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CNS Case Discussion

Jun 19 | 1:30 PM

The pandemic has taken toll on everything, specially medical education & training and resident doctors all across India got really little exposure of other cases like CNS. With this session, let's dissect one interesting CNS case with Dr. Ravindranath Sahay who is passionate about teaching young medicos and consultants & strongly believes clinical diagnosis of a condition.

welcome hi dr welcome you all we are here with again uh with her amazing session on cnn's a favorite faculty of mine from km has agreed to join us for this discussion today so uh to tell you about sir he has worked as a professor and head of unit in cengius medical college in km hospital mumbai pretty kids and he's passionate about teaching young students and we also have kunal with us who is a resident doctor at km hospital mumbai and uh he's a gold medalist in medicine and we will also be accompanied by dr yogesh uh who will also be uh presenting the case with kunal uh we will discuss a hemiplegia case right now we'll just dissect one cns case and learn about management and everything so let it be interactive one if anybody wants to ask something okay can you just tell uh everyone a bit about him pleasure and just neurological conditions that you are going to encounter okay so you as a first case you should know how to analyze that okay so hemiplegia is paralysis of one half of the body okay so the human body neurologically is in two parts okay one are right and left okay right half is represented on the left side of the brain and left side on the right side right so getting paralyzed means one side of the brain or its connection from the brain to the spinal cord is disrupted the brain is connected to the spinal cord through the cortical spinal tract or the pyramidal tract okay so if that disrupts only then you get a heavy pleasure okay so that is the first thing you need to understand about it uh 42 year old male abc resident of nala super mixed at a driver by occupation married right-handed came with complaints of weakness of the right side of the body and slurring of speech which was sudden onset five days ago a patient was apparently asymptomatic five days ago when he went to sleep at 12 30 a.m midnight but patient got up with inability to remove the right lower limb and right upper limb and could not get out of the bed in morning at six o'clock he could move the lower limb a bit and was possible to the right temperature along the body but could not lift the upper limb up so okay from what the complaint was okay this is very common complaint for patients with hemiplegia right so patient engine 40 is a driver by occupation okay you said right handed so here we analyze why you are keen on knowing what handedness he has so what does that tell you okay so a right-handed person okay his dominant hemisphere is the left lobe okay that's what it tells and why you want to know the dominant hemisphere it's something there should be some reason for using it so you want to know the dominant hemisphere speech yes because the broca's and the vernicas the speech areas are located in the dominant hemisphere okay so all right handles will have left loop formula is on the left side right forty percent of left-handed people also have left side dominance okay so a small proportion of the large population of humans only sixty percent of left-handed people have right low dominance dominance is of significance only because the speech area is located in that area okay in that loop right now here he says that the patient went to sleep and when he woke up in the morning okay he was paralyzed so the incident before he realized he was all right when he woke up he was paralyzed okay this is an acute onset even right and it is occurring in the morning so a neurological deficit is acute in onsen okay acute in the sense you can count over minutes to hours okay so in that during this period of time the patient got paralyzed so this suggests that it is a cerebrovascular accident blood flow to the brain has got disrupted somehow right so this is that's known as cva or cellular vascular accident so what are several vascular accidents so the several vascular accidents means what can go wrong with the cerebral vessel several arteries okay is that it causing cerebral hemorrhage or there could be a thrombosis within the cerebral artery so that's called cerebral artery thrombosis or an ambolus from elsewhere for example from the heart from the left side of the heart an embolus may come out and may block the cerebral artery one of the cerebral arteries okay so one of the three is a cerebral vascular acid so one of this incident happened either there was a hemorrhage or there was an acute thrombosis or there was an embolism but what is significant here you know is in the history you are saying that there was this event occurred in the morning when he woke up he found himself paralyzed so a vascular event occurring in the morning suggests that there is thrombosis thrombotic events occur in the morning okay because very comfortable just sleeping okay so during that time hemorrhage is very rare to occur okay so what would have happened is that these several activities were bent into a thrombotic event okay and why does the artery symbols okay and chosen there only is that at the site of thrombosis there must have been a atherosclerotic plaque so in his history we will be telling you you will find some reason for atherosclerosis to have happened okay so from the history till now it is that there is an acute onset neurological deficit