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Neuro Mini- OSCE - Slide 1

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									                     ‫بسم هللا الرحمن الرحيم‬


                       NEORO
                     MINI-OSCE
~Please note that~
= some notes are from other
references besides doctors’
slides.
= some topics were not
discussed in the seminars but
they are worth reading.
= Concentrate on the figures.
= not all neuro topics were
covered!!
= >Slide 30= nice MCQs
 Subarachnoid Hemorrhage
Causes:
•Ruptured aneurysm
•AVM
•Trauma to circle of willis esp MCA
-Mortality rate 35%
-Age 50-60 yrs


-Berry aneurysms are the most common cause.
History/PE:
Sudden-onset, intensely painful headache , neck
stiffness fever, vomiting, fluctuating LOC, sentinel
headaches, seizures, 3rd nerve palsy with pupil
involvement.
        DDx : hemorrhagic stroke, meningitis, migraine, trauma
        Evaluation:
        1. Head CT w/o contrast; blood in the subarachnoid
        space.
        2. If CT –ve , LP ; RBCs, xanthochromia* , elevated ICP.
        3. Four-vessel angiography if SAH confirmed.
        TT: lower ICP , treat HTN , IV fluids, Ca channel
        blockers , anticonvulsant , surgery; clippng/coiling
        aneurysm or AVM.
        Complications : Rebleeding , arterial vasospasm,
        obstructive hydrocephalus , extension into paranchyma.




*yellowish CSF due to breakdown of RBCs.
Case :41 year old female presented with worst headache
of her life. Following CT scan obtained. Your diagnosis
(Hint: Watch Red marked area)




Answer :Subarachnoid hemorrhage (SAH)
      Non contrast
           CT




                           Epidural Hematoma
                      >> Traumatic hmrg of arterial origin
                      Commonly due to lateral skull fracture
                     (blunt), tear in the Middle Meningeal
                     Artery .
                     •Hx/PE: lucid interval from several
                     minutes To hours then headache, progressive
                     Obtundation & hemiparesis.
MRI                  Ultimately leads to “ blown Pupil” *
                     •Evaluation : CT; lens shaped convex
                     Hyperdensity , may cross the midline.
                     •TT: emergent neurosurgical evacuation.
                     *fixed & dilated pupil
Subdural Hematoma

>>Intracranial hmrg occurs after head trauma
with rupture of the bridging veins esp. elderly
& alcoholics.
• Hx/PE : headache, change in mental status,
contralateral hemiparesis.
In contrast to Epidural H ; Changes can be
subacute & chronic or as dementia.
There may be a remote Hx of a fall.
• Evaluation : CT shows crescent-shaped,
concave hyperdensity , does NOT cross the
midline .
• TT: if symptomatic ; surgical evacuation.
   GROSS
   anatomy
              Epidural
               hmrg




Subdural     Subarachnoid
 hmrg           hmrg
NFTs




Amyloid
ß plaques
(A-ß)




MRI
Lobar     Pick
atrophy   inclusion
          bodies
Comparison of the microscopic
appearance of normal brain (left
side) and CJD brain (right side).
Note the many vacuoles
'sponginess' of the CJD brain.
CT head scan of
a patient with
normal pressure
hydrocephalus
showing dilated
ventricles. The
arrow points to
a rounded
frontal horn.




T2-weighted MRI
showing dilatation
of ventricles out
of proportion to
sulcal atrophy in
a patient with
NPH. the arrow
points to
transependymal
flow.
                               DDx of Dementia
                               Alzheimer
                               Disease
                               Vascular
                               Disease,MID
                               Drugs,
                               Depression,
                               Delirium
                               Ethanol
                               Medical/Meta
VP shunt system in the right   bolic Systems
lateral ventricle .
                               Endocrine
                               (thyroid,
                               diabetes)
                               Neurologic,
                               Nutritional
                               Tumor, Toxin,
                               Trauma
                               Infection,
                               Idiopathic.
                               Amnesia,
V-P                V-A         Autoimmune.
      Some CNS Developmental Anomalies                                                   Refer to
                                                                                         dr.Jamous
                                                                                         slides; full
                               ~caudal displacement cervico-medullary junction~          of good
                                                                                         pictures

