Zach London Profile picture
Jan 4, 2022 7 tweets 3 min read Read on X
"A bag with feet."

That's what the patient said he saw when we showed him the cookie jar picture. He was an older man who had been brought to the ED after being found driving his car around a field.

Here is what I think he was seeing:

#neurotwitter #tweetorial #MedEd
He was unable to focus on the whole picture at once.

This is a striking example of simultagnosia, which in his case was related to bilateral parieto-occipital strokes (Balint's syndrome.)
Another way to test for Simultagnosia is to ask a patient what they see in a picture like this. They may only see T's and not the big H.
Our patient also had the other classic features:
• Oculomotor apraxia (can't intentionally move his eyes towards an object.)
• Optic ataxia (can't accurately reach for something he was looking at.)
I get those terms confused sometimes, but it helps to focus on which part of the body isn't moving normally:

• OCULOMOTOR apraxia pertains to eye movements.
• Optic ATAXIA is the one that pertains to limb movements.
Here is ane example of optic ataxia:
So here's a real bag with feet, trying to demonstrate both:
And finally, a musical non-sequitur.

Here is the song I haven't been able to stop humming while writing this thread. It is by the Adam Schlesinger, one of the great American pop songwriters, who died in April 2020 from COVID19 at the age of 52.

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More from @zach_london

May 2
Ulnar neuropathy "at the wrist" is really in the hand. Guyon's canal is between the pisiform and hamate bones. It's close to the wrist, though.

The numbers in this image are the Zones where injuries can take place, and they each create a unique clinical picture. #tweetorial
1/6 Image
Let's count down from Zone 4. The superficial terminal branch, for practical purposes, is purely sensory, supplying the palmar aspect of the digits 4-5.

FYI: The dorsal ulnar cutaneous nerve (not shown) comes off in the forearm, supplies the backs of these fingers.
2/6 Image
Zone 3 is a motor branch that supplies the first dorsal interosseous. A lesion here could mimic the Split Hand in ALS, where the muscles on the side of the thumb are disproportionately weak.

I never met someone who was crucified, but I suppose that's one way to get this.
3/6 Image
Read 6 tweets
Oct 23, 2023
Saw another patient with sensory neuronopathy who had been misdiagnosed with functional neurological disorder.

What is sensory neuronopathy, and why do we keep missing it? A #tweetorial.
1/ Image
First order of business. Neuronopathy is not the same as neuropathy. There’s a NO right in the middle of it.

That helps you remember the answer to the question: Is this just numb feet in a patient with diabetes?
2/ Image
Where's the lesion?
Sensory neuronopathy is a syndrome of damage to the dorsal root ganglia. These little campers park up and down the spinal cord, so when they aren't working, the sensory loss or pain can be in the distribution of multiple roots.
3/ Image
Read 13 tweets
Jul 27, 2023
🧷🔥The Sensory Exam.🧊👈

Some neurologists just skip it. Compared to other parts of the exam, it's mired in subjectivity.

And slow! you could spend 10 minutes doing it and learn nothing.

But it can still be valuable, especially when done EFFICIENTLY. #tweetorial #neurology Image
In this🧵, we're talking about examining a patient who does NOT have a sensory deficit as their chief complaint.

The screening sensory exam in this situation should focus on things people might not bring up in the history. What on earth could that be? Image
The most common would be neuropathy.

Patients with numb feet may only complain of imbalance. Or pain. Or nothing.

So my screening sensory exam focuses on finding NUMB FEET. 👣

And here's a hot take: Neuropathy is almost always symmetric, so...
Read 15 tweets
Jul 16, 2023
I administered the Montreal Cognitive Assessment (MoCA) to the image-generating AI program DALL-E this morning. Thing really went off the rails.

Let's see how it did. 🧵 Image
"Do trails starting with 1-A-2-B etc."

Okay, that's not what we meant, but I see the confusion. 0 points. Image
"Copy a three dimensional cube."

Impressive, but that wasn't the assignment. 0 points. Image
Read 22 tweets
May 16, 2023
What do inkblots and puppies hugging teach us about the way the long tracts are organized in the spinal cord? Everything.

Behold, our favorite tracts in the cervical cord.

A = fibers to/from the arm
T = fibers to/from the trunk
L = fibers to/from the leg

#tweetorial
1/7 Image
Now let's just look at the arm fibers. For all three tracts, they are right up against the grey matter.

Want a #mnemonic to help you remember that?
2/7 Image
Well, some say the grey matter looks like a butterfly.

You love butterflies, so what do you do when we see one? You hug it.

That's why your arm fibers are right up in there. For butterfly hugs.
3/7 Image
Read 7 tweets
Mar 22, 2023
Not pointing fingers, but I think some of us are misusing the word "bulbar."

The Bulb is the archaic term for the medulla. So bulbar weakness refers only to muscles supplied by cranial nerves 9-12.

Let's play a game called "Is THIS bulbar weakness?"
1/🧵
Is THIS Bulbar Weakness?

Yes.

(The picture's not upside down... you're upside down.)

A lateral medullary stroke damages the nucleus ambiguus of CN X, leading to dysphagia, dysarthria, and dysphonia.
2/🧵
Is THIS Bulbar Weakness?

Yes!

This bulb is completely exhausted. (It needs to stop resting on its florals.)
3/🧵
Read 7 tweets

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