PRINCIPLES OF

LESION LOCALIZATION
IN NEUROLOGY

UM CRME University of Miami

Center for Research in Medical Education

 LESION LOCALIZATION
IN NEUROLOGY

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DIAGNOSING NEUROLOGIC
DISEASE BY LOCATION
Always start with
• Brain location-based diagnosis
• Brainstem before pathophysiologic diagnosis

• Cerebellum
• Spinal cord myelopathy
• Nerve Root radiculopathy
• Nerve neuropathy
• Neuromuscular junction myasthenia
• Muscle myopathy
 BRAIN ANATOMY BASICS
◼ Cerebral Cortex ◼ Cerebral Subcortex
➢ gray matter ➢ deep white matter “wires”
➢ “computer center” ➢ gray matter “balls”
➢ left → language ➢ motor modifier
➢ right → attention ➢ sensory relay

◼ Brainstem
◼ Cerebellum ➢ funnel/connector between
➢ coordination cerebrum and spinal cord
center ➢ nerves to face/head
➢ primitive centers
LEFT (DOMINANT) HEMISPHERE:
TYPICAL SIGNS (RIGHT SIDE & APHASIA)

Right Visual Field Aphasia

Deficit

Left Gaze Deviation

(Left Gaze Preference)
Right Hemiparesis
Right Hemisensory
Loss
RIGHT (NONDOMINANT) HEMISPHERE:
TYPICAL SIGNS (LEFT SIDE)

Left Hemi-inattention

Left Visual Field

Right Gaze Deviation Deficit

(Right Gaze Preference)

Left Hemiparesis
Left Hemisensory
Loss
NEUROLOGIC LOCALIZATION:
BRAIN

• lethargy/delirium (bicerebral)
• seizures (cortex)
• memory (thalamic or medial temporal)
• hemibody sensory/motor (contralateral)
• visual field (contralateral)
Cortex vs.Subcortex
• language (left) Left vs. Right
• neglect (right) Anterior vs. Posterior
 BRAINSTEM:
TYPICAL SIGNS (BOTH SIDES)

Crossed Signs
Quadriparesis (1 side of face and
contralateral body
Sensory Loss in
All 4 Limbs Hemiparesis
Hemisensory Loss
 BRAINSTEM:
TYPICAL SIGNS (CONTINUED)

Decreased LOC Vertigo, Tinnitus

Nausea, Vomiting
Hiccups, Abnormal
Respirations Eye Movement
Abnormalities:
Diplopia
Oropharyngeal Dysconjugate Gaze
Weakness: Gaze Deviation
Dysarthria, Dysphagia (Gaze Palsy)
NEUROLOGIC LOCALIZATION:
BRAINSTEM

• lethargy Midbrain vs.

Pons vs.
• “crossed” symptoms
Medulla
• diplopia = double vision
• vertigo
• dysarthria & dysphagia
• nausea and vomiting
• hiccups
CEREBELLUM:
TYPICAL SIGNS (COORDINATION)

Ipsilateral Limb
Ataxia Truncal or Gait
(dyscoordination) Ataxia (imbalance)
NEUROLOGIC LOCALIZATION:
SPINAL CORD

• weakness (para- or quadriparesis/plegia)*

• numbness (sensory level)
• urinary incontinence
• constipation autonomic dysfunction
• sexual dysfunction
Cervical vs. Thoracic vs. Lumbosacral
Anterior vs. Posterior
Right vs. Left

*Paresis is due to UMN lesion. Acutely (1st mins to days) tone &
reflexes may be decreased, but later become increased.
SPINAL CORD “LEVEL” LOCALIZES LESION:
KEY CERVICAL & THORACIC DERMATOMES

• Sensory level
–  sensation below (if C5
few dermatomes below
lesion = “hung level”)
T4
– “tight belt” sensation at
lesion level
• Reflex level
– reflex changes below
( acute,  chronic) T10
• Myeloradiculopathy
T12
– radiculopathy at level
of lesion, myelopathy
below lesion
C6
C8
C7
CLASSIC MYELOPATHIC PATTERNS

Complete/Transverse Myelopathy
• Transverse myelitis • Compressive
– multiple sclerosis myelopathy
– Devic’s syndrome – metastatic cancer
– sarcoid – meningioma
– lupus erythematosus – central disk herniation
– infection (viral, etc.) – vertebral fracture
– epidural hematoma
– epidural abscess
– Pott’s disease (TB)
 DIAGNOSIS BY MYELOPATHIC PATTERN:
TRAUMA OR COMPRESSION

PC
Brown- (JPS)
Séquard CST
Syndrome (UMN)
R
L
STT
(pain)

IPSI CONTRA
 vib & JPS  pin / temp
Weakness /  DTRs
DIAGNOSIS BY MYELOPATHIC PATTERN:
NEUROSYPHILIS

• “Tabes dorsalis”
• Posterior columns
• Sensory level to
vibration & JPS
DIAGNOSIS BY MYELOPATHIC PATTERN:
B12 DEFICIENCY OR HIV

• “Subacute combined
degeneration” or “HIV
vacuolar myelopathy”
• Posterior & lateral
columns
• Spastic paraparesis &
sensory level to
vibration & JPS
DIAGNOSIS BY MYELOPATHIC PATTERN:
SPINAL CORD INFARCTION