which includes upper limb lower limb okay both as is mentioning okay it occurred in the morning and acutely over minutes or hours so this is a central vascular accident and most likely a thrombotic cell vascular accident so kudo you can go on from here it progressed over the next two hours to complete inability to move right side of the body associated with slurring of speech which was noticed by the husband um by the way but a patient followed what the wife was saying over the next five days the weakness has been static patient has difficulty in eating the food with the food getting stuck in the mouth and sticking to the sides of the chick a patient has difficulty in turning in the bed and patient has a cough while eating or drinking there is no history of sensory loss there is no history of any loss of smell vision uh diplopia difficulty in opening the jaw dysphagia or weakness in shrugging of shoulders or hearing loss or tinnitus there is no history of bubble weather symptoms uh but patient was categorized in view of immobility there is no history of sweating syncope or greediness there is no history of severe headache preceding the event or vomiting or seizures there is no history of in the event occurring at the height of activity there is no history of any known heart disease chest pain palpitations breathlessness or syncope there is no history of polytypsia or repeated infections patient is a tobacco chewer denies any history of cigarette smoking or alcohol use there is no history of migraines headache there is no issue of convulsion prior to the weakness there is no history of tremors perspiration or decreased oral intake there is no history of fever with breathlessness or cough there is no history of unnoticed wound on the right leg or back there is no history of contractures of the wound there is no stress convergence post to the event and there is no history of loss of consciousness so like in his histories he said that he progressed when he woke up there was some degree of weakness and over two hours he was completely unable to move so this is slow progression okay over hours only is enough slow progression over days okay so this is suggesting a cerebrovascular accident it is a acute event okay so this is an acute event and it is occurred in the morning so most likely as i told you thrombotic even right yes and he says that patient has got slugging of speech okay the wife said do you have to be little particular about what was wrong with the speech there is a speech disorder okay the patient could understand you said you said patient could understand what the wife was saying but he was not able to speak i think that's what you want to say was he able to speak he was able to speak he was able to produce words but uh his whatever he was speaking was not uh clearly audible to the uh relative okay so patient the relative could not understand what is he so you will have to tell in the finding what you get right so these kind of speech disorders for once okay you are doing it so you realize that speech disorder can occur in two ways one patient is aphasic cannot speak at all okay he can understand and cannot speak at all so this is motor aphasia or broca's aphasia okay so when patient is able to understand and unable to speak right but then patient may be able to speak but cannot articulate properly okay so he's speaking but it is not very patient it cannot be understood what he's actually saying okay all the words are not formed very clearly so that's slurring of speech that is a different thing okay that doesn't have much neurological problem in that okay it is just that the mouth will be paralyzed so it is not able to articulate very well but what i expect here is that patient has inability to speak you ask that patient is right-handed okay therefore the dominant hemisphere is on the left and patient has developed right-sided hemiplegia that means the lesion is on the left so broca's area is likely to be involved here so patient will absent a patient will get broken just won't be able to speak at all right so that so this is okay why you ask that the patient is right-handed or left-handed right so dominant hemisphere you already decided his left hemisphere and he's got right-sided hemiplegia means the lesion is on the left so broca's areas are gone right and then in telling about what other features are there you are saying that food is sticking to the mouth on one side okay so the food is vaccinated buckle muscles are not necessary so buccal muscles are not able to move therefore food sticks between the gum and the cheek between gum and the cheek alveolar margin and the cheek right so this suggests that there is facial palsy as well okay so this we are going to probably tell so what is the implication of the history that i was trying to say okay now in this history like you said there is no history of polyurea politics here so best of all there is no history suggestive diabetes that's what you are probably implying so there is no history of diabetes yes what else is to be told is whether special is aware that he is hypertensive is there a history of hypertension so hypertension and diabetes these are the two things this has been known hypertensive who is taking one tablet in the morning daily since last two years so this suggests that there is hypertension but you do not know whether it is adequately controlled or not yes sir okay so then there is a reason for getting atherosclerosis okay atherosclerosis of the artery will occur the most important cause of atherosclerosis is uncontrolled hypertension okay the second most controlled two most