Ward Rounds in Clinical Neurology: Long and Short Cases Ravi Yadav, Girish Baburao Kulkarni
INDEX
Page numbers followed by, b refer to box, f refer to figure, fc refer to flowchart, and t refer to table
A
Abetalipoproteinemia 119, 169, 170
Acetylcholine receptor 159
anatomy of 159f
Acquired immunodeficiency syndrome 75
Adenoma, pituitary 32
Agnosia 23
localization of 24
types of 24
Agraphia 25
Alexias 6, 23, 25
central 25
peripheral 25
types of 25
Allodynia 126
Alpha adrenergic blocking agents 96
Alpha fetoprotein level 112
Alzheimer's disease 13
Amiodarone 33
Amphetamines 167
Amyloidopathy 11
Anita Harding's classification 110
Ankle jerk 72
Ankylosing spondylitis 84
Anomia agraphia 6
Antacids 162
Antiarrhythmics 162
Antibiotics 162
Antibodies, antinuclear 121, 133
Anticholinergics 177
Anticonvulsants 162
Antiepileptics 102
Antihypertensives 162
Antiphospholipid antibodies 167
Antistreptolysin O titer 169
Anxiety 16
Aphasia 3
progressive nonfluent 13
treatment of 7
Apoplexy, pituitary 46
Appetite, loss of 60
Apraxia 18, 19
causes of 20
conceptual 18
constructional 18, 19
dressing 18, 19
ideational 1820
ideomotor 1820
list of 21t
sympathetic 18
treatment of 20
types of 18, 103
Apraxic agraphia 22
Archicerebellum 104, 105
Areflexia 127
Arteries
anterior radiculomedullary 64
posterior radiculomedullary 64
radiculomedullary 64
Arteritic central retinal artery occlusion 37, 37f
Artery of Adamkiewicz 64
Arthritic leprosy 138
Astereognosia 24
Ataxias 99, 101, 103, 104, 111, 112, 114, 119
chronic progressive 104
classification 117b
dominantly inherited 107t, 108t
episodic 107
evaluation of 113
frontal 103t
hereditary causes of 119t
inherited of 119t
posterior column 119
recessively inherited 109t, 110t
spinocerebellar 107, 167
telangiectasia 112, 119
types of 103t
Athetosis 168
Atrophy 53, 145
multiple system 188
Auscultation, cardiac 168
Autoantibodies 155
Autonomous bladder 92, 95
Autosomal dominant inheritance 150
Avellis syndrome 54
Azathioprine 156
B
Back pain 72, 74, 79, 86, 87
Baclofen 177
Baer wave origin 191
Bancaud's phenomenon 193
Band-like sensation 74
Barrington's nucleus 91
Becker muscular dystrophy 149
Beevor's sign 72, 151
Behçet's disease 135
Binocular diplopia 40, 42
Binocular vision 40
Binswanger's disease 186
Bladder
bowel
dysfunction 80, 81
incontinence 80
signs 61
symptoms 80
disturbance 125
dysfunction, types of 92
neurogenic 86, 89
symptoms 73, 87, 180
types of 94
Blepharospasm 15
Blood
count, complete 121
sugar
fasting 121
postprandial 121
Body image agnosia 24
Botulinum toxin 177
Bradykinesia 187
asymmetric 179
Brain iron 167
Brainstem
lesions 95
stroke syndromes 53
Broca's aphasia 4, 6
Brody disease 144
Broken pursuits 102
Brown-Séquard syndrome 60, 66
Buccofacial apraxia 18
Bulbar palsy 48, 51, 52, 53t
muscular causes of 55
progressive 51
Bulbar symptoms 115
Bulbocavernosus reflex 95, 96f
C
Callosal apraxia 19
Calpainopathy 153
Carbamazepine 41, 137
Carbidopa 9
Carotid dissection 46
Carpal tunnel syndrome 173
Castleman disease 131
Cauda conus syndrome 83, 94
Cauda equina 89f
lesions 80, 81, 93
syndrome 80, 81, 81t, 83, 87, 89, 94
differential diagnosis of 90t
Caveolinopathy 144, 150
Cavernous sinus 44
Celiac disease 113
Central cord syndrome 67
Central disk herniation 90
Central nervous system 40, 166
Central retinal
artery occlusion 31, 36
vein occlusion 31
Cerebellar
artery, anterior inferior 45
ataxia 103t, 104, 108, 110, 114, 118t
acquired 105t
causes of 105t
early onset 110
genetic causes of 104
nongenetic 105t
subtypes of 105t
cognitive affective dysfunction 111
cortical atrophy, parenchymatous 110
dysfunction, signs of 111
lesion, localization of 104
signs 144
system 79
Cerebellum 103
Cerebral cortex 92
Cerebrospinal fluid 33, 41, 84
Cervical
cord, hemi-section of 69
dystonia 174
myelopathy 59
spinal cord 61f
