Introduction Department of Neurology CPC

Department of Neurology,
Sawai Man Singh Medical College
Hospital, Jaipur
CPC team & Dr. Monica Jain, Coordinator;
Dr. Lokendra Sharma Co coordinator

FACULTY and RESIDENTS
Faculty Position Numbers
Senior Professor 4
Professor 3
Associate Professor 3
Assistant Professor
(Ad hoc)
1
Senior specialist 1
Senior Resident `24
•Total Three
Neurology units in
SMS

Department of Neurology
• Total OPD attendance in yr. 2015 : 107069
(January to July 2016- >80,000)
• Total IPD attendance in yr. 2015 : 6195
• Operated daily at ground floor of the
Dhanwantri OPD block

Workload &Facilities Available in the
Department Investigation Number (2015)
Digital EEG 3966
NCS(VEP/BAEP) 4381
EMG 500
Video EEG 312
Ambulatory EEG 64
Total 9223

Labs in Dept. of Neurology
Machines Numbers
NCS/EMG 4
Digital EEG 3
Conventional
EEG
1(out of working
order)
Video EEG 1
Ambulatory EEG 1
Polysomnograph
y
1
Total 11
• Number of lab
technicians- 6

Neurointervention (DSA)
• Providing Diagnostic and Therapeutic
services in collaboration with Neurosurgery
Dept.
• Our’s was the first unit in Rajasthan to start
neurointerventional work in 2007

Dept. of Neurology
Neurointerventional procedures from
June 2007 onwards
Total
DSA
Types of Neurointervention
Coiling
of
Aneurysm
Tumour
Embolizaion
AVM
Embolization
Carotid
Angioplasty &
Stenting
Spinal
AVM/Tumour
Embolization
Intra-arterial
thromobolysis/
Intra-cranial
angioplasty/
Mechanical
Thrombectomy
1034 154 38 28 26 18 6

Other Specialty Services
• Botulinum toxin therapy for focal dystonias, and
spasticity
• Local steroid inj. in carpal tunnel syndrome
• Plasmapharesis in Neurological disorders
like - GBS
- MG
- NMO Spectrum disorder
• Regular OPD in Kanwatiya Hospital

Emergency Neurology
• 24 hour emergency services in CNM Centre
• Special treatments-IV thrombolysis for
ischemic stroke patients who present
within 4.5 hours of onset
• Speciality ICU – only 4 beds
• Stroke unit awaited

Publications, Awards, Honours
& Achievements of Faculty

• The current faculty of the department has
more than 400 publications in national and
international journals to its credit.
• Regular CME Programs are being organized in
the department.
• National and State Level Conferences have
been organized by the department

Fellowships
awarded to Dr. R S Jain
• National –Senior Research Fellowship, Council of
Scientific & Industrial Research, New Delhi
• National –Fellow Indian Academy of Neurology
(FIAN)
(1st Neurologist from Rajasthan honoured with
FIAN)
• International –World Federation of Neurology
Fellowship, London (U.K.)
• International –Alzheimer’s Disease&Related
Disorders Fellowship, Stockholm (Sweden)

Fellowships
• Fellowship of Borengham in Parkinson’s disease
2007 awarded to Dr.Anjani Kumar Sharma
• Fellowship of Indian College of Physicians (FICP)
2009 awarded to Dr.Anjani Kumar Sharma
• Junior Research Fellowship by CSIR in 1995
awarded to Dr. Bhawna Sharma
• Senior Research Fellowship by CSIR in 2000
awarded to Dr. Bhawna Sharma

Fellowships
• Fellowship in Cerebrovascular
intervention(Beijing China 2005-2006) awarded
to Dr. Trilochan Srivastava
• Indian Academy of Neurology fellowship (2004)
to study at The Institute of Neurology, Queen
Square, London awarded to Dr. Dinesh
Khandelwal
• Commonwealth Scholarship (2007) to study at
Southern General Hospital, Glasgow, UK
awarded to Dr. Dinesh Khandelwal

Awards - Dr.R S Jain
• Awarded first ever Times Wellness Rajasthan
Health Award 2013 for “Best Doctor in
Neurology” in Rajasthan
• Honoured with State Award by Hon. Chief
Minister, Rajasthan on 15th August,2013.
• Raja Pajvan Dev Award by Her Highness
Padmini Devi Ji in Sawai Jaipur Alankaran
Samaroh 2014.

