Neuro I - Medi

The patient has a *trochlear nerve palsy* affecting the *right eye*. Remember: the head tilt is opposite the affected eye. Neurological Exam I

The above patient presents with *blurry vision* or some vague problem when looking down, especially when reading a book or climbing stairs. Which eye is affected?

1) In addition to chest wall symptoms like those described in the patient in Case #10 this patient has left leg weakness, which could not be explained by a lesion in the thoracic nerve root. Instead, the most plausible localization is within the *thoracic spinal cord* on the left, in the one or two segments where the spinothalamic pathway has not yet crossed to the right side of the cord. 2) This is a focal lesion 3) Since it is progressive, it is a mass lesion. 4) The time course is chronic. 5) A chronic focal lesion is a neoplasm. A meningioma was removed and the patient is doing well after 3 months of physical therapy.

The pain involves the left side of her chest. No rash is present and for many months, the pain has been getting worse. It remains localized to a narrow and circumscribed area of her chest, making her think that it might be "heart trouble." In addition, she complains of difficulty walking and says that her left leg seems to be weak and stiff. 1. Where is the lesion? 2. Is the lesion focal, multifocal, or diffuse? 3. Is this a mass lesion or a non-mass lesion? 4. What is the temporal profile? 5. What diagnostic category is most likely

(A)*Positive Scotoma* - blackness or a sense of blockage of vision which suggests *retinal diseases*. (B)*Negative Scotoma* - absence of vision a *blank spot*, suggests *optic nerve lesions*.

The pictures A and B represent what? And what is their significance?

*Adie's Homes syndrome* = tonic pupil in presence of decreased DTRs of the lower extremities.

You examine a 25 year-old female for *migraine headaches*. Her examination is entirely normal except you notice a *middilated pupil* on the right that reacts poorly to light. Some pupillary constriction can be elicited with the accommodation response, but the *pupil then remains constricted* and dilates very *slowly*. You also notice that her *DTRs in her lower extremities are 0-1/4 bilaterally*. Your diagnosis is?

*Occipital Lobe* Occipital lobe lesions that spare the posterolateral striate cortex causes a contralateral *homonymous hemianopias* that are symmetrical, and tend to spare the macula.

You suspect a lesion in the?

*Supratentorial & Posterior Fossa* *Diffuse* *Toxic Metabolic* 1. The answer is (A) and or (B) *Supratentorial and posterior fossa* are affected due to the level of consciousness. Remember the reticular activating system? Certainly diffuse processes affect all of the nervous system however the most alarming problem is the *level of consciousness*. You will have to examine the other parts of the nervous system when the patient wakes up. 2. (D) Diffuse, as you *cannot* find any localizing signs. 3. *Toxic/metabolic is most likely*. At this age the patient probably has taken some form of toxin or medication and your workup should be toward uncovering the type of substance followed by appropriate treatment. The pupillary dilation/constriction will help guide you as to the class of substance taken. Clinical Diagnosis 1

A *2-year-old child* was seen by you at 1p.m. due to *stumbling and lethargy* associated with nausea and vomiting. The mother relates the child was in *good health this a.m.* but was difficult to arouse from his nap for lunch. You find the patient to be *somnolent, arouses to light pressure but falls back to sleep and his pupils are constricted but reactive to light*. The temp is normal and no other neurological signs are present. Which level? The process is? Cause?

*Peripheral * *Inflammatory* This patient has *Carpal Tunnel Syndrome*, compression of the median nerve under the flexor retinaculum of the wrist. however, in severe cases there may be atrophy of the thenar eminence. Based on this history you would expect *inflammation* (swelling) as the primary cause. If you answered *trauma* you would also be correct (as most Carpal tunnel syndromes occur as a result of repeated trauma to the wrist as in repetitive use of the hand would be the underlying cause Clinical Diagnosis 1

A *23 year old* male presents with *numbness and tingling of his right hand*. The patient's hand numbness *wakes him up at night* and he has to shake it for normal feeling to return. There is a *(+) Tinel's sign* over the median nerve of the wrist. The patient has no other complaints. Which level? Cause?

*Supratentorial* *Inflammatory* The visual pathways including the *optic nerve, tract, radiations and occipital lobe are above the tentorium.* This case associated with eye pain on movement and visual loss points to a *lesion of the optic nerve.* If you guessed *inflammatory* you would be correct. This case is classic of *Optic neuritis* and given the age of this patient, you will learn later on, you would suspect Multiple Sclerosis Clinical Diagnosis 1

A *23-year-old* graduate student was *studying late at night* for an examination. As he looked at his textbook, he realized he was having *difficulty reading through his left eye*. When he covered his left eye, his vision in the right eye seemed normal. However, when he covered his right eye, his vision in the *left eye was blurred*. Within several hours he *lost his vision completely*. Other than left ocular pain when he moved his eyes, he had no other symptoms. Which level? Cause?

