12 Neurology for Neurosurgeons
12.1 Electromyography and Nerve Conduction Studies (Nerve Conduction Velocity) (Table 12.1)
Electromyography (EMG) | ||
Normal | Abnormal | |
No electrical activity with muscle at rest |
Spontaneous electrical activity with may be a sign of:
Remember: Complex repetitive discharges are nonspecific (seen in both neuropathic and myopathic disorders) | |
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Nerve conduction velocity | ||
Nerve | Conduction velocity 1 | Distal latency |
Median nerve | Sensory: ≥ 49 m/s Motor: ≥ 49 m/s | 4.5 ms |
Ulnar nerve | Sensory: ≥ 49m/s Motor: ≥ 43 m/s | 3.7 ms |
Peroneal nerve | Motor: ≥ 37 m/s | 6.5 ms |
NCV includes not only the study of the velocity of electrical stimulation but also the latency (time needed from stimulation to recording site in milliseconds) and the amplitude (the intensity of response measured in millivolts) | ||
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12.2 Weakness (Table 12.2 )
Disease | Presentation | Diagnostics | Treatment |
Guillain–Barre 2 |
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Myasthenia |
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Lambert–Eaton |
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Polymyositis |
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Steroid myopathy |
| Vs Epidural lipomatosis:
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Note: When myopathy is suspected, investigate ability to stand up from chair/climb stairs. |
12.3 Parkinson’s Disease and Parkinson Plus Syndromes (Table 12.3)
Disease | Presentation | Diagnostic | Other | Treatment |
Symptoms common to all Parkinsonian syndromes:
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Disease-specific symptoms | ||||
Parkinson’s disease |
| Degeneration of compacta substantia nigra + Lewy bodies (alpha-synuclein) 4 |
Prognosis: Usually very good with treatment Often near-normal life expectancy | |
Progressive supranuclear palsy (Steele–Richardson–Olszewski syndrome) |
| “Hummingbird” sign on MRI (atrophy of midbrain with preservation of pons) | Tauopathy |
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Multiple system atrophy or Shy–Drager syndrome or olivopontocerebellar atrophy or striatonigral degeneration |
| Accumulation of alpha-synuclein in glial cells |
Prognosis: average survival 6 y | |
Corticobasal degeneration |
| Involves cerebral cortex and basal ganglia | Tauopathy |
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Note: Parkinson plus syndromes: progressive supranuclear palsy, multiple system atrophy, corticobasal degeneration. |
12.4 Side Effects of Antipsychotics (Table 12.4)
Disease | Presentation | Treatment |
Tardivedyskinesia |
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Drug-induced Parkinsonism |
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Note: Antipsychotics are dopamine antagonists as is metoclopramide (antiemetic). Risk is less with atypical antipsychotics (olanzapine) than typical (haloperidol). |
12.5 Various Movement Disorders (Table 12.5)
Disease | Presentation | Treatment |
Essential tremor or familial tremor or idiopathic tremor 7 |
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Dystonia |
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12.6 Dorsal Colum sfunction (Table 12.6)
Disease | Presentation | Other | Treatment |
B12 deficiency (subacute combined degeneration of spinal cord) |
| High levels of methylmalonic acid (MMA) → damages myelin | B12 injections or oral administration |
Friedreich’s ataxia |
| Autosomal recessive (expansion of GAA triplet reduces expression of mitochondrial protein frataxin) 9 |
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Tabes dorsalis or syphilitic myelopathy |
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Note: Dorsal column: proprioception, vibration, discriminative touch. |
12.7 Dementia (Table 12.7)
Disease | Presentation | Diagnostics | Other | Treatment |
Wernicke’s encephalopathy |
| MRI fluid-attenuated inversion recovery (FLAIR): signal is increased in:
| Deficiency of thiamine (vitamin B1) 10 as in:
| 100-mg thiamine (B1) IV + daily oral administration |
Korsakoff’s syndrome |
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Creutzfeldt–Jacob disease (CJD) |
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Alzheimer’s disease | The mostcommon cause of dementia | MRI: temporal and parietal atrophy | Neurofibrillary tangle (abnormally phosphorylated tau protein; may also be present in other diseases) + senile plaques (β-amyloid) |
Prognosis: death in 5 y: 70% |
Pick’s disease |
| MRI: frontal+ temporal atrophy | Tau proteins in neurons (silver staining: Pick’s bodies) | There is no therapy |
Lewy body disease |
| MRI: temporal+ parietal + occipital atrophy | Lewy bodies: alpha-synuclein protein in neurons |
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12.8 Multiple Sclerosis and Other Demyelinating Disorders (Table 12.8)
Disease | Presentation | Diagnostics | Other | Treatment |
Multiple sclerosis |
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| Prevalence increases with distance from equator |
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Devic’s disease or neuromyelitis optica (NMO) |
| Antibodies against astrocyte’s aquaporin-4 protein may be present (NMO-immunoglobulin G [IgG] test) 12 | Neurologic sequelae tend to be more severe and permanent than multiple sclerosis | Similar to acute multiple sclerosis:
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Balo’s concentric sclerosis |
| MRI: T2 sequence presents concentric layers of demyelination 13 |
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ADEM (acute disseminated/demyelinating encephalomyelitis) |
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Prognosis: mortality of 20% |
12.9 Vasculitis (Tabe 12.9)
Disease | Presentation | Diagnostics | Other | Treatment | |
Arteries involved | Symptoms | ||||
Wegener’s granulomatosis or granulomatosis with polyangiitis | Affects small and medium vessels |
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| Autoimmune |
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Behcet’s disease | Affects vessels of all sizes |
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| Association with HLA-B51: risk factor |
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Takayasu’s arteritis |
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Polyarteritis nodosa or Kussmaul–Maier disease |
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| Association with viral viral hepatitis (typically B and chronic) 16 |
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Giant cell arteritis or temporal arteritis | Affects the cranial branches (mostly external carotid) of the arteries of the aortic arch |
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| Often associated with polymyalgia rheumatica | Steroids (start immediately to prevent vision issues, even before biopsy when necessary, in case of strong suspicion) |