Neurologic Localization for M3s. Kevin Chan Teo Ting Wei Edited from Dr Eugene Gan s slides (Batch of 2016)
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1 Neurologic Localization for M3s Kevin Chan Teo Ting Wei Edited from Dr Eugene Gan s slides (Batch of 2016)
2 #1: Where is the lesion?
3 Where Upper/ Lower Symmetrical/ Asymmetrical Unilateral/ Bilateral Sensory Hallmarks Cortex Subcortical Brainstem Spinal Cord Anterior Horn Cell Plexus, Roots Peripheral nerves NMJ Muscles
4 Where Upper/ Lower Symmetrical/ Asymmetrical Unilateral/ Bilateral Sensory Hallmarks Cortex Upper Asymmetrical Unilateral +/- Crossed Cortical Signs Subcortical Upper Asymmetrical Unilateral +/- Lacunar Syndromes Brainstem Upper Asymmetrical Unilateral +/- Crossed Hemiparesis Spinal Cord Upper Symmetrical Bilateral - (SS lvl) Anterior Horn Cell Plexus, Roots Peripheral nerves Mixed Symmetrical Bilateral/ Unilateral Cord syndromes, ARU + Fasciculations, CNs affected Lower Asymmetrical Unilateral - Dependent on levels affected Lower Symmetrical Bilateral +/- Length-dep distal weakness NMJ Lower Symmetrical Bilateral + Prox weakness, fluctuating fatig Muscles Lower Symmetrical Bilateral + Prox weakness, check CN
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19 General Inspection (chronicity) UMN lesion LMN lesion Mixed lesion Minimal wasting, unless chronic Wasting, contractures Tone /- Reflexes /- Wasting, contractures, fasciculations Plantars Power Up-going plantars Clonus UL: flexors > extensors LL: extensors > flexors Down-going plantars +/- Dependent on site of lesion Globally reduced
20 #2: What is the etiology?
21 Differential Diagnoses (supporting risk factors) Sudden onset Vascular (stroke) Trauma Epilepsy (Todd s paralysis) Subacute onset Infection (TB abscess, meningitis) Inflammation (lupus, MS) Gradual onset Degeneration (PD) Demyelination (MS) SOL (hydrocephalus, neoplasm) Variable onset Metabolic (hypoglycemia great mimicker of neuro conditions) Toxic/paraneoplastic
22 Now, back to basics
23 Reflexes 1. Afferent (Sensory) 2. Efferent (AHC + Peripheral nerve) 3. Modulation (UMN)
24 Examples of Reflex Arcs Spinal -Biceps & Brachioradialis (C5-6) -Triceps (C7-8) -Hoffman s (C8) -Cremasteric Reflex (L1) -Knee Jerk (L3-4) -Babinski, Ankle Jerk (S1) -Anal Sphinctor Tone (S2-S4) Cranial -Pupilliary Light Reflex (CN II-III) -Corneal Reflex (CN V1 VII) -Jaw Jerk Reflex (CN V3 V3) -Gag Reflex (CN IX-X)
25 Teaching points about reflexes 1)An hyper-reflexic jerk (Nuclear) should prompt you to think upwards (Supra-nuclear) 2) A hypo-reflexic jerk should prompt you to think of - Afferent - Efferent
26 The neuro limbs exam 1. Inspection 2. Tone Hyper Normal Hypo 3. Reflexes Hyper Normal Hypo/Absent 4. Power Proximal vs Distal vs Other patterns 5. Sensation Pattern of loss (Glove and stocking vs Dermatomal vs Nerve Distribution) Modalities lost Pain + Temperature Fine Touch + Vibration 6. Cerebellar Involved/uninvolved
27 Important features of weakness 1. UMN vs LMN UMN: Spinal cord and above LMN: AHC and below 2. Proximal vs Distal Proximal: Myopathy, NMJ or MND Distal: Wide range of differentials. MND and myotonia dystrophica may present with distal weakness. 3. Unilateral vs Bilateral Unilateral: Peripheral nerve/plexus compression, spinal cord, strokes Bilateral: Myopathies, NMJ, MND, Cord syndromes, Cord transections 4. Sensory involvement If sensory involved, unlikely to be myopathy/nmj Glove and stocking: Peripheral neuropathy, cervical myelopathy Peripheral nerve distribution: nerve compression, mononeuropathy, mononeuritis multiplex Dermatomal: Radiculopathy 5. Specific distinguishing features Muscular pain/skin involvement points to myositis Fatigability and ocular involvement suggests MG 6. Misc. GBS can present with almost any pattern of LMN weakness, with or without sensory involvement
28 Weakness Bilateral upper motor neuron weakness with sensory level at L2 With a history of RTA? With signs of raised ICP? In an immunocompromised patient with fever? In a known cancer patient with back pain?
