Topical Diagnosis

Muhammad Iqbal Basri

Neuroanatomy Division
Department of Anatomy
Hasanuddin University
The Nervous System --Divisions
 Central nervous system (CNS)
1. Brain
2. Spinal cord
 Peripheral nervous system
(PNS)
1. Cranial n. （12 pairs)
2. Spinal n. (31 pairs)
3. Visceral n.
 Visceral sensory n.
 Visceral motor n.
 Sympathetic part
 Parasympathetic part
Neurological Diagnosis
1. Clinical Diagnosis
2. Topical Diagnosis NEUROANATOMY

3. Ethiological Diagnosis

FUNCTIONAL NEUROANATOMY

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General concept in localization
 Terminology: Dermatome, myotome, cornu anterior, columna
posterior,aphasia, dysarthria,dysphagia
 Focal vs generalized signs and symptoms
 Focal signs and symptoms: aphasia, focal weakness, double
vision (diplopia)
 Generalized signs and symptoms: dysarthria, generalized
weakness, confusion, blurry vision
 Upper vs lower motor neuron signs
 Upper motor neuron:increased tone (spasticity), increased
reflexes, pathological reflexes will be found
 Lower motor neuron: decreased tone (flaccidity),decreased
reflexes, no pathological reflexes, muscle atrophy
Nn.craniales

Hemiparesis - hemiplegia
Peripheral
nerves
Hemihypesthesia

Paraparesis
Monoparesis

Tetraparesis
General concept in localization
 Know where the clinically important tract cross:
 Tractus corticospinalis (motoris): it crosses in the pyramidal
decussation (medulla)
- Lesion below the medulla will cause ipsilateral weakness
- Lesion above the medulla will cause contralateral weakness
 Tractus spinothalamicus (pain and temperature) :crosses 2-3
spinal segments above the entry point into the spine
- Lesion will cause loss of sensation contralaterally,starting 2-3
dermatomal segments below the level of the lesions
 Fasciculus gracilis and cuneatus (proprioceptive) :crosses in
the medulla
Clinical diagnosis in neurology
History taking
Recognition of impaired function
Physical examination

Identification of what site of the

Localize the lesion
nervous system has been
(topical diagnosis)
affected (localization)

Definition of the most likely

etiology

Use of ancillary procedures to

determine which of the different
possible etiologies
Neurologic Examination

1. Consciousness (GCS)
2. High cortical function History
3. Meningeal Sign taking
4. Nervi craniales
5. Motoric function
6. Sensoric function
7. Autonom function
Localize a lesion
 Right cerebral hemisphere
 Left cerebral hemisphere
 Right internal capsule
(subcortical)
 Left internal capsula
(subcortical)
 Right brainstem
 Left brainstem
 Cerebellum
 Spinal cord
Localize a lesion

 Spinal cord
 Cornu anterior
 Peripheral nerves (radix
anterior, radix posterior, nervus
spinalis)
 Neuromuscular junction
 Muscle
 Generalized symptoms, no
specific local lesion
Part 1:Loss of consciousness (Coma)
 Ascending reticular
activating system
(ARAS) :midbrain,
upper pons
 Descending reticular
activating system:
lower pons, medulla
 Coma: diencephalic, A
bihemispheric B
 Cardiovascular center and
respiratory center
Part 2: High cortical function

 Memory disturbance -
Dementia
 Emotional
disturbance
 Language
disturbance - Aphasia
The Language Centre
Lesion on the dominant hemisphere

Right-handed Left-handed

95 % (left) 60 % (left)
5 % (right) 30 % (right)
10 % (Bilateral)

Language centre always on the dominant hemisphere

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 Language disturbance (Aphasia)

Motoric Aphasia
(Broca) Global Aphasia

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Conductive Aphasia
Sensoric Aphasia
(Wernicke)

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 Emotional disturbance
 Composition
 Limbic lobe: includes septal area, cingulated gyrus, parahippocampal
gyrus, hippocampus, dentate gyrus, temporal pole, anterior part of
insular lobe and so on
 Associated subcortical nuclei: amygdaloid body, septal nuclei,
hypothalamus, epithalamus, anterior nucleus group of thalamus,
tegmentum of midbrain
 Function: concerned with visceral activities, olfaction, emotion
and memory (H.O.M.E), so this system is called ‘visceral brain’

Limbic
System
Memory disturbance

Short-term Memory Long-term Memory

• Limited capacity(7 ± 2) • Unlimited capacity

• Working memory (ongoing • Procedural memory, semantic
process), easily disrupted memory, episodic memory
• It is often disturbance • Relatively permanent
(dementia)

