WHERES THE LESION?Neuroscience Core LectureAnwar Wardy, MD.NeuDepartment of NeurologyFKK UMJfkk umj 2011anwar wardy wWhy,. Sign and Symptom!!!

anwar wardy w

ALL OF COMPLAINTS NEUROLOGIC IN ORIGINWheres the lesion, ???? somewhere in the neuraxis.fkk umj 2011anwar wardy w

anwar wardy w

DIVISIONS OF THE NEURAXISCortical BrainSubcortical BrainBrainstemCerebellumSpinal CordRootPeripheral NerveNeuromuscular JunctionMusclefkk umj 2011anwar wardy w

anwar wardy w

OFF THE TOP OF MY HEAD . . .Imbalance = Cerebellum

Pneumonia = Brainstem (related dysphagia)

Loss of Dexterity = Peripheral Nervefkk umj 2011anwar wardy w

anwar wardy w

NEUROLOGIC EXAMINATIONHigher Cortical FunctionCranial NervesCerebellar Function MotorSensoryDeep Tendon ReflexesPathologic Reflexesfkk umj 2011anwar wardy w

anwar wardy w

THE NEURO EXAM SHOULD EVALUATE THE ENTIRE NEURAXISHigher Cortical Function: cortexCranial Nerves: subcortex, brainstemCerebellar Function: cerebellumMotor: motor homonculous, subcortical pyramidal tracts, BS, cord, radicle, PN, muscleSensory: ascending tracts, thalamus, subcortical tracts, sensory hononculousDeep Tendon Reflexes: afferent PN, radicle, cord, efferent PN, musclePathologic Reflexes:fkk umj 2011anwar wardy w

anwar wardy w

SCOTTS EXAM SHOWED:Higher Cortical Function: normalCranial Nerves: oropharyngeal dysarthriaCerebellar Function: hypotonia, assynergy, dysmetria, staccato dysarthria, intention tremor, appendicular ataxiaMotor: hypotonia, normal strengthSensory: decreased vibration and temperatureDeep Tendon Reflexes: areflexiaPathologic Reflexes: plantar flexing

fkk umj 2011anwar wardy w

anwar wardy w

SO WHERES THE LESION?fkk umj 2011anwar wardy w

anwar wardy w

Goals of MD TestingLocalizationSeverityNerveNMJAnterior HornMuscleFiber typePathologyTemporal courseAdapted from fig 1-2, Preston and Shapirofkk umj 2011anwar wardy w

anwar wardy w

fkk umj 2011anwar wardy w

anwar wardy w

fkk umj 2011anwar wardy wMAJOR FUNCTIONSBRAIN COMPONENTCerebral cortexBasal nucleiThalamusHypothalamusCerebellumBrain stem(midbrain, pons,and medulla)

anwar wardy w

CORTICAL BRAINDepends upon hemispheric dominance

Non-neurologists generalize:right: visual/spatial, perception and memoryleft: language and language dependent memory

Look for aphasias, apraxias, and agnosiasfkk umj 2011anwar wardy w

anwar wardy w

NEUROLOGIC EXAMINATION WHEN CORTICAL BRAIN IS LESIONEDHigher Cortical Function: aphasia, apraxia, agnosiaCranial Nerves: normalCerebellar Function: normalMotor: weakness if you hit the motor homonculousSensory: sensory abnormalities if you hit the sensory homonculousDeep Tendon Reflexes: hemi-hyper-reflexiaPathologic Reflexes: possibly Babinskis reflex or frontal release signsfkk umj 2011anwar wardy w

anwar wardy w

PRIMARY SOMATOSENSORY CORTEXLocated in the postcentral gyrus, this area:Receives information from the skin and skeletal musclesExhibits spatial discriminationSomatosensory homunculus caricature of relative amounts of cortical tissue devoted to each sensory functionfkk umj 2011anwar wardy w

anwar wardy w

PRIMARY MOTOR CORTEXLocated in the precentral gyrusComposed of pyramidal cells whose axons make up the corticospinal tracts Allows conscious control of precise, skilled, voluntary movementsMotor homunculus caricature of relative amounts of cortical tissue devoted to each motor functionfkk umj 2011anwar wardy w

anwar wardy w

NEUROLOGIC EXAMINATION WHEN BRAINSTEM IS LESIONED Higher Cortical Function: normalCranial Nerves:III, IV, VI: diplopiaV: decreased facial sensationVII: droopingVIII: deaf and dizzyIX, X, XII: dysarthria and dysphagiaXI: decreased strength in neck and shouldersCerebellar Function: normalMotor: hemi-paresis, UMNSensory: hemi-dysesthesiasDeep Tendon Reflexes: hemi-hyper-reflexiaPathologic Reflexes: Babinskis reflex fkk umj 2011anwar wardy w

