Cns

2. APPROACH TO A APPROACH TO A
PATIENT WITH CNS PATIENT WITH CNS
DISORDERDISORDER
DR M SHOAIB SHAFIDR M SHOAIB SHAFI

3. MAIN PRESENTING COMPLAINTS MAIN PRESENTING COMPLAINTS
OF CNSOF CNS
Headache, backache or neck painHeadache, backache or neck pain
Facial painFacial pain
Fits ,faints or funny turnsFits ,faints or funny turns
Dizziness or vertigoDizziness or vertigo
Disturbance of vision, hearing or smellDisturbance of vision, hearing or smell
Disturbance of memory, sphincter control, Disturbance of memory, sphincter control,
sleep, speech, language or gaitsleep, speech, language or gait

4. CONTD….CONTD….
Disorders of movementDisorders of movement
weaknessweakness
abnormal involuntary movementsabnormal involuntary movements
Acute confusional stateAcute confusional state
Coma and brain deathComa and brain death
Problem with brainstem functionProblem with brainstem function
Sensory disturbancesSensory disturbances

5. HOW TO APPROACHHOW TO APPROACH

6. APPROACH TO DIAGNOSISAPPROACH TO DIAGNOSIS

It involves two questions:It involves two questions:
Where is the lesion?Where is the lesion?
What is its etiology?What is its etiology?

7. Where is the lesion?Where is the lesion?
1) Is the lesion :1) Is the lesion :
Single,multiple or is it a diffuse processSingle,multiple or is it a diffuse process
Restricted to CNS or part of systemic illnessRestricted to CNS or part of systemic illness
2) Do the findings combine to form a 2) Do the findings combine to form a
recognizable clinical syndrome eg parkinsonism recognizable clinical syndrome eg parkinsonism

8. What is the etiology?What is the etiology?
VITAMINS-DVITAMINS-D
Vascular eg CVA, venous sinus thrombosisVascular eg CVA, venous sinus thrombosis
Infectious eg meningitis, cerebral abscess Infectious eg meningitis, cerebral abscess
Inflammatory eg acute transverse myelitis, MS, ADEMInflammatory eg acute transverse myelitis, MS, ADEM
Traumatic eg Extradural hematoma or SDHTraumatic eg Extradural hematoma or SDH
Autoimmune eg myesthenia gravis, GBSAutoimmune eg myesthenia gravis, GBS
Metabolic & toxic eg hypoglycemia, hyponatremia, Metabolic & toxic eg hypoglycemia, hyponatremia,
alcohol intoxication, uremiaalcohol intoxication, uremia
Iatrogenic eg antipsychotic induced parkinsonismIatrogenic eg antipsychotic induced parkinsonism
Neoplastic eg primary or secondary brain tumoursNeoplastic eg primary or secondary brain tumours
Seizures & psychiatric disordersSeizures & psychiatric disorders
Degenerative lesions eg alzheimers dementiaDegenerative lesions eg alzheimers dementia

9. HISTORYHISTORY
Onset of illness & its courseOnset of illness & its course
Comorbation of history by attendantsComorbation of history by attendants
Premorbid conditionPremorbid condition
Family historyFamily history
Medical historyMedical history
Drug use, abuse & toxin exposureDrug use, abuse & toxin exposure
Formulating an impression of the patientFormulating an impression of the patient
Precipitating factorsPrecipitating factors
Associated symptomsAssociated symptoms

10. PHYSICAL EXAMINATIONPHYSICAL EXAMINATION
GPE:GPE:
BPBP
PULSEPULSE
TEMPERATURETEMPERATURE
PURPURIC SPOTSPURPURIC SPOTS
RASHRASH
HANDS ( CLUBBING,SPLINTER HGES)HANDS ( CLUBBING,SPLINTER HGES)
FACE (FEATURES OF C.T DISORDER,EYE,SINUSES)FACE (FEATURES OF C.T DISORDER,EYE,SINUSES)
EAREAR
NECK (CAROTID,JVP,THYROID)NECK (CAROTID,JVP,THYROID)

11. SYSTEMIC EXAMINATIONSYSTEMIC EXAMINATION
CENTRAL NERVOUS SYSTEMCENTRAL NERVOUS SYSTEM
 CARDIOVACULAR EXAMINATION CARDIOVACULAR EXAMINATION
HEART MURMURHEART MURMUR
GASTROINTESTINAL EXAMINATIONGASTROINTESTINAL EXAMINATION
KIDNEYS, SPLEENKIDNEYS, SPLEEN
RESPIRATORY SYSTEMRESPIRATORY SYSTEM
PULMONARY INFECTIONPULMONARY INFECTION
PULMONARY EDEMA PULMONARY EDEMA

