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What is lesion and where is a lesion most likely to be? •Neurological history •Neurological examination •Time, duration, onset •Neuroanatomy •Focal- single, well defined anatomical lesion • Often unilateral •Diffuse- functional or anatomical part of nervous system • Often bilateral •Multifocal- multiple focal lesionsDescending tractsDescending tracts UMN LMN Motor cortex Descending tracts UMN Internal capsule Corticobulbar fibres Pons Motor cranial nerve Medulla LMN Spinal cordDescending tracts Motor cortex UMN Internal capsule Corticobulbar fibres Motor cranial Pons nerve Decussation of the Medulla pyramids LMN Corticospinal tract Spinal cord Spinal nerveCauses of UMN lesions Space occupying lesions • Stroke • Cancer • Abscess Demyelination of nerve axon • Multiple sclerosis • Fredricks ataxia ALS (Amyotrophic lateral sclerosis) Causes of LMN lesions Muscle Anterior horn Axon • Viruses • Any neuropathy Axon terminal • Polio • Cauda equina • Botulism • West Nile virus • Radiculopathy • Spinal muscular atrophy • Diabetic neuropathy • ALSUMN vs LMN lesion UMN LMN Inspection Pyramidal pattern posture Wasting Disuse atrophy fasciculations Tone Increased- Spasticity Decreased- hypotonic Power Decreased in pyramidal muscles Decreased Reflexes Increased/ brisk Reduced/absent Ankle clonus Down going plantar Upgoing extensor plantar Coordination Reduced Reduced/ normal Sensory changes • Ipsilateral at level of spinal cord or lower in brain stem • Contralateral loss- Upper brainstem or cerebral hemisphere A 58 year old man presents with sudden onset numbness down side of leg and top on foot following lifting a heavy shelf. Where is the site of the lesion? A. L2 B. L3 C. L4 D. L5 E. S1 A 58 year old man presents with sudden onset numbness down side of leg and top on foot following lifting a heavy shelf. Where is the site of the lesion? A. L2 B. L3 C. L4 D. L5 E. S1 A 60-year-old gentleman with a background of lumbar spondylosis and chronic back pain presents with gradually worsening bilateral upper limb paraesthesia. On examination, he has decreased power and reflexes in his arms. Lower limb examination normal. What is the most likely location A. Brain B. Brain stem C. Cervical D. Lumbar E. Thoracic A 60-year-old gentleman with a background of lumbar spondylosis and chronic back pain presents with gradually worsening bilateral upper limb paraesthesia. On examination, he has decreased power and reflexes in his arms. Lower limb examination normal. What is the most likely location A. Brain B. Brain stem C. Cervical D. Lumbar E. Thoracic A 23-year-old man is admitted to the emergency department following a stabbing incident. He has multiple lacerations to his flank and lower back which have been caused by a knife. After being stabilized he complains of his right leg 'feeling funny.' You perform a full neurological examination which reveals the following: • weakness in extension and flexion of the right knee • loss of proprioception and vibration below mid thigh in the right leg • loss of pain sensation below the mid thigh in left leg What is the cause? A. Cauda equina B. Conus medullaris syndrome C. Central cord syndrome D. Transection syndrome E. Brown-Sequard syndrome A 23-year-old man is admitted to the emergency department following a stabbing incident. He has multiple lacerations to his flank and lower back which have been caused by a knife. After being stabilized he complains of his right leg 'feeling funny.' You perform a full neurological examination which reveals the following: • weakness in extension and flexion of the right knee • loss of proprioception and vibration below mid thigh in the right leg • loss of pain sensation below the mid thigh in left leg What is the cause? A. Cauda equina B. Conus medullaris syndrome C. Central cord syndrome D. Transection syndrome E. Brown-Sequard syndromeBrown- Sequard syndrome •Hemisection of the spinal cord •stab injuries or lateral vertebral fractures A 64-year-old man presents with a eight-month history of generalised weakness. On examination he has fasciculation and weakness in both arms with absent reflexes. Examination of the lower limbs reveal increased tone and exaggerated reflexes. Sensation was normal and there were no cerebellar signs. What is the most likely diagnosis? A. Stoke B. Cerebellar tumour C. Amyotrophic lateral sclerosis D. Multiple sclerosis E. B12 deficiency A 64-year-old man presents with a eight-month history of generalised weakness. On examination he has fasciculation and weakness in both arms with absent reflexes. Examination of the lower limbs reveal increased tone and exaggerated reflexes. Sensation was normal and there were no cerebellar signs. What is the most likely diagnosis? A. Stoke B. Cerebellar tumour C. Amyotrophic lateral sclerosis D. Multiple sclerosis E. B12 deficiencyMotor neurone disease •Umbrella term for a a progressive, fatal condition where motor neurones stop functioning •Amyotrophic lateral sclerosis • most common •Progressive bulbar palsy • second most common • muscles of talking and swallowing •Progressive muscular atrophy •Primary lateral sclerosis A 50-year-old woman presents to the emergency department with weakness in her legs and says that she seems to keep tripping over her right foot. She is admitted and after in-depth investigations, she is about the typical symptoms of this condition.iven more information Which of the following features is typically spared in this condition? A. Breathing difficulties B. Emotional lability C. Ophthalmoplegia D. Slurred speech E. Swallowing difficulty A 50-year-old woman presents to the emergency department with weakness in her legs and says that she seems to keep tripping over her right foot. She is admitted and after in-depth investigations, she is about the typical symptoms of this condition.iven more information Which of the following features is typically spared in this condition? A. Breathing difficulties B. Emotional lability C. Ophthalmoplegia D. Slurred speech E. Swallowing difficultyMotor neurone disease •Degeneration of both upper and lower motor neurones • Except ocular motility •Sensory neurons spared •Presentation- • Progressive weakness of muscles throughout body • Often first noticed in upper limbs • Fatigue, clumsiness, tripping over, dysarthria • Weight lossMotor neurone disease •Diagnosis • Based on clinical presentation after excluding other conditions • Motor nerve conduction studies normal • Done by specialist •Management • No treatment • Riluzole- slow progression, extends survival by a few months • NIV- support breathing • QoL • Advanced directives, end of life planning, often die of respiratory failure A 33-year-old female has known secondary progressive multiple sclerosis and sees her neurologist for her regular 3-monthly follow-up appointment. She complains of clumsiness when walking and falling over regularly for no check for other cerebellar signs.s ataxic and the neurologist proceeds to Which of the following is a typical cerebellar sign? A. Hypotonia B. Dysphasia C. Resting tremor D. Hypertonia E. Dysgraphia A 33-year-old female has known secondary progressive multiple sclerosis and sees her neurologist for her regular 3-monthly follow-up appointment. She complains of clumsiness when walking and falling over regularly for no check for other cerebellar signs.s ataxic and the neurologist proceeds to Which of the following is a typical cerebellar sign? A. Hypotonia B. Dysphasia C. Resting tremor D. Hypertonia E. DysgraphiaCerebellar syndrome symptoms •Unilateral cerebellar lesions cause ipsilateral signs •D- Dysdiadochokinesia •A- Ataxia •N- Nystagmus •I- Intention tremor •S- Staccato speech- british consitution •H- hypotoniaThank you! Any questions