JC21, 22 - Where is the lesion I & II

Question 1

S/S of extrapyramidal system lesion

Answer 1

Movement disorders:

• Miscoordination of movement
• Akinesia/ Bradykinesia
• Stiffness/ Rigidity (Lead-pipe and cogwheel)
• Tremor
• Dysphagia
• Postural Instability

Question 2

S/S of cerebellar lesion (9)

Answer 2

Intention tremor

Dysmetria (past-pointing)
• Finger-nose test
• Heel-shin test

Dysdiadochokinesia

Dysarthria
• Slowed, slurred or scanning speech

Nystagmus
• Nystagmus on horizontal or vertical conjugate gaze
• Nystagmus towards the side of lesion

Wide-based gait

Truncal or limb ataxia
• Ataxia refers to lack of voluntary coordination of muscles
• Unable to perform tandem gait (heel-toe walking) despite normal strength

Pronator drift and rebound test
• Slow pronation of wrist and upward drift on pronator drift test
• Overshoot and bounce on rebound test

Romberg test
• Unsteadiness with eyes open

Question 3

S/S of peripheral nerve lesion

Answer 3

Motor and sensory dysfunction

Paresthesia, numbness

LMN signs: flaccid paralysis, muscle wasting, loss of tone, loss of power, areflexia

Question 4

Spinal nerve levels that form brachial and lumbosacral plexus

Answer 4

Brachial plexus = C5 – T1
• Anterior (ventral) rami of C5 through T1 nerve roots

Lumbosacral plexus = L1 – S4
• Anterior (ventral) rami of L1 through S4 nerve roots
• Lumbar plexus = L1 – L4
• Sacral plexus = L4 – S4

Question 5

Spinal nerve levels that form the sympathetic nervous system

Answer 5

Sympathetic nervous system
• Emerges from thoracic and lumbar spinal cord from T1 – L2

Question 6

Components of the parasympathetic nervous system

Answer 6

• Emerges from brainstem from CN III/ VII, IX, X (3, 7, 9, 10) (AND)
o CN III/ VII/ IX carry parasympathetic fibers to structures within H&N only
o CN X carry parasympathetic fibers to thoracic and abdominal viscera

• Emerges from sacral spinal cord from S2 – 4
o Innervate inferior abdominal viscera, pelvic viscera and arteries of erectile tissues in perineum
o e.g. Bladder emptying = S2 – 4 (Pelvic splanchnic nerve)

Question 7

Define possible locations of UMN lesions and LMN lesions

Answer 7

Question 8

UMN vs LMN lesion

• Structures involved
• Distribution
• Muscle tone
• Reflex

Answer 8

Question 9

UMN vs LMN lesion

• Muscle wasting
• Classical signs

Answer 9

Question 10

Frontal lobe

• Function
• Effects of damage on cognition/ behavior, physical control
• Positive phenomenon

Answer 10

Question 11

Parietal lobe (Dominant side)

• Function
• Effects of damage on cognition/ behavior, physical control
• Positive phenomenon

Answer 11

(Astereognosis - cannot tell shapes/ size/ objects by touch
Agraphesthesia - Impaired ability to recognize letters or numbers drawn by an examiner’s fingertip on the patient’s skin
Agraphia - cannot write)

Question 12

Parietal lobe (Non-Dominant side)

• Function
• Effects of damage on cognition/ behavior, physical control
• Positive phenomenon

Answer 12

Question 13

Parietal lobe (Non-Dominant side)

• Function
• Effects of damage on cognition/ behavior, physical control
• Positive phenomenon

Answer 13

Question 14

Temporal lobe

• Function
• Effect of damage on cognition and motor control
• Positive phenomenon

Answer 14

Question 15

Occipital lobe

• Function
• Effect of damage on cognition, motor control
• Positive phenomenon

Answer 15

Question 16

4 types of dysphasia

Answer 16

Receptive
Expressive
Conductive
Nominal

Question 17

Describe the nature and location of 4 types of dysphasia

Answer 17

Question 18

How to distinguish left-sided and right-sided lesions

Answer 18

Question 19

Components of the pyramidal system

Answer 19

Corticospinal and corticobulbar tract

Question 20

Outline the course of the corticospinal tract

Answer 20

Question 21

Outline the course of the corticobulbar tract

Answer 21

Question 22

Components of the basal ganglia?

