Clinical Features of Neurological Diseases 25022013 Final

7/27/2019 Clinical Features of Neurological Diseases 25022013 Final

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OVERVIEW OF CLINICAL PRESENTATIONOF NEUROLOGICAL DISEASES

Njideka U. Okubadejo, FMCPAssociate Professor & Consultant neurologist

Faculty of Clinical Sciences, CMUL & Lagos University Teaching Hospital

Idi Araba, Lagos State, Nigeria

NPMCN Radiology Update Course 2013


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OUTLINE

Introduction Clinical features of neurological diseases

Headaches

Altered sensorium

Vertigo

Muscle weakness

Movement disorders

Higher cortical dysfunction

Gait disturbance / imbalance

Sensory abnormalities

Common clinical scenarios



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INTRODUCTION

Important guide to radiological evaluation ofneurologic disorders

Inadequate clinical information can greatly hamper accuracy/utility of radiological

investigations

result in inappropriate interventions increase mortality and morbidity

Adverse financial consequences

LitigationNPMCN Radiology Update Course 2013


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NEUROLOGICAL DX AETIOLOGIES

Vascular

Infection /

Inflammatory

Trauma/Toxins

Autoimmune

Metabolic

Idiopathic

Neoplastic

Psychogenic/Seizures

Degenerative/Drugs

Endocrine

Congenital

(VITAMINS DEC)



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CLINICAL FEATURES OF NEURODX

Wide spectrum of features with localizing or non-

localizing value

Combination of clinical features and scenario improve

diagnosis

In evaluation: correct sequence of evaluation

Functional /anatomical localization

Aetiology (based on clinical scenario; age;

constitutional symptoms; geographic location;

associated non-neurologic features; mode of onset,

etc) NPMCN Radiology Update Course 2013


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CLINICAL FEATURES OF NEURODX

Important factors regarding aetiology include:

Mode of onset (acute v. subacute/chronic)

Temporal profile: ?: monophasic, recurrent/episodic,

stepwise, progressive

Age at onset: paediatric, young adult, middle age,

elderly?

Constitutional/other systemic symptoms: fever,

endocrine abnormality, skin, etc Clinical scenario: antecedent trauma, malignancy

Risk factor profile: family history, CVD risk factors



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CLINICAL FEATURES OF NEURODX ii

Headaches

Altered consciousness

Seizures

Syncope

Vertigo

Muscle weakness

Higher cortical dysfunction

Language disturbance

Cranial neuropathies

Movement disorders

Gait disturbance

Sensory abnormalities



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HEADACHE

Headache = pain in the head.

Symptoms suggestive of serious underlying dx

Worst headache ever

First severe headache

Subacute worsening over days or weeks

Abnormal neurological examination

Fever or unexplained systemic signs

Vomiting preceding headache

HA induced by bending, lifting, cough

Disturbance of sleep or HA immediately on awakening

Known systemic illness e.g. malignancy

Onset after age 55 yearsNPMCN Radiology Update Course 2013


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HEADACHE ii


Features of serious underlying causes of headache

Meningitis Generalized headache; associated nuchal

rigidity; photophobia; may be febrile;

focal signs

Intracranial hemorrhage Severe headache; altered sensorium; seizures; nuchal rigidity in

subarachnoid/intraventricular hrrhage;

bloody tap or xanthochromia

Brain tumor / SOL Pounding severe HA; associated

nausea/vomiting/progressive altered

sensorium; focal deficits; seizures

Glaucoma Severe eye oain; nausea or vomiting;

painful red eye


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ALTERED SENSORIUM

Coma (GCS


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VERTIGO

An illusory or hallucinatory sense of movement

of the environment (sense of spinning)

Can be physiologic or pathologic

Pathologic causes:

Visual: new glasses; diplopia

Somatosensory: peripheral neuropathy; myelopathy

vestibular: labyrinthine dx; 8th nerve dx; central

connectionsNPMCN Radiology Update Course 2013


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MUSCLE WEAKNESS

Reduction in normal power of one or more muscles

-plegia: complete weakness-paresis: mild or moderate weakness

Pattern

UMN: corticospinal tract involvement brain or spinal cord

LMN pattern: anterior horn cells, nerve roots, peripheralnerve

Myopathic: muscle or NMJ; proximal weakness typically

Distribution:

Hemi - one half of the body (corticospinal UMN)

Para both legs (spinal cord or cortex; flaccid or spastic)

Quadri all four limbs (UMN or LMN)

Mono one limb (UMN or LMN)



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MUSCLE WEAKNESS



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MUSCLE WEAKNESS



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MOVEMENT DISORDERS

Disturbance of fluent movt or unintended extra movement

Most have a biochemical rather than structural basal ganglia dx

Classified as: hyperkinetic or hypokinetic

Hemiballismus:

contralateral subthalamic nucleus lesion vascular, etc

Chorea:

acute/subacute toxins, drugs, pregnancy, hyperthyroidism,

antiphospholipid syndrome, rheumatic fever

Chronic; neurodegenerative dx e.g. Huntingtons disease

Myoclonus:

