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

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Commonmisinterpretsymptoms

• PalalysisVSnumbness

• DizzinessVSweaknessVSFa4gueVSataxia

• DysphasiaVSdysarthria

• BlurvisionVSDiplopia

• Blackout:lossofconsciousnessVSlossofvisionVSsimpleconfusion

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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

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Syndromeapproach‐2

• Spinalcordsyndrome– Transversecordsyndrome(complete,incomplete)

– Hemicordsyndrome

– Anteriorcordsyndrome

– Posteriorcordsyndrome

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• Cerecellarsyndrome‐ Pancerebellarsyndrome

‐ Hemicerebellarsyndrome

‐ Cerebellarvermissyndrome

Example

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PaQentHistory

Symptomatology

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Difficulttoopenhiseye

Symptomatology

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Doublevision“Diplopia”

Symptomatology:Eyeliddisorder

• Lidabnormali4espresentsas–Ptosis–Lidretrac4on–Insufficienteyelidclosure–Excessiveeyelidclosure

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Ptosis

WeaknessofLevatorpalpebrae

muscle

Excessiveeyelidclosure

Mullermuscle:Horner’ssyndrome

•Blephalospasm•Hemifacialspasm

Contrac4onofobicularisoculi

muscle

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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

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Druginducedblephalospasmanddyskinesia

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Superior tarsal muscle

(also known as

Müller's muscle)

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Awomanpresentwithdoublevision

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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

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32

EyeexaminaQon

33BilateralponQneinfarcQon

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Awomancomplainsslowprogressivediplopia,gaitdifficultyfor2weeks

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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

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Gaitabnormality

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AtaxiaGait

disturbance =

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Tandemwalk

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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

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PhysicalExaminaQon

“Confirmthethough,explorethenext”

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NeurologicalexaminaQon• Screening(general)neurologicalexaminaQon– Exameverypath:thetestsaremoresensi4ve

• Specific(focused)neurologicalexaminaQon– Examthedetailofabnormalneurologicalsignsorsymptomsrelevanttothehistoryandscreeningexam.

– thetestsaremorespecific

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Recordtheneurologicalsigns

• PresenceVSAbsence

• HardsignsVSSonsigns

• NormalVSabnormal• Lateralizingsign:

• TrueVSfalselocalizingsign

• Normalvaria4on

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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

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• Avoidmisinterpretsign• Misinterpretthenormalvaria4on• Confirmtheequivocalsign• Awarethesonsign• Awarethefalselocalizingsign

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Amanpresentedwithshakinghead

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Anoldwomanpresentwithabnormalhandmovement

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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

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Problemlist

“ReviewofpaQentspecificfeature”

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ListofproblemsIntegrateofHistoryandPE

• First:anatomicallocaliza4onoflesionorneurologysystem–Focal,Mul4‐focal,Diffuse–Nuclear,tract,systemdisorder–CNS,PNS,Boths

DifferenQaldiagnosisDiscussioneachproblemlist

• 1)

• 2)

• 3)

• 4)

• 5)

DifferenQaldiagnosis

“Rankofthepossibledisease”

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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.

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