1. Dr Sadik AL-Ghazzawi MRCP, FRCP UK Lecture 1
Medical Neurology
Dr Sadik AL-Ghazzawi
MRCP, FRCP UK
Lecture 1

2. Principles of clinical neurology Anatomy and physiology
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3. 1-Neuron (variety of neuron)
Nerve cells
Types of nerve cells
1-Neuron (variety of neuron)
2-Glial cells
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4. it is the framework which as the following functions :
a-Astrocyte:
it is the framework which as the following functions :
*supporting the neuron
*biochemical control of neuron environment
*blood brain barrier by Astrocyte foot processes.
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5. The function of these cells is the formation
b- Oligodendrocyte:
The function of these cells is the formation
and maintenance of the myelin sheath which
is value for transmission of action potential .
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6. Neuron
(Nerve cell )is the basic unit of the nerve system ,characterized by:
1-limitless connection.
2-Adaptability and variability of functions.
3-Has several projection.
4-The axon transmits the impulses which are generated in the neuron.
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7. Anatomical organization of the nervous system
ONE
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8. 1-Central nervous system (C.N.S.)
A-The brain :- which consist of :
* Cerebral context (CC) :-which consist of:
- Frontal lobe
-Occipital lobe
- Parietal lobe
-Temporal lobe
*Brain stem (mid brain, pones)
*Cerebellum
B- Spinal cord
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9. 2-Peripherals nervous system (P.N.S.) Cranial nerves(12 pairs
Spinal nerves ( 31 pairs) divided into :
Cervical spinal nerves (8 pairs)
Thoracic S N (12 pairs)
Lumbar SN (5 pairs)
Sacral SN (5 pairs)
Coccygeal SN ( 1 Pair)
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10. 3-Autonomic nervous system (A.N.S.)
It is divide into :
A-Parasympathetic autonomic nervous system
(crainio-sacral) ,this is because it run with cranial
nerves (3rd ,7th, 9th & 10th cranial nerves) and the
sacral spinal nerves ( 2nd ,3rd & 4th).
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11. B-Sympathetic autonomic nervous system
( Thoraco-Lumbar), this is because it
runs with thoracic spinal nerves & lumbar spinal
nerves (T1-L3) and also it run with the sympathetic trunk with its ganglia.
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12. Functional organization of the
nervous system
TWO
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13. Functional organization of the
nervous system
The nervous system is divided into the following parts according to the function of that part :
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14. 1-Cerebral hemispheres:
at that level the highest nervous system functions are carried
A-Anterior half
of the cerebral hemisphere
deals with executive functions of the human brain
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15. hemispheres deals with the perception of the environment .
B-Posterior half of the cerebral
hemispheres deals with the
perception of the environment .
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17. The nervous system is divided physiologically into:
1-The motor system:
which is responsible for different movement of different parts of the body.
Movement definition:
is a contraction or controlled relaxation of a group of muscles and never a single muscle
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18. (Precentral area of the frontal lobe:
To perform a voluntary movement we need the participation of the following:
A-The Motor Area
(Precentral area of the frontal lobe:
in this area the first spark for starting the action of movement
,i.e. cells of motor cortex = movement.
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19. b- timing of contraction and relaxation of the muscle fibers .
B-The cerebellum : which complements the function of the motor area by adding :
a-coordination
b- timing of contraction and relaxation of the muscle fibers .
3- Extrapyramidal motor system,
complement the function of the motor area by giving the movement its smooth and nice shape
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20. i.e.Cerebellum control the coordination of movement and
Extrapyramidal motor system control the shape and
smoothness of the movement ,while the motor area ignite
the spark of the voluntary movement .
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21. A group of anterior horn cells = muscle
4- Anterior horn cells of the spinal cord and motor cranial nuclei
5- The muscle fiber
SO,
A group of anterior horn cells = muscle
Cells of the motor cortex = movement
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22. Anatomy of the motor system
1-The motor system starts within the PCJ of the cerebral cortex of the frontal lobe .
2- motor signals passes within the corticospinal tract
through the internal capsule ,brain stem were motor fibers
coming from the motor cranial nuclei to join the CST to decent down to
3-the spinal cord (anterior horn of the spinal cord).
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23. The representations of the movement of different parts of
*PCJ initiates movements of different parts of the opposite side of the body.
The representations of the movement of different parts of
the body are represented from below-upward (upside
down) in the precentral jyris cells ( the foot ,legs ,thigh
,arm ,hand ,face and tongue )are represented upside
down were the cells of the movement of the foot are
uppermost and the cell of the movement of the tongue are the lower most.
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24. NOTE, This wide representation of the body in the precentral
jyrus leads to a limited loss of function when part of
the PCJ is affected ,example: monoplegia
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25. Which include the motor system from the cerebral cortex
Upper motor neuron
Which include the motor system from the cerebral cortex
down to the anterior horn cell of the spinal cord passing
through the corticospinal tract which decussates below the brain stem (lateral corticospinal tract).