• Honoured with
State Award by
Hon. Chief
Minister,
Rajasthan on 15th
August,2013

• Raja Pajvan Dev
Award by Her
Highness Padmini
Devi Ji in Sawai
Jaipur Alankaran
Samaroh 2014

Letters of Appreciation

First women Super-
specialist awarded State
Merit Certificate by
Hon'ble Chief Minister of
Rajasthan on 15th August,
2010 for outstanding
contribution in Medical
Field

Palatucci Advocacy
Leadership award
(2012) by American
Academy of Neurology
to
Dr Dinesh Khandelwal

Chapters in books
Dr. R S Jain :
• Neurosarcoidosis –Reviews in Neurology,
Indian Academy of Neurology
• Primary CNS Lymphoma - Reviews in
Neurology, Indian Academy of Neurology
Dr. Bhawna Sharma :
• Contributor - Year Book of Neurology, 2012
• Contributed chapters in Annual reviews of
Neurology

CHAIRPERSONS – Dr. U.S.Agarwal , Principal and controller,
Dr. Hemant Malhotra , PHOD,
Dept. of Medicine and CPC convener
Dr.R.S.Jain, PHOD, Dept.of Neurology
CPC MEET
DEPARTMENT OF NEUROLOGY,
SMS Medical College & HOSPITAL,
JAIPUR
DATE-12TH AUGUST 2016
TIME-8:00AM-9:00AM
VENUE-COLLEGE AUDITORIUM

SMSMC-CPC:
The TEAM
• DR. U.S. AGARWAL, Principal & Controller
• DR. HEMANT MALHOTRA, CONVENER (9829062040,
drmalhotrahemant@gmail.com)
• DR. PUNEET SAXENA, Dept. of Medicine (9414079182,
puneetsaxena96@yahoo.co.in)
• DR. ARADHANA SINGH, Dept. of Medicine (9166916692,
aradhanas610@yahoo.com)
• DR. MONICA JAIN, Dept. of Pharmacology (9828786533,
monicajain07@yahoo.com)

Presenter – Dr. Tushar Desai , SR Neurology
Neurology discussant – Dr. Trilochan Srivastava,
Professor , Dept. of Neurology
Orthopaedic discussant – Dr. Narendra Joshi,
Professor , Dept. of orthopaedics
Endocrinology discussant – Dr. Sandeep Mathur,
PHOD, Dept. of Endocrinology
CPC team & Dr. Monica Jain, Coordinator; Dr. Lokendra Sharma Co coordinator

Radiology discussant – Dr. Naima Mannan ,Professor,
Dept. of Radiology
Neurosurgery discussant – Dr.Achal Sharma,Professor,
Dept. of Neurosurgery
Physical Medicine and Rehabilitation discussant –
Dr. Mrinal Joshi ,PHOD ,
Dept. of PMR

Presenter – Dr. Tushar Desai ,
SR Neurology (3rd yr)

Foot Drop
Common Entity - Uncommon Etiology
SMS Medical College, JaipurCPC team & Dr. Monica Jain, Coordinator;

History
• 51-year-old male , garment shop worker
• Admitted in Neurology ward in Nov 14
• Insidious onset, gradually progressive, right foot
drop for six months on the background of low-
backache for last 5 years
• There were no radicular pains, sensory symptoms,
bladder/bowel or erectile dysfunction.
• Diabetes Mellitus diagnosed 6 months back

• No h/o trauma, weightlifting or weight loss
• No h/o intramuscular injection
• Past history - Not significant
• Personal history - Non addict, vegetarian

General Physical Examination
• Patient was conscious oriented
• No Pallor, icterus, clubbing, cyanosis,
lymphadenopathy and pedal edema
• P-80 ,BP-130/90
• All Peripheral vessels palpable ,no bruit

Local examination
• Skin -no discolouration or thickening.
• No hair loss
• No joint pain
• No bony deformity in foot

