Localization of Lesion lecture delivered by Dr Imran .ppt

about neurology lecture

2. Dr.IMRAN KHAN
F.C.P.S (Neurology)
Assistant Professor
Department of Neurology
Gujranwala Medical College

3. Localization of
Lesions in Neurology

4. Special Objective
•At the end of this activity, you will be
able to:
–localize the lesions within Nervous
System

5. Fears about Neurology

6. Fears about Neurology
•Most difficult exacting medical specialty
•Easily discouraged by what they see

7. Fears about Neurology
•Brief contact with
 Neuroanatomy
Neurophysiology
Neuropathology
•Series of maneuvers
•To evoke certain mysterious signs
•Difficult to pronounce
Babinski sign
Dys-diado-cho-kinesia

8. Fears about Neurology
•Little or no experience with tests
LP
EEG
NCS & EMG
CT & MRI scans
Angiography

9. Facts about Neurology

10. Facts about Neurology
•Most interesting
&
•dynamic specialty
•2 + 2 = 4
•Pin point the level of lesion

11. Facts about Neurology
•What is the best tool in establishing the
diagnosis?
•Ears – to listen
•Eyes – to see

12. Facts about Neurology
•What is the best tool in confirming the
diagnosis?
•Hands – to examine

13. Facts about Neurology
•What is the best tool in treating the
patient ?
•Tongue – to reassure & counsel

14. Change
Your
Lens
Change
Your
World

15. Basic Architect of Nervous System

16. Nervous
System
CNS PNS
Brain Spinal Cord
Pyramidal
Extra
Pyramidal
Cervical
Thoracic
AHC
Lumbar (FMS)
Sacral (CES)
Roots
Plexus
Nerves
NMJ
Muscle
Cerebral
Cortex
Corona
Radiata
Internal
Capsule
Mid Brain
Pons
Medulla
Oblongata
Basal Ganglia
Thalamus
Cerebellum
Basic Architect

17. MuscleNMJNervePlexusRootCES
CMS
Dorsal
Cord
Cervical
Cord
AHC
FMS MO Pons MB IC
CR
CC
Basal
Ganglia
ThalamusCerebellum

18. Please concentrate

19. Questions To Be Answered?
•Is it neurological disorder or Not?
•Where is the lesion?
–Is it LMN or UMN?
•What is the lesion?
–Is it vascular or non vascular event?

20. How To Prove Vascular
Event????
Basic Parameters

21. •Onset
–Sudden
•Very sudden – Seconds
•Just sudden – Minutes
•Slowly sudden – Hours
•Progression
–Maximum at the onset with rapid recovery
–Maximum at the onset with static phase
–Minimum at the onset with slow deterioration
over days but not more than 72 hours
Parameters for vascular event

25. MuscleNMJNervePlexusRootCE
CM
Dorsal
Cord
Cervical
Cord
AHC
FM MO Pons MB IC
CR
CC
Basal
Ganglia
ThalamusCerebellum
LMN
M
i
x
e
d
UMN
P
U
M
N
Q UMN Pyramidal
UMN Extra pyramidal

26. Stroke
Hemi (Crossed & Uncrossed)
Mono

27. Extra Pyramidal & Pyramidal System

28. Mono paresis
Weakness of one limb or some part of one limb or others
Cerebral Cortex

29. Hemi paresis
Weakness of one half of the body including face
Uncrossed
CN & Weakness on
same side
Crossed
Ipsilateral CN
Contralateral Weakness
Differential Dense
Difference
of
Power
No
Difference
of
Power
Internal
Capsule
Corona
Radiata
Brainstem
Pons
Mid
Brain
Medulla
Oblongata

30. 0 1 2 3 4 5 6 7 8 9 10
TIA RIND Stroke
Stroke in Evolution
Embolic
Hemorrhagic
Thrombotic

31. Case – 1
•A 27 years, christian lady, presented in OPD with C/O
generalized body pains, started about 07 to 08 months
back after an attack of gastroenteritis that lasted for few
days. She also developed mild to moderate generalized
headache associated with swelling of eyelids and redness
of eyes. She found to have eyelids swelling with
conjunctival hemorrhages. Her muscles were mildly tender
with normal power. Her CPK level was twice of normal.
1: What is the single most relevant positive finding in CBC?
2: What is the most likely diagnosis? Give justifications.
3:How can radiology department can help you in
investigating the disease?
4: Counsel the patient.

32. Difficulty in
getting up
Difficulty in
raising hands
Difficulty in
walk
Proximal
weakness
Muscle
disease
Myopathy
Painful
Painless
Acquired
Hereditary
Infective
Inflammatory
Early life
Late life
Trichinosis
PM
DM
IBM
DMD
BMD
OPMD
FSH-MD
LGMD

33. Myopathy
Inspection Palpation Tone
Power Reflexes Coordination Gait
Wasting
No Yes
Pain
No Yes
AcquiredHereditaryHereditaryAcquired
Decreased
Decreased Normal Decreased
Not
Commentable
Waddling
Gower
Proximal
Distal

34. Case – 2
•A 19 years girl is seeking advice for painless
swallowing difficulty for liquids that worsens in
the evening. She also concerns for the proximal
weakness that bothers her a lot, any time a day.
No other significant complaints.
1:What additional points you will ask from the
patient?
2:How will you confirm your provisional diagnosis?
3:How does steroids can affect the fate of the
disease?

