Ward Rounds in Clinical Neurology: Long and Short Cases

120 Pages·2019·6.967 MB·English

by  Ravi Yadav

r
Ward Rounds in
10 Section1:HigherMentalFunctions/CerebralHemisphere
CLINICAL NEUROLOGY
3rd symptom:Difficulty in wearingclothescan arisedue to limb weakness, pain in the limbsor
apraxias.However,inthispatientsincetherewasnoparesisorpainthedifficultyinwearingclothes
could be due to the dressing apraxia orsevere bradykinesia.The clinical assessment confirmed LONG AND SHORTCASES
.
bothofthese
4th symptom: Speech disturbances could be due to progressive dysarthria due to pyramidal
involvement or hypophonia and slurring as a part of Parkinsonism (Basal ganglia dysfunction).
The progressive lossof speech and inabilityto producesentencesover timeleadingtooneword
answerspointstowardsprogressiveaphasialocalizingtolanguagecircuit.
5lh symptom:Lackof interest point towardsapathywhich isan important featureoffrontallobe
dysfunctionandispresentinmostoftheParkinsoniansyndromes.Theappearanceofthissymptom
laterindicatestheprogressionofthepathologyinthispatient.
67h.symp/o/H.'Thejerkyarrhythmicmovementoftheleftlimbsuggeststhepresenceofaninvoluntary
movement that could be tremor, myoclonus or chorea. Given the symptoms of parkinsonism,
asymmetry and cognitive decline it is likely myoclonus or tremor. This would require clinical
assessmentforconfirmation(stimulussensitivity,corticalsensitivity).
Q.l. What is the anatomic localization of immediate, short-term, long-term and motor
memory?
Ans.Immediatememoryistheworkingmemorywhichlocalizestotheprefrontallobe.Short-term C'‘(/’t/iw/t'/iy ,
memoryistheepisodicmemorythatlocalizestomedialtemporallobe.Long-term memoryisthe
semanticmemorywhichlocalizestolateraltemporalandothercortices.Motormemoryistermed
astheproceduralmemoryandlocalizestobasalgangliaandcerebellum.
Q.2. What are the behavioral and psychiatric disturbances in Parkinsonian disorders and ^'"''inovation'1'^
whatarethetypicalsymptomsofdementia?
Ans.
(cid:127) Repeatingofquestionsorconversations, misplacingpersonal belongings,forgettingeventsor
appointments,gettinglostonafamiliarroute.
(cid:127) Poorunderstandingofsafetyrisks,inabilitytomanagefinances,poordecision-makingability,
inabilitytoplancomplexorsequentialactivities.
(cid:127) Inabilityto recognizefacesor common objectsor tofind objectsin direct viewdespitegood
acuity,inabilitytooperatesimpleimplements,ororientclothingtothebody.
(cid:127) Difficultythinkingofcommonwordswhilespeaking,hesitations;speech,spelling,andwriting
errors.
(cid:127) Unusual mood fluctuations such asagitation, impaired motivation, initiative, apathy, loss of
drive,socialwithdrawal,decreasedinterestinpreviousactivities,lossofempathy,compulsive
orobsessivebehaviors,sociallyunacceptablebehaviors.
Q.3.Whatarethefrontallobecircuitsanddescribethedeficitsduetotheirdysfunction?
Ans.
1. The dorsolateral circuit: Dysexecutive syndrome (impaired organizational skills, inattention, {
impairedjudgment,impairedsetshiftingandsequencing).
2. The orbitofrontal circuit: Emotional lability, irritability, antisocial behavior, mood disorder,
Obsessivecompulsivebehavior
3. Theanteriorcingulatecircuit:Apathy,impairedmotivation,reducedspeechanddisinhibition.
Chapter2:ApproachtoaCaseofDementia
of aggravatingand relievingfactors. Hiemovementshave not been noticed duringloud sounds,
lightortouch.
No history of falls while walking, delusions/hallucinations/disinhibition/bladder, urgency/
incontinence/postural giddiness/REM sleep behavior disorder/visual disturbances/swaying
whilewalking/tremorsinthelimbs/fluctuationinsymptoms.