Metabolic and neurologic aetiologies

Structural causes: brainstem or spinal lesions causing palatal or

segmental myoclonusNPMCN Radiology Update Course 2013


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MOVEMENT DISORDERS

Tremor

Rest tremor: maximal at rest (parkinsonian tremor)

Postural tremor (max. with limb postured against gravity; DD

acute: toxic/metabolic; insiduous: benign essential tremor

Intention tremor (max. during voluntary movt towards a

target; cause cerebellar disease)

Parkinsonism

Hypokinetic movt disorder

Tremor, bradykinesia (slowness), rigidity, postural

impairment)

DD: PD, multiple system atrophies, PSP, vascular,

drug/toxins, head trauma, etcNPMCN Radiology Update Course 2013


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HIGHER CORTICAL DYSFUNCTION

APHASIA

Language dysfunction due to damage to neuralnetwork including Wernickes, Brocas perisylvian,

temporal, prefrontal, posterior parietal regions

Due to left hemispheric lesion in 90% of right

handed, 60% left handed; small % no language

dominance; right dominance in others (incl. small

minority of right handed)

Causes: stroke, tumors, trauma, degenerative



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HIGHER CORTICAL DYSFUNCTION ii

APRAXIA:

Motor deficit not due to pyramidal, extrapyramidal,

cerebellar, or sensory dysfunction

Causes: left hemispheric lesions, focal premotor cortex

lesions, cortico-basal ganglionic degeneration (with

parkinsonism)

GERSTMANNS SYNDROME:

Acalculia, dysgraphia, finger anomia, right-left confusion

In isolation, due to left inferior parietal lobe (angular

gyrus) lesion



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HIGHER CORTICAL DYSFUNCTION iii

HEMISPATIAL NEGLECT Loss of attention to left sided stimuli (feeding,

dressing, etc)

Due to right hemispheric lesions

AGNOSIAS

Recognition deficits

e.g. face (prosopagnosia), objects (visual object

agnosia occipito-temporal region) due to

bilateral posterior cerebral artery infarcts



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HIGHER CORTICAL DYSFUNCTION iv

AMNESIAS

Due to dysfunction of the limbic system for memory(hippocampus, amygdala, entorhinal cortex, ant/medial

thalamic nuclei, medial/basal striatum, hypothalamus)

Controls declarative memory for recent experiences +behaviour (emotion, motivation, endocrine fxn)

Retrograde (prior memories) or anterograde (new

knowledge)

Caused by bilateral lesions in limbic network: tumors,

infarctions, head trauma, encephalitis, Wernicke-Korsakoff,

degenerative dementias (Alzheimers, Picks)NPMCN Radiology Update Course 2013


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HIGHER CORTICAL DYSFUNCTION iv

DEMENTIA:

acquired impairment in memory + impairment in one or

more cognitive domains, including: executive function;

language; praxis; gnosis

Causes:



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GAIT DISTURBANCE / IMBALANCE



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SENSORY ABNORMALITIES

Lesions at any level of neuraxis: parietal cortex, thalamus,

brainstem, spinal cord, spinal root, peripheral nerve, etc Distribution and nature important for localization

Parietal lobe:

Contralateral hemineglect; abnormal higher sensory fxn,

hemilateral loss of primary sensation (pseudothalamic)

Focal sensory seizures

Thalamus:

Hemisensory disturbance from head to toe (e.g. stroke)

Brainstem:

Harlequin pattern ipsilateral facial sensory loss and

contralateral body (lateral medulla)

Contralateral face/arm/leg pons and midbrainNPMCN Radiology Update Course 2013


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SENSORY ABNORMALITIES ii

Spinal cord:

Distribution of the sensory abnormality and accompanying

tract dysfunction is important

Hemisection

Contralat loss pain and temp below; ipsilat loss of

proprioception and muscle power below

Transection:

sensory level on trunk

Central canal (syrinx): sensory dissociation with loss of pain and temperature.

Nerve and root: discrete boundaries of sensory abnormality


VISUAL COMPLAINTS


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VISUAL COMPLAINTS

Impaired visual acuity

Visual field loss Hemifield

Homonymous hemianopsia

Quadrantanopia

Upper quadrant

Lower quadrant

Bitemporal

Conjugate gaze Disconjugate gaze (diplopia): cranial neuropathy;

myopathy; neuromuscular junction; brainstem



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COMMON CLINICAL SCENARIOS

Intracranial SOLs

Subacute/chronic onset typically Add-on signs and symptoms

Raised intracranial pressure

Stroke:

Abrupt onset

Stepwise deterioration if any

Subtype features: ischaemic; haemorrhagic (ICH v.

SAH)

Risk factor profileNPMCN Radiology Update Course 2013


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COMMON CLINICAL SCENARIOS

CNS infections: fever, headache, neurologic signs and symptoms

Exceptions: occasionally no fever

Inflammatory disease MS, NMO, CNS vasculitis Abrupt onset; relapsing or remitting course; visual

pathway involvement

Seizures Idiopathic or due to structural intracranial

abnormalities


Clinical Features of Neurological Diseases 25022013 Final

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