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Nina Ian John “G” Rachel Mark Ivz Jobe Jocelle Edo Gienah Jho Kath Aynz Je Glad

Nickie Ricobear Teacher Dadang Niňa Arlene Vivs Paul F. Rico F. Ren Mai Revs Mavis Jepay Yana Mayi Serge Hung Tope

S4L6: Neurologic Symptoms by Dr. Alfredo Guzman

OUTLINE

I. Primary Headache
A. Migraine International Classification of headache Disorders 2nd Ed. (1st revision)
B. Tension-Type Headache
C. Cluster Headache and other TAC PRIMARY HEADACHES
D. Other Primary Headache
II. Secondary Headache
A. Attributed to Head and Neck Trauma I. Migraine
B. Attributed to Cranial or Cervical Vascular Disorder
C. Attributed to Nonvascular Intracranial Disorder A. Migraine without Aura
D. Attributed to Substance or its Withdrawal
E. Attributed to infection Diagnostic Criteria:
F. Attributed to Disorder of Homeostasis a. At least 5 attacks fulfilling criteria B-D
G. Attributed to Disorder of cranium, neck, eyes, etc b. Headache attacks lasting 4-72 h (untreated or
H. Attributed to Psychiatric Disorder
unsuccessfully treated)
III. Cranial Neuralgias, Central and Primary Facial Pain and other
Headache c. Headache has ≥2 of the following characteristics
A. Cranial Neuralgias and central causes of pain  Unilateral location
B. Other headache, Cranial Neuralgia, Central and Primary  Pulsating quality
Facial Pain  Moderate or severe pain intensity
IV. Dizziness and Vertigo  Aggravation by or causing avoidance of routine
V. Limb Wekness physical activity
VI. Disorder of Gait d. During headache ≥1 of the following:
 Nausea and/or vomiting
 Photophobia and phonophobia
e. Not Attributed to another Disorder

Notes:
If <5 attacks but criteria B-E otherwise met, code as
probable migraine without aura
When attacks occur on ≥15 days per month for >3 mos.
Code as migraine without aura + Chronic migraine
Pulsating means varying with the heartbeat
In children,
 Attacks may last 1-72 h
 Occipital headache requires caution
In young children,
 Photophobia and/or phonophobia may be inferred from
their behaviour

 “Not attributed to another disorder” means Hx and PE do not


suggest any of the disorders or they suggest such disorders but is
ruled out by appropriate investigation, or such disorder is present
but headache does not occur for the first time in close temporal
relation to the disorder.

B. Migraine with Aura

Diagnostic Criteria:
a. At least 2 attacks fulfilling criterion B
b. Migraine aura fulfilling criterion B and C for one of the
subtypes
c. Not attributed to another disorder

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Subtypes include:  Heachache fulfilling criteria B-D for Migraine without
aura begins during the aura or follows onset of aura
1. Typical Aura with Migraine Headache within 60 min
Most migraine aura are associated with headache fullfilling d. At least one 1st or 2nd degree relative fulfills these criteria
criteria for migraine without aura e. Not attributed to another disease

Diagnostic Criteria: 5. Sporadic Hemiplegic Migraine


a. At least 2 attacks fulfilling criteria B-D
b. Aura consisting of ≥1 of the following, but no motor 6. Basilar-type migraine
weakness
 Fully reversible visual symptoms including postive Diagnostic Criteria:
and/or negative features  Same as #1 except
 Fully revesible senosry symptoms including positive b. Aura consisting of ≥2 of the following fully reversible
and/or negative features symptoms, but no motor weakness:
 Fully reversible dysphasic speech disturbance  Dysarthria
c. At least 2of the following:  Vertigo
 Homonymous visual symptom and/or unilateral  Tinnitus
sensory symptoms  Hypacusia
 At least one aura symptom develops gradually over ≥5  Diplopia
min and/or different aura symptoms occur in  Visual symptom simultaneously in both temporal and
succession over ≥5 min nasal fields of both eyes
 Each symptom lasts ≥5 and ≤60 min  Ataxia
d. Headache fulfilling criteria B-D for Migraine without aura  Decreased level of consciousness
begins during the aura or follows aura within 60 min  Simulateously bilateral paraesthesias
e. Not attributed to another disorder c. At least one of the following:
 At least one aura symptom develops gradually over ≥5
2. Typical Aura with non-migraine Headache min and/or different aura symptoms occur in
succession over ≥5 min
Diagnostic Criteria:  Each aura symptom lasts ≥5 min and ≤60 min
Same as #1 except
d. Headache does not fulfill criteria B-D for migraine without C. Childhood Periodic Syndroms that are commonly precursors of
aura begins during the aura or follows aura within 60 min Migraine