lesions of 68
spine 61f
vertebra 62
Cestan-Chenais syndrome 54
Chemotherapeutic agents 33
Cherry red spot 113
Chloroquine 33
Chorea 165, 167b,168-171
benign hereditary 167
causes of 167b
diagnosis of 170
late onset 169
postinfectious 167
Choreoacanthocytosis 169
Churg-Strauss syndrome 135, 136
Circle of Willis 201f, 202f
Claudication
neurogenic 82, 82t
vascular 82, 82t
Clioquinol 33
Cold agglutinins 120
Collet-Sicard syndrome 54
Color agnosia 24
Color vision, reduced 30
Compressive myelopathy, causes of 74, 75fc
Confusion 102
Connective tissue
disease 106
disorder 48, 115
Conus medullaris
lesions of 81
syndrome 80, 81, 81t, 87, 88
Conus-Cauda syndrome 77, 83, 84fc, 85
etiology of 84t
treatment of 83
Copper studies 185
Coronary artery disease 78
Corpus cavernosum 96
Corticobasal degeneration 186, 188
Corticobasal syndrome 11, 12
Corticorubrospinal tracts 66
Corticospinal tract 66
Cranial fossa, posterior 44
Cranial nerve 4, 27, 49, 143
examination 116, 158
involvement 60
Cranial neuropathy 43
Craniopharyngioma 32
C-reactive protein 35
Creutzfeldt-Jakob disease 105, 106
Cryoglobulinemic vasculitis, essential 136
Cyanosis 78
Cyclophosphamide 156
Cyclosporine 156
D
Danon disease 148
Darting tongue sign 168
Deep tendon reflexes 72, 74
Deep-brain stimulation 177
Dejerine's medial medullary syndrome 54
Dementia 8, 1416, 110
diagnosis of 12
evaluation of 14
frontotemporal 13
progressive 9
pugilistica 17
symptoms of 10
vascular 182
Dentatorubral pallidoluysian atrophy 107, 167
Depression 16
Dermatomyositis 142, 155
Detrusor-sphincter dyssynergia 94, 96
Diabetes mellitus 78, 120, 130
Diastematomyelia 84
Diplopia 40, 132
drooping, history of 141
painful 43
Disialosyl antibodies 120
Distal sensory neuropathy, human immunodeficiency virus -related 130
Disulfiram 33
Diuretics 102
Dopa-responsive dystonia 174, 175t
Dorsal column disease 119b
Dorsal myelopathy 71
Dorsal root 120b
ganglia 118
ganglionopathy 104
Dorsal spinocerebellar 65
Dorsal stream 23f
Double vision 143
Dry skin 113
Dual-energy X-ray absorptiometry scan 84
Duchenne-Becker muscular dystrophy 147
Duloxetine 137
Dysarthria 5, 7, 15, 49, 51, 103, 109, 111, 143
types of 7
Dyschromatopsia 33
Dysdiadochokinesia 102, 111
Dysesthesia 59, 126
painful 93
Dysexecutive syndrome 10
Dysferlinopathy 153
Dyskinesia, orolingual 169
Dysmetria 111
combination of 111
Dysphagia 15, 49, 51, 53, 143, 165
causes of 49, 50t
Dysphonia 5, 49, 51, 53
spasmodic 7
Dystonia 15, 168, 171, 172, 174, 176, 177
acute 177
childhood onset 175t
focal 174
heredodegenerative 175
idiopathic generalized 172
multifocal 173
musculorum deformans 173
orolingual 166
plus syndromes 174
primary 172174
segmental 172, 174
Dystonic flexion 173
Dystonic tremor 172
E
Eagle syndrome 54
Edinburgh handedness inventory 6
Electromyogram 196
Electrophysiology, role of 85
Emery-Dreifuss muscular dystrophy 147, 148
Encephalomyelitis, acute disseminated 33
Endocrinopathy 106
Energy metabolism 175
Epilepsy 17
Erythrocyte sedimentation rate 35
Escitalopram 158
Ethambutol 33
Exner's writing area 6
Extraocular movements 132
Extraocular muscle
disease 46
involvement of 147
Extrapyramidal
disorders 51
lesions 95
syndrome 163
system 79, 103
Eye
diseases, thyroid associated 46
movements 31, 103, 109
painful 30
Eyelids, drooping of 143
F
Fabry's disease 130
Facial
muscle 171
involvement 148
nerve involvement 129t
numbness, ipsilateral 51
palsy, bilateral 129
weakness 48
Fahr's syndrome 167
Fasciculus cuneatus 65, 68
Fasciculus gracilis 65, 68
Fibers
arrangement of 70f
frontocerebellar associative 103
Fine needle aspiration cytology 84
Finger agnosia 24
Finger nose finger test 111
Finger nose test, abnormal 111
Flaccid 7
bladder 92
Fluorescein angiography 34, 35
Folic acid deficiency 105
Friedreich's ataxia 110, 119
classic 109
