Neurology Exam and CNS Localization Quiz

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Questions and Answers

What is the primary initial step in the approach to localizing CNS lesions?

  • Cranial nerve examination
  • History taking (correct)
  • Motor examination
  • Sensory examination

Which aspect of the motor examination is NOT specifically mentioned for identifying lower motor neuron lesions?

  • Power assessment
  • Coordination testing (correct)
  • Tone evaluation
  • Reflex observation

How can one localize a cortical lesion through patient symptoms?

  • By evaluating gait and balance
  • By analyzing the type of aphasia presented (correct)
  • By observing the motor reflexes exhibited
  • By assessing sensory inputs like pain and touch

In a comprehensive neurological examination, which aspect is crucially highlighted for assessing consciousness?

<p>General condition observation (A)</p> Signup and view all the answers

Which of the following is essential for localization of CNS lesions in terms of sensory examination?

<p>Knowledge of dermatomes (C)</p> Signup and view all the answers

What primary sensory modalities remain intact despite sensory loss of stereognosis and graphesthesia in a patient with right side impairment?

<p>Pain and vibration (D)</p> Signup and view all the answers

In individuals with a lesion in the non-dominant hemisphere, which of the following symptoms is typically demonstrated?

<p>Neglect of stimuli on the left side (C)</p> Signup and view all the answers

Which type of motor neuron involvement characterizes left hemiplegia resulting from a right hemispheric lesion?

<p>Upper motor neuron type (C)</p> Signup and view all the answers

What cognitive deficit might be observed in a patient with a right hemisphere lesion that affects visual-spatial tasks?

<p>Difficulty with organization and perception of space (C)</p> Signup and view all the answers

How can one evaluate a patient's perception of neurological deficits in the context of right hemisphere lesions?

<p>By checking their drawing skills through a clock task (B)</p> Signup and view all the answers

In cortical dysfunction, which of the following is a possible manifestation in a patient with a dominant hemisphere lesion?

<p>Aphasia and loss of language skills (B)</p> Signup and view all the answers

What condition might be characterized by a patient's denial or neglect associated with a right hemisphere lesion?

<p>Anosognosia (A)</p> Signup and view all the answers

Which statement accurately describes the physiological consequences of lesions affecting afferent fibers versus efferent fibers?

<p>Afferent lesions result in loss of sensation but not motor function. (D)</p> Signup and view all the answers

What is the primary common cause of unilateral lesions in the posterior limb of the internal capsule?

<p>Hemorrhage or thrombosis of the lenticulostriate artery (D)</p> Signup and view all the answers

What type of paralysis occurs as a result of damage to the posterior limb of the internal capsule?

<p>Upper motor neuron paralysis (B)</p> Signup and view all the answers

Which sensory loss is associated with damage to thalamocortical fibers due to a unilateral lesion?

<p>Loss of somatic sensation (D)</p> Signup and view all the answers

What visual impairment results from damage to the optic radiation due to a subcortical lesion?

<p>Homonymous hemianopia (B)</p> Signup and view all the answers

Which of the following symptoms is NOT typically associated with lateral medullary syndrome?

<p>Contralateral hemiplegia (B)</p> Signup and view all the answers

Which cranial nerve effects occur due to crossed lesions in medullary syndrome?

<p>Ipsilateral cranial nerve effects (C)</p> Signup and view all the answers

Which statement accurately describes Wallenberg’s syndrome?

<p>It results from occlusion of the posterior inferior cerebellar artery (PICA). (B)</p> Signup and view all the answers

What effect does damage to the vestibular nuclei have in lateral medullary syndrome?

<p>Vertigo, nausea, and vomiting (C)</p> Signup and view all the answers

Which type of eye movement is affected by oculomotor nerve palsy?

<p>Medial eye movement (C)</p> Signup and view all the answers

What effect does trochlear nerve palsy have on a patient’s vision?

<p>Double vision downward and medially (A)</p> Signup and view all the answers

Which symptom is associated with abducent nerve palsy?

<p>Failure of eye abduction (A)</p> Signup and view all the answers

Why does oculomotor nerve palsy lead to pupil dilation?

<p>Parasympathetic paralysis (A)</p> Signup and view all the answers

In the presence of trochlear nerve palsy, which compensatory action do patients often adopt?

<p>Tilting the head away from the affected side (C)</p> Signup and view all the answers

Which artery's involvement is primarily associated with contralateral motor and sensory clinical features affecting the face and upper limb?

<p>Middle cerebral artery (C)</p> Signup and view all the answers

What is the result of a lesion in the anterior cerebral artery?

<p>Contralateral sensory dysfunction in the leg (B)</p> Signup and view all the answers

What sensory function is specifically lost with cortical lesions affecting higher sensory processing?

