Approach to Neurological Disease
-
Upload
neurologist-coffeecup -
Category
Documents
-
view
13 -
download
0
description
Transcript of Approach to Neurological Disease
ThinkinglikeneurologistIsitdifference?
Dr.SuratTanprawate,MD,FRCP(T)NorthernNeuroscienceCenter
ChiangmaiUniversity
ThinkinglikeaNeurologist
Where‘sthelesion?
What’sthelesion?
Seriesofstepstocollectdata
Chiefcomplaint
History
Confirma4onoflocaliza4on
Tippingthepoint
Task Goal
ReviewofPa4ent‐specificfeature
Listoftheproblems
Neurologicalexamina4on
Complaintexplorer
RankoforderofLikelihoodofpossibledisease Differen4aldiagnosis
Complexbrainprocessing
Chiefcomplaint
“Tippingthepoint”
5
ComponentofChiefComplaint
Symptom(s)orSyndrome
+
Timecourse(progressive,stable,fluctua4on)
Onset(sudden,acute,subacute,chronic)
6ExpandtheideaCollectthe
rightdata
Thepointshouldbeconcerned
• Avoidovergeneraliza4on• Avoidmisinterpretsymptoms• Avoidincompletechiefcomplaint• Avoidsteptothepresentillnessbeforehavinganideaflowchart
7
Commonmisinterpretsymptoms
• PalalysisVSnumbness
• DizzinessVSweaknessVSFa4gueVSataxia
• DysphasiaVSdysarthria
• BlurvisionVSDiplopia
• Blackout:lossofconsciousnessVSlossofvisionVSsimpleconfusion
9
Expandtheidea“Symptomatology
approach”
Symptomsapproach‐1
• Disorderofconsciousness– Levelofconsciousness– Contentofconsciousness
• Mentaldisorder– Memory– Intelligence– Personality– Behavioral– Demen4a
• HighercorQcalfuncQondisorder– Apraxia,aphasia,agnosia,
others
• Visualdisorder– Visualloss– Diplopia
Inyourhead
Symptomsapproach‐2
• Languageandspeechdisorder– Dysarthria– Dysphasia
• Lowercranialnervedisorder– Deafness/4nnitus– Ver4go– Balance/staggering– Swallowing– Voicechange
Inyourhead
Symptomsapproach‐3
• Sensorydisorder– Paindisorder
• Headacheandfacialpain
• Otherspaindisorder
– Numbness/4ngling
• Motordisorder– Weakness:eachpart
– Movementdisorder
• Sphincterdisorder
Inyourhead
Symptomsapproach‐4
• Episodicdisorder– Seizure/epilepsy
– Syncope
– TIA
– Abnormalmovement
– Migraine
Inyourhead
• MulQplecranialnervesyndrome
“syndromeofopthalmoplegia”
“syndromeofLowerCNinvolvement”
• Brainstemsyndrome
“Suddenonsetplusbrainstems/s”
Syndromeapproach‐1
• Parkinsonism– Bradykinesia
– Musclerigidity
– Res4ngtremor
– Posturalinstability
14
Syndromeapproach‐2
• Spinalcordsyndrome– Transversecordsyndrome(complete,incomplete)
– Hemicordsyndrome
– Anteriorcordsyndrome
– Posteriorcordsyndrome
15
• Cerecellarsyndrome‐ Pancerebellarsyndrome
‐ Hemicerebellarsyndrome
‐ Cerebellarvermissyndrome
Example
16
17
PaQentHistory
Symptomatology
18
Difficulttoopenhiseye
Symptomatology
19
Doublevision“Diplopia”
Symptomatology:Eyeliddisorder
• Lidabnormali4espresentsas–Ptosis–Lidretrac4on–Insufficienteyelidclosure–Excessiveeyelidclosure
20
21
Ptosis
WeaknessofLevatorpalpebrae
muscle
Excessiveeyelidclosure
Mullermuscle:Horner’ssyndrome
•Blephalospasm•Hemifacialspasm
Contrac4onofobicularisoculi
muscle
22
Ptosisapproach
Ptosis
Neurologicptosis
Non‐neurogenic(mechanical)ptosis
•Uni‐bilateral•Par4al‐complete
•Pupilinvolvement•EOMimpairment
Supranuclearlesion(cerebralptosis)•Contralateralcerebralhemisphere
LMN•Neuropathic(N,fascicle,CN)•NMJ•Myopathic
Congenitalptosis
Horner’ssyndrome
24
Druginducedblephalospasmanddyskinesia
25
Superior tarsal muscle
(also known as
Müller's muscle)
26
27
Awomanpresentwithdoublevision
28
Diplopiaapproach
Diplopia
Binoculardiplopia
Monoculardiplopia:
Mostlyopthalmologiccondi4on
Non‐misalignment:intermiient,non‐
organic
Misalignment
ComitantstrabismusChildhoodstrabismus
Incomitantstrabismus
MostlyNeuro‐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:ThinkingIdea• Direc4onofinvolvedmuscle
– Impairconsistentwithnerveinnerva4on(Nerve,nucleus)
– ifnot• Fluctua4on:NMJ
• Associatedwithproximalmuscleweakness:Muscledisease
• Ver4calgazeorHorizontalgazepathwayinvolvement:Internuclearlesion
31
32
EyeexaminaQon
33BilateralponQneinfarcQon
34
Awomancomplainsslowprogressivediplopia,gaitdifficultyfor2weeks
35
Eyemovement
• 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
39
Gaitabnormality
40
AtaxiaGait
disturbance =
41
Tandemwalk
42
Cerebellartest
Approachtoataxicpa4ent
Ataxic symptoms?-Nystagmus-Dysarthria-Trunkcal ataxia-Limb and gait -ataxia
Ataxic symptoms mimicker?