                      >> Type 1 or adult type : cerebellar ectopia; Caudal herniation of
                      cerebellar tonsils below foramen magnum.
Chiari Malformation




                      -Headache and suboccipital pain is the most common feature
                      -Syringomyelia (intramedullary cyst) is common as well as hydrocephalus.
                      -Sx : long tract sx , cerebellar syndrome, central cord syndrome
                      -MRI diagnostic test of choice
                      -TT : Posterior fossa decompression with C1,C2 laminectomy w/ or w/o
                      duroplasty.
                      >> Type 2 : primary dysgenesis of brain stem. rare in adults.
                      -caudally located cervico-medullary junction, pons, 4th ventricle below FM
                      level
                      -Sx : related to brain stem cerebellar and lower cranial dysfunction
                      -Critical warning signs : stridor, dysphagia, apneic spells
                      -MRI is the tool of choice.
                      -Associated w/: Hydrocephalus, Lower CN dysfunction, Bony anomalies,
                      Hydromyelia, beaking of tectum , Agenesis of CC and septum pellucidum
                      -TT: surgery.
In patients with Chiari malformation,
brain tissue extends down into the
spinal canal at the base of the neck
Dandy Walker Malformation


                            = agenesis of the cerebellar vermis with large post
                            fossa cyst communicating with enlarged 4th vent.
                            - Associated with hydrocephalus in 90%
                            -S & S : related to post. fossa syndrome;
                            In early infancy : slower motor development and
                            progressive enlargement of the skull.
                            In older children : symptoms of increased ICP, signs
                            of cerebellar dysfunction ; unsteadiness and lack of
                            muscle coordination or jerky movements of eyes.
                            increased head circum., bulging at the back of the
                            skull, and abnormal breathing patterns.
                            - Prenatal diagnosis is possible with U/S.
                            -TT: Shunting the cyst alone may solve the problem
MRI images comparing the brains of normal
patients (left) to patients with Dandy-Walker
malformation (right). The cerebellum, a brain
region involved in coordination and balance, is
pushed forward and under-developed in Dandy-
Walker patients, leaving an empty space filled
with fluid   .
                   Premature fusion of sutures causes failure of
                   normal skull growth

                   -Sagittal is the most common causing Scaphocephaly
Craniosynostosis




                   -Coronal in females, unilateral plagicephaly or bilateral
                   brachycephaly usually with syndromes.
                   -MeTopic causes Trigoncephaly
                   -Multiple fusion oxycephaly

                   -Signs : Small and abnormal shaped head, Palpation of bony
                   prominence over the suspected synostotic suture.
                   -Work up :Skull x-ray, ct scan and Tc bone
                   -TT: surgery by suturectomy , aims : *to allow brain grow
                   normally *to treat high ICP *cosmesis.
Primary craniosynostosis
When 1 or more sutures fuse
prematurely, skull growth
can be restricted
perpendicular to the suture.
If multiple sutures fuse
while the brain is still       CT image ;features of
increasing in size,            secondary craniosyn.
intracranial pressure can      with cerebral atrophy.
increase.                      Cerebral atrophy is not
                               present in primary
                               craniosyn.



Secondary craniosynostosis
More frequent than the
primary type, can result
from early fusion of sutures
due to primary failure of
brain growth. Since brain
growth drives the bony         Unilateral coronal deformity with
plates apart at the sutures,   retrusion of the orbit and harlequin eye
a primary lack of brain        deformity. Note the ipsilateral deviation
growth allows premature        of the nasal radix and the contralateral
                               deviation of the nasal tip.                 Fusion of coronal sutures bilaterally.
fusion of all the sutures.                                                 Note the increase transverse
                                                                           dimension and retrusion of the
                                                                           orbital rim
                AKA=Cranium bifidum
                = is a NTD characterized by sac-like protrusions of the brain
                and the membranes that cover it thro. openings in the skull.
                These defects are caused by failure of the neural tube
                to close completely during fetal development.
                - Occipital region is most common
Encephalocele




