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neuroanatomica
Obiective
Intotdeauna se incearca sa se
explice rezultatele pe baza
unei singure leziuni
Considera ca fiind o problema
multifocala doar atunci cand
dpdv anatomic nu poate fi
vorba doar de o leziune focala
Neurolocalizare
Exemplu de caz:
Menace absent
CN II, forebrain, cerebel, VII
Considera ca
Reflex palpebral (CN V, VII)
PLR normal (CN II, III)
Neurolocalizare
Divizarea functionala a
sistemului nervos
Intracranial (forebrain, brainstem,
cerebel)
Maduva spinarii(C1-C5, C6-T2, T3-L3,
L4-S3)
Neuromuscular (nerv periferic, JNM,
muschi)
Sistemele MNP vs.
MNC
Neuronii MNP
Corpul celular in substanta
cenusie a MS
Presente in TOATE segmentele
MS, DAR
au semnificatie functionala doar
in
Intumescenta C6-T2 si L4-S3 (ies
nervii pt membre)
Sistemele MNP vs.
MNC
Neuronii MNP
Functii
Legatura intre SNC (sistemul MNC)
si muschii efectori
Inervatia directa a muschilor efectori
Sistemele MNP vs.
MNC
Neuronii MNC
Corp celular in creier
Axonii parcurg TOATE
segmentele MS
Axonii se termina/fac sinapsa la
MNP
Sistemele MNP vs.
MNC
Neuronii MNC
FunctiI
Initiaza functia motorie voluntara
Mentin tonusul muscular pentru a mentine
postura impotriva gravitatiei
Inhiba extensorii (de ex. ei modereaza
activitatea)
Sistemele MNP vs.
MNC
Atat leziunile MNP cat si MNC
determina slabiciune (deficit)
Leziunile MNC
Pentru ca semnalul nu ajunge de la creier la
MNP
Leziunile MNP
Pentru ca semnalul nu trece de la MNC la
muschiul efector
Sistemul MNP vs. MNC
MNP MNC
Normal spre
Tonus
Hipotonic hipertonic/
muscular spastic
Severa (5-7
Fara/usoara
zile)
Apare incet
Atrofie Rapida
Atrofie
Atrofie de
MNP
Reflexe
Scazute datorita
pierderii integritatii
arcului refex
Afferent (senzitiv)
Eferent (neuron
alpha-motor)
Include corpul
celulare din
substanta cenusie
a MS
Jonctiunea
neuromusculara NMJ
Muschi efector
Muscle
MNP
Tonus muscular,
functia motorie
Scazut datorita
pierderii inervatiei
din sistemul MNC
ce asigura tonusul
muscular si
postura
Atrofia
Datorita pierderii
influentei trofice a
nervului
NMJ
Muscle
UMN
Functie motorie
Scazuta datorita
pierderii initierii,
deoarece
semnalul nu trece
de la SNC la
sistemul MNP
Reflexe, Tonus
muscular
Crescute datorita
pierderii inhibitiei
si a moderarii
efectuate de
sistemul MNC
Atrofie
Datorita scoaterii
din uz
Aplicatii clinice
Foloseste caracteristicile
semnelor MNC si MNP gasite
la examenul neurologic pentru
a localiza leziunile MS la
segmente spinale si/sau
cerebrale specifice
Localizare MS
Mb. Mb.
Leziune
toracice pelvive
C1-C5
C6-T2
T3-L3
L4-S3
Localizarea in MS
(Proprioceptia)
C1-C5
C6-T2
L4-S3
T3-L3
Localizarea in MS
(Reflexe)
C1-C5
C6-T2
L4-S3
T3-L3
Localizarea in MS
Mb Mb
Leziune
toracice pelvine
C1-C5
C6-T2
T3-L3
L4-S3 ?
Localizarea in MS
Mb Mb
Leziune
toracice pelvine
C1-C5
C6-T2
T3-L3
L4-S3 ? MNP
Localizarea in MS
Mb Mb
Leziune
toracic pelvin
C1-C5
C6-T2
T3-L3
C1-C5
C6-T2
L4-S3
T3-L3
Localizarea in MS
(Reflexe)
C1-C5
C6-T2
L4-S3
T3-L3
Localizarea in MS
Mb Mb
Leziune
toracic pelvin
C1-C5
C6-T2
T3-L3 ?