29 Weakness Weakness of left lower limb, power 5/5 on hip flexion and extension. Power 5/5 on knee flexion and extension. Power 3/5 on ankle dorsiflexion and 5/5 on plantarflexion. Knee jerk reflex 2+, ankle jerk 2+, plantar reflex downgoing. Sensory loss of pain and temperature to lateral aspect of leg and dorsum of foot Translation: Unilateral distal weakness with sensory loss Upper limb examination normal Likely levels Peripheral Nerve Common peroneal nerve Radiculopathy L4-L5 Plexus? How to differentiate? Hip Abduction
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31 Weakness Weakness of both lower limbs, power 3/5 on hip flexion and extension. Power 3/5 on knee flexion and extension. Power 4+/5 on ankle dorsiflexion and plantarflexion. Knee jerk reflex 1+, ankle jerk 2+, plantar reflex downgoing. No sensory loss of pain/temperature or vibration/proprioception Translation: Bilateral proximal weakness with hyporeflexia and no sensory loss (LMN proximal weakness, no sensory involvement) Similar upper limb pattern of weakness Likely levels Muscle NMJ
32 Weakness Bilateral proximal weakness with hyporeflexia and no sensory loss (LMN proximal weakness, no sensory involvement) In a 15 year old boy with a family history? In a 40 year old woman with a rash? In a 65 year old man with diplopia and whose weakness is worse at night? In a 70 year old man taking statins with muscle pain?
33 Weakness Weakness of both lower limbs, power 5/5 on hip flexion and extension. Power 5/5 on knee flexion and extension. Power 4/5 on ankle dorsiflexion and plantarflexion. Power 3+/5 on big toe extension. Knee jerk reflex 1+, ankle jerk 1+, plantar reflex absent. Sensory loss of pain and temperature in dorsal and plantar aspects of the feet. Similar findings in the upper limb Translation: Bilateral distal weakness with hyporeflexia and sensory loss involving both upper and lower limbs (LMN distal weakness with sensory involvment) Likely level Peripheral nerve (peripheral neuropathy)
34 Differentials for peripheral neuropathies Alcohol, AIDP B12 CIDP, carcinoma Diabetes, drugs Familial (HMSN, CMT)
35 The neuro cranial nerves exam 1. Smell 2. Pupils (CN 2 afferent, CN 3 efferent) Big/Small Reactive/Nonreactive 3. Visual Field (Somewhat cortical) Complete monocular blindness Bitemporal hemianopia Homonymous hemianopia (more vs less congruent) Homonymous hemianopia with macular sparing 4. EOMs (CN 3, 4 and 6) Simple vs Complex ophthalmoplegia Medical vs surgical third nerve 5. Sensation (CN V) Intact vs lost 6. Hearing (CN 8) Rinee and Webers 7. Motor (CN V 3, 7, 10, 11, 12) CN 7 UMN vs LMN
36 4 Cranial Nerve Rules 1. All cranial nerves except CN 1 and 2 arise from the brainstem 3, 4 from midbrain 5, 6, 7, 8 from pons 9, 10, 11, 12 from medulla 2. Cranial nerves group at several locations 3. Cranial nerves are in contact with the meninges and skull base CN 6 is particularly affected by meningitis, NPC and raised ICP due to its long intracranial course 4. Cranial nerves behave as peripheral nerves and are thus affected in peripheral neuropathies Most peripheral neuropathies affect limbs, but GBS/MFS can affect cranial nerves first
37 Approach Unilateral vs Bilateral UMN vs LMN 7 Isolated vs group vs random Long tract signs
38 Cranial nerve groups Cavernous sinus: 3, 4, V 1, 6 (sometimes V 2 ) Orbital apex: Cavernous sinus + CN 2 Cerebello-pontine angle: 5, 6, 7, 8 (Vestibular schwannoma/meningiomas) Jugular foramen: 9, 10, 11, 12
39 Cranial Nerve Innervation Besides Facial Nerve (lower half of motor nucleus) and Hypoglossal nerve, all other cranial nerve nuclei have bilateral innervation.