                - Cephalic meningocele if CSF with meninges protrude
                -Encephalocele if there is brain tissue
                -class.: nasofrontal, nasoethmoidal, naso-orbital…………
                -Sx : neurologic problems, Hydrocephalus, spastic
                quadriplegia, microcephaly , ataxia , developmental delay,
                vision problems, mental and growth retardation, and
                seizures.
                - Causes:exact cause is unknown, Research has indicated
                that teratogens ,trypan blue (a stain used to color dead tissues or cells blue),
                and arsenic may cause encephaloceles.
                - TT : Surgical resection and closure.
                    = Excess of CSF fluid with dilatation of ventricles and increased ICP
                    due to CSF circulation block or subnormal absorption.

                    -1-1.5 % of population
                    -Congenital 0.2- 3.5% of births
                    -Hydrocephalus ex vacue : dilated vents due to loss of brain cerebral
~ HYDROCEPHALUS ~




                    tissue.
                    Types: -Communicating (non obstructive): CSF block at the level of
                    arachnoid villi
                    -Non-communicating (obstructive) : block is proximal to arachnoid villi
                    -Arrested hydrocephalus : or compensated; no progression of
                    hydrocephalus that requires shunt.
                    Etiology:-Congenital: Chiari malformation with or without MM,
                    Aqueductal stenosis, Dandy walker.
                    -Acquired: Infectious, Post haemorrhage ,Secondary to masses, spinal
                    tumours due to increase in CSF protein
                    S&S: Adults:=high ICP; (Headache, Nausea and vomiting, Reduced LOC,
                    CN deficit, Irritability.)
                    Infants: Head enlarg. ,Wide and open fontanelles,Suture diastasis ,Poor
                    reflexes, Sun set eyes ,Cranio-facial disproporxn ,Thin scalp, Engorged

                    scalp veins Hypoactivity/irritability, Apneic spells, Scalp ulcers.
                    Dx: U/S through the fontanelle…………..mentioned in NPH above
                    TT: the aim is to optimize the neurological function and
~ HYDROCEPHALUS ~




                    get a good cosmetic appearance.

                    ~SHUNT problems:
                    -Undershunting: block can occur at any point proximal, valve and
                    distal
                    -disconnection
                    -Overshunting : causes; Subdural hematoma, Craniosynostosis
                    Slit ventricles
                    -Infection : 3-5%
                    ~Risks : Lower IQ, more seizures , mortality 10-15%
                    ~Staph epidermis is most common
                    ~Concepts of TT: IV antibiotics vancomycin ,Shunt removal ,EVD
                    Replacement when CSF is clear after 3 readings
      Facial Palsy




Patients with(
A) a facial nerve lesion and
B) a supranuclear lesion with forehead
   sparing
                   DIFFERENTIAL DIAGNOSIS FOR FACIAL
                              NERVE PALSY

Disease                Cause             Distinguishing factors
Nuclear (peripheral)
   Lyme disease         Spirochete        History of tick exposure, rash, or arthralgias;
                          Borrelia       exposure to areas where Lyme disease is endemic
                        burgdorferi
   Otitis media          Bacterial         Gradual onset; ear pain, fever, and conductive
                         pathogens                          hearing loss
   Ramsay Hunt         Herpes zoster     Pronounced prodrome of pain; vesicular eruption in
    syndrome               virus                       ear canal or pharynx
  Sarcoidosis or        Autoimmune                      More often bilateral
  Guillain-Barre         response
    syndrome
      Tumor            Cholesteatoma                       Gradual onset
                       , parotid gland
Supranuclear                                            Forehead spared
(central)                                   Emotional expressions may be not affected

 Multiple sclerosis    Demyelination              Additional neurologic symptoms
      Stroke             Ischemia,          Extremities on affected side often involved
                        hemorrhage
      Tumor             Metastases,       Gradual onset; mental status changes; history of
                       primary brain                          cancer
                           Bell's palsy is defined as an
                           idiopathic unilateral facial
                           nerve paralysis, usually self-
                           limiting. The trademark is
                           rapid onset of partial or
                           complete palsy ,usually in a
                           single day. It is thought that
                           an inflammatory condition
                           leads to swelling of the facial
                           nerve.Nerve swelling and
                           compression in the narrow
                           bone canal are thought to lead
                           to nerve inhibition, damage or
                           death. No readily identifiable
                           cause for Bell's palsy has been
Right sided facial palsy   found ,could be viral.
                           TT: steroids=prednisolone,
                           antiviral=acyclovir?
McDonald MRI criteria .




