NEUROLOGY II KC GANDA

DR. FRANZ RASAY

4 Questions for Neurological Problem:

1.) Is there a neurologic deficit? 3 signs of meningeal irritation:

2.) Where is the lesion? --> Levelize, Lateralize,
Localize  Nuchal rigidity: resistance of passive flexion of
3.) What is the nature of the lesion? the neck forward.
4.) What can we do? o When there is resistance laterally, and
resistance on forward flexion = cervical
 IS THERE A NEUROLOGIC DEFICIT? paratonia (secondary to prolonged
A. Presence of focal deficit bedridden patient)
 Kernig’s sign: “Knee”
 Dependent on what part of NS is affected
o (+) electric shock or pain in the back area or
 Involves the cerebral or supratentorial =
cervical area
memory deficit, seizure (cortical area),
 Brudzinski Sign: :Batok”
headache
o Passive flexion of the neck
 HAVE A COMPLETE HISTORY AND P.E & neuro
o *****
exam
 Presence of problem in the supratentorial DIFFERENTIATE:
area like Headache, Seizure, Memory
problem, Behavioral changes/ mood o Meningitis: (+) Fever
symptoms o Subarachnoid hemorrhage: thunderclap
 Presence of cranial deficit HA/ worst HA of patient’s life
[INFRATENTORIAL] = sudden visual loss
particularly unilateral ; Diplopia= EOM  Dizziness: disorientation of one’s self to space,
(3,4,6) involved; Sensory deficit= CN 5; time, place
Facial asymmetry= CN 7; Impairment of
Peripheral Dizziness Central Dizziness
muscle of mastication = CN 5; Ptosis = CN
Rotatory Non- rotatory
3; Bell’s palsy = CN 7 (closing of eyes); Feeling of unsteadiness/
Dysphagia = CN 9/10; Dysarthria = CN 12 imbalance
 Weakness: impairment or decrease in Hearing deficit, tinnitus (-)
motor strenghth (Upper or lower extremity Horizontal nystagmus Vertical nystagmus &
weakness; Bilateral lower extremity Horizontal nystagmus
weakness= quadriplegia ) (+) cereberal signs:
dysmetria,
 Sensory deficit: Numbness, tingling
 ALL INFRATENTORIAL LESION = IPSILATERALLY
sensation
 ALL SUPRATENTORIAL LESION =
B. Presence of signs & symptoms
CONTRALATERALLY
 Increase ICP:
a. headache
 Where is the lesion?
b. Diplopia secondary to lateral rectus
 Levelize: Supra/ Infra (cranial deficit, cerebellar
palsy (deviation to the right)
deficit, spinal cord)
c. Vomiting
 Lateralize: Right / Left
d. Papilledema
 Localize: what part of NS is affected
C. Presence of meningeal irritation
 CNS Infection: Meningitis
Patient with right facial asymmetry & RS weakness:
 Subarachnoid Hemorrhage: flooded
Levelize?
with flood in the subarachnoid area
 o Motor & sensory system deficit : contralateral WEAKNESS
o Both upper & lower part of the face: peripheral UPPER MOTOR NEURON LOWER MOTOR NEURON
palsy: Infratentorial Spasticity Flaccid
o Central facial palsy: deficit is in Supratentorial Hyperreflexive Hyporeflexive
area affecting the lower part of the face (+) Babinski (-) Babinski
Clonus (-)
because of double innervation
(-) Fasciculations
o Facial palsy on the left & weakness on the right:
o Delineation of UMN/ LMN?
cross deficit = Infratentorial area
o UPM: Motor cortex
o LMN: Anterior Horn Cell, Peripheral nerves,
 RS WEAKNESS, eyes mediated laterally= Medial
Neuromuscular junction, Muscle
rectus is affected CN3, Brainstem
Infratentorial
AHC PN NMJ M
Pure motor Mixed type Motor Mixed
FRONTAL LOBE SIGNS: (weakness) Distal motor Segmental Fluctuating Proximal
1. Grasp reflex problem sensory Problem
2. Palmomental reflex problem
3. Pout reflex (+) PAIN
4. Rooting reflex (+) (+)
5. Glabellar signs Fasciculation Fasciculation
**
dependent
PARIETAL LOBE SIGNS: on the
1. Right to Left Disorientation nerve
2. Agraphia affected
3. Finger agnosia
4. Agraphesthesia
 58 Y/O M, HTNsive, RS weakness, Lateral rectus
TEMPORAL LOBE SIGNS: palsy on the left, hyperreflexive:
o Silent areas - Levelize? INFRA
o SEIZURES- hyperactive neurons - Lateralize? LEFT
- Localize: Metencephalon
OCCIPITAL LOBE SIGNS:  On neuro exam, the ptn presents with HA, on
o Visual problems cortical mapping, you put a coin on the left
hand of the patient & did not identify the object
SPINAL CORD LESION: - What deficit? Astereognosis
1. Bilateral lower extremity weakness  Lateralize the lesion: Right (contralateral)
(Quadriplegia):  Ptn due to bilateral lower extremity weakness,
-ex: thoracic & lumber: quadriplegia neuro exam 0/5 on both extremities, 5/5 on
Cervical area: arms & legs upper, deficit in T10 area of pain & temperature
2. Definite sensory loss: dermatomal mapping is deficit, proprioception & vibration & fine
(T10) but move 2 spinal cord level up touch is intact, Babinski on bilateral lower ext
3. Urinary/ Bowel problem: S2-S4 lesion (anal (+), hyperreflexia
sphincter) - Lateralize: Either R & L
- Localize: T8