12. CENTRAL NERVOUS SYSTEMCENTRAL NERVOUS SYSTEM
GCS EGCS E
44VV
55MM
66
PUPILSPUPILS
HIGHER MENTAL FUCTIONHIGHER MENTAL FUCTION
Time- knows month or yearTime- knows month or year
Place- has general knowledge of where they arePlace- has general knowledge of where they are
Person- knows own name, able to name relatives or friendPerson- knows own name, able to name relatives or friend
 Memory- capability for early and recent recallMemory- capability for early and recent recall
CRANIAL NERVES CRANIAL NERVES

13. Primary sensationPrimary sensation
TouchTouch
PainPain
TemperatureTemperature
Sense of position and vibrationSense of position and vibration
cortical sensationcortical sensation
LocalizationLocalization
Two point discriminationTwo point discrimination
StereognosisStereognosis
GraphesthesiaGraphesthesia
Perceptual rivalryPerceptual rivalry
SENSORY SYSTEMSENSORY SYSTEM

14. BOTH UPPER & LOWER LIMBSBOTH UPPER & LOWER LIMBS
Bulk of musclesBulk of muscles
Tone of muscleTone of muscle
Power of musclesPower of muscles
ReflexesReflexes
GaitGait
Coordination of movementCoordination of movement
SpineSpine
MOTOR SYSTEMMOTOR SYSTEM

15. NystagmusNystagmus
Scanning speechScanning speech
Finger nose testFinger nose test
DysdiadochokinesiaDysdiadochokinesia
Rebound phenomenonRebound phenomenon
Pendular knee jerkPendular knee jerk
HypotoniaHypotonia
Heel knee shin testHeel knee shin test
Romberg signRomberg sign
Drunken gaitDrunken gait
CEREBELLAR SIGNSCEREBELLAR SIGNS

16. SPEECHSPEECH
DysphasiaDysphasia
DysarthriaDysarthria

17. SIGNS OF MENINGEAL SIGNS OF MENINGEAL
IRRITATIONIRRITATION
Neck stiffnessNeck stiffness
Kernigs signKernigs sign
Brudinzkis signBrudinzkis sign

19. INVESTIGATIONSINVESTIGATIONS
Finger stick glucose Finger stick glucose

CBC(wbc,plt) CBC(wbc,plt)
LFTs LFTs
PT, APTT& INRPT, APTT& INR
Creatinine Creatinine
Electrolytes Electrolytes
(Na,Ca,Mg,K)(Na,Ca,Mg,K)
Blood culture Blood culture

ECGECG
EchocardiogramEchocardiogram
Lumbar punctureLumbar puncture
NCS/ EMGNCS/ EMG
EEGEEG
CT headCT head
Cerebral angiographyCerebral angiography
Carotid Doppler Carotid Doppler
TestingTesting
MRI/ MRAMRI/ MRA
Evoked potentialsEvoked potentials

20. LIPID PROFILELIPID PROFILE
HYPERCOUGUBALE STATEHYPERCOUGUBALE STATE
HOMOCYSTEINURIAHOMOCYSTEINURIA
ANTICARDIOLIPIN ANTIBODIESANTICARDIOLIPIN ANTIBODIES
SLESLE
VASCULITISVASCULITIS

21. Tin-pot dictators have ravaged Asia, Latin America & Tin-pot dictators have ravaged Asia, Latin America &
Africa. They are the worst tyrants of post-colonial period. Africa. They are the worst tyrants of post-colonial period.
They have destroyed time-honored institutions & treated They have destroyed time-honored institutions & treated
their people like animals. They have caused internal their people like animals. They have caused internal
divisions &external confusion. The dictator is one animal divisions &external confusion. The dictator is one animal
who needs to be caged. He betrays his profession & his who needs to be caged. He betrays his profession & his
constitution. Not a single one of them has made a constitution. Not a single one of them has made a
moments contribution to history.moments contribution to history.

