Anatomic Localization

APPROACH TO A PATIENT WITH NEUROLOGICAL

DISEASE

Greg David V. Dayrit, M.D., FPCP,FPNA

Assistant Professor in Internal Medicine-Neurology

The ultimate goal of the neurologic history and

examination is:

I. To find out WHERE is the lesion?

A. Levelize the lesion along the neuraxis

B. Lateralize the lesion

C. Localize the lesionC. Localize the lesion

II. To figure out the Pathophysiology of the lesion –

disturbance in function

III. To discover the Pathology of the lesion – WHAT is

the lesion?

History Taking

1. General information

- name, age, sex, place of origin, handedness, status,

occupation.

- some diseases have a predilection for a particular - some diseases have a predilection for a particular

age, sex or place of origin

2. Chief complaint

3. History of present illness

History of Present Illness

Temporal Profile is very important !

1. Acute – cerebrovascular disease, seizures

2. Gradual – brain tumors or abscess2. Gradual – brain tumors or abscess

3. Periodic – after an attack, there is improvement

Ex. familial hypokalemic periodic paralysiS

4. Progressive – Malignant tumors

Neurologic Examination

• Congenital

• Hereditary

• Acquired

• Infectious

• Neoplastic

• Degenerative

• Vascular

• Trauma• Infectious

• Immunologic

• Trauma

• Demyelinating

Temporal and Spatial Features of Major Disease

Categories

NeoplasmInflammatory

(abscess,

Vascular

(infarct,

Focal

ChronicSubacuteAcute

DegenerativeInflammatory

(meningitis,

encephalitis)

Vascular

(Subarachnoid

hemorrhage)

Diffuse

(abscess,

myelitis)

(infarct,

hemorrhage)

Systems Affected by Neurologic Disorders

1. Consciousness system

2. Sensory system

3. Motor System

4. Internal Regulation System4. Internal Regulation System

5. Homoestasis

6. Vascular System

Neurologic Disorders Occur at these Levels:

1. Supratentorial level

2. Posterior Fossa level

3. Spinal level

4. Peripheral Level (Peripheral nerve, NMJ, Muscle)4. Peripheral Level (Peripheral nerve, NMJ, Muscle)

Neurologic History

• “If one were to choose between history,

examination and laboratory testing to arrive at

a correct diagnosis, the safest wager would be

on history.”on history.”

A.J.Dale, MD

Neurologic History

• “If I don’t know what the patient has after I have

taken the history, I am in serious trouble.”

Alan Yudell, MD

• “Listen to the patient. He is trying to tell you what is

wrong with him.”

Sir William Osler

Historical Dissection: Chronological Episodes

1. Symptoms (HPI)

2. Evaluation (PE/NE)

3. Diagnosis (DDx)

4. Treatment4. Treatment

5. Outcome/Prognosis


• Stethoscope

• Sphygmomanometer

• Ophthalmoscope

• Otoscope

• Pin

• Aromatic Substance

• Coin/Key

• Tuning Fork• Otoscope

• Neurological Hammer

• Tongue Depressor

• Wisp of cotton

• Sugar/Salt Crystals

• Tuning Fork

• Calorics testing

• Tape Measure

• Visual Acuity Charts


1. Mental status exam/language (MMSE)

2. Vital signs (including BMI)

3. Neurovascular

4. Cranial Nerves (12)

5. Muscle Strength (4)5. Muscle Strength (4)

6. Sensation

7. Reflexes

8. General Motor Survey

9. Spine survey

10. Meningeal signs

Mental Status Examination

• Orientation

• Attention – seven digits

• Learning- 3 objects

• Calculation• Calculation

• Abstraction

• Construction – draw a clock, cube

• Fund of information

• Recall - 3 objects from learning


Mental Status/Language

A) Comprehension

– Listening

– Reading– Reading

B) Expression

- Speaking

- Writing


2. Vital Signs

A. Height

B. Weight

C. TemperatureC. Temperature

D. Blood Pressure (lying and standing)

E. Pulse (lying and standing)

F. Respiratory Rate


3. Neurovascular

A. Cardiac Auscultation

B. Neck/Orbit/Cranium Auscultation

C. Pulse ExaminationC. Pulse Examination

Radial

Temporal

Carotid

Dorsalis pedis

Posterior tibial

Cranial Nerves

I. Olfactory – camphor, perfume

II. Optic

– fields: single eye finger counting in 4 quadrants

– Acuity: hand-held card, test eye separately– Acuity: hand-held card, test eye separately

