A RATIONALE FOR THE BRAIN A RATIONALE FOR the BRAIN Assoc. Prof. Warwick Carter MB.BS; FRACGP; FAMA A guide to the diagnosis of diseases that may cause neurological symptoms. 1 A RATIONALE FOR THE BRAIN CONTENTS Introduction SECTION ONE Headache Diagnostic Chart A chart that leads the user through the headache symptoms to possible diagnoses. SECTION TWO Diagnostic Algorithm for Neurological Symptoms Symptoms involving the brain and the conditions that may be responsible SECTION THREE Neurological Conditions The symptoms, signs, investigation and treatment of medical conditions that may cause neurological symptoms. Appendices Mini-Mental Test Glasgow Coma Scale 2 A RATIONALE FOR THE BRAIN INTRODUCTION This book is designed for both the medical student and the doctor who is not a specialist in neurology. It will take the user through a logical rationale in order to diagnose, and then treat, virtually every neurological condition likely to be encountered outside a specialist practice. There are two ways to reach a diagnosis, using the chart in Section One, or the Diagnostic Algorithms in Section Two. In Section One, the chart will guide the user through headcahe symptoms to a selection of possible diagnoses. In Section Two the algorithms will indicate the diagnoses possible with a variety of neurological presenting symptoms. Once a diagnosis has, or number of differential diagnoses have been made, a detailed explanation of the various diagnoses can be found in the largest part of the book, Section Three. This has been written in a style that should be easy to understand by even junior medical students, with technical terms explained in each monograph, but should still be useful to the non-specialist doctor. The symptoms, signs, investigations and treatment of a very wide range of appropriate conditions are explained, along with pictures of the more common conditions. I trust that you will find it useful. Warwick Carter Brisbane OTHER BOOKS IN THIS SERIES A Rationale for Rashes A Rationale for Eyes A Rationale for the Abdomen A Rationale for the Chest 3 A RATIONALE FOR THE BRAIN Section ONE HEADACHE DIAGNOSTIC CHART 4 A RATIONALE FOR THE BRAIN 5 A RATIONALE FOR THE BRAIN Section Two DIAGNOSTIC ALGORITHMS FOR NEUROLOGICAL SYMPTOMS 6 A RATIONALE FOR THE BRAIN Acromegaly DIAGNOSTIC See Head, Large ALGORITHMS Agnosia FOR Sensory suppression Parietal lobe lesions (astereognosis, personality changes) NEUROLOGICAL Gerstmann syndrome (agraphia, unable to calculate) SYMPTOMS AND SIGNS Agraphia Inability to write Cerebrovascular accident (hemiparesis, neurological signs) Cerebral disease (eg.Gerstmann syndrome) (R to L disorientation, agnosia, constructional disorders) Psychiatric disturbances Tremors or muscular weakness from any cause Dyslexia FORMAT Visual problems Presenting Symptom Amnesia (Alternate Name) Total or partial loss of memory Explanation of terminology Epilepsy (convulsions, faint, paroxysmal) System or other group of symptoms Cerebrovascular accident (headaches, confusion, Diagnoses that may present with this symptom weak) [alternate name of diagnosis] (other symptoms of Cerebral haemorrhage each diagnosis, or a discussion of the diagnosis) Transient global amnesia (temporary, compete Other entries to consider recovery, familial) Hysteria Cerebral trauma Clinical Sign Menopause (flushes, sweating, menstrual changes) (Alternate Name) [Abbreviation] Post-traumatic stress syndrome (nightmares, Exp: An explanation of the sign, with its depression) methodology described in sufficient detail to Hypothermia (shiver, confusion, arrhythmias) enable the practitioner to perform the test. Cerebral tumours (headache, nausea, neurological Int: The interpretation of the sign. signs) (+) The diseases, syndromes etc. that Viral encephalitis should be considered if the test is positive Meningitis (cerebral irritation) (++) The interpretation of an exaggerated or Hydrocephalus (papilloedema) grossly positive test Wernicke's encephalopathy (–) Ditto for a negative test result Alzheimer disease (irrational) (AB) Ditto for an abnormal test result Anoxia and hypoxia Phys: The pathophysiology of the sign to enable Psychiatric disorders (eg. fugue states) its significance to be better understood Hypoglycaemia Other entries to consider Hyponatraemia Alcohol and other drugs See also Memory Disturbance 7 A RATIONALE FOR THE BRAIN Transient ischaemic attack (brief, confusion, drop Ankle Clonus attack) Exp: Sharp dorsiflexion of foot causes repeated Cerebral tumour (headaches, nausea, amnesia) spasm of calf muscles and foot plantar Multiple sclerosis (diverse neurological anomalies) flexion. Sydenham's chorea (involuntary jerks, weak) Int: (+) Upper motor neurone lesions and Myasthenia gravis (weak, diplopia, ptosis) disease, functional