drpaviour.com
A Practical Approach to Common Neurological
Symptoms…...
Plus Some Uncommon Causes:
and how a surgeon can sometimes be helpful
Dr. Dominic Paviour
Consultant Neurologist
drpaviour.com
Summary
Headache
Tingling and Numbness
Balance problems
Dizziness
drpaviour.com
Headache
drpaviour.com
Intracranial structures & pain sensitivity
4
Pain Insensitive Structures in Brain Pain Sensitive Structures in Brain
drpaviour.com
Headache Classification Committee of
the International Headache Society
(IHS) 2013
drpaviour.com
A- Primary Headaches (90%)
1. Migraine including:
1.1 Migraine without aura
1.2 Migraine with aura
2. Tension-type headache, including:
2.1 Infrequent episodic tension-type headache
2.2 Frequent episodic tension-type headache
2.3 Chronic tension-type headache
2.4 Probable tension-type headache
3. Cluster headache and other trigeminal autonomic
cephalalgias, including:
3.1 Cluster headache
3.2 Other primary headaches
6
drpaviour.com
A- Primary Headaches (90%)
4. Other primary headaches4.1. Primary stabbing headache
4.2. Primary cough headache
4.3. Primary exertional headache
4.4. Primary headache associated with sexual activity
4.4.1. Preorgasmic headache
4.4.2. Orgasmic headache
4.5. Hypnic headache
4.6. Primary thunderclap headache
4.7. Hemicrania continua
4.8. New daily persistent headache (NDPH)
7
drpaviour.com
B- Secondary Headaches (10%)
5. Headache attributed to head and/or neck trauma,
including:5.2 Chronic post-traumatic headache
6. Headache attributed to cranial or cervical vascular
disorder, including:6.2.2 Headache attributed to subarachnoid hemorrhage
6.4.1 Headache attributed to giant cell arteritis
7. Headache attributed to non-vascular intracranial
disorder, including:7.1.1 Headache attributed to idiopathic intracranial hypertension
7.4 Headache attributed to intracranial neoplasm
8
drpaviour.com
Classification of Headache Primary
Migraine
“Tension type”
Cluster and other TAC
Secondary
Trauma
Cranial vascular disorder
SOL
Drug/substance or its withdrawal (caffeine/analgesic)
Infection
Sinus/dental disease
Systemic illness
Cranial Neuralgias
38%
35%
0.2%
Nausea/vomiting
Phono/photophobia
Osmophobia
Dizziness
concentration
Ptosis/meiosis
Sweating
Conjunctival injection
Nasal stuffiness
drpaviour.com
Acute migraine treatments
Sumatriptan 100mg +
Ibuprofen 800mg
Migraine prophylaxis
drpaviour.com
Warning Features in History
Any new headache in an individual patient, or a
significant change in headache characteristics,
should be treated with caution.
"I have never had a headache like this
before"
"This is the worst headache I have
ever had"
drpaviour.com
Specific Warning Features in History (1/5)
Thunderclap headache
(intense headache with “explosive” or
abrupt onset) ͢→ subarachnoid hemorrhage)
Estimated prevalence of sub-arachnoid
hemorrhage in the setting of thunderclap
headache is 43%
drpaviour.com
Specific Warning Features in History (2/5)
Headache with atypical aura (duration >1 hour,
or including motor weakness) ͢→ symptoms of
transient ischemic attack (TIA) or stroke
Aura without headache in the absence of a prior
history of migraine with aura ͢→ symptoms of TIA
or stroke
Aura occurring for the first time in a patient during
use of combined oral contraceptives ͢→ risk of
stroke
(migraine more likely) for all of these scenarios
drpaviour.com
Specific Warning Features in History (3/5)
New headache;
in a patient older than 50 years → symptom ͢of
temporal arteritis or intracranial tumour,
in a pre-pubertal child ͢→ requires specialist
referral and diagnosis
in a patient with a history of cancer, HIV infection
or immunodeficiency ͢→ secondary headache
drpaviour.com
Specific Warning Features in History (4/5)
Progressive headache, worsening over weeks or
longer ͢→ intracranial space-occupying lesion
Headache aggravated by postures or maneuvers that
raise intracranial pressure ͢→ intracranial tumour, CNS
infection - (migraine more likely)
drpaviour.com
Specific Warning Features in History (5/5)
Headache first occuring with exercise ͢
ruptured aneurysm (migraine more likely)
Headache hours to weeks after a history of
trauma, especially in an older person ͢
subdural hematoma
Similar new onset of headaches in an
acquaintance or family member ͢
environmental exposure such as carbon
monoxide
drpaviour.com
Less Common Headache Cases
New onset headache over 50
Headache after exercise
drpaviour.com
Case 1
64 year old right-handed lady.
