Diagnostic Decisions in Neurology

177 Pages·1985·2.528 MB·English

by  Professor Dr. med. Klaus Poeck (auth.)

Klaus Poeck
Diagnostic Decisions
in Neurology
With a Foreword by
Robert 1. Joynt
Springer-Verlag
Berlin Heidelberg NewY ork Tokyo
Professor Dr. med. KLAUS POECK
Head, Department of Neurology
Rheinisch-Westfalische Technische Hochschule
Pauwelsstra13e
5100 Aachen, FRG
ISBN-I 3 :978-3-642-70695-0 e-ISBN-13: 978-3-642-70693-6
DOl: 10.1007/978-3-642-70693-6
Library of Congress Cataloging in Publication Data. Poeck, Klaus. Diag
nostic decisions in neurology. Includes index. 1. Nervous system - Dis
eases - Diagnosis. 2. Neurologic examination. 3. Symptomatology. I. Title.
[DNLM: 1. Nervous System Diseases-diagnosis. WL 141 P743d]
RC348.P64 1985 616.8'075 85-18801
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© Springer-Verlag Berlin, Heidelberg 1985
Softcover reprint of the hardcover 1st edtion 1985
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Foreword
Throughout the course of history it has always been noted
that any ideas about brain function depended upon the highest
technological model of the day. Hence, in the Greek or Roman
era the ventricular system was singled out because of the devel
opment of hydraulics. Early in this century we drew the analo
gy between telephone circuits and the brain. Now it is popular
to characterize neural function as that of a sophisticated com
puter. Indeed, in many ways it may be. But, as yet, the pre
pared human brain will likely prevail in the sorting out of
information necessary for a proper diagnosis. In this manual,
Dr. POECK has provided the ground work for such prepara
tion.
We all admire the clever diagnostician, and usually ascribe
the skill to great intuition. Not so! It is the clinician who
has seen many patients, and has compiled a menu of choices.
Dr. POECK is such a clinician, and he has provided us with
his menu of choices. Use of these lists will likely aid the student
or resident physician in coming to a proper diagnosis but,
more importantly, will help train his or her mind to think
in a logical and systematic way.
ROBERT J. JOYNT, M.D., Ph.D.
Professor of Neurology and Dean
School of Medicine and Dentistry
University of Rochester
v
Preface
The introduction of new technology for the localization of
alterations in the peripheral or central nervous system has
provided invaluable assistance to the diagnostician. It cannot
be denied, however, that blind faith in, and uncritical applica
tion of, these ancillary methods have also produced many
false-positive findings. The latter have resulted in unnecessary
further and quite often invasive technical examinations, in
superfluous operative and medical treatment, and in psycho
logical trauma to the patient.
One should not, it is true, attempt to turn back the clock
and practise medicine, in particular make diagnoses, intuitive
ly, as though it were an art beyond rational control. However,
it is important not to lose sight of the fact that the signs
and symptoms with which the patient presents are a combina
tion of" objective" and" subjective" elements. Every medical
practitioner who has been active in the profession long enough
will know that not only are objective signs grouped in charac
teristic patterns, but subjective complaints (i.e., symptoms) are
likewise presented in rather stereotypical ways. Disease states
have their histories, and one has to learn these as carefully
as the signs found in physical and ancillary examinations. If
an additional laboratory finding provided, for example, by
neuroimaging of the spinal cord or recording of sensory
evoked potentials, does not correspond to the history the pa
tient has reported, then we should question the significance
of the laboratory findings.
It follows that the art of the diagnostician consists to a
large extent of listening attentively to the patient's history.
This is not passive listening; during every stage of the interview
one has to build up hypotheses which are tentatively confirmed
or rejected as careful questioning or, rather, soliciting of details
proceeds. At the end of history taking the field of diagnostic
possibilities should be narrowed to such a degree that the
physical examination, however important, is very unlikely to
yield any surprise findings. Ancillary examinations can then
be selected for clearly defined purposes.
This book is based on 30 years of work in the field of
neurology. For more than half of this time, I have been giving
VII
a course on neurologic differential diagnosis. I have attempted
to write the kind of hand book that reflects a pragmatic ap
proach to diagnosis. The introductory chapter will give some
indication as to how to use this little book.
I have learned a lot from my patients, and have taken
every chance to profit from valuable discussions with my clo
sest collaborators W. HACKE, M. HASSEL, E.B. RINGELSTEIN,
and H. ZEUMER.
Aachen, Summer 1985 KLAUS POECK
VIII
How to Use This Book
This book is intended to provide assistance at the bedside
or in the consultation room. To this end, I have refrained