40 DDx for eye movement problems Isolated 3 Medical: Usually DM Surgical: Usually PCA aneurysm Isolated 4 Usually congenital, unmasked when the squint decompensates Isolated 6 Usually DM, but look for skull base, cavernous sinus, meningeal and ICP causes first Complex ophthalmoplegia Consider MG and thyroid eye disease among other ddx
41 Tips CN 3 carries parasympathetic fibres on the outside, leading to a blown pupil when compressed but a normal pupil when ischemic (surgical vs medical 3 rd ) CN 6 has a long intracranial course and is compressed by raised ICP
42 Visual Fields
43 Brainstem rules of 4 4 Medial structures Medial lemniscus (DCML) Motor pathway (pyramidal pathway) Motor nuclei of 3, 4, 6 and 12 Medial Longitduinal Fasciculus (MLF) 4 Side structures Spinothalamic Sensory nucleus of 5 Sympathetic nerves Spinocerebellar tract
44 Misc. Radiation to the neck for NPC is a cause for cranial neuropathies, especially bilateral cranial neuropathies. Consider it when the deficits fit individual nerves but don t localise well anatomically
45 Eye movements
46 Eyes
47 Eyes 6 th nerve palsy Recent onset with early morning headache and vomiting? Tinnitus, sensorineural hearing loss and vertiginous giddiness? With contralateral limb weakness?
48 Eyes
49 Eye Complete left sided eye paralysis (3, 4, 6) with? Failure of depression of right eye With numbness over left side of face? Patient is NPL?
50 Eye
51 Eye 3rd nerve palsy With a longstanding history of DM and a normal pupil? With a blown pupil? With contralateral hemiplegia?
52 Cortical signs Dominant Cortex Language (Aphasia) Apraxia Gerstmann Syndrome (Dominant inferior parietal lobe) Writing (Dysgraphia) Calculation (Dyscalculia) Finger agnosia Left-right disorientation Nondominant Cortex Neglect Dressing (Dressing Apraxia) Construction/Drawing (Constructional Apraxia) Stereognosis Frontal Lobe Personality changes Failure to plan Contralateral gaze preference Primitive reflexes Disinhibition
53 Sensory System
54 Sensory System
55 Sensory System
56 Important features of numbness 1. If there is weakness, approach as a weak patient with sensory symptoms 2. Modalities affected Different modalities between limbs: Brown Sequard Dorsal columnar loss: bear in mind SCDC and syphilis 3. Distribution of loss 4. Symmetry of loss Peripheral neuropathies tend to be more symmetrical
57 Constellations Pattern Distal Nerve distribution Nerve distribution Limbs - Upper Both Ddx 1. Peripheral Neuropathy (Sensory PN, Pure SFSN etc.) 2. Cervical myelopathy 3. SCDC 4. Demyelinating diseases 1. Median/Radial/Ul nar neuropathy 2.? Brachial Plexopathy 1. Mononeuritis multiplex 2. Sensory neuronopathy
58 Constellations Pattern Dermatomal Dermatomal Limbs Upper Lower Ddx 1. Cervical radiculopathy 2. Cervical myelopathy 1. Acute Myelopathies 2. Cord transection/transverse myelitis
59 Case 1 Mr Darren Tan
60 Stem Mr Darren Tan is a 62 year old gentleman who presents with a 3 week history of leg weakness. Please examine the patient s lower limbs.
