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Localization in the Neuraxis

Localization in the Neuraxis. Fawaz Al- hussain Assistant Professor Stroke Neurologist For Internal Medicine Round Nov.10 th /2010. The Approach to a Patient with Neurologic Disease. Localization is important investigation modalities differ widely depending upon the level affected.

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Localization in the Neuraxis

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  1. Localization in the Neuraxis Fawaz Al-hussain Assistant Professor Stroke Neurologist For Internal Medicine Round Nov.10th/2010

  2. The Approach to a Patient with Neurologic Disease • Localization is important • investigation modalities differ widely depending upon the level affected

  3. Divisions of the Neuraxis • Cortical Brain • Subcortical area • Brainstem • Cerebellum • Spinal Cord • Root • Peripheral Nerve • Neuromuscular Junction • Muscle

  4. Neurologic Examination Higher Cortical Function Cranial Nerves Motor Sensory Deep Tendon Reflexes Coordination Special tests Gait

  5. Divisions of the Neuraxis • Cortical Brain • Subcortical area • Brainstem • Cerebellum • Spinal Cord • Root • Peripheral Nerve • Neuromuscular Junction • Muscle

  6. Cortical Brain • Depends upon hemispheric dominance • Non-neurologists generalize: • right: visual/spatial, perception and memory • left: language and language dependent memory • Through detailed examination, neurologists should lateralize and localize within a lobe

  7. Cortical Brain • Frontal Lobe: • L: • Broca’s Aphasia • R: ? • Both: • Primary motor cortex: motor homunculous • supplementary motor cortex: • Voluntary eye field • prefrontal cortex: personality, initiative

  8. Cortical Brain • Parietal Lobe: R: Lt hemispatial neglect dressing and constructional apraxia L: Gerstman’s Tetrad: L/R confusion, finger agnosia, acalculia, agraphia without alexia Werneke’s Aphasia (with Temporal lobe) Both: cortical sensory modalities

  9. Cortical Brain • Temporal: • Auditory cortex: Heschel’s gyrus • learning and memory: mid/inferior gyri • olfaction: limbic system • (Lt): Werneke’s Aphasia

  10. Cortical Brain • Occipital Lobe: • Micropsia/ macropsia • visual hallucinations: elemental and unformed • prosopagnosia: familiar faces • cortical blindness: striate cortices, normal pupil rx

  11. Divisions of the Neuraxis • Cortical Brain • Subcortical area • Brainstem • Cerebellum • Spinal Cord • Root • Peripheral Nerve • Neuromuscular Junction • Muscle

  12. Subcortical Brain Deep white radiating fibers • weakness • sensory abnormalities Visual radiating fibers: • deep parietal: bilateral inferior homonomousquadronopsia • deep temporal (Meyer’s loop): bilateral superior homonomousquadronopsia Basal Ganglia: extrapyramidal signs

  13. Divisions of the Neuraxis • Cortical Brain • Subcortical area • Brainstem • Cerebellum • Spinal Cord • Root • Peripheral Nerve • Neuromuscular Junction • Muscle

  14. Brainstem The Brainstem is basically spinal cord with embedded cranial nerves • Cranial neuropathies • Long Tract signs: (bilateral and crossed) • corticospinal (pyramidal): motor • spinothalamic: pain/temp • dorsal columns: proprioception/vibration • Autonomic dysfunction (LOC, eyes, mouth, heart, breathing)

  15. Divisions of the Neuraxis • Cortical Brain • Subcortical area • Brainstem • Cerebellum • Spinal Cord • Root • Peripheral Nerve • Neuromuscular Junction • Muscle

  16. Cerebellar Function Pure cerebellar signs  cerbellum Cerebellar and long tracts’ signs  brainstem

  17. Divisions of the Neuraxis • Cortical Brain • Subcortical area • Brainstem • Cerebellum • Spinal Cord • Root • Peripheral Nerve • Neuromuscular Junction • Muscle

  18. Spinal Cord 3 Functions: Motor  UMNL Sensory Autonomic Key ? sensory level

  19. Divisions of the Neuraxis • Cortical Brain • Subcortical area • Brainstem • Cerebellum • Spinal Cord Motor neurons (upper & lower) • Root • Peripheral Nerve • Neuromuscular Junction • Muscle