*Supratentorial* *Vascular* Supratentorial because the numbness is in the left face and hand (contralateral to the focal lesion). If you guessed 'Vascular' your correct. *thrombotic* event during the night. problem was in the distribution of the *middle cerebral artery.* Clinical Diagnosis 1

A *60 year old* male comes to see you for *numbness and a slight weakness* in his *left lower face*. He states it was present on awakening *yesterday morning* and it was not present when he went to bed. On further questioning: he has noticed *numbness and clumsiness in his left hand* when buttoning his shirt. Which level? Cause?

*Posterior Fossa & Peripheral* *Vascular* The patient is suffering from a peripheral nerve lesion involving the 6th cranial nerve located in the posterior fossa. Remember in the posterior fossa we try to distinguish between a lesion of the peripheral cranial nerves (after exiting the dura) and those within the brainstem (with additional brainstem or long tract findings). In this case there were no other brainstem findings indicating that only the right lateral rectus muscle was weak; thus a peripheral lesion. I would accept either posterior fossa or peripheral level as an answer as long as you know the distinction that I have illustrated. Vascular due to the sudden onset. Also his history of hypertension and coronary artery disease is highly suggestive that the patient has multiple vascular problems Clinical Diagnosis 1

A *65-year-old* man with a *history of hypertension, coronary artery disease presents with a complaint of sudden onset of double vision*. Further questioning reveals the diplopia occurs *only on horizontal gaze and not vertical gaze*. Other than *weakness of the right lateral rectus muscle*, there are no other neurological complaints or findings. Which level? Cause?

McArdle's disease (GSD - Type V)

A 17-year-old boy presented with *severe pain, stiffness, and "hardening" of his forearm muscles* while moving the contents of his friend's house. In the immediate aftermath, he noticed that his urine was "*Coca-Cola" colored*. Hours later, his physical examination results were normal with the exception of the muscle tenderness to palpation. His serum creatine kinase (CPK) level was increased *50 times normal*. His BUN was increased, and myoglobin was in his urine. The patient was admitted to the hospital and treated with vigorous IV hydration. His symptoms resolved within several days. A forearm exercise test demonstrated the expected *increase in venous ammonia* levels without the expected increase in lactate. Dx?

1. The patient has a *supratentorial lesion* 2. It is a *focal left lesion.* 3. It is, most likely, a *mass* until proven otherwise 4. Most likely, until proven otherwise, has a *subdural hematoma* due to the auto accident. (Subdural hematomas may occur up to 3 weeks after the trauma) Clinical Diagnosis 1

A 19-year-old man was in an *automobile accident.* Two weeks later, he gradually developed *progressive headaches and personality changed*, with reduced motivation. His family also noted that his *right face seemed to droop and he had mild weakness of his right arm and leg.* 1. What level do you suspect his problem is located (ST, PF, S, P, M)? 2. Is lesion focal (R,L,ML) or diffuse? 3. Is lesion a non-mass or mass (H, N, A)? 4. What do you suspect as the cause?

*Physiologic anisocoria* Physiologic anisocoria (Benign essential anisocoria). The pupil remains the same in low, ambient and bright light. Reassurance is all that is needed.

A 20 year-old female presents with a concern that her *right pupil is larger than the left*. She notices that It also varies from day to day and even from hour to hour and often will disappear. On examination you notice that the *left pupil demonstrates the same degree of asymmetry in size in low, ambient, and bright light conditions*. Your diagnosis is:

1) The abnormal sensory and motor function below a level in the mid-abdomen indicates a *focal lesion in the spinal cord*, at the thoracic level or above. 2) Focal 3) Since the symptoms are progressive, this is a mass lesion. 4) The time course is *subacute*. 5) A focal, subacute lesion is typically *inflammatory*, specifically, an abscess.