– Color plates: test eye separately

– Fundoscopy: disk margins, macula, vessels

– Pupils: size, shape, reactivity (direct/consensual)

Cranial Nerves

III Oculomotor, IV Trochlear, VI Abducens

- test 9 cardinal positions of gaze in both eyes simultaneously if there are no complaints of diplopia. Otherwise, test each eye separatelydiplopia. Otherwise, test each eye separately

- Maddox rod test: for subtle diplopia and localization of peripheral causes of diplopia

Cranial Nerves

V. Trigeminal

- tested during other portions of the exam:

- strength : manual muscle testing

- sensation: during sensory exam- sensation: during sensory exam

- corneal reflex: during test for reflexes

Cranial Nerves

VII. Facial

- Strength: tested during manual muscle testing

- Taste: rarely assessed unless with peripheral VII

nerve palsies. Use tongue depressor with single

substances applied to one side of the tongue. substances applied to one side of the tongue.

Instruct patient to protrude the tongue for

application, then raise the hand once they have

decided what the taste is.

Cranial Nerve

VIII Vestibulocochlear

- Hearing: finger rub testing. Rub your own thumb and index finger beginning 50 cm from the test ear, bringing the stimulus closer to the the test ear, bringing the stimulus closer to the patient’s head. Note the distance at which the stimulus is reliably perceived.

- Vestibular function: Nylen manuever, Romberg testing

Cranial Nerves

IX Glossopharyngeal

X Vagus

1. Pharyngeal “gag” reflex

2. Palatal elevation with phonation2. Palatal elevation with phonation

3. Heart rate response to deep breathing

XI Spinal Accessory Nerve

XII Hypoglossal


MUSCLE STRENGTH : 41 groups of muscles on each side

1. Bulbar

2. Neck

3. Upper limb3. Upper limb

4. Abdomen

5. Lower limb

6. Anal Sphincter


SENSATION

1. Vibration

2. Joint Position Sense

3. Light Touch

4. Pinprick4. Pinprick

5. Two-point Discrimination

6. Stereognosis

7. Double simultaneous stimulation

8. Temperature

9. Deep Pain - comatose


REFLEXES

• Bulbar

• Frontal release• Frontal release

• Upper limb

• Abdominal

• Lower Limb

• Perineal

• Plantar Responses


GENERAL MOTOR SURVEY

• 1. Watch patient walk down the hall unobserved

• 2. Walk across the room

• 3. Walk on toes then on heels• 3. Walk on toes then on heels

• 4. Squat and rise without use of upper limbs

• 5. Finger to nose (E/O, E/C)

• 6. Alternation/motion rates

• 7. Muscle Tone

Neurological Examination

SPINE

1. Nuchal signs

2. Spinal Percussion tenderness

3. Palpation of Paraspinal muscles for spasm

4. Passive straight leg raise4. Passive straight leg raise

5. Flexion-abduction-external rotation of the hip

6. Cervical and lumbar range of motion

7. Observations: scoliosis, lordosis

8. Manuevers: chin-chest, axial loading, rotation


OBSERVATIONS

• “ Normally developed, well-nourished, Filipino male, no acute distress”

• Mood

• State of mind

• Skin and scleral pigmentation

• Skin lesions, scars, birth marks

• Nerves (enlargement, tenderness, Tinel’s)

• Feet and Toes (Pes cavus)

• Abnormal masses

Principles of the Neurologic Examination

1. If you do not know what the patient has after a

thorough history, the exam will not likely give you

the answer, much less a battery of sophisticated

and costly tests.and costly tests.

2. Each neurologic examination must be tailored to

the patient at hand, the presenting problem, and

the diagnostic clues gleaned from the history.


3. Careful documentation is invaluable for assessing

severity, making judgments on the course

(whether the patient is better or worse), and

evaluating response to treatment.

4. Quantitation is a powerful tool in the neurologic

examination.


5. One of the greatest builders of confidence

between the patient and the physician is the ability

to convey what one knows, and what one does not

know. It is far less dangerous to admit ignorance know. It is far less dangerous to admit ignorance

than to “pull a diagnosis out of the air” simply

because it is expected.