KC GANDA
NEUROLOGY II KC GANDA
DR. FRANZ RASAY
SPINAL CORD

 Posterior Funinculus: Cuneate tract & Gracilis

tract= innervate proprioception & vibration  Secondary to LE weakness, hyporeflexia, (-)
 Lateral funiculus: Lateral spinothalamic tract = Babinski,flaccidity, (-) fasciculation,
pain & temperature segmental sensory problem
 Anterior funiculus: Anterior spinothalamic tract = - NEITHER because spinal cord
fine/ light touch - EMG-NCD: Electromyogram Nerve
conduction = for lower motor neuron deficit
 23 y/o UE weakness, inability to comb hair, neuro HEADACHE
exam: hyporeflexia, flaccidity on R ue, atrophy, (-) - Any pain/ discomfort in between the glabella/
Babinski occipital protuberance
- Localize: Muscle
 Noted fasciculations, distal weakness  Different pain sensitive structures:
- LOCALIZE: Muscle - Extracranial: outside the skull: skin, sinuses,
- Exception: distal myopathy eye, subq area, nasal area, ears, nasal
cavity
- Intracranial: inside the skull:
III. What is the nature of the lesion?
 Vessels
 Vascular: Stroke (sudden)
 Cavernous sinus or other sinuses
 Infection
 Dura & other meninges
 Toxic: ex. Pb poisoning, APAP
 Spinal nerves: cervical nerves
 Autoimmune: dermatomyositis, stroke
secondary to SLE
 Metabolic: ptn w/ multiple vomiting:
Hypokalemia
 Inflammatory: GBS/ AIDE  1st thing to do is to delineate if it is:
 Neoplastic: Vascular is sudden, Neoplastic is - Secondary HA: structural problems inside
progressive the brain; ex. Tumor, blood
 Congenital: hydrocephalus  Systemic illness: patient with HIV/ Ca
 Degenerative: Alzheimer’s disease  Neurologic problem
 Onset: ex. sudden severe HA=
*Plain CT Scan: Stroke- Bleed (with HA, high BP) subarachnoid
*Plain MRI: Infarct  Old patient: tumor
 Progressive: have a large tumor
 RS weakness, sudden onset  YES: 1 or more symptoms = secondary
-Stroke type
-Plain MRI
- Primary HA: not secondary to structural
 Progressive HA & weakness, secondary signs inside the brain
sensorium, vomiting, severe HA 1.) MIGRAINE
-Neoplastic 2.) Tension HA
-MRI w/ contrast 3.) Cluster HA