22. HOW TO LOCATE THE HOW TO LOCATE THE
LESION IN CNSLESION IN CNS

23. IMPORTANT STRUCTURESIMPORTANT STRUCTURES
Cerebral cortexCerebral cortex
Corona radiataCorona radiata
Internal capsuleInternal capsule
BrainstemBrainstem
(midbrain, pons, medulla oblongata, cerebellum)(midbrain, pons, medulla oblongata, cerebellum)
ThalamusThalamus
HypothalamusHypothalamus
Extrapyramidal systemExtrapyramidal system

24. Case scenarioCase scenario
A 45yrs old lady is brought to ER with c/o sudden weakness of A 45yrs old lady is brought to ER with c/o sudden weakness of
right half of body. O/Eright half of body. O/E
Patient drowsyPatient drowsy
BP = 180/110 mmHg BP = 180/110 mmHg
Pulse = 68/minPulse = 68/min
CNS: GCS 7/15CNS: GCS 7/15
Power decreased on rightPower decreased on right
Tone increased on rightTone increased on right
Right plantar upgoingRight plantar upgoing
Right facial nerve palsy (UMN type)Right facial nerve palsy (UMN type)
Explain the nature of lesion.Explain the nature of lesion.

25. CASE SCENARIOCASE SCENARIO
A 56yrs old gentleman with h/o uncontrolled A 56yrs old gentleman with h/o uncontrolled
hypertension presents in ER with sudden onset hypertension presents in ER with sudden onset
of weakness of left arm.of weakness of left arm.
Where is the lesion in brain?Where is the lesion in brain?

29. CEREBRAL DOMINANCECEREBRAL DOMINANCE
Two cerebral hemispheresTwo cerebral hemispheres
All the right handed persons and most of left All the right handed persons and most of left
handed persons have left hemisphere as the handed persons have left hemisphere as the
dominant one.dominant one.
Dominant hemisphere controls the speech. Dominant hemisphere controls the speech.

32. Frontal
Lobe
Parietal
Lobe
Occipital
Lobe
Temporal
Lobe
Cerebellum
Brain
Stem
Frontal Lobe
• Initiation
• Problem solving
• Judgment
• Inhibition of behavior
• Planning/anticipation
• Self-monitoring
• Motor planning
• Personality/emotions
• Awareness of
abilities/limitations
• Organization
• Attention/concentration
• Mental flexibility
• Speaking
(expressive language)
Temporal Lobe
• Memory
• Hearing
• Understanding language
(receptive language)
• Organization and sequencing
Parietal Lobe
• Sense of touch
• Differentiation:
size, shape, color
• Spatial perception
• Visual perception
Occipital Lobe
• Vision
Cerebellum
• Balance
• Coordination
• Skilled motor activity
Brain Stem
• Breathing
• Heart rate
• Arousal/consciousness
• Sleep/wake functions
• Attention/concentration

34. MEDIAL VIEWMEDIAL VIEW

35. HOMENCULUSHOMENCULUS

36. HOMENCULIHOMENCULI

42. Spinal cord begins at the end of medulla oblongata and Spinal cord begins at the end of medulla oblongata and
extends upto lumbar vertebra 2 or 3 in adults.extends upto lumbar vertebra 2 or 3 in adults.
Lower tapering part is called conus medularis and the Lower tapering part is called conus medularis and the
lowermost bundle of nerve fibres is called cauda equina.lowermost bundle of nerve fibres is called cauda equina.
It contains all the ascending and descending fibres. It contains all the ascending and descending fibres.
Lesion here can cause hemiplegia, paraplegia or Lesion here can cause hemiplegia, paraplegia or
quadriplegia.quadriplegia.

44. Cross section of cordCross section of cord

46. Main arteries are:Main arteries are:
Internal carotid arteriesInternal carotid arteries
Basilar arteriesBasilar arteries
Vertebral arteriesVertebral arteries
Anterior cerebral arteriesAnterior cerebral arteries
Middle cerebral arteriesMiddle cerebral arteries
Posterior cerebral arteriesPosterior cerebral arteries
These form a circle called CIRCLE OF WILLISThese form a circle called CIRCLE OF WILLIS

50. Areas of supplyAreas of supply
MCA supplies lateral surface of frontal, parietal MCA supplies lateral surface of frontal, parietal
& temporal lobe ie most of the motor & sensory & temporal lobe ie most of the motor & sensory
cortex except which lies on medial side and cortex except which lies on medial side and
controls legs.controls legs.
ACA supplies medial side of brain.ACA supplies medial side of brain.
PCA supplies the occipital lobe.PCA supplies the occipital lobe.

