T.H.

Important Clinicals of Neuroanatomy

Spinal Cord

➢ Tabes Dorsalis is caused by syphilis due to destruction of posterior root of spinal

cord.There is (1) stabbing pains in the lower limbs, (2) paresthesia in the lower limbs;
(3) hypersensitivity of skin to touch, heat, and cold; (4) loss of sensation in the skin
of parts of the trunk and lower limbs and loss of awareness that the urinary bladder
is full; (5) loss of appreciation of posture (6) loss of deep pain sensation, (7) loss of
pain sensation in the skin (8) ataxia of the lower limbs as the result of loss of
proprioceptive sensibility (9) hypotonia as the result of loss of proprioceptive
information that arises from the muscles and joints; and (10) loss of tendon reflexes
due to degeneration of the afferent fiber compone.
➢ Hemiplegia is a paralysis of one side of the body and includes the upper limb, one
side of the trunk, and the lower limb. Monoplegia is a paralysis of one limb only.
Diplegia is a paralysis of two corresponding limbs (i.e., arms or legs). Paraplegia is a
paralysis of the two lower limbs. Quadriplegia is a paralysis of all four limbs.
Upper Motor Lesion (UMN) Lower Motor Lesion (LMN)
Paralysis Group of muscles of one or Individual muscles are
more limbs are paralyzed involved
Muscle tone Spastic paralysis Flaccid paralysis
Deep tendon reflexes Exaggerated Absent
Superficial reflexes like Absent Absent
abdominal & cremasteric
reflexes
Plantar response Extensor (Babinski sign Absent
positive)
Muscle atrophy No Present due to denervation
Fasciculations & Fibrillations Absent Present
Other Loss of performance of fine There is muscle contracture
skilled movement & Clasp (shortening of paralyzed
knife reaction (due to muscles)
spasticity) is present
 ➢ Complete cord Transection syndrome: (due to fractural dislocation of vertebral column, by
bullet,stab wound, tumor)
Level of spinal cord Lesion Clinical Sign Cause
At the level of spinal cord Bilateral lower motor neuron Damage to neurons in anterior
Lesion paralysis & muscular atrophy gray column (lower motor
neuron lesion)

Below the lesion Bilateral upper motor neuron

Below the lesion
lesion i.e;
Bilateral spastic paralysis. Damage to descending tracts
other than corticospinal
Babinski sign positive Damage to corticospinal tracts
Bilateral loss of superficial
abdominal & cremaster reflex
Bilateral loss of all sensations Damage to ascending tracts in
(tactile, vibratory & posterior white column
propioceptive)

Loss of pain,temperature & Damage to lateral & anterior

light touch spinothalamic tract
Bladder & bowl function are Damage to descending
no longer voluntary autonomic fibres

Anterior Cord syndrome ( due to injury of anterior spinal artery or vertebral fracture)
Level of spinal cord lesion Clinical sign Cause
At the level of lesion Bilateral lower motor neuron Damage of anterior gray
paralysis & muscular atrophy column (LMN lesion)
Below the level of lesion Bilateral Upper motor neuron
lesion i.e;
Bilateral spastic paralysis Corticospinal & other
descending tracts
Bilateral loss of pain,
temperature, and light touch Damage to anterior & lateral
sensations. spinothalamic tracts
➢ Tactile discrimination and vibratory and proprioceptive sensations are preserved because
the posterior white columns on both sides are undamaged.
 ➢ Central cord syndrome is most often caused by hyperextension of the cervical region of
the spine. The cord is pressed on anteriorly by the vertebral bodies and posteriorly by
the bulging of the ligamentum flavum. There is
At the level of lesion; there is lower motor neuron lesion.
Below the level of lesion;
1)There is upper motor neuron lesion. The lower limb fibers are affected less than the upper
limb fibers because the descending fibers in the lateral corticospinal tracts are laminated,
with the upper limb fibers located medially and the lower limb fibers located laterally.
2)Bilateral loss of pain, temperature, light touch, and pressure sensations with
characteristic sacral sparing.Because the ascending fibers in the lateral and anterior
spinothalamic tracts are also laminated, with the upper limb fibers located medially and
the lower limb fibers located laterally, the upper limb fibers are more susceptible to
damage than the lower limb fibers.

