Localizing Signs

1. Localizing Signs Presented By Doug Kelly Elizabeth Matera Eric Yoder

2. Disclaimer The information contained herein was developed via large group discussion in the absence of faculty oversight. There are no guaranteed correct answers in this document, but rather the best guess of the group after reviewing all the symptoms in each case Use at your own risk and please double-check this against your notes and your own reasoning. If you have questions / challenges, please contact Doug immediately.

3. Definitions These are some symptoms that I constantly need to remind myself about Hemianalgesia � loss of pain sense on one side of the body; deficit in spinothalamics Hemianesthesia � loss of all sense modalities on one side of the body; deficit in spinothalamics and posterior columns Hemiparesis � Partial paralysis or weakness on one side of the body; deficit in corticospinals Extensor Plantar Response � Positive Babinski reflex; indicates UMN damage Ataxia � failure of muscular coordination; caused by cerebellar deficit Apraxia � failure to carry out a familiar purposeful movement in the absence of motor or sensory impairment; caused by UMN deficit Ptosis � paralytic drooping of the upper eyelid; caused by CN III deficit Dysarthria � Difficulty in speech articulation; associated with emotional distress, paralysis, and incoordination; typically a problem with motor innervation for the mouth/tongue

4. Case 1: Important Symptoms 71 yo male Progressive lower limb weakness Frequent Urination Lower Limb Pain Present Loss of Bladder, Bowel Function Impotence Lower limb weakness and atrophy Abdominal reflexes normal Cremasteric reflex absent No movement below the ankles Patellar and Achilles reflexes absent Leg muscle fasciculations Extended bladder with uncontrolled dribbling release

5. Case 1: Symptoms Explained Efferent Symptoms: Consider both upper and lower motor neurons Progressive lower limb weakness (UMN / LMN) Lower limb weakness and atrophy (LMN) No movement below the ankles (UMN / LMN) Leg muscle fasciculations Afferent Symptoms Lower Limb Pain Present (Spinothalamics Intact) Reflexes: Consider reflex arc, motor efferents and sensory afferents Cremasteric reflex absent (L1/L2) Abdominal reflexes normal Patellar and Achilles reflexes absent (L4, S1 respectively) Special: Consider the micturition center (S2 � S4), pudendal nerve components Impotence Frequent Urination Loss of Bladder, Bowel Function Extended bladder with uncontrolled dribbling release (Autonomic Bladder)

6. Case 1: Localizing Sign Lower limb weakness and atrophy (LMN deficit) Patellar and Achilles reflexes absent (L4, S1 respectively) Extended bladder with uncontrolled dribbling release (Autonomic Bladder, Micturition Center S2 � S4) Lesion likely in the Cauda Equina affected nerve roots for lower lumbar and sacral cord levels

7. Case 2: Important Symptoms Patient A 22 yo male Is burning his fingers while smoking, no pain response Slow healing ulcers on fingers, no pain Bilateral analgesia over hands and forearms Axillary pain response normal Patient B 28 yo male Neck stiffness x 6 months Dysarthria x 6 months Tongue deviates right; difficulty shrugging right shoulder; difficulty turning head to left Analgesia on right side of face and scalp Collar analgesia at the neck Position, vibration, and two-point discrimination absent at the toes Simliar but lesser defect in the fingers Superior abdominal and cremasteric reflexes absent bilaterally Positive Babinski Deep reflexes in arms are descreased, in the legs are hyperactive

8. Case 2: Symptoms Explained Patient A Afferent Symptoms Is burning his fingers while smoking, no pain response Slow healing ulcers on fingers, no pain Bilateral analgesia over hands and forearms (C5 � C8, spinothalamics) Axillary pain response normal Patient B Efferent Symptoms Neck stiffness x 6 months Dysarthria x 6 months (hypoglossal, facial) Tongue deviates right (hypoglossal) Difficulty shrugging right shoulder; difficulty turning head to left (CN XI, accessory nucleus) Afferent Symptoms Analgesia on right side of face and scalp (Spinal Trigeminal Nucleus and Tract) Collar analgesia at the neck (C2 � C4, spinothalamics) Position, vibration, and two-point discrimination absent at the toes (posterior columns, gracile) Simliar but lesser defect in the fingers (posterior columns, cuneate) Reflexes Superior abdominal and cremasteric reflexes absent bilaterally Positive Babinski Deep reflexes in arms are descreased, in the legs are hyperactive

9. Case 2: Localizing Signs Patient A Bilateral analgesia over hands and forearms (C5 � C8, spinothalamics) Lesion likely affects the anterior white commisure in or around the C5-C8 spinal cord level knocking out spinothalamics bilaterally Patient B Tongue deviates right (hypoglossal) Difficulty shrugging right shoulder; difficulty turning head to left (CN XI, accessory nucleus) Collar analgesia at the neck (C2 � C4, spinothalamics) Lesion is centrally located affecting the anterior white commisure in the C2-C4 region, becoming larger and progressing laterally in the caudal medulla to affect the accessory and hypoglossal nuclei

10. Case 3: Important Symptoms 62 yo female Progressive hearing loss on the right x 1 year Constant, high pitched sound on the right Double Vision Nystagmus on right lateral gaze (FP ? Left) Corneal reflex on the right elicits no response Corneal reflex on the left blinks only the left Right eye deviated nasally Jaw strength normal No hearing on the right Caloric testing on right produces no response Diminished sensation in the face Arms and Legs are normal for pain and temperature Falls to the right during tandem walk Ataxia on finger to nose test, intention tremor on grasping Babinski is negative