Frontal behavioral-spatial syndrome 12
Frontal beta fast activity, benzodiazepines-induced 203, 203f
Frontal lobe
circuits 10
lesions 103
Fukutin-related protein 144
Fundus 31
examination 33
fluorescein angiogram 37f
G
Gabapentin 138
Gag reflex 51
Gait 102, 116
imbalance 15
inspection of 146
steppage 79
Ganglionopathy 118
Gastroesophageal reflux disease 50
Gastrointestinal symptoms 183
Gaucher disease 175
Gerstmann-Straussler-Scheinker syndrome 107
Gesture training 21
Giant cell arteritis 46, 135, 136
Giant somatosensory-evoked potential 195, 195f
Glabellar tap 14
Global aphasia 6
Glycolytic enzyme defects 144
Glycoprotein, myelin-associated 120
Gottron sign 152
Gower's maneuver 149
Gradenigo syndrome 45
Graphesthesia 24
Grasping reflex 14
Guillain-Barré syndrome 42, 120, 129, 130, 134
H
Hallervorden-Spatz disease 180
Hartnup's disease 175
Headache 4, 41fc, 48
Hematoma, acute extradural 90
Hemianopia
altitudinal 34
right-sided 5
Hemicerebellum 105
Hemichorea 169
Hemidystonia, orthostatic 174
Hemogram 112
Henoch-Schönlein purpura 135, 136
Hepatic disease 75
Hepatic encephalopathy 17
Hepatitis C virus 120
Hereditary neuropathies 127, 134
Hexosaminidase deficiency 75
Higher mental function 40, 143
Homocysteinemia 175
Horn cell
diseases, anterior 51
disorders, anterior 145
Horner's syndrome 51, 60
Human immunodeficiency virus 75, 120
Human T-cell
leukemia 75
lymphotropic virus 120
Huntington's disease 167, 170
Hyperalgesia 126
Hyperemesis gravidarum 101
Hyperflexion 171
Hyperintense intramedullary lesion 61f
Hypersensitivity vasculitis 135
Hypertension 78
malignant 46
Hypertrophy, mild 143
Hypocupremia myelopathy 75
Hypokalemia 147
Hypokinetic movement disorders, causes of 180
Hyponatremia 105
Hypoperfusion, extensive choroidal 35
Hypopigmented patches 78
Hyporeflexia 127, 166
Hypotension, nocturnal 34
Hypothyroid myopathy 144
Hypotonia 111
I
Ichthyosis 113
Icterus 78
In vitro fertilization 101
Inflammatory myopathies 152, 154, 155
Infranuclear disorders 51
Inguinal region 83
Intervertebral disc, structures of 63
Intracranial pressure 46
Intracranial tension 5
Ischemia, choroidal 37f
Ischemic optic neuropathy, nonarteritic anterior 34
J
Jackson syndrome 54
Jaundice 48
Jerk nystagus 111
Jerky arrhythmic movement 10
Joint
hyperlaxity 146
pain 86
Jugular foramen 52
K
Kawasaki disease 136
Kayser-Fleischer ring 113
Kearns-Sayre syndrome 46, 55
Knee 83
jerk 72
medial aspect of 83
Knee-heel test, abnormal 111
L
Lambert-Eaton syndrome 160
Language 5
assessment 5
disorders 7
disturbances 5
presentation 13
Large fiber neuropathy 104, 127
Leber hereditary optic neuropathy 36
Leigh's disease 169
Leprosy 138
neuritis, reactional 138
neuropathy, classical 138
Lesch-Nyhan syndrome 175
Lesions
auprasacral 96
extramedullary
extradural 74
intradural 74
infranuclear 50
site of 53
supranuclear 50, 95
types of 61
Leukocytoclastic angitis, cutaneous 136
Leukodystrophies 113
Leukoencephalopathy, progressive multifocal 106
Levodopa 9, 177, 178, 187
Lewy body disease 186
Lhermitte's phenomenon 115
Limb
ataxia 51
girdle
muscular dystrophies 149
pattern 146
syndrome 160
hypotonia 168
kinetic apraxia 18, 19
lower 88f
numbness of 116
pain 160
upper 126, 130
weakness of 4
Lower cranial nerve
dysfunction 50
palsies 53, 54t
Lower motor neuron 45, 50, 53
bladder 92, 93, 93t
Lower spinal cord involvement 88
Lower urinary tract, innervations of 91f
Lumbosacral spine 85f
Lyme disease 17, 75, 129, 133
Lymphadenopathy 78
Lysosomal disorders 113
M
Macular nerve lesions 30t
Malabsorption syndrome 113
Mass lesions 106
Mayo clinic classification of dysarthria 7
McArdle's disease 147
McLeod syndrome 169, 170
Medial leg 83
Medial longitudinal fasciculus, rostral interstitial nucleus of 42
Medial reticulospinal tract 66
Medullary syndrome, lateral 50, 51t
Mendell's criteria 136
Meningioma, suprasellar 32
