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Neuro Exam
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  • 1. The Neurologic ExamThe Neurologic Exam Andy Jagoda, MDAndy Jagoda, MD Department of Emergency MedicineDepartment of Emergency Medicine Mount Sinai School of MedicineMount Sinai School of Medicine New York, New YorkNew York, New York
  • 2. Andy Jagoda, MD OverviewOverview • NeuroanatomyNeuroanatomy • HistoryHistory • PhysicalPhysical • Clinical ScenariosClinical Scenarios
  • 3. Andy Jagoda, MD IntroductionIntroduction • Facilitates CommunicationFacilitates Communication • Provides BaselineProvides Baseline • Directs TestingDirects Testing • Identifies Need For Life-Saving TherapiesIdentifies Need For Life-Saving Therapies • Risk ManagementRisk Management
  • 4. Andy Jagoda, MD Risk Management: Case #1Risk Management: Case #1 • A 46-year-old female with a long history ofA 46-year-old female with a long history of migraine headaches presented c/o a severemigraine headaches presented c/o a severe occipital HA that was different form her pastoccipital HA that was different form her past headaches in location and intensity. Neuroheadaches in location and intensity. Neuro exam “WNL”. Patient was treated withexam “WNL”. Patient was treated with Compazine, 10 MG IV, with “Resolution ofCompazine, 10 MG IV, with “Resolution of Headache” and discharged home toHeadache” and discharged home to “Follow-Up With PMD”.“Follow-Up With PMD”. • 18 hours later, patient was brought in by18 hours later, patient was brought in by EMS comatoseEMS comatose
  • 5. Andy Jagoda, MD Risk Management: Case #2Risk Management: Case #2 • A 64-year-old male presented with lower back painA 64-year-old male presented with lower back pain which had become progressively worse over the past 2which had become progressively worse over the past 2 weeks. The pain was primarily in the lower back withoutweeks. The pain was primarily in the lower back without radiation, with nonspecific numbness in the legs. PMH:radiation, with nonspecific numbness in the legs. PMH: presently being treated for prostatitis. Exam: “Mildpresently being treated for prostatitis. Exam: “Mild Paralumbar Tenderness”, “SLR -”, “Motor / SensoryParalumbar Tenderness”, “SLR -”, “Motor / Sensory Intact”, Knee DTR +2. patient was prescribed Motrin andIntact”, Knee DTR +2. patient was prescribed Motrin and told to follow-up with his PMD.told to follow-up with his PMD. • Patient developed irreversible renal damage.Patient developed irreversible renal damage.
  • 6. Andy Jagoda, MD NeuroanatomyNeuroanatomy • Central versus peripheralCentral versus peripheral – symmetrical vs asymmetricalsymmetrical vs asymmetrical • If central, what is the level:If central, what is the level: – CerebrumCerebrum – Brain StemBrain Stem – Spinal cordSpinal cord • If peripheral, is itIf peripheral, is it – NerveNerve – MuscleMuscle – NMJNMJ
  • 7. Andy Jagoda, MD NeuroanatomyNeuroanatomy
  • 8. Andy Jagoda, MD Central lesionsCentral lesions • Lesions in the cerebral cortex result inLesions in the cerebral cortex result in contralateral deficits of the face and bodycontralateral deficits of the face and body • Lesions at the midbrain result in contralateralLesions at the midbrain result in contralateral hemiplegia and ipsilateral peripheral paralysis ofhemiplegia and ipsilateral peripheral paralysis of III and IVIII and IV • Lesions at the pons result in contralateralLesions at the pons result in contralateral hemiplegia and ipsilateral deficits of V, VI, VII, VIIIhemiplegia and ipsilateral deficits of V, VI, VII, VIII • Lesions at the medulla result in contraleralLesions at the medulla result in contraleral hemiplegia and ipsilateral deficits of IX, X, XI, XIIIhemiplegia and ipsilateral deficits of IX, X, XI, XIII
