1. Clinical assessment Aims (1) Is it a stroke? (2) What part of the brain is affected? (3) What caused this stroke? Is it a haemorrhage or an infarct? Can we prevent a further stroke? (4) What are this patient’s problems? + (5) What can we do to treat this patient?

2. What part of the brain is affected?

3. Localising the lesion Establish what symptoms the patient had Identify their neurological signs Sometimes confirm with an image (CT or MRI scan)

4. Localisation depends on Neuroanatomy Cerebral hemispheres Cerebellar hemispheres Spinal cord Brainstem including PONS & Medulla Midbrain

5. Localisation of function in the brain

6. Localisation of functions Visual Cerebellum Coordination MotorSensory Brainstem Left parietal Language Right parietal Neglect

7. The homunculus

8. Deep white matter - the connecting fibres A small stroke there (or there) will result in a major deficit as the fibres are packed close together

9. Symptoms and Signs of a brainstem lesion Signs Eye movements Nystagmus Horners syndrome Ataxia Bilateral signs Symptoms Double vision Spinning vertigo Bilateral weakness Hiccups

10. Motor fibres cross in medulla Cortex Internal capsule Medulla Spinal cord Peripheral nerve Lower motor neurone A left hemisphere or left brainstem lesion will cause right sided weakness

11. Sensory fibre cross in spinal cord (pain & temp) or in medulla (JPS & vibration) A left hemisphere lesion will cause loss of sensation on right side Dissociated sensory loss i.e. loss of pain & temp but not JPS & vibration or visa versa brainstem or cord

12. Cerebellar fibres do not cross Left cerebellar hemisphere lesion causes ataxia of left limbs Midline cerebellar lesion causes truncal ataxia

13. Visual Pathways Eyes Optic nerves Optic chiasma Optic radiation Visual cortex LR Right FieldLeft Field

14. Computerised Tomography (CT)

15. Where is the lesion? Patient has Right arm weakness Right facial weakness Dysphasia

16. Localisation of functions Visual Cerebellum Coordination MotorSensory Brainstem Left parietal Language Right parietal Neglect

17. Motor fibres cross in medulla Cortex Internal capsule Medulla Spinal cord Peripheral nerve Lower motor neurone A left hemisphere or left brainstem lesion will cause right sided weakness

18. Where is the lesion? Complete paralysis of right side (face, arm & leg) Dysphasia Loss of right visual field

19. Visual Pathways Eyes Optic nerves Optic chiasma Optic radiation Visual cortex LR Right FieldLeft Field

20. Where is the stroke? Loss of all sensation in right face, arm and leg Mild weakness of right arm and leg

21. Sensory fibre cross in spinal cord (pain & temp) or in medulla (JPS & vibration) A left hemisphere lesion will cause loss of sensation on right side Dissociated sensory loss i.e. loss of pain & temp but not JPS & vibration or visa versa brainstem or cord

22. Where is the lesion? Patient started with truncal ataxia headache and vomiting He is now becoming drowsy

23. Cerebellar fibres do not cross Left cerebellar hemisphere lesion causes ataxia of left limbs Midline cerebellar lesion causes truncal ataxia

24. Where is the lesion? Patient complains of problems reading O/E right visual field defect (homonymous hemianopia)

25. Visual Pathways Eyes Optic nerves Optic chiasma Optic radiation Visual cortex LR Right FieldLeft Field

26. Sudden onset left leg weakness O/E: –unaware of problems –dense weakness of left, loss of sensation –doesn’t look to left Where is the lesion?

27. nystagmus in all directions ataxia of left arm & leg Where is the lesion?

28. Right arm & leg weakness No field defect Language OK Not drowsy Where is the lesion?

29. Clinical assessment Aims (1) Is it a stroke? (2) What part of the brain is affected? (3) What caused this stroke? Is it a haemorrhage or an infarct? Can we prevent a further stroke? (4) What are this patient’s problems? + (5) What can we do to treat this patient?