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Lyell Jones MD

@LyellJ

Nov 2

#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)

Read 6 tweets

Lyell Jones MD

@LyellJ

Sep 28

@ContinuumAAN

⬇️@ContinuumAAN Case:

A 41 year old man had 4 days of pain and severe right vision loss. Exam showed a right APD and normal eye movments. Fundoscopy and contrasted T1 below.

He recovered well after IV steroids. What’s going on, #neurotwitter? Poll in 🧵

What is the most likely diagnosis in this patient?

This patient had high titer of anti-myelin associated glycoprotein IgG1 antibodies, characteristic of MOG associated disorders (MOGAD)

Big clues:
➡️ Prominent disc edema and hemorrhage
➡️ Longitudinal perineural enhancement
➡️ Good recovery with steroids

Read 6 tweets

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

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