Sunteți pe pagina 1din 96

Localizare

neuroanatomica
Obiective

Localizarea leziunii pe baza


examenului neurologic
Diferentierea deficitelor MNC si
MNP
Diferentierea bolilor NM
generalizate de bolile maduvei
spinarii
Localizarea leziunilor
intracraniene
Recunoasterea indicatiilor pentru
leziunile multifocale
Neurolocalizare

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

Anomaliile la examenul neuro


= lista de probleme
Amintesteti caile implicate in
fiecare test
Care cale comuna este
implicata?

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

Cand vorbim de localizare


MNC si MNP,ne referim de fapt
la semnele clinice pe care le
vedem
Caracteristici MNP vs.
MNC

MNP MNC

Scazut spre Normal spre


Reflexe absent cerscut

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

L4-S3 Normal LMN


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
toracic pelvin
C1-C5

C6-T2

T3-L3 ?

L4-S3 Normal MNP


Localizarea in MS

Mb Mb
Leziune
toracic pelvin
C1-C5

C6-T2

T3-L3 ? MNC

L4-S3 Normal LMN


Localizarea in MS

Mb Mb
Leziune
toracic pelviv
C1-C5

C6-T2

T3-L3 Normal UMN

L4-S3 Normal LMN


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
Leziunea
toracic pelvin
C1-C5

C6-T2 ?

T3-L3 Normal MNC

L4-S3 Normal MNP


Localizarea in MS

Mb Mb
Leziunea
toracic pelvin
C1-C5

C6-T2 ? MNC

T3-L3 Normal MNC

L4-S3 Normal MNP


Localizarea in MS

Mb Mb
Leziunea
toracic pelvin
C1-C5

C6-T2 MNP UMN

T3-L3 Normal UMN

L4-S3 Normal LMN


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
Leziunea
toracic pelvin
C1-C5 ?

C6-T2 MNP MNC

T3-L3 Normal MNC

L4-S3 Normal MNP


Localizarea in MS

Mb Mb
Leziune
toracic pelvin
C1-C5 ? MNC

C6-T2 MNP MNC

T3-L3 Normal MNC

L4-S3 Normal MNP


Localizarea in MS

Mb Mb
Leziunea
toracic pelvin
C1-C5 MNC MNC

C6-T2 MNP MNC

T3-L3 Normal MNC

L4-S3 Normal MNP


Localizarea in MS

Mb Mb
Leziunea
toracic pelvin
C1-C5 MNC MNC

C6-T2 MNP MNC

T3-L3 Normal MNC

L4-S3 Normal MNP

??? MNP MNP


Localizare?
(daca semnele MNP sunt
pe toate membrele )
C1-C5

C6-T2
L4-S3
T3-L3
Localizarea in MS

Mb Mb
Leziunea
toracic pelvin
C1-C5 MNC MNC

C6-T2 MNP MNC

T3-L3 Normal MNC

L4-S3 Normal MNP


Neurom
uscular
sau MNP MNP
Bolile Neuromusculare
Neuropatii
Senzitive, motorii,
senzitivomotorii
Atrofie musculara rapida,
marcata
Deficite la examenul
neurologic

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

Trebuie sa stii componentele


cailor implicate
Aborbeaza examenul NC ca o
lista cu miniprobleme
Enumera componentele fiecarui
test al NC anormal
Compara pentru a gasi
comnenta comuna

Localizeaza la o leziune daca


este posibil
Daca nu e posibl, considera
boala multifocala
Localizare intracraniana
Brainstem, midbrain
Ataxie severa, pareza
Ataxie senzoriala sau ataxie
vestibulara daca NC VIII
Deficite la reactiile posturale
Ipsilateral
Deficite ale NC Ipsilateral
Manej, inclinarea capului daca
este implicare vestibulara
Cercuri mici, inguste
Spre (tipic) sau contra (paradoxical)
leziunii
Mentatie
Poate fi alterata daca SRA e afectat
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

Compara aceasta cu boli


ale MS
Daca sunt deficite PC
severe dar si ataxie si
pareza evidenta
Localizare intracraniana
De ce leziunile spinale dau slabiciune
si leziunile forebrain pastreaza
postura?
Postura este generata in midbrain
Caile merg cauda. Pana la MS (sistemele MNC,
MNP)
MS poarta fibrele motorii ale posturii si tonusului
Astfel leziunile din midbrain,
brainstem, sau MS afecteaza
postura si tonusul

Forebrain este important doar


pentru controlul motivat al
acestor sisteme
Mers compulsiv, pacing
Nu postura sau tonusul
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?

