neuro interactive cases Flashcards
what are the 2 things youve got to determine for neuro ddx
anatomy
pathology
where is the anatomy that the path can be
Brain Spinal cord Nerve roots Peripheral nerve(s) Neuromuscular junction
what can the pathology be
Vascular Infection Inflammation/Autoimmune Toxic/Metabolic Tumour/Malignancy
Hereditary/congenital
Degenerative
timescale of stroke and CVS
sudden onset
characteristic of inflammation
flare ups
associated symptoms with neuro
visual swallowing hearing neck stiffness weakness paresthesia bowel and bladder control
cranial nerves
I: sense of smell II: VA, VF, pupils, fundoscopy III, IV, VI: diplopia V: sensation, corneal reflex VII: facial palsy VIII: hearing IX, X: Speech, swallowing XI: Sternocleidomastoid, trapezius XII: tongue movements
order to test the optic nerve
AFRO
if can say number of fingers hold up - say do formally with snellen chart
if cant - do movement and light perception
order of upper and lower limb exam
Inspection Tone Power Reflexes Coordination Sensation Gait - at end because takes time in exam Back
UMN signs
increased tone - spasticity
reduced power
hyperreflexia
upgoing plantar reflex
LMN signs
reduced tone - flaccid
reduced power
hyporeflexia
diagnosis? Diplopia (bilateral 6th) Bilateral ptosis Slurred speech Dysphagia Sluggish pupillary response to light Descending symmetric muscle weakness Multiple skin abscesses on arms & legs
o Flaccid paralysis
o Power low
o Reflexes diminished
o So LMN lesion
o If stroke affecting CN6 and CN further down – pt wouldn’t be alive
o Not a problem in brain ¬– if had abscess in brain lobe = unilateral contralateral
o Brainstem – if all way up affecting CN6 and lower cranial – pt would be dead
o Spinal cord –would cause paralysis, spastic paraopesisis
o Peripheral – would cause peripheral neuropathy
o All of these things mean– neuromuscular problem – IV drug user – presented with botulinism which impairs neuromuscular transmission – block Ach release
ddx = miller fisher variant of Guillian Barre
miller fisher variant of Guillain Barre
typically characterized by a triad of ataxia, areflexia, and ophthalmoplegia
what do you get with NMJ problem
o Bilateral cranial neuropathy and descending muscle weakness
what is spastic paraperesis
weakness of both legs
increased tone - lift leg up - whole leg off bed
brisk reflexes
upgoing planters
cerebellar signs
Ataxia - unsteady gait
Nystagmus
Dysdiadochokinesia (test rapidly alternating movements)
Intention tremor (finger-nose-finger test - past pointing and dysmetria )
Speech: slurred, scanning
loss of sensation if cerebral cortex lesion
hemisensory loss - contralateral
loss of sensation of spinal cord lesion
up to a level - eg up to umbilicus
loss of sensation if nerve root lesion (radiculopathy)
dermatomes
loss of sensation of mononeuropathy lesion
loss at specific area
loss of sensation of polyneuropathy
glove and stocking pattern
what is postural tremor
when holding particular position eg holding out arms
55 yr old man Numbness & tingling in hands & feet PMH: type 1 DM On basal/bolus insulin HbA1C: 50 mmol/mol B12: 500 pg/ml (200 – 900) eGFR: 90 reduced sensation to pinprick - glove and stocking distribution
what would you prescribe
o Hands and feet – thinking peripheral neuropathy – dm
o Bolus – with each meal
o Get long acting and then bolus
o Duloxetine – treatment of peripheral neuropathy with dm
pathology of peripheral neuropathy
o Infection – retroviral disease - HIV
inflammation - Guillain Barre
toxic/metabolic - dm, alcohol, b12 deficiency, uraemia, amyloidosis
tumour - paraneoplastic feature of a malignancy
toxic/metabolic causes of peripheral neuropathy and clinical clues
Drugs - Hx Alcohol - Hx, high GGT and MCV B12 deficiency - macrocytic anaemia Diabetes - history, glucose/HbA1c, polyuria, polydipsia Hypothyroidism - TFT Uraemia - UE
Amyloidosis - History of myeloma or chronic infection/inflammation
Inflammation/Autoimmune
causes of peripheral neuropathy
Vasculitis, CTD, inflammatory demyelinating neuropathy
what is amyloidosis
deposition of abnormal protein because had infection/inflammation that interfere with structure or function
History of myeloma or chronic infection/inflammation
in myeloma plasma cells making Ig - form precursers of abnormal protein
or making abnormal inflamm markers in infection taht deposit as abnormal protein
tumour or malignancy causes fo peripheral neuropathy
Paraneoplastic
Paraproteinaemia
hereditory causes of peripheral neuropathy
Hereditary sensory motor neuropathy
34 yr old woman Weakness in legs Blurred vision increased tone, reduced power, and brisk reflexes reduced pinprick sensation in leg blurring of optic disk
what is cause of blurred vision
papillitis
o Pt young female with weakness, blurred vision - think inflammation
(papilledema wont affect vision, caused by raised ICP - blurred optic disk)
o Spastic paraparesis – spinal cord UMN
o Demyelination – MS if 2 lesions separated in time and space
o Inflammation of the optic nerve- papiliitis or optic neuritis
describe optic neuritis/papillitis
Blurred optic disc margins
Blurred vision
Pain on eye movement - inflammation = pain
causes of spastic paraparesis
in spinal cord - corticspinal/spinothalamic tracts
vascular: anterior spinal arteries
infection - spinal cord compression by TB (Potts disease)
inflammation - demyelination or transverse myelitis
toxic/metabolic - vit B12 deficiency
tumour/malignancy
what is transverse myelitis
inflammation of the spinal cord eg after mycoplasma pneumonia
what is MS
2 lesions
separated in time/space
60 year old man Pain & paraesthesia on anteriolateral thigh PMH: Type 2 Diabetes Metformin HbA1C: 60 mmol/mol
BMI: 30 kg/m2
reduced pinprick sensation on anterolateral thigh
most appropriate next step management?
