Videos 1 Flashcards
Presentation: 32 y/o female G1P0 at 38 weeks gestation complains of bilateral hand numbness and pain for 2 weeks
Signs and symptoms: sharp pains in three fingers (thumb, index, middle), swelling, needles in tips of fingers, difficulty grasping, pain especially in the morning
Improvement after birth, but still some tingling
EMG: medial distal latency that was 0.3 ms slower than the ulnar distal latency; impression - abnormal study showing mild R median neuropathy at the wrist
Bilateral carpal tunnel syndrome in pregnancy
What is the nerve affected in carpal tunnel syndrome?
Median neuropathy
Most common symptoms of carpal tunnel syndrome?
Wrist, hand, and arm pain associated with paresthesias in the hand, typically worse at night and disturbs sleep, most frequently present in the thumb, index, middle, and lateral aspect of the ring finger
Diagnostic tests for carpal tunnel syndrome?
Tinel’s sign (elicit paresthesias by gentle tapping over the median nerve)
Phalen’s maneuver (elicit paresthesias by having patient hold wrist in flexed position)
Weakness of median innervated muscles, especially the abductor pollicis brevis
Atrophy of thenar eminence in more severe cases
Most useful tests: nerve conduction studies and EMG
Rx carpal tunnel syndrome?
Removal of provoking factors and a neutral wrist splint
Surgical decompression if unsuccessful
Role of steroids is controversial
Presentation: 65 y/o male with a history of carcinoid tumor with new onset L facial weakness
Signs and symptoms: left lip with pain and some paralysis, lip not functioning normally when eating and drinking, some discomfort over left mastoid, decreased L eye blinking speed, paralysis of L facial muscles, easier to raise L eyelid when held tightly closed, unable to whistle
Electrodiagnostic study: L facial motor nerve with markedly reduced amplitude and normal distal latency; R facial motor nerve study borderline low amplitude with normal distal latency -> abnormal study showing L facial axonal neruopathy
Peripheral facial nerve palsy (Bell’s palsy)
What does the facial nerve innervate?
Motor, sensory, and parasympathetics to the muscles of facial expression, mucous membranes of the oral and nasal cavities, salivary + lacrimal glands, taste sensation from anterior 2/3 tongue (via lingual nerve and chorda tympani)
Most common symptoms of facial nerve palsy?
Facial weakness
Aching of the ear or mastoid region may be present, possible numbness or unusual facial sensation, but sensory testing is normal
Taste may be impaired if lesion proximal to chorda tympani
Hyperacusis if proximal to nerve to stapedius
Bell’s palsy is common in what populations? What is a suspected inciting factor?
Adults, DM, pregnancy
HSV
Rx Bell’s palsy?
Short course steroids and oral antiviral agents
Artificial tears and ophthalmic ointment to prevent corneal exposure
Presentation: 60 y/o woman with new onset vertex headache radiating to the left orbital region, left auricular region, left retromandibular area, and left posterior neck; trouble chewing, swallowing, controlling tongue
Severe headache on top of head, radiating down left face and back of the neck, tongue felt very thick, protrusion of tongue demonstrates deviation to the L, felt like a dividing line existed in the middle of the tongue, difficulty speaking, chewing, swallowing
T2 MRI shows asymmetric high-signal intensity of L CN XII
Hypoglossal nerve palsy
Common signs and symptoms of hypoglossal nerve palsy?
Unilateral lesion -> trouble controlling the tongue when chewing, speaking, or swallowing, deviation of the tongue to the affected side, possible ipsilateral atrophy and fasciculations
Causes of hypoglossal nerve palsy?
Isolated palsy is uncommon; most common cause -> tumor; can also occur in MS, GBS, trauma, stroke, surgery, infection
Supranuclear lesions do not result in denervation atrophy
Causes of hypoglossal nerve palsy?