A 21--‐year--‐old right--‐handed woman experienced a *sensation of numbness and tingling* over her *abdomen and in her legs*. The next day her legs began to feel *stiff and tight*, and she experienced *incomplete voiding* and difficulty in initiating her urinary stream. As the day progressed, the numbness and tingling became more pronounced in her mid--‐abdomen and below, and she noted *difficulty in walking*. She went to bed early that evening, and when she awoke the next morning, she was unable to stand. 1. Where is the lesion? 2. Is the lesion focal, multifocal, or diffuse? 3. Is this a mass lesion or a non-mass lesion? 4. What is the temporal profile? 5. What diagnostic category is most likely

1. *Spinal* 2. *Focal, left* 3. *Non mass* 4. Acute due to a gun shot at the time of onset 5. *Brown Sequard syndrome at the T10* level Clinical Diagnosis 2

A 21-year-old *soldier returned from Iraq* after sustaining a *gunshot wound in his spinal column*. On neurologic examination, you note that he has *weakness of the left lower extremity*. In addition, he has *lost of pain and temperature perception on the right side* from about the level of his navel downward. Vibration, joint position sense, and discriminatory function are reduced in the left leg and touch is normal. 1. What level is the lesion? 2. Is the lesion focal, multifocal, or diffuse? 3. Is this a mass lesion or a non-mass lesion? 4. What is the temporal profile? 5. What diagnostic category is most likely

1. *Organic* 2. *Affecting multiple levels* (neck stiffness (spinal level); reduced level of consciousness (posterior fossa/supratentorial level). 3. *Diffuse* 4. *Non-mass* 5. Cause is *infectious*: Most likely represents meningococcal (rash) meningitis and is definitely a neurological emergency. NOTE: Any neurological complaint in the presence of fever is infection until proven otherwise. Clinical Diagnosis 1

A 21-year-old female college student developed a *diffuse body rash, fever, and headache*. One day later, she began to complain of *neck and back pain, especially with neck flexion*. After 2 days, she developed *reduced level of consciousness* as well as continuing to have fever. Neurological examination demonstrated an altered level of consciousness and neck stiffness (*Kernig's and Brudzinski's*) otherwise the exam was normal. 1. Is her problem functional or organic? 2. What level do you suspect his problem is located (ST, PF, S, P, M)? 3. Is lesion focal (R,L,ML) or diffuse? 4. Is lesion a non-mass or mass (H, N, A)? 5. What do you suspect as the cause?

1) The altered level of consciousness indicates dysfunction in the brainstem, thalamus, or both cerebral hemispheres. The generalized seizures are indicative of *bi-hemispheric disease. (Reticular Activating System involvement).* 2) All of the abnormal neurologic findings (e.g., hyperreflexia and Babinski's signs, and altered consciousness) are symmetric. Thus the condition is *diffuse* or multiple levels. 3) *not a mass lesion* 4) The symptoms developed over 2 days, making them *subacute.* 5) A diffuse, subacute process could either be toxic-metabolic or inflammatory. In this case, the fever and stiff neck make *meningitis or encephalitis* most likely. A NEUROLOGICAL EMERGENCY. Clinical Diagnosis 2

A 22-year-old man was *well until two days ago,* when he developed *fever*, severe headache, nausea and vomiting. He became progressively more obtunded over the next day. He had *two generalized seizures in the morning* and was brought to the emergency room, where he was found to have a *fever and stiff neck*. He was *stuporous, and had generalized hyperreflexia* and *bilateral Babinski's signs.* 1. What level is the lesion? 2. Is the lesion focal, multifocal, or diffuse? 3. Is this a mass lesion or a non-mass lesion? 4. What is the temporal profile? 5. What diagnostic category is most likely

Baseline EKG, overnight polysomnography, and genetic counseling

A 35-year-old woman with genetically proven myotonic dystrophy presents to your clinic. Her chief complaint is fatigue. She has not seen a physician in several years. She complains of bilateral foot drop and distal hand stiffness but denies any other problems. Social History: She does not smoke or drink. She finished high school at 19 and took one semester of college work. She is recently married. In her family history, she reports that her father wears braces and uses CPAP at night. You recommend for the patient:

1. She most definitely has a problem. (Organic) 2. She has a *spinal cord injury* 3. *Focal* (Dermatomes above T4 are normal) and is midline in location (bilateral sensory and motor loss). 4.*Mass* (hemorrhage or compression causing ischemia) cannot be ruled out at this time. 5. *Trauma* is most likely the initial cause of her symptoms. Clinical Diagnosis 1

A 24-year-old woman was in an *automobile accident.* When examined by you in the ER, she had complete loss of *sensation from the level of the arms downward*. She *could not move her hands or legs* and had *no sensation below the axilla*. She was *incontinent* of urine. 1. Is her problem functional or organic? 2. What level do you suspect his problem is located (ST, PF, S, P, M)? 3. Is lesion focal (R,L,ML) or diffuse? 4. Is lesion a non-mass or mass (H, N, A)? 5. What do you suspect as the cause?

