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Localization in the Neuraxis
Localization in the Neuraxis
Localization in the Neuraxis
Localization in the Neuraxis
Localization in the Neuraxis
Localization in the Neuraxis
Localization in the Neuraxis
Localization in the Neuraxis
Localization in the Neuraxis
Localization in the Neuraxis
Localization in the Neuraxis
Localization in the Neuraxis
Localization in the Neuraxis
Localization in the Neuraxis
Localization in the Neuraxis
Localization in the Neuraxis
Localization in the Neuraxis
Localization in the Neuraxis
Localization in the Neuraxis
Localization in the Neuraxis
Localization in the Neuraxis
Localization in the Neuraxis
Localization in the Neuraxis
Localization in the Neuraxis
Localization in the Neuraxis
Localization in the Neuraxis
Localization in the Neuraxis
Localization in the Neuraxis
Localization in the Neuraxis
Localization in the Neuraxis
Localization in the Neuraxis
Localization in the Neuraxis
Localization in the Neuraxis
Localization in the Neuraxis
Localization in the Neuraxis
Localization in the Neuraxis
Localization in the Neuraxis
Localization in the Neuraxis
Localization in the Neuraxis
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Localization in the Neuraxis

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  • 1. Localization in the Neuraxis
    • Resident Core Lecture Series
    • David R. Renner, MD
    • University of Utah
    • Department of Neurology
  • 2. The Approach to a Patient with Neurologic Disease
    • The H&P accurately localizes most lesion
    • Divisions of the neuraxis have specialized functions
    • Damage to various divisions produce unique clinical deficits
    • Localization is important
      • investigation modalities differ widely depending upon the level affected
  • 3. Divisions of the Neuraxis
    • Cortical Brain
    • Subcortical Brain
    • Brainstem
    • Cerebellum
    • Spinal Cord
    • Root
    • Peripheral Nerve
    • Neuromuscular Junction
    • Muscle
  • 4. Neurologic Examination
    • Higher Cortical Function
    • Cranial Nerves
    • Cerebellar Function
    • Motor
    • Sensory
    • Deep Tendon Reflexes
    • Pathologic Reflexes
  • 5. Divisions of the Neuraxis
    • Cortical Brain
    • Subcortical Brain
    • Brainstem
    • Cerebellum
    • Spinal Cord
    • Root
    • Peripheral Nerve
    • Neuromuscular Junction
    • Muscle
  • 6. Cortical Brain
    • Depends upon hemispheric dominance
    • Non-neurologists generalize:
      • right: visual/spatial, perception and memory
      • left: language and language dependent memory
    • Through detailed examination, neurologists should lateralize and localize within a lobe
  • 7. Cortical Brain
    • Frontal Lobe :
      • L:
        • Broca’s Aphasia
      • R: ?