52. It includes:It includes:
Corticospinal tractsCorticospinal tracts
Extrapyramidal systemExtrapyramidal system
Cerebellum (for coordination)Cerebellum (for coordination)

53. CORTICOSPINAL PATHWAYCORTICOSPINAL PATHWAY
Neurons in precentral gyrusNeurons in precentral gyrus
Corona radiataCorona radiata
Posterior limb of internal capsulePosterior limb of internal capsule
Cerebral peduncle in ponsCerebral peduncle in pons
MidbrainMidbrain
Medulla oblongataMedulla oblongata
Decussation of fibres occur in pyramids of MO Decussation of fibres occur in pyramids of MO
and then descend as lateral corticospinal tracts.and then descend as lateral corticospinal tracts.

55. 5 PATTERNS OF MOTOR 5 PATTERNS OF MOTOR
WEAKNESSWEAKNESS
UMN weaknessUMN weakness
LMN weaknessLMN weakness
Muscle diseaseMuscle disease
Neuromuscular junctionNeuromuscular junction
Functional weaknessFunctional weakness

57. APPROACH TO WEAKNESSAPPROACH TO WEAKNESS
First determine whether its:First determine whether its:
Generalised weaknessGeneralised weakness
Weakness of all 4 limbsWeakness of all 4 limbs
HemiplegiaHemiplegia
ParaplegiaParaplegia
MonoplegiaMonoplegia
Patchy weaknessPatchy weakness

58. Weakness all 4
limbs
Upper motor
Neuron pattern
proximal>distal
Neuropathy
Distal sensory loss
Myopathy
No sensory loss
Cervical spinal cord
Or bilateral brainstem
Or hemisphere
Weakness in both
legs
Upper motor neuron
pattern
no
yes
no
no
yes
yes
no
no
Spinal cord, thoracic spine or above
Yes

59. Unilateral arm
And leg
Single limb
Patchy weakness
Variable weakness
Lesion in brainstem
Or hemisphere
Single root
Single named nerve
Multiple named nerves
Fatigues
Radiculopathy
Mononeuropathy
Mononeuritis
multiplex
Myesthenia
gravis
no
no
no
yes
no
yes
yes
yes
yes
yes
yes
no

60. Case scenarioCase scenario
A 50yrs old male suddenly develops weakness of A 50yrs old male suddenly develops weakness of
left half of body. O/E there is weak left arm & left half of body. O/E there is weak left arm &
leg with increased tone & upgoing plantar. There leg with increased tone & upgoing plantar. There
is sensory loss also.3 days later patient starts is sensory loss also.3 days later patient starts
complaining of agonizing pain down the left leg. complaining of agonizing pain down the left leg.
Patient says that he feels like as his flesh is being Patient says that he feels like as his flesh is being
torn away from bones.torn away from bones.
What is the lesion and where is the lesion?What is the lesion and where is the lesion?

61. Case scenarioCase scenario
A 46yrs old male is brought to OPD with A 46yrs old male is brought to OPD with
c/o sudden inability to walk & to hold the c/o sudden inability to walk & to hold the
objects. O/E pt is having right nystagmus. objects. O/E pt is having right nystagmus.
There is dysarthria & past pointing on right. There is dysarthria & past pointing on right.
When asked to walk, patient sways to right.When asked to walk, patient sways to right.
Where is the lesion in CNS?Where is the lesion in CNS?

62. 1:Generalised weakness1:Generalised weakness
Nerve lesion polyradiculopathyNerve lesion polyradiculopathy
Neuromuscular junctionNeuromuscular junction
myasthenia gravismyasthenia gravis
Muscle disease myopathyMuscle disease myopathy

63. 2:All four limbs---quadriplegia2:All four limbs---quadriplegia
UMN typeUMN type
LMN typeLMN type
Mixed upper & lower motor neuron typeMixed upper & lower motor neuron type
myopathymyopathy

64. 3:hemiplegia3:hemiplegia
Cerebral lesionCerebral lesion
Brainstem lesionBrainstem lesion
Hemisection of cordHemisection of cord

65. 4:paraplegia4:paraplegia
UMN TYPE spinal cord lesionUMN TYPE spinal cord lesion
LMN TYPE cauda equina lesionLMN TYPE cauda equina lesion

66. 5:Patchy weakness5:Patchy weakness
UMN multiple sclerosisUMN multiple sclerosis
LMN polyradiculopathyLMN polyradiculopathy
mononeuritis multiplexmononeuritis multiplex

68. Sensory PathwaysSensory Pathways
Main sensory pathways are:Main sensory pathways are:
Dorsal columnDorsal column
Lateral Spinothalamic tractLateral Spinothalamic tract