Headaches for 4 months Right more than left.
Initially she would just go to sleep when they came on.
She thinks they lasted about 3-6 hours - nausea, some blurry
vision, some photophobia and some phonophobia - some neck
stiffness.
She had migraine when she was younger.
PMHx “mini stroke” and adult onset Asthma CT scan shows old R MCA stroke - PFO found and closed.
Meds Cocodamol, prednisolone, Mometasone, Amitriptyline, Fluvastatin
and Cetirizine.
Examination was normal
drpaviour.com
Case 1
Likely diagnosis?
4 months of headache
Hemi-cranial headache
Nausea, photo/phono phobia
Prior Hx of migraine
Chronic Migraine?
But….
>50 yrs
Previous “stroke”
drpaviour.com
Case 1
Slightly cognitively slow?
FBC – eosinophilia
ESR slightly elevated
drpaviour.com
Case 1
FBC - eosinophilia.
CSF – prominent eosinophils in her CSF.
Viral screen was negative.
pANCA weakly positive with positive ANA and elevated C3.
drpaviour.com
Eosinophilia
ANA
pANCA
drpaviour.com
Diagnostic test undertaken with
assistance of a neurosurgeon
LEPTOMENINGES INFILTRATED BY LEUCOCYTES – ESPECIALLY EOSINOPHILS
CORTEX
VESSEL WALL INFILTRATED BY MACROPHAGES AND EOSINOPHILS
NORMAL VESSEL FOR COMPARISON
drpaviour.com
Case 1
CSS - Eosinophilic
Granulomatosis with
Polyangiitis (EGPA)
Asthma
Eosinophilia >10% of WCC
Vasculitis - skin, nerves,
kidney, lung, heart, CNS
Idiopathic
Hypereosinophilic
syndrome
Elevated Eosinophils
No other cause identified
Headache
Cognitive syndrome
Prev. Stroke
drpaviour.com
Case 2 - Headache after
badminton
drpaviour.com
Carotid dissection
Current practical management in absence
of stroke:
Imaging as appropriate to confirm
Dual antiplatelet therapy – aspirin +
clopidogrel
Re-image in 3-6 months to exclude false
aneurysm and confirm recanalisation
drpaviour.com
Tingling and NumbnessNeuropathy
drpaviour.com
CLASSIFICATION OF NEUROPATHYPATTERN:
mononeuropathy
multiple mononeuropathy (better than the
old-fashioned mononeuritis multiplex)
symmetrical polyneuropathy
plexopathy
radiculopathy
polyradiculoneuropathy.
drpaviour.com
CLASSIFICATION OF NEUROPATHY
TIME COURSE:
acute, reaching its nadir in <4 weeks, as in
Guillain-Barré syndrome (GBS)
subacute, reaching its nadir in 4–8 weeks
chronic, taking >8 weeks to develop.
drpaviour.com
CLASSIFICATION OF NEUROPATHYDEFICIT:
purely or predominantly sensory - diabetic distal
symmetrical polyneuropathy
purely motor - acute motor axonal neuropathy, a less
common form of GBS in the UK
motor and sensory - Charcot-Marie-Tooth (CMT) disease
autonomic; although autonomic involvement is
common in some neuropathies, pure autonomic
neuropathy is rare.
