CENTRAL NERVOUS SYSTEM

HISTORY OF PRESENT ILLNESS 1. Loss of Consciousness / Drowsiness

2. Convulsions 3. Headache 4. Vomiting 5. Deviation of angle of Mouth, Dribbling of Saliva & Inability to Close

Eyes 6. Inability to speak

7. Difficulty in swallowing, Hoarseness of voice, Nasal Regurgitation,

Nasal Twang, Dysarthria 8. Smell loss

9. Vision h / o Double vision, Dimness, Loss 10. Inability to Chew / Numbness over face 11. VIII nerve signs- Tinnitus, Giddiness, Vertigo, Hyperacousis,

Deafness
12. Weakness / inability to use limbs

Both upper limbs (UL), One half of the body (hemiplegia) Both LL (Paraplegia) All 4 limbs (Quadriplegia) Ask for Onset Sudden / within few hours / days / weeks / months (Gradual) Progression

progressive / Static / Improving Micturition, Stimuli like Light,

Triggering factors Sleep, Exercise, Posture, Reading, Cough, Eating, Sound, Smell, Heat & Cold

13.Wasting / thinning of limbs 14.Inability to get up / squat

15. Difficulty in Eating, Combing, Buttoning, Walking (daily activities) 16. Difficulty in Writing, Sewing (fine motor skills) 17. Abnormal movements -Inability to wear Chappals/ Chappals falling

off from foot, involuntary movements

18. Gait dragging the limb / broad based / high stepping, slowness,

Railing on to one side while walking, Unsteadiness of gait

19. Abnormal Sensations- Numbness & Tingling of Extremities, Feeling

of Walking on Cotton Wool

20. H /o Root Pain with radiation / constricting pain around any area 21. Micturition inability to pass urine / Fullness of bladder/ Retention

with overflow
22. Defecation

urgency , frequency & h/o Fecal Incontinence

ETIOLOGICAL HISTORY Ask for history of 1. Trauma / fall (head injury) 2. Cough with Expectoration 3. Hemoptysis 4. Chest pain & Breathlessness 5. Ear discharge 6. Fever associated exanthema 7. Drug intake- Oral Contraceptives, Phenothiazines, INH, Ethambutol, Vincristine 8. Joint Pain 9. Bleeding Diathesis 10. HT, DM 11. Vaccination, Dog bite (for paraplegia) PAST HISTORY: 1. Head/ Spinal injury 2. Infections TB, Encephalitis, Sepsis 3. Rheumatic fever (joint pain) 4. h/o STD Exposure, Discharge from Urethra, penile ulcer

5. 6. 7. 8. 9. 10. 11.

h/o Recurrent Abortions/ Still births (STD) Similar Episodes before any Surgery / Drug therapy/ Vaccination Ear discharge Natal history- full term/ premature, normal/ instrumental Postnatal history- Jaundice, Infection, Convulsions, Seizures, Infancy- injury

FAMILY HISTORY: DM, HT, TB, Seizures & similar illness PERSONAL HISTORY: Veg / non-veg, Smoker, Alcohol, Ganja, LSD addiction, Tobacco chewing, Marital status OCCUPATIONAL HISTORY: Exposure to Toxic chemical neuropathy, Encephalopathy Prolonged visual work under artificial light tension headache & irritation Overuse of certain joints carpal tunnel syndrome

PHYSICAL EXAMINATION
A. GENERAL EXAMINATION: 1. Consciousness

2.
3.

4.
5.

Comfortable / not Built, nutrition, stature, short neck Fever Skull- Shape & size, any Depression/ Bulge/ Scar, Bulging Fontanelle Hair- low hair line, alopecia, texture (soft/ coarse/ normal) Eyes- color of conjunctiva (blue), Bitots spot, Phlycten, subconjunctival Hemorrhage, KF ring, Icterus, Exopthalmos/ Enopthalmos

6. 7.

8.

Eye lids- ptosis (complete/ partial), Absence of closure of eye lid Anemia, Polycythemia, Cyanosis, Clubbing, LN Oral cavity angular stomatitis (Avitaminosis), Bleeding gums

9.
10.

11. 12.

Hematological signs- Petecheae, Purpura, Ecchymosis, Erythema Lower limb Calf muscle hypertrophy, edema of feet, foot deformity (Equinovarus/ club foot) Neurocutaneous markers
i.

13.

Haemangioma, Facial angiofibroma, Ash leaf shaped hypopigmented patch (tuberous sclerosis)

ii. Neurofibromas, Lisch Nodules, Caf au Lait (light coffee) Spots (neurofibromatosis)
iii. Oculocutaneous telangectasia (blood shot conjunctiva)

Ataxia telangectasia
14. 15. 16.

Thickened nerves, Trophic ulcers, Joint swelling Spine Kyphoscoliosis, Gibbus, Meningocele, Pilodinal sinus Examination of breast

B.

NEUROLOGICAL EXAMNATION 1. Higher functions a. Consciousness & perception: find if patient is in Coma / Stupor / Delirium; find out any perception disorder
Consciousness disorders Coma state of unconsciousness in which patient does not respond to any type of external stimuli / inner needs Deep coma = coma + absence of corneal & conjunctival reflexes Semicoma = arousable with preserved reflexes Stupor state of disturbed consciousness where patient shows some response to vigourous external stimuli like pain Disorientatio conscious but muddled in time, place & person n Delirium state of confusion with excitement & hyperactivity Akinetic patient is awake but lacks impulse to speak / action mutism Dementia Acquired global/ multifocal impairment of Cognitive function in presence of normal Consciousness Locked-in Global paralysis of limbs & cranial musculature, patient is syndrome receptive but unresponsive

Lesions Clouding of consciousness may be due to

1. Acute cerebral dysfunction (Cerebral hypoperfusion, metabolic disease, Encephalitis) 2. Focal lesions of thalamus esp. if medial & bilat. cause Delirium 3. Lesions of Brain stem Reticular activating System 1. 2. Perception disorders Delusion false beliefs [eg: he feels that he has cancer] Common in schizophrenia, GPI, depression Hallucinations false perception of sensations [ringing ears when no sound, seeing something which doesnt exist] Hallucinations before the attack of migraine Grandiose delusion in GPI 3. Illusion- misinterpretation of stimuli 4. Obsession recurrent & persistent thoughts that intrude in pts mind despite best efforts to get rid of them b. Appearance & Behaviour (noticed as the patient walks in)

Appearance- way of dressing, personal hygiene Behaviour disturbed / apathic/ Agitated / Confused c. Emotional state Elated, Euphoric, Excited / Depressed Emotional incontinence Pseudobulbar palsy, organic dementia, multiple Sclerosis, Cerebral atherosclerosis d. Cognitive functions 1. Speech & language: communication problem are obvious while talking to patient. Find out the type of problem aphasia / Dysarthria / Dysphonia
Disorder name Defect Dysarthria Speech pronunciation problem Causes i. Bulbar palsy difficulty in consonants (p, t, k) ii. Cerebellar Disease scanning & Robotic speech. Syllables pronounced individuallly (ask pt. to say Eyeay) iii. Pseudo bulbar palsy strangled & spastic speech, Difficulty with tongue twisters (British constitution as brizh conshishushon) Laryngeal disease / innervation defect Quiet voice => poor ventilatory capacity Fatiguing voice => in Myasthenia gravis, Parkinsonism (slow monotonous speech) (Refer below for causes)

Dysphonia

Loss of voice

Aphasia

Loss/ diffuculty in production & comprehension of spoken/ written language / both

Aphasia: Type Motor aphasia / Brocas aphasia (failure of motor aspects of speech & writing) Sensory aphasia / wernickes aphasia

Lesion Lesions at inferior frontal convolution of left hemisphere [brocas area] Large lesion involves Cortical & sub Cortical structures of Frontal & Superior Sylvian fissure including Insula [upper division of it mca territory] posterior parieto-temporal region

Characteristics Poorly articulated & Nonfluent speech with Reduced no. of words & errors of syntax & grammar (telegraphic speech) Impaired comprehension of spoken & written language Fluent speech devoid of meaning (jargon aphasia) Unawareness of speech deficit Inability to repeat phrases /words spoken by examiner with normal fluency & comprehension Same as brocas & wernickes respectively Marked elements of both brocas & wernickes aphasia

Conduction aphasia Transcortical Global

Perisylvian area with damage to fibres of arcuate fasciculus Motor antrsuprr to Brocas area Sensory postrinfrr to Wernickes area Large lesion of middle cerebral arterys area / l tint. Carotid artery/ trauma

i. ii. iii. iv. v.

