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Neurology Cairo University Notes
Neurology Cairo University Notes
Motor System
Differentiation between UMNL & LMNL:
1. Muscle power
2. Muscle
wasting
3. Muscle tone
4. Deep reflexes
5. Pathological
deep reflexes
6. Clonus
7. Superficial
reflexes
8. Plantar reflex
(Babinski)
9. Fasciculations
UMNL
LMNL
May be present
Absent
May be present
Absent
Sensory System
Types of Sensations:
Somatic
Superficial
Pain
Temp.
Touch
Deep
Cortical
Vibration
Joint
Muscles
Nerves
Visceral
Sensations from
internal viscera
Tactile Localization
2 point discrimination
Stereognosis
Graphosthesia
Special
Smell
Vision
Hearing
Dissociated sensory Loss: Lost Pain &Temp. and preserved Touch & Deep..
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Cranial Nerves
Olfactory I
Optic Nerve II
Function: Sense of Vision
Lesion : Differs according to the site in the pathway:
1. Lesion in the optic nerve:
- Ipsilateral loss of vision
- Loss of direct & consensual light reflex.
2. Lesion in the optic chiasma:
- Bitemporal Hemianopia.
3. Lesion in the optic tract:
- Contralateral Homonymous Hemianopia (bilateral half blindness).
4. Lesion in the optic radiation (upper fibers):
- Lower quadrant Contralateral Homonymous Hemianopia.
- Preservation of the light reflex.
5. Lesion in the optic radiation (lower fibers):
- Upper quadrant Contralateral Homonymous Hemianopia.
- Preservation of the light reflex.
In complete lesion of the optic radiation, there will be:
- Contralateral Homonymous Hemianopia (bilateral half blindness).
- Preservation of the light reflex.
6. Lesion in the occipital lobe:
- Contralateral Homonymous Hemianopia (bilateral half blindness).
- Preservation of light reflex
- Preservation of the macular vision (due to double blood supply).
MOST IMPORTANT: Optic Tract and Optic Radiation..
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Occulomotor III
Function: Extra ocular ms. Movement, elevation of upper eyelid, papillary constriction
Lesion:
A) External ophthalmoplesia:
1. Ptosis
2. Divergent paralytic squint (the eye looks out & down due to the unopposed action
of the lateral rectus "Cr N 6 " & the superior oblique " Cr N 4 " ).
3. Diplopia
B) Internal ophthalmoplesia:
1. Ipsilateral mydriasis.
2. Ipsilateral loss of light reflex: loss of direct light reflex on the affected eye.
Trochular IV
Abducent VI
Trigeminal V
Sensory:
- Ophthalmic
- Maxillary
- Mandibular
Motor:
- Ms of Mastication: Temporalis, Masster, Mylohyoid, Tensor Palate, anterior belly of
Digastric.
N.B. Trigeminal conducts sensations from face (except angle of mandible supplied by C2) ,
anterior 2/3 of tongue and buccal activity.
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Facial VII
Motor: Platysma, Posterior belly of digastrics, Stapedius, Stylohyoid, Facial muscles.
Sensory: ant. 2/3 of tongue
Autonomic: Lacrimal, Submandibular & Sublingual salivary glands
Differentiation between UMNL & LMNL of Facial Paralysis
UMNL
LMNL
Horners Syndrome:
Partial Ptosis
Myosis
Enophthalmos
Anhydrosis
Stroke
Transient Ischemia attacks (TIAs) predispose to stroke.
Risk factors of stroke:
1. Non-modifiable:
Age: old
Sex: male : Female = 3 : 1
Type A personality: Nervous, intellectual.
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2. Modifiable:
a) High risk:
Heart disease: especially valvular heart diseases & AF
Hyperlipidemia: total cholesterol, LDL, HDL.
HYPERTENSION: cause endothelial damage.
Diabetes mellitus.
Cigarette smoking.
b) Less risk:
Obesity.
Diet: rich in saturated fat & cholesterol.
Physical inactivity.
Psychological stress.
Hyperurecemia.
Homocysteinemia.
Heavy alcohol intake.
CCPs.
