Localization in Neurology PDF

2023/2024 LOCALIZATION IN NEUROLOGY SHAPING THE FUTURE OF MEDICAL EDUCATION FM.UCP.PT Raquel Gil-Gouveia  LOCALIZATION IN NEUROLOGY...

2023/2024 LOCALIZATION IN NEUROLOGY SHAPING THE FUTURE OF MEDICAL EDUCATION FM.UCP.PT Raquel Gil-Gouveia  LOCALIZATION IN NEUROLOGY HISTORY TAKING & OBSERVATION 1. WHERE is the lesion? TOPOGRAPHIC DIAGNOSIS 2. WHAT is the lesion? SYNDROMIC DIAGNOSIS 3. What CAUSES the lesion? ETHIOLOGIC DIAGNOSIS LOCOMOTOR SHAPING THE FUTURE OF MEDICAL EDUCATION RAQUEL GIL-GOUVEIA2 2023 FM.UCP.PT  LOCALIZATION IN NEUROLOGY WHAT IS THE LESION ? 1. TYPE of symptoms POSITIVE NEGATIVE Paraesthesia / Pain Hyposthesia, Anesthesia Visual illusions/ hallucinations Vision loss Tremor, Tics, Jerks Hearing loss Chorea, athetosis Weakness/ paresis Dystonia Aphasia Dysarthria, dysphagia 2. TIME course of symptoms TRANSIENT ACUTE SUBACUTE PROGRESSIVE TIA Vascular Inflammatory Degenerative Seizure Epileptic Infectious Oncological Aura Trauma Metabolic Vertigo Toxic Syncope Autoimmune T.G. Amnesia Uhthoff's phenomenon Amyloid 'spells’ Fluctuating weakness LOCOMOTOR SHAPING THE FUTURE OF MEDICAL EDUCATION RAQUEL GIL-GOUVEIA3 2023 FM.UCP.PT  MERIDIANS OF LONGITUDE: THE DESCENDING AND ASCENDING PATHWAYS MOTOR PATHWAY PROPRIOCEPTION PAIN, TEMPERATURE, TOUCH SENSORY PATHWAYS UMN LMN Weakness UMN Nerve/ Root Fasciculations/ 0 + Atrophy Tone ↑ ↓ Reflexes ↑ ↓/0 LOCOMOTOR SHAPING THE FUTURE OF MEDICAL EDUCATION Plantar Resp. ↑ ↓ RAQUEL GIL-GOUVEIA 2023 FM.UCP.PT  PARALLELS OF LATITUDE: CENTRAL AND PERIPHERAL NERVOUS SYSTEMS LOCOMOTOR SHAPING THE FUTURE OF MEDICAL EDUCATION RAQUEL GIL-GOUVEIA5 2023 FM.UCP.PT  CENTRAL NERVOUS SYSTEM LOCOMOTOR SHAPING THE FUTURE OF MEDICAL EDUCATION RAQUEL GIL-GOUVEIA 2023 FM.UCP.PT  CENTRAL NERVOUS SYSTEM - HEMISPHERIC LESIONS BRODMANN AREAS IN THE HUMAN BRAIN Visual Association Cortex Primary Auditory LOCOMOTOR SHAPING THE FUTURE OF MEDICAL EDUCATION RAQUEL GIL-GOUVEIA 2023 FM.UCP.PT  CENTRAL NERVOUS SYSTEM - CORTICAL HEMISPHERIC LESIONS FRONTAL LOBE BRODMANN AREAS IN THE HUMAN BRAIN ORBITOFRONTAL – Behaviour (disinhibition, impulsivity, confabulation, lack of empathy, indifference, antisocial behaviours, overeating) DORSOLATERAL PREFRONTAL – Cognition (low verbal fluency, reduced attention, working memory deficits, poor organization and planning). DORSOMEDIAL PREFRONTAL – Initiative (altered energy, motivation, drive, and affect) PREMOTOR CORTEX (6 Lateral) - Motor routines in response to external clues SUPPLEMENTARY MOTOR AREAS (6 medial) - Motor programming EYE FIELDS (8) - Initiates voluntary saccades BROCA’s AREA (44/45, dominant hemisphere) – Language PRIMARY MOTOR CORTEX (4) - Contralateral movement LOCOMOTOR SHAPING THE FUTURE OF MEDICAL EDUCATION