Neurology Short Cases Flashcards
Test for orientation, Calculation, short-term and long-term memory
Orientation: tell time, place, person
Calculation: serial 7s from 100 or serial 3s from 20
Short-term: Repeat 3 objects then test after 5 mins
Long-term: Recall home address, telephone number
Test for comprehension, expression and repetition of language
Comprehension: Follow simple commands
Expression: Name objects
Repetition: Repeat a given phrase
Outline of GCS
Score for good or poor prognosis
>11 = good prognosis <4 = poor prognosis
1) Eye opening: spontaneous, to speech, to pain, none
2) Verbal response: Orientated, confused, words, sounds/ grunts, none
3) Motor response to “stick out tongue”: obey command, localize to pain in supraorbital area and hand move up to chin, localize to pain in supraorbital area and elbow flex, Decorticate position, Decerebrate position, none
Test for sensory inattention
Test for visual inattention
Sensory: Touch patient on each upper limb with patient’s eyes closed
Tell which part is touched
Visual: first do visual field test (normal), then ask patient to point to finger which moves on either side of visual field
Test for bradykinesia?
10 second test: flex and extend fingers as quickly as possible, or finger opposition
Wrist rotation as fast as possible
Stomping foot
Interpret:
- Slurred speech
- Deconjugate eye movement
- Cannot balance, cannot tandem-walk
- Power normal in UL and LL
- Fails to do hand clap test
- Fails to accurately place finger in finger-nose test
Causes?
Cerebellar syndrome
- Dysarthria
- Nystagmus
- Intention tremor with past-pointing and dysdiadochokinesia
- Wide-based, ataxic gait (MUST EXCLUDE MUSCLE WEAKNESS FIRST)
Causes:
1) Cerebellar degeneration: idiopathic, paraneoplastic, familial
2) Toxins and drugs: alcohol, anti-convulsant
3) Cerebellar infarct, hemorrhage, tumor
Investigations for cerebellar syndrome
CT/ MRI brain
Serum: paraneoplastic anti-neuronal autoantibodies
CSF: infection and inflammation
Interpret:
Dysphagia +/- hoarseness of voice
Partial ptosis and loss of sweating on left face
Nystagmus towards the left side
Loss of pain and temperature sensation below the face on right
Loss of some facial sensation
Ddx?
Causes?
Lateral medullary syndrome
Ddx:
Acute vestibular neuronitis
Benign positional vertigo
focal neurological signs are absent except nystagmus
Causes:
Brainstem infarct from local thrombotic occlusion (Vertebral artery 85%, PICA 15%), arterial thromboembolism (vertebral artery dissection), cardioembolism
Brainstem hemorrhage
Acute brainstem demyelination: MS
Leukoencephalopathy (drugs, hypertension, autoimmune disease)
Interpret:
Impaired visual acuity , afferent pupillary defect with poor direct and consensual pupillary light response
Impaired adduction in one eye with nystagmus in the contralateral eye (nystagmus + deconjugate gaze)
Unsteady and stiff gait, Increased ankle and knee reflexes + bilateral Babinski reflex, weak LL
Some dysarthria intention tremor and post-pointing
Dx?
DDx?
Multiple sclerosis: demyelinating disease of CNS, relapsing-remitting symptoms
Optic neuritis
Internuclear opthalmoplegia
Spastic paraparesis
Cerebellar signs
Ddx:
- Neuromyelitis optica
CNS manifestation of rheumatological disease
Interpret:
Lack of facial expressions, some drooping saliva, infrequent blinking
Forward flexion of trunk on standing
Soft and monotonous voice
Stiff, shuffling gait with little arm swing
Resting tremor asymmetrical
Slow movement
Dx?
Ddx?
Other motor signs?