from detailed discussion of anatomical or physiological as
pects. Likewise, there will be very few, if any, considerations
of treatment, as these are given in the available textbooks
of neurology.
The chapters do not correspond to anatomical regions or
parts of the nervous system, since in many instances we do
not know at the beginning of the diagnostic procedure where
to locate the disease process. Nor are the chapters centered
on disease entities, because these will be recognized only at
the end, not at the beginning of our diagnostic considerations.
The chapter headings highlight prototypical situations re
ported by patients, or patterns of signs and symptoms. Conse
quently, the chapters are in alphabetical order.
At the beginning of each chapter the principal diagnoses
that have to be taken into consideration are listed. This list,
with numbered items corresponding to the sequence of items
in the text, will immediately give the reader an idea of the
challenge he has to meet in a given situation. For each diagnos
tic possibility the pros and cons are then discussed, and the
potential contribution of ancillary examinations is evaluated.
Extensive cross-referencing is intended to facilitate compari
son with similar situations or patterns of findings.
It is hoped that on the basis of the suggestions given in
this book the reader will more easily be able to recognize
the condition with which the patient is afflicted.
IX
Contents
1. Abnormal Posture of the Head 1
2. Acute Blindness ..... 5
3. Acute Confusional State . . 7
4. Acute or Recurrent Headache 12
5. Acute Hemiplegia . . . . . 19
6. Acute Paralysis of Extraocular Muscle(s) 22
7. Acute Unilateral Seventh Nerve (Facial) Palsy 27
8. Brown-Sequard's Syndrome (Mostly Cervical Local-
ization) . . . . . . . . . . 31
9. Burning Feet and Restless Legs 34
10. Cerebellar Ataxia . 37
11. Choreic Syndrome ..... 42
12. Dementia ......... 46
13. Facial "Hyperkinesia" (Involuntary Movements of
Facial Musculature) . . . . . . . . 51
14. First Epileptic Seizure(s) in Adulthood 55
15. Footdrop, Bilateral 59
16. Footdrop, Unilateral 62
17. Homer's Syndrome . 66
18. "Hypersomnia" 70
19. Impairment in Anteflexion of the Head 73
20. Lesions of Cranial Nerves, Bilateral 76
21. Lesions of Cranial Nerves, Unilateral 80
22. Monocular Loss of Vision . . . . . 84
23. Muscular Weakness, Proximal 88
24. Painful States of the Shoulder and Upper Arm 92
25. Paraplegia of Chronic Evolution 98
26. Progressive Clouding of Consciousness 102
27. Progressive Wasting of Hand Muscles 105
28. Ptosis of the Upper Eyelid . . . . . 11 0
29. Pupillary Abnormality Plus Areflexia 114
30. Sensory Disturbance of the Tongue 117
31. Sudden Loss of Consciousness 119
32. Sudden Loss of Posture (With and Without Loss of
Consciousness) . . . 122
33. Sudden Loss of Speech ....... 126
34. Symmetrical Areflexia ....... 130
35. Transverse Syndrome of the Spinal Cord 135
XI
36. Tremor at Rest . . . . . . . . . . . 139
37. Twilight State .......... . 143
38. Unilateral Fits Affecting Limb(s) or Face 147
39. Vertigo ...... . 150
40. Weakness Upon Exercise 155
41. Wrist Drop 158
Subject Index 161
XII
1 Abnormal Posture of the Head
1.1 Unilateral Paralysis of Extraocular Muscles
1.1.1 Trochlear Nerve Palsy
1.1.2 Abducent Nerve Palsy
1.2 Complete Homonymous Hemianopia
1.3 Paralysis of Horizontal Gaze
1.4 Ocular Tilt
1.5 Posterior Fossa Tumor
1.6 Paralysis of the Accessory Nerve
1.7 Retroflexion of the Head in Ocular Myopathy
1.8 Benign Ocular Torticollis
In the conditions discussed in this chapter the head is either turned
or tilted to one side, or both. The description is not comprehensive,
in that abnormal posture as observed in comatose or poorly reactive
patients following extensive damage to the cerebral hemispheres and/or
brain stem is not analyzed. The pathophysiological mechanism underly
ing the abnormal posture in these patients, who are mostly to be found
in the intensive care unit, is inadequately known, especially since many
of these patients harbor more than one eNS lesion.
1.1 Unilateral Paralysis of Extraocular Muscles
The most frequent cause is unilateral paralysis of one of the extraocular
muscles.
1.1.1 Trochlear Nerve Palsy
It may be difficult to detect the vertical divergence of the eyes in troch
lear nerve palsy. Frequently, the patients do not give a very clear de
scription of diplopia on downward gaze, e.g., when walking downstairs.
Most of them, however, keep their head turned and tilted toward the
nonaffected side in order to compensate for the paralyzed inward rotat
ing function of the superior oblique muscle. If the head and gaze are
held straight, one may notice a slight elevation of the affected eye,
which increases when the eye is abducted, because in this position
the superior oblique muscle should move the eye downward. The verti
cal divergence becomes most evident when the head is tilted toward
the affected side, because now the action of the superior rectus muscle
is not balanced at all by the superior oblique muscle (Bielschowskys
sign).
1