Dr.

Ragess

Post Graduate Resident

Where is the lesion? What is the lesion? What can be done?

1) Cognitive impairment 2) Motor weakness 3) Sensory impairment 4) Postural instability and

Imbalance 5) Autonomic disturbances 6) Abnormal movements

Knowledge of Basic functional anatomy and different pathways

Cortical Brain Subcortical Brain Brainstem Cerebellum Spinal Cord Root Peripheral Nerve Neuromuscular Junction Muscle

Corticospinal tract extend from UMN in motor cortex through internal capsule, brainstem and into spinal cord which ends at the level between D12 and L1 Lesion involving the UMN or corticospinal tract produce spasticity or upper motor neuron type of findings (UMN i.e spasticity))

Lesion

below the level of spinal cord produces lower motor neuron type of findings ( LMN ie flaccidity) All the cranial nerve nuclei in brainstem have bicortical supranuclear control except lower half of 7th nerve nucleus and 12 th N nucleus

Upper motor neuron Lesion

Weakness

Lower motor neuron lesion

Weakness

Increased tone (Spasticity)

Brisk deep tendon reflexes

Decreased tone ( Flaccidity)

Absent or diminished deep tendon reflexes

Plantars up going

Plantars down going

Cortical Area

Function Problem Solving, Emotion, Complex Thought Coordination of complex movement Initiation of voluntary movement Receives tactile information from the body Processing of multisensory information Complex processing of visual information Detection of simple visual stimuli Speech production and articulation Language comprehension

Prefrontal Cortex Motor Association Cortex

Primary Motor Cortex

Primary Somatosensory Cortex Sensory Association Area Visual Association Area Visual Cortex Speech Center (Broca's Area) Wernicke's Area

Hemiplegia with facial weakness of upper motor neuron (UMN) type on the same side

Hemisensory disturbance including face on same side Astereognosis, sensory inattention, etc.
Speech defect ( dominant hemisphere) Visual field defect ( homonymous hemianopia) Disorientation in time , Place , person Memory impairment, behavior disturbance Seizures etc.

Either Intellectual impairment, personality change Urinary incontinence Mono or Hemiparesis Released primitive reflexes Left Brocas aphasia

Right Parietal Left sided sensory loss or neglect Agraphesthesia Left inferior quadrantinopia Dressing apraxia Facial Agnosia Right Temporal Confusional state Facial agnosia Left superior quadrantinopia

Left Parietal Right sided sensory loss or neglect Agraphesthesia Right inferior quadrantinopia Limb apraxia Left Temporoparietal Agraphia Acalculia Finger agnosia Left Right disorientation Wernickes Aphasia Alexia Right superior quadrantinopia

Visual field defects

Hemiplegia with facial weakness of upper motor neuron(UPN) type on the same side Hemisensory disturbance including face on same side

No Speech defect
Visual field defect ( homonymous hemianopia)

Extrapyramidal features including tremor, rigidity, bradykinesia or chorea

A small stroke there (or there) will result in a major deficit as the fibres are packed close together

Patient has Right arm weakness Right facial weakness Dysphasia

Mild weakness of right arm and leg

(face, arm & leg) Dysphasia Loss of right visual field

Ataxia

Vertigo, Vomiting, Diplopia, Dysarthria, Dysphagia,

Crossed hemiplegia - with cranial nerve on one side and hemiplegia on opposite side Midbrain - Ipsilateral 3rd nerve with contralateral hemiplegia Ipsilateral cerebellar signs

Pons - Ipsilateral 6th + 7th nerve( lower motor neuron) with contralateral hemiplegia Ipsilateral cerebellar sign Ipsilateral hornors
Medulla - Ipsilateral 10th or 12th N Ipsilateral cerebellar signs Ipsilateral hornor's syndrome Contralateral hemiplegia or hemianesthesia

Cervical Quadriplegia (Spastic) Sensory loss with level in the neck or upper limbs Sphincter disturbance(retention) Dorsal Paraplegia (Spastic) Sensory loss (sensory level on abdomen or chest Sphincter disturbance (retention) Lumbosacral Paraplegia (Flaccid) Sensory loss in lower limbs especially saddle area Loss of anal sphincter tone and reflex Sphincter incontinence

Pain is the hallmark and provocative maneuvers exacerbate the pain Sensory loss in a dermatome motor deficit confined to a particular myotome (LMN type) Usually No sphincter involvement

Level Function C1-C6 Neck flexors C1-T1 Neck extensors C3, C4, C5 Supply diaphragm (mostly C4) C5, C6 Shoulder movement, raise arm (deltoid); flexion of elbow (biceps); C6 externally rotates the arm (supinates) C6, C7 Extends elbow and wrist (triceps and wrist extensors); pronates wrist C7, T1 Flexes wrist C7, T1 Supply small muscles of the hand T1 -T6 Intercostals and trunk above the waist T7-L1 Abdominal muscles L1, L2, L3, L4 Thigh flexion L2, L3, L4 Thigh adduction L4, L5, S1 Thigh abduction L5, S1, S2 Extension of leg at the hip (gluteus maximus) L2, L3, L4 Extension of leg at the knee (quadriceps femoris) L4, L5, S1, S2 Flexion of leg at the knee (hamstrings) L4, L5, S1 Dorsiflexion of foot (tibialis anterior) L4, L5, S1 Extension of toes L5, S1, S2 Plantar flexion of foot

Biceps Brachioradialis Triceps Finger jerk Knee jerk Ankle jerk

C5-6 C5-6 C7-8 C8-T1 L3-4 S1

Distal weakness (LMN type) Distal sensory loss No sphincter involvement

Proximal weakness Preserved tendon reflexes No sensory loss No sphincter involvement

Pure motor weakness which may involve any skeletal muscle group Intermittent or variation in degree of weakness during the day Fatiguability

Neck stiffness Kerning's sign Brudzinski sign Contralateral sign Head jolting