Neurological examination Flashcards
What are causes of horner’s syndrome? (6)
- carcinoma of lung apex (usually SCC)
- Neck - thyroid malignancy, taruma
- Carotid artery lesion - aneurysm, dissection, pericarotid tumour, cluster headache
- Brain stem lesions - vascular disease (Esp LMS), syringobulbia, tumour
- Retro-orbital lesions
- Syringomyelia
What are causes of anosmia?
Bilateral:
- URTI
- Meningioma of the olfactory groove (late)
- ethmoid tumours
- head trauma (including crimbriform plate #)
- meningitis
- hydrocephalus
- congenital - Kallman’s syndrome (hypogonadotrophic hypogonadism)
Unilateral:
- meningioma of the olfactory groove (early)
- Head trauma
What are causes of absent light reflex but present accomodation?
- midbrain lesion (Argyll Robertson pupil)
- Ciliary ganglion lesion (e.g. Adie’s pupil)
- Parinaud’s syndrome
- Bilateral anterior visual pathway lesions (bilateral afferent pupil deficits)
What are causes of absent convergence but intact light reflex?
- Cortical lesion - cortical blindness
2. midbrain lesions - rare
What are causes of constricted pupils?
- Horner’s syndrome
- Argyll Robertson pupil
- Pontine lesion - often bilateral, but reactive to light
- Narcotics
- Pilocarpine drops
- Old age
What are causes of dilated pupils?
- Mydriatics, atropine poisoning of cocaine
- Third nerve lesion
- Adie’s pupil
- Iridectomy, lens implant, iritis
- Post-trauma, deep coma, cerebral death
- Congenital
What is the cause and features of Adie’s pupil?
Lesion in efferent parasympathetic pathway.
- dilated pupil
- decreased/absent reaction to light (direct and consensual)
- Slow or incomplete reaction to accommodation with slow dilation afterwards
- Decreased tendon reflexes
- patients commonly young women
What are causes of Argyll Robertson pupil?
Lesion of iridodilator fibres in the midbrain:
- syphilis
- diabetes mellitus
- alcoholic midbrain degeneration (rarely)
- other midbrain lesions
What are features of Argyll Robetson pupil?
- small, irregular, unequal pupil
- nil reaction to light
- prompt reaction to accommodation
- if tabes associated, decreased reflexes
What are causes of papilloedema?
- SoL - causing raised ICP or retro-orbital mass
- Hydrocephalus (associated with enlarged ventricles)
a. obstructive - block in 3rd ventricle, aqueduct or outlet to 4th ventricle (e.g. tumour)
b. communicating
c. increased formation - choroid plexus papilloma
d. decreased absorption - tumour causing venous compression, subarachnoid space obstruction from meningitis - Benign intracranial hypertension
a. idiopathic
b. OCP
c. Addison’s disease
d. drugs - nitrofurantoin, tetracycline, vit a, steroids
e. lateral sinus thrombosis
f. head trauma - HTN - grade 4
- Central retinal vein thrombosis
- Cerebral venous sinus thrombosis
- High CSF protein level - GBS
What are causes of optic atrophy?
- Chronic papilledema or optic neuritis
- Optic nerve pressure or division
- Glaucoma
- Ischaemia
- Famililal - retinitis pigmentosa, leber’s disease, friedreich’s ataxia
What are causes of optic neuropathy?
- MS
- Toxic - ethambutol, chloroquine, nicotine, alcohol
- Metabolic - B12 def
- Ischaemia - DM, temporal arteritis, atheroma
- Familial - Leber’s disease
- Infective - infectious mononucleosis (glandular fever)
What are causes of cataract?
- Old age - senile cataract
- endocrine - DM, steroids
- Hereditary or congenital - dystrophica myotonica, refsum’s disease
- Ocular disease - glaucoma
- Irradiation
- trauma
What are causes of ptosis?
