The document outlines the components of a neurological examination, including: 1) Gathering a patient history with details of present illness, past medical history, family history, and socioeconomic status. 2) Performing a physical exam including vital signs, general exam, and focused neurological exam of cranial nerves, motor and sensory systems. 3) Evaluating mental status, cognition, and primitive reflexes. 4) Localizing neurological deficits based on involved pathways, tracts, and regions of the brain or spinal cord.

1. RABIA SALEEM SAFDAR
Postgraduate trainee
Pediatrics Unit I
7/3/20151

2.  History
 General physical examination
 Neurological examination
7/3/20152

3.  Biodata of Patient(name,age,sex,address)
 Chief complaint
 Quality of symptoms
 Mode of onset
 Course since onset
 Frequency of symptoms
 Severity of symptoms
 Precipitating factors if any
 Ameliorating factors like medications
 Pevious diagnostic evaluation
7/3/20153

4.  Prior medical history
 Natal perinatal and postnatal history
 Developmental milestones
 Immunization
 Trauma
 Surgery previously done
 Previously or present medications used
 Any bleeding disorder
 Previous history of any neurological problem
 Previous infection especially involving CNS
7/3/20154

5.  Family History
 Family tree
 Consanguinty
 Relatives having similar problems
 Age and state of health of living relatives
 Age and cuase of death of deceased relatives
7/3/20155

6.  Socioeconomic status
 History of contact of TB
 History of measels
 History of travelling
7/3/20156

7. • Smell
• Visual defect
• Diplopia
• Ptosis
• Hearing disturbance
• Vertigo,
Lightheadedness
• Swallowing difficulty
• Speech disturbance
• Sleep disturbance
• Involuntary
movement
• Weakness
• Gait disturbance
• Incoordination
• Muscle atrophy
• Tremor
• Muscle Cramps
• Bladder/bowel
control
• Weight change
• Pain
• Numbness
• Paresthesia/
aneasthesia
• Headache
• Seizure/syncope
• Memory
• Behavior/Mood
change
• Aphasia
SYSTEMIC INQUIRY RELEVANT TO CNS
7/3/20157

8. Involves review of systems
 Skin
 Eyes ear nose throat
 Respiratory
 Cardivascular
 Gastrointestinal
 Musculoskeletal
 Endocrinology
 Psychiatric
7/3/20158

9.  Higher mental functions
 Systemic review
►Cranial Nerve examination
► Sensory system
►Pyramidal System
► Extrapyramidal System
► Cerebellum
► Evaluation of Speech and Language
7/3/20159

10.  Appearance and behavior
 Level of Consciousness
 Orientation with time and space
 Intelligence level
 Memory
 Thought process
 Primitive reflexes
7/3/201510

11. Level of Consciousness
 Level of consciousness implies awareness of surroundings.
 Consciousness is dependent on the normal functioning of the
reticular activating system, which originates in the pons and
projects to the cortex of bilateral hemispheres via the
thalamus.
 The reticular activating system activates the cortex when one
awakens and inhibits the cortex when in sleep.
 The hypothalamus is also important in maintaining level of
alertness.
7/3/201511

12.  Level of Consciousness
 During brain herniation,compression of the reticular
activating system may produce profound coma
 Metabolic abnormalities such as hyperglycemia or drugs
may produce coma by impairing neuronal function diffusely
within the brain.
7/3/201512

13.  Evaluation of a comatose patient requires
examination of four steps
 Pupils and Fundoscopy
 Ocular movements
 Motor response to pain
 Pattern of breathing
7/3/201513

14.  Pupil Examination
Normal pupils are 3 – 4mm in diameter & equally
bilaterally reactive,constrict briskly & symmetrically
in response to light
7/3/201514

15. PUPIL LESION
Slightly smaller but reactive Early stage of thalmic damage
Fixed dilated(7mm) pupil
( non- reactive)
Oculomotor nerve lesion
Fixed midsized pupils(5mm) Mid brain lesion
Pinpoint pupils(1-1.5mm) Pontine lesion,opioid
overdose
Asymmetrical pupils Normal in 20 % of population
but reactive..
If one pupil is sluggish to react
than the other think mid brain
or oculomotor lesion
7/3/201515