➢ Brown Sequard syndrome: (caused by fracture dislocation of the vertebral column, by a

bullet,stab wound, or tumor )
Level of spinal cord lesion
At the level of lesion
Below the lesion
Clinical sign
1.Ipsilateral lower motor
neuron paralysis & muscular
atrophy
2.Ipsilateral band of cutaneous
anaesthesia
1.Ipsilateral upper motor
neuron lesion i.e;
Ipsilateral spastic paralysis.
Babinski sign positive.
Ipsilateral loss of superficial
abdominal & cremaster reflex
2.Ipsilateral loss of tactile
discrimination, vibratory and
proprioceptive sensations
3.Contralateral loss of pain
and temperature sensations
4.Contralateral but not
complete loss of tactile
sensation.
Cause
1.Damage to anterior gray
column
2. Damage to posterior nerve
roots
Damage to descending tracts
other than corticospinal
Damage to corticospinal tracts
2.Damage to ascending tracts
in posterior white column
3.Damage to crossed lateral
spinothalamic tracts on the
same side of the lesion
4.Damage to crossed anterior
spinothalamic tracts on the
side of the lesion
 ➢ Syringomyelia is a developmental abnormality in the formation of the central
canal,affecting brainstem and cervical region of the spinal cord. At the site of the lesion,
there is cavitation and gliosis in the central region of the neuroaxis.
1.Loss of pain and temperature sensations in dermatomes on both sides of the
body.This loss has a shawllike distribution caused by the interruption of the lateral
spinothalamic tracts as they cross the midline in the anterior gray and white
commissures.
2.Tactile discrimination, vibratory sense, and proprioceptive sense are normal because
ascending tracts in the posterior white column are unaffected.
3.Lower motor neuron weakness is present in the small muscles of the hand.
4.Bilateral spastic paralysis of both legs may occur, with exaggerated deep tendon
reflexes and the presence of a positive Babinski response.
5.Horner syndrome (interruption of the descending autonomic fibers in the reticulospinal
tracts) may be present.
➢ Poliomyelitis is an acute viral infection of the neurons of the anterior gray columns of
the spinal cord and the motor nuclei of the cranial nerves.Following death of the motor
nerve cells, there is paralysis and wasting of the muscles. The muscles of the lower
limb are more often affected than the muscles of the upper limb. Respiration may be
threatened due to the paralysis of intercostal muscles and diaphragm.The muscles of the
face,pharynx,larynx, and tongue may also be paralyzed.
➢ Multiple sclerosis is a common disease confined to the CNS, causing demyelination of
the ascending and descending tracts. It is a disease of young adults.
➢ Amyotrophic lateral sclerosis (Lou Gehrig disease) is a disease confined to the
corticospinal tracts and the motor neurons of the anterior gray.The lower motor neuron
signs of progressive muscular atrophy, paresis, and fasciculations are superimposed on
the signs and symptoms of upper motor neuron disease with paresis, spasticity, and
Babinski response. The motor nuclei of some cranial nerves may also be involved.

Brainstem

➢ Arnold-Chiari malformation is a congenital anomaly in which there is a herniation of the

tonsils of the cerebellum and the medullaoblongata through the foramen magnum into the
vertebral canal resulting in the blockage of the exits in the roof of 4th ventricle causing
internal hydrocephalus.
➢ Lateral medullary syndrome of Wallenberg is caused by thrombosis of posterior inferior
cerebellar artery (branch of vertebral artery). It includes
Structure involeved Clinical sign
Inferior cerebellar peduncle Loss of equilibrium (ataxia) and giddiness
Lateral spinothalamic tract Loss of sensation of pain and temperature over
the contralateral half of the body
Spinal nucleus and tract of the trigeminal nerve Loss of sensation of pain and temperature over
the ipsilateral half of the head and face
Nucleus ambiguus Difficulty in swallowing (dysphagia) and in
speech (dysarthria)
Vestibular nuclei Vomiting, nystagmus and vertigo
Descending autonomic fibres Ipsilateral Horner’s syndrome characterized by
ptosis, miosis, enophthalmos, anhydrosis and
loss of ciliospinal reflex
➢ Medial medullary syndrome is caused by thrombosis of medullary branch of vertebral artery.
Structures affected Clinical sign
Corticospinal fibres (pyramids) Contralateral hemiplegia
Hypoglossal nucleus and nerve fibres Ipsilateral (lower motor neuron type) paralysis
of muscles of tongue (on protrusion, tongue
deviates to the side of lesion)
Medial lemniscus Contralateral loss of sensation of fine touch,
sense of movement and sense of position