1) *Supratentorial Level* weakness of left face, arm, leg imply right sided focal lesion 2) Focal 3) It is progressive thus a *mass lesion*. 4) The time course is *chronic* (3 months). 5) Again, a focal, chronic lesion implies a *neoplasm*. *right subdural hematoma* (SDH) Clinical Diagnosis 2

A 28-year-old *accountant and part-time boxer* has been brought to the urgent care clinic by his wife because he has become *irritable and abusive*. She reports that he has had *intermittent headaches for 3 months*, and the headaches have become more severe. He has been *unable to work* for about a week because of excessive drowsiness, and he *sleeps for up to 24 hours* if not awakened. On neurologic examination, he is drowsy but able to follow commands. He has mild to moderate *weakness in his left arm and leg*, and a *left pronator drift*. Tendon reflexes are hyperactive on the left with a *Babinski's response*. The lower part of his face *droops slightly on the left side*. 1. What level is the lesion? 2. Is the lesion focal, multifocal, or diffuse? 3. Is this a mass lesion or a non-mass lesion? 4. What is the temporal profile? 5. What diagnostic category is most likely

1) The patient has symptoms confined to the distribution of a *single nerve root*. This makes a lesion in the nerve root itself most likely 2) In any case, the lesion is focal 3) The lesion is not progressive, so it is not a mass lesion. 4) The time course is subacute 5) The process is probably inflammatory, and probably due to shingles. Comment: A rash in a dermatomal distribution is very suggestive of herpes zoster reactivation, which can produce sensory symptoms (especially pain) in the same distribution. This occurs particularly often in immunocompromised individuals, including those receiving chemotherapy for cancer.

A 30--‐year--‐old man with *Hodgkin's disease* began to experience severe pain beginning in his *back and encircling the left side* of his chest in a band 3 cm wide just below his breast. The pain was very intense at first but subsided somewhat, coincident with a rash that appears in precisely the same distribution. He is still having pain in that area two weeks later, and notes *diminished touch sensation in the region of pain*. 1. Where is the lesion? 2. Is the lesion focal, multifocal, or diffuse? 3. Is this a mass lesion or a non-mass lesion? 4. What is the temporal profile? 5. What diagnostic category is most likely

*Have normal intelligence* IQ plays no role. The patient must have prior knowledge of the objects presented before the stroke occurred

A 63 year-old patient presented with a *stroke* that caused *weakness in his left face and upper arm* which, for the most part has resolved after 3 days. Currently you find that he is still demonstrating some *Dysprosody* and has some *difficulty recognizing familiar objects*. You show him a pen and is still unable to name them. You suspect a visual and *tactile agnosia*. The requirements for making this diagnosis are all of the following except:

A. *Optic nerve.* B. *Retrobulbar optic neuritis* = decreased visual acuity or blindness, afferent pupil, and a normal funduscopic Examination

A 32 year-old woman presents to the ER complaining of *blurred vision and pain in the right eye*. Evaluation: *decreased visual acuity* in the *right eye* and funduscopic examination of both eyes is normal. There is a relative *afferent pupillary defect on the right*, and testing of the right visual field shows a *small central scotoma*. The most likely localization of the lesion: What do you call this finding?

*Third-nerve Palsy* She should be referred to an emergency department immediately for a neurosurgery consultation for possible intracranial aneurysm, magnetic resonance imaging and angiography of the brain, and possibly a cerebral angiogram. The third cranial nerve travels within the subarachnoid space between the posterior cerebral and superior cerebellar arteries

A 37-year-old woman presents to an urgent care clinic with acute onset of a headache and a *droopy left eyelid*. Visual acuity is *20/20* in each eye. When you lift up her left upper eyelid, you discover that the eye is *deviated outward and downward*. When you assess ocular motility, the *left eye can't elevate*, adduct or depress. The only motility present in the eye is the ability to look away from the nose. The *left pupil also appears dilated* compared to the right pupil. The right eye shows no motility deficits. What is your diagnosis?

*Ask the patient how to use silverware, thread a needle, strike a match and light a candle* Ideomotor apraxia is more complicated requiring sequential actions

A 3rd year *KCOM student* on rotation presents the case of a patient with a *brain tumor* who is experiencing some *frontal lobe difficulties*. The student believes that the patient has an *ideomotor apraxia*. You confirm this by:

Myotonic dystrophy

A 40-year-old man presents with weakness of all four extremities, facial weakness, and dysarthria of several months' duration. Neurologic examination revealed bilateral ptosis; a "hatchet face," depicting the facial weakness; weakness on flexion and extension of the hands, fingers, feet, and toes; distal atrophy of the muscles of the extremities; slow relaxation of the hand grip; and myotonia of the thenar eminence and tongue. In addition the patient demonstrated premature baldness, cataracts, and testicular atrophy. The diagnosis was confirmed by EMG and muscle biopsy. What is the diagnosis?