Treatmenthistory:PatienthadbeentriedonLevodopa/Carhidopa110mgthricedailywithminimal
improvementduringwalking.
General physical examination: Patient was conscious but not fully oriented to time, place and
person.Thespeech washypophonic,monotonous, nonfluentwith reduced verbal output.Single
word comprehension, object naming and repetition was preserved. Agrammatism was present.
Shecouldnotspeakinsentences.Apraxiaofspeechwaspresent.Stutteringofspeechwaspresent.
Comprehensionwasimpairedforcomplexsentences.Frontalreleasesignswerepresent.Bilateral
palmomentalreflex,graspreflexandsnout reflexwerepresent.Gropingand utilization behavior
wasalsopresent.
Parietal lobe functions:Calculation wasimpaired for both simple and complexcalculations.She
was unable to copy and unable to hold the pen.The constructional apraxia was present both
ideomotor and ideational apraxia were present. Alien limb phenomenon of frontal type was
present.Corticalsensations,stereognosis,graphesthesiaand2-pointdiscriminationwereimpaired.
Digitspan:Therewasreducedforwardandbackwarddigitspan.MotorLuria’scouldnot bedone
duetopoorcomprehension.Therewasnoperseveration.
Motorsystem:Therewasnoweaknessorwasting.Therigidityandbradykinesiawerepresentinall
thefourlimbsbutleftupperlimbwasmorerigidthantherightupperlimb.Thepatienthadaflexed
andstoopedpostureofbody.Allthedeeptendon jerkswerepresent.Plantarreflexwasbilaterally
flexor.
Involuntary movements:Stimulus sensitive myoclonus was present mainly on left upper limb.
Dystonia of left upper limbwasalso present. Rigidity of all 4 limbswas present although it was
moreontheleftside.Therewerenotremorsatrest/posture/action.
SUMMARY OF THE CASE
A 54-year-old lady presenting with progressive dementia with asymmetrical extrapyramidal
featuresof slowness,rigidityand involuntary myoclonic movementsof theleft hand.Theexami-
nation showed frontal dysexecutive features, parietal lobar dysfunction (dressing apraxia and
ideomotorapraxia)andcorticalsensorylosswithcorticalmyoclonusinleftupperlimb.
SYMPTOM ANALYSIS OF THE CASE
1st symptom:Slownessof activities in this patient was the firstsymptom suggesting that brady-
kinesiaduetothepredominantactivityofindirectpathwayofthebasalgangliawouldlead tothis
symptom.However,theexaminationwouldconfirmit.
2ndsymptom:Memorydisturbancesintheformofmisplacingobjects,moneyhandlingproblems
andnavigationrelatedproblemspointouttowardstheinvolvementoftheworkingmemory(Frontal
lobe dysfunction), calculation defects (Parietal lobe dysfunction) and navigational difficulties
(visuospatialdefectsfromparietallobe).
Ward Rounds in
CHAPTER
CLINICAL NEUROLOGY
Approach to a Case of Dementia
LONG AND SHORT CASES
PawanRaj,RaviYadav
Editors
RaviYadav
MBBSMDDM(Neurology)MNAMS
AdditionalProfessor
CASE STUDY
DepartmentofNeurology
A54-year-oldladyeducatedupto10thstandard presentedwith:
NationalInstituteofMentalHealthandNeurosciences
(cid:127) Slownessofactivitiesfor2years.
(AnInstituteofNationalImportance)
(cid:127) Memorydisturbancesfor2years.
Bengaluru,Karnataka,India
(cid:127) Difficultyinwearingclothesfor1year.
(cid:127) Speechdisturbancesfor1year
(cid:127) Lackofinterestinday-to-dayworkfor1year. GirishBaburaoKulkarni
MBBSMDDM(Neurology)MNAMS
(cid:127) Jerkymovementsoflimbsfor1year.
Professor
She developed slownessin dailyactivities (bathing, dressing, walking, speaking) for 2years.
