WHERES THE LESION?

Why,. Sign and Symptom!!!

Neuroscience Core Lecture
Anwar Wardy, MD.Neu
Department of Neurology
FKK UMJ

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All of Complaints Neurologic in Origin

Wheres the lesion, ????

somewhere in the neuraxis.

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 Divisions of the Neuraxis
1. Cortical Brain
2. Subcortical Brain
3. Brainstem
4. Cerebellum
5. Spinal Cord
6. Root
7. Peripheral Nerve
8. Neuromuscular
Junction
9. Muscle
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 IIndependent learning

Case discussion during weekly didactics

Student presentations on a topic
Consider some online material to
supplement didactics or case discussions
Group-study meeting
SPICES.))

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 Major Diagnoses for clerkship
(Kuasai Sebelum Masuk RS)
*Psychosis Pain
Schizophrenia *Stroke
Substance induced SAH
In context of delirium Hemorrhage
Ischemic
*Mood disorders *Headache
Depression *Movement Disorders
Bipolar disorder Parkinsons ,Essential tremor,
Anxiety Huntingtons
*Substance abuse and Neuromuscular
dependence Myasthenia & ALS
*Delirium *Dementia
*Dementia *Epilepsy
Multiple Sclerosis
Neurosurgery Pediatric
Head and spinal cord injury Well child neurology examination
Radiculopathy and Static and progressive
myelopathy encephalopathies
Brief survey of neuro-oncology Pediatric epilepsy

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 Didactic Topics
(Umumnya di Indonesia)
Emergency psychiatry Weakness Neuromuscular
Schizophrenia problems
Mood Disorders Numbness sensory changes
Psychopharmacology Neurological exam and what it
Confusion or memory problems means
(Dementia and delirium) Pediatric neurology exam
Child psychiatry Loss of consciousness differential
Personality development (seizure, syncope, coma)
Substance dependence (alcohol Epilepsy- Adult and pediatric
and others) Sleep disorders
Neuroscience review Pain and headache
Eating disorders Stroke
Personality disorders Shaking-Movement disorders
Psychotherapy Disorders of intracranial pressure
Anxiety disorders Head and spinal cord injury
Systems of practice in psychiatry Neuro-oncology

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 Off the Top of my Head . . .

Imbalance = Cerebellum

Pneumonia = Brainstem (related dysphagia)

Loss of Dexterity = Peripheral Nerve

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 Neurologic Examination
Higher Cortical Function
Cranial Nerves
Cerebellar Function
Motor
Sensory
Deep Tendon Reflexes
Pathologic Reflexes

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 The Neuro Exam Should
Evaluate the Entire Neuraxis
Higher Cortical Function: cortex
Cranial Nerves: subcortex, brainstem
Cerebellar Function: cerebellum
Motor: motor homonculous, subcortical pyramidal
tracts, BS, cord, radicle, PN, muscle
Sensory: ascending tracts, thalamus, subcortical
tracts, sensory hononculous
Deep Tendon Reflexes: afferent PN, radicle, cord,
efferent PN, muscle
Pathologic Reflexes:
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 Alcohol Pad Sniff Test (exp)

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 Scotts Exam Showed:
Higher Cortical Function: normal
Cranial Nerves: oropharyngeal dysarthria
Cerebellar Function: hypotonia, assynergy,
dysmetria, staccato dysarthria, intention tremor,
appendicular ataxia
Motor: hypotonia, normal strength
Sensory: decreased vibration and temperature
Deep Tendon Reflexes: areflexia
Pathologic Reflexes: plantar flexing
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 So Wheres the Lesion?

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 Goals of MD Testing

Localization Severity

Muscle NMJ Nerve Anterior Horn

Fiber type Pathology Temporal

anwar wardy w
course
Adapted from fig 1-2, Preston and Shapiro fkk umj 2011
 Snellen chart for measuring
visual acuity

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 Hand held visual
acuity card
There are hand held
cards that look like
Snellen Charts but are
positioned 14 inches
from the patient. These
are used simply for
convenience. Testing
and interpretation are
as described for the
Snellen.