3. Typical Aura without Headache Subtypes include:


Migraine aura is sometimes associated with a headache that
does not fulfill these criteria 1. Cyclical Vomiting
Or occurs wihtout headache
2. Abdominal Migraine
Diagnostic Criteria:
Same as #1 except Diagnostic Criteria:
d. Headache does not occur during aura or follow aura within a. At least 5 attacks fulfilling criteria B-D
60 min b. Attacks of abdominal pain lasting 1-72 h
c. Abdominal pain has all of the following characteristics:
4. Familial Hemiplegic Migraine (FHM)  Midline location, periumbilical or poorly localized
 Dull or “just sore” quality
Diagnostic Criteria:  Moderate or severe intensity
a. At least 2 attacks fulfilling criteria B and C d. During abdominal pain ≥2 of the following:
b. Aura consisting of fully reversible motor weakness and ≥1  Anorexia
of:  Nausea
 Fully reversible visual symptoms including postive  Vomiting
and/or negative features  Pallor
 Fully revesible senosry symptoms including positive e. Not attributed to another disorder
and/or negative features
 Fully reversible dysphasic speech disturbance 3. Benign Paroxysmal Vertigo of Chilhood
c. At least 2 of the following:
 At least one aura symptom develop over gradually ≥5 D. Retinal Migraine
min and/or different aura symptoms occur in
succession over ≥5 min
 Each aura symptom last ≥5 min and <24 h

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E. Complications of Migraine II. Tension-Type Headache

1. Chronic Migraine A. Infrequent episodic tension-type headache

Diagnostic Criteria: Diagnostic Criteria:


a. Headache fulfilling criteria C and D for migraine without aura a. At least 10 episodes occurring <1 d/mo (<12 d/y) and fulfilling
on ≥15 days per month for > 3 months criteria B-D
b. Not attributed to another disorder b. Headache lasting from 30 min to 7 days
c. Headache has ≥2 of the following characteristics:
Notes:  Bilateral location
 When medication overuse is present, this is the most likely  Pressing/tightening (non-pulsating) quality
cause of chronic symptoms  Mild or moderate intensity
 Code according to antecedent migraine subtype +  Not aggravated by routine physical activity
Probable chronic migraine + Probable MOH d. Both of the following:
 Post withdrawal code is:  No nausea or vomiting (anorexia may occur)
 Chronic migraine + antecedent migraine subtype if  No more than one of photophobia or phonophobia
symptoms persist beyond 2 months e. Not attributed to another disorder
 Medication-overuse headache +antecedent migraine
subtype if, before 2 months, improvement occurs and Subtypes:
these criteria are no longer fulfilled
 Chronic 1. Infrequent Episodic TTH Associated with Pericranial
 Denotes persistence over a period of more than 3 Tenderness
months
 For primary headache disorders that are more usually Diagnostic Criteria:
episodic, chronic is used whenever headache occurs a. Episodes fulfilling criteria A-E for Infrequent Episodic TTH
on more days than not over more than 3 months with b. Increased pericranial tenderness on manual palpation
TAC as exemption
2. Infrequent Episodic TTH Not Associated with pericranial
2. Status Migrainosus Tenderness
3. Persistent aura without infarction
4. Migrainous Infarction Diagnostice Criteria:
5. Migraine-triggered Seizures a. Episodes fulfilling criteria A-E for Infrequent Episodic TTH
b. No increased pericranial tenderness
F. Probable Migraine
B. Frequent episodic tension-type headache
1. Probable Migraine without aura
Diagnostic Criteria:
Diagnostic Criteria:  Same as A except
a. Attacks fulfilling all but one of criteria A-D for Migraine a. At least 10 episodes occurring on ≥1 but ≤15 d/mo for ≥3 mo
without aura (≥12 and <180 d/y) and fulfilling criteria B-D
b. Not attributed to another disorder
Subtypes:
2. Probable Migraine with aura
1. Frequent Episodic TTH Associated with pericranial
Diagnostic Criteria: tenderness
a. Attacks fulfilling all but one of criteria A-D for Migraine with
aura Diagnostic Criteria:
b. Not attributed to another disorder a. Episodes fulfilling criteria A-E for Frequent Episodic TTH
b. Increased pericranial tenderness on manual palpation
3. Probable Chronic Migraine
2. Frequent Episodic TTH not associated with pericranial
Diagnostic Criteria: tenderness
a. Headache fulfilling criteria C and D for Migraine without aura
on ≥15 d/mo for >3 mo Diagnostic Criteria:
b. Not attributed to another disorder but there is, or has been a. Episodes fulfilling criteria A-E for Frequent Episodic TTH
within the last 2 mo, medication overuse fulfilling criterion B b. No increased pericranial tenderness
for any of the subforms of Medication-overuse headache

