UMNL VS LMNL

UMNL LMNL
Muscle power Paralysis or weakness below the level of the lesion. Paralysis or weakness at the level of the lesion.
Muscle No wasting, & if present it is late and due to disuse Early & marked wasting due to loss of muscle tone.
wasting atrophy.
Muscle tone Hypertonia (spasticity) below the level of the lesion. Hypotonia (flaccidity) at the level of the lesion.
Deep reflexes Hyperreflexia below the level. Hyporeflexia at the level.
Pathological May be present. Absent.
deep reflexes
Clonus May be present. Absent.
Superficial Lost if the lesion is above the segmental supply of Lost if the lesion involves the supply of the reflex.
reflexes the reflex.
Babinski Positive, i.e. dorsiflexion of the big toe ± fanning of Plantar flex ion of the toes, or no response.
the other toes.
Fasciculations Absent May be present in irritative lesion of the AHCs.

OPTIC NERVE LESIONS

Optic Nerve - Ipsilateral loss of vision.
- Loss of direct & consensual. light reflex.
Optic Chiasma - Bitemporal Hemianopia.
Optic Tract - Contralateral Homonymous Hemianopia (bilateral half blindness).
Optic Radiation (lower - Upper quadrantic Contralateral Homonymous Hemianopia.
fibres) - Preservation of the light reflex.
Optic Radiation (upper - Lower quadrantic Contralateral Homonymous Hemianopia.
fibres) - Preservation of the light reflex.
- Contralateral Homonymous Hemianopia (bilateral half blindness
Occipital Lobe: - Preservation of the light reflex.
- Preservation of the macular vis.ion (due to double blood supply).

OCULOMOTOR NERVE LESION

External ophthalmoplesia Internal Ophthalmoplegia
1. Ptosis 1. lpsilateral mydriasis.
2. Divergent paralytic squint ( the eye looks 2. Ipsilateral loss of light reflex: loss of
out & down due to the unopposed action direct light reflex on the affected eye.
of the lateral rectus " Cr N 6 " & the
superior oblique " Cr N 4 " ).
3. Diplopia.

TRIGEMINAL NEURALGIA (Tic douloureux)

KEY POINTS
 DEFINITION: Severe attacks of pain along one or more of the sensory branches of the trigeminal nerve,
usually the maxillary or mandibular.
 ETIOLOGY: UNKNOWN, but may be due to (Nerve root compression, DS & DM.)
 CP: unilateral stabbing, burning, electric shocks seconds to minutes of One or more branches of the TN ⇧ by
Movements of the jaw  Spontaneously, or by potent analgesics Ass. è facial muscles spasms.
 TTT: - Medical (Carbamazepine, Analgesics) - Surgical (Resection, Decompression)
 FACIAL NERVER
UMNL LMNL
Causes 1. Vascular: Embolism, Thrombosis,
Hge. 1. Pontine Lesions. } Nuclear Lesions
2. Traumatic: Head injury. 2. Cerebello-Pontine Angle
3. Inflammatmy: Post-encephalitic. 3. Facial Canal Lesions. Infra-nuclear
4. Neoplastic: Glioma. Lesions
5. Demyelinating: DS. 4. Extracranial Lesions.
6. Degenerative: MND
CP • Dropping of the angle of the mouth. CP of UMNL + Leveling
• Deviation of the mouth to the healthy +
side • Inability to raise the eye brows.
on showing the teeth. • Inability to close the eyes.
• Dribbling of saliva. • Absence of wrinkles of the forehead on looking
• Flattening of the naso-labial fold. upwards.
• Inability to blow the cheek.
• Accumulation of food behind the cheek.

LEVELING OF LMNL FACIAL NERVE

SITE OF LESION CAUSES
Pontine Lesions (Nuclear Lesions) 1. Vascular:
1. Paralysis of facial muscles. - Vetebro-basilar insufficiency.
2. No impaitment of taste sensation. - Millard-Gubler syndrome.
3. No impairment of salivation or lacrimation. 2. Infective: Encephalitis, Poliomyelitis.
4. May be other LMN cranial palsies on the 3. Neoplastic: Glioma.
same side or hemiplegia on the opposite side. 4. Demyelinating: DS.
Cerebello-Pontine Angle Lesion (ALL)
1. Paralysis of facial muscles. 1. Infective: Basal meningitis.
2. l taste on anterior 2/3s of tongue. 2· Neoplastic:
3. l salivary & lacrimal secretions. - Acoustic neuroma, Meningioma.
4. Associated Cr. 5, 6 & 8 palsies on same side.
5. Ipsilateral cerebellar ataxia.
Facial Canal Lesion (If)
1. Paralysis of facial muscles. 1. Traumatic: Fracture base.
2. ↓ taste on anterior 2/3s of tongue, and 2. Infective: Otitis media, Herpes zoster.
↓ salivation if chorda tympani is involved. 3. Neoplastic: Facial neuroma.
3. Diminished lacrimation if the greater 4. Bell's palsy.
superficial petrosal nerve is involved.
4. Hyperacusis if the nerve to Stapedius is involved.
1. Neuropathy: Diabetes, Leprosy.
Extracranial Lesions 2. Myopathy: Facioscapulohumeral.
(After its exit from the stylomastoid foramen) 3. Myasthenia.
Paralysis of facial muscles only. 4. Invasion by a tumour: (parotid).
5. Injury to the nerve during surgery.
 BELL'S PALSY
KEY POINTS
 DEFINITION: It is an acute LMN paralysis of the face, due to a non-suppurative
inflammation
and edema of the facial nerve in the FACIAL CANAL
 ETIOLOGY: UNKNOWN maybe due to (Air drafts, HZV, AI)
 CP: 1. PAIN:
• The entire course of the disease may be PAINLESS, OR,
• The disease may also present with acute PAIN behind the ipsilateral ear.
2. PARALYSIS: "one or two days after the pain "
• Complete paralysis of the facial muscles on the affected side of LMN features +
Level
 COMPLICATIONS: Crocodile tears, Corneal ulcers, Incomplete recovery
 Treatment: REASSURANCE, PHYSIOTHERAPY, Medical (Steroids, Corneal protection)
Surgery (Decompression, Section of the regenerating fibres for tear, Plastic)