69. Dorsal ColumnDorsal Column
It is concerned with joint position sense, It is concerned with joint position sense,
vibration and touchvibration and touch
Axons proceed in the posterior column to dorsal Axons proceed in the posterior column to dorsal
column nuclei in medullacolumn nuclei in medulla
Second order neurons decussate and ascend in Second order neurons decussate and ascend in
medial lemniscus to thalamusmedial lemniscus to thalamus
From thalamus fibres relay in parietal sensory From thalamus fibres relay in parietal sensory
cortexcortex

70. Lateral spinothalamic tractLateral spinothalamic tract
It is concerned with pain and temperatureIt is concerned with pain and temperature
Fibres synapse in posterior horns and decussate Fibres synapse in posterior horns and decussate
in the center of cord in the center of cord
Later they pass in lateral column as Later they pass in lateral column as
spinothalamic tract and join medial leminiscus to spinothalamic tract and join medial leminiscus to
reach thalamusreach thalamus

73. Symptoms of Sensory disturbancesSymptoms of Sensory disturbances
Complaints like:Complaints like:
Being unable to feel feet on the floorBeing unable to feel feet on the floor
Unable to judge temperature of bath waterUnable to judge temperature of bath water
Pins and needle sensationsPins and needle sensations
Sensory ataxiaSensory ataxia
Paraesthesias and pain in nerve root region of Paraesthesias and pain in nerve root region of
supplysupply

74. Patterns of Sensory lossPatterns of Sensory loss
Single nerve lesion e.g., median n. lesionSingle nerve lesion e.g., median n. lesion
Root lesionRoot lesion
as in cervical or lumbar disc protrusionas in cervical or lumbar disc protrusion
Peripheral nerve lesion Peripheral nerve lesion
e.g., neuralgias, glove and stocking sensory losse.g., neuralgias, glove and stocking sensory loss
 Brain stem lesions:Brain stem lesions:
loss of pain and temperature on ipsilateral half of face loss of pain and temperature on ipsilateral half of face
and opposite half of body (e.g. lateral medullary and opposite half of body (e.g. lateral medullary
syndrome)syndrome)

75. Patterns of Sensory lossPatterns of Sensory loss
(continued-----) (continued-----)
Thalamic lesion:Thalamic lesion:
hemisensory loss of all modalities and severe hemisensory loss of all modalities and severe
deep seated burning pain deep seated burning pain
(Dejerine roussy syndrome )(Dejerine roussy syndrome )
Cortical lesion (parietal lobe )Cortical lesion (parietal lobe )
Hemisensory loss of all modalitiesHemisensory loss of all modalities
Spinal cord lesionsSpinal cord lesions

76. SPINAL CORD LESIONSSPINAL CORD LESIONS

77. CASE SCENARIOSCASE SCENARIOS
Gulzar bibi, 65 yr old lady presented via opd Gulzar bibi, 65 yr old lady presented via opd
with c/o gradual weakness of both the legs for with c/o gradual weakness of both the legs for
last 2months associated with urinary and fecal last 2months associated with urinary and fecal
incontinence. There is also a c/o tingling and incontinence. There is also a c/o tingling and
burning sensation in the legs. burning sensation in the legs.

78. O/EO/E
An old lady lying in bed, conscious.An old lady lying in bed, conscious.
No abnormality on inspectionNo abnormality on inspection
Power 0/5 in both the legsPower 0/5 in both the legs
Tone decreased in both the legsTone decreased in both the legs
Reflexes diminishedReflexes diminished
Plantars bilaterally upgoingPlantars bilaterally upgoing
Spine normalSpine normal
Sensory level at T6Sensory level at T6
what is the investigation of choice?what is the investigation of choice?

79. MRI spine showed degenerative spondylitis at MRI spine showed degenerative spondylitis at
mid and lower thoracic spine,most evident at mid and lower thoracic spine,most evident at
T8 & T9 causing cord compression.T8 & T9 causing cord compression.

80. Case 2Case 2
Mr Fazal kareem, an 80yr old gentleman Mr Fazal kareem, an 80yr old gentleman
presented in ER with c/o weakness of legs, presented in ER with c/o weakness of legs,
constipation & urinary retention. Patient constipation & urinary retention. Patient
referred to surgical unit as a case of intestinal referred to surgical unit as a case of intestinal
obstruction and urinary retention. Later no obstruction and urinary retention. Later no
surgical abnormality detected. Medical surgical abnormality detected. Medical
consultation taken. consultation taken.

81. O/EO/E
BULK equal bilaterallyBULK equal bilaterally
TONE increased in both the legsTONE increased in both the legs
POWER 2/5 in both legsPOWER 2/5 in both legs
REFLEXES diminishedREFLEXES diminished
PLANTARS upgoingPLANTARS upgoing
SENSORY LEVEL T4SENSORY LEVEL T4
Clinical diagnosis?Clinical diagnosis?

