A presentation introducing medical students who have just finished their basic sciences years to clinical neurosciences.

1. AN INTRODUCTION
TO CLINICAL NEUROSIENCES
WALID MAANI
PROFESSOR OF NEUROSURGERY
08/18/12 FOURTH YEAR LECTURE 1

2. IT IS VERY DIFFICULT TO
DO
THIS IN ONE HOUR
08/18/12 FOURTH YEAR LECTURE 2

3. PRESENTATON OF CENTRAL NERVOUS
SYSTEM PROBLEMS
• HOW DO CRANIAL LESIONS PRESENT?
• HOW DO SPINAL PROBLEMS PRESENT?
08/18/12 FOURTH YEAR LECTURE
3

4. PRESENTATION OF CRANIAL LESIONS
SULCI
THIS IS HOW THE
INTRACRANIAL
CONTENTS ARE VENTRICLE
ARRANGED AS SEEN
ON MAGNETIC CHOROID PLEXUS
RESONANCE MIDLINE
IMAGING (MRI)
T1 WEIGHTED MRI
08/18/12 FOURTH YEAR LECTURE
4

5. PRESENTATION OF CRANIAL LESIONS
 SUDDEN:
 CEREBRO-VASCULAR ACCIDENTS
 INTRACEREBRAL HEMORRHAGE
 SUBARACHNOID HEMORRHAGE
 INFARCTION
 TRAUMA
 RAPID:
 INFECTION
 GRADUAL:
 NEOPLASTIC LESIONS
08/18/12 FOURTH YEAR LECTURE
5