  • 9. Andy Jagoda, MD Anatomy of the Spinal CordAnatomy of the Spinal Cord • Corticospinal Tracts: motor fromCorticospinal Tracts: motor from cerebral cortex: cross in the lowercerebral cortex: cross in the lower medullamedulla • Spinothalamic Tracts: pain andSpinothalamic Tracts: pain and temperature: cross 1 or 2 levels abovetemperature: cross 1 or 2 levels above entryentry • Posterior Column: proprioception andPosterior Column: proprioception and vibrationvibration
  • 10. Andy Jagoda, MD Spinal Cord : Vascular SupplySpinal Cord : Vascular Supply • Single AnteriorSingle Anterior • Paired posterior from vertebral arteries (ExceptPaired posterior from vertebral arteries (Except in cervical cord)in cervical cord) • Radicular Arteries from aorta:Radicular Arteries from aorta: – Varying degrees of contributionVarying degrees of contribution – Great radicular artery of Adamkiewicz T-10 to L-2Great radicular artery of Adamkiewicz T-10 to L-2 (Major source of blood flow to 50% of anterior cord in(Major source of blood flow to 50% of anterior cord in 50% of patients)50% of patients) • Anterior perfuses anterior and central cordAnterior perfuses anterior and central cord
  • 11. Andy Jagoda, MD UMN vs LMNUMN vs LMN • UMN increased DTR (after SS)UMN increased DTR (after SS) LMN decreased DTRLMN decreased DTR • UMN muscle tone increasedUMN muscle tone increased LMN tone decreased, atrophyLMN tone decreased, atrophy • UMN no fasciculationsUMN no fasciculations LMN fasciculationsLMN fasciculations
  • 12. Andy Jagoda, MD UMN vs LMN WeaknessUMN vs LMN Weakness • Mylopathy = Spinal Cord Process = UMNMylopathy = Spinal Cord Process = UMN findings (spasticity, weakness, atrophy,findings (spasticity, weakness, atrophy, sensory findings, bowel and bladdersensory findings, bowel and bladder complaints)complaints) • Radiculopathy = Nerve Root Process = LMNRadiculopathy = Nerve Root Process = LMN findings (Paresthesias, Fasciculations,findings (Paresthesias, Fasciculations, Weakness, decreased DTR)Weakness, decreased DTR) • Patient may have a radiculopathy withPatient may have a radiculopathy with mylopathy below the lesionmylopathy below the lesion
  • 13. Andy Jagoda, MD The Neuro Exam: HistoryThe Neuro Exam: History • Neuro complaints may be primary orNeuro complaints may be primary or secondary to other system diseasesecondary to other system disease – InfectionInfection – OverdoseOverdose – Metabolic DisorderMetabolic Disorder
  • 14. Andy Jagoda, MD The Neuro Exam: HistoryThe Neuro Exam: History • History often provides the key sinceHistory often provides the key since the neuro exam may be normalthe neuro exam may be normal – Subarachnoid HemorrhageSubarachnoid Hemorrhage – Carbon Monoxide PoisoningCarbon Monoxide Poisoning – Subdural HematomaSubdural Hematoma – Nonconvulsive SeizuresNonconvulsive Seizures
  • 15. Andy Jagoda, MD The Neuro Exam: HistoryThe Neuro Exam: History • Time of OnsetTime of Onset • Type of OnsetType of Onset • ProgressionProgression • TraumaTrauma • Associated SymptomsAssociated Symptoms
  • 16. Andy Jagoda, MD The Neuro Exam: HistoryThe Neuro Exam: History • Factors that make it better/worseFactors that make it better/worse • Past Symptoms / EventsPast Symptoms / Events • Past Medical HistoryPast Medical History • Occupational / Environ ExposuresOccupational / Environ Exposures
  • 17. Andy Jagoda, MD The Neuro Exam: PhysicalThe Neuro Exam: Physical • Vital SignsVital Signs • Head: Evidence of TraumaHead: Evidence of Trauma • Neck: Bruits, RigidityNeck: Bruits, Rigidity • Heart: MurmursHeart: Murmurs • Abdomen: Masses / DistentionAbdomen: Masses / Distention • Skin / Scalp: Lesions / TendernessSkin / Scalp: Lesions / Tenderness
  • 18. Andy Jagoda, MD The Neuro Exam: PhysicalThe Neuro Exam: Physical • Mental StatusMental Status • Cranial NervesCranial Nerves • MotorMotor • SensorySensory • CoordinationCoordination • ReflexesReflexes
