Resident Tutorial

Long case Board

Examination
Surat Tanprawate, MD, FRCPT
Northern Neuroscience Center
Chiangmai University

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By

Dr. Surat

Present
“Fear factors in Long Case
Neuro Examination”
and
“How to approach to ataxia”
 Fear Factors

• Hard to get neurological history

• Hard to do the physical
neurological exam
• Hard to conclude the results
• Hard to make neurological
diagnosis
 Fear Factors
• Hard to get
Symptomatology
neurological history
• Hard to do the physical Practice the physical
exam
neurological exam
• Hard to conclude the Practice to list the
results problem
• Hard to make To know the common
neurological diagnosis diseases
Key Concept

Symptoms
approach

“Algorithm”
Key Concept

Symptoms
&Signs

“Specific
examination”
Key Concept

To diagnose

“Problem list
and Conclusion”
Symptomatology

Syndrome
 Symptomatology
• Disorder of
consciousness • Visual disorder
• Level of
consciousness • Visual loss
• Content of • Ocular motility
consciousness disorder
• Mental disorder
• Diplopia
• Memory
• Intelligence • Abnormal ocular
ossilation
• Personality
• Behavioral
• Dementia
 Symptomatology
Lower cranial nerve disorder
• Deafness/tinnitus
• Vertigo
• Balance/staggering
• Swallowing
• Voice change

Multiple Cranial Nerve Disorders

 Symptomatology
• Sensory disorder • Sphincter
• Pain disorder disorder
• Headache and facial pain
• Others pain disorder • Episodic
• Numbness/tingling disorder
• Motor disorder – Seizure/epilepsy
• Weakness – Syncope
• Movement disorder – TIA
• Gait abnormality – Abnormal movement
• Ataxic disorder – Migraine
 Syndrome
• Amnistic and Dementia syndrome

• Neuro-opthalmology syndrome

• Syndrome of Multiple cranial nerve disorder

• Stroke syndrome
• Cortical stroke syndrome

• Lacunar stroke syndrome

• Brain stem stroke syndrome

• Spinal cord syndrome

Ataxia
 Algorithm

Gait abnormality
Ataxia

Specific examination

Specific examination
-confirm ataxic disorder
-for categorized ataxia

Conclusion and Diagnosis

Greek
word
A=nega.ve
Taxi=order
 Ataxia
Algorithm
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
• Gait
abnormality

Cerebellar’s disease
-Where’s the lesion (cerebellum,
cerebellar peduncle, cerebellar
tract)
-What’s the lesion
Neuroanatomy
Neurophysiology
 Function of
cerebellum

• Coordinating skill voluntary

movement
• Muscle activity
• Control equilibrium
• Muscle tone
 Function of
cerebellum
• Lesion
• Incoordination (ataxia) of
volitional movement
• Tremor (ataxic or intention
tremor)
• Disorder of equilibrium and gait
• Diminish muscle tone
 Cerebellar
pathway

To
a7ributed

sensorimotor

network:

• cerebral
cortex
• basal
motor
nuclei
• thalamus
• re:cular
forma:on
Func.onal
Zone
 Part of Cerebellum
Functional Deep Nuclei Connections Functions
divisions
Vermis Fastigial Vestibular nucleus Axial and proximal
(face, proximal Reticular formation muscle control
body) Medial descending Progressive movement
system

Intermediate zone Interposed Red nucleus Distal muscle control

(spinal cord) Motor cortex Progressive movement
Lateral descending
system

Lateral zone Dentate Red nucleus Motor planning

(cortex, pons) Thalamus Initiation
Motor, premotor Timing
cortex
Flocculonodular Vestibular nuclei, Vestibular nuclei Axial equilibrium
lobe visual system Eye movements
Vestibular reflexes
 Basic
Anatomy
–
Cerebellar
peduncles
Cerebellar Tracts connect to Major pathways Connections
peduncles brain stem

Superior Brachium Afferent Rubral, thalamic,

conjunctivuum Efferent Dentate, spinal cord

Middle Brachium pontis Afferent Pontine nuclei

only

Inferior Restiform body Afferent Vestibular, olive, Spinal

Efferent cord
Receives from
Flocculonodular lobe
Blood Vessel
 Ataxia
Algorithm
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
• Gait
abnormality

