Aprroach To Neurologic Diagnosis

Approach to a
Neurologic Diagnosis
Robert A. Barja, MD, FPCP, FPNA
I. History
II. Physical & Neurological
Examination
III. Ancillary Procedures
2
Neurologic Problem
3 Questions Asked
Is there a neurologic problem?
Where is the neurologic problem?
What is the neurologic problem?

3
Focal neurologic deficits
Increased intracranial pressure
Signs of meningeal irritation
4
Meningeal irritation
Headache / Vomitting with
a. Nuchal rigidity
b. (+) Brudzinski
c. (+) Kernig
5
6
Increased ICP
a. Papilledema
b. Diplopia with internal squint (lateral rectus
palsy 2 to Abducens nerve paralysis
c. Deterioration in the level of consciousness
d. Bulging fontanel, separation of sutures, rapid
enlarging head size.
7
Papilledema
8
Right Left
Lateral Rectus Paralysis

Patient is looking to the right
9
10
a. Disturbance in higher intellectual functions
eg : Memory impairment
Emotional and behavioral changes (organic)
Language disturbance
Seizure
b. Cranial nerve deficits
eg : diplopia, dysphagia, dysarthria
facial numbness & sensory impairment
c. Weakness or paralysis of extremities
d. Incoordination, poor equilibrium
e. Reflex asymmetry, pathological reflexes ( + Babinski)
f. Sensory impairment in trunk and extremities
11
Neurologic Examination
Mental status
Cranial nerves
Motor
Cerebellar
Reflexes
Sensory
12
Levelize
Lateralize
Localize
13
14
15
Ascending pathways
Descending pathways
Fibers passing in both directions
Disease Category
Congenital / Degenerative
developmental Neoplasm
Trauma Vascular
Infection
Metabolic/Endocrine Demyelinating
Intoxication Immunologic
Nutritional deficiency
17
Congenital / developmental Craniostenosis, Spina bifida
Aneurysm, AVM
Trauma Epidural, Subdural, Subarachnoid,

Intracerebral Hemorrhage
Infection Meningitis, Encephalitis, Brain Abscess
Metabolic/Endocrine Hypoglicemia, Hypoxia

Hyponatremia, Hypercalcemia
Intoxication Drug Overdose, Chemicals, Poison
Nutritional deficiency Vit B1, B6, B12 deficiency

18
Degenerative Alzheimer, Parkinsons disease
Amyotropic Lateral Sclerosis
Neoplasm Primary or metastatic
Vascular Cerebral Infaction or hemorrhage

Subarachnoid hemorrhage
Demyelinating Post Infectious / post vaccinal Encephalomyelitis

Multiple Sclerosis
Polymyositis, Dermatomyositis
Immunologic Guillain-Barre, Myasthenia Gravis
19
History
Age of onset
Onset and course
Other medical data
Family history
Social history
20
Temporal Profile
Vascular Toxin & Metabolic
- Onset of Illness
Neurologic Impairment
Infection
- Course of Illness
Neoplasm
Degenerative
1 2 3 4 5 6 7 2 3 4 2 3 4 5 6 1 2 3
Days Weeks Months Years
21
Type of lesion
1. Focal mass lesion (neoplasm, abscess)
Infarction, hematoma
2. Multifocal multiple tumors, abscesses

Multiple Sclerosis
3. Diffuse Toxic - Metabolic Encephalopathy

Peripheral neuropathy
Myopathy
22
Case # 1
20-year-old- sales lady
Midback pain for 6 months
Progressive numbness and weakness of both
lower extremities for 2 months
Difficulty of urination on day of admission
NE : Weakness of both lower extremities

KJ ++++, AJ +++, (+) Babinski bilateral
Can not feel pin prick from soles to umbilicus
23
Increased intracranial pressure
Signs of meningeal irritation
24
Levelize
Lateralize
Localize
25
Neurologic Examination
Mental status
Cranial nerves
Motor
Cerebellar
Reflexes
Sensory
26
Lesion Upper Motor Lower Motor

