Rapidly Progressing Weakness If a patient has acute onset upper and/or lower extremity weakness (7 days or less), do not miss structural cord compression as this is a neurologic emergency. Obtain STAT MRI of the entire spine without contrast. If there is a history of cancer, obtain the MRI with and without contrast to evaluate for epidural mets. If weakness is hyperacute, get MRI with DWI to assess for spinal cord ischemia. If weakness is <48h, also get CTH and CTA head/neck to rule out basilar artery occlusion. If they are diffusely areflexic/hyporeflexic, also do an LP to evaluate for AIDP. You will also need to order telemetry, NIF/FVC q4h, and start IVIG ideally after serum studies collected unless contraindications. Timing of Symptoms Onset of Symptoms Minutes ago
Hours ago
Days ago
Weeks ago
Months ago
Years ago
Time to nadir Minutes
Hours
Days
Weeks
Months
Years
Location of Weakness Asymmetric
Symmetric
Proximal and symmetric (MG, LEMS, myopathy)
Proximal and distal symmetric (GBS, spinal cord)
Pattern of Weakness Ascending (GBS, spinal cord)
Descending
Descending and involving cranial nerves (Botulism)
Bilateral facial weakness (GBS, myasthenia, botulism, Lyme, HIV, sarcoid, syphilis, severe critical illness)
Location of numbness/tingling if present Symmetric
Asymmetric
Face
Torso
Back
Extremities
Loss of sensation from neck/chest/waist down (spinal cord)
Circumferential truncal sensory loss (spinal cord)
Ventral shield pattern of sensory loss on trunk (GBS)
Differential Diagnosis GBS, MG, LE, etc. Diplopia, dysarthria, dysphagia (Brainstem stroke, GBS, MG, botulism, Bickerstaff encephalitis)
Ocular or EOM involvement (Myasthenia, botulism, less likely LEMS, Miller Fisher/Bickerstaff GBS)
Respiratory symptoms present (GBS, botulism, MG, high cervical lesion)
Preceding viral illness (GBS, para-infectious transverse myelitis)
Altered mental status (ADEM)
Severe muscle pain (Rhabdomyolysis)
Stroke Patient underwent surgery (Peri-operative stroke)
Vascular risk factors with bilateral LE weakness only (Bilateral ACA stroke)
Following aortic aneurysm rupture/repair (Anterior spinal artery infarct)
Spinal Cord Bowel, bladder, sexual dysfunction present (Cauda equina, spinal cord)
Saddle anesthesia present (Cauda equina, conus medullaris of spinal cord)
Autoimmune Lhermittes phenomenon (shooting pain with neck flexion) (Spinal cord)
Upper extremity motor predominant presentation, abdominal pain, neuropsychiatric symptoms (Porphyria neuropathy)
Bleed History of fall/trauma (Compressive spondylotic myelopathy, spinal hematoma)
Current or recent anti-coagulation (Retroperitoneal hematoma)
Bleeding diathesis (Retroperitoneal/spinal hematoma)
Recent lumbar puncture (spinal hematoma)
Hyperacute onset (seconds to minutes) with severe deficits (Brain and/or spine ischemia/hemorrhage)
Symptoms worse with exercise, valsalva, steroids (Spinal dural AV fistula)
Exposure Recent rash and/or tick bite (Tick paralysis, Lyme radiculoneuritis or myelitis)
Recent rash and/or mosquito bite (West Nile myelitis)
Food-borne exposure, IV drug use-particularly black tar heroin, wound (Botulism)
Abdominal symptoms, hair loss, Mees lines (Arsenic motor neuropathy)
Recent heroin use (Heroin myelopathy)
Nitrous oxide abuse (NO induced sub-acute combined degeneration)
Hexane/toluene huffing (Severe toxic polyradiculoneuropathy)
Heavy alcohol use/recent binge (Acute alcohol myopathy)
Severe muscle pain and infection, immobility, trauma, or toxic medication (i.e. statin) or drug exposure (Rhabdomyolysis)
Lead, thallium, arsenic exposure (Heavy metal toxicity)
Recent pharyngitis and/or lymphadenopathy (Diphtheric polyneuropathy)
Received any of the following meds (MG exacerbation) Nutrition/Metabolic Dietary restrictions, gastric bypass, eating disorder, alcoholism, hyperemesis, poor PO intake, chronically ill, chronic hemodialysis (Deficiencies of B1, B12, copper, folate, vitamin E)
Hyponatremia corrected too rapidly or normonatremia in the setting of alcoholism, liver disease, malnourishment (Osmotic demyelination syndrome)
Severe hypo/hypernatremia, hypo/hyperkalemia, hypercalcemia, hypo/hypermagnesemia, hypoglycemia
Hypo/hyperparathyroid (Metabolic)
Hypothyroid (Metabolic)
Hypo/hyperkalemia and prior episodes (Periodic paralysis)
Muscle paralytic in the setting of renal failure (Prolonged neuromuscular junction blockade)
Malignancy Active cancer currently on checkpoint-inhibitor (Checkpoint inhibitor neuromuscular adverse effect)
New constitutional symptoms (Paraneoplastic, Lambert Eaton Myasthenic Syndrome)
Other Sepsis, Organ failure, Receive muscle paralytic, Receive high dose steroids (Critical illness neuropathy/myopathy)
Autonomic symptoms present (GBS, spinal cord lesion above T6, LEMS, botulism, porphyria, amyloidosis)
Prior Workup Respiratory Parameters NIF: _______
FVC: _______
Evaluated by respiratory therapy/speech/PT/OT during the hospitalization
Head CT and CTA head/neck (basilar, ACA occlusion)
CT spine (acute fracture)
CT abdomen/pelvis (RP bleed)
MRI brain w/wo (Stroke, demyelination, cranial nerve involvement, leptomeningeal)
MRI spine w/wo including DWI (Spinal pathology including spinal cord ischemia)
Lumbar puncture
EMG/NCS