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The foundations of clinical neurology include anatomy and physiology, the patient
history, the neurologic examination, and the intellectual exercise of identifying where in
the nervous system is the site, and what is the nature of the pathology.
THE INTERPRETATION OF PHYSICAL SIGNS FOUND UPON CLINICAL
EXAMINATION OF A PATIENT WITH NEUROLOGICAL PROBLEMS DEPENDS
HEAVILY UPON YOUR PRACTICAL KNOWLEDGE OF NEUROANATOMY!
In order to for the physician to come up with a differential diagnosis, a correct diagnosis,
and a prognosis for pathology and diseases affecting the nervous system, two questions
need to be answered: Where is the lesion? and What is the lesion? The information
in this handout is intended as an introduction to clinical thinking to help you in the CASEBASED PROBLEM SOLVING exercises which are a scheduled activity of the Brain and
Behavior I course.
SOME DEFINITIONS
Lesion-a zone of localized dysfunction within the CNS or PNS and may be anatomic
(structural damage) or physiologic (absence of demonstrable anatomic abnormalities).
Differential diagnosis-the process of making a diagnosis by comparing and analyzing
the similarities and differences between the signs, symptoms, and other findings
associated particularly with two or more diseases sharing certain characteristics; similar
conditions are systematically eliminated from consideration
SOME GENERALIZATIONS
Manifestations of neurologic disease by be negative (loss of function) or positive
(abnormalities resulting from inappropriate excitation). Some neurological disorders
affect primarily gray matter, others affect primarily white matter, and some disorders
affect both gray and white matter. Neurologic disease can result in syndromes (a
constellation of signs and symptoms frequently associated with each other and suggest
a common origin). Many pathologic processes result in lesions that are larger than any
single nucleus or tract. In these cases neighborhood signs (combinations of signs and
symptoms) may help to localize the lesion. Dysfunction of the nervous system can be
CLINICAL CORRELATIONS
Think of the nervous system as you
would an electrical circuit (later we
will call these wires line segments).
The longitudinal systems (motor and
sensory) lead to and from the cerebral
hemispheres and conduct impulses
from one segment to another.
Segmental wires (nerves) come
off of these intersegmental cables.
If there is damage to an intersegmental
cable, there will be a loss of function
beyond that point. Damage to a
segmental wire will result in a
loss of function confined to that
individual segment.
Major nervous system connections. (A), cranial
nerves; (B), spinal nerves. Note the long
intersegmental pathways leading to and from higherSEGMENTAL PATHWAYS
centers and multiple, short segmental pathways
(cranial and spinal nerves) to the peripheral level.
INTERSEGMENTAL PATHWAYS
LOCALIZATION is determined by the level of the nervous system in which the pathway
function is interrupted. To aid in localization, the functions of each of the major
anatomical levels are summarized below:
LEVEL
SUPRATENTORIAL
POSTERIOR
FOSSA
SPINAL
PERIPHERAL
CLINICAL FINDING
SIDE OF LESION
COMMON
SEGMENTAL SIGNS
OF THE LEVEL
Vision
Olfaction
Cognition
Memory
Intelligence
Behavior
Seizures
Hearing
Tinnitus
Vertigo
Diplopia
Dysarthria
Dysphagia
Neck/back pain;
findings related to
specific spinal level
Limb pain without back
pain; loss of sensation
and muscle weakness
in distribution of a
nerve
EXAMPLE 2:
A patient is found to have the following: (1) reduced pinprick sensation on the left
forehead and (2) reduced pinprick sensation on the palmar surface of the little
finger of the right hand. Where is the lesion?
EXAMPLE 3:
A patient is found to have reduced vibration sense in the left foot and reduced
pinprick sensation on the palmar surface of the little finger of the right hand.
Where is the lesion?
EXAMPLE 4:
A patient is found to have reduced vibration sense in the left and right foot and
the left and right hand. Where is the lesion?
This page and the following page are to help you begin developing a
vocabulary for lesion localizing as you work through case-based problems.
THE LOCATION OF LESIONS
The following is a systematic survey of the nervous system with examples of lesions that
can be located in the following anatomic sites. It is by no means all-inclusive.
Roots: segmental motor deficit (may be mediated through several nerves if a plexus
lesion); sensory difficult due to dermatomal overlap
Spinal cord: decussation pattern is staggered for fine touch and pain and
temperature-permits localization within the cord; LMN signs and symptoms at the
level of injury with UMN signs and symptoms below the level of injury
Brainstem: functional deficits of the long tracts and cranial nerve signs and
symptoms can localize the lesion to the medulla, pons, or midbrain
Diencephalon: hypothalamus-endocrinologic and visual abnormalities; thalamussensory and motor dysfunction; subthalamus-dyskinesias (hemiballism);
epithalamus- compression of the cerebral aqueduct (hydroencephalus)
Tumors: primary tumors of brain and spinal cord directly invade and destroy brain
tissue; hydroencephalus from compression of the ventricular system; progresses
over weeks, months, or years
Demyelinating diseases: can produce multiple lesions in the CNS white matter
SELECTED REFERENCES
Adams, R.D., Victor, M., and Ropper, A.H. Principles of Neurology. (6th edition). New
York: McGraw-Hill. 1997.
Brazin, P.W., Masdeu, J.C., and Biller, J. Localization in Clinical Neurology. (3rd edition).
Boston: Little, Brown and Company (Inc), 1996.
DeMeyer, W.E. Technique of the Neurologic Examination. (4th edition). New York:
McGraw-Hill, Inc. 1994.
Fitzgerald, M.J.T. Neuroanatomy: Basic and Clinical. (3rd edition). Philadelphia:
Saunders and Company. 1996.
Plum, F., and Posner, J.B. The Diagnosis of Stupor and Coma. (3rd edition). Philadelphia:
F.A. Davis Company. 1982.
Ross, R.T. How to Examine the Nervous System. (3rd edition). Connecticut: Appleton and
Lange. 1999.
Wilkinson, I.M.S. Essential Neurology. (3rd edition). Oxford: Blackwell Science. 1999.
Patten, J. Neurological Differential Diagnosis. (2nd edition). New York: Springer-Verlag,
1996.