Introduction Department of Neurology CPC

CPC team & Dr. Monica Jain, Coordinator; Dr. Lokendra Sharma Co coordinator

Department of Neurology,Sawai Man Singh Medical College Hospital, Jaipur

FACULTY and RESIDENTS

Faculty Position Numbers

Senior Professor 4

Professor 3

Associate Professor 3

Assistant Professor(Ad hoc)

Senior specialist 1

Senior Resident `24

•Total Three Neurology units in SMS

Department of Neurology

• Total OPD attendance in yr. 2015 : 107069 (January to July 2016- >80,000)

• Total IPD attendance in yr. 2015 : 6195

• Operated daily at ground floor of the Dhanwantri OPD block

Workload &Facilities Available in the Department Investigation Number (2015)

Digital EEG 3966

NCS(VEP/BAEP) 4381

EMG 500

Video EEG 312

Ambulatory EEG 64

Total 9223

Labs in Dept. of Neurology

Machines Numbers

NCS/EMG 4

Digital EEG 3

Conventional EEG

1(out of working order)

Video EEG 1

Ambulatory EEG 1

Polysomnography

Total 11

• Number of lab technicians- 6

Neurointervention (DSA)

• Providing Diagnostic and Therapeutic services in collaboration with Neurosurgery Dept.

• Our’s was the first unit in Rajasthan to start neurointerventional work in 2007

Dept. of Neurology Neurointerventional procedures from

June 2007 onwards

Total DSA

Types of NeurointerventionCoiling

of Aneurysm

Tumour Embolizaion

AVM Embolization

Carotid Angioplasty &

Stenting

Spinal AVM/Tumour Embolization

Intra-arterial thromobolysis/

Intra-cranial angioplasty/Mechanical

Thrombectomy

1034 154 38 28 26 18

Other Specialty Services

• Botulinum toxin therapy for focal dystonias, and spasticity

• Local steroid inj. in carpal tunnel syndrome • Plasmapharesis in Neurological disorders like - GBS - MG - NMO Spectrum disorder• Regular OPD in Kanwatiya Hospital

Emergency Neurology

• 24 hour emergency services in CNM Centre• Special treatments-IV thrombolysis for

ischemic stroke patients who present within 4.5 hours of onset

• Speciality ICU – only 4 beds

• Stroke unit awaited

Publications, Awards, Honours & Achievements of Faculty

Department of Neurology

• The current faculty of the department has more than 400 publications in national and international journals to its credit.

• Regular CME Programs are being organized in the department.

• National and State Level Conferences have been organized by the department

Fellowships awarded to Dr. R S Jain • National –Senior Research Fellowship, Council of

Scientific & Industrial Research, New Delhi• National –Fellow Indian Academy of Neurology (FIAN) (1st Neurologist from Rajasthan honoured with FIAN) • International –World Federation of Neurology

Fellowship, London (U.K.)• International –Alzheimer’s Disease&Related

Disorders Fellowship, Stockholm (Sweden)

Fellowships

• Fellowship of Borengham in Parkinson’s disease 2007 awarded to Dr.Anjani Kumar Sharma

• Fellowship of Indian College of Physicians (FICP) 2009 awarded to Dr.Anjani Kumar Sharma

• Junior Research Fellowship by CSIR in 1995 awarded to Dr. Bhawna Sharma

• Senior Research Fellowship by CSIR in 2000 awarded to Dr. Bhawna Sharma

Fellowships

• Fellowship in Cerebrovascular intervention(Beijing China 2005-2006) awarded to Dr. Trilochan Srivastava

• Indian Academy of Neurology fellowship (2004) to study at The Institute of Neurology, Queen Square, London awarded to Dr. Dinesh Khandelwal

• Commonwealth Scholarship (2007) to study at Southern General Hospital, Glasgow, UK awarded to Dr. Dinesh Khandelwal

Awards - Dr.R S Jain

• Awarded first ever Times Wellness Rajasthan Health Award 2013 for “Best Doctor in Neurology” in Rajasthan

• Honoured with State Award by Hon. Chief Minister, Rajasthan on 15th August,2013.