Metaiidobenzjlguanidine 188
Metamorphosis 30
Methanol 33
Methotrexate 156
Methyl prednisolone 156
Methylmalonic academia 175
Methylprednisolone, intravenous 34
Milkmaid sign 168
Mitochondrial disease 112
Mitochondrial disorders 110
Mixed serotonin-noradrenaline reuptake inhibitor 138
Miyoshi myopathy 151
Monocular diplopia 40, 41
Mononeuritis multiplex 81, 132, 133
Morphine 138
Motor aphasia 4, 6
Motor examination 116
Motor memory 10
Motor predominant neuropathies 129t
Motor system 4, 125, 142, 143, 184
examination 86
Multifocal acquired demyelinating sensory 128
Multiple cranial neuropathy 51
Multiple nerve palsy 43
Muscle
biopsy 154
diseases 145, 153
classification of 145, 146
symptoms of 144
disorders 51, 141
hypertrophy 146
palpation of 146
percussion of 146
relaxants 177
small 143
stretch reflexes 146
Muscular dystrophy 145, 153
facioscapulohumeral 150
treatment of 157
Myasthenia 160
diagnosis of 160
graded, severity of 160
gravis 46, 159, 162t
treatment of 161fc
Myasthenic syndromes, inherited 160
Mycophenolate mofetil 157
Myelomeningocele 84
Myelopathy 73, 104
acute necrotizing 75
compressive 74t
hallmark of 73
level of 73t
noncompressive 73, 74, 74t, 75t
Myoclonus 171
Myofibrillar myopathies 148, 151, 154
Myopathy 147, 148
diagnosis of 147
Myotonic dystrophy 55
N
Nailfold capillary density 152
National Institute of Neurological Disorders and Stroke 182
Neck extensor, Predominant 147
Neck vessels, magnetic resonance angiography of 201f
Necrotizing myopathy, immune-mediated 155
Needle biopsy 154
Neisseria meningitidis 200
Nerve
conduction study 117, 121, 134
disorders 51
involvement 138
palsy 43
root 52
Nervous system examination 60
Neuroacanthocytosis 167, 169
Neuroaxis 103
Neurodegeneration 167, 190
Neuroferritinopathy 187
Neurogenic bladder
localization of 94t
management of 96
Neurogenic disorders 50
Neuroleptics 102
Neuromuscular disorders 50
Neuromuscular junction 159
disease 47
disorders 44, 51, 139, 145, 158
Neuromyelitis optica 33
Neuro-ophthalmologic abnormalities 40, 41fc
Neuropathic pain medications 137t
Neuropathy 81, 126
axonal 127
chronic ataxic 120
chronic demyelinating 127, 128
painful 130t
small fiber 127, 129t
vasculitic 136
Neurosyphilis 17
Niemann-Pick disease 175
Nodose ganglion 52
Nonaka myopathy 151
Nonarteritic central retinal artery occlusion 36f
Non-reflex bladder 92
Nuclear
disorders 51
lesions 50
Nutrition, total parenteral 106
Nutritional deficiency 17
Nyhan syndrome 169
Nystagmus 103
downbeat 114
fast component of 102
O
Obsessive-compulsive disorders 16
Ocular eye movements 43
Ocular syndrome 160
Oculobulbar syndrome 160
Oculomotor
apraxia 114
function, abnormal 111
Oculopharyngeal muscle dystrophy 55
Olanzapine 7
Opalski syndrome 54
Opercular syndrome 52, 53t
Ophthalmoplegia 120
causes of 47
chronic external 46
external 114
painful 39, 43, 46
supranuclear 43
total left 40
Opioids 138
Oppenheim dystonia 173
Opsoclonus 114
Optic
atrophy 114
chiasma 31
chiasmal disorders 46
nerve 33
compression of 32
disc drusen 190
lesions 30, 30t
sheath meningioma, primary 32
neuritis 31, 33, 34
acute 190
anterior 33
treatment trial 34
neuropathy
anterior ischemic 31, 35
chronic relapsing inflammatory 33
compressive 32
infiltrative 32
ischemic 34
nonischemic 190
posterior ischemic 35
Optokinetic nystagmus 166
Oral prednisone 34
Orbital disease 32
Orbital fissure, superior 44
Orbital muscle disease 46
Orbitofrontal circuit 10
Overlap syndrome 153
P
Paleocerebellum 104, 105
Palmomental reflex 14
Pancerebellar syndrome 104
Pancerebellum 105
Pandysautonomia, acute 130
Papilledema 31, 128
bilateral 125
Papillitis 31, 33
Parakinesia 170
Paramedian pontine reticular formation 42
Paraparesis 72, 74
Paraproteinemia 120
Parasellar region 44
Parasympathetic fibers 93
Paresthesia 68, 80, 115, 116, 126, 166