Neuron Neuron
Atrophy (-) (+)
Fascicula;on (-) (+)
Tone Increased Decreased
Weakness Movement below level Muscles at level of
of lesion lesion
Supercial reexes (-) (-)
Deep tendon reexes (-)
Pathological reexes (+) Babinski (-) Babinski
27
Spinal effector mechanisms
Dorsal horn
interneuron
From motor neuron
Proprioceptive fibers
From cutaneous
receptor Dorsal horn interneuron
From
muscle
spindle
Dorsal root
ganglion
To motor neuron
Ventral root
To motor neuron
Alpha motor axon

Upper motor neuron

Cerebrum
Brainstem
Spinal cord (lateral corticospinal tract)
Lower motor neuron

Anterior horn cell (spinal cord)
Peripheral nerve
Neuromuscular junction
Muscle
29
FOCAL NEUROLOGIC DEFICITS
A. CEREBRAL DYSFUNCTION
Seizure
Language disorder aphasia
Organic mental, behavioral & personality changes
Contralateral
Hemiparesis with Babinski & cranial nerve deficits
Hemisensory deficits
Homonymous hemianopsia/quadrantanopsia
30
Upper motor neuron
- Cerebrum
- Brainstem
31
- Spinal cord (lateral corticospinal tract)

B. BRAINSTEM DYSFUNCTION
Crossed motor/sensory syndrome
Ipsilateral cranial nerve deficits
Contralateral hemiparesis with Babinski
Ipsilateral limb ataxia
Internuclear opthalmoplegia median
longitudinal fasciculus syndrome
32
33
Spinal Cord Dysfunction
Weakness " Lower motor neuron at level of lesion
" Upper motor neuron below level of
lesion
Objec;ve sensory Diminished/absent sensa;on below

decits level of lesion
Autonomic Present
disturbances
34
Ascending pathways
Descending pathways
Fibers passing in both directions
SPINAL CORD DYSFUNCTION
CERVICAL THORACIC LUMBAR
36
Disease Category
Trauma Vascular
Infection
37
Aneurysm, AVM



38


Multiple Sclerosis
39
Case # 2
15-year-old male
Diarrhea for 3 days 2 weeks PTC
Weakness and numbness both lower extremities
3 days PTC
Day of admission weakness both LE
NE : Weakness of both LE and both UE

( > feet and hands)
Generalized areflexia
Normal sensation
40
Lesion Upper Motor Neuron Lower Motor Neuron
Atrophy (-) (+)

of lesion lesion
41
Plexus
Nerve Root
Spinal Nerve
Anterior Horn Cell Peripheral Nerve
Neuromuscular
Junction
Muscle Fibers
Lower motor neuron

- Anterior horn cell (spinal cord)
- Peripheral nerve
- Neuromuscular junction 42
- Muscle
Peripheral Nerve Dysfunction
Weakness Distal, symmetrical
Objec;ve sensory Distal, symmetrical

decits
Autonomic disturbances May be present
Reexes Areexia
43
Disease Category
Trauma Vascular
Infection
44
Aneurysm, AVM



45


Multiple Sclerosis
46
Case # 3
50-year-old female pharmacist
For 3 months progressive weakness of both LE and
UE
Marked loss of weight inspite of voracious appetite
NE : Bilateral weakness of both thigh flexion

and extention and both shoulder abduction
and adduction
DTR ++ (-) Babinski
Normal sensation
47
Lesion Upper Motor Neuron Lower Motor Neuron
Atrophy (-) (+)

of lesion lesion
48
Plexus
Nerve Root
Spinal Nerve
Neuromuscular
Junction
Muscle Fibers
Lower motor neuron

- Anterior horn cell (spinal cord)
- Peripheral nerve
- Neuromuscular junction 49
- Muscle
Muscle Dysfunction
Weakness Proximal,
symmetrical
Objective sensory None
deficits
Autonomic None
disturbances
Reflexes Depending of
severity of
weakness
50
Disease Category
Trauma Vascular
Infection
51
Aneurysm, AVM



