localizing signs and symptoms in neurology dr. suhail al-shammri frcp (c) associate. professor....
TRANSCRIPT
Localizing Signs And Symptoms In Neurology
Dr. Suhail Al-Shammri FRCP (C)Associate. Professor. Faculty of
Medicine,Kuwait University
Language :
Aphasia- language disturbance fluency, comprehension,repitition,
naming,reading,writing and handedness.
Dysarthria- abnormal speech articulation
NON-APHASIA
Fluent aphasia
Cranial Nerves : OLFACTORY Loss of smell: Anosmia Diminished : Hyposmia Distorted :dysosmia
Causes Of Anosmia
Local nasal disease:cold.rhinitis,polyps Head injury: Fracture of frontal base Degenerative:
Alzheimer’s disease Parkinson’s disease
Endocrine: Addison’s disease, diabetes
Cranial Nerve Function: optic
nerve
Visual acuity: reduced in : refraction error obstruction of light- catarct retinal or optic nerve disease
Visual fields-confrontation hemianopia- loss of half of visual
field quadrantanopia- loss of quarter
Visual Fields
Homonymous hemianopia- loss of same half of visual field in each eye.
Bitemporal hemianopia- loss of temporal fields in each eye.
Perimetry- to detect small spots of visual loss(scotoma) or blind spot
Extinction or neglect- perception of one stimulus on double stimulation
PAPILLEDEMA
PATHOLOGICAL SWELLING WITH ELEVATION OF THE OPTIC DISC CAUSED BY RAISED INTRACRANIAL PRESSURE
Optic Nerve: Papilledema
loss of venous pulsation blurring of optic disc margins venous engorgement elevation of optic disc retinal hemorrhage visual acuity usually spared Enlarged blind spot
PAPILLEDEMA
CAUSES OF PAPILLEDEMA:Increased ICP
Mass lesions:tumors,abscess, hematoma
Cerebral edema: trauma Infections: meningitis, encephalitis Venous sinus thrombosis Idiopathic intracranial hypertension
CAUSES OF PAPILLEDEMA:Medical disorders Severe anemia Accelerated hypertension Lead poisoning Polcythemia rubra vera Carbon dioxide retention Drugs: tetracyclines, steroids,excess
vit A
OPTIC NEURITIS
Acute inflammation of the optic nerve Papillitis Retrobulbar neuritis
Optic Nerve:Fundoscopy Papillitis- optic disc inflammation
usually unilateral,painful visual acuity is impaired
Causes: Demyelination: Multiple sclerosis Viral Post-infectious
OPTIC ATROPHY
small pale sharply demarcated optic disc
end-stage of various diseases visual acuity is usually impaired
Afferant Pupillary Defect
Oculomotor Nerves
Eye movements controlled by six extraocular muscles: superior rectus, medial rectus,inferior
rectus and inferior oblique(oculomotor) lateral rectus (abducens nerve) superior oblique (trochlear nerve) eyelid elevation,pupillary size,shape and
reactivity to light and accommodation(oculomotor nerve)
Nystagmus
Abnormal involuntary rhythmic eye movement- at rest or induced slow deviation of one eye in one
direction and quick corrective movement in opposite direction
“End- point” nystagmus: occurs normally with gaze too far laterally
Asymmetric horizontal nystagmus:indicate central or vestibular lesion
Nystagmus
Up-beating or downbeating nystagmus indicates brain-stem disease.
Congenital nystagmus: present at birth horizontal beating reduced or disappears on convergence usually associated with rduced visual
acuity
NYSTAGMUS
Oculomotor nerve palsy
Eye is down and out upper eyelid droops(ptosis) pupil is dilated, unreactive to light the concept of pupillary sparing
differentiates between diabetic and compressive neuropathy.
