Lesions

Question 1

Bulbar palsy clinical presentation

Answer 1

LMN weakness of muscles supplied by cranial nerves with cell bodies within the medulla: IX, X, XII
Tounge: wasted, flaccid, fasciculating, fast movements
Dysphagia?
Soft palate elevation?
Quiet, nasal speech?
Jaw jerk/gag reflex absent?

Question 2

Pseudobulbar palsy clinical presentation

Answer 2

Bilateral UMN disease of medullary cranial nerves
Tongue: stiff/spastic, slow movements, no wasting
Dysphagia?
Normal soft palate elevation
Gravelly ‘donald duck’ speech / slurred high pitched dysarthria
Exaggerated jaw jerk
Mood disturbances

Question 3

Causes of bulbar palsy

Answer 3

Degenerative: motor neurone disease
Vascular: stroke 
Inflammatory: Guillain-barre 
Infective: botulism 
Neoplastic: brainstem tumours 
Congenital

Question 4

Causes of pseudobulbar palsy

Answer 4

Degenerative: MND
Vascular: stroke
MS
Head trauma

Question 5

Frontal cerebral hemisphere lesion presentation

Answer 5

Intellectual impairment, personality change
Urinary incontinence
Mono/hemiparesis
Broca’s aphasia (if left frontal)

Question 6

Left temporo-parietal cerebral hemisphere lesion presentation (dominant hemisphere)

Answer 6

Agraphia: inability to write
Alexia: word blindness 
Acalculia: inability to calculate
Wernicke's aphasia 
Contralateral sensory neglect

Question 7

Right temporo-parietal cerebral hemisphere lesion presentation

Answer 7

Failure of face recognition

Contralateral sensory neglect

Question 8

Occipital cerebral hemisphere lesion presentation

Answer 8

Visual field defects

Visuospatial defects

Question 9

Lateral cerebellar lesion presentation

Answer 9

Ipsilateral pathological signs
Broad, ataxic gait: test heel-toe walking, +ve Rhomberg test suggests sensory (rather than cerebellar) ataxia
Titubation: rhythmic head tremor
Dysarthria: slurred, staccato speech
Nystagmus: towards the side of the lesion
Dysmetric saccades: inability to change eye focus
Upward drift (if pronator drift also present = UMN pathology also)
Rebound phenomenon
Hypotonia: decreased in pure cerebellar disease
Mild hyporeflexia
Dysmetria: imprecise coordination
Dysdiadochokinesis: clumsy rapid alternating movements

Question 10

Cerebellar examination investigations

Answer 10

Full neurological exam
TFTs
Antineuronal antibodies
MRI brain

Question 11

Midline cerebellar lesion presentation

Answer 11

Rolling, broad, ataxic gait
Difficulty standing/sitting unsupported
Cannot perform Rhomberg’s with eyes open/closed
Vertigo/vomiting if extension into 4th ventricle

Question 12

Causes of bilateral cerebellar dysfunction

Answer 12

Alcohol
Drugs: phenytoin, anti-epileptics
Paraneoplastic cerebellar degeneration: antineuronal antibodies present, common with breast/SCC of lung
Severe hypothyroidism

Question 13

Causes of unilateral cerebellar dysfunction

Answer 13

MS
Stroke
Tumour: acoustic neuroma, meningioma

Question 14

Components of the basal ganglia

Answer 14

Corpus striatum: caudate nucleus, globus pallidum, putamen
Subthalamic nucleus
Substantia nigra
Parts of the thalamus

Question 15

Basal ganglia lesion presentation

Answer 15

Bradykinesia progressing to akinesia: slowness of movement/loss of power of voluntary movement
Muscle rigidity
Involuntary movements…
Tremor
Dystonia: spasms
Athetosis: writhing involuntary movements of hands/face/tongue
Chorea: jerky involuntary movements
Hemiballismus: violent involuntary movements, proximal muscles of one arm

Question 16

Clinical syndromes resulting from basal ganglia pathology

Answer 16

Parkinsonism
Huntingtons
Hemiballismus

Question 17

Causative lesion of a central scotoma

Answer 17

Macula lesion e.g. diabetic maculopathy

Question 18

Causative lesion of monocular loss of vision

Answer 18

Ipsilateral optic nerve lesion

Question 19

Causative lesion of bitemporal hemianopia/quadrantopia

Answer 19

Optic chiasm lesion
Affects the nasal fibres from each eye
Superior bitemporal quadrantanopia: pressure from below chiasm (e.g. pituitary tumour)
Inferior bitemporal quadrantanopia: pressure from above the chiasm (craniopharyngoma, carotid aneurysm, meningioma)

Question 20

Causative lesion of homonymous hemianopia

Answer 20

Contralateral optic tract lesion

Question 21

Causative lesion of homonymous quadrantanopia

Answer 21

Contralateral optic radiation lesion…
Temporal lesion: superior homonymous quadrantopias
Parietal lesion: inferior homonymous quadrantopias

PITS = parietal inferior, temporal superior

Question 22

Causative lesion of macular sparing homonymous hemianopia/quadrantanopia

Answer 22

Defect in visual cortex (occipital lobe)

Question 23

What are the symptoms of a S1 lesion?

Answer 23

S1- ankle plantar flexion and hip extensors
Sharp/searign pain in buttock, thigh, foot, toes
Numbness in foot or toes
Weakness in the leg and foot muscles- foot drop

Question 24

What are the symptoms of a C5 root lesion?

Answer 24

C5- control the deltoids and the biveps

Question 25

Ulnar nerve palsy

Answer 25

Loss of sensation in ring and little fingers Loss of coordination of fingers Tingling or burning sensation in hand Loss of grip strength

Question 26

Radial nerve palsy

Answer 26

Numbness from the triceps down to the fingers Problems extending wrist or fingers Pinching and grasping problems Wrist drop