Acute Peripheral Neurologic Lesions

Acute Peripheral Acute Peripheral Neurological LesionsNeurological Lesions

Peripheral Nervous SystemPeripheral Nervous System Serves sensory, motor, and autonomic Serves sensory, motor, and autonomic

functionsfunctions Sensory symptoms-numbness, tingling, Sensory symptoms-numbness, tingling,

dysesthesias, pain, and ataxia, due to dysesthesias, pain, and ataxia, due to proprioceptive dysfunctionproprioceptive dysfunction

Motor symptoms-weaknessMotor symptoms-weakness Autonomic symptoms-orthostatic Autonomic symptoms-orthostatic

symptoms, bowel or bladder dysfunction, symptoms, bowel or bladder dysfunction, gastroparesis, and sexual dysfunction.gastroparesis, and sexual dysfunction.

Peripheral Nervous SystemPeripheral Nervous System In peripheral nerve process there is In peripheral nerve process there is

reduction or absence of reflexes.reduction or absence of reflexes. When the sensory component is involved, When the sensory component is involved,

test for proprioception, vibratory sensation, test for proprioception, vibratory sensation, and pain and temperature sensibilityand pain and temperature sensibility

When the motor system is involved there is When the motor system is involved there is wasting, fasciculations, and weakness.wasting, fasciculations, and weakness.

Autonomic dysfunctions may cause Autonomic dysfunctions may cause anhidrosis, pupillary dysfunction, anhidrosis, pupillary dysfunction, orthostatic hypotension, and tachy- and orthostatic hypotension, and tachy- and bradyarrhythmias.bradyarrhythmias.

Localization of neurological Localization of neurological diseasedisease

Most muscle-related processes result in Most muscle-related processes result in weakness of large proximal muscles along as weakness of large proximal muscles along as pain, tenderness, and elevation of CK.pain, tenderness, and elevation of CK.

Diseases that affect other components of the Diseases that affect other components of the peripheral nervous system seldom cause peripheral nervous system seldom cause tenderness and elevation of CK.tenderness and elevation of CK.

Neuromuscular junction processes can affect Neuromuscular junction processes can affect large proximal muscles and affect bulbar large proximal muscles and affect bulbar musculature resulting in pupillary dysfunction, musculature resulting in pupillary dysfunction, diplopia, dysarthria, or dysphagia.diplopia, dysarthria, or dysphagia.

MyopathiesMyopathies PolyomyositisPolyomyositis

-Inflammatory myopathy-Inflammatory myopathy-chronic complaints of -chronic complaints of

proximal proximal symmetric symmetric weaknessweakness -may -may have muscle pain and tendernesshave muscle pain and tenderness

-may have dysphagia and few -may have dysphagia and few progress progress to respiratory failure to respiratory failure

-no sensory loss, -no sensory loss, reflexes should be reflexes should be intact intact

PolyomyositisPolyomyositis ManagementManagement -should be assessed for -should be assessed for

potential potential respiratory compromise and respiratory compromise and aspiration aspiration risk.risk. -long term treatment--long term treatment-immunosuppressiveimmunosuppressive agents such as steroids agents such as steroids and methotrexateand methotrexate

Differential diagnosis includes Lambert-Differential diagnosis includes Lambert-Eaton myasthenic syndrome, inclusion body Eaton myasthenic syndrome, inclusion body myositis, toxic myopathies, and myositis, toxic myopathies, and dermatomyositis.dermatomyositis.

MyopathiesMyopathies DermatomyositisDermatomyositis

-Can affect children-Can affect children-similar to polyomyositis -similar to polyomyositis

except for except for violaceous rash violaceous rash over face and handsover face and hands -muscle -muscle weaknessweakness -no -no sensory or reflex abnormalitiessensory or reflex abnormalities --treatment is immunosuppressiontreatment is immunosuppression

-elevated sed rate and CPK-elevated sed rate and CPK

Other MyopathiesOther Myopathies Drug induced Drug induced Viral myositis causes an acute Viral myositis causes an acute

myopathy involving the heart, myopathy involving the heart, associated with febrile illness, associated with febrile illness, myalgia, and elevated CK levels.myalgia, and elevated CK levels.