82. CASE 3CASE 3
Miss maryam, 16 yr old presented in OPD with Miss maryam, 16 yr old presented in OPD with
c/o progressively increasing difficulty in c/o progressively increasing difficulty in
walking. O/Ewalking. O/E
POWER 3/5 in both legsPOWER 3/5 in both legs
TONE increasedTONE increased
REFLEXES hyperreflexiaREFLEXES hyperreflexia
Plantars upgoingPlantars upgoing
Ankle & knee clonus positiveAnkle & knee clonus positive
Sensory level T6 Sensory level T6

83. Patient had pulmonary TB 3yrs back, took Patient had pulmonary TB 3yrs back, took
ATT for 2months.ATT for 2months.
MRI spine showed two soft tissue density MRI spine showed two soft tissue density
masses in thoracic spine causing cord masses in thoracic spine causing cord
compression.compression.
Histopathology of the mass showed Histopathology of the mass showed
features consistent with the diagnosis of features consistent with the diagnosis of
-------?-------?

84. CASE 4CASE 4
A 30 yrs man is brought to ER after an RTA causing A 30 yrs man is brought to ER after an RTA causing
injury to spine. O/E:injury to spine. O/E:
Vitals stableVitals stable
Power 0/5 in the legsPower 0/5 in the legs
Reflexes absent Reflexes absent
Tone decreased in both legsTone decreased in both legs
Plantars non-specificPlantars non-specific
Complete absence of all sensations below the umbilicusComplete absence of all sensations below the umbilicus

85. What is the lesion?What is the lesion?

Where is the lesion?Where is the lesion?

86. CASE 5CASE 5
A 40 yrs old male, victim of earthquake with spinal injury A 40 yrs old male, victim of earthquake with spinal injury
is admitted in the ward. Examination of legs shows:is admitted in the ward. Examination of legs shows:
Power 0/5 in left legPower 0/5 in left leg
Tone increased in left legTone increased in left leg
Left plantar upgoingLeft plantar upgoing
Reflexes brisk on left sideReflexes brisk on left side
Absent joint position & vibration sense on leftAbsent joint position & vibration sense on left
Absent pain & temperature sensation on rightAbsent pain & temperature sensation on right
What is the pathology? What is the pathology?

87. CASE 6CASE 6
A 57 yrs old man is brought to ER with c/o sudden A 57 yrs old man is brought to ER with c/o sudden
inability to walk. O/E power reduced in both legs with inability to walk. O/E power reduced in both legs with
upgoing plantars. There is loss of pain & temperature upgoing plantars. There is loss of pain & temperature
sensation in both legs but joint position sense is intact.sensation in both legs but joint position sense is intact.
What is your diagnosis? What is your diagnosis?

88. CASE 7CASE 7
A 48 yrs old male is brought to ER with c/o weakness A 48 yrs old male is brought to ER with c/o weakness
of all the four limbs over a period of 1year. However of all the four limbs over a period of 1year. However
there is no incontinence. Thre is also dysphagia. there is no incontinence. Thre is also dysphagia.
Examination reveals UMN quadriplegia with visible Examination reveals UMN quadriplegia with visible
fasciculations over the tongue. Uvula deviates to left fasciculations over the tongue. Uvula deviates to left
when 10when 10
thth
nerve is examined. nerve is examined.
Where is the lesion & what is the pathology?Where is the lesion & what is the pathology?

89. CASE 8CASE 8
A 42 yrs old lady comes in OPD with c/o numbness of A 42 yrs old lady comes in OPD with c/o numbness of
both the hands and difficulty in holding the objects. both the hands and difficulty in holding the objects.
O/E there is absent pain & temperature sensation over O/E there is absent pain & temperature sensation over
the hands and forearms. Sensory loss is dissociated. the hands and forearms. Sensory loss is dissociated.
Sense of vibration and joint position sense is intact. Sense of vibration and joint position sense is intact.
There is weakness of small muscles of hands. There is weakness of small muscles of hands.
What is your impression?What is your impression?

