cerebrum clinical presentation

1. THE CEREBRUM (Applied)
Dr. Md. Ziaul Hoque
MD Phase B Student
Department of Neurology

2. Outlines of discussion
• Radiological location of parts of cerebrum
• Lobe wise dysfunctions of cerebrum
• The disconnection syndrome
• Disorders of the cerebrum
• Disorder of speech and language
• Memory disturbance

5. Dominance & Handedness
Left Cerebral
Hemisphere is
dominant in -
– 90-95% Right
handed person
– 60% Left handed
person

6. Dysfunction of different lobes of cerebrum

7. Dysfunction of Frontal Lobe
Unilateral Bilateral
Either right or left Dominant Both
Contralateral hemiplegia Right hemiplegia
Broca’s aphasia
Bilateral hemiplegia
Pseudobulbar palsy
Gaze palsy &
Head turning
Sympathetic apraxia of
left hand
Gait apraxia
Sphincter incontinence
Apathy,
Loss of initiative
Elevation of mood,
Increased talkativeness
etc.
Abulia or
Akinetic mutism
Rigidity of thinking etc
Anosmia Frontal release sign.

8. Dysfunction of Parietal Lobe
Either right or left Dominant Nondominant
Contralateral
hemisensory loss
(Hemianaesthesia)
Bilateral Ideational apaxia Visuospatial disorder
Bilateral Ideomotor apaxia Topographic memory loss
Contralateral
homonymous inferior
quadrantanopia
Alexia without agraphia
(pure word blindness)
Constructional apraxia
Dressing apraxia
Contralateral
Hemineglect
Gerstman syndrome
• Acalculia
• Agraphia
• Right left confusion
• Finger agnosia
Anosognosia
Visual inattention Astereognosis/ Tactile
agnosia
Confusion
Agraphesthesia

9. PARIETAL LOBE DYSFUNCTIONS
• DOMINANT HEMISPHERE:
 Gerstmann’s syndrome

Inferior parietal lobule
Tetrad of-
Finger agnosia
Rt.-Lt.confusion
Acalculia
Agraphia

10. Dysfunction of Temporal Lobe
Unilateral Bilateral
Either Rt or left Dominant Nondominant Both
Contralateral
homonymous superior
quadrantanopia
Wernicke’s
aphasia
Inabilty to
judge spatial
relationship
Amnesia
(Korsakoff
amnesic defect)
Seizure Nominal/anomic
aphasia
Amusia Cortical deafness
Deafness
Auditory, visual,
olfactory and gustatory
hallucination
Pure word
deafness/auditory
verbal agnosia
Agnosia for
sound
Apathy
Delirium-confusional
state
Kluver Bucy
syndrome
Emotional and
behavioral change
Disturbance of time
perception

11. Dysfunction of Occipital Lobe
Unilateral Bilateral
Either Rt or left Dominant Nondominant Both
Contralateral
congruent
homonymous
hemianopia
Alexia
without
agraphia
Visual illusion/
Metamorphosia
Cortical
blindness
Anton
syndrome
Elementary/
unformed
hallucination
Visual
object
agnosia
Visual
halllucination
Balint
syndrome
Hemichromatopsia Loss of
topographic
memory &
visual
orientation
Prosopragnosia
Achromatopsia

12. Clinical Scenario
A 60-years-old diabetic & hypertensive male
Presented with sudden onset of bilateral visual loss.
On examination :
Visual acuity - Reduced to hand movement on both eyes.
Fundoscopy - Normal on both side.
Both direct and consensual light reflex was present bilaterally.

14. OCCIPITAL LOBE DYSFUNCTIONS
BILATERAL OCCIPITAL DISEASE:
Cortical
blindness

15. OCCIPITAL LOBE DYSFUNCTIONS
 Anton’s syndrome
 Baliant’s syndrome
 Achromatopsia

16. Antons syndrome
• Denial of blindness
• Patients act as though they could see
• Collide with object on attempting to walk
• Offer excuse for the difficulties
Lesion extends beyond the striate cortex to involve the visual
association areas.

17. Clinical Scenario
A 50-year-old hypertensive male presented with history of
• Difficulty in seeing objects for last 2 weeks
• Required assistance for daily activities…

18. On examination:
• He had severe difficulty in
– pursuit eye movement on both side and
– reaching out to objects held by the examiner.
• He could recognize a key & a pen individually,
but failed to identify them when presented
simultaneously .