Pierderea feedbackului in timp


real pentru a coordona miscarile
Nu interfereaza functia
sistemelor MNC si MNP, deci nu
exista slabiciune
MNC inca trimit semnale catre
sistemul MNP
MNP inca trimite semnale catre
muschii efectori
Localizare multifocala

Rezervata situatiilor care nu


pot fi explicate pe baza unei
singure leziuni
Exemplu
Deficit NC II stang (fara RFM)
Deficit NC VIII drept (vestibular
central)
Cap inclinat (spre dreapta)
Nistagmus spontan (Vertical)
Leziune L4-S3
Reflexe absente pe ambele mb
pelvine (semne MNP)
LMN mb pelvine (trebuie sa fie L4-S3
sau boala NM)
Mb toracice normale (deci nu poate fi
boala NM)
Obiective

Localizarea leziunii pe baza


rezultatelor examenului
neurologic
Diferentierea slabiciunii MNC vs.
MNP
Diferentierea bolilor generalizate
NM vs. bolile MS
Localizarea leziunilor
intracraniene
Recunoasterea indiciilor pentru
leziuni multifocale
Exemplu de caz:
Stretch

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

CBC, Serum chemistry profile,


UA
ALT, ALKP mild elevation
Most likely due to steroid
administration prior to referral
Otherwise unremarkable
Exemplu de caz:
Stretch
Neurological Exam
Mentation
Alert, anxious
Appropriate for situation

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

Pelvic limbs - Normal to hyper-


reflexic
Patellar: 2-3
Cranial tibial: 2
Gastrocnemius: 2
Exemplu de caz:
Stretch
Neurological Exam
Withdrawal reflexes normal all
four limbs
Perineal reflex normal
Cutaneous trunci reflex
Absent caudal to L2

Cranial nerve exam normal


Palpation
Hyperaesthetic at
thoracolumbar junction
Exemplu de caz:
Stretch
Neurological Exam
Sensory Perception
Superficial pain perception
Normal thoracic limbs
Absent pelvic limbs

Deep pain perception


Absent pelvic limbs
Exemplu de caz:
Stretch

Neuroanatomic Localization?
Exemplu de caz:
Stretch

Explanation
Think of chart, UMN vs.
LMN signs
Thoracic limbs - Normal
Pelvic limbs - UMN

The localization is T3-L3


Exemplu de caz:
Stretch

Lesion Thoracic Limbs Pelvic Limbs

C1-C5 UMN UMN

C6-T2 LMN UMN

T3-L3 Normal UMN

L4-S3 Normal LMN

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

Forebrain lesions can


cause proprioceptive
deficits, but not
paraplegia
Exemplu de caz:
Stretch
Explanation
Pelvic limbs are
UMN Lesio
n is
Proprioceptive Lesion must be T3-L3

deficits indicate caudal to T2


Lesion must
that both pelvic cranial to L4 or
limbs are else reflexes
would be
involved decreased

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

CBC, Serum chemistry profile,


UA
Unremarkable
Case Example: Bandit

Neurological
Exam
Case Example: Bandit

Neurological exam abnormalities


Mentation alert and appropriate
Gait
Tetraparesis
Ataxia
Non-ambulatory, very weakly
ambulatory
Requires support to stand and maintain
posture
Postural reactions
CP placing (knuckling) is normal if
supporting body
Delayed, weak hopping in all four
limbs
Case Example: Bandit

