Approach to the Patient with Neurologic Disease

Questions to be answered!!!

• Is there a lesion• Where is the lesion• What is the lesion• Is there treatment

Locate the Lesion(S)

The first priority is to identify the region of the nervous system that is likely to be responsible for the symptoms. Can the disorder be mapped to one specific location, is it multifocal, or is a diffuse process present? Are the symptoms restricted to the nervous system, or do they arise in the context of a systemic illness? Is the problem in the central nervous system (CNS), the peripheral nervous system (PNS), or both? If in the CNS, is the cerebral cortex, basal ganglia, brainstem, cerebellum, or spinal cord responsible? Are the pain-sensitive meninges involved? If in the PNS, could the disorder be located in peripheral nerves and, if so, are motor or sensory nerves primarily affected, or is a lesion in the neuromuscular junction or muscle more likely?

Symptoms in nervous system could be due

to functional or structural derangement of

Upper motor neuron –up to Cranial Nuclei and Anterior Horn Cell.

Lower motor neuron – Cranial Nuclei and Anterior Horn cell downwards.

Upper motor neuron

Movement paralysis Reflex movement

present voluntary absent.

Hypertonia/ Spasticity Disuse atrophy Superficial reflexes lost

deep exaggerated.

Lower motor neuron Muscle paralysis Both absent

Hypotonia Wasting, fasciculations Both lost

Symptoms localisations

I Acute Subacute Chronic

IIProgressiveRegressiveRemitting &

relapsing

They could be :-

A Natural Neural NetworkLayers of Cerebral Cortex

Mind is literally life-like. The Universe and Life are literally mind-like. "                                                                Peter Winiwarter (2008). Network Nature. www.bordalierinstitute.com

Mind is literally life-like. The Universe and Life are literally mind- like”.                                                              Peter Winiwarter (2008).

Network Nature.www.bordalierinstitute.com

The Nervous System

• Major division - Central vs. Peripheral

• Central or CNS- brain and spinal cord

• Peripheral- nerves connecting CNS to muscles and organs

Central Nervous System

Peripheral Nervous System

Peripheral Nervous System

• 3 kinds of neurons connect CNS to the body– sensory– motor– interneurons

• Motor - CNS to muscles and organs

• Sensory - sensory receptors to CNS

• Interneurons: Connections Within CNS

SpinalCord

Brain

Nerves

Peripheral nervous system

Skeletal(Somatic)

Sympathetic Parasympathetic

Autonomic

Peripheral Nervous System

Central Nervous System

• Brain and Spinal CordSpinalCord

Brain

Gray and White Matter

• Gray matter = neuron cell bodies, dendrites, and synapses– forms cortex over cerebrum and cerebellum– forms nuclei deep within brain

• White matter = bundles of axons– forms tracts that connect parts of brain

Lobes and Fissures • Longitudinal fissure (green)

• Frontal lobe• Central sulcus (yellow)

– precentral & postcentral gyrus

• Parietal lobe• Parieto-occipital sulcus• Occipital lobe• Lateral sulcus (blue)• Temporal lobe• Insula

Functional Regions of Cerebral Cortex

Clinical method of Neurology

• Series of steps

• History

• Examination

History

• Chief complaints

• Temporal profile - Onset, Progression,

Duration

• Personal, Family, Social History

Objective of History

• Possible Anatomical and Etiological Diagnosis

e.g. Right Hemiplegia with Aphasia

Tingling sensation in the index and middle finger.

• Hypothesis generation

Detailed Neurological Examination

• To confirm or refute the hypotheses of history

• To localize the lesion

• Anatomical and etiological diagnosis

The Diagnostic Law

• The Law of Parsimony

Only one EtiologyOnly one Lesion

• Occams Razor

The simplest and the most straightexplanation is the correct.

Differential Diagnosis

• Most likely to Least likely

• Epidemiology.

• Treatable Disease

Investigations to Confirm Diagnosis• Hematological, Biochemical,

• Neuroimaging, Neurophysiology,

• Histopathology, Genetic studies.

