Neurophilia
@bobvarkey
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Neuro-intensivist & Interventionalist, Autodidact, Philomath, Iconoclast, Isolophile, Bibliophile, Technophile & Investor@ Kochi, Kerala.
Lourdes Hospital, Kochi
Joined July 2009
Clinical pearl; A One minute Neuro hand exam, I call.'Check your Six'. Ask your patient to give you a boy scout salute (three finger salute- median/ulnar), an Ok (ant interroseus), then play 'Rock (median), Paper (radial), Scissors (Ulnar) and sign off with a Thumbs up (radial)
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Clinical pearl; Knuckle and IP joint hyperpigmentation in a proven case of Vitamin B12 deficiency. Due to increased melanin synthesis secondary to reduced intra cellular glutathione
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Tweetorial. 1/š§µ. Scapular winging. A young man with shoulder pain after a road traffic accident. His back looks like this
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Clinical pearl; Unilateral asterixis is almost always associated with a structural contralateral cerebral or an ipsilateral cerebellar pathology. Bilateral asterixis is metabolic/toxic in origin.
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Clinical pearl: Quick and easy detection of UMN weakness - finger rolling or what I like to call the āSatellite signā- subtle weakness of left sideā”ļøgradual orbiting of the weaker side ( left index) by the normal right index finger
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Convergence retraction nystagmus with a left 6th nerve palsy
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MRI for the non-radiologists. Do the terms FFE, GRE, T2*, SWI, SWAN & Phase imaging confuse you? Here is a handy reference sheet for that. Without going into any of the physics of MRI, the 1st point to understand is;.1. T2* (pronounced "T2-star") is the basis of other sequences,
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Clinical pearl: The closer to the paw, the more the claw! Distal ulnar nerve lesions cause More clawing than proximal ulnar nerve lesions
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Clinical pearl; WEBINO=Wall-eyed bilateral internuclear ophthalmoplegia with Midbrain exotropia, b/l ADduction impairment, ABducting eye nystagmus & Gaze evoked Upbeat nystagmus
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Here's a link to the poster explaining each cognitive disorder in 'microscopic' detail. [
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An unusual cause of Parkinsonism. This young man presented with recent onset features of Parkinsonism and hypokinesia with decrement response. He had been taking Reserpine for the past 6 months after which his problems had started. Rauwolfia Serpentina ( active ingredient
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Clinical pearl; An easy way to remember the MCA segments. It looks like a staircase. The horizontal parts are M1 & M3, the vertical parts are M2 & M4
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Bilateral Oppenheim's sign- Dorsiflexion of great toes elicited by downward stroking of the medial side of the tibia
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No pain, no gain! Young man with severe headache, disorientation of 2 days duration. MRI outside-left temporal hematoma. O/e agitated, wernicke's aphasia, right hemiparesis
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Hole'y Smokes. A š§µ about a rare case I've never seen again! Why a neurological history is absolutely essential to the diagnosis of these "holes in the brain'
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When infrared thermography saved the day! Picked up evolving fasciitis when all other tests were negative , by demonstrating a warmer left legā¦
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Clinical pearl: Up up, down down. Higher ( cortical lesions) with synkinetic wrist extension can be distinguished from lower radial nerve palsy with finger/wrist drop. Clenching the fistā”ļø wrist extension in cortical lesions & wrist flexion in radial palsy. ā¬ļøCortical strokeā¬ļø
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Facial myokymia is classically associated with a pontine glioma, multiple sclerosis, and other intrinsic brainstem pathologies.
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Clinical pearl: Looks can be deceiving. The UMN innervation of most cranial nerves is bilateral which means that each cranial nerve receives impulses from the left and right hemisphere. Exceptions to this rule are CN 5,7 &12.
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Suspected Lambert Eaton Myasthenic syndrome patient with Initially absent knee jerk that is enhanced briefly by tapping the tendon repeatedly.
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Clinical pearl; Propofol frenzy; Presented with a cluster of seizures, now on Propofol 40mg/hr, being Rx as ongoing status epilepticus, but cEEG is normal (shows only myogenic artefacts). Dx as Frenzy & advised to stop Propofol [idiosyncratic SE due to NMDA receptor activation]
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Clinical pearl: Tardive generalised chorea after 20 years of Rx for schizophrenia. Better with Tetrabenazine.