➢ Medullary tegmental paralysis(Babinski-Nageotte syndrome) results from Lesion at

pontomedullary junction involving all the above structures.It is combination of medial and
lateral medullary syndromes
➢ Pontine Hemorrhage results from hemorrhage from basilar artery ; anterior, inferior, and
superior cerebellar arteries.There will be facial paralysis on the side of the lesion (involvement
of the facial nerve nucleus and lowermotor neuron palsy) and paralysis of the limbs on the
opposite side(damage to corticospinal fibers).There is often paralysis of conjugate ocular
deviation (damage to abducent nerve nucleus and the medial longitudinal fasciculus).There
may be pinpoint pupils (sympthetic fibres) with bilateral paralysis of face and limb.Patient
may become poikilothermic.
➢ Weber syndrome is produced by occlusion of branch of posterior cerebral artery that supplies
the midbrain,results in the necrosis of brain tissue involving the oculomotor nerve &crus
cerebri. There is ipsilateral ophthalmoplegia & contralateral paralysis of the lower part of face,
tongue, and arm and leg; eyeball deviated laterally ( paralysis of medial rectus muscle) ,
drooping (ptosis) of the upper lid,pupil is dilated and fixed to light & accommodation.
➢ Benedikt syndrome involves brain necrosis affecting medial lemniscus and red nucleus,
producing contralateral hemianesthesia and involuntary movements of the limbs ofthe
opposite side.
➢ Alternating Hemiplegias occur when the descending corticospinal fibres along with the
cranial nerve nuclei and nerve fibres (abducent & facial nerve) get affected due to vascular
occlusion. Such a lesion, seen usually in the brainstem vascular occlusions, result in
contralateral hemiplegia and ipsilateral lower motor neuron paralysis of the cranial nerve.
This is called as alternating hemiplegia or crossed hemiplegia.

Cerebellum

➢ Cerebellar disease: Lesion in one cerebellar hemisphere gives rise to signs and symptoms that
are limited to the same side of the body. It includes
1)Hypotonia (diminished muscle tone)
2)Postural Changes and Gait: Head is often rotated and flexed, and the shoulder on the side
ofthe lesion is lower than on the normal side. The patient assumes a widebase when he or she
stands and is often stiff legged to compensate forloss of muscle tone. When the individual
walks, he or she lurches and staggers toward the affected side.These are more pronounced
with the eyes closed (Romberg’s sign).
3)Ataxia (Disturbances of Voluntary Movement):The muscles contract irregularly and
weakly.Intention Tremors occurs when fine movement ( buttoning clothes,writing,and
shaving).
4)Asynergia: Muscle groups fail to work harmoniously,and there is decomposition of
movement.When patient is asked to touch tip of the nose with the index finger, movements
are not properly coordinated, and the finger either passes the nose (past-pointing) orhits the
nose.
5)Dysdiadochokinesia is the inability to perform alternating movementsregularly and rapidly.
Ask the patient to pronate and supinate theforearms rapidly.
6)Reflexes: Movement produced by tendon reflexes tends to continue for a longer period of
time than normal i.e;The pendular knee jerk
7)Nystagmus, which is ataxia of the ocular muscles, is arhythmical oscillation of the eyes. It is
more easily demonstrated whenthe eyes are deviated in a horizontal direction. This rhythmic
oscillationof the eyes may be of the same rate in both directions (pendular nystagmus) or
quicker in one direction than in the other (jerk nystagmus).
8)Dysarthria is ataxia of the muscles of the larynx.Articulation is jerky, and the syllables are
separated from one another.Speech tends to be explosive and syllables are slurred.

➢ Cerebellar syndrome (vermise syndrome): Its most common cause is medulloblastoma of

vermise in children.Since vermis is unpaired and influences midline structures, muscle
incoordination involves head & trunk and not the limbs.There is a tendency tofall forward or
backward. There is difficulty in holding the head steady and in an upright position. There also
may be difficulty in holding the trunk erect.
 ➢ Cerebellar Hemisphere Syndrome is caused by tumors of one cerebellar hemisphere.The
symptoms and signs are unilateral and involve muscles on diseased side.Movements of the
limbs, especially the arms, are disturbed. Swaying and falling to the side of lesion often
occur.Dysarthria and nystagmus are common findings.