  • 19. Andy Jagoda, MD The Neuro Exam: Initial ApproachThe Neuro Exam: Initial Approach • PosturePosture – DecorticateDecorticate – DecerebrateDecerebrate – Facial or body asymmetryFacial or body asymmetry • Hemiparesis results in external rotation ofHemiparesis results in external rotation of the foot of the affected sidethe foot of the affected side
  • 20. Andy Jagoda, MD Mental Status ExamMental Status Exam • AVPUAVPU • GCSGCS • OrientationOrientation – Speech (dysarthria vs aphasia)Speech (dysarthria vs aphasia) – ComprehensionComprehension
  • 21. Andy Jagoda, MD Mental Status ExamMental Status Exam • Confusion assessment method (CAM)Confusion assessment method (CAM) – Acute onset / fluctuating courseAcute onset / fluctuating course – InattentionInattention – Disorganized thinkingDisorganized thinking – Altered level of consciousnessAltered level of consciousness • Mini-mental status examMini-mental status exam – Score affected by education and ageScore affected by education and age – <20 = cognitive impairment<20 = cognitive impairment
  • 22. Andy Jagoda, MD Acute Altered Mental StatusAcute Altered Mental Status • Intracranial lesionIntracranial lesion • Metabolic disorderMetabolic disorder • ToxinToxin • InfectionInfection • Ictal stateIctal state • Postictal statePostictal state • PsychogenicPsychogenic
  • 23. Andy Jagoda, MD Cranial Nerve ExamCranial Nerve Exam • Focus exam on II - VIIIFocus exam on II - VIII • Symmetrical vs asymmetricalSymmetrical vs asymmetrical
  • 24. Andy Jagoda, MD Evaluation of II, III, IV, VIEvaluation of II, III, IV, VI • Visual acuityVisual acuity • Visual fieldsVisual fields • Examine the cornea, pupil, fundiExamine the cornea, pupil, fundi • Check afferent functionCheck afferent function • Extraocular movementsExtraocular movements – Accentuated when looking in the direction of theAccentuated when looking in the direction of the paralyzed muscleparalyzed muscle – Differentiation can be facilitated by placing aDifferentiation can be facilitated by placing a colored glass over one eyecolored glass over one eye
  • 25. Andy Jagoda, MD Cranial Nerve IICranial Nerve II • Visual acuityVisual acuity • Visual fieldsVisual fields • FundoscopyFundoscopy • Swinging flashlight testSwinging flashlight test
  • 26. Andy Jagoda, MD III NerveIII Nerve • Emerges from brainstem next toEmerges from brainstem next to posterior cerebral arteryposterior cerebral artery • May be compressed by herniationMay be compressed by herniation • Runs in the lateral wall of theRuns in the lateral wall of the cavernous sinuscavernous sinus
  • 27. Andy Jagoda, MD LR MR MR LR IO IO SRSR IR SO SO IR III Cranial NerveIII Cranial Nerve • ParasympatheticsParasympathetics • Levator PalpebraeLevator Palpebrae • Inferior Obliques, Medial, Inferior,Inferior Obliques, Medial, Inferior, and Superior Rectus Musclesand Superior Rectus Muscles
  • 28. Andy Jagoda, MD LR MR MR LR IO IO SRSR IR SO SO IR III Cranial Nerve ParalysisIII Cranial Nerve Paralysis • PtosisPtosis • Dilated PupilDilated Pupil • Paralyzed eye is deviated out and down;Paralyzed eye is deviated out and down; SO and LR control eyeSO and LR control eye
  • 29. Andy Jagoda, MD III Cranial Nerve LesionsIII Cranial Nerve Lesions • Progressive lesions after passageProgressive lesions after passage through the dura usually usually causesthrough the dura usually usually causes a ptosis and pupil dilatation firsta ptosis and pupil dilatation first • Lesions in the nucleus cause motorLesions in the nucleus cause motor deficits firstdeficits first • Intact pupil indicates a peripheralIntact pupil indicates a peripheral ischemic lesionischemic lesion