19. Balint syndrome
. A triad of -
(1) Optic ataxia
(2) Oculomotor apraxia
(3) Simultanagnosia.
Cause : Stroke involving bilateral parieto-occipital area of
brain (border zone between Brodmann area 7 & 19)

20. The Disconnection Syndrome

21. The Disconnection Syndrome
• Interregional connections of the cerebrum are required for
all natural sensory and motor functions.
• Lesions of the cerebral connecting pathways are known
as Disconnection syndrome.
• Two types-
– Intrahemispheric
– Interhemispheric

22. Intrahemispheric Disconnection Syndrome
Conduction aphasia
– Fluent paraphasic speech
– Relatively preserved
comprehension
– Severely impaired repetition
Site of Lesion:
Arcuate fasciculus

23. Intra hemispheric Disconnection Syndrome (cont.)
• Pure word deafness :
Lesion in the left superior temporal gyrus
Interruption of connection between
the primary & association auditory cortex,
also with language network resulting-
• Impaired comprehension of spoken words
• Impaired repetition
• No hearing defect
• Nonverbal sound can be heard without difficulty

24. Interhemispheric Disconnection Syndrome
Alexia without agraphia
• Inability to read
• Color anomia & difficulty in copying
word may be present.
• No difficulty in repetition, writtng or
naming objects
Site of Lesion:
Splenium & dominant occipital lobe

25. Interhemispheric Disconnection Syndrome (cont.)
Lesion of the entire corpus callosum
• Unable to match an object held in one
hand with that in the other
• Unable to match objects seen in either
half of visual field
• Unable to name object held in left hand.
• Alexic in left visual field.
Congenital agenesis
of corpus callosum

26. Interhemispheric Disconnection Syndrome (cont.)
Lesion anterior part of
Corpus callosum
(posterior to genu but anterior
to spenium)
– Apraxia of the left sided
limbs.

27. DISORDERS OF CEREBRUM

28. DISORDERS OF CEREBRUM
Vascular diseases:
Ischaemia
Haemorrhage

29. Case scenario
A 77-year- old woman presented with the sudden
onset of left-sided weakness and
numbness.
On examination, in addition to the weakness and
sensory loss, she had a
left homonymous hemianopia and was unaware of
her deficits, denying that there was
anything wrong with her.
Her eyes were deviated to the right.

31. Diffusion-weighted sequences
Importantly, other diseases, such as active
multiple sclerosis (MS) lesions, abscesses, or
tumors such as primary CNS lymphoma can
also demonstrate restricted diffusion.
If there is corresponding hypointensity (referred
to as “drop-out”) on the apparent diffusion
coeffi cient (ADC) map, then the diagnosis is
confirmed in the appropriate clinical setting.
.

32. Ischaemic stroke

33. Haemorhagic stroke

34. Wake up stroke
DWI-FLAIR-mismatch was shown to identify patients
within 3–4.5 h with high specificity and positive
predicted value
PWI-DWI mismatch

37. Case scenario
A 76-year-old man with hypertension and
diabetes underwent a coronary bypass artery
graft that was complicated by severe blood
loss. When he awoke, he was unable to move
his proximal right arm and would not speak
unless he became upset.

38. Watershed strokes

39. Case scenario
A 65-year-old man presented with confusion
and cortical blindness. His blood pressure in
the emergency room (ER) was 231/180.

40. Case scenario

41. Posterior reversible encephalopathy syndrome
PRES
PRES Occurs in the setting of rapid,severe
increases in blood pressure
It presents with a combination of visual loss,
seizures,headaches, and altered mental status.

42. CNS Vasculitis
• Ischemic stroke is the most common CNS
presentation.
• However, patients may suffer from a wide range
of clinical presentations including hemorrhages,
meningitis, and cognitive dysfunction.
• Involvement of the extracranial vessels leads to
headaches, visual loss, jaw claudication, and
cranial tenderness.
• Systemic symptoms such as fever, weight loss,
and malaise

43. CNS Vasculitis

44. Case scenario
• A 30-year-old female presented with double
vision and ataxia.
Three years earlier she had an episode where
she lost vision in her left eye for two weeks.
On examination, she was mildly ataxic, with
brisk reflexes, and both horizontal and vertical
nystagmus.

45. DISORDERS OF CEREBRUM
Demyelinating
MS

46. Case scenario
• An 18-year-old boy presented with seizures
with altered level of consciousness. His
attendent also gives the h/o fever, headache ,
lethargy, myalgia , malaise, fever, and vomiting
for 7 days

47. ADEM

48. CASE SCENARIO
• A 25-year-old woman had repeated episodes
of the sudden onset of fear on unpleasant
odor. These were followed by her losing
consciousness for several minutes and making
bizarre lip-smacking movements.

49. CASE SCENARIO

50. CASE SCENARIO
• A 23-year-old female presented with a cluster
of seizures. She was otherwise healthy. She
had been acting oddly for the past two weeks.
She was thinking that her neighbors were
spying on her. She was found missing two days
prior to her presentation in the emergency
room. The patient was diaphoretic on exam
and appeared paranoid about hospital staff.

