Clinical correlations - Notes (all sections) Flashcards
Damage to dorsal and ventral cochlear nuclei sx
deafness in ipsilateral ear
deafness in ipsilateral ear
X dorsal and ventral cochlear nuclei in medulla X auditory portion of CN 8
damage to vestibular nuclei (in medulla)
nystagmus, vertigo, problems with balance
loss of gag reflex on the affected side
CN 9 X
CN 10 damage sx
- hoarseness due to loss of control of larynx
- problems swallowing
- asymmetry of soft palate
Why is bilateral loss of CN 10 devastating?
choking (nucleus ambiguus) loss of parasymp. control to the heart and gastrointestinal tract (nucleus ambiguus and dorsal motor nucleus of CN 10).
CN 11 damage sx
- inability to elevate ipsilateral shoulder 2. difficulty to turn head 3. fasciulation and atrophy of sternomast. and trapezius
CN 12 damage sx
- deviation of tongue towards side of weakness 2. paralysis of ipsilateral tongue muscles 3. fasciulations and atrophy of tongue muscles ipsilaterally
Loss of discrete somesthetic infromation on same side of the lesion
damage to both the DORSAL FUNICULUS and DORSAL PART OF LATERAL FUNCIULUS
Before they cross, axons of the anterolateral system usually pass through the ____
lissauer’s tract
Axons of the anteriolateral system cross in the _____
anterior white commisure
dissociated sensory loss is a symptom of dmaage to the ____
spinal cord pain and temp is on one side, fien touch, vibration, and joint position on another
damage to this pathway anywhere at its length can cause horners syndrome
hypothalmoreticulospinal pathway
termination of the hypothalmoreticulospinal pathway
interomediolateral cell column
cause of flaccid muscle, hypothonia, hyporeflexic, fascuulations
lesion of peripheral nerve, or early UMN X
UMN injury involves damage to the
brains descending motor pathways
what can happen early with UMN injury?
flaccid paralysis, then become hyperreflic and hyerptonic (spastic paralysis)
positive bainksi response is seen with
UMN injury
The Babinski response (positive Babinski reflex) is seen again with ____ tract damage
corticospinal, since the corticospinal tract is no longer surpressing spinal reflex
Pinealoma sx?
- Problems sleeping - Tinnitis (? X inferior olive) - Papilledemia (hydrocephalus by blocking the cerebral aqueduct)
ddK is _____ injury
lateral cerebellar
nystagmus, balance problems, wide based gait can be explained by ____ injuey
medial cerebellar injury
intention tremor is ____ injury
lateral cerebellar
pupillary light reflex is mediated by ____ areas
pretectal areas
upward gaze requires an intact _____
posterior commisure
what can cause loss of pupillary light reflex and loss of accommodation reflexes?
loss of both pretectal regions
pupillary light reflex requires damage to
both prectatal regions or damage to LMN occulomotor nerve
deafness in one ear
CN VIII peripherally meaning medulla
completel paralysis of the face
LMN CN 7 meaning pons
internal strabismus
LMN CN 6 meaning pons
External strabismus
LMN CN 6 meaning pons
You should never shift a dx ____ to accomodate additional reported sx.
caudally (down) — (so X usually is at the level of the highest sx)
If sx are in the head, this usually rules out ____
spinal cord injury EXCEPT with horners
If symptoms persist overtime and are unilateral it is likely caused by a ____
tumor
Diseases or tumors are usually bilateral?
disease
If the lesion is in the spinal cord, then what can be said about all sensory and motor sx?
they are on the same side as the X, except with pain and temperature
If lesion is in the brainstem, the lesion is on the SAME side as the ____
highest symptom; lower sx will be on the opposite side
if the X is in the FOREBRAIN, all sensory and motor sx are on the ____ of the body as the X.
OPPOSITE… except for olfactory
if the X is in the FOREBRAIN, all sensory and motor sx are on the ____ of the body as the X.