• Raja Pajvan Dev Award by Her Highness Padmini Devi Ji in Sawai Jaipur Alankaran Samaroh 2014.

• Honoured with State Award by Hon. Chief Minister, Rajasthan on 15th August,2013

• Raja Pajvan Dev Award by Her Highness Padmini Devi Ji in Sawai Jaipur Alankaran Samaroh 2014

Letters of Appreciation

First women Super-specialist awarded State

Merit Certificate by Hon'ble Chief Minister of

Rajasthan on 15th August, 2010 for outstanding

contribution in Medical Field

Palatucci Advocacy Leadership award

(2012) by American Academy of Neurology

toDr Dinesh Khandelwal

Chapters in books

Dr. R S Jain :• Neurosarcoidosis –Reviews in Neurology,

Indian Academy of Neurology • Primary CNS Lymphoma - Reviews in

Neurology, Indian Academy of Neurology Dr. Bhawna Sharma :• Contributor - Year Book of Neurology, 2012• Contributed chapters in Annual reviews of

Neurology

CHAIRPERSONS – Dr. U.S.Agarwal , Principal and controller,

Dr. Hemant Malhotra , PHOD, Dept. of Medicine and CPC convener

Dr.R.S.Jain, PHOD, Dept.of Neurology

CPC MEET DEPARTMENT OF NEUROLOGY,

SMS Medical College & HOSPITAL,JAIPUR

DATE-12TH AUGUST 2016TIME-8:00AM-9:00AM

VENUE-COLLEGE AUDITORIUM

SMSMC-CPC:The TEAM

• DR. U.S. AGARWAL, Principal & Controller• DR. HEMANT MALHOTRA, CONVENER (9829062040,

drmalhotrahemant@gmail.com)• DR. PUNEET SAXENA, Dept. of Medicine (9414079182,

puneetsaxena96@yahoo.co.in)• DR. ARADHANA SINGH, Dept. of Medicine (9166916692,

aradhanas610@yahoo.com)• DR. MONICA JAIN, Dept. of Pharmacology (9828786533,

monicajain07@yahoo.com)

Presenter – Dr. Tushar Desai , SR Neurology

Neurology discussant – Dr. Trilochan Srivastava, Professor , Dept. of NeurologyOrthopaedic discussant – Dr. Narendra Joshi, Professor , Dept. of orthopaedics

Endocrinology discussant – Dr. Sandeep Mathur,

PHOD, Dept. of Endocrinology CPC team & Dr. Monica Jain, Coordinator; Dr. Lokendra Sharma Co coordinator

Radiology discussant – Dr. Naima Mannan ,Professor,

Dept. of Radiology

Neurosurgery discussant – Dr.Achal Sharma,Professor, Dept. of Neurosurgery

Physical Medicine and Rehabilitation discussant – Dr. Mrinal Joshi ,PHOD ,

Dept. of PMR

Presenter – Dr. Tushar Desai , SR Neurology (3rd yr)

Foot Drop

Common Entity - Uncommon Etiology

Department of Neurology SMS Medical College, Jaipur

History• 51-year-old male , garment shop worker• Admitted in Neurology ward in Nov 14 • Insidious onset, gradually progressive, right foot

drop for six months on the background of low-backache for last 5 years

• There were no radicular pains, sensory symptoms, bladder/bowel or erectile dysfunction.

