Principles of Neurological Diagnosis 1. Localization 2. Etiology.
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Transcript of Principles of Neurological Diagnosis 1. Localization 2. Etiology.
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Principles of Neurological Diagnosis
1. Localization2. Etiology
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Example 1 A 25 YO male, acute paraparesis
with urinary incontinence, severe LBP:
Localization: spinal cord Etiology: acute disc herniation
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Example 2 A 75 YO female with diabetes and
HBP, sudden weakness of left side limbs
Localization: right hemisphere Etiology: intracerebral hemmorhage
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Gross Anatomy of the CNS
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Subsystems for this talk Motor system Sensory system Visual and ocular Blood supply
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Motor system Lower motor neuron Upper motor neuron (origin of the corticospinal tract) Brainstem nuclei that project to the cord Basal ganglia Cerebellum Premotor frontal cortex Prefrontal cortex
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Lower motor neuron Motor unit Fasciculation Weakness & atrophy Root – plexus – nerve
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Upper motor neuron
Origin at prerolandic motor cortex
Humunculus, somato-topic arrangement
Posterior capsule Isolated movements
evoked by electrical stimulation
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Paralysis due to UMN lesion
Weakness distribution (additional systems, crossed syndromes, sparing of midline bilateral muscles)
‘Classic UMN’ picture: spasticity, increased tendon reflexes, positive Babinski’s, (spinal shock)
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Patterns of paralysis
Monoplegia without atrophy Monoplegia with atrophy Hemiplegia Paraplegia Tetraplegia
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Cortico BulbarTract
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Basal ganglia
Negative signs: hypokinesia, bradykinesia
Positive signs: involuntary movements
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Extrapyramidal Clinico-Pathological Correlations
SymptomMorbid anatomy
Unilateral Rigidity + TremorContralat Substantia Nigra
Unilateral hemibalismusContralat subthalamic nuc (Luis)
choreaCaudate and putamen
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Cerebellar dysfunction Incoordination – ataxia (dysmetria, dysdiadochokinesis) Intention tremor Dysarthria (slurred speech) Nystagmus Disordered gait and equilibrium
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Sensory system
Skin or visceral sense organs Distribution by nerve, root,
CNS Primary afferent (DRG) Spinal tracts:
Dorsal columns Spinothalamic Spinocerebellar
Thalamus and cortex Descending analgesic tract
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Dorsal Columns
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Sensory dysfunction
Positive - paresthesia, pain, allodynia, hyperalgesia
Negative – hypesthesia, anesthesia, analgesia
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Symptoms and Signs in Neurology
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MotorFasciculationInvoluntary Movement
Weakness paralysis
Hypotonia
SensoryParesthesia, pain, allodynia,
hyperalgesia
Hyp/anesthesiaHyp/analgesia
AutonomicHyperhydrosisDiarrhea
ImpotenceOrthostatism
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Visual system Retina, optic nerve, chiasm, tract, radiation, cortex
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Ocular movements
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Blood supply
Circle of Willis
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MRA of the Circle of Willis
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Middle cerebral artery
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Ant & Post Cerebral Arteries
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Exercise I
30 YO man, weakness of right lower limbOn exam:Weak, spastic, hyper-reflexic right legLoss of touch on Rt legLoss of pain and temp. on Lt legHemi-Sensory level D8
Spino DorsalThalamic Columns
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Exercise II
70 YO female, weakness of right side, speech difficulty
On exam: Rt hemiparesis Motor
dysphasia
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Exercise III
60 YO male, Rt side weakness
On exam: Rt hemi-
paresis Lt facial
weakness