SAME
X to the ___ can cause prosposagnosia
inferior temporal lobe
bilateral X to parahippocampal gyrus and uncus can lead to?
amnesia
bilateral X to heschl’s gyrus would produce
inability to understand spoken language
unilateral X to hescls gyrus would produce
little sx
what could cause inaiblity to understand spoken lanauged?
bilateral X to heschls gyrus OR left auditory cortex and corpus callosum X
lesion in the optic chiasm causes?
a loss of vision in the temporal half of both visual fields: bitemporal hemianopsia
what does X in optic nerve cause?
loss of vision in affected eye, loss of pupillary reflex
what does X in the optic tract cause?
A lesion of the right optic tract causes a complete loss of vision in the left hemifield: contralateral “homonymous” hemianopsia.
what sx to X of the precentral gryus?
paresis (weakness) and movement deficits on the OPPOSITE side of the body
what are sx to X of the postcentral gyrus?
somatic sensory deficits (e.g. loss of touch, limb position) on the OPPOSITE side of the body.
X to the superior and middle frontal gyri?
premtoor area; forms of apraxia, if in dominant hemisphere the ability to write is impaired
X to the superior parietal lobule causes what sx?
it is controlled with guiding movement sx are apraxia, inability to bring object under control of movement
X to the inferior parietal lobule can cause ___
the inability to read (since angualr gyrus is the gateway for visual info to reach wernickes)
X to the inferior frontal gyrus
contians brocas area, leads to the inability to generate fluent speech
how to test for CN 4 palsy?
have pt look nasal, if he cannot look down he may have trochlear nerve palsy. may also have double vision in nasal position.
unilateral LMN CN 7 X symptoms
motor deficits in half the face on the affected side
lesions to what notably impact the ability to write
superior and middle frontal lobes (premotor areas)
What supplies blood to brocas area?
MCA
What supplies blood to the areas of the temporal lobe involved in memory?
PCA
What supplies blood to the leg and foot areas of primary motor and primary somatosensory?
aca
what supplies blood to the primary visual cortex
PCA
cause of socotomas
X in the occipital lobe (in half of the visual field contralateral to vision)
sx of occipital lobe X
scotoma (blind spots) in half of the visual field opposite the lesions
pt gets lost in his own home, displays neglect to one half of his body
inferior parietal lobule
deep, compulsive repretitive behaviors may be due to damage to the
prefrontal cortex, often seen with personality changes
wallenbergs syndrome is seen with ___ occulusion
PICA
sx with PICA occulsion
Wallenburg’s syndrome: vertigo, loss of balance, ipsilateral “cerebellar signs”, loss of facial pain sensation, hoarseness
sx with Basilar branch occulusion
paralysis and loss of sensation in the face, body and limbs; can also affect eye movements and cause diplopia
sx with AICA occulusion
ipsilateral cerebellar signs, facial paralysis, ipsilateral hearing loss, loss of pain and temp over face ispilaterally
what occuluded vessels can you see ispilateral cerebellar signs?
aica, pica, superior cerebellar
sx with superior cerebellar stroke
ipsilateral cerebellar signs, contralateral pain and temperature loss, Horner’s
what sx with unilateral PCA stroke
blindness in the visual field OPPOSITE to the affected side, alexia (left side).
what sx with bilateral pca stroke
if bilatera,l as with “top of the basilar” occlusion: bilateral blindness, memory loss, somatosensory loss, coma & death
sx with posterior communicating stroke
contralateral paresis, coma & death
sx with aca stroke
contralateral paralysis and sensory loss in leg and foot; sometimes, apraxia
sx with MCA stroke
contralateral apralysis and sensory loss apraxia aphasia partial blindness
rigidity signals ___ damage
basal gang.
what is akinesia? what damage does it signify?