Isolated palsy is uncommon; most common cause -> tumor; can also occur in MS, GBS, trauma, stroke, surgery, infection
Supranuclear lesions do not result in denervation atrophy
Presentation: 53 y/o male complaining of L neck and shoulder pain and arm weakness
Severe pain in shoulder and neck, unable to raise L arm, loss of strength in L arm, hand muscles seem to be fine, more proximal muscle weakness
Wasting, atrophy of muscles in arm
Fasciculations present on flexor region of forearm
L scapula winging, decreased shoulder abduction, L arm drifting, decreased strength and muscle tone, finger strength seems intact, sharp pinprick intact, reflexes present
2 months later, pain gone, strength returning
4 months later, decreased winging, increased strength
EMG: L median and ulnar motor and sensory nerve conduction studies normal. Needle exam showed abnormal resting and voluntary activity in L pronator teres, bicep, and deltoid. Increased motor unit potential duration and a few large polyphasic potentials in each of these areas. L cervical parapsinal needle exam reveals normal resting activity -> abnormal study showing acute and chronic denervation in the C5-C6 myotomes without parapsinal abnormalities
Upper trunck brachial plexopathy (Parsonage-Turner syndrome)
Lack of cervical paraspinal abnormalities makes cervical radiculopathy less likely
The brachial plexus is formed from the ventral primary rami (spinal nerves or roots) of ___ through ___.
C5; T1
Note that a prefixed plexus (when C4 contributes a branch to the plexus) is seen in 2/3 of cases
The brachial plexus is divided into what 5 components?
Roots Trunks (upper, middle, lower) Divisions (anterior, posterior) Cords (lateral, posterior, medial) Branches
Typically, the brachial plexus is composed of ___ roots, ___ trunks, ___ divisions, and ___ cords.
5; 3; 6; 3
Brachial plexus injuries may be complete or incomplete. They may be pre-ganglionic or post-ganglionic. They can cause what symptoms?
Muscle weakness, nerve and shoulder pain, paresthesias or dysesthesias, absent muscle stretch reflexes, and sensory loss
Application of full pressure sensation to the thumb, middle finger, and little finger evaluates what nerves?
Thumb: C6 spinal nerve, median nerve, lateral cord
Middle: C7 spinal nerve, median nerve, lateral cord
Little: C8 spinal nerve, ulnar nerve, medial cord
Which is more prominent in plexopathy - motor or sensory changes?
Motor
What clinically relevant motor function should be tested in suspected plexopathy?
Shoulder abduction (C5)
Elbow flexion, forearm pronation/supination (C6)
Extensors of forearm, hand, fingers (C7)
Finger extensors, flexors, wrist flexors (C8)
Hand intrinsics (T1)
Causes of plexopathy?
High-energy trauma to the upper extremity and neck
Erb-Duchenne type (C5-C6, upper trunk) - traumatic separation fo the head and shoulder, birth injury, idiopathic brachial plexitis (Parsonage-Turner)
Characteristic features of Parsonage-Turner?
Intense cervical and shoulder pain
Shoulder girdle and upper extremity weakness and atrophy
Dx Parsonage-Turner
Electrophysiologic testing
MRI of the plexus (normal)
Causes of lower brachial plexopathies?