<p>Stereognosis (B)</p> Signup and view all the answers

What describes patients with subcortical visual dysfunction?

<p>They may experience visual field defects. (B)</p> Signup and view all the answers

Which condition is characterized by an inability to recognize objects?

<p>Agnosia (A)</p> Signup and view all the answers

What behavioral changes are associated with lesions in the prefrontal association area?

<p>Diminished social skills (B)</p> Signup and view all the answers

Hypersexuality is a dysfunction associated with which area of the brain?

<p>Limbic association area (C)</p> Signup and view all the answers

Which cognitive function is affected by apraxia?

<p>Executing purposeful movements (A)</p> Signup and view all the answers

What results from damage to the left frontal eye field?

<p>Inability to abduct the right eye and adduct the left eye (A)</p> Signup and view all the answers

Which syndrome is characterized by failure to abduct the eye ipsilaterally to the lesion and failure to adduct both eyes?

<p>One and a half syndrome (C)</p> Signup and view all the answers

What effect does irritation of the frontal lobe, such as in epilepsy, typically have on eye movement?

<p>Involuntary movement away from the epileptic side (B)</p> Signup and view all the answers

What is the primary role of the medial longitudinal fasciculus (MLF) in eye movement?

<p>Coordination between the abduction and adduction of the eyes (C)</p> Signup and view all the answers

What is one of the outcomes of damage to the paramedian pontine reticular formation (PPRF)?

<p>Inability to abduct the left eye (B)</p> Signup and view all the answers

What condition could lead to diplopia due to improper overlapping of images?

<p>Tumor in the frontal eye field (A)</p> Signup and view all the answers

What movement is impaired in a patient with internuclear ophthalmoplegia?

<p>Adduction of the ipsilateral eye (D)</p> Signup and view all the answers

Which cranial nerve is primarily responsible for eye abduction?

<p>Abducens nerve (VI) (A)</p> Signup and view all the answers

Flashcards

CNS Lesion Localization

The ability to determine the location of a neurological problem within the central nervous system.

History Taking

This includes gathering information about the patient's medical history, symptoms, and any prior injuries or conditions.

Neurological Examination

Thorough assessment of motor function, sensation, coordination, reflexes, and cranial nerve activity.

Dermatomes

Regions of skin innervated by specific spinal nerve roots. Knowing dermatomes helps pinpoint the level of spinal cord involvement.

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Aphasia Assessment

Assessing speech for fluency, articulation, repetition, and comprehension. Different types of aphasia (language impairment) can indicate the location of a brain lesion.

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Astereognosis

Loss of the ability to recognize objects by touch, even though the sense of touch itself is intact.

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Agraphaesthesia

Loss of the ability to identify numbers or letters drawn on the skin, even though the sense of touch is intact.

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Visual-spatial problem

A condition where someone has difficulty with spatial awareness and perception, often affecting their ability to judge distances, navigate, and perceive the environment.

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Neglect

A neurological condition characterized by a lack of awareness of and attention to one side of the body or space.

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Denial

A condition where someone denies or minimizes their neurological deficits, despite clear evidence to the contrary.

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Hemiplegia

Loss of voluntary muscle movements, often affecting one side (hemiplegia) and typically presenting with weakness or paralysis. It is often associated with upper motor neuron lesions and characterized by spasticity.

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Hypertonia

An abnormal increase in muscle tone, leading to stiffness and resistance to movement.

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Hyperreflexia

An exaggerated reflex response to a stimulus, often observed in individuals with neurological conditions.

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Hyperphagia

A neurological disorder that involves excessive hunger and eating. It can be caused by various factors including brain lesions.

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Hemiplegia (excluding upper face)

A condition characterized by paralysis or weakness on one side of the body, excluding the upper half of the face, due to damage to the motor cortex.

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Hemorrhagic Stroke

A type of stroke that occurs when a blood vessel in the brain bursts, causing bleeding.

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Thrombotic Stroke

A blockage in a blood vessel that supplies blood to the brain, causing a stroke.

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Lenticulostriate Stroke

A specific type of stroke caused by a blockage in the lenticulostriate artery, which affects a region of the brain known as the internal capsule.

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Corticospinal Tract

The pathway in the brain that transmits signals from the motor cortex to the spinal cord, controlling voluntary movements.

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Somatosensory Loss

A neurological condition that affects the ability to feel touch, temperature, and pain on one side of the body.

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Homonymous Hemianopia

A type of visual field defect where a person loses sight in half of their visual field on the same side of both eyes.

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What is the cortical homunculus?