Methods of testing Assess output of speech & fluency Naming of shown objects [eg: pen, comb] Ask to carry out commands like pick up the pencil Repetition of spoken words Writing find if error inform, grammer, syntax 2. Memory past & present Memory How to test Remote marriage date, mother or fathers birth date / memory job / schools name, / school mates name Recent memory Ask about the day & what breakfast he had? Tell a short story & ask to recall after 3-5 mins Short term Ask to repeat the numbers / names & in reverse memory order. Show pictures & ask to recall after few mins 3. Orientation: Time ask the patient to tell year, date, month, day, morning / evening Place hospital / house, city

Person able to identify

4. Intelligence

This is tested based on the following criteria i. Abstract thinking ask pt to explain meaning of common proverb
ii. Reasoning- ask pt to compare objects/ differentiate between a lie &

a truth iii. Judgement what pt does on seeing house on fire?

iv. Attention ask pt to sequentially subtract 7 from 100 down to 0 v. Calculations solve simple numerical problems e.

visuospatial fntns Pt is asked to copy a drawing of 5 pointed star / 3 dimensional box

Constructional apraxia / visuospatial agnosia results in difficulty in drawing lines needed in correct spatial correlation

Apraxia Defect in ability to carry out known motor acts in absence of motor weakness/ sensory loss / ataxia Seen in damage of left parietal cortes / parietal white fibres of lt or both hemispheres tested by asking pt to use objects / imitate certain movements Types Limb kinetic apraxia Ideomotor Ideational apraxia Buccofacial apraxia Motor disability of onelimb, in absence of gross wkness / ataxia Inability to do the command despite comprehending the command & adqt motor & sensory fntns i.e., defect in execution Loss of ideas behind skiled movements Pt name & describe object but not know how to manipulate it Pt cant perform learned skiled movementsof mouth, lips, tongue in absence of motor paralysis of concerened muscles

Agnosia Failure to recognize known objects in presenc of intact sensory, auditory & visual pathway Type Tactile agnosia Description Pt not recog objects though Lesion Rt & lt parietal operculum

Visual agnosia Propasognosia Anosognosia

sensory, motor & coordination normal Not recog object seen with eyes though visual pathway intact Objs color, size are described Inability to identify familiar face Lack of awareness to recog paralysed limb

Postr. Insula Bilat / left occipitotemporal Parieto occipital lesion Rt parietal lobe lesion

Handedness rt / lt g. Sleep duration, intermittent awakening, day time sleeping (narcolepsy), sleep walking & other motor activities (somnambulism), sleep aneuresis
f. Disorders Dyssomnia Intrinsic Extrinsic Parasomnia Arousal disorders Asso. With REM slp Disorders asso with medical/ psychiatric disorder Somnambulism Sleep eneuresis

Psychophysiologic, idiopathic, narcolepsy Adjustment sleep disorder, altitude insomnia,food allergy insomnia Confusional arousal, sleep walking Nightmares, sleep paralysis, sleep related painful erection Mental disorder- schizophrenia, anxiety, depression Neurological disorder parkinsomnism, sleep related epilepsy Medical- sleeping sickness, COPD, chronic renal failure, drugs Common in children & adolescents Primary fsilure to attain continence since birth Secondary emotional disturbance, UT Infection &malformations, Epilepsy, Cauda equina lesion

Lobar functions & lesions:

Frontal Parietal Temporal Occipital Personality, emotion, social behaviour Dominant lobe-language, calculation, appreciation of size, shape, texture & weight Non-dominant lobe - spatial orientataion, construction skill Dominant- Speech, Language, Olfaction, Varbal memory, Auditory perception Non dominant- Muscle tone, Non- verbal memory (face, shape, music) Analysis of vision

Frontal lobe Lesions Unilateral frontal Right/ left lobe Contra lateral spastic Hemiplegia Anosmia [orbital part] Impaired memory

Prefrontal

Bilat frontal

Dominant left lobe Parietal lobe lesions 1. Unilat. Lobe Lt / Rt 2. Dominant Lt lobe

Presence of primitive reflexes [grasping & sucking] Elevation of mood, Talkativeness Loss of initiative Bilateral Hemiplegia, Pseudobulbar palsy Prefrontal lesion-abulia / akinetic mutism, lack of attention & problem solving ability, labile mood, Primitive reflexes Agraphia, Apraxia of lips & tongue, Loss of Verbal Fluency

3. Non dominant Rt lobe 4. Bilat

Cortical sensory loss, mild hemiparesis, homonymous inferior quadrantanopia, neglect of one half of body In addition to defects in (1) above Disorders of Language[alexia], Gertsman syndrome [defect in writing, calculaton, finger agnosia, Right & left disorientation], Tactile Agnosia Bilateral Ideomotor & Ideational Apraxia In addition to (1) Dressing apraxia, Anosognosia, Construction Apraxia, Visuospatial disorders Visuospatial imperception, topographic memory loss, Anosognosia, Construction apraxia, Spatial disorientation

Temporal lobe lesions 1. unilat Rt / Lt 2. dominant Lt. lobe 3. non dominant Rt. Lobe 4. bilateral Hallucinations auditory, visual, olfactory, gustatory Emotional & behavioural changes, Dreamy state with Uncinate seizures, Homonymous superior Quadrantinopia In addition to (1) Alexia, Color anomia (Splenium of corpus callosum) In addition to (1) Inability to judge spatial relationships in some cases Impairment of non verbal memory Agnosia fo sounds & some qualities of music a. Korsakoff amnesic defect b. Apathy & Placidity c. Increased sexual activity d. Sham rage b + c + d = Kluver Bucy syndrome

Occipital lobe lesions 1. unilat (Rt / Contralat. Homonymous hemianopia central/ peripheral Lt) Elementary Hallucinations in irritativee lesion 2. dominant left In addition to (1)

lobe 3. non dominant rt lobe 4. bilateral

Alexia & Color anomia (Splenium of cor. Callosum), Object agnosia in addition to(1) Loss of visual orientation & topographic memory, Contralateral homonymous hemianopia, hallucinations Cortical blindness (pupils reactive) Loss of color perception, Inability to identify familiar faces (Proposognosia)

2.