ANATOMIC LOCALIZATION

Greg David V. Dayrit, MD, FPCP,FPNA

Internal Medicine-Neurology

Core Faculty

The ultimate goal of the neurologic history

and examination is:

I. To find out WHERE is the lesion?

A. Levelize the lesion along the neuraxis

B. Lateralize the lesionB. Lateralize the lesion

C. Localize the lesion

Steps in the Diagnosis of Neurologic

Disease

1. Data Gathering

2. Anatomic Localization

3. Etiologic Diagnosis

Benefits of Localization

1. Directs Diagnostic Work-up

2. Estimates the extent of the lesion

3. Limits the Differential Diagnosis

Steps in Localization

1. List down all abnormal neurologic signs

2. Determine all possible neuro-anatomic correlates

per sign

3. Look for “intersections” – the point where all signs 3. Look for “intersections” – the point where all signs

can be explained. If not, consider two or more

lesions.

Signs and Symptoms in Neurologic Disease

Neurologic diagnosis depends on answers to two

questions that are considered separately and in

sequence:

1. Where is the Lesion? (3 L’s)

2. What is the nature of the disease?

Signs and Symptoms in Neurologic Disease

•Patient age

•Sex

•Ethnicity

•Socioeconomic considerations•Socioeconomic considerations

•Tempo of disease

•Duration of symptoms

•Medical history

•Physical & neurological examination

Dictum in Neurology

“Try to explain all “Try to explain all

neurological signs on the

basis of one lesion”

REVIEW OF ABNORMAL

NEUROLOGIC FINDINGS AND

THEIR SIGNIFICANCETHEIR SIGNIFICANCE

Abnormal Cerebral Function

Diffuse or focal

1. Aphasia

2. Apraxia

3. Agraphia

4. Acalculia4. Acalculia

5. Memory Impairment

6. Alexia

7. Personality Changes

8. Loss of Insight and Judgment

9. Right-Left Disorientation

10. Anomia

VISION & EOM’s

1. Monocular Blindness

2. Visual Field Defects

3. Extraocular Muscle Disorders

4. Ptosis4. Ptosis

Visual Field Defects

DEAFNESS

1. Conductive-type

2. Sensorineural type

3. Mixed type3. Mixed type

Conductive vs Sensorineural Hearing Loss

Weber

Lateralizes

Rinne Test

Conductive Loss

Good ear No AC > BC

Bad Ear Yes BC > AC

Sensorineural Loss

Good ear Yes AC > BC

Bad ear No AC > BC

NASOPHARYNGEAL SYMPTOMS

1. Dysphagia

2. Impaired Gag reflex

3. Nasal Twang3. Nasal Twang

4. Hoarseness

SPEECH DIFFICULTY

1. Dysphasia

2. Dysarthria

3. Tongue Deviation

MOTOR WEAKNESS

1. Hemiparesis

2. Paraparesis

3. Quadriparesis3. Quadriparesis

4. Monoparesis

VII. SENSORY LOSS

A. Crude vs. Cortical Sensation

1. Crude - pain, temperature, pressure, vibration

sense

2. Cortical2. Cortical

A) astereognosis

B) agraphesthesia

C) sensory extinction

SENSORY LOSS

B. Distribution

1. Hemisensory Loss

2. Sensory Level

3. Specific Dermatomal Distribution3. Specific Dermatomal Distribution

4. Distal > Proximal Neuropathy

5. Sensory Dissociation

ATAXIA

A. Sensory ataxia: 2’ to impaired sensory input (as in

peripheral neuropathies), worsened by darkness,

eye closure, or rapid head movements

B. Cerebellar ataxia: unsteadiness associated with

hypotonia, intention tremor and truncal instability

MOVEMENT DISORDERS

Positive signs:

• Rigidity

• Hypertonicity

• Chorea

Negative signs

• Akinesia

• Bradykinesia

• Abnormal postural • Chorea

• Ballismus

• Athetosis

• Tics

• Abnormal postural

movements

GAIT DISTURBANCE

a. Steppage gait – foot extensor weakness

b. Spastic gait – due to corticospinal tract damage, feet drag with little knee movement, leg internally rotatedrotated

c. Parkinsonian gait – stiff, slow movement with flexed posture and small steps

GAIT DISTURBANCE

d. Ataxic gait – wide-based gait with unsteady

movement and abrupt irregular placement of

feet and swaying of trunk

e. Paretic gait – due to quadriceps paralysis, e. Paretic gait – due to quadriceps paralysis,

necessitates locking of knee (hyperextension)

on supporting leg to prevent collapse.