  • 30. Andy Jagoda, MD LR MR MR LR IO IO SRSR IR SO SO IR IV Cranial NerveIV Cranial Nerve • Superior obliqueSuperior oblique • Causes eye to turn in and downCauses eye to turn in and down • When paralyzed, eye can not turnWhen paralyzed, eye can not turn down when it is rotated indown when it is rotated in
  • 31. Andy Jagoda, MD LR MR MR LR IO IO SRSR IR SO SO IR VI Cranial NerveVI Cranial Nerve • Lateral rectusLateral rectus • Long course; goes through the CS,Long course; goes through the CS, not within the wallnot within the wall • Paralysis impairs abductionParalysis impairs abduction
  • 32. Andy Jagoda, MD Conjugate GazeConjugate Gaze • Controlled by supranuclear connectionsControlled by supranuclear connections • Medial longitudinal fasciculus isMedial longitudinal fasciculus is responsible for coordinating theresponsible for coordinating the oculomotor nerves; lesions result inoculomotor nerves; lesions result in impairment of LR and MR moving inimpairment of LR and MR moving in sync, ie, contralateral eye does not passsync, ie, contralateral eye does not pass the midlinethe midline • Multiple sclerosisMultiple sclerosis
  • 33. Andy Jagoda, MD Causes of III, VI, VI CN ParalysisCauses of III, VI, VI CN Paralysis • Isolated cases usually due to vascular causes:Isolated cases usually due to vascular causes: HTN, DM, AtherosclerosisHTN, DM, Atherosclerosis • TumorsTumors • Increased intracranial pressureIncreased intracranial pressure • Colloid cyst of the III ventricleColloid cyst of the III ventricle • Wernicke-Korsakoff syndromeWernicke-Korsakoff syndrome • Myasthenia, BotulismMyasthenia, Botulism • Toxic drug reactionsToxic drug reactions
  • 34. Andy Jagoda, MD Cranial Nerve VCranial Nerve V • Sensory: corneal reflexesSensory: corneal reflexes • Motor: jaw strength and muscleMotor: jaw strength and muscle bulkbulk • Corneal reflex may be abnormal inCorneal reflex may be abnormal in cerebellopontine angle lesions: testcerebellopontine angle lesions: test in patients with hearing deficits orin patients with hearing deficits or vertigovertigo
  • 35. Andy Jagoda, MD Cranial Nerve VIICranial Nerve VII • MotorMotor – SmileSmile – Bury eyelashesBury eyelashes – Nasolabial foldNasolabial fold – Forehead has bihemispheric innervationForehead has bihemispheric innervation centrallycentrally • Taste anterior 2/3Taste anterior 2/3
  • 36. Andy Jagoda, MD Cranial Nerves VIII - XIICranial Nerves VIII - XII • VIII - vestibular function / hearingVIII - vestibular function / hearing • IX - taste / sensation posteriorIX - taste / sensation posterior pharynxpharynx • X - SCM; chin to the opposite sideX - SCM; chin to the opposite side • XII - tongueXII - tongue
  • 37. Andy Jagoda, MD Motor ExamMotor Exam • StrengthStrength – Primary concern: can patient breathePrimary concern: can patient breathe – Key test: drift of extremityKey test: drift of extremity • ToneTone – Hypertonia: subacute or chronic corticospinalHypertonia: subacute or chronic corticospinal lesionlesion – Hypotonia: LMN lesion or acute UMNHypotonia: LMN lesion or acute UMN – Rigidity: basal ganglia diseaseRigidity: basal ganglia disease
  • 38. Andy Jagoda, MD Motor ExamMotor Exam • BulkBulk – Wasting correlates with LMNWasting correlates with LMN • FasciculationFasciculation – Anterior horn cell lesionAnterior horn cell lesion • TendernessTenderness – Metabolic / inflammatory muscle diseaseMetabolic / inflammatory muscle disease
  • 39. Andy Jagoda, MD Motor ExamMotor Exam • 00 = no movement= no movement • 11 = flicker but no movement= flicker but no movement • 22 = movement but can not resist gravity= movement but can not resist gravity • 33 = movement against gravity but can not= movement against gravity but can not resist examinerresist examiner • 44 = resists examiner but weak= resists examiner but weak • 55 = normal= normal