Answer 22

Question 23

Weber syndrome

• Area of infarct
• Arteries involved
• Clinical manifestation

Answer 23

Weber syndrome
• Site of lesion = Anterior cerebral peduncle in midbrain
• Midbrain stroke syndrome due to occlusion of paramedian branches of PCA or basilar bifurcation perforating arteries

• Characterized by ipsilateral oculomotor nerve palsy and contralateral hemiparesis
o (Ipsilateral) LMN CN III palsy
o (Contralateral) UMN CN VII palsy (Corticobulbar tract)
o (Contralateral) Hemiplegia (Corticospinal tract)

Question 24

Pattern of midbrain lesion

Answer 24

• CN III – IV palsy
• Contralateral UMN hemiparesis (Corticospinal tract)

Question 25

Parinaud syndrome - Site of lesion - Causes - Clinical manifestation

Answer 25

Parinaud syndrome • Site of lesion = Dorsal midbrain (tectum) • Constellation of neuroophthalmologic findings seen with dorsal midbrain lesions including abnormalities of vertical gaze and convergence • Caused by multiple sclerosis, pinealoma or vascular lesion • Clinical manifestation o Loss of vertical gaze o Nystagmus on attempted convergence o Pseudo-Argyll Robertson pupil (bilateral small pupils that reduce in size on a near object (i.e., they accommodate), but do not constrict when exposed to bright light (i.e., they do not react))

Question 26

Outline clinical manifestation of pontine lesions

Answer 26

* CN V – VIII palsy * Contralateral UMN hemiparesis (Corticospinal tract) * Cerebellar signs (Cerebellar peduncle) * Dysconjugate eye movements (Paramedian pontine reticular formation (PPRF)) * Internuclear ophthalmoplegia (INO) (Medial longitudinal fasciculus (MLF)

Question 27

Outline clinical manifestation of medulla oblongata lesion

Answer 27

Medulla oblongata lesions • CN V, IX – XII palsy • Contralateral UMN hemiparesis (Corticospinal tract) • Cerebellar signs (Cerebellar peduncle)

Question 28

Wallenberg syndrome - Site of lesion - Causes

Answer 28

Lateral medullary syndrome (Wallenberg syndrome) • Site of lesion = Lateral medulla • Causes of Wallenberg syndrome o Brainstem infarction due to occlusion of vertebral artery and its lateral medullary penetrating arteries or PICA (\< 15%) (from local thrombotic occlusion, cardioembolism or arterial thromboembolism from vertebral artery dissection) o Brainstem hemorrhage o Brainstem demyelination (multiple sclerosis) o Leukoencephalopathy with brainstem involvement (hypertension, drugs, autoimmune disease)

Question 29

Clinical manifestations of Lateral medullary syndrome

Answer 29

o (Ipsilateral) LMN CN V palsy (Loss of all sensory modalities or paraesthesia of face) plus (Contralateral) Loss of pain and temperature sensation or paraesthesia in trunk and limbs (Spinothalamic tract) o (Ipsilateral) LMN CN IX, X palsy (Dysphagia/ Dysarthria/ Hoarseness of voice due to vocal cord paralysis/ Uvula deviation/ Loss of gag reflex  Aspiration pneumonia or hiccups) o (Ipsilateral) LMN CN XI palsy o (Ipsilateral) Cerebellar signs (Cerebellar ataxia with nystagmus towards the side of lesion) (Inferior cerebellar peduncle and cerebellar connections) o (Ipsilateral) Horner’s syndrome (Descending sympathetic fibres injury) o Vestibulocerebellar disturbance\* (almost always present) leading to vertigo, nystagmus, vomiting and ipsilateral limb ataxia (Vestibulospinal tract)