Mb Mb
Leziune
toracic pelvin
C1-C5
C6-T2
T3-L3 ? MNC
Mb Mb
Leziune
toracic pelviv
C1-C5
C6-T2
C1-C5
C6-T2
L4-S3
T3-L3
Localizarea in MS
(Reflexe)
C1-C5
C6-T2
L4-S3
T3-L3
Localizarea in MS
Mb Mb
Leziunea
toracic pelvin
C1-C5
C6-T2 ?
Mb Mb
Leziunea
toracic pelvin
C1-C5
C6-T2 ? MNC
Mb Mb
Leziunea
toracic pelvin
C1-C5
C1-C5
C6-T2
L4-S3
T3-L3
Localizarea in MS
(Reflexe)
C1-C5
C6-T2
L4-S3
T3-L3
Localizarea in MS
Mb Mb
Leziunea
toracic pelvin
C1-C5 ?
Mb Mb
Leziune
toracic pelvin
C1-C5 ? MNC
Mb Mb
Leziunea
toracic pelvin
C1-C5 MNC MNC
Mb Mb
Leziunea
toracic pelvin
C1-C5 MNC MNC
C6-T2
L4-S3
T3-L3
Localizarea in MS
Mb Mb
Leziunea
toracic pelvin
C1-C5 MNC MNC
Miopatii
slabiciune
+/- atrofie musculara,
hipertrofie
Poate fi un nivel CK
Tipic reflexele si
proprioceptia sunt normale
Jonctiunopatii
Tipic slabiciune episodica
(ex., myasthenia gravis); NMJ
dar cateva nu sunt
episodice (ex., paralizia de
capuse, botulism)
Muscle
Fara atrofie musculara
Localizare intracraniana
Brainstem,
midbrain
De ce ipsilateral?
Nervii cranieni
Ies din midbrain,
brainstem si
raman ipsilateral
Reactiile
posturale
Fibrele PC urca
ipsilateral prin MS
prin fascicule
Se incruciseaza in
trunchiul cerebral
anterior spre
forebrain
contralateral
Localizare intracraniala
Constienta
De ce este
alterata atat
in boli ale
forebrain
cat si a
brainstem?
Gandeste-te
la caile SRA
RAS
Localizare intracraniana
Forebrain
Constienta
modificata, atacuri
convulsive
Deficite
contralaterale
Reflex de amenintare
Stimulare nazala
Proprioceptie
PC,
Wheelbarrowing
Cercuri largi, cap
inclinat
Inspre leziune
Sindrom Hemi-
inatentie
Mananca dintr-o
jumatate a bolului
The man who
mistook his wife
for a hat, Oliver
Saks
Localizare intracraniana
Forebrain
Discrepanta intre postura si
proprioceptie
Ataxie / pareza mica sau absenta
Postura este generata in midbrain
Caile implica brainstem, MS, cerebel
Forebrain este minim implicat, prin
urmare postura este pastrata
Constienta poate fi afectata in legatura
cu constientizarea posturii
Adoarme pe picioare, poticnire
In ciuda posturii aproape
normaledeficite PC evidente
Aceasta este una din cheilebolilor
forebrain
Localizare intracraniana
Cerebel
Ataxie cerebeloasa, fara
slabiciune
Largirea bazei de sustinere
Tremor de intentie
Fara deficite PC
Dar poate fi incomod, mers de
cocos
Reflexe spinale intacte
Constienta normala
Reflexele NC intacte
R. de amenintare poate fi absent
ipsilateral
Localizare intracraniana
De ce cerebelul afecteaza
postura dar nu si tonusul?
Case Example:
Stretch
4 year old MN
Dachshund
Chief Complaint:
Acute onset
paraplegia
Exemplu de caz:
Stretch
Physical Examination
TPR WNL
Auscultation normal
No general physical findings
Gait
Paraplegic (non-ambulatory)
Proprioceptive ataxia?
Exemplu de caz:
Stretch
Neurological Exam
Postural reactions
Normal both thoracic limbs
Absent both pelvic limbs
CP placing absent
Hopping absent
Extensor postural thrust absent
Exemplu de caz:
Stretch
Neurological Exam
Myotatic Reflexes
Thoracic limbs - Normal
Triceps: 2
Biceps: 2
Extensor carpi radialis: 2
Neuroanatomic Localization?
Exemplu de caz:
Stretch
Explanation
Think of chart, UMN vs.