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C. Chronic tension-type headache III. Cluster Headache and other Trigeminal Autonomic Cephalalgia

Diagnostic Criteria: A. Cluster Headache


a. Headache occurring on ≥15 d/mo (≥180 d/y) for > 3 mo and
fulfilling criteria B-D Diagnostic Criteria:
b. Headache lasts for hours or may be continuous a. At least 5 attacks fulfilling criteria B-D
c. Headache has ≥2 of the following characteristics: b. Severe or very severe unilateral orbital, supraorbital and/or
 Bilateral location temporal pain lasting 15-180 min if untreated
 Pressing/tightening (non-pulsating) quality c. Headache is accompanied by ≥1 of the following:
 Mild or moderate intensity  Ipsilateral conjunctival injection and/or lacrimation
 Not aggravated by routine physical activity  Ipsilateral nasal congestion and/or rhinorhea
d. Both of the following:  Ipsilateral eyelid edema
 Not >1 of photophobia, phonophobia, mild nausea  Ipsilateral forehead and facial sweating
 Neither moderate or severe nausea not vomiting  Ipsilateral miosis and/or ptosis
e. Not attributed to another disorder  A sense of restlessness or agitation
d. Attacks have a frequency from ½ d to 8 d
Subtypes: e. Not attributed to any disorder

1. Chronic TTH associated with Pericranial Tenderness Subtypes:

Diagnostic Criteria: 1. Episodic Cluster Headache


a. Headache fulfilling criteria A-E for Chronic TTH
b. Increased pericranial tenderness on manual palpation Diagnostic Criteria:
a. Attacks fulfilling criteria A-E for Cluster headache
2. Chronic TTH not associated with pericranial Tenderness b. At least 2 cluster periods lasting 7-365 d and separated by
pain free remission periods of ≥1 mo
Diagnostic Criteria:
a. Headache fulfilling criteria A-E for Chronic TTH 2. Chronic Cluster Headache
b. No increased pericranial tenderness
Diagnostic Criteria:
D. Probable tension-type headache a. Attacks fulfilling criteria A-E for Cluster headache
b. Attacks recur every over >1 y without remission periods or
Subtypes: with remission period lasting <1 mo

1. Probable Infrequent Episodic TTH For TAC, chronic is not used until the condition has been unremitting
for more than 1 year.
Diagnostic Criteria:
a. Episodes fulfilling all but one criteria A-D for Infrequent B. Paroxysmal Hemicrania
episodic TTH
b. Episode do not fulfill criteria for migraine without aura Diagnostic Criteria:
c. Not attributed to another disorder a. At least 20 attacks fulfilling criteria B-D
b. Attacks of severe unilateral orbital, supraorbital or temporal pain
2. Probable Frequent Episodic TTH lasting 2-30 min
c. Headache is accompanied by >/=1 of the following:
Diagnostic Criteria:  ipsilateral conjunctival injection and/or lacrimation
a. Episodes fulfilling all but one criteria A-D for Frequent  ipsilateral nasal congestion and/or rhinorrhoea
episodic TTH  ipsilateral eyelid oedema
b. Episode do not fulfill criteria for migraine without aura  ipsilateral forehead and facial sweating
c. Not attributed to another disorder  ipsilateral miosis and/or ptosis
d. Attacks have a frequency >5/d for > half of the time,although
3. Probable Chronic TTH periods with lower frequency may occur
e. Attacks are prevented completely by therapeutic dosesof
Diagnostic Criteria: indomethacin
 Same as Chronic TTH except: f. Not attributed to another disorder
e. Not attributed to another disorder but there is, or has been
within the last 2 months, medication overuse fulfilling
criterion B for any of the subtypes of Medication-overuse
headache

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Subtypes: b. Occurs during sexual activity and incerases with sexual
excitement
1. Episodic Paroxysmal Hemicrania c. Not attributed to another disorder