Hemiplegia
C/p:
General
Acute Onset
Stage of flaccidity (2-6 weeks)
Neuronal shock
Tone flaccidity
-ve superficial
Deep reflexes
reflexes
Planter reflex
Coma Asymmetry lateralization sign
Gradual Onset
Remittent onset(DS)
Stage of spasticity
Weakness
ULExtensors
LLFlexors
Spasticity
ULFlexors
LLExtensors
-ve
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Specific Site
Ipsilateral
Spinal
Brown-Squared Syndrome
Dicuss.
Brain Stem
Crossed
Cerebral
dicussation
Capsular
Complete
Acute onset associated with syncope, hiccup, vomiting, vertigo and pain over the face.
Ipsilateral cerebellar ataxia (nystagmus, dysarthria, incoordination).
Ipsilateral Horner's syndrome.
Ipsilateral palate-pharyngeo-laryngeal paralysis & weakness of sternomastoid & trapezius.
Ipsilateral loss of pain and temperature sensations over the face.
Contralateral loss of pain and temperature sensations over the body.
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Paraplegia
Extra-medullary
Intra-medullary
HISTORY
Onset
Sphincteric affection
Painful
Late or absent
Painless
Early
CLINICAL PICTURE
Sensory
Sphincteric affection
Sensory level:
Jacket sensory loss:
Below which all types of
Of dissociated nature (lost
sensations are diminished. pain & temp. & preserved
touch & deep).
Sacral affection:
Early loss of sensations in
the saddle area (S3,4,5).
Late or absent
Sacral spare:
Preserved sensations in
the saddle area (S3,4,5).
Early
Marked of pressure.
Complete dynamic block.
Froin's syndrome.
Diagnostic
Possible vertebral lesion.
Saddle-shaped block.
Moderate of pressure.
Partial dynamic block.
NO Froin's syndrome.
Diagnostic
Normal
Fusiform-shaped block.
INVESTIGATIONS
CSF
CT & MRI
Plain X-ray
Myelography
Froin's syndrome:
Marked increase in proteins leading to:
- Spontanous coagulation.
- Xanthochromia. (yellowish discoloration)
- Cyto-albuminous dissociation. ( proteins BUT near normal cell count)
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Pier Marie Foix test: Firm +ve planter flexion of toes and foot resulting in spontaneous flexion of
hip and knee, if paraplegia is passing from extension to flexion.
Cauda Equina
Clinical picture of CONUS MEDULLARIS LESION:
1.
2.
3.
4.
Chorea
-
Static
Irregular
Sudden
Jerky
Pseudopurposive
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-
Marie's Ataxia
-
Peripheral neuritis
Causes of motor neuropathy:
1.
2.
3.
4.
Alcoholic neuropathy.
Arsenic neuropathy.
Diabetic neuropathy.
Leprotic neuropathy.
Vitamin deficiency neuropathy.
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Epilepsy
Generalized
Partial
Grand Mal
Petit Mal
- Carbamazepine
- Phenytoin
Atonic Seizures
- Valproate
- Succinamide
Simple
- Valproate
- Clonazepam
Anti-epileptic drugs:
1.
2.
3.
4.
5.
6.
Barbiturates (Phenobarbitone).
Hydantoin (Epanutin).
Carbamazepine.
Clonazepam.
Valproate.
Succinamide.
Important Reflexes
Deep reflexes:
Upper limbs:
-
Lower limbs:
-
Superficial reflexes:
o Planter reflex S1,2
Others:
o Adductor L4
o Jaw C2
o Supraspinatus C3,4
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PartialGeneralized
Complex
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o Gluteal L4,5
o Cremasteric L1
o Anal reflex: S3,4,5
EXAMS
Put () or (x)
Underlined words = explain why the statement is wrong
1.
2.
3.
4.
5.
6.
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postural reflexes & ECG changes.
28. Polyneuropathy loss of reflexes distal than proximal.
29. Jaw is supplied by C2.
30. There is sacral spare in intramedullary tumor.
31. In myopathy there is lost ankle & preserved knee.
32. Brown Sequard syndrome is accompanied by ipsilateral loss of superficial sensations &
temperature and contralateral loss of deep sensations.
