Acute Neurologic

Conditions:
An OCSE Primer
Cb[ecLlves
W 1o make neurology as easy and
palnless as posslble for Lhe
medlcal sLudenL
W 1o lnvolve Lhe sLudenLs ln learnlng
Lhe dlfferenL dlseases ln
neurology
CuLllne
l reLesL
ll lnLeracLlve Cases
l Case 1
l Sub[ecLlve
ll Cb[ecLlve
lll AssessmenL
lv ulagnosls
v 8evlew of Selzures
ll Case 2
l Sub[ecLlve
ll Cb[ecLlve
lll AssessmenL
lv ulagnosls
v 8evlew of Peadache
lll Case 3
l Sub[ecLlve
ll Cb[ecLlve
AssessmenL
lll ulagnosls
lv 8evlew of 8raln 1rauma
#retest
reLesL
1 lor Lhe pasL Lwo monLhs a 36 year old woman
experlences severe rlghLslded orblLal paln lasLlng 2 Lo 3
hours 1he aLLacks occur Lhree Llmes a day and each
aLLack ls assoclaLed wlLh con[uncLlval ln[ecLlon Learlng
and nasal dralnage Alcohol ls rellably able Lo provoke an
aLLack Whlch of Lhe followlng ls Lhe llkely dlagnosls?
A ClusLer headache
8 Mlgralne wlLh aura
C Mlgralne wlLhouL aura
u 1enslonLype headache
Answer A C|uster headache presenLs wlLh headache cyc|es
|ast|ng weeks to months and occurrlng one or more t|mes per
year AssoclaLed wlLh foca| un||atera| orb|ta| pa|n tear|ng
nasa| dra|nage and con[unct|va| |n[ect|on
reLesL
2 A prevlously well 8monLh old glrl was broughL Lo Lhe cllnlc
due Lo sLlffenlng of exLremlLles LhaL lasLed for 30 seconds 1he
moLher broughL Lhe chlld Lo cllnlc afLer noLlclng LhaL she was
warm Lo Louch 1he chlld appeared lrrlLable and was
lnconsolable LhroughouL Lhe consulL WhaL ls Lhe mosL
lmporLanL dlfferenLlal dlagnosls LhaL musL be consldered ln
Lhls paLlenL?
A ularrhea
8 uengue
C CnS lnfecLlon
u neumonla
Answer C lor a chlld who presenLs wlLh f|rst s|mp|e febr||e
se|zure Lhe ma[or d|fferent|a| d|agnos|s LhaL musL be ruled
ouL ls CNS |nfect|on Conslder dolng |umbar puncture among
paLlenLs suspecLed of havlng CnS lnfecLlon
reLesL
3 A 22year old woman reporLs a scoLoma progresslng across
her lefL vlsual fleld over Lhe course of 30 mlnuLes followed by
lefL hemlcranlal Lhrobblng paln nausea and phoLophobla Per
broLher and moLher have slmllar headaches Whlch of Lhe
followlng sympLoms should nC1 be seen ln Lhls condlLlon?
A SenslLlvlLy Lo sound
8 unllaLeral ln locaLlon
C Severe paln
u Peadache lmproved by acLlvlLy
Answer u aLlenLs wlLh m|gra|ne are characLerlzed by
severe un||atera| throbb|ng headache whlch worsens w|th
act|v|ty Nausea vom|t|ng and sens|t|v|ty to ||ght and sound
are assoclaLed facLors
reLesL
4 An 8year old glrl was broughL Lo your cllnlc due Lo
progresslve decllne ln school performance 1he Leacher
noLlced LhaL Lhe glrl would ofLen sLare ouL ln space durlng Lhe
mlddle of Lhe class AddlLlonally Lhe moLher reporLed LhaL she
would ofLen sLop ln Lhe mlddle of playlng and rapldly bllnk hls
eyes WhaL wlll be found ln an LLC LesL of Lhls paLlenL?