  • 40. Andy Jagoda, MD Sensory ExamSensory Exam • Pain / TempPain / Temp - cross at entrance,- cross at entrance, ascend in spinal thalamic tractascend in spinal thalamic tract • Light touchLight touch - ascend in posterior- ascend in posterior column, cross in the brain stemcolumn, cross in the brain stem • VibrationVibration - posterior column, cross- posterior column, cross in the brain stemin the brain stem
  • 41. Andy Jagoda, MD Sensory ExamSensory Exam • Dermatomal deficit accompaniedDermatomal deficit accompanied with pain suggests peripheral lesionwith pain suggests peripheral lesion • Central deficits are not dermatomalCentral deficits are not dermatomal and usually result in loss ofand usually result in loss of sensation not painsensation not pain • Thalamic pain syndromeThalamic pain syndrome
  • 42. Andy Jagoda, MD Sensory ExamSensory Exam • DistributionDistribution – Right vs left vs bilateralRight vs left vs bilateral – DermatomalDermatomal – Distal versus proximalDistal versus proximal • Stocking gloveStocking glove • Cape likeCape like • Pinprick versus light touchPinprick versus light touch
  • 43. Andy Jagoda, MD Sensory ExamSensory Exam • Double simultaneous testingDouble simultaneous testing – Establish sharp / dullEstablish sharp / dull – Check cheek, dorsum of hands, dorsum ofCheck cheek, dorsum of hands, dorsum of feetfeet – Test both sides simultaneously with pinTest both sides simultaneously with pin • lateralizes pain, significant sensory deficitlateralizes pain, significant sensory deficit • initially no lateralization but on repeat 15 secinitially no lateralization but on repeat 15 sec later, lateralization suggests subtle deficitlater, lateralization suggests subtle deficit
  • 44. Andy Jagoda, MD CoordinationCoordination • Requires integration of cerebellar, motor, andRequires integration of cerebellar, motor, and sensory functionssensory functions • Balance requires (2 of 3)Balance requires (2 of 3) – visionvision – vestibular sensevestibular sense – proprioceptionproprioception • Falling with eyes open or closed = cerebellarFalling with eyes open or closed = cerebellar • Falling only with eyes closed = posteriorFalling only with eyes closed = posterior column or vestibularcolumn or vestibular
  • 45. Andy Jagoda, MD ReflexesReflexes • Symmetry / upper vs lowerSymmetry / upper vs lower – 0 = absent0 = absent – 1 = hyporeflexia1 = hyporeflexia – 2 = normal2 = normal – 3 = hyperreflexia3 = hyperreflexia – 4 = clonus (4 = clonus (usuallyusually indicates organic disease)indicates organic disease) • Superficial reflexes (corneal, pharyngeal,Superficial reflexes (corneal, pharyngeal, pharyngeal, abdominal, anal, cremasteric,pharyngeal, abdominal, anal, cremasteric, bulbocavernosus)bulbocavernosus) • Pathologic reflexes: babinskiPathologic reflexes: babinski
  • 46. Andy Jagoda, MD HysteriaHysteria (conversion vs malingering)(conversion vs malingering) • Blindness: opticokinetic testBlindness: opticokinetic test • Hand drop on face test for coma or UE weaknessHand drop on face test for coma or UE weakness • Hemianesthesia: if real, patient cannot performHemianesthesia: if real, patient cannot perform finger-to nose with eyes closed; vibration remainsfinger-to nose with eyes closed; vibration remains intact (if bony skeleton intact)intact (if bony skeleton intact) • Weakness: elbow extension or flexor test; wristWeakness: elbow extension or flexor test; wrist extensor testextensor test • Unilateral LE weakness: thigh abduction test,Unilateral LE weakness: thigh abduction test, hoover testhoover test