90. CASE 9CASE 9
A 65 yrs old gentleman is brought to OPD with c/o progressively A 65 yrs old gentleman is brought to OPD with c/o progressively
increasing generalised weakness, anorexia, SOB & easy increasing generalised weakness, anorexia, SOB & easy
bruisability. There is previous h/o partial gastrectomy due to bruisability. There is previous h/o partial gastrectomy due to
unknown reason. O/E:unknown reason. O/E:
An elderly gentleman with marked pallor, bilateral pitttting edema An elderly gentleman with marked pallor, bilateral pitttting edema
feet & bruises over the arms and legs.feet & bruises over the arms and legs.
Vitals stableVitals stable
GIT: no abnormalityGIT: no abnormality

91. LABSLABS
 Hb = 5.7 g/dlHb = 5.7 g/dl
MCV = 116 FlMCV = 116 Fl
Serum albumin = 2.7 g/dlSerum albumin = 2.7 g/dl
PT = 22sec/ 14 secPT = 22sec/ 14 sec
What is your diagnosis & management plan?What is your diagnosis & management plan?

92. CNS: CNS:
POWER 3/5 in legsPOWER 3/5 in legs
REFLEXES : absent ankle reflex on both sidesREFLEXES : absent ankle reflex on both sides
PLANTARS: upgoingPLANTARS: upgoing
Absent sensations upto kneesAbsent sensations upto knees

93. COMPLETE SECTIONCOMPLETE SECTION

Bilateral loss of all modalities below the level of Bilateral loss of all modalities below the level of
lesionlesion

94. HemisectionHemisection
Contralateral loss of pain and temperatureContralateral loss of pain and temperature
Ipsilateral loss of touch and pressureIpsilateral loss of touch and pressure
Below the level of lesionBelow the level of lesion
Brown sequard syndromeBrown sequard syndrome

96. Contralateral loss of pain and
Temp with preservation of
Dorsal column
(e.g.syringomyelia)

97. Spinal cord lesionsSpinal cord lesions
Posterior column lossPosterior column loss
Anterior spinal artery syndrome:Anterior spinal artery syndrome:
Involvement of lateral spinothalamic tract with Involvement of lateral spinothalamic tract with
preservation of dorsal columnpreservation of dorsal column

102. Cerebral CortexCerebral Cortex
Contralateral hemiplegia with hemisensory lossContralateral hemiplegia with hemisensory loss
Left hemisphere; dominant:Left hemisphere; dominant:
AphasiaAphasia
Cortical sensory lossCortical sensory loss
Right hemisphereRight hemisphere
Inattention, denial, constructional apraxia, Inattention, denial, constructional apraxia,
dressing apraxia, spatial disorientationdressing apraxia, spatial disorientation

104. Corona radiataCorona radiata

Contralateral weakness mostly monoplegiaContralateral weakness mostly monoplegia
Sensory loss according to area involvedSensory loss according to area involved

105. Internal capsuleInternal capsule
Dense contralateral hemiplegia and sensory lossDense contralateral hemiplegia and sensory loss
Face, arm and leg equally affectedFace, arm and leg equally affected

106. MidbrainMidbrain
Involvement of:Involvement of:
 Third and fourth cranial nervesThird and fourth cranial nerves
Descending corticospinal and corticobulbar Descending corticospinal and corticobulbar
tractstracts
Reticular formationReticular formation
Red nucleusRed nucleus

107. Clinical syndromes associated with Clinical syndromes associated with
lesionlesion
WeberWeber´s syndrome: Contralateral hemiplegia and ´s syndrome: Contralateral hemiplegia and
ipsilateral third nerve lesionipsilateral third nerve lesion
Benedikt´s syndrome: third nerve palsy with Benedikt´s syndrome: third nerve palsy with
involuntary movements of opposite limbs (red involuntary movements of opposite limbs (red
nucleus involvement)nucleus involvement)
Akinetic mutism:Akinetic mutism:
Involvement of reticular formation; patient makes Involvement of reticular formation; patient makes
no voluntary movements except that of eyesno voluntary movements except that of eyes

108. Weber syndromeWeber syndrome

109. Lesions in ponsLesions in pons
It contains 5It contains 5
thth
, 6, 6
thth
,7,7
thth
& 8 & 8
thth
cranial nerve nuclei. cranial nerve nuclei.
Lateralized lesion in pons causes ipsilateral CN Lateralized lesion in pons causes ipsilateral CN
involvement with crossed paralysis or sensory loss as in involvement with crossed paralysis or sensory loss as in
Millard Gubler syndrome. (6Millard Gubler syndrome. (6
thth
and 7 and 7
thth
nerve palsy) nerve palsy)
Central pontine lesion may cause coma, hyperthermia Central pontine lesion may cause coma, hyperthermia
& pinpoint pupils.& pinpoint pupils.
Locked in syndrome: only eye movement is possible. Pt Locked in syndrome: only eye movement is possible. Pt
is able to communicate via eye signals.is able to communicate via eye signals.