      • B:
        • precentral gyrus: motor homunculous
        • supplementary motor cortex: eye and head turn
        • prefrontal cortex: personality, initiative
        • paracentral lobule: cortical inhibition of voiding B/B
  • 8. Cortical Brain
    • Parietal Lobe :
      • R:
        • anosognosia: left hemineglect
        • dressing and constructional apraxia
        • geographic agnosia
      • L:
        • Gerstman’s Tetrad (not triad): L/R confusion, finger agnosia, acalculia, agraphia without alexia
        • Werneke’s Aphasia
  • 9. Cortical Brain
    • Parietal Lobe :
      • B:
        • abnormal posture and passive movement
        • localization of touch
        • 2-point discrimination
        • astereognosis
        • perceptual rivalry
  • 10. Cortical Brain
    • Temporal :
      • R:
        • hearing language
      • L:
        • hearing sounds, rhythm, rhythm, music
      • B:
        • learning and memory: mid/inferior gyri
        • olfaction: limbic
        • Auditory cortex: Heschel’s gyrus
  • 11. Cortical Brain
    • Occipital Lobe :
      • R:
        • micropsia
        • macropsia
      • B:
        • visual hallucinations: elemental and unformed
        • prosopagnosia: familiar faces
        • cortical blindness: striate cortices, normal pupil rx
        • Anton’s: (para)striate, denial of obvious blindness
        • Balint’s: inability to direct voluntary gaze with visual agnosia
  • 12. Neurologic Examination when Cortical Brain is Lesioned
    • Higher Cortical Function
      • aphasia, apraxia, agnosia
    • Cranial Nerves : normal, unless forced eye deviation
    • Cerebellar Function : normal
    • Motor :
      • weakness of face/arm>leg (or vice versa) if motor homunculous is hit
      • hypertonia if corticospinal tracts are hit
    • Sensory :
      • sensory abn of face/arm>leg (or vice versa)
    • Deep Tendon Reflexes :
      • hyper-reflexia
    • Pathologic Reflexes :
      • Babinski’s reflex if corticospinal tracts are hit
      • Frontal release signs (nonspecific), possibly Kernig and/or Brudzinski
  • 13. Divisions of the Neuraxis
    • Cortical Brain
    • Subcortical Brain
    • Brainstem
    • Cerebellum
    • Spinal Cord
    • Root
    • Peripheral Nerve
    • Neuromuscular Junction
    • Muscle
  • 14. Subcortical Brain
    • Deep white radiating fibers produce equal involvement of face/arm/leg
      • weakness
      • sensory abnormalities
    • Visual radiating fibers: (know how visual abnormalities morph with lesions from anterior to posterior brain)
      • deep parietal: bilateral homonomous quad on the floor
      • deep temporal (Meyer’s loop): bilateral homonomous quad in the sky
  • 15. Neurologic Examination when Subcortical Brain is Lesioned
    • Higher Cortical Function : normal
    • Cranial Nerves :
      • visual field cuts
    • Cerebellar Function : usually normal
    • Motor :
      • weakness in face=arm=leg
      • hypertonia
    • Sensory :
      • sensory abnormalities in face=arm=leg
    • Deep Tendon Reflexes :
      • hemi-hyper-reflexia
    • Pathologic Reflexes :
      • Babinski’s reflex if corticospinal tracts are lesioned
      • frontal release signs (nonspecific)
  • 16. Divisions of the Neuraxis
    • Cortical Brain
    • Subcortical Brain
    • Brainstem
    • Cerebellum
    • Spinal Cord
    • Root
    • Peripheral Nerve
    • Neuromuscular Junction
    • Muscle
  • 17. Brainstem
    • CN symptoms characterize BS disease
    • The Brainstem is basically spinal cord with embedded cranial nerves
      • cause symptoms of spinal cord disease, also
      • Long Tract signs: (bilateral and crossed)
        • corticospinal (pyramidal): motor
        • spinothalamic: pain/temp to the thalamus
        • dorsal columns: prioprioception/vibration to thal.