Parkinson’s disease: degeneration of dopaminergic nigrostriatal neurons (neuromelanin), decrease dopamine activity
Ddx:
- Progressive supranuclear palsy: no resting tremor
- Lewy body dementia: hallucination and psychosis in early stage, dementia later
- Multisystem atrophy: Bilateral cord palsy causing stridor + pyramidal or cerebellar signs
- Wilson’s disease: young, Kayer- Fleischer ring, limb contractures, psychosis, jaundice
- Cerebral small vessel diseases - Parkinsonism features
- Benign essential tremor: Postural tremor symmetrical
Bradykinesia
Power, sensation and deep tendon reflexes preserved
Interpret:
Symmetrical proximal limb and neck weakness
Muscle tenderness
Normal sensation, no atrophy
+/- Purple heliotropic rash in butterfly distribution over cheeks and eyelids, blanches with pressure
Dx?
Ddx?
Cause?
Polymyositis
Dermatomyositis (with purple heliotropic rash)
Ddx:
- Polymyalgia rhuematica: temporal arteritis
- Limb girdle muscular dystrophy
- Myasthenia gravis: fatigable, involves eyes
- SLE: rash, myositis, photosensitive butterfly rash on face
Cause:
Underlying malignancies: ovarian, pancreatic, breast, nasopharyngeal… etc
Interpret:
- Cannot name objects
- Cannot repeat sentences
- Can understand fully
- Non-fluent speech an cannot find right words
Expressive dysphasia
Broca area in inferolateral frontal lobe
Interpret:
- Cannot understand
- Fluent speech, fast but words do not make sense
Dx?
Formal term to describe the pattern of speech?
Receptive dysphasia
Wernicke’s area in temporal lobe
Paraphasia: forming sentences that don’t make sense
Neologism: forming new words
Causes of dysphasia?
Ischemic stroke*
Hemorrhagic stroke
Dementia: Alzheimer’s, frontotemporal dementia
Encephalitis: HSV
Tumor in relevant area
How to accurately test for receptive dysphasia
Test with 2-3 stages of command
Partial receptive dysphasia might be able to obey one stage command
Interpret: (not likely tested)
- Clawing of fingers
- Ulcers and scars on hands
- Wasting of small hand muscles and ulnar area of forearms
- Some dermatomal loss of pain and temperature sensation of upper limbs
+/- Horner’s syndrome, kyphoscoliosis, short neck
Dx?
Causes?
Other signs if the brain stem is involved?
Syringomyelia (syringobulbia)
Foramen magnum lesion causing expansion of central spinal canal
Spina bifida, tumor, trauma
+/- Diplopia and nystagmus (medial longitudinal bundle)
+/- Facial numbness (trigeminal sensor nuclei)
+/- weakness of SCM and trapezius (XI)
+/- soft palatal paralysis, dysarthria, tongue muscle wasting and fasciculation (XII nuclei)
Describe the lesion that causes syringomyelia
Fluid-filled expanded syrinx arising from central spinal cord in the cervical and thoracic regions
Affects decussating fibers of spinothalamic tract + anterior horn of spinal segments + sympathetic fibers at C8/T1 +/- Corticospinal tract
Interpret:
Flexed right elbow, no movement
Spasticity of right upper arm and weakness
Brisk biceps, supinator and triceps reflexes of right upper limb
Drooling of saliva
Hemiplegic
No cortical signs
Cerebral infarction or subcortical hemorrhage - stroke
Causes of partial ptosis (3)
How to differentiate?
Horner’s syndrome: Partial* ptosis, miotic reactive pupil*, anhidrosis, enophthalmos
Myasthenia gravis: Partial ptosis that worsens with gaze, time of day + opthalmoplegia
Partial CNIII palsy: complete ptosis with opthalmoplegia and dilated unreactive pupil
Size and response of pupils
Interpret:
Complete ptosis of right eye with right dilated pupil in depressed and abducted position
Right efferent pupillary reflex defect
Bilateral afferent responses spared
Dysconjugate eye movement: right eye cannot look up and adduct
Complete CNIII palsy
Interpret:
Symmetrical spasticity and weakness of bilateral LL
Brisk knee and ankle reflexes, symmetrical
Clonus in right ankle
Bilateral Babinski reflex
Reduced sensation in all modalities in both lower limbs
Spastic paresis caused by thoracic cord lesion (most likely), e.g. vertebral collapse caused by bony metastasis
Interpret:
Facial numbness and drooling on right side
Recent URTI
Loss of nasolabial fold on right face
Right upper and lower facial muscle weakness
Cannot close right eyelid
Increase lacrimation from right eye
No loss of sensory sensation
Other signs and symptoms?