KC GANDA
 EPIDEMIOLOGY CLINICAL PATHOLOGY DIAGNOSIS TREATMENT OTHERS
MANIFESTATION

1.) MIGRAINE

Common At least 2 out of 4:

Migraine - Young “PUMA”  Familial: very sensitive artery  No  Abortive treatment:
adults  Pulsating causing pulsation of external diagnostic -NSAIDS
- W>M  Unilateral carotid artery = dec. cerebral tool
 Moderate in blood flow = cortical  Prophylactic treatment:
severity spreading depression (prevent the
 Activity in daily  This release chemicals like: occurrence, 2 or more
living CGRP, Peptides, Substance B, HA per week that
impairment Glutamate impair activities of
 Activating trigeminal vascular living)
system - Anti- convulsant:
 Activation is secondary to Valproic Acid, CBZ
some precipitant: coffee, - Anti- depressants:
fatigue/ lack of sleep Amytriptillin
- Beta blocker: -olols
- ARBS: -sartans
Neurogenic  Aura
Migraine

Complicated  Pulsating,  Prophylactic treatment  Stroke

Migraine unilateral mimickers:
 Numbness BUT all
 Slurring of speech neurologic
abnormalities
subsides
 Can lead to
migranous
infarct because
of prolonged
constriction of
blood vessel
KC GANDA
 NEUROLOGY II KC GANDA
DR. FRANZ RASAY
can cause
stroke

Status - Lasts 72 hrs - IV Steroids

Migranosus - 3-4 days/ - Other Anti
week, convulsant
continuous - Hydrate patient
2.) TENSION  Young adult Opposite of PUMA  Secondary to contraction of - CLinical - Anti-depressant - Associated
HA & early  Non pulsating different muscles  (Amytriptyline) with anxiety,
adulthood  Bilateral impinge different nerves depression &
 W =M  Mild to moderate (cervical/ trigeminal)  fatigue
in severity HEADACHE
 Will not impair
activity in daily
living
3.) Cluster HA  Young  Periorbital area  Unknown -CLinical  Diagnostic &
aka. Alarm Adult associated with  Associated with CN 5 Therapeutic: 100%
clock HA  Men lacrimation OXYGEN
 -TRIPTANS
MISCELLANEOUS HA

1.) Trigeminal - MRI W/ - Carbamazepine  Painful event

Neuralgia - Stab like, electric - Idiopathic MRA >MOA: Na blocker in neuro
- Aka: Tic shock like pain - Non idiopathic: Vascular roots  Affects the V2
Douloureux over the facial of Basilar Artery (Mandibular)
area & V3
(Maxillary)
 Associated with
Multiple
sclerosis, CT
Angle tumor &
Aneurysm of
Basilar Artery

KC GANDA
2.) Herpes - Secondary - Eye: Herpes Zoster - Antiviral -
Zoster to a virus Ophthalmicus - Anti depressant
- Aka: post - Ear: Herpes Zoster Auricularis - Anti convulsant
herpectic - Ramsay Hunt Syndrome:
neuralgia Vesicles in the pinna/
external auditory canal w/
associated deafness &
dizziness
3.) Trochlear - CN 4 -Superior oblique muscle with - Carbamazepine
Neuralgia innervates intort eye medially 
SO ADDUCTION = pain in
superomedial area
4.) Vago- - Pain upon - Carbamazepine
glossophary swallowing
ngeal
neuralgia
5.) Costen - Secondary - Most common cause: - Amitriptyline
Syndrome to pain on malocclusion of dentures - Anti convulsant
chewing or - Secondary to irritation of
trigeminal nerve
6.) Temporal - > 60 y/o - Can ;ead to - HA in temporal area - ESR ( > - Steroids
Arteritis - Male blindness - Can cause occlusion of 50mm/
headache in ophthalmic artery hr)
temporal
area
prominent,
tender,
pulsating

KC GANDA