1. *Peripheral* (lateral femoral cutaneous nerve) 2. *Focal*, right 3. *Non mass* 4. Acute 5. *Traumatic/vascular*: This is the classic case of *Meralgia Paresthetica* seen usually in patients with tight fitting garments or people wearing their belts too tight due to weight gain causing *compression of the lateral femoral cutaneous nerve* as it exits under the inguinal ligament (therefore traumatic). Clinical Diagnosis 2

A 48-year-old woman experienced the *abrupt onset of pain*, followed by paresthesia and loss of feeling in a rather circumscribed area along the *lateral aspect of her right thigh*. Neurologic examination showed a localized area of *decreased perception of pin prick, temperature, and touch.* The results of the rest of the examination were normal. 1. What level is the lesion? 2. Is the lesion focal, multifocal, or diffuse? 3. Is this a mass lesion or a non-mass lesion? 4. What is the temporal profile? 5. What diagnostic category is most likely

1) The altered level of consciousness indicates dysfunction in the *brainstem, thalamus, or both cerebral hemispheres* ( 2) Diffuse or Multiple levels (Supratentorial, Posterior fossa and spinal) 3) Non-mass 4) Acute and Progressive 5) The findings mean she has either a *vascular* (specifically, subarachnoid hemorrhage), toxicmetabolic, or traumatic due to the diffuse nature of her complaint. Clinical Diagnosis 2

A 44-year-old *left-handed woman* suddenly developed a *severe bilateral temporal and occipital headache*. She also complained of a *stiff neck*. When she tried to lie down, she experienced severe nausea and vomiting twice. She was taken immediately to the hospital, where she was noted to be somnolent. She responded appropriately when stimulated and moved all four limbs equally. Her level of *consciousness deteriorated* over the next 4 hours, to a point where she could *not be aroused even with vigorous stimulation.* 1. What level is the lesion? 2. Is the lesion focal, multifocal, or diffuse? 3. Is this a mass lesion or a non-mass lesion? 4. What is the temporal profile? 5. What diagnostic category is most likely

1. Peripheral 2. Focal 3. Non Mass (no mass was palpated) 4. Chronic over the past 3 months. 5. *Traumatic* due to repeated use of the hand causing swelling (causing compression) of the median nerve in the carpal canal. When swelling is sufficient then vascular compromise occurs thus ischemia to the nerve and if not corrected then atrophy of the opponens pollicis will ensue. Clinical Diagnosis 2

A 46-year-old *assembly line worker, at Premium Standard Farms in Milan Missouri*, noted numbness and pain in the *first 3 digits of his right hand* with repetitive use and progressive over the last 3 months . He also had weakness of his right thumb (*opponens pollicis*) but not of other muscles of the hand. The history and examination is otherwise normal. 1. What level is the lesion? 2. Is the lesion focal, multifocal, or diffuse? 3. Is this a mass lesion or a non-mass lesion? 4. What is the temporal profile? 5. What diagnostic category is most likely

1) The right facial numbness and left body numbness indicates a lesion on the right between the *pons* and C2 level of the spinal cord. The left arm and leg weakness and stiffness further restrict the possible localization to the region between the pons and the low medulla. Finally, the tinnitus and hearing loss in the right ear localize the lesion further, to the *right pons* or pontomedullary junction. 2) *focal lesion* 3) It is *progressive* so it is a *mass lesion.* 4) The progression has taken place over several years, making it *chronic* 5) A focal, chronic lesion is a *neoplasm*

A 47--‐year--‐old man developed *ringing in his right ear* several years ago, and it has grown worse over time. His hearing in that ear also has gradually deteriorated. Over the same time period, he has *developed weakness and loss of feeling in the right side of his face*, and he now notes *stiffness, weakness, and numbness of his left arm and leg* Where is the lesion? 2. Is the lesion focal, multifocal, or diffuse? 3. Is this a mass lesion or a non-mass lesion? 4. What is the temporal profile? 5. What diagnostic category is most likely

*Amaurosis fugax* Most likely due to *carotid artery disease*. Always suspect carotid vascular disease in patients with cardiovascular disease. The key here is sudden vision loss lasting seconds. These people are going to stroke if an aggressive approach is not taken. Remember: *Optic atrophy* - occurs after optic neuritis and is permanent. *Retrobulbar neuritis* - the blindness may last for weeks to months or is permanent. *Afferent pupillary defect* occurs when the patient is blind and no light is transmitted via the optic nerve. *Papilledema* is a swollen disc and the patients vision is normal or slightly blurred.

A 50 year-old male is seen in your office with the complaint of *multiple episodes of visual blindness* in his left eye. The episodes are brief lasting seconds. The patient has no eye pain during the events and feels fine otherwise. He has a *past history of angina*. Based on history alone you suspect?