110. Lesions in medullaLesions in medulla
Medial medullary syndrome:Medial medullary syndrome:
Weakness and loss of postural sense in limbs on Weakness and loss of postural sense in limbs on
side oposite to lesion with ipsilateral paralysis of side oposite to lesion with ipsilateral paralysis of
tongue.tongue.

111. Lateral medullary/pica/wallenberg Lateral medullary/pica/wallenberg
syndromesyndrome
DysphagiaDysphagia
DysarthriaDysarthria
DizzinessDizziness
Hiccups and vomitingHiccups and vomiting
Ipsilateral horners syndromeIpsilateral horners syndrome
Ipsilateral cerebellar lesionIpsilateral cerebellar lesion
Ipsilateral sensory loss in faceIpsilateral sensory loss in face
Contralateral loss of pain and temperature in limbsContralateral loss of pain and temperature in limbs
Ninth and tenth cranial nerve palsiesNinth and tenth cranial nerve palsies
Pyramidal tract is not involvedPyramidal tract is not involved

112. Lateral medullary syndromeLateral medullary syndrome

113. Unilateral
Cranial nerve
abnormalities
Contralateral
Hemiplegia or
tetraplegia
IIIrd nerve palsy
VI and/ or VII
XII ± IX and XI
Midbrain lesion
Pontine lesion
Medullary lesion
Combined V
VII and VIII
Combined III, VIth
And V
Combined IX,
X and XI
Cerebellopontine
lesion
Cavernous sinus
lesion
Jugular foramen
syndrome
yes
No
No
No
yes
yes
No
No
yes
yes
Multiple Cranial nerve abnormalities

116. Middle cerebral arteryMiddle cerebral artery
It constitutes 2/3 of all cerebral infarctsIt constitutes 2/3 of all cerebral infarcts
Contralateral hemiparesis and sensory loss, arm Contralateral hemiparesis and sensory loss, arm
and face most affectedand face most affected
Expressive aphasia(dominant hemisphere)Expressive aphasia(dominant hemisphere)
Anosogonosia and spatial disorientation (non-Anosogonosia and spatial disorientation (non-
dominant)dominant)
Contralateral inferior quadrantanopiaContralateral inferior quadrantanopia

117. Anterior cerebral arteryAnterior cerebral artery
It constitutes two percent of all infarctsIt constitutes two percent of all infarcts
Contralateral hemiparesis and sensory loss, Contralateral hemiparesis and sensory loss,
worse in legworse in leg
Incontinence of urineIncontinence of urine
Loss of verbal fluency but preserved ability to Loss of verbal fluency but preserved ability to
repeatrepeat

118. Posterior cerebral arteryPosterior cerebral artery
As it supplies occipital lobe, so lesion causes As it supplies occipital lobe, so lesion causes
visual field defects, contralateral homonymous visual field defects, contralateral homonymous
hemianopiahemianopia

121. Frontal lobeFrontal lobe
Intellectual impairementIntellectual impairement
Personality changesPersonality changes
Urinary incontinenceUrinary incontinence
Mono or hemiplegiaMono or hemiplegia
Motor aphasiaMotor aphasia

122. Parietal lobeParietal lobe
Loss of cortical sensationsLoss of cortical sensations
ApraxiaApraxia
Contralateral homonymous lower quadrantanopiaContralateral homonymous lower quadrantanopia
Dominant lobe involvement causes acalculia, agraphia, Dominant lobe involvement causes acalculia, agraphia,
finger agnosia, right left disorientation----Gerstmann finger agnosia, right left disorientation----Gerstmann
syndrome syndrome
Non-dominant lobe involvement causes sensory and Non-dominant lobe involvement causes sensory and
visual inattention, spatial neglect, apraxia, anosogonosia visual inattention, spatial neglect, apraxia, anosogonosia
and autopagnosiaand autopagnosia

123. Temporal lobeTemporal lobe
Auditory or olfactory hallucinationsAuditory or olfactory hallucinations
Auditory or visual illusionsAuditory or visual illusions
Contralateral homonymous quadrantanopiaContralateral homonymous quadrantanopia
déjà vu phenomenondéjà vu phenomenon

124. Occipital lobeOccipital lobe
Visual inattention Visual inattention
Visual lossVisual loss
Visual agnosiaVisual agnosia
Homonymous hemianopia with macular sparingHomonymous hemianopia with macular sparing