61 Physical examination: Inspection Patient appears alert and comfortable at rest No signs of muscle wasting, muscle bulk in both legs appears symmetrical No fasciculations
62 Physical examination: Tone Increased tone bilaterally Presence of clonus bilaterally
63 Physical examination: Reflexes Bilateral brisk knee-jerk reflexes Bilateral brisk ankle-jerk reflexes Bilateral upgoing plantar reflexes
64 Physical examination: Power R+L Hip flexion 2/5 R+L Hip extension 2/5 R+L Knee flexion 2/5 R+L Knee extension 2/5 R+L Ankle dorsiflexion 2/5 R+L Ankle plantarflexion 2/5 R+L Big toe extension 2/5 R+L Big toe flexion 2/5
65 Physical examination: Sensation Widespread loss of pin-prick, fine touch and vibration sensation below the hips Loss of proprioception bilaterally
66 Physical Examination: Summary Bilateral increased tone and clonus Bilateral brisk knee-jerk, ankle-jerk reflexes and upgoing plantar reflexes Bilateral weakness of all lower limb muscles with power of 2/5 Bilateral loss of pain, fine touch, vibration and proprioception
67 Gait + UL Examination Unable to ambulate Absence of pronator drift Biceps reflex normal Triceps reflex normal Brachioradialis reflex normal Shoulder abduction 5/5 Finger flexion 5/5 Finger abduction 5/5 Gross sensation intact
68 Where is the lesion? Cortex? Subcortex? Brainstem? Spinal cord? Anterior Horn Cell? Plexus? Peripheral nerves? Neuromuscular junction? Muscles?
69 Spinal Cord!!!!!! Lesion likely between T1 L1 Complete examination by requesting to perform abdominal reflexes, digital rectal examination.
70 Case 2 Mr Ming Shan
71 Stem Mr Ming Shan is a 40 year old male who presents with weakness of the arms. Please examine the patient s upper limbs.
72 Physical examination: Inspection Patient appears alert and comfortable at rest No signs of muscle wasting, muscle bulk in both legs appears symmetrical No fasciculations
73 Physical examination: Tone Pronator drift present Normal tone bilaterally, no spasticity/rigidity
74 Physical examination: Reflexes Biceps reflex normal Triceps reflex normal Brachioradialis reflex normal
75 Physical examination: Power R Shoulder abduction 3/5 L Shoulder abduction 4/5 R+L Shoulder adduction 5/5 R+L Elbow flexion 4/5 R+L Elbow extension 5/5 R+L Wrist flexion 5/5 R+L Wrist extension 5/5 R+L Finger flexion 5/5 R+L Finger abduction 5/5
76 Physical examination: Sensation Normal pin-prick, fine touch, vibration and proprioception sensation
77 Physical Examination: Summary Normal tone, reflexes, sensation R Shoulder abduction 3/5 L Shoulder abduction 4/5 R+L Shoulder adduction 5/5 R+L Elbow flexion 4/5
78 Cerebellar + Cranial Nerve + LL Examination Dysmetria? PEARL Presence of diplopia in all gaze-directions Patient unable to give a wide smile LL reflexes all normal 3/5 weakness in hip flexion, knee extension Gross sensation of LL intact
79 Where is the lesion? Cortex? Subcortex? Brainstem? Spinal cord? Anterior Horn Cell? Plexus? Peripheral nerves? Neuromuscular junction? Muscles?