6. PRESENTATION OF CRANIAL LESIONS
 SUDDEN:
CEREBRO-VASCULAR ACCIDENTS
INTRACEREBRAL HEMORRHAGE
SUBARACHNOID HEMORRHAGE
INFARCTION
TRAUMA
 RAPID:
INFECTION
 GRADUAL
NEOPLASTIC LESIONS
08/18/12 FOURTH YEAR LECTURE
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7. INTRACEREBRAL HEMORRHAGE
08/18/12 FOURTH YEAR LECTURE
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8. INTRACEREBRAL HEMORRHAGE
 MAY CAUSE DEATH
 MAY CAUSE LOC
 DESTRUCTION OF BRAIN AREA
PRESENTS WITH:
 SUDDEN HEADACHE
 SUDDEN PARALYSIS
 SPEECH PROBLEMS
 SENSORY DISTURBANCES
 VISUAL DISTURBANCES
08/18/12 FOURTH YEAR LECTURE
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9. PRESENTATION OF CRANIAL LESIONS
 SUDDEN:
CEREBRO-VASCULAR ACCIDENTS
INTRACEREBRAL HEMORRHAGE
SUBARACHNOID HEMORRHAGE
INFARCTION
TRAUMA
 RAPID:
INFECTION
 GRADUAL
NEOPLASTIC LESIONS
08/18/12 FOURTH YEAR LECTURE
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10. SUBARACHNOID HEMORRHAGE
08/18/12 FOURTH YEAR LECTURE
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11. SUBARACHNOID HEMORRHAGE
 MAY CAUSE DEATH
 SUDDEN HEADACHE
 LOC
 EPILEPSY
 NECK RIGIDITY
 MAY BE ASSOCITAED
WITH PARALYSIS IF
ACCOMPANIED BY
INTRACEREBRAL
HEMORRHAGE
08/18/12 FOURTH YEAR LECTURE
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12. PRESENTATION OF CRANIAL LESIONS
 SUDDEN:
CEREBRO-VASCULAR ACCIDENTS
INTRACEREBRAL HEMORRHAGE
SUBARACHNOID HEMORRHAGE
INFARCTION
TRAUMA
 RAPID:
INFECTION
 GRADUAL
NEOPLASTIC LESIONS
08/18/12 FOURTH YEAR LECTURE
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13. INFARCTION
08/18/12 FOURTH YEAR LECTURE
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14. INFARCTION
 MAY BE ISCHAEMIC
 MAY BE HEMORRHAGIC
 MAY BE UN-NOTICED
 LOC
 EPILEPSY
 DESTRUCTION OF BRAIN:
 PARALYSIS
 SPEECH PROBLEMS
 VISUAL PROBLEMS
 SENSORY PROBLEMS
08/18/12 FOURTH YEAR LECTURE
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15. PRESENTATION OF CRANIAL LESIONS
 SUDDEN:
CEREBRO-VASCULAR ACCIDENTS
INTRACEREBRAL HEMORRHAGE
SUBARACHNOID HEMORRHAGE
INFARCTION
TRAUMA
 RAPID:
INFECTION
 GRADUAL
NEOPLASTIC LESIONS
08/18/12 FOURTH YEAR LECTURE
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16. TRAUMA
EXTRADURAL HEMATOMA BRAIN CONTUSION
08/18/12 FOURTH YEAR LECTURE
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17. TRAUMA
 HISTORY OF TRAUMA
 DEATH
 LOC
 EPILEPSY
 PARALYSIS
 SPEECH PROBLEMS
 VISUAL PROBLEMS
08/18/12 FOURTH YEAR LECTURE
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18. PRESENTATION OF CRANIAL LESIONS
 SUDDEN:
CEREBRO-VASCULAR ACCIDENTS
INTRACEREBRAL HEMORRHAGE
SUBARACHNOID HEMORRHAGE
INFARCTION
 RAPID:
INFECTION
 GRADUAL
NEOPLASTIC LESIONS
08/18/12 FOURTH YEAR LECTURE
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19. INFECTION
THE UNDERSURFACE OF THE BRAIN IN MENINGITIS
08/18/12 FOURTH YEAR LECTURE
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20. INFECTION
 GRADUAL
 FEVER
 LETHARGY
 NECK RIGIDITY
 LOC
 EPILEPSY
 PARALYSIS
 DEATH
08/18/12 FOURTH YEAR LECTURE
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21. PRESENTATION OF CRANIAL LESIONS
 SUDDEN:
CEREBRO-VASCULAR ACCIDENTS
INTRACEREBRAL HEMORRHAGE
SUBARACHNOID HEMORRHAGE
INFARCTION
 RAPID:
INFECTION
 GRADUAL
NEOPLASTIC LESIONS
08/18/12 FOURTH YEAR LECTURE
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22. NEOPLASTIC LESIONS
BRAIN METASTASES BRAIN GLIOMA
08/18/12 FOURTH YEAR LECTURE
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23. NEOPLASTIC LESIONS
 GRADUAL
 EPILEPSY
 PARALYSIS
 SENSORY PROBLEMS
 SPEECH PROBLEMS
 VISUAL PROBLEMS
 BALANCE PROBLEMS
 BEHAVIOUR CHANGES
08/18/12 FOURTH YEAR LECTURE
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24. THE NORMAL PICTURE
T1 WEIGHTED MRI T2 WEIGHTED MRI
08/18/12 FOURTH YEAR LECTURE
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25. NOW IMAGINE IF WE ADD SOMETHING
ELSE TO THE CONTENTS
DISPLACED BRAIN OEDEMA
MIDLINE BRAIN OEDEMA
THE ORIGINAL DEFORMED
MIDLINE VENTRICLE
TUMOR MASS TUMORS
MENINGIOMA ON MRI T2 MULTIPLE LESIONS ON CT
08/18/12 FOURTH YEAR LECTURE
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26. ADDITION OF NEW CONTENTS
• INCREASE IN THE INTRACRANIAL PRESSURE
• IRRITATION OF THE AREA
• PRESSURE ON THE AFFECTED AREA
• DESTRUCTION OF THE AFFECTED AREA
• OBSTRUCTION OF THE CSF PATHWAYS
• HORMONAL PROBLEMS
08/18/12 FOURTH YEAR LECTURE
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27. INCREASE IN THE INTRACRANIAL PRESSURE
• SYMPTOMS:
• HEADACHE
• VOMITING
• VISUAL PROBLEMS
• INCREASE IN THE SIZE OF THE HEAD
08/18/12 FOURTH YEAR LECTURE
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28. INCREASE IN THE INTRACRANIAL PRESSURE
• SYMPTOMS: IS A MORNING
• HEADACHE HEADACHE WHICH
• VOMITING RESPONDS TO
• VISUAL PROBLEMS SIMPLE ANALGESIA. IT
• INCREASE IN THE SIZE DOES NOT INDICATE
OF THE HEAD TYPE OF PROBLEM
08/18/12 FOURTH YEAR LECTURE
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29. INCREASE IN THE INTRACRANIAL PRESSURE
IS A MORNING
• SYMPTOMS: VOMITING AND IS
• HEADACHE
PROJECTILE IN
• VOMITING
NATURE. IT RESEMBLES
• VISUAL PROBLEMS
•
MIGRAINE VOMITING
INCREASE IN THE SIZE
OF THE HEAD OR THE VOMITING
ASSOCIATED WITH
PREGNANCY
08/18/12 FOURTH YEAR LECTURE
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30. INCREASE IN THE INTRACRANIAL PRESSURE
COULD BE IN THE
• SYMPTOMS: FORM OF BLURRED
• HEADACHE
VISION OR DECREASED
• VOMITING
ACUITY OR FIELD
• VISUAL PROBLEMS
•
DEFECT IN ONE OR
INCREASE IN THE SIZE
OF THE HEAD BOTH EYES. DEFECTS
CAN INDICATE SITE OF
PATHOLOGY
08/18/12 FOURTH YEAR LECTURE
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31. INCREASE IN THE INTRACRANIAL PRESSURE
• SYMPTOMS: THIS OCCURS
• HEADACHE
ONLY IN CHILDREN
• VOMITING
BECAUSE THE
• INCREASE IN THE SIZE
OF THE HEAD CRANIAL SUTURES
HAVE NOT UNITED
YET.
08/18/12 FOURTH YEAR LECTURE
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32. INCREASE IN THE INTRACRANIAL PRESSURE
IS SWELLING OF THE
• SIGNS OPTIC DISC AND
• PAPILLOEDEMA IS SEEN BY
OPHTHALMOSCOPY
NORMAL FUNDUS
08/18/12 PAPILLOEDEMA LECTURE
FOURTH YEAR 32

