Medicine: Clinical Neurology

a neurological examination involves::

• Mental Status

• Cranial Nerves

• Motor Examination

• Sensory Examinaton

• Coordination

• Gait

mental status involves:

• Level of consciousness/alertness

• Attention

• Memory

• Language

• Calculations and visuao-spatial tasks

what are some ways to test attention?

Serial sevens, digit span, “world” backwards

what does language involve?

fluency, comprehension, naming, repetition, reading, aphasia

what are types of memory?

• Recent vs. remote memory

• Anterograde vs. retrograde amnesia

what are types of aphasia?

• receptive (Wernicke’s) - temporal lobe

  • can’t understand

• expressive (Broca’s) - frontal lobe

• global

  • mix of both receptive and expressive

• conduction

  • comprehension intact but trouble with repetition

calculations and visu-spatial tasks involve:

– Simple calculations

– Right/left discrimination

– Finger indentification

– Reading/writing ability

– Copying shapes/geometric figures

– Gnosis

which lobe is responsible for calculations and visuo-spatial tasks?

parietal lobe

how can frontal lobe be tested?

• clock drawing test

• sequencing tasks

• set switching

• frontal release signs

what are frontal release signs?

exists in newborns and usually goes away but in pts with frontal lobe deficits, these reflexes may come back

• grasp

• paratonia (resistance in limbs)

• palmomental (twitch on palm)

• glabellar (unable to suppress blink reflex)

what is the clinical relevance of CN I (olfactory)?

– Head/Facial Trauma

– Frontal lobe masses

– Parkinson’s Disease (loss of smell can be first sign)

– Epilepsy

t/f: when testing CN I, it is important to use pleasant smells because noxious odors can stimulate the trigeminal nerve.

true

what are monocular visual defects?

• primary ocular disease (retinal disease, glaucoma)

• anterior to optic chiasm

what are binocular visual defects?

• optic chiasm

• posterior to optic chiasm

• occipital cortex

when performing a pupillary light reflex exam, what 2 things should we look for?

• direct

• consensual

an optic nerve lesion leads to loss of direct and consensual responses

CN III (oculomotor) is located where?

midbrain

eyelid opening is controlled by what muscle?

levator palpebrae

extrinsic deficit of the oculomotor n CN III will show what clinical presentation?

• eye deviation “down and out”

• pupil fixed and dilated

intrinsic deficit of the oculomotor n CN III will show what clinical presentation?

• eye deviation

• spares pupil

pupillary constriction is controlled by S/PS pathway

PS

trochlear n (CN IV) is located where

midbrain

deficits to the trochlear n. (CN IV) presents as

– Vertical diplopia (double vision)

– Hypertropia (eye deviates upward)

– Often there is a head tilt, usually towards opposite side of lesion

abducens n (CN VI) is located where

pons

deficit to the abducens n (CN VI) presents as

eye deviated medially, limited abduction of ipselateral eye

deficits to the trigeminal n (CN V) presents as

• facial sensory loss (anterior to ear)

• jaw deviation ipsilateral to lesion

deficits to the facial n (CN VII) presents as

– Peripheral facial weakness (eyelid as well as mouth)

– Taste loss ipsilateral to lesion

– Hyperacusis ipsilateral to lesion

deficits to the vestibulocochlear n (CN VIII) presents as

Lesions lead to sensory hearing loss and (peripheral) vertigo

deficits to the glossopharyngeal (IX) and vagus (X) presents as

– Dysarthria/dysphagia

– Inability to elevate palate (contralateral uvulal deviation)

deficits to the hypoglossal n (CN XII) presents as

Lesions lead to ipsilateral tongue deviation

Pupillary reflexes are linked to which CNs?

II

oculocephalic reflexes are linked to which CNs?

III, VI, VIII

“doll’s eyes'“ - move pts head side to side but eyes should stay staring straight ahead

vestibulo-ocular reflexes are linked to which CNs?

