International Journal of Neurology and Neurosurgery

(a) Title: Painful diabetic peripheral neuropathy- a current concepts review of clinical examination findings for use in patient selection for treatment and research., (b) Abstract body: Diabetes is a global epidemic and one of the most leading complications of diabetes is peripheral neuropathy. Recent research and clinical practice focus is growing on symptomatic or painful diabetic peripheral neuropathy (PDPN) due to the rising healthcare costs and impending disability. The objective of this review is to elaborate the clinical examination findings in symptomatic PDPN patients. The various clinical examination methods reported in MEDLINE, EMBASE, SCOPUS, Ovid, CINAHL and Google Scholar were searched independently and 66 suitable trials were identified. The selected studies are grouped under each of the clinical examination findings and are described under chief complaints, presenting history, subjective examination, objective examination, investigations and differential diagnosis in the review. Through a thorough history and subjective examination, identification of possible mechanism of neuropathic pain in these patients would facilitate focused objective examination that can again be confirmed using investigations. A proposed clinical decision-making algorithm is presented after this review to base treatment decisions from clinical findings. The clinical examination findings explained in this review would facilitate clinicians, researchers and stakeholders to understand the complex clinical presentation of symptomatic patients with painful diabetic peripheral neuropathy, and to develop better assessment methods in the future for earlier identification of such patients to initiate further management.

Key words: symptoms and signs, diabetic neuropathy, neuropathic pain, assessment.  

An 18 year old female presented with recurrent generalized tonic clonic seizures of four years duration. After the first episode she was evaluated at a local hospital and was detected to have a right parieto-occipital lesion and was advised surgery but she defaulted from treatment. She presented with a 30 day history of headache and vomiting and on examination was alert with stable vital signs. She had left homonymous hemianopia and fundus examination revealed papilledema. She did not have  any other cranial nerve or focal neurological deficits. Her systemic examination was unremarkable. Computerized tomogram of brain showed a large heterogeneous cortical based lesion in the right parietooccipital lobe with enhancing hyper dense irregular wall and central hypodensity suggestive of necrosis. Small area of calcification was seen in the inner wall of the lesion. There was no perilesional oedema. Figure 1A, B). Her magnetic resonance imaging which was done earlier showed a right parieto-occipital lesion which was isodense on T1 weighted sequences, hyperintense on T2 weighted and FLAIR sequences with irregular contrast enhancement. There was no perilesional edema. (Figure 1 C, D)  

A 36 year old lady with possible sporadic Creutzfeldt-Jakob disease which manifested with rapidly progressive cognitive decline and abnormal behaviour, pyramidal, extrapyramidal signs and akinetic mutism. Scalp EEG findings show diffuse slowing of background activity of delta range. MRI brain revealed high signal intensity in bilateral caudate nuclei and putamen on T2WI, FLAIR sequence and DWI. The role of MRI in diagnosis of the CJD is discussed.