Neuro.txt

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laureng
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277072
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Neuro.txt
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2014-06-17 18:09:52
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peripheral neuropathy dorsal spinothalamic sensory motor cerebellar ataxia dissociative
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Neuro SC
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  1. Causes of peripheral neuropathy
    • DM 30%
    • Hereditary 30%
    • Idiopathic 30%
    • Drugs & toxins - Isoniazid, vincristine, phenytoin, nitrofurantoin, ciaplatin, amiodarone, heavy metals
    • Alcohol
    • Metabolic - DM, uraemia, hypothyroidism, porphyria
    • AID - GBS
    • Neoplastic - lung adenoCa
    • B12/B1 deficiency
    • B6 excess
    • CT disease
    • Vasculitis
    • Hereditary
  2. Causes of motor peripheral neuropathy
    • GBS
    • CIDP
    • Acute intermittent porphyria
    • DM
    • Pb poisoning
  3. Causes of sensory peripheral neuropathy
    • Carcinoma (lung, ovary, breast)
    • Paraproteinaemia
    • B6 excess
    • Sjogrens
    • DM
    • Syphilis
    • Idiopathic
  4. Causes of painful peripheral neuropathy
    • DM
    • EtOH
    • B1/12 deficiency
    • Porphyria
    • Arsenic or thallium
  5. Causes of mononeuritis multiplex
    • Acute - usually vascular
    • DM
    • Polyarteritis nodosa
    • CT disease (SLE, RA)
    • Chronic:
    • Multiple compressive neuropathies
    • Sarcoidosis
    • Leprosy
    • Lyme disease
    • Idiopathic
  6. Charcot-Marie Tooth
    • AD
    • Clinically: pes cavus, distal muscle atrophy, absent reflexes, slight or NO Sn loss in limbs, thickened nerves, optic atrophy
  7. Complete brachial plexus
    • LMN signs entire arm
    • Sn loss whole arm
    • Horner's syndrome
  8. Upper trunk brachial plexus (C5-6)
    • Loss of shoulder movement and elbow flexion
    • (Waiter's too position)
    • Sn loss to lateral aspect of arm/forearm + thumb
  9. Lower brachial plexus (C8, T1)
    • Claw hand with paralysis of the intrinsic hand muscles
    • Sn loss ulnar side of hand and forearm
    • Horner's syndrome
  10. Radial nerve palsy (C5-8)
    • Wrist & finger drop
    • Triceps loss
    • Sn loss over snuff box
  11. Medial nerve palsy (C6-T1)
    • Muscles of forearm except flexor carpi ulnaris and half of flexor digitorum profundus (clasp hands, index finger pokes up = in/above cubital fossa) + LOAF muscles of the hands
    • - Lateral two lumbricals
    • - Opponens pollicis
    • - Abductor pollicis brevis
    • (Hand flat on table and pen touch with thumb = at/above the wrist)
    • - Flexor pollicis brevis
    • Sn loss thumb, index, middle and lateral half of ring finger (palmar)
  12. Ulnar nerve palsy (C8-T1)
    • Wasting of intrinsic muscles of the hands (except the LOAF)
    • Weak finger Ab and Ad
    • Ulnar claw
    • Sn loss little and medial aspect of ring finger (both sides)
  13. Femoral nerve palsy (L2-4)
    • Weak knee extension
    • Slight hip flexion weakness, normal Ad
    • No knee jerk
    • Sn - inner thigh and leg
  14. Sciatic nerve palsy (L4-S2)
    • Weak knee flexion + all muscles distal to the knee
    • Normal knee jerk
    • No ankle jerk or plantar response
    • Sn loss - posterior thigh and all below the knee
  15. Common peroneal nerve palsy (L4-S1)
    • Foot drop and ever soon ONLY
    • Normal reflexes
    • Sn largely normal
  16. Causes of foot drop
    • Common peroneal nerve palsy
    • Sciatic nerve palsy
    • Lumbosacral plexus lesion
    • L4/5 root lesion
    • Periphery motor neuropathy
    • Distal myopathy
    • MND
    • Precentral gyrus lesion

