2. APPROACH TO A
PATIENT WITH CNS
DISORDER
DR M SHOAIB SHAFI

3. MAIN PRESENTING COMPLAINTS
OF CNS






Headache, backache or neck pain
Facial pain
Fits ,faints or funny turns
Dizziness or vertigo
Disturbance of vision, hearing or smell
Disturbance of memory, sphincter control,
sleep, speech, language or gait

4. CONTD….





Disorders of movement
weakness
abnormal involuntary movements
Acute confusional state
Coma and brain death
Problem with brainstem function
Sensory disturbances

5. HOW TO APPROACH

6. APPROACH TO DIAGNOSIS
It involves two questions:

Where is the lesion?

What is its etiology?

7. Where is the lesion?
1) Is the lesion :
 Single,multiple or is it a diffuse process
 Restricted to CNS or part of systemic illness
2) Do the findings combine to form a
recognizable clinical syndrome eg parkinsonism

8. 









What is the etiology?
VITAMINS-D
Vascular
eg CVA, venous sinus thrombosis
Infectious
eg meningitis, cerebral abscess
Inflammatory eg acute transverse myelitis, MS, ADEM
Traumatic
eg Extradural hematoma or SDH
Autoimmune
eg myesthenia gravis, GBS
Metabolic & toxic eg hypoglycemia, hyponatremia,
alcohol intoxication, uremia
Iatrogenic
eg antipsychotic induced parkinsonism
Neoplastic
eg primary or secondary brain tumours
Seizures & psychiatric disorders
Degenerative lesions
eg alzheimers dementia

9. HISTORY









Onset of illness & its course
Comorbation of history by attendants
Premorbid condition
Family history
Medical history
Drug use, abuse & toxin exposure
Formulating an impression of the patient
Precipitating factors
Associated symptoms

10. PHYSICAL EXAMINATION
GPE:









BP
PULSE
TEMPERATURE
PURPURIC SPOTS
RASH
HANDS ( CLUBBING,SPLINTER HGES)
FACE (FEATURES OF C.T DISORDER,EYE,SINUSES)
EAR
NECK (CAROTID,JVP,THYROID)

11. SYSTEMIC EXAMINATION

CENTRAL NERVOUS SYSTEM

CARDIOVACULAR EXAMINATION
HEART MURMUR
GASTROINTESTINAL EXAMINATION
KIDNEYS, SPLEEN
RESPIRATORY SYSTEM


PULMONARY INFECTION
PULMONARY EDEMA

12. CENTRAL NERVOUS SYSTEM

GCS

PUPILS
HIGHER MENTAL FUCTION






E4V5M6
Time- knows month or year
Place- has general knowledge of where they are
Person- knows own name, able to name relatives or friend
Memory- capability for early and recent recall
CRANIAL NERVES

13. SENSORY SYSTEM

Primary sensation

Touch
Pain
Temperature
Sense of position and vibration




cortical sensation

Localization
Two point discrimination
Stereognosis
Graphesthesia
Perceptual rivalry





14. MOTOR SYSTEM
BOTH UPPER & LOWER LIMBS







Bulk of muscles
Tone of muscle
Power of muscles
Reflexes
Gait
Coordination of movement
Spine

15. CEREBELLAR SIGNS










Nystagmus
Scanning speech
Finger nose test
Dysdiadochokinesia
Rebound phenomenon
Pendular knee jerk
Hypotonia
Heel knee shin test
Romberg sign
Drunken gait

16. SPEECH

Dysphasia

Dysarthria

17. SIGNS OF MENINGEAL
IRRITATION



Neck stiffness
Kernigs sign
Brudinzkis sign

19. INVESTIGATIONS
Finger stick glucose
CBC(wbc,plt)
LFTs
PT, APTT& INR
Creatinine
Electrolytes
(Na,Ca,Mg,K)
Blood culture
ECG
Echocardiogram
Lumbar puncture
NCS/ EMG
EEG
CT head
Cerebral angiography
Carotid Doppler
Testing
MRI/ MRA
Evoked potentials

20. 





