LOCALIZATION NEUROLOGY EPISODE VI HEARING LOSS AND GAIT ATAXIA
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1 LOCALIZATION NEUROLOGY EPISODE VI HEARING LOSS AND GAIT ATAXIA
2 EPISODE VI HEARING LOSS APPROACH and DIAGNOSIS 2
3 Cochlea and Auditory nerve Pons (superior olive) lateral lemniscus Inferior colliculus Thalamus (median geniculate body) Auditory cortex 3
4 TUNNING FORK TEST RINNE S Test and WEBBER S Test Rinne s test: Air Conduction > Bone Conduction = normal or SNHL Bone Conduction > Air Conduction = CHL or dead ear Webber s test: in CHL heard loudest in the affected ear In SNHL heard louder in the unaffected ear
5 CAUSE of HEARING LOSS Acoustic Trauma (Noise) Age related Genetic Ototoxic Drugs: aminoglycoside, furosemide Infection: VDRL Illness (examples) Autoimmune Disease Meniere s Syndrome Acoustic Neuromas 5
6 DIPOLPIA Supranuclear Infranuclear Long tract sign INO 1 1/2 Extraaxial Exclude NMJ, muscle Intraaxial group Ungroup Foramen syndrome Subarachnoidal space
7 SNHL Intrinsic Unilateral long tract signs Extrinsic Exclude NMJ, muscle Bilateral Bilateral CN8 bilateral lesion IMPOSSIBLE Ungroup EXACTLY Pontine lesion Subarachnoid space CN8 lesion Group: foramen syndrome Ungroup: subarchnoid space or base of skull Isolated CN8 : vestibular neuritis, Meniere s disease
8 EPISODE VI ATAXIAS APPROACH and DIAGNOSIS 8
9 Ataxia Approach 1. Weakness? 2. Sensory ataxia: failure of proprioceptive information to the CNS disorders of spinal cord or peripheral nerves can be compensated for by visual inputs 3. Vestibular: vestibular organ, brain stem lesion 4. Cerebellar: cerebella signs/acute or chronic
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12 Midline CerebellarLesion anterior and posterior parts of the vermis concerned with posture, locomotion, position of head relative to trunk, control of EOM s cerebellar signs resulting from midline cerebellar disease disorders of stance/gait truncal ataxia postural disturbances rotated postures of the head (titubation) disturbances of eye movements
13 Hemispheric CerebellarLesion cerebellar hemisphere and dentate nucleus on each side concerned with the planning of movement in connection with neurons in the Rolandicregion of the cerebral cortex (fine skilled) lesions result in abnormalities of skilled voluntary movements hypotonia, dysarthria, dysmetria, dysdiadochokinesia, excessive rebound (over shoot) and pendulum reflexes impaired check, kinetic and static tremors, past-pointing (dysmetria)
14 Cerebellar Signs Over shoot
15 CerebellarAtaxia acute Stroke or Transient ischemic attack (TIA) brain stem syndromes, cerebellar Multiple sclerosis (MS) Postviralinfection (cerebellitis) eg. Chickenpox uncommon complication, appear in healing stages of the infection and last for days or weeks, resolves completely Toxic reaction phenobarbital, benzodiazepines, alcohol, heavy metal (lead or mercury), solvent poisoning (paint thinner)
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17 CerebellarAtaxia chronic Cerebral palsy Arnild Chiari malformations: type I, II, III Paraneoplastic syndromes: Anti Yo rare, degenerative disorders triggered by immune response to tumor most commonly from lung, ovarian, breast or lymphatic Tumor: metastasis, hemangioma Degeneration: alcohol, phenytoin Genetic disease: SCA, EA
18 Autosomal Dominant Ataxias Spinocerebellar ataxias labeled 28 autosomaldominant ataxia genes (SCA1-SCA28) according to their order of discovery cerebellarataxia and cerebellardegeneration are common to all types, but other signs and symptoms-age of onset are differ depending on the specific gene mutation Episodic ataxia six types of ataxia that are episodic rather than progressive (EA1-EA6) all but the first two are rare. EA1 : brief ataxic episodes last seconds or minutes, triggered by stress, being startled or sudden movement, associated with muscle twitching EA2: longer episodes from 30 minutes to six hours, triggered by stress some cases symptoms resolve in later life, not shorten life span symptoms may respond to medication, such as acetazolamide(diamox) or phenytoin 18
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21 Repeats and autosomaldominant ataxias Anticipation repeat size expands during transmission, the larger the repeat size the earlier the age of onset and more severe symptoms
22 Spino-CerebellarAtaxia Type 3 (SCA 3) MJD Clinical features: Adult (after 40) onset gait ataxia, Parkinsonian signs, ophthalmoparesis or nystagmus, leg areflexia, Babinski signs, nystagmus, mild cerebellar tremors, diabetes Inheritance: Autosomal dominant About 40 % of dominant ataxias in one study Chromosome: 14q24.3-q32 Mutation: CAG repeat expansion in ATXN3 gene Testing: Gene testing available
23 Autosomal Recessive Ataxias Friedreich's ataxia: involves damage to cerebellum, spinal cord and peripheral nerves Progressive limb and gait ataxia usually beginning before 25 rate of disease progression varies (wheelchair within 15 years) axonal polyneropathy: absent DTR but BBK (+) muscles weaken, waste and deformities (pes clavus) slow-slurred speech fatigue death from cardiomyopathy and heart failure GAA trinucleotide repeat expansions in frataxin gene (9q13) Ataxia-telangiectasia Congenital cerebellar ataxia: type refers to ataxia that results from damage to the cerebellum that's present at birth Wilson's disease 23
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