11. Case 3: Symptoms Explained Efferent Symptoms Double Vision (Likely due to paralyzed r. lat. rect.) Right eye deviated nasally (Right lateral rectus paralyzed) Jaw strength normal (CN V motor normal) Afferent Symptoms Progressive hearing loss on the right x 1 year (CN VIII) Constant, high pitched sound on the right (CN VIII) Nystagmus on right lateral gaze (FP ? Left) (CN VIII) No hearing on the right (CN VIII) Caloric testing on right produces no response Diminished sensation in the face (CN V, Spinal Trigeminal Tract / Nucleus) Arms and Legs are normal for pain and temperature (Spinothalamics) Reflexes Corneal reflex on the right elicits no response (CN V sensory, CN VII motor) Corneal reflex on the left blinks only the left (CN V sensory, CN VII motor) Babinski is negative (UMN Intact) Special Falls to the right during tandem walk (Spinocerebellar tract to cerebellum) Ataxia on finger to nose test, intention tremor on grasping (Spinocerebellar)

12. Case 3: Localizing Signs Right eye deviated nasally Must be a abducens nerve lesion on the right. Left eye is able to move medially, ruling out a abducens nucleus lesion on the right. No hearing on the right (CN VIII) Unilateral hearing loss points to a nerve defect. A defect of the nucleus or higher would likely produce a bilateral deficit because fibers split bilaterally No direct or consensual corneal reflex on the right (CN VII motor) This constellation of signs points to peripheral nerve damage of CN VI, VII, and VIII which convienently exit the brainstem in the cerebellopontine angle

13. Case 4: Important Symptoms 52 yo male Episodic dizziness Hoarseness Poor coordination in right limb movement Ataxia and falls to the right Nystagmus present (to the left) Right palate doesn�t elevate Right vocal cords immobile Loss of pain and temperature sense of the right face No taste on the right tongue No tongue deviation Right ptosis Right pupil constricted Loss of pain and temperature sense of left neck and trunk

14. Case 4: Symptoms Explained Efferent Symptom Hoarseness (Nuc. Ambiguus, CN X) Right palate doesn�t elevate Right vocal cords immobile No tongue deviation Right ptosis Right pupil constricted Afferent Symptom Nystagmus present (to the left) Loss of pain and temperature sense of the right face No taste on the right tongue (Right solitary nuc., CN Loss of pain and temperature sense of left neck and trunk Special Episodic dizziness Poor coordination in right limb movement Ataxia and falls to the right

15. Case 4: Localizing Signs Loss of pain and temperature sense of the right face Loss of pain and temperature sense of left neck and trunk The above signs are collectively known as alternating hemianalgesia. This is caused by a lateral medullary syndrome (Wallenberg syndrome) where the lateral spinothalamic and spinal trigeminal nucleus are damaged.

16. Case 5: Important Symptoms 62 yo female Sudden sharp occipital headache Dizziness, falling to the left Hemianesthesia on left face, trunk and limbs Hemiparesis on the left Increased muscle tone and reflexes on the left Positive Babinski on the left Weakness in lower left face Brow wrinkling intact Tongue deviation (unspecified direction) Constant rhythmical tremor on the left; worst with movement Ataxia on the left Ptosis of right eyelid Dialated right pupil Right eye globe rotated outward with no up/down mobility Light reflex absent in right pupil Light reflex on the right elicited left consensual response

17. Case 5: Symptoms Explained Efferent Symptoms Hemiparesis on the left Increased muscle tone and reflexes on the left Weakness in lower left face Brow wrinkling intact (facial nuclei intact) Tongue deviation (unspecified direction) Ptosis of right eyelid Dialated right pupil Right eye globe rotated outward with no up/down mobility Afferent Symptoms Hemianesthesia on left face, trunk and limbs Reflexes Positive Babinski on the left Light reflex absent in right pupil Light reflex on the right elicited left consensual response Special Dizziness, falling to the left Constant rhythmical tremor on the left; worse with movement Ataxia on the left

18. Case 5: Localizing Signs Left Hemiparesis Right oculomotor nerve/nucleus signs: Ptosis, pupil dilation, globe rotated outward with no up/down mobility Left Hemianesthesia (face, trunk and limbs) The combination of these signs points to a midbrain defect that affects: Right oculomotor and edinger-westphal nuclei Right corticospinals in the cerebral peduncle Right spinothalamics

19. Case 6: Important Symptoms 77 yo male, Hx HTN Sudden onset left hemiplegia, dysarthria Slumped to the left, became lethargic Facial drooping on the left Left limbs immobile Oriented x3 Speech fluent but dysarthric Placed numbers 1-12 on the right half circle when asked to draw a clock PEARRL No response to stimulus in left visual hemifield Tonic right gaze deviation Slight left deviation of the tongue Denied ownership of his own left hand Normal sensory perception on the left with impaired localization Astereoagnosia and agraphesthesia on the left Exaggerated reflexes on the left

20. Case 6: Symptoms Explained Efferent Symptoms Sudden onset left hemiplegia, dysarthria Slumped to the left, became lethargic Facial drooping on the left Left limbs immobile Speech fluent but dysarthric Slight left deviation of the tongue Exaggerated reflexes on the left Afferent Symptoms No response to stimulus in left visual hemifield Tonic right gaze deviation Normal sensory perception on the left with impaired localization Astereoagnosia and agraphesthesia on the left Reflexes PEARRL Special Oriented x3 Placed numbers 1-12 on the right half circle when asked to draw a clock Denies ownership of his own left hand

21. Case 6: Localizing Signs No response to stimulus in left visual hemifield Placed numbers 1-12 on the right half circle when asked to draw a clock Denies ownership of his own left hand These symptoms are classic for right sided neglect syndrome caused by damage to the superior parietal lobule in the right cortex