Oculomotor nerve palsy
Nuclear: result in contralateral superior rectus palsy
Fascicular: Long tract signs Weber’s syndrome: contralateral
hemiplegia Benedikit’s syndrome: contralateral
ataxia and intention tremor Peripheral: Partial or complete
Oculomotor nerve palsy: CAUSES Diabetes Compressive:
Aneurysm Cavernous sinus lesions:
Affect oculomotor nerves First and second divisions of trigeminal Oculosympathetic fibers
Cavernous sinus lesions:Causes Aneurysm Caroticocavernous fistula or
thrombosis Expanding pituitary tumor Granuloma: Sarcoidosis
Oculomotor nerve palsy
Abducens nerve palsy:
eye is adducted and doesn’t cross midline
Nuclear lesions cause Gaze palsy CAUSES:
Diabetes Atherosclerosis Multiple sclerosis Raised intracranial pressure
Abducens nerve palsy
Internuclear ophthalmoplegia Adducting eye does not move past
midline and the abducting eye develops nystagmus
Adduction is spared during convergence
Result from lesion of the medial longitudinal fasciculus(MLF)
Internuclear ophthalmoplegia
Trochlear nerve palsy
Vertical diplopia(double vision) especially on looking downword
Head tilt toward side opposite paretic superior oblique muscle
Isolated trochlear nerve palsy is often due to HEAD TRAUMA
Argyll Robertson pupil-small irregular pupil costricts to light not to accommodation - neurosyphilis
Trochlear nerve palsy
Trigeminal Nerve
Corneal Reflex: lightly touching cornea normally causes brisk bilateral eye closure. Blink will not occur on side of facial
nerve paralysis. Touching cornea on the side of
ophthalmic division dysfunction will not result in eye blink
Trigeminal Nerve
Facial sensation - loss of sensation can occur independantly in each trigeminal nerve division.
Muscles of mastication : atrophy of temporalis or masseter
muscles. Jaw deviation toward weak side in
unilateral lesions.
Facial Nerve
Lower motor neuron palsy : produces weakness of all facial
muscles including forehead on same side as lesion.
Upper motor neuron palsy : Unilateral lower facial weakness
sparing the ability to wrinkle forehead and partially close eyelids.
Horner’s Syndrome
Damage to the sympathetic nerve supply to eye
Characterized by : small pupil (miosis) slight drooping of eyelid (ptosis) impaired sweating (anhydrosis) on
that side of the face
Vestiulocochlear nerve
Weber’s test: In sensorineural deafness sound is
heard better in the normal ear. In conductive deafness sound is heard
better in diseased ear. Rinne test :
Air conduction is louder than bone conduction in normal individuals and in those with sensorineural deafness
Vestibulocochlear nerve
Caloric test : unilateral vestibular stimulation is
accomplished by instillation of cold or warm water into one external auditory meatus .
It induces nystagmus Warm water- towards stimulated ear Cold water- away from stimulated ear
Glosopharyngeal and Vagus nerve
Unilateral vagal nerve lesion result in palatal asymmetry with uvula deviating towards normal side.
Palatal weakness results in nasal quality to voice
Vocal cord weakness result in Horseness.
Hypoglossal Nerve
Unilateral lesion : tongue deviates toward weak side.
In long-standing lesion : atrophy of affected side of tongue
Case 3
A patient is found to have : Reduced joint position sense in the
left foot. Reduced pin prick sensation on the
palmar surface of the little finger of the right hand
Case 4
A patient is found to have : reduced joint position sense in the
left foot reduced pin prick sensation on the
palmar surface of the little finger of the right hand.
Weakness of left ankle dorsiflexion Hperreflexia at left knee
Case 5
A patient found to have: reduced joint position sense in the left
foot. Reduced joint position sense in the
right foot. Reduced joint position sense in the left
hand reduced joint position sense in the
right hand
Case 6
A patient is found to have: reduced joint position sense in the
left foot. Reduced pin prick sensation on the
palmar surface of little finger of the right hand
reduced visual acuity in the left eye