  • 47. Andy Jagoda, MD Pitfalls In The Neurologic ExamPitfalls In The Neurologic Exam • Not getting a complete history utilizingNot getting a complete history utilizing family or observersfamily or observers • Not performing a systematic examNot performing a systematic exam • Jumping to conclusions beforeJumping to conclusions before gathering all the datagathering all the data • Misinterpreting old lesions for newMisinterpreting old lesions for new • Misinterpreting limitations from pain asMisinterpreting limitations from pain as neurologic deficitsneurologic deficits
  • 48. Andy Jagoda, MD PearlsPearls • Lesions of the cerebral cortex result inLesions of the cerebral cortex result in sensory and motor defects confined to thesensory and motor defects confined to the contralateral side of the bodycontralateral side of the body • Brain stem and spinal cord lesions resultBrain stem and spinal cord lesions result in ipsilateral as well as contralateralin ipsilateral as well as contralateral defects due to varying patterns ofdefects due to varying patterns of crossovercrossover
  • 49. Andy Jagoda, MD PearlsPearls • Unilateral pain syndromes without motorUnilateral pain syndromes without motor deficits suggest possible thalamicdeficits suggest possible thalamic pathologypathology • A careful exam of CN II, III, IV, and IV isA careful exam of CN II, III, IV, and IV is indicated in patients with headache orindicated in patients with headache or suspected processes that cause increasedsuspected processes that cause increased ICPICP • Testing for pronator drift is the best screenTesting for pronator drift is the best screen for muscle weakness of central originfor muscle weakness of central origin
  • 50. Andy Jagoda, MD The Neurologic ExamThe Neurologic Exam Case ScenariosCase Scenarios
  • 51. Andy Jagoda, MD Case Scenario #1Case Scenario #1 A 46-year-old female with a long historyA 46-year-old female with a long history of migraine headaches presented c/o aof migraine headaches presented c/o a severe occipital HA that was differentsevere occipital HA that was different from her past headaches in location andfrom her past headaches in location and intensity. If an aneurysm is suspectedintensity. If an aneurysm is suspected to be causing the patient’s symptoms,to be causing the patient’s symptoms, which cranial nerve should your examwhich cranial nerve should your exam focus on?focus on? A. III B. VI C. VII D. IVA. III B. VI C. VII D. IV
  • 52. Andy Jagoda, MD III NERVEIII NERVE • Emerges from brainstem next to posteriorEmerges from brainstem next to posterior cerebral arterycerebral artery • Runs in the lateral wall of the cavernous sinusRuns in the lateral wall of the cavernous sinus • May be compressed:May be compressed: – HerniationHerniation – AneurysmAneurysm • Posterior communicating arteryPosterior communicating artery • ICA in the cavernous sinus (IV, V and VI nervesICA in the cavernous sinus (IV, V and VI nerves also involved)also involved)
  • 53. Andy Jagoda, MD Case Scenario #2Case Scenario #2 A 64-year-old male presented C/0 lowA 64-year-old male presented C/0 low back pain which has becomeback pain which has become progressively worse over the past 2progressively worse over the past 2 weeks. The pain was primarily in the lowweeks. The pain was primarily in the low back without radiation; C/O nonspecificback without radiation; C/O nonspecific numbness in the legs. Which nerve rootnumbness in the legs. Which nerve root is responsible for plantar flexion and theis responsible for plantar flexion and the ankle jerk?ankle jerk? A. L3 B. L4 C. L5 D. S1 E. S2A. L3 B. L4 C. L5 D. S1 E. S2
  • 54. Andy Jagoda, MD Lower Extremity InnervationLower Extremity Innervation • L 3 / L 4 = Patellar reflexL 3 / L 4 = Patellar reflex • L 5 = Big toe extensionL 5 = Big toe extension • S 1 = Achilles reflexS 1 = Achilles reflex