significant risk factor for getting atherosclerosis and therefore cva is smoking the third is hyperlipidemia or dyslipidemia okay fourth is uncontrolled diabetes mellitus okay so these four reasons okay tobacco lipids diabetes and on top of it all is uncontrolled hypertension so these are all significant here's all of them not all of them he doesn't seem to be having diabetes you do not know if he doesn't give history of diabetes so you have to find that out okay so that's it i can summarize it as 42 year old male with acute onset history of right side dead hemiparesis with slurring of speech is probably a case of a cerebrovascular accident which is more likely to be shimming than hemorrhagic so ischemic means what you're saying thrombotic so why you think scheming early okay and there was yesterday you could count the time okay in hours so when he woke up he found the village and over two hours he got completely paralyzed so this is progressing over ours okay so this would suggest thrombosis okay a valid room patient is conscious oriented to time place in person uh general examination uh the pulse is 17 bits per minute regular the blood pressure is 140 by 90 millimeters of mercury uh peripheral pulses are well felt uh so there is no parallel cyanosis clubbing or lymphatic correct or edema the patient was examined uh technician is higher mental functions so the speech the comprehension is preserved patient can repeat up to five words uh without word output is normal there are no grammatical errors but there is slurring with dysarthria present uh other higher mental functions are normal uh the cranial examination so the seventh cranial now uh there is a deviation of angle of mouth to the left on smiling there is weakness of the right-sided buccinator muscle there is no weakness of the orbicularis ocular muscles and on frowning uh both both sides frowning is present uh the test sensation is not lost uh all other perennial examination is normal and what it says is general examination patient is conscious okay he was also conscious when they even when he woke up in the morning he was conscious so alteration of consciousness or loss of consciousness would suggest okay yes a hemorrhagic event okay the cva was embraced okay so this wasn't so his consciousness is still intact now his speech as he says that he can speak he can repeat words okay but if the person can speak then this is not aphasia this is just dysarthria okay what was expected what patient will become a physical but he hasn't so he's been lucky okay lucky depend where the sight of lesion is okay right speech is preserved only articulation is a problem so now you have to be very specific here okay to make out whether patient can speak like we i'm doing or any anybody else all of you are doing okay or is unable to speak okay so this is important but then as i can make out you are saying patient is disastrous that means in word formation in articulation there is problem okay so that and then another positive point there is the blood pressure is 140 by 90 okay so 140 by 90 is still hypertension right so therefore his blood pressure is not well controlled right and he's been in hospital so he must have received treatment also despite that it is 1490 okay so the blood pressure you solve 140 by 90. okay so it is raised is hypertension right so that is one reason to have got a circular vascular accident okay now the pulse you said is 72 bits per minute so grade is normal what is important is whether it is regular or not so the rhythm is irregular that means patient is not fibrillating stimulating fibrillation of the heart okay atrial fibrillation okay would be the major reason for an embolic event okay so it doesn't look like this patient has okay so only thing positive is high blood pressure so therefore with cva that you can almost guess correctly okay that this is thrombotic right karima has asked how slurring of speech can be differentiated from motor aphasia that happens because the face is paralyzed one side again saying right side is not functioning so without moving the right side if you want to speak only with the left half how i am sounding okay so it is difficult to understand but i can speak everything okay so that a physic would not be able to say in a word you cannot speak okay it's like i can tell your name i can say okay any word i can so patient loses the ability to speak all together so very much is that clear you wanted some more clarification on that but if i paralyze one half side of my face and just do it like that so it is difficult to understand what i'm saying okay but then i can speak okay if you pay attention you can still make out what i'm saying right so that is look at this r3 this r3 difficulty in articulation so patient can understand what is being spoken okay like if how do you make out that patient can understand you ask him to do something okay raise your hand the person will be able to raise your show your tongue you can do that okay but don't ask him to raise his paralyzed hand and you say you cannot understand okay so rights and paralysis so you ask the person to raise the left hand so be careful okay so he is can follow what is being said okay but if you ask him anything you will you look like there is wanting to say but okay he's not able to speak he won't be able to speak at all okay so this is a tool that has taken okay this is very frequently in the [Music] right so you can no but as soon as heavy projects start getting admitted you can check on this right i think i have answered anybody else yeah there is one more question why are we thinking in terms of