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Diagnosis of Neurosurgical Disease

The neurosurgeon first speaks with the patient to get  information about the onset and severity of symptoms and other historical information that help to make a diagnosis and formulate a treatment plan.  The physical examination in the neurosurgical office usually focuses on the neurologic examination (mental state, cranial nerves -- including those for vision, eye movement, taste, hearing, and smell -- , movement and strength, sensation, and reflexes.

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Diagnosis of Neurosurgical Disease

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Differential diagnosis

 

The differential diagnosis is a list of the possible pathophysiologic processes that could be causing the patients symptoms and signs consistent with the data from history, physical, and diagnostic studies.  

 

 

Example of             Differential diagnosis:

 

 

    Presentation:   Headaches, nausea vomiting.  Papilledema on ophthalmoscopic exam.

 

                             > Differential diagnosis at this point (before CT or MR): 

                subarachnoid hemorrhage, subdural hematoma, brain tumor, brain abscess, hydrocephalus

 

 

    Workup:  CT shows a mass of the frontal lobe that is large and takes up contast dye.

 

                             >Differential diagnosis at this point : 

                subarachnoid hemorrhage, subdural hematoma, brain tumor, brain abscess, hydrocephalus  

                       

  (CT "ruled out" [eliminated from the differential diagnosis] some of the possibilities based on history and examination only).

 

 

      Workup:   A stereotactic brain biopsy is done.  

                        Malignant tumor cells are found on microscopic examination of the biopsy specimen.  No evidence of infection.

 

                             > Differential diagnosis at this point : 

                subarachnoid hemorrhage, subdural hematoma, brain tumor, brain abscess, hydrocephalus  

 

 

 

Neurosurgical Diagnosis page TOP

 

 

Table: Steps to formulation of a neurosurgical diagnosis

Syndrome    

 

A characteristic combination of symptoms that can be characteristic (pathognomonic) of a particular disease.

 

Neurosurgical Diagnosis page TOP

 

Diagnosis table

 

 

          DISEASE

 

Epidemiology 

P   r   e   s   e   n   t   a   t   i   o   n

Pathophysiology

Differential Workup
History Symptoms Signs

 

age, sex, racial predispositions

how the disease came on what the patient complains of findings on physical -- including neurological -- exam findings on physical -- including neurological -- exam Disease 1 tests (imaging, laboratory, etc.) to rule Disease 1 in or out
Disease 2 tests to rule Disease 2 in or out
Disease 3 tests to rule Disease 3 in or out
Disease 4 tests to rule Disease 4  in or out
Disease x tests to rule Disease x in or out

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Each neurosurgical disease is characterized by distinct features of epidemiology (age, sex, racial predispositions), history (how the disease came on), symptoms (what the patient complains of), and signs (findings on physical -- including neurological -- exam).  Tests (imaging, laboratory, etc.) help eliminate incorrect possibilities from the differential diagnosis.

 

 

Acromegaly

 

Epidemiology 

P   r   e   s   e   n   t   a   t   i   o   n

Pathophysiology

Differential Workup
History Symptoms Signs

 

acromegaly can affect either sex

the onset of symptoms is usually progressive and insidious the patient frequently notices that the size of his/her face, fingers, toes, ... is increasing findings on physical -- including neurological -- exam     MRI brain (special attention to sella, rule out pituitary adenoma)
   
   
   
   

table TOP           /           Diagnoses TOP                                Neurosurgical Diagnosis page TOP                          table TOP           /           Diagnoses TOP

 

 

Aneurysmal subarachnoid hemorrhage 

 

Epidemiology 

P   r   e   s   e   n   t   a   t   i   o   n

Pathophysiology

Differential Workup
History Symptoms Signs

 

middle-age (uncommon in children).   May be more common in women.  Some racial groups may be predisposed.  Familial predisposition presumed but genetics not known.

sudden onset of "worst headache in my life"

Classic history of present illness aneurysmal subarachnoid hemorrhage 

uncommon:

seizure.  bad prognosis:  loss of consciousness without seizure.

    

  		what the patient complains of headache, stiff neck, pain in eyes with light neck rigidity, retinal hemorrhage Aneurysm rupture tests (imaging, laboratory, etc.) to rule aneurysm in or out

angiogram, MR/CT angiography, lumbar puncture

Meningitis tests to rule meningitis in or out
Intracranial mass tests to rule intracranial mass in or out
Disease 4 tests to rule Disease 4  in or out
Disease x tests to rule Disease x in or out

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Acoustic neuroma

(aka Vestibular Schwannoma)

 

Epidemiology 

P   r   e   s   e   n   t   a   t   i   o   n

Pathophysiology

Differential Workup
History Symptoms Signs

 

Neurofibromatosis type 2

more common in women

increasing difficulty hearing -- typically unable to hear through telephone earpiece