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81 Characteristics of MG Weakness in muscles is more marked in the evening. Muscle weakness which increases with exercises and is painless Associated with other autoimmune conditions such as thyrotoxicosis, diabetes mellitus, rheumatoid arthritis etc. Can sometimes be caused by D- penicillamine
82 Unilateral ptosis Myasthenia gravis Horner s syndrome Lung apex (pancoast tumour) Neck (carotid artery dissection) T1 pathology Lateral medullary/pontine syndrome CN III palsy Single nerve lesion Cavernous sinus / superior orbital fissure / orbital apex syndrome Midbrain lesions Myotonic dystrophy Congenital
83 Bilateral ptosis Myasthenia gravis CN III nuclear lesions Myotonic dystrophy Congenital
84 Case 3
85 STEM This is your pediatrics short-case station. Jennifer, 15y/o Chinese adolescent, has had multiple hospital admissions for urinary tract infections. Please perform a neurological examination of her lower limbs.
86 Physical Examination: Inspection Cheerful, alert and comfortable No signs of dysmorphism, appropriate growth No physical abnormalities Left BKA, Right AFO No fasciculations noted Customized motorized wheelchair by bedside
87 Physical Examination: Tone Decreased tone; floppiness
88 Physical Examination: Reflexes Absent knee-jerk reflex Absent ankle-jerk reflex Down-going plantars
89 Physical Examination: Power Bilateral hip extension: 0/5 Bilateral hip flexion: 5/5 Bilateral knee extension: 0/5 Bilateral knee flexion: 0/5 Right ankle dorsiflexion: 0/5 Right ankle plantarflexion: 0/5 Right big toe extension: 0/5 Right big toe flexion: 0/5
90 Physical Examination: Sensation Intact sensation of all modalities when tested over bilateral mid-thighs Loss of sensation of all modalities when tested over bilateral medial knees, right medial malleolus, right interdigital web-space of big and second toe and right lateral sole of foot
91 Physical Examination: Summary Left BKA, Right AFO Decreased tone; floppiness Absent knee-jerk and ankle-jerk reflexes, down-going plantars Bilateral weakness of all LL muscles from knee distally + hip extension with power of 0/5 Bilateral loss of sensation of all modalities from medial knees distally
92 Physical Examination: Back & Abdomen Midline scar Oblique scar along left flank No vertebral abnormalities No pressure sores
93 Physical Examination: Others Upper limbs? Cerebellar examination? Cranial nerves? Head examination? Developmental assessment?
94 Case 4
95 STEM This is your IM short-case station. Mr Chander, 45y/o Chinese, presents to the A&E with complaint of difficulty eating. Please perform a cranial nerve examination.
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97 Physical Examination: Inspection Alert and comfortable, communicable Vitals stable Presence of left facial droop with loss of left nasolabial fold and smoothening of left forehead creases
98 Physical Examination: CN V, VII, VIII Facial sensation fully intact Inability to raise left eyebrow, inability to bury left eyelashes, drooping of left angle of mouth when asked to smile, asymmetrical appearance when asked to puff up cheeks Hearing intact
99 Physical Examination: CN I, II, III, IV, VI PEARL (direct and consensual) Full extra-ocular movements, no RAPD
100 Physical Examination: CN IX, X, XI, XII No dysarthria/dysphonia, uvula central No tongue deviation Power of SCM and trapezius full
101 Physical Examination: Summary Presence of left facial droop with loss of left nasolabial fold and smoothening of left forehead creases Inability to raise left eyebrow, inability to bury left eyelashes, drooping of left angle of mouth when asked to smile, asymmetrical appearance when asked to puff up cheeks Other CN intact
102 Physical Examination: Others Upper limbs? Lower limbs? Head and neck examination? Acoustic reflex? Taste and oral examination? Assessing complications?
