Localising the lesion
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Transcript of Localising the lesion
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Localising the lesionEd Hutchison and Paul Swift
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AimsApproachUMN vs. LMNSpinal tractsCerebellumCerebrumVisual lesionsCases
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Approach to localising the lesion
Be systematic!
…A patient presents with arm weakness…
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Muscle – e.g. diabetic myopathy
NMJ – e.g. myasthenia gravis
Peripheral nerve – e.g. GBS
Spinal cord – e.g. cord compression
Cerebrum – e.g. Stroke
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Timeline
Immediate
Intermediate
Long-term
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UMN vs. LMN???
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UMN vs. LMNUMN LMNHyperreflexia HyporeflexiaHypertonia HypotoniaClonus Muscle wastingNo muscle wasting/fasciculation
Fasciculation
Plantars upgoing (lower limbs)
Plantars downgoing (lower limbs)
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Pyramidal vs. Extrapyramidal
Pyramidal ExtrapyramidalWeakness TremorSpasticity ChoreaPronator drift HemiballismusLoss of skilled movement AthestosisHyperreflexia DystoniaChange in tone/tendon reflexesPlantars upgoingLoss of abdominal/cremasteric reflex
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Clonushttp://www.youtube.com/watch?feature=player_detailpage&v=8GC8F2UMYbQ#t=42
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Facial nerve palsiesBulbar vs. pseudobulbarPseudobulbar = UMN of CN IX-XII
Spastic tongueSparing of forehead
Bulbar = LMN of CN IX-XIITongue wasting/fasciculationAffects all facial muscles
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The tracts
Dorsal column
Corticospinal
Spinothalamic
?
?
?
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Lateral Spinothala
micPain and temperatureDecussates at the level of the spinal cord
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Anterior Spinothala
micCrude touch and pressureDecussates at the level of the spinal cord
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Dorsal columnsDiscrimination, proprioception, vibration.Crosses at the medulla.
Subacute combined degeneration of the cord,Tabes dorsalis,Spinal trauma.
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Corticospinal Tracts
Descending motor tracts.Cross at the medulla.
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Brown-Sequard
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Brainstem
Symptoms/signs:• Dysarthria• Dysphagia/drooling• Tongue weakness• Absent palatial
movement
CN IX-XII
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CerebellumCerebellospinal tractsIpsilateral – DO NOT CROSS
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Blood Supply
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Cerebellar Signs– dysdiadochokinesia – ataxia (truncal and limb)
– nystagmus
– intention tremor
– slurred speech
– hypotonia
DANISH
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CausesAlcoholThiamine deficiencyCVAFriedreich’s ataxia
Etc etc…
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The Homunculus
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Cerebral Artery Territories
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Circle of WillisAnterior cerebral artery
Middle cerebral artery
Posterior cerebral artery
Basilar artery
A = ?
B = ?
?Anterior spinal artery
Vertebral artery
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Speech Centres
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Tono manhttp://www.youtube.com/watch?v=6CJWo5TDHLE
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Broca’s dysphasiahttp://www.youtube.com/watch?v=1aplTvEQ6ew
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Stroke SyndromesTACS – all 3 PACS – 2 of 3 LACS POCSHemiplegia/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
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Visual DefectsIpsilateral blindessBilateral hemianopia
Left homonymous hemianopia
Left superior quadrantanopia
Left homonymous hemianopia with macular sparing
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Cases
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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
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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
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Case 323, 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
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Case 456 male6 month history of progressive weakness of his right hand. Also had problems with swallowing and has choked whilst eating on several occasionso/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
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Things we’ve not had time to cover
Peripheral neuropathiesMotor neuroneParkinson’sHuntington’sGBSMyasthenia gravis
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Peripheral NeuropathiesA – alcoholB – B12 deficiencyC – CKDD – drugs/diabetesE – every vasculitis