Cerebrum

➢ Thalamic syndrome occurs due to vascular lesionof thalamic branch of posterior cerebral
artery.1) Threshold for appreciation of touch,pain,temperature is lowered. 2)Sensation that is
normal may appear to be exaggerated or unpleasant. 3)There may be spontaneous pain.
4)Emotions may be abnormal.
Part of cerebrum affected
Primary motor area (4)
Premotor area (6)
Frontal eye field (8)
Prefrontal area (9,10,11,12)
Motor speech area / Broca(44,45)
First somatosensory area (1,2,3)
Second somatosensory area
areas behind the main sensory area (areas 5
and 7)
Sensory speech area/Wernicke area (40)
Left perisylvian area (Broca + wernicke area)
Primary auditory area (41, 42)
Auditory association area (22)
Sign & symptom
Contralateral monoplegia ( hemiplegia)
Jacksonian Epileptic seizures
Apraxia (Skilled movements are affected)
Deviation of eyes to side of lesion
Personality changes
Expressive/motor aphasia–Difficulty in spoken
speech or writing (agraphia). Non-fluent speech
and telegraphic language. Key words spoken are
normal.
Contralateral sensory loss
inability to appreciate pain and temperature
Inability to identify objects by feeling them
Receptive/sensory aphasia–Loss of ability to
understand spoken and written speech. Spoken
speech is fluent but contains paraphasias
(substitution of a word with a non-word, out of
context word, and neologism)
Global aphasia (sensory & motor aphasia)
Slight bilateral loss of hearing if one side is
affected. Bilateral involvement of auditory area
will result in deafness.
Word deafness (auditory verbal agnosia)–
Inability to interpret meaning of the sounds
heard
Primary visual area (17)
Visual association area (18, 19)
Contralateral homonymous hemianopia with
macular sparing in vascular lesions (No macular
sparing in trauma or tumours)
Visual agnosia–Loss of ability to recognize
objects, Word blindness–alexia

➢ The arterial supply of internal capsule is of great clinical significance.Thrombosis in an

artery supplying the internal capsule (cerebral thrombosis) leads to a stroke that results
in contralateral hemiplegia.As the tracts passing through the internal capsule are closely
packed, even a small lesion can cause extensive paralysis. Sensations can also be lost.
Reflexes are exaggerated as in a typical upper motor neuron paralysis.
➢ Alzheimer disease is a degenerative disease of the brain occurring in middle to late life. Early
memory loss, a disintegration of personality, completedisorientation, deterioration in speech,
and restlessness are commonsigns.
➢ Thalamic Hand:The contralateral hand is held in abnormal posture with thalamic lesions. The
wrist is pronated and flexed,metacarpophalangeal joints are flexed and the interphalangeal
joints are extended.The fingers can be moved actively, but the movements are slow. The
condition is due to altered muscle tone in the different muscle groups.
➢ Cauterization of intralaminar nuclei of thalamus has been shown to relieve severe and
intractable pain associated with terminal cancer.

Reticular formation & Limbic system

➢ Damage to the reticular formation causes persistent unconsciousness & coma.

➢ Limbic structures are involved in the development sensations of emotions. Hippocampus
is concerned with recent memory.
➢ The symptoms of schizophrenia include chronically disordered thinking, blunted affect,
emotional withdrawal,Paranoid delusions and auditory hallucinations. It results from excess
of dopamine in limbic receptors.
➢ Lesions of amygdaloid complex (temporal lobe) lead to the Kluver-Bucy syndrome.They
become docile & show no evidence of fear or anger and are unable to appreciate objects
visually.They have an increased appetite and increased sexual activity ( even with male and
female).