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26. Lesion of UMN above the decussating results in :
Loss of some voluntary movement on the opposite side of the body .
Preservation of the reflex activity (difference between UMN and LMN ).
Heightened (increase the reflex activity because of the loss of the inhibitory action of the UMN on the LMN .
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27. Upper motor neuron lesion results in :
A-Positive phenomenon (increase reflex activity )
b- Negative phenomenon (loss of voluntary movement).
Signs of UMN dysfunction
Muscle paralysis on the opposite side of the body for the voluntary movement
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28. spastic type , which has pyramidal distribution i.e: involve
Hypertonia: increase in the muscle tone ,which is of clasp knife type or
spastic type , which has pyramidal distribution i.e: involve
the flexor muscles of the upper limb and the extensor
muscles of the lower limb.
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29. All on the opposite side. Loss of abdominal reflexes
Hyperreflexia.
Extensor planter
All on the opposite side.
Loss of abdominal reflexes
No muscle atrophy but long term disuse atrophy.
Normal electrical activity in the muscle fibers.
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30. Anatomy of lower motor neuron
Include, Anterior horn cells
2- Anterior nerve roots
3- Peripheral motor nerves
4- Muscles
i.e .Motor unit=AHC +Axon +Group of muscle fibers
Note: the nutrition of the muscles depend on the LMN integrity.
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31. Signs of LMN dysfunction
1-Paralysis of all movements (voluntary and involuntary), the difference between UMN and LMN.
2- Hypotonia (flaccidity): loss of muscle tone.
3-Hporeflexia or areflexia.
4-Preservation of the abdominal reflexes
5-Flexor planter reflex
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32. 6- Wasting of the muscles supplied by the LMN in 2-3 weeks time, this is because the nutrition of the muscles depends on the integrity of the LMN.
7- Fibrillation (spontaneous single fiber contraction), which is invisible and it is electromyographic feature.
8- Fasciculation: Spontaneous contraction of a group of a muscle fibers (visible).
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33. cerebral hemisphere to complement the function of
2-Basal ganglia----- (EPS) which are collection of ganglions in the depth of the
cerebral hemisphere to complement the function of
the motor system(PS) for optimum motor control.
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34. This part of the brain deals with the
3-Thalamus,
This part of the brain deals with the
appreciation and attention to the sensory perception .
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35. 4-Limbic system , deals with the emotions and memory .
5-Hypothalam the part of the brain which
deals with the internal body functions (internal environment).
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36. A-harboring the sensory and the motor
6-Brain stem,
That part of the central nervous system which has the following functions:
A-harboring the sensory and the motor
pathways entering and leaving the cerebral hemisphere .
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37. B-Housing nuclei of the cranial nerves (3rd &4th)
which control the conjugate eye movements
( internuclear mechanism of the conjugate eye movements) .
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38. C-containing the central nuclei for the cardio-respiratory control.
D-Maintenance of the arousal of the human brain .
(RAS)
E-Complement the cerebellum for the balance control .
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39. B-It contains and control the lower order motor reflexes.
7-Spinal cord,
it has the following functions:
A-Containing the afferent and efferent fibers to the central nervous system.
B-It contains and control the lower order motor reflexes.
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40. C-Primary processing of the sensory information
coming through the sensory system, including the
pain sensation analysis.
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41. 8-Peripheral nervous system which compose of:
A-Afferent and efferent connection.
B-Sensory cells in the dorsal root ganglia .
C-Motor cells in the anterior horn of the spinal cord .
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42. These 3 divisions of the peripheral nervous
system compose the essential parts of the (lower motor neuron unit) .
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43. 9-The autonomic nervous system, ( sympathetic and parasympathetic ) .
9-The autonomic nervous system, ( sympathetic
and parasympathetic )
has the following function:
A-Unconscious neural control of the body physiology.
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44. B-Cardiovascular and respiratory system control.
C-Smooth muscles and the glands of gastrointestinal
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45. Note:- The ANS is controlled centrally by diffuse
modulatory system in the brain stem , limbic
system and frontal lobe (the arousal and
background behavioral responses to threat.
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46. Clinical skills in Solving Neurological Problem
ONE
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47. Neurological diagnosis . divided, to, 1-Functional diagnosis.
1-fundamental clinical skills of history –taking & physical examination.
Neurological diagnosis . divided, to,
1-Functional diagnosis.
2-Etiological diagnosis
3-anatomical diagnosis,(what is the site of the lesion in the N.S.)
4-pathological diagnosis,(what disease process has occurred at the site).
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48. important in determining both the anatomical & pathological diagnosis.
The history.
Rule ONE
important in determining both the anatomical & pathological diagnosis.
Rule TOW-
many neurological patients have no abnormal
signs, or simply have physical features that
confirm clinical suspicions base on the history.
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49. Rule THREE
In complex problems, the history can only yield a , short list, of potential site of the lesion(s) & final localization must wait the formal examination.
Rule FOUR -
this is because disease at one site in the N.S may produce symptoms mimicking a lesion at another site.
