Neurolocalization In Pediatrics

Presenter:Degalem T.(Pediatrics Resident)

Moderator:Dr.Ashenafi T(Assistant prof.of
Pediatrics)

August 20,2020
 Presentation outlines
 Objectives
 Introductions
 Neuroanatomy in the neuraxis/Divisions
 Upper /Lower motor lesion
 Localizing in the neuraxis
 Referrences
 Objectives
 After this seminar session;
 We will have the concept of functional neuroanatomy
 We will be able to know the upper and lower motor lesions
 We will able to correlate the physical findings with the
neurologic insults/Localize the lesions
 Introduction
 Neurologic system is composed of the Central and
peripheral nervous systems
 Central Nervous system includes the brain and the spinal
cords
 Peripheral nervous system is composed of the cranial and
other peripheral nerves as a continuation of the spinal cord.
 The anterior horn cells , part of the lower motor system, are
the transitions between the upper and lower motor systems
 Cerebral cortex has motor and sensory roles
 The CNS works in a continuous system of networks so that
interruption of messages and responses does not occur
Division in the neuraxis system

 Cortical area &subcortical areas

 Brainstem area
 Cerebellum
 Spinal cord
 AHC
 Spinal nerve root
 Nerve plexus
 Peripheral nerve
 Neuromuscular junction
 muscle
 Neurolocalization
• It is the diagnostic practice of determining the insults from
signs or symptoms
• ‘Topographic representation of the brain’
 For decision of imaging/other investigations
 To predict possible progression and prognosis
 Reduces ‘incidentaloma’
 DDX=Localization x time
Why Neurolocalization ?
 Approach to localize neurologic lesions
1-Recognition of impaired functions (real neurologic case?)
 Weakness & its distribution ( unilteral , bilateral , proximal
or distal)
 Language/mental status/sphincter /vision/behavior changes
 Weather sensory is affected or not (less usefull in children)
 Which component of sensation is affected
2- Identifying which part of nervous system is affected
 Weather it is upper or lower motor
 Complete neurologic examination is the fundamental step
 Cont....
3-list possible etiology
4-Do ancillary procedures to identify the likely etiology
 Proper history &examinations
 Consider the age of the child while interpreting the
findings (eg -babinski test for infants)
5-Finally confirm with imaging in vague cases/can be
multiple site lesion
 Cont....
Do possible through systemic physical
examinations
Stepwise neurologic examinations
Try to classify as either a diffuse process or
localized process
Other deformities( scoliosis ,contractures....)
 Neurologic exam....
 Cortical functions and mental ststus
 Cranial nerves and meningeal signs
 Cerebellar functions , Gait and Stance
 Motor and sensory exams
 Reflexes(DTR, Superficial reflexes , pathologic reflexes)
 Seizures , movement disorders , posturing
 Cerebral Cortex
 It is the largest part of brain derived from the telencephalon
 It is the gray matter serving as the motor and sensory area
 composed of sulci and gyri
 The larger sulci called fissures separate the cortex into 4
lobes each with unique functions
 Inferior to sylvian fissure=temporal lobe(inferior lobe)
 Anterior to Rolandic /central sulcus=frontal lobe
 Posterior to Rolandic sulcus=parietal lobe
 Posterior to parietooccipital sulcus=occipital lobe
 Cerebral cortex...
It has 2 hemispheres connected each by the white
matter commisures of corpus callosum , anterior and
posterior commisures and the commisure of fornix
The cortex is also in continuation with the
diencephalon
The precentral gyrus is the primary motor cortex and
the postcentral gyrus is the primary sensory cortex.
The cortex is labelled by broadmann system in
numbers as a village in a country=52!
Each the broadmann area has its own function.
 Lobes..
Frontal lobe Temporal lobe
 Language(expressive ,non  Gnosia-recognition
verbal)  Dressing
 Motor cortex area  Language/receptive
 Cortical inhibition of bowel and  Geographic gnosia
bladder  Visiual field
 Personality/excutive function  memory
 Eye/head turn-supplementary
motor cortex
 Praxis
 Cognitive function
 Lobes
Parietal lobe Occipital lobe
 Posture and passive  Cortical Vision
mov’nt  Voluntary gaze
 2 point discrimination  Familiar face
 Stereognosis recognition/face gnosia
 Hearing
 Learning/memory
 olifaction
 Cerebral cortex
• It functions in a crossed system (the left hemisphere
controls the right side of body mov’t and vice versa)
 Cortical to cortical communication is by the association
fibers and it connects to the diencephalon by tracts .
 There are 3 main clinically relevant tracts for motor
&somatosensory function of the body-1 motor + 2 sensory
tracts that span the brain , brainstem & s.cord.
 Motor= corticospinal tract(pyramidal –descending tract)
• Anterolateral/spinothalamic & posterior column- sensory
ascending tracts via brainstem
Gross cerebral cortical structure
Cerebral cortex...
Broadmann’s representation
Motor Homunculus representation
 Corticospinal tract
 Motor neuron cell arising from motor cortex along with the
CBT and descends down to the s.cord.
 All these fibers are excitatory and uses gluatamate as a
neurotransmitter.
 They control voluntary,discrete skilled mov’nt of the distal
muscle
 These fibers arise from precentral(60%)&postcentral
gyrus(40%).
40% of it arises from broadmann area 4 and 20% from
the broadmann area 6