Hippocampus

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Hippocampus
Hippocampal
formation
Dentate gyrus

Short-term memory
(recent memory)
Part 3: Meningeal Sign

 Meninges : duramater,
arachnoidmater, piamater
 Meningeal sign:
meningitis, subarachnoid
hematome
 Irritation lesion
 Part 4: Cranial Nerves

 Facial muscles : facial nerve

(VII)
 Mastication muscles :
mandibularis nerve (branch of
N.V)
 Ocular movement : N. III,
N.IV and N. VI
 Sensoric on the face:
Trigeminal Nerve (N.V)
 Deglutitio : N.IX, N.X
 Taste : N. VII, N.IX
 Muscles for lingua : N.XII
Names of cranial nerves
 Ⅰ Olfactory nerve
 Ⅱ Optic nerve
 Ⅲ Oculomotor nerve
 Ⅳ Trochlear nerve
 Ⅴ Trigeminal nerve
 Ⅵ Abducent nerve
 Ⅶ Facial nerve
 Ⅷ Vestibulocochlear nerve
 Ⅸ Glossopharyngeal nerve
 Ⅹ Vagus nerve
 Ⅺ Accessory nerve
 Ⅻ Hypoglossal nerve
Classification of cranial nerves
 Sensory cranial nerves: contain only afferent (sensory) fibers
 ⅠOlfactory nerve
 ⅡOptic nerve
 Ⅷ Vestibulocochlear nerve
 Motor cranial nerves: contain only efferent (motor) fibers
 Ⅲ Oculomotor nerve
 Ⅳ Trochlear nerve
 ⅥAbducent nerve
 Ⅺ Accessory nerv
 Ⅻ Hypoglossal nerve
 Mixed nerves: contain both sensory and motor fibers---
 ⅤTrigeminal nerve,
 Ⅶ Facial nerve,
 ⅨGlossopharyngeal nerve
 ⅩVagus nerve
Facial paresis

• Innervate to facial muscles :

m.occipitofrontalis (A),
m.orbicularis oculi (B),
m.orbicularis oris (C)
• Central type of facial paresis :
all of the facial muscles involved
(A,B,C)
• Peripheral type of facial
paresis: m. Occipitofrontalis is
not involved (B and C)

Lagophtalmus
Part 5: Motoric system
Characters
 Representation is inverted,
but head and face are upright
 A body part is represented by
a cortical area proportional to
its use rather than its size
 Receiving fibers from
precentral gyrus, VA, VL and
VPL, sending out fibers to
form pyramidal tract,
controlling voluntary
movements
 Homunculus motoris
 upper motor neuron
Corticospinal tract

Corticospinal tract

Decussation of pyramid

Lateral corticospinal tract

Anterior corticospinal tract

Lower motor neuron

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Corticonuclear
tract
Nucleus of oculomotor n.

Nucleus of trochlear n.

Motor nucleus of trigeminal n.

Nucleus of abducent n.
Sup. part of nucleus of facial n.
Inf. part of nucleus of facial n.

Nucleus of ambiguus
Nucleus of hypoglossal n.
Nucleus of accessory n.

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Extrapyramidal system

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 The Spinal Cord
Position
 Lies in vertebral canal

 Continuous above with medulla

oblongata at level of foramen
magnum
 Ends below at lower border of
L1 in adult; at birth at level of
L3
Peripheral nerves
 Look for lower motor neuron signs in motor lesion and either diffuse
sensory loss or focal sensory loss that follows a particular nerve’s
distribution
 Nerve root (radiculopathy): pain and numbness in dermatome supplied
by nerve root
 Local (mononeuropathy): focal weakness and or numbness in the distribution
of the affected nerve
 Diffuse (polyneuropathy) :Numbness or paresthesia in bilateral hands and feet
(stocking glove)
Neuromuscular junction
 Look for fluctuating weakness and muscle wasting
 Mysthenia gravis: produces worsening double vision, ptosis and
weakness with exercise
 Lambert-Eaton Syndrome: produces improving weakness with
exercise
Muscle
 Look for weakness without
sensory changes
 Proximal weakness without
sensory changes
 Pain in the muscles may be
present
 Myositis is often associated
with skin rash, alopecia, joint
pain and swelling
 Hereditary myopathies are
associated with exercise
intolerance and progrssive
weakness
Lesion on the spinal cord A

B
A.Tetraparese (UMN)
B.Tetraparese (UMN, LMN)
C.Paraparese (UMN) C
D.Paraparese (UMN,LMN)
E. Conus medullary D
syndrome
E
F. Cauda equina syndrome
F
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Part 6: Sensoric system