16.  Fundoscopy
To see
 Papilledema:disc margins are blurred,colour of disc
is pink and hyperemic,congested veins
 Optic atrophy: optic disc becomes pale
7/3/201516

17.  Ocular Movements
Check when cervical trauma has been ruled out
Pathway tested: Medial longitudinal fasciculus
Control centers :
 FRONTAL EYE FIELD
 PARAMEDIAN PONTINE RETICULAR FORMATION
Tests performed
1. Doll`s eye maneuver(oculocephalic reflex)
2. Caloric test(irrigation with cold water)
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18. 7/3/201518

19. LESION SYMPTOMS
RIGHT ABDUCENT Right eye cannot look right
RIGHT
PPRF(paramedian
pontine reticular
formation)
Neither eye can look right
LEFT MEDIAL
LONGITUDIONAL
FASCICULUS
Internuclear ophthalmoplegia left eye cannot look right,
Right eye has nystagmus
LEFT FRONTAL EYE
FIELD
Neither eye can look right but slow drift towards left
7/3/201519

20. A patient has the appearance
shown in the diagram below on
attempted gaze to the right. All
other ocular movements are
normal. Where is the lesion?
The abducens nerve innervates the lateral rectus
muscle and mediates lateral gaze. The inability to
abduct the right eye suggests a lesion in the right
abducens nerve.
7/3/201520

21. A patient has the appearance shown in the
diagram below on attempted gaze to the left (A)
or right (B). Convergence is normal. Where is
the lesion?
BILATERAL MEDIAL LONGITUDIONAL FASCICULUS :The patient can
abduct both eyes (lateral gaze is normal), but cannot adduct both
eyes (medial gaze is impaired on voluntary eye movements).
However, both oculomotor nuclei and nerves are intact since
convergence is normal. Thus the lesion is in the medial longitudinal
fasciculus (MLF), and information from the abducens nucleus is not
reaching the oculomotor nucleus to mediate the medial
component of voluntary conjugate gaze.
7/3/201521

22. Cold caloric testing and
appropriate responses when the brainstem is
intact (top) and when a pontine lesion is
present
(bottom) is demonstrated.
Cold water irrigation—nystagmus to
opposite side
Warm water irrigation--- nystagmus to
same side
COWS----cold opposite,warm same
7/3/201522

23.  Motor response to pain
 Look for lateralizing signs such as asymmetry of
movement either spontaneously or to painful stimulation
 Decorticate posturing is characterized by tonic flexion of
the arms and extension of the legs and implies a lesion at
the level of the midbrain
 Decerebrate posturing is manifest as tonic adduction
and extension of the arms and legs and suggests a lesion
at the level of the pons.
7/3/201523

24. Decorticate posturing is
illustrated on the left. Decerebrate
posturing
is on the right.
7/3/201524

25.  Respiratory patterns
 Cheyne-Stokes respiration:respiratory pattern of metabolic
disease.
 Central neurogenic hyperventilation:manifest as rapid
shallow breathing, indicates midbrain dysfunction.
 Cluster or apneustic breathing:suggests pontine injury.
 Ataxic, shallow breathing: results from medullary lesion.
7/3/201525

26. RESPONSE SCORE
EYE OPENING
`Spontaneous 4
To Speech 3
To Painful Stimulus 2
None 1
BEST MOTOR RESPONSE
Obeys Command 6
Localizes Pain 5
Withdrawl 4
Abnormal Flexion 3
Extensor Repnse 2
None 1
BEST VERBAL RESPONSE
Oriented 5
Confused 4
Inaappropriate words 3
Incomprehensible words 2
None 1
7/3/201526