33. IRRITATION OF THE AREA
THERE ARE MANY FORMS
THIS LEADS TO OF EPILEPSY:
EPILEPSY IF THE GRAND MAL
LESION IS ON THE PETIT MAL
PARTIAL COMPLEX
SURFACE OF THE
ETC.
CEREBRUM. THE CORTEX EPILEPSY MAY LEAD TO:
MUST BE IRRITATED TO SUFFOCATION
PRODUCE EPILEPSY TEMPORARY PARALYSIS
(TODD’S) OR
PERMANENT BRAIN
DAMAGE
08/18/12 FOURTH YEAR LECTURE
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34. PRESSURE ON THE AFFECTED AREA
or
tum val
e of o
• DEPENDS ON WHETHER: Sit r rem
a fte
• SUPRATENTORIAL
• INFRATENTORIAL
08/18/12 FOURTH YEAR LECTURE
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35. PRESSURE ON THE AFFECTED AREA
DESTRUCTION OF THE AFFECTED AREA
• SUPRATENTORIAL:
• FRONTAL
• TEMPORAL
• PARIETAL
• OCCIPITAL
• INFRATENTORIAL:
• LATERAL
• MIDLINE
08/18/12 FOURTH YEAR LECTURE
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36. PRESSURE ON THE AFFECTED AREA
DESTRUCTION OF THE AFFECTED AREA
 SUPRA TENTORIAL LESIONS:
 FRONTAL LOBE AFFECTION:
DISTURBANCE OF ORIENTATION
BEHAVIORAL CHANGES
SPHINCTER PROBLEMS
MOTOR SYMPTOMS ON THE OPPOSITE SIDE
08/18/12 FOURTH YEAR LECTURE
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37. PRESSURE ON THE AFFECTED AREA
DESTRUCTION OF THE AFFECTED AREA
 TEMPORAL LOBE AFFECTION:
EXPRESSIVE DYSPHASIA OR APHASIA
VISUAL FIELD DEFECTS
SENSORY SYMPTOMS ON THE OPPOSITE
SIDE
MOTOR SYMPTOMS ON THE OPPOSITE SIDE
08/18/12 FOURTH YEAR LECTURE
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38. PRESSURE ON THE AFFECTED AREA
DESTRUCTION OF THE AFFECTED AREA
 PARIETAL LOBE AFFECTION:
 RECEPTIVE DYSPHASIA OR APHASIA
 SENSORY SYMPTOMS ON THE OPPOSITE SIDE
 MOTOR SYMPTOMS ON THE OPPOSITE SIDE
 ASTEREOGNOSIS
 LACK OF TWO POINT DISCRIMINATION
 SPATIAL DISORIENTATION
 FINGER AGNOSIA
08/18/12 FOURTH YEAR LECTURE
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39. PRESSURE ON THE AFFECTED AREA
DESTRUCTION OF THE AFFECTED AREA
 OCCIPITAL LOBE AFFECTION:
 VISUAL FIELD DEFECTS
(HOMONYMOUS HEMIANOPIA)
08/18/12 FOURTH YEAR LECTURE
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40. PRESSURE ON THE AFFECTED AREA
DESTRUCTION OF THE AFFECTED AREA
 INFRATENTORIAL TUMORS
 ATAXIA
 NYSTAGMUS
 OBSTRUCTION OF CSF
FLOW
TOP:
MEDULLOBLASTOA
BOTTOM:
ASTROCYTOMA
08/18/12 FOURTH YEAR LECTURE
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41. DESTRUCTION COULD RESULT FROM
OCCLUSION OF A MAJOR ARTERY
 INTERNAL CAROTID ARTERY
ANTERIOR CEREBRAL
MIDDLE CEREBRAL
 BASILAR ARTERY
POSTERIOR CEREBRAL
08/18/12 FOURTH YEAR LECTURE
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42. DESTRUCTION COULD RESULT FROM OCCLUSION
OF A MAJOR ARTERY
 INTERNAL CAROTID ARTERY
ANTERIOR CEREBRAL
MIDDLE CEREBRAL
 BASILAR ARTERY
POSTERIOR CEREBRAL
08/18/12 FOURTH YEAR LECTURE
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43. DESTRUCTION COULD RESULT FROM
OCCLUSION OF A MAJOR ARTERY
• CONTRALATERAL
 INTERNAL CAROTID
HEMIPLEGIA
ARTERY
• MILD SENSORY DEFICIT
 ANTERIOR CEREBRAL
 MIDDLE CEREBRAL