• Diabetes Mellitus diagnosed 6 months back

• No h/o trauma, weightlifting or weight loss • No h/o intramuscular injection• Past history - Not significant• Personal history - Non addict, vegetarian

General Physical Examination

• Patient was conscious oriented• No Pallor, icterus, clubbing, cyanosis,

lymphadenopathy and pedal edema • P-80 ,BP-130/90• All Peripheral vessels palpable ,no bruit

Local examination

• Skin -no discolouration or thickening.• No hair loss • No joint pain • No bony deformity in foot

Systemic Examination

• Chest-NAD • CVS- NAD• Per abdomen –NAD

Neurological examination• Higher mental function-Normal• Speech -Normal• Cranial nerves-Normal• Motor exam Right Left

Bulk Normal Normal

Tone NormalDecreased slightly in foot dorsiflexors

Normal

Power Right LeftUpper limb 5/5 5/5Lower limb-hip joint

5/5 5/5

knee joint 5/5 5/5

ankle -dorsi-flexion

2/5 5/5

ankle plantar-flexion

5/5 5/5

EHL weak strong

Dorsiflexion-2/5

Plantarflexion-5/5

RIGHT ankle joint

Superficial reflexes

• Abdominal and cremasteric reflex –normal• Anal sphinchter tone and Bulbocavernous reflex-

normal• Plantars –B/L mute

Deep tendon reflexes

Biceps reflex

Triceps reflex

Supinator reflex

Knee reflex

Ankle reflex

Right Normal Normal Normal Brisk Absent

Left Normal Normal Normal Brisk Absent

• 50% sensory loss to pinprick at the right L4 dermatome level .

• Cerebellar signs- absent• No spinal or cranial deformity• SLR test -Negative

Summary• 50 year old ,non addict ,presented with insidious

onset, gradually progressive, right foot drop on the background of low backache for last 5 years with

• LMN + subtle UMN signs • Right ankle dorsiflexors MRC grade 2/5, B/L absent ankle reflex, B/L brisk knee reflex with

B/L mute plantars along with sensory loss in right L4 dermatome and negative SLR.

Diagnostic possibilities

• Orthopedic• Medical

Orthopaedic discussant

Dr. Narendra Joshi Professor , Dept. of orthopaedics

Endocrinology discussant

Dr. Sandeep Mathur

PHOD, Dept. of Endocrinology

LOCALIZATION OF LESIONLMN causes of foot drop

MUSCLE NEURO-MUSCULAR JUNCTION

NERVE PLEXUS RADICLE ANTERIOR HORN CELL

LOCALIZATION OF LESION

UMN LMN

BRAIN SPINAL CORD

FOOT DROP

Investigations

• Hemogram, biochemistry including thyroid function tests and vitamin B12 level were normal.

• Serum HIV was negative• B. Sugar controlled on OHA

Nerve conduction Studies

Motor nerve conduction studies

Right Left

Peroneal NR(Non recordable) S/O axonal affection

Decreased amplitude(>50% loss) S/O axonal affection

Tibial nerve Normal Normal

Sensory nerve conduction studies

Sural Normal Normal

F WAVE

Peroneal NR NR

Tibial Normal Normal

H Reflex

Tibial NR NR

Nerve conduction Studies

? Asymmetric Diabetic Neuropathy(Rt>>Lt)

Points in favour• Common cause of

neuropathy.• B/L ankle reflex absent• B/L common peroneal

nerve conduction affected

Points against• B/L knee reflex brisk• Tibial and sural nerve

conduction normal

Classification of diabetic neuropathiesGeneralised symmetric neuropathies

Focal and Asymmetric neuropathies

Combinations

Classification of diabetic neuropathiesGeneralised symmetric neuropathies• Distal sensory or sensorimotor polyneuropathy• Small fibre neuropathy• Autonomic neuropathy• Large fibre sensory neuropathy

Classification of diabetic neuropathiesFocal and Asymmetric neuropathies• Cranial mononeuropathy(single or multiple)• Truncal mononeuropathy (thoracic radiculopathy)• Limb mononeuropathy (single or multiple)• Proximal motor neuropathy (lumbar

radiculoplexopathy ,amyotrophy)Combinations• Polyradiculoneuropathy• Diabetic neuropathic cachexia

Diabetic neuropathy and foot drop• Common peroneal neuropathy is the most common

of all lower limb mononeuropathies.• Diabetes mellitus responsible for 10-12 % cases.• Sensory deficit not accompanied by pain or

paresthesia

MRI LS Spine

Mild L4-L5 disc indentation

MRI LS Spine

? L4-L5 Radiculopathy

Points in favour• Age• Chronic low back pain• Unilateral foot drop • Sensory loss in right L4

dermatome.• B/L F wave and H reflex absent. • Mild nerve root compression at

L4-L5 disc.