A ulffuse slow waves
8 SymmeLrlc 3 Pz splke and wave dlscharges
C AsymmeLrlc 3 Pz splke and wave dlscharges
u AsymmeLrlc 3 Pz splke and wave dlscharges
Answer 8 bsence se|zure ls marked by sudden br|ef |apses
of consc|ousness wlLhouL loss of posLural conLrol CfLen seen
ln chlldren where Leachers reporL LhaL Lhe chlld ls
daydream|ng LLC shows symmetr|c 3 nz sp|ke and wave
d|scharges
reLesL
3 A 4year old boy experlences eplsodes of loss of body Lone
wlLh assoclaLed falls Pe also presenLs wlLh lnsLances of
sponLaneous muscle conLracLlons lasLlng for 10 seconds
followed by relaxaLlon of muscle conLracLlon for
approxlmaLely 1 mlnuLe ln lnLervlewlng Lhe moLher lL was
dlsclosed LhaL Lhe chlld's school performance was
deLerloraLlng LLC shows 13 Lo 2Pz splke and wave
dlscharges 1he mosL llkely dlagnosls ls?
A Landaukleffner syndrome
8 LennoxCasLauL syndrome
C !uvenlle myoclonlc epllepsy
u lebrlle selzure
Answer 8 ennoxGastaut syndrome presenLs wlLh Lrlad of
mu|t|p|e se|zure types LLG sp|ke and wave d|scharges 3 nz
and |mpa|red cogn|t|ve funct|on
reLesL
6 A 36 year old man came Lo your cllnlc afLer a bouL of loss of
consclousness Cranlal C1 scan was done and showed
WhaL ls Lhe llkely dlagnosls?
A Lpldural hemaLoma
8 Subdural hemaLoma
C Subarachnold hemaLoma
u ulffuse axonal ln[ury
Answer 8 Subdura| hematoma CkLSCLN1 Sn9LD and
n9LkDLNSL w|th MIDINL SnII1
reLesL
7 A 32year old male arrlved ln your cllnlc due Lo sudden
sLoppage of resplraLlon whlle sleeplng 1he paLlenL presenLs
wlLh headache and Lachycardla SaglLLal M8l scan was done
and showed
WhaL ls Lhe llkely dlagnosls?
A Subfalclne hernlaLlon
8 uncal hernlaLlon
C osLerlor hernlaLlon
u 1onslllar hernlaLlon
Answer 1ons|||ar hern|at|on noLe cerebe||ar tons||s
compress|ng the medu||a affecLlng Lhe resp|ratory center
reLesL
8 A 19year old male was broughL Lo Lhe emergency room
afLer endurlng a headon vehlcular crash 1he paLlenL opens
hls eye upon puLLlng pressure Lo Lhe sLernum Pe also exhlblLs
adducLlon of Lhe arm lnLernal roLaLlon of Lhe shoulder
pronaLlon of Lhe forearm and flexlon of Lhe wrlsL Pe ls able Lo
respond Lo quesLlons coherenLly buL Lhere ls some
dlsorlenLaLlon and confuslon WhaL ls Lhe paLlenL's Clasgow
Coma Scale (CCS) score?
A 7
8 8
C 9
u 10
Answer C 9 whlch ls lndlcaLlve of moderate bra|n |n[ury
CCS ls helpful ln Lhe lnlLlal assessmenL of Lhe consclousness of
a person Check LraumaLlc braln ln[ury secLlon for furLher
deLalls on Lhe CCS
reLesL
9 An 6 year old boy arrlved ln your cllnlc due Lo weakness
wlLh repeaLed eplsodes of vomlLlng and a mornlng headache
1he paLlenL subsequenLly developed a sLumbllng galL and
frequenL falls M8l was performed wlLh Lhe followlng plcLure
seen WhaL ls Lhe mosL llkely dlagnosls?
A ClloblasLoma mulLlforme
8 Cllgodendroglloma
C MedulloblasLoma
u Lpendymoma
Answer C Medu||ob|astoma Lhe most common ma||gnant
braln Lumor ln ch||dren whlch arlses from the cerebe||um
reLesL
10 A coronal M8l was performed on a 31 year old male
paLlenL who had progresslve loss of memory wlLh recenL
changes ln personallLy WhaL ls Lhe mosL llkely dlagnosls?