Diagnostic Criteria: 2. Orgasmic Headache


a. Attacks fulfilling criteria A-F for Paroxysmal Hemicrania
b. At least 2 cluster periods lasting 7-365 d and separated by Diagnostic Criteria:
pain free remission periods of ≥1 mo a. Sudden severe (“explosive”) headache fulfilling criterion B
b. Occurs at orgasm
2. Chronic Paroxysmal Hemicrania c. Not attributed to another disorder

Diagnostic Criteria: V. Hypnic headache


a. Attacks fulfilling criteria A-F for Paroxysmal Hemicrania
b. Attacks recur every over >1 y without remission periods or Diagnostic Criteria:
with remission period lasting <1 mo a. Dull headache fulfilling criteria B-D
b. Develops only during sleep, and awaken patient
C. Short-lasting unilateral neuralgiform headache attacks with c. At least 2 of the following characteristics:
conjunctival injection and tearing (SUNCT)  Occurs >15 time per month
 Last ≥ 15 min after walking
Diagnostic Criteria:  First occurs after age of 50 years
a. At least 20 attacks fulfilling criteria B-D d. No autonomic symptoms and no more than one of nausea,
b. Attacks of unilateral orbital, supraorbital or temporal stabbing or photophobia or phonophobia
pulsating pain lasting 5-240 s e. Not attributed to another disorder
c. Pain is accompanied by ipsilateral conjunctival injection and
lacrimation VI. Primary Thunderclap Headache
d. Attack occur with frequency 3-200 per day
e. Not attributed to another disorder Diagnostic Criteria:
a. Severe head pain fulfilling criteria B and C
D. Probable trigeminal autonomic cephalalgia b. Both of the following characteristics:
 Sudden onset, reaching maximum intensity in <1 min
Diagnostic Criteria:  Lasting from 1 h to 10 d
a. Attacks fulfilling all but one of the specific criteria for c. Does not recur regularly over subsequent weeks or months
 Cluster headache d. Not attributed to another disorder
 Paroxysmal hemicrania
 SUNCT VII. Hemicrania Continua
b. Not attributed to another disorder
Diagnostic Criteria:
Subtypes: a. Headache for >3 mo fulfilling criteria B-D
b. All of the following characteristics:
1. Probable Cluster Headache c. At least one of the following autonomic features occurs during
2. Probable Paroxysmal Hemicrania exacerbations, ipsilateral to the pain:
3. Probable SUNCT d. Complete response to therapeutic doses of indomethacin
e. Not attributed to another disorder
IV. Other Primary Headache
VIII. New Daily-persistent headache (NDPH)
I. Primary Stabbing Headache
Diagnostic Criteria:
II. Primary Cough Headache a. Headache for >3 mo fulfilling criteria B-D
b. Headache is daily and unremitting from onset or from <3 d from
III. Primary Exertional Headache onset
c. At least 2 of the followingpain characteristics:
IV. Primary Headache associated with Sexual activity  Bilateral location
 Pressing/tightening (non-pulsating) quality
Subtypes:  Mild to moderate intensity
 Not aggravated by routing physical activity
1. Preorgasmic Headache d. Both of the following:
 Not >1 photophobia, phonophobia or mild nausea
Diagnostic Criteria:  Neither moderate or sever nausea nor vomiting
a. Dull ache in the head and neck associated with awareness e. Not attributed to another disorder
of neck and//or jaw muscle contraction & fulfilling criterion B

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Notes: Headache Danger Signals on PE:
 New daily persistent headache has many similarities to chronic  Abnormal vital signs especially fever or hypertension
TTH  Altered level of consciousness
 Unique in that headache is daily and unremitting from, or almost  Meningeal irritation
from,the moment of onset  Papilledema or fundal hemorrhage
 A clear recall of such onset is necessary for the diagnosis  Uneuqal pupils
 If there is or has been within the lat 2 mo medication overuse  Weakness or sensory loss in the face and limbs
fulfilling criterion B for any of the subtypes of medication-overuse  Reflex asymmetry or abnormal plantar response
headache, the diagnosis cannot be new daily persistent headache  Clumsiness or loss of balance
 Tender, poorly-pulsatile cranial arteries