Cranial nerves
Pure motor cranial nerves Pure sensory cranial nerves Both motor & sensory cranial nerves 3,4,6,11,12 1,2 & 8 5,7,9 & 10

Olfactory nerve

o rule out local lesion o Sense of smell in each nostril separately o Items used Tea, Coffee, Astafoedia
Lesions Anosmia: loss of smell sensation Causes - nasal diseases, head injury, tumours of anterior cranial fossa, chronic basal meningitis (TB, Syphilis, Neoplasm), Kallmans syndrome (anosmia, obesity, hypogonadism)

Optic nerve o Visual acuity each eye separately at 6 mts; At Bedside Snellens charts o Visual field by confrontation method
o Colour vision Red, Green, Blue & Yellow

o Fundus examination
Lesions 1. decreased visual acuity Primary ocular disorders, Refractory errors, Papillitis, Retrobulbar neuritis 2. unilateral loss of vision Ocular lesions, Carotid hemiplegia 3. defects of visual field (scotoma = characteristic field defects) Types of scotoma Name Definition Central Loss confined to Scotoma Central region of

Types & causes Unilateral diseases of Choroid, multiple sclerosis

field of vision Para central scotoma

Bilateral (biltl) vit B12 deficiency Disease of Choroid / Retina near the macula Unilat. vascular disease like retinal embolism, retinal artery occlusion Bilat toxic causes like Alcoholism, B12 diseases Arcuate (comma shaped) Glaucoma damaging nerve bundle in retina / optic nerve Long standing papilloedema, bilat. lesions of Striate (visual) Cortex, Retinitis pigmentosa, Hysteria Homonymous nasal field of one eye & temporal of other Heteronymous loss of nasal / temporal of both eyes Bitemporal lesion of optic chiasm (pituitary tumor), compression in mid-line Binasal lateral compression of chiasma Lesions of optic radiation & calcarine cortex Superior - temporal lobe Inferior parietal lobe

Concentric constriction Hemianopia

Concentric constriction of visual field Loss of vision in one half of visual field

Quadrantanopia

4. 5. 6. 7.

papilloedema all causes of raised intra cranial tension (tumors, abscess), central vein occlusion, HT, Polycythemia, Toxins (vit. A intoxication. Hypoparathyroidism) primary optic atrophy Neuro- syphilis, Sellar / Para sellar tumor, Fredreichs ataxia, Lebers optic atrophy, Multiple sclerosis color blindness hereditary & bilat. Visual cortex lesions pupilary reflex Afferent lesions (optic merve) Efferent lesions (3rd nerve) Direct reflex lost, Consensual reflex preserved Pupil fixed & dilated direct reflex lost, Accomodation also lost Response is seen in contra lat. Pupil

III, IV & VI nerves 1. Ocular movements

Action of ocular muscle

Elevators Depressors Abductors Adductors Internal rotators (intorsion ) External rotators (extorsion)

Sup rectus, Inf oblique Inf rectus, Sup oblique Lat rectus, Inf oblique Med rectus, Inf oblique Sup rectus, Sup oblique Inf rectus, Inf oblique

Lesions Diplopia (double vision) Types Uni & Binocular; Crossed & Uncrossed Uniocular Due to ocular conditions Binocular Weakness of Muscles; Occurs when Eyes are open Crossed Paralysis of ADDUCTOR Muscle - Medial, Superior & Inferior recti palsy Uncrossed Paralysis of ABDUCTOR Muscle Lat rectus, Sup & Inf. Oblique palsy 2. Pupil position, size, shape, equal / unequal Pupil size (normal 3-5 mm) Miotic Mydriatri c <3 mm >5mm Old age, Horners syndrome, Pontine hemorrhage, Drugs like morphine, Neostigmine, Organo phosphate poisoning 3rd nerve palsy, Optic atrophy, Infants Drugs like Atrophine, Pethidine Seen in diseases Neurosyphilis (tabes dorsalis), DM, encephalitis, Disseminated Sclerosis

Special types of pupil Definition Argyl Small, irregular, unequal. Robertson Light reflex lost Accommodation pupil reflex preserved, Poor response to mydriatric Horners syndrome (Sympathetic lesion) Hippus Miosis, Anhydrosis, Enopthalmos, Ciliospinal reflex absent

Vasculitis, encephalitis, Syringomyleia, Pan coasts tumor, Cervical rib, Brain stem lesion, pontine glioma Multiple sclerosis, Syphilis, Neoplasm

Alternate rhythmic dilatation & contraction of pupil

3. Reaction of light direct & consensual

4. Accommodation & ciliospinal reflex 5. Nystagmus vertical / horizontal / rotatory

Definition - Involuntary, Conjugate, Rhythmic oscillations of Eye. Normally occurs on extreme gaze, lasting for 10 secs Types- Pendular & Jerky Definition Pendular Rapid horizontal oscillations to either side of midline, of Equal amplitude,Seen on forward gaze Jerky Occular oscillations of Unequal amplitude with slow drift in 1 direction & fast correcting movement in the other, fast phase determining the direction of Nystagmus Causes Visual defects from Infancy Macular abnormalities, Chorioretinitis, Albinism, High infantile myopia, Opacities in the media, Retinitis pigmentosa Refer below

Types & cause of Jerky Nystagmus: 1. Horizontal To & fro movement of eye ball in horizontal plane 2. Vertical Up & down movement of eye ball in vertical plane 3. Rotatory Osscilatory movement of eye ball whch is rotatory in character Rare forms of Nystagmus:

Lesions of Vestibular nerve& nuclei, Medial longitudinal bundle, Cerebellum [Nystagmus to the side of lesion] Seen in conditions involving Brain stem Vascular accident, Encephalitis, Multiple sclerosis, Syringobulbia, druds [ anticonvulsants, BZD, Barbiturates], Wernickes encephalopathy Seen in Labyrinthine disorders

See saw nystagmus Convergence retraction nystagmus Upbeat nystagmus Downbeat nystagmus Rebound nystamus

6. Ptosis narrowing of palpebral fissure) Partial / complete, uni / bilateral

Bilateral Myasthenia gravis, Myopathy, Bilat. Horners, Snake bite, Botulism Lesions of 3rd nerve inMid brain (levator palpebra superioris

Unilatera l

involvement) Pea aneurysm, Herniation of uncus, Cavernous sinus thrombosis, DM, HT, Collagen disease, Horners syndrome, Trauma 3rd nerve palsy with papillary sparing

Congenital Ptosis due to Aplasia of 3rd nerve nuclei

Trigeminal nerve
Motor temporalis, masseter, Pterygoids Sensory sensations over the face Corneal & conjunctival reflex Lesions Name Nuclear lesion Preganglionic nerve lesion Affected area Diseases affecting Pons, Medulla, Upper cervical cord(C2) Preganglionic Assiociated lesions of other cranial nerves esp VI, VII, VIII (Characterised by severe facial pain) Diseases Tumor, Demylination, Vascular lesions, Syringomylia / Syringobulbia Tumors (Meningoma, Nasopharyngeal carcinoma, Cerebello-pontine angle tumor), Meningeal irritation (Acute / chronic meningitis, Carcinomatus meningitis) Tumors, Abscess, Herpes-zoster opthalmicus a. Cavernous sinus lesion b. Gradenigos syndrome c. Superior orbital fissure syndrome

Gasserian ganglion lesions Post ganglionic lesions

Facial nerve
Motor: eye- Frowning, eye closure, Raising of Eye brows, Browing, Mouth & cheek whistle, showing teeth, nasolabial fold, platysma Sensory: taste in antr 2/3 of tongue Lesions Types unilat. & bilat.; each being futher divided as upper motor neuron type (UMN) & lower motor neuron type(LMN) Lesions Causes Unilateral UMN Usually vascular, Cerebral tumor, Multiple Sclerosis LMN Bell s palsy, Parotid tumor, Head injury, Skull base tumors, DM, HT Bilateral UMN Vascular, Motor neuron disease LMN Guilian barre Syndrome (GBS), Sarcoidosis Uveoparotid Fever, Leprosy, Leukemia, Lymphoma