thrombosis with history uh why can't it be hypertensive hemorrhagic stroke yeah exactly so so make this clear okay you this is not confirmed but clinically this is before imaging came before scans and mri scan came okay people used to diagnose clinically so that's exactly what i was saying so why you're suspecting okay these are the reasons why you're suspecting one onset that's why in history the onset is important patient went to bed hail and hearty but when he woke up in the morning he found he was paralyzed he was having weakness okay so this event has occurred in the morning so vascular events occurring in the morning are commonly thrombotic blood clots more in the morning myocardial infarction heart attacks will occur more in the morning okay several vascular accidents okay let me elaborate more because you're doing everything you are supposed to know everything so it is not just morning okay big trial was done on this so large group of people okay were made to wake up at 12 o'clock in the noon okay so that morning is avoided to see whether vascular events occur so it was found that when they woke up at the population that were made to wake up at 12 even they had on waking up they would get thrombotic events so it was not morning but it is to do with waking up okay so vascular events occurring on waking up most likely it is thrombotic okay so there has to be some reason why this is happening so this is not very clear but what is um what explanation has been given is this that in the morning why promoting events occur more is because the blood flow is very sluggish okay slow flow of blood sympathetic stimulation is at its lowest okay and the viscosity of the blood is high okay through the night person is sleeping so he's breathing out has not taken any fluid okay so he's losing vapor from his breath so blood gets discussed so increased viscosity and sluggish flow of blood may be the reason why early waking hours have from boating events okay this is very common you see patient went to the toilet fell down and was paralyzed so the relatives feel that he fell down and therefore he has got paralyzed actually he got paralyzed so he fell in the toilet okay the first thing president wakes up and goes to the first event is going visiting the loop is one it was in the morning and second thing he woke up in the morning and found himself weak on one side and then the weakness progressed over two hours ago two so that the patient was completely paralyzed so complete paralysis and onset of weakness okay there is a time lapse of two hours so this slowly developing okay it is acute but over ours so this is suggesting thrombosis okay a hemorrhage or an embolism will be what is known as catastrophic event last moment patient was fully normal next moment patient is fully paralyzed the entire paralysis occurs instantaneously okay so that would suggest hemorrhage right plus there is no loss of consciousness hemorrhage will be assorted with loss of consciousness he also told in his history there was no convulsions okay so not getting convulsion okay convulsion will occur if there is an irritative lesion so in a vascular event most likely due to hemorrhage so anybody else for asking yeah with hypertension should we consider other etiology for it like autoimmune or vascular impact or so good thinking okay so 42 probably she's thinking too young to get okay but then hypertension occurs at around you means 30 seconds okay so when you develop so if you are suspicious okay just suspicion should include everything you can i did i don't think it is because of atherosclerosis occupation maybe having autoimmune what sarvatha is suggesting okay so that theoretically it can be but then practically it is not possible 42 year old he is known hypertensive right and the description of the event okay so he's a tobacco chewer and hypertensive so atherosclerosis is the most likely event the major reason for losing consciousness is vasospasm that occurs that time okay when hemorrhage occurs okay body tries to reduce the pressure okay so vasospasm occurs okay so there is an acute cerebral edema that begins to happen okay plus that area is very irritating because how is it that paralysis occurs so immediately and so completely so the bleed is very tiny okay that is not sufficient to cause so much of illusion but then where the breed occurs around that there is significant edema okay very regional leading mites at the number of around the lesion okay so that causes the deficit and also loss of consciousness extremes of stress okay either emotional stress or straining systolic hypertension others okay so history would suggest at peak of the person was emotional and got angry so that time okay even that straining at stool older people okay they get prosthetic loudness they begin morning straining and passing urine okay so this strain raises the systolic pressure and hemorrhages occur at that time embolism can occur any time of the day the weakness of the right-sided buccinator muscle uh the frowning on both sides is present there is no weakness of the orbicularis ocular muscle uh the findings are suggestive of right-sided type of facial pulsy other cranial nerve examinations are normal the gag reflex is present so the sensory examination uh is normal for both the touch pressure temperature uh and touch pressure vibration proprioception and pain temperature there is no loss of cortical sensations and in the motor system the nutrition is a equally adequate the tone on the right side of the body is increased yes sir the power on the right side in all muscle groups and shoulder elbow and wrist is