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Thinking
like
neurologist

Is
it
difference?

Dr.
Surat
Tanprawate,
MD,
FRCP(T)
Northern
Neuroscience
Center
Chiangmai
University
Thinking
like
a
Neurologist

Where
‘s
the

lesion?
What’s
the

lesion?
Series
of
steps
to
collect
data
Task
 Goal

Chief
complaint
Tipping
the
point

History


Complaint
explorer
Neurological
examina4on Confirma4on
of
localiza4on

List
of
the

problems Review
of
Pa4ent‐specific
feature
Rank
of
order
of
Likelihood
of
possible
disease Differen4al
diagnosis
Complex
brain
processing
Chief
complaint
“Tipping
the
point”

5
Component
of
Chief
Complaint
Symptom(s)
or
Syndrome
+
Time
course(progressive,
stable,
fluctua4on)
Onset(sudden,
acute,
subacute,
chronic)

Collect
the

Expand
the
idea
right
data 6
The
point
should
be
concerned

• Avoid
over
generaliza4on
• Avoid
misinterpret
symptoms
• Avoid
incomplete
chief
complaint
• Avoid
step
to
the
present
illness

before
having
an
idea
flow
chart

7
Common
misinterpret
symptoms

• Palalysis
VS
 • Blur
vision
VS

numbness Diplopia
• Dizziness
VS
 • Blackout:
loss
of

weakness
VS
Fa4gue
 consciousness
VS
loss

VS
ataxia of
vision
VS
simple

• Dysphasia
VS
 confusion
dysarthria
Expand
the
idea
“Symptomatology

approach”

9
Symptoms
approach‐1

• Disorder
of
consciousness
In
your
head – Level
of
consciousness
– Content
of
consciousness
• Mental
disorder
– Memory
– Intelligence
– Personality
– Behavioral

– Demen4a

• Higher
corQcal
funcQon

disorder
– Apraxia,
aphasia,
agnosia,

others
• Visual
disorder
– Visual
loss
– Diplopia
Symptoms
approach‐2
• Language
and
speech
 In
your
head
disorder
– Dysarthria
– Dysphasia

• Lower
cranial
nerve

disorder
– Deafness/4nnitus
– Ver4go
– Balance/staggering
– Swallowing
– Voice
change
Symptoms
approach‐3


In
your
head • Sensory
disorder
– Pain
disorder
• Headache
and
facial
pain
• Others
pain
disorder
– Numbness/4ngling
• Motor
disorder

– Weakness:
each
part
– Movement
disorder
• Sphincter
disorder
Symptoms
approach‐4
• Episodic
disorder In
your
head
– Seizure/epilepsy
– Syncope
– TIA
– Abnormal
movement
– Migraine

Syndrome
approach‐1
• Parkinsonism • MulQple
cranial
nerve

– Bradykinesia syndrome
– Muscle
rigidity “syndrome
of

– Res4ng
tremor opthalmoplegia”
– Postural
instability “syndrome
of
Lower

CN
involvement”
• Brain
stem
syndrome
“Sudden
onset
plus

brain
stem
s/s”
14
Syndrome
approach‐2
• Spinal
cord
 • Cerecellar
syndrome
syndrome ‐ Pancerebellar

– Transverse
cord
 syndrome
syndrome(complete,
 ‐ Hemicerebellar

incomplete)
syndrome
– Hemicord
syndrome
‐ Cerebellar
vermis

– Anterior
cord

syndrome
syndrome
– Posterior
cord

syndrome
15
Example
16
PaQent
History
17
Symptomatology

Difficult
to
open

his
eye

18
Symptomatology

Double
vision
“Diplopia”

19
Symptomatology:
Eyelid
disorder
• Lid
abnormali4es
presents
as
–Ptosis
–Lid
retrac4on
–Insufficient
eyelid
closure
–Excessive
eyelid
closure