Differences between UMN Bells phenomenon (movement of eye ball upwards & inwards on closing eyelids- well seen) Emotional fibres spared Associated with Long Tract signs Exaggerated Jawjerk Corneal reflex present

&

LMN type of facial palsy Bells phenomenon absent Emotional fibres involoved Absent Normal Jaw Jerk Absent

Vestibulocochlear nerve Acuity of hearing (eg- rubbing of paper) in both ears separately Rinnes test: using tuning fork ( 256 or 512hz) over mastoid process & then lateral to ear & find out when it is louder. Positive Air > Normal ear Bone Nerve deafness(sensorineural deafness) Negativ Bone > Middle ear deafness (conductive e Air Deafness) Webers test: place vibrating tuning fork over middle of fore head, Point of Application (middle of forehead) (No lateralization) Better in Normal Ear (lateralized to normal side) Better heard in Affected Ear (lateralized to affected side) Normal Nerve deafness on Opposite side Conductive deafness on Same side

Lesions of VIII nerve Vertigo = hallucinations of movement of either the body / the surroundings causes peripheral labyrinthine disorders, Cerebellar lesions, VBI Deafness neural Peripheral labyrinthine disorders Acoustic neuroma, Meniere s disease, Vestibular neuronitis

IX & X neves [glossopharyngeal & vagus]: Gag reflex & say ah & look for deviation in uvula Sensations in posterior 1/3rd of tongue & pharynx

Lesions of IX, X, XI nerves Palate remains immobile on both sides Dysphagia, Nasal regurgitation, Pharyngeal reflex absent Unilateral Palatal arch on that side is at lower level than on healthy side Bilateral GBS, Polyneuritis, Myasthenia gravis, Motor neuron Disease PICA, Tumor, Demylination, Syringobulbia, Secondaries, meningioma, Stroke

Accessory nerve Trapezius & sternomastoid shrugging of shoulder with & without resistance, turning head on both sides separately with & without resistance Hypoglossal nerve Appearance of tongue, wasting / contracted/ Fasciculations Movement of tongue & deviation of tongue
Lesions of XII nerve Causes infarction, tumour, MND, VB aneurysm, trauma, meningioma, metastasis Types LMN & UMN Differences between Wasting Fibrillation Tongue Tone Deviation Protrusion Jaw jerk 3. LMN & Present Present Flaccid Towards affected side Possible Normal UMN of XII nerve Absent Absent Small & spastic Difficult Exaggerated

Motor system: a. Nutrition (bulk of muscle) i. comparing with Opposite side, palpating the muscles ii. Note any wasting / hypertrophy & its distributionpredominantly Proximal / Distal / Both Feel for muscles Atrophic muscle Flabby Hypertrophic Firm / muscle Rubbery iii. Measure the circumference of limbs

Upper limbs Arm Forearm Lower limbs Thigh Leg

Lesions Hypertrophy physiological / pathological Muscle wasting 1. generalized 2. upper limbs i. predominant Proximal muscle

1. 10cm Above Olecranon 2. 10 cm Below Olecranon 1. 18cm Above patella 2. 10cm below Tibial tuberosity

ii. Predominant Distal muscle iii. small muscle of hand

Spinal muscular disease, Motor neuron disease, Syringomyelia, Compressive lesion (C5- C6), Lesion of upper brachial plexus (Br Plxs) like Erbs paralysis, late stage of muscular dystrophies, inflammatory disease (poliomyelitis, Poliomyositis) Motor neuron disease, syringomyelia, Cervical cord tumors (C8,T1), lesion of lower Br. Plxs (Klumpkes paralysis), cervical rib, cervical gland enlargement, Pancoast syndrome, traumatic lesion of Radial, Median, Ulnar nerves, peripheral neuropathy, Peroneal muscular atrophy Vertebral lesion (metastasis), spinal cord lesions (syringomyelia, tumors), antr. Horn cells (motor neuron disease, poliomyelitis), root lesions, br. Plxs (klumpkes paralysis, cervical rib), peripheral nerve lesion (hansens disease, Carpal tunnel syndrome), disuse atrophy (fracture plaster)

3. lower limbs Only Lower limbs Upper limbs in addition LL Cauda equina lesion, Peripheral neuropathy, peroneal muscular atrophy, poliomyelitis, peripheral nerve trauma (lat. Popliteal nerve), tarsal tinnel syndrome Peroneal muscular atropy, Chronic poly neuropathy, Spinal muscular atrophy, Hansens disease

b. Tone (degree of tension present in a muscle at rest )

Normal / hypertonia / hypotonia Hypertonia- resistance on passive movement Spastic / rigid

Definition Spasticity State of hypertonia in which tone in antigravity muscle groups > muscles assisted by Rigidity State of hypertonia in which tone in antigravity muscle groups = muscles assisted by

Diseases Types of rigidity Plastic / lead pipe rigidity

gravity Pyramidal lesion (UMN)

gravity Extra pyramidal lesion

Cog wheel rigidity

Uniform resistance offered to passive Parkinsonism (post 1. movement encephalitic) 2. basal ganglia neoplasms 3. catatonia Resistance offered to passive mvmt 1. parkinsons disease interrupted by alternate contractions 2. over dose of reserpine, of agonist & antagonist muscle due to Chlorpromazine Asso. Tremor 3. carbon monoxide poisoning

Causes of hypotonia i. lesions of motor side of Reflex arc- Poliomyelitis, Polyneuritis, trauma of peph. nerve ii. lesions of sensory side of - Tabes dorsalis, herpes zoster, carcinomatous neuropathies iii. combined motor & sensory lesions syringomyelia, cord / root compression iv. cerebellar lesions, Chorea Clonus Sudden stretching of muscle produces reflex contraction. If stretch maintained during subsequent contraction further reflex contraction occurs & continues till stimulus removed Dorsiflexion of the foot after flexing the hip & knee ( ankle clonus), sharp movement of patella downwards ( knee clonus) Sustained clonus => pyramidal tract lesion (UMN) Illsustained => tense persons, after straining (defecation)

c. Power Tested in all joints (flexion, extension, abduction, adduction) Grading (Medical Research Council)
Grade 0 Grade1 Grade 2 Grade3 Grade 4 Grade 5 No visible contraction Visible musle contraction, but no movement of joints Movement with gravity eliminated Movement against gravity Movement against resistance Normal power

d. Coordination upper limb 1. 2. 3. 4. 5. 6. 4. lower limb Finger Toe test ii. Heel Knee test iii. Tandem walking
i.