Shealsostartedforgettingthemoneytransactionsfor2years.Thisprogressedovernext6months. DepartmentofNeurology
She started misplacing the objects like spectacles, bags in the house.She would not remember NationalInstituteofMentalHealthandNeurosciences
ifshehad taken thetabletsandwhenandwhatshehad forthebreakfast.Shedevelopedwayfind- (AnInstituteofNationalImportance)
ingdifficultiesandproblemsinnavigatinginsidethehouse.Sincelast1year,thehusbandnoticed Bengaluru,Karnataka,India
change in daily routine in the form of getting up late, reduced activity, not caring to cook food
withoutinsight.Shewould not makeeffortstoeat food and would eat a piece of bread with milk
withoutaskinganyoneforfood. Forewords
She had difficulty in wearingclothes;initially notedin theform of wearing the blouseinside Kameshwar Prasad
outwhichwasinfrequenttobeginwithbutforlast12monthsoccursdailyanddifficultyinuntying
PramodKumar Pal
theknot.Shealsodevelopeddifficultyin brushingteethfor3months,inabilitytolockandunlock
MadhuriBehari
doorswithkeys,difficultyinwearingslippersandwearingontheoppositefeet.Therewasalackof
insighttothesemistakes.
Gradually, herspeech volumeand clarity'alsoworsened.Shedevelopedstutteringofspeech,
taking multiple attempts to pronounce a word for the last 1 year. She did not speak sentences.
Whilesinglewordswere meaningful and appropriate to thequestionasked,she had difficulty in
comprehendingcomplexsentences.
She also became confined to herself, not talking, reduced speech output, sat at one place
withoutinteraction.Shewasaquiet person beforebutshewould extend courtesytowardsguests
forfurtherfood,tea,etc.and used toengageinsocialactivities.Afterthis,shestoppedgreetingthe
guestsandpreferrednottospeakunlessspokento.
She stopped being affectionate/playful towards nephew/niece staying at home.She usually JAYPEE BROTHERS MEDICALPUBLISHERS
usedtoputhersareeoverheadasapartofcustomwhichshestoppedsince1year. TheHealthSciences Publisher
She also developed jerkiness of the left forearm leading to inability in bolding objects from
New Delhi |London|Panama
left hand.The movements wereshock-like and not present duringthe sleep.There isno history
Chapter1:ApproachtoaCaseofAphasia 7
m
K
Q.8.VVliatisdysarthriaanditsvarioustypes?
IAYPCEiJaypeeBrothersMedicalPublishers(P)Ltd. Ans.Dysarthriaisabnormalarticulationofsoundsorphonemes.Totallossofabilitytoarticulate
isanarthria.
Headquarters —
JaypeeBrothersMedicalPublishers(P)Ltd Mayoclinicclassificationofdysarthria(Duffy,1995) 6types:
4838/24,AnsariRoad,Daryaganj 1. Flaccid:Lowermotorneuron,btdbarweakness,myasthenia.
NewDelhi110002,India 2. Spastic:Bilateral upper motor neuron (or) unilateral UMN—strokes, tumors, Primary lateral
Phone:[phone] sclerosis.
Fax:[phone]
Email:[email protected] 34.. AHtyapxoick:inCeetrice:bEelxltarrapdyisreaamseidsa(ls—troPkaer,kdinesgoenn’serdaitsievaesdei.sease).
OJ.Pv.eMrseedaicsaOlLfftidces Jaypee-HighlightsMedicalPublishersInc 5. Hyperkinetic:Extrapyramidal—Dystonia,Huntington’sdisease. —
83VictoriaStreet,London CityofKnowledge,Bid.235,2ndFloor 6. Mixed-spasticand flaccid:Upper and lower motor neuron involvement Amyotrophiclateral
.
SW1H0HW(UK) Clayton,PanamaCity,Panama sclerosis,multiplestrokes
Phone:[phone] Phone:[phone]
Fax:[phone] Fax:[phone] Q.9.Howspeechandlanguagedisordersaretreated?
Email:[email protected] Email:[email protected] Ans.TreatmentofAphasia
JaypeeBrothersMedicalPublishers(P)Ltd (cid:127) Client-specificbehaviorsaretargeted.
Bhotahity,Kathmandu,Nepal (cid:127) Targetgreatestimprovementinfunctionalcommunication.
