INTRODUCTION TO NEUROLOGY

Matobogolo Boaz Masalu,

MD,MMED
Jan 2022
"From the brain and the brain only arise our
pleasures, joys, laughter and jests, as well as
our sorrows, pains, griefs, and tears.... These
things we suffer all come from the brain, when it
is not healthy, but becomes abnormally hot,
cold, moist or dry."
 Contents
• Definition
• Nervous system
• Signs/ symptoms of Neurology diseases
• Neurology exam
• Investigations for Neurology diseases
• Categories of Neurology diseases
• Clinical cases
 Definition
 Neurology is a branch of medicine that deals
with diseases of the nervous system
 Divisions of the Vertebrate Nervous
System
 Central Nervous System-the brain and the spinal cord
 Peripheral Nervous System-the nerves outside the
brain and spinal cord.

 Two Division of the PNS

Somatic Nervous System-the nerves that convey
messages from the sense organs to the CNS and
from the CNS to the muscles and glands
Autonomic Nervous System-a set of neurons that
control the heart, the intestines, and other organs
 Nervous System Anatomy: Gross
Organization
• Central Nervous System (CNS)
– Brain
– Spinal cord
• Peripheral Nervous System
(PNS)
– Cranial and spinal nerves
– Motor and sensory
– Somatic NS
• “Conscious control”
– Autonomic NS
• “Unconscious control”
 Nervous System Anatomy: Cells

• Neurons (Nerve Cells)

– Receive, process, and transmit information

• Glia
– Not specialized for information transfer
– Primarily a supportive role for neurons
Neurons
 Neurons

• Neuron Doctrine
– Santiago Ramon y Cajal,
1891
– The neuron is the Above: sparrow optic tectum
functional unit of the Below: chick cerebellum
nervous system
• Specialized cell type
– Very diverse in structure
and function
– Sensory, interneurons,
and motor neurons
Neuron: Structure

Axon

Axon hillock
 Neuron Structure – Cell Body (=
Soma)

• contains the usual cellular organelles

• synthesis & metabolism occurs primarily in the soma
• the outer cell membrane contains the receptors for incoming
information (stimuli)
• most cell bodies are located within the CNS
– clusters of neuron cell bodies in the CNS are called nuclei
– clusters of neuron cell bodies in the PNS are called ganglia
Neuron Structure - Processes
• dendrites
– short, tapering, highly branched
processes or extensions from soma
– not myelinated
– the location for some cell organelles
– sites of receptive or input regions
– transfer information to the cell body
– transmit graded potentials - not action
potentials
Neuron Structure - Processes
• axons
– a long thin cylindrical cytoplasmic projection
– starts at a cone-shaped region – the axon hillock
– may be long (1 meter) or short (1 mm)
– a long axon is called a nerve fiber
– transmit information away from the soma
– ends in many branches
• known as axonal terminals
• may be 10,000 on one nerve
• form synapses (junctions) with neighboring neurons
or with effector cells (muscles or glands)
• filled with axoplasm and surrounded by an
axolemma
• action potentials start at the axon hillock
(trigger zone); travel along the axon to the
axon terminal
• axon terminal has the secretory component
– Action Potential (nerve impulse) arrival causes
the release of stored neurotransmitters
– neurotransmitters transfer the message across a
synapse to the next neuron or to an effector
– neurotransmitters can excite or inhibit the action
of the next cell in the pathway
Myelin

• Lipid-rich substance
• Produced by Schwann cells and
Oligodendrocytes that wrap around axons
• Gaps between = Nodes of Ranvier
 Demyelination
• Loss of the myelin sheath that insulates axons
• Examples:
– Multiple sclerosis(Loss of myelin in white matter of spinal cord)
– Acute disseminated encephalomyelitis
– Alexander’s Disease
– Transverse myelitis
– Chronic inflammatory demyelinating neuropathy
– Central pontine myelinosis
– Guillain-Barre Syndrome
• Result:
– Impaired or lost conduction
– Neuronal death
– Symptoms vary widely and depend on the collection of neurons
affected
Central Nervous System:
“CNS”

Spinal Cord
Brain
 The Nervous System
The Spinal Cord-part of the CNS found within the spinal
column
– The spinal cord communicates with the sense
organs and muscles below the level of the head
Bell-Magendie Law- the entering dorsal roots
carry sensory information and the exiting
ventral roots carry motor information to the
muscles and glands
Dorsal Root Ganglia-clusters of neurons outside
the spinal cord
 The Spinal Cord
• Foramen magnum to L1 or L2
• Runs through the vertebral canal of the vertebral
column

• Functions
1. Sensory and motor innervation of entire body inferior to
the head through the spinal nerves
2. Two-way conduction pathway between the body and
the brain
3. Major center for reflexes
 Frontal lobe
• Motor cortex: voluntary movement, high up is
supply to leg, low down is face and arms
• Broca’s speech area
• Frontal association cortex: emotional behaviour,
personality
• Lesions: motor disturbance, weakness opposite side
of body, expressive asphasia, change in personality
and intellect
 Parietal lobe
• Sensory cortex
• Parietal association cortex: integration of sensory
information
• Upper optic radiations
• Wernickes area ( temporo-parietal)
• Lesions: sensory disturbance opposite side of body
and astereognosis (inability to recognise objects by
touch), lower quadrantic homonymous defects,
receptive aphasia
 Temporal lobe
• Auditory cortex
• Limbic system ( hippocampus, thalmus and
conections): emotions, behaviour, memory
• Lower optic radiations
• Lesions: upper quadrantic defects, confusional
states, epilepsy, hallucinations
 Occipital lobe
• Visual cortex
• Occipital association cortex: integration and
recognition of visual stimuli
• Amygdala: link to limbic system, behaviour
• Lesions: aggressive behaviour, visual disturbance and
hallucinations, homonymous hemianopic field
defects, blindness (Antons syndrome)
 Cerbellum
• Posture, muscle tone and co-ordination
• Connections to motor cortex and vestibulo
system
 Brainstem: midbrain, pons, medulla
• Midbrain: CN 3,4 • Ascending and
• Pons: CN 5,6,7,8 descending pathways
• Medulla: CN 9,10,11,12
Brain stem and cranial nerves
 Cranial nerves: MOTOR
• Brainstem contains cranial nerve nuclei
• Each cranial nerve receives supranulcear/presynaptic
fibres from both cerebral hemispheres. Lesions here
would be UMN
• From each cranial nerve nuclei to the motor end
plate run infranuclear/postsynaptic fibres. The nuclei
supply's muscle on the same side. Lesions are LMN
 Cranial Nerves: SENSORY
• Reverse
• Cranial nerve nuclei on brain stem will receive
sensory input from the same side of the face
• The nuclei will give bilateral innervation to
both cerebral cortex’s
Connection cerebellum to brain stem
Brain stem: CN, ascending and
decending pathways, ANS
 Very basically
• MOTOR: Cortex internal capsulebrain
stem spinal cordsynapses in horn cell
nerve rootnerveNMJmuscle
• UMN=presynaptic=neurone form cortex to
horn cell
• LMN=postsynaptic=neuron form horn cell to
muscle
 Very basically continued
• SENSATION: Sensory fibresnervenerve
rootsynapses at horn cellspinal
cordbrain steminternal capsulecortex
UMN/central sensory pathways
Spinal cord
LMN/peripheral sensation
• UMN • LMN
• Cortex, internal capsule, • Horn cell, nerve root,
brainstem, spinal cord nerve, neuromuscular
• Hypertonic, junction, muscle
hyperreflexic, extensor
• Wasted flacid,reduced
plantars
reflexes
• UMN end when they
synapse in horn cells
Ascending and Descending
pathways
 Ascending and descending pathways
• Connection between cerebrum and body (muscle,
sensation)
• Corticospinal/pyramidal tract = voluntary
movement
• Dorsal columns = vibration, proprioception and fine
touch
• Lateral spinothalamic = pain and temperature
• Anterior spinothalamic = pressure and crude touch
 Corticospinal/pyramidal
• Frontal cortex
• Internal capsule
• Brain stem
• Decussate/cross in medulla
• Spinal cord
• Terminate anterior horn cell in spinal cord
• ALL ONE NEURONE=UMN!
Corticospinal/pyramidal tract
Connection from spine to periphery
 Lesion in corticospinal tract: 4 points
to think about
• Lesion can be in cortex, internal capsule, brain
stem or spinal cord
• Neurones are pre-synaptic/UMN
• It crosses in the medulla SO left cortex and
internal capsule supply anterior horn cell and
hence nerves on the right side of the body
• Brain stem contains CN nuclei
 Lesions corticospinal tract
• Cortex and internal • Brain stem: UMN
capsule: UMN paralysis on opposite side
paralysis on opposite of body = contralateral
side of body = hemiplegia AND cranial
nerve palsy’s on the side
contralateral of the lesion ( commonly
hemiplegia CN 5,6,7)