nervous disorders, Hypothyroidism (fatigue, cold intolerance, dry skin) epilepsy, tuberous sclerosis, Wilson's Phaeochromocytoma (hypertension, sweating, disease, uraemia, encephalitis, multiple headache) sclerosis, CVA, cirrhosis, Creutzfeldt-Jakob Motor neurone disease (weak, myalgia) disease, encephalitis lethargica, alcohol Creutzfeldt-Jakob syndrome (Parkinsonian-like withdrawal, drugs, benign idiopathic effects) Phys: With an upper motor neurone lesion there is Landau-Kleffner syndrome (acquired aphasia, no inhibition of the tendon stretch reflex epilepsy) See also Ankle Jerk Machado-Joseph syndrome (rigidity, limb weakness) Moebius syndrome (ptosis, fixed facies) Shy-Drager syndrome (tremor, vertigo) Ankle Jerk Guillain-Barré syndrome (weak, dysphagia) Exp: With patient kneeling on a chair, or supine, Alcohol and other drugs the Achilles tendon is struck firmly, causing spasm of the calf musculature Int: (–) Peripheral neuropathies, polio, tabes dorsalis, posterior root tumour, spinal Asterixis tumours, subacute combined degeneration See Tremor, Flapping of the cord, syringomyelia, multiple sclerosis, hypothyroidism, diabetes mellitus, beriberi, often absent in elderly Ataxia (++) Upper motor neurone lesions, Exp: Lack of proper coordination. An unsteady, encephalitis, anxiety, tetanus, uncontrolled gait and/or a clumsy nose- hyperthyroidism, cord transection finger test Phys: Reflex absence due to interruption of the Int: (+) Subacute combined degeneration of reflex arc or muscular disease Exaggeration cord, multiple sclerosis, Friedreich's ataxia, due to lack of suppression of reflex by tabes dorsalis, cerebellar lesions, posterior cortical centres. Acts at L2, L3, L4 column lesions, poliomyelitis, See also other signs listed under Reflexes hydrocephalus, postviral, transient ischaemic attack, foramen magnum lesions, Creutzfeldt-Jakob disease, metabolic Anosmia disorders, alcohol abuse, Angelman Loss of the sense of smell syndrome, Bassen-Kornzweig Nasal infections (discharge, fever, headache) syndrome,Louis-Bar syndrome, Machado- Hypothyroidism (fatigue, dry skin, cold intolerance) Joseph syndrome, Marinesco-Sjögren Frontal lobe tumour (amnesia, fits, aphasia) syndrome, Roussy-Levy syndrome, Shy- Brain abscess (preceding infection, neurological Drager syndrome, Strachan syndrome, changes) Wernicke-Korsakoff syndrome Fracture of skull involving olfactory plate Phys: Sensory (posterior column) and motor Kallmann syndrome (hypogonadism) (cerebellar) forms. Former may be Drugs (eg. phenol, chromium) compensated for by ocular impressions (poorer coordination with eyes shut) See also Heel-Knee Test; Nose-Finger Test; Romberg's Sign Aphasia and Dysarthria Loss of the power of speech, or difficulty in speaking Cerebrovascular accident (confusion, neurological Athetosis changes) (Torsion Dystonia) Involuntary, slow, writhing movements 1 A RATIONALE FOR THE BRAIN Cerebral palsy Dementia (inappropriate responses) Hemiplegia from any cause Hypothyroidism (constipated, weak) Cerebrovascular accident (aphasia, headache, Drugs (eg. sedatives, tranquillizers) confusion) See also Vertigo Wilson's disease (copper poisoning) Lesch-Nyhan syndrome (gout, retarded, mutilation) Juvenile Huntington's chorea Ballism Dystonic juvenile movement disorders See Chorea Louis-Bar syndrome (telangiectasia of face and flexures) Extrapyramidal lesions Basal ganglia lesions Behavioural Problems Encephalitis lethargica See Mental Retardation; Overactive; Swearing, Kernicterus (jaundice, infant) Uncontrolled Hallervorden-Spatz disease (iron deposits in brain) Idiopathic and paroxysmal dystonias Drugs (eg. phenothiazines, diazoxide) Blackout See also Choreiform Movements See Syncope Aura Bradykinesia A premonition or sensation preceding a Abnormally slow movement paroxysmal disorder Parkinson's disease (tremor, rigidity, disturbed Epilepsy (twitching, loss of consciousness) balance) Anaphylaxis (oedema, itch, rash) Cerebrovascular accident (mental changes, Migraine (headache, visual disturbances) paralysis) Transient ischaemic attack (various CNS Cerebellar disease (disturbed balance) symptoms) Hypothyroidism (constipation, dry skin, bradycardia) Arthritis (joint pain) Babinski's Sign Frontal lobe tumour (personality changes, disturbed (Plantar Reflex) balance) Exp: Normally, slow plantar flexion of the great Depression (early waking, loss of interest) toe and fanning of the other toes occurs Dementia (mental changes) when the lateral side of the sole is stroked Drugs (eg. sedatives, tranquillizers) firmly with a pointed object, from the heel towards the toes. Positive with extension of great toe Brudzinski's Sign Int: (+) Corticospinal tract lesions, coma, post Exp: The head is flexed on the chest, causing the epileptic seizure, upper motor