A Cllgodendroglloma
8 CnS lymphoma
C Menlngloma
u ClloblasLoma mulLlforme
Answer u aLlenLs wlLh g||ob|astoma mu|t|forme are marked
by progress|ve changes |n memory persona||ty or neuro|og|c
def|c|ts due Lo tempora| and fronta| |obe |nvo|vement lL
presenLs wlLh r|ngenhanc|ng |es|ons ln M8l lL ls Lhe most
common ma||gnant prlmary braln Lumor ln adu|ts
nteractive Cases
Case 1
llle aLlenL #16347
A 21year old man reporLs several eplsodes over Lhe prevlous
4 years durlng whlch he losL consclousness Pe had no
warnlng of Lhe lmpendlng eplsodes and wlLh each eplsode he
ln[ured hlmself vldeo camera fooLage made by Lhe moLher
showed LhaL he abrupLly develops a blank sLare and sLopped
Lalklng Pls body became sLlff and he arched hls back AfLer
several seconds of Lhls Lype of posLurlng hls arms and legs
sLarLed shaklng vlolenLly uurlng one of Lhese eplsodes he
dlslocaLed hls rlghL shoulder Pe rouLlnely urlnaLed ln hls panLs
and felL Llred afLer Lhe eplsodes
uear docLor
lease help me flnd ouL whaL's wrong wlLh my son
Case 1 Sub[ecLlve
Jhat are the re|evant f|nd|ngs |n h|storytak|ng that are
|mportant to d|agnose th|s pat|ent? Jhat are the |mportant
steps needed |n h|story tak|ng to proper|y d|agnose th|s
pat|ent?
Sa||ent features
oss of consc|ousness
St|ffen|ng of body w|th subsequent v|o|ent shak|ng of
extrem|t|es
Ur|nat|on and t|redness after the ep|sodes
ke|evant n|stor|ca| Informat|on
1 ls Lhe paLlenL really havlng a selzure? kUL CU1 MIMICS
1ake noLe of oLher condlLlons LhaL may mlmlc a selzure and
rule Lhem ouL flrsL Check Lhe Lable ln Lhe subsequenL sllde
Case 1 Sub[ecLlve
Case 1 Sub[ecLlve
ke|evant n|stor|ca| Informat|on
2 ueLermlne SLI2UkL 19L Check selzure presenLaLlon
2 WhaL ls Lhe CUSL of the se|zure? 1o deLermlne Lhls ask
Lhe paLlenL for rlsk facLors and predlsposlng evenLs LhaL could
lead Lo developmenL of selzures
ask abouL famlly hlsLory of selzures posslble
Lrauma cancer sysLemlc lllness sLress sleep deprlvaLlon
hormonal changes Loxlns medlcaLlon use lllegal drug abuse
3 uoes Lhe paLlenL need N1ICCNVUSN1 therapy?
CbLaln deLalled lnformaLlon abouL selzure and posL
lcLal presenLaLlon of Lhe paLlenL (can also geL vldeo) need for
medlcaLlons are dependenL on selzure Lype presenLed by Lhe
paLlenL
kecap Iour 1h|ngs to Lstab||sh |n n|story
kUL CU1 MIMICkLkS SLI2UkL 19L LS1ISn CUSL
DL1LkMINL NLLD ICk MLDS
Case 1 Cb[ecLlve
Jhat are the re|evant f|nd|ngs |n the phys|ca| exam|nat|on
that are |mportant to d|agnose th|s pat|ent?
erform a compleLe neurologlc examlnaLlon Lo be able Lo
deLermlne wheLher Lhe paLlenL has speclflc cerebral
hemlsphere dlseases A general physlcal examlnaLlon can be
also underLaken Lo be able Lo see wheLher Lhe paLlenL has an
lnfecLlon sysLemlc lnfecLlon or Lrauma whlch may explaln Lhe
developmenL of newonseL selzure
8ecap
9hys|ca| exam|nat|on ln paLlenLs wlLh selzures ls malnly used
Lo deLecL posslble CUSLS of selzures
Case 1 AssessmenL
Jhat are the |aboratory tests that must be undertaken for
th|s pat|ent? Jhat can be seen |n the d|agnost|c tests |n th|s
case?