- Myasthenia gravis
- Myopathy (hereditary, congenital, mitochondrial)
- Horner’s syndrome
- CNIII palsy
- Senile ptosis, due to dehiscence of the levator palpebrae muscle
What are causes of diplopia?
Eye muscle problem:
- CN, INO
- Myasthenia, myopathy, thyroid eye disease
Nystagmus
What are causes of poor vision?
- MS
- Stroke
- Ischaemic optic neuropathy
- Pituitary lesions
- Diabetes-cataracts, retinopathy
What should be tested in a patients with ptosis or diplopia?
- pupillary response (direct, indirect, RAPD)
- EOM - puruit
- Fatigue of upgaze
- Visual fields
- Visual acuity
- Fundoscopy
- Check for weakness of other facial muscles
What should be tested in a patient with poor vision?
- Visual acuity
- Fundoscopy
- Visual fields +/- neglect
- Pupillary response - Direct, indirect, afferent pupillary defect
- EOM - pursuit
What are causes of a CNIII palsy?
- PCOM aneurysm
- DM/hypertension (generally pupil sparing)
- Brainstem lesion (stroke, tumour or demyelination)
- Sphenoid wing meningioma
- Cavernous sinus lesion
- Infection - basal meningitis
What are causes of a CNVI palsy?
- Ischaemia, DM, HTN
- False localising sign in high ICP
- Cavernous sinus lesions
- Acoustic neuroma
- Nasopharyngeal CA
- Basal meningitis
What distinguishes horners and brainstem/pancoast’s
BSL - horners + ipsilat loss of pain/temp on face, contralat limbs.
Pancoast’s - weakness and loss of reflexes in ipsilateral limb
What are examples of synucleoopathies?
Idiopathic parkinson’s disease
Multi-system atrophy
What are examples of tauopathies?
Cortico-basal degeneration (CBD)
Progressive supranuclear palsy (PSP)
What are DDx of movement disorders?
- Parkinson’s disease
- Parkinson’s mimics:
- essential tremor
- drug induced PD
- Progressive supranuclear palsy
- corticobasal degeneration
- multisystem atrophy
What are components of the movement disorder examination?
- Gait
- Rigidity and muscle-coactivation
- bradykinesia
- tremor assessment - distraction techniques.
- check tremor at rest, posture and action
- writing
- vocal tremor - Saccadic eye movements
- Dyspraxia
- Glabellar tap
- Postural reflexes
What are clinical features of parkinson’s disease?
Bradykinesia + at least one of:
- rigidity
- rest tremor (3-6Hz) of hands, legs, eyelids, jaw and lips
- postural instability
What are supportive criteria for IPD?
At least 3 for diagnosis of definite IPD:
- unilateral onset
- persistent asymmetry affecting side of onset most
- rest tremor present
- progressive
- excellent response to levodopa
- levodopa response at least 5 years
- clinical course greater than 10y
- severe levodopa induced chorea
What are non-motor aspects of parkinson’s disease?
Autonomic - bowel and bladder
Mood - depression/anxiety
REM sleep disturbance
Cognition - slowing, dementia in later stages
What are features of essential tremor?
- Bilateral action tremor
- exacerbated by posture holding and action
- Upper limbs > head > voice
- Head tremor can be induced by phonation
What are drugs implicated in Drug induced PD?
Anti emetics
Neuroleptics
Antidepressants - Fluoxetine/sertraline
Calcium antagonists - diltiazem, nifedipine, verapamil
Anti-epileptics - phenytoin, valproic acid
Anti-arrhythmics - amiodarone
Anti-hypertensives - captopril, methyldopa
OCP
Lithium
What clues are suggestive of atypical parkinsonism?
- marked symmetry early
- truncal more than appendicular
- early onset dementia
- early hallucinations
- early postural instability
- impaired vertical gaze
- square wave jerks
- apraxia of eyelid opening/closing
- prominent motor apraxia
- alien limb phenomenon
- pyramidal signs
- autonomic symptoms
What are key features of PSP?