33. Autonomic epilepsy is type of generalized epilepsy.
34. Parasagittal tumor can cause paraplegia.
35. Trigeminal nerve supplies sensation to all face except angle of mandible by C1.
36. There is spare of sacral sensations in intramedullary paraplegia.
37. In Brown Sequard syndrome there is ipsilateral loss of deep sensations, superficial
sensations, pain & temperature.
38. There is early wasting in LMNL.
39. Peripheral neuropathy affects periphery & more in extensors than flexors.
40. Extramedullary paraplegia present with pain.
41. Causes of extramedullary paraplegia include meningioma, neurofibroma,
syringomyeloma.
42. LMNL presents early with early wasting
43. UMNL includes hyperreflexia, pathological deep reflexes, fasciculations & +ve Babiniski.
44. Complete partial seizures present with aura, loss of consciousness, automatism and
amnesia.
45. Intramedullary paraplegia presents with jacket sensory loss and dissociation and late
sphincteric affection.
46. Intramedullary paraplegia presents with jacket sensory loss, loss of pain, touch preserved
temperature.
47. Spasticity affects flexors of UL & LL with hyperreflexia.
48. Crossed hemiplegia is characterized by pyramidal weakness of one side & LMNL of cranial
nerves on opposite side.
49. Dissociated sensory means lost pain & touch sensation with preserved deep sensation
50. Lost knee reflex & preserved ankle reflex is a sign of myopathy
51. dystonia is involuntary, very slow, torsion movement associated with hypotonia during
the movement
52. carbamazepine, clonazepam, isonized, valproate & succinimide all are antiepileptic
agents
53. trochlear nerve (supplying the inferior oblique muscle) is tested by asking the patients to
look inwards & downwards
54. Lesion of the optic radiation cause contralateral homonymous heminanopia with
preserved light reflex
55. Upper motor neurone facial nerve lesion affects voluntary, emotional & associative
movements
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T
T
T
F
F
F
T
F
T
F
T
T
T
F
T
F
T
F
F
F
F
F
T
F
F
F
T
F
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56. meningioma, neurofibroma, glioma, pott's disease all are causes of extra medullary
paraplegia
Idiopathic
Aura
Amnesia
Absence
Automatisam
Answer: A
2) All are superficial reflexes except:
a.
b.
c.
d.
abdominal
cremasteric
gluteal
brachio-radialis
Answer: D
3) Cerebral hemiplegia contains:
a.
b.
c.
d.
coma
convulsions
dysphasia
complete hemiplegia
Answer: D
4) Marie's ataxia
a.
b.
c.
d.
e.
affects neo-cerebellum
preserved superficial sensations
exaggerated deep reflexes
mental impairment
lost deep sensations
Answer: E
5) All are deep sensations except:
a. muscle sense
b. nerve sense
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c. tendon sense
d. tactile localization
e. vibration sense
Answer: D
6) All causes motor neuropathy except:
a.
b.
c.
d.
lead neuropathy
alcoholic
porphyria
diphteric
Answer: B
7) All cause hypotonia except:
a. cerebellar ataxia
b. chorea
c. dystonia
Answer: C
8) fredreich's ataxia characterized by following except:
a.
b.
c.
d.
Answer: D
9) Root value of knee reflex is:
a.
b.
c.
d.
L2
L3
L 2,3
L 2.3.4
Answer: D
10) All are cortical sensations except:
a. tactile discrimination
b. localization
c. stereogenesis
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d. Romberg
Answer: D
11) The following are the muscles supplied by the trigeminal nerve except :
a.
b.
c.
d.
e.
temporalis
masseter
mylohyoid
posterior belly of digastric
tensor palate
Answer: D
12) The root supply of supraspinatus reflex is:
a.
b.
c.
d.
e.
C 2,3
C 3,4
C 3,4,5
C 4,5
C 5,6
Answer: B
13) The root supply of cremasteric reflex is:
a.
b.
c.
d.
e.