III, VI, VIII

– Cold water injected into ear canal

– Eyes deviate towards injected side

– Nystagmus (fast beating) to opposite side

corneal reflexes are linked to which CNs?

V, VII

gag reflexes are linked to which CNs?

IX, X

motor exams should involve:

• bulk and tone

• strength

• reflexes

• Babinski/Hoffman

how is strength graded on a motor exam?

scale 0-5

hypotonia, fascilations, and atrophy are signs of…?

LMN weakness (bulk and tone exam)

spasticity, lack of atrophy are signs of…?

UMN weakness (arm tends to be flexed, leg extended during bulk and tone exam)

how are reflexes graded on a motor exam?

scale 0-4

0: areflexic

4+: clonus

dorsal column pathways

where does it cross? what are the sensory modalaties?

– Crosses at medulla

– Light Touch

– Proprioception/Vibration

spinothalamic pathways

where does it cross? what are the sensory modalaties?

– Crosses in spinal cord

– Pain (pin prick)

– Temperature

coordination exams primarily assesses which lobe function?

cerebellum

what are some coordination exams and signs of deficit?

• Finger-to-nose/Heel-to-Shin

– Dysmetria

– Intention tremor

• Rapid Alternating Movements

• Mirror movements

how can we test gait?

• station/balance

  • getting up from chair

  • pull test

  • Romberg test (closed eyes) to assess dorsal column pathway, not cerebellar function

• propulsion

  • stride length, arm-swing

  • speed

  • turning

  • heel/toe/tandem gait

what are some abnormal gaits?

• ataxic (wide base)

• spastic hemiplegic gait (children)

• parkinsonian gait (tremor in hand, diminished arm swing)

when taking a history of someone with headaches/facial pain, what is important to collect?

– Acuity of onset

– Duration to maximal severity/Pain Scale

– Quality of pain (Pressure, squeezing, pounding, throbbing, stabbing)

– Distribution of pain

– Triggers

– Relieving/exacerbating factors

“Thunderclap” Headache is a red flag symptom of…?

Ruptured aneurysm

positional component Headache is a red flag symptom of…?

intracranial pressure

Headache on awakening is a red flag symptom of…?

mass lesion, elevated pressure

focal neurological signs is a red flag symptom of…?

mass lesion, dissection

neck rigidity is a red flag symptom of…?

meningeal irritation

new Headache in elderly patient is a red flag symptom of…?

temporal arteritis

what is the most common headache type?

tension headaches

characteristics of tension headaches

• Lifetime prevalence of 69% in men, 88% in women

• “dull”, “pressure”, “squeezing”

• Usually bilateral but can be unilateral

• Non-pulsatile

• Can have photophobia but usually no nausea

• No aura

what are the types of migraines?

• Migraine without aura (“Common”)

• Migraine with aura (“Classic”)

• Hemiplegic Migraine (“Complicated”)

• Status Migrainosis

what is common in patients with migraines?

family history

characteristics of migraines

About 18% of women, 6% of men

– Unilateral location

– Pulsating quality

– Moderate to severe pain “8/10”

– Avoidance of routine physical activity

– Duration: 4-72 hours if untreated

what are some associated features with migraines?

• Nausea/vomiting

• Photophobia/phonophobia

• Triggers

  • Foods: preservatives, MSG, chocolate, cheese, alcohol

  • Poor sleep

  • Other environmental (smells, lights)

childhood migraine variants include:

• cyclic vomiting

• abdominal pain, “colic”

characteristics of migraine with aura

– No motor weakness

– at least one of the following:

• reversible visual symptoms

• reversible sensory symptoms

• reversible dysphasic speech disturbance

• vertigo

• each symptom lasts ≥5 and ≤60 minutes

characteristics of hemiplegic migraine

• Motor weakness also part of aura

• Aura otherwise the same

• Diagnosis of exclusion

characteristics of cluster headaches

• Uncommon

• Men > Women (4-5 to 1)

• Features:

  • Unilateral, excruciating pounding/penetrating pain

    • Peri-orbital, temporal, scalp, maxilla

  • Autonomic features

    • Ptosis, lacrimination

  • Come in clusters with periods of remission

who is the classic cluster headache patient?

male, 40’s, heavy drinker/smoker

what are treatments for migraines?