• Ant. spinal artery territory

• Anterior 2/3 of cord
– lateral columns
– spinothalamic tracts
• Spastic paraparesis &
sensory level to pain &
temp
DIAGNOSIS BY MYELOPATHIC PATTERN:
SYRINX / SYRINGOMYELIA

• Usually cervical
• Cause old trauma or congenital
• Central cord
– anterior horn cells
– anterior white commissure
– possibly lateral columns
• Hand weakness & atrophy
• Cape-distribution pin/temp loss
(at level of syrinx)
• Possible spastic paraparesis
(below level of syrinx)
NEUROLOGIC LOCALIZATION:
NERVE & NERVE ROOT

• LMN weakness and/or sensory

symptoms in specific patterns
– peripheral neuropathy: distal > proximal
– mononeuropathy: one nerve distribution
– radiculopathy: dermatomal pattern

Axon vs.Myelin
NEUROPATHIC SENSORY SYMPTOMS
& FINDINGS

• Anesthesia = lack of sensation

• Hypesthesia = decreased (or absent) sensation

• Paresthesia = abnormal spontaneous sensation

• Dysesthesia = abnormal sensation to stimulation
 NEUROLOGIC LOCALIZATION:
AXON VS. MYELIN IN PERIPHERAL NEUROPATHY

Axonal Demyelinating
Toxic-metabolic/Vascular Autoimmune
• Diabetes mellitus • Guillain-Barré Syndrome =
• Lyme disease AIDP (acute inflammatory
• HIV infection demyelinating
polyradiculoneuropathy
• Acute intermittent porphyria
• CIDP (chronic)
• Lead toxicity
• Barium salt toxicity
• Mononeuritis multiplex Axon: Abnormal EMG
Myelin: Abnormal NCV
 ELECTROMYOGRAPHY &
NERVE CONDUCTION VELOCITY

EMG: “Needle test” NCV: “Shock test”

NEEDLE

MUSCLE
FIBER

Stim Rec

Stim = Stimulating Electrode

OSCILLOSCOPE Rec = Recording Electrode
NERVE-ROOT DISTRIBUTIONS
CERVICAL DERMATOMES
Radiculopathy Localization
by Sensation History & Exam
C5

History: Where the pain ends

Exam: Where the pin goes

C6
C8
C7
NERVE-ROOT DISTRIBUTIONS
THORACIC DERMATOMES

Radiculopathy Localization
by Sensation History & Exam

T4
History: Where the pain ends
Exam: Where the pin goes

T10
T12
NERVE-ROOT DISTRIBUTIONS
LUMBOSACRAL DERMATOMES

L1
Radiculopathy Localization
L2 by Sensation History & Exam

History: Where the pain ends

L3 Exam: Where the pin goes

L L
4 5

LS
5 1
DEEP TENDON REFLEX
DERMATOME LEVELS
C 7-8 Triceps

C 5-6 Biceps
C 5-6 Brachioradialis

L 3-4 Knee (Patella)

S 1-2 Ankle (Achilles)

NEUROLOGIC LOCALIZATION:
MUSCLE

• proximal > distal weakness

• weakness is not fatigable
• no sensory complaints other than
possible myalgias

“Hair, chair, and stair weakness”

MUSCLE DISEASE = MYOPATHY
PROXIMAL WEAKNESS, NO FATIGABILITY

• thyroid
• polymyositis
• dermatomyositis
• muscular dystrophies
• drug induced (steroid, AZT, statin, etc.)
NEUROLOGIC LOCALIZATION:
NEUROMUSCULAR JUNCTION

• proximal > distal weakness

– episodic
– fatigable (worse late in day, after exercise)
• extraocular/bulbar weakness
• no sensory complaints

Presynaptic vs.
Postsynaptic
EMG REPETITIVE STIMULATION:
RESPONSE TO 3-5 HZ STIMULUS

• Normal
– consistent response
Normal

• Myasthenia gravis
– postsynaptic NMJ
– decremental response
Decremental Response

• Lambert-Eaton
– presynaptic NMJ
– incremental response
Incremental Response
 NMJ DISEASE = MYASTHENIA
PROXIMAL WEAKNESS, YES FATIGABILITY

Neuromuscular Junction / Nicotinic ACh Disease

• Myasthenia Gravis • Organophosphates /
• Lambert-Eaton Nerve Agents
Myasthenic Syndrome – CNS (e.g., seizures)
– strength may increase – muscarinic (SLUDGEM)
transiently on initial • Drug-Induced
contraction Myasthenia
– rarely ocular/bulbar sxs – aminoglycosides
• Botulism – D-penicillamine
– ocular/bulbar sxs prominent,
precede limb sxs
– muscarinic sxs
NEUROLOGIC LOCALIZATION:
DIZZINESS/GAIT IMBALANCE

• Lightheadedness = hypoperfusion
–  heart output or blood volume
• Vertigo = hallucination of movement
– ear, CN 8, brainstem, cerebellum
• Cerebellar ataxia = dyscoordination
– cerebellum or cerebellar tracts/peduncles
• Sensory ataxia = proprioception deficit
– peripheral nerve or posterior spinal cord
THE END
UM CRME University of Miami

Center for Research in Medical Education