Central Nervous system - movement disorder ( ataxia, vertigo, parkinson etc) Flashcards
define ATAXIA
- lack of smooth and intensional movement
- symptom of particular disease process
- divided into 2 types
1) Motor cerebellar ataxia
2) Sensory Ataxia
What is motor cerebellar ataxia
Disorder of Cerebellum
(problem with the intergration of propioception signal - NB pathways are fine)
- lesion is ipsilateral
a) lateral cerebelar lesion
- cause limb incoordination
b) Midline cerebellar lesion
- Axial co-ordination problem less common ( may affect internal capsule, thalamic nucleus, frontal lobe)
What is sensory cerebellar ataxia
Failure of transmission of propioception to CNS via Peripheral Nerve
( Dorsal column or cerebellar input)
What are the causes of Ataxia
- Drug intoxication - ethanol, dilantin
- Metabolic - hyponatremia
- Peripheral Nerve - Alcohol peripheral neuropathy
- Vestibulopathy - meneiere disease
- Cerebellar disorder - infarction, mass, degeneration
- Posterior Column disorder - Vit B12 deficiency
What are the clinical presentations for ataxia
- difficulty ambulating - weakness and falls
- worsen with loss of visual input ( More Sensory ataxia)
- Cerebellar gait - wide space with unsteady irregular step
What is dysmetria
inacurate fine movement
What is Dysdiadokinesia
Clumpsy rapid movement
Dyssynergia
breakdown of movements into parts( Jacksonian movement)
Romberg test
- unsteady with eyes open - cerebellar pathology
- unsteady with eyes close - Sensory ataxia
What is true vertigo
illusion of movemet of the environment
What are the 3 main areas of the vestibular system that can be involved
1) Otological disease - of middle or inner ear
2) Vestibular nerve or end organ alone
3) Vestibular nuclei in the brainstem
With the otological cause, vertigo is associated with what clinical features
- hearing loss
- tinnitus
- ear discharge
- otalgia
- fullness or blockage
Vestibular nerve or endorgan alone
Present with vertigo alone
With regard to vestibular nuclei lesion - vertigo is associated with what clinical features?
- loss of consciousness
- diplopia
- other visual disturbance
- paraesthesiae
- limb paresis or weakness
- dysarthria
- dysphagia
What are important test during examination that can assist with the diagnosis of vertigo
1) Test of hearing
2) Webber and Rhinne test ( tuning fork)
3) Features of nystagmus
4) Examine cranial nerves and cerebellar function - Rhomberg tests
How do you perform Rinne Test
Rinne Test
- The doctor strikes a tuning fork and places it near the base of your mastoid bone.
- The doctor asks you to say when you no longer hear the sound.
- The doctor notes the time and moves the tuning fork near the ear canal.
- The doctor asks you to say when you no longer hear the sound.
- The doctor compares the time intervals for the two steps
What is the result of the Rinne Test
- In an ear with a hearing loss, if air conduction is better than bone, the deficit is sensorineural.
- If bone conduction is better than air, the loss is conductive in nature
How do you perform Webber Test
- The doctor strikes a tuning fork and places it on the middle of your head.
- The doctor asks you where the sound is coming from: the left ear, the right ear, or both.
What is the result of Weber tests
- Normal hearing will indicate sound in both ears.
- Conductive loss will indicate the sound travels towards the poor ear.