difficulty initiating movement
signs of increase intercranial presure
- retinal vessels of optic nerve enorged – optic nerve becomes DILATED (papilledema) - headache -nausea vomitting cognitive impariment LOC
with increase intercranil pressure FRONTAL LOBE FUNCTION is often compromised causing
unsteady gait where the foot barely leaves the floor (magnetic gait) incontinence
In multiple sclerosis, the ____ content of CSF is disproportionately increased
gamma globulin (protein)
what do X of the posterior limb cause?
dramatic symptoms of sensory loss and paralysis.
what does loss of epicritic sense entail?
loss of 1. sterogenesis (cant recognize tactile shapes in hand) 2. position sense - can lead to shuffling gait, reaching inaccuracies 3. loss of vibration - insesntive to high frequency stimulation 4. simpe touch intact but sensitivity decreased
what deep white matter tract connects brocas, wernickes, and the auditory cortex
superior longitudinal fasiculus
____ interconnects orbital frontal cortex-based reward and punishment centers with temporal lobe-based memory representations.
uncinate fasciculus
damage to the posterior comissure could lead to problems with
pupillary light reflex and upward gaze
same side loss of protopathic can be seen with X to ___
ALS 1. dorsal root axons 2. lissaeurs tract or dorsolateral fasciulus 3. dorsal horn
opposite side loss of protopathic can be seen with X to ___
ALS - 1. anterolateral tract in spinal cord 2. ALS synapsing in the brainstem 3. VPL, DM, intalaminar in thalamus 4. post central gyrus
loss of protopathic sx include
Reduced pain Reduced sense of warming or cooling skin Simple touch intact but reduced in sensitivity
positive babinksi indicates ___ sign
UMN
no muscle atrophy indicates UMN or LMN sign?
UMN
dorsal peripheral nerve damage causes
loss of sensation and then weakne mvoement then atrophy and fasciulations as the muscle are dying
Weakness or outright paralysis cof central descending tracts will cause
first hypotonia (sudden loss of descending connections) then hypertonia
LMN weakness is weakness of the
peripheral motor nerve
UMNC weaknes is weakness of the
central motor pathways
the entire ipsilateral face is paralyzed with
LMN facial nerve damage (to nuclei or nerve)
UMN damage to facial nerve will cause
lower quadarant to be damaged on the opposite side
UMN damage of CN 7 includes damage to the
forebrain, corticobulbar tract damage rostral to the pons
when the motor cortex or cingulate area is damaged, or the cortico-bulbar pathway on one side of the brain is damaged rostral to the facial nucleus, the remaining____ axons can compensate so little deficit is noted.
cortico-bulbar
Ipislateral loss of epicritic sense can occur from X of the
Dorsal column/lemniscal sys.
- dorsal root axons
- gracile or cuneate fasiculus (spinal cord)
- gracile or cuneate nuceli (medulla)
Contralateral loss of epicritic sense can occur from X of the
- medial lemniscus going up the medulla, pons, midbrain to thalamus
- VPL in thalamus
- post central gyrus
what does loss of epicritic sense include?
loss of
- sterogenesis (cant recognize tactile shapes in hand)
- position sense - can lead to shuffling gait, reaching inaccuracies
- loss of vibration - insesntive to high frequency stimulation
- simpe touch intact but sensitivity decreased
why is EPICRITIC information coming into the spinal cord suspectible to injury?
it comes in as large diameter dorsal root axons – vulnerable to insult from ischemia, toxicity, bacteria, etc
so: early sx of peripheral nerve disease shows as epicritic
ipsilateral loss of protopathic informaiton is seen witn
ALS
- dorsal root axons
- lissaeurs tract or dorsolateral fasciulus
- dorsal horn
spinocerebellar carries ___ information from the ___
proprioceptive (muscle and joint position) from the trunk and limbs
ipislateral loss of propathic from head and neck
caused by X of
- spinal tract of CN 5
- spinal n. of 5 in the medull
contralateral loss of propathic from head and neck
caused by X of
- after the spinal nulceus in the medulla (where it crosses) so a pons or midbrain region
- in the vpm
loss of proprocpetive from face on the same side can be due to
X trigmeminal nerve
X mescephalic nucleus of 5
X menscephalic tract of CN 5
X motor n. of 5 in the pons
X cerebellum
loss of chewing on the same side can be caused by
X motor n. of 5 in the pons
X trigeminal nerve
corticobulblar controls hypoglossal cranial nerve ncueli mostly
contralaterally
corticobulblar controls facial cranial nerve ncueli mostly
both
The bilateral projections from the surviving CB can sustain considerable movement on both sides of the patient
Usually only the___ and ___ are affected by a unilateral CB lesion
tongue and face (CN 7)
damage to the corticospinal in the brainstem therefore impairs movement mainly on the ____ side of the body.