• MENTAL CONFUSION
 BASILAR ARTERY • CLOUDING OF THE
 POSTERIOR CEREBRAL CONSCIOUSNESS
08/18/12 FOURTH YEAR LECTURE
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44. DESTRUCTION COULD RESULT FROM
OCCLUSION OF A MAJOR ARTERY
 INTERNAL CAROTID • COMA
 ARTERY • CONTRALATERAL
 ANTERIOR CEREBRAL
FLACCID HEMIPLEGIA
 MIDDLE CEREBRAL
• HEMIANESTHESIA
 BASILAR ARTERY
• HEMIANOPIA
 POSTERIOR CEREBRAL
• MOTOR APHASIA
• SENSORY APHASIA
08/18/12 FOURTH YEAR LECTURE
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45. DESTRUCTION COULD RESULT FROM
OCCLUSION OF A MAJOR ARTERY
 INTERNAL CAROTID
ARTERY
 ANTERIOR CEREBRAL • CONTRALATERAL
 MIDDLE CEREBRAL HEMIANESTHESIA
 BASILAR ARTERY • CONTRALATERAL
 POSTERIOR CEREBRAL HOMONYMOUS
HEMIANOPIA
• SENSORY APHASIA
08/18/12 FOURTH YEAR LECTURE
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46. OBSTRUCTION OF CSF PATHWAYS
WILL LEAD TO DILATATION OF THE
VENTRICULAR SYSTEM AND SIGNS AND
SYMPTOMS OF
INCREASED INTRACRANIAL PRESSURE.
SEEPAGE
OF CSF DILATED
VENTRICLES
NORMAL ABNORMAL
08/18/12 FOURTH YEAR LECTURE
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47. OBSTRUCTION OF CSF PATHWAYS
IN INFANTS AND LITTLE
CHILDERN IT WILL
LEAD TO ENLARGMENT OF
THE HEAD DUE TO THE
FACT THAT SUTURES
ARE NOT CLOSED.
HYDROCEPHALUS COULD
BE OBSTRUCTIVE OR
COMMUNICATING
08/18/12 FOURTH YEAR LECTURE
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48. OBSTRUCTION OF CSF PATHWAYS
BESIDE ENLARGMENT OF THE HEAD,
DILATATION OF THE VENTRICULAR SYSTEM
WILL LEAD TO DETERIORATION OF THE
LEVEL OF CONSCIOUSNESS.
ASSESSMENT OF THE LOC IS DONE GENERALLY
BY THE USE OF THE GLASGOW COMA SCALE
(GCS)
08/18/12 FOURTH YEAR LECTURE
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49. OBSTRUCTION OF CSF PATHWAYS
THE GLASGOW COMA SCALE
Points Eye Opening Best Verbal Response Best Motor Response
6 Follows command
5 Appropriate Localizes pain
4 Inappropriate Withdraws
3 To voice Moaning Flexion
2 To pain Incomprehensible Extension
08/18/12 FOURTH YEAR LECTURE
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50. THE GLASGOW COMA SCALE
• A NORMAL PERSON WOULD SCORE 15
• 6 FROM FOLLOWING COMMAND
• 5 FROM APPROPRIATE VERBAL RESPONSE
• 4 FROM SPONTANEOUS EYE OPENING
• A DEAD PERSON SCORES 3
• 1 FROM NO MOTOR RESPONSE
• 1 FROM NO VERBAL REPONSE
• 1 FROM NO EYE OPENING
08/18/12 FOURTH YEAR LECTURE
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51. HORMONAL PROBLEMS
USUALLY IN PROBLEMS OF THE PITUITARY
GLAND OR THE PINEAL BODY.
INCREASE PITUITARY SECRETION LEADS TO:
 ACROMEGALLY
 GIGANTISM
 GALACTORRHOEA
 AMENORRHOEA
DECREASED SECRETION LEADS TO:
HYPOPITUITRISM
08/18/12 FOURTH YEAR LECTURE
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52. HORMONAL PROBLEMS
USUALLY IN PROBLEMS OF THE PITUITARY
GLAND OR THE PINEAL BODY.
INCREASE PITUITARY SECRETION LEADS TO:
 ACROMEGALLY
 GIGANTISM
 GALACTORRHOEA
 AMENORRHOEA
DECREASED SECRETION LEADS TO:
HYPOPITUITRISM
08/18/12 FOURTH YEAR LECTURE
52