  • 55. Andy Jagoda, MD Case Scenario #3Case Scenario #3 A 30-year-old female is in an MVA hitting her headA 30-year-old female is in an MVA hitting her head on the dash. The next day she developed a suddenon the dash. The next day she developed a sudden onset severe right frontal HA, that persisted. Oneonset severe right frontal HA, that persisted. One day later she developed left sided arm weaknessday later she developed left sided arm weakness that lasted 2 hours. In the ED she had an ODthat lasted 2 hours. In the ED she had an OD ptosis and OD miosis. Her motor / sensory examptosis and OD miosis. Her motor / sensory exam was “WNL”. What is your initial impression?was “WNL”. What is your initial impression? A.A. HysteriaHysteria B.B. Subarachnoid bleedSubarachnoid bleed C.C. Epidural hematomaEpidural hematoma D.D. Carotid artery dissectionCarotid artery dissection E.E. Entrapment syndromeEntrapment syndrome
  • 56. Andy Jagoda, MD Pupil ConstrictionPupil Constriction • Disruption of the sympatheticsDisruption of the sympathetics – Horner’sHorner’s – Carotid artery dissectionCarotid artery dissection – Pontine hemorrhagePontine hemorrhage • ToxinsToxins – NarcoticsNarcotics – CholinergicsCholinergics
  • 57. Andy Jagoda, MD Case Scenario #4Case Scenario #4 A 50-year-old female c/o a diffuse headache forA 50-year-old female c/o a diffuse headache for two months that is constant. There is no past HAtwo months that is constant. There is no past HA history. She claims that intermittently her visionhistory. She claims that intermittently her vision seems blurred but otherwise denies symptoms.seems blurred but otherwise denies symptoms. On exam: VSS; VA: 20/40. CN: diplopia on farOn exam: VSS; VA: 20/40. CN: diplopia on far lateral gaze bilaterally. Which of the following islateral gaze bilaterally. Which of the following is the most likely diagnosis.the most likely diagnosis. A.A. Occipital Lobe StrokeOccipital Lobe Stroke B.B. Pituitary AdenomaPituitary Adenoma C.C. Multiple SclerosisMultiple Sclerosis D.D. Myasthenia GravisMyasthenia Gravis E.E. Intracranial HypertensionIntracranial Hypertension
  • 58. Andy Jagoda, MD Idiopathic Intracranial HypertensionIdiopathic Intracranial Hypertension (Benign Intracranial(Benign Intracranial Hypertension, Pseudotumor Cerebri)Hypertension, Pseudotumor Cerebri) • Syndrome Defined By Signs And Symptoms OfSyndrome Defined By Signs And Symptoms Of High ICP Without Apparent Intracranial MassHigh ICP Without Apparent Intracranial Mass • 50% Have An Identifiable Underlying Etiology50% Have An Identifiable Underlying Etiology • Altered Absorption Of Csf At The Arachnoid VillusAltered Absorption Of Csf At The Arachnoid Villus • Alteration Due To Either:Alteration Due To Either: – Elevated Pressure Within The Sagittal SinusElevated Pressure Within The Sagittal Sinus – Increased Resistance To Drainage Of Csf Within TheIncreased Resistance To Drainage Of Csf Within The VillusVillus
  • 59. Andy Jagoda, MD Physical FindingsPhysical Findings • PapilledemaPapilledema • Visual disturbanceVisual disturbance 50 - 80%50 - 80% – Blindness inBlindness in 10%10% – Decreased visual acuityDecreased visual acuity 30%30% – Transient visual obscurationTransient visual obscuration 68%68% – Enlarged blind spotEnlarged blind spot – ScotomasScotomas – VI nerve palsy (false localizing)VI nerve palsy (false localizing) 38%38%
  • 60. Andy Jagoda, MD Case Scenario #5Case Scenario #5 A 20-year-old college student flips his car, hitting headA 20-year-old college student flips his car, hitting head on the dash. He arrives in the ED in full spinalon the dash. He arrives in the ED in full spinal immobilization. On exam he has 2/5 strength in hisimmobilization. On exam he has 2/5 strength in his wrists, 3/5 strength in his deltoids, 5/5 strength in hiswrists, 3/5 strength in his deltoids, 5/5 strength in his LE. He complains of numbness in his arms but is ableLE. He complains of numbness in his arms but is able to distinguish sharp from dull. DTRs intact. What isto distinguish sharp from dull. DTRs intact. What is your leading diagnosis?your leading diagnosis? A.A. Central Cord SyndromeCentral Cord Syndrome B.B. Anterior Cord SyndromeAnterior Cord Syndrome C.C. Spinal Epidural HemorrhageSpinal Epidural Hemorrhage D.D. Subdural HemorrhageSubdural Hemorrhage E.E. Brown - Sequard SyndromeBrown - Sequard Syndrome
