LMCC Preparation Back to Basics

1. LMCC PreparationBack to Basics Neurology Dr. C.R. Skinner 14 April 2010

2. Major Topics • Neurology Made Simple Review • Headache • Trauma • Infections • Cerebrovascular Disease • Demyelination • Seizures • Degenerative Diseases • Sleep Disorders

3. Neurology Made SimpleQuestions • Is the Problem Neurological? • If So , Where Is It in the Nervous System ? • What Is the Most Likely Cause ? • Is This Problem Serious Enough to Require Urgent Referral ? • How to Stabilize the Patient During Transport

4. NEUROLOGY MADE SIMPLEIS THE PROBLEM NEUROLOGICAL? • Are there hard organic features ? • Is the behaviour bizarre ? • Is there a history of seizures, drugaddiction or of psychiatric illness ? • Do the signs and symptoms make sense ?

5. NEUROLOGY MADE SIMPLEINTRODUCTION • NEUROLOGICAL PROBLEM • WHERE IS THE LESION • WHAT IS THE CAUSE • INVESTIGATION • TREATMENT • PROGNOSIS

6. Localization Matrix

7. NEUROLOGY MADE SIMPLEINTRODUCTION • NEUROLOGICAL PROBLEM • WHERE IS THE LESION • WHAT IS THE CAUSE • INVESTIGATION • TREATMENT • PROGNOSIS

8. Etiology Matrix

9. NEUROLOGY MADE SIMPLEINVESTIGATIONS • History • Physical • According to presumed localizationand etiology • Metabolic systemic CSF • Structural • Neurophysiological

10. Time Sequence • When was the person last neurologically normal? • What was the speed of onset of the symptoms? • What was the state of the patient’s health in the last few days, weeks, months? • What medications is the patient taking and has there been any recent changes? • Are there any significant other medical or surgical problems?

11. ESSENTIAL HISTORICAL FEATURESHISTORY OF PRESENT ILLNESS • Headache • Loss Of Consciousness • Weakness • Difficulty With Vision , Hearing , Taste • Numbness • Weakness • Dizziness • Lightheadedness , Vertigo, Off balance • Fatigue • Loss Of Balance • Loss Of Coordination • Difficulty Swallowing, Chewing • Urinary And Stool Incontinence • Sexual Dysfunction • Sleep Difficulties

12. Etiology Matrix

14. NEUROLOGY MADE SIMPLELOCALIZATION ANALYSIS • Muscle • Neuromuscular junction • Peripheral nerve • Spinal cord • Brain stem • Thalamus or basal ganglia • Cortex • Cerebellum

15. Localization Matrix

16. Muscle

17. Neuromuscular Junction

18. Peripheral Nerves

25. Lateral Medullary Syndrome • Ipsilateral • Pain numbness, impaired sensation over half of face • Ataxia of limbs with falling towards side of lesion • Vertigo, nausea, vomiting • Horner’s syndrome • Contralateral • Impaired pain and temperature sensation over half of the body and some of the face

26. Lateral Pontine Syndrome • Ipsilateral • Horizontal, vertical nystagmus vertigo, nausea, vomiting, oscillopsia • Facial paralysis • Paralysis of conjugate gaze to side of lesion • Deafness, tinnitus • Ataxia • Impaired sensation over face • Contralateral • Impaired pain and thermal sense over half of body

27. Ventral Midbrain SyndromeWeber’s Syndrome • Ipsilateral • Diplopia, dilated pupil • Ataxia • Contralateral • Hemiplegia, mainly upper limb and face

28. CORRELATIVE FACTORSCAPSULE, THALAMUS AND BASAL GANGLIA • Hemi-sensory or motor signs • Sensory signs of primary modalities • Sensory involvement of the trunk • Lack of cortical signs • Uniform motor signs in arm ,leg and face • Hypertension risk factor

29. CORRELATIVE FACTORSCORTICAL • Aphasia and right sided weaknessfluent, non - fluent, paraphasia • Weakness - arm and face more than leg • Visual field defects • Cortical sensory disturbanceinattentionleft-rightacalculiaagnosiaapraxia

30. CerebellumBasal Ganglia • Modulating structures • Rule out other systems first • Ipsilateral Rule for pure cerebellar lesions

31. FINAL CHECKLISTTHINGS NOT TO MISS • MUSCLEPOLYMYOSITIS, POLYMYALGIA RHEUMATICA • NEUROMUSCULARMYASTHENIA • PERIPHERAL NERVEGUILLAIN - BARRE SYNDROME • SPINAL CORDACUTE SPINAL CORD COMPRESSION

32. FINAL CHECKLISTTHINGS NOT TO MISS • BRAIN STEM • STROKE, MULTIPLE SCLEROSIS • MENINGITISLISERIA, TB • GUILLAIN - BARRE - FISHER VARIANT • TUMORS

33. FINAL CHECKLISTTHINGS NOT TO MISS • CORTEX • STROKE • HERPES ENCEPHALTIS • SEIZURES • TUMORS • SUBARACHNOID HEMORRHAGE

34. Circulation of CSF Circulation du LCR

35. Case • This 20 year old man presents with a three day history of abnormal behaviour consisting of hallucinations, delusions of grandeur and memory loss for recent events. • He had been " up north " fishing just prior to the onset of these symptoms.

36. Case • Physical Exam • Fever 38.0 C • Inattentive • Poor short term memory • Left upper quadrantopsia • Hyperflexia Left upper and lower limb

37. Case 1 • Where is the lesion? • why? • What is the cause? • What are the immediate treatment priorities?

40. Herpes Simplex Encephalitis • Any time of year, any age, any sex • Selective infection of temporal lobes • New onset seizures or behaviour disturbance • Treat if you suspect - Acyclovir 30 mgm/kg-day

41. Herpes SimplexTreatment • Acyclovir IV • Management of ICP (max at 8 – 10 Days) • Head up • Hyperventilation • Mannitol • Hypertonic Saline • Seizure treatment

42. CASE 2 This 24 year old soldier was doing his early morning run with his regimental company. He developed an acute severe headache which caused him to stop and fall to the ground. On examination, he was alert, oriented, moving all four limbs with a normal neurological examination. Where is the lesion ?

43. CT Scan without contrast

44. Subarachoid Hemorrhage CT Scan Subarachnoid Blood

45. Subarachnoid Hemorrhage • Worse headache of life • Sudden onset, often with activity • Signs of meningeal irritation • Kernig, Brudzinski • Focal signs • Signs of coma • Positive CT scan • Positive LP

46. Subarachnoid Hemorrhage • Blood in subarachnoid space • Require urgent referral for angiogram • Use acetaminophen not ASA for headache

47. Subarachnoid HemorrhageInvestigations • CT Scan - 90 - 95% sensitive • LP - nearly 100% sensitive • rbc in CSF • xanthochromic in CSF after 12 – 18 hours • Angiogram • Treatment • surgical clipping • coiling

48. Subarachnoid HemorrhageTreatment • Clipping • Coiling

49. Giant Aneurysm

50. GDC Coil