Outstretched arms test Finger Nose test Nose Finger Nose test Finger to Finger test Pronation Supination test Pointing & Past pointing test

Involuntary movements
Name Chorea Definition semi-purposive, irregular, non- repetitive &brief jerky movement arising in proximal joints & appearin g to flit from one part to other randomly Increased on attempting voluntary movement & Exacerbated by emotional disturbance Slow writhing movement Best seen at wrists (flexing), fingers (writhing), foot (inverted) Proximal joints of one arm resulting in Wild, Rapid, Flinging movement of wide radius, occurring constantly with short periods of freedom Involuntary sustained muscle contractions frequently causing Twisting & repetitive movements Causes & types Lesion in caudate nucleus Genetic huntingtons, hereditary Hemichorea stroke, tumor, trauma, post thalamectomy Drug neuroleptics, phenytoin, alcohol, oral contraceptives Symptomatic chorea Encephalitis lethargica, sub dural hematoma, Cerebrovascular disease, hypoparathyroidism, hypernatremia , primary polycythemia Lesion in putamen

Athetosis

Hemiballis mus

Lesion in subthalamic nucleus Most dramatic of all involuntary movements may injure patient / bystanders Genetic primary generalized D, Focal adult onset D Heredito degenerative Ataxia telangectasia, Lipid storage diseases, Wilsons diseases, Parkinsons disease Symptomatic Athetoid cerebral palsy, cerebral anoxia, post-encephalitic dystonia Drugs neuroleptics, Mn poisoning,

Dystonia

Tremors

Rhythmical & oscillatory movement of body part caused by rhythmic contractions of agonst & antagonist muscles

Myoclonus

Rapid, brief shock like muscle jerks that are often repetitive & rhythmical

Tics

Repetitive, irregular stereotyped movements / vocalizations that can be imitated, Irregular, non rhythmic contraction of muscle fascicles Contraction of individual muscles Involuntary nodding of head

Fasciculatn Fibrillation Titubation

Levodopa Hemidystonia stroke, trauma, tumor, AV malformations Rest tremors parkinsons disease, post encephalitic parkinsonism, drug induced parkinsonism Postural - physiological, thyrotoxicosis, anxiety, alcohol, caffeine Intentional lesions of cerebellum & its connections in diseases like multiple sclerosis, Spinocerebellar degeneration, tumor Generalized progressive myoclonic encephalopathies, hereditary myoclonus, metabolic (Tay- sachs & Battens disease), Alzheimers disease Metabolic Uremia, hyponatremia, hypocalcemia, hepatic failure Drug induced, alcohol & drug withdsnal Focal / segmental spinal tumor/ infarct/ trauma, palatal myoclonus Simple tics transient tic of childhood, chronic simple tic Complex multiple tics chronic multiple tics Symptomatic tic encephalitis lethargica, drug induced, post traumatic Motor neuron disease, syringomyelia, cervical spondylosis, peroneal muscular atrophy, poliomyelitis (in recovery stage) Denervation hypersensitivity Easily perceived over the tongue where they are easily seen under mucus membrane Lesions of Vermis of cerebellum

f.

Gait Patient is asked to walk in a straight line for at least 9 metres, & asked to turn and walk back
Gait Circumductio n gait Seen in Hemiparesis Description Pt. throws his lower limb outwards at hip joint (circumduction), & leans towards opposite healthy side Affected arm adducted at shoulder & flexed at elbow, wrist & fingers Adductor spasm causes legs to cross each other & each foot trips the other Marked spasm of adductors of lower limbs

Spastic gait Scissors gait

Lesion of UMN involving both lower limbs Marked spastic gait as in cerebral diplegia

High stepping gait High stepping & stamping gait

Pts with foot drop

Posterior column lesion (gross loss of position sense)

Ataxic gait

Cerebellar lesion

Shuffling gait

Extra pyramidal lesion Associated with rigidity esp. Parkinsonism

Waddling gait

Primary muscular diseaseproximal weakness of lower limbs(muscular dystrophy)/ bilateral hip problem (congenital dislocation of hips)

Pt raises foot high to overcome foot drop & on keeping foot down toe hits ground first There is no ataxia Pt not know where his foot is & so on walking raises foot high up in air & brings it down forcefully (stamping gait), heel touches ground first More prominent in dark / pts eyes closed Pt is ataxic & reels in any direction including backwards & walks on a broad base Difficulty in tandem walking Series of small flat footed shuffles Parkinsonism pt. stooped posture (universal flexion) & walks in small, shuffling steps as if trying to catch up with center of gravity Automatic assoc. upper limb absent Pt walks with broad base with exaggerated lumbar lordosis

Lesions of Extra pyramidal system Sign Resting tremor Muscular rigidity Hypokinesia Chorea Hemiballismus Dystonia, Athetosis Site of lesion Substantia Nigra, Red nucleus SN, Putamen SN, Putamen, Globus pallidus Caudate nucleus Sub thalamic nucleus Putamen

Signs & symptoms of Parkinsons disease & Parkinson plus syndrome (progressive supranuclear palsy, Dementia with Lewy bodies, Multiple system atrophy) Feature Tremor Tone Movements Thought process Parkinsons disease Rest tremor (pill rolling) Rigidity -cogwheel (best seen in UL) / lead pipe(best seen in LL & trunk) Bradykinesia Bradyphrenia (slow thought) Parkinson plus syndrome Action tremor & impotence Marked axial rigidity -

Saccades & pursuit movements Facial expressions Handwriting Posture Gait ANS dysfunction 4. Sensory system:

Slight jerky saccades Pursuit eye movements Facial hypomimia (lack of facial expression) Micrographia (small hand writing) Stooped Festinant (short shuffling gait) Mild

Vertical supranuclear saccade (PSP) Broken pursuit (MSA) Falls early in disease course Ataxic Severe

i. Spinothalamic sensations a. Touch Skin is lightly touched with Cotton wool shaped to a point with eyes open & closed in dermatomal areas b. Pain Superficial pain - Sharp pin is used Deep pain squeezing of muscles (usually of calf) & tendons c. Temperature Hot & cold water
Sensory levels (spinal cord shorter; end at L1) Vertebrae Lower cervical T1-6 T7 -9 T10 T11 T12 L1 Segmental level of spinal cord +1 +2 +3 Overlies L1 & 2 L3 & 4 L5 sacral & coccygeal segments

ii.

Posterior column sensations Vibration sense 128 hz preferred over 512 hz as 128 hz fork decays later Only stem of fork touched (not the pongs) on bony prominences Joint sense Eyes closed Joint fixed & digit moved up / down Ask pt. to tell direction of movement Repeated many times avoid alternate movements

In posterior column deficit there is numbness in affected limb Position sense Pts eyes closed & ask pt to Tip of Forefinger of one hand with other Place forefinger on tip of nose & heel on knee accurately d. Rombergs sign Pt stands upright with feet together & eyes closed In proprioceptive / vestibular deficit balance is impaired & pt may fall if not caught Minimal lesions demonstrated by asking to stand on toe with eyes closed e. Lhermettes sign / barber chair sign In lesion of postr column of cervical region sudden flexion / extension of neck give rise to Electric shock like sensation that travls rapidly down trunk & even hands, feet + ve in Multiple sclerosis, Cervical spondylosis, Syringomyelia, tumor of cervical cord, Subacute combined degeneration of spinal cord
iii.

Cortical sensations 1. Tactile localization Ability to correctly localize pt. touched with head of pin / finger tip 2. Tactile discrimination Finger pulp & lips 3-5 mm well recog. Palm 2-3 cm Sole 4 cm Dorsum of foot, > 5 cm Legs, Back
Loss of Tactile Discrimination in presence of intact Posterior Column sensation => Parietal lobe lesion

3. Stereognosis Ability to identify object purely by feel of its shape & size Use familiar objects 4. Barognosis 5. Graphesthesia

Ability to recognize letters/ numbers / diagrams written on skin with blunt point Loss of graphaesthesia (agraphaesthesia) seen in lesions of parietal lobe when peripheral sensations are normal

6. Cortical inattention

Various Sensory signs & Lesions

Tot Contralat loss of all sensation Contralat loss of only Exteroceptive sensatn Contralat loss of only Proprioceptive sense Contralat loss of Position sense & Cortical sensatn + disturbance of light touch & pain contralat Hyperalgesia & Hyperesthesia Loss of Pain & Temp on Same side of Face & Opp. Side of body Unilat. Loss of pain & temp below definite level Glove & Stocking anaesthesia, (all sensation lost over a clearly defined part of body like area of glove & stoking) Patchy area of sensory loss loss of sensation of Saddle type chronic polyneuritis, Leprosy, tabes dorsali mononeuritis multiplex impairment of sensation over lowest sacral segm. it affects all forms of sensations accompanied by loss of leg reflexes & sphincter control indicates major lesion of cauda equina if touch is preserved => lesion near conus in which partial lesion of thalamus Lesion of medulla affecting descending root of V nerve & asc. Spinothalamic tract of rest from rest of the body Brown Sequard syndrome lesion of peripheral nerve / sensory root as in diabetes mellitus, polyneuropathy, mononeuritis multiplex extensive lesion of thalamus, usually vascular Partial lesion of thalamus, Lesion in lat. Part of brain stem partial lesion of thalamus, lesion in medial part of brain stem parietal lobe lesion / lesion between thalamus & cortex

plantar reflexes may be extensor & knee jerk may be loss of Vibration sense alone loss of Position & Vibration only retained if affecting lower limbs =>intrinsic cord lesions like multiple sclerosis, syringomyelia postr. Column lesion as in tabes dorsalis, subacute combined degeneration

i.

