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Localising the lesion Ed Hutchison and Paul Swift

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Aims Approach UMN vs. LMN Spinal tracts Cerebellum Cerebrum Visual lesions Cases

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Approach to localising the lesion

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Muscle e.g. diabetic myopathy NMJ e.g. myasthenia gravis Peripheral nerve e.g. GBS Spinal cord e.g. cord compression Cerebrum e.g. Stroke

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Timeline Immediate Intermediate Long-term

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UMN vs. LMN ???

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UMN vs. LMN UMNLMN HyperreflexiaHyporeflexia HypertoniaHypotonia ClonusMuscle wasting No muscle wasting/fasciculationFasciculation Plantars upgoing (lower limbs)Plantars downgoing (lower limbs)

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Pyramidal vs. Extrapyramidal PyramidalExtrapyramidal WeaknessTremor SpasticityChorea Pronator driftHemiballismus Loss of skilled movementAthestosis HyperreflexiaDystonia Change in tone/tendon reflexes Plantars upgoing Loss of abdominal/cremasteric reflex

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Clonus http://www.youtube.com/watch?feature=player_detailp age&v=8GC8F2UMYbQ#t=42

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Facial nerve palsies Bulbar vs. pseudobulbar Pseudobulbar = UMN of CN IX-XII Spastic tongue Sparing of forehead Bulbar = LMN of CN IX-XII Tongue wasting/fasciculation Affects all facial muscles

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The tracts Dorsal column Corticospinal Spinothalamic ? ? ?

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Lateral Spinothalamic Pain and temperature Decussates at the level of the spinal cord

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Anterior Spinothalamic Crude touch and pressure Decussates at the level of the spinal cord

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Dorsal columns Discrimination, proprioception, vibration. Crosses at the medulla. Subacute combined degeneration of the cord, Tabes dorsalis, Spinal trauma.

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Corticospinal Tracts Descending motor tracts. Cross at the medulla.

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Brown-Sequard

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Brainstem Symptoms/signs: Dysarthria Dysphagia/drooling Tongue weakness Absent palatial movement CN IX-XII

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Cerebellum Cerebellospinal tracts Ipsilateral DO NOT CROSS

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Blood Supply

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Cerebellar Signs dysdiadochokinesia ataxia (truncal and limb) nystagmus intention tremor slurred speech hypotonia DANISHDANISH

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Causes Alcohol Thiamine deficiency CVA Friedreichs ataxia Etc etc

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The Homunculus

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Cerebral Artery Territories

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Circle of Willis Anterior cerebral artery Middle cerebral artery Posterior cerebral artery Basilar artery A = ? B = ? ? Anterior spinal artery Vertebral artery

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Speech Centres

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Tono man http://www.youtube.com/watch?v=6CJWo5TDHLE

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Brocas dysphasia http://www.youtube.com/watch?v=1aplTvEQ6ew

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Stroke Syndromes TACS all 3PACS 2 of 3LACSPOCS Hemiplegia/hemi sensory loss See leftNo visual field defect Bilateral motor or sensory Visual field disturbance Pure motorConjugate eye movement disturbance Disturbance in higher function e.g. dyphasia/dysphag ia Pure sensoryCerebellar dysfunction Sensory-motorHemiplegia or cortical blindness Ataxia

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Visual Defects Ipsilateral blindess Bilateral hemianopia Left homonymous hemianopia Left superior quadrantanopia Left homonymous hemianopia with macular sparing

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Cases

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Case 1 57 year old man complaining of weakness and altered sensation in upper limbs and lower limbs Loss of sensation from shoulders and down, urinary incontinence On Examination: CN intact Upper limbs weakness, hypotonia, reduced reflexes Lower limbs spasticity, hyper-reflexia and Babinski +ve, reduced sensation from shoulders down

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Case 2 85 year old man with long standing (20yr) history of balance problems worse in the dark. Gait is high stepping On Examination: CN intact Motor intact Loss of proprioception with +ve Rombergs test

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Case 3 23, female presents to her GP with a 2 week history of bilateral leg weakness having started with pins and needles and numbness in her hands and feet. She has had a few days of urinary incontinence which has resolved. 2 years ago she had an episode of blurred vision and pain in the right eye which lasted a month and fully resolved

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Case 4 56 male 6 month history of progressive weakness of his right hand. Also had problems with swallowing and has choked whilst eating on several occasions o/e he has wasting of his upper and lower limbs and some fasciculation's were noted his right plantar was up going and his reflexes were generally brisk

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Things weve not had time to cover Peripheral neuropathies Motor neurone Parkinsons Huntingtons GBS Myasthenia gravis

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Peripheral Neuropathies A alcohol B B12 deficiency C CKD D drugs/diabetes E every vasculitis