DANIL HAMMOUDI.MD

SINOE MEDICAL ASSOCIATION

 

 

PATHOLOGY LECTURES

SURGICAL LECTURES

RADIODIAGNOSIS

SURGICAL PATHOLOGY

USMLE2

USMLE

USMLEPHARM

PHYSIOLOGY [COMING SOON]

PEDIATRY

USMLE NEUROLOGY PART I

 

DETAILS ARE COMING FOR EACH OF THESE SYNDROME

ABNORMAL GAIT

(excluding orthopaedic causes)

 

hemiplegia (cerebrovascular accident involving motor cortex or pyramidal tract)

parkinsonism (shuffling / festinant)

cerebellar ataxia (wide-based gait; staggers to side of lesion):

·        multiple sclerosis

·        cerebellar tumours

·        paraneoplastic syndrome

·        hereditary degenerations

sensory ataxia [dorsal column involvement; Rombergism = ataxia worse on closing eyes]:

·        tabes dorsalis

·        subacute combined degeneration

·        diabetic pseudotabes

·        Friedreich's ataxia

·        multiple sclerosis

foot-drop (high-stepping; toe scrapes ground):

·        poliomyelitis

·        hereditary sensorimotor neuropathies, eg. peroneal muscular atrophy

·        lateral popliteal nerve palsy (mononeuropathy):

  • trauma

·        heavy metal poisoning (rare)

waddling gait (wasting disorders of pelvic girdle or proximal lower limb muscles; positive Trendelenburg sign):

·        muscular dystrophies

spastic paraparesis ('scissors gait'):

·        any cause of cord compression or transverse myelitis

ANOSMIA

 

 

·         nasal or sinus disease (commonest cause)

·         frontal lobe tumour (overlying olfactory tract)

·         Kallman's syndrome [gonadotrophin deficiency + anosmia]

·        tabes dorsalis

·        cerebral anoxia

·        damage to 1st order fibres:

·         infective damage

·        trauma to cribriform plate

CHRONIC RELAPSING POLYNEUROPATHY

 

 

·        idiopathic polyneuropathy (Guillain-Barre syndrome variant)

·        acute intermittent porphyria

·         beri-beri (B1 deficiency)

·        intoxications

AMNESIA

 

 

degenerative disease:

·        Alzheimer's disease

·        Huntington's chorea

infections:

·        meningitis

·        encephalitis

·        Creutzfeldt-Jakob disease

metabolic/endocrine:

·        Wernicke-Korsakoff syndrome

·        hypoglycaemia

drugs:

·        benzodiazepenes

other causes:

·         cerebrovascular accident (especially with involvement of thalamus, basal forebrain and hippocampus)

·        intracerebral tumours

·        cerebral hypoxia

·         post-neurosurgery, eg. bilateral temporal lobectomy, mammillary body surgery

·        transient global amnesia

·        head injury

·        psychosis

·        malingering

CSF LYMPHOCYTOSIS

 

 

infections

·         tuberculous meningitis [very high proteins, very low glucose]

·         viral meningitis [proteins normal or slightly raised, glucose normal]

·        fungal meningitis

·        meningovascular syphilis

·        cerebral abscess

·        cerebral toxoplasmosis

·        rarely: leptospirosis, Q fever, listeriosis [+ brainstem signs, eg. dysarthria]

other causes

·         sarcoidosis [proteins normal or slightly raised; glucose normal]

·        CNS lymphoma or leukaemia

·        Behçet's disease

STROKE WITHOUT LOSS OF CONSCIOUSNESS

 

 

·        brainstem stroke (vertebral artery embolism / dissection, etc)

·        demyelination

DIZZINESS

 

cardiovascular:

·        postural hypotension

·        cardiac arrhythmias

·        cardiac outflow obstruction, eg. aortic stenosis

neurological:

·        certain types of epilepsy

·        vertigo (various causes)

other:

·        fever

·        psychiatric / emotional

·        severe anaemia

FASCICULATIONS

 

 