103 Review: Approach to CN palsies CN pathologies can happen in: Isolated Together as a group (rules of 4) No pattern Together with signs in UL and LL
104 Rules of 4 Level of brainstem Midbrain/diencephalon Pons Medulla Cranial nerves I, II, III, IV V, VI, VII, VIII IX, X, XI, XII Cranial nerves involved III, IV, V1, V2 III, IV, V1, VI Pathology/lesion Cavernous Sinus Syndrome Superior Orbital Fissure Syndrome V, VII, VIII, cerebellum Cerebellopontine angle lesion IX, X, XI, XII Lesions in the posterior fossa
105 Review: Approach to CNVII
106 Review: Approach to CNVII Intracranial (intratemporal vs extratemporal) vs extracranial 5 P s (pons, posterior fossa, petrous bone, parotid, peripheries)
107 Case 5
108 STEM This is your IM short-case station. Mr Lim was brought to the A&E by NH staff for?weakness. He has background dementia with BPSD and is uncommunicative. Please perform a neurological examination of his lower limbs
109 Physical Examination: Inspection Resting in bed, comfortable, smiling inappropriately, stable vitals Symmetrical; no fasciculations
110 Physical Examination: Tone Increased tone/rigidity over right lower limb with presence of clonus Normal tone of left lower limb
111 Physical Examination: Reflexes Brisk knee-jerk and ankle-jerk reflexes and upgoing plantars for right lower limb Normal reflexes and down-going plantars for left lower limb
112 Physical Examination: Power Right/left hip extension 3/5; 5/5 Right/left hip flexion 3/5; 5/5 Right/left knee extension 3/5; 5/5 Right/left knee flexion 3/5; 5/5 Right/left ankle dorsiflexion 3/5; 5/5 Right/left ankle plantarflexion 3/5; 5/5 Right/left big toe extension 3/5; 5/5 Right/left big toe flexion 3/5; 5/5
113 Physical Examination: Sensation Intact sensation of all modalities of lower limbs
114 Physical Examination: Cerebellum Heel-shin test positive Patient not keen to ambulate
115 Physical Examination: Summary Increased tone/rigidity over right lower limb with presence of clonus Brisk knee-jerk and ankle-jerk reflexes and upgoing plantars for right lower limb Diminished power of 3/5 of right lower limb Intact sensation of all modalities of both LLs
116 Physical Examination: Others Upper limbs? Cranial nerves? Cardiovascular examination?
117 Discussion What if he presented with headache, nausea and vomiting with weakness? What if he presented with right-sided facial weakness with left-sided hemiparesis? What if he presented with right-sided hemiparesis and expressive aphasia?
118 #1: Where is the lesion?
119 Where Upper/ Lower Symmetrical/ Asymmetrical Unilateral/ Bilateral Sensory Hallmarks Cortex Upper Asymmetrical Unilateral +/- Crossed Cortical Signs Subcortical Upper Asymmetrical Unilateral +/- Lacunar Syndromes Brainstem Upper Asymmetrical Unilateral +/- Crossed Hemiparesis Spinal Cord Upper Symmetrical Bilateral - (SS lvl) Anterior Horn Cell Plexus, Roots Peripheral nerves Mixed Symmetrical Bilateral/ Unilateral Cord syndromes, ARU + Fasciculations, CNs affected Lower Asymmetrical Unilateral - Dependent on levels affected Lower Symmetrical Bilateral +/- Length-dep distal weakness NMJ Lower Symmetrical Bilateral + Prox weakness, fluctuating fatig Muscles Lower Symmetrical Bilateral + Prox weakness, check CN
120 #2: What is the etiology?
121 Differential Diagnoses (supporting risk factors) Sudden onset Vascular (stroke) Trauma Epilepsy (Todd s paralysis) Subacute onset Infection (TB abscess, meningitis) Inflammation (lupus, MS) Gradual onset Degeneration (PD) Demyelination (MS) SOL (hydrocephalus, neoplasm) Variable onset Metabolic (hypoglycemia great mimicker of neuro conditions) Toxic/paraneoplastic
122 #3: What are the complications?
123 Complications Medical Contractures, neuropathic ulcers Complications of prolonged immobilization Functional Body function, activity, participation Social Patient, family, community Psychological Depression, mania Financial
124 Neuro Approaches Approach to weakness/numbness Approach to hemiparesis Approach to spastic/flaccid paraparesis Approach to foot drop Approach to CN lesions Approach to ophthalmoplegia Approach to ptosis Approach to movement disorders
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