LIPID PROFILE
HYPERCOUGUBALE STATE
HOMOCYSTEINURIA
ANTICARDIOLIPIN ANTIBODIES
SLE
VASCULITIS

21. Tin-pot dictators have ravaged Asia, Latin America &
Africa. They are the worst tyrants of post-colonial period.
They have destroyed time-honored institutions & treated
their people like animals. They have caused internal
divisions &external confusion. The dictator is one animal
who needs to be caged. He betrays his profession & his
constitution. Not a single one of them has made a
moments contribution to history.

22. HOW TO LOCATE THE
LESION IN CNS

23. IMPORTANT STRUCTURES








Cerebral cortex
Corona radiata
Internal capsule
Brainstem
(midbrain, pons, medulla oblongata, cerebellum)
Thalamus
Hypothalamus
Extrapyramidal system

24. 







Case scenario
A 45yrs old lady is brought to ER with c/o sudden weakness of
right half of body. O/E
Patient drowsy
BP = 180/110 mmHg
Pulse = 68/min
CNS: GCS 7/15
Power decreased on right
Tone increased on right
Right plantar upgoing
Right facial nerve palsy (UMN type)
Explain the nature of lesion.

25. CASE SCENARIO


A 56yrs old gentleman with h/o uncontrolled
hypertension presents in ER with sudden onset
of weakness of left arm.
Where is the lesion in brain?

29. CEREBRAL DOMINANCE



Two cerebral hemispheres
All the right handed persons and most of left
handed persons have left hemisphere as the
dominant one.
Dominant hemisphere controls the speech.

32. Frontal Lobe
• Initiation
• Problem solving
• Judgment
• Inhibition of behavior
• Planning/anticipation
• Self-monitoring
• Motor planning
• Personality/emotions
• Awareness of
abilities/limitations
• Organization
• Attention/concentration
• Mental flexibility
• Speaking
(expressive language)
Parietal Lobe
• Sense of touch
• Differentiation:
size, shape, color
• Spatial perception
• Visual perception
Parietal
Lobe
Frontal
Lobe
Occipital Lobe
Occipital
Lobe
• Memory
• Hearing
• Understanding language
(receptive language)
• Organization and sequencing
Cerebellum
• Balance
• Coordination
• Skilled motor activity
Temporal
Lobe
Temporal Lobe
• Vision
Cerebellum
Brain
Stem
Brain Stem
• Breathing
• Heart rate
• Arousal/consciousness
• Sleep/wake functions
• Attention/concentration

34. MEDIAL VIEW

35. HOMENCULUS

36. HOMENCULI

42. 



Spinal cord begins at the end of medulla oblongata and
extends upto lumbar vertebra 2 or 3 in adults.
Lower tapering part is called conus medularis and the
lowermost bundle of nerve fibres is called cauda equina.
It contains all the ascending and descending fibres.
Lesion here can cause hemiplegia, paraplegia or
quadriplegia.

44. Cross section of cord

46. Main arteries are:
 Internal carotid arteries
 Basilar arteries
 Vertebral arteries
 Anterior cerebral arteries
 Middle cerebral arteries
 Posterior cerebral arteries
These form a circle called CIRCLE OF WILLIS


50. Areas of supply



MCA supplies lateral surface of frontal, parietal
& temporal lobe ie most of the motor & sensory
cortex except which lies on medial side and
controls legs.
ACA supplies medial side of brain.
PCA supplies the occipital lobe.

52. 


It includes:
Corticospinal tracts
Extrapyramidal system
Cerebellum (for coordination)

53. CORTICOSPINAL PATHWAY







Neurons in precentral gyrus
Corona radiata
Posterior limb of internal capsule
Cerebral peduncle in pons
Midbrain
Medulla oblongata
Decussation of fibres occur in pyramids of MO
and then descend as lateral corticospinal tracts.