35. Painless
Proximal
Weakness
Eye
Symptoms
Throat
Symptoms
Fluctuation
Diurnal
Variation
Fatigue with exertion
Fatigue at rest
Post-synaptic
Pre-synaptic
MG
LEMS
NMJ
Disorder

36. NMJ Disorder
Inspection Palpation Tone
Power Reflexes Coordination Gait
Myasthenic
Face Painless Decreased
Decreased
with exertion
Normal Decreased
Not
Commentable
Waddling
Gower
Increased
with exertion
Drooping lids
Forehead wrinkle
Triangular face

37. Case – 3
•A 47 years male is concerning for the persistent
cold sensations in the feet for the last 08
months. He also described the burning in his
soles about 01year that were replaced with
numbness. He is used to go to toilets many
times at night. His feet are cold and with good
distal pulses. His DTR are depressed in lower
limbs.
1:What is the most relevant blood test for this
patient?
2:How will you confirm your diagnosis?
3:Enlist atleast 05 complications.

38. Distal
Symptoms
&
Signs
(Majority)
Motor
Sensory
Fasciculation
Cramps
Myokymia
Negative
Positive
Autonomic
Positive
Negative
Negative
Positive
Large fiber
Small fiber
Restless leg
Tightness
Weakness
Fatigue
Loss of reflex
Hypotonia
Deformities
Negative
Positive
Tingling
Pins & Needles
↓ Vibration
↓ JPS
Areflexia
Hypotonia
Ataxia
BurningJabbingShooting
↓ Pin prick
↓ Temperature
Hypotension
Arrhythmia
↓ Sweating
Impotence
Retention
Hypertension
Arrhythmia
↑ Sweating

39. Neuropathy
Inspection Palpation Tone
Power Reflexes Coordination Gait
Wasting
No Yes
Pain
No Yes
Small Large Large Small
Decreased
Decreased Normal Decreased Sensory High stepping
Gover
Distal
Proximal
Small Large
Deformity
No
Yes
Acquired
Hereditary

40. Case – 4
•A 67 years old smoker wasted male
presented with severe pain and numbness
in right upper limb without any neck pain.
He did not allow anybody to even touch.
His limited examination shows normal
neck movement and there is ptosis on
right side.
1:What are different investigations
available? Give justification with priority.
2:What is the your diagnosis?

41. Unilateral
Limb
Pain in
Limb
Trauma
or
Tumor
Motor
Sensory
Autonomic
Without
Backache
LMN
Features
Plexopathy
NCS & EMG
MRI Plexus

42. Plexopathy
Inspection Palpation Tone
Power Reflexes Coordination Gait
Wasting
(Unilateral)
No Yes
Not AllowedAllowed
Acute Chronic
Acute Chronic
Decreased
Decreased Absent Decreased
Not
Commentable
Depending on
Site & Stage
Proximal
Distal
Fixed
(Contractures)

43. Case – 5
•A 47 years old lady is seeking advice for neck
pain that sometimes radiate to both upper limbs.
She also noticed slight weakness in both upper
limbs. Examination reveals restricted neck
movement with diminished reflexes in upper
limbs and slightly exaggerated response in lower
limbs.
1:What is the investigation of choice?
2:What are the complications associated with the
condition?

44. Backache
Radicular pain
Minimal
or
Localized
Motor
Sensory
Reflex
deficit
Movement
Worsens
Radiculopathy

45. Radiculopathy
Inspection Palpation Tone
Power Reflexes Coordination Gait
Minimal
Wasting
Usually
Unremarkable
Usually
Unaffected
According to
Level
Normal
According
to
Level
Not
Affected
Depending on
Site

46. Case – 6
•A 34 years old field worker developed sudden
onset severe lower backache that radiates in
both legs posteriorly associated with swelling of
lower abdomen. He could not bear weight on his
feet. He also had lower backache off and on for
the last few years. Examination reveals LMN
paraparesis with loss of sensation in legs. His
bladder was also palpable.
1:What is the first step in the management?
2:What is the investigation of choice?

47. Acute onset
Backache with
Radiation
Sensory
Motor
Sphincters
Flaccid
Paraparesis
&
Saddle
anesthesia
Cauda
Equina
Syndrome
Multiple
Roots

49. Case – 7
•A 34 years old field worker developed sudden
onset severe lower backache that radiates in
both legs posteriorly associated with swelling of
lower abdomen. He could not bear weight on his
feet. He also had lower backache off and on for
the last few years. Examination reveals flaccid
lower limbs with upgoing plantars with loss of
sensation in legs. His bladder was also palpable.
1:What is the first step in the management?
2:What is the investigation of choice?