lose weight
what is meralgia parasthesia
Compression of lateral femoral cutaneous nerve
treatment of meralgia parasthesia
- Reassure
- Avoid tight garment
- Lose weight
if persistent
• Carbamazepine
• Gabapentine
what does the median nerve supply - sensation
lateral 3 dingers and half of ring finger
what does the ulnar nerve supply - sensation
medial fingers
what does radial nerve supply
back of hand - test base of thumb
what is radiculopathy
disease of the nerve roots
lumosacral radiculopathy
Pain in the buttock, radiating down the leg below the knee (‘sciatica’)
Compression by
Disc herniation
Spinal canal stenosis eg osteophytes
60 year old man Recurrent falls Tremor at rest Rigidity More forgetful Dysphagia Micrographia Limited upgaze
most likely dx
progressive supranuclear palsy
parkinsons symptoms
Tremor, rigidity, bradykinesia
what does parkinsons disease affect
Dopaminergic neurons
Substantia nigra
progressive supranuclear palsy (Steele-Richardson syndrome) features
Parkinsonian features, upgaze abnormality
lewy body dementia features
Features of Alzheimer’s disease, Parkinson’s & hallucinations
A 55-yr-old man Confusion & chest pain No headache or neck stiffness Recently moved to a new house. Temp: 37oC PR 110, BP 120/60 Normal CVS/Resp/GI/Neuro exam ECG: sinus tachycardia, widespread ST depression Urinalysis: NAD Blood glucose: 7.0 mmol/L WCC: 7 CRP < 5 CT head: NAD
What is the most likely cause of his confusion?
- Not stroke – seen on CT
- Not infection – low CRP
- No other features of inflammation
- Toxic – metabolic – urinalysis, toxic screen – CO possibility
causes of apparent confusion and low AMTS - and the clinical clues
post-ictal - history of seizure
dysphagia (receptive/expressive) - other features of stroke/TIA
dementia - history of IHD/PVD, signs of excess alcohol
depressive pseudodementia - Elderly, withdrawn, poor eye contact
Precipitating factor
types of dementia
Vascular (multi-infarct)
Alcoholic
Alzheimer’s disease
Inherited e.g. Huntington’s disease (HD)
ddx of confusion/reduced consciousness
Hypoglycaemia Vascular Bleed: sudden onset Headache, collapse Subdural haematoma (Fall, fluctuating consciousness) Infection: ? Temp, ? Intracranial, ? Extra-cranial Inflammation Malignancy Metabolic/Toxic: Drugs, U&Es, LFTs, Vitamin deficiencies, Endocrinopathies
qns in AMTS (abbreviated mental test score)
DOB Age Time Year Place Recall (West Register Street) Recognize doctor/nurse Prime Minister Second WW Count backwards from 20 to 1
eyes GCS
4 = Spontaneous 3 = Opens in response to voice 2 = Opens in response to painful stimuli 1 = Does not open
verbal GCS
5 = Oriented 4 = Confused 3 = Words 2 = Sounds 1 = No sounds
motor GCS
6 = Obeys commands 5 = Localizes pain 4 = Withdraws to painful stimuli 3 = Abnormal flexion 2 = Extension 1 = No movements
features of meningitis
fever, neck stiffness, kernig’s sign (lie on back, pain when straighten knee)
features of SAH and investigations
Sudden onset
CT, LP (xanthochromia)
features and investigations of giant cell arteritis
Polymyalgia rheumatica
(Shoulder girdle pain, stiffness, constitutional upset)
> 50 years
ESR, steroids, Bx
treatment of giant cell arteritis
Steroid – prednisolone – urgent otherwise risk of them going blind
feature of migraine
Throbbing, vomiting, photo/phonophobia, FHx, Aura
pituitary apoplexy
IV hydrocortisone, bleed into pit tumour – see by endo and neurosurgeon
management of stroke
< 4.5 hours
CT: no haemorrhage
Thrombolysis (if no contraindications)
> 4.5 hours
CT head (exclude haemorrhage)
Aspirin (300mg), Swallow assessment
Maintain hydration, oxygenations, monitor glc
managment of TIA
Aspirin Don’t treat BP acutely unless > 220/120 or other indication ECG, Echocardiogram Carotid Doppler - do they need carotid endarterectomy Risk factor modification
40 year old
Backache
LMN weakness
Admitted to HDU
Regular FVC
Cardiac monitor
IVIG
most likely dx
o When LMN weakness – need to measure FVC and cardiac monitor – risk need admission to ITU for vent support
o Cardiac feature – autonomic features
o Guillain barre – LMN – get radiculopathy – back ache becasyue the nerve roots are affected
o Really need to measure FVC!
features of cauda equina syndrome
bowel and bladder symptoms