progression of 61
Parietal lobe dysfunction 9
Parkin mutation 180
Parkinson's disease 11, 51, 95, 186, 188, 190
diagnosis of 181
juvenile 175t
Parkinsonism plus disorders 51
Paroxetine 7
Perineal sensory loss 93
Perineum, sensory dermatomes of 88f
Periodic lateralized epileptiform discharges, causes of 191
Peripheral nerve 94, 118
Peripheral neuropathies 81, 93, 118, 119b, 120t, 123, 125, 133, 137, 145
Peroxisomal disorders 113
Petrosal ganglion 52
Pharyngeal weakness 151
Phenoxybenzamine 96
Phenytoin, antiepileptics like 41
Phosphenes 33
Photostress test 30
POEMS syndrome 129, 131
prognosis of 131
Polyarteritis nodosa 135, 136
Polycythemia 169
Polyglutamine expansion 11
Polyneuropathy, chronic inflammatory demyelinating 129
Polyphasics 197
Polyradiculoneuropathy 145
chronic inflammatory demyelinating 120, 134
Polyradiculopathy
acute inflammatory demyelinating 129
chronic immune sensory 120
Pontine micturition center 91, 94
Postsynaptic membrane 159
Prazosin 96
Prednisone 156
Pregabalin 138
Pressure
hydrocephalus, normal 186
palsies 134
Primary young onset dystonia 174
Proptosis 43
Prosopagnosia 184
Proteins, monoclonal 127
Pseudobulbar palsy 51, 52, 53t
Pseudodystonia 176
Pseudomonas aeruginosa 200
Ptosis 114
Pulse rate 49
Pupil dilatation 43
Pupillary reflex 31
Pure neuritic leprosy 138
Pyogenic meningitis 200
Pyramidal disorders
acute unilateral 50
bilateral 50
chronic unilateral 50
R
Radicular involvement, level of 82
Radicular pain 80, 81
Radiculopathy 118
Red blood cells 121, 169
Reflex 116
arc 93
of perineum, spinal levels of 88f
Renal disease 75
Renal function test 121
Respiratory muscle involvement 148
Reticulospinal tract, lateral 66
Retinitis pigmentosa 114
Retrobulbar neuritis 33
Rheumatoid arthritis 84
Rheumatological disorders 133
Rippling muscle disease 150
Risperidone 7
Rituximab 157
Romberg's test 133
Root pain 74
Rooting reflex 14
Rostral pontine tegmentum 91
S
Saccade intrusions 109
Sacral dermatomes 79
Sacral plexopathy 82
Schmidt's syndrome 54
Sclerosis, multiple 75
Scoliosis 109, 119
Scotoma, central 30
Seizure 48
Sellar compressive lesions 32
Semantic dementia 13
Sensory ataxia 103, 103t, 104, 115, 117, 118b, 118t, 120, 121, 121fc, 121t, 122
acquired causes of 120t
clinical manifestations of 117
etiology of 117
immune-mediated 122
Sensory ataxic
gait 116
neuropathies 119, 130t
Sensory examination 79, 116
Sensory ganglionopathy 119b, 120b
Sensory loss 73, 80, 116
level of 68
posterior column 109
Sensory nerve
action potential 117, 121
fibers 93
Sensory neuron cell 122
Sensory neuropathy 119
Sensory pathways 103
Sensory signs 83
Sensory symptoms 183
Sensory system 60, 185
Sialorrhea 15
Sicca symptoms 115
Simultagnosia 24
Single-photon emission computed tomography 188
Sjögren's syndrome 14, 60, 75, 84, 112, 120, 121, 130
Skeletal anomalies 146
Skew deviation 43
Sleep disorders 183
Slow saccades 102, 114
Snout reflex 14
Sodium oxybate 177
Somatic fibers 93
Somatosensory-evoked potentials 121
Speech 5, 7, 53, 60, 102
apraxia of 21
disorders 5
treatment of 7
disturbances 10
normal 116
spontaneous 4, 5
Sphenoid wing meningioma 32
Spike wave discharges, causes of 189
Spinal artery 63
anterior 63, 64
posterior 64
Spinal canal stenosis 85f
Spinal cord 57, 63f, 74, 94
anatomy of 62
arterial supply of 63, 65f
cross-section of 66, 66f
infarction syndrome 68
injury 87
lesions 68, 94
patterns of 69f
types of 66, 67
major tracts of 65
posterior column 104
terminates 62
tracts 70f
Spinal muscular atrophy 67
Spinal nerves 63f
Spinal shock, bladder in 95
Spinal stenosis 90
Spinoreticulothalamic tract 65
Spinothalamic tract 68
anterior 65
lateral 65
Sporadic corticobasal degeneration 12
Staphylococcus aureus 75
Status dystonicus 199
management of 199f
Status epilepticus 199
management of 199f
Status migrainosus 198
Stiff person syndrome 112