55. 5 PATTERNS OF MOTOR
WEAKNESS





UMN weakness
LMN weakness
Muscle disease
Neuromuscular junction
Functional weakness

57. APPROACH TO WEAKNESS






First determine whether its:
Generalised weakness
Weakness of all 4 limbs
Hemiplegia
Paraplegia
Monoplegia
Patchy weakness

58. Weakness all 4
limbs
yes
Upper motor
Neuron pattern
Cervical spinal cord
Or bilateral brainstem
Or hemisphere
no
no
proximal>distal
no
Neuropathy
Distal sensory loss
yes
Myopathy
No sensory loss
no
Weakness in both
legs
no
yes
Upper motor neuron
pattern
Yes
Spinal cord, thoracic spine or above

59. Unilateral arm
And leg
yes
Lesion in brainstem
Or hemisphere
no
Single limb
Single root
no
yes
Radiculopathy
no
no
Patchy weakness
Single named nerve yes
yes
Multiple named nerves yes
Mononeuropathy
Mononeuritis
multiplex
no
Variable weakness
yes
Fatigues
yes
Myesthenia
gravis

60. Case scenario


A 50yrs old male suddenly develops weakness of
left half of body. O/E there is weak left arm &
leg with increased tone & upgoing plantar. There
is sensory loss also.3 days later patient starts
complaining of agonizing pain down the left leg.
Patient says that he feels like as his flesh is being
torn away from bones.
What is the lesion and where is the lesion?

61. Case scenario


A 46yrs old male is brought to OPD with
c/o sudden inability to walk & to hold the
objects. O/E pt is having right nystagmus.
There is dysarthria & past pointing on right.
When asked to walk, patient sways to right.
Where is the lesion in CNS?

62. 1:Generalised weakness



Nerve lesion
polyradiculopathy
Neuromuscular junction
myasthenia gravis
Muscle disease
myopathy

63. 2:All four limbs---quadriplegia




UMN type
LMN type
Mixed upper & lower motor neuron type
myopathy

64. 3:hemiplegia



Cerebral lesion
Brainstem lesion
Hemisection of cord

65. 4:paraplegia


UMN TYPE
LMN TYPE
spinal cord lesion
cauda equina lesion

66. 5:Patchy weakness


UMN
LMN
multiple sclerosis
polyradiculopathy
mononeuritis multiplex

68. Sensory Pathways
Main sensory pathways are:
 Dorsal column
 Lateral Spinothalamic tract

69. Dorsal Column




It is concerned with joint position sense,
vibration and touch
Axons proceed in the posterior column to dorsal
column nuclei in medulla
Second order neurons decussate and ascend in
medial lemniscus to thalamus
From thalamus fibres relay in parietal sensory
cortex

70. Lateral spinothalamic tract



It is concerned with pain and temperature
Fibres synapse in posterior horns and decussate
in the center of cord
Later they pass in lateral column as
spinothalamic tract and join medial leminiscus to
reach thalamus

73. Symptoms of Sensory disturbances






Complaints like:
Being unable to feel feet on the floor
Unable to judge temperature of bath water
Pins and needle sensations
Sensory ataxia
Paraesthesias and pain in nerve root region of
supply

74. Patterns of Sensory loss
Single nerve lesion e.g., median n. lesion
 Root lesion
as in cervical or lumbar disc protrusion
 Peripheral nerve lesion
e.g., neuralgias, glove and stocking sensory loss
 Brain stem lesions:
loss of pain and temperature on ipsilateral half of face
and opposite half of body (e.g. lateral medullary
syndrome)


75. Patterns of Sensory loss
(continued-----)
Thalamic lesion:
hemisensory loss of all modalities and severe
deep seated burning pain
(Dejerine roussy syndrome )
 Cortical lesion (parietal lobe )
Hemisensory loss of all modalities
 Spinal cord lesions


76. SPINAL CORD LESIONS

77. CASE SCENARIOS

Gulzar bibi, 65 yr old lady presented via opd
with c/o gradual weakness of both the legs for
last 2months associated with urinary and fecal
incontinence. There is also a c/o tingling and
burning sensation in the legs.

78. O/E
An old lady lying in bed, conscious.
 No abnormality on inspection
 Power 0/5 in both the legs
 Tone decreased in both the legs
 Reflexes diminished
 Plantars bilaterally upgoing
 Spine normal
 Sensory level at T6
what is the investigation of choice?