RAQUEL GIL-GOUVEIA 2023 FM.UCP.PT  CENTRAL NERVOUS SYSTEM - CORTICAL HEMISPHERIC LESIONS BRODMANN AREAS IN THE HUMAN BRAIN PARIETAL LOBE SUPERIOR (5,7) – Planned movements, Visuospatial perception, Secondary sensory processing (Sensory abnormalities (asterognosis, graphestesia and 2 point discrimination), sensory and hemispatial neglect) INFERIOR (39.40) – Emotion perception, Body Image and Maths (anosognosia, apraxia AND.Gerstmann Syndrome: (Dominant Hemisphere) Right-to-left confusion finger agnosia, dysgraphia and dyslexia, dyscalculia, contralateral hemianopia / lower quadrantanopia;. Hemispatial Neglect and Topographic Disorientation (Non-dominant hemisphere). Bálint’s syndrome (Bilateral Lesions) Simultanagnosia, optic ataxia and optic apraxia PRIMARY SENSORY CORTEX (1,2,3) - Contralateral Sensory Information (both from spinotalamic and dorsal column pathways) LOCOMOTOR SHAPING THE FUTURE OF MEDICAL EDUCATION RAQUEL GIL-GOUVEIA 2023 FM.UCP.PT  CENTRAL NERVOUS SYSTEM - CORTICAL HEMISPHERIC LESIONS BRODMANN AREAS IN THE HUMAN BRAIN TEMPORAL LOBE SUPERIOR AND MIDDLE GYRUS – Auditory Processing and Language PRIMARY AUDITORY Cortex (41,42) – Detection of sound Association Cortex (21,22) – Auditory processing Wernicke’s AREA (39/40, dominant hemisphere) – Language INFERIOR GYRUS (20) – Visual processing and Memory Fusiform Gyrus (37) – Stimuli recognition, Facial Emotion perception (Prosapagnosia / Synesthesia) MEDIAL TEMPORAL LOBE (perirhinal 35, 36 and parahippocampal 28 cortex) - Long Term Memory (anterograde and retrograde amnesia) TEMPORAL POLE (38)- Semantic processing (prosapagnosia, language). LOCOMOTOR SHAPING THE FUTURE OF MEDICAL EDUCATION RAQUEL GIL-GOUVEIA 2023 FM.UCP.PT  CENTRAL NERVOUS SYSTEM - CORTICAL HEMISPHERIC LESIONS OCCIPITAL LOBE BRODMANN AREAS IN THE HUMAN BRAIN V1 (striate) (17) –Orientation, spatial frequency, colour, edges (contrast) V2 (18) – additional complexity in patterns and multiple orientations (field defects, cortical blindness, metomorphopsias, palinopsia, visual hallucinations) V3, V4 and V5 (18, 9) VENTRAL– Visual representation colour information, form recognition DORSAL – Global motion/ Spatial organization Motion perception (direction and visual patterns) and eye movement and self- motion Dominant hemisphere: color blindness (achromatopsia) and visual agnosia; Non-dominant hemisphere: simultanagnosia, environmental agnosia LOCOMOTOR SHAPING THE FUTURE OF MEDICAL EDUCATION RAQUEL GIL-GOUVEIA 2023 FM.UCP.PT  CENTRAL NERVOUS SYSTEM - CORTICAL HEMISPHERIC ASYMMETRIES LOCOMOTOR SHAPING THE FUTURE OF MEDICAL EDUCATION RAQUEL GIL-GOUVEIA 2023 FM.UCP.PT  CENTRAL NERVOUS SYSTEM - LANGUAGE FLUENCY NON-FLUENT FLUENT COMPRE- NO NO YES YES HENSION REPETITION NO YES NO YES NO YES NO