opposite
since mostly lateral corticopsinal which crosses and the pyrmida decessations
unilateral patholgoy of the corticobulbar tract sx
will weaken movement of the head and neck opposite of the X
does not significantly weakend since most cn actually get bilateral input from CB
damage to lateralc orticiospinal tract occurs with
X to the tract below the pyramids decussations in the medulla
In the few surgical case studies of isolated CS damage (lesion of the medullary pyramid), the sx were
modest: temporary weakness, permanent Babinski’s sign, and permanent loss of independent finger movements.
mostly the pyramidal tracts are damaged with the brainstem tracts so sx area outright pralysis
Frontal lobe lesions often cause ___
severe paralysis because the precentral (motor) and premotor areas of cortex contribute to both direct and indirect motor pathways
damage to a Brainstem-spinal pathways at the level of the medulla wiill cause
problems with movement on the opposite side of the body
damage to a Brainstem-spinal pathways at the level of the spinal caord wiill cause
problems with mvoement on the same side of the body
damage to the temporal lobe could damage ___ visual field
upper visual field
Consequently damage to the parietal lobe or superior bank of visual cortex can result in scotomas in the _____ visual field.
lower
loss of endinger westphalnucleus will lead to a
dilated pupil that fails to constrict to light
if pt has hearing loss in one ear it must be to
CN 8 or cochlear nuclei
what lesions could results in an inability to understand spoken language
X hescls gyrus in both hemispheres, damage to the left auditory cortex, damage to corpus callosum (since heschls on right and left communicate through this)
damage to optic nerve – effect on pullairy light reflex
+ light in pislateral eye
Damaged optic nerve – light in ipsilateral eye =
NO direct, NO consensual
damage to optic nerve – effect on pullairy light reflex
+ light in contralateral eye
Both direct and consensual INTACT
damage to occulomotor nerve/EW nucelus
+ light in ipsilateral eye effects
= NO direct, but the consensual is INTACT
Damaged oculomotor nerve /EW nucleus
+ light in contralateral eye =
Direct INTACT, NO consensual
Damage to medial midbrain (ie. Bilateral Pretectal nuclei and/or both EW nuclei)
NO direct, NO consensual
C
input?
what does damage to this cause?
inferior cerebellar peduncle
receives input from opposite infeiror olive nulcei in medulla
often seen with PCA stroke. damage causes
- ataxia
- intention tremor to the ipsilateral side of the body
- lean towards side of the lesion
- clumsiness of ipsilateral hand
Damage to the _____ medulla rostral to the pyramidal decussation will result in motor loss on the OPPOSITE side of the body.
ventral
damage to the corticobulbar tracts will have ____ effects on cranial nerves
contralateral * except for hypoglossal
The bulk of cortibobulbar axons control cranial nerve nuclei on opposite side the origin of these axons in the cortex
ROmberg’s sign
what is it
what causes it
loss of balance more proncounced when patients eyes are closed
seen with vestibular nuclei damage in the pons
X facial nucelus in the pons
- paralysis of ipsilateral facial muscles
- drying of cornea due to loss of parasymps of lacrimal
- loss of corneal reflex
- painful sensitivity to sound due to weakness of stapedius
lesions to corticobulbar axons projecting to the facial nucleus
contralateral facial paralysis below the forehead