Phone:[phone] (cid:127) Startfromsimpletomorecomplextasks.
Email:[email protected] (cid:127) Reinforcetheresponse—givefeedback.
Website:www.jaypeebrothers.com (cid:127) Teachself-monitoringskills.
Website:www.jaypeedigital.com (cid:127) Trainspouse/relativetoevoke,promptandsupportthepatient.
©2019,JaypeeBrothersMedicalPublishers Majority improve spontaneously (in days, weeks, months) (Neuronal plasticity). Other
methodsreassurance,speechrehabilitation.Prognosisbetterforleft-handedpersons.
The viewsandopinions expressedinthis bookare solely those of theoriginalcontributor(s)/author(s) anddonot
necessarilyrepresentthoseofeditor(s)ofthebook. TreatmentofSpeechDisorders
All rights reserved.No part of this publication may be reproduced,stored or transmitted in any form or by any Dependsontypeofdysarthriaandnaturalhistoryofthedisease:
means,electronic,mechanical,photocopying,recordingorotherwise,withoutthepriorpermissionin writingofthe
publishers. (cid:127) Pacing devices, palatal lifts, communication boards, visual cues, pharyngeal flap, vocal cord
All brand names and product names used in this book are trade names,service marks,trademarks or registered tefloninjection.
trademarksoftheirrespectiveowners.Thepublisherisnotassociatedwithanyproductorvendormentionedinthis (cid:127) Speechtherapy,psychotherapy.
book. (cid:127) Botulinumtoxin—injection(forspasmodicdysphonia).
Medicalknowledgeandpracticechangeconstantly.Thisbookisdesignedtoprovideaccurate,authoritativeinforma (cid:127) For stuttering Behavioral techniques, altered auditory feedback, pharmacotherapy-
tionaboutthesubjectmatterinquestion.However,readersareadvisedtocheckthemostcurrentinformationavailable risperidone,olanzapine,paroxetine.
onproceduresincludedandcheckinformationfromthemanufacturerofeachproducttobeadministered,toverify
the recommended dose, formula, method and duration of administration, adverse effects and contraindications.
It is the responsibility of thepractitioner to take all appropriate safety precautions.Neither the publisher nor the
author(s)/editor(s)assumeanyliabilityforanyinjuryand/ordamagetopersonsorpropertyarisingfromorrelatedtouse
ofmaterialinthisbook.
Thisbookissoldontheunderstandingthatthepublisherisnotengagedinprovidingprofessionalmedicalservices.
Ifsuchadviceorservicesarerequired,theservicesofacompetentmedicalprofessionalshouldbesought.
Every effort has been made where necessary to contact holders of copyright to obtain permission to reproduce
copyrightmaterial.Ifany havebeeninadvertently overlooked,thepublisher willbepleasedtomakethenecessary
arrangementsatthefirst opportunity.TheCD/DVD-ROM(ifany)providedinthesealedenvelopewiththisbookis
complimentaryandfreeofcost.Notmeantforsale.
Inquiriesforbulksalesmaybesolicitedat:[email protected]
WardRoundsinClinicalNeurology:LongandShortCases
FirstEdition:2019
ISBN:978-93-5270-590-0
PrintedatSanatPrinters
|||
‘ . Section1:HigherMentalFunctions/CerebralHemisphere
Q.2.Wherearethecentersforlanguagelocatedandwhat istheirfunctionand bloodsupply
totheareas?
Ans. There are four main language areas (Perisylvian Area): 2 receptive and 2 executive which
aresituatedinthelefthemisphereinright-handedperson:
1. Reception: It is situated in the posterior superior temporal gyrus (area 22) and Heschl’s
gyri(area41and42).Posteriorpartofarea22in planumtemporaleisWernicke’sarea (Blood
supplyisbyinferiordivisionoftheleftmiddlecerebralartery).
2. Receptivearea:Angulargyrus(area39) in inferiorparietal lobule,anteriortovisual receptive
areas.
3. Execution: Posterior end of inferior frontal convolution (area 44 and 45), called as Broca’s
area(Bloodsupplyisbyupperdivisionofleftmiddlecerebralartery).