    • *** check ankle reflex:
    • Absent - think S1 lesion
    • Normal - Common peroneal nerve palsy
    • Increased - UMN lesion
  17. Subacute combined degeneration of the cord - Clinically
    • Symmetric posterior column loss --> Ataxic gait
    • Symmetric UMN signs in LL with absent ankle jerks
    • Periphery Sn neuropathy (rarely, and mild if present)
    • Occasional dementia and optic atrophy
  18. Brown-Séquard syndrome - Clinically
    • Motor - UMN ipsilateral side below lesion & LMN ipsilateral at the level
    • Sn - Contralateral loss of pain and temperature
    • - Ipsilateral loss of vibration and position sense
    • - Normal light touch
  19. Brown-Séquard causes
    • MS
    • Angioma
    • Glioma
    • Trauma
    • Myelitis
    • Post-XRT myelopathy
  20. Dissociative Sn loss - spinothalamic loss
    • Syringomyelia
    • Brown-Séquard - Contralateral leg
    • Anterior spinal artery thrombosis
    • LMS
    • Peripheral neuropathy
  21. Dissociative Sn loss - Dorsal column
    • Subacute combined degeneration of the cord
    • Brown-Séquard - Ipsilateral leg
    • Spinocerebellar degeneration (Friedrich's ataxia)
    • MS
    • Tabes dorsalis
    • Peripheral neuropathy (DM or hypothyroidism)
  22. Syringomyelia clinically
    • Loss of pain and temperature over the neck shoulders and arms (Cape distribution)
    • Weakness, atrophy and areflexia of arms
    • UMN signs in LL
  23. Causes myopathy
    • Hereditary
    • Acquired = PACE PODS
    • Polymyositis/Dermatopolymyositis
    • Alcohol
    • Carcinoma
    • Endocrine - hypothyroidism/hyperthyroidism, Cushing, acromegaly, hypopituitarism
    • Periodic paralysis
    • Osteomalacia
    • Drugs - chloroquine, steroid
    • Sarcoidosis

    • Paraneoplastic syndrome
    • Alcohol
    • CT disease
  24. Lateral cutaneous nerve of the thigh
  25. Normal motor
    Loss lateral thigh Sn
  26. Femoral nerve
    • L2-4
    • Motor: knee F
    • Reflexes: absent knee
    • Sn: loss medial thigh and knee
  27. Common peroneal nerve
    • L4-S1
    • Ankle DF and Ev
    • Normal reflexes
    • Lateral leg and too of foot Sn loss
  28. Sciatic nerve
    • L4-S2
    • All muscles below the knee and hamstrings
    • Normal knee, absent ankle and plantar reflexes
    • Sn loss of posterior thigh and leg
  29. LL myotomes
    • Hip F L2-3 (lift your knee)
    • Hip E L5-S2 (pushing through)
    • Hip Ab L4-S1
    • Hip Ad L2-4
    • Knee F S5-L1 (kick your bum)
    • Knee E L3-4 (kick the door)
    • Ankle PF S1-2 (point your shoe)
    • Ankle DF L4-5
    • Ankle In/Ev L5-S1
    • Stand in heels L4-5
    • Stand on toes S1
  30. UL myotomes
    • Shoulder Ab C5-6
    • Shoulder Ad C6-8
    • Elbow F C5-6
    • Elbow E C7-8
    • Wrist F C6-7
    • Wrist E C7-8
    • Fingers F & E C7-8
    • Fingers Ab & Ad C8-T1
  31. Radial nerve palsy
    • C5-8
    • Motor: triceps, brachiosaurus kid and hand extensors
    • (Elbow F, pronate, straight wrist and fingers, then check triceps for high lesion)
    • Sn - snuff box
  32. Median nerve palsy
    • C6-T1
    • At wrist: thumb pen touch (abductor pollicis brevis)
    • At cubital fossa: clasping test, index finger points up

    Sn: palmar thumb and 2.5 fingers
  33. Ulnar nerve palsy
    • C8-T1
    • Wasting small muscles of hand + ulnar claw
    • Test with paper between thumb and lateral aspect of index fingers