A conduction lesion affecting the left ear

A 50--‐year--‐old, right handed male, accompanied by his wife, is seen in your office complaining of *numbness and tingling in his feet.* You notice he keeps asking you to *repeat questions*. His wife states that he's becoming more *hard of hearing*. During the auditory examination you initially notice the patient could hear you rubbing your fingers together better in his left ear. The Weber test lateralized to the left and *bone conduction was better than air*. The remaining examination was positive for *peripheral neuropathy.* These auditory findings most likely indicate:

1) The aphasia, right hemianopia, and right hemiparesis localize the lesion to the *left cerebral cortex* (supratentorial) 2) *focal* 3) It is also progressive, so it is a *mass lesion* (until proven otherwise) 4) The time course is *chronic* 5) *Neoplasm* is most likely Comment: In this case, MRI and surgical biopsy confirmed the diagnosis of Glioma. The patient was treated with radiation therapy and chemotherapy. Clinical Diagnosis 2

A 55-year-old woman has been brought to the emergency room by her husband because she seems *confused* and is having progressively *more difficulty expressing her thoughts.* For at least the last *ten weeks* she has had *increasing clumsiness and weakness in her right arm and leg*, and she is bumping into objects in her home. On examination she has a *right homonymous hemianopia*, aphasia, a mild right hemiparesis (face, arm, leg), and *increased reflexes* on the right side with a *positive Babinski's* sign on the right. 1. What level is the lesion? 2. Is the lesion focal, multifocal, or diffuse? 3. Is this a mass lesion or a non-mass lesion? 4. What is the temporal profile? 5. What diagnostic category is most likely?

1) The reduced pinprick sensation over the left face and right body imply a *focal lesion on the left, between the pons and the C2 level of the spinal cord*. The weakness of the left palate confines the lesion to the medulla, because only lower motor neuron lesions produce unilateral palatal weakness. Ataxia of the left arm and leg is also consistent with a lesion in this location, because a lesion in the medulla can disrupt cerebellar connections. 2) Focal confined to the left medulla 3) The symptoms began acutely 4) The symptoms have not progressed, so this is not a mass lesion. 5) A focal, acute lesion with a static time course implies either a vascular (ischemic) or traumatic etiology, and there is no history of trauma in this case. more than likely this is due to vascular disease of the PICA. If a Horner's syndrome was found then you have a *Wallenberg's Syndrome* due to vascular insufficiency involving the *lateral medullary artery*. It's the only syndrome in the brainstem that I want you to know.

A 57--‐year--‐old woman has come to the emergency room because in the *middle of a business meeting* earlier today she sudden *became dizzy and experienced nausea and vomiting*. On examination, she has dysarthria, dysphagia (with weakness of the left palate), loss of pinprick sensation over the* left side of her face and right side of her body*, and ataxia of left side her arm and leg. Seven hours have passed and there has been no improvement. 1. Where is the lesion? 2. Is the lesion focal, multifocal, or diffuse? 3. Is this a mass lesion or a non-mass lesion? 4. What is the temporal profile? 5. What diagnostic category is most likely

1. *Peripheral* (Remember dermatomal patterns of nerve roots and peripheral nerves and deep tendon reflexes assist you in localizing the lesion). 2. *Focal* and on the right. 3. *Non-mass* 4. With her past history of vascular disease ...the cause is *vascular until proven otherwise.* Additional history might find a history of peripheral vascular disease. On examination you would want to make sure that her arterial pulses were normal in her lower extremities. At first glance, the cause is considered to be due to *compression (trauma) of the common peroneal nerve* over the fibular head causing ischemia (vascular). Additional history finds that the patient is unable to lay on her back and favors sleeping on her right side, with a pillow between her legs, for the past 20 years. Another way to look at it is that she was normal when she went to bed the night before and woke up with a foot drop. Something happened during the night. Clinical Diagnosis 1

A 58-year-old female with a history of a *light stroke 9 years ago* that left her with *short term memory problems*. She *smoked ½ pack/day for 25 years* and had intermittent *low back pain for 20 years*. She presents to you with a history of waking up 3 weeks ago with *weakness in her right lower extremity associated with a foot drop*. It has not progressed or improved. She has dorsiflexion weakness and a *numbness from the lateral mid-calf* to the dorsum of the affected foot. She has no reflex in her right patella. 1. What level do you suspect his problem is located (ST, PF, S, P, M)? 2. Is lesion focal (R,L,ML) or diffuse? 3. Is lesion a non-mass or mass (H, N, A)? 4. What do you suspect as the cause?

