MSC Neuro 2025 P1
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Inabilitytoplantarflexfootand toes.
Atrophyofposteriorlegmusclesandsolemuscles.
Gaitdisturbance(di icultywalkingontoes).
Peroneal(Fibular)NerveSyndrome
Function:
Motor:dorsiflexion(footextension),toeextension,eversion(turningfoot outward).
Sensory:dorsumoffoot,anterolaterallowerleg.
Clinicalmanifestations:
Footdrop:inabilitytodorsiflexfootand toes.
"Horse'sfoot":foothangsdownandrotatedslightlyinward.
"Cockgait"or"steppagegait":highfootliftingwithtoe-firstfootcontact duringwalking.
Atrophyofanteriorandlaterallegmuscles.
Sensorylossoveranterolateralleganddorsalfoot.
Diagnosis:
Inabilitytodorsiflexfoot,di icultywalkingonheels.
Muscleatrophyofanterolateralleg.
Characteristicgait abnormalities.
TunnelSyndromes(EntrapmentNeuropathies)
Commonatsitesofnervecompression:e.g.,tarsaltunnel(tibial nerve),fibular head(peronealnerve).
Symptoms:pain,paresthesia,weakness innerve distribution.
Conservativetreatmentincludes:
NSAIDsandanalgesics
Physicaltherapy(nerve gliding,strengthening)
Splintingororthotics
Localinjections(steroids,anesthetics)
Avoidanceofpressure/compression triggers
Surgicaldecompressionindicatedifnoimprovementafter3-6monthsof conservativetreatmentorprogressiveneurologicaldeficit.
ConservativeTherapy
Vasculartherapytoimprovenerve perfusion.
AntioxidantsandneurotropicBvitamins.
Physicalmodalities:electricalstimulation,massage, nerve stimulationtechniques.
Rehabilitation:gaittraining, muscle strengthening, orthotics.
SurgicalIndications
Persistentsymptomsrefractorytononinvasivemeasures.
Progressive muscleweakness oratrophy.
Confirmednerveentrapmentonelectrophysiologicstudies.
Traumaticnerveinjuryrequiringdecompressionorrepair.
45.Brachialplexuslesionsyndromes.
BrachialPlexusLesionSyndromes
1.ShoulderPlexopathy Etiology
Injuries duetotrauma, woundsofhealingbones
Prolongeduseofhigh tourniquetduringsurgery
Compressionbetweenclavicleandfirstrib
Shoulderdislocationorfracturesinvolvingshoulder/headregion
ClinicalPresentation
Entireplexuslesion:
Peripheralparalysis/paresisandanesthesiaofshoulderandforearm
Uppertrunklesion(Duchenne-Erbpalsy):
Paralysisandatrophyofproximalarmmuscles:deltoid,biceps, brachialis, brachioradialis,supinator
Lossofshoulderabductionandelbowflexion
Preservedhandandfingermovement
Painandparesthesiaonlateraledgeofshoulderandforearmwithreduced sensation
Lowertrunklesion(Dejerine-Klumpkepalsy):
Paralysisandatrophyofsmallhandmusclesandfinger/handflexors
Preservedshoulderandforearmmovement
Sensorylossonpalmarsurfaceoflittlefingerandulnarsideofotherfingers andforearm
Di erentialDiagnosis
Cervicalosteochondrosis
Humeroscapularperiarthritis(Dupley’ssyndrome)causingpainfullimitationof shouldermovement
Diagnosis
Clinicalexaminationwithneurologicaltestsofmusclestrengthandsensory function
Electromyography(EMG)andnerve conductionstudiestolocalizeandassess severity
Treatment
Conservative:Analgesics,vitaminB complex,C,nicotinic acid, thiocticacid
Anticholinesterasedrugs
Physicaltherapyandmassage,reflexology,physiotherapy
Reconstructivemicrosurgicaloperationsfor traumaticorpersistentnerve damage
46.Bernard-Hornersyndrome,mechanism,topicalvariants.
Bernard-HornerSyndrome(Horner’s Syndrome)
Mechanism
Causedbydamagetothe sympatheticnervoussystempathwaysupplyingthe face andeyeontheipsilateralside.
Sympatheticinnervationoriginatesfromthree-neuronchain:
1.First-orderneuron:fromhypothalamustospinalcordlevelsC8–T2 (ciliospinalcenterofBudge)
2.Second-orderneuron:fromspinalcord,across thorax,tosuperiorcervical ganglion
3.Third-orderneuron:fromsuperiorcervicalganglionalonginternalcarotid arteryintoorbit
Lesionsatanypoint—central, preganglionic,orpostganglionic—causethe syndrome.
ClinicalFeatures
Ptosis:droopingofuppereyelid(duetoparalysisofMüller’smuscle,suppliedby sympatheticnerves;milderthanoculomotornerve palsy).
Miosis:constrictedpupildue tounopposedparasympatheticactivity.