Systemic Examination
• Chest-NAD
• CVS- NAD
• Per abdomen –NAD

Neurological examination
• Higher mental function-Normal
• Speech -Normal
• Cranial nerves-Normal
• Motor exam
Right Left
Bulk Normal Normal
Tone Normal
Decreased
slightly in foot
dorsiflexors
Normal

Power Right Left
Upper limb 5/5 5/5
Lower limb-hip
joint
5/5 5/5
knee joint 5/5 5/5
ankle -dorsi-
flexion
2/5 5/5
ankle plantar-
flexion
5/5 5/5
EHL weak strong
Dorsiflexion-
2/5
Plantarflexion-
5/5
RIGHT
ankle
joint

Superficial reflexes
• Abdominal and cremasteric reflex –normal
• Anal sphinchter tone and Bulbocavernous reflex-
normal
• Plantars –B/L mute

Deep tendon reflexes
Deep
tendon
reflexes
Biceps
reflex
Triceps
reflex
Supinator
reflex
Knee
reflex
Ankle
reflex
Right Normal Normal Normal Brisk Absent
Left Normal Normal Normal Brisk Absent

• 50% sensory loss to pinprick at the right L4
dermatome level .
• Cerebellar signs- absent
• No spinal or cranial deformity
• SLR test -Negative

Summary
• 50 year old ,non addict ,presented with insidious
onset, gradually progressive, right foot drop on the
background of low backache for last 5 years with
• LMN + subtle UMN signs
• Right ankle dorsiflexors MRC grade 2/5,
B/L absent ankle reflex, B/L brisk knee reflex with
B/L mute plantars along with sensory loss in right L4
dermatome and negative SLR.

Diagnostic possibilities
• Orthopedic
• Medical

Orthopaedic discussant
Dr. Narendra Joshi
Professor , Dept. of orthopaedics

Endocrinology discussant
Dr. Sandeep Mathur
PHOD, Dept. of Endocrinology

LOCALIZATION OF LESION
LMN causes of foot drop
MUSCLE NEURO-
MUSCULAR
JUNCTION
NERVE PLEXUS RADICLE ANTERIOR
HORN CELL

UMN LMN
BRAIN SPINAL CORD
FOOT DROP

Investigations
• Hemogram, biochemistry including thyroid function
tests and vitamin B12 level were normal.
• Serum HIV was negative
• B. Sugar controlled on OHA

Nerve conduction Studies

Motor nerve
conduction studies
Right Left
Peroneal NR(Non recordable) S/O
axonal affection
Decreased amplitude(>50%
loss) S/O axonal affection
Tibial nerve Normal Normal
Sensory nerve conduction
studies
Sural Normal Normal
F WAVE
Peroneal NR NR
Tibial Normal Normal
H Reflex
Tibial NR NR
Nerve conduction Studies

? Asymmetric Diabetic
Neuropathy(Rt>>Lt)
Points in favour
• Common cause of
neuropathy.
• B/L ankle reflex absent
• B/L common peroneal
nerve conduction affected
Points against
• B/L knee reflex brisk
• Tibial and sural nerve
conduction normal

Classification of diabetic neuropathies
Generalised symmetric neuropathies
Focal and Asymmetric neuropathies
Combinations

Generalised symmetric neuropathies
• Distal sensory or sensorimotor polyneuropathy
• Small fibre neuropathy
• Autonomic neuropathy
• Large fibre sensory neuropathy

Focal and Asymmetric neuropathies
• Cranial mononeuropathy(single or multiple)
• Truncal mononeuropathy (thoracic radiculopathy)
• Limb mononeuropathy (single or multiple)
• Proximal motor neuropathy (lumbar
radiculoplexopathy ,amyotrophy)
Combinations
• Polyradiculoneuropathy
• Diabetic neuropathic cachexia

Diabetic neuropathy and foot drop
• Common peroneal neuropathy is the most common
of all lower limb mononeuropathies.
• Diabetes mellitus responsible for 10-12 % cases.
• Sensory deficit not accompanied by pain or
paresthesia

MRI LS Spine
Mild L4-L5 disc
indentation

MRI LS Spine

? L4-L5 Radiculopathy
Points in favour
• Age
• Chronic low back pain
• Unilateral foot drop
• Sensory loss in right L4
dermatome.
• B/L F wave and H reflex
absent.
• Mild nerve root compression
at L4-L5 disc.
Point against
• No H/O radicular pain
• B/L brisk knee reflex