1.*Supratentorial.* Remember face, arm, leg contralateral to lesion 2.*Focal left* 3.*Neoplasm*. Remember any presentation that is focal, chronic and progressive is a neoplasm until proven otherwise. Clinical Diagnosis 1

A 60-year-old man presents with a *3 month gradual decline* of strength in his *right face and right upper and lower extremities*. He first noticed a weakness in his face then his hand that progressed for 2 months. This was followed by a progressive weakness in his *right leg* to a point where he is now *falling*. Which level? The process is? Cause?

*Anosognosia* - due to a parietal lobe damage in the non-dominant hemisphere

A 65 year-old patient presents with a sudden onset of *speech difficulties* and a *weakness in his left hand.* Your examination finds a receptive *Dysprosody* and the patient seems to deny that he has any problem even though he is *unable to use his right upper extremity*. You attempt to show him that he is unable to use his arm by picking it up and asking him to move his fingers, which he is unable to do. He still claims that nothing is wrong. This patients demonstrates:

1) Diffuse 2) Since it is diffuse, this is not a mass lesion. 3) The deficits have progressed over several months, making this a *chronic problem*. 4) A diffuse, chronic disorder can be a degenerative disease, a congenital/developmental problem, or a toxic-metabolic disorder. *degenerative disease* is most likely. Alzheimer's Disease Clinical Diagnosis 2

A 69-year-old right handed *retired executive* is seeing her internist for a routine checkup. Her husband mentions that she has undergone a *marked personality change* over the past several months. He also notes that she has been *forgetful* for about a year and keeps asking the same things over and over. She *no longer seems interested in her personal appearance*. The mental status examination confirms these observations. Her speech is *fluent*, but she frequently pauses because *she can't think of a word*. She has difficulty following complicated commands. She can only remember one of three items after a 5 minute delay, and she recalls no current events. She is unable to subtract *two-digit numbers in her head*. The remainder of her examination is normal. 1. Is the lesion focal, multifocal, or diffuse? 2. Is this a mass lesion or a non-mass lesion? 3. What is the temporal profile? 4. What diagnostic category is most likely

1) Facial weakness ipsilateral to body weakness suggests a *focal lesion high in the pons or above.* 2) Focal 3) There has been no progression, so this is not a mass lesion. 4) The symptoms developed acutely 5) A focal lesion that developed acutely and is improving is usually a vascular lesion.

A 72--‐year--‐old right--‐handed man noted the abrupt feeling of *heaviness in his left arm while watching television*. His left leg gave out when he tried to stand, and he fell to the floor. He called for help, and when his wife came into the room, she noted that the *left corner of his face was sagging*. He could still speak. He had no symptoms other than the weakness of his entire left side. Over the next several hours he improved slightly. 1. Where is the lesion? 2. Is the lesion focal, multifocal, or diffuse? 3. Is this a mass lesion or a non-mass lesion? 4. What is the temporal profile? 5. What diagnostic category is most likely?

1. *Multiple levels*(supratentorial - memory, spinal - abnormal gait and sensory loss) 2. Considered *diffuse* due to multiple levels but with a vibratory level at C5 one might conclude that a focal process is in place but it does not answer the memory problem. 3. *Non-mass* (a specific mass cannot answer all the patients complaints) 4. Subacute (weeks) 5. *Metabolic - B12 deficiency* (this condition is prevalent in the elderly due to poor nutrition). Clinical Diagnosis 2

A 75-year-old woman has *reduced appetite* and has lost weight because of *poor nutritional intake*. Over the past 4 weeks she has noticed a *progressive decline in her gait*. She also has noticed a *mild reduction in her memory*. Neurological examination shows *decreased joint position sense* and vibration sense in her upper and lower extremities and a vibratory level at approximately *C5*. Laboratory studies disclosed *macrocytic anemia*. 1. What level is the lesion? 2. Is the lesion focal, multifocal, or diffuse? 3. Is this a mass lesion or a non-mass lesion? 4. What is the temporal profile? 5. What diagnostic category is most likely

1. NO; The L2-L3 roots correspond to hip flexion, the L5-S1 roots to knee flexion, and the L4-L5 roots to ankle dorsiflexion. Thus, no single root lesion could produce this pattern of weakness. 2.This pattern is typical of an *upper motor neuron lesion*, which usually produces more weakness in the *flexors* of the lower extremity than in the extensors.

A patient has weakness of his hip flexion, knee flexion, and ankle dorsiflexion in the left lower extremity. Based on this limited amount of information. Answer BOTH of the questions before you scroll below for the answer. 1. Is this distribution of weakness consistent with a single root lesion? 2. Is this pattern of weakness suggestive of any other lesion localization?

