Localization in clinical

Neurology
3rd year lecture
Integrated CNS module
Why?
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Why?
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• Second level
• Provisional diagnosis.
• Third level
• Proper investigations
• Fourth level selection.
• Fifth level
• Proper management.
History of Past Illnesses
• Why?
• Search for possible pathophysiologic risk factors.
• Search for co-morbidity.
• How?
• Past history of similar conditions.
• Fever or trauma of neurological significance.
• Relevant medical illness.
• Relevant surgeries.
• Drug history.
• Recent vaccination, blood transfusion, contraceptive pills.
History of the Present Illness
• Why?
• Define the affected structure (Physiology).
• Define the localization of the affected structure (Anatomy).
• Define the way that structure is affected (Pathology).
• How?
• Analysis of the complaint and leading questions, to define the affected
structure and its localization.
• Define the duration of each symptom and its fate (course) to reach the
pathology.
• Arrange the symptoms chronologically.
• Formulate the history.
Analysis of the complaint and leading
questions
• Why?
• Define the affected structure (Physiology), localization of the affected
structure (Anatomy) and the way that structure is affected (Pathology).
• What?
• Headache, Disturbed consciousness, Seizures and Speech.
• Cranial nerves.
• Motor system.
• Sensory system.
• Sphincter control.
• Hypothalamic manifestations.
• Symptoms of other systems 'affection.
Analysis of the complaint and leading
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questions
• How?
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• Characteristic
Second level distribution of the symptom.
• • Third level
Associated symptoms of the same system.
• Fourth level
• Associated symptoms of other systems.
• Fifth level
• Duration and course of each symptom.
• How?
Analysis of Weakness?
• Weakness is the most common neurological complaint.
• It is a symptom of motor system disturbance.
• Other motor system symptoms include impaired tone, impaired
muscle state, abnormal involuntary movements, incoordination.
• It could be due to a lesion involving many structures including; cortex,
sub-cortex, internal capsule, para-thalamic region, brain- stem, spinal
cord, roots, peripheral nerves, neuromuscular junctions, skeletal
muscles.
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Anatomy oftext
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• Second level
• Third level
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of Motor
Power
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Anatomy
of Motor
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Anatomy of
Motor
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Weakness due to muscular diseases
• Isolated muscle disease like sarcomas causes localized symptoms and
surgical mass (not a neurological disease).
• Hereditary and metabolic muscular diseases cause bilateral, almost
symmetrical weakness, more proximal (bulky muscles).
• Associated with hypotonia, late atrophy (bulky), no abnormal
involuntary movements and no incoordination.
• No other non-motoric symptoms.
• N.B. On examination late hypo-reflexia (bulky and nerve intact).
Weakness due to neuromuscular junction diseases

• Characterized by diurnal variation (significant fatigability) and specific

marsh.
• In primary MG cranial weakness first and in secondary myasthenia
skeletal weakness first.
• No constant weakness early in the disease, no change of tone and
muscle state, no involuntary movements, and no incoordination.
• No symptoms of other system affection.
• N.B. on examination there is usually hyper-reflexia (hyper-excitability)
Click to editdue
Weakness Master
to peripheral
title stylenerve diseases
• Isolated
Edit Masternervetextlesion
stylescauses weakness, and atrophy in the muscles
supplied
• Secondby this particular nerve and associated with sensory deficits
level
in its•skin
Thirdtopographic
level distribution.
• Fourth level
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Weakness due to peripheral nerve diseases
• In peripheral neuropathy (hereditary and metabolic) weakness is
bilateral and symmetrical, more distal (long nerves more vulnerable),
associated with hypotonia, early atrophy (no nerve growth factor). No
involuntary movements, but sensory incoordination may be present.
• Associated with impairment of superficial sensation (glove and
stocking hypoesthesia), deep sensation and autonomic functions
(sphincters and postural hypotension).
• N.B. on examination there is early hyo-reflexia.
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Weakness
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• Isolated root lesion causes
• Second level
due
• Third level to
• Fourth level
weakness, and atrophy in the
muscles supplied by this root and
radicular
• Fifth level associated with sensory deficits in
its skin topographic distribution
(roots) (dermatomes).

