Localising the lesion - PowerPoint Presentation

Slide1

Localising the lesion

Ed Hutchison and Paul SwiftSlide2

Aims

Approach

UMN vs. LMN

Spinal tracts

Cerebellum

Cerebrum

Visual lesions

CasesSlide3

Approach to localising the lesion

Be systematic!

…A patient presents with arm weakness…Slide4

Muscle – e.g. diabetic myopathy

NMJ – e.g. myasthenia gravis

Peripheral nerve – e.g. GBS

Spinal cord – e.g. cord compression

Cerebrum – e.g. StrokeSlide5

TimelineSlide6

UMN vs. LMN

???Slide7

UMN vs. LMN

UMN

LMN

Hyperreflexia

Hyporeflexia

Hypertonia

Hypotonia

Clonus

Muscle wasting

No muscle wasting/fasciculation

Fasciculation

Plantars

upgoing

(lower limbs)

Plantars

downgoing

(lower limbs)Slide8

Pyramidal vs. Extrapyramidal

Pyramidal

Extrapyramidal

Weakness

Tremor

Spasticity

Chorea

Pronator

drift

Hemiballismus

Loss of skilled movement

Athestosis

Hyperreflexia

Dystonia

Change

in tone/tendon reflexes

Plantars

upgoing

Loss of abdominal/

cremasteric

reflexSlide9

Clonus

http://

www.youtube.com

/

watch?feature

=player_detailpage&v=8GC8F2UMYbQ#t=42Slide10

Facial nerve palsies

Bulbar vs.

pseudobulbar

Pseudobulbar

= UMN of CN IX-XII

Spastic tongueSparing of foreheadBulbar = LMN of CN IX-XIITongue wasting/fasciculationAffects all facial musclesSlide11
Slide12

The tracts

Dorsal column

Corticospinal

Spinothalamic

?

?

?Slide13

Lateral

Spinothalamic

Pain and temperature

Decussates at the level of the spinal cordSlide14

Anterior

Spinothalamic

Crude touch and pressure

Decussates at the level of the spinal cordSlide15

Dorsal columns

Discrimination, proprioception, vibration.

Crosses at the medulla.

Subacute

combined degeneration of the cord,

Tabes

dorsalis

,

Spinal trauma.Slide16

Corticospinal

Tracts

Descending motor tracts.

Cross at the medulla.Slide17

Brown-SequardSlide18

Brainstem

Symptoms/signs:

Dysarthria

Dysphagia/drooling

Tongue weakness

Absent palatial movement

CN IX-XIISlide19

Cerebellum

Cerebellospinal

tracts

Ipsilateral

– DO NOT CROSSSlide20

Blood SupplySlide21

Cerebellar Signs

–

dysdiadochokinesia

–

ataxia (truncal

and limb)

–

nystagmus

–

intention tremor

–

slurred speech

–

hypotonia

D

A

N

I

S

HSlide22

Causes

Alcohol

Thiamine deficiency

CVA

Friedreich’s

ataxiaEtc etc…Slide23

The HomunculusSlide24

Cerebral Artery TerritoriesSlide25
Slide26

Circle of Willis

Anterior cerebral artery

Middle

cerebral artery

Posterior

cerebral artery

Basilar

artery

A = ?

B = ?

?

Anterior spinal artery

Vertebral arterySlide27

Speech CentresSlide28

Tono man

http://

www.youtube.com

/

watch?v

=6CJWo5TDHLESlide29

Broca’s dysphasia

http://

www.youtube.com

/

watch?v

=1aplTvEQ6ewSlide30

Stroke Syndromes

TACS –

all 3

PACS – 2 of

3

LACS

POCS

Hemiplegia/

hemisensory

loss

See left

No visual field

defect

Bilateral motor or sensory

Visual

field disturbance

Pure motor

Conjugate eye movement disturbance

Disturbance in higher function – e.g.

dyphasia

/dysphagia

Pure sensory

Cerebellar dysfunction

Sensory-motor

Hemiplegia or cortical blindness

AtaxiaSlide31

Visual Defects

Ipsilateral

blindess

Bilateral hemianopia

Left homonymous hemianopia

Left superior

quadrantanopia

Left homonymous hemianopia with macular sparingSlide32

CasesSlide33

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 downSlide34

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 Romberg’s testSlide35

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 resolvedSlide36

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 briskSlide37

Things we’ve not had time to cover

Peripheral neuropathies

Motor neurone

Parkinson’s

Huntington’s

GBSMyasthenia gravisSlide38

Peripheral Neuropathies

A – alcohol

B – B12 deficiency

C – CKD

D – drugs/diabetes

E – every vasculitis