The part of the brain responsible for controlling voluntary movements and receiving sensory information from the body. Areas of the homunculus map to specific body parts, allowing for localization of neurological lesions.

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What are the clinical features of a middle cerebral artery stroke?

A stroke affecting the middle cerebral artery leads to weakness and sensory loss in the face and upper limb on the opposite side of the body. Speech problems (aphasia) and neglect of one side of space can also occur.

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What are the clinical features of an anterior cerebral artery stroke?

A stroke affecting the anterior cerebral artery results in weakness and sensory loss in the leg on the opposite side of the body.

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What is the effect of a subcortical lesion on sensory processing?

Primary sensory functions, like pain and vibration, are affected. This happens due to damage in pathways carrying these sensations from the body to the brain.

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What is agnosia, and where does it occur?

Patients with a cortical lesion in the visual association area can see but cannot recognize objects. They may still be able to identify the shape and color of the object, but they lack the ability to understand its meaning or purpose.

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What is apraxia, and where does it occur?

Patients with a cortical lesion in the visual association area can see but cannot perform complex, learned movements.

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What are the effects of a lesion in the prefrontal association area?

Patients with a cortical lesion in the prefrontal association area may experience changes in personality, behavior, and emotional regulation.

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What are the effects of a lesion in the limbic association area?

The limbic association area is involved in emotional processing, memory, and motivation. Lesions can lead to reduced aggression, lack of emotions, or changes in sexual behavior.

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Oculomotor Nerve Palsy: Adduction Impairment

Failure of the eye to move towards the nose (adduction). This occurs because the medial rectus muscle, which controls this movement, is paralyzed.

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Oculomotor Nerve Palsy: Pupil Dilation

Dilation of the pupil (the black circle in the center of the eye). This is caused by the loss of parasympathetic input to the pupil constrictor muscle, which is normally responsible for shrinking the pupil.

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Oculomotor Nerve Palsy: Ptosis

Drooping of the upper eyelid (ptosis). This happens because the levator palpebrae superioris muscle, which lifts the eyelid, is partially or completely paralyzed.

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Oculomotor Nerve Palsy: Diplopia

Double vision (diplopia). This occurs because the affected eye cannot move in sync with the healthy eye, leading to two different images.

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Abducent Nerve Palsy: Abduction Impairment

Failure of the eye to move away from the nose (abduction). This is due to paralysis of the lateral rectus muscle, responsible for this movement.

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Binocular vision

The overlapping of images from each eye to create a single image; a process that relies on proper muscle function.

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Diplopia

A condition where the eyes are unable to move together properly, resulting in double vision.

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Frontal eye field

The part of the brain responsible for controlling voluntary eye movements, particularly those involved in shifting gaze.

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Medial longitudinal fasciculus (MLF)

A bundle of nerve fibers that connects the brain to the eye muscles, allowing for the coordination of eye movements.

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Nystagmus

A type of eye movement that is rapid, jerky, and involuntary, often associated with certain neurological conditions.

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One-and-a-half syndrome

A neurological syndrome characterized by the inability to move the eye on the side of the brain lesion away from the lesion (abduction), and also difficulty moving the eye towards the lesion (adduction) along with problems with eye movement in the opposite eye.

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Internuclear ophthalmoplegia (INO)

A neurological condition that affects the ability to adduct one eye (move it inward) while the other eye abducts (moves outward) normally but with nystagmus. It occurs when the MLF is damaged.

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Paramedian pontine reticular formation (PPRF)

A brain area that plays a crucial role in coordinating horizontal eye movements, particularly those that shift gaze to the opposite direction.

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Study Notes

Localization of CNS Lesions

  • Objectives for students include learning how to locate CNS lesions, understanding the importance of anatomy and neurophysiology in localization, recognizing neurological syndromes, localizing cortical lesions from aphasia types, and localizing CNS lesions from eye movements.

Approach to Localize the Lesion

  • History: General condition (consciousness, gait, orientation to place, person, and time), speech (normal or aphasia/dysarthria), sensory examination (pain, temperature, touch, and joint positions), and motor examination (tone, power, reflexes, coordination). Cranial nerve examination is crucial, as it helps identify brainstem lesions.

  • Examinations: General condition, consciousness, gait, orientation to place, person, and time, speech, sensory examination (pain, temperature, touch, dermatomes), motor examination (tone, power, reflexes, coordination), cranial nerve examination.

The Level of the Lesion in a Patient with Hemiplegia

  • Lesions can be in cortical or subcortical areas (e.g., thalamus, internal capsule, basal ganglia). Differentiation between left- and right-sided cortical lesions uses speech and dominance differences.