Classic history of present illness vestibular schwannoma

  		ringing in the ear, headache, tinnitus, facial numbness hearing loss, absent corneal reflex affects the cranial nerves (7, 5, 8, ...) in the subarachnoid space Vestibular Schwannoma tests (imaging, laboratory, etc.) to rule Acoustic neuroma in or out
Cerebellopontine angle mass tests to rule Disease 2 in or out
Cerebellopontine vascular lesion tests to rule Disease 3 in or out
Disease 4 tests to rule Disease 4  in or out
Disease x tests to rule Disease x in or out

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Arteriovenous malformation, cerebral

 

Epidemiology 

P   r   e   s   e   n   t   a   t   i   o   n

Pathophysiology

Differential Workup
History Symptoms Signs

 

all ages, both sexes

sudden onset of headache with focal or global neurologic deficit.  seizures. shunting.

Classic history of present illness arteriovenous malformation (intracranial)

 

what the patient complains of depends on the location of the lesion

headache, seizures, weakness

an AVM can cause problems by a number of different mechanisms:

1. mass effect

2. shunting with ischemia and focal neurologic deficit and/or epilepsy

3. hemorrhage

 Arteriovenous malformation subarachnoid hemorrhage:  CSF analysis
Aneurysm subarachnoid hemorrhage:  CSF analysis, CT scan head
Subarachnoid hemorrhage tests to rule Disease 3 in or out
Mass tests to rule Disease 4  in or out
Disease x tests to rule Disease x in or out

table TOP           /           Diagnoses TOP                                Neurosurgical Diagnosis page TOP                         Neurosurgical Diagnosis page TOP                          table TOP           /           Diagnoses TOP

 

 

 

 

Brachial plexus injury

 

Epidemiology 

P   r   e   s   e   n   t   a   t   i   o   n

Pathophysiology

Differential Workup
History Symptoms Signs

 

men much more common

Classic history of present illness brachial plexus injury pain, weakness, numbness in the arm arm pain, weakness, loss of sensation the brachial plexus can be torn by excessive pulling forces up (pulling the arm up and out from the shoulder) and down (pulling the arm down and out from the shoulder).

Erb's palsy

Klumpke's paralysis

 

 Brachial plexus injury tests (imaging, laboratory, etc.) to rule Disease 1 in or out

electromyography/nerve conduction study (EMG/NCS) (brachial plexopathy)

Cervical radiculopathy tests to rule Cervical radiculopathy in or out
Spinal cord tumor tests to rule Spinal cord tumor in or out
Myopathy tests to rule Disease 4  in or out
Disease x tests to rule Disease x in or out

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Brain death

Epidemiology 

P   r   e   s   e   n   t   a   t   i   o   n 

Tests
History Symptoms Signs

 

any age, sex

trauma, tumor, hemorrhage, meningitis, etc. 

patient unconscious

whole brain criteria 

cerebral cortex

brainstem

 EEG, Flow study

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          DISEASE

 

Epidemiology 

P   r   e   s   e   n   t   a   t   i   o   n

Pathophysiology

Differential Workup
History Symptoms Signs

 

age, sex, racial predispositions

how the disease came on what the patient complains of findings on physical -- including neurological -- exam findings on physical -- including neurological -- exam Disease 1 tests (imaging, laboratory, etc.) to rule Disease 1 in or out
Disease 2 tests to rule Disease 2 in or out
Disease 3 tests to rule Disease 3 in or out
Disease 4 tests to rule Disease 4  in or out
Disease x tests to rule Disease x in or out

table TOP           /           Diagnoses TOP                                Neurosurgical Diagnosis page TOP                         Neurosurgical Diagnosis page TOP                          table TOP           /           Diagnoses TOP

 

 

 

 Carpal tunnel syndrome (median nerve entrapment at the wrist

Epidemiology 

P   r   e   s   e   n   t   a   t   i   o   n 

Tests
History Symptoms Signs

 

patients who do work repetitive flexion and extension wrist motions (typists, plumbers, etc.)

 

repetitive wrist trauma (particularly frequent in some occupations -- plumber, typist, etc.)  

Classic history of present illness Carpal tunnel syndrome

weakness in hand

Pain, weakness, numbness

hand and/or arm pain 

Carpal tunnel syndrome tests: electromyography/nerve conduction study (EMG/NCS) >>> (carpal tunnel syndrome)

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          DISEASE

 

Epidemiology 

P   r   e   s   e   n   t   a   t   i   o   n

Pathophysiology

Differential Workup
History Symptoms Signs

 

age, sex, racial predispositions

how the disease came on what the patient complains of findings on physical -- including neurological -- exam findings on physical -- including neurological -- exam Disease 1 tests (imaging, laboratory, etc.) to rule Disease 1 in or out
Disease 2 tests to rule Disease 2 in or out
Disease 3 tests to rule Disease 3 in or out
Disease 4 tests to rule Disease 4  in or out
Disease x tests to rule Disease x in or out

table TOP           /           Diagnoses TOP                                Neurosurgical Diagnosis page TOP                         Neurosurgical Diagnosis page TOP                          table TOP           /           Diagnoses TOP