Stimulus sensitive myoclonus 9
Straight leg raising 86
Straussler-Scheinker disease 181
Streptococcus pneumoniae 200
Stress incontinence 92
Striatal dapamine transporter 188
Stroke 104
Sub-acute combined degeneration 67, 106
Subthalamic nucleus 179
Suck reflex 14
Superficial reflexes 72
Supranuclear gaze palsy 114
Supranuclear palsy, progressive 12, 186, 188
Suprasellar compressive lesions 32
Swinging light test 30
Swollen disc 33
Sydenham's chorea 167, 169, 170
Synaptogenic disorders 44
Synucleinopathy 11
Syphilis 75
Syringobulbia 51
Syringomyelia 67
Systemic lupus erythematosus 75, 106, 167
T
Tabes dorsalis 67, 104
Tacrolimus 156
Tactile agnosia 24
Takayasu's arteritis 135, 136
Tangier disease 135
Tapia syndrome 54
Tay-Sachs disease 113
Telangiectasia 113
Temporal arteritis 135
Tethered cord syndrome 84
Tetrabenazine 177
Thiamine deficiency 105
Thoracic cord 69
Thoracic vertebra 62
Thrombolytics 38
Tibial muscular dystrophy 151
Tolosa-Hunt syndrome 46
Toxic chemotherapy 120
Tramadol 138
Transverse myelitis 75
Triphasic waves 194f
causes of 193
Truncal ataxia 111
Tubercular meningitis 200
Tuberculosis 106
U
Unconsciousness 48
Upper motor neuron 4, 50, 53, 72, 93, 93t
Uremia 17
Urinary frequency 16
Urinary incontinence 92
mixed 92
Urinary symptoms, relation of 92
Urinary tract, lower 89
Urine
storage 92
voiding 92
V
Vagus nerve stimulation 52
Vagus nucleus 52
Valley sign 149
Valsalva maneuver 87
Vascular endothelial growth factor 129
Vasculitis 133, 135
nonsystemic 136
pathologic features of 136
primary 135
secondary 135
small vessel 136
syndromes 135
Venereal disease research laboratory 121
Venlafaxine 137
Verbal dissociation apraxia 19
Vernet syndrome 54
Vertebra
anatomy of 64f
parts of 62
Vertebral column 62
anatomy of 63f
Vertebral deformity 74
Vertebral tenderness 74
Vertigo 51
Vestibulo-ocular reflex 42
Vestibulospinal tract 66
Villaret syndrome 54
Viral hepatitis A, acute 133
Vision
for-perception 23
loss
acute binocular 32
acute monocular 31
painless loss of 36
Visual acuity 4, 30, 31
reduced 30
Visual agnosia 24
Visual cortex 23f
Visual disturbances 9
Visual evoked potentials 33, 190
Visual field 31
Visual loss 29, 31
chronic progressive 32
transient monocular 31
Visuospatial agnosia 24
Visuospatial defects 9
Vitamin
B12 deficiency 75, 105
deficiency 105
E deficiency 105, 113, 119
Vocal cord 151
Voiding dysfunction 92
Vomiting 48
W
Wallenberg's syndrome 50, 54
Wegener's granulomatosis 135, 136
Weight loss 86
Welander distal myopathy 151
Wernicke's aphasia 5, 6
Wernicke's area 6
Westphal variant 170
Whipple's disease 17, 110
Wilson's disease 113, 167, 169, 170, 175, 187
Wounds, nonhealing 78
Writer's cramp 174
Y
Young onset dementia 16
Z
Zinc toxicity 104
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Chapter Notes

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1Higher Mental Functions/Cerebral Hemisphere
  • Approach to a Case of Aphasia
    Girish Baburao Kulkarni, Krishnan A
  • Approach to a Case of Dementia
    Pawan Raj, Ravi Yadav
  • Approach to Apraxia
    Ragasudha B, Ravi Yadav
  • Approach to Agnosia and Alexia
    Ragasudha B, Ravi Yadav
2

Approach to a Case of AphasiaCHAPTER 1

Girish Baburao Kulkarni,
Krishnan A
 
PATIENT NO. 1
A 42-year-old right-handed graduate lady presented with:
  • Recurrent episodes of right-sided limb weakness for two months.
  • Speaking difficulty for two months.
She had four discrete episodes of weakness. Initially, two episodes over two consecutive days, and later two more episodes.
During her initial two episodes, she developed sudden onset of distal right upper limb weakness with heaviness in the right leg which progressed over five minutes and lasted for 10 minutes. There was no history of speech or visual symptoms and the weakness improved completely.