Trauma, especially traction in the abducted position
Malignancies (pancoast tumor)
Complication of CABG -> lower trunk or medial cord involvement
Presentation: 44 y/o female, progressive hand numbness and pain. Four years ago, she began to experience tingling in the medial aspect of her left hand. It progressed to involve her entire L hand and the fourth and fifth fingeres of her R hand. She also complained of electric shock-like pains down the medial aspect of both arms. Hot water made the symptoms worse. She had difficulty writing and holding objects. She can no longer exercise. The pain comes in waves that last approximately 15 minutes and then ease up. It is worse when she is hugged. No visual changes, double vision, weakness, dysarthria, vertigo, bowel/bladder issues
Pain radiates down through the arms and fingers when flexing or extending the neck
On exam, hyperreflexia of upper and lower extremities
Skin lesions on arms and leg, non-painful, present for at least 7 years
MRI spine: intramedullary enhancing mass with expansile surrounding edema from C3 to C7
MRI brain: no mass, enhancement, focal findings; cerebellar tonsils borderline low
CXR: bilateral hilar and R paratracheal LAD
Pathologic findings of skin biopsy
Subacute cervical myelopathy due to sarcoidosis
Radiologic DDx - intramedullary enhancing SC mass with surrounding edema
Ependymoma Demyelinating disease MS Mets Transverse myelitis
Rx sarcoidosis
Corticosteroids
Presentation: 48-year old F with bilateral lower extremity weakness and flexion spasms of both legs. Needs to catheterize every 2 hours
4 years ago, numbness of lower extremities began, preceded by low back pain, difficulty controlling bladder, bowel function normal
On exam: good UE strength, movement, LE hyperreflexic, pinprick sensation intact to level of umbilicus, dull sensation below umbilicus
Ischemic myelopathy (antiphospholipid antibody syndrome)
Most common causes of acute partial transverse spinal cord lesion?
Cord compression
Spinal cord trauma
Acute parainfectious or demyelinating myelopathy
Central cord syndromes caused by tumors or hemorrhages
Ischemia
What are the three basic vascular systems supplying the spinal cord?
- Three spinal arteries (single anterior spinal artery and paired posterior spinal arteries)
- Radicular arteries
- Terminal extramedullary and intramedullary arteries
The anterior spinal artery arises from the two intracranial ___ arteries and descends in the anterior sulcus of the spinal cord, supplying the anterior 2/3 of the spinal cord, which includes what?
Vertebral; anterior horns, CSTs, lateral STT
The two posterior spinal arteries also most commonly arise from the vertebral arteries and descend along the posterior surface fo the spinal cord as an anastomotic network. They supply the posterior 1/3 of the cord, including what?
Dorsal columns
Where do the anterior and posterior spinal arteries join?
Conus medullaris
What radicular artery supplies the lower anterior thoracic and lumbosacral spinal cord? Where does it arise from and where does it enter the spinal canal?
Arteria radicularis magna (aka artery of Adamkiewicz)
Arises from the aorta, enters on the left side at T11-L2 in 60% of people and T8-10 in 40%
Causes of spinal cord vascular disease?
Thrombotic and embolic (arterial or venous) infarctions
Lacunar infarctions
TIAs
Hematomyelia
Hemorrhage (epidural, subdural, subarachnoid)
Vascular malformations
Presentation of spinal cord ischemia?
Paralysis and loss of pain and temperature below the level of the infarct
Spares position/vibration/light touch
Bladder and bowel function are impaired
May be associated radicular or girdle pain, back pain
The anterior spinal artery syndrome most commonly occurs in what watershed areas?
Where the distal branches of the systems anastomose, between T1 and T4, and at L1
What is the most common cause of spinal cord ischemia?
Aortic disease
Procedure of choice in suspected spinal cord ischemia?
MRI to r/o compressive lesion
If not available, radiographs + spinal CT myelography
Then LP to exclude inflammatory, infectious, neoplastic causes
Presentation: 62 y/o male with a history of CAD, HTN, HLD, and prior L hemispheric cortical infarct developed sudden onset language difficulties and R-side weakness 1 week after quadruple CABG
Signs and symptoms: difficulty getting words out, comprehension intact, non-fluent aphasia, words are mispronounced and slurred, takes a long time to enunciate
Imaging: L-sided infarct in the fronto-temporal region corresponding to Broca’s area
Non-fluent aphasia secondary to L frontal infarction
What is aphasia?
Loss or impairment of language processing caused by brain damage
List the most common perisylvian aphasias.
Broca’s
Wernicke’s
Global
Conduction
What are the other 4 traditional aphasic syndromes?