79. MRI spine showed degenerative spondylitis at
mid and lower thoracic spine,most evident at
T8 & T9 causing cord compression.

80. Case 2
Mr Fazal kareem, an 80yr old gentleman
presented in ER with c/o weakness of legs,
constipation & urinary retention. Patient
referred to surgical unit as a case of intestinal
obstruction and urinary retention. Later no
surgical abnormality detected. Medical
consultation taken.

81. O/E






BULK equal bilaterally
TONE increased in both the legs
POWER 2/5 in both legs
REFLEXES diminished
PLANTARS upgoing
SENSORY LEVEL T4
Clinical diagnosis?

82. CASE 3
Miss maryam, 16 yr old presented in OPD with
c/o progressively increasing difficulty in
walking. O/E
 POWER
3/5 in both legs
 TONE
increased
 REFLEXES hyperreflexia
 Plantars upgoing
 Ankle & knee clonus positive
 Sensory level
T6

83. Patient had pulmonary TB 3yrs back, took
ATT for 2months.
MRI spine showed two soft tissue density
masses in thoracic spine causing cord
compression.
Histopathology of the mass showed
features consistent with the diagnosis of
-------?

84. CASE 4







A 30 yrs man is brought to ER after an RTA causing
injury to spine. O/E:
Vitals stable
Power 0/5 in the legs
Reflexes absent
Tone decreased in both legs
Plantars non-specific
Complete absence of all sensations below the umbilicus

85. What is the lesion?
Where is the lesion?

86. CASE 5







A 40 yrs old male, victim of earthquake with spinal injury
is admitted in the ward. Examination of legs shows:
Power 0/5 in left leg
Tone increased in left leg
Left plantar upgoing
Reflexes brisk on left side
Absent joint position & vibration sense on left
Absent pain & temperature sensation on right
What is the pathology?

87. CASE 6


A 57 yrs old man is brought to ER with c/o sudden
inability to walk. O/E power reduced in both legs with
upgoing plantars. There is loss of pain & temperature
sensation in both legs but joint position sense is intact.
What is your diagnosis?

88. CASE 7


A 48 yrs old male is brought to ER with c/o weakness
of all the four limbs over a period of 1year. However
there is no incontinence. Thre is also dysphagia.
Examination reveals UMN quadriplegia with visible
fasciculations over the tongue. Uvula deviates to left
when 10th nerve is examined.
Where is the lesion & what is the pathology?

89. CASE 8



A 42 yrs old lady comes in OPD with c/o numbness of
both the hands and difficulty in holding the objects.
O/E there is absent pain & temperature sensation over
the hands and forearms. Sensory loss is dissociated.
Sense of vibration and joint position sense is intact.
There is weakness of small muscles of hands.
What is your impression?

90. CASE 9
A 65 yrs old gentleman is brought to OPD with c/o progressively
increasing generalised weakness, anorexia, SOB & easy
bruisability. There is previous h/o partial gastrectomy due to
unknown reason. O/E:
An elderly gentleman with marked pallor, bilateral pitttting edema
feet & bruises over the arms and legs.
Vitals stable
GIT:
no abnormality

91. LABS
Hb = 5.7 g/dl
 MCV =
116 Fl
 Serum albumin = 2.7 g/dl
 PT
= 22sec/ 14 sec
What is your diagnosis & management plan?


92. CNS:




POWER
3/5 in legs
REFLEXES : absent ankle reflex on both sides
PLANTARS: upgoing
Absent sensations upto knees

93. COMPLETE SECTION
Bilateral loss of all modalities below the level of
lesion

94. Hemisection


Contralateral loss of pain and temperature
Ipsilateral loss of touch and pressure
Below the level of lesion
Brown sequard syndrome

96. Contralateral loss of pain and
Temp with preservation of
Dorsal column
(e.g.syringomyelia)

97. Spinal cord lesions
Posterior column loss
 Anterior spinal artery syndrome:
Involvement of lateral spinothalamic tract with
preservation of dorsal column