        • (due to decusation of long tracts, BS lesions do not produce horizontal motor/sensory levels as in the cord, but rather vertical levels of hemiparesis/hemidysesthesias)
  • 18. Neurologic Examination when Brainstem is Lesioned
    • Higher Cortical Function : normal
    • Cranial Nerves :
        • III, IV, VI: diplopia
        • V: decreased facial sensation
        • VII: drooping
        • VIII: deaf and dizzy
        • IX, X, XII: dysarthria and dysphagia
        • XI: decreased strength in neck and shoulders
    • Cerebellar Function : usually normal
    • Motor : hemi-paresis (may be crossed), hemi-hypertonia, spasticity
    • Sensory : hemi-dysesthesias (may be crossed)
    • Deep Tendon Reflexes : hemi-hyper-reflexia, brisk jaw jerk
    • Pathologic Reflexes : Babinski’s reflex
  • 19. Divisions of the Neuraxis
    • Cortical Brain
    • Subcortical Brain
    • Brainstem
    • Cerebellum
    • Spinal Cord
    • Root
    • Peripheral Nerve
    • Neuromuscular Junction
    • Muscle
  • 20. Cerebellar Function
    • Some people believe that one can not test specifically for cerebellar abnormalities
      • no one test on examination reliably evaluates the cerebellum
    • H: hypotonia
    • A: assynergy of (ant)agonist muscles
    • N: nystagmus
    • D: dysmetria, dysarthria
    • S: stance and gait
    • T: tremor
  • 21. Neurologic Examination when the Cerebellum is Lesioned
    • Higher Cortical Function : normal
    • Cranial Nerves : usually normal
    • Cerebellar Function :
      • nystagmus
      • flaccid dysarthria
    • Motor :
      • normal bulk and strength with ipsilateral hemi-hypotonia
      • intention worse than positional ipsilateral tremor
      • axial instability with dysmetria
    • Sensory : normal
    • Deep Tendon Reflexes : normal
    • Pathologic Reflexes : normal
      • (plantar flexing to plantar stimulation)
  • 22. Divisions of the Neuraxis
    • Cortical Brain
    • Subcortical Brain
    • Brainstem
    • Cerebellum
    • Spinal Cord
    • Root
    • Peripheral Nerve
    • Neuromuscular Junction
    • Muscle
  • 23. Spinal Cord
    • Sensory level
    • Spasticity/hypertonia
    • Weakness :
      • extensors worse than flexors
      • distal > proximal
    • Bowel and Bladder involvement:
      • retention comes first, then detrusor hyperactivity
      • (both produce incontinence)
  • 24. Neurologic Examination when the Spinal Cord is Lesioned
    • Higher Cortical Function : normal
    • Cranial Nerves : normal
    • Cerebellar Function : normal
    • Motor :
      • weakness (extensors worse than flexors) below the lesion
      • para-hypertonia below the lesion with spasticity
    • Sensory :
      • horizontal level usually lower than the lesion, poorly localizing
      • may be somewhat assymetric
    • Deep Tendon Reflexes :
      • para-hyper-reflexia below the level, possibly clonus
    • Pathologic Reflexes :
      • loss of superficial reflexes (Beavor’s sign, cremasteric, anal wink, etc)
      • Babinski’s reflex
  • 25. Divisions of the Neuraxis
    • Cortical Brain
    • Subcortical Brain
    • Brainstem
    • Cerebellum
    • Spinal Cord
    • Root
    • Peripheral Nerve
    • Neuromuscular Junction
    • Muscle
  • 26. Root/Radiculopathy
    • Pain is the hallmark of a radiculopathy
      • Sensory abnormalities in a dermatome
      • provocative maneuvres exacerbate
      • sharp, stabbing, hot, electric, radiating
    • Weakness in a myotome (assymetric)
      • proximal (C5C6)
      • distal (L5S1)
  • 27. Neurologic Examination when a Root is Lesioned
    • Higher Cortical Function : normal
    • Cranial Nerves : normal
    • Cerebellar Function : normal
    • Motor :
      • assymetric weakness, atrophy, and fasiculations in a myotome
      • tone should be normal, unless multiple roots are severed
    • Sensory :
      • assymetric dysesthesias confined to a dermatome
      • anesthesia requires >1 root transection
    • Deep Tendon Reflexes :
      • hypo- to a-reflexia if the root carries a reflex
    • Pathologic Reflexes :
      • Spurling’s sign
      • dural tension signs may be present (straight leg, crossed straight leg, reverse straight leg, etc)
  • 28. Divisions of the Neuraxis
    • Cortical Brain
    • Subcortical Brain
    • Brainstem
    • Cerebellum