27. RESPONSE SCORE
EYE OPENING
`Spontaneous 4
To Speech 3
To Painful Stimulus 2
None 1
BEST MOTOR RESPONSE
Obeys Command 6
Localizes Pain 5
Withdrawl 4
Abnormal Flexion 3
Extensor Repnse 2
None 1
BEST VERBAL RESPONSE
Smiles oriented to sounds,follows objects 5
Crying interactcs 4
Consolable inappropriate 3
Inconsistently consolable Moaning 2
No response 1
7/3/201527

28.  Primitive reflexes
 Primitive reflexes are automatic stereotypic
movements directed from the brainstem and require
no cortical involvement (thought).
 Must be abated in order for proper neurological
organization of the brain to develop.
7/3/201528

29. Causes of retained Primitive Reflexes
 Children born via cesarean section
 Trauma
 Toxicity exposure
 Anesthetics
 Early walkers
 Head injuries
 Excessive falls
 Chronic ear infections
7/3/201529

30. 7/3/201530

31. 7/3/201531

32. 7/3/201532

33.  12 pairs of cranial nerves
 3 Types
 SENSORY I , II, VIII
 MOTOR III, IV, VI, XI, XII
 MIXED V,VII,IX,X
7/3/201533

34. NO NAME FUNCTION
I OLFACTORY Smell
II OPTIC Sight
III OCULOMOTOR Eye movements except lateral rectus and
sup.oblique
IV TROCHLEAR Superior oblique
V TRIGEMINAL Mastication,facial sensations
VI ABDUCENT Lateral rectus
VII FACIAL Fascial movements taste ant 2/3rd of tongue
VIII VESTIBULOCOCHLEAR Hearing,balance
XI GLOSSOPHARYNGEAL Taste from post.1/3rd of tongue,caritid bodyand
baroreceptors,parotid,pharyngeal muscles
X VAGUS Taste from epiglottic area,swalloing,palate
elevation,abd viscera
XI ACESSORY Head turning,shuolder shrugging
XII HYPOGLOSSAL Tongue movements
7/3/201534

35. CRANIAL NERVE NUCLEI LOCATION
I and II Directly goes to cerebral
cortex
III,IV midbrain
V,VI,VII and VIII pons
IX,X,XI,XII medulla
7/3/201535

36. You are testing the blink reflex on your patient. When
you touch a piece of cotton to the right eye, both
eyelids close in a blink. When you touch the left eye,
neither eye closes. Which of the following cranial
nerves is involved in a lesion?
Left trigeminal. The trigeminal nerve (CN 5) is the afferent arm of
the blink reflex (corneal reflex) and the facial nerve (CN 7) is
the efferent arm. If there is a lesion of left CN 5, sensation of
touching the cornea will not be conveyed centrally, and
neither eye will blink.
7/3/201536

37. 7/3/201537

38. Reflexes Afferent Efferent
Corneal V (i) VII
Jaw jerk V (iii) sensory V (iii) motor
Gag IX IX , X
pupillary II III
CRANIAL NERVE REFLEXES
7/3/201538

39. Direct & consensual
light reflexes –
Pathway
7/3/201539

40. Direct & consensual light reflexes – Pathway
7/3/201540

41. Cornea or Conjunctiva
↓
Ophthalmic branch of the TGN
↓
Main sensory ganglion of the TGN
↓
Internuncial neurons connect with the motor nucleus of the facial
nerve on Both sides (Through the medial longitudinal fasciculus)
↓
Facial nerve
↓
Orbicularis oculi of both sides
↓
Closure of the eyelids
Corneal reflex : Light touching of the cornea or conjunctive results in blinking of the
eye lids
7/3/201541

42.  Accommodation reflex
When the eyes are directed from a distant object to
a near object:
 Medial recti contracts (Brings convergence)
 Lens thickens to increase the refractory power by
contracting ciliary muscles
 Pupils constrict to restrict light waves to the thickest
central part of the lens
7/3/201542

