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Ed Hutchison and Paul Swift

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1 Ed Hutchison and Paul Swift
Localising the lesion P Ed Hutchison and Paul Swift

2 Aims Approach UMN vs. LMN Spinal tracts Cerebellum Cerebrum
Visual lesions Cases P

3 Approach to localising the lesion
Be systematic! E …A patient presents with arm weakness…

4 Muscle – e.g. diabetic myopathy
NMJ – e.g. myasthenia gravis E Peripheral nerve – e.g. GBS Spinal cord – e.g. cord compression Cerebrum – e.g. Stroke

5 Timeline Immediate Intermediate Long-term E

6 UMN vs. LMN ??? P

7 UMN vs. LMN UMN LMN Hyperreflexia Hyporeflexia Hypertonia Hypotonia
Clonus Muscle wasting No muscle wasting/fasciculation Fasciculation Plantars upgoing (lower limbs) Plantars downgoing (lower limbs) P

8 Pyramidal vs. Extrapyramidal
Weakness Tremor Spasticity Chorea Pronator drift Hemiballismus Loss of skilled movement Athestosis Hyperreflexia Dystonia Change in tone/tendon reflexes Plantars upgoing Loss of abdominal/cremasteric reflex Extrapyramidal system: basal ganglia P

9 Clonus age&v=8GC8F2UMYbQ#t=42

10 Facial nerve palsies Bulbar vs. pseudobulbar
Pseudobulbar = UMN of CN IX-XII Spastic tongue Sparing of forehead Bulbar = LMN of CN IX-XII Tongue wasting/fasciculation Affects all facial muscles E

11 E

12 The tracts Dorsal column ? Corticospinal ? P ? Spinothalamic

13 Lateral Spinothalamic
Pain and temperature Decussates at the level of the spinal cord P

14 Anterior Spinothalamic
Crude touch and pressure Decussates at the level of the spinal cord P

15 Dorsal columns Discrimination, proprioception, vibration.
Crosses at the medulla. P Subacute combined degeneration of the cord, Tabes dorsalis, Spinal trauma.

16 Corticospinal Tracts Descending motor tracts. Cross at the medulla. P

17 Brown-Sequard P

18 Brainstem CN IX-XII Symptoms/signs: Dysarthria Dysphagia/drooling
Tongue weakness Absent palatial movement E

19 Cerebellum Cerebellospinal tracts Ipsilateral – DO NOT CROSS E

20 Blood Supply E

21 D A N I S H Cerebellar Signs – dysdiadochokinesia
– ataxia (truncal and limb) – nystagmus – intention tremor – slurred speech – hypotonia E

22 Causes Alcohol Thiamine deficiency CVA Friedreich’s ataxia Etc etc… E

23 The Homunculus P

24 Cerebral Artery Territories

25 P

26 ? Circle of Willis Anterior cerebral artery Middle cerebral artery
Posterior cerebral artery Basilar artery E Vertebral artery A = ? Anterior spinal artery B = ?

27 Speech Centres arcuate fasciculus  conduction aphasia E

28 Tono man E

29 Broca’s dysphasia E

30 Stroke Syndromes TACS – all 3 PACS – 2 of 3 LACS POCS
Hemiplegia/hemisensory loss See left No visual field defect Bilateral motor or sensory Visual field disturbance Pure motor Conjugate eye movement disturbance Disturbance in higher function – e.g. dyphasia/dysphagia Pure sensory Cerebellar dysfunction Sensory-motor Hemiplegia or cortical blindness Ataxia E

31 Visual Defects Ipsilateral blindess Bilateral hemianopia
Left homonymous hemianopia Left superior quadrantanopia P Left homonymous hemianopia with macular sparing

32 Cases

33 Case 1 57 year old man complaining of weakness and altered sensation in upper limbs and lower limbs Loss of sensation from shoulders and down, urinary incontinence On Examination: CN intact Upper limbs weakness, hypotonia, reduced reflexes Lower limbs spasticity, hyper-reflexia and Babinski +ve, reduced sensation from shoulders down C-spine C4 E

34 Case 2 85 year old man with long standing (20yr) history of balance problems worse in the dark. Gait is high stepping On Examination: CN intact Motor intact Loss of proprioception with +ve Romberg’s test Tabes dorsalis (dorsal columns) P

35 Case 3 23, female presents to her GP with a 2 week history of bilateral leg weakness having started with pins and needles and numbness in her hands and feet. She has had a few days of urinary incontinence which has resolved. 2 years ago she had an episode of blurred vision and pain in the right eye which lasted a month and fully resolved E

36 Case 4 56 male 6 month history of progressive weakness of his right hand. Also had problems with swallowing and has choked whilst eating on several occasions o/e he has wasting of his upper and lower limbs and some fasciculation's were noted his right plantar was up going and his reflexes were generally brisk P

37 Things we’ve not had time to cover
Peripheral neuropathies Motor neurone Parkinson’s Huntington’s GBS Myasthenia gravis E

38 Peripheral Neuropathies
A – alcohol B – B12 deficiency C – CKD D – drugs/diabetes E – every vasculitis P

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