now zero on the left side it is five similarly in the lower limb in all muscle groups in hip ankle and knee it is zero on the left side it is five so the reflexes on the right side are uh three plus biceps triceps supinator knee and ankle on the left side all these reflexes are uh normal two-plus plantars are uh up going on the right side and it is down going on the left side okay so just just a moment okay so we'll just analyze this okay contact these higher functions that we did speech okay so cranial nerve this is significant right you can ask also okay so all current users are intact except for the facial okay seven now when you're saying oxygenator is weak so you have to tell you have concluded vaccinator is weak okay so which muscle what function does the buccinator how you check that and when you said angle of the mouth is deviating to the left okay that means the angular angle of the original cavity angularly origin there is several muscles here levator angular is angular is depressor angle so it is not moving at all so the muscle of the angularis muscles okay they are all paralyzed right but you said patient can shut his eyes patient can wrinkle and frown that means only the lower part of the face is paralyzed yes that you said okay you can yes frowning okay frowning is upper part of the face three movements occur in the upper part which one would you call upper part okay the upper part would include from above wrinkling okay frowning and shutting the eye just removed to be easy and the muscle wrinkling by frontal belly of occipital frontalis just frontalis will do okay frowning corrugator superciliaris and shutting the eyes orbicular is oculi so these three movements are intact only the lower part of the face so here you what else okay you probably have missed okay but then what you have to tell about is from above the nasolabial fold okay so this patient if you just such complete paralysis of the face there would be loss of the nasolabial fold this nice angle okay and when patient smiles only one side this side would not move okay and cannot blow his cheek okay we cannot do this so we say whistle run to us we actually ct is not important he is able to do this movement of the lip is important okay so actually you are checking the lip movement orbicularis so these are all paralyzed so only the lower part of the face on the right side is paralyzed so this suggests upper motor neuron facial paralysis okay so i think this most of you will be knowing why this happens but then if somebody is not knowing it would be that we did it and we did not know okay so to just to make everybody aware so why the lower part has only got paralyzed because see the facial nerve starts from the bones okay any nerve starts from its lower motor neuron right any now peripheral nerve starts from the motor aspect of the peripheral nerve starts from the lower motor neuron which is the anterior horn cell in the spinal cord okay for cranial nerves the cranial nerve do not start from the spinal cord they start from the brainstem so therefore they are from where they start their lower motor neuron can't be called anterior concept so it's called cranial nerve nucleus okay so the cranial nerve nucleus for the seventh nerve okay is in the pawns and in the pawns there is not one single new neuron okay there are clusters of neuron right this is a large area to be covered face okay all movements of the face so for the upper part there is one cluster of neuron for lower part there is another cluster very close together you realize like that right now this lower motor neuron the nucleus is connected to the upper motor neuron in the motor cortex okay so for like limb muscle your biceps your quadriceps they are connected to the upper motor neuron on the opposite side right but for all cranial nerve they are connected to the opposite side and also from the same side okay nature has given this protection if your cranial nerve is an animal species cannot survive all the functions of the cranial nerve are essential all right so if that those movements are not there then the species cannot survive that individual cannot survive humans we live in in a protected environment okay so we can survive therefore as a neurological evolution okay the cranial nerve nuclei have got connected to both motor cortex the left sorry opposite as usual for any neuron but also to the same side it is like your icu ventilator it is connected to one electrical port but also to another but to two phases of supply that one trips the other one is still there because it is serving vital function when the lateral person will die same thing okay the cranial nerve nuclei all of them have bilateral innervation from both motor cortex opposite as usual and from the same okay the facial nerve nucleus supplying the lower up part of the face has just one connection unilateral connection from the opposite motor just like your limb muscle okay so if there is a legion on the right okay or the in this case it is on the left okay so only the lower part of the face has got paralyzed okay so ideally you should have had all cranial nerves paralysis but because the other cranial nerves have bilateral innervation so they have skipped right so this is the implication right so this goes in your diagnosis so where is the lesion okay when you have pin pointing plus what do you call this kind of neurological deficit right so this was about the cranial nerve so rest of them are dense and dr kunal says that seven nerve is involved in an upper motor neuron lesion so at the moment all that you can say is that where is the nucleus of the seventh