diseases
Weakness due to radicular (roots)
diseases
• Systemic radiculopathy like in Guillen-Barre syndrome weakness is
bilateral and symmetrical, more proximal (less root value), associated
with hypotonia, atrophy, no involuntary movements, but sensory
incoordination may be present.
• Associated with dermatomal sensory deficits and radicular pains, but
no autonomic deficits (autonomic fibers join peripheral nerves
directly).
• N.B. Early stretch signs and areflexia is usually evident.
Weakness due to AHC diseases
• Focal AHC affection will cause segmental weakness, atrophy and
fasciculation without segmental sensory affection. But spinal cord
affection may be evident (long tract deficits below level and sphincter
impairment).
• Systemic AHC affection (Motor Neuron Disease) causes bilateral and
symmetrical, weakness, atrophy and fasciculation. This is usually
associated with tongue fasciculation, hyper-reflexia (tonic atrophy),
intact sensations, sphincters and abdominal reflexes.
Weakness due to pyramidal tract lesions
• This could be systemic (in hereditary and metabolic diseases) or focal
at 6 levels;
• Spinal cord.
• Brain-stem.
• Para-thalamic.
• Capsular.
• Subcortical.
• Cortical.
Weakness due to systemic pyramidal tract
lesions
• This is characterized by bilateral and symmetrical distal weakness
(unilateral cortical representation) affecting more extensors of upper
limbs and flexors of lower limbs (pro-gravity with less hypertonia) and
associated with hypertonia (more in the anti-gravity muscles). Neither
involuntary movements, nor incoordination and nor sphincter
affection are evident.
• N.B. There is usually bilateral hyperreflexia, and plantar reflexes may be extensor. But abdominal reflexes are
usually intact.
Weakness due to spinal cord pyramidal tract
lesions
• Below the level (LEVEL is the hallmark) of the lesion there is weakness
of pyramidal distribution, associated with hypertonia on the same
lesion side. No involuntary movements, and no incoordination are
evident.
• Weakness is early bilateral (Paraplegia) especially in intra-medullary
lesions resulting in early sphincter impairment (incontinence at the
conus, retention at dorsal levels and precipitancy at cervical levels).
• There could be also, deep sensory level on the lesion side, and
superficial sensory level on the contralateral side.
• At the level radical manifestation may be evident.
Weakness due to brain stem pyramidal
lesions
• Contralateral (above decussation at the lower medulla) weakness of
pyramidal distribution, associated with hypertonia. No involuntary
movements, and no incoordination are evident.
• Ipsilateral cranial nerve palsy (CROSSED deficit is the hallmark).
• Weakness could be bilateral especially in intra-medullary lesions
resulting in sphincter impairment (usually precipitancy ).
• There could be also, other long tracts deficit, dissociated
ophthalmoplegia, conjugate eye movement palsy and vertigo.
Weakness due to para-thalamic pyramidal
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lesions
• Contralateral
Edit Master text weakness
styles of pyramidal distribution, ipsilateral ataxia
(involvement
• Second levelof the cortico-ponto-cerebellar tract).
• Third level
• Pyramidal affection above the medulla involve contralateral 12 th
• Fourth level th nerve affection
nerve affection and
• Fifth level above the pons contralateral 7
of UMN type (Hemiplegia).
• Contralateral thalamic pain could be present (thalamic involvement).
Weakness due to capsular pyramidal
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lesions
• Contralateral
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hemiplegia (sever and equally affecting upper
and lowerlevel
• Second limbs) weakness (closely impact fibers) of pyramidal
distribution, associated with hypertonia.
• Third level
• Fourth level
• Contralateral hemi-hypoesthesia
• Fifth level and hemianopia could be present.
Weakness due to subcortical pyramidal
lesions
• Contralateral weakness (hemiplegia) of pyramidal distribution not
equally affecting upper and lower limbs (fibers are dispersed to reach
different destinations).
• Contralateral partial hemi-hypoesthesia and quadri-anopia could be
present.
• Occasionally subcortical dysphasia may be present in lesions involving
speech-dominant hemisphere.
Weakness due to cortical pyramidal
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lesions
• Contralateral
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styles
• Second level
• Associated cortical manifestations as seizures, dysphasia, apraxia, or
• Third level
cortical sensory deficit.
• Fourth level
• Fifth level
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• Second level
• Third level
• Fourth level
Sensory
• Fifth level system
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• Second level
• Third level
• Fourth level
Sensory
• Fifth level system
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• Second level
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• Fifth level
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• Second level
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Sensory
• Fifth level system
Analysis of the complaint and leading
questions
• What?
• Headache, Disturbed consciousness, Seizures and Speech.
• Cranial nerves.
• Motor system.
• Sensory system.
• Sphincter control.
• Hypothalamic manifestations.
• Symptoms of other systems 'affection.

• You then repeat the same for every other system.

• Arrange the analyzed symptoms chronologically mentioning the
course of each one.
• Decide the Onset, course and duration of the disease.
Onset, Course and Duration of the Disease
• Why?
• This will decide the pathology.
• How?
• The Onset is how the picture of the disease was completed? (dramatic,
sudden, rapid, or gradual).
• The Course is summation of the course of symptoms (stationary, regressive, or
progressive).
• The Duration is the duration of the very first relevant symptom, from your
opinion, not from the patient’s opinion.
The Onset
• What?
• The Onset is how the picture of the disease was completed? (dramatic, sudden,
rapid, or gradual).
• How?
• The duration between the very first symptom from your analysis point of view and
the last symptom is converted into an adjective.
• Dramatic >>>within seconds
• Sudden >>>within hours up to 48 hours
• Rapid >>>within days up to 2 weeks
• Gradual >>>within more than 2 weeks
• For mono-symptomatic disease it’s the duration needed to reach the maximum
intensity of it.
The Course
• What?
• This is how the fate of symptoms went throughout the disease.
• How?
• If all the symptoms are alike, then this is the course of the disease.
• If even one symptom is progressive, then the course of the disease is
progressive.
• If symptoms aggregate in time, the course is episodic (intermittent when they
reach the baseline and remittent if the don’t).
ClickDuration
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• What?
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• Second
The Duration
level is the duration of the very first relevant symptom, from your
opinion, not from the patient’s opinion.
• Third level
• Fourth level
• Fifth level
Formulation of the present history
• Why?
• To convert symptoms into structures (physiology and anatomy).
• Describe the cascade of events (pathology).