LMN signs
Thoracic limbs - Normal
Pelvic limbs - UMN
Multifocal or
LMN LMN
Neuromuscular
Exemplu de caz:
Stretch
Explanation
Lesion must be caudal to T2
because thoracic limbs are
normal
Cannot be cranial to
T2 (C1-C5, C6-T2,
or intracranial)
because thoracic
limbs would be
abnormal
Cannot be
brainstem or
midbrain or else
should have cranial
nerve deficits
Reflexes are
intact, and
potentially
exaggerated,
thus UMN
If it were LMN,
reflexes would
be decreased or
absent due to
impairment of
Exemplu de caz:
Stretch
Diagnostic
Imaging
Myelogram
Extradural
compressive
lesion at L1-
L2
Consistent
with Type I Mineralized disc material
disc
herniation
CT scan
Mineralized
material Spinal cord
causing
extradural
compression
at L1
Exemplu de caz:
Stretch
Does this fit
with our
localization?
Diagnosis: Type
I IVDD at L1-L2
Case Example: Bandit
Case Example:
Bandit
6 year old M Terrier
Chief Complaint:
Rapidly progressive
weakness over 1
week duration
Non-ambulatory
Attitude, appetite
normal
Urination, defecation
normal, but cannot
stand/posture
Case Example: Bandit
Physical examination
TPR WNL
Auscultation normal
Seems somewhat painful, non-
specific
No general physical findings
Neurological
Exam
Case Example: Bandit
Sensory Perception
Superficial pain perception intact
all four limbs and trunk
Palpation
Normal palpation and muscle
mass
Case Example: Bandit
Neuroanatomic
Localization?
Case Example: Bandit
Explanation
We know all four limbs are
affected because
We have weakness and ataxia in
all limbs
We have postural reaction deficits
in all four limbs
Intracranial is unlikely because
Thoracic Pelvic
Lesion
Limbs Limbs
C1-C5 UMN UMN
Bandits localization is
Neuromuscular
Reflexes are reduced in all four
limbs
Reflex arcs of the LMN system are
not intact
Either Peripheral nerve, NMJ, or
Muscle
Polyneuropathy, junctionopathy, or
polymyopathy
Chief complaint
Tremors, seizures of several
weeks duration
Sensitive on right shoulder (tries
to bite owner if touched on right
shoulder)
Acute onset, progressive
Case Example: Scarlett
Neurological Examination
Mentation alert and
appropriate
Gait normal, no ataxia or
paresis
Circles to right (wide
circles)
Postural Reactions
Normal Right thoracic, right
pelvic limbs
Slow/absent Left thoracic,
pelvic limbs
Reflexes normal
Case Example: Scarlett
Cranial nerve exam - all normal
except:
Menace
Absent OS
Normal OD
Nasal sensation
Decreased to left nostril
Normal to right nostril
Hemi-hyperaesthesia
Exaggerated response to tactile
stimulation of right side of body
Relative decreased/inattentive
response to tactile stimulation of
left side of body
Case Example: Scarlett
Neuroanatomic
localization?
Case Example: Scarlett
Neuroanatomic localization?
Intracranial
Forebrain
Right hemisphere lesion
Explanation:
Detailed explanation to follow.
Case Example: Scarlett
Explanation
Gait
Normal locomotion is generated in
midbrain, integrated at
pons/medulla; forebrain not
necessary for normal gait
Pathway - midbrain, brainstem, spinal
cord, peripheral nerve
Explanation
Gait
Circling right
Could be ipsilateral vestibular
dysfunction, but no vestibular ataxia or
head tilt, no abnormal nystagmus
Could be contralateral forebrain due to
inattention to contralateral environment
Ignores left side, therefore tends to
circle right
Circling is toward side of forebrain
lesion
Case Example: Scarlett
Explanation
Postural reactions
Sensory proprioceptive information
travels up spinal proprioceptive
tracts to contralateral cerebral
cortex
Pathway - peripheral n., ipsilateral spinal
cord, ipsilateral brain stem, contralateral
cerebral cortex
Explanation
Menace deficit (OS)
Lack of response to stimulus (not true
lack of vision) due to decreased
integration of threatening gesture
Pathway CN II, forebrain, cerebellum,
CN VII
Explanation
Nasal sensation deficit (left)
Lack of conscious response, as
above
Hypalgesia due to lesion in
contralateral cerebral/somesthetic
cortex
Pathway CN V, forebrain
Explanation
Seizures
True seizures originate in forebrain
Hemineglect (left)
Lack of conscious response to
stimuli on left
Pathway sensory input travels to
contralateral forebrain
Diagnostic tests
CSF Analysis
WBC (10 WBC/ul: 61% lymphs/39%
monos; 0 RBC)
Normal protein
Infectious Disease Panel
unremarkable
MRI
Multifocal areas of inflammation/edema in
forebrain
Predominantly right hemisphere lesions