Approach To Neurological Disease

Thinking
like
neurologist Is
it
difference? Dr.
Surat
Tanprawate,
MD,
FRCP(T) Northern
Neuroscience
Center Chiangmai
University

Thinking
like
a
Neurologist Where
‘s
the
 lesion? What’s
the
 lesion?

Series
of
steps
to
collect
data Task


Goal


Chief
complaint Tipping
the
point History
 Complaint
explorer Neurological examina4on

List
of
the
 problems Rank
of
order
of Likelihood
of
possible
disease

Confirma4on of
localiza4on Review
of Pa4ent‐specific
feature

Differen4al
diagnosis

Complex
brain
processing

Chief
complaint “Tipping
the
point” 5

Component
of
Chief
Complaint Symptom(s)
or
Syndrome + Time
course(progressive,
stable,
fluctua4on) Onset(sudden,
acute,
subacute,
chronic)

Collect
the
 right
data

Expand
the
idea

6

The
point
should
be
concerned • • • •

Avoid
over
generaliza4on Avoid
misinterpret
symptoms Avoid
incomplete
chief
complaint Avoid
step
to
the
present
illness
 before
having
an
idea
flow
chart

7

Common
misinterpret
symptoms
 • Palalysis
VS
 • Blur
vision
VS
 numbness Diplopia • Dizziness
VS
 • Blackout:
loss
of
 weakness
VS
Fa4gue
 consciousness
VS
loss
 VS
ataxia of
vision
VS
simple
 confusion • Dysphasia
VS
 dysarthria

Expand
the
idea “Symptomatology
 approach”

9

Symptoms
approach‐1
 In
your
head

• Disorder
of
consciousness – Level
of
consciousness – Content
of
consciousness

• Mental
disorder – – – – –

Memory Intelligence Personality Behavioral
 Demen4a


• Higher
corQcal
funcQon
 disorder

– Apraxia,
aphasia,
agnosia,
 others

• Visual
disorder – Visual
loss – Diplopia

Symptoms
approach‐2 • Language
and
speech
 disorder – Dysarthria – Dysphasia


• Lower
cranial
nerve
 disorder – – – – –

Deafness/4nnitus Ver4go Balance/staggering Swallowing Voice
change

In
your
head

Symptoms
approach‐3
 In
your
head

• Sensory
disorder – Pain
disorder • Headache
and
facial
pain • Others
pain
disorder

– Numbness/4ngling

• Motor
disorder
 – Weakness:
each
part – Movement
disorder

• Sphincter
disorder

Symptoms
approach‐4 • Episodic
disorder – Seizure/epilepsy – Syncope – TIA – Abnormal
movement – Migraine


In
your
head

Syndrome
approach‐1 • Parkinsonism – Bradykinesia – Muscle
rigidity – Res4ng
tremor – Postural
instability

• MulQple
cranial
nerve
 syndrome “syndrome
of
 opthalmoplegia” “syndrome
of
Lower
 CN
involvement” • Brain
stem
syndrome “Sudden
onset
plus
 brain
stem
s/s” 14

Syndrome
approach‐2 • Spinal
cord
 syndrome – Transverse
cord
 syndrome(complete,
 incomplete) – Hemicord
syndrome – Anterior
cord
 syndrome – Posterior
cord
 syndrome

• Cerecellar
syndrome ‐ Pancerebellar
 syndrome ‐ Hemicerebellar
 syndrome ‐ Cerebellar
vermis
 syndrome

15

Example 16

PaQent
History 17

Symptomatology Difficult
to
open
 his
eye 18

Symptomatology Double
vision “Diplopia” 19

Symptomatology:
Eyelid
disorder • Lid
abnormali4es
presents
as –Ptosis –Lid
retrac4on –Insufficient
eyelid
closure –Excessive
eyelid
closure 20