—
4. Exner'swritingarea posteriorendof2ndfrontalconvolution.
Dedicated to
Q.3. What is the normal distribution of handedness in general population? How it is deter-
mined?
Our
Ans.About90-95%generalpopulationareright-handed(theyinnatelychooserighthand). Patientswhoarethefinalbenefactorsand
Edinburgh handednessinventory:Thisinventorydeterminesthe handedness by assessingwhich purposeofthemedicalprofession
hand is used for various daily routine tasks (10 types like: writing, drawing, throwing a ball,
Studentswhoareacquiringtraininginneurology
scissor, toothbrush, knife, spoon, broomstick, strike a matchbox, open a box lid). Each task is
Teacherswhohavetaughtusneurology
givenascoreandafinalscoreisgeneratedwhichsuggeststhehandedness.
Our familieswhosupportedus
Determining handedness: Ask which hand is preferred for throwing a ball, threading a needle,
sewing, using a tennis racket or hammer, which eye is used for sighting a target with a rifle or
lookingthroughakey-hole,telescope,etc.(Eyepreferencecoincideswithhandpreference). Mywife,Pramila
Mydaughter,Sanyukta
Q.4.WhatarethefeaturesofBroca'saphasia?
Ans. Patients with Broca’s or motor aphasia have nonfluent spontaneous speech, which is —RaviYadav
telegraphic, dysarthric or mute, impaired naming, reading and repetition, writing may be Mywife,Sandhya
dysmorphic or dysgrammatic, can have associated right hemiparesis, right hemisensory loss or
evenapraxiaofleftlimbs.Comprehensionwillbenormal. Myson,Shreeram
Mydaughter,Sanjana
Q.5.WhatarethefeaturesofWernicke’saphasia?
—GirishBaburaoKulkarni
Ans.The spontaneousspeech will befluentwith paraphasicerrors, usuallyspeech will be non-
dysarthric and can be logorrheic. Comprehension is impaired with difficulty in pointing things
and answering to yes and no questions. Naming, reading writing and repetition are impaired.
Can have associated right hemianopia.In pureWernicke'saphasia motor andsensorysigns are
usuallyminimalorabsent.
Q.6.Whatarethefeaturesofglobalaphasia?
Ans. Patients are usually mute or have nonfluent spontaneous speech, impaired naming,
comprehension, repetition, reading and writing.They have associated dense right hemiparesis,
hemisensorylossandrighthemianopia.
Q.7.Whatisanomiaagraphiaandalexia?
Ans.
(cid:127) Anomiaisimpairednaming
(cid:127) Agraphiaisimpairedwriting
(cid:127) Alexiaisimpairedreading.
Chapter1:ApproachtoaCaseofAphasia
No history of ear discharge, fever, trauma, menstrual irregularities or consumption of
hormonalpreparations.
On Examination
General physical examination: She had mild pallor. Blood pressure, cardiac, abdominal and
respiratorysystemswerenormal.
Neurological Examination
Shewasright-handed,withnoformaleducation.Shewasconscious,abletowalkaround.
Minimental status examination (MMSE): Could not be assessed because of her language
.
disturbances
Language Assessment
(cid:127) Spontaneousspeech:It wasfluent,effortless, with paraphasicerrors,speech had no meaning.
She could not speak about fer personal details(name, address, occupation), and shespeaks
irrelevantly,couldnotdescribeapicture.
(cid:127) Comprehension:Severelyimpairedwithinability topoint tosaid objectand could not answer
toyandnquestions.
(cid:127) Repetition:Could notunderstandthecommands.
(cid:127) Naming:Notabletodo.
(cid:127) Reading:Couldnotbeassessed.
(cid:127) Writing:Couldnotwritehername.
Fundus was normal no papilledema, visual acuity was grossly normal with right-sided
hemianopia.
Mildright-sidedUMNfacialnervepalsy.
Motor,sensoryandcerebellarsystem:Normal.