Point against• No H/O radicular pain• B/L brisk knee reflex

Myeloradiculopathy

• Chronic low back pain• B/L knee jerk were brisk• B/L ankle jerks were absent• Mild nerve root

compression at L4-L5 disc.• B/L F wave and H reflex

absent.

Point against• B/L plantars were not

extensors

Points in favour

MRI Cervical & Dorsal spine

Serpinginous lesion

Neuroimaging• Neuro-Radiologist

Department of RadiodiagnosisCPC August 2016

Dr. Ravi Prakash SainiGuided By : Dr. Naima Mannan

MRI Cervical & Dorsal spine

Serpinginous lesion

• Spinal cord edema plus dilated perimedullary vascular channels seen as vascular flow voids from C7 to D8 without an intramedullary lesion are typical for an Spinal AVM (dAVF)

Spinal cord with

Perimedullary flow voids

CT Angiography Spine

Tortuos dilated vascular channels

• There is long segment collection of tortuous vessels channel noted in posterior part of spinal cord extending from C7 TO D8 levels

suggestive of spinal cord AVM.

Four types of AVM

• Type 1- single coiled vessel (dural AV fistula)• Type 2- intramedullary glomus AVM• Type 3- juvenile• Type 4- intradural perimedullary (AV fistula) Subtype i- single arterial (ASA) small fistula Subtype ii- multiple arterial (ASA & PSA), multiple

medium fistulae Subtype iii- multiple arterial (ASA & PSA), single

giant fistula

• Feeding artery is not visualised.• DSA to look for feeding artery

NEUROLOGY

Neuro-intervention-Dr.Trilochan Srivastava

Spinal digital subtraction angiography

Spinal DSA

AP View

Spinal dAVF

Intercostal art

Perimedullary vein

Radicular art

Fistula

Oblique View

FINAL DIAGNOSIS

Myeloradiculopathy

Management of Spinal dAVF

• Neurosurgery• Glue Embolization

Neurosurgery

Dr. Achal Sharma , Professor , Dept. of Neurosurgery

Micro-catheterization of fistula(dAVF)

Micro-catheterization of dAVF

After Embolization

Glue (nBCA) Embolization(Nov 14)

Glue cast

Follow-up (April 15)Rt DF 3/5 PF 5/5

Relief in back pain

Absent prominent flow voids

Follow-up (April 15)

Glue cast

Follow-up (April 15)

Normal cord with subtle hyperintensity

MRI SPINEPre-Embolization Post Embolization

Prominent flow voids Absent

flow voids

MRI SPINEPre-Embolization Post Embolization

Cord edema with prominent perimedullary vessels

Absent cord edemaand perimedullary vessels

Spinal CT Angiography (Sept 15)Rt DF 4/5, Rt PF 5/5

Glue cast

CT Angiography SpinePre-Embolization Post -Embolization

Serpinginous lesion Absent Serpinginous lesion

Clinical Improvement in patient

• Relief in backpain• Improvement in power of dorsiflexors of right ankle

joint from MRC grade 2/5 to 4/5

Foot Drop• Foot drop is defined as

weakness of the anterior tibialis and is frequently accompanied by weakness of the extensor hallucis longus (EHL) and extensor digitorum longus (EDL)

LOCALIZATION OF LESIONLMN causes of foot drop

MUSCLE NEURO-MUSCULAR JUNCTION

NERVE PLEXUS RADICLE ANTERIOR HORN CELL

Motor neuron disease-ALS

Anterior compartment syndromeInclusion body myositis,Myotonic dystrophy,Scapuloperoneal myopathy