YES GLOBAL MIXED BROCA MOTOR WERNICKE SENSORY CONDUC APHASIA ANOMIC APHASIA TransC TransC APHASIA TransC -TION EXPRESSIVE DYSPHASIA RECEPTIVE DYSPHASIA LOCOMOTOR SHAPING THE FUTURE OF MEDICAL EDUCATION RAQUEL GIL-GOUVEIA 2023 FM.UCP.PT  CENTRAL NERVOUS SYSTEM - HEMISPHERIC SUBCORTICAL LESIONS VISUAL SYSTEM LOCOMOTOR SHAPING THE FUTURE OF MEDICAL EDUCATION RAQUEL GIL-GOUVEIA 2023 FM.UCP.PT  CENTRAL NERVOUS SYSTEM - HEMISPHERIC LESIONS LOCOMOTOR SHAPING THE FUTURE OF MEDICAL EDUCATION RAQUEL GIL-GOUVEIA 2023 FM.UCP.PT  CENTRAL NERVOUS SYSTEM - BASAL GANGLIA ➜ Ventral STRITATUM ⥢ GPi/SNr + Ventral PALLIDUM ➜ CAUDATE body ⥢ GPi/SNr ➜ PUTAMEN ⥢ GPi/SNr ➜ CAUDATE head ⥢ GPi/SNr LOCOMOTOR SHAPING THE FUTURE OF MEDICAL EDUCATION RAQUEL GIL-GOUVEIA 2023 FM.UCP.PT  CENTRAL NERVOUS SYSTEM - CEREBELLUM Truncal ataxia 1. Oculomotor deficits VERMIS Dysarthria ANTERIOR Gait ataxia Vertigo LOBE Head tremor 4. Dysmetria Dysdiadochokinesia Ataxia vermis POSTERIOR Intention Tremor LOBE Nystagmus Hypotonia Dysarthria 3. 2. LOCOMOTOR SHAPING THE FUTURE OF MEDICAL EDUCATION RAQUEL GIL-GOUVEIA 2023 FM.UCP.PT  CENTRAL NERVOUS SYSTEM - BRAINSTEM LESIONS LOCOMOTOR SHAPING THE FUTURE OF MEDICAL EDUCATION RAQUEL GIL-GOUVEIA 2023 FM.UCP.PT  CENTRAL NERVOUS SYSTEM - BRAINSTEM LESIONS MESENCEPHALON (MIDBRAIN) Pupillary reflex (afferent, CN II; efferent, CN III) Vestibulo-cephalic reflex and vestibulo-ocular reflex (VOR) (afferent, CN VIII; efferent, CN III and VI); LOCOMOTOR SHAPING THE FUTURE OF MEDICAL EDUCATION RAQUEL GIL-GOUVEIA 2023 FM.UCP.PT  CENTRAL NERVOUS SYSTEM - BRAINSTEM LESIONS PONS Corneal reflex (afferent, CN V; efferent, CN VII); Vestibulo-cephalic reflex and vestibulo-ocular reflex (VOR) (afferent, CN VIII; efferent, CN III and VI); LOCOMOTOR SHAPING THE FUTURE OF MEDICAL EDUCATION RAQUEL GIL-GOUVEIA 2023 FM.UCP.PT  CENTRAL NERVOUS SYSTEM - BRAINSTEM LESIONS MEDULLA OBLONGATA. Gag and Cough reflexes (afferent, CN IX; efferent, CN X) LOCOMOTOR SHAPING THE FUTURE OF MEDICAL EDUCATION RAQUEL GIL-GOUVEIA 2023 FM.UCP.PT  CENTRAL NERVOUS SYSTEM - SPINAL LESIONS LOCOMOTOR SHAPING THE FUTURE OF MEDICAL EDUCATION RAQUEL GIL-GOUVEIA 2023 FM.UCP.PT  PERIPHERAL NERVOUS SYSTEM LOCOMOTOR SHAPING THE FUTURE OF MEDICAL EDUCATION RAQUEL GIL-GOUVEIA 2023 FM.UCP.PT  PERIPHERAL NERVOUS SYSTEM - ROOT LESIONS RADICULAR LESION PAIN SENSORY DERMATOME MUSCLE WEAKNESS (MYOTOME) HYPOREFLEXION CAUDA EQUINA LESION LOWER BACK PAIN SADDLE ANESTHESIA DISTAL WEAKNESS HYPOREFLEXION SPHINCTER DYSFUNTION IMPOTENCE LOCOMOTOR SHAPING THE FUTURE OF MEDICAL EDUCATION RAQUEL GIL-GOUVEIA 2023 FM.UCP.PT  PERIPHERAL NERVOUS SYSTEM - ROOT LESIONS LOCOMOTOR SHAPING THE FUTURE OF MEDICAL EDUCATION RAQUEL GIL-GOUVEIA 2023 FM.UCP.PT  PERIPHERAL NERVOUS SYSTEM - PLEXUS LESIONS Erb’s palsy (upper roots, C5-6). WEAKNESS– abduction at shoulder, lateral rotation of BRACHIAL arm, supination of forearm, and flexion at shoulder.