·        motor neurone disease [fasciculations are present in different muscle groups, including face]

·         poliomyelitis (early stages)

·        spinal muscular atrophy

·        cervical spondylosis

·        syringomyelia

 

HEADACHE

 

migrainous:

·        classical migraine

·        common migraine

·        complicated migraine:

·         hemiplegic

·         ophthalmoplegic

·         basilar artery migraine

·         acute confusional state

·        Alice in Wonderland syndrome

non-migrainous vascular headaches:

·        systemic febrile infections

·        convulsive states

·        severe hypertension / hypertensive encephalopathy

·        hypoxia and / or hypercapnoea

·        temporal arteritis

·        alcohol excess

·        drugs (antihistamines, nitrates, nifedipine)

other headaches:

·         cluster headaches ('migrainous neuralgia')

·        muscular contraction headache ('tension headache')

psychogenic:

·        depression

·        conversion or delusional state

·        hypochondriasis

raised intracranial pressure: (traction headache)

·         intracerebral tumours (1° or metastases)

·        subdural haematoma

·        cerebral abscess

·        post-lumbar puncture

·        benign intracranial hypertension

intra-cranial inflammation:

·        meningitis / encephalitis

·        subarachnoid haemorrhage

miscellaneous causes:

·         post-head injury (partly psychogenic / compensation neurosis)

·         alcohol hangover (early morning headache)

·        dural sinus thrombosis

·         post-ictal (following generalised seizure)

·        food poisoning

·        Paget's disease of skull

·        normal-pressure hydrocephalus

·        trigeminal neuralgia

·        uraemia

·        CO poisoning

·        phaeochromocytoma

·        hypoglycaemia

·        hypothyroidism

·        effort-induced:

·        benign exertional headache

·        cough-induced

·        coital cephalalgia

referred:

·        dental problems

·        temporo-mandibular joint disease

·        otitis media / externa

·        sinusitis

·        cervical spondylosis

·        'eye strain'

·        acute glaucoma

·        'ice-cream headache'

HORNER'S SYNDROME

 

 

·        Pancoast tumour (T1 also involved) [commonest cause]

·        brainstem vascular disease (lateral medullary syndrome)

·        brainstem demyelinating disease

·        syringomyelia (bilateral Horner's syndrome)

·        intrinsic cervical cord disease (vascular or neoplastic)

·        cervical node metastases

·        local (neck) neoplasia

·        local (neck) trauma, eg. stab wound

·        carotid or aortic aneurysm

·        cervical sympathectomy

HORNER'S SYNDROME AND 12TH NERVE PALSY

 

jugular foramen lesions:

·        meningioma

·        neurofibroma

·        glomus jugulare tumour

other:

·        syringomyelia / syringobulbia

·        brainstem vascular disease (lateral medullary syndrome)

 

LOWER CRANIAL NERVE LESIONS (IX TO XII)

 

·         syringobulbia (nuclei in medulla affected)

·        posterior fossa tumours

·         basal meningitis (cranial nerve course in posterior fossa affected)

·         nasopharyngeal carcinoma (spreading to base of skull)

·         Paget's disease (affecting foramina at base of skull)

·        sarcoidosis

·        diabetes mellitus

·        porphyrias

jugular foramen lesions:

·         thrombophlebitis (following neck or skull suppuration)

·        glomus jugulare tumour

 

PERIPHERAL NEUROPATHY

[classified according to whether predominantly sensory or motor]

 

motor neuropathy:

anterior horn cell disease:

·        poliomyelitis

·        motor neurone disease

disease affecting roots:

·        arachnoiditis

·        neurofibroma

peripheral nerve trauma

'die-back' neuropathies (distal)

 

sensory neuropathy:

·        cord lesions

·        dorsal root ganglion lesions (eg. zoster)

·        peripheral nerve lesions (as above)

WASTING OF SMALL MUSCLES OF HAND

(classified according to whether unilateral or bilateral)

 

cord lesions affecting anterior horn cells at T1 level:

·        motor neurone disease

·        Friedreich's ataxia

·        syringomyelia

·        cord compression

·        polio

·        meningovascular syphilis

·        Charcot-Marie-Tooth disease

 

T1 root lesions:

·        cervical spondylosis

·        'dumb-bell' neurofibroma

 

brachial plexus lesions (lower cord - T1):

·        cervical rib

·        Pancoast tumour

·        Klumpke's paralysis (traumatic)

 

peripheral nerve lesions:

·        median and ulnar nerve lesions

 

muscle disease / other:

·        disuse atrophy

·        rheumatoid arthritis

 

OLIGOCLONAL BANDS

(RAISED CSF IMMUNOGLOBULINS)

 

·         demyelination (multiple sclerosis)

·        neurosyphilis

·        sarcoidosis

·        systemic lupus erythematosus

·         subacute sclerosing panencephalitis (following measles)

·        meningitis

·        Guillain-Barre syndrome

PARKINSONISM

 

1° / idiopathic:

·         Parkinson's disease ('paralysis agitans')

·        juvenile parkinsonism

poisoning:

·         heavy metals (copper, manganese, iron, 6-hydroxydopa)

·        MPTP in drug addicts

·        carbon monoxide

drugs:

·        dopamine antagonists:

·         phenothiazines, butyrophenones and thioxanthines

·        metoclopramide, prochlorperazine and cinnarizine

·        dopamine depletion:

·         reserpine

·        tetrabenazine

infections:

·        meningovascular syphilis

·        post-encephalitis (following 1914-18 influenza pandemic causing encephalitis lethargica)

hereditary:

·        Huntington's disease

·        Wilson's disease

·        familial basal calcification

·        familial parkinsonism

·        Hallervorden-Spatz disease

·        Guam complex (familial parkinsonism + dementia + amyotrophic lateral sclerosis)

multiple system atrophy:

·         Shy-Drager syndrome (parkinsonism + autonomic neuropathy + atonic bladder)

·        olivo-ponto-cerebellar atrophy

·        cortico-basal degeneration

other / miscellaneous causes:

·         trauma (especially boxers - 'post-pugilistic encephalopathy')

·        surgery to substantia nigra

·        hypoxia

·        cerebral tumours

·        Steele-Richardson syndrome / progressive supranuclear palsy (parkinsonism + impaired downward gaze + dementia)

PES CAVUS

 

 

neurological disease:

·         peroneal muscular atrophy (hereditary sensorimotor neuropathy)

·        Friedreich's ataxia (may be only finding in ‘forme fruste’ of disease)

·        Refsum's disease

·        leprosy

·        spinal dysraphism / syringomyelia

·        polio

·        polyneuritis

·        cerebral palsy

·        meningomyelocoele

·        tibial nerve lesion [paralysis of small muscles of foot]

 

non-neurological causes:

·        muscular dystrophy

·         contracture of plantar fascia [as in Dupuytren's contracture]

·        idiopathic

 

SPINAL CORD COMPRESSION

 

extradural (vertebral disorders; 45%):

collapsed vertebral body:

·        metastases

·        osteoporosis

·        1° tumours of bone

·        central disc prolapse

other:

cervical spondylosis

rarer causes:

·        Paget's disease

·        ankylosing spondylitis

·        rheumatoid arthritis:

·        atlanto-axial and/or sub-axial subluxation

·        trauma:

·         crush fracture

·        whiplash injury

·        canal stenosis:

·         cervical

·        lumbar

·        infections:

·         brucellosis

·         tuberculosis

·        epidural abscess

 

meningeal (intradural) causes (45%):

tumours:

·         meningioma (usually thoracic)

·         neurofibroma

·        metastases from lymphoma or leukaemia

other:

·        syphilitic meningitis

 

spinal cord (intra-medullary) lesions (5-10%):

tumours:

·         glioma

·         ependymoma

·         angioma

·        metastases

 

TRANSIENT LOSS OF CONSCIOUSNESS

 

decreased cerebral blood flow:

invreased vagal tone:

·        vasovagal syncope

·        cough syncope

·        micturition syncope

postural syncope (orthostatic hypotension):

·        fluid / blood loss, including heat syncope

·         anti-hypertensive drugs (over-treatment of HT)

·        adrenal insufficiency

·        autonomic neuropathy

·        elderly (various factors)

associated with head movements:

·         vertebro-basilar insufficiency (usually + diplopia and vertigo)

·        carotid sinus hypersensitivity

exertional syncope (indicates severe limitation of cardiac output):

·        aortic or pulmonary stenosis

·        hypertrophic cardiomyopathy

·        pulmonary hypertension

·        steal syndromes

cardiac arrhythmias (3%):

·         tachycardia, eg. VT, SVT

·        bradycardias / sick sinus syndrome

·        transient asystole or ventricular fibrillation

intracerebral pathology:

·        cerebral infarction or haemorrhage

·        cerebral contusion / concussion

 

epilepsy:

generalised:

·         grand mal (tonic-clonic)

·         petit mal ('absence seizures')

·        akinetic (atonic) seizures

·        myoclonus with loss of consciousness

partial (focal; usually no LOC, unless with 2° generalisation):

·        simple partial seizures

·        complex partial seizures

·        secondarily generalised partial seizure

·        temporal lobe epilepsy

·        Jacksonian seizures

 

other:

hysterical faints

unknown cause (40%)

 

ABSENT LOWER LIMB REFLEXES WITH EXTENSOR PLANTAR RESPONSE

 

·        diabetes mellitus + cervical myelopathy

·        motor neurone disease

·        Friedreich's ataxia

·         taboparesis (= tabes dorsalis [extensor plantars] + general paresis [absent reflexes])

·        subacute combined degeneration of cord (B12 deficiency)

·        conus medullaris syndrome (but not cauda equina compression which gives only LMN lesions)

 

ATAXIA

 

cerebellar disease:

posterior fossa tumours:

  • acoustic neuroma
  • 1° cerebellar tumours
  • metastases

degenerative cerebellar disease:

  • hereditary:
  • ataxia-telangiectasia
  • Friedreich's ataxia

para-infectious:

  • Guillain-Barre syndrome
  • acute ataxia of childhood / young adults
  • HIV disease

toxic / drugs:

  • anti-convulsant drugs (nystagmus usually gross and vertical)
  • alcohol intoxication
  • sedatives

other:

  • multiple sclerosis

·        brainstem vascular disease

·        paraneoplastic syndromes

·         brainstem tumours (rare)

 

dorsal column disease (sensory ataxia; positive Romberg's sign):

·         vitamin B12 deficiency (subacute combined degeneration of the cord)

  • tabes dorsalis (syphilis)

 

CEREBELLO-PONTINE ANGLE LESION

 

·         acoustic / vestibular neuroma [80%; widened IAM; enhances +C]

·         meningioma [10%; hyperdense; enhances even more +C]

·        epidermoid [5%; low density (fat-containing); no C enhancement]

others [5%]:

·        metastases

·         glomus jugulare tumour [associated erosion of jugular foramen]

·        chordoma [most arise from clivus]

COMA AND GLYCOSURIA

 

 

·        diabetic keto-acidosis

·        stroke

·        aspirin overdose

·        other causes of coma in a poorly controlled diabetic

 

CARPAL TUNNEL SYNDROME

 

endocrine / metabolic disease

myxoedema

acromegaly

diabetes mellitus

pregnancy / oral contraceptive pill

premenstrual fluid retention

any other cause of generalised oedema

connective tissue disease

rheumatoid arthritis

systemic lupus erythematosus

scleroderma

other / miscellaneous

amyloidosis

trauma to wrist / prolonged pressure over wrist, including occupational

 

NB: to differentiate carpal tunnel syndrome from:

T1 lesion (cervical spondylosis, etc.)

motor neurone disease

syringomyelia

STROKE

(CEREBROVASCULAR ACCIDENT)