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

What is the associated

signs?
 Associated signs

With With mild

Pure
Brainstem hemiparesis
cerebellum
signs

Classified Classified Involve fronto-

Cerebellar Brainstem Ponto-
syndrome Syndrome? Cerebellar
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
 Cerebellar syndrome and its disorders
Cerebellar
 Regions
 Distribu.ons
of
 Common

syndromes involved deficits causes
Cerebellar
 Cerebellar Ipsilateral
head
&
 Infarct,
neoplasm,

hemisphere
 hemisphere body abscess,

syndrome demyelina:on

Rostral
vermis
 Ant,
sup
vermis Gait,
trunk Alcoholism,


syndrome thiamine
def

Caudal
vermis
 Flucculonodular,
 Axial
 Midline
neoplasm

syndrome post
vermis diisequilibrium

Pancerebellar
 All
regions Bilateral
 Toxic,
metabolic,


syndrome symmetrical
signs
 infec:ous,

of
cerebellar
 paraneoplas:c,

dysfunc:on degenera:ve
 Posterior inferior cerebellar artery (PICA)
Anterior inferior cerebellar artery (AICA)
Superior cerebellar artery (SCA)
Posterior cerebral artery (PCA)

PICA = lateral medulla & inferior cerebellum

AICA = lateral caudal pons & part of cerebellum
SCA = superior cerebellum & rostral laterodorsal pons
PCA = midbrain, thalamus, medial surface of occipital lobe, inferior and medial
surfaces of temporal lobe
Brainstem Vascular Territories
 SYNDROME STRUCTURES DAMAGED CLINICAL SYMPTOM

Lateral medullary (PICA, Corticospinal tract Contralateral hemiplegia

Wallenberg’s)syndrome (pyramid)
Spinothalamic tract Contralateral hemisensory
Damage Level:
loss
Lateral medullar

Trigerminal spinal Ipsilateral facial hemisensory

nucleus loss
Vascular supply
PICA
Nucleus ambiguous Ipsilateral palatal, pharyngeal,
vocal cord paralysis
Dysarthria, dysphagia

Sympathetic fiber Ipsilateral Horner’s

syndrome

Vestibular nuclei Vertigo, N/V

Cerebellum Ipsilateral cerebellar sign

 SYNDROME STRUCTURES DAMAGED CLINICAL SYMPTOM

Lateral inferior Vestibular nucleus Ipsilateral vertigo, N/V,

pontine syndrome nystagmus
(AICA stroke syndrome) Cochlear nucleus Ipsilateral deafness
Damage Level:
Lateral inferior pons
Nuclear of CN7 Ipsilateral facial palsy

Cerebellum Ipsilateral ataxia

CN 5 Ipsilateral hemisensory
loss of face
Spinothalamic tract
Contralateral hemisensory
loss
 Neurological
examination in
ataxia
 Patient Video

Nystagmus
 Patient Video

Intention tremor
 Patient Video

Finger to Nose Test

 Patient Video

Ataxic gait
 Patient Video

Ataxic speech
What’s lesion?
Time, Caused, Onset
Medical History
Neurological Signs
 Time Caused Onset
• Subacute
• Sudden • Intoxication
• Vascular
• Chronic
• Acute • Hereditary
• Intoxication • Paraneoplastic
• Viral, Post infectious syndrome
• Hypothyroid
• Intoxication
Symmetrical ataxia
plus syndrome
• Acquired
• Wernicke’s encephalopathy
• Miller Fisher syndrome
• Hereditary
• SCA
• FA
 Pt.
with
progressive
ataxia
Imaging
• to exclude identifiable
structural lesion
• Atrophy of cerebellum or
spinal cord

Evaluate
•Accurate family history
AD • Phenotype AR

SCA1,2 Singleton patient

MJD
SCA6,
7
FA
SCA10,12 Acquired causes
-Alcohol/medication AT
DRPLA
-Hypothyroid AVED
SCA17 -Vit.B12 Abetalipoproteinemia
-Anti-HIV AOA
-Paraneoplastic study
-GAD Ab
Mitochondrial
disorder
Next Episode: Neuro-opthalmology approach
Diplopia, Visual loss, Ptosis

END
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