Reflxes: Superficial reflexes

5. Reflex Corneal Conjunctiva l Pharyngeal Palatal Scapular Technique Corneal edge with cotton wisp, Pt look in opp. Direction Bulbar conj. With wisp of cotton Posterior pharyngeal wall tickled Soft palate tickled Stroke skin in interscapular area Abd. Wall lightly stroked from without inwards, all 4 quadrants Upper & inner part of thigh stroked downward & inward direction Pts thigh externl rotated, Knee slight flexed, Ankle fixed with hold of examiner, outer sole stroked with blunt key, then forward, & inward along metatarsophalangeal joints Segm. Innervation Afferent V nerve Center pons Efferent VII nerve -doAff IX nerve Cen medulla Eff X nerve Aff V nerve Cen medulla Eff X Aff C4-5 Cen C4-5 Eff dorsal scapular nerve Upper abd: T7- T9 Mid :T9- 10 Lower: T11,12 Aff femoral nerve Seg L1,2 Eff genitofemoral nerve Aff tibial nerve Seg L5, S1,2 Eff tibial nerve Normal result Brisk closure of eyes -doContraction of pharyngeal muscles Soft palate moves up Contraction of scapular muscles Muscles in quadrant stimulated contract & umbilicus moves in that direction Contraction of cremasteric muscle puls up scrotum & testicle on that side Big toe flex at metatarsophalangeal jt. & flexion of other toes Babinskis sign extension of big toe with extension & faning out of other toes

Abdominal

Cremasteric

Plantar

Clinical Significance of Babinskis sign 1. Lesions of corticospinal tract (pyramidal tract) 2. infancy ( upto 1year)

3. 4. 5. 6. 7.

deep sleep deep anesthesia narcotic overdose alcohol intoxication post traumatic state

Other methods of eliciting Plantar reflexes 1. Oppenheim reflex firm stroke with finger & thumb down either side of antr, brdr. Of tibia , more pressure on mdl side 2. Gordon reflex calf muscles squeezed 3. Chaddock reflex light stroke below lat. malleolous

ii.

deep reflexes
Spinal segment involved Biceps C5 Triceps C7 Supinator C5, 6 Hoffman C7, 8, T1 Knee L3, 4 Ankles L5, S1 Pectoral C7 Deltoid C5 All reflexes should be tested on both sides 0 1 2 3 4 Grading Absent Present as Normal jerk Brisk as a normal Knee jerk Very brisk Clonus

iii. Reflex Inverted radial reflex Inverted biceps Inverted Knee reflex

Inverted reflexes Procedure Supinator jerk => absence of elbow flexion but there is finger flexion Biceps jerk absent & triceps exaggerated Biceps reflex => no flexion of elbow but extension of elbow due to triceps contraction Knee jerk => no extension instead flexion of knee due to contraction of hamstrings Lesion Presence => C5,6 segment lesion Presence=>C5,6 segment lesion Presence=>Lesion of L2,3,4

Other allied reflexes Procedure Reflex Hoffmann reflex Wartenbergs reflex Terminal phalanx of pts mid finger flicked downwards between examiners finger & thumb Ptshand supinated, slightly flexing fingers with thumb in adduction , Examiner pronates his hand & links his hand with that of pts fingers. Both flex their fingers & pull against each others resistance Lesion In hypertonia tips of other fingers flex & thumb flexes and adducts Normally thumb extends but terminal phalanx may flex slightly In hypertonia => thumb adducts & flexes strongly Indicating pyramidal tract lesion

v.

sphincteric reflexes ask the pt. for difficulties in Swallowing, Defecation, Miicturition, Sexual function primitive reflexes (released reflexes) Deficit of frontal function release primitive motor behavior which includes following reflexes Reflex Pout reflex Grasp reflex Description Rubbing of chin causes pouting / sucking lip movements Pt tends to grasp objects esp examiners fingers when they are placed in his palm, esp in contact Palmo mental reflex between thumb & index finger Scratching the palm produces unilateral contraction of mentalis muscle Non specific sign sometimes seen in normal people also Clinical inference Polysynaptic reflex released by frontal lobe disease / diffuse degenerative brain disease -

vi.

6. Autonomic nervous system i. check pupillary response to light & accommodation ii. skin dryness => absence of sweating iii. resting tachycardia- present / not iv. pulse rate slowing with deep inspiration v. trophic changes in distal skin absence of hair growth, nail bed
Bladder Innervation Innervation Segment Part innervated

Parasymp. Emptying Symp. (also carries pain sensation ) filling Somatic Types of Bladder & Incomplete spastic / uninhibited bladder

S2,3,4 T11, 12, L1,2 S2,3,4

Detrussor muscle via pelvic nerve Trigone muscle via presacral & hypogastric nerves External sphincter & perineal muscle pudendal nerve

Complete spastic / reflex / automatic / hypertonic bladder Autonomous bladder / hypotonic Sensory paralytic (afferent pathway lesion ) Atonic bladder (reflec arc lesion) Motor paralytic (efferent pathway lesion )

Levels of Lesions, clinical condition Post central loss of awareness of bladder fullness, incontinence Precentral difficulty in initiating micturition Frontal inappropriate micturition, loss of social control (like infants bladder) Lesion in spinal segments above S2,3,4 Lesion at S2,3,4 & Cauda equina Seen in DM, Syringomyelia, Tabes dorsalis Intact voluntary initiation of micturition Urinary retention- overflow incontinence Frequent urinary tract infection Seen in Tabes dorsalis, Conus & Cauda Seen in lumbar canal stenosis Lumbo-sacral meningio- myelocele Painful urinary retention

7. Cerebellar signs Part Archicerebellum Paleocerebellu m Neocerebellum Parts Connected to Vestibular nuclei Spinal cord Cerebral cortex Function Maintain equilibrium Maintain posture Center of voluntary movements

Lesions of cerebellum Clinical signs 1. Hypotonia , 2. Dysmetria (inappropriate range of movement) 3. Intention tremor 4. Adiadochokinesia 5. Rebound phenomenon

6. Nystagmus quick & towards direction of gaze, occasionally skew deviation in acute lesions 7. Jerky, explosive speech, Disturbance of articulation & phonation in lesion of vermis 8. Gait staggering towards affected side + ataxia 9. Pendular knee jerk 10. Titubation Causes 1. Fredreichs ataxia (other signs scoliosis, pes cavus, Ataxia, Dysarthria, Nystagmus, Muscle weakness, Optic atrophy, Deafness) 2. Cerebellar abscess (acute) & tumors, paraneoplastic syndrome 3. Vascular causes 4. Hypothyroidism 5. Alcohol 6. Drugs like Phenytoin, Babiturates, Aminoglycosides 7. Refsums disease

8. spine & cranium

a. Anomalies i. Gibbus = localized angular deformity caused by fracture, potts disease, TB, Metastatic malignant deposit ii. Lordosis = increased backward bending of spine Increased cervical lordosis Loss of cervical laordosis Increased lumbar lordosis Loss of lumbar lordosis iii. Ankylosing spondylitis Acute lesions, rheumatoid arthritis, cervical spondylosis Muscular dystrophies Acute disc collapse, aging, ankylosing spondylitis

Scoliosis = lateral curvature of spine Postural, congenital, unequal limb in length, acute disc collapse, Extensive fibrosis of lungs, inflammatory disorders Kyphoscoliosis = lateral + posterior bending of spine (kypho = backward bending) Congenital, poliomyelitis, neuromuscular disorders Tenderness Height- neck ratio Auscultation over skull b. Signs of meningeal irritation Usually meningitis, sub-arachnoid hemorrhage

iv. v. vi. vii.

