a practical approach to common neurological symptoms… · drpaviour.com a practical approach to...

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A Practical Approach to Common Neurological

Symptoms…...

Plus Some Uncommon Causes:

and how a surgeon can sometimes be helpful

Dr. Dominic Paviour

Consultant Neurologist

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Summary

Headache

Tingling and Numbness

Balance problems

Dizziness

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Headache

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Intracranial structures & pain sensitivity

4

Pain Insensitive Structures in Brain Pain Sensitive Structures in Brain

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Headache Classification Committee of

the International Headache Society

(IHS) 2013

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A- Primary Headaches (90%)

1. Migraine including:

1.1 Migraine without aura

1.2 Migraine with aura

2. Tension-type headache, including:

2.1 Infrequent episodic tension-type headache

2.2 Frequent episodic tension-type headache

2.3 Chronic tension-type headache

2.4 Probable tension-type headache

3. Cluster headache and other trigeminal autonomic

cephalalgias, including:

3.1 Cluster headache

3.2 Other primary headaches

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A- Primary Headaches (90%)

4. Other primary headaches4.1. Primary stabbing headache

4.2. Primary cough headache

4.3. Primary exertional headache

4.4. Primary headache associated with sexual activity

4.4.1. Preorgasmic headache

4.4.2. Orgasmic headache

4.5. Hypnic headache

4.6. Primary thunderclap headache

4.7. Hemicrania continua

4.8. New daily persistent headache (NDPH)

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B- Secondary Headaches (10%)

5. Headache attributed to head and/or neck trauma,

including:5.2 Chronic post-traumatic headache

6. Headache attributed to cranial or cervical vascular

disorder, including:6.2.2 Headache attributed to subarachnoid hemorrhage

6.4.1 Headache attributed to giant cell arteritis

7. Headache attributed to non-vascular intracranial

disorder, including:7.1.1 Headache attributed to idiopathic intracranial hypertension

7.4 Headache attributed to intracranial neoplasm

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Classification of Headache Primary

Migraine

“Tension type”

Cluster and other TAC

Secondary

Trauma

Cranial vascular disorder

SOL

Drug/substance or its withdrawal (caffeine/analgesic)

Infection

Sinus/dental disease

Systemic illness

Cranial Neuralgias

38%

35%

0.2%

Nausea/vomiting

Phono/photophobia

Osmophobia

Dizziness

concentration

Ptosis/meiosis

Sweating

Conjunctival injection

Nasal stuffiness

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Acute migraine treatments

Sumatriptan 100mg +

Ibuprofen 800mg

Migraine prophylaxis

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Warning Features in History

Any new headache in an individual patient, or a

significant change in headache characteristics,

should be treated with caution.

"I have never had a headache like this

before"

"This is the worst headache I have

ever had"

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Specific Warning Features in History (1/5)

Thunderclap headache

(intense headache with “explosive” or

abrupt onset) ͢→ subarachnoid hemorrhage)

Estimated prevalence of sub-arachnoid

hemorrhage in the setting of thunderclap

headache is 43%

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Specific Warning Features in History (2/5)

Headache with atypical aura (duration >1 hour,

or including motor weakness) ͢→ symptoms of

transient ischemic attack (TIA) or stroke

Aura without headache in the absence of a prior

history of migraine with aura ͢→ symptoms of TIA

or stroke

Aura occurring for the first time in a patient during

use of combined oral contraceptives ͢→ risk of

stroke

(migraine more likely) for all of these scenarios

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Specific Warning Features in History (3/5)

New headache;

in a patient older than 50 years → symptom ͢of

temporal arteritis or intracranial tumour,

in a pre-pubertal child ͢→ requires specialist

referral and diagnosis

in a patient with a history of cancer, HIV infection

or immunodeficiency ͢→ secondary headache

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Specific Warning Features in History (4/5)

Progressive headache, worsening over weeks or

longer ͢→ intracranial space-occupying lesion

Headache aggravated by postures or maneuvers that

raise intracranial pressure ͢→ intracranial tumour, CNS

infection - (migraine more likely)

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Specific Warning Features in History (5/5)

Headache first occuring with exercise ͢

ruptured aneurysm (migraine more likely)

Headache hours to weeks after a history of

trauma, especially in an older person ͢

subdural hematoma

Similar new onset of headaches in an

acquaintance or family member ͢

environmental exposure such as carbon

monoxide

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Less Common Headache Cases

New onset headache over 50

Headache after exercise

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Case 1

64 year old right-handed lady.

Headaches for 4 months Right more than left.

Initially she would just go to sleep when they came on.

She thinks they lasted about 3-6 hours - nausea, some blurry

vision, some photophobia and some phonophobia - some neck

stiffness.

She had migraine when she was younger.

PMHx “mini stroke” and adult onset Asthma CT scan shows old R MCA stroke - PFO found and closed.

Meds Cocodamol, prednisolone, Mometasone, Amitriptyline, Fluvastatin

and Cetirizine.