STROKE

 ETIOLOGY: Ischemic 85% (Thrombosis [Most commonly athero], Embolism ), Hge 15%
 RISK FACTORS: Non- modifiable [old, ♂, Type A, FH], Modifiable [esp. HTN]
 CP: HEMIPLEGIA, HEMIANESTHESIA, Speech problems, Vision problems, Ataxia,
Cranial nerve paralysis.
 CLINICAL TYPES: Stroke in evolution, Completed stroke
 INVESTIGATIONS: CT, MRI, Cardiac & vascular imaging, CBC, PT, APTT, For RF
 TREATMENT:
General care (Skin, Swallowing & nutrition, Balance of fluids, Breathing, Bladder,
Bowels)
Sx (↓ brain edema, Prophylaxis against STRESS ULCER, PHYSIOTHERAPY)
Specific:
I. Ischemic Stroke
1. Fibrinolytic therapy, tPA 3 to 4.5h,
2. Endovascular therapy [Stent retriever system, Penumbra system, MERCI])
3. Control of blood pressure
4. Antiplatelets: LDA, Clapidagrel, Ticlopidine, Dipyridamole
5. Anticoagulants . 6. Treatment of the cause.
II. Hemorrhagic stroke
1. Control of blood pressure. 2. Inracranial Pressure Control
3. Antifibrinolytic drugs 4. Surgery
 TIAs

 ETIOLOGY: Ulcerated CA athero palques, Thrombi in AF, Vasculitis or Hyperviscosity

 CP:
Carotic TIA VB TIA
Transient
(Headache, Convulsions, Ipsilateral Syncope, Diplopia., Ophthalmoplegia.
Blindness, Contralateral Hemiparesis & ,Vertigo or tinnitus, Bulbar symptoms,
Hemihyposthesia, Aphasia in lesions of the Hemiparesis, hemianaesthesia., Ataxia.
DOMINANT HEMISPHERE)
 PROGNOSIS: ABCD2 Score ● INVESTIGATIONS: As Stroke
 TREATMENT: Antiplatelets: LDA, Clapidagrel, Ticlopidine, Dipyridamole,
Anticoagulants , Treatment of the cause, Enartrectomy, Bypass, Stent

HEMIPLEGIA

 DEFINITION: △ Lesion at any point of the cortex down to C5

 CLASSIFICATIONS ACCORDING TO THE SITE OF LESION
a) At the Level of the Lesion:
1. Ipsilateral localised LMNL.
Spinal 2. Ipsilateral loss of all sensations.
(Brown- b) Below the Level of the Lesion:
Sequard 1. Ipsilateral hemiplegia (UMNL).
Syndrome)
2. Ipsilateral deep sensory loss.
3. Contralateral superficial sensory loss for pain & temperature.
4. Touch diminishes on both sides.
1. Mid-Brain Lesion:
a) Weber's syndrome: Hemiplegia + 3rd CN paralysis
Brain stem b) Benedict s syndrome: Hemiplegia & Hemiataxia + 3rd CN paralysis
(Crossed 2. Pontine Lesion:
Hemiplegia) a) Millard Gubler Syndrome: Hemiplegia + 6th & 7th CN paralysis
b) Foville Syndrome: Hemiplegia + Loss of conjugate eyes movement
3. Medullary Lesion:
a) Avellis Syndrome: Hemiplegia + 9th & 10th CN paralysis
b) Jackson's Syndrome: Hemiplegia + 10th & 1th CN paralysis
Coma, Convulsions, Contralateral cortical sensory loss,
Cortical Homonymous hemianopia, Aphasia and agraphia
paralysis usually involves one limb (monoplegia) esp. in vascular lesions.
Complete hemiplegia associated é UMNL 7th & 12th CNs
Capsular "All are on the opposite side of the lesion".
Hemihyposthesia , Hemianopia
No convulsions, No aphasia, No coma.