Basal Ganglia

➢ Disorders of the basal nuclei are of two general types.Hyperkinetic disorders ( excessive &
abnormal movements) i.e; chorea, athetosis, and ballism. Hypokinetic disorders ( lack or
slowness of movement).Parkinson disease includes both types of motor disturbances.
➢ Chorea involves involuntary, quick, jerky, irregular movements that are nonrepetitive i.e; Swift
grimaces and sudden movements of the head or limbs
➢ Huntington disease is autosomal dominant disease.There is a single gene defect on
chromosome 4.This gene encodes a protein, huntingtin.The codon (CAG) that encodes
glutamine is repeated many more times than normal.There is degeneration of the GABA-
secreting & acetylcholine-secreting neurons of striatonigral-inhibiting pathway. This results in
the dopa-secreting neurons of the substantia nigra becoming overactive; thus, nigrostriatal
pathway inhibits the caudate nucleus and the putamen.Disease involves:
1. Choreiform movements ( involuntary movements of extremities) and twitching of the face
(facial grimacing). Later,more muscle groups are involved, so the patient becomes immobile
and unable to speak or swallow. 2. Progressive dementia occurs with loss of memory and
intellectual capacity.
➢ Sydenham chorea (St. Vitus' dance) is disease of childhood in which there are rapid, irregular,
involuntary movements of the limbs, face,and trunk.The condition is associated with
rheumatic fever. Antigens of the streptococcal bacteria are similar in structure to proteins
present in the membranes of striatal neurons.The host's antibodies not only combine with
bacterial antigens but also attack membranes of neurons of basal ganglia.
➢ Hemiballismus is a form of involuntary movement confined to one side of the body. It involves
the proximal extremity musculature,andthe limb suddenly flies about out of control in all
directions.The lesion (small stroke)occurs in the opposite subthalamic nucleus.
➢ Parkinson Disease: There is degeneration of the neurons of substantia nigra (that send their
axons to corpus striatum) & it results in reduction in the release of neurotransmitter
dopamine within corpus striatum.This leads to hypersensitivity of the dopamine receptors in
the postsynaptic neurons in the striatum.Following signs & symptoms ( PAR)
1)P= Postural disturbances: Patient stands with a stoop with arms flexed. The patient walks by
taking short steps and often is unable to stop.
2)A=Akinesia:There is a difficulty in initiating and performing new movements.The
movements are slow, the face is expressionless, and the voice is slurred and unmodulated.
Swinging of the arms in walking is lost.
3)R=Rigidity. This differs from the rigidity caused by lesions of the uppermotor neurons in that
it is present to an equal extent in opposing muscle groups.If tremor is absent, the rigidity is
felt as resistance to passive movement (plastic rigidity). If the tremor is present,muscle
resistance is overcome as a series of jerks, called (cogwheel rigidity).
4)R=Resting Tremor (due to alternating contraction of agonists & antagonists).
There is no loss of muscle power and no loss of sensibility. Since corticospinal tracts are
normal, the superficial abdominal reflexes are normal, and there is no Babinski response. The
deep tendon reflexes are normal.
Postencephalitic parkinsonism developed following the viral encephalitis outbreak of 1916-
17 .Iatrogenic parkinsonism can be a side effect of antipsychotic drugs (drugs which block D2
 receptors)e.g., phenothiazines,Meperidine analogues.Atherosclerotic parkinsonism can occur
in elderly hypertensive patients. Treatment includes
1)By elevating brain dopamine level. Unfortunately, dopamine cannot cross the blood-brain
barrier, but its immediate precursor L-dopa can and is used.
2) Selegiline inhibits monoamine oxidase, which is responsible for destroying dopamine
3)Transplantation of human embryonic dopamine-producing neurons into the caudate
nucleus and putamen & Pallidotomy (surgical lesions in the globus pallidus).
➢ Athetosis consists of slow, sinuous, writhing movements that mostcommonly involve the
distal segments of the limbs. Degeneration of globus pallidus occurs with a breakdown of the
circuitry involving thebasal nuclei and the cerebral cortex.

CSF & Ventricles

➢ Lumbar puncture is performed to obtain samples of cerebrospinal fluid for various

diagnostic and therapeutic purposes.In this procedure, a needle is introduced into
the subarachnoid space through the interval between the third and fourth lumbar
vertebrae.With the patient lying on his or her side or in the upright sitting position,
with the vertebral column well flexed, the space between adjoining laminae in the
lumbar region is increased to a maximum.Structures through which the needle
passes during a lumbar puncture are 1.Skin; 2.Superficial fascia; 3.Supraspinous
ligament; 4.Interspinous ligament; 5.Ligamentum flavum; 6.Areolar tissue. Purpose of
lumbar puncture is 1.estimate CSF pressure 2. To collect CSF 3. To introduce air &
radiopaque dyes to subarachnoid space 4. Spinal Anaesthesia
➢ Quenkenstedt’s Sign is positive when there is block in the subarachnoid space.When internal
jugular vein in the neck is compressed,cerebral venous pressure is increased & absorption
of CSF is inhibited.When there is a CSF block, there is no rise in manometer reading and
queckenstedt sign is said to be positive.
➢ Hydrocephalus:An abnormal increase in the quantity of CSF can lead to enlargement of
the head in children.Abnormal pressure of CSF leads to degeneration of brain
tissue.Hydrocephalus may be caused by excess production of CSF, by obstruction to its
flow,or by impaired absorption through the arachnoid villi. It is classified as
obstructive/non-communicating, when there is obstruction to flow of CSF from the
ventricular system to the subarachnoid space or as communicating, when such
obstruction is not present.
➢ Intracranial pneumography is replacement of cerebrospinal fluid within the ventricles and
subarachnoid space with air or oxygen. Because the air or gas is less dense than the fluid or
neural tissue, ventricles and cerebral gyri can be visualized. In an encephalogram, the air or
oxygen is introduced through a spinal tap.Radiographs of the skull are then made. In a
ventriculogram, air or oxygen is introduced into the lateral ventricle through a needle inserted
through a hole in the skull (in a young child, the needle may be inserted through a suture).
Radiographs of the skull then are made.In ventriculography, only the ventricles are visualized.

Written by

Tayyab Hasnain (KEMU)