Characters
 Sensory representation,
like motor area, is
crossed and inverted
 Receiving and interpret
sensation from opposite
side of body
 Homunculus sensoris
Conscious proprioceptive Central thalamic
radiation
and fine touch pathway
VPL
of trunk and limbs 3°neurons

Medial lemniscus
Gracile and cuneate nuclei
2°neuron
Decussation of medial lemniscus
Fasciculus cuneatus
T4

Fasciculus gracilis
Spinal ganglion
1°neuron

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Unconscious
proprioceptive
pathway
Superior cerebellar peduncle

Inferior cerebellar peduncle

Anterior
Spinocerebellar
Posterior spinocerebellar tract tract

Lamina Ⅴ-Ⅶ

Nucleus
Spinal ganglion thoracicus

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 Central thalamic
Pain, temperature radiation
and simple touch VPL 3°neurons
pathway of trunk and
limbs
Spinal lemniscus

anterior spinothalamic tract

LaminaⅠ,Ⅳ~Ⅶ
Lateral spinothalamic tract
2°neuron

Spinal ganglia
1°neuron

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Pain, temperature and simple Central
touch pathway of head and thalamic
radiation
face
VPM
3°neurons

Pontine nucleus of V Trigeminal lemniscus

2°neuron
Trigeminal ganglion
1°neuron

Spinal tract of trigeminal n.

Spinal nucleus of V
2°neuron

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Dermatome system

T4 – papilla mammae
T6 – processus xiphoideus
T10 – umbilicus
L1 – inguinal ligament
 Visual pathway

Optic nerve

Optic chiasma

Optic tract

Lateral geniculate body

Optic radiation

Visual area

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Optic nerve

Optic chiasma

Optic tract

Lateral geniculate
body

Optic radiation

Visual area

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Pupillary reflexes
Sphincter pupil
Ciliary muscle

Ciliary ganglia

Occculomotor n.

Accessory oculomotor nuclei

Pretectal area

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 Auditory
pathway
Transverse temporal gyrus

Acoustic radiation

Medial geniculate body

Lateral lemniscus
Cochlear nuclei

Trapezoid body Cochlear nerve

Spinal organ

Bipolar neuron of
cochlear ganglion

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Part 7: Autonomic system

 Bowel and Bladder

dysfunction:
Retention or
Incontinence
 Controlled by : the
brain and spinal cord
 Autonomic nervous
system :
sympathetic part,
para sympathetic
part
Part 7: Autonomic system Ⅲ

 Centre of symphatetic:
cornu lateral of spinal
cord segment T1-L3 Ⅶ

 Centre of para
sympathetic: located in Ⅸ

four pairs
parasympathetic nuclei Ⅹ

in brain stem and in

sacral parasympathetic
nucleus of spinal cord
segments S2~S4
Case Study

Muh.Iqbal Basri
Anatomy Department
Hasanuddin University
Case 1

 Laki-laki, 56 tahun, tiba-tiba mengalami

kelemahan tubuh sebelah kanan, disertai
mulut mencong ke kiri, bicara pelo dan tidak
bisa memahami pembicaraan. Laki-laki
tersebut termasuk right-handed.
Case 2

 Wanita, 42 tahun,kesulitan menggerakkan

tubuh bagian kiri secara perlahan-lahan.
Wanita tersebut mempunyai riwayat nyeri
kepala kronik.
Case 3

 Laki-laki,25 tahun, tidak sadar akibat

mengalami kecelakaan LL. Pada
pemeriksaan fisis didapatkan pupil anisokor
(ø ki=2,0;ka=4mm).
Case 4

 Wanita, 35 tahun, mulai tidak sadar sejak 12

jam yang lalu, sebelumnya mengeluh nyeri
kepala dan demam selama 4 hari. Pada
pemeriksaan fisis didapatkan tanda rangsang
meninx.
Lumbar spinal puncture (spinal tap)
Case 5

 Wanita, 15 tahun, mengeluh tidak dapat

melihat benda yang berada tepat
dihadapannya. Hal itu dialami secara
perlahan-lahan. Tidak terdapat riwayat
demam maupun trauma kepala.
References
Peter Duus. Topical Diagnosis in Neurology.
Thieme. New York

Paul W. Brazis. Localization In Clinical Neurology.

Lippincot Wiliiams & Wilkins

Adel Afifi. Functional Neuroanatomy.

THANK YOU
Motor units and innervation ratio

Innervation ratio
Fibers per motor
neuron
Extraocular muscle 3:1
Gastrocnemius 2000:1

Purves Fig. 16.4