Myaesthenia gravis

Common peroneal ,Sciatic neuropathy

Lumbosacral plexopathy

L5 radiculopathy

LOCALIZATION OF LESION

UMN LMN

BRAIN SPINAL CORD

FOOT DROP

StrokeParasagittal tumours-Meningioma , metastasis

MyelopathySpondylosismetastasis

Foot Drop – LMN causes

• It is usually caused by LMN pathology, commonly disruption of conduction from the common peroneal nerve (L4-L5)

• L4-L5 radiculopathy is the next most common recognized cause of foot drop, usually caused by herniated nucleus pulposus or foraminal stenosis

Common Peroneal neuropathy is the most common cause

• Nerve entrapment• Diabetes mellitus• Inflammatory neuropathy• Trauma, masses or pressure near the fibular head• Intraneural tumors• Vascular pathology

Foot Drop – LMN causes

WEAKNESS OF DEEP PERONEAL NERVE

COMMON PERONEAL NERVE

SCIATIC NERVE

LUMBOSACRAL PLEXUS

L5 RADICULOPATHY

FOOT DORSIFLEXION

PRESENT PRESENT PRESENT PRESENT PRESENT

FOOT EVERSION

PRESENT PRESENT PRESENT PRESENT

FOOT INVERSION

PRESENT PRESENT PRESENT

KNEE FLEXION PRESENT PRESENT PRESENT

GLUTEI MUSCLES

PRESENT PRESENT

DECREASED ANKLE REFLEX

PRESENT PRESENT PRESENT

SENSORY LOSS IN

DEEP PERONEAL NERVE

COMMON PERONEAL NERVE

SCIATIC NERVE

LUMBOSACRAL PLEXUS

L5 RADICULOPATHY

WEBSPACE OF GREAT TOE

PRESENT PRESENT PRESENT PRESENT PRESENT

DORSUM OF FOOT

PRESENT PRESENT PRESENT PRESENT

LATERAL CALF PRESENT PRESENT PRESENT PRESENT

LATERAL KNEE PRESENT PRESENT PRESENT

POSTERIOR THIGH

PRESENT PRESENT

Central or UMN causes of Foot Drop

• Central or UMN causes are extremely rare but must be considered

• Compression of these fibers along the path from the cortex, internal capsule , the cerebral peduncles, and the ventral spinal cord, can potentially result in disruption of signal to the lumbar nerve roots

Myelopathy & foot drop The UMNs of the leg are

organized somatotopically from the medial motor cortex down the internal capsule to the ventral gray matter of the spinal cord, where they are grouped in longitudinally oriented columns

Foot area

Affected area

Spinal dAVF• They comprise 3%–16% of all

compressive spinal cord lesions

• Attributed to 30% of idiopathic myelopathies.

• They are most often diagnosed on imaging by a neuroradiologist

• They can present with symptoms of myelopathy and radiculopathy mimicking a plethora of pathologies.

ONLY SINGLE CASE REPORTEmbolization of a spinal dural AV fistula after super selective

WADA test spinal AV fistula presenting as foot drop• NeuroIntervent Surg 2012;4:A70-A71 ,V Nduku et al

• Reported a case of a 79-year-old female who presented with back pain and a left foot drop. MRI suggested edema in the conus medullaris

• Spinal angiogram revealed serpiginous enhancement from T11-L1 consistent with a type I AVM (Dural AV fistula)

• She eventually underwent successful embolization with complete occlusion of the Spinal AVF

TAKE HOME MESSAGE

• Although rare and underappreciated, Central causes of foot drop must be included in the workup once peripheral causes have been ruled out

• A thorough history and physical examination may reveal signs of UMN disease, including hyperreflexia, and Babinski response

• Neurophysiology studies should be included in the workup and can assist in ruling out peripheral causes

• Most central causes of foot drop(identified on imaging) can have rather dramatic recovery following resection or decompression

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9TH SEPTEMBER 2016

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