Sign i. Neck stiffness ii. Kernigs sign

Procedure Passively but gently flex pts neck

Normal chin touch chest without pain

In Meningeal irritation Flexion causes Pain in posterior part of neck & Movement is resisted by spasm of extensor muscles Pain & Spasm of hamstrings in Meningeal irritation of lower part of spinal sub-arachnoid space

Pt supine on bed Passively extend pts knee on either side when hip is fully flexed Brudzinkis sign Ophisthotonus

no pain / spasm (this test is less sensitive than neck stiffness)

iii. iv.

9. OTHER SYSTEMS CVS Look for Hypertension, valvular heart disease, [AF] TOF, Peripheral pulsation, carotid pulse & bruit RS: Look for Evidence of TB, lung abcess, bronchiectiasis, corpulmonale, bronchogenic carcinoma ABDOMEN: Look for Hepato-spleenomegaly, ascitis, polycystic diseases, hepatocellular failure, any mass

Blood supply of CNS

Blood supply of cerebrum
Artery Anterior cerebral artery Middle cerebral artery Area supplied Entire Mdl surface + 2 cm strip along Superolat surface & Mdl of Orbital surface Entire Ltl surface + Lat of orbital surface Superior divisison brocas area Inferior division Wernicks area Lesions Hubners branch (antr int capsule) => faciobrachial monoplegia Main trunk=> Contralat leg, micturirtion & cognition affected Lenticulo-striate (LS) branch [int capsule - superior half] , Medial & lat striate branches (corpus striatum) Occlusion of LS vessels =>hemiparesis without cognitive defect & no sensory loss Terminal branch => hemiparesis affecting face & arm Main trunk => combination of above

Posterior cerebral artery

Mdl surface of Temp & Occp lobes & their Tentorial surface, Cerebellum, Medulla, Pons, Midbrain, Thalamus, Sub thalamus

Terminal occlusion=>visual cortex Thalamogeniculate branch=> various thalamic & capsular features like hemianopia, Speech arrest, tremor, dystonia, contralat sensory loss Main trunk=> all above effects

Vertebral artery branches a. Meningeal b. posterior, c. spinal, d. anterior spinal e. medulary f. postereior inferior cerbellar Infarction of posterior inferior cerebellar artery Infarct Level Paramedian infarct Basillary infarct Posterolat infarct (wallenberg s syndrome) Regions involved 12th nerve nucl, mdl lemniscus & medullary pyramid infr olive & pyramid Symp. Tract, spinothalamic tract, nuc of tract of 5th nerve, lower vestibular nuc, infr cerbellar peduncle, 9th & 10th nerve nuclei Clinical Effects tongue weakness, paralysis& absent uni/bi lat position sense Contralat ataxia & motor adaptation failure and contralat hemiplegia Ipsilat horners, facial numbness & ataxia, loss of contralat pinprick sensation & vestibular disturbance, speech & swallowing difficulty

Basilar artery branches 1. Pontine artery 2. Labyrinthine artery 3. anterior inferior Cerebellar artery Infarction of anterior inferior cerebellar artery Infarct Level Regions involved Clinical Effects

Paramedian infarct Basillary infarct Posterolat infarct

6th & 7th nerve nuclei & mdl lemniscal tract 6th & 7th nerve fascicles & pyramidal pathways Symp. Pathway , Spinothalamic tract, middle cerebellar peduncle, 5th nerve nucleus, vestibular, cochlear & eye movemt control nuclei

Lat gaze failure , LMN facial wekness & loss of contra lat body position sense Diplopia, LMN facial weakness & contralat UMN facial weakness Ipsilat sensory loss in face Ipsilat clumsiness of body & loss of contralat pin prick sensation, Nystagmus & horners syndrome

4. superior Cerebellar artery Infarction of superior cerebellar artery Infarct Level Paramedian infarct Basillary infarct (webers syndrome) Posterolat infarct Regions involved Red nucleus & 3rd nerve nucleus 3rd nerve fascicule & cerebral peduncle Spinothalamic, Mdl lemniscus, & symp. Tracts & superior cerebellar peduncle Clinical Effects Contralat ataxia & 3rd nerve palsy Ipsilat 3rd nerve palsy & contralat hemiplegia (face & body) Total contralat sensory loss, ipsilat hoirners syndrome& sometimes ipsilat ataxia

5. posterior cerebral artery

Stroke
Definition acute neurological injury occurring due to vascular pathological processes that manifest as brain infarct /hemorrhage Major causes Age, Obesity, HT, Smoking, DM, Alcohol, Oral contraceptives Hematological causes Polycythemia, thrombocytopenia, Sickle cell disease, leukemia, prorein C & S deficiency Cardiac causes Rheumatic valve disease, atrial fibrillation , myocardial infarction, cardiomyopathy, patent foramen ovale Unusual causes Marfans syndrome, AIDS, cervical irradiation, drug abuse, scleroderma Clinical classification 1. completed stroke 2. evolving stroke Rapid onset Persistent ND that does not progress beyond 96 hours Gradual step wise development of ND

3. transaient ischemic attack 4. Reversible Ischemic Neurological Deficit (RIND) Blood supply of Internal capsule

Focal ND resolves completely within 24 hours The ND completely resolves within 1- 3 weeks

5. Superior half by lenticulostriate , branch of MCA 6. Inferior half anteriorly ACA (Hubners artery), 7. Posterior limb 8. Anterior 1/3 posterior communicating 9. Posterior 2/3 anterior choroidal artery 10. ACA supplies bladder & leg areas Blood supply of spinal cord 11. Anterior 2/3rd of cord - one anterior spinal artery 12. Posterior 2/3rd of cord - a pair of posterior spinal artery

Spinal cord
Relationship of spinal segments Vertebrae Lower cervical T1-6 T7 -9 T10 T11 T12 L1 Position of fibres Column Posterior column Lateral & Anterior Column Segmental level of spinal cord +1 +2 +3 Overlies L1 & 2 L3 & 4 L5 sacral & coccygeal segments

Position of Fibres Fibres from Lower Limb are placed medially near central canal & from Upper Limb are placed laterally Corticospinal & Spinothalamic tracts

Arrangement of fibres Anterior to postr (central canal to dorsum) Medial to lateral

Touch , Position, movement, Vibration & pressure sense Cervical, thoracic, lumbar, sacral

