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Orbital surface:
•unilateral or bilateral anosmia
A patient with a frontal lobe space-occupying lesion on one side may cause optic atrophy in one
eye, due to compression of the optic nerve, and papilloedema in the other eye, due to
secondarily raised intracranial pressure - Foster Kennedy syndrome.
Hemiplegic Gait This girl has a right
hemiparesis. Note how she holds
her right upper extremity flexed at
the elbow and the hand with the
thumb tucked under the closed
fingers (this is "cortical fisting").
There is circumduction of the right
lower extremity.
Parietal Lobe Signs
The parietal lobe is the principal sensory area of the cerebral cortex. The manifestations of
damage may be specific to the dominant or non-dominant hemisphere, or it may be general:
•loss of vision on one side of the visual field of both eyes (homonymous hemianopsia)
•visual illusions such as micropsia (objects appear smaller) and macropsia (objects appear
larger)
•visual hallucinations, displaying elementary forms, such as zig-zags and flashes, in one half
of the visual field only for each eye. (In contrast, temporal lobe visual hallucinations display
complex forms, and fill the entire visual field.)
Limbic Signs
Damage to the Limbic System involves loss or damage to memory, and may
include:
Oculomotor (CNIII) Oculomotor Midbrain Eye movement Eye deviates down & out
Trochlear (CNIV) Trochlear Midbrain Eye movement Diplopia, lateral deviation of eye
Abducent (CNVI) Abducent Pons Eye movement (Abduction) Medial eye deviation
Facial (CNVII) Motor Pons Facial expresssion Paralysis of facial nerve muscles (+ hyperacuisis)
Glossopharyngeal (CN Nucleus ambiguus Medulla Taste Loss of taste (posterior 1/3rd of tongue)
IX)
Inferior salivatory Medulla Salivation Insignificant
Vagus (X) Nucleus ambiguus Medulla Swallowing & talking Dysphagia & hoarseness of voice
Spinal accessory Spinal accessory Cervical cord Neck & shoulder movement Head turning/shoulder shrugging weakness
Hypoglossal (XII) Hypoglossal Medulla Tongue movement Atrophy of tongue muscles, deviation on protrusion,
fasciculaations
Meningism
• Meningism is the triad of nuchal rigidity (neck stiffness), photophobia
(intolerance of bright light) and headache.
• "Meningismus" is the term used when the above listed symptoms are
present without actual infection or inflammation; usually it is seen in
concordance with other acute illnesses in the pediatric population.
• Related clinical signs include Kernig's sign and three signs all named
Brudzinski's sign.
Meningism
The main clinical signs that indicate meningism are nuchal rigidity, Kernig's
sign and Brudzinski's signs. None of the signs are particularly sensitive.
•Nuchal rigidity is the inability to flex the head forward due to rigidity of the
neck muscles; if flexion of the neck is painful but full range of motion is
present, nuchal rigidity is absent.
• The cheek sign, in which pressure on the cheek below the zygoma leads
to rising and flexion in the forearm.
• Brudzinski's reflex, in which passive flexion of one knee into the abdomen
leads to involuntary flexion in the opposite leg, and stretching of a limb
that was flexed leads to contralateral extension
Meningism signs
Encephalitis
Introduction
•Encephalitis is an acute infection and inflammation of the brain itself. This is in contrast to meningitis,
which is an inflammation of the layers covering the brain.
•Encephalitis is generally a viral illness. Viruses such as those responsible for causing cold sores,
mumps, measles, and chickenpox can also cause encephalitis. A certain family of viruses, the
Arboviruses are spread by insects such as mosquitoes and ticks. The equine (meaning horse), West Nile,
Japanese, La Crosse, and St. Louis encephalitis viruses are all mosquito-borne. Although viruses are the
most common source of infection, bacteria, fungi, and parasites can also be responsible.
•The illness resembles the flu and usually lasts for 2-3 weeks. It can vary from mild to life-threatening,
and even cause death. Most people with a mild case can recover fully. Those with a more severe case
can recover although they may have damage to their nervous system. This damage can be permanent.
•Japanese encephalitis virus is the most common arbovirus in the world (virus transmitted by blood-
sucking mosquitoes or ticks) and is responsible for 50,000 cases and 15,000 deaths per year. Most of
China, Southeast Asia, and the Indian subcontinent are affected.
Encephalitis
Causes
Viral
•Viral encephalitis can be due either to the direct effects of an acute infection, or as one of
the sequelae of a latent infection. Usually cause by arboviruses spread by mosquitoes and
ticks. A common cause of encephalitis in humans is herpes (HSE) which may cause
inflammation of the brain.
•The signs and symptoms of encephalitis are the same for adults and children. Signs and
symptoms may last for 2-3 weeks, are flu-like, and can include 1 or more of the following :
Fever, Fatigue, Sore throat, Stiff neck and back, Vomiting, Headache, Confusion, Irritability,
Unsteady gait, Drowsiness, Visual sensitivity to light
•More severe cases may involve these signs and symptoms: Seizures, Muscle weakness,
Paralysis, Memory loss, Sudden impaired judgment, Poor responsiveness
•Neurological examinations usually reveal a drowsy or confused patient. Stiff neck, due to the
irritation of the meninges covering the brain, indicates that the patient has either meningitis
or meningoncephalitis.
Encephalitis
• CT scan often is not helpful, as cerebral abscess is uncommon. Cerebral abscess is more
common in patients with meningitis than encephalitis. Bleeding is also uncommon except in
patients with herpes simplex type 1 encephalitis. Magnetic resonance imaging offers better
resolution.
• In patients with herpes simplex encephalitis, electroencephalograph may show sharp waves
in one or both of the temporal lobes.
• Lumbar puncture procedure is performed only after the possibility of prominent brain
swelling is excluded by a CT scan examination. Examination of the cerebrospinal fluid obtained
by a lumbar puncture procedure usually reveals increased amounts of protein and white
blood cells with normal glucose, though in a significant percentage of patients, the
cerebrospinal fluid may be normal.
• Diagnosis is often made with detection of antibodies in the cerebrospinal fluid against a
specific viral agent (such as herpes simplex virus) or by polymerase chain reaction that
amplifies the RNA or DNA of the virus responsible (such as varicella zoster virus).
Encephalitis
Treatment
•Encephalitis is usually a viral illness, which means that antibiotics are not used to treat it. The only available
vaccine for prevention is for Japanese encephalitis.
•Treatment is usually symptomatic. People with encephalitis are kept hydrated with IV fluids while monitoring for
brain swelling.
•Herpes encephalitis can cause rapid death if not diagnosed and treated promptly. Therefore, medication is usually
started when the doctor suspects herpes to be the diagnosis without waiting for the confirmatory results.
•Reliably tested specific antiviral agents are available only for a few viral agents (e.g. acyclovir for herpes simplex
virus) and are used with limited success for most infection except herpes simplex encephalitis.
•In patients who are very sick, supportive treatment, such as mechanical ventilation, is equally important.
•Corticosteroids (e.g. methylprednisolone) are used to reduce brain swelling and inflammation.
Neurological changes
seen in Encephalitis