WHERE’S THE

LESION?
Why,…. Sign and Symptom!!!
Neuroscience Core Lecture
Anwar Wardy, MD.Neu
Department of Neurology
FKK UMJ

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ALL OF COMPLAINTS NEUROLOGIC IN
ORIGIN

Where’s the lesion, ????

……… somewhere in the
neuraxis.

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 DIVISIONS OF THE NEURAXIS

Cortical Brain Neuromuscular

Subcortical Brain Junction
Brainstem Muscle
Cerebellum
Spinal Cord
Root
Peripheral Nerve
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 OFF THE TOP OF MY HEAD . . .

Imbalance = Cerebellum

Pneumonia = Brainstem (related

dysphagia)

Loss of Dexterity = Peripheral Nerve

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 NEUROLOGIC EXAMINATION

Higher Cortical Function

Cranial Nerves
Cerebellar Function
Motor
Sensory
Deep Tendon Reflexes
Pathologic Reflexes

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 THE NEURO EXAM SHOULD
EVALUATE THE ENTIRE NEURAXIS

Higher Cortical Function: cortex

Cranial Nerves: subcortex, brainstem
Cerebellar Function: cerebellum
Motor: motor homonculous, subcortical
pyramidal tracts, BS, cord, radicle, PN, muscle
Sensory: ascending tracts, thalamus, subcortical
tracts, sensory hononculous
Deep Tendon Reflexes: afferent PN, radicle,
cord, efferent PN, muscle
Pathologic
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 SCOTT’S EXAM SHOWED:

Higher Cortical Function: normal

Cranial Nerves: oropharyngeal dysarthria
Cerebellar Function: hypotonia, assynergy,
dysmetria, staccato dysarthria, intention tremor,
appendicular ataxia
Motor: hypotonia, normal strength
Sensory: decreased vibration and temperature
Deep Tendon Reflexes: areflexia
Pathologic Reflexes: plantar flexing
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 SO WHERE’S THE
LESION?

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 Goals of MD Testing

Localization Severity

Muscle NMJ Nerve Anterior Horn

Fiber type Pathology Temporal

anwar wardy w course
Adapted from fig 1-2, Preston and Shapiro fkk umj 2011
 Brain component

Cerebral cortex
Cerebral cortex

Basal nuclei
(lateral to thalamus)
Basal nuclei

Thalamus
(medial) Thalamus

Hypothalamus
Hypothalamus
Cerebellum
Cerebellum

Midbrain
Brain stem
Brain stem Pons (midbrain, pons,
and medulla)
Medulla Spinal cord
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BRAIN COMPONENT MAJOR FUNCTIONS
1. Sensory perception
Cerebral cortex 2. Voluntary control of movement
3. Language
4. Personality traits
5. Sophisticated mental events, such as thinking memory,
decision making, creativity, and self-consciousness

Basal nuclei 1. Inhibition of muscle tone

2. Coordination of slow, sustained movements
3. Suppression of useless patterns of movements
1. Relay station for all synaptic input
Thalamus
2. Crude awareness of sensation
3. Some degree of consciousness
4. Role in motor control
1. Regulation of many homeostatic functions, such as temperature
Hypothalamus control, thirst, urine output, and food intake
2. Important link between nervous and endocrine systems
3. Extensive involvement with emotion and basic behavioral patterns
1. Maintenance of balance
Cerebellum
2. Enhancement of muscle tone
3. Coordination and planning of skilled voluntary muscle activity

Brain stem 1. Origin of majority of peripheral cranial nerves

(midbrain, pons, 2. Cardiovascular, respiratory, and digestive control centers
and medulla) 3. Regulation of muscle reflexes involved with equilibrium and posture
4. Reception and integration of all synaptic input from spinal cord;
arousal and activation of cerebral cortex
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5. Role wardy w cycle
in sleep-wake
 CORTICAL BRAIN

Depends upon hemispheric dominance

Non-neurologists generalize:
right: visual/spatial, perception and memory
left: language and language dependent
memory

Look for aphasias, apraxias, and agnosias

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 NEUROLOGIC EXAMINATION WHEN
CORTICAL BRAIN IS LESIONED
 Higher Cortical Function: aphasia, apraxia, agnosia
 Cranial Nerves: normal
 Cerebellar Function: normal
 Motor: weakness if you hit the motor homonculous
 Sensory: sensory abnormalities if you hit the sensory
homonculous
 Deep Tendon Reflexes: hemi-hyper-reflexia
 Pathologic Reflexes: possibly Babinski’s reflex or frontal
release signs

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PRIMARY SOMATOSENSORY CORTEX

 Located in the postcentral

gyrus, this area:
Receives information from
the skin and skeletal
muscles
Exhibits spatial
discrimination
 Somatosensory
homunculus – caricature
of relative amounts of
cortical tissue devoted to
each sensory function