• How?
• Now we know which structures are affected and their physiological and/ or
anatomical relationships.
• We also know how the disease process was implemented.
Click to editDiagnosis
Provisional Master title style
• What?
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• Answer
Second level
3 questions
• Third
WHERE level
? > Physio-anatomical diagnosis
• WHAT
• Fourth
? > level
Pathological diagnosis
• FURTHER• Fifth level ? > Questions that are still needed to be answered by examination
QUERIES
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WHERE ? Master title style
• Focal
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diseases text styles
• Seconddisease
• Systemic level
• Third level
• Multifocal diseases
• Fourth level
• Fifth level
• Disseminated diseases
WHERE ?
• Focal diseases
• Diseases that affect anatomically related structures (affected structures could
be grouped in one anatomical region, like the internal capsule)
• This include vascular, traumatic, inflammatory and space occupying diseases
• Systemic disease
• Diseases affecting functionally related structures (affected structure could not
be grouped in one focus, but they have physiological, biochemical or genetic
relations)
• This include metabolic, toxic and hereditary diseases
WHERE ?
• Multifocal diseases
• Affected structures could be grouped in more than one focus, each one
should involve more than one structure
• This include multiple vascular, traumatic, inflammatory or space occupying
diseases
• Disseminated diseases
• Multifocal disease that are partially selective (frequently affecting or sparing
nearby structures)
• This is seen mainly in demyelinating diseases like multiple sclerosis
WHAT ?
• Vascular diseases
• They have dramatic or sudden onset and stationary or regressive course
• Traumatic diseases
• They have dramatic or sudden onset and stationary or regressive course
• Inflammatory diseases
• They have rapid onset and stationary or regressive course
• Space occupying diseases
• They are gradual and progressive (could regressive on treatment)
• Metabolic, Toxic and Hereditary diseases
• They are gradual and progressive (could be regressive on treatment)
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Further Queries
Master
? title style
• What?
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• Second
These arelevel
questions that could not be answered by the analysis and
formulation
• Third levelof the history and should be searched for during the examination.
• This could
• Fourth level missing data, conflicting data, justifying or confirming data.
include
• Examples•are Fifth level
stroke but no obvious risk factors, pyramidal affection but no
spasticity, nerve lesion but no atrophy, etc.
Neurological Examination
• Why?
• To confirm provisional diagnosis or choose between differential diagnoses.
• How?
• Answer queries put after history tacking.
• Suggest further queries that need to be answered by instigations and
treatment.
• The same process should be repeated every time you see the patient during
follow ups after starting treatment.
 Examples
1. a 16y old female with irrelevant past history was presented to the neurology clinic with gradual onset and
progressive course during the past year duration ,,, she reported weakness in both lower limbs with difficulty
standing from sitting, climbing upstairs with normal movement in her feet around ankle joint during walking
and controlling her slippers in position … she denied any sensory symptoms and reported no change in
control of urination ,,, on examination her deep tendon jerks were elicited and plantar response was flexor
plantar … the most suitable diagnosis for her condition from the following diseases would be:
•
A. Cervical transverse myelitis
B. Dorsal cord tumor
C. Limb girdle muscle dystrophy (muscle disease)
D. Old ischemic cerebral stroke
 Examples
2. 75 years old male patient with history of uncontrolled hypertension presented to the emergency department
with sudden onset of sensory loss on the left side of the face and right upper limb and lower limb, MRI brain
done, the expected site of the lesion is
A. left brain stem infarction
B. right temporal infarction
C. left frontal hematoma
D. right brainstem infarction
 Examples
3. 40 years old male patient, with irrelevant past medical history, complained of bilateral lower limb heaviness
that developed and evolved over a period of one week, on examination, he showed sensory loss till level of
umbilicus, the most likely diagnosis for the condition would be:
•
A. Anterior cerebral artery infarction
B. Dorsal cord infarction
C. cervical cord myelitis
D. dorsal cord myelitis
 Examples
4. A 56 years old male presented with progressive hands weakness and
atrophy. He also complained of difficult swallowing and fasciculation in
both deltoids and thigh muscles. The affected structures are:
A.The skeletal muscles.
B.The peripheral nerves.
C.The anterior horn cells.
D.The cervical spinal cord.
 Examples
5. 65 years old female patient known to be diabetic 20 years ago and she is uncontrolled on antidiabetic
treatment, complained of dysthesia in both lower limbs, she sought advice at neurology clinic, on examination
what is the expected pattern of sensory loss
A. dissociative sensory loss
B. glove and stocking pattern
C. jacket sensory loss pattern
D. sensory loss in the saddle area
Thank You