• Spinal cord: signs same

side as lesion:UMN,
unilateral or bilateral
 Lateral spinothalamic tract

• Starts in posterior horn of spinal cord

(receives information from pain and temperature sensors
via peripheral nerves)
• Cross to opposite side of spinal cord
• Lateral spinothalamic tract in spinal cord
• Brain stem
• Internal capsule
• Cortex
Lateral Spinothalamic tract
Spinal cord
Peripheral connection
 Lesions of lateral spinothalamic tract
• Brain stem:
• Spinal cord: contralateral loss pain
contralateral loss of and temperature, with
pain and temperature ipsilateral/same side
Look for sensory level loss to face

• Cortex and internal

capsule: contralateral
face, arm and leg
 Dorsal columns: vibration,
proprioception and fine touch

• Posterior root ganglion (receives information

from peripheral sensors via peripheral nerves )
• Posterior/dorsal columns on same
side/ipsilateral spinal cord
• Cross in medulla
• Internal capsule
• Sensory cortex
Dorsal columns
Connection to the periphery
 Lesions of dorsal columns
• Spinal cord: • Brain stem: crossed
ipsilateral/same side sensory loss to body,
loss of vibration, ipsilateral CN palsy's
proprioception, fine
touch • Cortex and internal
capsule: crossed face,
arm , leg
Anterior spinothalamic tract: pressure
and crude touch

• Posterior root ganglion (information from

peripheral sensors via peripheral nerves)
• Cross in spinal cord
• Brain stem
• Internal capsule
• Sensory cortex
Connection to the periphery
Lesions of anterior spinothalamic tract
• Spinal cord: • Brain stem:
contralateral loss contralateral loss with
ipsilateral CN palsys
• Internal capsule and
cortex: contrlateral
face, arm, leg
 Peripheral connections for
ascending and descending tracts
 Peripheral connections
• From the ascending and descending pathways
• Motor will be LMN
• Upper neurones synapse/end at anterior horn cell
( muscle) or posterior horn cell (sensation)
• Nerve
• Neuromuscular or neurosensory junction
• Muscle or somatic sensor
Peripheral connections
Brachial plexus
Dermatomes
Median nerve
• Loss sensation medial
radial 3.5 fingers
• LMN:
Lateral lumbricals
Opponens pollicis
Abductor pollicis
Flexor pollicis
 Lesions in periphery
• Motor: Will all be LMN pattern
• Sensory: pattern may be:
glove and stocking
mononeuropathy
polyneuropathy
dermatomal pattern
 LMN Lesions
• Anterior horn cell: polio
• Nerve root: radiculopathy ie C5/C6 compression
• Nerve:
(1) peripheral neuropathy:
(2) Local nerve neuropathy: ie damage to median nerve
or commmon peroneal nerve
• NMJ: Myasthenia gravis
• Muscle: Myopathy
 Peripheral Sensory lesions
• Horn cell: dermatomal pattern
• Nerve root: radiculopathy ie C5/C6
compression
• Nerve:
(1) peripheral neuropathy: glove and stocking
(2) Local nerve neuropathy: ie damage to
median nerve or commmon peroneal nerve,
ditrubution of the affected nerve
Peripheral sensation
 Use sensory symptoms to determine
level of LMN problem
• Anterior horn cell: no sensory disturbance
• Nerve root: dermatomal
• Nerve:
(1) peripheral neuropathy: glove and stocking
(2) Local nerve neuropathy: distribution of affected
nerve ie median nerve
• NMJ: No sensory loss
• Muscle: No sensory loss
 Use sensory to determine level of
UMN problem
• Cortex and internal capsule: contralateral
face, arm, leg
• Brain stem:
Midbrain: contralateral sensory loss
Pons and medulla: ipsilateral facial loss ( CN5)
with contralateral sesory loss
• Spinal cord: sensory level, dermatomal
pattern
 Clinical symptoms/ signs
1. Fever
2. Headache
3. Neck stiffness
4. Pain
5. Altered level of consciousness
6. Convulsions
7. Weakness
8. Blurring of vision/loss of vision
9. Loss of hearing/ Deafness etc
 Neurologic Exam
• Neuro exam is complicated & is not intuitive,
therefore it requires an orderly, systematic
approach
• Use the patient’s history to guide you on
which areas of the exam to concentrate
 Components of Neuro Exam
• Higher center (level of consciousness, speech,
orientation etc)
• Signs of meningismus
• Cranial Nerves
• Motor System
• Sensory System
• Reflexes
• Coordination
• Gait & Balance
 Higher center
More detailed assessment of higher levels of
cognitive function includes all components of
MMSE:
• Orientation (person, place, time)
• Attention (spelling or counting backwards)
• Memory (recent & remote)
• Speech (fluency, coherency)
• Insight, judgement, planning
 Brief Assessment of Mental Status –
Glasgow Coma Scale
Clinical Status Score

Eye Opening Opens eyes spontaneously 4

Opens eyes to verbal stimuli 3
Opens eyes to painful stimuli 2
No response 1
Verbal Response Oriented, conversant 5
Disoriented, conversant 4
Inappropriate responses 3
Incomprehensible sounds 2
No response 1
Motor Response Obeys verbal commands 6
Localizes to pain 5
Withdraws from pain 4
Decorticate (flexion) to pain 3
Decerebrate (extension) to pain 2
No response 1
 Cranial Nerves
I Olfactory smell
II Optic vision

III Oculomotor Eye movement, pupillary constriction

IV Trochlear Eye movement (depression & abduction)

V Trigeminal Facial sensation & muscles of mastication

VI Abducens Eye movement (abduction)

VII Facial Facial movement + motor to stapedius muscle,

sensation of outer ear, taste of anterior 2/3 of
tongue, parasympathetic fibers to
submandibular, sublingual, lacrimal glands

VIII Vestibulocochlear Hearing & equilibrium

IX Glossopharyngeal Sensory to posterior oropharynx,, taste of post

1/3 of tongue, motor to stylopharyngeus
muscle, parasympathetic fibers to parotid gland,
sensory to external ear

X Vagus Sensory & motor for lower pharynx & larynx,

parasympathetic fibers to all structures in chest
& abdomen up to L colic flexure
XI Accessory Motor to trapezius & sternocleidomastoid

XII Hypoglossal Motor to muscles of tongue

CN I - Olfactory Nerve
CN II - Optic Nerve
CN III (Oculomotor), CN IV (Trochlear),
& CN IV (Abducens)

CN III = medial, superior, inferior rectus + inferior oblique + levator palpebrae

CN IV = superior oblique
CN IV = lateral rectus (CN III also pupillary constriction & accomodation)
CN V - Trigeminal Nerve

