Cases Flashcards
A 70 year-old right-handed person presented with progressive gait instability and some “trouble looking upwards.” He had a tendency to lose his balance when walking. He was an avid birdwatcher and indicated that every day he would go out and “look up into the trees at the birds.”
The patient stated “I had more trouble over the past couple of years because I couldn’t look up without bending my whole neck back.”
Diagnosis: upward gaze paresis
Limb ataxia
MRI showed a pineal cyst compressing nerves responsible for eye movement and motor movement.
In most cases, a pineal cyst does not cause signs or symptoms. The majority of pineal cysts are small (roughly 80% are less than 10 mm in diameter) and asymptomatic. Symptomatic lesions are often larger (but not always), and occur most often in women in their second decade of life. Larger cysts (with a diameter >15 mm) may lead to various neurologic symptoms. Symptoms may be due to the cyst’s proximity to other structures in the brain, or hydrocephalus from compression of the cerebral aqueduct (a channel connecting the 3rd and 4th ventricles of the brain).[5]
When a pineal cyst does cause symptoms, they may include headaches (the most common symptom), hydrocephalus, disturbances in vision, and Parinaud syndrome. Although rare, people with symptomatic pineal cysts may have other symptoms such as difficulty moving (ataxia), mental and emotional disturbances, vertigo, seizures, sleep (circadian rhythm) troubles, vomiting, hormonal imbalances that may cause precocious puberty, or secondary parkinsonism.[5][6]
A 34-year old cardiothoracic surgeon developed left neck and shoulder pain, with numbness and tingling radiating down the ulnar aspect of his arm into the 4th and 5th fingers. On exam, he had some weakness of the intrinsic muscles of the left hand and decreased sensation to pinprick and light touch over the left fourth and fifth digits. The remainder of the exam was normal.
You had pain, but also decrease in sensation. Think of dermatome map and that points you to C8. What about ulnar nerve.
The left neck pain lets you know it is up near the vertebral column.
The motor, weakness of intrinsic muscles of hand.
Most likely is herniation between C7 and T1 impinging on C8.
A 24-year old person was drinking heavily with some friends on the 4th of July weekend and fell from a second-story balcony. They struck their back on a hard object on the way down and landed in a seated position, and immediately noticed a complete loss of movement and sensation in the legs. In the emergency room, exam was notable for flaccid tone and loss of all sensory and motor function in both lower extremities.
So very different from a spinal nerve impingement, this is a total transection where everything is lost.
Interruption of these long pathways is the reason spinal cord injuries leads to major loss in function BELOW THE LEVEL OF THE LESION.
Descending efferents can’t reach targets,
Ascending sensory output can’t reach the brain.
A 43- year old lady was seen in clinic with progressive leg weakness. She reports that at the age of 9 weeks, she had an illness causing weakness of both legs which kept her in hospital until the age of 6. During that time, she had several foot and ankle operations and had used leg braces into young adulthood. Afterwards, she learned to walk well, and excelled at swimming.
At the age of 36, she complained of right arm dysfunction with pain, followed by weakness in her right arm and leg and some falls. This progressed slowly and severely limited her mobility to a few yards with crutches. Over the course of a few years she had progressive left leg weakness and the need for a wheelchair.
The foot is dropped (refer the picture) - problem with anterior tibia, some wasting of muscles, \Symptoms
Weakness in the R leg mostly, but also the L leg
- Atrophy of the leg muscles
- Time course: Progressive, and she had had a similar illness as a baby
- Localization: broadly affects limbs (mainly lower)
Cranial nerve testing: normal • Observation: Lower limb wasting. No upper limb wasting.
• Strength test: Lower limbs had global weakness
bilaterally—more in the right.
• Reflexes: No reflexes in the lower limbs.
• Sensory examination: Normal
• MRI of the brain and whole spine normal, with mild scoliosis
and minimal degenerative disease.
• EMG (electromygraphy) studies showed partial denervation
of leg muscles.
Lower motor neuron syndrome
- Weakness or paralysis
- Atrophy
- Hyporeflexia or areflexia
- Decreased tone (resistance to passive movement) “flaccid paresis/paralysis”
- Fibrillations, positive sharp waves or fasciculations, measured by EMG
Symptoms will be in the muscles that are innervated by the motor neurons!
This patient has post-polio syndrome. She has a history of polio. She also has a broad area of lower motor neurons. She also had a period of years which she was neurologically stable _usually 15 years, followed by progressive weakness in the same muscles originally affected.
A 51- year old man was found to be progressively unresponsive the morning after a head injury. The night before, he fell down a flight of cement stars at 12:00AM, following a domestic altercation.
He struck his left temporal area and lost consciousness for about 15 minutes. After that, when the police arrived, he was awake, smelled of alcohol, and refused medical treatment.
In the morning, when the guards came to summon him for a court appearance, he was difficult to arouse, thrashing about incoherently, and had vomited and defecated. An ambulance brought him to the ER.
The neurological exam showed the following: • unresponsive to commands • Agitated • Left pupil fixed—not constricting to light and fixed in dilated position • right arm and leg paralyzed
After a short time, patient was in respiratory distress, so patient was intubated.
Epidural hematoma - period of lucidity but things got really bad when the herniation happened
73 yr old come to physician because of 2 month history of diffuse weakness and tingling of arms and legs. Neurologic examination shoes weakness of extensor and flexor muscles of lower extremities. Knee and ankle deep tendon reflexes are exaggerated. Sensation to vibration and position is decreased in all extremities but more severe in lower. Patient most likely has what?
Vit B deficiency
35 yr old contracts something similar to the flu, receives no treatment and is sick for a few days. 25 days later he develops pins and needles in fingers and toes. 3 days after that he has trouble speaking and eating, next day upon waking he difficulty walking. He goes to hospital and is barely able to lift his arms. What does he have
Guillain Barre syndrome
64 yr old with non-Hodgkin lymphoma comes to physician because of a 3 week history of progressive numbness in hands and feet, weakness in legs when he stands, he receives a third course of chemo 4 weeks ago, physcial examination shows areflexia. What drug can cause this effect?
Vincristine- common chemotherapy drug affecting long axons.
Motor weakness in right arm, lower face only.
So you’re thinking corticobulbar and corticospinal.
But is not including the legs.
So the lesion is in the primary motor cortex where the arm and face are.
Debbie is a 16-year-old girl who plays the piano and violin and has an active social life. Over the last four years, she has complained on-and-off to her parents that her arms and shoulder hurt and sometimes feel numb. At first, at about age 12, it was in her right shoulder (lateral aspect), but then moved to both sides.
Her parents were concerned and recommended that she take breaks from her music (mainly the violin) for several weeks to relieve her symptoms. Recently, however, it has gotten worse, and her pediatrician referred her to a pediatric neurologist because of progressive arm and shoulder pain and numbness.
When she arrived at the neurologist, she said that her major problem was that she had pain in both shoulders and lateral arms, and both hands felt “numb.” She did not have any gait problems, bladder incontinence, or other symptoms. The neurological exam was notable for decreased pinprick sensation on the lateral aspect of both arms and forearms, and in a cape distribution in her shoulder areas and superior-anterior chest area. The remainder of the exam was normal.
What dermatome levels are affected, what two things are abnormal, what would the lesion likely be?
C4-C6 (medial forearm is not affected so no T’s)
- She only has sensory symptoms, it is common that there is also motor weakness and vibration/position loss.
- She has paresthesia (burning/tingling) with sensory loss, this is poorly understood.
Syringomyela, only compressing the ventral commissure for pain and temperature. Likely a congenital malformation because of lack of trauma prior.