in the pons so the lesion is above pulse that's all you can localize at this moment so now motor finding so this is cranial nerve done i'll yes so first thing in motor examination you said the nutrition is intact it is supposed to be intact okay nutrition depends on the intactness of the lower motor neurons so this is not a lower motor neuron disease with the lower motor is not involved therefore nutrition remains normal there are one reason for nutrition to be affected men atrophy to occur is disused okay because the limb is not being used so there may be muscle but it's too early in the day patient has been just paralyzed few days back okay so that is not set in as yet disuse the trophy is not certain so nutrition is known now in your presentation for rest of you okay one thing you have to one hurdle in your path is your you clearing your md exam so when you're telling your findings okay so you tell first like tone okay so he said tone is increased on the right that's what you said kunal the one on the left is normal you first tell norman the tone on the left side is normal as compared to that okay yeah yeah so the tone is increased right which type so you have to commit that okay it's the patient so spasticity is suggestive just suggesting that this upper motor neuron okay you have told about so spasticity is there is sparse density so the right half of the body right upper limb lower that is involved all muscles are involved in an upper motor neuron lesion right so this also helps you in localizing like you said upper limb upper limb the root value starts from c5 cervical 5th 6 7 8 t1 so the lesion is above that you have already said facial is involved so this is going to be there okay the lesion is above pawn so that is above c5 cc but then you are telling your findings so upper limb is involved in hypertonia that means the legion is above c5 okay same for the lower limit so it is just you are telling what is obvious it should be there okay after that you said power is zero okay that means there is no movement so you should say that power on the left is five by five so you tell normal is five by five so as compared to that i am saying there is no movement zero okay then deep tendon reflexes so you do a two plus three plus or how what do you mean what do you want to convey okay so you ideally is not to tell in two plus three somebody knows very theoretical examiner may ask what a grade of power it so that that is easy for you what you have to comment on is the reflexes deep tendon reflexes are normal on the left side you can commit upper limb biceps triceps brachioradialis finger flexion okay these reflexes are normal as compared to that on the right side the biceps is exaggerated it is increased bicep reflex is increased so you have to commit it is increased or normal or less so by saying three what you meant was it is increased okay so that if there is hyper reflexive same in the lower limit hyper reflex as compared so in the lower limb the deep tendon reflexes are normal on the left side as compared to that which is exaggerated on the right the knees are anchored and you said about plantar so plantar reflex on the left is plunder going is down going or plantar flexion on the right side it is extensive plantar extensor okay this is abnormal right that is also suggesting that there is a upper motor neuron lesion if you say plantar the root value is l5 s1 so that just tells you that lesion is above l5 s1 you have already told there is facial upper motor facial pulses so lesion is already above pawn so these are all going to happen ok if they are not there then it is surprising okay you could ask right so that was about the reflexes superficial reflexes the abdominal should be absent if you test the abdominals they will be absent on that side okay these different reflexes are just to know which the lesion you localize the lesion where it is okay like you said knee jerk is exaggerated so you know the root value of the knee jerk is l234 so the lesion is above l2 you have already generalities in the bonds okay so any questions here is under control of the upper motor neuron the brain controls the lower motor neuron right now tone by definition what is stone tone is resistance to passive movement you do a passive movement okay the muscle resists that that means muscle contracts when you do a passive movement right so tone is happens reflexively okay as soon as you move the muscle the muscle will contract okay in response so this is a reflex now what the upper motor neuron does is it modulates the lower motor neuron to cause appropriate response if you move the muscle the muscle will just contract and try to maintain its original position right if you move the biceps the biceps ideally should contract to its full strength but it just contrasts gently okay so why this happens is the upper motor neuron controls the lower motor neuron and modulates modulates the response of the lower motor neuron negatively the upper motor neuron has a negative impact on the lower motor neuron so far as stone is concerned so it doesn't allow okay the biceps to contract fully that is what normally happens okay now if there is an upper motor neuron lesion then the upper motor is no more modulating the lower motor neuron right so when you move the muscle you'll contract to its full strength okay that's why hypertonia occurs right in upper motor neuron lesion the lower motor neuron is no more modulated right so therefore the reflex is exaggerated so tone is also a reflex just like deep tendon reflex so it gets exaggerated right somebody i think i just remember was asking why there