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Localization in Neurology
Localization in Neurology
Localization in Neurology
1. cortex
56 AF
.
localization
MCQ
?
1. 56 risk
cardiovascular cancer
2. AF cardioembolic stroke
ischemic stroke warfarin DDx
intracerebral hemorrhage setting
3. vascular cause
etiology localization
4. global aphasia lesion
frontotemporal lobe left dominant hemisphere
80% dominant hemisphere language ability
6.apraxia
7.visual field defect
basic . Gerstmann syndrome
dominant parietal lobe left right confusion, finger agnosia, acalculia,
agraphia
2. subcortical lesion
56 underlying disease hypertension 3
localization
1. hypertension risk cardiovascular risk factor
stroke MI
2.
brainstem lesion
brainstem ipsilateral lesion
lesion
lesion thalamic lesion
subcortical area right thalamic lesion thalamus
lesion internal capsule
subcortial area
1. pure motor weakness contralateral lesion; internal capsule
cortical
lesion leg arm area supply vessel
? motor power 1 different
2. pure sensory loss contralateral lesion; thalamus lesion
3. dysarthria clumsy hand; internal capsule ; genu
bulbar involvement corticobulbar tract genu of internal capsule
lesion motor
weakness lesion internal capsule
4. ataxic hemiparesis; pons, corona radiata, internal capsule cerebellar
signs lesion vertigo ataxia
5. mixed motor and sensory loss lesion ; subcortial area; internal
capsule+thalamus
2. brainstem
localization 3 cortical and subcortical lesion
brainstem lesion
. brainstem 90%
RS CVS . 20
misconcept brainstem structure
cranial nucleus, fasicle, cerebellar tract, corticospinal
tract, spinothalamic tract. RS, CVS lesion
1 level
brainstem reticular activating system(RAS), RS, CVS center
1.cranial nucleus, fasicle involvement; LMN type, ipsilateral lesion
2. cerebellar signs; ipsilateral lesion
3. motor weakness; lesion medullar decussation
contralateral lesion lesion medullar decussation
fiber
brainstem
characteristics
2. 35 CNT dz
sexual active life risk HIV demyelinating
disease multiple sclerosis .
requirement resident med diag
DDx
3. 10 post viral
syndrome transverse myelitis
4. sensory loss up to T10 level , level of
lesion T10 dermatome MRI level
whole spine
5. loose sphincter tone. autonomic
involvement
5. polyneuropathy
localization 5 nerves lesion; polyneuropathy
polyneuropathy symmetry , asymmetry
4,5,6 symmetric lesion
asymmetric lesion
mononeuritis multiplex nerve entrapment resident
. Guillain Barre syndrome(GBS)
focus resident symmetry GBS
40 10 5
dysarthria, nasal voice,
motor weakness grade 3 all, decrease sensation at both palms and feet, facial
diplegia. DTR 0 all
1. 40 active sexual life risk HIV asso. GBS
Hx of CNT dz
2. infectious diarrhea
degree of dehydration
GBS most common organism asso
campylobacter jejuni diarrhea metabolic
disturbances ; hypokalemia, hyponatremia
6. facial diplegia
facial nerve bilateral lesion lower motor neuron type
7. DTR 0 areflexia nerve lesion
8. respiratory involvement
typical GBS sensory and motor involvement
key nerve areflexia, sensory impaired, motor
weakness without fluctuation GBS investigation
LP cell protein albuminocytologic dissociation
nerve conduction
velocity
IVIG,
plasma exchange
6.
neuromuscular junction
localization 6 neuromuscular junction
Myasthenia gravis Lambert
Eaton myasthnia gravis characteristic
1. pure motor proximal weakness
2. normoreflexia
3. fluctuation/fatiquability
localization
38
facial diplegia, partial ptosis both eyes, proximal muscle weakness grade3,
DTR 2+, limited EOM, sensory; intact, dyspnea,
.....
