NEUROLOGIC DIAGNOSIS

Set of symptoms or signs in which causation can be localized to an anatomic site in the CNS or PNS

Focal Neurologic Deficits

Symptoms of Cerebral Deficits

disturbance in higher intellectual functions

Symptoms of Brainstem Deficits

cranial nerve deficits 

Symptoms of Motor Pathway Deficits

weakness or paralysis of extremities

Symptoms of Cerebellar Deficits

incoordination and poor balance

Symptoms of Reflex Deficits

asymmetry in DTRs, pathological reflexes

Symptoms of Somesthetic system Deficits

Sensory impairment

Symptoms of ANS Deficits

autonomic disturbances (bowel, bladder, sex)

3 volumes that make up the intracranial pressure

• Brain parenchyma 

• CSF

• Blood volume 

Sum of volumes of brain, CSF, and intracranial blood is constant 

Increase in one should cause decrease in one or both of the remaining two

What is this doctrine known as?

Monroe Kelly doctrine

Increased Intracranial Pressure can lead to:

Headache/Vomiting with: 

• Papilledema → swelling of optic disc

• Diplopia with internal squint (lateral rectus palsy secondary to abducens nerve lesion)

• Decreased level of consciousness 

• Bulging fontanel, separation of sutures, rapidly enlarging head (in babies)

• In adults, cerebellar tonsil herniation

If the symptoms of increased intracranial pressure is acute with trauma it can be:

• Epidural hematoma

• Subdural hematoma

• Subarachnoid hemorrhage

• Parenchymal Hemorrhage or intracerebral hemorrhage

If the symptoms of increased intracranial pressure is acute s trauma c fever it can be:

Acute meningitis

If the symptoms of increased intracranial pressure is acute s trauma s fever it can be:

• Cerebral Infarction

• Cerebral Hemorrhage

• Subarachnoid Hemorrhage

If the symptoms of increased intracranial pressure is chronic it can be:

• Mass Lesion (Tumor)

• Chronic Meningitis

• Hydrocephalus

Symptoms of meningeal irritation:

Headache/Vomiting with: 

• Nuchal rigidity 

• Brudzinski sign 

• Kernig sign

Acute symptoms of meningeal irritation c fever can be:

Acute meningitis

Acute symptoms of meningeal irritation s fever can be:

SAH (Subarachnoid Hemorrhage)

Chronic symptoms of meningeal irritation c fever can be:

Chronic meningitis

Identify if it is in the CNS of PNS and what level

Levelize

Review:
(Refer to part 1 of Neurological Exam Cards to test yourself)

Patterns of Weakness: Identify

Hemispheric Lesion

Patterns of Weakness: Identify

Brainstem Lesion

Patterns of Weakness: Identify

Spinal cord lesion

Patterns of Weakness: Identify

Polyneuropathy

Patterns of Weakness: Identify

Myopathy

More stuff just look at it I guess

Cerebral Lesion symptoms
(Memorize / Use common sense)

• Seizure

• Language problem (dysphasia or aphasia) → dominant hemisphere 

• Behavioural, personality, and mental changes (delirium, dementia)

• Contralateral hemiparesis with Babinski 

• Contralateral hemisensory deficit 

• Contralateral homonymous hemianopia/quadrantanopsia (visual field deficit)

Brainstem Lesion
(Memorize / Use common sense)

Crossed Motor/Sensory Syndrome 

• Ipsilateral cranial nerve deficit 

  • Do not decussate from the brainstem to the structures they innervate 

• Contralateral hemiplegia with Babinski 

• Contralateral hemisensory deficit

Review of CN brainstem level

• Cerebral - CN I and II 

• Midbrain - CN III and IV 

• Pons - CN V, VI, VII, and VIII 

• Medulla - CN IX, X, XI, and XII

• Paralysis of the whole half of face 

• Lesion in the ipsilateral facial nucleus or facial nerve 

Peripheral Facial Palsy

• Spastic gait disorder

• Bilateral corticospinal signs with or without bladder symptoms 

• Cutaneous sensory loss or sensory level

Spinal Cord Lesion

Plexuses

Brachial plexus → C5-T1 roots

Lumbosacral plexus → L1-S2

Peripheral Nerve Dysfunction

• Weakness

• Sensory deficits

• Autonomic disturbances

• Reflexes

Peripheral Nerve Dysfunction

• Distal, symmetrical

• Distal, symmetrical

• May be present

• Areflexia

Types of peripheral neuropathy:

• Mononeuropathy

• Polyneuropathy

• Mononeuropathy multiplex

MUSCLE DYSFUNCTION

• Weakness

• Objective sensory deficits

• Autonomic disturbances

• Reflexes

MUSCLE DYSFUNCTION

• Proximal, symmetrical

• None

• None

• Depending on severity of weakness

NMJ DYSFUNCTION

• Motor dysfunction

• Sensory dysfunction

• Autonomic dysfunction

• Reflexes

NMJ DYSFUNCTION

• Predilection for motor cranial nerves; Proximal, fluctuating weakness

• None

• None

• Normal

Most common NMJ dysfunction =

Myasthenia gravis

Extrapyramidal System Lesion can lead to:

Increased tone → rigidity

Abnormal involuntary movements → dyskinesia 

• Rest tremor 

• Chorea 

• Athetosis 

• Ballismus 

• Dystonia

Identify if Pyramidal lesion or Extrapyramidal lesion:

• SPASTICITY

• RIGIDITY

• muscle stretch reflex (MSR) not necessarily altered 

• Extensor toe sign

• Tends to affect antagonistic pairs of muscles about equally

Identify if Pyramidal lesion or Extrapyramidal lesion:

• Pyramidal

• Extrapyramidal

• Extrapyramidal

• Pyramidal

• Extrapyramidal

Identify if Pyramidal lesion or Extrapyramidal lesion:

• EMG inactive with the muscle at complete rest

• Tends to predominate in one set of muscles (i.e. UE flexors, knee extensors, and ankle plantarflexors)

• Lead-pipe phenomenon often with cogwheeling and tremor at rest

• Clasp-knife phenomenon  in hemiplegic, quadriplegic, monoplegic, or paraplegic

• Clonus and hyperactive muscle stretch reflex (MSR)

Identify if Pyramidal lesion or Extrapyramidal lesion:

• Pyramidal

• Pyramidal

• Extrapyramidal

• Pyramidal

• Pyramidal

Identify if Pyramidal lesion or Extrapyramidal lesion:

• EMG tends to show electrical activity with the muscle as relaxed as the patient can make it

• Examiner elicits clasp-knife phenomenon, catch-and-yield sensation, by a quick jerk of the resting extremity

• Examiner elicits lead-pipe phenomena of rigidity by making a slow movement of the patient’s resting extremity

• usually in all four extremities but may have a “hemi” distribution 

Identify if Pyramidal lesion or Extrapyramidal lesion:

• Extrapyramidal

• Pyramidal

• Extrapyramidal

• Extrapyramidal

Cerebellar Lesion where there is:

• Intention tremor 

• Dysmetria 

• Dysdiadochokinesia

Hemisphere Lesion (Ipsilateral Limb Ataxia)

Cerebellar Lesion where there is:

• truncal ataxia 

• No limb ataxia

Disease Categories (VINDICATE)

• Vascular

• Infectious 

• Neoplastic 

• Degenerative 

• Inflammatory/latrogenic/idopathic 

• Congenital 

• Autoimmune/allergic 

• Traumatic 

• Endocrine/metabolic

Temporal profile of disease

The most frequent neurologic disease with sudden onset and rapid course of neurologic deficit.

Cerebrovascular disease

The most frequent neurologic disease with insidious onset and slowly progressive course of neurologic deficit.

Mass lesion 

Degenerative Disease

Neurologic disease that may be acute, subacute, or chronic.

• Infection 

• Metabolic/endocrine 

• Intoxination 

• Demyelinating disease