Lesions
o Localization of segmental level Order of importance First note Segmental symptoms like root pain, hyperalgesia, atrophic paralysis Next is upper limit of sensory loss upper limit of area of analgesia indicates lower segment compressed Remember that sensory level for pain sensation suggest that, lesion is several segments lower than actual site Segment Foramen magnum signs Atrophy of sterno mastoid muscle Downbeat Nystagmus C2 sensory loss & cerebellar signs Horners syndrome Cervicomedullary junction (hemiplegia cruciata) C2 segment Lower cranial nerve palsy Paralysis of ipsilateral lower limb & contralateral UL (due to arm fibress ccrossing before the leg fibres at lower part of medulla) 1. Sub-occipital pain / sensory loss 2. Descending tract of Vnerve (pain & temp. loss over face 3. Exaggerated trapezius reflex Loss of trapezius reflex 1. Inverted biceps jerk 2. Inverted brachioradialis jerk (supinator jerk) 3. Sensory loss over deltoid 1. Dimished biceps & supinator reflex 2. Exaggerated finger flexor reflex 1. 2. 3. 4. Paresis of flexors & extensors of wrist & fingers Preservation of biceps & supinator reflex Exaggerated finger flexor reflex Inverted triceps reflex

C3 C5

C6 C7

C8 & T1

Thoracic segments T3 T4 T6

1. Weakness & wasting of small muscles of hand 2. UMN signs in lower limb 3. Uni / bilat. Horners syndrome 1. Girdle pain / paraesthesia 2. Segmental LMN involvement 3. ANS dysfunction Sensory impairment in axilla Sensory impairment below level of nipple Abdominal reflex impaired

T10

+ ve beevors sign (intact upper abd reflex & absent lower abd. Reflex with pull of umbilicus >3 cm on raising the head) 1. 2. 3. 4. 1. 2. 3. 1. 2. 3. 4. 1. 2. 3.

T12

L3, L4

S!, S2

S3, S4

Abdominal reflex preserved Sensory loss in LL staring from level of groin Brisk ankle & knee jerk Absence of cremasteric reflex Hip flexion preserved Atrophic paralysis of quadriceps & adductors of hip Loss of knee jerk & ankle jerk Atrophic paralysis of intrinsic muscles of foot, calf muscles Knee jerk preserved Ankle jerk & plantar reflex lost Anal & bulbocavernous preserved Saddle anesthesia Bladder & bowel involved Normal reflexes in LL

Compression of spinal cord Effects of compression Slow spinal compression affects First the pyramidal tract Next posterior column Spinothalamic tract LMN signs Anterior horn cell Posterior root Posterior column Pyramidal tract LMN signs (weakness, wasting, fasciculation) Root pain/ girdle pain (trunk) Lhermittes sign (unpleasant / electric sensation) Constriction band around trunk UMN signs

Differentiating between
1. Intra-medullary & Extra medullary lesions

Motor UMN signs Spasticity & muscle spasm LMN signs Muscle atrophy Trohic changes Fasciculation Sensory Root pain . Funicular .. Dys& paraesthesias Dissociated sensory loss. Sacral sensation. Joint position sense . Lhermittes sign . ANS Bowel & bladder disturbance Investigation X-ray of spine Effect of lumbar puncture . 2.

Common & persistent 1or 2 segments at site of root compression Not common Rare Common Not present Rare Absent Lost Lost Present Late Bony changes seen Signs & symptoms are pptd / increased

Less common Wide due to antr. Horn involvement Present Common Rare Present Common Present Sacral sparing for Pain & Temp Spared Absent Early Not seen No such effect

Mode of onset Vertebral pain (local tenderness) 3.

Extra-dural & Intra dural lesion Asymmetrical Symmetrical Uncommon Common

Lesions of Conus medullaris Onset Symmetrical Disso. Sensory loss Present Root pain Rare Fasciculation Rare Decubitus ulcer Rare Bladder & bowel Early

Cauda equina Asymmetrical Absent Common Common Common Early / late depending on root involvement Epiconus

4.

Lesions of Bladder involvement Faecal incontinence Saddle anesthesia Motor symptoms

Conus medullaris & Distension Present Present Absent Absent

Absent Paralysis of LL

muscles Short description of some CNS diseases Paraplegia Most common causes 2. 3. 4. 5. 6. Trauma (parasagittal region), Tumor TB Thrombosis- of sagittal sinus, ACA (uni/ bilat) Transeverse myelitis

Quadriplegia Types spastic & flaccid Spastic Flaccid Cerebral palsy, Cerebral anoxia, Brainstem SOL, Syringobulbia, MND, demyelinating disease, Craniovertebral anomaly, Fracture of cervical spine , cervical spondylosis, cervical cord tumors, hematomyelia Poliomyelitis, Polyneuropathy, Guilliane Barre Syndrome (GBS), Porphyria, diphtheria, Infectious mononucleosis, Polymyositis, Periodic paralysis Features Commonest type UMN & LMN signs (pyramidal tract & antr. Horn) LMN signs (antr. Horn) Onset > 50year, gradually progressive UMN signs(pyramidal tract) LMN signs (cranial nerve nuclei) UMN signs (cortico bulbar fibres) Weakness of facial & bulbar muscles Neural deafness Abnormal GTT Prognosis (years) 5 10 3 2 2 (Good longevity)

Motor neuron diseases Disease (% of total cases) Amyotrophic Lateral Sclerosis ALS (50 %) Progressive Muscular atrophy (10%) Primary lat. Sclerosis (5%) Progressive Bulbar palsy (25%) Pseudo Bulbar Palsy (10%) Madras MND (More males affected , 10-30 years)

Peripheral neuropathy Classification 1. based on mode of onset Acute <1 week Sub acute Chronic 1 week 1 month > 1 month

GBS, Porphyria, Toxins (vincristine), pan- autonomic DM, Amyloidosis, Paraneoplastic HIV Neuropathy, Hereditary Sensory neuropathy

2. based on system affected Motor GBS, Porphyria, Diptheria, Infectious mononucleosis, Lupus

Sensory Mixed

Toxic- Pb, Al, Thallium, Triortho cresyl phosphate, Opioid Idiopathic Toxic Cisplatinum, Vit B12, Enitro-furantoin, Pyridoxine DM, Amyloidosis, Leprosy, HIV Drugs- Alcohol, Dapsone, Phenytoin, INH, EMB, amiodarone Metal poison Au, Hg, Pb Industrial chemicals Hereditary neuropathy, CRF, PBS

3. symmetrical / asymmetrical 4. recurrent GBS, Porphyria, CPD, Beri-beri GBS (Guillian Barre Syndrome) Progressive weakness of arms & legs Areflexia, Hypertonia, Plantar flexor Usually Symmetrical Mild sensory symptoms /signs No bladder involvement Myasthenia Gravis Onset - Insidious / sub acute Ptosis- Uni / bi lateral; Pupils- spared Palatal palsy/ weakness Proximal weakness, weakness more in evening & disappears at rest Poly myositis Myopathies Fever, muscle ache & tenderness Symmetrical weakness of proximal & trunk muscles Ocular & facial muscles spared Pharyngeal muscles may be involved Reflexes usually depressed ECG changes Arrhythmia may occur Congenital & familial Onset gradual & slowly progressive Symmetrically bilat. Selective group of muscles wasted / hypertrophied Kyphoscoliosis No sensory / bladder disturbances Description of few types of myopathies Duchennes Inheritance Onset Distribution Sex linked recessive 3 years Proximal > distal Becker Sex linked recessive 15-20 years Same as Facioascapulohumera l Autosomal dominant 7-25 years Face, arms & scapula Limb girdle Autosomal recessive 20-30 years Shoulder &

of weakness Cardiac involvement Progress Prognosis

Pelvic > shoulder Common Rapid Death 10-30 years

Duchene Absent Slow Normal

Absent Slow Normal

pelvic girdle Common Variable Varies