Topical Diagnosis: Muhammad Iqbal Basri
Topical Diagnosis: Muhammad Iqbal Basri
Topical Diagnosis: Muhammad Iqbal Basri
3. Ethiological Diagnosis
FUNCTIONAL NEUROANATOMY
3
General concept in localization
Terminology: Dermatome, myotome, cornu anterior, columna
posterior,aphasia, dysarthria,dysphagia
Focal vs generalized signs and symptoms
Focal signs and symptoms: aphasia, focal weakness, double
vision (diplopia)
Generalized signs and symptoms: dysarthria, generalized
weakness, confusion, blurry vision
Upper vs lower motor neuron signs
Upper motor neuron:increased tone (spasticity), increased
reflexes, pathological reflexes will be found
Lower motor neuron: decreased tone (flaccidity),decreased
reflexes, no pathological reflexes, muscle atrophy
Nn.craniales
Hemiparesis - hemiplegia
Peripheral
nerves
Hemihypesthesia
Paraparesis
Monoparesis
Tetraparesis
General concept in localization
Know where the clinically important tract cross:
Tractus corticospinalis (motoris): it crosses in the pyramidal
decussation (medulla)
- Lesion below the medulla will cause ipsilateral weakness
- Lesion above the medulla will cause contralateral weakness
Tractus spinothalamicus (pain and temperature) :crosses 2-3
spinal segments above the entry point into the spine
- Lesion will cause loss of sensation contralaterally,starting 2-3
dermatomal segments below the level of the lesions
Fasciculus gracilis and cuneatus (proprioceptive) :crosses in
the medulla
Clinical diagnosis in neurology
History taking
Recognition of impaired function
Physical examination
1. Consciousness (GCS)
2. High cortical function History
3. Meningeal Sign taking
4. Nervi craniales
5. Motoric function
6. Sensoric function
7. Autonom function
Localize a lesion
Right cerebral hemisphere
Left cerebral hemisphere
Right internal capsule
(subcortical)
Left internal capsula
(subcortical)
Right brainstem
Left brainstem
Cerebellum
Spinal cord
Localize a lesion
Spinal cord
Cornu anterior
Peripheral nerves (radix
anterior, radix posterior, nervus
spinalis)
Neuromuscular junction
Muscle
Generalized symptoms, no
specific local lesion
Part 1:Loss of consciousness (Coma)
Ascending reticular
activating system
(ARAS) :midbrain,
upper pons
Descending reticular
activating system:
lower pons, medulla
Coma: diencephalic, A
bihemispheric B
Cardiovascular center and
respiratory center
Part 2: High cortical function
Memory disturbance -
Dementia
Emotional
disturbance
Language
disturbance - Aphasia
The Language Centre
Lesion on the dominant hemisphere
Right-handed Left-handed
95 % (left) 60 % (left)
5 % (right) 30 % (right)
10 % (Bilateral)
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Language disturbance (Aphasia)
Motoric Aphasia
(Broca) Global Aphasia
39
18
19
Conductive Aphasia
Sensoric Aphasia
(Wernicke)
14
Emotional disturbance
Composition
Limbic lobe: includes septal area, cingulated gyrus, parahippocampal
gyrus, hippocampus, dentate gyrus, temporal pole, anterior part of
insular lobe and so on
Associated subcortical nuclei: amygdaloid body, septal nuclei,
hypothalamus, epithalamus, anterior nucleus group of thalamus,
tegmentum of midbrain
Function: concerned with visceral activities, olfaction, emotion
and memory (H.O.M.E), so this system is called ‘visceral brain’
Limbic
System
Memory disturbance
Hippocampus
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Hippocampus
Hippocampal
formation
Dentate gyrus
Short-term memory
(recent memory)
Part 3: Meningeal Sign
Meninges : duramater,
arachnoidmater, piamater
Meningeal sign:
meningitis, subarachnoid
hematome
Irritation lesion
Part 4: Cranial Nerves
Lagophtalmus
Part 5: Motoric system
Characters
Representation is inverted,
but head and face are upright
A body part is represented by
a cortical area proportional to
its use rather than its size
Receiving fibers from
precentral gyrus, VA, VL and
VPL, sending out fibers to
form pyramidal tract,
controlling voluntary
movements
Homunculus motoris
upper motor neuron
Corticospinal tract
Corticospinal tract
Decussation of pyramid
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Corticonuclear
tract
Nucleus of oculomotor n.
Nucleus of trochlear n.
Nucleus of abducent n.
Sup. part of nucleus of facial n.
Inf. part of nucleus of facial n.
Nucleus of ambiguus
Nucleus of hypoglossal n.
Nucleus of accessory n.
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27
Extrapyramidal system
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29
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The Spinal Cord
Position
Lies in vertebral canal
B
A.Tetraparese (UMN)
B.Tetraparese (UMN, LMN)
C.Paraparese (UMN) C
D.Paraparese (UMN,LMN)
E. Conus medullary D
syndrome
E
F. Cauda equina syndrome
F
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Part 6: Sensoric system
Characters
Sensory representation,
like motor area, is
crossed and inverted
Receiving and interpret
sensation from opposite
side of body
Homunculus sensoris
Conscious proprioceptive Central thalamic
radiation
and fine touch pathway
VPL
of trunk and limbs 3°neurons
Medial lemniscus
Gracile and cuneate nuclei
2°neuron
Decussation of medial lemniscus
Fasciculus cuneatus
T4
Fasciculus gracilis
Spinal ganglion
1°neuron
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Unconscious
proprioceptive
pathway
Superior cerebellar peduncle
Anterior
Spinocerebellar
Posterior spinocerebellar tract tract
Lamina Ⅴ-Ⅶ
Nucleus
Spinal ganglion thoracicus
39
Central thalamic
Pain, temperature radiation
and simple touch VPL 3°neurons
pathway of trunk and
limbs
Spinal lemniscus
Spinal ganglia
1°neuron
40
Pain, temperature and simple Central
touch pathway of head and thalamic
radiation
face
VPM
3°neurons
Spinal nucleus of V
2°neuron
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Dermatome system
T4 – papilla mammae
T6 – processus xiphoideus
T10 – umbilicus
L1 – inguinal ligament
Visual pathway
Optic nerve
Optic chiasma
Optic tract
Optic radiation
Visual area
43
Optic nerve
Optic chiasma
Optic tract
Lateral geniculate
body
Optic radiation
Visual area
44
Pupillary reflexes
Sphincter pupil
Ciliary muscle
Ciliary ganglia
Occculomotor n.
Pretectal area
45
Auditory
pathway
Transverse temporal gyrus
Acoustic radiation
Lateral lemniscus
Cochlear nuclei
Bipolar neuron of
cochlear ganglion
46
Part 7: Autonomic system
Centre of symphatetic:
cornu lateral of spinal
cord segment T1-L3 Ⅶ
Centre of para
sympathetic: located in Ⅸ
four pairs
parasympathetic nuclei Ⅹ
Muh.Iqbal Basri
Anatomy Department
Hasanuddin University
Case 1
Innervation ratio
Fibers per motor
neuron
Extraocular muscle 3:1
Gastrocnemius 2000:1