    Sn: palmar little and 0.5 ring finger
  34. Brachial plexus
    • Upper: C5-6 shoulder
    • Middle: C7 triceps
    • Lower: C8-T1 hand & horners
  35. MCA CVA
    • UMN face
    • UMN arm > leg
    • Homonymous hemianopia
    • Dominant lobe: Aphasia
    • Non-dominant lobe: Graohaesthesia, tactile extinction, visual and sensory inattention, inferior quadrantanopia
  36. PCA CVA
    • Hemianaesthesia (loss of all Sn)
    • Homonym ours hemianopia
  37. ACA CVA
    • UMN leg > arm
    • Cortical Sn loss of leg only
    • Urinary incontinence
  38. Parietal lobe - Dominant
    • AALF
    • Acalculia
    • Agraphia
    • L-R disorientation
    • Finger agnosia
    • (Gerstmann's Syndrome)
  39. Parietal lobe - Non-dominant
    • Cortical Sn (Sn requiring higher processing)
    • - Graphaesthesia (number/letter)
    • - Tactile extinction (feels stimulus on individual sides but not when both touched together)
    • Sensory & Visual inattention
    • - VF testing (Inf. Quadrantanopia)
    • - Tactile agnosia (inability to recognize objects by touch)
    • - Two point discrimination (must be 3cm apart in hand/foot)
    • Dressing/Constructional apraxia
    • - Top inside out
    • - Copy a drawn house
    • Spatial neglect
    • - Numbers on a clock (R) side lesion, all numbers on the left)
  40. Temporal lobe
    • Short and long term memory
    • - WW2 ended
    • - 3 Objects
  41. Frontal lobe
    • Primitive reflexes
    • - Grasp (grasp C/L to lesion)
    • - Palmomental (I/L contraction of obicularis oris on stroking thenar eminence)
    • - Pout & Snout (stroke the upper lip)
    • Interpret a proverb
    • Anosmia
    • Gait apraxia (feet glued to the floor)
    • Optic atrophy
  42. U/L CN 3-6
    Cavernous sinus
  43. U/L CN 5, 7, 8
    Cerebellopontine angle
  44. U/L CN 9-11
    Jugular foramen lesion
  45. B/L CN 10-12
    • Bulbar palsy if LMN
    • Pseudobulbar palsy if UMN
  46. Midbrain
    CN 3-4
  47. Pons
    CN 5-8
  48. Medulla
    CN 9-12
  49. Parkinson's disease
    • Bradykinesia
    • Increased tone (cog wheeling)
    • Resting tremor
    • Glabellar tap
    • Gait
    • Handwriting
    • Vertical gaze (SNP)
    • Postural BP (MSA)
    • Fx tests

    Normal Sn and power

    • Ix - sleep study for REM sleep disorder
    • Depression screen
  50. MS
    • Any combination of motor and Sn loss - UMN pattern
    • INO
    • Optic atrophy
    • Red desaturation
    • Hoffmann's sign
    • Cerebllar signs

    • Exclude SC compression
    • LP - protein, increased IgG, ICB
    • VEP
    • Brain and SC MRI
    • [B12] - exclude subacute combined degeneration of the spine
  51. MND
    • Combined UMN and LMN signs
    • Always fasciculations
    • Reflexes present until late
    • No Sn changes
  52. Subacute combined degeneration of the cord
    • B12 deficiency
    • Loss posterior columns --> no vibration/proprioception leading to an ataxic gait
    • B/L UMN signs in LL with absent or exaggerated reflexes
    • Rarely peripheral Sn loss
    • Optic atrophy
    • Dementia
  53. Syringomyelia
    • Loss pain, temperature (cape distribution)
    • Amyotrophy (loss muscle, reflexes)
    • UMN signs in LL
  54. Pronate drift
    • Downward with pronation - UMN weakness
    • Upward drift - cerebellar
    • Searching - loss of proprioception
  55. Myotonic dystrophy
    • Autosomal dominant
    • Frontal baldness
    • Expressionless triangular facies
    • Atrophy temporalis
    • Partial ptosis
    • Cataracts
    • Weak neck flexion
    • Percussion myotonia
    • Weakness and wasting on distal muscle groups
    • Normal Sn
    • Gynaecomastia
    • Cardiomyopathy and arrhythmias
    • Ask for urine for glucose (DM)
  56. Cerebellar disease
    • Nystagmus - jerky horizontal with fast aspect towards lesion
    • Assess speech - British constitution or West Register Street --> Jerky, explosive and loud
    • Upward pronation drift
    • Intention tremor and past-pointing
    • Rapidly alternating movements
    • Rebound
    • Heel shin
    • Truncal ataxia
    • Pendular knee jerks
    • Staggering gait - towards lesion

    If obvious U/L cerebellar signs --> CN 5/7/8 for cerebellopontine tumour or lateral medullary syndrome

    If B/L signs look for MS, Friedriche's ataxia (pes cavus) and hypothyroidism
  57. Causes of U/L cerebellar signs
    • SOL
    • Ischaemia (vertebra basilar )
    • MS
    • Trauma
  58. Causes of B/L cerebellar disease
    • Drugs (phenytoin)
    • Alcohol
    • Friedriche's ataxia
    • Hypothyroidism
    • Paraneoplastic syndrome
    • MS
    • Trauma
    • Arnold-Chiari malformation
    • Large SOL
  59. Clinical features of Friedrich's ataxia
    • Autosomal recessive
    • Young person
    • B/L cerebellar signs
    • Pes cavus
    • Kyohoscholiosis
    • UMN signs in limbs except areflexic
    • Peripheral neuropathy
    • Posterior column loss in limbs
    • Cardiomyopathy
    • DM
    • Normal mentation

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