Examination was normal

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Case 1

Likely diagnosis?

4 months of headache

Hemi-cranial headache

Nausea, photo/phono phobia

Prior Hx of migraine

Chronic Migraine?

But….

>50 yrs

Previous “stroke”

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Case 1

Slightly cognitively slow?

FBC – eosinophilia

ESR slightly elevated

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Case 1

FBC - eosinophilia.

CSF – prominent eosinophils in her CSF.

Viral screen was negative.

pANCA weakly positive with positive ANA and elevated C3.

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Eosinophilia

ANA

pANCA

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Diagnostic test undertaken with

assistance of a neurosurgeon

LEPTOMENINGES INFILTRATED BY LEUCOCYTES – ESPECIALLY EOSINOPHILS

CORTEX

VESSEL WALL INFILTRATED BY MACROPHAGES AND EOSINOPHILS

NORMAL VESSEL FOR COMPARISON

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Case 1

CSS - Eosinophilic

Granulomatosis with

Polyangiitis (EGPA)

Asthma

Eosinophilia >10% of WCC

Vasculitis - skin, nerves,

kidney, lung, heart, CNS

Idiopathic

Hypereosinophilic

syndrome

Elevated Eosinophils

No other cause identified

Headache

Cognitive syndrome

Prev. Stroke

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Case 2 - Headache after

badminton

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Carotid dissection

Current practical management in absence

of stroke:

Imaging as appropriate to confirm

Dual antiplatelet therapy – aspirin +

clopidogrel

Re-image in 3-6 months to exclude false

aneurysm and confirm recanalisation

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Tingling and NumbnessNeuropathy

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CLASSIFICATION OF NEUROPATHYPATTERN:

mononeuropathy

multiple mononeuropathy (better than the

old-fashioned mononeuritis multiplex)

symmetrical polyneuropathy

plexopathy

radiculopathy

polyradiculoneuropathy.

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CLASSIFICATION OF NEUROPATHY

TIME COURSE:

acute, reaching its nadir in <4 weeks, as in

Guillain-Barré syndrome (GBS)

subacute, reaching its nadir in 4–8 weeks

chronic, taking >8 weeks to develop.

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CLASSIFICATION OF NEUROPATHYDEFICIT:

purely or predominantly sensory - diabetic distal

symmetrical polyneuropathy

purely motor - acute motor axonal neuropathy, a less

common form of GBS in the UK

motor and sensory - Charcot-Marie-Tooth (CMT) disease

autonomic; although autonomic involvement is

common in some neuropathies, pure autonomic

neuropathy is rare.

The underlying pathology - identified by nerve

conduction tests as:

axonal

demyelinating

mixed.

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Polyneuropathy

Differential diagnosis symmetrical generalised

neuropathy is much more extensive and complicated

than that of mononeuropathies

Most cases are accounted for by a few diagnoses

diabetes mellitus

alcohol and prescribed meds

Nutritional/metabolic

Diagnosis can be simplified by considering chronic and

acute situations.

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Neuropathy causes - common

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Neuropathy – first line tests

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Neuropathy

– second

line tests

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Neuropathy – genetics?

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Case 3 73 yo male

Summer of 2015 - catching his big toe occasionally when he

walked.

He occasionally catches his feet on the floor when he is walking

in his shoes.

Initially saw a physiotherapist - some concern he may have a

lumbosacral radiculopathy.

MRI of the lumbar spine - mild degenerative changes

Prior Hx Ca prostate treated 10 years ago

Simvastatin for a high cholesterol.

Drank 25-35 units of alcohol regularly throughout his adult life up

until giving it up completely four years ago.

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Case 3 Subtle thenar and hypothenar muscle wasting

Slightly reduced power but normal sensation.

Reflexes are diminished.

There is a jerky irregular tremor too.

In the lower limbs, reflexes are diminished

power is preserved proximately but reduced distally graded at 3-4/5

in the small muscles of the foot and in inversion and eversion.

Sensation to pinprick, vibration and joint position sense is

diminished particularly in the lower limbs and Romberg’s test is

positive.

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Case 3 - tests

FBC, U+E, LFT, B12, Folate, Glucose, HbA1c, TFT, ANA

All normal

Ig’s – IgM elevated 11.0g/L (0.5-2.0)

Paraprotein 10g/L – IgM Kappa

Urine Bence Jones –ve

Anti MAG Ab strongly +ve >70,000

Arrows show myelinated fibres

(reduced in number, consistent with

non-specific axonal neuropathy).

H&E.

Reduced numbers of myelinated

fibres and (arrow) axonal cluster

consistent with non-specific axonal

neuropathy. Toluidine blue.

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Chronic Immune mediated patchy demyelinating

neuropathy

CIDP

MFMN – CB

Anti MAG

POEMS

GALOP

MGUS?