                                   Sclerosis
                                   Multiple
                          The most
                          sensitive test to
                          detect lesions and
                          changes in the
                          CNS of patients
                          with MS is the
                          MRI,
                          Neurologists use
                          serial MRIs to
                          confirm diagnosis
                          and monitor
                          worsening of
                          symptoms
~ McDonald MRI criteria .


 Three out of 4 of the following must be present to be
 considered a lesion compatible with MS:
 Nine T2 hyperintense lesions (if no Gd) or 1 Gd-
 enhancing lesion present


 One or more juxtacortical lesions


 One or more infratentorial lesions


 Three or more periventricular lesions
 A spinal cord lesion can substitute for any other
 cerebral lesion.
??? NEURO MCQs ???
 Q)Which of following could not be the diagnosis here?
 (a) Left IIIrd nerve palsy (b) Myasthenia gravis (c) Horners
 syndrome (d) Left VIth nerve palsy (e) Lambert-Eaton Syndrome
 Answer:
 d) Left VIth nerve palsy(
 This is the only option that does not cause ptosis!



 Q) A young farmer presented with these acutely painful lesions on
 his lower legs.
 Not long afterwards his friends noticed he had an unusual facial
 appearance. In that he could not smile, close his left eye or
 wrinkle his forehead on the left.
 1.What are the painful lesions on his lower legs ?a) Erythema
 multiforme( b) Chronic plaque psoriasis( c) Necrobiosis
 Diabeticorum( d) Erythema marginatum( e) Erythema nodosum
 Answer: e) Erythema nodosum
 2.What is the most likely diagnosis? (a) Lyme disease (b)
 Sarcoidosis (c) Diabetes (d) Guillian Barre Syndrome (e) Bells
 palsy
 Answer:(b) Sarcoidosis
 This patient presents with painful red lesions on his shins
 together with a facial palsy.The facial appearance represents a
 VII nerve palsy, in this instance a lower motor neurone VII.
Q)A 45 year old lady presents after a 6 week history of a painful
neck. The pain is described as shooting in nature and 10/10 on a
severity score. Now she describes a 3 day history of right arm
weakness .Examination reveals weakness on right shoulder abduction
(4/5) and right elbow flexion (4/5). Reflexes in her right arm are all
absent apart from triceps. There are no sensory findings. The
remainder of the examination is normal .
What is the most likely diagnosis( ?a) CVA( b) Cervical myelopathy( c)
Brachial neuritis( d) Radial nerve palsy( e) Frozen shoulder
Answer:
(c) Brachial neuritis
History is an acute onset, painful event affecting shoulder abduction
(C5) and elbow flexion (C6). Examination demonstrates weakness in
these myotomes and loss of biceps reflex (C5, C6) and supinator (C6),
with sparing of triceps (C7).
This is a fairly characteristic description of brachial neuritis. I would
also expect the muscle brachioradialis (C6) also to be affected and
therefore weak.
Q)A slighty overweight lady has the following fundal
appearance .
[Photo from: William F. Hoyt Neuro-Ophthalmology
Collection]
You also notice that she has a VIth nerve palsy .
1.How would you describe the above appearance( ?a) Normal
fundus( b) Optic atrophy( c) Papilloedema( d) Retinitis
pigmentosa( e) Foster-Kennedy Syndrome
Answer(c) Papilloedema
The retinal photograph demonstrates raised intracranial
pressure, as shown by the papilloedma, with evidence of a
pink disc, blurred margins and haemorrhages.
2.Which one of the following tests would you most like to
perform? (a) Visual field testing (b) Visual acuity (c) Lumbar
puncture (d) CT scan (e) Colour vision with Ishara plates
Answer:(d) CT scan
All of the mentioned investigations are appropriate here,
though given the papilloedema, a space-occupying lesion must
first be excluded.
3.All of the above investigations are subsequently
performed. Brain imaging does not reveal any abnormality.
What is the most likely diagnosis? (a) Glioma (b) Meningioma
(c) Pituitary adenoma (d) Cortical venous sinus thrombosis (e)
Benign intracranial hypertension
Answer:(e) Benign intracranial hypertension
This case is classic for benign intracranial hypertension. It
usually presents in young women with a raised BMI.
                           A patient with normal IQ presents to the epilepsy clinic after several
                           episodes of loss of consciousness and you notice these skin lesions
                           1.What are these skin lesions( ?a) Shagreen patchs( b) Melanomas( c)
                           Café-au-lait spots( d) Benign naevi( e) Vitiligo
                           Answer:(c) Café-au-lait spots
                           2. You discover that his brother and father also have similar skin
                           lesions.What is the diagnosis( ?a) Tuberous sclerosis( b)
                           Neurofibromatosis type I( c) Neurofibromatosis type II( d) Downs
                           syndrome( e) Hereditary haemorrhagic telangiectasia
                           Answer: (b) Neurofibromatosis type I (chromosome 17)

