Diagnosis and Localization of Neurologic Disorders
Strategies in Clinical Diagnostic Reasoning
- Probabilistic, causal and deterministic Probabilistic - dx in order of probability - considers prevalence of disease in populations - Occam's Razor or Principle of Parsimony - the most likely solution is the simplest - the least complex diagnosis is most likely correct - never make on diagnosis one will do Causal (best used since it is very solid) - rely/based on pathophysiologic model - determines consistency of a clinical fnding based on the model ( if a px comes to you with a headache, you will look into the mechanisms and narrow the structures which can produce pain the head) Deterministic - uses "if-then" rules - fow charts and graphic displays (requires the presence of positive or negative data for us to be able to go through the fow chart and end up with a fnal diagnosis) (abdominal pain example) Problems - not all patients are simple - not all patients follow the classical thingy (they don't read textbooks) Sources of Diagnostic Errors - failure to recognize a probable diagnostic hypotheses - faulty information gathering and processing - underestimate the prevalence - faulty data interpretation - errors of reasoning, inadequate data base, inadequate fund of knowledge Pathologic Processes behave in certain ways depending on location in the nervous system and in certain other ways related to their inherent nature. (hypoxia -> afects certain parts of the central nervous system) Fisher's Rules: A selection of actions relevant to clinical reasoning and Diagnostic Principles - In arriving at a clinical diagnosis, think of the fe most common fndings found in a given disorder. If at least three of these fve are not present in a given patient, the diagnosis is likely wrong (deterministic) - resist the temptation to prematurely place a case or disorder into a diagnostic cubbyhole that fts poorly. Allowing it to remain unknown stimulates continuing activity and thought. - the details of a case are important; their analysis distinguishes the expert from the journeyman - Pay particular attention to the specifcs of the patient with a known diagnosis; it will be useful later when similar phenomena occur in an unknown case - Fully accept what you have heard or read only when have verifed it yourself - Maintain a lively interest in patients as people Neurologists Engage in 2 basic clinical exercises - where is the lesion (anatomy and physiology) and what is the lesion (pathology) - Anatomic Diagnosis and Etiologic DX - missing something here ** **SLIDE something Is there a lesion? - need to diferentiate psychiatric or physiologic complaints from pathologic symptoms ex. hysterical paralysis, paresthesias, goosebumps - diference between signs vs symptoms, subjective vs objective fndings - objective signs like changes in refexes, anatomically distribution of numbness or weakness should be sough - if organic, is it primarily neurological or is it an efect of a systemic drug, medication or toxic problem Where is the lesion? - the major features to be determined in the anatomical dx of neurologic disorders are the following: - is the responsible lesion focal, strictly confned to a single well-circumscribed area? - more more ** Levels of Neuraxis - Supratentorial - cerebral hemisphere: thinking, intelligence, memory, emotion, control, voluntary, action, sensation, vision language - side of lesion manifests contralaterally - loss of sensation and/or weakness on opposite side of the face and body - more (summary) - infrantentorial/posterior fossa - cerebellum: balance, coordination of movements - Brainstem - midbrain lesion - eye movement - Pons - Facial sensation and movement, hearing balance - loss of sensation and or weakness on one side of face and same side of the body(ipsilateral to the side of the face), cranial nerve defcit(ipsilateral to cranial nerve), cerebellar defcit(ipsilateral) - hearing loss, tinnitus, vertigo, dysplasia (more) - Cord - Cervical - neck muscles and hand fxns - thoracic - chest and abdominal - lumbar - leg and foot fxn - sacral - sphincter function - Spinal/Cranial Nerve Root - sensory level, loss of pain and temp on one side, weakness and position sense on the opposite side of the body - ipsilateral to the loss of position sense and weakness - neck or back pain, fndings relate to specifc... (more) - Peripheral Nerves - loss of sensation to all modalities of sensation in the distribution of nerve or globe stocking distribution - ipsilateral to sensory loss, cranial nerve or to side of - limb pain without back pain, loss of sensation and muscle weakness in distribution of nerve - Neuromuscular Junction - Muscle Diferentiating UMN from LMN Paralysis UMN (nucleus and