The underlying pathology - identified by nerve
conduction tests as:
axonal
demyelinating
mixed.
drpaviour.com
Polyneuropathy
Differential diagnosis symmetrical generalised
neuropathy is much more extensive and complicated
than that of mononeuropathies
Most cases are accounted for by a few diagnoses
diabetes mellitus
alcohol and prescribed meds
Nutritional/metabolic
Diagnosis can be simplified by considering chronic and
acute situations.
drpaviour.com
Neuropathy causes - common
drpaviour.com
drpaviour.com
Neuropathy – first line tests
drpaviour.com
Neuropathy
– second
line tests
drpaviour.com
Neuropathy – genetics?
drpaviour.com
Case 3 73 yo male
Summer of 2015 - catching his big toe occasionally when he
walked.
He occasionally catches his feet on the floor when he is walking
in his shoes.
Initially saw a physiotherapist - some concern he may have a
lumbosacral radiculopathy.
MRI of the lumbar spine - mild degenerative changes
Prior Hx Ca prostate treated 10 years ago
Simvastatin for a high cholesterol.
Drank 25-35 units of alcohol regularly throughout his adult life up
until giving it up completely four years ago.
drpaviour.com
Case 3 Subtle thenar and hypothenar muscle wasting
Slightly reduced power but normal sensation.
Reflexes are diminished.
There is a jerky irregular tremor too.
In the lower limbs, reflexes are diminished
power is preserved proximately but reduced distally graded at 3-4/5
in the small muscles of the foot and in inversion and eversion.
Sensation to pinprick, vibration and joint position sense is
diminished particularly in the lower limbs and Romberg’s test is
positive.
drpaviour.com
Case 3 - tests
FBC, U+E, LFT, B12, Folate, Glucose, HbA1c, TFT, ANA
All normal
Ig’s – IgM elevated 11.0g/L (0.5-2.0)
Paraprotein 10g/L – IgM Kappa
Urine Bence Jones –ve
Anti MAG Ab strongly +ve >70,000
Arrows show myelinated fibres
(reduced in number, consistent with
non-specific axonal neuropathy).
H&E.
Reduced numbers of myelinated
fibres and (arrow) axonal cluster
consistent with non-specific axonal
neuropathy. Toluidine blue.
drpaviour.com
Chronic Immune mediated patchy demyelinating
neuropathy
CIDP
MFMN – CB
Anti MAG
POEMS
GALOP
MGUS?
drpaviour.com
Anti MAG neuropathy Neuropathy: Clinical Features
(MAG antibody+ by ELISA & Western blot)Epidemiology: Male 70%
Onset Age: Usually > 50 years; Mean 67
years; Range 46 to 87 years Sensory Gait ataxia
Sensory loss (100%) Distal Legs > Arms Symmetric Panmodal
Pain (28%) Weakness (50% to 70%)
Distal Legs > > Arms Symmetric (80%)
Gait disorder (70%) Tandem gait: Poor Onset: Early in neuropathy
syndrome Often most disabling feature Frequently improves with
treatment Tremor (30%)
Intention Arms > Legs Onset: Develops later in disease
course Poor response to treatment May cause prominent disability:
Fine movements of hands Tendon reflexes: Reduced, Legs
> Arms Time Course: Slowly Progressive
(years)
drpaviour.com
Balance Problems
drpaviour.com
Common causes of dizziness
Single episode of prolonged vertigo
Vestibular neuritis – nystagmus towards healthy side,
improves over days
Acute BS/cerebellar lesion – vertigo plus BS/cerebellar
signs
First episode of vestibular migraine – Hx of migraine
Menieres – associated loss of hearing, tinnitus and
fullness
Other – bacterial labyrinthitis/drug or etoh tox
drpaviour.com
Common causes of dizziness
Recurrent Vertigo
Vestibular migraine – attacks secs-days, Hx of
migraine
Menieres disease – 20mins to hrs with loss of
hearing and fullness/tinnitus
TIA – minutes, assoc. ataxia and dysarthria,
diplopia or loss of vision
Vestibular paroxysmia
Perilymph fistula – vertigo after trauma –
provoked by cough, sneeze, strain or loud noise
Other – AI inner ear disease, syphilis, Pagets,
EA2, FHM, acoustic neuroma
drpaviour.com
Positional vertigo
BPPV – commonest ++ but central
causes can mimic some features
PC-BPPV – 80%
HC-BPPV – 20%
Brief attacks <30s provoked by turning in
bed, symptomatic for months then free of
symptoms for years
drpaviour.com
Acute isolated vertigo
ACUTE ISOLATED VERTIGO
Usually benign – BUT making a specific diagnosis is important
stroke can present with isolated vertigo
identifying benign conditions will reassure the patient and ensure expedient management.
