Pyramidal Syndrome

Question 1

Define Pyramidal Syndrome

Answer 1

Group of motor deficits and clinical signs resulting from damage of the corticospinal and coricobulbar tracts which play a crucial role in the control !of voluntary! movements

Question 2

What part of the CNS is affected in Pyramidal syndrome?

Answer 2

Precentral gyrus and its coriticospinal (anterior and lateral) as well as the corticobulbar tracts

Question 3

In 1 sentence what is the corticospinal tract

Do the same for the corticobulbar tract

Answer 3

Theyre both involved in voluntary movements. Corticospinal is for the body and corticobulbar is for the face, head and neck

Question 4

List 5 causes of Pyramidal syndrome

Answer 4

Stroke/TIA
MS
TBI/spinal cord injury
Brain tumour/lesion/haematoma
Infectious (HIV-related encephalopathy)
Cerebral palsy
Neurodegenerative diseases

Question 5

Pyramidal syndrome is characterised by 4 features. What are they?

Answer 5

1) Weakness
2) Hyperreflexia/increased deep tendon reflexes
3) Spasticity (increased tone)
4) Babinski sign positive

Question 6

In a general sense, what movements are preserved and what movements are lost/weakened in pyramidal syndrome?

Answer 6

Preserved: UL flexion and pronation. LL Extension

Weakenes/loss: UL extension and supination. LL flexion

Question 7

A patient had a stroke and has a pattern of symptoms consistent with pyramidal syndrome. What position will you find the patient in?

Answer 7

They will have their UL flexed and pronated while their LL fixed in extension.

Question 8

How do you assess for spasticity

Answer 8

Quick movements would elicit a catch of the opposite movement. e.g. when extending arm quickly, there will be a catch in flexion preventing extension (in pyramidal syndrome)

Question 9

A patient says they have a stiff leg. How would you assess for it

Answer 9

Tested by rolling the leg. Normally should be loose and wiggly whereas in this case it will be stiff like rolling a log

Question 10

A patient is walking towards you and you immediately notice that they likely have pyramidal syndrome. What do you see?

Answer 10

Circumductive Gait. Patient swinging leg when walking because its so stiff. Remember everyhting int he lower limb is in extension.

Question 11

How do you assess for ankle clonus

Answer 11

Ankle clonus +ve when there is 3 or more sustained beats (plantar flexion)

Question 12

Trace the path of a reflex and how it is affected in pyramidal syndrome

Answer 12

Stretch receptors of a tendon is stimulates
The afferent sensory neuron sends the signal to the spinal cord (posteriorly at the dorsal root).
In the spinal cord, the sensory neuron synapses with an Interneuron (or directly with the motor neuron in simple reflexes). This interneuron, governed by a UMN normally inhibits the signal to modulate the reflex, however in pyramidal syndrome, the UMN is compromised => interneuron fails to inhibit the synapse => hyperreflexia
The signal is then transferred via the motor neuron at the ventral horn anteriorly to the muscle or effector

Question 13

If I have a stroke on my right side. Where will my eyes be?

Answer 13

They will look towards the pathology (think of it as a deficit). If I had a seizure, I would be looking away from the pathology as there is increased activity

Question 14

You are performing an examination on a patient with suspected pyramidal syndrome. How will you assess and what findings are you expecting elicit to confirm?

Answer 14

1) Spasticity: UL extension, supination. LL flexion. These movements must be done fast to show the spasticity. We would expect a “catch” in the opposite direction

2) Tone: Tested by rolling the leg. Normally should be loose and wiggly whereas in this case it will be stiff like rolling a log

3) Gait: Circumductive Gait

4) Hyperreflexia/increased deep tendon reflexes

5) Ankle clonus: +ve when there is 3 or more sustained beats (plantar flexion)

6) Eyes:

Question 15

If a lesion occurs in the dominant hemisphere, what additional symptoms may the patient experience?

Answer 15

Left sided in most people. There will be speech and behavioural changes as well as aphasia and apraxia

Question 16

If I have a stroke on my left side. I would have motor deficit on which side?
How about cranial nerves?

Answer 16

Contralateral motor deficit while there is ipsilateral cranial nerve deficit (with exceptions in VII, XI, XII)

Question 17

Typically in a stroke causing pyramidal syndrome, the ipsilateral cranial nerves are effected. What are the 3 exceptions?

Answer 17

Cranial nerve VII: UMN causes contralateral lower facial weakness (LMN ipsilateral whole face)
Cranial nerve XI (Contralateral SCM but ipsilateral shoulder elevation/trapezius)
Cranial nerve XII (Contralateral tongue weakness)

Question 18

If I ask a person, with a left MCA stroke with a pyramidal pattern, to stick out their hands in front of them, what will occur?

Answer 18

Left sided stroke, therefore right sided weakness =>right upper limb will not be raised (or at least show obvious weakness)

Question 19

anatomically, where would the lesion be if there is contralateral symptoms?
What about ipsilateral symptoms?

Answer 19

Contralateral sx: lesion between pre-central gyrus and medulla

Ipsilateral sx: lesion between the medulla and spinal cord