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Clinical pearl: Myoclonus-dystonia: affects the neck, torso, and arms ā”ļømyoclonus + dystonia. May improve with alcohol & maybe Autosomal dominant ( SCGE Gene mutation) OR sporadic
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The arterial supply to the brain in 3 D- virtual anatomy App
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The FOUR score is easier to perform and more informative in neurological conditions. The GCS is designed for Head trauma and should be restricted to the@ Wijdicks EF, Bamlet WR, Maramattom BV et al Validation of a new coma scale: The FOUR score. Ann Neurol. 2005 Oct;58(4):585-93
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Clinical pearl; Foot drop-localisation. š© with right leg FD.
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Hemimasticatory spasm is a disorder of the trigeminal nerve ā”ļøinvoluntary jaw closure due to spasmodic unilateral contraction of jaw-closing muscles- masseter and temporalisā”ļø similar to hemifacial spasm. Our patient had a normal MRI & responded to clonazepam/ trihexyphenidyl.
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Posterior circulation with one Vertebral artery erased for clarity
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The other Babinski sign- In Hemifacial spasm-āorbicularis oculi contracts & the eye closes, the internal part of the frontalis pulls down the medial part while the lateral part risesā In Blepharospasm both parts go down. In functional disordes both parts go up with eye closure
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Doc, My anxiety is gone, but i cant walk or talk for the past week!.A 45 yr š©with severe anxiety, who has been on Sertraline 150mg for 6 months.
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Bilateral high stepping gait with a high knee lift in a case of chronic inflammatory neuropathy
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@WeaponizedSmirk Why not turn the clock back 500 years and go back to the original inhabitants? Atleast they wonāt bother the rest of the world.
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Clinical pearl; Re-emergent tremor in Parkinsonās disease-postural tremor that disappears & reappears after a short latency on moving from rest to posture. During this brief time , there is no postural tremor. This differentiates the postural tremor of Essential tremor from PD
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Emergency consult for a right blown pupil in the hematology ward. Patient looks fine except for a right dilated unreactive pupil. Where could the lesion be ?
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Clinical pearl : Bilateral Internuclear ophthalmoplegia in chronic Multiple sclerosis. Note the adduction lag in the adducting eyes. Abducting eye nystagmus is seen during some of the movements- probably partially compensated due to long standing MS
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Clinical pearl; Looks Can't be deceiving! Two axillary folds hide a whole story. Young man with left sided wasting. O/e has ā¬ļø appearance.
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Pro tip; from a lecture by Dr Bloem. How to differentiate Parkinsonās disease from atypical Parkinsonism in a jiffy? PD patients are able to maintain tandem walking even late into their course. The ATP patient has early tandem ataxia ( PSP, MSA etc )ā”ļøPD pt 5 yrs after onset)
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A confusing presentation- elderly lady with sudden onset unsteadiness after a colonoscopy. On exam - had bilateral limb ataxia and gait ataxia
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Clinical pearl; Left UL rhythmic Action Myoclonus simulating tremor due to a strategic cortical bleed. Subsides on rest. MRI brainā¬ļø
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Clinical pearl- Epileptic hippus- pupillary diameter oscillation during a status epilepticus
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Clinical pearl; Round the house sign in PSP. Due to dysfunction of the riMLF (the vertical saccade manager), the eyes take a round about route going up and down instead of the shortest straight routes.
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Parinaud's syndrome with restricted upgaze, eyelid retraction & convergence retraction nystagmus. A useful mnemonic is UNCLE-.Upgaze restriction.Nystagmus.Convergence insufficiency or spasm.Light- near dissociation (ARP).Eyelid retraction
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Pourfour du Petit (PDP) syndrome. [Aka -Reverse Hornerās syndrome] Characterised by Unilateral mydriasis, Eyelid retraction & Ipsilateral Facial Hemihyperhidrosis
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Two Wartenberg signs in pyramidal weakness ;[1] Wartenberg's Window- abduction of the 5th finger and a gap between the 4th and 5th fingers on finger extension-also seen in ulnar neuropathy ā¬ļø
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Clinical pearl; What posterior BPPV (left side) really looks like! Delayed onset, horizonto-rotary nystagmus to the left (affected ear) with fatiguability.
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Clinical oddity; Focal neuromyotonia in SLE.A 42 year old with a 10 year history of Systemic lupus erythematosus with painful spasms of her left 4th and 5th fingers for 2 weeks.