It descends down through different pathways
CST....
 Corticospinal tract
• CST→subcortical white matter(posterior limb of internal
capsule)→middle 3/5 of cerebral peduncle →basis pontis
→cervicomedullary junction(decussation in 70-90%) → AHC ,then
to muscle.
• The decusation continues below the pyramids and only 2% of CST
remains ipsilateral supplying the axial&proximal muscle groups.
• The extrapyramidal tracts include the basal ganglia and the
cerebellum
 Involves as circuit of CST and action initiation with coordinations
• After once in the s.cord , the CST travels posterolaterally
synapsing on the same side of alpha motor neurons of the AHCs.
 Corticobulbar tract(CBT)
• UMN arising from cortex descending with the CST
• CBT→ genu of IC →medial part of the cerebral
peduncle→basis pontis→intermixed with the CST
• Provides bilateral input to the trigeminal&hypoglossal
nerves as well to the facial nucleus supplying the upper
face muscles.
• Based on the above course, the pyramidal system can be
seen as 2 systems
 First order neurons- cell bodies at precentral gyrus
 Second order neurons-cell bodies at the AHCs
CBT...
 Internal capsule
 It is a compact white matter where efferent&afferent nerve
fibers pass to and from the cerebral cortex
 It is in continous with corona radiata and cerebral peduncle.
 Has 3 major parts(from anterior to posterior in horizontal
section)
 Anterior limb-frontopontine & corticostriatal projections
 Genu-Corticobulbar tract
 Posterior limb-Corticospinal tracts
• Thalamic radiations constitute the largest portion of the
internal capsule.
Cortical fibers descend through the internal capsule
down...
 Spinal Cord Level
 CST continues ipsilaterally down to the s.cord after
crossing at the medullary pyramids(cervicomedullary area).
 The CST as an UMN ends at the conus medullaris
level(L3) in term babies and reaches to L1-2 level by 2
months(Adult level).
 The anterior horn cell is part of the LMN
 The cord is made up of a large H –shaped central grey
matter containing many nerves and peripheral white matter
area containing many ascending and descending tracts.
 Ascending tracts= Spinothalamic and dorsal column tracts
 Descending tracts=Lateral Corticospinal tract(LCST)
Anatomy..31 paired nerves.
Lamination in the s.cord
 s.cord...
 In cervical region the spinous process of cervical vertebra
matches the corresponding cord segment
 Other regions
 Upper thoracic=2 discripancy
 Lower thoracic=3 discripancy the cord lags behind
 T11=L3 cord level
 T12=S1 cord segment
CST , Dorsal column&STT...
 Upper vs Lower motor lesions
 The classical pathway for upper motor tract is that of the
corticospinal tract along with CBT.
 Motor cortex→→Internal capsule→→Brain stem→→
Medullary pyramid(Decussation site) →Spinal cord→AHCs
 The classical Lower motor pathway,
 S.cord(anterior horn cells)→Spinal nerve
root→plexus→Peripheral nerve→NMJ→Muscle
UMN vs LMN...
Upper vs Lower motor lesions
 UMN lesions sxx  LMN lesions sxx
 Spastic  Hypotonic/floppy
 Hyperreflexia  Decreased tendon reflexes
 No dominant muscle atrophy  Muscle atrophy
unless from disuse atrophy  Fasciculations
 Babinski positive/Hoffman  No seizures
sign  Spared superficial reflexes
 Diminished or altered
superficial reflexes
 No muscle fasciculations
 Pronator drift( ?parietal lobe )
 ±Altered mental status/seizure
 Cortical Lesions
 Corticospinal tract descends through the medullary
pyramids and hence called pyramidal tract.
 CST passes in the posterior part of Internal capsule.
 Corticobulbar tract descends and supplies the brain stem.
 Extrapyramidal/Indirect systems descend from cortex to
supply the s.cord but do not directly pass in the medullary
pyramids.
 Lesion localization in the cortex is the most complex and
become easy as the lesions are very distal(like muscle)
Cortical fibers descend through the internal capsule down...
 possible features of Cortical Lesions
 Motor weakness /sensory deficit/±seizure
 Language disturbance (?dominant sphere & Presylvian
plexus)
 Altered mental status (diffuse hemispheric or bilateral
process)
 Agnosia & apraxia
 Normal cranial nerves/upper motor type uncrossed facial
weakness
 Normal bladder function unless bilateral
 Vision disturbance(cortical blindness)
 Frontal release signs( brudzinsky , kernig...)
Course of the visual fibers from the retina to the occipital cortex. A, B, C, D, E, F, and G
show the sites of various lesions that may affect the fields of vision .
Optic pathways...
 Subcortical Lesions including IC
 Usually refers to the deep white radiating fibers
 Unlike cortical lesions, subcortical lesions usually produce
diffuse signs
 Lesions here usually produce similar degree of weakness in
faces , legs and arms (can be pure motor type)
 Sometimes the language can be affected
 Higher cortical function is somehow spared
 Sensory disturbance is equal in the face/arms/legs
 Visual field cuts
 Other signs( movement disorders ,rigidity).
CST at the IC
 Lesions of the brainstem
 The brainstem is a compact site with cranial nerve nuclei ,
ascending & descending tracts with nerve fascicles closer
one another.
 Ideally brainstem is s.cord with constellation of cranial
nerves.
 Rule of 4 in cranial nerve origin
 4 above the pons- CN III&IV –mid brain
 4 from the pons -CN V-VIII -pons
 4 below the pons-CN IX-XII-medulla
 Is a pathway for Reticular activating pathways
 Brainstem lesions...

