Localization in Neurology

Francis Gerwin U. Jalipa, MD

Internal Medicine – Adult Neurology
Reference

• Biller. DeMyer’s the Neurologic Examination. 7th ed.

• Blumenfeld. Neuroanatomy through Clinical Cases. 2nd ed.
• Brazis. Localization in Clinical Neurology. 7th ed.
Localization

• Latin term “locus” – site

• Diagnostic exercise of determining from the signs or symptoms of
the patient what site of nervous system has been affected by the
process
• The clinical diagnosis should precede the use of ancillary
diagnostic tests
Steps of Clinical Diagnosis in Neurology

1. Recognition of impaired function

2. Localization
3. Definition of the most likely etiology
4. Use of ancillary procedures
Recognition of Impaired Function

• After doing a complete history and physical examination

• Abnormal behavior, impaired posture or gait, weakness, sensory
disturbances, pain
Neurologic Physical Examination

• Mental status
• Higher cortical function
• Cranial nerves
• Motor
• Sensory
• Cerebellar
• Reflexes
• Meningeals
• Autonomics
Localization

• Needs a thorough knowledge of neuroanatomy

• Identify where the different affected pathways meet
• Where is the lesion?
• Is the lesion focal, multifocal or diffuse?
Brief Review of Neuroanatomy

• Central nervous system (CNS)

• Brain
• Spinal cord
• Peripheral nervous system (PNS)
• Motor neuron
• Nerve
• Neuromuscular junction
• Muscle
Upper Motor Neuron vs. Lower Motor Neuron
Lesion

• Early or acute lesions of the CNS can initially present with LMN
features and later UMN features
Corticospinal Tract

• Disproportionate hemiparesis (faciobrachial

weakness)
• Contralateral corticosubcortical
• Leg more severely affected than the arm and
face
• Contralateral paracentral lobule
• Proportionate / pure hemiplegia
• Internal capsule, cerebral peduncle, basis pontis,
medullary pyramid
Corticospinal Tract

• Alternating hemiplegia (crossed signs)

• Ipsilateral cranial nerve involvement and contralateral
hemiplegia
• Brainstem
• Paraparesis / paraplegia
• Cerebrum (parasagittal)
• Cervical or thoracic spinal cord
• Nerves or plexus
Corticospinal Tract

• Quadriparesis / quadriplegia
• High cervical spinal cord
• Bilateral involvement of the corticospinal tract in the
brainstem
• Diffuse involvement of the PNS
• Paraparesis / paraplegia
• Cerebrum (parasagittal)
• Cervical or thoracic spinal cord
• Nerves or plexus
Corticospinal Tract

• Monoplegia / monoparesis
• Involvement of the cortical representation of the limb
• Nerve root, plexus or nerve
• Combined upper and lower motor neuron signs
• Motor neuron
• Generalized distal weakness
• Nerve
• *Some myopathies
• Proximal weakness
• Myopathies
• Neuromuscular junction (fatigable weakness with
predilection for involvement of the EOMs and proximal
muscles)
• *Some neuropathies
Corticobulbar Tract

• Central facial paresis

• Sparing of the upper portion of the face
• Lesion is above the facial nucleus
• Peripheral facial paresis
• Upper and lower portions of the face are affected
• Lesion is in the facial nucleus or facial nerve
Somatosensory System

• Spinothalamic tract
• Pain
• Temperature
• Dorsal column pathway
• Vibration sense
• Proprioception
Somatosensory System

• Positive sensory symptoms

• Paresthesia (spontaneous sensations without stimulation)
• Hyperesthesia (Exaggerated sensation)
• Dysesthesia (Altered sensation)
• Allodynia (Painful response to non-noxious stimulation)
• Hyperpathia (Exaggerated sensation to painful stimulus)
• Negative sensory symptoms
• Hypesthesia (Decreased sensation)
• Anesthesia (Complete loss of sensation)
Somatosensory System

• Cerebrum
• Localizes sensory loss in the contralateral half of the body
• Thalamus
• Sensory loss to all modalities on the contralateral face
and body
• Brainstem
• Crossed findings
• Loss of pain and temperature or vibration and position
sense on the ipsilateral face
• Loss of pain and temperature or vibration and position
sense on the contralateral body
Somatosensory System

• Spinal cord
• Sensory loss below the level of the lesion (“Sensory cut)
• Others:
• Brown-Sequard syndrome: Contralateral loss of pain and
temperature sensation with ipsilateral loss of vibration
sense, proprioception and weakness
• Central cord: Dissociated sensory loss
• Dorsal root
• Radicular pain or paresthesia with sensory loss in
dermatomal distribution
Somatosensory System

• Dorsal root ganglion

• Similar to dorsal root lesion
• There may be diffuse involvement
• Polyneuropathy
• Distal symmetric loss
• Rare proximal sensory loss
• Mononeuropathy
• Sensory symptoms mainly in the distribution
of the sensory supply of the nerve
Tips on Localization per Structure
Cerebral Cortex

• Aphasia
• Apraxia
• Agnosia
• Acalculia
• Right-left disorientation
• Seizure
• Behavioral changes
• Cortical blindness
Visual Pathway
 Horizontal gaze
Primary Gaze to the opposite
side

Vertical gaze

Horizontal gaze
to the
ipsilateral side
Subcortical Structures

• Internal capsule
• Pure motor and/or sensory impairment that
is proportionate
• Basal ganglia
• Movement disorders
Brainstem
Midbrain
• Crossed motor or sensory loss
• Pupillary involvement
• Vertical gaze paresis
Pons
• Crossed motor or sensory loss
• Ipsilateral horizontal gaze
paresis
• Peripheral facial palsy
Brainstem

Medulla oblongata
• Crossed motor or sensory loss
• Cranial nerve XII involvement
Cerebellum
Cerebellum

• Truncal ataxia
• Cerebellar vermis
• Appendicular ataxia (Dysmetria, dysdiadochokinesia, leg dystaxia)
• Ipsilateral cerebellar hemisphere
• Eye movement abnormalities (nystagmus)
• Flcoculonodular lobe
Cerebellum
Spinal Cord

• Sensory cut
• Paraplegia / quadriplegia
• Bowel and bladder involvement
Peripheral Nervous System

Peripheral Nerves
Motor Neuron Dorsal Root (Multiple)
• Combination of UMN • Pain, paresthesia or • LMN signs
and LMN signs sensory loss in • Weakness LMN signs
• Asymmetric weakness dermatomal distribution
of the extremities and • Symmetric distal
• Normal motor function weakness of sensory loss
face
• No sensory • ± Autonomic symptoms
involvement • Weakness or numbness
• No bowel or bladder in nerve distribution
involvement
Peripheral Nervous System

Peripheral Nerves Neuromuscular

(Single) Junction Muscle
• LMN signs • Fatigable weakness • Proximal weakness
• Motor or sensory loss in a • EOM, facial and • ± EOM involvement
nerve distribution proximal extremity
weakness • Normal sensation

• Normal sensation
Definition of the most likely etiology

• Vascular
• Infectious
• Trauma
• Autoimmune
• Metabolic
• Iatrogenic
• Neoplastic
• Congenital
• Degenerative