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Calcaneal numbness and ankle swelling after a fall- [Baxterās Entrapment neuropathy] -Entrapment or compression) of the Inferior Calcaneal Nerve (1st branch of the Lateral Plantar Nerve ).
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Carotid stent explantation after stenting restenosis occurs. When a vascular surgeon friend in need is a friend in deed!
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Clinical pearl: Leg motor restlessness (LMR) ā”ļø similar Restless legs syndrome (RLS) in that sufferers have an urge to move the legs. However in LMR it is not worse in the evening and NOT relieved by movement Unlike RLS. It seems to be extremely common in our state;Kerala.
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Clinical pearl: Orofacial and limb dyskinesias in NMDAR encephalitis. Note the lip mutilation.( pt consent for video without identification obtained)Pt is tracheostomised & off Ventilator.
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Reflex irradiation ( Pathological spread of reflex muscle activity to synergistic neighbouring motor neurone pools). Note adduction of right thigh on eliciting the left knee jerk.
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Clinical pearl; Oculomotor apraxia (OMA). A defect or absence of the ability to perform voluntary eye movements to command, while eye movements are otherwise unimpaired in any direction. To command, OMA pts head thrust or /blinking to initiate eye movement to objects of interest
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Clinical pearl; Opsoclonus-rapid, repetitive conjugate involuntary chaotic multidirectional (horizontal, vertical, and torsional components) eye movements without intersaccadic intervals. OMS can occur as a para-infectious COVID manifestation.
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Clinical pearl- Pathological reappearance of a symmetric tonic neck reflex (STNR) in severe brain edema. Neck flexion produces symmetrical arm flexion and lower limb extension
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Clinical pearl;41 year old vegetarianšØwas admitted with progressive Paresthesia and weakness of of UL and LL-1 year duration. O/E-knee jerk: Brisk,Ankle jerk absent. Joint sense/ Vibration impaired hips, spastic gait, Rhombergs :+ve.
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Clinical pearl; ' A Hot Carotid'. A 74 year old man with acute onset weakness and tremors of the right hand.
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Vestibulo-ocular reflex (VOR) cancellation test-when the head and eye rotate together, this reflex suppresses the VOR to maintain stable vision. This is one of the most sensitive tests of Cerebellar dysfunction (flocculus and paraflocculus). This pt with fixation difficulty
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This is a representation of the Cortical supply of the MCA branches. Orbitofrontal artery (OA).Prefrontal artery. (PF).Precentral artery (PC).Central artery (aka Rolandic artery) [CA].Anterior parietal artery [AP].Posterior parietal artery [PA].Angular artery [AA]
Hope this was useful and simplified this complex anatomy!.
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Clinical oddity; A mountain of a clot! A young post partum š©āš¦° 20 days after LSCS with worsening headache and quadriparesis. MRI- right > left hemispheric edema. MRA- shows complete occlusion of the SSS and TS
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Convergence- retraction nystagmusā”ļø irregular, jerky nystagmus, associated with convergence and retraction of both eyes, especially on attempted upgaze.ā”ļø? damage to the supranuclear fibers, which have an inhibitory effect on the midbrain convergence or divergence neurons.
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Clinical pearl; 35 yr old with severe left sided headache & diplopia x 4 days. O/E- Left 6th nerve palsy. CTA, MR, MRA normal. PMH- h/o head injury with closed multiple skull # 1.5 years ago. D/d- Meningitis, Raised ICP, dural A-V fistula. 1/š§µ
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An office test for POTS, OH and OI.The 10-minute NASA Lean Test (NLT).ā¢Steps-.ā¢[1] Make the pt rest and lie down for 10 minutes.ā¢[2] Then stand up for 10 minutes, and with her/his heels 6-8 inches from the wall, and shoulder blades touching it
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Semaglutide's popularity is soaring as a rapid weight loss drug and a panacea for everything from Heart failure to Idiopathic intracranial hypertension. However, it is associated with significant adverse effects such as a 9-fold increase in pancreatitis, 4 fold increase of
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This is how small a Carotid stent really is! The wonders of technology .
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Myasthenia gravis was diagnosed in the course of a fundus exam.