Ptosis

Excessive
 eyelid
closure

Weakness
of
 Levator
palpebrae
 muscle

Contrac4on
of
 obicularis
oculi
 muscle

Muller
muscle: Horner’s
syndrome

•Blephalospasm •Hemifacial
spasm 21

Ptosis
 approach 22

Ptosis

 Non‐neurogenic(mechanical)
 ptosis

Neurologic

ptosis Congenital
ptosis

•Uni‐bilateral •Par4al‐complete

Supranuclear
 lesion(cerebral
ptosis) •Contralateral
 cerebral
hemisphere

•Pupil
involvement •EOM
impairment

LMN •Neuropathic(N,
 fascicle,
CN) •NMJ •Myopathic


Horner’s
 syndrome

Drug
induced
blephalospasm
and
 dyskinesia

24

Superior tarsal muscle (also known as Müller's muscle)

25

26

A
woman
present
with
 double
vision

27

Diplopia approach 28

Diplopia

Monocular
diplopia:
 Mostly
opthalmologic
 condi4on

Binocular
diplopia Non‐misalignment: intermiient,
non‐ organic

Misalignment

Comitant
 strabismus Childhood
 strabismus

Incomitant
 strabismus Mostly
Neuro‐ opthalmologic
 disease

• Supranuclear(UMN) • FEF: horizontal conjugate gaze • Diffuse frontal and occipital: vertical conjugate gaze

• Internuclear • Nuclear and pathway • •

PPRF, abducen interneuron, MLF riMLF, INC, PC

• Nuclear(LMN) • Cranial nerve nuclei • Fascicle, Nerve, NMJ and Muscle(LMN) • • • •

Faciculus Cranial nerve NMJ Muscle

Diplopia:
Thinking
Idea • Direc4on
of
involved
muscle – Impair
consistent
with
nerve
innerva4on(Nerve,
 nucleus) – if
not • Fluctua4on:
NMJ • Associated
with
proximal
muscle
weakness:
Muscle
 disease • Ver4cal
gaze
or
Horizontal
gaze
pathway
involvement:
 Internuclear
lesion

31

Eye
examinaQon 32

Bilateral
ponQne
infarcQon

33

A
woman
complains
slow
progressive
 diplopia,
gait
difficulty
for
2
weeks 34

Eye
movement 35

• Supranuclear(UMN) • FEF: horizontal conjugate gaze • Diffuse frontal and occipital: vertical conjugate gaze

• Internuclear • Nuclear and pathway • •

PPRF, abducen interneuron, MLF riMLF, INC, PC

• Nuclear(LMN) • Cranial nerve nuclei • Fascicle, Nerve, NMJ and Muscle(LMN) • • • •

Faciculus Cranial nerve NMJ Muscle

38

Gait
 abnormality 39

Gait
 disturbance

=

Ataxia

40

Tandem
walk 41

Cerebellar
test 42

Approach
to
ataxic
pa4ent Ataxic symptoms? -Nystagmus -Dysarthria -Trunkcal ataxia -Limb and gait -ataxia Ataxic symptoms mimicker? •Mild
weakness •Apraxia •Abnormal
movement

True Ataxia

Ataxia: disease other than cerebellum

Cerebellar’s disease -Where’s the lesion (cerebellum, cerebellar peduncle, cerebellar tract) -What’s the lesion

Where’s
lesion? Associated
sign

Pure cerebellum

Classified Cerebellar syndrome

With Brainstem signs

Classified Brainstem Syndrome?

With mild hemiparesis

Involve frontoPontoCerebellar Pathway “Ataxic hemiparesis”

Classified
cerebellar
syndrome

Cerebellar Unilateral hemispheric intermediate, syndrome lateral zones

Rostral vermis syndrome

Ant, sup vermis

Caudal vermis syndrome

Flucculo nodular, post vermis

All Pan cerebellar regions syndrome

Symmetrical
ataxia
plus
syndrome • Acquired
 – Wernicke’s
encephalopathy – Miller
Fisher
syndrome – Normal
pressure
hydrocephalus(frontal
lobe
 ataxia)

• Hereditary
 – Spinocerebellar
ataxia(SCA)

Back
to
our
case Nuclear
complex
 of
oculomotor
 nerve Rostral
vermis
 syndrome 47