L 3,4
L 1,2,3
L 2,3
L 1,2
L1
Answer: E
14) The following are cortical sensations except:
a.
b.
c.
d.
e.
tactile localization
stereognesis
nerve sense
graphosthesia
perceptual rivanly
Answer: C
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lead neuropathy
diphtheritic neuropathy
arsenic neuropathy
perphysia
acute infective neuropathy
Answer: C
16) friedreich's ataxia is characterized by the following except:
a.
b.
c.
d.
e.
Answer: E
17) Horners syndrome is characterized by the following except:
a.
b.
c.
d.
e.
incomplete ptosis
miosis
enophthalmos
anhydrosis
parasympathetic paralysis
Answer: E
18) Intra medullary paraplegia is characterized by the following except:
a.
b.
c.
d.
e.
sacral spare
jacket sensory loss
dissociated sensory loss
early bladder disturbances
the froin's syndrome
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Answer: E
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45) 37-Horner syndrome includes all except:Complete ptosis
46) 38-Pathological reflexes are : Finger,Patellar adductor,Jaw
Neurology 2009
MODEL EXAM (I)
Put () or (x)
1. Lesion of optic radiation leads to contra-lateral homonymous hemianopia with lost light reflex.
2. The trochlear nerve (supplying inferior oblique muscle) lesion leads to failure of eye movement
inward & downward.
3. Trigeminal nerve supplies the temporalis, pterygoids, posterior belly of digastric & masseter
muscles.
4. LMNL of trigeminal nerve affects voluntary movements, emotional & associated movements of
the face.
5. Brown Squared syndrome is characterized by contra-lateral superficial sensory loss & ipsi-lateral
deep sensory loss.
6. Crossed hemiplegia means hemiplegia & LMNL of cranial nerve on the opposite side of the lesion.
7. Occlusion of posterior inferior cerebellar artery (Wallenberg's syndrome) is characterized by ipsilateral Horner's syndrome, ipsi-lateral loss of superficial sensations on the face & contra-lateral
hemiparesis.
8. In Piere Marie Foix test; firm passive planter flexion of the toes & foot results in spontaneous
flexion of hip & extension of the knee if paraplegia is passing from extension to flexion.
9. Intramedullary paraplegia is painless with symmetrical weakness, jacket sensory loss of
dissociative in nature with sacral spare & late bladder disturbance.
10. Conus Medullaris lesion is characterized by early urinary & fecal incontinence, impotence &
dissociated sensory loss of the saddle area.
11. Causes of motor neuropathy include Lead, Porphyria, diphtheria, Leprosy & Landry Guillian Barre.
12. Marie's ataxia is characterized by neocerebellar ataxia, exaggerated deep reflexes, ocular nerve
palsy & mental impairment.
13. Chorea is involuntary, static, sudden jerky & dysrythmic movement.
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14. Root supply of cremastric reflex is L2.
15. Root supply of planter reflex is S1.
16. Root supply of adductor reflex is L3, 4, 5.
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Temporalis.
Anterior belly of digastrics.
Mylohyoid.
Stylohyoid.
Masseter.
Answer: D
2- Brown- Sequard syndrome is characterized by the following except:
abcde-
Ipsilateral hemiplegia.
Contralateral deep sensory loss.
Lesion of one side of S.C.
Contralateral superficial sensory loss.
Touch diminishes on both sides.
Answer: B
3- Intramedullary paraplegia is characterized by the following except:
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F
T
F
F
F
F
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abcde-
Symmetrical.
Jacket sensory loss.
Dissociated sensory loss.
Cyto-albuminous dissociation.
Sacral spare.
Answer: D
4- All of the following are causes of sensory neuropathy except:
abcde-
Diabetes mellitus.
Leprosy.
Diphtheria.
Alcohol.
Arsenic.
Answer: C
5- Maries ataxia is characterized by the following except:
abcde-
Mainly neo-cerebellar.
Preserved deep reflexes.
Mental impairment.
Extrapyramidal manifestations.
Lost sensation.
Answer: E
6- The root supply of the gluteal reflex is:
abcde-
L4,L5
S1,S2
L5,S1,S2
L5,S1
L3,L4
Answer: A
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