52


Multiple Sclerosis
53
Case # 4
40-year-old male
s/p splenectomy (2003)
Fever, headache, vomitting for 3 days
PE : febrile
NE : Resistance on passive flexion of the neck
54
Meningeal irritation
a. Nuchal rigidity
b. (+) Brudzinski
c. (+) Kernig
55
56
MENINGEAL IRRITATION
ACUTE CHRONIC
(+) Fever (-) Fever (+) Fever
Subarachnoid hemorrhage Chronic meningitis

Acute meningitis
Cranial CT Scan
(-)
CSF examination
57
Case # 5
14-year-old male
Generalize Tonic Clonic convulsion x 3years
Headache and vomitting x 1month
NE : Bilateral papilledema
Normal visual acuity
58
Papilledema
59
60
Type of lesion
1. Focal mass lesion (neoplasm, abscess)
Infarction, hematoma
2. Multifocal multiple tumors, abscesses

Multiple Sclerosis
3. Diffuse Toxic - Metabolic Encephalopathy

Peripheral neuropathy
Myopathy
61
INCREASED INTRACRANIAL PRESSURE
ACUTE CHRONIC
(+) Trauma (-) Trauma
Epidural hematoma Subarachnoid hemorrhage Mass

Subdural hematoma Acute Menigitis Meningitis (chronic)
Subarachnoid hemorrhage Hydrocephalus
Intracerebral or contusion hematoma
Cranial CT scan or
Cranial MRI
(-)
62
CSF examination
ACUTE CHRONIC
Cranial CT Scan or
Cranial MRI
Cerebral infarction 1. Neoplasm

1. Thrombotic 2. Abscess
2. Embolism 3. Subdural hematoma
(chronic)
Cerebral hemorrhage
(Hypertensive) 4. Granuloma
5. Cyst
63
Approach to a
Thank You
The Consciousness
System
" Diffuse bilateral cerebral

dysfunction
" ARAS
The Consciousness
System
Altered Level of Consciousness
A. STRUCTURAL
Primary CNS Lesion
B. Functional
Secondary CNS Dysfunction to a systemic
problem (Metabolic-Toxic Encephalopathy)
STRUCTURAL
(+) Meningeal Irritation
(+) Increased Intracranial Pressure
(+) Focal Neurological Deficits Cranial
CT scan
ACUTE CHRONIC ACUTE CHRONIC
Cranial Mass
CT scan C Infarction
Subarachnoid Mass lesion Neoplasm
hemorrhage C Hemorrhage
C meningitis Abscess
Hemorrhage (trauma)
Hydrocephalus Subdural hge
Meningitis
Granuloma
Cyst
CSF
FUNCTIONAL
(-) Meningeal Irritation
(-) Increased Intracranial Pressure
(-) Focal Neurological Deficits
ENCEPHALOPATHY
Metabolic-Endocrine
Toxic
Nutritional deficiency (B1, B6, B12)
CAUSES
I. STRUCTURAL INTRACRANIAL DISORDER

A. Trauma
1. Epidural, subdural, subarachnoid, intracerebral
hemorrhage
2. Diffuse axonal injury
B. Cerebrovascular Events
1. Cerebral infarction
2. Cerebral hemorrhage
3. Subarachnoid hemorrhage
C. Infection
1. Meningitis
2. Encephalitis
3. Abscess
CAUSES
I. STRUCTURAL INTRACRANIAL DISORDER
D. Inflammatory Disorder
1. Autoimmune vasculitis or cerebritis
2. Demyelinating disease
a. Post-infectious encephalomyelitis
b. Postvaccinal encephalomyelitis
E. Neoplasm
C. Hydrocephalus
CAUSES
II. METABOLIC / TOXIC DISORDER

A. Global hypoxia - ischemia
B. Electrolyte or acid-base disorders
pH disturbances
Hyper- or Hyponatremia
Hyper- or Hypocalcemia
Hyper- or Hypoglycemia
C. Drug Intoxication or withdrawal
CAUSES
II. METABOLIC / TOXIC DISORDER
D. Organ system dysfunction

