Update for the practical doctor
Notes by dr. Claudio Italiano
When we have to visit a patient of neurological relevance, we need to evaluate some signs that he presents:
-vigilance
-the motricity
-the speech
-the ability to perform gestures on command
-muscle tone, spasticity, contractions, clones, etc.
In this page, in short, you can review the signs of easier confirmation, to go
back to a diagnostic hypothesis.
Patients with acute cerebral vasculopathy may present:
• confusional state, up to amazement and coma or, even worse, psychomotor
agitation, sign of encephalic hemorrhage (!)
• deficiency in limb movements, "side signs", ie paresis or paralysis or lateral
hyposthenias, expressions of an ischemic-hemorrhagic insult in one of the two
hemispheres, that against lateral to the side affected by the paresis.
• Perform the Mingazzini maneuver: if the patient is asked to keep the arms
raised forward, if there is a motor deficit, the arm affected by the paresis
will fall slowly; likewise the same maneuver is carried out with the lower limbs,
inviting it to keep the legs raised and the thighs bent, so that if the lower
limb falls, this is an expression of deficit.
They are characterized by:
• Monoplegia
• It is the isolated paralysis of a limb (brachial, crural), or of the face and
tongue; we talk about monoparesi if the paralysis is not complete.
• Diplegia
This term indicates any bilateral paralysis, that is to say, two parts of the
body that are more or less exactly symmetrical. We have facial, brachial, etc.
We have cerebral diplegia, such as the sum of two hemiplegias, for bilateral
lesions of the pyramidal system in the brain, and as outcomes of cerebral
cerebropathies.
• Paraplegia
Paraplegia can be established abruptly (for spinal hemorrhages resulting from
vasculopathies, traumas, transverse myelitis, poliomyelitis, polyneuritis)
presenting with the characters of flaccid paralysis or more frequently in a
progressive manner (by medullary compression, lues, multiple sclerosis) and
almost always with the characters of spastic paralysis. Spastic paraplegia
sometimes represents the late phase of a flaccid form
• We talk about the sign of the Babinski when crawling the ventral surface of
the sole of the foot, you will get an opening movement of the toes: sign of the
positive Babinski. Decerebration is frequently observed in destructive or
compressive lesions in the midbrain or in lesions on the upper bridge. The
lesion is located between the red nucleus and the vestibular nuclei, while the
vestibular nuclei themselves and the lateral reticular spinal tract and nucleus
are intact.
Peripheral palsy of the VII pair or Bell's palsy, differential diagnosis with
facio-brachio-crural hemiplegia
A person who tries to smile and raise his eyebrows, suffering from Bell's palsy
on his diseased side will present lagophthalmos, ie the fall of the lower
palpebral fissure with the dryness of the conjunctiva and its irritation and in
addition the deflection of the buccal rim towards the side healthy, for
hypotonous on the sick side. In these cases it is not possible to document
central lesions. In general, the cause of the paresis of the facial that may
occur in the diabetic patient (cf. diabetic neuropathy) or as a result of
perfrigerations with suffering of the nerve itself or for infections (eg a case
of our knowledge had a tooth decay) is unknown.
A persistent loss of consciousness and other vital functions (motility,
sensibility) including the vegetative functions that can sometimes be altered,
that is the breath and the cardioregulation activity. In summary it is due to
alteration of the central nervous system metabolism that we know depends on fuel
and oxidizing agent, that is glucose and oxygen, so when those factors of the
metabolism are no longer derives a suffering with the shutdown of the state of
vigilance and, therefore, the coma. But it is not that the subject immediately
falls into a deep coma, that is, it does not suddenly plunge into the deepest
state of torpor! Sometimes this happens gradually, in degrees (cf. coma and
classification)
Species in the patient with central lesions of an acute nature, especially if
hemorrhagic, it is possible to observe convulsive crises with limb clones,
Jacsonian march and generalization of crises with loss of consciousness.
Epilepsy is a word that derives from the Greek "epilepsy" and means a chronic
condition, that is lasting over time, determined, so to speak, by a sudden "electric
discharge" of the brain neurons, ie of the nerve cells of the cerebral cortex
that they are in fact equipped with electro-chemical pulse transmission; it is
not, however, a disease but a pathological syndrome, that is a set of symptoms
that must be interpreted and placed within the basic pathology, as we will
explain later (in fact I have epilepsy but for example I have a injury in the
brain that causes it)
Aphasia is the loss of the ability to produce or understand the language, due to
injuries to the areas of the brain responsible for its processing. It is caused
by lesions of the brain areas primarily responsible for language processing (Broca's
area and Wernicke area) or other areas of connection with different brain
centers variously involved in the function. These areas are generally located in
the left hemisphere for the right-handed subjects (in the rare cases in which
they are located in the right hemisphere, we speak of "crossed aphasia"). In
left-handed individuals, in 60% of cases they are in the right hemisphere, while
in the remaining 40% in the left hemisphere or in both.
The alterations included in the term aphasia may concern various aspects of
language:
• comprehension
• production
• repetition
• structuring.
• If you suspect that apraxia is accompanied, as often happens, by aphasia (a
disorder that can compromise verbal comprehension), then you can request to
perform simple gestures: es. do bye with your hand or OK with your fingers.
Movement of the patient with vasculopathy and peripheral lesions of the
pyramidal system and extrapyramidal system
• Ataxia (from the Greek ataxia, disorder) is a disorder consisting in the
progressive loss of muscle coordination which therefore makes it difficult to
perform voluntary movements. The center of muscle movement coordination is the
cerebellum that processes the impulses brought to the muscles from the spinal
cord and peripheral nerves. Ataxia can therefore be caused by problems both in
the spinal cord and in the peripheral nerves. The consequences are manifested by
the lack of coordination between trunk and arms, trunk and head, etc. There are
also associated disorders, such as incoordination of eye movements, incontinence,
difficulty swallowing and involuntary movements of limbs, head and trunk.
There are four types of ataxia:
-
or cerebellar ataxia, with neoplastic, inflammatory or vascular lesion of the
cerebellum;
-
or sensory ataxia, caused by lesions at the level of the proprioceptive fibers
of large diameter at the level of the peripheral nervous system, or at the level
of the spinal cord along the posterior cords. The pathologies responsible for
sensory ataxia are multiple and include: autoimmune, infectious, metabolic,
toxic, genetic, neoplastic and paraneoplastic diseases
-
or labyrinthine ataxia, in which the inner ear is involved;
-
or cerebral ataxia, in which the cortex of the frontal, temporal or parietal
region is involved.
- Proof-nose-index = documents dysmetria or motor incoordination, expression of
ataxia
• Anserin Gait = is an important sign of muscular dystrophy, atrophy of
spinal muscles or, rarely, of congenital hip dislocation. The gait is the result
of the progressive dysfunction of the pelvic girdle muscles mainly the gluteus
medius, the hip flexors and the hip extensors.
• Creeping gait = it is typical of subjects with hemiparesis due to ischemic
stroke.
• Propulsive gait = characterized by a rigid and curved posture, where the head
and neck of the patient are inclined forward, the flexed, rigid arms are held
away from the body, the fingers are extended, the knees and hips are rigidly
bent .
• Spastic gait = paretic or hypostenic gait is a rigid gait, with dragging of
the foot caused by the unilateral hypertonus of the leg muscles.
(M. of Parkinson)
o Stepping gait = paretic or hypostenic gait is a rigid gait, with dragging of
the foot caused by the unilateral hypertreat of the leg muscles.
To deepen the theme: