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Feb 1 • 6 tweets • 3 min read
Throwback #ContinuumCase!

A 59 year old developed slowly progressive imbalance and falls. Exam showed a mild spastic quadriparesis.

Cervical T2 and post-contrast T1 MR below. What’s the diagnosis, #neurotwitter?🧵
What treatment would you recommend for this patient?
The image demonstrates:

➡️ Multisegment T2 signal prolongation in the cervical cord
➡️ Central canal stenosis
➡️ “Pancakelike” transverse enhancement just below the level of maximal stenosis
➡️ On axial, enhancement mainly in cord white matter

Altogether, suggestive of…
Spondylotic cervical myelopathy!

This characteristic pattern of compressive myelopathy was beautifully described by @EoinFlanagan14 and colleagues in this report in @ANA_journals

onlinelibrary.wiley.com/doi/full/10.10…
Key points from this case:

➡️ Not all cord signal is inflammatory/immune
➡️ Spondylotic myelopathy may show characteristic “pancakelike” enhancement
➡️ These patients are usually symptomatic: treatment is decompression
➡️ Enhancement may persist months to years post-surgery
Thanks to @shamik_b and @EoinFlanagan14 for a great image and article on Spondylotic and Other Structural Myelopathies in the February 2021 issue of @ContinuumAAN!

journals.lww.com/continuum/Full…

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More from @LyellJ

Lyell Jones MD Profile picture
Nov 17, 2022
#ContinuumCase!

A 56 year-old developed progressive imbalance and dream enactment behavior. On exam he had an ataxic dysarthria and prominent limb dysmetria

In addition to cerebellar atrophy on his brain MR, you notice a subtle abnormality. What’s going on, #neurotwitter? 🧵
Which of the following diagnoses are associated with the “hot cross bun” sign on MRI?
The “hot cross bun” sign is an abnormal appearance (usually T2 prolongation) in a cruciform pattern in the pons

➡️ Thought to reflect degeneration of median raphe nuclei and transverse pontocerebellar fibers

radiopaedia.org/cases/hot-cros…
Read 6 tweets
Lyell Jones MD Profile picture
Nov 2, 2022
#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 Profile picture
Sep 28, 2022
⬇️@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 🧵 Image
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 Profile picture
Jun 17, 2022
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
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
Imaging was performed with a concern for multiple radiculopathies.

MRI showed no structural root lesions. But is it normal? 3/8 Image
Read 8 tweets
Lyell Jones MD Profile picture
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 Profile picture
Jun 30, 2021
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

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