CNS & ANS clinical notes

Spinal tap / Lumbar puncture:

4th lumbar space
Needle passes through the following layers:
1. Skin
2. Superficial fascia
3. Supraspinous ligament
4. Interspinous ligament
5. Ligamentum flavum
6. Areolar connective tissue ——internal vertebral venous plexus
7. Dura mater
8. Arachnoid mater
Normal CSF pressure 60 - 150 mmHg of water

Intracranial hemorrhage:
1. Epidural hemorrhage:
● Damage to middle meningeal artery
● Raised ICP
● Blood clot exerts pressure on precentral gyrus

2. Subdural hemorrhage
● Damage to superior cerebral veins
● Caused by blow to the front or back of head

3. Subarachnoid hemorrhage:
● Rupture or congenital aneurysm of cerebral arterial circle ( circle of Willis)

4. Cerebral hemorrhage:
● Rupture of lenticulostriate artery branch of MCA
● Contralateral hemiplegia

Viral diseases:
1. Herpes simplex:
Moves by axonal transport to dorsal root ganglion
2. Rabies:
Moves by axonal transport in both sensory and motor nerves
3. Polio:
From GI tract to anterior gray horn of spinal cord to brainstem
4. Syphilis:
Resides in posterior gray horn

Nerve cell body injury:

● Degeneration of entire neuron
● Neuronal debris is engulfed by microglial cells
● Neighboring astrocytes proliferate and form scar tissue

Nerve cell process injury:

Wallerian degeneration:
Damage spreads distal to the site of lesion
 CNS & ANS clinical notes
Retrograde degeneration:
Damage spreads proximal to the site of lesion

Phantom limb:
● Severe pain in the absent limb after amputation
● Due to pressure on nerve fibers at the end of stump

Ascending Tract Injury:

1. Lateral spinothalamic:
● Contralateral loss of pain and thermal sensations
● Below level of lesion

2. Anterior spinothalamic:
● Contralateral loss of fine touch and pressure sensations
● Below the level of lesion
● Discriminative/crude touch sensation will still be present

3. Dorsal column medial lemniscus:

● Ipsilateral loss of position and movement of limbs
● Ipsilateral loss of vibratory sensations
● Ipsilateral loss of two point discrimination
● Below level of lesion

Tabes dorsalis:
Caused by syphilis
Causes destruction of nerve fibers at entry point into posterior root of S.C
Signs and symptoms:
● Stabbing pain in lower limbs
● Paresthesia (lower limb paralysis)
● Hypersensitivity of skin
● Loss of sensation
● Loss of proprioception
● Ataxia of lower limb
● Hypotonia
● Loss of tendon reflexes

Descending Tract Injuries:

Upper Motor Neuron Lesions
1. Pyramidal tract lesions:
● Positive babinski sign
● Superficial abdominal reflex absent
● Cremasteric reflex absent
● Fine skilled voluntary movements lost
 CNS & ANS clinical notes

2. Extrapyramidal tract lesions:

● Spastic paralysis
● Hypertonicity of muscles
● Exaggerated deep muscle reflexes
● Clonus (rapid oscillatory movement of muscle)
● Clasp knife reaction

Lower motor neuron lesions

● Flaccid paralysis
● Atrophy
● Lose reflexes
● Muscle fasciculations (twitching)
● Muscle contractures (shortening of muscle)

Spinal Shock Syndrome:

Acute severe damage to spinal cord
Signs and symptoms:
● All functions below level of lesion are lost
● Sensory impairment
● Flaccid paralysis
● Depressed segmental spinal reflexes

Destructive spinal cord injuries:

1. Complete cord transection syndrome:
● Bilateral paralysis
● Lower motor neuron paralysis symptoms at site of lesion
● Upper motor neuron paralysis symptoms below level of lesion
● Bilateral loss of all sensations below level of lesion
● Loss of voluntary control of bladder and bowel functions

2. Anterior spinal cord syndrome:

● Bilateral lower motor neuron paralysis at site of lesion
● Muscular atrophy (anterior gray horn damage)
● Bilateral spastic paralysis (UMN injury signs) below level of lesion
● Bilateral loss of pain, temperature, fine touch sensations below level of lesion

