OVERVIEW OF CLINICAL PRESENTATION OF NEUROLOGICAL DISEASES

Njideka U. Okubadejo, FMCP

Associate Professor & Consultant neurologist Faculty of Clinical Sciences, CMUL & Lagos University Teaching Hospital Idi Araba, Lagos State, Nigeria

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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 of neurologic disorders Inadequate clinical information can
greatly hamper accuracy/utility of radiological investigations result in inappropriate interventions increase mortality and morbidity Adverse financial consequences Litigation
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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 nonlocalizing 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

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 years
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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

Glaucoma

Pounding severe HA; associated nausea/vomiting/progressive altered sensorium; focal deficits; seizures Severe eye oain; nausea or vomiting; painful red eye
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ALTERED SENSORIUM
Coma (GCS<8)
Diffuse cortical dysfunction Brainstem reticular activating system dysfunction Causes: metabolic, structural intracranial abnormalities e.g. vascular, trauma, SOL Accompanying neurologic features aid definitive diagnosis

Drowsiness/ stupor: similar aetiology as coma Delirium/ acute confusional state: metabolic, vascular, trauma, toxic/drug induced
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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 connections
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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, peripheral nerve 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 myoclonus
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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, etc
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HIGHER CORTICAL DYSFUNCTION

APHASIA
Language dysfunction due to damage to neural network 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

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

Caused by motor, sensory, cerebellar or vestibular dysfunction Characteristic gaits: Cerebellar ataxic gait: broad based + incordination/nystagmus Sensory ataxic gait: positive Rombergs sign dorsal column Hemiparetic gait: arm adduction and leg circumduction CVA Scissors gait spastic paraparesis Steppage gait foot drop (unilateral: L5; sciatic n., peroneal n; bilateral: lumbosacral ) Waddling gait: proximal myopathy Parkinsonian gait: short, shuffling, festinant (basal ganglia disease) Apraxic gait: stuck; hesitant cortical disease, NPH
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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 midbrain NPMCN Radiology Update Course 2013

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
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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 profile
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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
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