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

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

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

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

Timeline Immediate Intermediate Long-term E

UMN vs. LMN ??? P

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

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

Clonus http://www.youtube.com/watch?feature=player_detailp age&v=8GC8F2UMYbQ#t=42

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

E

The tracts Dorsal column ? Corticospinal ? P ? Spinothalamic

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

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

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

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

Brown-Sequard P

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

Cerebellum Cerebellospinal tracts Ipsilateral – DO NOT CROSS E

Blood Supply E

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

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

The Homunculus P

Cerebral Artery Territories P

P

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

Speech Centres arcuate fasciculus  conduction aphasia E

Tono man http://www.youtube.com/watch?v=6CJWo5TDHLE E

Broca’s dysphasia http://www.youtube.com/watch?v=1aplTvEQ6ew E

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

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

Cases

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

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

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

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

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

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