Dizziness

David Newman-Toker, neuro-otology
Senior author of "HINTS to diagnose stroke"

1/ What is dizziness?
-Dizziness→ impaired perception of spatial orientation without vertigo
-Vertigo→ illusion of motion (spinning/non-spinning)
>Subjective (person)→ MC peripheral
>Objective (environment)→ MC central

2/

Mirror Movements (Spiegelschrift)

1st described by Dr. Friedrich Albrecht Erlenmeyer (1849–1926)
Grundzüge ihrer Physiologie und Pathologie, 1879

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1/ Definition

"Involuntary movements on one side that mirror voluntary actions on the other"
-Normal in <7–10yo (corpus callosum myelination), 70% healthy children (on speed-based task)

2/

Syncope vs Seizure

Fainting by love in Philadelphia Museum of Art
The Doctor's Visit by Jan Steen

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1/ Syncope spectrum

-Normal
-Prodrome→ early autonomic sx
-Presyncope→ near-syncope
-Intermediary→ gray-out/ syncope threshold
-Syncope
-Recovery

2/

Cognitive Changes

Alois Alzheimer (1864 – 1915), German psychiatrist and neuropathologist

1/ Referral

-word-finding difficulty (tip-of-the-tongue phenomenon)
-memory complaints (often vague, sometimes language-related)
-dissect complaints into domains

2/

Headache - Basics

Figure from Codex Vindobonensis 93 (12th century)

1/ Primary or Secondary?

1st question - onset

Hyperacute→ think vascular
Acute/subacute→ broader ddx
Chronic→ reassure if unchanged

Use SNOOP4 for screen secondary causes

2/

Diagnosing Neuropathy
Clinical Pearls

"There are numbness, tingling, and burning pains in the feet, with weakness of the legs, so that the patient walks with difficulty and unsteadiness"

Sir William Osler (1849 – 1919), Canadian physician

1/ Presentation
Referral "neuropathy," self-dx googling numbness/tingling
-hard≠numbness≠tingling≠weak

-true negative sx (loss) are more specific
>unable feel floor T°
>unable sense sand/cold surfaces

-positive sx (gain) are non-SP
>dd: CVI, MSK, compression, positional
2/

Tuning Forks

"If you want to find the secrets of the universe, think in terms of energy, frequency, and vibration"

Nikola Tesla (1856 –1943), Serbian-American engineer

1/ History

1550 Gerolamo Cardano - transmission of sound per skull
1684 Schelhammer - fork to differentiate hearing disorders
1711 John Shore - invented TF
1834 Johann Heinrich Scheibler - different frequencies
1855 - Weber test
1870 - technical improvements

2/

Head (Holocephalic) tremor

"... is just an irritation..."

Katherine Hepburn

1/ ET

- no-no
- type 1 (enhanced) & 2 (msc activation not req for posture)
- ET meds, if no response botox



2/ youtube.com/shorts/uMA_wPY…

Pourfour du Petit Syndrome
The reverse Horner syndrome!

François Pourfour du Petit (1664–1741)
- 1st to describe

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1/ Definition

“ipsilateral mydriasis, hyperhidrosis, and eyelid retraction”

2/

Apraxia!
The disorder of motor cognition

Hugo Karl Liepmann (1863 - 1925)

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1/ Definition

“Inability to perform a higher motor task”

It can’t be explained by weakness, sensory loss, or lack understanding

2/

House of Words: Aphasias!

Armand Trousseau (1801 – 1867)
French internist

1/ History

Late 18th, Gall
- speech function localized frontal lobes

Dax, 1986
- aphasia & L hemisphere

Broca, 1861
- lesion L inferior frontal convolution

Trousseau, 1862
- coined aphasia term

Wernicke, 1864
- speech comprehension

Lichtheim, 1885
- subcortical aphasia

2/

ETHOS Diencephalon!!!

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1/ Diencephalon location
- around the 3rd ventricle

The cavity of the diencephalon is ----- the 3rd ventricle
All of the structures of the diencephalon are around the 3rd ventricle, so the cavity of the diencephalon is the 3rd ventricle.

2/

The Examination in Coma

“the father of modern neurological surgery”

American neurosurgeon Harvey Williams Cushing (1869–1939)

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1/ Definition

“a state of unarousable unresponsiveness”

Parts
a. level of consciousness
b. vital signs (BP & breathing pattern)
c. cranial nerves (fundoscopy + vision + brainstem)
d. motor & sensory
e. reflex
f. meningeal signs

2/

Drifts!!!

French neurologist Jean Alexandre Barré (1880–1967)

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1/ The four types of drift

“pronator, cerebellar, parietal, and functional”

- pronator drift (pyramidal drift) was the 1st to be described
- Dr. Barre was the 1st to report it

2/

Brachial plexus!!!

“Erb-Duchenne palsy, Erb-Charcot paralysis, Erb's point, Erb-Westphal symptom, Erb's spot”

German neurologist Wilhelm Heinrich Erb (1840–1921)

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1/ Components

“Ready To Drink Cold Beer”

Root (5): C5-T1
Trunk (3): upper, middle, lower
Division (6): anterior & posterior from each of the trunks
Cord (3): lateral, posterior, medial
Branch (5)

2/

Signs of tetany!!!

“Trousseau sign of malignancy, Trousseau sign of latent tetany, Trousseau–Lallemand bodie”

French internist Armand Trousseau (1801–1867)

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1/ Definition

Tetanus
- it is different disease w/ different pathology

Tetanic contractions (physiologic tetanus)
- broad range of muscle contraction types

Tetany
- a type of tetanic contraction

2/

Meningeal signs

“Brudziński neck sign, Brudziński symphyseal sign, Brudziński cheek sign, Brudzinski's reflex”

Polish pediatrician Józef Polikarp Brudziński (1874–1917)

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1/ Definitions

Meningitis
-inflammation of leptomeninges & underlying subarachnoid CSF

Meningismus
-morbid state characterized by meningitic syndrome (triad: headache, photophobia, nuchal rigidity)

Meningism
-synonymous of meningismus
-neck stiffness w/o meningeal inflammation
2/

Autonomous Sensory Zones
(peripheral nerves)

Median nerve illustration by Guttmann (1939)

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1/ Definition

“regions where single nerve roots supply distinct and non-overlapping areas of skin”

- small portion of dermatome
- few nerve roots have such autonomous zones
- great variability

2/

Inverted & Perverted Reflexes

The first description of the paradoxical (inverted) triceps reflex

French neurologist Alexandre-Achille Souques (1860–1944)

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1/ Definition

“elicitation of the movement opposite to that normally seen when the reflex is elicited”

2/

Myotonic disorders!

“after a fright, or in an unexpected joyous movement, this convulsive constriction occurs in all limbs…the victim can not stand upright”

Prussian physician Asmus Julius Thomas Thomsen (1815–1896)

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1/ Definition

“difficulty in relaxation of a muscle after maximum voluntary contraction”

It can be specifically
- aggravated by conditions
- affecting regions of the body
- triggered

2/

Dermatome!!!

“Dermatomal man, early twentieth century”

University of Edinburgh Image Collections

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1/ History

“dermatomal charts are primarily derived from 3 sources”

Head & Campbell
-herpetic eruptions

Foerster
-rhizotomy in chronic pain
-dermatomal overlap

Keegan & Garrett
-various diseases
-exam & surgical correlate: 53%

American neurosurgeon John Jay Keegan(1889-1978)
2/