V1 = ophthalmic
V2 = maxillary
V3 = mandibular (also includes motor fibers)
 CN VII - Facial Nerve

mediates facial movements, taste (ant 2/3), salivation, lacrimation

CN VIII - Vestibulocochlear Nerve
CN IX (Glossopharyngeal) & CN X
(Vagal Nerves)

CN IX – taste (post 1/3) + swallowing &

salivation
CN X – swallowing, phonation, elevation
of palate, parasympathetic innervation of
thorax & abdomen
 CN XI - Spinal Accessory Nerve

head & shoulder movement

(trapezius & sternocleidomastoid muscles)
CN XII - Hypoglossal Nerve
 Motor Exam
• First assess muscle bulk, tonicity
• Assess strength in all 4 extremities
• Be sure to assess both proximal & distal
muscles
• Assess in systematic fashion (e.g.
rostrocaudal)
 Motor Exam
Grading motor strength:
• 5/5 = movement against gravity with full
resistance
• 4/5 = movement against gravity with some
resistance
• 3/5 = movement against gravity only
• 2/5 = movement with gravity eliminated
• 1/5 = visible muscle contraction but no
movement
• 0/5 = no contraction
 Sensory Evaluation
Includes the following:
• Light touch
• Proprioception (joint position)
• Vibration (tuning fork)
• Pain (pin prick)
• Temperature
 Deep Tendon Reflexes
• Triceps – C7 (radial nerve)
• Biceps – C5 (musculoskeletal nerve)
• Brachioradialis – C6 (radial nerve)
• Patellar – L4 (femoral nerve)
• Achilles – S1 (tibial nerve)
• Babinksi – stroke bottom of foot, if great toe
moves upward = positive Babinski & is
indicative of upper motor neuron lesion
 Coordination
Assesses cerebellar function
• Finger to nose
• Heel to shin
• Tapping index finger against thumb
• Romberg (also involves proprioception)
• Examine gait (normal, tandem, & heels &
toes)
 Investigations
• Routine ( FBP+ ESR), UA, Bs for Mps, Electrolytes
• LP (lumbar puncure) aka spinal tap
• Electroencephalograms (EEG):
 Electrodes are attached to the subject’s scalp,
and the device records the patterns of brain
waves.
 Event-Related Potentials: The momentary
changes in electrical activity of the brain when a
particular stimulus is presented to the subject.
• Imaging Technology
• Utrasound
• Plain X-rays
• CT scan
• Magnetic Resonance Imaging (MRI): Gives clear
pictures of the structure of the brain.
• Functional MRI: Image shows regions of the brain with
heightened neural activity, with different colors
reflecting high or low levels of blood flow, oxygen
uptake, and the like.
• Angiography
• PET scans- use radioactive labels attached to glucose

99
Categories of Neurological diseases
• Infectious
• Genetic – Congenital
• Traumatic
• Degenerative
• Toxic
• Metabolic
• Neoplastic
• Inflammatory - Immune
 Clinical cases

Using your neuroanatomy knowledge

 Case 1
• 33yr old
• NYY
• Weak legs, unable to stand
• O/E Legs:
Muscle bulk normal, Tone increased
Power 3/5 all muscle groups
Reflexes +++, plantars up going
Sensory level at T10 for all modalities
• Were is the lesions?
 Case 2
• 22 year old NYN
• Weakness of left leg, numbness of right leg
• O/E
Left leg: hypertonic and hyper-reflexic, sensation
normal
Right leg: normal motor examination, complete loss of
pain and temperature to T5, reduced proprioception
• Were is the lesion?
 Case 3
• 50 year old hypertensive
• Sub-acute onset left arm and leg weakness
• O/E Weak left arm and leg
• Were is the lesion?
 Case 4
• 60 year old man
• Keeps falling over things, feels like he is
walking on stones
• O/E bilateral foot drop, loss of ankle reflexes,
stocking sensory level to knees bilaterally
• Were is the lesion?