is hypotonia hypotonia after a stroke after a hemiplegia in the early phases that's called spinal shock or neuronal shock so there's something very simple the lower motor neuron all its life has been connected to the upper motor neuron ever since this individual was born the upper motor neuron is connected to the lower motor suddenly when there is an upper motor neuron lesion so that the lower motor neuron doesn't know how to function on its own though there is no lesion so it goes in a state of temporary shock a temporary period of shock transient shock okay which may be for hours days weeks if it is not fixed how long it depends on what is the severity of the lesion okay so the lower motor neuron loses its function temporarily okay then it realizes that nothing is wrong with me so it starts functioning again so spinal shock is a short period of time after an upper motor neuron lesion when the lower motor neuron loses its function and regains it after the period of shock right so that's why hypertonia occurs with right sided upper motor neuron facial pulse that's it there's no sensory involvement you can say so no sensory involvement that's it other than that you don't have to tell anything right so if this is the finding then you don't tell pathology first you have to tell where is the lesion there is a lesion of the neurological system so lesion you that is the anatomical diagnosis you make after physiological functionally right-sided me please right-center upper falls due to a lesion in the left internal capsule that's it okay you can argue why you're saying somebody asks you yeah then my judgment your judgment is it is in the left internal capsule right then you tell what is the pathology due to a cerebrovascular accident that is for sure it has occurred acutely so you commit you don't say maybe maybe it is a cerebrovascular accident okay now you can't be so heroic so you say probably a thrombotic event okay unless you image okay you cannot say for 100 okay sometimes there are great zones but this one is the two clearer case okay so this one is you can tell for certainty this is a thrombotic even what you said is ischemic so ischemia means what you're saying is thrombotic the cerebrovascular accident thrombotic in nature right that's the pathology and why do you think it occurred why you think the etiology of the last why you think it occurred so due to hypertension and tobacco use till now you have found out you didn't find him to be hyperlipidemic or diabetic okay so you have to investigate and then come to diagnosis if you have not done no investigation is available patient is unable to tell you but what he has told is that tobacco use and hypertension so this is because of hypertension and tobacco use so you commit that so that's the full diagnosis one go i'll tell okay this is a case of right sided hemiplegia with right sided upper motor neuron facial palsy due to a lesion in the left internal capsule okay the cause being a cerebral vascular accident most probably the most likely a thrombotic even the etiology being hypertension and tobacco use over i told so you're again yes so neurological deficit especially strokes will occur not in a very proximal artery involvement okay because in the nervous system there are there is intense anastomosis okay so if you block the carotid okay nothing will happen because of the circle of village so neurological deficits occur only if the end arteries the terminal branch which do not anastomose they are involved this is a tiny artery which is involved right you can yeah i have to say which crit and which yeah cerebral arteries involved okay that you can right so here it is little different because equal upper limb lower limb phase equally involved right sensory involvements can occur in internal capsular religion okay so in now in hemipedia in neurological deficits like these extensive okay sensory lesions can occur why if there is a thalamic region along internal capsule and thalamus may get involved in certain artery involvement so if the thalamus gets involved then there will be hemi anesthesia all modalities will be lost but if it is an internal capsule illusion then only we could not actually mention okay there is no cortical there is no loss of particle sensations so in internal capsular regions only cortical sensations will get lost okay the thalamus is before that fibers from thalamus pass through the internal capsule before going to the sensory cortex so only the particle sensations okay so that sensory involvement may occur okay in hemiplegia so that's it any other more question yeah so we have some questions autonomic uh or not while studying genesis yes that you can mention okay along with sensory usually it doesn't involve autonomic nervous system okay but we are assuming here we are talking only of internal capsular region okay the lesion can occur anywhere so kunal just one question and question for everybody else whether you have understood so internal capsule is a place okay so what has got damaged in the internal capsule what was the in the drill capsule that has got damaged and caused this resistance yes correct okay so corticospinal tract passes through the internal capsule so there is a lesion in the drill capsule so the corticospinal tract has got involved okay so actually the neurological structure that has got damaged is the corticospinal tract okay so the corticospinal tracts when it enters the small body occupies a very narrow area all the fibers of the body okay pass through this narrow area and remain like that bundled after that so if there is a lesion in the internal capsule