    • Cortical lesions: aphasia or nondominant hemisphere dysfunction (depending on involved hemisphere).
    • Subcortical lesions: internal capsule, basal ganglia, thalamic dysfunction.
    • Brainstem lesions: cranial nerve signs, often with crossed hemiplegia.
    • Spinal cord lesions: facial involvement is absent with paralysis on the same side.
    • Corticonuclear and corticospinal fibers are crossed; cranial nerves affect the same side, and corticospinal fibers affect the opposite.

Cortical Lesions (Dominant vs. Non-Dominant Hemisphere)

  • Dominant Hemisphere (Usually Left):

    • Right hemiplegia (upper motor neuron type).
    • Sensory loss of sterognosis and graphesthesia; intact primary sensations (e.g., pain, vibration).
    • Aphasia: loss of localizing the touch so loss of details of sensation.
  • Non-Dominant Hemisphere (Usually Right):

    • Left hemiplegia (upper motor neuron type).
    • Sensory loss of sterognosis and graphesthesia; intact primary sensations (e.g., pain, vibration).
    • Visual-spatial problems (intact vision, but loss of awareness of things on the left side); neglect and denial (patients may not be oriented to their neurological deficits).
    • Speech is usually intact; loss of tone and emotions of speech..

Cortical vs. Subcortical Lesions

  • Cortical Dysfunction: Aphasia (dominant hemisphere), neglect/seizure (non-dominant hemisphere) are typical. This can involve various vascular lesion involvements (e.g., middle cerebral artery affecting face and upper limbs, and anterior cerebral artery affecting legs). Sensory dysfunction can involve issues with higher order processing like stereognosis, two-point discrimination, and graphesthesia. Subcortical lesions show issues with primary sensory modalities like pain, vibration, and visual disturbances that can have visual field defects.

Effects of Lesions in Cortical Association Areas

  • Parieto-occipitotemporal association area: Agnosia (inability to recognize objects), apraxia (inability to perform skilled, purposeful movements), aphasia (impaired language communication).
  • Prefrontal association area: Changes in personality and behavior.
  • Limbic association area: Decreased aggression, decreased/lack of emotions, hypersexuality, and hyperphagia (increased appetite).

Effects of Unilateral Lesion in the Posterior Limb of the Internal Capsule (Subcortical Lesion)

  • Common Causes: Hemorrhage or thrombosis of the lenticulostriate artery.
  • Effects:
    • Paralysis/paresis of the opposite side of the body (hemiplegia), excluding the upper half of the face.
    • Loss of somatic sensation on the opposite side of the body.
    • Damage to the optic radiation leads to temporal hemianopia (damage to the optic tracts often results in homonymous hemianopia).
    • Lesion to the auditory radiation can cause diminished hearing.

Brain Stem Lesion

  • Most common lesions are medullary syndromes (e.g., lateral and medial medullary syndrome).
  • Medullary syndromes are characterized by crossed lesions because of the brain stem's crossover.

Lateral Medullary Syndrome (Wallenberg's Syndrome)

  • Result: Occlusion of the posterior inferior cerebellar artery (PICA).
  • Characterized by:
    • Contralateral loss of pain and temperature (spinothalamic tract).
    • Ipsilateral loss of pain and temperature, facial sensations (spinal trigeminal nucleus).
    • Vertigo, nausea, vomiting (vestibular nuclei).
    • Ipsilateral Horner's syndrome (descending sympathetic).

Medial Medullary Syndrome

  • Result: Occlusion of branches of the anterior spinal artery.
  • Characterized by:
    • Contralateral hemiplegia (damage to pyramidal tracts or corticospinal fibers).
    • Contralateral loss of position, vibration, and discriminatory touch (medial lemniscus).
    • Ipsilateral tongue deviation and paralysis (hypoglossal nucleus or nerve).

Single Cranial Nerve Lesions (III, IV, VI)

  • Oculomotor Palsy: Failure of eye adduction, pupil dilation, ptosis (drooping eyelid), and double vision.
  • Abducent Nerve Palsy: Failure of eye abduction, and double vision lateral to the affected eye.
  • Trochlear Nerve Palsy: Double vision (diplopia) downward and medially, head tilt away from the affected side to avoid double vision.

Eye Movements

  • Eye movement examination is critical for localizing and diagnosing neurological conditions, especially in brainstem lesions. Cranial nerves III, IV, and VI control eye movements.

Aphasia

  • Difficulty in understanding and/or producing language. Different types of aphasia have different characteristics.

Internuclear Ophthalmoplegia (IN)

  • Damage to the medial longitudinal fasciculus (MLF) interferes with conjugate eye movements. The characteristics and cause can vary.
  • Diagnosis is usually possible by assessing eye movements.

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