Abortive

– NSAID’s

– Triptans (avoid in hemiplegic migraine)

– Muscle relaxants (tension)

– Anti-emetics (migraine)

– Corticosteroids

– Oxygen (cluster)

what migraine treatment should be avoided in hemiplegic migraine?

triptans

what should be avoided in migraine treatment?

avoid analgesic rebound (tolerance buildup, take more and more drugs)

if at least 2 days of headache a month, what treatments can be considered?

• Tricyclic antidepressants

  • amitriptyline, nortriptyline

• Beta blockers (non-selective)

  • propranolol

• Calcium channel blockers

  • verapamil

• Antiepileptics

  • Topiramate, valproic acid

• Botulinum Toxin

what is trigeminal neuralgia?

Paroxysmal attacks of pain lasting from a fraction of a second to 2 minutes, affecting one or more divisions of the trigeminal nerve

• V2, V3 more common

• V1 relatively rare

pain from trigeminal neuralgia has at least 1 of what characteristics?

– intense, sharp, superficial or stabbing

– precipitated from trigger areas or by trigger factors

t/f: in trigeminal neuralgia, there is no clinically evident neurological deficit and is not attributed to any other disorder

true

what treatment options are there for trigeminal neuralgia?

• Antiepileptics

  • carbamazepine, oxcarbazepine, phenytoin

  • gabapentin

• Muscle relaxants

  • Baclofen

• Surgical

  • Rhizotomy

  • Microvascular decompression

  • Gamma knife

what are the types of movement disorders?

• tremor: rhythmic, oscillatory, across a fixed axis

• chorea: random, irregular

• myoclonus: rapid, jerk-like movements

• dystonia: sustained contractions

• tics: semi-voluntary, stereotyped

tardive dyskinesia is due to…?

chronic dopamine antagonist use

– Antipsychotics

– Anti-emetics

charceristics of tardive dysinesia?

hyperkinetic movements

• choreic movements most common (esp orofacial, buccolingual distribution)

• dystonia, tics

what is the pathophysiology behind tardive dyskinesia?

pathophysiology unclear (dopamine receptor hypersensitivity)

what are treatment options for tardive dyskinesia?

– Stop offending medication

– Dopamine blocking agents

– Benzodiazepines

– VMAT2 inhibitors (dopamine depleters like Tetrabenazine, deutetrabenazine, valbenazine)

– Botulinum toxin (if dystonic)

what is a common tic disorder?

Tourette’s Syndrome

characteristics of Tourette’s syndrome?

• common (1% of population)

• childhood onset (7 yo average)

• motor and vocal tics

what are some neurobehavioral symptoms of Tourett’es syndrome?

– Attention deficit disorder

– Obsessive compulsive behaviors

– Learning disabilities

what are treatment options for Tourette’s syndrome?

– Tics: dopamine blockers/depleters

– Behavioral: clonidine, methylphenidate, SSRI’s

what muscles do hemifacial spasms affect?

Myoclonus/dystonia of facial muscles

– Orbicularis oculi/eyelids (blepharospasm)

– Lower face

hemifacial spasms are caused by…?

Idiopathic or structural/compressive lesion involving facial nerve

– Vascular

– Mass

– Demyelinating lesion (MS)

what are treatment options for hemifacial spasms?

responds to botulinum toxin injections

what is palatal myoclonus?

A involuntary, rhythmic movement of the palate (Persists in sleep)

what is palatal myoclonus caused by?

– Brainstem lesion involving triangle of Guillain-Mollaret (Red nucleus, inferior olivary nuclues, dentate nucleus)

– Idiopathic

what are treatment options for palatal myoclonus?

– Clonazepam

– Valproic acid

– Carbamazepine

– Botulinum toxin