48

Physical
 ExaminaQon “Confirm
the
though,
 explore
the
next” 49

Neurological
examinaQon • Screening(general)
neurological
 examinaQon – Exam
every
path:
the
tests
are
more
sensi4ve

• Specific(focused)
neurological
examinaQon – Exam
the
detail
of
abnormal
neurological
signs
 or
symptoms
relevant
to
the
history
and
 screening
exam. – the
tests
are
more
specific 50

Record
the
neurological
signs • • • • • •

Presence
VS
Absence Hard
signs
VS
Son
signs Normal
VS
abnormal Lateralizing
sign:
 True
VS
false
localizing
sign Normal
varia4on 51

General
neurological
examina4on • Mental
status • Cranial
nerve
 – 1‐12
CN
func4on

• Limb
 – Voluntary
movement – Muscle:
bulk,
tone,
power
 – Coordina4on:
FTN,
HTS,
rapid
 alterna4ng
movement – Reflex:
tendon,
plantar
 response – Sensa4on:
pinprick,
JPS,
 vibra4on
sense

• Gait
and
balance • Romberg
test

The
point
should
be
concerned • • • • •

Avoid
misinterpret
sign Misinterpret
the
normal
varia4on Confirm
the
equivocal
sign
 Aware
the
son
sign Aware
the
false
localizing
sign 53

A
man
presented
with
 shaking
head

54

An
old
woman
present
with
 abnormal
hand
movement

55

Focused
neurological
examinaQon • Which
kind
of
test – Depend
on:
History,
Screening
neurological
 examina4on – Complete
the
focused
examina4on:
 • More
detail • Complete
the
syndrome
you
thought • Need
extensive
skill
for
specifica4on

56

Concept
of
“son”
neurological
sign • “Hard
sign”:
 – neurological
sign
result
from
a
lesion
at
a
known
 site
or
that
affect
a
known
pathway

• “Son
sign”:
 – Any
structural
or
func4onal
devia4on
found
more
 frequently
in
brain
impairment
persons
than
in
 normal
persons – Does
not
correlate
with
any
par4cular
type
of
brain
 lesion
at
any
par4cular
site,
or
interrup4on
of
any
 par4cular
tract

Concept
of
“false”
localizing
sign • True
sign
that
occurs
secondary
to
a
lesion
 elsewhere
in
the
CNS.
 • The
sign
is
not
false,
but
is
distant
from
the
 actual
site
of
primary
lesion • Cause: – Shin
of
brain:
compress
or
displace
structure
 (distant)
or
blood
vessel
(ACA,
MCA) – Hydrocephalus:
CN
6
palsy,
Pretectal
(sylvian)
 syndrome

59

Problem
list “Review
of
paQent
 specific
feature” 60

List
of
problems

Integrate
of
History
and
PE

• First:
anatomical
localiza4on
of
lesion
or
 neurology
system – Focal,
Mul4‐focal,
Diffuse – Nuclear,
tract,
system
disorder – CNS,
PNS,
Boths

DifferenQal
diagnosis Discussion
each
problem
list • 1) • 2) • 3) • 4) • 5)

DifferenQal
 diagnosis “Rank
of
the
possible
 disease” 63

DifferenQal
diagnosis

Integrate
of
History
and
PE • First:
anatomical
localizaQon
 • Second:
cause
of
lesion of
lesion
or
neurology
 – Congenital,
Gene4c system – Trauma – Focal,
Mul4‐focal,
Diffuse – Nuclear,
tract,
system
disorder – CNS,
PNS,
Boths

– – – – – – –

Tumor Infect/Inflamma4on Vascular Toxic/metabolic/Nutri4onal Degenera4on/Demyelina4on Idiopathic Psychogenic


Series
of
steps
to
collect
data Task


Goal


Chief
complaint Tipping
the
point History
 Complaint
explorer Neurological examina4on

List
of
the
 problems Rank
of
order
of Likelihood
of
possible
disease

Confirma4on of
localiza4on Review
of Pa4ent‐specific
feature

Differen4al
diagnosis

Combine it together

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