SECONDARY HEADACHES I. Attributed to Head and/or Neck Trauma

Diagnostic Criteria: A. Acute post-traumatic headache


A. Headache with one (or more) of the following characteristics and B. Chronic post-traumatic headache
fulfilling criteria C and D C. Acute headache attributed to whiplash injury
B. Another disorder known to be able to cause headache has been D. Chronic headache attributed to whiplash injury
demonstrated E. Headache attributed to traumatic intracranial hematoma
C. Headache occurs in close temporal relation to the other disorder and/or F. Headache attributed to other head and/or neck trauma
there is other evidence of a causal relationship G. Post-craniotomy headache
D. Headache is greatly reduced or resolves within 3 mo (shorter in some
disorders) after successful treatment or spontaneous remission of the II. Attributed to Cranial or Cervical Vascular Disorder
causative disorder
A. Ischemic Stroke or Transient Ischemic attack
 Before treatment of spontaneous resolution, criterion D is not fulfilled, B. Non-traumatic intracranial hemorrhage
and code as headache probably attributed to [disorder]. C. Unruptured vascular malformation
D. Arteritis
Primary Headache E. Carotid or vertebral artery pain
Diagnosis Primary + Secondary
only F. Cerebral venous thrombosis
Temporal relation of G. Other Intracranial vascular disorder
other disorder to
Loose Close
headache III. Attributed to Non-vascular Intracranial Disorder
exacerbation
Degree of A. High CSF pressure
Slight Marked B. Low CSF pressure
exacerbation
Other evidence that C. Non-infectious inflammatory disease
other disorder can D. Intracranial neoplasm
Weak Strong E. Intrathecal injection
cause secondary
headache F. Epileptic seizure
Other disorder Headache returns to G. Chiari malformation type I
Headache unchaged H. Syndrome of transient headache and neurological deficit with
eliminated previous pattern
CSF lymphocytosis (HaNDL)
I. Other non-vascular intracranial disorder
Don’t miss the following on PE:
 Focal neurologic signs (presence is indicative of 2O headache) IV. Attributed to a Substance or its Withdrawal
 Signs of Local dse of extracranial structures
 Signs of neck movement restrictions
 Thickening of the temporal arteries
A. Induced by acute substance use or exposure
 Signs of systemic dse B. Medication-overuse headache (MOH)
 Abnormal blood pressure  systemic hypotension can cause C. Adverse event attributed to chronic medication
traction on the pain sensitive structures in the cranial vault D. Substance withdrawal

V. Attributed to Infection
Headache Danger Signals on History:
 Sudden onset of new severe headache A. Intracranial infection
 Progressively worsening headaches B. Systemic infection
 Onset with exertion, coughing, straining, and/or sexual activity C. HIV/AIDS
 Onset after age 50 D. Chronic post-infection headache
 Associated with drowsiness, chronic malaise, myalgia, arthralgia, fever,
progressive visual disturbances, weakness, clumsiness, and loss of
balance

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VI. Attributed to Disorder of Homeostasis d. (replacing D and E) A causative lesion, other than vascular
compression, has been demonstrated by special
A. Hypoxia and/or hypercapnia investigations and/or fossa exploration
B. Dialysis headache
C. Arterial hypertension B. Glossopharyngeal neuralgia
D. Hypothyroidism C. Nervus intermedius neuralgia
E. Fasting D. Superior laryngeal neuralgia
F. Cardiac Cephalagia E. Nasociliary neuralgia
G. Disorder of Homeostasis F. Supraorbital neuralgia
G. Other terminal branch neuralgia
VII. Attributed to Disorder of Cranium, Neck, Eyes, Ears, Nose, H. Occipital neuralgia
Sinuses, Teeth, Mouth and other Facial or Cranial Structures I. Neck-tongue syndrome
J. External compression headache
A. Disorder of cranial bone K. Cold-stimulus headache
B. Disorder of neck L. Constant pain caused by compression, irritation or distortion of cranial
C. Disorder of eyes nerves or upper cervical roots by structural lesions
D. Disorder of ears M. Optic neuritis
E. Rhinosinusitis N. Ocular diabetic neuropathy
F. Disorde of teeth, jaws or related structures O. Head or facial pain attributed to herpes zoster
G. Temporomandibular (TMJ) disorder P. Tolosa-Hunt syndrome
H. Other disorder of the above Q. Opthalmoplegic migraine

VIII. Attributed to Psychiatric Disorders Diagnostic Criteria:


a. At least 2 attacks fulfilling criterion B
A. Somatisation disorder b. Migraine-like headache accompanied or followed within 4 days of
B. Psychotic disorder its onset by paresis of ≥1 of the 3rd, 4th and/or 6th cranial nerve
c. Parasellar, orbital fissure and posterior fossa lesions ruled out by
appropriate investigations
CRANIAL NEURALGIA, CENTRAL AND
PRIMARY FACIAL PAIN AND HEADACHE R. Central causes of facial pain
S. Cranial neuralgia or other centrally mediated facial pain
I. Cranial Neuralgias and Central Causes of Pain