43. Accommodation reflex
7/3/201543

44. WHAT IS THE LESION?
WHERE IS THE LESION?
Left sided facial palsy, LMN type lesion
7/3/201544

45. 7/3/201545

46. LOCALIZATION OF LESIONS OF
7/3/201546

47.  Sensory modalities
 Superficial sensation
 light touch
 pain
 temperature sensibility
 Deep sensation
 joint and vibratory sensibility
 pain from deep muscle and ligamentous structures
7/3/201547

48.  Neuroanatomical pathways
 Spinothalmic tract
 Lateral spinothalamic tract(pain, temp)
 Anterior spinothalamic tract(touch ,pressure)
 Dorsal column tract(position,vibration)
7/3/201548

49. Tract 1st order
neuron
Synapse 1 2nd order neuron Synapse 2 3rd order
neuron
Dorsal
column
Sensory
nerve
ending―cell
body in
dorsal root
ganglion―
ascend ipsi -
lateral in
spinal cord
Ipsilateral
nucleus cuneatus
n gracilis
Decussate in
medulla―ascend
contralaterally in
medial leminiscus
VPL of
thalmus
Sensory
cortex
7/3/201549

50. Tract 1st order
neuron
Synapse 1 2nd order
neuron
Synapse
2
3rd
order
neuron
Anterolateral
Spinothalmic
tract
Sensory nerve
ending―cell
body in dorsal
root
ganglion—
enters spinal
cord
Ipsilateral
grey matter
of spinal
cord
Decussate
and ascend
contralaterall
y
VPL
Of
thalmus
Sensory
cortex
7/3/201550

51. 7/3/201551

52.  Peripheral nerve lesion
 Isolated nerve palsy(Mononeuropathy)
 Mononeuritis multiplex
 Sensory peripheral neuropathy(polyneuropathy)
 Root lesion
 Spinal cord
 Brainstem
 Thalamus
 Cortex
7/3/201552

53.  Isolated nerve palsy(Mononeuropathy)
Sensory loss is in the distribution of that
nerve invoved.
Example
 Ulnar nerve lesion(sensory loss is over the medial
one and a half fingers both anteriorly and posteriorly)
7/3/201553

54. Sensory distribution of the
ulnar nerve .
7/3/201554

55.  Mononeuritis multiplex
Combinations of peripheral nerve lesions
occur, usually caused by nerve infarcts
secondary to vasculitis or diabetic
vasculopathy.
7/3/201555

56.  Sensory peripheral neuropathy
 Disease affecting peripheral nerves may affect the
Schwann cell myelin sheath (demyelinating neuropathy)
or the nerve axons (axonal neuropathy).
 Peripheral neuropathy characteristically symmetrical
and greater distally than proximally(gloove and
stocking pattern).
7/3/201556

57.  Sensory peripheral neuropathy
 In any peripheral nerve or root lesion the sensory or motor
arc of the deep tendon reflex can be interrupted leading to
diminished or absent deep tendon reflexes.
 Distal reflexes (ankle) are diminished more than proximal
reflexes (biceps).
7/3/201557

58.  Root lesion(Rediculopathy)
The location of common root paresthesias are
 C-5 shoulder region;
 C-6 thumb;
 C7 middle finger;
 C-8 5th finger;
 L-4 knee
 L-5great toe
 S-1 medial sole of the foot
7/3/201558

59. 7/3/201559
SYMPTOMS OF NERVE ROOT LESION

60. 7/3/201560

61.  Spinal cord
 Ascending and descending pathways are interrupted
sensation is usually diminished distal to the lesion
 Localizing signs would be
 Localized root pain
 Sensory loss below the level of the lesion,
 An absent root reflex at the level of the lesion
 Increased reflexes below this level.
7/3/201561

62.  Common cord syndromes are:
 Brown-Séquard syndrome
 Central cord syndrome (cervical)
 Complete cord transection
7/3/201562

63. 7/3/201563

64. Cortic
ospina
l
Tract
(moto
r)
Dorsal
Column
(Joint
Position
sense
light
touch)
Pyramidal
Tract
Weaknes
Absent
Position
&
Vibration
sense
Absent pain
& temperature
Brown-Séquard syndrome
• ipsilateral plegia below the
lesion
• ipsilateral proprioception
and light touch loss below the
lesion
• contralateral pain and
temperature loss below the
lesion
7/3/201564