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Anti MAG neuropathy Neuropathy: Clinical Features

(MAG antibody+ by ELISA & Western blot)Epidemiology: Male 70%

Onset Age: Usually > 50 years; Mean 67

years; Range 46 to 87 years Sensory Gait ataxia

Sensory loss (100%) Distal Legs > Arms Symmetric Panmodal

Pain (28%) Weakness (50% to 70%)

Distal Legs > > Arms Symmetric (80%)

Gait disorder (70%) Tandem gait: Poor Onset: Early in neuropathy

syndrome Often most disabling feature Frequently improves with

treatment Tremor (30%)

Intention Arms > Legs Onset: Develops later in disease

course Poor response to treatment May cause prominent disability:

Fine movements of hands Tendon reflexes: Reduced, Legs

> Arms Time Course: Slowly Progressive

(years)

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Balance Problems

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Common causes of dizziness

Single episode of prolonged vertigo

Vestibular neuritis – nystagmus towards healthy side,

improves over days

Acute BS/cerebellar lesion – vertigo plus BS/cerebellar

signs

First episode of vestibular migraine – Hx of migraine

Menieres – associated loss of hearing, tinnitus and

fullness

Other – bacterial labyrinthitis/drug or etoh tox

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Common causes of dizziness

Recurrent Vertigo

Vestibular migraine – attacks secs-days, Hx of

migraine

Menieres disease – 20mins to hrs with loss of

hearing and fullness/tinnitus

TIA – minutes, assoc. ataxia and dysarthria,

diplopia or loss of vision

Vestibular paroxysmia

Perilymph fistula – vertigo after trauma –

provoked by cough, sneeze, strain or loud noise

Other – AI inner ear disease, syphilis, Pagets,

EA2, FHM, acoustic neuroma

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Positional vertigo

BPPV – commonest ++ but central

causes can mimic some features

PC-BPPV – 80%

HC-BPPV – 20%

Brief attacks <30s provoked by turning in

bed, symptomatic for months then free of

symptoms for years

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Acute isolated vertigo

ACUTE ISOLATED VERTIGO

Usually benign – BUT making a specific diagnosis is important

stroke can present with isolated vertigo

identifying benign conditions will reassure the patient and ensure expedient management.

The important causes of acute isolated vertigo are:

acute idiopathic unilateral peripheral vestibulopathy (“vestibular neuritis or neuronitis”/“labyrinthitis”)

cerebellar stroke

migrainous vertigo

“missed” BPPV

bilateral vestibular failure.

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Signs that indicate peripheral vs. central disorder

Head impulse test VOR suppression

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Chronic dizziness

Poorly compensated vestibular lesion

Visual vertigo – worse in visually busy surrounds

Motorist disorientation – sensation of car moving/tilting

Functional disorders

Chronic migraine

Menieres – late stage

Degenerative ataxias

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Case 4 72 yo male

two to three-year history of progressive problems with walking and

balance.

He has developed a shuffling gait and stumbles a little on steps but

he has had no falls.

cognitive problems, slowly progressing, tends to forget simple things

and often asks questions over and over again.

His wife thinks his reasoning is not so good as it was.

He did have some urinary symptoms but those have settled after a

prostate operation two years ago.

He has a prior history of ischaemic heart disease and he has had a

myocardial infarction in the past and had a coronary artery bypass

graft last year.

About 10 or more years ago, he was a cyclist in a road traffic

accident that he has no recollection of. Apparently, he was found by

the side of the road unconscious by a police officer. We do not have

any old images for comparison.

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Case 4

On examination, he walks with a narrow-based shuffly gait. There

are no other parkinsonian signs. There is no eye movement

disorder. I did not formally assess cognitive function. His postural

reflexes are impaired both on a forward and a backward pull test.

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Case 4 On examination, he walks with a narrow-based shuffly

gait. There are no other parkinsonian signs. There is no eye

movement disorder. I did not formally assess cognitive

function. His postural reflexes are impaired both on a

forward and a backward pull test.

LP revealed a relatively normal opening pressure and normal

CSF constituents.

He does not think his walking got any better after the lumbar

puncture but it is not clear to me that he had a large volume

tap.

MMSE - 28/30.

Pre-procedure timed walk was 14 seconds and post-procedure

12 seconds.

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Case 5

Paroxysmal vertigo

57 yo female

Multiple attacks of “spinning sensation” daily

Last 5-30 seconds

No nausea

No sequelae

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Case 5

Recurrent paroxysmal vertigo and tinnitus

DDx?

BPPV?

Meniere’s?

Migraine

Perilymph fistula

Syphilis

Functional/psychological

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Case 5

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Figure 2 Example of MRI (CISS sequence) Axial (A) and coronal oblique (B) constructive

interference in steady state (CISS) magnetic resonance images reveal bilateral neurovascular

cross-compression between the vestibular nerve (arrowheads) and the anterior inferior

cerebellar artery (arrows).

Hüfner K et al. Neurology 2008;71:1006-1014

How can you tell a Neurosurgeon when you

meet one?

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