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 Brain component

Cerebral cortex
Cerebral cortex

Basal nuclei
(lateral to thalamus)
Basal nuclei

Thalamus
(medial) Thalamus

Hypothalamus
Hypothalamus
Cerebellum
Cerebellum

Midbrain
Brain stem
Brain stem Pons (midbrain, pons,
and medulla)
Medulla Spinal cord
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TABLE 5-1: Overview of Structures and Functions of the Major Components of the Brain.
BRAIN COMPONENT MAJOR FUNCTIONS
1. Sensory perception
Cerebral cortex 2. Voluntary control of movement
3. Language
4. Personality traits
5. Sophisticated mental events, such as thinking memory,
decision making, creativity, and self-consciousness
Basal nuclei 1. Inhibition of muscle tone
2. Coordination of slow, sustained movements
3. Suppression of useless patterns of movements

Thalamus 1. Relay station for all synaptic input

2. Crude awareness of sensation
3. Some degree of consciousness
4. Role in motor control
1. Regulation of many homeostatic functions, such as temperature
Hypothalamus control, thirst, urine output, and food intake
2. Important link between nervous and endocrine systems
3. Extensive involvement with emotion and basic behavioral patterns
1. Maintenance of balance
Cerebellum
2. Enhancement of muscle tone
3. Coordination and planning of skilled voluntary muscle activity

1. Origin of majority of peripheral cranial nerves

Brain stem
2. Cardiovascular, respiratory, and digestive control centers
(midbrain, pons,
3. Regulation of muscle reflexes involved with equilibrium and posture
and medulla)
4. Reception and integration of all synaptic input from spinal cord;
arousal and activation of cerebral cortex
5. Role in sleep-wake cycle anwar wardy w
 Cortical Brain
Depends upon hemispheric dominance

Non-neurologists generalize:
right: visual/spatial, perception and memory
left: language and language dependent memory

Look for aphasias, apraxias, and agnosias

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 Neurologic Examination when
Cortical Brain is Lesioned
Higher Cortical Function: aphasia, apraxia, agnosia
Cranial Nerves: normal
Cerebellar Function: normal
Motor: weakness if you hit the motor homonculous
Sensory: sensory abnormalities if you hit the sensory
homonculous
Deep Tendon Reflexes: hemi-hyper-reflexia
Pathologic Reflexes: possibly Babinskis reflex or frontal
release signs

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 Primary Somatosensory Cortex

Located in the postcentral

gyrus, this area:
Receives information from
the skin and skeletal muscles
Exhibits spatial discrimination
Somatosensory homunculus
caricature of relative
amounts of cortical tissue
devoted to each sensory
function

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 Bells
Bell's Palsy
Facial Nerve Paralysis
Causes
Infectious Disease
Herpes Ophthalmicus
Ramsey Hunt Syndrome
Assorted Pages in
Cranial Nerve
Progressive Bulbar
Paralysis
Trigeminal Neuralgia

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 Primary Motor Cortex
Located in the precentral
gyrus
Composed of pyramidal
cells whose axons make up
the corticospinal tracts
Allows conscious control of
precise, skilled, voluntary
movements
Motor homunculus
caricature of relative
amounts of cortical tissue
devoted to each motor
function

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 Neurologic Examination when
Brainstem is Lesioned
Higher Cortical Function: normal
Cranial Nerves:
III, IV, VI: diplopia
V : decreased facial sensation
VII : drooping
VIII : deaf and dizzy
IX, X, XII: dysarthria and dysphagia
XI : decreased strength in neck and shoulders
Cerebellar Function: normal
Motor: hemi-paresis, UMN
Sensory: hemi-dysesthesias
Deep Tendon Reflexes: hemi-hyper-reflexia
Pathologic Reflexes: Babinskis reflex
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 Skala Kekuatan Otot.
0; Tidak terdapat konraksi otot yang
terlihat.
1; Kontraksi dapat terlihat.
2.Gerakan aktif penghilangan gravitasi.
3.Gerakan aktif terhadap gravitasi.
4.Gerakan aktif dengan tahanan.
5.Gerakan aktif terhadap tahanan
penuh.
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 Koordinasi.
Cara berdiri: Uji Romberg, pasien berdiri mata terbuka kaki rapat,
kemudian pejamkan mata selama 20-30 detik.Sedikit terjadi
goyangan perhatikan pada saat tangan direntangkan dgn mata
tertutup selama 20-30 detik, terjadi penyimpangan pronasi dan fleksi
kearah bawah; hemiparese.