3. Central cord syndrome:

● Bilateral lower motor neuron paralysis at site of lesion
● Muscular atrophy
● Bilateral spastic paralysis below level of lesion
● Sacral sparing (laterally located lower limb fibers of corticospinal tract)
● Bilateral loss of pain, temperature, light touch, pressure sensations below level of lesion
● Sacral sparing

4. Brown sequard syndrome:

● Ipsilateral lower motor neuron paralysis in segment of lesion
● Muscular atrophy
● Ipsilateral upper motor paralysis and signs below level of lesion
 CNS & ANS clinical notes
● Ipsilateral cutaneous anesthesia in segment of lesion
● Ipsilateral loss of proprioception, two point discrimination, vibration (damage to DCML) below
level of lesion
● Contralateral loss of pain and temperature below level of lesion
● Partial contralateral loss of tactile sensation below level of lesion

5. Syringomyelia:
Due to developmental anomalies of central canal
● Shawl-like symptoms
● Loss of pain and temperature sensations on both sides of level of lesion
● Lower motor neuron weakness in small muscles of hand
● Horner syndrome
● Bilateral spastic paralysis of both legs

Arnold Chiari malformation:

● Herniation of cerebellar tonsils and medulla through foramen magnum
● Causes internal hydrocephalus

Wallenberg / Lateral medullary syndrome:

● Thrombosis of PICA or vertebral artery
● Signs and symptoms:
○ Dysphagia
○ Dysarthria
○ Analgesia.
○ Thermoanesthesia
○ Vertigo
○ Nystagmus
○ Ipsilateral horner syndrome
○ Cerebellar signs
○ Contralateral loss of pain and sensation

Medial Medullary Syndrome:

● Thrombosis of vertebral artery (medullary branch)
● Signs and symptoms
○ Contralateral hemiparesis (paralysis of half side)
○ Contralateral impairment of proprioceptive, vibrative and touch sensations
○ Paralysis of tongue, deviation towards paralyzed side
 CNS & ANS clinical notes
Weber Syndrome:
● Occlusion of posterior cerebral artery
● Necrosis of brain tissue involving oculomotor nerve + crus cerebri
● Signs and symptoms:
○ Ipsilateral ophthalmoplegia
○ Contralateral paralysis of lower face, tongue, limbs
○ Lateral deviation of eyeball
○ Ptosis
○ Fixed, dilated pupil

Benedikt Syndrome:
● Necrosis of medial lemniscus + red nucleus
● Signs and symptoms
○ Contralateral hemianesthesia
○ Involuntary limb movements contralaterally

Cerebellar Disease:
Lesion in a cerebellar hemisphere produces signs and symptoms limited to the same side of body
Signs and symptoms:
● Dysdiadochokinesia (Inability to perform alternating movements regularly and rapidly)
● Ataxia
● Nystagmus
● Intention tremors
● Scanning speech
● Hypotonia

Vermis Syndrome:
Most common cause is medulloblastoma in vermis of children
Signs and symptoms:
● Tendency to fall forward and backward
● Difficulty in holding an upright, steady head
● Difficulty in holding the trunk erect

Cerebellar hemisphere syndrome:

Caused by tumors of cerebellum
Signs and symptoms:
● Swaying and falling to one side of lesion
● Dysarthria
● Nystagmus
● Inability to perform coordinated movements

Alzhimer’s Disease:
● Formation of plaques around cortical regions
● Plaques composed of beta amyloid
● Early sites are hippocampus and entorhinal cortex
● Signs and symptoms:
○ Early memory loss
○ Disintegration of personality
○ Disorientation of speech
 CNS & ANS clinical notes
Jacksonian epileptic seizure:
Irritative lesion of the primary motor area (area 4)

Broca’s motor speech area lesion:

● Left inferior frontal gyrus
● Expressive aphasia (loss of ability to produce speech)
● Words can be written and understood by patient

Wernicke’s sensory speech area lesion:

● Receptive aphasia
● Fluent speech is produced
● Patient is unaware of meaning of the words

Destruction of both sensory and motor speech areas produces global aphasia

Lesions of insula:
● Difficulty in pronouncing phonems
● Produce sounds close to target word but not exact

Lesions of angular gyrus:

● Alaxia (Unable to read)
● Agraphia (Unable to write)

Somesthetic association area:

● Astereognosis (Unable to appreciate texture, size and form of objects)