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50. 1-probe the history in specific areas. 2-timing of symptoms.
presenting complain;
1-allow the patient sufficient uninterrupted time to speak. age. occupation. handedness. hemisphere dominance.
History
1-probe the history in specific areas.
2-timing of symptoms.
onset, progression, duration, recovery, frequency.
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51. Discriminate questions ;is
To differentiate between tow pathology which
could produce similar clinical picture .e.g. ,
Glove & stocking sensory loss in peripheral
neuropathy & C. spinal cord disease.
(neck pain , injury, sphincter dysfunction)
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52. Gait, facial expression, hand shake, speech, cognitive function.
Examination .
Initial impression,
Gait, facial expression, hand shake, speech, cognitive function.
(Screen) examination,
1-level of consciousness.
2-cognitive function.
3-speech.
4-cranial nerves.
5-neck & trunk
6-limbs-motor & sensory examination.
7-gait.
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53. 2-a complete general examination must therefore accompany that of the
1-Neurological disease may produce systemic signs and systemic disease may affect the nervous system
2-a complete general examination must therefore accompany that of the
central nervous system.
3-in particular , note the following:
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54. Temperature Evidence of weight loss Septic source, teeth ,ears
Blood pressure Breast lumps
Skin marks, e.g. reshes
Neck stiffness lymph adenopathy
café-au-lait spots
Pulse irregularity hepatic & splenic angiomata
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55. Carotid bruit enlargement Anterior fontanelle baby
Cardiac murmurs Prostatic irregularity Head circumference
Cyanosis /respiratory
insufficiency
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56. CNS examination is described systematically from the head downward
and include:
1-Conscious level and higher cerebral function
2-Cognitive skills –Memory –Reasoning -Emotional states
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57. -Motor system –wasting - tone -power -Sensory system- pain -touch
2-Cranial nerves(1-12)
3-Upper limbs
-Motor system –wasting
- tone
-power
-Sensory system- pain
-touch
-temp
-proprioception
-stereognosis
-Reflexes
-Coordination -
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58. -motor system - -wasting -tone -power -sensory system - -pain -touch
4-Trunk
-sensation
-reflexes
5-Sphincters
6-Lower limbs
-motor system wasting
-tone
-power
-sensory system pain
-touch
-tempt
-proprioception
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59. coordination-gait,- stance
-reflexes
coordination-gait,- stance
*Alternatively the examiner may prefer to work
through individual systems for the whole
body,e.g.motor system, sensory system
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60. Symptomology in Nervous System
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61. Central Nervous System
(Upper Motor Neuron)
1-Brain
2-Spinal Cord
UMN Lesion
1-Cognitive disorders
2-Spastisity
3-Hyperreflexia
4-Sensory alteration
5-Pathological reflexes
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62. 1-Cerebral Hemispheres 1-White Matter Tracts 2-Cerebellum
3-Basal Ganglia
4-Brain Stem
Ii-Spinal Cord
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63. A-Cortical (gray matter) lesions Defect in Higher cortical functions
1-Dementia.
2-Aphasia.
3-Seizures.
B-Subcortical (white matter) lesions
1-Hemiparesis
2-Hemisensory defects.
C-mixed cerebral lesions
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64. Peripheral Nervous System(PNS)
Lower motor neurons
A-Weakness
B-Flaccidity.
C-Sensory alterations.
D-loss of deep tendon reflexes.
E-absence of pathological reflexes
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65. -Cranial nerves iii—xii Spinal nerves & nerve roots—
Cauda equina
Lmn (anterior horn cell, neve root , plexus ,peripheral nerves,
Neuromuscular junction,skeletal muscles).
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66. Higher cortical functions
TWO
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67. 5/24/2019

68. Higher cortical functions 1-Frontal lobe functions
a- Executive functions
b- Behavioral function
c- Motor area
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69. The functional area of the frontal lobe are :
1-Primary motor cortex (pre central jyrus)
2-Brocas area (speech center)
3-Frontal eye field center (Broadman 8)
4-Higher order motor control
5-Micturation center
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70. Frontal lobe syndromes:
1-Personality changes: with diffuse frontal lobe damage.
2-Behavioral disturbances
3-Antisocial behavior
4-Expressive dysphasia
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71. 7-Contralateral hemiparesis
5-Incontinence
6-Anosmia
7-Contralateral hemiparesis
8-Return of primitive reflexes i.e. sucking reflex ,grip reflex.
9-Focal motor seizure
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72. Parietal lobe function: Integration of sensory perception.
Dominant parietal lobe dysfunctions:
Language disorder
Calculations disorders
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73. is the inability to perform complex organized function in
Apraxia :
is the inability to perform complex organized function in
the presence of a normal basic motor ,sensory and
cerebellar system (planning and ideation disorder) .
It is resulted from sensory inattention and spatial perception disorder .
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74. It contains the following: 1- Primary auditory cortex
Temporal lobe
It contains the following:
1- Primary auditory cortex
2- Primary vestibular cortex
3- Memory function
Occipital lobe
It contains the visual and image processing.
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