Localizing Signs And Symptoms In Neurology

Dr. Suhail Al-Shammri FRCP (C)Associate. Professor. Faculty of

Medicine,Kuwait University

Language :

Aphasia- language disturbance fluency, comprehension,repitition,

naming,reading,writing and handedness.

Dysarthria- abnormal speech articulation

NON-APHASIA

Fluent aphasia

Cranial Nerves : OLFACTORY Loss of smell: Anosmia Diminished : Hyposmia Distorted :dysosmia

Causes Of Anosmia

Local nasal disease:cold.rhinitis,polyps Head injury: Fracture of frontal base Degenerative:

Alzheimer’s disease Parkinson’s disease

Endocrine: Addison’s disease, diabetes

Cranial Nerve Function: optic

nerve

Visual acuity: reduced in : refraction error obstruction of light- catarct retinal or optic nerve disease

Visual fields-confrontation hemianopia- loss of half of visual

field quadrantanopia- loss of quarter

Visual Fields

Homonymous hemianopia- loss of same half of visual field in each eye.

Bitemporal hemianopia- loss of temporal fields in each eye.

Perimetry- to detect small spots of visual loss(scotoma) or blind spot

Extinction or neglect- perception of one stimulus on double stimulation

PAPILLEDEMA

PATHOLOGICAL SWELLING WITH ELEVATION OF THE OPTIC DISC CAUSED BY RAISED INTRACRANIAL PRESSURE

Optic Nerve: Papilledema

loss of venous pulsation blurring of optic disc margins venous engorgement elevation of optic disc retinal hemorrhage visual acuity usually spared Enlarged blind spot

PAPILLEDEMA

CAUSES OF PAPILLEDEMA:Increased ICP

Mass lesions:tumors,abscess, hematoma

Cerebral edema: trauma Infections: meningitis, encephalitis Venous sinus thrombosis Idiopathic intracranial hypertension

CAUSES OF PAPILLEDEMA:Medical disorders Severe anemia Accelerated hypertension Lead poisoning Polcythemia rubra vera Carbon dioxide retention Drugs: tetracyclines, steroids,excess

vit A

OPTIC NEURITIS

Acute inflammation of the optic nerve Papillitis Retrobulbar neuritis

Optic Nerve:Fundoscopy Papillitis- optic disc inflammation

usually unilateral,painful visual acuity is impaired

Causes: Demyelination: Multiple sclerosis Viral Post-infectious

OPTIC ATROPHY

small pale sharply demarcated optic disc

end-stage of various diseases visual acuity is usually impaired

Afferant Pupillary Defect

Oculomotor Nerves

Eye movements controlled by six extraocular muscles: superior rectus, medial rectus,inferior

rectus and inferior oblique(oculomotor) lateral rectus (abducens nerve) superior oblique (trochlear nerve) eyelid elevation,pupillary size,shape and

reactivity to light and accommodation(oculomotor nerve)

Nystagmus

Abnormal involuntary rhythmic eye movement- at rest or induced slow deviation of one eye in one

direction and quick corrective movement in opposite direction

“End- point” nystagmus: occurs normally with gaze too far laterally

Asymmetric horizontal nystagmus:indicate central or vestibular lesion

Nystagmus

Up-beating or downbeating nystagmus indicates brain-stem disease.

Congenital nystagmus: present at birth horizontal beating reduced or disappears on convergence usually associated with rduced visual

acuity

NYSTAGMUS

Oculomotor nerve palsy

Eye is down and out upper eyelid droops(ptosis) pupil is dilated, unreactive to light the concept of pupillary sparing

differentiates between diabetic and compressive neuropathy.

Oculomotor nerve palsy

Nuclear: result in contralateral superior rectus palsy

Fascicular: Long tract signs Weber’s syndrome: contralateral

hemiplegia Benedikit’s syndrome: contralateral

ataxia and intention tremor Peripheral: Partial or complete

Oculomotor nerve palsy: CAUSES Diabetes Compressive:

Aneurysm Cavernous sinus lesions:

Affect oculomotor nerves First and second divisions of trigeminal Oculosympathetic fibers

Cavernous sinus lesions:Causes Aneurysm Caroticocavernous fistula or

thrombosis Expanding pituitary tumor Granuloma: Sarcoidosis

Oculomotor nerve palsy

Abducens nerve palsy:

eye is adducted and doesn’t cross midline

Nuclear lesions cause Gaze palsy CAUSES:

Diabetes Atherosclerosis Multiple sclerosis Raised intracranial pressure

Abducens nerve palsy

Internuclear ophthalmoplegia Adducting eye does not move past

midline and the abducting eye develops nystagmus

Adduction is spared during convergence

Result from lesion of the medial longitudinal fasciculus(MLF)

Internuclear ophthalmoplegia

Trochlear nerve palsy

Vertical diplopia(double vision) especially on looking downword

Head tilt toward side opposite paretic superior oblique muscle

Isolated trochlear nerve palsy is often due to HEAD TRAUMA

Argyll Robertson pupil-small irregular pupil costricts to light not to accommodation - neurosyphilis

Trochlear nerve palsy

Trigeminal Nerve

Corneal Reflex: lightly touching cornea normally causes brisk bilateral eye closure. Blink will not occur on side of facial

nerve paralysis. Touching cornea on the side of

ophthalmic division dysfunction will not result in eye blink

Trigeminal Nerve

Facial sensation - loss of sensation can occur independantly in each trigeminal nerve division.

Muscles of mastication : atrophy of temporalis or masseter

muscles. Jaw deviation toward weak side in

unilateral lesions.

Facial Nerve

Lower motor neuron palsy : produces weakness of all facial

muscles including forehead on same side as lesion.

Upper motor neuron palsy : Unilateral lower facial weakness

sparing the ability to wrinkle forehead and partially close eyelids.

Horner’s Syndrome

Damage to the sympathetic nerve supply to eye

Characterized by : small pupil (miosis) slight drooping of eyelid (ptosis) impaired sweating (anhydrosis) on

that side of the face

Vestiulocochlear nerve

Weber’s test: In sensorineural deafness sound is

heard better in the normal ear. In conductive deafness sound is heard

better in diseased ear. Rinne test :

Air conduction is louder than bone conduction in normal individuals and in those with sensorineural deafness

Vestibulocochlear nerve

Caloric test : unilateral vestibular stimulation is

accomplished by instillation of cold or warm water into one external auditory meatus .

It induces nystagmus Warm water- towards stimulated ear Cold water- away from stimulated ear

Glosopharyngeal and Vagus nerve

Unilateral vagal nerve lesion result in palatal asymmetry with uvula deviating towards normal side.

Palatal weakness results in nasal quality to voice

Vocal cord weakness result in Horseness.

Hypoglossal Nerve

Unilateral lesion : tongue deviates toward weak side.

In long-standing lesion : atrophy of affected side of tongue

Case 3

A patient is found to have : Reduced joint position sense in the

left foot. Reduced pin prick sensation on the

palmar surface of the little finger of the right hand

Case 4

A patient is found to have : reduced joint position sense in the

left foot reduced pin prick sensation on the

palmar surface of the little finger of the right hand.

Weakness of left ankle dorsiflexion Hperreflexia at left knee

Case 5

A patient found to have: reduced joint position sense in the left

foot. Reduced joint position sense in the

right foot. Reduced joint position sense in the left

hand reduced joint position sense in the

right hand

Case 6

A patient is found to have: reduced joint position sense in the

left foot. Reduced pin prick sensation on the

palmar surface of little finger of the right hand

reduced visual acuity in the left eye