features Rule of 4
 Normal higher cortical functions
 Usually multiple CN palsies
 Crossed deficits(eg-weber sxx)
 Sensory deficit
 Altered mentation(RAS)
 Respiratory /cardiac
compromise
 Decerebrate rigidity
 Cerebellum
 Located in the posterior fossa dorsal to pons & medulla
 Separated from occipital lobe by tentorium cerebelli
 Has 3 lobes
 Anterior lobe
 Posterior lobe
 Flocculonodular lobe
• Mainly functions as coordination &control of motor
functions and tone as well.
 Cerebellar lesions
 Normal cortical functions
 Usually normal CN
 Nystagmus / dysarthria
 Ataxia/tremor
 Usually normal sensory
 No pathologic reflex or is
pendulous
 hypotonic
Cerebellar signs based on zonal parts
Area of cerebellum Clinical features
Floculonodular area Nystagmus , extraocular mov’t
disorders
Vermis(central) Gait ataxia
Hemispheric Appendicular ataxia
pancerebellar Combined features
Summary
basal ganglia ,thalami &IC
 Lesions of the s.cord
 Cervical spinal segment is the largest of all the spinal
segments followed by the thoracic segments
 Lesions of the spinal cord can produce different patterns of
weakness and sensory abnormality depending on the
site/severity.
 Patterns of lesions can be
 Complete transection/transverse
 Partial transection/Hemisections
 Central cord syndrome
 Anterior/anterior spinal artery syndrome
 Cauda equina/conus medullaris sxx
 Clinical signs of cord lesions..
 UMN signs below the level of the lesions
 Classically produce ipsilateral weakness with dorsal root
disturbance and contralateral pain & temprature
disturbance.
 Usually clear sensory level below the lesion
 Sphincter dysfunctions
 Can be sometimes mixed UMN &LMN lesions (cauda
equina sxx)
 Possible scoliosis/other deformity
 Cont...
 Upper cervical area= quadriparesis
 Lower cervical area= paraparesis with distal forearm
weakness
 Toracic &below area= paraparesis/plegia
 Sensory levels/Dermatomes
 Nipple level= T4
 Umbilicus level=T10
 Inguinal level=T12-L1
Cont....
 Posterior column
 Positions&vibrations
 Spinothalamic tracts
 Pain&Tempratue
 Autonomic dysfunctions
 Bladder-retention/incontinence/neurogenic bladder
 Bowel-constipation/incontinence
 Possible blood pressure changes
 Change in sweating
 S.cord...

