Neurologic Disorders

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Bell’s Palsy - definition

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nerve that controls the muscles of the face becomes injured or even stops working altogether. This causes the facial muscles to become weak or paralyzed.

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Bell's Palsy is common in?

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DM and pregnancy.

may also be associated with trauma, infection, neoplasia, or toxins

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What virus is thought to be associated w/ Bell's Palsy?

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HSV or varicella zoster virus

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Bell's Palsy - presentation/PE

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* sudden onset of unilateral facial paralysis
* Prodrome consisting of ear pain or hyperacusis
* Eyebrow sagging/Inability to close the eye
* Disappearance of nasolabial fold
* Mouth drawn to the non affected side

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Imaging should be conducted in Bell's Palsy to what end?

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* Rule out tumor

* EMG for atypical or prolonged presentation

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Bell's Palsy - Tx

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* Usually resolves completely on its own

* Can use short-course glucosteroids, prednisone, Acyclovir

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GUILLAIN- BARRE SYNDROME - definition

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* condition that causes mild or severe ascending muscle weakness. Person’s immune system attacks their own nervous system, damaging the nervous system

* different types of GBS. MC is “acute inflammatory demyelinating polyneuropathy,” or “AIDP.”

* bimodal distribution: 15-35 years and 50-75 years

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2/3 of patient with GBS give a history of?

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antecedent URI or GI.

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GBS may occur after what events?

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* Infection: campylobacter jejuni enteritis
* After Immunizations
* After Trauma, surgery, Hodgkin’s

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GBS- cardinal presentation

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* progressive, fairly symmetric ascending muscle weakness accompanied by absent or depressed deep tendon reflexes.

* progresses over a period ~2 weeks, by 4 weeks have reached the nadir

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GBS - additional S/S

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Dysautonomia:
* tachycardia/arrhythmias
* hypo /hypertension
* flushing, sweating, incontinence

Neuropathic and radicular pain

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Lab findings in GBS?

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* elevated CSF protein with normal WBC (at one week). Change will occur at week 2& 3

* EMG of weak muscles shows reduced recruitment

* NCS (Nerve conduction studies) – reveal absent responses or slowed conduction velocities

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GBS - Tx

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* Supportive: BP, Resp, PT

* Disease modifying:
• Plasmapheresis
• IV immunoglobulin
• NO prednisone

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Multiple Sclerosis - definition

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Autoimmune inflammatory demyelinating disease

* Most common neurologic disorder

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Relapsing-remitting MS - definition

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* symptoms of MS come and go, flare up called an attack.

* attacks can last for days to weeks and usually get better slowly. In between pt often feel pretty normal, some have problems that last after

* MC type of MS.

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Secondary progressive MS - definition

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* symptoms come and go at first but then begin to steadily get worse.

* happens to many people who start out with relapsing-remitting disease

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Primary progressive MS - definition

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symptoms steadily get worse from the beginning.

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Progressive relapsing MS - definition

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symptoms steadily get worse, and on top of that there are also attacks that come and go.

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MS - Presentation

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* primary symptoms: weakness, numbness, tingling, or unsteadiness
* retrobulbar optic neuritis
* diplopia, disequilibrium
* Urinary urgency or bowel symptoms

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secondary progressive MS - presentation

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in addition to other S/S

* "band-like" abdominal or chest pressure
* cerebellar symptoms

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MS - PE

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* Hyperreflexia, spasticity, positive babinski’s sign

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Preferred imaging for MS?

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MRI – test of choice
1) Characteristic lesion is the cerebral or spinal plaque. Discrete region of demyelination with relative preservation of axons.
2) Multiple foci

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Primary MS - Tx

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- Considered empiric; Intravenous glucocorticoid monthly pulses (typically 1000 mg of methylprednisolone)

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Secondary progressive or relapsing remitting MS - Tx

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indefinite treatment with:
1) Intravenous cyclophosphamide and glucocorticoid
2) Methotrexate oral or subcutaneous w/ or w/o monthly glucocorticoid
3) Consider addition of an interferon

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MS attack Tx?

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Corticosteroids for recovery from acute relapses—IV to oral

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Additional Tx for MS?

