Common neurologic symptoms

NA SHAO
Coma
Coma-definition
 coma is a state of unarousable unresponsiveness.

 patient lies with eyes closed and does not open them even to vigorous
stimulation.

Clinical approach to the patient with altered consciousness begins with the
ABSs: airway, breathing, and circulation.
Coma-approach to patient
 The mental status exam in patients with altered consciousness primarily

assesses the level pf responsiveness.

 The cranial nerve exam includes the testing of important brainstem reflexes,
including the pupillary, corneal, and oculocephalic reflexes.

 The remainder of the examination should be dedicated to looking for focal

abnormalities.
Coma-structural causes
 acute ischemic stroke---brainstem, unilateral cerebral hemisphere (with edema)

Acute intracranial hemorrhage---intraparenchymal, subdural, epidural

Brain tumor (with edema or hemorrhage)---primary, metastatic

Brain abscess
Coma-diffuse causes
 metabolic---glucose abnormality;

Hepatic failure

Uremia

toxic—alcohol, sedatives, psychotropic drugs

Infectious

Respiratory failure

Subarachnoid hemorrhage.
Coma-laboratory and radiological studies
 if a structural cause of coma is suspected, urgent head imaging, usually a head CT
should be performed.

If a diffuse cause is suspected, an extensive workup for metabolic, toxic, or infectious
causes should be undertaken.

Head CT should be performed before lumbar puncture.

Electroencephalogram can assess the depth of coma and can occasionally suggest a
specific diagnosis.
Coma-treatment
 Depends on etiology.

Prognostic factors for coma or altered consciousness include both etiology and
patients age.
Locked-in syndrome
 different from coma.

 with no abnormality of consciousness.

 large lesion in the base of the pons.

 Diagnosis---the locked-in syndrome leaves patients unable to move the

extremities and most of the face, all other motor function is lost except vertical
eye movements of blinks.
Weakness
 one of the most common presenting neurologic complaints.

 the diagnosis rests on determining what the pattern of weakness is , searching

for associated signs and symptoms, and using laboratory tests and EMG to
confirm clinical hypotheses.
Weakness—approach to patients
1. Identify which muscles are weak.

2. Determine the pattern of weakness --- locate on muscle, NMJ, nerve, root,
plexus, cord, brain

3. Look for associated signs and symptoms, are they consistent with localization?

4. Consider the differential diagnosis or disorders within localization

5. Use lab tests and EMG if needed.

Weakness-location
 primary muscle disorders typically cause symmetric proximal weakness and can

affect neck muscles.

Sensory signs and symptoms are typically not present in primary muscle
disorder.

CK level is elevated.

Weakness-location
Spinal cord disorders lead to weakness in a upper motor neuron pattern below
the lesion and weakness in a nerve root pattern at the level of the lesion.

May be sensory loss below the level of the lesion due to interruption of
ascending tracts.

Reflexes below the level of the lesion are typically increased, Babinski sings
may be present.

Bladder and bowel incontinence may occur.

Weakness-location
Cerebral hemispheric lesion lead to weakness of the contralateral sides in
upper motor neuron pattern.

Cerebral hemispheric lesions may have accompanying cognitive signs, such as

aphasia and neglect.
Dizziness
Dizziness, a nonspecific term that describe a sensation of altered spatial
orientation.

Discomfort in the head.

may also be called “light-headedness” or “wooziness” by patients.

Caused by circulatory, metabolic, endocrine, degenerative.

Vertigo
Vertigo may be defined as any abnormal sensation of motion between a
patient and the surroundings.

Vertigo maybe central or peripheral.

Syncope
 syncope is a transient loss of consciousness and postural tone that results form

brain hypoperfusion.

Prior to losing consciousness, patients often report light-headedness and a

variety of visual symptoms (blurred or tunnel vision, graying or blacking out),
cognitive slowing.

Causes: central or peripheral.

Gait
Hemiparetic gait suggests hemispheric dysfunction, most often stroke.

Paraparetic gait typically suggests spinal cord disease.

Akinetic-rigid gait is a feature of parkinsonian syndromes.

Waddling gait suggests proximal muscle (hip girdle) weakness.

Hemiparetic gait
Paraparetic gait
Akinetic-rigid gait
Waddling gait
Ataxia gait
Wallenberg syndrome
syndrome caused by occlusion of the posterior inferior cerebellar artery,
marked by ipsilateral loss of facial pain and temperature sensation, ipsilateral
limb ataxia, and contralateral loss of pain and temperature sensations in the
trunk and extremities.