1. 38 asso CNT dz, HIV
2. facial diplegia facial palsy lower motor neuron
3. limited EOm, ptosis(CN3) Cranial nerve
involvement 3,4,6
4. fatiquability
NMJ lesion
5. proximal muscle weakness grade3,
generalized proximal weakness
6. bulbar involvement
7. dyspnea respiratory involvement MG
diaphragmatic muscle weakness
8. DTR 2+ normoreflexia
9. sensory intact pure motor weakness
7. muscle
localization 7 basic neurology
muscle core feature muscle disorder
1. muscle pain exclude
2. pure motor weakness
3. normoreflexia severe muscle destruction
hyporeflexia
4. proximal muscle weakness proximal part
muscle mass select distal part
. common
proximal muscle
5. creatinine phosphokinase
early
very chronic CPK
6. EMG; myopathic pattern resident neuro
newbie 5
basic
63 HCTZ,
simvastatin, fenofibrate, glipizide
1 proximal muscle
weakness grade 2, DTR 2+ , sensory; intact, CN; intact, generalized muscle
tenderness, CPK 5,678 mg/dl
1. 63
cardiovascular disease
2. HCTZ, simvastatin, fenofibrate, glipizide ;
side effect drug interaction
HCTZ
hypokalemia, hyponatremia proximal part
CPK
fenofibrate group simvastatin drug interaction
rhabdomyolysis
CPK
3.
proximal muscle weakness grade 2 generalized muscle
tenderness generalized proximal muscle weakness with muscle
pain proximal pain muscle disorder
rhabdomyolysis drugs interaction
inflammatory myopathy ; polymyositis DDx
3-5 CPK
resident long case short case
dermatomyositis polymyositis inclusion body myositis
basic localization in neurology
point
neuro point basic
resident neuro deep
reference
reference 5555
reference
like
. resident .
goodnight la
approach etiology
1. Infection
2. Trauma
3. Tumors/ neoplasm
4. Metabolic
5. Toxin/ drugs
6. Vascular
7. Demyelinating
8. Neurodegenerative
9. Congenital
10. Inflammatory
1. etiology sudden focal
neurodeficits vascular cause key sudden
2. ischemia or hemorrhage ischemia brain
edema develop increased intracranial pressure
symptoms 48-72 . stroke large area
infarcts observe neurosigns NPO complication brain
herniation, hemorrhagic transformation tube aspirate
hemorrhage space occupying lesion expand
3. vessel territory
- anterior circulation : internal carotid a. > MCA , ACA
- posterior circulation: vertebrobasilar system: PCA
vessel basic anatomy motor strip area
parasagittal area dorsolateral supply ACA supply MCA
1 motor grading MCA get
subcortical MCA
lenticulostriate a. lacunar infarcts proximal MCA
PCA visula field defect homonymous hemianopia with macular
sparing( macular supply MCA ) vertebrobasilar
brain stem lesion
4. resident venous infarcts arterial infarcts
.... iphone
5. TOAST classification
TOAST classification
1. cardioembolism
posterior cir. ?
!!!
" "
repeated stroke
carotid bruit
carotid stenosis
transient monocular
blindness or amarousis fugax
*** characteristics a. to a. emboli
1. metabolic syndrome
2. transient monocular blindness or amarousis fugax
3. carotid bruit
4. repeated stroke; same side ACA or MCA
posterior circulation carotid bruit
2.2 fixed intracranial stenosis; fixed lesion vessel brain
MCA left
brain neurodef
diarrhea with
shock ( ) BP drop
vessel constrict BP cerebral blood flow
extern ( extern on
duty ) low knowledge treat shock staff
infarct
resuscitate volume TIA
!!! vessel
style!!!
**** characteristics fixed intracranial stenosis
1. associated with hemodynamic change
2. repeated stroke; same side and same artery. STEREOTYPE!!