Summary
Middle aged lady with no premorbid diseases presented with subacute onset of new headache
with raised intracranial tension.Oneweeklater,shedeveloped languagedisturbancessuggestive
ofsensoryorWernicke’saphasiawithmildUMNfacialpalsyandright-sidedhemianopialocalizing
tolefttemporoparietalregionofbrain.Onfurtherevaluationshewasfoundtohaveleft temporo-
parietalvenousinfarctduetocerebralvenousthrombosis.
Q.l.Definelanguageandspeechandinwhatwaytheirdisturbancesmanifest?
Ans. Languageisdefined ascomplexsystem of communication withsymbolsand soundsand it
also hasrulesfor their use.Speech is defined asarticulation and phonation of languagesounds
anditisapartoflanguage.
The disturbances of language are called as aphasias, which means loss or impairment of
production orcomprehension ofspokenorwritten languagesecondarytoacquired lesion of the
brain.
Disorders of speech includes dysarthria (defective articulation with intact mental functions
and normalsyntax),dysphonia (alteration or lossof voicedue to laryngeal disorder or itsinner-
vation),andstuttering.
E| Section1:HigherMentalFunctions/CerebralHemisphere
Contributors
Neurological Examination
Minimentalstatusscore(MMSE):27/30.
Language
(cid:127) Spontaneousspeech:Reducedfluency(categoryandverbal)andword output,usesfewwords
to answer rather than sentences,speech was effortful, occasional paraphasiaswere present, AnishMehta MDDM KrishnanA MBBSDM(Neurology)
noneologisms.Prosodynormal,nodysarthria. SeniorResident SeniorResident
(cid:127) Comprehension:AnswersYesandNotoquestionsandpointingtotheobjectscorrectly. DepartmentofNeurology NationalInstituteofMentalHealthand
(cid:127) Writing:Writingspontaneously,writinginresponsetocommandtocopyandtodictationwere MSRamaiahMedicalCollegeandHospital Neurosciences
impaired. Bengaluru,Karnataka,India Bengaluru,Karnataka,India
(cid:127) Repetition:Couldrepeatsentencesupto4-5words.
(cid:127) Naming:Couldnameobjects,colors,etc.buthaddifficultyin namingpartsoftheobjects. BirinderSinghPaul MDDM PawanRaj MBBS
(cid:127) Reading:Couldreadfewwordsbutcould notreadcontinuously. AssociateProfessor SeniorResident
DepartmentofNeurology
DepartmentofNeurology
NationalInstituteofMentalHealthand
DayanandMedicalCollegeandHospital
Cranial Nerves Ludhiana,Punjab,India Neurosciences
(cid:127) Visualacuityrightside6/9,leftside6/12withright-sidedhemianopia. Bengaluru,Karnataka,India
(cid:127) Pupillaryreactionopticfundusandeyemovementswerenormal.
(cid:127) Right-sideduppermotorneuron(UMN)facialpalsywasseen. DeeptiVibha MDDM PradeepKallollimath MDDM
AssistantProfessor AssistantProfessor
(cid:127) Othercranialnervesnormal. DepartmentofNeurology DepartmentofNeurology
(cid:127) Motorsystem:Rightelbowandwristextension4/5,restofthepowerwasnormal. AllIndiaInstituteofMedicalSciences KarnatakaInstituteofMedicalSciences
(cid:127) Sensorysystem:Normal. NewDelhi,India Hubballi,Karnataka,India
Summary DevangiDesai MD RagasudhaB MBBSPhD{ClinicalNeuroscience)Scholar
JuniorResident
this middle-aged lady with 5 years history of hypertension presented with episodes of left Professor DepartmentofClinicalNeurosciences
DepartmentofMedicine
monocular visual loss and reduced carotid volume suggestive of left carotid artery disease with NationalInstituteofMentalHealthand
PramukhswamiMedicalCollegeandHospital
recent symptoms of motor and language disturbances in the left-sided carotid/middle cerebral Anand,Gujarat,India Neurosciences
artery territory. She had motor weakness pyramidal in nature localizing above the pons and Bengaluru,Karnataka,India
language disturbance in the form of Motor (Broca's) aphasia localizing to left frontal motor
speecharea.Inherrepetition wasalsoinvolvedsuggestiveofcorticallocalizationofthelanguage GirishBaburaoKulkarni MBBSMDDM(Neurology)MNAMS RavinderJeetSingh MBBSDM
disturbances. Professor AssistantProfessor
DepartmentofNeurology DepartmentofNeurology
NationalInstituteofMentalHealthand NationalInstituteofMentalHealthand
PATIENT NO. 2 Neurosciences Neurosciences
Bengaluru,Karnataka,India Bengaluru,Karnataka,India
A42-year-oldladywithnoformaleducation, right-handed presented with historyofheadacheof
15daysandspeechdisturbancesfromthepast7days.