Right lower motor neuron facial palsy/ right facial nerve palsy/ Bell’s palsy
Loss of taste in anterior 2/3 of tongue and hyperacusis
Examine external auditory meatus and eardrum: exclude otitis media and Ramsay-Hunt syndrome
Difference in epileptic seizure and epilepsy?
Epileptic seizure = Brief and unprovoked stereotyped disturbance of behavior, emotion, motor function or sensation due to cortical neuronal discharge
Epilepsy: recurrent unprovoked seizures
Interpret:
Increased fatigue in general Increase fatigue in all four limbs Double vision, both pupils reactive to light, impaired abduction of right eye increased fatigue later in the day Decreased exercise tolerance from limb weakness No dysarthria or dysphagia Coherent speech 4/5 muscle power All reflexes normal No cerebellar signs
Dx?
Test?
MG
Tensilon test: IV edophonium ejection
Acetylcholine receptor antibody test
Nerve stimulation test
Describe the gait pattern in cerebral stroke, cerebellar stroke and parkinsons
hemiplegic gait (stroke),
wide-based ataxic gait (cerebellar),
shuffling, festinating gait with stooped posture and lack of arm swing (Parkinsonism)
Signs of meningeal irritation/ meningitis
→ Brudzinski’s sign: passive neck flexion → hip flexion
→ Kernig’s sign: knee extension with flexed hip → hamstring spasms
Distinguish between dysphasia, dysarthria and dysphonia
□ Dysphasia: disorder in use of language (content)
→ Site: higher centres, hemispheric
□ Dysarthria: difficulty with articulation
→ Site: motor apparatus for articulation and related nerves
□ Dysphonia: altered quality of voice with ↓volume
→ Site: vocal cords and related nerves
Causes of dysarthria
→ Pseudobulbar palsy: spastic dysarthria
→ Facial weakness: slurred speech
→ Extrapyramidal disease: monotonous speech (due to bradykinesia and rigidity)
→ Alcohol intoxication, cerebellar diseases: loss of coordination, slow/slurred speech
Dominant Parietal lobe signs
Dominant parietal lobe signs:
→ Acalculia: ask to calculate, eg. serial 7s
→ Agraphia: ask to write
→ Left-right disorientation: ask to show left or right hand
→ Finger agnosia: ask to name each fingers
→ Dysphasias
Non-dominant parietal lobe signs
Non-dominant parietal lobe signs:
→ Sensory and visual inattention/extinction:
- Normal bilateral sensory fields
- Stimuli from one side disappear when two sides are tested together
- Usually tested together with PNS sensory examination
→ Spatial neglect: ask to fill in numbers on an empty clock face
→ Construction apraxia: ask to copy an object you drew
→ Dressing apraxia: ask to put shirt (that has been turned inside out) back on
Visual field defect in parietal lobe lesion
→ Homonymous lower quadrantanopia
Test for CNI
Causes of loss of smell
Test smell
□ Place aromatic non-irritant materials close to nose, eg. alcohol swipes
Nasal cavity:
→ URTI (most common)
→ Smoking
Olfactory receptors:
→ Aging
Olfactory bulb and fibres: → Ethmoid tumours → Basal skull fracture or frontal fracture → Pituitary surgery → Meningioma of olfactory groove → Meningitis
Subsequent tests for visual acuity defects e.g. patient cannot even read first 2 lines
□ Can pt count fingers?
□ If no, can pt detect movement?
□ If no, can pt respond to light?
