CLINICAL NEUROLOGY

MADE EASY

Brentia Sonnekus
Edited by Prof Carr
2017
 PRINCIPLES:

1. Always work with the same SYSTEM from A-Z

2. Pay attention to the TIMELINE in the history
3. Decide what the DEFICIT is (ex UMN weakness)
4. Ask SPECIFIC related questions (ex Sphincters)
5. LOCALISE to anatomical level (ex Cord)
6. Look for PHYSICAL pointers (ex Gibbus)
7. Differential for CAUSE (ex Compression)

What?
Where?
Why?
Approach To Any Neurology Case

HISTORY & EXAMINATION

Handedness
Level of education
Higher Function
Head & Neck
Cranial Nerves
Motor Inspection •Atrophy •Fasciculations
Reflexes •Babinski •Clonus
Tone
Power

Sensation Light-touch
Pin-prick
Proprioception •Vibration

Co-ordination Finger-Nose •Dysdiadochokinesis

Heel-Shin

Posture & Gait Tandem

Romberg

?Deficit ?Anatomical level ?Cause

 Once you are able to answer the 3 most
important questions , the rest is easy

 To help with differential , think per

deficit & anatomical localisation

 If you struggle with this, divide it into

broad categories :

 Idiopathic
 Genetic
 Tumour
 Vascular
 Demyelination
 Infection
 Inflammation
 Infiltration
 Vasculitic
 Paraneoplastic
 Metabolic/Toxic/Vitamin/Drugs
DEFICIT ANATOMY DIFFERENTIAL
Frontal lobe
Higher Function Temporal lobe Many
Parietal lobe
Occipital lobe
Brainstem  Stroke
CN Subarachnoid  Meningitis
Specific area  Cavernous sinus
Exit points  Orbit
Brain Stroke
Motor: UMN Brainstem Demyelination (ADEM)
Cord Infection
Neoplasm
Anterior horn cell  Motor neuron disease
Motor: LMN Root  Cervical Spondylosis
Plexus  Brachial Amyotrophy
Nerve  Guillain Barre Syndrome
NM junction  Myasthenia Gravis
Muscle  Polymyositis
Sensation:
Hemi sensory Cortex
Cross sensory Brainstem Many
Sensory level Spinothalamic tracts
Proprioception Dorsal columns
Glove & stocking Peripheral nerve
Motor deficit
Co-ordination Sensory deficit Many
Cerebellum
Vestibular
Posture/Gait
Hemiplegia Cerebral hemisphere
Spastic Paraparesis Cord
Parkinson’s Basal ganglia
Cerebellar ataxia Cerebellum Many
Sensory ataxia Proprioception
Proximal myopathy Proximal weakness
Footdrop Distal weakness
Apraxia Frontal lobe
You have to commit to a specific deficit!

Then use an approach for each:

1. to localise pathology
2. give a differential diagnosis
 HIGHER FUNCTION (CORTEX)

Frontal Lobe
Anosmia (rare)
Personality change
Primitive reflexes (Grasp/Palmomental/Pout & Snout)
Urine incontinence
Gait apraxia
Broca’s Aphasia (expressive)

Temporal Lobe
Memory loss
Confabulation (rare)
Wernicke’s Aphasia (receptive)

Occipital Lobe
Homonymous hemianopia
Cortical blindness
 Parietal Lobe

Dominant Aphasia

• Name objects
• Repetition
• Comprehension
• Reading
• Writing
• Spontaneous speech
• Paraphasic errors
Non-dominant

Neglect
• Spatial neglect
• Dressing apraxia
• Constructional apraxia
• Visual
• Auditory
• Tactile agnosia
Agraphaesthesia
2 Point discrimination
 CRANIAL NERVES
4 Anatomical Sites:
1. Brainstem  Midbrain 3&4
 Pons 5-8
 Medulla 9-12 (“Bulb”)

2. Subarachnoid Space  Meningitis

3. Specific Regions  Cerebellopontine angle

 Cavernous Sinus 3-6

4. Exit point from Skull  Orbit

 Jugular foramen
Multiple Cranial Nerve Lesions
Cavernous Sinus ③④⑤⑥
Cerebellopontine angle ⑤⑦⑧
Jugular foramen Unilat ⑨⑩⑪
Bulbar/Pseudo Bilat ⑨⑩⑫
Myasthenia Eye & Facial mm
Orbital myopathy Eye mm

Causes:

INSIDE STEM OUTSIDE STEM

long tract signs/signs of
intrinsic brainstem lesion
vs just cranial nerve affected

Congenital: Arnold Chiari

Tumour: Nasopharyngeal
Chronic Meningitis: Carcinomatous/TB/Sarcoid
Brainstem: Vascular/Tumour
Guillain Barre
Mononeuritis Multiplex eg. DM
Paget’s disease
 MOTOR
UMN syndrome LMN syndrome