Liver (hepatic encephalopathy)
Kidney (uremia)
Thyroid (myxedema, thyrotoxicosis)
Adrenal (hyper- or hypocalcemia)
E. Vitamin B1, B6 or B12 deficiencies
F. Temperature disorder (hyper- or hypothermia
G. Seizure and post-ictal state
Clinical Manifestations of
Headache/vomiting
Nuchal rigidity
Kernigs sign
Brudzunskis sign
ACUTE CHRONIC
(+) Fever (-) Fever (+) Fever
Acute meningitis Subarachnoid hemorrhage Chronic meningitis
Cranial CT Scan
(-)
CSF examination

Headache/vomiting
Papilledema
Abducens nerve paralysis (lateral rectus palsy)
Altered level of consciousness
Bulging fontanel, gaping sutures, rapidly enlarging
head size in infants & children
ACUTE CHRONIC
(+) Trauma (-) Trauma
Epidural hematoma Mass

Subdural hematoma Meningitis (chronic)
Subarachnoid hemorrhage Hydrocephalus
Intracerebral or contusion hematoma
Cranial CT scan or
Cranial MRI
(-)
CSF examination
Clinical Manifestations
A.Cerebral Dysfunction
C.Brainstem Dysfunction
D.Cerebellar Dysfunction

A. CEREBRAL DYSFUNCTION
Seizure
Language disorder aphasia
Organic mental, behavioral & personality changes
Contralateral
Hemiparesis with Babinski & cranial nerve deficits
Hemisensory deficits
Homonymous hemianopsia/quadrantanopsia

B. CEREBELLAR DYSFUNCTION
Hemisphere lesion
intention tremor
dysmetria
dysdiadochokinesia
Vermis lesion
truncal ataxia
no limb ataxia

B. BRAINSTEM DYSFUNCTION
Crossed motor/sensory syndrome
Ipsilateral cranial nerve deficits
Contralateral hemiparesis with Babinski
Internuclear opthalmoplegia median
longitudinal fasciculus syndrome
ACUTE CHRONIC
Cranial CT Scan or
Cranial MRI
Cerebral infarction 1. Neoplasm

1. Thrombotic 2. Abscess
2. Embolism 3. Subdural hematoma
(chronic)
Cerebral hemorrhage
(Hypertensive) 4. Granuloma
5. Cyst
WITHOUT
Meningeal Irritation
Increased ICP
Focal Neurologic Deficits
ENCEPHALOPATHY
Metabolic/Endocrine
Toxic
Nutritional Deficiency
STRUCTURAL vs METABOLIC COMA
EXAMINATION SUGGESTIVE of STRUCTURAL SUGGESTIVE of
CNS COMA METABOLIC COMA
Blood pressure Increased Decreased
Respiration Ataxic Regular or rhythmic
Temperature Increased Normal or decreased
Fundi Possible papilledema Usually normal
Pupils Asymmetric Normal, usually;

Reactive, even when
brainstem function is
depressed
STRUCTURAL vs METABOLIC COMA
EXAMINATION SUGGESTIVE of SUGGESTIVE of

STRUCTURAL CNS METABOLIC COMA
COMA
Oculocephalic / 2nd Asymmetric or absent Usually intact
oculovestibular
response
Neck suppleness Stiff or normal Normal
Posture Asymmetric Symmetric
Reflexes Asymmetric Symmetric
Myoclonus/ asterixis Rare Frequent

Immediate Measures
in Comatose Patients
Maintain clear airway, normal breathing and
circulation
IV access
Draw blood for examination
Insert foley catheter
Monitor urine output
Give emergency treatment
Thiamine 100 mg/IV
D50W 50cc IV
Naloxone (Narcan) 0.4 to 0.8 mg IV
Determine depth of coma
Treatment of Coma
Secondary to CNS Lesion
1. Lower raised intracranial pressure
a. Hyperventilation CO2 pressure to 24-30
Hg
b. 20% Mannitol 0.5 to 1 gram / kg IV
over 20-30 min
c. Dexamethasone 10 mg IV then 4-6 mg
q6hrs
d. Ventricular drainage cerebral ventricular
enlargement 20 CSF obstruction
Treatment of Coma
Secondary to CNS Lesion
2. Treat seizures, if present