Suspect trichinosis in pt with Suspect trichinosis in pt with myalgias, proximal and bulbar myalgias, proximal and bulbar muscle weakness, facial edema, and muscle weakness, facial edema, and eosinophilia.eosinophilia.

Disorders of the Neuromuscular Disorders of the Neuromuscular junction- Botulismjunction- Botulism

Ingestion of food contaminated with Ingestion of food contaminated with Clostridium botulinum.Clostridium botulinum.

Adults often report exposure to home Adults often report exposure to home canned foodscanned foods

Infants exposure to honeyInfants exposure to honey Bulbar weaknessBulbar weakness Exraoccular movements are Exraoccular movements are

sometimes abnormalsometimes abnormal

BotulinismBotulinism Absence of pupillary light reflexAbsence of pupillary light reflex Proximal limb weaknessProximal limb weakness Sensation is intact, normal Sensation is intact, normal

mentation, reflexes are usually mentation, reflexes are usually normalnormal

Treatment-antibiotics in infants and Treatment-antibiotics in infants and immune serum and admission to the immune serum and admission to the hospitalhospital

Guillain-Bare SyndromeGuillain-Bare Syndrome Most common form of acute Most common form of acute

generalizedgeneralized neuropathyneuropathy Patients often report recent viral Patients often report recent viral

illness, especially gastroenteritisillness, especially gastroenteritis Associated with Campylobacter jejuniAssociated with Campylobacter jejuni

Guillain-Barre SyndromeGuillain-Barre Syndrome Numbness and tingling of the lower Numbness and tingling of the lower

extremities followed by weakness of the extremities followed by weakness of the legs and then arms.legs and then arms.

Weakness more pronounced in the legsWeakness more pronounced in the legs Lack of deep tendon reflexesLack of deep tendon reflexes May be facial weakness involving the May be facial weakness involving the

foreheadforehead Chance of respiratory failure and lethal Chance of respiratory failure and lethal

autonomic fluctuationsautonomic fluctuations

Guillain-Barre SyndromeGuillain-Barre Syndrome ManagementManagement

-Lumbar puncture (high CSF -Lumbar puncture (high CSF protein, nl protein, nl cell count and glucose)cell count and glucose)

-Should be -Should be admitted for monitoringadmitted for monitoring --When vital capacity is under 1 liter, When vital capacity is under 1 liter,

intubate.intubate.-Plasma exchange or IV -Plasma exchange or IV

immunoglobulinimmunoglobulin

Focal neuropathies-Carpal Focal neuropathies-Carpal Tunnel SyndromeTunnel Syndrome

Most commonly see entrapment Most commonly see entrapment neuropathy.neuropathy.

Intermittent pain and/or numbness in Intermittent pain and/or numbness in the thumb and first two fingers.the thumb and first two fingers.

Symptoms reproduced with Symptoms reproduced with compression of the nerve over the compression of the nerve over the carpal tunnel or by tapping over the carpal tunnel or by tapping over the nerve.nerve.

Treatment-wrist splints and ortho Treatment-wrist splints and ortho referralreferral

Focal neuropathiesFocal neuropathies Ulnar neuropathyUlnar neuropathy

-Numbness of the fourth and fifth -Numbness of the fourth and fifth fingersfingers -weakness and wasting of -weakness and wasting of hypothenar hypothenar eminence is late findingeminence is late finding

Entrapment of deep peroneal nerveEntrapment of deep peroneal nerve-at the fibular head causing foot -at the fibular head causing foot

drop drop and and numbness of the web numbness of the web between great and between great and second toe second toe

Focal NeuropathiesFocal Neuropathies Meralgia parestheticaMeralgia paresthetica

-entrapment of lateral femoral -entrapment of lateral femoral cutaneouscutaneous nerve of the thigh.nerve of the thigh.

-numbness and -numbness and dysesthesias on lateral dysesthesias on lateral aspect of upper leg.aspect of upper leg.