Petit mal:
Epileptic seizure
● Patient stares blankly into space
● Sudden loss of consciousness

Kluver Bucy Syndrome:

● Unilateral or bilateral destruction of amygdaloid nucleus
● Temporal lobe removal
● Signs and symptoms:
○ Docile behavior
○ No fear or anger
○ Hypersexuality
○ Increased appetite

Thalamic hand:
● Contralateral hand is held in abnormal posture
● Altered muscle tone in different muscle groups

Hypothalamic lesion:
● Obesity
● Sexual disorders
● Hyperthermia and hypothermia
 CNS & ANS clinical notes
● Diabetes incipidus
● Sleep disturabnce
● Emotional disorders

Autonomic Nervous System defects

Urinary bladder dysfunction:
1. Atonic bladder:
Occurs during phase of spinal shock
● Bladder wall muscle relaxed
● Becomes greatly distended and overflows
● No voluntary control

2. Automatic reflex bladder:

● Lesion above level of parasympathetic outflow (S2 - S4)
● Normally found in infancy
● Bladder fills and empties reflexly
● Voluntary control is not possible

3. Autonomous bladder:
● Destruction of sacral segment of spinal cord or cauda equina
● Flaccid bladder wall
● Bladder fills to max capacity and overflows
● Continual dribbling
● No reflex or voluntary control

Horner Syndrome:
Caused by interruption of sympathetic nerve supply to head and neck (level of T1)
Signs and symptoms:
● Miosis
● Ptosis
● Anhydrosis
● Enophthalmos
● Vasodialation of skin arterioles

Argyll Robertson pupil:

● Caused by neurosyphillitic lesion interrupting fibers running from pretectal nucleus to Edinger
westphal nucleus
● Miotic pupil
● Non-raective to light
● React briskly to accomodation

Frey syndrome:
● Caused by wounds of parotid gland
● During regeneration, secretomotor fibers join the fibers of sweat glands
● Stimulus of saliva production produces sweat
 CNS & ANS clinical notes
Corcodile tears:
● Caused by injury to facial nerve
● Fibers of submandibular and sublingular are diverted to lacrimal gland
● Produces tearing in association with salivation

Hishprung Disease:
● Failure of development of myenteric plexus in distal colon
● Peristalsis / bowel movements are absent
● Proximal part of colon gets distended

Meningeal headache:
Nerve supply of dura mater:
● Above tentorium: trigeminal nerve
● Headahe reffered to forehead and face
● Below tentorium: 1st three cervical nerves
● Headache referred to back of head and neck

Astrocytoma of pons:
● Ipsilateral paralysis
● Ipsilateral facial nerve paralysis
● Nystagmus
● Weakness of jaw
● Contralateral hemiparesis
● Contralateral sensory defect of limbs

Locked in syndrome:
● Caused by lesions affecting ventral pons and midbrain
● Blinking and vertical gaze is spared
● Ability to think and reason
● Motor action of body is lost
● Complete paralysis

Pontine hemorrhage:
● Pinpoint pupils
● Paralysis
● Pyrexia poikilothermic

Basal ganglia lesions:

1. Chorea:
● Involuntary
● Quick
● Jerky
● Irregular movements
● Non repetitive

2. Huntington disease:
● Autosomal dominant
● Single gene defect on chromosome 4
 CNS & ANS clinical notes
● Signs and symptoms:
○ Choreiform movements.
(Involuntary movements of extremities followed by facial twitching)
○ Progressive dementia
○ Enlarged lateral ventricles due to caudate nucleus degeneration

3. Sydenham chorea:
● Associated with rheumatic fever
● Rapid, irregular, involuntary movements
● Choreiform moveents that are transient

4. Hemiballismus:
● Lesion of contralateral subthalamic nucleus
● Involuntary movement of one side of the body

5. Athetosis:
● Degeneration of globus pallidus
● Slow
● Sinous
● Writhing movements of distal parts of limbs

6. Parkinson’s:
● Damage to substantia nigra
● Damage to a lesser extent to globus pallidus, putamen, caudate nucleus
● Reduction of release of dopamine
● Signs and symptoms:
○ Tremor (Slow, present at rest)
○ Bradykinesis (Difficulty in initiating movements)
○ Postural disturbances (Stooping of back)
○ Rigidity (Plastic/cogwheel rigidity)