up) - weakness occur in muscle groups - atrophy is mild and late in onset - (+) spasticity - hyperactive DTRs - (+) babinski/clonus LMN (cranial nerve exiting from the nucleus) - weakness occurs in nerve distribution - atrophy is marked and early in onset - (+) faccidity - hypoactive or absent DTRs - (-) babinksi/clonus (exception is spinal and cerebral shock) How to report refexes Pattern of Distribution of weakness - hemiparesis - paraparesis - quadriparesis - monoparesis Diferential Localization of Paralysis - monoplegia - with atrophy - nerve, spinal nerve root, early spinal cord disease - without - cerebral cortex or early cord disease - hemiplegia - cerebral cortex; involves face, arm and leg with cerebral signs like seizures, aphasia, headache, agnosia and hemianopsia on the contralateral side - Brainstem - midbrain: ipsilateral 3rd CN palsy with weakness on opposite side - Pons: contralateral ataxia with paralysis, ipsilateral cn 5 6 7 8 defcits - medulla: atrophy of tongue, dysarthria, hoarseness, dysphagias, CN 9 10 11 12 defects with contralateral paresis - lateral cord disease: brown sequard syndrome - paraplegia - from cord, spinal roots, peripheral nerve - quadriplegia - cervical cord, medulla or brainstem, bilateral cerebral disease, muscular dystrophy - isolated muscle groups - Hysterical paralysis Levels of Lesion - peripheral level - variable sensory loss associated with arefexia which may or may not be associated with motor and autonomic... - spinal - segmental defcit - limited to one level of the body and usually caused by lesions in the nerve roots of spinal nerves such as disc herniation resulting in nerve root compression - "radicular pain" specifc pain along dermatome afected; sharp and dart like in character; aggravated with sneezing, coughing straining, paresthesia/hypersthesia along dermatome - +/- loss of refex and weakness / autonomic disturbance depending on level - posterior fossa - cranial - intersegmental defcit .... (skipped fast) is the responsible lesion difuse and non-focal - a difuse lesion may involve only a single level or may involve multiple levels - in general, a lesion is considered to be difuse if it involves bilateral regions in the nervous system without extending across the midline as a single circumscribed lesion WHere is the lesion? Focal or difuse? level in the neuroaxis? If cerebral - what love, cortical or subcortical if cerebellar - rostral, caudal, pancerebellar, de myers? If brainstem - level, axial or intraxial if cord - level? intra or extra medullary LMN - neuropathy What is the Lesion? (Question Number 2) Degenerative Neoplastic Vascular Infammatory/Infectious Toxic-Metabolic Traumatic **- the manner of onset (development) and duration of symptoms gives the clue Development of Symptoms (onset) can be classifed as Acute- within minutes Subacute- within days Chronic- within weeks or months Summary Onset: Focal Acute: Vascular (infarct, IC Hge) Subacute: Infammatory Chronic: Neoplasm Onset: Difuse Acute: Vascular Subacute: Infammatory Chronic: Degenerative Diferentiation between mass and nonmass lesions: - mass lesion: when signs and symptoms, whether acute subacute or chronic suggest a progression of a focal lesion - non mass lesion: when the lesion is difuse in location or when signs and symptoms suggest a non-progressive focal abnormality Summary Is there a lesion? Focal or Difuse? LEvel at Neuroaxis? UMN or LMN? Axial or IntraAxial? Right or Left? Specify If cerebral - lobe, cortical or subcortical If cerebellar - rostral, caudal, pancerebellar, de myers If brainstem If cord Case Study A 57 year old lady while developed severe headache and dizziness while taking breakfast. She vomited once and fell from her chair. She was found conscious but unable to take. She was brought to the ER with a BP of 200/100 and cardiac rhythm of 112, in atrial fbrillation. In addition, she had apical beat at 6th ICS LAAL. She was awake but could not say any word. She Understood a few simple commands. Her pupils were equal There was weakness of the lower half of her right face on smiling. She had no corneal refex on the right face. Gag was weak. She had tongue deviation to the right. Her arm could not be raise don command. Her leg would move sideways only when given painful stimulus. Her refex were absent on the right, +2 on the left. She had a babinski on the right. Sensory tests could be confrmed because she was unable to talk (-) Kernigs. This is a Upper Motor Lesion, Supra Tentorial, Cerebral Frontal and Temporal Hemisphere, Left Focal, Acute, Vascular, consider infarct or hemorrhage. Diagnosis: Left Frontal and Temporal Lobe Lesion probably secondary to vascular pathology like hypertensive hemorrhage vs cerebral infarct from cardioembolism