Applied Neurological Injuries Sammy case s.case@warwick.ac.uk

A 64 year old man presents to A&E with weakness in the right side of his face and right arm. He is conscious and able to communicate with you although his speech is slightly slurred and doesn’t make much sense. What is your diagnosis based on these symptoms? Stroke Where is the infarct? Left middle cerebral artery Why does he have these symptoms? Left middle cerebral supplies the motor cortex in the frontal lobe and Wernicke’s area (located in the superior temporal gyrus) What is the treatment plan for a patient presenting with stroke? Urgent CT/MRI – to differentiate ischaemic from haemorrhagic stroke Thrombolysis with alteplase if an ischaemic stroke is diagnosed (~3hr window) Haemorrhage evacuation (get the blood out!) using decompression surgery Nil by mouth until swallowing screening given Draw the three cerebral arteries territories!

Transient Ischaemic Attacks Define a TIA A transient episode of neurologic dysfunction caused by ischemia without acute infarction. Symptoms will be the same as a stroke but the patient will make a complete recovery within 24 hours. What symptom is classic of a TIA but doesn’t occur in stroke? Amaurosis fugax – painless, transient, monocular vision loss What scoring system is used to predict the risk of a stroke following a TIA? ABCD2 score – age, blood pressure, clinical features (speech and weakness), duration of TIA, diabetes What scoring system is used to predict the risk of stroke in a patient with AF? CHADS2 (or CHA2DS2-VASc) – congestive heart failure, hypertension, age, diabetes, prior stroke or TIA (worth 2 points)

An 18 year old male is brought into A&E by paramedics after being found on the street with a gunshot wound in his back. He is unable to move or feel fine touch on the left side of his body below the wound and can’t feel pain or temperature on the right side of his body below the wound. What is your diagnosis based on his symptoms? Brown-Séquard Syndrome What tracts have been damaged to cause his symptoms? Left (ipsilateral) Dorsal column – fine touch Left (ipsilateral) Corticospinal tract – motor Left (contralateral) Spinothalamic tract – pain and temperature What would a patient’s symptoms be if they had suffered infarction of the anterior spinal artery? Motor paralysis below the level of the lesion due to interruption of the corticospinal tract Loss of pain and temperature below the level of the lesion due to interruption of the spinothalamic tract Intact proprioception and vibratory sensation due to intact dorsal column Remember! The anterior spinal artery supplies the anterior two thirds of the spinal cord. The posterior spinal arteries supply the posterior third.

Name that tract!

A 23 year old female is admitted to hospital with a decrease in consciousness level, photophobia and neck stiffness. Meningitis is suspected. What investigation would you perform to confirm this diagnosis? Lumbar puncture At what level would you perform the lumbar puncture? How would this differ if your patient were a neonate? L4/L5. L5/S1 in a neonate as the spinal cord extends to around L3 (as opposed to adults where it terminates at L1) What would a lumbar puncture show if the diagnosis were bacterial meningitis? CSF - Decrease in glucose levels, Increase in WBC count. What system do we use to assess level of consciousness? What is the range of scores? What are the three parameters? Glasgow Coma Scale 3-15 Eye opening response, Best verbal response, Best motor response

A 62 year old female presents to A&E after waking up and noticing the right side of her face was drooping and she was unable to blink. She also complains that everyday noises are suddenly very loud and her sense of taste is reduced. What examination would be most helpful in developing a diagnosis? Cranial nerve examination What is the most likely diagnosis given the clinical picture? Cranial Nerve VII palsy – Bell’s Palsy What is the difference between a LMN and UMN lesion of CNVII? In a LMN lesion, the patient can’t wrinkle their forehead – the lesion must be either in the pons or outside the brainstem. In a UMN lesion, the upper facial muscles are partially spared as the receive bilateral innervation from both hemispheres of the brain.

Name that Cranial Nerve! A – Optic nerve (from the optic chiasm) B – Trochlear nerve (exits dorsally) C – Trigeminal nerve (has a large sensory root and smaller motor root. Exits at junction of pons) D – Facial nerve (emerges between the pons and medulla) E – Glossopharyngeal nerve (emerges from anterior medulla) F – Vagus nerve (emerges from the medulla between the pyramids and inferior cerebellar peduncle) Remember! I and II emerge outside of the brainstem II, and IV emerge from the midbrain V, VI, VII and VIII emerge from the pons IX, X, XI and XII emerge from the medulla

GCS questions Adult, moves hand towards head when you apply pressure above the eye socket. They are disoriented but able to form sentences. They open their eyes in response to speech. 12 – M5, V4, E3 Adult, can obey simple commands and opens their eyes when they hear you speak. They can talk to you in sentences and seem a little confused and unsure of where they are. 13- M6, V4, E3 Adult, opens their eyes when they hear you shouting for help. They groan and make sounds which you cannot recognise as words. They do not respond to pain. 6- M1, V2, E3