A. Trigeminal neuralgia II. Other headache, cranial neuralgia, central or primary facial pain

Subtypes: A. Headache not elsewhere classified


B. Head unspecified
1. Classic Trigeminal Neuralgia

Diagnostic Criteria:
a. Paroxysmal attacks of pain lasting from a fraction of 1 sec to
2 min, affecting one or more divisions of the trigeminal nerve Dizziness
and fulfilling criteria B and C a term that patient may use to describe vertigo, faintness,
b. Pain has ≥1 of the following characteristics: disorientation, drowsiness, light-headedness, visual disturbances
 Intense, sharp, superficial or stabbing or even legs unsteadiness
 Precipitated from trigger areas or by trigger factors
c. Attacks are stereotyped in the individual patient Vertigo
d. There is no clinically evident neurologic deficit illusion or hallucination of movement
e. Not attributed to another disorder the perceived movement may be rotational, swaying, rocking, or
heaving in quality
2. Symptomatic Trigeminal Neuralgia
 Vertigo is either peripheral or central
Diagnostic Criteria:  Vertigo from supranuclear lesion is uncommon, therefore the main
 Same as #1 except: consideration would be between
a. Paroxysmal attacks of pain lasting from a fraction of 1 sec to  a peripheral lesion (labyrinthine, vestibular nerve or ganglion)
2 min, with or without persistence aching between  brainstem lesion
paroxysm, affecting one or more divisions of the trigeminal  cerebellar lesion
nerve and fulfilling criteria B and C  vertigo is usually not the sole manifestation of a brainstem disease –
always look for ipsilateral cranial nerve deficits and contralateral
pyramidal signs

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 in vertigo due to cerebellar lesions, there may be signs of ipsilateral Symptom Brainstem lesions Cerebellar lesions
incoordination which are absent in peripheral vestibular lesions  May be  Brainstem connections
Vertigo
 vertigo may be the sole manifestation of vestibular dysfunction, this can prolonged involved
be confirmed by neuro-otological testings Nystagmus  Vertical  Horizontal (coarse)
(fast phase) nystagmus  (towards the lesion)
Differential Diagnosis for Vertigo: Gait  Hemiparesis  Ataxia on side of the lesion
 Usually
A. Labyrinthine failure Hearing  Unaffected
unaffected
 Meniere’s disease  Ipsilateral
 Benign Positional Vertigo cranial nerve
 Labyrinthitis  Unilateral cerebellar signs
palsies
 Motion sickness Other signs from an ipsilateral cerebellar
 Contralateral
hemispheric lesion
pyramidal
B. Vestibular Nerve lesions involvement
 Vestibular neuronitis
Investigations in Cases of Vertigo:
C. Cerebellopontine angle lesions
 Acoustic neuroma A. Hallpike Maneuver
 Granulomatous diseases
 Vascular lesions  performed with patient sitting on a bed, and asked to fall
backwards so that his head is below the plane of his body
D. Brainstem lesions  the positioned head is turned 30 degrees to the affected side and
 Brainstem stroke syndrome the patient is asked to look to the turned side
 Demyelinating Diseases  after a latent period of few seconds, vertigo may be experienced
 Neoplastic infiltration  there’s accompanying torsional nystagmus with upper pole
beating towards the floor
E. Cerebellar diseases  the direction of the nystagmus are reversed on sitting up again

Note: In peripheral (labyrinthine) lesions, symptoms and signs


Localization of Lesion in Vertigo:
last for about 30 sec. and fatigue with repetition such
that they cannot then be reproduced
Labyrynthine Vestibular Nerve Cerebellopontine
Symptom
failure lesion angle lesion
 Common  may be
Vertigo  Rare
 Short attacks prolonged
 Horizontal  Horizontal
Nystagmus
and/or rotary and/or rotary  Horizontal
(fast
 (opposite to  (opposite to  (towards lesion)
phase)
lesion) lesion)
 Ataxia on side of
 Veers toward  Veers toward
Gait the lesion; may
the lesion the lesion
have hemiparesis
 Conductive or  Sensorineural
 Sensorineural
Hearing sensorineural high pitch loss
loss
loss early
 5th, 7th, 9th, 10th B. Caloric Testing
nerve lesion
 +/- 7th nerve or
Other  Ipsilateral  with the patient in lying position, head is raised 30 degrees, so
 none 5th nerve
signs cerebellar signs that the horizontal canals are vertical
lesions
 Contralateral  each external meatus is irrigated for 30 sec with cold and warm
pyramidal signs water
 normal response: “COWS”