Cara berjalan:
1. Berjalan menjauh, berputar dan kembali.
2. Berjalan jinjit atau berjungkit (bergantian)
3. Melompat ditempat dengan ke.2 kaki
4. Lakukan gerakan dengan melipat 1 tungkai.
Bergantian berdiri dari kursi dan berjinjit, melompat dan jongkok
sesuai kebutuhan.Kelemahan motorik, ataksia serebral, parkinson
dan hilangnya keseimbangan posisi dapat mempengaruhi semua
performa.
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 Lanjutan:

Kelemahan
koordinasi,
inkoordinasi pada
buruknya indra-posisi
(propioseptif) dapat
terjadi bila pasien
diminta untuk menahan
tangannya keatas, dan
kita menepuk tangan
tersebut kearah bawah.
Bila kembali keposisi
semua secara perlahan;
Normal
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 Cerebellar Function

Some people believe that one can not test specifically for
cerebellar abnormalities
no one test on examination reliably evaluates the cerebellum

H: hypotonia
A: assynergy of (ant)agonist muscles
N: nystagmus
D: dysmetria, dysarthria
S: stance and gait
T: tremor
 Neurologic Examination when the
Cerebellum is Lesioned
Higher Cortical Function: normal
Cranial Nerves: normal
Cerebellar Function:
nystagmus
staccato dysarthria (abnormality of prosody)
Motor:
hemi-hypotonia
intention > positional tremor
axial instability with dysmetria
Sensory: normal
Deep Tendon Reflexes: normal
Pathologic Reflexes: none

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 Spinal Cord
Sensory level (horizontal)
Weakness below the lesion (paraparesis)
UMN signs below the lesion
Bowel and bladder incontinence

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 Neurologic Examination when the
Spinal Cord is Lesioned
Higher Cortical Function: normal
Cranial Nerves: normal
Cerebellar Function: normal
Motor: weakness below the lesion
Sensory: horizontal level
Deep Tendon Reflexes: hyper-reflexia below the
lesion
Pathologic Reflexes: Babinskis reflex

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 Root/Radiculopathy

Pain is the hallmark of a radiculopathy

Sensory abnormalities in a dermatome
provocative maneuvres exacerbate the pain
Weakness in a myotome (assymetric)
LMN findings

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 Neurologic Examination when a
Root is Lesioned
Higher Cortical Function: normal
Cranial Nerves: normal
Cerebellar Function: normal
Motor: assymetric weakness in a myotome
Sensory: pain and dysesthesia confined to a
dermatome
Deep Tendon Reflexes: hypo- to a-reflexia if the root
carries a reflex
Pathologic Reflexes: none
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 Peripheral Nerve
(presuming nonfocality)
Weakness: distal predominant
Sensory Dysesthesias: distal predominant

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 Neurologic Examination with
Diffuse PN Lesioning
Higher Cortical Function: normal
Cranial Nerves: normal
Cerebellar Function: normal
Motor: weakness is distal predominant
Sensory: dysesthesias are distal predominant
Deep Tendon Reflexes: loss of distal reflexes
Pathologic Reflexes: mute responses to plantar
stimulation

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 Neuromuscular Junction
Fatiguability is the hallmark
Weakness: proximal and symmetric
exacerbated with use, recovers with rest
often affects facial muscles (ptosis, dysconjugate
gaze, slack jaw)
Sensation: preserved

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 Neurologic Examination in
Disorders of the NMJ
Higher Cortical Function: normal
Cranial Nerves: fatiguabile ptosis, dysconjugate gaze, slack
jaw
Cerebellar Function: normal
Motor: fatiguable proximal weakness in both UEs and LEs
Sensory: normal
Deep Tendon Reflexes: normal
Pathologic Reflexes: none

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 Muscle
Weakness of proximal arm and leg muscles
symmetric
Sensation is normal
though patients complain of cramping and aching

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 Neurologic Examination in
Disorders of Muscle
Higher Cortical Function: normal
Cranial Nerves: ptosis, dysconjugate gaze, dysphagia,
dysphonia, (dysarthria)
Cerebellar Function: normal
Motor: proximal weakness in both UEs and LEs, atrophy
and fasiculations, hypotonia
Sensory: normal
Deep Tendon Reflexes: preserved until late in the disease
Pathologic Reflexes: none

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 Thank You
1 Desember 2010

Terima Kasih
Wassalam,wr wbr
Anwar Wardy W

FK.UMJ, Dept.Neuropsikiatri anwar wardy w