History

• Patient

Intelligence, Language, Social, Cultural

• Neurologist

Personality, Situation

Chief complaints

• Exact meaning

e.g. dizziness/chakkar, ? Is it true vertigo

• Precise onset

• Progression

Other History

• Personal History

• Family History, Pedigree charting

• Previous Illness

Review of other Neurologic Systems• H M F• Cranial Nerves• Motor• Reflexes• Sensory• Gait, Coordination • Involuntary Movements

• Titrate as per history • Titrate using several tests

from easy to difficult• Tailor to the clinical situation• 2 minutes for a comatose

emergency patient• 1 hour for unusual patient

in the office• Focused examination for

Headache

TEST FUNCTIONS OF DIFFERENT PARTS OF THE NERVOUS SYSTEMNormal Function or Abnormal signs

LOOK FOR PRESENCE OF ABNORMAL SIGNS (To confirm a lesion) OR

ABSENCE OF SIGNS (To refute a lesion)

HMF

Attention, Comprehension, level ofconsciousness/alertness, CooperationAttention - Spell WORLD, months of year, digit span forward & backward Comprehension – During historyAlertness – Awake , drowsy, lethargic

Involves Language, memory, fund of knowledge, Education, cooperation

• Orientation• Time, place, person • Tests attention, language, recent and long

term memory

• Memory• 3 minute recall• 3 objects, short story• Check registration• Recall after 3 minutes• Papez circuit

• Remote memory• Historical events• Personal events• Frontal lobe, cerebellum

Memory

Papez Circuit

Amnesia

• Anterograde Amnesia

Inability to form new memories• Retrograde Amnesia

Inability to recollect earlier events

• Mesial Temporal lesions• MTLS• Herpes Encephalitis• Head Injury• PCA infarcts• Alzheimer's dementia• Thalamic Lesions

Language• Spontaneous Speech• Comprehension• Naming• Reading • Repetition• Writing

Gerstmann’s Syndrome • Calculations• Right-Left Confusion• Finger Agnosia• Agraphia

Dominant Parietal lobe

(inferior parietal lobule)

Apraxia

• Apraxia -inability to follow a motor command that is not due to a primary motor deficit or a language impairment

• Impaired higher-order planning, programming or conceptualization of the motor task

• Pretend to comb you hair • Pretend to strike a match and blow it out

• Ideomotor apraxia • Ideational apraxia• Constructional apraxia• Dressing apraxia• Ocular apraxia

Hemineglect

• Inability to pay attention to or notice stimuli from one-half of the visual field

• While copying a drawing, omit the material on the left

• eat only the food on the right half of the plate, leaving that on the left.

Hemineglect

• Nondominant Parietal Lobe• Abnormality in attention/Neglect to one

side of the universe (vision, sensation and power are normal)

• Anosognosia• Lack of awarness or denial of the deficit,

hemiplegia• Antons syndrome – denial of cortical

blindness

Frontal Lobe Tests

Frontal Lobe Tests

• Abstract thinking and Logic

If Mary is taller than Jane, and Jane is taller than Ann, who's the tallest?"

"Don't cry over spilled milk"? • Delusions and Hallucinations• Mood

Depressed, Anxious, Maniac

Cranial nerves

• Olfactory

Test smell of coffee, soap in each nostril

(Olfactory groove meningioma)

Optic Nerve

• Visual Acuity• Color Vision (Red desaturation)• Visual field by confrontation• Visual extinction• Menace reflex

Visual Field

Visual acuity

Pupillary light reflex &Swinging Flashlight

Cranial Nerves III, IV, VI

SaccadesPursuitDiplopiaConvergenceNystagmusOptokinetic nystagmusOculocephalic or Dolls Eye reflex

Extraocular Muscle Palsy

Left VI

Left III

Left IV

Trigeminal Nerve

• Facial Sensation• Corneal reflex• Massetors, Pterygoid,

Temporalis muscles

Facial Nerve

Prior Reports and Opinions

• Reviews earlier evaluation

• Forms New Hypothesis

• Critical thinking

Screening Neurological Examination• Mental Status• Cranial Nerves• Motor System• Sensory System• Reflexes• Gait• Rombergs Test• Involuntary movements

Willis pathological Diagnosis

• Hereditary• Congenital• Traumatic• Inflammatory• Vascular• Neoplastic • Degenerative• Metabolic• Autoimmune• Nutritional

Pathways in Neurological Diagnosis

• Hypotheticodeductive Method

• Pattern recognition

Hypotheticodeductive system

• Observations early on • Hypothesis (Broad and Vague)• Conclusions• Revision of conclusion• Alternate hypothesis• Rapid and multiple hypothesis

Pattern Recognition

• Experts method• Weigh and structure data• What is most significant• Structure data to make sense and form known

pattern• Look for key features• Each symptom has limited possibilities• Ask questions which have distinguishing power• Odd feature may refute hypothesis

Thank You