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Symptomatic treatment for spasticity, neurogenic bladder, and fatigue

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Myasthenia Gravis - definition

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Rare autoimmune disorder of neuromuscular transmission. Occurs at any age, tends to be a bimodal distribution to the age of onset with an early peak in the second and third decades (female predominance) and a late peak in the sixth to eighth decade (male predominance

Weakness is the result of an antibody-mediated, T-cell dependent immunological attack directed at proteins in the postsynaptic membrane of the neuromuscular junction

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Myasthenia Gravis - Presentation

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* cardinal feature is fluctuating skeletal muscle weakness, often with true muscle fatigue.

* Fatigue is manifest by worsening contractile force of the muscle , not a sensation of tiredness

* Slow progressive course

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2 clinical forms of MG?

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1) Ocular – limited to eyelids and extra-ocular muscle

2) Generalized – often ocular, variable combination of bulbar, limb and respiratory muscles

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MG - PE findings?

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* ptosis and/or diplopia
* Bulbar symptoms: dysarthria, dysphagia, fatiguable chewing
* Sensation is normal and no reflex changes
* Loss of expression on the face
* Trouble breathing
* Pos. hard to lift the arms or legs, open the fingers, or lift a foot.

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Myasthenic crisis

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* deadly due to respiratory mm failure

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Lab testing for MG?

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1) Serologic testing
2) ELECTROPHYSIOLOGIC CONFIRMATION
3) Bedside tests (the Tensilon test and the ice pack test)
4) CT to rule out thymoma

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SEROLOGIC TESTING Lab for MG?

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positive AChR-Ab or MuSK-Ab assays have seropositive myasthenia gravis (SPMG).

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four basic therapies for MG include?

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1) symptomatic treatments (anticholinesterase agents)
2) chronic immunotherapies (glucocorticoids and other immunosuppressive drugs)
3) rapid immunotherapies (plasma exchange and intravenous immune globulin [IVIG])
4) thymectomy

* Avoid amicoglycosides will worsen condition

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Trigeminal Neuralgia - definition

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* paroxysmal, stereotyped attacks of usually intense, sharp, superficial or stabbing pain in the distribution of one or more branches of the fifth cranial (trigeminal) nerve

* Common cause of facial pain. MC cranial neuralgia

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TN - Presentation

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* Paroxysmal, stereotyped attacks of usually intense, sharp, superficial or stabbing pain
* Pain is MC in the second and third division of the trigeminal nerve.
* Pain triggered by touch, movement, drafts, eating
* Unlike some other facial pain syndromes, TN typically does not awaken patients at night.

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TN - PE findings

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* Facial muscle spasms can be seen with severe pain
* Pain triggered by touch lasting several seconds described as electric, shock-like or stabbing
* Pain severe enough to cause pt to wince, "tic" like appearance

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TN - imaging

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* CT scans and radiologic contrast studies are normal with classic trigeminal neuralgia
* Have to rule out MS or brainstem neoplasm esp in children

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TN - Tx

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* Medications to control pain
* Carbamazepine or Oxcarbazepine
* Baclofen, Phenytoin, or Iamotrigine if others are ineffective
* Surgical exploration or decompression of the nerve root

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TN more often occurs in?

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Women MC
Middle and later life

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Stuporous - definition

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pts respond only to repeated vigorous stimuli.

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Comatose - definition

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pts are in the state of being unarousable reflex movements and posturing may be present

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Potential PE findings in a stuporous/comatose pt?

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* Diplopia * Doll’s eyes * Dysarthria
* Dyskinesia tardive * Dystonia * Nystagmus
* Paresthesia * Ptosis * Tics * Papillary changes
* Breathing changes

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Labs for a stuporous or comatose pt?

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• Noncontrast CT scan of the head to look for intercranial hemorrhage, herniation, or other lesions that require immediate surgery`
• CBC= glucose, calcium
• Liver and kidney fxn tests

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Stuporous/comatose pt - Tx

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• Give IV dextrose, naloxone, and thiamine
• Supportive therapy for respiration and BP
• All comatose patients should be referred to a neurologist or neurosurgeon