Clinical case strategy workshop week 5 Flashcards
State the cause for pts symptoms/name of disease. Explain the cause of each finding. State the location of the lesion.
Patient presents with difficulty walking and R leg weakness
Exam:
- R leg weak with increased tone, brisk reflexes, and upgoing toes (Babinski sign)
- Loss of vibration, position sense, and 2-point discrimination on the right, below the T7 dermatome
- Loss of pain and temperature sensation on the left, below the T9 dermatome
- Loss of all sensory modalities and muscle twitches on a thin strip along the right abdomen
Brown-Sequard Syndrome (spinal cord hemisection)
Complete anesthesia at T7?
T7 dorsal root
Any lower motor neurons directly damaged?
T7 ventral root – abdominal fasciculations
Spastic paralysis? Upper or lower motor neuron?
Corticospinal tract disruption – UMN
Why is the pin level (sensory level) below the lesion (T9)?
Fibers in the tract of Lissauer spared – 1-2 levels above/below lesion
Lesion at T7 on right side of spinal cord
State the cause for pts symptoms/name of disease. Explain the cause of each finding. State the location of the lesion.
Patient complaining of:
- Vertigo, nausea, and vomiting
- L face numbness
- Hoarse voice, trouble swallowing
- Left hand incoordination
- Hiccups
Exam:
- Imbalance with sitting and standing due to vertigo
- L eye – miosis (small pupil) and ptosis (lid droop)
- Horizontal/rotatory nystagmus, increased when looking to the right
- Absent L gag reflex
- Drooping L soft palate
- L face loss of pain/temperature
- R arm/body/leg loss of pain and temperature
- L arm & leg ataxia (incoordination)
Laryngoscopic Exam:
-Left vocal cord paralysis
Lateral Medullary Syndrome (Wallenberg’s Syndrome)
Ipsilateral
- Vertigo, nausea/vomiting - vestibular nuclei
- Gag (dec taste) - solitary nucleus/tract
- Horner’s syndrome – descending sympathetic fibers
- Limb ataxia - inf. cerebellar peduncle
- Facial temperature & pain loss – spinal trigeminal tracts
- Palate and vocal cord paralysis – CN 9 & 10
- Hoarseness, dysphagia - nucl. Ambiguus (CN 9/10)
Contralateral
-Body pain and temperature loss - spinothalamic tr.
Blood vessel?
Posterior inferior cerebellar artery (PICA) Usually branches off the ipsilateral vertebral artery
Why is light touch still intact on the face, but pain and temp affected?
The chief or principal trigeminal nucleus and mesencephalic trigeminal nucleus (light touch) are in the pons, while the spinal trigeminal tracts (pain/temp) run down from the caudal midbrain into the lateral medulla
What about motor and light touch to the rest of the body?
Pyramids and medial lemniscus run medial to the lesion
Brainstem damage causes sensory and motor deficits on the same side of the face/head and the opposite side of the body. The exception to this is the descending hypothalamics that travel in the lateral brainstem to innervate sympathetic preganglionics in the thoracolumbar cord-lateral brainstem lesions cause ipsilateral Horner’s syndrome.
State the cause for pts symptoms/name of disease. Explain the cause of each finding. State the location of the lesion.
Patient presents with weakness and numbness in both legs, as well as inability to urinate
Exam:
- Weakness and spasticity in both legs, increased reflexes and upgoing toes in both legs
- Loss of pain and temperature sensation bilaterally, at T7 and below on both sides
- Intact vibration and proprioception everywhere
- Band of fasciculations on the abdomen, approx T6-T8
Anterior Spinal Artery Syndrome
Is the lesion peripheral, spinal or intracranial?
Spinal (T6 level)
Why is the sensation of pain and temperature lost, but preserved for touch?
Involvement of spinothalamic tracts but sparing the dorsal columns
What about the fasciculations?
Damage to the anterior horn cells at the level of the lesion
Explain the bladder problems
Upper motor neuron control of the urinary sphincter
What is the location of the lesion?
Anterior thoracic cord
State the cause for pts symptoms/name of disease. Explain the cause of each finding. State the location of the lesion.
Patient presents complaining of weakness and double vision
Exam:
- Right eye ptosis, eye deviated inferior/laterally
- Fixed, dilated R pupil
- Spastic weakness and hyperreflexia of the left arm and leg, as well as weakness of the left lower face (sparing the forehead and eye closure)
- Resting tremor of the left hand
Weber syndrome (older name is superior alternating hemiplagia)
Explain the eye findings
Complete R third nerve palsy, including both oculomotor and parasympathetic fibers
Is this an intraaxial (brainstem) or extraaxial (brain) lesion?
Intraaxial because of long-tract involvement
Likely the third nerve fascicle affected, not the nerve itself
Why is the weakness on the opposite side from the eye findings?
Corticospinal decussation occurs lower down (medulla)
What about the tremor?
Hemibody parkinsonism from involvement of the contralateral substantia nigra (Remember that basal ganglia project to the ipsilateral cortex but because the motor cortex controls the contralateral side of the body, basal ganglia symptoms present contralateral to the lesion)
Where is the lesion?
Right ventral midbrain, affecting the cerebral peduncle
Blood vessel involved (classically)
Paramedian branches of either PCA or top of the basilar
Spares sensory fibers (both spinothalamic and lemniscal), which are in the dorsal/lateral midbrain
State the cause for pts symptoms/name of disease. Explain the cause of each finding. State the location of the lesion.
Patient presents after suffering a third degree burn - picked up something hot without realizing it, felt no burning nor pain
Exam:
- Severe, third degree burn on the right hand. Scars on both arms and hands from previous injuries, amputated thumb
- Complete loss of pain and temperature sensation in both shoulders, arms, hands and the upper portion of the chest, front and back
- Intact sensation above the shoulders and below the nipples on both sides
- Mild to moderate atrophy and weakness of small hand muscles bilaterally, occasional fasciculations in the hands and forearms
Central cord syndrome
Is the lesion peripheral, spinal or intracranial?
Spinal
What is the level of the lesion?
Between C-5 and T-1
Why is the sensation of pain and temperature lost, but preserved for touch?
Pain/temp fibers cross in the center of the cord, other fibers uncrossed and laterally located
Explain the atrophy and fasciculations.
Extension to lower motor neurons (ventral horn/roots) at C8-T1
Why no symptoms below the level of the lesion?
Spared spinothalamic tracts, only affects central crossing fibers at affected levels
What is the location of the lesion?
Central cervical cord
Syringomyelia: Fluid filled cavity in the spinal cord
Spinal cord tumors
Congenital abnormalities of the craniocervical junction
Post-traumatic
Delayed sequela of approx 1% of spinal cord injuries
Symptoms can begin anywhere from a few months to up to 30 yrs after injury (avg of 9 years)
Patients present with central cord syndrome that can progressively worsen or spontaneously stabilize
Other causes of central cord syndrome: multiple sclerosis, Devic’s, or intramedullary spinal cord tumor