 

 

 

 

Epidemiology 

P   r   e   s   e   n   t   a   t   i   o   n 

Tests
History Symptoms Signs

Cauda equina compression

Cauda equina compression epidemiology:

Middle aged 

 

Cauda equina compression history:

Lumbar stenosis

Acute disc herniation (history of heavy lifting, bending, frequently patient hears a "pop" and then has severe back and leg pain)

Classic history of present illness Cauda equina syndrome

Cauda equina compression symptoms:

Pain, weakness, numbness

Cauda equina compression signs:

leg weakness and numbness

sphincter incontinence

Cauda equina compression tests: 

MR LS spine, CT myelogram

table TOP           /           Diagnoses TOP                                Neurosurgical Diagnosis page TOP                          table TOP           /           Diagnoses TOP

 

 

          DISEASE

 

Epidemiology 

P   r   e   s   e   n   t   a   t   i   o   n

Pathophysiology

Differential Workup
History Symptoms Signs

 

age, sex, racial predispositions

how the disease came on what the patient complains of findings on physical -- including neurological -- exam findings on physical -- including neurological -- exam Disease 1 tests (imaging, laboratory, etc.) to rule Disease 1 in or out
Disease 2 tests to rule Disease 2 in or out
Disease 3 tests to rule Disease 3 in or out
Disease 4 tests to rule Disease 4  in or out
Disease x tests to rule Disease x in or out

table TOP           /           Diagnoses TOP                                Neurosurgical Diagnosis page TOP                         Neurosurgical Diagnosis page TOP                          table TOP           /           Diagnoses TOP

 

 

 

 

Epidemiology 

P   r   e   s   e   n   t   a   t   i   o   n 

Tests
History Symptoms Signs

Cervical radiculopathy due to disc herniation

Cervical disc herniation epidemiology:

middle-aged and older, men and women

 

Cervical disc herniation history:

Sometimes provoked by trauma

Classic history of present illness Cervical disc herniation

Cervical disc herniation symptoms:

1. myelopathy

2. radiculopathy

Cervical disc herniation signs:

arm pain weakness

Cervical disc herniation tests: 

MR cervical spine >>> (cervical disc herniation),  myelogram

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Cervical myelopathy

Epidemiology 

P   r   e   s   e   n   t   a   t   i   o   n 

Tests
History Symptoms Signs

 

Cervical myelopathy epidemiology:

Usually due to stenosis  due to degenerative arthritis but can result from any pathology (tumor, blood clot, etc.) that causes dysfunction of the spinal cord in the neck. 

Cervical myelopathy history:

Usually insidious onset.

Cervical myelopathy symptoms:

Weakness and numbness in all extremities. 

Incontinence.

Cervical myelopathy signs:

Weakness.  Spasticity (hyperactive reflexes)

Cervical myelopathy tests: 

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Cervical myelopathy

Epidemiology 

P   r   e   s   e   n   t   a   t   i   o   n 

Tests
History Symptoms Signs

Cervical stenosis

Cervical stenosis epidemiology:

Men and women.  Older patients: hard, younger patients: soft, discs

Cervical stenosis history:

Occasionally history of neck injury with sudden onset paralysis of legs and arms .  Frequently painless myelopathy.  Spasticity.  Bladder/bowel sphincter compromise.

Classic history of present illness Cervical stenosis

Cervical stenosis symptoms:

Pain, weakness, numbness

Radiculopathy

Cervical stenosis signs:

leg weakness gait instability

Radiculopathy

Cervical stenosis tests: 

MR cervical spine >>> (cervical stenosis), myelogram

 

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Metastasis, brain

 

Epidemiology 

P   r   e   s   e   n   t   a   t   i   o   n

Tests
History Symptoms Signs

 

Patient with cancer

 

frequently known cancer elsewhere in  body

Classic history of present illness brain metastasis

variety of symptoms

variety of signs

CT head, MR of brain

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Subdural hematoma, acute

 

Epidemiology 

P   r   e   s   e   n   t   a   t   i   o   n

Tests
History Symptoms Signs

 

Subdural hematoma (acute) epidemiology:

Young men most commonly 

 

Subdural hematoma (acute) history:

1. history of head trauma (frequently acceleration-deceleration) 

2. patient with bleeding disorder

Classic history of present illness acute subdural hematoma

Subdural hematoma (acute) symptoms:

1. headache

2. focal neurologic deficit

 

Subdural hematoma (acute) signs:

1. headache

2. focal deficit

3. altered mental status

Subdural hematoma (acute) tests: 

CT head >> (