65. Central cord syndrome (cervical)
• shawl distribution pain and
temperature loss
• sparing of light touch and
proprioception
• lower motor neuron weakness
of the affected cord levels
(anterior horn cell involvement)
Shawl
distribution
pain &
temperature
loss if anterior
horn
cells involved
get flaccid
weakness of
involved
levels.
Lesion involved
crossing pain and
temperature fibers
in the
anterior commisure
7/3/201565

66. Complete cord transection.
• loss of all modalities below
the level of the lesion
7/3/201566

67. Neurological examination revealed:
---paralysis and increased DTRs of left leg
---loss of vibration and proprioception of left leg
---loss of pain and temperature sensation in the right leg
Where is the lesion?
This is an example of the Brown-Sequard syndrome (hemisection of the spinal
cord). Tracts involved in a lesion of the left spinal cord involve (1) the left
corticospinal tract, which will synapse with lower motor neurons in the left
limbs; (2) the left dorsal column containing primary sensory neurons for
vibration and proprioception from the left limbs; and (3) the left spinothalamic
tract containing secondary sensory neurons for pain and temperature sensation
coming from the right limbs (the pain/temperature neurons cross at the level of
entry in the anterior commissure after synapsing in the dorsal horn).
7/3/201567

68.  Brainstem
Brainstem lesions at the level of the medulla has:
 Ipsilateral loss of pain and temperature of the face
 Contralateral loss on the body.
 Light touch and proprioceptive loss is contralateral
 Above this level all sensory modality findings are
contralateral to the side of the lesion because all pathways
have crossed.
7/3/201568

69.  Thalamus
 Thalamic lesions produce contralateral loss of all sensory
modalities in the face,extremities and trunk.
 Stimulation may be perceived as uncomfortable and
painful(dysesthesia).
7/3/201569

70.  Cortical lesions
 Lesions of the cerebral cortex cause diminution of all sensory
modalities on the contra lateral side of the body.
 In addition, higher integrative sensory functions are impaired
causing defects in stereo gnosis, two-point discrimination etc
7/3/201570

71. Lesion FINDINGS
Peripheral nerve All sensory modalities are affected.
The borders are sharply demarcated.
There may be hyperesthesia, discomfort and pain
Root All sensory modalities are affected.
Sensory loss is vague but in a dermatomal distribution.
Pain is present and may radiate in the dermatome
distribution.
Spinal cord There is sensory dissociation.
A unilateral lesion produces ipsilateral loss of light touch
and proprioception and contralateral loss of pain and
temperature
SUMMARY
Characteristics of sensory system lesions
7/3/201571

72. Lesion Findings
Medulla There is sensory dissociation.
Pain and temperature are lost on the ipsilateral side of the
face and contralateral side of the body.
Light touch and proprioception are lost on the contralateral
side of the body.
Upper brainstem There is sensory dissociation.
All sensory modalities are now crossed and on the same side.
Unilateral lesions cause contralateral loss of sensory
modalities
Thalamus Sensory dissociation is no longer present.
Ipsilateral lesions produce contralateral loss of all modalities.
Cerebral cortex Sensory dissociation is absent.
Ipsilateral lesions produce contralateral loss of all modalities.
Discriminative sensory functions are lost.
7/3/201572

73. LOCALIZATION OF LESIONS OF
7/3/201573

74. Tract 1st order
neuron
Synapse 1 2nd order
neuron
Synapse 2 D
E
S
C
E
N
D
I
N
G
T
R
A
C
T
Lateral
Corticospinal
tract
UMN:
Cell body in
motor cortex
descend s
ipsilaterally
through
internal
capsule until
decussate at
pyramid and
descends
contralaterally
Cell body of
anterior horn of
spinal cord
LMN
leaves
Spinal cord
Neuro-
muscular
junction
7/3/201574