3. Treat infection, if present
4. Treat respiratory and metabolic alkalosis
and acidosis
5. Treat hyperthermia
ACUTE WEAKNESS
PARAPARESIS or QUADRIPARESIS: (+) BABINSKI
(-) CN deficits
(-) ICP
(-) Meningeal Irritation
SPINAL CORD INJURY
(+) trauma (-) trauma

Spine x-rays
Spine MRI
TRAUMATIC TRANVERSE MYELOPATHY

MYELOPATHY CORD COMPRESSION
ACUTE WEAKNESS
PARAPARESIS or QUADRIPARESIS: (+) BABINSKI
Weakness " Lower motor neuron at level of lesion

" Upper motor neuron below level of
lesion
Objec;ve sensory Diminished/absent sensa;on below level

decits of lesion
Autonomic Present
disturbances
CERVICAL THORACIC LUMBAR
DIFFERENTIAL DIAGNOSIS of
1. Trauma Cord contusion
Cord transec;on
Hematomyelia
2. Infec;on PoXs disease
Vertebral osteomyeli;s
Epidural abscess (acute, chronic)
3. Neoplasm Primary menigioma, schwannoma
Metasta;c to the spine, epidural space
4. Degenera;ve Cervical spondylosis

Intravertebral disc hernia;on
DIFFERENTIAL DIAGNOSIS of
5. Immunological Pos;nfec;ous
Post vaccina;on
Acute transverse myelopathy
Mul;ple sclerosis
6. Inammatory SLE
Rheumatoid arthri;s
Acute necro;zing myeli;s
Arachnoidi;s
7. Vascular Arteriovenous malforma;on
Epidural & subdural hematoma (an;coagulant
therapy)
8. Congenital Arnold Chiari malforma;on
Syringomyelia
Spine Trauma or Unstable Spine
Immobilize the neck or back

Check vital signs
Above C5 injury diaphragm paralysis
Complete transection cervical spinal cord loss of
sympathetic control hypotension & bradycardia
Cervical spine x-rays (AP & Lat)
Neurosurgical consult
ANTI-INFLAMMATORY THERAPY
Trauma: for acute traumatic
SPINAL CORD INJURY
1. Methylprednisolone 30mg/kg IV bolus over 15
minutes
2. 45 minute pause
3. Methylprednisolone 5.4 mg/kg/hr continuous IV
infusion over the next 23 hours
Tumor
Dexamethasone, 100mg/IV bolus immediately
NEUROIMAGING
Hemodynamically stable and not in

respiratory distress
MRI of the spine
Myelogram with CR scan
For anatomic localization and a working
differential diagnosis
ACUTE WEAKNESS
PARAPARESIS or QUADRIPARESIS: (-) BABINSKI
Plexus
Nerve Root
Spinal Nerve
Neuromuscular
Junction
Muscle Fibers
MYONEURAL JUNCTION DYSFUNCTION
Weakness Fluctua;ng
Objec;ve sensory None
decits
Autonomic None
disturbances
Reexes Normal
MUSCLE DYSFUNCTION
Weakness Proximal, symmetrical
Objec;ve sensory None