  • 61. Andy Jagoda, MD Central Cord SyndromeCentral Cord Syndrome • Hyperextension injuries, tumor,Hyperextension injuries, tumor, syringomyeliasyringomyelia • MUDMUD • Paresis or plegia of arms > legsParesis or plegia of arms > legs • Posterior column sparedPosterior column spared
  • 62. Andy Jagoda, MD Central Cord SyndromeCentral Cord Syndrome • Sensation ue>le; sacral sparingSensation ue>le; sacral sparing • Perforating branches of anteriorPerforating branches of anterior spinal artery at greatest risk forspinal artery at greatest risk for vascular insultvascular insult • Good prognosisGood prognosis
  • 63. Andy Jagoda, MD Case Scenario #6Case Scenario #6 A 23-year-old female presents complaining of feelingA 23-year-old female presents complaining of feeling generally weak with the sensation that she isgenerally weak with the sensation that she is dragging her feet when she walks. On exam herdragging her feet when she walks. On exam her sensation is intact; motor strength is 5/5 in all majorsensation is intact; motor strength is 5/5 in all major muscle groups; deep tendon reflexes are 2/2 in themuscle groups; deep tendon reflexes are 2/2 in the UE, 2/2 at the knees, and and 0/2 at the ankles. WhatUE, 2/2 at the knees, and and 0/2 at the ankles. What is your major concern?is your major concern? A.A. Spinal StenosisSpinal Stenosis B.B. Conus MedularisConus Medularis C.C. Guillian BarreGuillian Barre D.D. Polymyalgia RheumaticaPolymyalgia Rheumatica E.E. Myasthenia GravisMyasthenia Gravis
  • 64. Andy Jagoda, MD Guillain-BarreGuillain-Barre • Acute polyneuropathyAcute polyneuropathy • Symmetric ascending weaknessSymmetric ascending weakness • Arrflexia (LMN)Arrflexia (LMN) • No meningeal signs, fever, signs ofNo meningeal signs, fever, signs of systemic illnesssystemic illness • CSF: increased protein withoutCSF: increased protein without pleocytosispleocytosis
  • 65. Andy Jagoda, MD Case Scenario #7Case Scenario #7 A 30-year-old male with AIDS complains of diffuseA 30-year-old male with AIDS complains of diffuse weakness that is progressive in the LE associated withweakness that is progressive in the LE associated with paresthesias; there is no back pain. On exam he has 4/5paresthesias; there is no back pain. On exam he has 4/5 upper extremity strength, 2/5 lower extremity strength;upper extremity strength, 2/5 lower extremity strength; DTRs are 2/2 in the UE and 4/2 in the LE. His plantarDTRs are 2/2 in the UE and 4/2 in the LE. His plantar reflexes are upgoing upgoing bilaterally.reflexes are upgoing upgoing bilaterally. Which of the following is the most likely diagnosis?Which of the following is the most likely diagnosis? A.A. MyelopathyMyelopathy B.B. NeuropathyNeuropathy C.C. MyopathyMyopathy D.D. Neuromuscular Junction DiseaseNeuromuscular Junction Disease E.E. RadiculopathyRadiculopathy
  • 66. Andy Jagoda, MD HTLV-1 Associated MyelopathyHTLV-1 Associated Myelopathy • Progressive lower extremity weaknessProgressive lower extremity weakness (arms more than legs)(arms more than legs) • SpasticitySpasticity • Paresthesias are common; sensoryParesthesias are common; sensory deficits are raredeficits are rare • Symmetric upper motor neuronSymmetric upper motor neuron paraparesisparaparesis • Sphincter disturbancesSphincter disturbances

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