Anomic aphasia
Three types of transcortical (motor, sensory, mixed) -> repetition is preserved
Compare the fluency, comprehension, and repetition in Broca’s, Wernicke’s, Global, and Conduction aphasia.
Repetition is impaired in all 4
Broca: non-fluent, relatively intact comprehension
Wernicke: fluent, impaired comprehension
Global: non-fluent, impaired comprehension
Conduction: fluent, intact comprehension
Location of Broca’s area?
Posterior inferior frontal gyrus anterior to the motor strip of the dominant hemisphere
Most common cause of Broca’s?
Arterial occlusion of the L MCA feeding the posterior portion of the inferior frontal gyrus and lower portion of the central gyrus
Location of Wernicke’s area?
Posterior superior temporal gyrus of the dominant hemisphere
Case: 63 y/o R-handed man, retired construction worker, part-time professional musician with a history of HTN and HLD presents with sudden onset R-sided weakness and language difficulties, treated with IV tPA
Fluent aphasia (word salad), difficulty with language, but able to speak with fluency, difficulty naming objects correctly, reading sentences/words correctly
Motor function intact
Wernicke’s aphasia 2/2 L MCA infarction
Case: 78 y/o hypertensive M evaluated because of a 12-month history of recurrent brief non-positional spells of slurred speech, double vision, circumoral numbness, L-sided weakness, loss of balance. Recently received platelet anti-aggregants and was Rx with warfarin without resolution of spells
Attacks last 5-15 minutes each, diplopia, slurred speech, uncontrolled balance, double vision images side by side, numbness in lips and face, no headache, LOC, tinnitus, difficulty swallowing
Vertrobasilar TIAs due to high-grade basilar artery stenosis
What is supplied by the vertebrobasilar arterial system?
Brainstem, cerebellum, labyrinths
The basilar artery is formed by the ___ at the level of the ___. What three branches suppply the cerebellum?
Vertebral arteries; pontomedullary junction
Posterior inferior cerebellar artery (PICA) - originates from vertebral
Anterior inferior cerebellar artery (AICA) and superior cerebellar artery - originate from basilar
What is a TIA?
Transient episode of focal neurological or retinal dysfunction of acute onset secondary to impaired blood supply in a vascular territory
Last <24 hours, leave no residual deficits
Symptoms suggestive of vertebrobasilar TIA?
Usually bilateral weakness or clumsiness, but may be unilateral or shifting
Bilateral, shifting, or crossed (ipsilateral face and contralateral body) sensory loss or paresthesias
Bilateral or contralateral homonymous visual field deficits or binocular vision loss
2+ of the following: vertigo, diplopia, dysphagia, dysarthria, ataxia
Symptoms not acceptable as evidence of TIA:
-Syncope, dizziness, confusion, urinary or fecal incontinence, and generalized weakness
-Isolated occurrence of vertigo, diplopia, dysphagia, ataxia, tinnitus, amnesia, drop attacks, or dysarthria
Compare the neurovascular findings in carotid vs. vertebrobasilar TIA.
Carotid: carotid bruit, decreased carotid pulse
Vertebrobasilar: vertebral or basilar bruit
Compare the cerebral symptoms in carotid vs. vertebrobasilar TIA.
C: transient aphasia and dysarthria
VB: none
Compare the CN symptoms in carotid vs. vertebrobasilar TIA.
C: ispilateral amaurosis fugax, contralateral HH
VB: transient findings including diplopia and syarthria
Compare the motor reflex/cerebellar gait symptoms in carotid vs. vertebrobasilar TIA.
C: transient contralateral weakness or clumsiness
VB: transient bilateral weakness or clumsiness
Compare the sensory symptoms in carotid vs. vertebrobasilar TIA.
