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This material is for group discussion on Clinical Neuroanatomy.
Lecturer : dr. Gregory Budiman, M.Biomed
Medical Faculty, University of Indonesia

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  1. 1. CASE STUDY ON CLINICAL NEUROANATOMY ANSWERS TO CASE STUDIES Lecturer : dr. Gregory Budiman, M.Biomed Medical Faculty, University of Indonesia
  2. 2. Case 1 <ul><li>Mr. Y,forty years of age,had a car accident and was rushed to ER. The patient was still conscious but he could not t walk. The paralysis was found at the right hand and leg. On examination, hematoma was conspicuously found at the back of the neck. The patient could not sense any pain on his left side of the body from his leg to the base of his neck. His right eye was spotted to develop pupil constriction, ptosis and enophtalmus. </li></ul>
  3. 3. Keywords <ul><li>Paralysis of the right leg and right arm </li></ul><ul><li>Loss of pain sensation from foot upto base of the neck at the left </li></ul><ul><li>Right eye: pupillary constriction, ptosis, and enophthalmus. </li></ul>
  4. 4. Where was the possible location of the patient's nerve lesion? <ul><li>Based on areas of dermatoma, patient had loss of pain up to base of the neck. The possible location of lesion: spinal cord segments C4-T1. </li></ul><ul><li>The paralysis is on the right side, so the lesion is at spinal cord on the right side. </li></ul>
  5. 5. Spinothalamicus Fasciculus gracilis dan cuneatus The damaged pathways Sensory: -Spinothalamic tract (pain, temperature, tenderness to the touch) derived from the right side of the body. -Fasciculus gracilis and cuneatus (proprioceptive and discriminative) derived from the right side of the body.
  6. 6. LMN LMN UMN Motor: -Lower motor neurons to the muscles at segments C4-T1. -Corticospinal tract to the muscles below segment T2 on the right side.
  7. 7. <ul><li>Tendon reflexes </li></ul><ul><li>- Reflex of right biceps: negative due to damaged LMN. </li></ul><ul><li>-Reflex of right patella: </li></ul><ul><ul><li>At the beginning : negative due to spinal shock </li></ul></ul><ul><ul><li>After 2-3 weeks : ++++ (strongly positive) due to normal LMN and disconnected inhibition pathway. </li></ul></ul>
  8. 8. DISCRIMINATIVE EXAMINATION OF TWO POINTS: -Left leg could discriminate the two points pressed on the skin -Right leg could not discriminate the two points pressed on the skin.
  9. 9. HORNER SYNDROME: PUPILLARY CONSTRICTION, PTOSIS, ENOPHTALMUS - Damage of sympathethic innervation to the head area at the superior cervical ganglions has caused ptosis and enophthalmus. -Damage of sympathethic innervation leads to excessive parasympathetic work causing pupil constriction.
  10. 10. Sympathetic innervation to the head region : Ggl cervicalis superior m. Levator palpebrae m. Dilatator pupillae Gld. lacrimalis Plexus caroticus Gld.parotis Gld submandibularis Gld. sublingualis Cornu intermediolateralis Segmen T1
  11. 11. CASE 2: <ul><li>A patient that is examined by an ophtalmologist reveals the following symptoms: </li></ul><ul><ul><li>The pupil reflex is negative when the left eye is highlighted by a flashlight. </li></ul></ul><ul><ul><li>The accomodative reflex is positive . When the patient sees approaching objects, the axis of his eyeballs becomes convergent and pupils constrict. </li></ul></ul>
  12. 12. Key words <ul><li>Pupillary reflex: negative  no pupillary constriction </li></ul><ul><li>Accomodation reflex: positive  pupillary constriction, thickening of the lens, and convergence of eye axis </li></ul>
  13. 15. Location of lesion: area pretectal (pupil argyll Robertson).
  14. 16. CASE 3: <ul><li>A patient has paralysis of the facial muscle so that his mouth is retracted to the left. Both of his eyes can still be closed even though his right eye contraction has weakened. He has developed paralysis of his right hand but both of his legs can still be moved normally. </li></ul>
  15. 17. Keywords <ul><li>Paralysis of right facial muscles </li></ul><ul><li>Both of eyes can still closed </li></ul><ul><li>Paralysis of the right arm </li></ul><ul><li>Both of legs are normal </li></ul>
  16. 18. THE POSSIBILITY OF LESION FORMATION: -At cerebral cortex, due to the same locations of the facial and hand muscle paralysis. -The damaged area is the vascularized area of a. cerebri media.
  17. 19. M Orbicularis Oculi is bilaterally innervated whereas the facial muscles under the orbital area are contralaterally innervated .
  18. 20. TYPES OF PARALYSIS: - Facial muscles, the type of paralysis: UMN -Reflex of cornea: positive, normal. -Arm muscles,the type of paralysis: UMN, reflex of biceps: ++++ -Both were exposed to UMN damage in the motoric area of the cerebral cortex.
  19. 21. CASE 4: <ul><li>A patient has developed paralysis of the facial muscles causing retraction of his mouth to the left and his right eye can not be closed. His leg and hand muscles have developed paralysis on the left side. </li></ul>
  20. 22. Keywords <ul><li>Paralysis of right facial muscles </li></ul><ul><li>Right eye cannot be closed </li></ul><ul><li>Paralysis of left leg and left arm </li></ul>
  21. 23. LMN LMN UMN SITES OF LESIONS: - At the brainstem (pons), on the right side due to the paralysis of the facial muscle paralysis on the right side. -The paralysis of the extremity muscles on the left side a hemiplegi alternans.
  22. 24. THE DAMAGED PATHWAYS: -Corticospinal tracts going to the left arm and leg. -Corticobulbar tracts going to medulla oblongata (Nucl.N.XII) on the left side. -Lower motor neurons, nucleus n. VII. TYPES OF PARALYSIS: -Facial muscles: type of paralysis: UMN -Tongue muscles: (N.XII) type of paralysis: UMN -Leg and arm muscles,type of paralysis: UMN.