(Waiter’s tip) NUMBNESS –over the lateral aspect of upper limb ABSENT Bicipital reflex Klumpke’s palsy (lower roots, C8-T1). WEAKNESS -intrinsic hand muscles (Total Claw Hand) NUMBNESS –medial side of upper limb Upper lumbar roots LUMBOSACRAL WEAKNESS– hip flexion, knee extension, or adduction NUMBNESS –medial thigh, anterior thigh, and medial leg ABSENT knee jerk Lower lumbar / sacral WEAKNESS– hip extension, knee flexion, foot NUMBNESS –posterior thigh, dorsum of the foot, and perineum ABSENT ankle jerk LOCOMOTOR SHAPING THE FUTURE OF MEDICAL EDUCATION RAQUEL GIL-GOUVEIA 2023 FM.UCP.PT  PERIPHERAL NERVOUS SYSTEM - NERVE LESIONS LOCOMOTOR SHAPING THE FUTURE OF MEDICAL EDUCATION RAQUEL GIL-GOUVEIA 2023 FM.UCP.PT  PERIPHERAL NERVOUS SYSTEM - NERVE LESIONS LOCOMOTOR SHAPING THE FUTURE OF MEDICAL EDUCATION RAQUEL GIL-GOUVEIA 2023 FM.UCP.PT  LOCALIZATION SUMMARY HEMISPHERES CONTRALATERAL SYMPTOMS HIGHER BRAIN FUNCTIONS (H. DOMINANCE) BEHAVIOUR, INITIATIVE, GNOSIS, PRAXIS (LANGUAGE, NEGLECT) CORTICAL PRIMARY COTEX FUNCTIONS MOTOR, SENSORY, VISION, AUDITION WHITE MATTER TRACTS DISCONNEXION SYNDROMES / LONG TRACTSYMPTOMS SUBCORTICAL BASAL GANGLIA EXTRAPYRAMIDAL SYNDROMES CEREBELLUM IPSILATERAL SYMPTOMS HEMISPHERES LIMB ATAXIA, TREMOR VERMIS and FLOCCULUS GAIT AND TRUNCAL ATAXIA; OCULOMOTOR and VERTIGO BRAINSTEM CROSSED SYMPTOMS MESENCHEPHALUS OCULOMOTOR + LONGITUDINAL TRACTS/ ATAXIA PONS FACIAL SYMPMTOMS + LONG. TRACTS/ ATAXIA MEDULLA LOWER CN SYMPTOMS + LONG. TRACTS/ ATAXIA SPINAL CORD DISSOCIATED SYMPTOMS At each level... ANTERIOR BILATERAL MOTOR + PAIN/TEMPERATURE, NORMAL PROPRIOCEPION POSTERIOR BILATERAL PROPRIOCEPTION, NORMAL MOTOR + PAIN/TEMPERATURE HEMISECTION PROPRIOCEPTION + MOTOR lesion side + PAIN/TEMPERTURE contralateral CENTRAL CORD SYNDROME MOTOR UPPER> LOWER LIMBS + PAIN/TEMPERATURE PROXIMAL TOTAL BILATERAL MOTOR + PAIN/TEMPERATURE + PROPRIOCEPION SPINAL ROOT RADICULAR SYMPTOMS (PAIN) + DERMATOME / MYOTOME of ONE ROOT PLEXUS REGIONAL SYMPTOMS (PAIN) + TRUNK SENSORY and MOTOR PATTERN NERVE(S) LOCAL SYMPTOMS / BILATERAL DISTAL SENSORY and/or MOTOR of ONE NERVE / DISTAL LOCOMOTOR SHAPING THE FUTURE OF MEDICAL EDUCATION RAQUEL GIL-GOUVEIA 2023 FM.UCP.PT  GAIT LOCOMOTOR SHAPING THE FUTURE OF MEDICAL EDUCATION RAQUEL GIL-GOUVEIA 2023 FM.UCP.PT  ABNORMAL GAIT PATTERNS LOCOMOTOR SHAPING THE FUTURE OF MEDICAL EDUCATION RAQUEL GIL-GOUVEIA 2023 FM.UCP.PT  ABNORMAL GAIT PATTERNS LOCOMOTOR SHAPING THE FUTURE OF MEDICAL EDUCATION RAQUEL GIL-GOUVEIA 2023 FM.UCP.PT  2023/2024 LOCALIZATION IN NEUROLOGY SHAPING THE FUTURE OF MEDICAL EDUCATION FM.UCP.PT Raquel Gil-Gouveia