Approach to Nervous System Dr. Amal Alkhotani MD, FRCPC Neurology,EEG & Epilepsy

Aim of neurological evaluation Recognize common neurological complaints Localize the lesion Identify possible pathological differential diagnosis Order specific investigations

Neurological complaints Can be divided according to the system involved. Cognitive complaints. Cranial nerves abnormalities. Motor impairments. Sensory impairments. Coordination problems.

Nervous system Central nervous system Peripheral nervous system Autonomic nervous system

Common neurological complaints Headache Weakness Numbness and paresthesia Seizure

History Determine:- - The patient handedness. - The nature of the complaint. - The extent of any deficit. - The time course. - The pattern. - Precipitating or reliving factors. - Previous treatment & other investigation. - The current neurological status. Past history. Social history. Systemic inquiry. Risk factors.

Examinations Cognitive assessment Cranial nerves examinations Motor system Sensory system Autonomic

Approach to acute motor weakness Dr. Amal Alkhotani MMBCH, FRCPC

Objectives To recognize the anatomy of motor pathway. To localize the lesion. Diagnostic approach to a patient with acute weakness. Provide differential diagnosis of acute weakness.

Motor pathway Upper motor neuron unit Lower motor neuron unit

Case 1 70 year old right handed male present with one hour history of Rt sided weakness. What further history would you like to obtain?

History of weakness Pattern of weakness. Onset. Course. Associated symptoms ( speech, sensory, conscious level, headache, abnormal movements) Risk factors.

Localization begin with identifying the pattern of weakness:- - Generalized weakness. - Monoplegia. - Hemiplegia. - Paraplegia. - Quadriplegia. - Focal weakness.

Case 1 Sudden onset of right face and arm weakness. Associated with inability to speak. Not progressive. He is known to have type 2 diabetes mellitus and hypertension. What examination would you like to do?

Vital signs. CVS & carotid exam. Detailed neurological exam.

UMN signs Increase tone. Increase reflexes. No atrophy. Up going planter response.

LMN signs Atrophy. Fasciculation. Decrease tone. Decrease reflexes. Down going planter response.

Case 1 Bp 200/100 HR 75 regular. No carotid bruit. Normal systemic exam. Neurologically :- Speech non fluent, unable to name, repeat but follow commands. ( what type of speech abnormality he has?) RT facial drop. RT sided weakness arm > leg. Where is the lesion?

Aphasia is a disorder of language rather than speech. Muteness is a complete loss of speech, may represent severe aphasia. It also may represent anarthria or even ca be seen in psychogenic syndromes such as catatonia. Anomia is inability to produce a specific name. Paraphasic speech refers to the presence of errors in the patient speech output.

Language Exam Spontaneous speech. Naming. Comprehension. Repetition. Reading. Writing.

Types of Aphasia Broca’s aphasia. wernicke’s aphasia. Global aphasia. Anomic aphasia. Conduction aphasia. Transcortical aphasia.

Case 1 Bp 200/100 HR 75 regular. No carotid bruit. Normal systemic exam. Neurologically :- Speech non fluent, unable to name, repeat but follow commands. ( what type of speech abnormality he has?) RT facial drop. RT sided weakness arm > leg. Where is the lesion?

Middle Cerebral Artery Stroke Weakness face & arm worse than leg. Associated symptoms:- - Aphasia ( Dominant) - Sensory symptoms - Neglect ( Non dominant) - Visual field cut The most common type of acute stroke.

Anterior cerebral artery Leg weakness No associated speech or sensory symptoms.

Posterior cerebral artery Visual field cut No motor weakness

Differential diagnosis of acute weakness of cerebral origin Stroke. Trauma. Tumour. Infection. Demylinating lesion. Functional ( Todds paralysis) Migraine. Psychogenic.

Investigation CT brain.

Case 1 CBC. Coagulation profile. ECG & cardiac enzymes. Serum electrolytes & Glucose. Fasting Lipid. Carotid doppler. Echocardiogram.

Stroke Stroke is the most common cause of acute neurological insult in adult. Can be hemorrhagic or ischemic. Early recognition is important to minimize the functional disability.

70 year old RHD female with long standing DM & HTN present with left sided weakness. Her exam showed BP 180/90 Dysarthric speech. Dense plegia of face, arm & leg. No other associated neurological signs. Where is the lesion? What do you call this type of stroke? Case 2

Small noncortical infracts caused by occlusion of small penetrating arteries. Most common type of stroke in middle east. Can be either pure motor, pure sensory, ataxia with hemiparesis, sensory motor or dysartheria clumsy hand syndrome. No associated cortical finding Work up mainly include risk factor identification. Lacunar Strokes

Summary Diagnosis begin with localization. Carful history and examination help making the right localization.

Self study Pattern of weakness in spinal cord injury Lower motor neuron weakness