Example:
a. canal paresis (peripheral lesion)
 no response to irrigation of the external meatus
 Labyrinthine lesions
 Nerve lesions
 Vestibular ganglion lesion

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b. directional preponderance Patterns of LMN Weakness:
 Brainstem vestibular nuclei lesion
I. Anterior Horn Cell diseases
may be diffused or confined to restricted group of muscles

Causes:
 Weakness in the limbs can result from pathology anywhere along the  genetic (Spinal muscular atrophy)
UMN pathway (cortex, subcortical fibers, brainstem, spinal cord), from  Idiopathic (ALS)
lesions in the LMN (anterior horn cells, nerve roots, plexus, peripheral  Infectious (Poliomyelitis)
nerves) or from disorders arising from the NMJ or the muscles  Toxic (chemical exposure, eg. Triorthocresylphosphate)

Patterns of Motor Weakness due to UMN Lesion: II. Radiculopathy (root lesions) and Plexopathy (plexus lesions)
a root lesion will cause muscle weakness in the corresponding
I. Spastic hemiparesis and ipsilateral facial weakness myotome
if the dorsal roots are also involved, there will be accompanying
a. hemispheric cortex: sensory loss in defined dermatomal distribution
 aphasia (dominant hemisphere) a plexus lesion will cause weakness in muscles innervated by a
 involvement of the face and arm alone, or number of nerve roots which comprise the plexus
 leg alone, depending on the site of the lesion accompanying sensory loss over several dermatomes may be
b. internal capsule: present
 dense hemiplegia
c. upper brainstem: Examples of Plexopathies:
 upper cranial nerve palsies
 certain characteristic sensory changes A. Brachial Plexus
a. Erb’s palsy (C5-6)
II. Spastic hemiparesis and contralateral facial weakness upper plexus injury (loss of shoulder abduction and
elbow flexion
a. Lower brainstem involvement b. Klumpke’s palsy (C8-T1)
 Lower cranial nerve palsies lower plexus injury (loss of function of the intrinsic
 certain characteristic sensory changes muscles of the hand and long flexors and extensors of
the fingers)
III. Spastic hemiparesis sparing the face c. Thoracic outlet syndrome
the brachial plexus and the subclavian artery are
a. Unilateral upper cervical cord lesions compressed by fibrous band or a cervical rib
 Brown-Sequard syndrome d. Neuralgic amyotrophy
acute brachial plexus neuropathy which may follow
IV. Spastic quadriparesis infections, vaccination, or surgery; accompanied by
severe pain
a. Lower brainstem lesions
 Lower cranial nerve palsies depending on the site of the B. Lumbosacral Plexus
lesion a. Lesions in the lumbosacral plexus includes:
b. High cervical cord lesions  trauma following abdominal surgery or pelvic surgery
 No cranial nerve deficits  neoplastic infiltration
 Loss of sensory modalities below the site of the lesion  granulomatous lesions
 compression due to aortic aneurysm
V. Spastic Paraparesis
III. Disorders of the peripheral nerves
a. Thoracic cord lesions
 Loss of all sensory modalities below the level of the lesion a. Mononeuropathy
disease of a single peripheral nerve
VI. Spastic monoparesis  Carpal Tunnel syndrome
b. Multifocal neuropathy (Mononeuropathy multiplex)
a. Unilateral thoracic cord lesion many single peripheral nerves are involved
 Brown-Sequard syndrome at the thoracic level  Diabetic neuropathy, Sarcoidosis, Leprosy
c. Polyneuropathy (Peripheral neuropathy)
more widespread involvement of the peripheral nerves
typically in a symmetric distal distribution
 GBS, Vit B12 deficiency

