CLINICAL

NEUROLOGY
Zheng Xiao
Dept. Neurology ,1st Hospital , CQUMS
 Outline

v Brief Introduction
v Localization of Neurologic Diaease
Cranial Nerve
Localization of Sensory System Deficits
Localization of Motor System Deficits
Reflex
v Summary
 Brief Introduction
v About Clinical Neurology
v Investigative Examinations

v Etiology

v Diagnosis of Neurologic Disease

v Anatomy Review of Nervous System

 About Clinical Neurology
v history of neurology
early view:
modern neuroscience:

v The medical specialty concerned with

the diagnosis and treatment of disorders
of the nervous system (the brain, the
spinal cord, the nerves) and
neuromuscular / muscular diseases.
 Investigative Examinations
v Lumbar puncture
v Electrophysiologic studies
 Electroencephalography
 Evoked potentials
 Electromyography and nerve conduction studies
 Repetitive nerve stimulation
v Cranial and spinal imaging studies
 X-Rays
 CT scan or MRI
 Positron emission tomography
 Single-photon emission computed tomography
v Ultrasonography(TCD)
v Angiography
v Biopsies (brain, muscle, nerve)
 Etiology
v Cerebral vascular disease
v Infection

v Tumor

v Head trauma

v Intoxication

v Degenerative diseases

v Autoimmune disease

v Hereditary and metabolic disorders

v Nutritional disorders
Diagnosis of Neurologic Disease

Is it Neurologic Disease?

What is the Location of

the Lesion?

What is the Underlying

Etiology?
 Is it a Neurologic Disease?

Detailed history
History of present illness,
Mode of onset
Course of the illness
Associated symptoms
Previous medical history,
Family history

Neurological Examinations
What is the Location of the Lesion?
Neurological Examinations
Conscious State
Cranial Nerves
Motor System
Sensory System
Reflexes
The location of symptoms/signs may provide a
clue to their origin.
 What is the Underlying Etiology?
Medical History; Neurologic Examinations; Investigative Examinations

The course of complaints provides a guide to their cause

1. epilepsy,TIA 2. stroke 3a: tumor 3b:MS 4: AD, PD

Anatomy Review of Nervous System

Major Divisions of Nervous System

Central Nervous System

The brain
Spinal cord

Peripheral Nervous System

Cranial nerves
Spinal nerves
Major Divisions of Nervous System
Peripheral Nervous System

subdivisions(Peripheral Nervous System):

v Afferent Nerves (sensory/to cns)
v Efferent Nerves (motor/away from cns)

 Somatic Nerves (Voluntary), CNS to skeletal ms

 Autonomic Nerves (Involuntary), CNS to heart, organs,
glands.
further subdivided into
v 1) Sympathetic
v 2) Parasympathetic
 The Brain
Cerebral Hemispheres
• 2 Hemispheres
4 major divisions:
1) Frontal Lobe
2) Temporal Lobe
3) Parietal Lobe
4) Occipital Lobe
Internal Capsule (see next
slide)
Diencephalon
Thalamus
hypothalamus
Brain stem
Midbrain
pons
medulla
Cerebellum
The Brain-- Internal Capsule

v Horizontal section of right

cerebral hemisphere.
 Spinal cord
v Grey matter
v White matter

v Anterior horn
(Anterior roots-motor)
v Posterior horn
(Posterior roots-
sensory)

v Ascending tract:
spinothalamic tract,
dorsal column
(fasciculus gracilis,
fascilulus cuneatus)
v Descending tract:
corticalspinal tract
 Cranial Nerves
• 12 pairs, exiting skull
through foramina

I OLFACTORY-
II OPTIC-
III OCULOMOTOR-
IV TROCHLEAR
V TRIGEMINAL;
VI ABDUCENS
VII FACIAL
VIII ACOUSTIC
IXGLOSSOPHARYNGEALL
X VAGAL
XI ACCESSORY
XII HYPOGLOSSAL
 Spinal Nerves
• 31 pairs
• Each connected to spinal
cord by 2 roots (anterior
root—cell bodies in the
anterior horn; posterior
root—cell bodies in the
spinal ganglion)
 localization of Sensory System
Deficits
v About sensation
v Sensory pathways

v Localization of Sensory System Deficits

 Sensation
Senses: Means by which brain receives
information about environment and body
–General senses
–Special senses
Sensation or perception: Conscious
awareness of stimuli received by sensory
receptors
 Senses
General senses: Distributed over large part of
body
•Superficial senses
Pain, Temperature, light Touch
•Deep senses
Joint Position,Vibration,Pressure
•Cortical Senses
Stereognosis, Graphesthesia, Two-point
discrimination
Special senses
Smell, taste, sight, hearing, balance
Sensory pathways
Spinothalamic pathway(1)
 Spinothalamic pathway(2)
Receptor Nerve Terminal Nerve Trunk Nerve Plexus