PRINCIPLES OF LOCALIZATION

• Each nervous system area has specific functions

and circumscribed nervous system lesions

produce characteristic clinical signs and

symptoms:symptoms:

HEMISYNDROMES

• Symptoms confined to only one side of the body

are produced by disorders of cerebral hemispheric

motor and sensory pathways

BEHAVIORAL SYNDROMES

Disorders involving “higher cortical functions”

• Aphasias: inability to understand or express words

• Apraxias: failure to execute voluntary acts

• Agnosias: failure to understand meaning of • Agnosias: failure to understand meaning of

stimulus

FRONTAL LOBE SYNDROMES

• Localized contralateral paralysis

• Focal motor epileptic seizures

• Reappearance of primitive reflexes

• Perseveration• Perseveration

• Apathy

• Motor aphasia

• Uninhibited social behavior

PARIETAL LOBE SYNDROMES

• Contralateral sensory hemisyndromes

• Agnosia/inattention

• Apraxia• Apraxia

• Abnormal tactile discrimation

• Neglect

• R to L disorentation

TEMPORAL LOBE SYNDROMES

• Contralateral homonymous visual field defects

• Repetitive language disorders (Wernicke’s

aphasia)

• Memory disturbances• Memory disturbances

• Epileptic seizures (Complex Partial type)

OCCIPITAL LOBE SYNDROMES

• Contralateral visual field defects

• Alexia

• Color recognition disturbances

BASAL GANGLIA SYNDROMES

• Loss of neurons in substancia nigra or globus

pallidus – hypokinesia (reduced movement),lack

of associated movement

• Loss of neurons in striatum – hyperkinesia• Loss of neurons in striatum – hyperkinesia

(increased involuntary movements),

choreoathetosis

THALAMIC SYNDROMES

• Impairment of contralateral sensation

• Delayed sensation/unpleasant sensation

• Abnormal contralateral posturing (particularly

of hands)of hands)

HYPOTHALAMIC SYNDROMES

• Impaired regulation of temperature

• Salt and water metabolism

• Feeding

• Sleep-wake cycle• Sleep-wake cycle

• Altered sexual functioning

• Endocrine disturbances

BRAINSTEM SYNDROMES

• “Crossed deficits”

• Altered consciousness

• Cranial nerve deficits

• Impaired ocular motility• Impaired ocular motility

• Vertigo, ataxia, nystagmus

CEREBELLAR SYNDROMES

• Ataxia, Dysmetria, Dysdiadochokinesia

• Intention tremor

• Hypotonia

• Sustained nystagmus• Sustained nystagmus

SPINAL CORD SYNDROMES

I. Transection

• spastic paralysis of extremities below level of lesion

• loss of sensation below level of lesion (sensory • loss of sensation below level of lesion (sensory level)

• paralysis of rectal sphincter function, abnormal bladder function

• disturbed sexual function


II. Brown-Sequard syndrome (Spinal cord hemisyndrome)

• Ipsilateral spastic weakness

• Ipsilateral loss of proprioception

• Contralateral loss of pain and temperature below • Contralateral loss of pain and temperature below

level of lesion


III. Anterior Spinal Artery Syndrome

• Paralysis and dissociated sensory loss (loss of

pain and temperature sense, but preservation

of proprioception) below level of lesion of proprioception) below level of lesion


IV. Central cord syndrome

• Loss of all sensations and voluntary motor

control except in sacral dermatomes

PERIPHERAL NERVE SYNDROMES

• Dermatomal sensory loss or radicular distribution

of pain or numbness

• Flaccid paralysis/weakness

• Hyporeflexia• Hyporeflexia

Neuroanatomic Structure Routine Neurologic

Examination

Cortex Cerebral Function Test

Cranial Nerves Cranial Nerve Test

Cerebellum Cerebellar Function Test

Pyramidal Tract Motor Function Test

Spinothalamic Tract Sensory Test

Spinal Cord & its Nerves Reflexes

SUMMARY

• Review the basic neuroanatomical structures and its

functional correlates

• Review important neurological signs and its

anatomical basisanatomical basis

• Read Demeyer book

Documents

Anatomic Localization