One and half months later, she was apparently normal and doing her routine work in the morning, when suddenly she developed difficulty in speaking. Her word output reduced to one or two and she started communicating with gestures. She was able to comprehend the spoken word but could not read and write. She could not name persons and objects around her. There was no limb and visual symptoms. The speech disturbances were gradually improving when she presented but still she was facing difficulty in conversing due to difficulty in naming objects and persons, even though her comprehension was normal.
Two days prior to her presentation to our hospital, she again developed sudden onset of mild right-sided upper limb more than lower limb weakness without new speech or visual symptoms. The weakness progressed over 15–20 minutes, then started improving.
No visual symptoms were associated with any of these recent episodes.
She was known hypertensive from the past 5 years on regular treatment. She had experienced 5–6 attacks of transient blurring of vision in her left eye lasting for few minutes recovering spontaneously fully over 15 minutes one year prior to her present illness.
 
On Examination
She was moderately built and nourished. Pulse rate—76/minute, regular, reduced volume in left carotid artery. No bruits. Blood pressure in right upper limb 180/90 mm Hg, left upper limb 160/90 mm Hg. Cardiac and respiratory system examination were normal.
  • Handedness—Right-handed
  • Education—Graduate
  • Cardia, respiratory system—Within normal limits.4
 
Neurological Examination
Minimental status score (MMSE): 27/30.
 
Language
  • Spontaneous speech: Reduced fluency (category and verbal) and word output, uses few words to answer rather than sentences, speech was effortful, occasional paraphasias were present, no neologisms. Prosody normal, no dysarthria.
  • Comprehension: Answers Yes and No to questions and pointing to the objects correctly.
  • Writing: Writing spontaneously, writing in response to command to copy and to dictation were impaired.
  • Repetition: Could repeat sentences up to 4–5 words.
  • Naming: Could name objects, colors, etc. but had difficulty in naming parts of the objects.
  • Reading: Could read few words but could not read continuously.
 
Cranial Nerves
  • Visual acuity right side 6/9, left side 6/12 with right-sided hemianopia.
  • Pupillary reaction optic fundus and eye movements were normal.
  • Right-sided upper motor neuron (UMN) facial palsy was seen.
  • Other cranial nerves normal.
  • Motor system: Right elbow and wrist extension 4/5, rest of the power was normal.
  • Sensory system: Normal.
 
Summary
This middle-aged lady with 5 years history of hypertension presented with episodes of left monocular visual loss and reduced carotid volume suggestive of left carotid artery disease with recent symptoms of motor and language disturbances in the left-sided carotid/middle cerebral artery territory. She had motor weakness pyramidal in nature localizing above the pons and language disturbance in the form of Motor (Broca's) aphasia localizing to left frontal motor speech area. In her repetition was also involved suggestive of cortical localization of the language disturbances.
 
PATIENT NO. 2
A 42-year-old lady with no formal education, right-handed presented with history of headache of 15 days and speech disturbances from the past 7 days.
Headache was acute in onset, continuous, throbbing, bifrontal, associated with vomiting, no photophobia or phonophobia, or visual disturbances, not relieved with analgesics associated with difficulty in doing work.
Eight days after the onset of headache she suddenly developed speech disturbances. Relatives noticed that she was not able to understand the spoken words and she was speaking but nobody could understand the meaning of the sentences. She was calling her relatives by different words which had no meaning, was speaking irrelevantly and they could not make out meaning from her speech.
No history of loss of consciousness, visual symptoms, weakness of limbs, seizures or sensory disturbances.5
No history of ear discharge, fever, trauma, menstrual irregularities or consumption of hormonal preparations.
 
On Examination
General physical examination: She had mild pallor. Blood pressure, cardiac, abdominal and respiratory systems were normal.
 
Neurological Examination
She was right-handed, with no formal education. She was conscious, able to walk around.
Minimental status examination (MMSE): Could not be assessed because of her language disturbances.
 
Language Assessment
  • Spontaneous speech: It was fluent, effortless, with paraphasic errors, speech had no meaning. She could not speak about her personal details (name, address, occupation), and she speaks irrelevantly, could not describe a picture.
  • Comprehension: Severely impaired with inability to point to said object and could not answer to y and n questions.
  • Repetition: Could not understand the commands.
  • Naming: Not able to do.
  • Reading: Could not be assessed.
  • Writing: Could not write her name.
Fundus was normal no papilledema, visual acuity was grossly normal with right-sided hemianopia.
Mild right-sided UMN facial nerve palsy.
Motor, sensory and cerebellar system: Normal.
 
Summary
Middle aged lady with no premorbid diseases presented with subacute onset of new headache with raised intracranial tension. One week later, she developed language disturbances suggestive of sensory or Wernicke's aphasia with mild UMN facial palsy and right-sided hemianopia localizing to left temporoparietal region of brain. On further evaluation she was found to have left temporoparietal venous infarct due to cerebral venous thrombosis.
Q.1. Define language and speech and in what way their disturbances manifest?