Myeloradiculopathy
• Chronic low back pain
• B/L knee jerk were brisk
• B/L ankle jerks were absent
• Mild nerve root
compression at L4-L5 disc.
• B/L F wave and H reflex
absent.
Point against
• B/L plantars were not
extensors
Points in favour

MRI Cervical & Dorsal spine
Serpinginous
lesion

Neuroimaging
• Neuro-Radiologist

Department of Radiodiagnosis
CPC August 2016
Dr. Ravi Prakash Saini
Guided By : Dr. Naima Mannan

• Spinal cord edema plus
dilated perimedullary
vascular channels seen
as vascular flow voids
from C7 to D8 without
an intramedullary
lesion are typical for an
Spinal AVM (dAVF)
Spinal
cord
with
edema
Perimedullary
flow voids

CT Angiography Spine
Tortuos dilated
vascular channels

• There is long segment collection of tortuous vessels
channel noted in posterior part of spinal cord
extending from C7 TO D8 levels
suggestive of spinal cord AVM.

Four types of AVM
• Type 1- single coiled vessel (dural AV fistula)
• Type 2- intramedullary glomus AVM
• Type 3- juvenile
• Type 4- intradural perimedullary (AV fistula)
Subtype i- single arterial (ASA) small fistula
Subtype ii- multiple arterial (ASA & PSA), multiple
medium fistulae
Subtype iii- multiple arterial (ASA & PSA), single
giant fistula CPC team & Dr. Monica Jain, Coordinator;

• Feeding artery is not visualised.
• DSA to look for feeding artery
NEUROLOGY

Neuro-intervention-Dr.Trilochan Srivastava
Spinal digital
subtraction
angiography

Spinal DSA

Spinal DSA
AP ViewCPC team & Dr. Monica Jain, Coordinator;

Spinal dAVF
Intercostal
art
Perimedullary
vein
Radicular
art
Fistula

Oblique ViewCPC team & Dr. Monica Jain, Coordinator;

FINAL DIAGNOSIS
Myeloradiculopathy

Management of Spinal dAVF
• Neurosurgery
• Glue Embolization

Neurosurgery
Dr. Achal Sharma , Professor ,
Dept. of Neurosurgery

Micro-catheterization of fistula(dAVF)

Micro-catheterization of dAVF

After Embolization

Glue (nBCA) Embolization
(Nov 14)
Glue cast

Follow-up (April 15)
Rt DF 3/5 PF 5/5
Relief in back pain
Absent
prominent
flow voids

Glue cast

Normal cord with subtle hyperintensity

MRI SPINE
Pre-Embolization Post Embolization
Prominent
flow voids Absent
flow
voids

MRI SPINE
Pre-Embolization Post Embolization
Cord edema with prominent
perimedullary vessels
Absent cord edema
and perimedullary vesselsCPC team & Dr. Monica Jain, Coordinator;

Spinal CT Angiography (Sept 15)
Rt DF 4/5, Rt PF 5/5
Glue cast
Glue cast

Pre-Embolization Post -Embolization
Serpinginous lesion Absent
Serpinginous
lesion

Clinical Improvement in patient
• Relief in backpain
• Improvement in power of dorsiflexors of right ankle
joint from MRC grade 2/5 to 4/5

Foot Drop
• Foot drop is defined as
weakness of the anterior
tibialis and is frequently
accompanied by weakness
of the extensor hallucis
longus (EHL) and extensor
digitorum longus (EDL)

LMN causes of foot drop
MUSCLE NEURO-
MUSCULAR
JUNCTION
NERVE PLEXUS RADICLE ANTERIOR
HORN CELL
Motor
neuron
disease-ALS
Anterior compartment syndrome
Inclusion body myositis,
Myotonic dystrophy,
Scapuloperoneal myopathy
Myaesthenia gravis
Common peroneal ,
Sciatic neuropathy
Lumbosacral plexopathy
L5 radiculopathy