53. HORMONAL PROBLEMS
DUE TO THE OVER
SECRETION OF THE
GROWTH HORMONE
AFTER THE EPIPHYSIS
HAD UNITED:
 INCREASE NOSE SIZE
 INCREASE HAND SIZE
 INCREASE FEET SIZE
 INCREASE JAW SIZE
08/18/12 FOURTH YEAR LECTURE
53

54. HORMONAL PROBLEMS
USUALLY IN PROBLEMS OF THE PITUITARY
GLAND OR THE PINEAL BODY.
INCREASE PITUITARY SECRETION LEADS TO:
 ACROMEGALLY
 GIGANTISM
 GALACTORRHOEA
 AMENORRHOEA
DECREASED SECRETION LEADS TO:
HYPOPITUITRISM
08/18/12 FOURTH YEAR LECTURE
54

55. HORMONAL PROBLEMS
DUE TO THE OVER
SECRETION OF THE
GROWTH HORMONE
BEFORE THE EPIPHYSIS
HAD UNITED.
08/18/12 FOURTH YEAR LECTURE
55

56. HORMONAL PROBLEMS
USUALLY IN PROBLEMS OF THE PITUITARY
GLAND OR THE PINEAL BODY.
INCREASE PITUITARY SECRETION LEADS TO:
 ACROMEGALLY
 GIGANTISM
 GALACTORRHOEA
 AMENORRHOEA
DECREASED SECRETION LEADS TO:
HYPOPITUITRISM
08/18/12 FOURTH YEAR LECTURE
56

57. EXAMPLES OF PITUITARY LESIONS
08/18/12 FOURTH YEAR LECTURE
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58. PRESENTATION OF SPINAL LESIONS
• SUDDEN:
• VASCULAR ACCIDENTS
• INTRASPINAL HEMORRHAGE
• INFARCTION
• RAPID:
• INFECTION
• DEMYLINATION
• GRADUAL:
• NEOPLASTIC LESIONS
08/18/12 FOURTH YEAR LECTURE
58

59. PRESENTATION OF SPINAL LESIONS
 SPINAL CORD LESIONS
LOSS OF POWER BELOW THE LEVEL
LOSS OF SENSATION BELOW THE LEVEL
LOSS OF SPHINCTERIC CONTROL
 ROOT LESIONS
PAIN ALONG A ROOT
LOSS OF POWER IN A MUSCLE OR GROUP
LOSS OF SENSATION IN A DERMATOME
LOSS OF A REFLEX OR REFLEXES
LOSS OF SPHINCTERIC CONTROL
08/18/12 FOURTH YEAR LECTURE
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60. PRESENTATION OF SPINAL LESIONS
 ACUTE PRESENTATION  CHRONIC PRESENTATION
 LOSS OF POWER  LOSS OF POWER
 LOSS OF SENSATION  LOSS OF SENSATION
 HYPOTONIA  HYPERTONIA
 DECREASED REFLEXES  INCREASED REFLEXES
 MUTE PLANTER REFLEX  EXTENSOR PLANTER
REFLES ( BABINISKI)
08/18/12 FOURTH YEAR LECTURE
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61. PRESENTATION OF CORD LESIONS
EXAMPLE OF A
SPINAL CORD LESION
(TUMOUR)
INTRADURAL SPINAL
CORD TUMOR ON T2
WEIGHTED
MRI
08/18/12 FOURTH YEAR LECTURE
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62. PRESENTATION OF ROOT LESIONS
EXAMPLE OF A
SPINAL ROOT LESION
(PROLAPSED DISC)
PROLAPSED DISC ON
T1
WEIGHTED MRI
08/18/12 FOURTH YEAR LECTURE
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