decits
Autonomic None
disturbances
Reexes Depending of severity of
weakness
ACUTE WEAKNESS
PARAPARESIS or QUADRIPARESIS: (-) BABINSKI
Distal, symmetrical peripheral neuropathy
Guillain Barre syndome
Proximal symmetrical myopathy
Hypokalemia
Fluctuating weakness myoneural junction
Myasthenia gravis
Guillain Barre Syndrome
TREATMENT
Supportive and symptomatic
Respiratory function must be closely monitored
Plasmapheresis
2 to 4 L of plasma exchanged for 5% albumin during each
treatment every 2 days for 5 treatments
High dose IV immunoglobulin (IVIG)
0.4g/kg per day for 5 consecutive days
NOTE: Above when initiated within 10 days of the onset of symptoms, can
speed the onset of recovery
Myasthenia Gravis
TYPES of CRISIS
Myasthenic Crisis
Increase in the severity of the disease relative to the
treatment (undertreatment)
Occurs during added stress (infection, surgery,
anesthesia, medication changes)
Cholinergic crisis
Excess of anticholinesterase drugs relative to the
severity of the disease (overtreatment)
Evidence of excessive acetylcholine effect (abdominal
cramps, sweating, lacrimation, bradycardia, miosis,
muscle cramps, fasciculation)
Myasthenia Gravis
TREATMENT
Maintain ventilation (endotracheal tube or
tracheostomy)
Withdraw all medications used to treat myasthenia
After 24 hours, gradually reintroduce anti-
myasthenia medication
Plasmapheresis will result in marked improvement
in patients with either myasthenic or cholinergic
crisis
Your brain is a masterpiece,divided
into two parts,
left and right
In the left nothing is right
and
in the right nothing is left

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Approach to a

Where is the neurologic problem?

What is the neurologic problem?

Increased intracranial pressure

Signs of meningeal irritation

Lateral Rectus Paralysis

Trauma Epidural, Subdural, Subarachnoid,

Infection Meningitis, Encephalitis, Brain Abscess

Metabolic/Endocrine Hypoglicemia, Hypoxia

Intoxication Drug Overdose, Chemicals, Poison

Nutritional deficiency Vit B1, B6, B12 deficiency

Neoplasm Primary or metastatic

Vascular Cerebral Infaction or hemorrhage

Demyelinating Post Infectious / post vaccinal Encephalomyelitis

2. Multifocal multiple tumors, abscesses

3. Diffuse Toxic - Metabolic Encephalopathy

NE : Weakness of both lower extremities

Increased intracranial pressure

Signs of meningeal irritation

Lesion Upper Motor Lower Motor

Pathological reexes (+) Babinski (-) Babinski

From motor neuron

Alpha motor axon

Upper motor neuron

Lower motor neuron

FOCAL NEUROLOGIC DEFICITS

Objec;ve sensory Diminished/absent sensa;on below

Trauma Epidural, Subdural, Subarachnoid,

Infection Meningitis, Encephalitis, Brain Abscess

Metabolic/Endocrine Hypoglicemia, Hypoxia

Intoxication Drug Overdose, Chemicals, Poison

Nutritional deficiency Vit B1, B6, B12 deficiency

Neoplasm Primary or metastatic

Vascular Cerebral Infaction or hemorrhage

Demyelinating Post Infectious / post vaccinal Encephalomyelitis

NE : Weakness of both LE and both UE

Lesion Upper Motor Neuron Lower Motor Neuron

Atrophy (-) (+)

Pathological reexes (+) Babinski (-) Babinski

Anterior Horn Cell Peripheral Nerve

Lower motor neuron

Weakness Distal, symmetrical

Objec;ve sensory Distal, symmetrical

Autonomic disturbances May be present

Trauma Epidural, Subdural, Subarachnoid,

Infection Meningitis, Encephalitis, Brain Abscess

Metabolic/Endocrine Hypoglicemia, Hypoxia

Intoxication Drug Overdose, Chemicals, Poison

Nutritional deficiency Vit B1, B6, B12 deficiency

Neoplasm Primary or metastatic

Vascular Cerebral Infaction or hemorrhage

Demyelinating Post Infectious / post vaccinal Encephalomyelitis

NE : Bilateral weakness of both thigh flexion

Lesion Upper Motor Neuron Lower Motor Neuron

Atrophy (-) (+)

Pathological reexes (+) Babinski (-) Babinski

Anterior Horn Cell Peripheral Nerve

Lower motor neuron

Trauma Epidural, Subdural, Subarachnoid,

Infection Meningitis, Encephalitis, Brain Abscess

Metabolic/Endocrine Hypoglicemia, Hypoxia

Intoxication Drug Overdose, Chemicals, Poison

Nutritional deficiency Vit B1, B6, B12 deficiency