Lab LesLs Check elecLrolyLe levels llver enzymes Loxlcologlc
screenlng lumbar Lap (lf suspecLlng CnS lnfecLlon)
8raln lmaglng Check for sLrucLural abnormallLles ln Lhe braln
Can use a C1 scan or an M8l
LLG kLUIkLD ln paLlenLs wlLh selzures
lor Lhe paLlenL LLC resulLs would mosL llkely be
Icta| phase (durlng selzure) progress|ve |ncrease |n
genera||zed |owvo|tage fast act|v|ty fo||owed by genera||zed
h|ghamp||tude po|ysp|ke d|scharges
9ost|cta| phase (afLer selzure) d|ffuse s|ow|ng
kecap
ab tests and |mag|ng nL9 LS1ISn CUSL
LLGCSSII SLI2UkL and determ|ne 9kCGNCSIS
Case 1 ulagnosls
nIS1Ck f|nd|ngs holds Lhe key for Lhls paLlenL
Sa||ent features
Loss of consclousness
SLlffenlng of body wlLh subsequenL vlolenL shaklng of
exLremlLles
urlnaLlon and Llredness afLer Lhe eplsodes
ulagnosls
Genera||zed ton|cc|on|c se|zures
A Review of Seizures
Selzures
Def|n|t|on of Se|zures
Sudden short durat|on change |n motor act|v|ty and/or
behavlor LhaL resulLs from abnorma| e|ectr|ca| act|v|ty |n the
bra|n
Def|n|t|on of Lp||epsy
2 or more unprovoked selzures aL leasL 24 hours apart
8LCA
SLlZu8L Sudden shorL duraLlon change ln moLor acLlvlLy
LlLLS? 2 or more unprovoked selzures 24 hours aparL
1ypes of Selzures
Iebr||e Se|zures
AssoclaLed wlLh fever of temperature 384 degrees
Ce|s|us
AffecLs ch||dren from 16 months up to S years of age
SLNCL of IN1kCkNI INILC1ICN (kUL CU1 w|th
UMk 9UNC1UkL |f nIGn SUS9ICICUS!)
D|fferent|ate beLween s|mp|e febr||e se|zure vs comp|ex
febr||e se|zure
S|mp|e Iebr||e Se|zure Comp|ex Iebr||e Se|zure
Cenerallzed Lonlcclonlc local selzure
LasLs for a few seconds13
mlnuLes
13 mlnuLes
Cnce ln 24 hours 8epeaLed or mulLlple ln 24
hours
1ypes of Selzures
I|rst step D|fferent|ate wheLher paLlenL has 9k1I
SLI2UkLS or GLNLkI2LD SLI2UkLS
9k1I SLI2UkLS c||n|ca| and LLG changes ||m|ted to CNL
cerebra| hem|sphere
GLNLkI2LD SLI2UkLS c||n|ca| and LLG changes |nvo|ves
C1n hem|spheres
2
nd
step Determ|ne whlch spec|f|c subtype of selzure Lhe
paLlenL has
GLNLkI2LD SLI2UkLS a 1onlcclonlc b Absence c
Myoclonlc d 1onlc e ALonlc
9k1I SLI2UkLS a Slmple parLlal selzure b Complex
parLlal selzure
Cenerallzed Selzures
1 1on|cC|on|c Se|zure
1nkLL 1nINGS 1C kLMLMLk
a 9kLMCNI1Ck SM91CMS
mood changes sleep dlsLurbances anxleLy
lrrlLablllLy cry
b 1CNICCCNIC 9nSL
MuSCLL becomes 1LnSL (ton|c phase) LvCLvlnC
1C L8lCu Cl MuSCLL CCn18AC1lCn Anu 8LLAxA1lCn
(c|on|c phase)
c 9CS1IC1 9nSL
8LPAvlC8AL Anu ML1A8CLlC Su8LSSlCn (feel
Llred excesslve sallvaLlon confuslon and can suddenly
