Where is the Lesion?

Notes from Gilbert Ward Rounds.

Disclaimer: wrote this from my personal notes from Gilbert’s rounds plus some extra stuff. Tried to write word
for word what he said but Supplement with your own reading.

Upper and Lower is not enough. Must know Location.

CNS: Brain and spinal cord ( “Upper Motor Lesions” )

PNS: Neuromuscular junction, Muscle and peripheral nerve ( “Lower Motor Neuron Lesions” )

THE KEY FOR FINDING LESIONS IS TO REALIZE THE PATTERN OF WEAKNESS.

Patterns: Distal Vs Proximal?

Symmetrical vs Asymmetrical

Unilateral vs Bilateral

UMN: Key Findings

Brain: Distal Weakness

Hemiparesis aka asymmetrical and unilateral
Hemianaesthesia

Spinal Cord: Distal Weakness

Symmetrical weakness
Bilateral

(General rules from Gilbert for the Motor exam. However not always true e.g in brown sequard
syndrome with hemisection of the cord corticospinal tract findings are not symmetrical. And also TSP
affects spinal cord and causes proximal weakness. Always weird and wonderful exceptions in all things
medicine.)

LMN: Key Findings

NMJ: Symmetrical, bilateral, Proximal weakness (usual differentials: Myasthenia Gravis, Lambert Eaton)

Muscle: Symmetrical Bilateral, Proximal weakness (usual differentials: polymyositis and

dermatomyositis)

But NMJ has FATIGUABILITY.

Peripheral nerves: Distal weakness.

CNS

Brain: Lobes or hemispheres

When localizing best way to describe the brain is Supra and infratentorial (above or below tentorium
ceribelli)

Infratentorial: Brainstem or Cerebellum

Supratentorial: Cortical or sub cortical

NOTE WELL Paresis (usually hemiparesis) + Cranial nerve findings = always brain lesion.

This Parameter HAS to be satisfied for the lesion to be located in the brain.

Paresis in brain lesions have a pyramidal type distribution i.e. weaker in extensors of
upper limb and flexors of lower limb. (However just to note.. this pattern of weakness is
present in normal patients. Think about it. Your biceps (flexors) are stronger than your
triceps (extensors) so Gilbert calls this a useless sign. However may be exaggerated in
brain lesions so keep an eye out. Also weakness is worse distally

Localizing brain lesions: When there are cross signs, the brain lesions are Infratentorial. A cross sign is
whether hemiparesis is on opposite side of cranial nerve lesions. Location of lesion = where cranial
nerves affected exit.

If there are no cross signs i.e the hemiparesis and CN finding are on the same side, the lesion is
Supratentorial i.e. Cortical or sub cortical

Cortical lesions: seizures (focal discharge of cortical neurons), gaze preference and aphasia
(speech centre’s (brokre’s and Wernicke) in temporal lobe).

Subcortical: seizures, gaze preference and aphasia are absent and there are no cross signs.

Can be Corona radiate or internal capsule or basal ganglia

Dense hemiparesis i.e. power = 0. Means the lesion is internal capsule (fibers are close
together) lesion affects all fibers.

If power is 2 or above, implies lesion is corona radiate (fiber are spread out)

May or may not be present: Hypertonia, hypereflexia, +ve babinski, clonus

Spinal Cord.
Must always be present:

1. Symmetrical weakness or loss of sensation e.g both limbs and not hemiparesis,
2. If weakness is more distal than proximal (implies CNS in general)
3. the presence of a sensory level (area on torso where above it sensation is fine but
below it there is little to sensation to pin or light touch.

May or may not be present: Hypertonia, hypereflexia, +ve babinski, clonus.

Miscellaneous Info:
Complex Partial Seizures: ALTERATION of Consciousness. NOT Loss. i.e decreased levels of awareness
with normal awakeness (person is awake but not aware as to wth is going on) may be associated with
aura or amnesia.

Loss of consciousness is never a complex partial seizure. It is a generalized seizure.

Aphasia:

It is a disorder of language not speech. Disorders of speech are called dysarthria.

Language is the use of words, gestures, signs, diagrams to communicate.

There are 3 parameters: Fluency, Comprehension, and Repetition

Global aphasia: abnormalities in all 3.

Brokers aphasia: Normal Comprehension, Abnormal Fluency and Repetition.

Wernicke’s aphasia: Normal Fluency, Abnormal comprehension and repetition.

Nb: Medical definition of Fluency is the ability to put 5 words or more together in a sentence regardless
of speed and regardless of stuttering.

e.g if someone who stutters says: ttthhhhhhhe bird iiiiissssss in ttthhheeee trrreee and it takes 2
minutes In the true definition of the word they are still fluent.