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