75. 7/3/201575

76.  Inspection and observation
 Muscle tone
 Muscle power
 Tendon reflexes
 Co-ordination
 Gait
7/3/201576

77. Inspection and observation
 Size and bulk of muscle
 Any obvious wasting
 Visible fasciculations
 Position of the limb
 General body posture
 Scar marks or lacerations
 Ulceration
 Swelling
 Hip: Internaly rotated in anterior dislocation of hip
Externaly rotation-posterior dislocation of hip
7/3/201577

78.  Muscle tone
The resistance of a muscle against the passive
movement of the joint
Assessed by
 Observing the position of the extremities at rest
 By pulpating the musle belly
 Determining the resistance against passive stretch
7/3/201578

79.  Hypertonia
 Spasticity: consists of an increase in tone that affects different
muscle groups to different extent.
 Rigidity: consists of increased resistance to passive movement
that is independent of direction of movement i-e it effects the
flexors as well as extensors equally.
 Hypotonia : defined as reduced resistance to the passive
movement-the distal portion of the limb is easily waved when limb
is shaken to and fro.
 Paratonia: it seems to be rigidity when the examiner moves
the limb rapidly but normal tone when the limb is moved slowly.
7/3/201579

80.  Muscle power
Checked in individual muscles and compared on both sides so that
the minor degree of weakness can be recognized
Grading of muscle power according to MEDICAL RESEARCH COUNCIL
Grade Muscle power
5 Normal power
4 Active movement against resistance and gravity
3 Active movement against gravity not resistance
2 Active movement possible only with gravity eliminated
1 Flicker or trace of movements
0 No movement
7/3/201580

81.  Tendon Reflexes
 Superfial reflexes
 Planter reflex
 Abdominal reflex
 Anal reflex
 Cremasteric reflex
 Deep tendon reflexes
 Knee jerk
 Ankle jerk
 Biceps jerk
 Supinator jerk
 Triceps jerk
7/3/201581

82. SUPERFICIAL REFLEXES
REFLEX HOW
EXCITED
CLINICAL
RESULT
LEVEL OF
CORD
PLANTAR REFLEX Scrathing laterally
on sole of foot
Flexion of big
toe(downward
movement)
L5 ,S1
SCAPULAR REFLEX Scrathing skin in
intrascapular region
Contraction of
scapular muscles
C 5 to T 1
ABDOMINAL
REFLEX
Scrathing on
abdominal wall
below costal margin
and in iliac fossa
Contraction of
abdominal muscles
T 7 to T 12
ANAL REFLEX Scratching near anus Contraction of anal
sphincter
S3, S4
CREMESTERIC
REFLEX
Stoking skin at
upper and inner
thigh
Upward movement
of testes
L1,L2
7/3/201582

83. REFLEX SEGMENTAL
INNERVATION
NERVE
KNEE REFLEX L3,L4 Femoral
BICEPS JERK C 5,C 6 Musculocutaneous
BRACHIORADIALIS
JERK
C 5, C6 Radial
TRICEPS JERK C 7,C8 Radial
ANKLE JERK S 1,S 2 Tibial
JAW JERK Pons Mandibular branch
of trigeminal nerve
7/3/201583

84. 0 ABSENT
1 PRESENT (as normal ankle jerk)
2 BRISK
3 VERY BRISK
4 CLONUS
7/3/201584

85.  Coordination
 Finger nose test
 Heel Knee test
7/3/201585

86. 7/3/201586

87.  Gait Disturbances in Pyramidal Tract Lesions
 HEMIPLEGIC GAIT:Patient does not lift his leg off the
ground so that toes remain in contact with ground.Leg
swings forward and outward in a circular fashion(ONLY ONE
LEG INVOVED)
 SPASTIC GAIT (Scissor Like Gait)
Patient don’t lift his feet from the ground UMN paraplegia
7/3/201587