    • Spinal Cord
    • Root
    • Peripheral Nerve
    • Neuromuscular Junction
    • Muscle
  • 29. Peripheral Nerve (presuming nonfocality)
    • Weakness : distal predominant, (a)symetric
    • Sensory Dysesthesias : distal predominant
    • Autonomic involvement may occur
    • Trophic changes : smooth shiny skin, vasomotor abnormalities (edema, temperature dysregulation, vascular flushing), hair loss, nail changes
  • 30. Neurologic Examination with Diffuse PN Lesioning
    • Higher Cortical Function : normal
    • Cranial Nerves :
      • may be abnormal (know which peripheral CN’s associate with specific diseases)
    • Cerebellar Function : normal
    • Motor : weakness is distal predominant if the PN is diffuse
      • atrophy, fasiculations, (hypotonia)
    • Sensory :
      • dysesthesias, anesthesias, hyperpathia, allodynia, etc
    • Deep Tendon Reflexes :
      • distal predominant hypo- to a-reflexia
    • Pathologic Reflexes :
      • mute responses to plantar stimulation
  • 31. Divisions of the Neuraxis
    • Cortical Brain
    • Subcortical Brain
    • Brainstem
    • Cerebellum
    • Spinal Cord
    • Root
    • Peripheral Nerve
    • Neuromuscular Junction
    • Muscle
  • 32. Neuromuscular Junction
    • Fatiguability is the hallmark
    • Weakness : proximal and symmetric
      • exacerbated with use, recovers with rest
      • often affects facial muscles (ptosis, dysconjugate gaze, slack jaw)
      • muscles have normal bulk and tone
    • Sensation : preserved
  • 33. Neurologic Examination in Disorders of the NMJ
    • Higher Cortical Function : normal
    • Cranial Nerves :
      • fatiguability in ptosis, dysconjugate gaze, slack jaw
    • Cerebellar Function : normal
    • Motor :
      • fatiguable proximal weakness in both UE’s and LE’s
      • no atrophy or fasiculations
      • tone may be slightly decreased
    • Sensory :
      • normal, though may complain of lowback pain
    • Deep Tendon Reflexes :
      • may be hypo- to a-reflexic in LEMS
      • may be normal in MG
    • Pathologic Reflexes : none
  • 34. Divisions of the Neuraxis
    • Cortical Brain
    • Subcortical Brain
    • Brainstem
    • Cerebellum
    • Spinal Cord
    • Root
    • Peripheral Nerve
    • Neuromuscular Junction
    • Muscle
  • 35. Muscle
    • Weakness of proximal arm and leg muscles
      • symmetric
    • Sensation is normal
      • though patients complain of cramping, aching, and atrophy
  • 36. Neurologic Examination in Disorders of Muscle
    • Higher Cortical Function : normal
    • Cranial Nerves :
      • ptosis, dysconjugate gaze, slack jaw, bow-string lip, myopathic facies, dysphagia, dysphonia, (dysarthria)
    • Cerebellar Function : normal
    • Motor :
      • usually proximal weakness in both UE’s and LE’s
      • atrophy and fasiculations
      • diffuse hypotonia
      • accentuated primary and secondary curvature, scoliosis
    • Sensory :
      • normal, though may complain of lowback pain
    • Deep Tendon Reflexes : preserved until late in the disease
    • Pathologic Reflexes : ? Myotonia or cramping
  • 37. Just a Few Things to Remember
    • Not all aphasias and apraxias are cortically based
      • thalamus
    • The absence of Babinski’s reflex does not imply a lesion distal to the cord
      • basal ganglia
      • thalamus
      • cerebellum
    • Compromised attention span results from lesioning:
      • brain stem and RAS
      • diencephalon: both sides
      • bilateral cerebral hemispheres
  • 38. Just a Few Things to Remember
    • Some neurologic diseases hit more than one level in the neuraxis
    • The tempo of progression allows one to narrow a differential diagnosis remarkably well . . . Always always always clarify this issue with the patient
    • Parsimony rules
    • Never fabricate part of the exam for sake of being “thorough”
  • 39. Just a Few Things to Remember
    • If you do not think of a complete differential diagnosis, you can not expect to catch the interesting diagnoses.
    • You must think of the possibile accademic diagnoses at this point in your career.
    • Patients pay you to rule out the worst first
    • When you are unsure of a diagnosis, it is important to communicate this to patients and other physicians.

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