Headache was acute in onset,continuous, throbbing, bifrontal, associated with vomiting, no HardeepSinghMalhotra MBBSMDDM(Neurology) RPraovfeinssdorraKumarGarg MBBSMDDM(Neurology)
photophobia or phonophobia, or visual disturbances, not relieved with analgesics associated AdditionalProfessor DepartmentofNeurology
DepartmentofNeurology
withdifficultyindoingwork. KingGeorge'sMedicalUniversity
KingGeorge'sMedicalUniversity
Eightdaysaftertheonsetofheadacheshesuddenlydevelopedspeechdisturbances.Relatives Lucknow,UttarPradesh,India Lucknow,UttarPradesh,India
noticedthatshewasnotabletounderstand thespokenwordsandshewasspeakingbutnobody
could understand the meaningof thesentences.Shewascallingher relatives bydifferent words RaviYadav MBBSMDDM(Neurology)MNAMS
whichhadnomeaning,wasspeakingirrelevantlyandtheycould notmakeoutmeaningfromher ImranRizvi MD AdditionalProfessor
SeniorResident DepartmentofNeurology
speech.
DepartmentofNeurology NationalInstituteofMentalHealthand
No historyof lossof consciousness,visualsymptoms, weaknessof limbs,seizuresorsensory KingGeorge'sMedicalUniversity Neurosciences
disturbances. Lucknow,UttarPradesh,India Bengaluru,Karnataka,India
viii WardRoundsinClinicalNeurology
CHAPTER
RohanMahale MBBSDM SoahamDesai MDDM
AssociateProfessor Professor
DepartmentofNeurology DepartmentofNeurology
MSRamaiahMedicalCollegeandHospital PramukhswamiMedicalCollegeandHospital
Approach to a Case of Aphasia
Bengaluru,Karnataka,India Anand,Gujarat,India
SeenaVengalil MDDM VaibhavWadwekar MDDM
PostdocFellowinNeuromuscularDisorders AdditionalProfessor
DepartmentofNeurology DepartmentofNeurology GirishBaburaoKulkarni,KrishnanA
NationalInstituteofMentalHealthand JawaharlalInstituteofPostgraduateMedical
Neurosciences EducationandResearch(JIPMER)
Bengaluru,Karnataka,India Puducherry,India
SheshagiriDV MBBSDM VikramVHolla MDDM
SeniorResident SeniorResident PATIENT NO. 1
DepartmentofNeurology DepartmentofNeurology
NationalInstituteofMentalHealthandNeurosciences KingGeorge'sMedicalUniversity A42-year-oldlight-handedgraduateladypresentedwith:
Bengaluru,Karnataka,India Lucknow,UttarPradesh,India (cid:127) Recurrentepisodesofright-sidedlimbweaknessfortwomonths.
(cid:127) Speakingdifficultyfortwomonths.
Shehadfourdiscreteepisodesofweakness.Initially,twoepisodesovertwoconsecutivedays,
andlatertwomoreepisodes.
Duringher initial twoepisodes,shedevelopedsudden onset ofdistal right upper limbweak-
nesswithheavinessintherightlegwhichprogressedoverfiveminutesandlastedfor i0minutes.
Therewasnohistoryofspeechorvisualsymptomsandtheweaknessimprovedcompletely.
One and half months later, she was apparently normal and doing her routine work in the
morning,when suddenlyshe developed difficulty in speaking.Her word output reduced toone
or two and she started communicating with gestures.She was able to comprehend the spoken
wordbutcouldnotreadandwrite.Shecouldnotnamepersonsandobjectsaroundher.Therewas
no limb and visual symptoms, ihe speech disturbances were gradually improving when she
presented butstillshewasfacingdifficultyin conversingduetodifficulty'in namingobjectsand
persons,eventhoughhercomprehensionwasnormal.