urlnaLe)
Cenerallzed Selzures
2 1yp|ca| bsence Se|zure
1nkLL 1nINGS 1C kLMLMLk
a Usua||y CnIDnCCD onset
Appear Lo be uA?u8LAMlnC wlLh CC8 SCPCCL L8lC8MAnCL
b ccompan|ed by mu|t|p|e short durat|on I1Lk
MC1Ck s|gns w|th NC post|cta| confus|on
8apld bllnklng chewlng small hand movemenLs
c LLG shows 3 nz sp|ke and wave d|scharge
ulfferenLlaLe from typ|ca| bsence whlch ls characLerlzed by
|ess abrupt onset and term|nat|on of symptoms more
pronounced changes |n tone LLG 2S nz sp|ke and s|ow
wave assoc|at|on w|th MLN1 kL1kD1ICN
Cenerallzed Selzures
3 Myoc|on|c Se|zures
Sudden brlef muscle conLracLlon lnvolvlng one parL of Lhe
body or enLlre body
kLMLMLk kILI ILkkING ] 1JI1CnING
LLG 8llaLerally synchronous splke and wave dlscharge
4 1on|c Se|zures
Sudden lncrease ln Lone of muscles
kLMLMLk S1IIILNING
S ton|c
Sudden loss of muscle Lone (eyellds may droop person
may drop Lhlngs or fall Lo Lhe ground)
kLMLMLk DkC9 ]kINL1IC SLI2UkL
arLlal Selzures
1 S|mp|e 9art|a| Se|zure
local selzure wlLh no obvlous alLeraLlons ln consclousness
Can have moLor auLonomlc (flushlng plloerecLlon) vlsual
(flashlng llghLs formed halluclnaLlons) psychlc sympLoms
(feellngs of fear de[ vu)
An example ls an Au8A
2 Comp|ex 9art|a| Se|zure
local selzure wlLh LranslenL loss of consclousness seen
uurlng selzure 8ehavloral arresL wlLh auLomaLlsms
(chewlng llp smacklng plcklng hand movemenLs)
osLselzure confuslon amnesla
kLC9 9k1I SLI2UkL ICC |n CkIGIN (S1k1S |n CNL
nLMIS9nLkL)
S|mp|e 9art|a| Se|zure NC CSS CI CCNSCICUSNLSS
Comp|ex 9art|a| Se|zure JI1n CSS CI CCNSCICUSNLSS
Lpllepsy Syndromes
1 Iuven||e Myoc|on|c Lp||epsy
a Slngle or repeaLed myoclonlc [erks on awakenlng
b Larly adolescence
c lamlly hlsLory of epllepsy
2 ennoxGastaut Syndrome
a MulLlple selzure Lypes (seen ln chlldhood)
b LLC slowlng 3Pz splke and wave dlscharge
c oor cognlLlve funcLlon
3 Mes|a| 1empora| obe Lp||epsy Syndrome
a MosL commonly assoclaLed wlLh lnLracLable complex
parLlal selzures
b Memory lmpalrmenL
c Loss of cell populaLlons wlLhln hlppocampus
Case 2
Lpllepsy Syndromes
1 Iuven||e Myoc|on|c Lp||epsy
a Slngle or repeaLed myoclonlc [erks on awakenlng
b Larly adolescence
c lamlly hlsLory of epllepsy
2 ennoxGastaut Syndrome
a MulLlple selzure Lypes (seen ln chlldhood)
b LLC slowlng 3Pz splke and wave dlscharge
c oor cognlLlve funcLlon
3 Mes|a| 1empora| obe Lp||epsy Syndrome
a MosL commonly assoclaLed wlLh lnLracLable complex
parLlal selzures
b Memory lmpalrmenL
c Loss of cell populaLlons wlLhln hlppocampus
Case 3