102. Cerebral Cortex




Contralateral hemiplegia with hemisensory loss
Left hemisphere; dominant:
Aphasia
Cortical sensory loss
Right hemisphere
Inattention, denial, constructional apraxia,
dressing apraxia, spatial disorientation

104. Corona radiata


Contralateral weakness mostly monoplegia
Sensory loss according to area involved

105. Internal capsule


Dense contralateral hemiplegia and sensory loss
Face, arm and leg equally affected

106. Midbrain
Involvement of:
 Third and fourth cranial nerves
 Descending corticospinal and corticobulbar
tracts
 Reticular formation
 Red nucleus

107. Clinical syndromes associated with
lesion
Weber´s syndrome: Contralateral hemiplegia and
ipsilateral third nerve lesion
 Benedikt´s syndrome: third nerve palsy with
involuntary movements of opposite limbs (red
nucleus involvement)
 Akinetic mutism:
Involvement of reticular formation; patient makes
no voluntary movements except that of eyes


108. Weber syndrome

109. Lesions in pons




It contains 5th, 6th,7th & 8th cranial nerve nuclei.
Lateralized lesion in pons causes ipsilateral CN
involvement with crossed paralysis or sensory loss as in
Millard Gubler syndrome. (6th and 7th nerve palsy)
Central pontine lesion may cause coma, hyperthermia
& pinpoint pupils.
Locked in syndrome: only eye movement is possible. Pt
is able to communicate via eye signals.

110. Lesions in medulla

Medial medullary syndrome:
Weakness and loss of postural sense in limbs on
side oposite to lesion with ipsilateral paralysis of
tongue.

111. Lateral medullary/pica/wallenberg
syndrome









Dysphagia
Dysarthria
Dizziness
Hiccups and vomiting
Ipsilateral horners syndrome
Ipsilateral cerebellar lesion
Ipsilateral sensory loss in face
Contralateral loss of pain and temperature in limbs
Ninth and tenth cranial nerve palsies
Pyramidal tract is not involved

112. Lateral medullary syndrome

113. Unilateral
Cranial nerve
abnormalities
Contralateral
Hemiplegia or
tetraplegia
Multiple Cranial nerve abnormalities
No
yes
IIIrd nerve palsy yes
No
VI and/ or VII
No
XII ± IX and XI
yes
Combined V
VII and VIII
yes
No
Cerebellopontine
lesion
Midbrain lesion
Combined III, VIth yes
And V
No
Cavernous sinus
Pontine lesion
lesion
Combined IX,
X and XI
Medullary lesion
Jugular foramen
syndrome

116. Middle cerebral artery





It constitutes 2/3 of all cerebral infarcts
Contralateral hemiparesis and sensory loss, arm
and face most affected
Expressive aphasia(dominant hemisphere)
Anosogonosia and spatial disorientation (nondominant)
Contralateral inferior quadrantanopia

117. Anterior cerebral artery




It constitutes two percent of all infarcts
Contralateral hemiparesis and sensory loss,
worse in leg
Incontinence of urine
Loss of verbal fluency but preserved ability to
repeat

118. Posterior cerebral artery

As it supplies occipital lobe, so lesion causes
visual field defects, contralateral homonymous
hemianopia

121. Frontal lobe





Intellectual impairement
Personality changes
Urinary incontinence
Mono or hemiplegia
Motor aphasia

122. Parietal lobe





Loss of cortical sensations
Apraxia
Contralateral homonymous lower quadrantanopia
Dominant lobe involvement causes acalculia, agraphia,
finger agnosia, right left disorientation----Gerstmann
syndrome
Non-dominant lobe involvement causes sensory and
visual inattention, spatial neglect, apraxia, anosogonosia
and autopagnosia

123. Temporal lobe




Auditory or olfactory hallucinations
Auditory or visual illusions
Contralateral homonymous quadrantanopia
déjà vu phenomenon

124. Occipital lobe




Visual inattention
Visual loss
Visual agnosia
Homonymous hemianopia with macular sparing