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Clinical neurological syndroms

Clinical neurological syndroms. Kateřina Zárubová. Syndrom. association of several clinical features, signs (observed by a physician) and symptoms (reported by the patient) that occur together in characteristic combination important for topic diagnosis. Physical examination in neurology.

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Clinical neurological syndroms

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  1. Clinical neurological syndroms Kateřina Zárubová

  2. Syndrom • association of several clinical features, signs (observed by a physician) and symptoms (reported by the patient) that occur together in characteristic combination • important for topic diagnosis

  3. Physical examination in neurology A. Medical history B. Neurological examination - verification of normal function - looking for patologic signs C. Basic steps in making neurological dg.: - 1. syndromologic diagnosis (list of patotologic signs) - 2. topical diagnosis (localization of the lesion) - 3. etiologic diagnosis

  4. Centraland peripheral nervous system

  5. Central and peripheral nervous system • Brain • Spinal cord • Cranial nerves • Peripheral nerves

  6. Central nervous systemBrain Supratentorial area • cortex • white matter of hemispheres • thalamus • bazal ganglia Infratentorial area • brainstem • cebellum

  7. Brain lobesCortical functions • Frontal lobe - reasoning, planning, parts of speech, movement • Parietal lobe- orientation, recognition, perception of somatosensory stimuli • Occipital lobe- visual processing • Temporal lobe- perception and recognition of auditory stimuli, memory, speech

  8. Frontal lobe - frontal part • A4: Primary motor cortex - controls voluntary movements of specific body parts • A6: Premotor cortex, SMA - contributes to the control of movements, planning of complex movements

  9. Frontal lobe - frontal part • A8: frontal eye field control of eye movements • A44: Broca´s area responsible for producing language

  10. Homunculus: the "little person" • Somatotopic representation of the different body parts • The face and hand motor area are the largest • Neurons rise to the fibers of the corticospinal tract

  11. Corticospinal tract the main pathway for control of voluntary movement

  12. Frontal lobe syndromes Impairment of movement (paresis) and/or behavior diturbance • Primary motor cortexContralateral (mono)paresis • Broca's area aphasia • nonfluent speach, agrammatism • pt. can understand language but cannot properly form words or produce speech • A 8- frontal eye field deviation of the eyes towards the side of the injury

  13. Frontal lobe - prefrontal part • modifies the cognitive behavior, personality expression, decision making, social behavior • controls emotions, problem solving, memory, judgment, and social and sexual behavior

  14. Prefrontal lobe syndromes changes in personality,behavior diturbance • Disinhibition, emotional lability, sociopathy, sexual disinhibition, impulsiveness, puerility,pseudopsychopathic disorder • Apathy, personality changes, abulia, lack to ability to plan, poor working memory

  15. Parietal lobe A 1, 2, 3: primarysomatosensory area (gyruspostcentralis) - connectionsfrom thalamus A 5, A 7: associationareas integrationofsomatosensory, visual, auditory informations

  16. Parietal lobe

  17. Features of parietal lobe lesions • Somatosensory area - contralateral hemisensory loss • Association areas - • agnosia -loss of ability to recognize objects, persons, sounds, shapes (while the specific sense is not defective) (tactile, auditory, visual) • apraxia – inability to perform complex movements

  18. Agnosia Astereognosia – inability to determine shapes by touch Agraphaesthesia – inability to read numbers or letters drawn on hand, with eyes shut

  19. Apraxia • Apraxia (damage specifically the posterior parietal cortex), the individual has difficulty with the motor planning to perform tasks or movements

  20. Parietal lobe syndromes Damage to therightparietal lobe canresult in Neglect syndrome - neglecting part ofthe body orspace

  21. Temporal lobe • A 41,42 primary auditory region • A 22 Wernicke‘ s area – comprehension, naming, verbal memory • Adjacent areas – involved in high-level auditory processing • Hipokampus – essential for memory and learning function

  22. Temporal lobe syndromes Sensory aphasia- lesion involve the Wernicke s area in language-dominant hemisphere – (comprehensioon, naming, verbal memory) Impairment of memory – lesions affecting the hippokampus Possible disturbance of spatial orientation (non-dominant hemis.) Irritative phenomena – partial seizures (olfactory, gustatory hallucinations)

  23. Occipital lobe • The occipital lobe - visual processing center • The primary visual cortex - Brodmann area 17

  24. Occipital lobe syndrome • Homonymous hemianopsia • Bilateral lesions - can lead to cortical blindness • Occipital lesions can cause visual hallucinations

  25. Aphasia • Broca´s aphasia • damage to Broca´s area • can understand speach • cannot produce speach • Wernicke´s aphasia • damage to Wernicke´s area • can produce speach • cannot understand speach