3. metabolic syndrome
3. Lacunar infarction or small vessel occlusion
longstanding hypertension evidence long standing
hypertension LVH common basal ganglia, thalamus , pons,
cerebellum vessel cortex
lacunar syndrome
*** characteristics lacunar infarction or small vessel occlusion
1. involve cortex
2. area CT
3. lacunar syndrome
4. asso. long stnading hypertension
4. determined cause rare cause arterial dissection, vasculitis,
hypercoagulability stroke in the young
5. undetermined cause work up
cryptogenic, mechanism work up
focal diffuse
focal localization structure
lesion temporal area meninges, bone, sinus, vessel,
brain parenchyma localization
step etiology
etiology key .......
......
2.1 infection exclude CNS infection
secondary headache
cns infection
cns infection stiffness of
neck , signs of increased intracranial pressure (. signs
symptoms of increased intracranial pressure !!!)
approach CNS infection
!!!
2.2 trauma head injury exclude EDH, SDH, ICH
increased intracranial pressure focal neurological
deficits epidural hematoma lucid interval
http://ihs-classification.org///10.04.00_homoeostasis.html
hypoglycemia http://ihsclassification.org///10.05.00_homoeostasis.html
2.5 toxin, drugs; common nitric oxide
, carbonmonoxide, alcohol, drugs abuse, medication overuse headache
( ), tropine, digitalis, disulfiram, hydralazine, imipramine,
nicotine, nifedipine, nimodipine
http://ihsclassification.org//03_/08.00.00_substance.html
2.6 vascular cause; stroke ischemia hemorrhage AVM
arterial hypertension dialysis hypotension
... subarachnoid hemorrhage (SAH)
*****
- worst headache
- sudden headache vascular cause sudden
- meningism; stiffness of neck, Kernig positive
subarachnoid hemorrhage irritate meninges
-signs and symptoms of increased intracranial pressure;
papilledema, enlarged blind spot
-subhyaloid hemorrhage
sinus diffuse
localization non specifics
4. approach etiology
stroke
investigation
stroke
review paper
standard textbook
anatomy
admit point goodnight
Vertigo
vertigo neuro ENT approach vertigo
true vertigo
dizziness chief complaint
vertigo true
vertigo component retropulsion, spinning sensation true
vertigo vertigo sensory ataxia
https://www.youtube.com/watch?v=wgWOmuB1VFY
link
-peripheral vertigo ( BPPV benign paraxysmal
positional vertigo) nystagmus
latency 5-20 seconds central
- maneuver peripheral vertigo fatiquability/habituation
nystagmus central
3.7 duration peripheral central
seniority
1
555 ( )
transient loss of consciousness syncope vs non syncope
syncope
1. Neurally-mediated reflex dysautonomia rare
autonomic involvement reflex
2. Orthostatic hypotension .
BP
Step 1
Pre symptomatic phase
witness
seizure
SNSD one direction
( )
syncope
prodrome
( senario 555 )
hypogly
Seizure aura lobe
Occipital lobe
Temporal lobe
(de ja vu)
Parietal lobe paresthesia
Frontal lobe orbitofrontal
Step 2
Symptomatic phase
cloudy
1. Duration
absence seizure
complex partial seizure
versive seizure lesion frontal lobe
extremely away from lesion deviate lesion
Syncope seconds
2. Abnormal movement syncope loss of tone or brief muscle
contraction seizure
- stereotype pattern
-rhythmic movement
- jerky component seizure
3. Eye deviation syncope eye deviate nystagmus
sezure
4. Self injury head injury seizure
5. Incontinence loose sphincter seizure
6. Frothing , drooling seizure
7. Hypoxic feature cyanosis seizure
syncope
Step 3
Post symptomatic phase
hypoxia seizure 3-4
brain hypoxia syncope hypoxia
1. Post ictal confusion
2. Post ictal aphasia language deficit primary lesion
dominant hemisphere
3. Todd's paralysis primary lesion
frontal lobe
step localization
1. Aura lobe
2. Abnormal movement focal secondary to GTCs
primary lesion
3. Eye deviation imply frontal eye field *** remember seizure: look away from
lesion (irritative lesion) stroke: look into the lesion( destructive lesion)
pathway basic eye movement
4. Post ictal aphasia; dominant hemisphere
5. Todd's paralysis
neuro good night good morning