Ans. Language is defined as complex system of communication with symbols and sounds and it also has rules for their use. Speech is defined as articulation and phonation of language sounds and it is a part of language.
The disturbances of language are called as aphasias, which means loss or impairment of production or comprehension of spoken or written language secondary to acquired lesion of the brain.
Disorders of speech includes dysarthria (defective articulation with intact mental functions and normal syntax), dysphonia (alteration or loss of voice due to laryngeal disorder or its innervation), and stuttering.6
Q.2. Where are the centers for language located and what is their function and blood supply to the areas?
Ans. There are four main language areas (Perisylvian Area): 2 receptive and 2 executive which are situated in the left hemisphere in right-handed person:
  1. Reception: It is situated in the posterior superior temporal gyrus (area 22) and Heschl's gyri (area 41 and 42). Posterior part of area 22 in planum temporale is Wernicke's area (Blood supply is by inferior division of the left middle cerebral artery).
  2. Receptive area: Angular gyrus (area 39) in inferior parietal lobule, anterior to visual receptive areas.
  3. Execution: Posterior end of inferior frontal convolution (area 44 and 45), called as Broca's area (Blood supply is by upper division of left middle cerebral artery).
  4. Exner's writing area—posterior end of 2nd frontal convolution.
Q.3. What is the normal distribution of handedness in general population? How it is deter- mined?
Ans. About 90–95% general population are right-handed (they innately choose right hand).
Edinburgh handedness inventory: This inventory determines the handedness by assessing which hand is used for various daily routine tasks (10 types like: writing, drawing, throwing a ball, scissor, toothbrush, knife, spoon, broomstick, strike a matchbox, open a box lid). Each task is given a score and a final score is generated which suggests the handedness.
Determining handedness: Ask which hand is preferred for throwing a ball, threading a needle, sewing, using a tennis racket or hammer, which eye is used for sighting a target with a rifle or looking through a key-hole, telescope, etc. (Eye preference coincides with hand preference).
Q.4. What are the features of Broca's aphasia?
Ans. Patients with Broca's or motor aphasia have nonfluent spontaneous speech, which is telegraphic, dysarthric or mute, impaired naming, reading and repetition, writing may be dysmorphic or dysgrammatic, can have associated right hemiparesis, right hemisensory loss or even apraxia of left limbs. Comprehension will be normal.
Q.5. What are the features of Wernicke's aphasia?
Ans. The spontaneous speech will be fluent with paraphasic errors, usually speech will be non-dysarthric and can be logorrheic. Comprehension is impaired with difficulty in pointing things and answering to yes and no questions. Naming, reading writing and repetition are impaired. Can have associated right hemianopia. In pure Wernicke's aphasia motor and sensory signs are usually minimal or absent.
Q.6. What are the features of global aphasia?
Ans. Patients are usually mute or have nonfluent spontaneous speech, impaired naming, comprehension, repetition, reading and writing. They have associated dense right hemiparesis, hemisensory loss and right hemianopia.
Q.7. What is anomia agraphia and alexia?
Ans.
  • Anomia is impaired naming
  • Agraphia is impaired writing
  • Alexia is impaired reading.7
Q. 8. What is dysarthria and its various types?
Ans. Dysarthria is abnormal articulation of sounds or phonemes. Total loss of ability to articulate is anarthria.
Mayo clinic classification of dysarthria (Duffy, 1995)—6 types:
  1. Flaccid: Lower motor neuron, bulbar weakness, myasthenia.
  2. Spastic: Bilateral upper motor neuron (or) unilateral UMN—strokes, tumors, Primary lateral sclerosis.
  3. Ataxic: Cerebellar diseases (stroke, degenerative disease).
  4. Hypokinetic: Extrapyramidal—Parkinson's disease.
  5. Hyperkinetic: Extrapyramidal—Dystonia, Huntington's disease.
  6. Mixed-spastic and flaccid: Upper and lower motor neuron involvement—Amyotrophic lateral sclerosis, multiple strokes.
Q.9. How speech and language disorders are treated?
Ans. Treatment of Aphasia
  • Client-specific behaviors are targeted.
  • Target greatest improvement in functional communication.
  • Start from simple to more complex tasks.
  • Reinforce the response—give feedback.
  • Teach self-monitoring skills.
  • Train spouse/relative to evoke, prompt and support the patient.
Majority improve spontaneously (in days, weeks, months) (Neuronal plasticity). Other methods reassurance, speech rehabilitation. Prognosis better for left-handed persons.
Treatment of Speech Disorders
Depends on type of dysarthria and natural history of the disease:
  • Pacing devices, palatal lifts, communication boards, visual cues, pharyngeal flap, vocal cord teflon injection.
  • Speech therapy, psychotherapy.
  • Botulinum toxin injection (for spasmodic dysphonia).
  • For stuttering—Behavioral techniques, altered auditory feedback, pharmacotherapy-risperidone, olanzapine, paroxetine.