51. CASE SCENARIO

52. CASE SCENARIO
• A 30-years-male known case of VSD presented
with headaches and left-sided weakness.

53. CASE SCENARIO

54. CASE SCENARIO
• A 28-year-old man developed Headache
,vomiting , diplopia
O/E
There is left sided abducens nerve palsy with
bilateral Papilledema

55. CASE SCENARIO

56. Case scenario
• A 65-year-old woman presented with
personality changes, paranoia, and confusion
over the course of several months.
On exam, she had mild bilateral papilledema
and weakness of her legs.

57. Case scenario

58. Case scenario
• A 56-year-old man presented to the hospital
with a seizure. He had been complaining of
headaches for the past several months and
becoming “slow” as per family.
• He also noticed that he was “bumping into
things” for the past few months.

59. Case scenario

60. Case scenario
• A 67-year-old man presented with a partial
seizure with secondary generalization.
• His daughter said that he had been
increasingly confused over the past few
weeks.
• He has significant smoking history

61. Case scenario

62. DISORDERS OF CEREBRUM
Traumatic:
Contusion

63. Case scenario
A 72-year-old woman was brought in by her family.
The patient herself said that she felt well, but her
family said that she had been “forgetting
everything” recently.
For example, she would purchase the same
products at the grocery store, forgetting that
she had bought them only several days earlier.
She had also become paranoid, feeling that
someone was moving her glasses and wallet.
She had no awareness of her deficits.

64. DISORDERS OF CEREBRUM
Degenerative:
Alzheimer disease
Pick disease

66. Case scenario
• 50 years old male, presented with complaints
of forgetfulness, talking irrelevantly since last
18 months. Patient developed symptoms of
confusion, ataxia, and altered behaviour 2
years back, for which he was treated as a case
of encephalitis. He later progressed to show
symptoms of amnesia. Neurological
examination revealed MMSE 15/30 ,absent
deep tendon reflexes

68. Case scenario
• A 65-year-old man presented with rapid-onset
dementia.
• On exam, he knew his name, but not his age
or the location. He thought he was in his office
, though he had not worked in several months.
He hada profound startle response to any
unexpected noise..

71. Case scenario
• A 59-year-old woman presented with several
falls.
On examination, she had asymmetric rigidity
with a shuffling gait.
She also developed uncontrolled movements
of her left arm.

72. An 8-year-old boy presented with
progressive dementia, blindness, and
seizures.

73. DISORDERS OF CEREBRUM
Inborn error of metabolism:
Leukodystrophy
Canavan disease

74. Case scenario
• An 8-year-old boy presented with mental
retardation and seizures since infancy. He had
a large “port-wine stain” on his upper face on
the right side.

75. Case scenario
• An 8-year-old child with MR developed
intractable seizures and mental retardation.
• The patient had autistic features and language
delays, but no focal motor or sensory deficits.

76. Case scenario

77. DISORDERS OF CEREBRUM
Developmental Disorders:
Lissencephaly (Agyria)
Pachygyria/Polymicrogyria
Holoprocencephaly (lobar/alobar)
Agenesis of corpus callosum

78. Apraxia
A disorder in which an
attentive patient loss the
ability to execute previously
learned activities in the
absence of weakness, ataxia,
sensory loss or
extrapyramidal derangement
that would be adequate to
explain the deficit
– Ideomotor apraxia
– Ideational apraxia
– Oral buccal lingual
apraxia
– Gait apraxia
– Constructional
apraxia
– Dressing apraxia

79. Disorders of speech and language

80. Disorder of Language

81. Aphasia
Anomic aphasia
Conduction
Transcortical sensory
Wernicke
Transcortical motor
Broca
Mixed transcortical
Global
Aphasia
Fluency
Comprehension
Repetition
+
-
+
-
+
-
+
-
+
-
+
-
+
-

82. Aphasia
Type Fluency Comprehension Repetition Naming
Broca’s Impaired Preserved Impaired Impaired
Wernicke’s Preserved Impaired Impaired Impaired
Global Impaired Impaired Impaired Impaired
Transcortical
motor
Impaired Preserved Preserved Impaired
Transcortical
sensory
Preserved Impaired Preserved Impaired
Isolation Impaired Impaired Preserved Impaired
Conduction Preserved Relatively
Preserved
Impaired Impaired
Anomic/
nominal
Preserved Preserved Preserved Impaired

83. Memory and intellectual disorders

84. • Known as dementia
• Defined by involvement of multiple cognitive
domains (memory, intellect, personality,
affection &mood)
• Causes may be reversible or irreversible
• Manifested by several ways
• Assessed by MMSE
• Treatment according to aetiology
• Prognosis variable

85. Dementia
Reversible causes Irreversible causes
Hypothyriodism
Thiamine deficiency
Vitamin B12 deficiency
Normal pressure hydrocephalus
Subdural hematoma
Chronic infection
Brain tumor
Drug intoxication
Autoimmune encephalopathy
Alzheimer’s
Frontotemporal dementia
Vascular
Parkinson’s
Dementia with lewy bodies
Huntington’s
Leukoencephalopathies

86. THANK YOU