Enophthalmos:apparentsinkingofeye into orbit(due toparalysisoforbital muscles).
Anhidrosis:lossofsweatingontheipsilateral faceorbodydependingonlesionsite.
Vasodilationandhyperemia:reddeningofconjunctivaduetoloss ofsympathetic vasoconstriction.
Heterochromia: (lightiriscolorona ectedside)seenincongenitalorlong-standing casesinchildren.
Decreasedciliospinalreflex.
Visualadaptationtodimlightimpaireddue topersistentmiosis.
VariantsbyLesionSite |
|
|
LesionLocation |
Features |
CommonCauses |
|
|
Stroke,tumor, |
First-order |
Ipsilateralhemibody |
syringomyelia,lateral |
(central) |
anhidrosis,miosis,ptosis |
medullarysyndrome |
LesionLocation |
Features |
CommonCauses |
|
Ipsilateralfaceanhidrosis; |
|
|
morecommon; |
Pancoasttumor,cervical |
Second-order |
associatedwith thoracic |
rib,trauma,thoracic |
(preganglionic) |
lesions |
surgery |
|
Minimalorabsentfacial |
Carotiddissection,cluster |
Third-order |
anhidrosis(branchhas |
headache,cavernous |
(postganglionic) |
left) |
sinus pathology |
Diagnosis
Oxymetazolinetest(Amphetaminetest): assessesintegrityofsympatheticpathway.
Sluggishpupillaryreactiontolightanddilation.
Imaging: CT/MRIofneck, chest,brain tolocalizecause.
Biomicroscopy:conjunctivalvesselinjection,irispigmentation.
Treatment
Treatunderlyingcause(tumor,dissection,etc.).
Symptomatic:neurostimulation,surgicalcorrectionforptosis ifneeded.
47.Meningealsyndrome(Meningism):manifestations,diagnosis.
MeningealSyndrome
Manifestations
Generalcerebralsymptoms:
Intense headache(di useorlocalized:forehead,occiput)
Vomiting(sudden,oftenwithoutnausea,unrelatedtofoodintake)
Fever
Photophobia(sensitivitytolight)andphonophobia(sensitivitytosound)
Inseverecases: psychomotoragitation,delirium,hallucinations,seizures,lethargy, stupor,coma
Actual meningealsymptoms(reflectmeningealirritation):
Necksti ness: inabilitytopassivelyflextheneck duetomusclerigidity(notjust pain)
Meningealposture:patientliesonsidewithheadthrownbackandlegsflexed ("pointingdog"posture)
Kernig’ssign:unabletostraightenkneewhenhipisflexed→painor resistance
Brudzinski’ssigns:
Upper:passive neckflexioncausesinvoluntaryleg andarmflexion
Lower:passiveextensionofone legcauses involuntaryflexion ofopposite leg
Buccal:pressurebelow zygomaticarchescausesshoulderraisingand forearmflexion
Shoulder:passiverotationofheadcausescontralateralshoulderandarm flexion
Levinson’ssign:active neckflexioncausesmouthopening
Gordon’ssign:calfmusclecompressionproduces extensortoeresponse
Lesage’ssign(children):whenliftedbyarmpits,legsflexand remainflexed
Bikele’ssign(infants): resistancetoarmextension
Diagnosis
Historyandexamination: Identifyheadache,fever,necksti ness,associated symptoms
Lumbarpuncture:
MeasureCSFpressure
Analyzeappearance(color,clarity)
Cellcount(pleocytosisininfection)
Protein,glucose levels
Microbiological studies (Gramstain,culture,PCR)
Imaging(CT/MRI):toexclude masslesionorelevatedintracranialpressure beforeLP
Clinicaltests:PositiveKernig’sandBrudzinski’ssignssupportmeningealirritation diagnosis
48.Intracranialhypertensionsyndrome,characteristics. Leartificial correction.
IntracranialHypertensionSyndromeisaconditioncharacterizedbyanincreaseinpressure withintheskull,a ectingbraintissue,cerebrospinalfluid(CSF),andbloodvessels uniformly.
Aspect
Cause
SymptomsinAdults
Symptomsin
Children/Newborns
Signs
Diagnosis
MedicalCorrection
Details
Increasedintracranialpressure(ICP)duetobrain pathology(tumors,trauma,hemorrhage, encephalitis),cerebraledema,orsystemiccauses (heartfailure,COPD,hypercapnia)
Intenseheadache(worseinmorning/night),vomiting withoutnausea,nausea,visualdisturbances(blurred vision,diplopia,papilledema),drowsiness,irritability, seizures,hypertension,bradycardia,respiratory irregularity
Vomiting, prolongedcrying,developmentaldelay, bulgingfontanel, 'settingsun'eyes(downward gaze withsclerashowingabovepupils),poorlightreflex
Papilledemawithoptic nerveswelling,hemorrhages onfundus,pupillarychanges,cranialnervepalsies (esp.VI),muscleparesis,increasedBP,bradycardia, abnormalpulse
Clinicalexam,fundoscopy(papilledema),imaging (CT/MRI),lumbarpuncturewithICP measurement andCSFanalysis
-Maintainairway,oxygenation
-Elevatehead15-30°toimprovevenousdrainage
-Restrictfluidsto~1.5L/day;avoidfreewater(e.g., 5%glucose)
-Managebloodpressure, fever,seizures,agitation
-Avoidvasodilators
-Osmoticdiuretics(mannitol),loopdiuretics
Aspect |
Details |
|
(furosemide) |
|
-Corticosteroids (fortumors) |
|
-Mechanicalventilationandhyperventilation(acute |
|
cases) |
|
-Surgicalintervention(ventriculardrainage)if |
|
indicated |
|
Long-term ICP monitoringcriticalforsevere cases; |
Prognosis/ |
outcomedependsoncause andpromptnessof |
Monitoring |
treatment |
49.Dislocationbrainsyndromes. Clinicalcharacteristics.
