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Localising the lesion

Localising the lesion . Ed Hutchison and Paul Swift. Aims. Approach UMN vs. LMN Spinal tracts Cerebellum Cerebrum Visual lesions Cases. Approach to localising the lesion. Be systematic!. …A patient presents with arm weakness…. Muscle – e.g. diabetic myopathy.

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Localising the lesion

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  1. Localising the lesion Ed Hutchison and Paul Swift

  2. Aims • Approach • UMN vs. LMN • Spinal tracts • Cerebellum • Cerebrum • Visual lesions • Cases

  3. Approach to localising the lesion Be systematic! …A patient presents with arm weakness…

  4. Muscle – e.g. diabetic myopathy NMJ – e.g. myasthenia gravis Peripheral nerve – e.g. GBS Spinal cord – e.g. cord compression Cerebrum – e.g. Stroke

  5. Timeline

  6. UMN vs. LMN • ???

  7. UMN vs. LMN

  8. Pyramidal vs. Extrapyramidal

  9. Clonus • http://www.youtube.com/watch?feature=player_detailpage&v=8GC8F2UMYbQ#t=42

  10. Facial nerve palsies • Bulbar vs. pseudobulbar • Pseudobulbar = UMN of CN IX-XII • Spastic tongue • Sparing of forehead • Bulbar = LMN of CN IX-XII • Tongue wasting/fasciculation • Affects all facial muscles

  11. The tracts ? Dorsal column Corticospinal ? ? Spinothalamic

  12. Lateral Spinothalamic Pain and temperature Decussates at the level of the spinal cord

  13. Anterior Spinothalamic Crude touch and pressure Decussates at the level of the spinal cord

  14. Dorsal columns Discrimination, proprioception, vibration. Crosses at the medulla. Subacute combined degeneration of the cord, Tabesdorsalis, Spinal trauma.

  15. Corticospinal Tracts Descending motor tracts. Cross at the medulla.

  16. Brown-Sequard

  17. Brainstem CN IX-XII • Symptoms/signs: • Dysarthria • Dysphagia/drooling • Tongue weakness • Absent palatial movement

  18. Cerebellum Cerebellospinal tracts Ipsilateral – DO NOT CROSS

  19. Blood Supply

  20. Cerebellar Signs D A N I S H – dysdiadochokinesia – ataxia (truncal and limb) – nystagmus – intention tremor – slurred speech – hypotonia

  21. Causes • Alcohol • Thiamine deficiency • CVA • Friedreich’s ataxia Etc etc…

  22. The Homunculus

  23. Cerebral Artery Territories

  24. Circle of Willis Anterior cerebral artery Middle cerebral artery ? Posterior cerebral artery Basilar artery A = ? Vertebral artery Anterior spinal artery B = ?

  25. Speech Centres

  26. Tono man • http://www.youtube.com/watch?v=6CJWo5TDHLE

  27. Broca’s dysphasia • http://www.youtube.com/watch?v=1aplTvEQ6ew

  28. Stroke Syndromes

  29. Visual Defects Ipsilateralblindess Bilateral hemianopia Left homonymous hemianopia Left superior quadrantanopia Left homonymous hemianopia with macular sparing

  30. Cases

  31. Case 1 • 57 year old man complaining of weakness and altered sensation in upper limbs and lower limbs • Loss of sensation from shoulders and down, urinary incontinence • On Examination: • CN intact • Upper limbs weakness, hypotonia, reduced reflexes • Lower limbs spasticity, hyper-reflexia and Babinski +ve, reduced sensation from shoulders down

  32. Case 2 • 85 year old man with long standing (20yr) history of balance problems worse in the dark. • Gait is high stepping • On Examination: • CN intact • Motor intact • Loss of proprioception with +ve Romberg’s test

  33. Case 3 • 23, female presents to her GP with a 2 week history of bilateral leg weakness having started with pins and needles and numbness in her hands and feet. She has had a few days of urinary incontinence which has resolved. 2 years ago she had an episode of blurred vision and pain in the right eye which lasted a month and fully resolved

  34. Case 4 • 56 male • 6 month history of progressive weakness of his right hand. Also had problems with swallowing and has choked whilst eating on several occasions • o/e he has wasting of his upper and lower limbs and some fasciculation's were noted his right plantar was up going and his reflexes were generally brisk

  35. Things we’ve not had time to cover • Peripheral neuropathies • Motor neurone • Parkinson’s • Huntington’s • GBS • Myasthenia gravis

  36. Peripheral Neuropathies • A – alcohol • B – B12 deficiency • C – CKD • D – drugs/diabetes • E – every vasculitis

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