Neurology is so cool:

A 61 year old man comes in for another opinion on his diagnosis of ALS

Several years of progressive upper limb weakness

Exam: upper limb fasciculations, brisk lower limb reflexes

One look at the C-spine MR and you know it’s not ALS. What’s going on? The imaging demonstrates a spinal longitudinal extradural CSF collection (SLEC)

➡️ Indicates a dural tear (usually ventral) and a fast CSF leak

There are relatively few mimics of ALS, and bibrachial amyotrophy from a CSF leak is one not to be missed

A 41 year old patient comes in with her mother for evaluation of double vision

On exam you notice a right eye hyperdeviation more prominent with adduction. Exam otherwise normal

Her brain MRI showed this ⬇️ (FLAIR left, GRE right)

What is this? Is the mystery solved? Back to the patient, a little more history:

She recalled intermittent vertical diplopia dating back at least 10 years, persistent for the last year

Her mother recalls that her high school photos showed a leftward head tilt…

A 59 year old patient is brought to clinic by her family for cognitive decline. They want to start her on lecanemab

She has a history of hypertension and migraine. On exam she has mild executive, attention, and memory impairment

This is her imaging. What would you do? Just curious: would you start lecanemab in this hypothetical patient?

A 61 year old woman comes to see you for debilitating, lancinating right upper tooth and mid-facial pain

The pain persisted despite multiple tooth extractions and pain medications, including opioids

You may know the diagnosis already, but do you know what to do? Other features of her pain:

⚡️Severe
⚡️Electric or lightning-like
⚡️Brief (5-10 seconds)
⚡️Occur 20-30 times daily
⚡️Worst in a right V2 distribution, triggered by light touch

With a normal neurologic examination, the most likely diagnosis is:

⚡️Trigeminal neuralgia⚡️

A 61 year old man comes to see you for muscle cramps

“Cramps. You mean like the kind in your calf that wake you up at night?”

“No doc, they look like this…”

What’s going on here?? A little more history:

In addition to these muscle movements he has had fatigue and some difficulty standing

On exam you see these reproducible wave-like muscle contractions with percussion, and mild symmetric proximal limb weakness

CK: 635 u/L

You get a call to consult on an ICU patient with episodes of loss of consciousness

You log in to Epic to get her history, test results, etc

Unfortunately, you get BSoD (blue screen of death).

What to do?

You decide to go see the patient. Let’s solve this mystery The patient is a 67 year old woman with episodes of loss of consciousness, leading to a few falls

She “feels strange” before the events, and immediately returns to normal afterward

She’s otherwise well, but has had some memory decline and morning headaches recently…

A 19 year old is brought to the ED after 2 days of progressive confusion and drowsiness

Last week he had a fever and runny nose. Got better.

He soon becomes unresponsive and requires intubation

This is his MRI performed the next day. What’s going on? What do you do? More data:

Exam: Afebrile. Arouses briefly to noxious stimulus. Less movement and brisker reflexes on the left

MRI: asymmetric T2 hyperintensities in cortex, white matter, and deep gray (minimal enhancement)

CSF: 4 cells, protein 89 mg/dL, no bands, no sign of infection

A 9 year old girl is brought to clinic for persistent headaches

She’s had 1-2 severe headaches/month for the last year, missing school

Headache diagnosis relies on the history… how do you establish that in a young child?

How will you treat these headaches?

How can art help? There’s an extra level of difficulty constructing a history in the pediatric setting. Collateral headache history from parents, caregivers, and family is crucial

If you like mnemonics, OPQRST is helpful:

Onset
Provocation
Quality
Radiation
Severity
Time

The 71 year old patient in your office has had progressive imbalance and falls

She has brisk reflexes on exam, so you order an MRI. Results below (T2 left, T1 with contrast right)

What’s going on here?? What is your next move for this patient? #ContinuumCase

A 77 year old woman comes in following a seizure. Her imaging shows a nonenhancing T2 hyperintense right medial temporal lesion

Biopsy shows mild hypercellularity suspicious for low grade glioma

What next? Hint: you might’ve done something different just a few years ago The patient is otherwise healthy and lives independently. She has a normal neurologic exam and is tolerating her antiseizure medication

What do you do next in this #ContinuumCase?

A 39 year old woman with relapsed, refractory B-cell lymphoma undergoes CAR T-cell therapy

On day 5: mild fever and headache

On day 14: somnolent, then unresponsive. CT below

You’re the neurologist on call.

What do you see?
What’s going on?
What do you do? Patients undergoing CAR T therapy are medically complex: underlying malignancy, conditioning chemotherapy, risk of infection, and the treatment itself

Differential for encephalopathy in these patients is broad: metabolic, infectious, and other causes

What about the CT?