Twodayspriortoherpresentationtoourhospital,sheagaindevelopedsuddenonset of mild
right-sided upperlimb morethan lowerlimbweaknesswithout newspeechorvisualsymptoms.
Hieweaknessprogressedover15-20minutes,thenstartedimproving.
Novisualsymptomswereassociatedwithanyoftheserecentepisodes.
Shewasknown hypertensivefromthepast5yearson regulartreatment.She hadexperienced
5-6 attacks of transient blurring of vision in her left eye lasting for few minutes recovering
spontaneouslyfullyover15minutesoneyearpriortoherpresentillness.
On Examination
—
She was moderately built and nourished. I’ulse rate 76/minute, regular, reduced volume in
left carotid artery. No bruits.Blood pressure in right upper limb 180/90 mm Hg, left upper limb
160/90mmHg.Cardiacand respiratorysystemexaminationwerenormal.
—
(cid:127) Handedness Right-handed
—
(cid:127) Education Graduate
—
(cid:127) Cardia,respiratorysystem Withinnormallimits.
6
Foreword
LateDrCMillerFisherusedtosay,'youlearnneurologystrokebystroke'.Whathemeantisthat
by analyzing each of stroke in detail,i.e. structures involved, site of lesion, nature of lesion,
etiopathogenesis of the lesion and resulting functional disability; a student can master the
.
fundamentals of neurology Even though technology and molecular biology has advanced
rapidly and tremendously, still Dr Fisher's statement remains largely true. I would slightly
modify thestatement,ifImay,tosay that'youlearn neurologycase bycase'.Eachcase needs
tobeanalyzedindetailasabovethroughsymptomanalysistodeducethestructuresinvolved
.
and all the above-mentioned steps to arrive at a diagnosis and management Needless to
mentionthatinemergency,youmaynot completeall the steps before startingmanagement,
.
and sometimes management steps are clear even when the diagnosis is not entirely clear
In such situations, management takes precedence over the final diagnosis. However, funda-
mental point is that each case needs in-depth analysis.No two cases are identical.They vary
fromeachotherineithergrossorsubtlewaytomeritdetailedanalysis.
Case by case analysis in neurology is facilitated by a well-organized neuroanatomy and a
.
well-established methodology passedon fromgenerationtogeneration of teachers Unfortu-
nately, this practice seems to be under threat by time constraints and the technological
advancessuchasCTandMRI.ItisinthiscontextthatthisbookWardRoundsinClinicalNeurology
is very timely and usefulfor studentsof neurology.Ward roundsare longer inneurologythan
in other super-specialties of medicine,because each caseis analyzedin detail.However,they
are also the source of joy and fulfillment in the profession. As each case is unique,it poses
.
different questions and different challenges This variation from case to case provides new
learning opportunities,and prevents monotony and boredom and makes job of neurologists
enjoyableandprofessionallysatisfying.
I am confident the book will help students to approach different types of cases appro-
priately,efficiently and joyfully.Dr Ravi Yadav has done a great job of bringing together an
eclectic group of contributors, who have painstakingly delineated approaches to all major
clinical presentations encountered in neurology practice. I congratulate Dr Ravi Yadav and
all the contributors for successfully completing this great work. I am sure the students will
.
immenselyenjoyreadingthebookandgreatlybenefitfromit
KameshwarPrasad
ProfessorandPlead,DepartmentofNeurology
Chief,NeurosciencesCentre
Director,ClinicalEpidemiologyUnit
AllIndiaInstituteofMedicalSciences
NewDelhi,India
S E C T I O N
Higher Mental Functions/
Cerebral Hemisphere
ApproachtoaCaseofAphasia
GirishBaburaoKulkarni,KrishnanA
ApproachtoaCaseofDementia
PawanRaj,RaviYadav
ApproachtoApraxia
RagasudhaB,RaviYadav
ApproachtoAgnosiaandAlexia
RagasudhaB,RaviYadav