The Very First Top Ten List Letterman's "Top Ten List" made its debut on September 18, 1985, with a ranking of "Things That Almost Rhyme With Peas." There were thousands of funnier ones to come, but Dave rightly defended that seminal list as "solid network programming material" and continued offering up his nightly Top Ten until the final "Late Show" 30 years later. Photo by NBC/Getty Images
Start video at 3:26.
Here Bill Murray and Harold Ramis start in 1984’s ghostbusters, and they both present with lateral gaze. Bill is having a stroke whereas Harold is having a seizure. Which side are they coming from?
Hint: Look at the lesion!
Two forms of neurological badness: Global inattention (delirium) Up to 80% of mechanically ventilated patients 10% increase in mortality per day (Shehabi) Structral inattention Measuring Attention: MOTYB (83% sens/91% spec for CAM+; Gusmao-Flores CCM 2012; O’Regan Neuropsych 2014; Hodgkinson 1972) 20->1 in 30 seconds (AMTSE; Hodgkinson 1972) Spelling DLROW or counting from 100 by 7s (MMSE; Folstein 1983)
You’ve just seen a run of patients with psychiatric disorders when this man shows up. His neighbor called because he was outside without a coat on a very cold day. You begin talking to him…
This is fluent aphasia or so-called Wernicke’s aphasia. This results from a relatively focal lesion and may have few if any associated signs. Patients may be anxious or agitated because no one understands them and they may have fast speech as a result mimicking bipolar mania.
Look for ANY mild hemiparesis – have patients turn their heads when you do drift testing. Check a Babinski. Usually they CANNOT repeat or name, whereas psychiatric patients may cooperate briefly. And look to history.
A 60 y/o man arrives with a few days of progressive, symmetric leg weakness; he hasn’t had much pain except some nagging low back pain from the past several years. Reflexes are diminished…
There are two major concerns: Cauda equine syndrome – ischemic, traumatic, spontaneous Guillain Barre
Neither situation is particularly good. You have a decision to make – is the nerve or the cord? History can be helpful, obviously but in the absence of decent history: Check rectal tone Check pulses Check breathing
48 y/o man found down s/p initial operative decompression. He was extubated and doing well on POD4 when I met him. On exam, he was following simple commands with minimal verbal output and had intact cranial nerves; I felt his flap and it was very full, approaching tense; the JP drain had been removed the day before. That evening, he became sonorous and pupils dilated. His flap became extraordinarily tense and he was intubated, taken to CT with the following image, thought to be related to a bleeding middle meningeal artery.
Complications after hemicraniectomy are common (Stiver 2009). Drain outputs can also be helpful.
68 y/o man with cardiac risk factors who was found down with bilateral weakness and a dysconjugate gaze. CT demonstrated L cerebellar infarct occluded the left foramen of Luschke and creating obstructive hydrocephalus. His exam demonstrated “withdrawal in BLE” but that’s not good enough. Increasing spasticity is a clear indicator that something is compressing those corticospinal tracts above the upper motor neuron and the only way that happens bilaterally is anterior spinal cord or – in someone with known pathology – increase massing effect on the midbrain or in the ventricular system.
Pick up your patients’ legs in the bed – its easy and important to follow!
*coronal image is not from this patient
Downward gaze and skew deviation: Sunsetting sign comes from tectal pressure which you can see from progressive hydrocephalus Vertical skew comes from tegmental pressure which you might get from brainstem stroke
Half of patients deteriorate in a median of 4.5 days in those with BIFRONTAL CONTUSIONS (Peterson 2011). Highest risk in those with > 10 cm^3 in each frontal lobe.
Clinical scenario: small R ICH on CT, admitted to the ICH for observation somewhat sleepy with mild L hemiparesis. RN notes shivering; on admission, he had not had signs of infection and the RN checks his temperature which is normal.
Shivering in a patient with coma is not well reported; we normally think of shivering during TTM or as rigors during sepsis. Ipsilateral shivering has been described in relation to contralateral cerebral peduncle (central herniation) and normothermic shivering without piloerection are thought to be due to injury of the reticulospinal tract (Wijdicks JAMA 2009).
Example shows expanding ICH lesion of the type that might cause midbrain destruction, peduncular compression, and compression of the reticulospinal tract
Signs of neurological badness
Brandon foreman md
Signs of Herniation or Increasing
Mass Effect warranting ICP
Changes in pupillary exam
Extensor Posturing or No Motor Response
Decrease of > 2 in GCS
*Neurological badness is defined broadly as any
of the following in the absence of reasonable
• Decline in the total GCS ≥ 2 or motor GCS ≥ 1 (Fan
2013, Morris 1998)
• Decline in the NIHSS > 2 (Kwan 2006)
• New focal neurological deficit lasting > 1 hour
>Top 10 Signs of neurological badness
10. Lateral Gaze