50. Acute onset
Backache with
Radiation
Sensory
Motor
Sphincters
LMN
Featutres
Paraparesis
with
Upgoing
Plantars
Conus
Medullaris
Syndrome
Multiple roots
Filum terminale

51. Case – 8
•A 57 years old male admitted for the evaluation
of painless generalized weakness – proximal >
distal for the last 02 years. He also concerns for
the swallowing difficulty that bothers him
occasionally. There is no history of DM. He has
generalized wasting with proximal weakness. He
has generalized areflexia. His CPK was normal.
1:What is your working diagnosis?
2:How will you confirm your diagnosis?

52. Progressive
Painless
Motor symptoms
Peripheral
Distal>Proximal
No ASOC
No Eye
involvement
No Cerebellar
features
No Sensory
disturbances
No Sphincteric
disturbances
AHC
Peripheral
Central
LMN
UMN
Mixed
LMN
UMN
Mixed
SMA
PMA
PLS
ALS
Bulbar

53. Case – 9
•A 40 years, banker presented in ED with C/O mild
discomfort at mid dorsal region followed by inability to
move lower limbs and could not pass urine for the
last 16 hours. O/E his vitals were stable. Head, neck
& ULs were normal. His LLs revealed UMN type
features with SL at T8, without any significant
tenderness over spine.
1: What therapeutic step will be more appropriate? Give
justifications.
2: Name 02 investigations with justifications.
3:Name 03 D/D with justifications.
4: Enlist complications of the condition.
5: Enlist steps for rehabilitation.

54. Spastic Para paresis
UMN features in lower limbs with sparing of upper limbs
Motor
Sensory
Sphincters
Motor
Sphincters
Spinal Cord
T2 to T12
Brain
Pain Motor Sensory Sphincter
Pain Motor Sensory Sphincter

55. Pain Motor Sensory Sphincter
Pain Motor Sensory Sphincter
Extra Dural Intra Dural
Extra Medullary
Intra Medullary

57. Case – 10
•A 40 years, banker presented in ED with C/O mild
discomfort at cervical region followed by inability to
move all limbs and could not pass urine for the last
16 hours. There is no swallowing difficulty. O/E his
vitals were stable. He has UMN features in all
limbs with SL at T4, without any significant
tenderness over spine.
1: Where is the lesion?
2: What is the most likely cause of the condition?

58. Spastic Quadri paresis
UMN features in all limbs with sparing of medulla oblongata
Motor
Sensory
Sphincters
Spinal Cord
Above C5
Pain Motor Sensory Sphincter
Pain Motor Sensory Sphincter

59. Managing Exam
Stress
A Comprehensive
Course

61. Recognizing Exam Anxiety
Stress helps
Stress
hinders
Poor
Average
Good

62. COGNITIVE
- Becoming
overly sensitive
to criticism
- Constantly
looking for
negative signs
BEHAVIOURAL
-Taking out
frustrations on
others
- Changes in
eating patterns
-Disturbed sleep
PHYSIOLOGY
-Shortness of
breath
-Frequent
illness
-Chronic pain
e.g.
headaches
EMOTIONAL
- Lack of positive
emotions
- Feeling tired and
not able to cope
-Irritability
Stress Reactions

63. Planning your study
•Where does your time go?
–168 hours in the week – use them wisely
•Allocate time for essential tasks e.g. eating,
sleeping, travel time, chores
•Schedule in time for studying – including
breaks
•Balance preparation across easy/difficult,
interesting/boring; don’t get stuck on studying
for first exam only
•Schedule time for YOU e.g. relaxation, social,
exercise
•Be aware of procrastination

65. The day of the exam
•Have a light meal before the exam
•Arrive at the venue early
•If you tend to get nervous around
people who stand around stressing
about exams – stay away from them!
•Go to the bathroom before your exam

66. During the exam
•Practice controlled breathing
•Use your reading time wisely
•Start with the questions you find easiest
•Don’t concern yourself with how long
others are taking – ignore everyone else
as much as you can

67. After the exam
•Avoid over-analysing
•Reward yourself (within reason)

70. Examination Technique
Basic steps

71. Prerequisites?
How to build good
Rapport?
Steps?
Happy ending?
Maintain rapport?
Recollect yourself?
Within you
With you
Extreme confidence
Minimum sweating
Reasonable dressing
Admit card
Instruments
Natural smile
Volume of speech
Clear Introduction
Consent
Sit for few moments
Redress/Cover
Greet with smile
Any discomfort
Systematic
If possible
Neither low nor high
Who are you?
Clarity like clear water
Head to toe or reverse
Keep the privacy/Screen
Good light
At least once
Make sure
At least greet
If chair is provided

73. T
H
A
N
K
S

74. Good luck!