Answer: *Lower face* Comment: For a patient to have face, arm, and leg weakness all on the same side of the body, there must be an upper motor neuron lesion which typically spares forehead muscles, because there is bilateral cortical input to the portion of the facial nerve nucleus controlling those muscles. Therefore the lesion is cortical

A patient has weakness of the right face, distal arm > leg. Based on this limited amount of information. Question: Which is likely to be weaker, the forehead or the lower face?

*Parkinson's disease* Recent research has found the hyposomia is the earliest finding in Parkinson's disease and Alzheimer's disease.

Hyposomia is the earliest manifestation of :

No visual loss The physician sees a swollen disc, and the patient sees as usual; due to papilledema

Does the patient complain of visual loss? What is this?

The physician sees a swollen disc and the patient sees nothing (blind); due to *optic neuritis* (papillitis).

Does the patient complain of visual loss? What is this?

The patient usually has a reduction in visual acuity. This is *optic atrophy* which is a result of a healed optic neuritis commonly seen in *multiple sclerosis*. The atrophy occurs after the neuritis heals and remains for life Neurological Exam I

Does the patient have normal visual acuity? What is it and what is the cause?

1. The magnitude of this patient's pupillary asymmetry is greatest in the dark, so the *sympathetic system is not functioning normally in the right eye*. The smaller pupil is therefore the abnormal one. 2. Thus this patient has a sympathetic lesion on the right. 3. A right sided ptosis would be expected. ...probably a Horner's syndrome (you have 2 of the 3 components for the diagnosis, miosis and ptosis....you only need anhydrosis to make it complete). Comment: With sympathetic lesions, the pupillary asymmetry is greatest in the dark, whereas with parasympathetic lesions, the asymmetry is greatest in bright light.

In the dark, a patient's *Left pupil is 3 mm larger than the right*. In bright light, the pupil is only 1 mm larger than the right. 1. Which pupil is abnormal, the right or the left? 2. Which pathway is abnormal, the sympathetic or the parasympathetic? 3. Is this patient likely to have ptosis? If so, on which side?

Answer: *Isolated trochlear nerve palsy* (in the left eye) Answer: to his right. Head tilt will be away from the affected eye; his left eye is abnormal Neurological Exam I

During college when I'd be tired or staring off into space I'd get brief *double vision*, which I could correct by just shifting my head around a bit until my eyes corrected it. Otherwise, I seemed fine. After college, Coworkers would comment on me *tilting my head and staring at things,* something I didn't even realize I was doing. About a week or two in, after spending hours reading manuals, looking at old CRT terminals, and staring at blackboards, I began to see *double*. In the past, a bit of head shaking and tilting would have corrected it. Now, nothing, short of *covering one eye with paper would allow me to see one image*. It freaked me out. I'm not normally one with health anxiety, but I started to think, "brain tumor!" I could no longer drive (it's tough to drive when two lanes of traffic looks like four). What is your diagnosis? Which way did the patient tilt his head to decrease his diplopia?

1. Posterior fossa due to V, VII, and VIII symptoms and opposite long tract signs 2. Focal 3. Mass is most likely 4. Chronic (over years) 5. This is a classic presentation of an *acoustic neuroma* on the right causing the cranial nerve abnormalities and as it grows and applies pressure on other cranial nerves and brainstem (long tract findings develop). Clinical Diagnosis 2

Over *several years*, a 50-year-old man noted the *onset of ringing in his right ear* and then *loss of hearing in that ear*. He also experienced *right facial weakness and decreased sensation*. In the weeks, before you examined him, he noted *stiffness and weakness of his left arm and leg*. 1. What level is the lesion? 2. Is the lesion focal, multifocal, or diffuse? 3. Is this a mass lesion or a non-mass lesion? 4. What is the temporal profile? 5. What diagnostic category is most likely

The physician sees nothing *a normal disk* and the patients sees nothing (blind); due to acute *retrobulbar neuritis*. If the patients vision is normal this fundus is normal Neurological Exam I

Question: If the patient cannot see, what is the cause? If the patient can see what does this represent?

A. The patients *left eye* B. CN III C. Microvascular injury to the nerve (pupils are hard to see but are normal). D. Patch the good eye and symptoms usually improve within 6 weeks. Answer: *Diabetes and hypertension* Neurological Exam I

This 60 year-old man presents with the *diplopia* and the above abnormal eye movements. It occurred suddenly and although the picture doesn't clearly demonstrate the pupils are equal and reactive. He has no previous neurological history of any abnormality. A. Which eye is abnormal B. Which nerve is abnormal C. What is your diagnosis D. What is your advice to the patient? What is the most common cause of this condition?