88. SIGN UMN lesion LMN lesion
Weakness Present Present
Atrophy Absent Present
Fasciculations Absent Present
Reflexes Brisk Dimished
Tone Increase Decrease
Babinski Upgoing Downgoing
Spastic paralysis Present Absent
UMN lesions may ipsilateral or contralateral while LMN lesions are usually
ipsilateral. 7/3/201588

89. Cardinal features
 Weakness or paralysis
 Spasticity
 Brisk reflexes
 Upgoing plantars
 Loss of superficial abdominal reflexes
7/3/201589

90. Sites
 Motor cortex
 Internal capsule
 Brain stem
 Spinal cord
7/3/201590

91.  Lesion of motor cortex results in monoplegia
 Specific menifestations are present according
to the lobes involved
7/3/201591

92. 7/3/201592

93. 7/3/201593

94. 7/3/201594

95. LOBES IMPORTANT
REGIONS
DEFICIT AFTER LESION
FRONTAL LOBE Primary motor
cortex
Contralateral spastic paresis(area of
homonculus affected),premotor:apraxia
Frontal eye field Eye deviation to ipsilateral side
Broca`s area Expressive aphasia
Prefrontal cortex Frontal lobe syndrome:poor
judement,difficulty in
concentrating,inappropriate social
behaviour
PARIETAL LOBE Primary
somatosensory
Contralateral hemihypesthesia
Superior parietal
lobule
Contralateral asteriognosis,apraxia
Inferior parietal
lobule
Contralateral hemianopia, rt n lft confusion
(dominant)alexia,dyscalculia,unilateral
neglect(non- dominant)
7/3/201595

96. LOBES IMPORTANT REGION DEFICIT AFTER LESION
TEMPORAL Primary auditory cortex Deafness :bilateral
damage
Wernick s area Receptive aphasia
Hippocampus Bilateral lesion leads to
poor short term and long
term memory
Olfactory bulb Ipsilateral anosmia
Mayer loop Contralateral upper
quadrantanopia
OOCIPITAL Primary visual cortex Cortical blindness with
macular sparing
7/3/201596

97. Internal capsule lesion
 Produces dense hemiplegia and facial nerve palsy of
opposite side(uncrossed hemiplagia)
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98. 7/3/201598

99. Characteristics of internal capsule lesion:
1- Hemi-plegia i.e. paralysis of the muscles present in
the opposite side of the body due to damage of
pyramidal and extra- pyramidal tracts fibers.
2- Hemi-anesthesia i.e. loss of all sensations from the
opposite side of the body due to damage of sensory
radiation.
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100. 3- Hemi-anopia i.e. loss of vision in the opposite halves
of visual fields of both eyes. So, lesion in the right
internal capsule leads to loss of vision in the left
halves of visual fields of both eyes. It is due to
damage of optic radiation.
4- Decrease hearing; it is due to damage of auditory
radiation. No deafness because each ear is bilaterally
represented in the cerebral cortex.
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101.  Brain stem lesion produces crossed hemiplegia i-e
cranial nerve is affected on one side and the
hemiplegia of the opposite side
 If 3rd nerve is involved. Lesion is in mid-brain
 If 6th and 7th nerve is involved,lesion is in pons.
 If 9th and 10th nerves are involved, lesion is in
medulla
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102.  Spinal cord
 Whenever there is a lesion of spinal cord ,there will
be UMN signs below the level of lesion
 Upper limb involved ---- above C 5
 Absent abdominal reflexes----- above T 8
 Specific sensory level is always present
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103. Cardinal features
 Weakness or paralysis
 Wasting of individual muscles
 Hypotonia
 Diminished tendon jerks
 Downgoing plantars
 Fasciculations
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104.  Sites
 Nuclei of cranial nerves
 Anterior horn cells
 Nerve roots
 Nerves(crania and peripheral)
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105.  Cranial nerves: Produces paralysis of muscles supplied
by the cranial nerves and LMN type of lesion of cranial
nerve
 Anterior horn cell : paraparesis or quadriparisis
 Root: muscle supplied by root is paralysed
 Single peripheral nerve :muscle supplied by that
nerve is paralysed
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106. 7/3/2015106