UMN LMN
BRAIN SPINAL CORD
FOOT DROP
Stroke
Parasagittal tumours-
Meningioma ,
metastasis
Myelopathy
Spondylosis
metastasis

Foot Drop – LMN causes
• It is usually caused by LMN
pathology, commonly
disruption of conduction from
the common peroneal nerve
(L4-L5)
• L4-L5 radiculopathy is the
next most common
recognized cause of foot drop,
usually caused by herniated
nucleus pulposus or foraminal
stenosis CPC team & Dr. Monica Jain, Coordinator;

Common Peroneal neuropathy is the most common
cause
• Nerve entrapment
• Diabetes mellitus
• Inflammatory neuropathy
• Trauma, masses or pressure near the fibular head
• Intraneural tumors
• Vascular pathology
Foot Drop – LMN causes

WEAKNESS OF DEEP
PERONEAL
NERVE
COMMON
PERONEAL
NERVE
SCIATIC
NERVE
LUMBOSACR
AL
PLEXUS
L5
RADICULOPAT
HY
FOOT
DORSIFLEXION
PRESENT PRESENT PRESENT PRESENT PRESENT
FOOT
EVERSION
PRESENT PRESENT PRESENT PRESENT
FOOT
INVERSION
PRESENT PRESENT PRESENT
KNEE FLEXION PRESENT PRESENT PRESENT
GLUTEI
MUSCLES
PRESENT PRESENT
DECREASED
ANKLE REFLEX
PRESENT PRESENT PRESENT

SENSORY
LOSS IN
DEEP
PERONEAL
NERVE
COMMON
PERONEAL
NERVE
SCIATIC
NERVE
LUMBOSACR
AL PLEXUS
L5
RADICULOPAT
HY
WEBSPACE OF
GREAT TOE
PRESENT PRESENT PRESENT PRESENT PRESENT
DORSUM OF
FOOT
PRESENT PRESENT PRESENT PRESENT
LATERAL CALF PRESENT PRESENT PRESENT PRESENT
LATERAL KNEE PRESENT PRESENT PRESENT
POSTERIOR
THIGH
PRESENT PRESENT

Central or UMN causes of
Foot Drop
• Central or UMN causes are extremely
rare but must be considered
• Compression of these fibers along the
path from the cortex, internal capsule ,
the cerebral peduncles, and the ventral
spinal cord, can potentially result in
disruption of signal to the lumbar nerve
roots

Myelopathy & foot drop
The UMNs of the leg are
organized somatotopically
from the medial motor
cortex down the internal
capsule to the ventral gray
matter of the spinal cord,
where they are grouped in
longitudinally oriented
columns
Foot
area
Affected
area

Spinal dAVF
• They comprise 3%–16% of all
compressive spinal cord
lesions
• Attributed to 30% of
idiopathic myelopathies.
• They are most often
diagnosed on imaging by a
neuroradiologist
• They can present with
symptoms of myelopathy and
radiculopathy mimicking a
plethora of pathologies.CPC team & Dr. Monica Jain, Coordinator;

ONLY SINGLE CASE REPORT
Embolization of a spinal dural AV fistula after super selective
WADA test spinal AV fistula presenting as foot drop
• NeuroIntervent Surg 2012;4:A70-A71 ,V Nduku et al
• Reported a case of a 79-year-old female who presented
with back pain and a left foot drop. MRI suggested
edema in the conus medullaris
• Spinal angiogram revealed serpiginous enhancement
from T11-L1 consistent with a type I AVM (Dural AV
fistula)
• She eventually underwent successful embolization with
complete occlusion of the Spinal AVFCPC team & Dr. Monica Jain, Coordinator;

TAKE HOME MESSAGE
• Although rare and underappreciated, Central causes of
foot drop must be included in the workup once peripheral
causes have been ruled out
• A thorough history and physical examination may reveal
signs of UMN disease, including hyperreflexia, and Babinski
response
• Neurophysiology studies should be included in the workup
and can assist in ruling out peripheral causes
• Most central causes of foot drop(identified on imaging) can
have rather dramatic recovery following resection or
decompression

NEXT CPC MEET
• DEPARTMENT OF GASTROENTEROLOGY
9TH SEPTEMBER 2016

Introduction Department of Neurology CPC

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