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PRIMARY MOTOR CORTEX

 Located in the precentral

gyrus
 Composed of pyramidal
cells whose axons make
up the corticospinal tracts
 Allows conscious control
of precise, skilled,
voluntary movements
 Motor homunculus –
caricature of relative
amounts of cortical tissue
devoted to each motor
function
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 NEUROLOGIC EXAMINATION WHEN
BRAINSTEM IS LESIONED
 Higher Cortical Function: normal
 Cranial Nerves:
III, IV, VI: diplopia
V: decreased facial sensation
VII: drooping
VIII: deaf and dizzy
IX, X, XII: dysarthria and dysphagia
XI: decreased strength in neck and shoulders
 Cerebellar Function: normal
 Motor: hemi-paresis, UMN
 Sensory: hemi-dysesthesias
 Deep Tendon Reflexes: hemi-hyper-reflexia
 Pathologic Reflexes: Babinski’s reflex
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 CEREBELLAR FUNCTION
 Some people believe that one can not test specifically for
cerebellar abnormalities
 no one test on examination reliably evaluates the cerebellum

H: hypotonia
A: assynergy of (ant)agonist muscles
N: nystagmus
D: dysmetria, dysarthria
S: stance and gait
T: tremor
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 NEUROLOGIC EXAMINATION WHEN THE
CEREBELLUM IS LESIONED
 Higher Cortical Function: normal
 Cranial Nerves: normal
 Cerebellar Function:
 nystagmus
 staccato dysarthria (abnormality of prosody)
 Motor:
 hemi-hypotonia
 intention > positional tremor
 axial instability with dysmetria
 Sensory: normal
 Deep Tendon Reflexes: normal
 Pathologic Reflexes: none

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 SPINAL CORD
Sensory level (horizontal)
Weakness below the lesion
(paraparesis)
UMN signs below the lesion
Bowel and bladder incontinence

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 NEUROLOGIC EXAMINATION WHEN THE
SPINAL CORD IS LESIONED

Higher Cortical Function: normal

Cranial Nerves: normal
Cerebellar Function: normal
Motor: weakness below the lesion
Sensory: horizontal level
Deep Tendon Reflexes: hyper-reflexia below
the lesion
Pathologic Reflexes: Babinski’s reflex

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 ROOT/RADICULOPATHY

Pain is the hallmark of a radiculopathy

Sensory abnormalities in a dermatome
provocative maneuvres exacerbate the pain
Weakness in a myotome (assymetric)
LMN findings

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NEUROLOGIC EXAMINATION WHEN A ROOT
IS LESIONED
Higher Cortical Function: normal
Cranial Nerves: normal
Cerebellar Function: normal
Motor: assymetric weakness in a myotome
Sensory: pain and dysesthesia confined to a
dermatome
Deep Tendon Reflexes: hypo- to a-reflexia if the
root carries a reflex
Pathologic Reflexes: none
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 PERIPHERAL NERVE
(PRESUMING NONFOCALITY)

Weakness: distal predominant

Sensory Dysesthesias: distal predominant

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NEUROLOGIC EXAMINATION WITH DIFFUSE
PN LESIONING

Higher Cortical Function: normal

Cranial Nerves: normal
Cerebellar Function: normal
Motor: weakness is distal predominant
Sensory: dysesthesias are distal predominant
Deep Tendon Reflexes: loss of distal reflexes
Pathologic Reflexes: mute responses to plantar
stimulation

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 NEUROMUSCULAR JUNCTION

Fatiguability is the hallmark

Weakness: proximal and symmetric
exacerbated with use, recovers with rest
often affects facial muscles (ptosis,
dysconjugate gaze, slack jaw)
Sensation: preserved

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NEUROLOGIC EXAMINATION IN DISORDERS
OF THE NMJ

 Higher Cortical Function: normal

 Cranial Nerves: fatiguabile ptosis, dysconjugate gaze,
slack jaw
 Cerebellar Function: normal
 Motor: fatiguable proximal weakness in both UE’s and
LE’s
 Sensory: normal
 Deep Tendon Reflexes: normal
 Pathologic Reflexes: none

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 MUSCLE

Weakness of proximal arm and leg muscles

symmetric
Sensation is normal
though patients complain of cramping and
aching

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NEUROLOGIC EXAMINATION IN DISORDERS
OF MUSCLE

 Higher Cortical Function: normal

 Cranial Nerves: ptosis, dysconjugate gaze, dysphagia,
dysphonia, (dysarthria)
 Cerebellar Function: normal
 Motor: proximal weakness in both UE’s and LE’s, atrophy
and fasiculations, hypotonia
 Sensory: normal
 Deep Tendon Reflexes: preserved until late in the
disease
 Pathologic Reflexes: none

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THANK U

Wassalam, Wr Wbr

Jakarta, January 11
Anwar Wardy W
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