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Periodic alternating gaze [PAG] is an involuntary continuous cyclic horizontal sustained.conjugate deviation of the eyes, which alternates sides with a cycle of 1ā2 min.šTweetorial. f
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If you need a Mnemonic its TRAWL - Trapezius & Rhomboid Are Winged Laterally , SWIM - Serratus Winging Is Medially.
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Symptomatic left Holmes tremor ( postural and intentional > rest) coarse proximal > distal upper and lower limb tremor. Bubbly thalamiās lesion on the right-Bx awaited
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Clinical pearl ā”ļøPolyminimyoclonusā”ļø intermittent, low-amplitude, arrhythmic movements commonly of several fingers, with āamplitudes just sufficient to produce visible joint movements in Bimelic amyotrophy (Bimelic Hirayama)
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Epidemic of Stimulus sensitive generalised epilepsy.
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Downbeat nystagmus simplified. 65 š©āš¦° with new walking difficulty and dizziness. AMPAR Ab positive. WB PET CT negative. Improvement with Rituximab 1gm/mth x 2 dosesšWhy DBN ?
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Clinical pearl: Brain fry ! Acute brain (cortical) injury cytotoxic edema and infarction due to Electrocution. Frontal and temporal lobes
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Severe peripheral myoclonus in a young š©āš¦± with Ehlers Danlos syndrome & multiple surgeries for recurring joint dislocations. Has left leg constant jerks even in sleep , relieved only by forced ankle dorsiflexion. Multiple MRIs of brain , spine , EEG and video EEGs normal. No
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Clinical pearl- Severe Carpal tunnel syndrome with thenar wasting & APN ( abductor pollicis weakness)
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Came in with complaints of feeling of weakness of left index tip. Flummoxed me a bit till the full exam
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Low low high high : Low medullary lesions cause a lower eye on the same side - in this case the left eye. A high midbrain lesion will cause the ipsilateral higher eye
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[2] [Wartenberg thumb reflex] (adduction, flexion, and opposition of the thumb INSTEAD of a normal response of abduction and extension on forceful flexion of the fingers at the distal IP joints)
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Clinical pearl: One & a half syndrome with upbeat nystagmus due to a left pontine + bimedullary infarction
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Young šāāļøw/a recent pca infarct- cause undetermined. This zebra led onto further questioning and the culprit
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Decrementing response in Parkinsonās with slow reduction in amplitude of finger movements
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Rebound nystagmus is a common sign of cerebellar disturbance. During eccentric gaze holding - nystagmus is seen and a REBOUND nystagmus [beating briefly to the OPPOSITE side] is seen on resuming primary gaze after a period of eccentric gaze holding.The nystagmus is transient
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Tele-stroke rule out!.Acute wrist drop - peripheral- with further wrist flexion on making a fist- characteristic of radial palsy. In a cortical stroke synergy would cause the flexed wrist to remain neutral or extend
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Another fascicular 3rd nerve palsy (Pupil sparing) mimicking a non-compressive 3rd nerve palsy- Due to the peculiar arrangement of fascicles in the midbrain, in this case with left 3rd nerve palsy and dysarthria, the medial-most Pupillary fascicles were spared.
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Clinical pearl-Limb shaking Transient Ischemic Attack (LS-TIA) during transient occlusion of the right ICA during angioplasty of a right ICA near occlusive stenosis. LS-TIA is a rare manifestation of carotid-occlusive disease
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Dysfunction of the six- Opposition weakness-in carpal tunnel syndrome with opponens Pollicis . Pincer grasp lost. Can we used to check for both weakness of the median nerve & Ulnar nerve (opponens digiti minimi). In this case, the right side is weaker than the left
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Clinical pearl: Intermittent convergence spasm in encephalitis. Both Medial recti go into spasm intermittently with normalisation after the spasms
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Ocrelizumab is finally available on the Indian market. Wonderful news for our primary progressive and active secondary progressive Multiple sclerosis patients
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I can't believe that even after hundreds of thousands of spine surgeries, classic spinal cord anatomy teaching leaves out the important 'Posterior radiculo-medullary arteries'. We all know the anterior radiculo-medullary arteries and the Great or arteria radicularis magna,
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Complete left Oculomotor nerve palsy- Ptosis, dilated pupil, restricted movements except abduction (Abducens) and Intorsion (Trochlear)
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The most common sites of venous stenosis in Idiopathic intracranial hypertension (IIH).- the transverse- sigmoid junction, posterior sigmoid and distal superior sagittal sinus
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