C: transient contralateral loss
VB: transient bilateral loss
Case: 33 y/o male with sudden onset severe posterior neck pain, dizziness, unsteadiness, N/V
Head CT normal
Block mason whose work involves heavy lifting
Signs and symptoms: sharp pain in the back of the neck, dizziness, falling to L or R, vomiting; pain feels like needles being jabbed in the neck
Nystagmus, eye movements not smooth (occur in a bumpy/step-wise fashion), decreased temperature sensation on L face and R upper and lower extremities, decreased coordination by FNF, decreased postural stability when sitting (falls to L), vocal tics
Lateral medullary syndrome (Wallenberg syndrome) due to a vertebral artery dissection
Causes of Wallenberg syndrome?
Most commonly - occlusion of the intracranial segment of the vertebral artery
Less commonly - occlusion of PICA
Presentation of Wallenberg syndrome?
Ipsilateral Horner syndrome, loss of pain and temperature in the face, weakness of the palate, pharynx, and vocal cords, and cerebellar ataxia
Contralateral hemi loss of pain and temperature
Signs and symptoms of vertebrobasilar dissection?
Occipital or posterior neck pain, mastoid pain, vertebrobasilar TIAs, variations of the lateral or medial medullary infarction, cerebellar infarction, PCA infarction
Case: 61 y/o AA female with poorly controlled HTN evaluated because of acute onset L hemibody numbness; BP 204/100
Numbness down L side of face, arm, and leg, no HA, vomiting, nausea, difficulty with speech, vision, diplopia, no history of similar episode
EOM intact, muscle strength intact, normoreflexic, negative Babinski, decraesed light touch sensation on L side of face and body compared to R, decreased pinprick, proprioception intact bilaterally
Imaging: small hemorrhage in thalamus
Pure sensory stroke due to thalamic hemorrhage
Features of a pure sensory stroke?
Unilateral numbness, paraesthesias, hemisensory deficit involving the face, arm, trunk, and leg
Possible causes of pure sensory stroke?
VPN of the thalamus
Corona radiata
Parietal cortex
Differentiate pontine vs. thalamic pure sensory syndrome.
Pontine: vibration and position sense are often reduced; sensation to pinprick and temperature are preserved; ipsilateral impairment of smooth pursuit and vestibuloocular reflex
Thalamus: both STT and medial lemniscal modalities are compromised
Case: 72 y/o female with tremors
Primarily on L side, walking pace slowed significantly, no falls, handwriting capacity diminished, handwriting smaller, cognition intact
One year later, stroke caused tremor to disappear
Parkinsonian tremor
Case: 75 y/o female with hand tremors
Shaky hands, head bobbling, voice shaky, alcohol ingestion decreases tremor, certain letters and words are more difficult to enunciate, motor function intact, coordination intact (FTN), writing/drawing ability intact
Essential tremor
Features of essential tremor?
Slowly progressive postural and/or kinetic tremor, usually affecting both hands and forearms and less commonly the head and voice
Involvement of the face, trunk, and lower limbs is rare
Absent at rest, present with maintained posture, most evident at the end of a goal-directed movement
DDx - essential tremor
Parkinson’s
Dystonic tremor
Management of essential tremor?
Primidone (older) and propranolol (younger) are first line
Case: 58 y/o female with painful spasms of her neck and R shoulder
Problem with head turning and shoulder pulling up on the R side, painful at times, rubbing jawline helps relax the muscles, possible family history
Torticollis
Causes of dystonia?
Dopamine blocking drugs (neuroleptic/antipsychotic medications, anti-emetics like prochlorperazine or metoclopramide) - generalized
Hereditary (dystonia muscularum deformans, cerebral palsy) - generalized
Spasmodic torticollis, blepharospasm, dystonic writer’s cramp, spasmodic dysphonia, oromandibular dystonia - focal
Wilson’s disease - focal
Management of focal dystonia?
Mild - no treatment
Severe - botulinum toxin injections
Anticholinergics or benzos