A 24 year old man had progressive painless weakness and numbness over 4 months

EMG: Demyelinating polyradiculoneuropathy
CSF: protein 398, no cells

✅ Diagnosis: CIDP. Started IVIG and steroids. Mission accomplished.

Here’s the problem: he didn’t get better

A #ContinuumCase You take a closer look.

On exam he has diffuse weakness, length-dependent sensory loss, and areflexia

You review his electrophysiology. Moderate slowing of velocities + conduction block (74% block of amplitude on this tibial motor study⬇️)

All still fits CIDP

The 62 year old man in your office clearly doesn’t want to be there. “My family made me come in.”

After working outside on a hot day, he had a brief loss of consciousness. Neuro exam showed mild sensory loss in his feet. ECG below

How would you approach this #ContinuumCase?🧵 More about the spell: he felt lightheaded beforehand, no abnormal movements, and immediately returned to normal thereafter. He has occasional brief lightheadedness on standing

He has a history of coronary disease, treated hypertension, and diabetes

What’s your next move?

A 75 year old woman comes to the ED with 3 days of low back pain, imbalance, and tingly feet

She has diabetes and melanoma. “I just finished my first round of chemo last week!”

She has moderate lower limb weakness & absent reflexes

How would you approach this #ContinuumCase?🧵 New spine pain and neurologic deficit in the setting of active malignancy is an emergency!

Fortunately, her spine MRI showed no sign of cord or cauda equina compression. So what’s going on here?

Let’s think it through

A 48 year old woman comes to clinic with her teenage children. The reason:

“Mom wakes up screaming at night, and it scares us.”

What do you do next for this patient?

A things-that-go-bump-in-the-night #ContinuumCase🧵 The episodes occur several times per week and consist of screaming, sitting up in bed, followed by confusion. Once, she ran from the room.

She appears frightened during the events, and has a vague sense of recall for being chased.

Her neurologic exam is normal.

What’s next?

A 52 year old woman comes in for evaluation of daily headaches. They’ve been present for about 2 years, occur on awakening, and resolve after her morning coffee.

Her neurologic exam is completely normal.

What do you do next for this patient?🧵#ContinuumCase She has a history of migraine and mild hypertension. She’s a light snorer, and gets up 3x a night for the bathroom. She does not have excessive daytime sleepiness, and she has no systemic symptoms (eg weight loss) but she is fatigued

Which of the following will you recommend?

Because you read Continuum and follow #ContinuumCases, your reputation as a neurologic detective has grown.

You get paged with a curbside:

MICU: “Hi, neurology, we have a diabetic patient with uncontrolled movements, we’re worried he’s in status and…”

You: “I’m on my way.” At the bedside you see a 57 year old man who is drowsy but oriented following IV lorazepam and levetiracetam. He has low-amplitude writhing movements of all limbs.

After reviewing his MR (non-con T1), which blood test are you most interested in obtaining?

A 47 year old woman developed imbalance and falls 1 year after gastric bypass surgery. Good diet and takes a vitamin. Her cervical MRI is below

Here’s the twist: serum B12, ceruloplasmin, folate, and urine copper were all NORMAL. What’s going on here?! #ContinuumCase Her exam showed severe proprioceptive sensory loss and gait ataxia, so the “inverted V” T2 hyperintensity in the dorsal columns is no surprise. Another clue: her EMG showed an axonal peripheral neuropathy

What next?

A #ContinuumCase conundrum:

A 52 year old develops abrupt left face and arm weakness. DWI below

The case seems straightforward until you notice on exam, in addition to somnolence and left hemiparesis, he has bleeding gums…

Time to solve a mystery, #neurotwitter!🧵on 🧠&🩸 First the imaging: his DWI shows an acute right hemispheric ischemic cerebral infarction. SWI shows a convexal subarachnoid hemorrhage, and subcortical microhemorrhages

What next?

#ContinuumCase!

A 48 year old is found unresponsive by her family. She was intubated for respiratory depression with no response to naloxone. She was comatose with intact brainstem reflexes

Urine drug screen was negative. MRI below (DWI⬆️/FLAIR⬇️)

What’s the diagnosis???🧵 The MRI shows restricted diffusion and T2 hyperintensity in the cerebellum, temporal lobe, and basal ganglia.

A few possibilities here, what do you think is most likely?

#ContinuumCase, plot twist edition:

A 28 year old PGY2 neurology resident is asked by her attending to review 2 scans and determine the diagnosis: Alzheimer disease (AD) or dementia with Lewy bodies (DLB).

What should she say, #neurotwitter?🧵 How would you respond?