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IV. Disorders of the neuromuscular junction (NMJ) Causes:
the weakness predominantly affects the proximal muscles  Spinal Cord diseases / compression
may be become widespread in advanced stages  Spinal trauma or surgery
in myasthenia, ocular muscles are characteristically affected  Birth injuries or congenital deformities (eg Cerebral
the outstanding feature: easily fatiguable muscles  Palsy, Spina bifida)
wasting is relatively uncommon; reflexes are frequently normal  Multiple Sclerosis (MS)
Myasthenia gravis  Motor neuron Diseases (eg ALS, Primary lateral Sclerosis)
 Lambert-Eaton Myasthenic Syndrome  Parasaggital meningiomas
 Botulism  Subacute Combined Degeneration of the Cord
 Drug-induced NMJ malfunction
D. Pakinsonian Gait
V. Disorders of muscles stooped posture and loss of arm swing
in myopathies, limb weakness is bilateral and proximal in the steps are short and the shuffling (festinating gait)
upper and/or lower limbs there may be difficulty starting, stopping, and turning
muscle wasting may be severe and is restricted to the weak having started walking, patient leans forward and the pace
muscle quickens, as though the patient has to catch up on himself
groups
tone is reduced and is proportional to the muscle wasting E. Gait of Sensory Ataxia
 Progressive Muscular Dystrophies (Duchenne) due to impaired proprioception by lesions involving the peripheral
 Inflammatory Myopathies (Polymyositis) nerves, posterior root, dorsal columns of the spinal cord, or the
ascending fibers to the parietal lobes
the gait is “stamping” (shoe soles are equally worn out)

Causes:
 Posterior Spinal Cord lesions
A. Cerebellar Ataxia
 Vit. B12 deficiency
patient stands and walks on a wide-based gait (the feet spaced
 Tabes dorsalis
widelyapart)
 Cervical Spondylosis
gait is unsteady, with irregularity of stride
 MS
trunk sways and the patient may veer towards one side
in mild cases, the only manifestation of gait disturbance may be
Sensory peripheral neuropathies include:
difficulty walking heel-toe in a straight line
 Hereditary
always look for cerebellar signs in the limbs; ataxia of gait may
 Charcot-Marie-Tooth disease
be the only sign of cerebellar dysfunction (midline cerebellar
 Metabolic
lesions
 Diabetic Neuropathy
Causes:  Inflammatory
 Multiple Sclerosis  GBS
 Alcoholic Cerebellar Degeneration  Malignancy
 Anticonvulsant therapy  paraneoplstic Syndrome
 Posterior Fossa Tumors  Toxic
 Cerebellar Paraneoplastic Syndromes  alcohol, drugs
 Hereditary Cerebellar Ataxias
F. Steppage Gait
B. Hemiparetic Gait arises from weakness of the pretibial and peroneal muscles of the
there is a characteristic posture on one side (flexion of the upper LMN-type
limb and extension on the lower limb patient has “footdrop” and is unable to dorsiflex and evert the foot
the extended lower limb moves stiffly and is swung round in a leg is lifted high on walking so that the toes clear the ground
semicircle to avoid scraping the foot across the floor (the outer on striking the floor, there is “slapping” noise (shoe soles are worn
sole of the shoe is become worn) in the anterior and lateral aspects)

Causes:
Causes:
 Charcot-Marie-Tooth disease (bilateral footdrop)
 Cerebral hemispheric stroke syndromes
 Fibular fracture (lateral popliteal nerve palsy)
 Infiltrating neoplasms (Glioblastoma multiforme)
 Anterior horn cell disease (Poliomyeltis)
 Traumatic Head Injury

G. Myopathic Gait
C. Spastic Gait
waddling gait; due to weakness of the proximal muscles of the
seen in patients who have spastic paraparesis or bilateral
lower limb girdle
hemiplegia
weight is alternately placed on each leg, with the opposite hip and
legs move slowly and stiffly, the thighs are strongly adducted
one side of the trunk tilting up towards the weight-bearing side,
suchthat the legs may cross as the patient walks (scissor gait)
the weak gluteal muscles cannot stabilize the weight-bearing hip

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Causes:
 Muscular Dystrophies (eg. Duchenne, Becker’s)
 Endocrine Myopathies (eg Cushing’s Disease)
 Metabolic Myopathies (eg. Periodic paralysis)
 Inflammatory Myopathies

H. Apraxic Gait
Walks with feet placed apart, and with small, hesitant steps
“walking on ice”
there is difficulty initiation of walking, and with advances cases, as
if the patient is stuck to the floor
due to frontal lobe disease; look for primitive frontal reflexes

Causes:
 Bilateral subcortical stroke
 Normal-pressure hydrocephalus
 Alzheimer diseases
 Frontal Subdural hematoma
 Frontal lobe tumors

I. Antalgic Gait
arises from pain (painful hip or knee) due to arthritis
Patient tend to weight-bear mainly on the affected side
tendency to hobble

J. Hysterial Gait
does not conform to any of the mentioned abnormal gait
may take a number of forms and is variable in character
no abnormal formal neurological deficits

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