20
Excessive

Ptosis eyelid
closure
Weakness
of
 Contrac4on
of

Levator
palpebrae
 obicularis
oculi

muscle muscle

Muller
muscle: •Blephalospasm
Horner’s
syndrome •Hemifacial
spasm
21
Ptosis

approach
22
Ptosis


Non‐neurogenic(mechanical)

ptosis
Neurologic

ptosis
Congenital
ptosis

•Uni‐bilateral •Pupil
involvement
•Par4al‐complete •EOM
impairment

LMN Horner’s

Supranuclear
 •Neuropathic(N,

lesion(cerebral
ptosis) fascicle,
CN) syndrome
•Contralateral
 •NMJ
cerebral
hemisphere •Myopathic

Drug
induced
blephalospasm
and

dyskinesia 24
Superior tarsal muscle
(also known as
Müller's muscle)

25
26
A
woman
present
with

double
vision 27
Diplopia
approach
28
Diplopia Monocular
diplopia:

Mostly
opthalmologic

condi4on
Binocular
diplopia
Non‐misalignment:
intermiient,
non‐
organic

Misalignment

Comitant
 Incomitant

strabismus strabismus
Childhood

strabismus
Mostly
Neuro‐
opthalmologic

disease
• Supranuclear(UMN)
• FEF: horizontal conjugate
gaze
• Diffuse frontal and
occipital: vertical
conjugate gaze
• Internuclear
• Nuclear and pathway
• PPRF, abducen
interneuron, MLF
• riMLF, INC, PC
• Nuclear(LMN)
• Cranial nerve nuclei
• Fascicle, Nerve,
NMJ and
Muscle(LMN)
• Faciculus
• Cranial nerve
• NMJ
• Muscle
Diplopia:
Thinking
Idea
• Direc4on
of
involved
muscle
– Impair
consistent
with
nerve
innerva4on(Nerve,

nucleus)
– if
not
• Fluctua4on:
NMJ
• Associated
with
proximal
muscle
weakness:
Muscle

disease
• Ver4cal
gaze
or
Horizontal
gaze
pathway
involvement:

Internuclear
lesion

31
Eye
examinaQon
32
Bilateral
ponQne
infarcQon 33
A
woman
complains
slow
progressive

diplopia,
gait
difficulty
for
2
weeks
34
Eye
movement
35
• Supranuclear(UMN)
• FEF: horizontal conjugate
gaze
• Diffuse frontal and
occipital: vertical
conjugate gaze
• Internuclear
• Nuclear and pathway
• PPRF, abducen
interneuron, MLF
• riMLF, INC, PC
• Nuclear(LMN)
• Cranial nerve nuclei
• Fascicle, Nerve,
NMJ and
Muscle(LMN)
• Faciculus
• Cranial nerve
• NMJ
• Muscle
38
Gait

abnormality
39
Gait

disturbance = Ataxia

40
Tandem
walk
41
Cerebellar
test
42
Approach
to
ataxic
pa4ent
Ataxic symptoms?
-Nystagmus
-Dysarthria
-Trunkcal ataxia
-Limb and gait -ataxia
Ataxic symptoms
mimicker?

•Mild
weakness True Ataxia


•Apraxia Ataxia: disease
•Abnormal
movement other than cerebellum

Cerebellar’s disease
-Where’s the lesion (cerebellum,
cerebellar peduncle, cerebellar
tract)
-What’s the lesion
Where’s
lesion?
Associated
sign

Pure cerebellum With With mild hemiparesis


Brainstem
signs

Classified
Cerebellar Involve fronto-
syndrome Classified Ponto-
Brainstem Cerebellar
Syndrome? Pathway
“Ataxic hemiparesis”
Classified
cerebellar
syndrome

Cerebellar Unilateral
hemispheric intermediate,
syndrome lateral zones

Rostral Ant,
vermis sup vermis
syndrome

Caudal Flucculo
vermis nodular,
syndrome post vermis

Pan All
cerebellar regions
syndrome
Symmetrical
ataxia
plus
syndrome
• Acquired

– Wernicke’s
encephalopathy
– Miller
Fisher
syndrome
– Normal
pressure
hydrocephalus(frontal
lobe

ataxia)
• Hereditary

– Spinocerebellar
ataxia(SCA)
Back
to
our
case
Nuclear
complex

of
oculomotor

nerve

Rostral
vermis

syndrome
47
48
Physical

ExaminaQon
“Confirm
the
though,

explore
the
next”
49
Neurological
examinaQon
• Screening(general)
neurological

examinaQon
– Exam
every
path:
the
tests
are
more
sensi4ve
• Specific(focused)
neurological
examinaQon
– Exam
the
detail
of
abnormal
neurological
signs

or
symptoms
relevant
to
the
history
and

screening
exam.
– the
tests
are
more
specific

50
Record
the
neurological
signs

• Presence
VS
Absence
• Hard
signs
VS
Son
signs
• Normal
VS
abnormal
• Lateralizing
sign:

• True
VS
false
localizing
sign
• Normal
varia4on

51
General
neurological
examina4on
• Mental
status • Gait
and
balance
• Cranial
nerve
 • Romberg
test
– 1‐12
CN
func4on
• Limb

– Voluntary
movement
– Muscle:
bulk,
tone,
power

– Coordina4on:
FTN,
HTS,
rapid

alterna4ng
movement
– Reflex:
tendon,
plantar

response
– Sensa4on:
pinprick,
JPS,

vibra4on
sense
The
point
should
be
concerned

• Avoid
misinterpret
sign
• Misinterpret
the
normal
varia4on
• Confirm
the
equivocal
sign

• Aware
the
son
sign
• Aware
the
false
localizing
sign

53
A
man
presented
with

shaking
head 54
An
old
woman
present
with

abnormal
hand
movement 55
Focused
neurological
examinaQon
• Which
kind
of
test
– Depend
on:
History,
Screening
neurological

examina4on
– Complete
the
focused
examina4on:

• More
detail
• Complete
the
syndrome
you
thought
• Need
extensive
skill
for
specifica4on

56
Concept
of
“son”
neurological
sign
• “Hard
sign”:

– neurological
sign
result
from
a
lesion
at
a
known

site
or
that
affect
a
known
pathway
• “Son
sign”:

– Any
structural
or
func4onal
devia4on
found
more

frequently
in
brain
impairment
persons
than
in

normal
persons
– Does
not
correlate
with
any
par4cular
type
of
brain

lesion
at
any
par4cular
site,
or
interrup4on
of
any

par4cular
tract
Concept
of
“false”
localizing
sign
• True
sign
that
occurs
secondary
to
a
lesion

elsewhere
in
the
CNS.

• The
sign
is
not
false,
but
is
distant
from
the

actual
site
of
primary
lesion
• Cause:
– Shin
of
brain:
compress
or
displace
structure

(distant)
or
blood
vessel
(ACA,
MCA)
– Hydrocephalus:
CN
6
palsy,
Pretectal
(sylvian)

syndrome
59
Problem
list
“Review
of
paQent

specific
feature”
60
List
of
problems
Integrate
of
History
and
PE

• First:
anatomical
localiza4on
of
lesion
or

neurology
system
– Focal,
Mul4‐focal,
Diffuse
– Nuclear,
tract,
system
disorder
– CNS,
PNS,
Boths
DifferenQal
diagnosis
Discussion
each
problem
list
• 1)
• 2)
• 3)
• 4)
• 5)
DifferenQal

diagnosis
“Rank
of
the
possible

disease”
63
DifferenQal
diagnosis
Integrate
of
History
and
PE
• First:
anatomical
localizaQon
 • Second:
cause
of
lesion
of
lesion
or
neurology
 – Congenital,
Gene4c
system – Trauma
– Focal,
Mul4‐focal,
Diffuse – Tumor
– Nuclear,
tract,
system
disorder – Infect/Inflamma4on
– CNS,
PNS,
Boths – Vascular
– Toxic/metabolic/Nutri4onal
– Degenera4on/Demyelina4on
– Idiopathic
– Psychogenic

Series
of
steps
to
collect
data
Task
 Goal

Chief
complaint
Tipping
the
point

History


Complaint
explorer
Neurological
examina4on Confirma4on
of
localiza4on

List
of
the

problems Review
of
Pa4ent‐specific
feature
Rank
of
order
of
Likelihood
of
possible
disease Differen4al
diagnosis
Combine it together
Thank you
for your
attention.
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