Neurological exam abnormalities


Myotatic Reflexes
Pelvic Limbs
Patellar 1 (decreased) L and R
Cranial tibial 1 (decreased) L and R
Thoracic Limbs
Triceps 0 (absent) L and R
Biceps 0 (absent) L and R
Extensor carpi radialis 1 (decreased) L
and R
Flexor withdrawal Reflexes
0 - absent/severely decreased in all
four limbs
Case Example: Bandit

Cranial Nerve Examination


No deficits on cranial nerve
exam

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

Profound tetraparesis, so cannot be


forebrain
No deficits on cranial nerve exam
Normal mentation

THEREFOREwe are most


likely dealing with a lesion
caudal to the brainstem
Case Example: Bandit

No go back and think through


the chart for UMN vs. LMN
signs
Where does Bandit fit?

Are his thoracic limb reflexes


UMN or LMN?
Are his pelvic limb reflexes UMN
or LMN?
Case Example: Bandit

Thoracic Pelvic
Lesion
Limbs Limbs
C1-C5 UMN UMN

C6-T2 LMN UMN

T3-L3 Normal UMN

L4-S3 Normal LMN


Multifoca
l or
LMN LMN
Case Example: Bandit

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

We would only consider


multifocal if we ruled out
neuromuscular disease first
Attempt to give all patients one
Case Example: Bandit
Diagnosis: Coonhound paralysis
(Acute polyradiculoneuritis)
This affects predominantly the ventral
(motor) nerve roots and nerves and
thus causes profound weakness

This predominantly motor effect


explains why Bandit had better
sensory function (CP placing) than
motor function (hopping, which
requires more strength)

This syndrome can be idiopathic (no


raccoon exposure) or can occur
following exposure to raccoon saliva.
Case Example: Scarlett

Case Example: Scarlett


7 month old, FS Maltese

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

General Physical Examination


TPR - WNL
Normal auscultation
No general physical findings

CBC, Serum chemistry profile,


UA
Unremarkable
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

All other tests were normal,


including:
Palpebral
Normal OU (CN V, VII intact)
PLR
Normal OU (CN II, III intact)
Case Example: Scarlett

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

THEREFOREif gait is normal,


unlikely to have lesion in these areas
Case Example: Scarlett

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

BUT we know reflexes are normal, so it


cannot be peripheral nerve
We also know gait is normal so it is
unlikely to be spinal cord or brainstem
We are left with contralateral forebrain
(right forebrain)
Case Example: Scarlett

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

BUT we know PLR is normal (so cannot be


CN II)
We also know Palpebral reflex is normal
(so cannot be CN VII)
We do not see cerebellar ataxia or other
cerebellar signs
THEREFOREwe are left with
contralateral forebrain and decreased
conscious Response to stimuli
Case Example: Scarlett

Explanation
Nasal sensation deficit (left)
Lack of conscious response, as
above
Hypalgesia due to lesion in
contralateral cerebral/somesthetic
cortex
Pathway CN V, forebrain

BUT we know Palpebral reflex is


normal, so it cannot be due to CN V
THEREFOREwe are left with
contralateral forebrain and decreased
conscious Response to stimuli
Case Example: Scarlett

Explanation
Seizures
True seizures originate in forebrain

Hemineglect (left)
Lack of conscious response to
stimuli on left
Pathway sensory input travels to
contralateral forebrain

Therefore, environmental stimuli is


being ignored on contralateral side
If decreased responses to stimuli on
left, then lesion is in right forebrain
Case Example: Scarlett

How to work through this


process?
List all components of the
pathways for these abnormal
tests
Rule out components that you
know are intact
Look for the common arm of the
remaining pathways for all of
these abnormal tests

For Scarlett Right forebrain (right


cerebral hemisphere)

Next slide for MRI results


Case Example: Scarlett

Note: MRI Marker denotes Right side of brain


Case Example: Scarlett

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

Multifocal Inflammatory Disease


Diagnosis: Necrotizing encephalitis of
toy breed dogs
Objectives

Localize lesion based on neuro


exam results
Differentiate UMN vs. LMN
weakness
Differentiate generalized NM
disease vs. spinal cord disease
Localize intracranial lesions
Recognize indications of
multifocal lesion