Tone: Spastic Tone: Normal/

Reflexes: , Clonus Reflexes: 
Plantar:  Atrophy
Power: UMN pattern: Fasciculations
 Flexors stronger in arms
 Extensors stronger in legs
 Upper Motor Neurone Lesion
Cortex/corona radiata/internal capsule/brainstem/cord

 BRAIN
Vascular (thrombus/embolus/haemorrhage)
Compressive (tumour)/Demyelinating (Multiple Sclerosis)
Infiltrative/Infection
 BRAINSTEM
 CORD Acute = FLOPPY PARAPLEGIA
Chronic = SPASTIC PARAPARESIS

Spinal Cerebral
 Compression
neoplasm/degenerative/infective/vascular
 Syrinx
 Syphilis  Sagittal sinus thrombosis
 Vit B12  Hydrocephalus
 Infarct  Multiple bilat infarcts
 Motor Neurone Disease
 Radiation
 Myelitis
HTLV1
Viral (herpes/zoster/CMV)
HIV
Multiple Sclerosis
Sarcoid
Connective
TB MMR
 Lower Motor Neurone Lesion
The 6 anatomical stations in LMN weakness:
1. Anterior horn cell (neuronopathy)
2. Root (radiculopathy)
3. Plexus (plexopathy)
4. Nerve (neuropathy)
5. Neuromuscular junction
6. Muscle (myopathy)
 PERIPHERAL NEUROPHATIES

Anterior horn cell

Root
 Spondylosis
 Meningeal (infections, neoplasm)
 Tumours (neurofibroma, mets)
 Trauma

Plexus
 Thorasic Outlet Syndrome (cervical rib)
 Neuralgic Amyotrophy
 Malignant infiltration
 Trauma

Mononeuropathy (Compression)
Mononeuritis Multiplex (DM, Vasculitis)
Polyneuropathy (motor/sensory/sensorimotor/autonomic) AXON/MYELIN
ACUTE/CHRONIC/RELAPSING/PROGRESSIVE/STATIC/RECOVERING
Idiopathic
Genetic Charcot Marie Tooth
AIDP Guillain Barre
CIDP Inflammatory Demyelinating Polyradiculoneuropathy
Metabolic DM, CKD, Porphyria, Amyloid
Toxic Alcohol
Vitamins Thiamine, Pyridoxine, B12
Drugs INH, ARV
Vasculitic SLE, RA, Sarcoid, PAN, Churg-Strauss, Giant cell
Paraneoplastic Neuronal Ab
HIV DILS
Autonomic DM, Amyloid, GBS
Cranial Vascular, Infiltrative, Paraneoplastic, Pachymeningitis
 MUSCLE DISEASES (proximal weakness)

Inflammatory Polymyositis
Dermatomyositis
Inclusion body myositis
Viral/Bacterial/Parasitic
Sarcoid
RA
Endocrine Cushings
Thyroid
Acromegaly
Osteomalacia
Hypo Kalemia
Toxic Alcohol
Drugs Steroids
Statins
Fibrates
NM Junction Myasthenia Gravis
Lambert Eaton

INVESTIGATIONS:
CK: Dystrophy & Inflammatory
EMG: Myopathic, Neuropathic, Myotonic,
Repetitive stimulation decrement/increment
Biopsy: Dystrophy, Myositis & Denervation
MRI: Myositis
Genetic: Dystrophy & Mitochondrial
 SENSATION
Cross Section of Spinal Cord:

Motor Pathway Corticospinal tract X in Medulla

Sensory Pathways Spinothalamic tract  Pain X in Cord

 Temperature
Dorsal column  Proprioception X in Medulla
 Vibration

Sensory Pattern:

Hemi Sensory X sensory Level Myotome Mononeuropathy Polyneuropathy -

Cerebral Brainstem Cord Root Single Nerve Many Nerves Myopathy
 CO-ORDINATION
MOTOR DEFICIT
SENSORY DEFICIT / Proprioception (sensory ataxia)
VESTIBULAR
 Coordinating smooth & learned movements
CEREBELLAR  Posture & Balance control

Vermis (speech & truncal & tandem)

Ant lobes (lower limb)
Hemispheric (ataxia)

Posture (hypotonic)
Gait (broad-based)
Tremor (intention, past pointing, dysdiadochokinesis)
Ataxia
Nystagmus (coarse horizontal jerk)
Dysarthria (scanning speech)
Genetic
Vascular
Infection
Tumour
Toxic
Multiple sclerosis
Hypothyroid
Paraneoplastic
 GAIT DISORDERS

Hemiplegia Arc

Spastic Paraparesis Scissors

Parkinson’s Hesitant,shuffle,freeze

Cerebellar ataxia Wide base

Sensory ataxia Slapping

Proximal myopathy Waddling

Footdrop High step

Apraxia Glued, supine = ok

Hysterical Inconsistent