BrainDislocationSyndrome
Pathogenesis
Braindoesnot fullyoccupyskull;subarachnoidspacesandcisternsallow displacement.
Increasedintracranialpressureorfocal lesionscausedisplacement(dislocation)of brainstructures throughnaturalduralfoldsorskullopenings (foramina).
Brainherniationisanalogoustoahernia; criticalcomplicationsarise whenbrain tissueispinched(infringed)compressingbloodvesselsanddisruptingcirculation.
Typesofherniation:Protrusion→Wedging→Infringement(increasedseverity).
Dislocations:lateral(transverse)oraxial(longitudinal)(alongbrainstemaxis).
TypesofDislocationSyndromes(clinicallysignificantones)
No. |
DislocationType |
Location&Description |
|
|
Causescingulategyrus herniation, |
|
Displacementofcerebral |
compressesanteriorcerebralartery, |
|
hemispheresunder |
leadstolateralventricledeformation |
1 |
falciformprocess |
andedema |
No. |
DislocationType |
Location&Description |
|
|
Temporallobe herniatesthrough |
|
Temporotentorial |
tentorialnotch,compressingmidbrain |
2 |
Displacement |
andcranialnerves(IIIpalsy) |
|
|
Cerebellartonsilsherniatethrough |
|
Cerebellar-tentorial |
foramenmagnum,compressingmedulla |
3 |
Displacement |
andupperspinalcord(life-threatening) |
|
Displacementofpons |
Ponsdisplacedintointerpeduncular |
4 |
throughcerebellarforamen |
cistern |
|
Fillingofmiddle&side |
|
5 |
cisternsaroundpons |
Compressionofbrainstemstructures |
|
Displacementofposterior |
|
|
corpuscallosumdorsalinto |
Seenwithhydrocephalus,severebrain |
6 |
cistern |
swelling |
|
Displacementoffrontal gyri |
|
7 |
intochiasmaticcistern |
Causesvisualdisturbances |
|
|
Braintissue bulgesthroughskulldefect |
8 |
Externaldislocation |
(fromtrauma) |
ClinicalFeatures
Dependonlocation,size,speedofherniation
Earlysigns:headache, consciousnessalteration,oculomotor palsy(dilatedpupil), hemiplegia
Ipsilateralpupildilation(due tothirdnervecompression)with medialrectuspalsy
Hemiparesisipsilateraltolesion(Kernohan'snotchphenomenon)
ElevatedICPsigns:vomiting,bradycardia,hypertension
Alteredrespiratorypatterns;comainadvancedcases
Cerebellartonsilherniation→respiratoryandcardiovascularfailure →death
Diagnostics
Imaging: CT,MRItoconfirmherniationtype and plansurgical intervention
Echoencephalographycandetectlateraldisplacementsbutnotaxial
Lumbarpuncture iscontraindicatedduetoriskofprecipitatingherniation
Treatment
Addressunderlyingcause (tumor,hemorrhage,edema)urgently
Medicaltherapy:barbiturateanesthesia,controlledhypothermia,controlled hyperventilation,corticosteroids(tumors)
Surgicaldecompression(decompressivecraniotomy,ventriculardrainage)
Earlyinterventioncriticaltopreventfatalbrainstemdamage
50.Examinationofcerebrospinalfluid,thecompositionofcerebrospinalfluidinnormal andpathologicalconditions. Cerebrospinalfluiddynamicssamples.
CerebrospinalFluid (CSF)Study
NormalCSFCharacteristics
Volume:~150 mltotal,renewed~6times/day
Appearance:Clear,colorless
Pressure:80–120mmH2O
Protein:~0.3g/L(15-40 mg/dL)
Cells:1–5/mm³,mostlyleukocytes
Glucose:2.7–3.7mmol/L(~2/3of bloodglucose)
Chlorides:~110mmol/L
Functions:Nutrientsupply,wasteremoval,neurotransmittertransport,bactericidal activity
CSFCollectionMethods
Lumbarpuncture:Mostcommon, betweenL3-L4