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Lyell Jones MD

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Nov 2 • 6 tweets • 3 min read

#ContinuumCase!

A 71 year old has had 18 months of frequent falls

While eating, he leaves food on the closest part of the plate

His exam shows slow saccades, limb dyspraxia, and axial rigidity

Sagittal T1 MR below. What’s going on here, #neurotwitter? 🧵

What’s the most likely diagnosis in this patient?

The combination of

➡️ Falls
➡️ Slowed saccades (especially vertical)
➡️ Axial rigidity
➡️ Midbrain atrophy

All suggest the diagnosis of progressive supranuclear palsy (PSP)

PSP is a rare 4-repeat tauopathy with an increasingly diverse array of phenotypes:

➡️ Parkinsonism
➡️ Vertical gaze paresis
➡️ Gait freezing (⬆️⬆️ falls!)
➡️ Cognitive impairment
➡️ Corticobasal syndrome

Imaging of patients with PSP may demonstrate midbrain atrophy, including:

➡️ In sagittal plane, the “hummingbird” sign
➡️ In axial plane, the “Mickey Mouse” or “morning glory” sign

@HopkinsMedNews

Thanks to Dr. Alex Pantelyat @HopkinsMedNews for the case and an excellent discussion of PSP and CBS, all in the latest issue of @ContinuumAAN, guest edited by Dr. Kathleen Poston @pddoc!

journals.lww.com/continuum/Full…

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Lyell Jones MD

@LyellJ

Jun 17

Solving the Case of the Vanishing Leg:

“My right leg is disappearing.”

➡️ 48 years old
➡️ Whole right lower limb weakness, atrophy
➡️ Progressive
➡️ Painless

What’s going on? 🧵1/8

https://twitter.com/LyellJ/status/1392906522594848768

As always, start with the patient (before the data). Where does this localize?

Weakness and atrophy often localize to nerve (motor neuron especially when no sensory symptoms)

➡️ BUT, some asymmetric myopathies can present similarly

Simple rubric to localize weakness: 2/8

https://twitter.com/LyellJ/status/1392906522594848768

Imaging was performed with a concern for multiple radiculopathies.

MRI showed no structural root lesions. But is it normal? 3/8

Read 8 tweets

Lyell Jones MD

@LyellJ

Jul 1, 2021

How to Muscle Twitches:

To mark the new academic year, a special July 1 edition celebrating all those muscle twitches out there today #medtwitter #neurotwitter

Myoclonus:

Brief, lightning-quick muscle contractions (or, brief pause of contraction ➡ asterixis)

Usually generated in UMN >>> LMN
Many causes: epileptic, neurodegenerative, toxic (opioids), physiologic

July 1: look out for hypnic myoclonus (sleep jerks) on hour 6 of rounds

Fasciculations:

Brief contraction of a few muscle fibers. Always localizes to LMN/axon (not UMN or muscle)

Common. You've had one while reading this tweet. More frequent in peripheral nerve disorders

July 1: fasciculation epidemics after lectures on causes of fasciculations

Read 5 tweets

Lyell Jones MD

@LyellJ

Jun 30, 2021

@AANMember

How to Quality:

Delivering high value care to patients has to start with an understanding of quality of care. Extremely proud of this team’s first report of quality of neurologic care in the US, using Axon Registry data @AANMember @GreenJournal 1/
n.neurology.org/content/early/…

This analysis is the culmination of years of development, millions of patient encounters, and hundreds of neurologist and staff volunteers dedicated to high quality care.

But it still represents an early step in improving outcomes 2/

In 2003 McGlynn and colleagues reported the seminal description of healthcare quality in the US. Until now we haven’t had a view specific to neurology 3/

nejm.org/doi/full/10.10…

Read 5 tweets

Lyell Jones MD

@LyellJ

May 13, 2021

How to Weakness:

Localization is a barrier in neurology, but fortunately there are only 4 locations that cause most weakness:

1 Upper motor neuron
2 Lower motor neuron
3 Neuromuscular junction
4 Muscle

First you have to determine if there IS weakness.

Neurologically speaking, weakness is a loss of muscle power. You find it on the exam.

Weakness is NOT fatigue, sleepiness, numbness, imbalance, or pain. You determine THIS in the history.

So where can weakness localize?

Upper motor neuron (UMN):

Pattern:
➡️Often hemiparesis, paraparesis, or quadriparesis
➡️Deltoid, triceps, wrist/finger extensors, hip/knee flexors, and foot dorsiflexors most affected

Clues:
➡️Spasticity, hyperreflexia, upgoing toes

Read 7 tweets

Lyell Jones MD

@LyellJ

Mar 27, 2021

How to Neurology

(in 4 tweets. Please keep this between us, for job security reasons)

After taking a history (detailed onset timeline, better than ID’s) and examining the patient, there are only 4 questions to answer:

1. Does the patient have a neurological problem?

(many neurological mysteries are because the answer to this question was “no”)

2. If there is a neurological problem, where is it?

It has to be somewhere.

This is localization, and where we lose a lot of folks. HOWEVER, just try to decide between:

➡️ Focal (caused by lesion in 1 place)

or

➡️ Diffuse (isolated lesion cannot account for findings)

Read 6 tweets

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