Dorsal Root Posterior Root Ganglion

Posterior Horn

Anterior Commissure

Spinothalamic Tract

Nucleus Ventralis Posterior Lateralis Thalami

Sensory Cortex Internal Capsule

Spinothalamic damage
LHS
spinothalamic pathway spinal cord injury

Loss of sensation of:

•Touch
•Pain
•Warmth/cold
in right leg
Dorsal column pathway(1)
 Dorsal column pathway(2)
Receptor Nerve Terminal Nerve Trunk Nerve Plexus

Dorsal Root Posterior Root Ganglion

Posterior Funiculus
Fasciculus Gracilis or cuneatus

Nucleus of cuneatus or Gracilis（in medulla）

Medial Lemniscus

Nucleus Ventralis Posterior Lateralis Thalami

Sensory Cortex Internal Capsule

Dorsal column damage(1)

LHS
dorsal column spinal cord injury
pathway

Loss of sensation of:

•joint position
•pressure
•vibration
in left leg
Dorsal column damage(2)
 Sensory Pathways Summary

1. three order neurons, two synapses

2. 1st and 3rd neuron locate at the same place

3. Different receptors, carry different information

4. 2nd neuron locate at different place,

5. different levels of decussation.

 Sensory Pathways Summary
Info carried 2nd Projection Effect of
neuron to somato- injury in
(cross sensory spinal
over cortex? cord
point)
Spino- pain spinal Yes Loss of
thalamic temp cord function:
touch opposite
side

Dorsal Joint position medulla Yes Loss of

column vibration function:
pressure same
side
Location and lamination of sensory
pathways in the spinal cord

medial lateral
Superficil s.
C T L S
deep s.
S L T C

C-cervical T-thoracic
L-lumbar S-sacral
Segmental and peripheral
distribution
 Phenomena of Sensory
Disturbances

v Loss of sensation:
Dissociated sensory loss and complete sensory loss
anesthesia，hypesthesia//analgesia，hypalgesia
v Abnormal sensation
Parethesia，hyperesthesia，hyperpathia
v pain
Localization of Sensory System
Deficits(1)

Terminal Type

Stocking-and-glove sensory loss

§Symmetric
§Distally Dominant
 Localization of Sensory System
Deficits(2)
Nerve Trunk Type

Ulnar nerve, radial nerve,median nerve, superficial peroneal nerve, tibial nerve
Localization of Sensory System
Deficits(3)
Posterior Horns
or
Root type

Segmental pattern
Localization of Sensory System
Deficits(4)
Central Cord
Or
Anterior Combining type

§ Segment
§ Symmetric
§ Bilateral
Localization of Sensory System
Deficits(5)
transection type

§ Transverse complete sensory loss

§ UMN paralysis
§ autonomic dysfunction
Localization of Sensory System
Deficits(7) Cord Hemisection
Hemisection type (Brown-Sequard
Syndrome)
Below the Lesion:
Ipsilateral
§Insult of
Pyramidal
§Vibration
§Joint Position
Sense
Contralateral
§ loss of pain
§Temperature
Appreciation
Localization of Sensory System
Deficits(8-1)
Medulla(Cross type): Brainstem
crossed sensory deficit:
ipsilateral face and
contralateral limbs and
trunk.
Localization of Sensory System
Deficits(8-2)
Brainstem

Upper brainstem(half type):

loss of all superficial and deep
sensation over the
contralateral side of the body.
Localization of Sensory System
Deficits(9)
Thalamic
(Half Type)

§Involvement of all sensations

on the contralateral side
§Spontaneous pain
Localization of Sensory System
Deficits(10)
Internal
Capsule

3H Syndrome
Hemiparesis
Hemianopia
Hemiparesthesia
Localization of Sensory System
Deficits(11)
Cortical Sensory disturbances

impairs
Discriminative
sensory
function on the
opposite side of
the body.
involved the
single arm or
leg.
Summary

Figure 12.17b
Figure 12.17b
Thank you!
Figure 12.16c