Evaluation of Neurologic Deficit Without Apparent Cause: The Importance of a Multidisciplinary Approach

Abstract

Background/Objective: A patient presenting with an acute neurologic deficit with no apparent etiology presents a diagnostic dilemma. A broad differential diagnosis must be entertained, considering both organic and psychiatric causes.Methods: A case report and thorough literature review of acute paraplegia after a low-energy trauma without a discernible organic etiology.Results: Diagnostic imaging excluded any bony malalignment or fracture and any abnormality on magnetic resonance imaging. When no organic etiology was identified, a multidisciplinary approach using neurology, psychiatry, and physical medicine and rehabilitation services was applied. Neurophysiologic testing confirmed the absence of an organic disorder, and at this juncture, diagnostic efforts focused on identifying any psychiatric disorder to facilitate appropriate treatment for this individual. The final diagnosis was malingering. Conclusions:The full psychiatric differential diagnosis should be considered in the evaluation of any patient with an atypical presentation of paralysis. A thorough clinical examination in combination with the appropriate diagnostic studies can confidently exclude an organic disorder. When considering a psychiatric disorder, the differential diagnosis should include conversion disorder and malingering, although each must remain a diagnosis of exclusion. Maintaining a broad differential diagnosis and involving multiple disciplines (neurology, psychiatry, social work, medical specialists) early in the evaluation of atypical paralysis may facilitate earlier diagnosis and initiation of treatment for the underlying etiology.

Acute onset of tetraparesis, arreflexia and respiratory distress in an otherwise healthy male

“…Additionally, it highlights the importance of obtaining a psychosocial history as soon as possible after stabilisation to perhaps mitigate further expensive and potentially invasive testing in patients who may have a psychogenic aetiology of paralysis. It also supports the multidisciplinary approach recommended for evaluation of such patients as advocated by Smith et al 6 and the importance of tools, such as the Spinal Injuries Center test9 to help clinically evaluate patients suspected of having conversion paralysis.…”

“…Case series and reports show a similar variability in the constellation of exam findings. Some cases demonstrate preservation of deep-tendon reflexes in lower extremity paresis with or without loss of bowel and bladder function 5–7. Other reports have demonstrate loss of deep-tendon reflexes with lower extremity paresis 8.…”

Patients with isolated vertigo attack preceding stroke have different clinic characteristics: a retrospective study

“…2D). This difference was even more noticeable for territorial infarction located in posterior cerebellum with a median of 4.84 versus 1.78 cm 3 . By using a receiver operating characteristic (ROC) curve, a cutoff volume of > 3.99 cm 3 for infarction located in the posterior cerebellum was found to be determine IVA from VAH with speci city of 76.2% and sensitivity of 73.4%; AUC (95% CI) = 0.718 (0.615, 0.820), p = 0.002 (Fig.…”

“…However, due to the absence of highly sensitive diagnostic tools, the ability to clinically ascribe transient vertigo symptom to ischemic attack remains limited [1,2]. This holds particularly true when the atypical symptom presented with normal neurologic examination ndings [3] 3 . Therefore, recurrent vertigo attack always misdiagnosed as migraine or Ménierè's disease rather than ischemic events.…”

Local Anaesthesia Systemic Toxicity (LAST) – A Stroke Mimicker

“…Given the absence of any objective findings to explain the patient's neurological deficit, one should consider functional disorder such as conversion disorder. Functional magnetic resonance imaging identifies abnormal brain activity during patient's examination (Smith et al 2007). Other differentials were high cervical cord injury and pontine stroke.…”