Question 30

``` # Define the location of conus medullaris and cauda equina Define the clinical manifestations of lesion at either location ```

Answer 30

 Conus medullaris • Termination of spinal cord with its pia mater • Ends at the level of L1/2 • Lesion at conus medullaris = **_Mixed UMN and LMN lesions_**  Cauda equina • Bundles of lumbar and sacral spinal nerves caudal to the termination of spinal cord • Floats in CSF within the subarachnoid space • Composed of lumbar, sacral and coccygeal nerve roots from L2 – C0 (10 pairs) • Lesion at cauda equina = **_LMN lesion ONLY_**

Question 31

Spinal cord lesion: General pattern of UMN and LMN signs at spinal cord level and spinal root level

Answer 31

Question 32

Spinal cord lesion: General pattern of UMN and LMN signs at spinal cord level and spinal root level

Answer 32

Question 33

Spinal cord lesion above C5 * Pattern of deficits

Answer 33

Question 34

Spinal cord lesion between C5 and T1 Clinical manifestation

Answer 34

Upper limbs: LMN signs Lower limbs: UMN signs Respiratory distress (Lesion below C5) o Intact diaphragmatic function o Inhale via diaphragm and accessory muscles o Exhale primarily through passive recoil of chest wall and lungs since primary muscles of exhalation including internal intercostal and abdominal wall muscles are paralyzed

Question 35

Spinal cord lesion between T2 and T12 Pattern of deficit

Answer 35

T2 – T12 • Upper limbs: Spared • Lower limbs: UMN signs • Sphincter disturbances o Sympathetic nervous system: Hypogastric nerve (T10 – L2) • Erectile dysfunction o Thoracolumbar erection centre (psychogenic erection by visual input) = T11 – L2

Question 36

Spinal cord lesion between L1 and S4 Pattern of deficit

Answer 36

* Upper limbs: Spared * Lower limbs: LMN signs • Sphincter disturbances o Sympathetic nervous system: Hypogastric nerve (T10 – L2) o Parasympathetic nervous system: Pelvic splanchnic nerve (S2 – 4) • Erectile dysfunction o Thoracolumbar erection centre (psychogenic erection by visual input) = T11 – L2 o Sacral erection centre (reflex erection by tactile stimulus) = S2 – 4

Question 37

Segmental/ Complete transection syndrome of spinal cord Causes Pattern of Sensory, Motor and Autonomic deficits

Answer 37

Question 38

Brown sequard syndrome Causes Pattern of sensory, motor and autonomic deficit

Answer 38

Causes: Trauma e.g. knife, bullet; asymmetrical compression from tumor or spondylosis, radiation necrosis

Question 39

Central cord syndrome Cause Pattern of sensory, motor and autonomic deficit

Answer 39

Clinical features depend on extent: * At the level without extension \>\> bilateral spinothalamic * Extends anteriorly \>\> Anterior horns deficit, LMN at the level only * Extends laterally \>\> Lateral CST deficit, UMN below the level Causes: * Acute: spinal hemorrhage, trauma, transverse myelitis, cervical spondylosis with hyper-extension injury * Chronic: syringomyelia, tumor

Question 40

Anterior cord syndrome Causes Patterns of sensory, motor and autonomic deficit

Answer 40

Causes: * DM, Atrial fibrillation, invasive intravascular procedures, acute hypoperfusion

Question 41

Posterior cord syndrome Causes Pattern of sensory, motor and autonomic deficit

Answer 41

Question 42

Conus medullaris syndrome Cause Pattern of sensory, motor and autonomic deficit

Answer 42

Question 43

Cauda equina syndrome Causes Pattern of sensory, motor and autonomic deficit

Answer 43

Question 44

Cauda equina syndrome Causes Pattern of sensory, motor and autonomic deficit

Answer 44

Question 45

Name all tracts affected by Brown-sequard syndrome

Answer 45

Question 46

List all tracts affected by central cord syndrome

Answer 46

Question 47

List all tracts affected by anterior cord syndrome

Answer 47

Question 48

List all tracts affected by posterior cord syndrome

Answer 48

Question 49

Peripheral nerve lesion * 2 patterns of lesion * General neurological deficit pattern

Answer 49

Question 50

NMJ lesion * 2 categories * Examples * General deficit pattern

Answer 50

Question 51

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Question 52

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Question 53

Answer 53

Question 54

Neoplastic causes of spinal cord compression

Answer 54

Question 55

Answer 55