitis)
Subarachnoid Haemorrhage
Raised intracranial pressure  Herniation
Acute Spinal cord compression
Acute Neuromuscular respiratory paralysis
Acute Visual loss
Delirium
Clinical scenario
35 years old lady
2/7 ago started with pins and needles in
feet followed by difficulty walking then in
the last 24 hours unable to hold a cup in
her hands and could not get out of the bed
Past: Had diarrhoeal illness2 weeks ago.
O/E:-
O/E
Hypotonia
Faccid weakness
Areflexia
Bilateral Bell’s palsy
No UMN signs
Glove and stocking sensory disturbance
Diagnosis ??
GBS
History
Examination
–
–
–
–
–
–
–
–
Flaccid weakness
Hypotonia
Hyporeflexia
Cranial nerves involvement
Respiratory muscle involvement
Autonomic involvement
Sensory disturbance
No UMN signs
GBS
Mortality rate 3 to 5 %
Symmetric rapidly progressive, ascending, flaccid
paralysis from a demyelinating poly radiculoneuropathy
Post infective, post inflammatory
10% starts in ULs
Progresses over the initial days up to 4 weeks
Plateaux and then improves afterwards
Proximal weakness
Bells palsy in 50%
Prior infection GIT/Resp
Diagnosis of GBS
Classical history & findings
Neurophysiology: Slowing of nerve conduction
Serology: Campylobactor, CMV, EBV, HSV,
Mycoplasma
Antibodies: Anti GM1, Anti GQ1b
CSF analysis: High protein with normal cells
(Albumino-cytological dissociation)
(? Neuro-imaging)
Papilledema in GBS
Treatment
Admit and observe  HDU/ITU
Monitor FVC
Artificial ventilation in 23% patients
Mortality from cardiac causes and
respiratory infections
IVIG
Plasma exchange
GBS - IVIG
Easy administration
Safety profile
0.4 g/kg/day for 5 days
IVIG vs Plasmapheresis
Studies showed equal efficacy
IVIG alone, Plasmapheresis alone and
Plasmapheresis followed by IVIG : - have
equal outcome.
Clinical Scenario
70 years old male
H/o difficulty chewing food
Choking and coughing on food
CT normal, MR scan normal
Sent home ? Stroke
Symptoms continued with good days and
bad days
Diagnosis ??