The important causes of acute isolated vertigo are:
acute idiopathic unilateral peripheral vestibulopathy (“vestibular neuritis or neuronitis”/“labyrinthitis”)
cerebellar stroke
migrainous vertigo
“missed” BPPV
bilateral vestibular failure.
drpaviour.com
Signs that indicate peripheral vs. central disorder
Head impulse test VOR suppression
drpaviour.com
Chronic dizziness
Poorly compensated vestibular lesion
Visual vertigo – worse in visually busy surrounds
Motorist disorientation – sensation of car moving/tilting
Functional disorders
Chronic migraine
Menieres – late stage
Degenerative ataxias
drpaviour.com
Case 4 72 yo male
two to three-year history of progressive problems with walking and
balance.
He has developed a shuffling gait and stumbles a little on steps but
he has had no falls.
cognitive problems, slowly progressing, tends to forget simple things
and often asks questions over and over again.
His wife thinks his reasoning is not so good as it was.
He did have some urinary symptoms but those have settled after a
prostate operation two years ago.
He has a prior history of ischaemic heart disease and he has had a
myocardial infarction in the past and had a coronary artery bypass
graft last year.
About 10 or more years ago, he was a cyclist in a road traffic
accident that he has no recollection of. Apparently, he was found by
the side of the road unconscious by a police officer. We do not have
any old images for comparison.
drpaviour.com
Case 4
On examination, he walks with a narrow-based shuffly gait. There
are no other parkinsonian signs. There is no eye movement
disorder. I did not formally assess cognitive function. His postural
reflexes are impaired both on a forward and a backward pull test.
drpaviour.com
Case 4 On examination, he walks with a narrow-based shuffly
gait. There are no other parkinsonian signs. There is no eye
movement disorder. I did not formally assess cognitive
function. His postural reflexes are impaired both on a
forward and a backward pull test.
LP revealed a relatively normal opening pressure and normal
CSF constituents.
He does not think his walking got any better after the lumbar
puncture but it is not clear to me that he had a large volume
tap.
MMSE - 28/30.
Pre-procedure timed walk was 14 seconds and post-procedure
12 seconds.
drpaviour.com
drpaviour.com
drpaviour.com
drpaviour.com
drpaviour.com
drpaviour.com
drpaviour.com62/141=0.44
drpaviour.com
drpaviour.com
Case 5
Paroxysmal vertigo
57 yo female
Multiple attacks of “spinning sensation” daily
Last 5-30 seconds
No nausea
No sequelae
drpaviour.com
Case 5
Recurrent paroxysmal vertigo and tinnitus
DDx?
BPPV?
Meniere’s?
Migraine
Perilymph fistula
Syphilis
Functional/psychological
drpaviour.com
Case 5
drpaviour.com
Figure 2 Example of MRI (CISS sequence) Axial (A) and coronal oblique (B) constructive
interference in steady state (CISS) magnetic resonance images reveal bilateral neurovascular
cross-compression between the vestibular nerve (arrowheads) and the anterior inferior
cerebellar artery (arrows).
Hüfner K et al. Neurology 2008;71:1006-1014
How can you tell a Neurosurgeon when you
meet one?
drpaviour.com
020 7042 1850