-usually after weight loss or -usually after weight loss or pelvic pelvic proceduresprocedures

Focal neuropathiesFocal neuropathies Mononeuritis multiplexMononeuritis multiplex

-multiple nerve dysfunctions -multiple nerve dysfunctions caused bycaused by vasculitisvasculitis

-usually affects -usually affects both sides of the bodyboth sides of the body --differential diagnosis includes differential diagnosis includes multiple multiple compression neuropathies compression neuropathies andand multifocal motor multifocal motor neuropathyneuropathy

Focal Neuropathies-Bell’s PalsyFocal Neuropathies-Bell’s Palsy Most common cause of acute facial Most common cause of acute facial

paralysisparalysis Sudden facial weakness, difficulty Sudden facial weakness, difficulty

with articulation, problems keeping with articulation, problems keeping an eye closed, or inability to keep an eye closed, or inability to keep food in the mouth one side.food in the mouth one side.

One sided weakness of the face One sided weakness of the face involving the foreheadinvolving the forehead

Bell’s PulsyBell’s Pulsy TreatmentTreatment

-acyclovir-acyclovir-Steroid controversial-Steroid controversial

-Eye care to avoid -Eye care to avoid corneal abrasionscorneal abrasions -lacrilube -lacrilube and patchingand patching

Focal neuropathies-Lyme Focal neuropathies-Lyme diseasedisease

Multiple neurologic manifestationsMultiple neurologic manifestations Arthralgias and fatique initiallyArthralgias and fatique initially Common neurologic sign is seventh Common neurologic sign is seventh

nerve pulsynerve pulsy Weakness in the limbsWeakness in the limbs May see selected decreased deep May see selected decreased deep

tendon reflexestendon reflexes

Lyme DiseaseLyme Disease ManagementManagement

-serum and CSF lyme antibodies-serum and CSF lyme antibodies-CSF pleocytosis and -CSF pleocytosis and

increased protein increased protein with a normal with a normal glucoseglucose -treat with -treat with 3 week course of IV 3 week course of IV antibiotics either rocephin or antibiotics either rocephin or

doxycycline doxycycline

Plexopathies-Brachial NeuritisPlexopathies-Brachial Neuritis Affects younger individualsAffects younger individuals Excruciating back, shoulder, or arm Excruciating back, shoulder, or arm

pain followed by weakness of arm or pain followed by weakness of arm or shoulder girdle.shoulder girdle.

On exam there is weakness along the On exam there is weakness along the distribution of brachial plexus.distribution of brachial plexus.

Differential diagnosis includes Differential diagnosis includes cervical radiculopathies, Pancoast cervical radiculopathies, Pancoast tumortumor

Plexopathies-lumbarPlexopathies-lumbar Occurs in diabetic patientsOccurs in diabetic patients Presents with back pain followed by Presents with back pain followed by

weakness.weakness. Sensory findings are absentSensory findings are absent Deep tendon reflexes are diminished Deep tendon reflexes are diminished

on the affected side.on the affected side. Bowel and bladder function are not Bowel and bladder function are not

affectedaffected

HIV-Associated Peripheral HIV-Associated Peripheral Neurologic DiseaseNeurologic Disease

CMV radiculitisCMV radiculitis -may be seen in the -may be seen in the latter stages of latter stages of AIDS AIDS -Acutely -Acutely weakweak -Primarily lower extremity -Primarily lower extremity involvementinvolvement -Varying degrees of bowel -Varying degrees of bowel and bladder and bladder dysfunction dysfunction --Hyporeflexia and decreased sensationHyporeflexia and decreased sensation

-Rectal tone may be impaired-Rectal tone may be impaired

CMV RadiculitisCMV Radiculitis ManagementManagement

-lumbar puncture reveals -lumbar puncture reveals pleocytosispleocytosis and increased and increased proteinprotein -MRI of -MRI of lumbarosacral spine lumbarosacral spine demonstrates swelling and clumping demonstrates swelling and clumping of of cauda equina cauda equina

-IV gancyclovir started at -IV gancyclovir started at 5mg/kg q 12 h 5mg/kg q 12 h X 14 d X 14 d