 

ischaemic cerebral lesions

·        thrombosis / atherosclerosis (commonest cause)

·        embolism (esp. in atrial fibrillation)

·        arteritis / vasculitis:

·        polyarteritis nodosa

·        systemic lupus erythematosus

·        syphilis

·        tuberculosis

·        giant cell arteritis

·        arteriospasm:

·        hemiplegic migraine

·        subarachnoid haemorrhage

·        hypotension

 

haemorrhagic cerebral lesions

hypertension (1° intra-cerebral bleed; usually lacunar)

subarachnoid haemorrhage:

·        rupture of saccular aneurysm

·        AVM [5%]

·        extension of intra-cerebral bleed

·        diffuse vascular disease in elderly

·        trauma

bleeding from tumours

trauma (extra-dural or sub-dural haematoma)

 

tumours (5%)

DYSARTHRIA

 

·        stutter

·        alcohol intoxication [cerebellar dysarthria]

·         cranial nerve palsies (VIIth, IXth, Xth or XIIth)

·         cerebellar lesions [scanning / staccato speech, especially in ms]

·         parkinsonism [slow, quiet, slurred, monotonous speech]

·         pseudobulbar palsy [spastic dysarthria; rarely monotonous and high-pitched]

·         progressive bulbar palsy (motor neurone disease - rare)

·         general paralysis of the insane (syphilis; rare)

·         mechanical defects, eg. cleft palate, ill-fitting dentures

·         deafness, esp. in childhood [loss of monitoring of speech]

·        Friedreich's ataxia

FITS (SEIZURES)

 

idiopathic epilepsy (commonest cause)

 

local causes:

focal intracranial lesions (± raised intracranial pressure):

tumours

cerebral abscess

subdural haematoma

angioma

inflammatory and demyelinating conditions:

meningitis

encephalopathies, eg. SSPE

toxoplasmosis

acute or subacute encephalitis

neurosyphilis

cerebral cysticercosis

cerebral malaria

multiple sclerosis

trauma:

perinatal brain injury

head injury

congenital abnormalities:

various forms of cerebral palsy

cerebral malformations

degenerations and inborn errors of metabolism:

neuronal storage disorders

diffuse sclerosis

leucodystrophy (various)

encephalopathies of infancy and childhood (including 'infantile spasms')

phakomatoses (neurocutaneous syndromes or ectodermal dysplasias):

tuberous sclerosis

neurofibromatosis

von Hippel-Lindau syndrome

cerebral vascular disease:

·         atheroma (causing thrombosis, embolism and haemorrhage)

·         vasculitis, eg. systemic lupus

·         eclampsia

·         hypertensive encephalopathy

·         polycythaemia

·         intracranial aneurysms

·        any other cause of cerebral ischaemia

other:

·         Pick's disease and Alzheimer's disease

·         subacute spongiform encephalopathy

·        Creutzfeldt-Jakob disease

 

generalised causes:

·        exogenous poisons / drugs:

·         alcohol (and its withdrawal)

·         insulin

·         amphetamines

·         imipramine and derivatives

·         barbiturates (and withdrawal)

·         antihistaminics

·         intrathecal penicillin

·         MAOI's

·         pyridoxine analogues

·        intrathecal contrast media

·         cocaine

·         strychnine

·         lead

·         chloroform

·         ether

·         camphor

·         phosphorus insecticides

·         lignocaine

·        certain amino-acids

·        anoxia:

·         asphyxia

·         profound anaemia

·         hypotension

·         CO, CO2, N2O, etc.

·        any other cause of cerebral anoxia

·        metabolic:

·         renal failure

·         hepatic failure

·         hypoglycaemia

·         hyperkalaemia

·        alkalosis

·         porphyria

·         pyridoxine (B6) deficiency

·         hyperpyrexia (esp. in children 6 months to 6 years)

·        hyponatraemia / water intoxication

·        endocrine:

·         1° hypoparathyroidism

·         pseudohypoparathyroidism

·        hypoadrenalism

·         pituitary disease

·        thyroid disease