Clinical assessment

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 Midbrain Cerebellar hemispheres Brainstem including PONS & Medulla Spinal cord

5. Localisation of function in the brain

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

7. The homunculus

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

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

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

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 L R Eyes Optic nerves Optic chiasma Optic radiation Visual cortex Right Field Left Field

14. Computerised Tomography (CT)

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

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

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

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

19. Visual Pathways L R Eyes Optic nerves Optic chiasma Optic radiation Visual cortex Right Field Left 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 L R Eyes Optic nerves Optic chiasma Optic radiation Visual cortex Right Field Left Field

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

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

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

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?