Gradually progressive, 40 older
Postural instability and falls in 1st year AND vertical supranuclear palsy
What are detailed features of PSP?
- astonished facial expression
- low blink rate with gritty eyes
- vertical supranuclear gaze paralysis
- dysphagia/dysarthrophonia
- early postural instability and falls
- hummingbird sign (midbrain)
- tau positive
- limb dystonia
- urinary incontinence uncommon and late
What are behavioural features of PSP?
- Apathy for disability
- frontal impulsivity, rocket sign and reckless turns
- frontal disinhibition - applause sign, pallilalia
- depression greater than 50%
What are supportive criteria for PSP?
- symmetric akinesia or rigidity
- retrocollis
- poor response to levodopa
- early dysphagia/dysarthria
- early cognitive impairment
- normal smell
- nil visual hallucinations
- no REM behaviour disorder
What are features of corticobasal degeneration?
- insidious and progressive
- no response to levodopa
- akinetic rigid syndrome
- focal or segmental myoclonus
- asymmetrical dystonia
- limb apraxia/alien limb phenomenon
- cortical sensory loss/dyscalculia
- speech and language impairment
- frontal executive dysfunction
- visuospatial deficits
What are features of Multiple System Atrophy?
Autonomic failure - postural drop, urinary incontinence or erectile dysfunction
Plus (Parkinsonism) - bradykinesia+rigidity/tremor/postural instability/poorly levodopa responsive
OR
Cerebellar - gait ataxia w cerebellar dysarthria, limb ataxia, cerebellar eye signs less common early
When should a myopathy or NMJ disorder be considered?
Symmetric, proximal weakness +/- wasting
Normal sensation
If normal/reduced reflexes - myopathy, MG
If reflexes absent - spinal muscular atrophy, LEMS
What should be checked in myopathy or NMJ disorders?
Waddling gait?
Facial muscle/neck strength
Winging of scapula?
Fatiguability? - MG
Clues: dermatomyositis - heliotrope rash, gottron’s sign, mechanics hands
Mitochondrial - short stature, low set ears, may have ptosis
Myotonic dystrophy - frontal balding, ptosis, hatchet like facies
What are hereditary causes of myopathy?
Muscular dystrophies - Duchenne’s, Becker’s, Limb-girdle, fascioscapulohumeral, Oculopharyngeal, Emery Dreifuss
Myotonic dystrophy
Distal myopathies - Nonaka, Welander, Miyoshi
Mitochondrial myopathy
Metabolic myopathies
What are acquired causes of myopathies?
Autoimmune - polymyositis, dermatomyositis, necrotising autoimmune myopathy, Anti-synthetase myositis, inclusion body myositis
Toxic - EtOH and drugs (steroids, statins, amiodarone, Li)
Endocrine - hypothyroidism, hyperthyroidism, acromegaly, hypopituitarism, cushing’s syndrome
Periodic paralysis
Osteomalacia
Sarcoidosis
HIV
What are anti-Jo-1 Ab assocaited with?
antisynthetase antibodies
- autoimmune muscle disease, interstitial lung disease, arthritis, raynaud’s, fever and or mechanics hands
What are dermatomyositis antibodies?
Anti-TIF1: strong association w cancer
Anti-MDA5 - severe skin ulceration and severe ILD
Anti-Mi-2: skin manifestations that respond well to Rx
What are antibodies associated with necrotising autoimmune myopathy?
Anti-SRP: severe myopathy, possible cardiac involvement
Anti-HMG-CoA reductase - statin associated autoimmune myopathy
What are features of myotonic dystrophy?
AD, DMPK, CTG repeat, genetic anticipation, 2nd-4th decade
CM, Conduction defects, early christmas tree cataracts, somnolescence
DDx of multiple CNS lesions?
- SLE
- Sjogren’s syndrome
- Behcet’s disease
- Small vessel ischaemia
- Acute disseminated encephalomyelitis
- Meningovascular syphilis
- Sarcoidosis
- Paraneoplastic
- Multiple emobli