 A=Brown –sequard sxx

 B=Complete transsection
 S.Cord lesion syndromes
Site Clinical signs
Transverse myelitis Complete loss of both motor and sensations
Flaccid/areflexia=acute shock state
UMN lesion sign=later on
Bladder dysfunctions
Hemisection(BSS) Ipsilateral motor deficit with position and vibration
disturbance
Contralateral loss of pain and temperature sensations
Central cord sxx Dissociated sensory loss(spares the post.column)
Cape sensory loss(cervical area)

Anterior cord sxx Weakness, loss of bowel&bladder functions,

pain&temprature sensation
Spares the post .column
Cauda equina sxx Mixed lesions , saddle pain & temprature loss
S.Cord lesions...
S.cord sxx..
Sphincter disturbances in s.cord lesions
 Approach to Hemiplegia/paresis
1-Determine the facial weakness pattern
2-compare weakness of the upper and lower limb
3-other signs/symptoms of dysfunction
 Sensory/language/seizure
 Anosognosia(denial of self condition)/homonymous
hemianopia
 Hemiplegia...
Above the upper pons
 Hemiplegia/paresis
 Uncrossed supra nuclear facial palsy(paralysed lower face
same side to the hemiplegia)
 Sensory deficit
 Aphasia/seizure
 The Lesion is likely at Motor cortex, corona radiata &IC
 The upper pons and cerebral peduncle lesions can also
cause the above features.
facial and extremities ...uncrossed
 Cont...
• Fascioscapular dominance paresis(UE+face>>>LE)
 Lateral part of corticosubcortical lesions
• Crural dominance paresis(LE>>>UE+face)
 Paracentral region(more medial)
• If the paresis is UE=LE=face
 Likely in the Internal capsule
• Pure motor paresis can occur in
 Sometimes in the IC
 Basis pontis ,cerebral peduncles & medullary pyramids
 Cont...
 Crossed lesions –brainstem lesions
 Ipsilateral cranial nerve palsy with contralateral weakness
 paraplegia/paresis...
For paraparesis/plegia , the lesion can be
 Cerebellum like in parasagittal masses
 Cervical/thoracic level cord lesions
 Peripheral causes(GBS....)
 A very medial bilateral lesions over the leg cortex area
or bilateral anterior cerebral artery stroke or sagittal
sinus thrombosis
References
Neurology and Clinical Neuroanatomy , Aaron
L.Berkowitz ,MD,PHD, 2016
Bradley’s Neurology in clinical practice ,6th edition
Dejong’s Neurologic Examination ,7th edition
Clinical Pediatric Neurology,Gerald
M.Fenichel,2009
Localization in Clinical neurology,5th Edition,2007
THANK YOU!!!
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