anwar wardy w

CEREBELLAR FUNCTIONSome people believe that one can not test specifically for cerebellar abnormalitiesno one test on examination reliably evaluates the cerebellumH: hypotoniaA: assynergy of (ant)agonist musclesN: nystagmusD: dysmetria, dysarthriaS: stance and gaitT: tremorfkk umj 2011anwar wardy w

anwar wardy w

NEUROLOGIC EXAMINATION WHEN THE CEREBELLUM IS LESIONEDHigher Cortical Function: normalCranial Nerves: normalCerebellar Function:nystagmusstaccato dysarthria (abnormality of prosody)Motor: hemi-hypotoniaintention > positional tremoraxial instability with dysmetriaSensory: normalDeep Tendon Reflexes: normalPathologic Reflexes: nonefkk umj 2011anwar wardy w

anwar wardy w

SPINAL CORDSensory level (horizontal)Weakness below the lesion (paraparesis)UMN signs below the lesion Bowel and bladder incontinencefkk umj 2011anwar wardy w

anwar wardy w

NEUROLOGIC EXAMINATION WHEN THE SPINAL CORD IS LESIONEDHigher Cortical Function: normalCranial Nerves: normalCerebellar Function: normalMotor: weakness below the lesionSensory: horizontal levelDeep Tendon Reflexes: hyper-reflexia below the lesionPathologic Reflexes: Babinskis reflexfkk umj 2011anwar wardy w

anwar wardy w

ROOT/RADICULOPATHYPain is the hallmark of a radiculopathySensory abnormalities in a dermatomeprovocative maneuvres exacerbate the painWeakness in a myotome (assymetric)LMN findings

fkk umj 2011anwar wardy w

anwar wardy w

NEUROLOGIC EXAMINATION WHEN A ROOT IS LESIONEDHigher Cortical Function: normalCranial Nerves: normalCerebellar Function: normalMotor: assymetric weakness in a myotomeSensory: pain and dysesthesia confined to a dermatomeDeep Tendon Reflexes: hypo- to a-reflexia if the root carries a reflexPathologic Reflexes: nonefkk umj 2011anwar wardy w

anwar wardy w

PERIPHERAL NERVE(PRESUMING NONFOCALITY)Weakness: distal predominantSensory Dysesthesias: distal predominant

fkk umj 2011anwar wardy w

anwar wardy w

NEUROLOGIC EXAMINATION WITH DIFFUSE PN LESIONINGHigher Cortical Function: normalCranial Nerves: normalCerebellar Function: normalMotor: weakness is distal predominant Sensory: dysesthesias are distal predominantDeep Tendon Reflexes: loss of distal reflexesPathologic Reflexes: mute responses to plantar stimulationfkk umj 2011anwar wardy w

anwar wardy w

NEUROMUSCULAR JUNCTIONFatiguability is the hallmarkWeakness: proximal and symmetricexacerbated with use, recovers with restoften affects facial muscles (ptosis, dysconjugate gaze, slack jaw)Sensation: preservedfkk umj 2011anwar wardy w

anwar wardy w

NEUROLOGIC EXAMINATION IN DISORDERS OF THE NMJHigher Cortical Function: normalCranial Nerves: fatiguabile ptosis, dysconjugate gaze, slack jawCerebellar Function: normalMotor: fatiguable proximal weakness in both UEs and LEsSensory: normalDeep Tendon Reflexes: normalPathologic Reflexes: nonefkk umj 2011anwar wardy w

anwar wardy w

MUSCLEWeakness of proximal arm and leg musclessymmetricSensation is normalthough patients complain of cramping and achingfkk umj 2011anwar wardy w

anwar wardy w

NEUROLOGIC EXAMINATION IN DISORDERS OF MUSCLEHigher Cortical Function: normalCranial Nerves: ptosis, dysconjugate gaze, dysphagia, dysphonia, (dysarthria)Cerebellar Function: normalMotor: proximal weakness in both UEs and LEs, atrophy and fasiculations, hypotoniaSensory: normalDeep Tendon Reflexes: preserved until late in the diseasePathologic Reflexes: nonefkk umj 2011anwar wardy w

anwar wardy w

THANK UWassalam, Wr Wbr

Jakarta, January 11Anwar Wardy Wfkk umj 2011anwar wardy w

anwar wardy w

*TABLE 5-1: Overview of Structures and Functions of the Major Components of the Brain.*TABLE 5-1: Overview of Structures and Functions of the Major Components of the Brain.