You examine a 78 year old right handed man who is dysphasic and the nurses tell you that he has suffered
     from a stroke .1.Which one of the following clinical signs would you expect to find( ?a) Left extensor
     plantar( b) Left homonymous hemianopia( c) Left sided hemiplegia( d) Right homonymous hemianopia( e)
     Right lower motor neurone VIIth nerve palsy
Answer:(d) Right homonymous hemianopia
This first man is right handed so left hemisphere dominant, with affected speech therefore the stroke has
     affected the left hemisphere involving speech centre in left temporal lobe.
Clinical signs expected would be a right homonymous hemianopia, right upper motor neurone VII nerve palsy,
     right hemiplegia - with increased tone, reflexes and an extensor plantar on the right.

2: Afterwards you examine the gentleman in the next bed who is also right handed. Visual field testing
    demonstrates a lower left quadrantanopia.
    Where is the lesion causing this visual field defect? (a) Right temporal lobe (b) Right parietal lobe (c)
    Left temporal lobe (d) Right temporal lobe (e) Optic chiasim
Answer:(b) Right parietal lobe
This second man, is also right handed so therefore left hemisphere dominant. He has a left visual field
    defect, therefore right sided brain pathology in his parietal lobe. A temporal lobe lesion would give a
    superior quadrantanopia.
3. In the same man, which of the following features may also be present( ?a) Agraphia( b) Acalculia( c) Left-
Right disorientation( d) Finger agnosia( e) Constructional apraxia
Answer:(e) Constructional apraxia
As this gentleman has a lesion in his non-dominant parietal lobe, constructional or dressing apraxia may be
seen. All the other features are dominant parietal lobe signs.




A 50 year old male presents with a lower motor neurone VIIth nerve palsy, his family are
    concerned that he has suffered a stroke. He has deafness in his right ear which he says is
    long-standing though has seen ENT who diagnosed this as sensorineural deafness. He now
    also complains of double vision on right lateral gaze with horizontal separation of the
    images .
You examine his eyes, and find incomplete abduction of the right eye on right gaze. The rest
    of his eye movements are full. The pupils are equal and react appropriately to light and
    accommodation .What do you diagnose ?
(a) Right VIth nerve palsy( b) Right IIIrd nerve palsy( c) Right IVth nerve palsy( d) Right
    Horners( e) Right internuclear opthalmoplegia
Answer:(a) Right VI palsy
2: His corneal reflex is absent. Where do you place the pathology? (a) Cavernous sinus (b)
    Jugular foreman (c) Midbrain (d) Cerebellopontine angle (e) Skull base
Answer:(d) Cerebellopontine angle
This is a case of a cerebellopontine angle lesion. Which presents with senroineural deafness
    (therefore the underlying cause most likely to be an acoustic neuroma) - VIII, LMN VII,
    VI nerve and V nerve palsies.The corneal reflex will be lost first.Other potential causes
    include a meningioma.
    Cogetto…
    Orientishimus 
    Good luck




~Done by: We’am Al-Zayadneh
~C3

								
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