- Sensorineural loss will indicate the sound travels towards the good ear
What are the features of the Nystagmus suggesting peripheral nystagmus vs central vertigo
Peripheral Vertigo
- Combined horizontal and torsional
- inhibited by fixation of eyes onto object
- fades after a few days
- does not change direction with gaze to either side
Central Vertigo
- Purely vertical, horizontal, or torsional
- not inhibited by fixation of eyes onto object
- may last weeks to months
- may change direction with gaze towards fast phase of nystagmus
What are other features that differentiate peripheral from central vertigo
Peripheral Vertigo
1) Imbalance - Mild to moderate, able to walk
2) Nausea & vomiting - May be severe
3) Hearing loss or tinnitus - common
4) Non auditory Neurologic symptoms - rare
5) Latency following provocative test - longer ( up to 20 seconds)
Central Vertigo
1) Imbalance - Severe and unable to walk or stand still
2) N&V - Varies
3) Hearing loss or tinnitus - rare
4) Non auditory neurologic symptoms - common
5) Latency - short ( up to 5 seconds)
Associated symptoms for different causes of Vertigo
SYMPTOM SUGGESTED DIAGNOSIS
1) Aural fullness - Acoustic neuroma; Ménière’s disease
2) Ear or mastoid pain - Acoustic neuroma; acute middle ear disease (e.g., otitis media, herpes zoster oticus)
3) Facial weakness - Acoustic neuroma; herpes zoster oticus
4) Focal neurologic findings - Cerebellopontine angle tumor , CVA ; multiple sclerosis (especially findings not explained by single neurologic lesion)
5) Headache- Acoustic neuroma; migraine
6) Hearing loss - Ménière’s disease; perilymphatic fistula; acoustic neuroma; cholesteatoma; otosclerosis; transient ischemic attack or stroke involving anterior inferior cerebellar artery; herpes zoster oticus
7) Imbalance - Acute vestibular neuronitis (usually moderate); cerebellopontine angle tumor (usually severe)
8) Nystagmus- Peripheral or central vertigo
9) Phonophobia, photophobia - Migraine
10) Tinnitus - Acute labyrinthitis; acoustic neuroma; Ménière’s disease
What are the causes of vertigo associated with hearing loss
DIAGNOSIS - CHARACTERISTICS OF HEARING LOSS
a) Acoustic neuroma - Progressive, unilateral, sensorineural
b) Cholesteatoma - Progressive, unilateral, conductive
c) Herpes zoster oticus (i.e., Ramsay Hunt syndrome) - Subacute to acute onset, unilateral
d) Ménière’s disease - Sensorineural, initially fluctuating, initially affecting lower frequencies; later in course: progressive, affecting higher frequencies
e) Otosclerosis - Progressive, conductive
f) Perilymphatic fistula - Progressive, unilateral
g) Transient ischemic attack or stroke involving anterior inferior cerebellar artery or internal auditory artery - Sudden onset, unilateral
The common readily distinguishable vestibular pathologies are
(1) Middle ear disease affecting the inner ear
• Acute inflammatory problems.
• Tympanic membrane perforation with infection: Check for cholesteatoma (white keratin).
• Post middle ear surgery: patients may present to ED with vertigo after mastoidectomy or stapedectomy.
• Glomus tumour: pulsatile tinnitus with a red swelling behind an intact tympanic membrane.
(2) Inner ear disease
a) BPV
b) Meniere’s disease
c) Acute Labyrinthitis / Vestibular neuronitis
Central vertigo
- Cranial nerve disorder - CNS VIII, VII, V eg Herpes Zoster Oticus
- CNS disease - Vascular causes - basilar migraine, MS, Toxic causes
- Cervical causes
What are the treatment for the acute vertigo
1) Prochlorperazine - antiemetic, CNS suppression
2) IV Diazepam - Vestibular suppresion action
3) Haloperidol - for vomiting and vertigo
4) Promethazine - anticholinergics and antihistamine
5) Vestibular rehabilitation exercises
6) Surgery
What are the types of multi- system atrophy in Multiple system Atrophy
- Striatonigral degeneration - : clinical picture resembles Parkinson’s disease but without tremor. These patients do not respond to anti-Parkinson medications and often develop adverse reactions to these agents.
- Shy-Drager syndrome: clinical picture consists of Parkinson’s disease combined with severe autonomic neuropathy (particularly postural hypotension). Other important clinical features are impotence and bladder disturbances.
- Olivopontocerebellar atrophy: combination of extrapyramidal manifestations and cerebellar ataxia. Patients may also have autonomic neuropathy and anterior horn cell degeneration.
- Parkinsonism and motor neuron disease: rare.
What is the pathology in Shy-Drager syndrome?
In 1960, Shy and Drager described changes in the brainstem and ganglia; subsequently, loss of neurons has been shown in the autonomic nervous system and in the cells of the intermediolateral column of the spinal cord.
- Positron emission tomography shows decreased uptake of dopamine in the putamen and caudate lobe
What are the clinical picture of Multiple system atrophy?
History • Dizziness when standing up (due to postural hypotension). • Dysphagia. • Ataxia. • Symptoms of Parkinson's disease. • Impotence, bladder disturbances. • Anhidrosis.
Examination
• Mask-like facies and other features of bradykinesia.
• Increased tone (rigidity).
• Cerebellar signs.
What is Parkinson’s
is a progressive neurodegenerative condition
What is the cause of parkinson
result of insufficient quantities of the neurotransmitter dopamine in a part of the brain called the substantia nigra.
- Genetic factors
- Environmental toxins
- Accelerated ageing
- Free Radicals
What are the symptoms and signs of parkinson disease
- Tremor
- Stiffness
- Bradykinesia
- Loss of Balance
Other symptoms Skin sensations and pain Constipation Fatigue Depression Altered speech (may be slurred and slow) Difficulty with writing Numbness Walking difficulty Dementia (memory loss) Decreased blinking Increased saliva production Emotional changes
What are the treatment for parkinsonism?
1) Medication - Dopamine agonist eg Levodopa
2) Physiotherapy
3) Brain Surgery