Ataxia: disease other than cerebellum
Cerebellar’s disease-Where’s the lesion (cerebellum, cerebellar peduncle, cerebellar tract) -What’s the lesion
True Ataxia•Mildweakness•Apraxia•Abnormalmovement
Where’slesion?
Associatedsign
Pure cerebellum
ClassifiedCerebellarsyndrome
WithBrainstem
signs
ClassifiedBrainstem
Syndrome?
With mild hemiparesis
Involve fronto-Ponto-CerebellarPathway“Ataxic hemiparesis”
Cerebellar hemispheric syndrome
Rostral vermis
syndrome
Caudal vermis
syndrome
Pancerebellar syndrome
Unilateral intermediate, lateral zones
Ant, sup vermis
Flucculonodular, post vermis
All regions
Classifiedcerebellarsyndrome
Symmetricalataxiaplussyndrome
• Acquired– Wernicke’sencephalopathy
– MillerFishersyndrome
– Normalpressurehydrocephalus(frontallobeataxia)
• Hereditary– Spinocerebellarataxia(SCA)
Backtoourcase
47
Nuclearcomplexofoculomotor
nerve
Rostralvermissyndrome
48
PhysicalExaminaQon
“Confirmthethough,explorethenext”
49
NeurologicalexaminaQon• Screening(general)neurologicalexaminaQon– Exameverypath:thetestsaremoresensi4ve
• Specific(focused)neurologicalexaminaQon– Examthedetailofabnormalneurologicalsignsorsymptomsrelevanttothehistoryandscreeningexam.
– thetestsaremorespecific
50
Recordtheneurologicalsigns
• PresenceVSAbsence
• HardsignsVSSonsigns
• NormalVSabnormal• Lateralizingsign:
• TrueVSfalselocalizingsign
• Normalvaria4on
51
Generalneurologicalexamina4on
• Mentalstatus• Cranialnerve
– 1‐12CNfunc4on
• Limb– Voluntarymovement
– Muscle:bulk,tone,power– Coordina4on:FTN,HTS,rapid
alterna4ngmovement
– Reflex:tendon,plantarresponse
– Sensa4on:pinprick,JPS,vibra4onsense
• Gaitandbalance• Rombergtest
Thepointshouldbeconcerned
53
• Avoidmisinterpretsign• Misinterpretthenormalvaria4on• Confirmtheequivocalsign• Awarethesonsign• Awarethefalselocalizingsign
54
Amanpresentedwithshakinghead
55
Anoldwomanpresentwithabnormalhandmovement
56
FocusedneurologicalexaminaQon
• Whichkindoftest–Dependon:History,Screeningneurologicalexamina4on
–Completethefocusedexamina4on:• Moredetail
• Completethesyndromeyouthought
• Needextensiveskillforspecifica4on
Conceptof“son”neurologicalsign
• “Hardsign”:– neurologicalsignresultfromalesionataknownsiteorthataffectaknownpathway
• “Sonsign”:– Anystructuralorfunc4onaldevia4onfoundmorefrequentlyinbrainimpairmentpersonsthaninnormalpersons
– Doesnotcorrelatewithanypar4culartypeofbrainlesionatanypar4cularsite,orinterrup4onofanypar4culartract
Conceptof“false”localizingsign
• TruesignthatoccurssecondarytoalesionelsewhereintheCNS.
• Thesignisnotfalse,butisdistantfromtheactualsiteofprimarylesion
• Cause:– Shinofbrain:compressordisplacestructure(distant)orbloodvessel(ACA,MCA)
– Hydrocephalus:CN6palsy,Pretectal(sylvian)syndrome
59
Problemlist
“ReviewofpaQentspecificfeature”
60
ListofproblemsIntegrateofHistoryandPE
• First:anatomicallocaliza4onoflesionorneurologysystem–Focal,Mul4‐focal,Diffuse–Nuclear,tract,systemdisorder–CNS,PNS,Boths
DifferenQaldiagnosisDiscussioneachproblemlist
• 1)
• 2)
• 3)
• 4)
• 5)
DifferenQaldiagnosis
“Rankofthepossibledisease”
63
DifferenQaldiagnosisIntegrateofHistoryandPE
• First:anatomicallocalizaQonoflesionorneurologysystem– Focal,Mul4‐focal,Diffuse
– Nuclear,tract,systemdisorder
– CNS,PNS,Boths
• Second:causeoflesion– Congenital,Gene4c
– Trauma
– Tumor
– Infect/Inflamma4on
– Vascular– Toxic/metabolic/Nutri4onal
– Degenera4on/Demyelina4on
– Idiopathic
– Psychogenic
Seriesofstepstocollectdata
Chiefcomplaint
History
Confirma4onoflocaliza4on
Tippingthepoint
Task Goal
ReviewofPa4ent‐specificfeature
Listoftheproblems
Neurologicalexamina4on
Complaintexplorer
RankoforderofLikelihoodofpossibledisease Differen4aldiagnosis
Combine it together
Thank you for your
attention.
www.neurologycoffeecup.com