  26. Motor system

  27. Motor system

  28. Basic terms • Paresis: decrease in muscular strength, partial paralysis • Plegia: loss of muscle strength, complete paralysis • monoparesis: one limb affected • diparesis: 2 limbs affected • triparesis: 3 limbs affected • quadriparesis: all limbs affected • hemiparesis: limbs of one body side affected (left / right)‏ • paraparesis: both lower limbs affected

  29. Central lesion Periferal lesionspasticparesis flaccid paresis Upper motor neuron Lower motor neuron

  30. Upper motor neuron Pyramidal tract the main pathway for control of voluntary movement • axons travel in: corticobulbar, corticospinal tract - through capsula interna • terminate in: - the cranial nerve nuclei (brainstem) - anterior horn cells (spinal cord)

  31. Lesion of the upper (central) motor neuron, pyramidal tract cause: Central (spastic) paresis • disturbance of movement motor weakness • increased reflexes • incresaed muscle tone • paretic pyramidal signs • spastic pyramidal signs

  32. Central paresis power paretic pyramidal signs irritative pyramidal signs hyperreflexia

  33. Typická lokalizace v capsula interna: hemoragie

  34. Peripheral nervous system • anteriorhorncellsofthespinalcord • spinalnervs, roots (ventral, dorsal) • plexus • periferalnerves • neuromuscular junction • muscle

  35. Lesion of lower (peripheral) motor neuron • Peripheral (flaccid) paresis/paralysis • weakness is limited to segmental or focal patterns • Hypotonia • Hyporefflexia/areflexia • Muscle fasciculations • Atrophy

  36. Basic different between periferal and central involvement

  37. SomatosensorysystemSensitivity • anesthesia: loss of sensitivity • hypestesia: decrease of sensitivity • hyperesthesia: increase in sensitivity • paresthesia: sensation of burning, numbness, tingling

  38. Somatosensitive tracts Spinothalamic tract: pain temperature touch Posterior column proprioreception (muscle spindles, Golgi tendon organ) pallestesia = vibration sense joint position sense

  39. BG

  40. Basal gangla – major functions • Body posture • Regulation of muscle tone • Coordination of voluntary and automatic movements • planning and control motor movements, • learning/establishing new motor patterns

  41. Extrapyramidal syndromesDamage to these nuclei can cause motor abnormalities • Hypokinetic • parkinsonism • - hypokinesia • - rigidity • - rest tremor • - postural disturbance • Indipendentlecture • Hyperkinetic • tremor • chorea • dystonia • myoklonus • tic

  42. Cerebellum • regulation of muscle tone • balance • movement coordination Cerebellar injury results: - in movements that are slow and uncoordinated - patients tend to sway

  43. MRI Imaging

  44. Cerebellum • Archicerebellum (pars flokulonodularis) • vestibular afferentation - balance • Paleocerebellum (vermis) • afferentation from spine cord - posture, gait • Neocerebellum (cerebellar hemispheres) • afferentation from cerebral cortex –coordination

  45. Paleocerebellar syndrome Axial ataxia (axial disequilibrium)‏ • astasia – uncertain standing with wide basis, deviations, falls without side preference • abasia – uncertainty when walking, widen basis, deviations, falls without side preference • large asynergy – dysfunction of axial muscles coordination • titubation – swaying tremor of the head and upper trunk • dysarthria

  46. Neocerebellar syndrome Limb ataxia, ipsilateral to affected cerebellar hemisphere • hypermetria • dysdiadochokinesis • intention tremor • hypotonia – increased passiveness, excursion range of joints

  47. Vestibular apparatus • Balance • Regulation of muscle tone • Coordination of movements of the head and eyes

  48. Vestibular syndromes • Subjective symptoms: • vertigo, nausea • Objective signs: • Nystagmus • Balance disorder • Tonic deviations of the trunk and limbs

  49. Nystagmus Involuntary fast movements of both eyeballs with slow (pathological) and fast (compensatory) component. Nystagmus results from disruption of vestibular system and its neural connections Direction             determined by fast component (horizontal, rotational, vertical, combined etc.)‏ Intensity    I.   grade:  present only when looking in direction of the fast component II.  grade:  apparent in forward gaze as well III. grade:  persisting even when looking on the opposite side

  50. Differentiation between peripheral and central vestibular syndrome Peripheral Central (harmonic) (dysharmonic) Intensity of vertigohigh mild, moderate Nystagmus one direction changes direction Tonic deviation one direction variable direction Compensation relatively fast slow, difficult Other symptoms auditory brainstem

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