  20. Motor neurons Pure motor deficit(s) • Upper (primary Lateral sclerosis) in motor cortex • Lower motor neurons in spinal cord Spread: leg  arm  bulbar bulbar  arm and leg

  21. Divisions of the Neuraxis • Cortical Brain • Subcortical area • Brainstem • Cerebellum • Spinal Cord • Root • Peripheral Nerve • Neuromuscular Junction • Muscle

  22. Root/Radiculopathy Radicular pain:hallmark Sensory abnormalities in a dermatomes Weaknessin a myotomaldistn

  23. Divisions of the Neuraxis • Cortical Brain • Subcortical area • Brainstem • Cerebellum • Spinal Cord • Root • Peripheral Nerve • Neuromuscular Junction • Muscle

  24. Peripheral Nerve(presuming nonfocality) Weakness (LMN) Numbness +/- autonomic  all are consistent with PN distribution

  25. Divisions of the Neuraxis • Cortical Brain • Subcortical area • Brainstem • Cerebellum • Spinal Cord • Root • Peripheral Nerve • Neuromuscular Junction • Muscle

  26. Neuromuscular Junction • Fatigability: hallmark • Weakness: proximal and symmetric • muscles have normal bulk and tone • EOMs, bulbar, arms, and legs • Sensation: preserved

  27. Divisions of the Neuraxis • Cortical Brain • Subcortical area • Brainstem • Cerebellum • Spinal Cord • Root • Peripheral Nerve • Neuromuscular Junction • Muscle

  28. Muscle • Weakness • Symmetric • Proximal • + atrophy & absent DTRs • Sensation is normal • though patients complain of cramping, & aching • myalgia

  29. Few Things to Remember Accurate Hx and P/E are needed Some neurologic diseases hit more than one level in the neuraxis  include all involved Never fabricate part of the exam Always localize before making DDx list The localization plus the tempo of progression allow one to narrow a differential diagnosis

  30. Case-1 32 y/o male with reduced endurance and mild weakness in his legs His older brother has weakness too P/E: mild atrophy in legs with fasciculation but increased muscle tone. (N) sensory exam Localize?

  31. Case-1 32 y/o male with reduced endurance and mild weakness in his legs His older brother has weakness too P/E: mild atrophy in legs with fasciculation but increased muscle tone. (N) sensory exam Localize? Motor Neuron Disease  familial ALS

  32. Case-2 55 y/o lady with sudden diplopia and weakness in Rt (F,A,L) Localize?

  33. Case-2 55 y/o lady with sudden diplopia and weakness in Rt (F,A,L) Localize? Midbrain lesion  ischemic stroke

  34. Case-3 75 y/o lady with increased misnaming stuff over 2 years P/E: decreased lexical fluency and some paraphasic errors No other neurological signs Localize?

  35. Case-3 75 y/o lady with increased misnaming stuff over 2 years P/E: decreased lexical fluency and some paraphasic errors No other neurological signs Localize? Lt frontal lobe  frontal dementia

  36. Case-4 35 y/o man with Rt blindness, dysarthria, dysphagia, and weakness in Rt arm and leg plus Lt leg and sensory level at T-4 Localize?

  37. Case-4 35 y/o man with Rt blindness, dysarthria, dysphagia, and weakness in Rt arm and leg plus Lt leg and sensory level at T-4 Localize? Multiple lesions  at least brainstem and T-spine  MS

  38. Case-5 16 y/o girl with gait ataxia and poor coordination in 4 limbs + nystagmus when looks to Rt side Localize?

  39. Case-5 16 y/o girl with gait ataxia and poor coordination in 4 limbs + nystagmus when looks to Rt side Localize? cerebellar  spinocerebellar ataxia

  40. Case-6 50 y/o lady with diplopia on/off worse at evenings In exam: partial ptosis in Rt eye Localize?

  41. Case-6 50 y/o lady with diplopia on/off worse at evenings In exam: partial ptosis in Rt eye Localize? NM junction  Myasthenia gravis

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