attack before this was telling about the penetrating branch or the final branch so the vascular supply is very tiny so one tiny lesion has called such extensive paralysis that means all the fibers have got damaged all the fibers were trying to go through a very narrow area and there is the lesion of it okay but after the internal capsule the fibers remain packed like that okay so below the internal capsule there could be lesions still causing hiv okay so like in the brainstem okay a lesion in the brainstem can cause so so long as we are there so suppose it is not in the entire capsule it is in the midbrain its the first part of the brain stem after the internal capsule is the midbrain so if there is a lesion in the midbrain then corticospinal tract will get damaged and structures near the cortical spinal tract will also get damaged in the brain a significant areas neurological structure okay just adjacent to the cortical spinal tract is the nucleus of the third node so if there's a lesion in the midbrain along with corticospinal tract the third nerve nucleus will get damaged so patient will get a third nerve paralysis so that's why it is important when you're saying which cranial nerves facial nerve and that also upper motor neuron okay so that you have to commit which granular it could have been paralysis right side upper limb lower limb and lower part of the face with the third nerve paralysis on the left side if that would was the situation then your localization would occur in the left midbrain okay so because the cranial now nucleus has got involved therefore same sided gradient of calcium and opposite side hemiplegia okay so that way so it is not this case has the lesion in the neural capsule there before you are getting this manifestation so picking up which cranial of involvement is there is significant right you no need to know what is the upper motor neuron lesion or the lower motor neuropathy okay hemiplegia can't be lower molten resonation hemiplegia is always an upper body neurology but your the difference in the basic difference so that's why you do motor system examination okay so in upper like first thing you look for is the nutritional status of the muscle the bulk of the muscle is bulk is normal or not so in upper motor neuron lesion okay the bulk will be preserved whereas in lower motor neuron there will be atrophy of muscle okay so next is you look for tone the second point upper motor is you look for tone in upper motor neuron lesion there will be hypertonia okay but which type of hypotonia spasticity or class knife hypotonia okay in lower motor neuron lesion there'll be hypotonia tone will be lost okay then power okay power will be lost in both but in upper motor neuron lesions a small lesion will cause extensive paralysis large number of muscles limbs will be involved okay the large number of muscles in all the limbs will be involved whereas in lower motor only that muscle which the lower motor neuron supplies will get affected so small group of paralysis in lower motor right deep tendon reflexes upper motor neuron lesion the deep tendon reflexes will be exaggerated hyperreflexia after the period of neuronal shock after that period there will be hyper reflexion whereas in lower motor neuron lesion it will be lost reflexes are supposed to be lost in motor neuron okay is superficial reflexes one can distinguish like plantar reflex if l5 s1 is affected that is the lower motor neuron for plantar okay so in l5 s1 legion planter will be absent in lesion upper motor neuron lesions means lesions occurring above l5 s1 the plantar will become extensive there is not another one all the tracks which are going into the brain or exiting the brain they can exit only through the internal capsule there is no other rasta no other way for tracks to either enter into it or exit so all tracks pass through okay so corticospinal tract is a descending tract motor tract all the sensory tracts okay thalamo particle from thalamus after that the sensory tracks also pass through the internal capsule right so both motor and sensory tracks pass okay so the ideal image is to do a mri scan but it may not be available okay so you may do a ct scan okay of the brain to see your diagnosis cv is confirmed or not and which type of cva because your treatment depends on that right so ct scan has one shortcoming that in early part of the lesion within 48 hours of getting a stroke of this neurological deficit the ct scan cannot pick up in fact because that area hasn't changed okay so it cannot pick up an info it can pick up hemorrhage right so therefore mri scan is better in the sense if it is available then it will tell you is hemorrhage or not but then still with diagonals from ct scan you can diagnose in the sense if the c patient has got hemiplegia and the ct scan is normal so you conclude that this is thrombotic okay this is not showing hemorrhage so absence of hemorrhage means it is thrombosis right so that way you can conclude so why you want to know is the management the early management okay hinges on this okay the first four hours after getting a stroke is called the golden r you can retrieve in this period okay once the neurons are damaged okay they cannot recover there's no regeneration of neurons so before the damage is complete okay some palliative thing can be done okay palliative in the sense that something you can save the neurons you can save the neurons okay so it is absolutely essential all medical facilities world over okay have got a system where patient getting a stroke should be in the hospital within four hours okay and you do an imaging and confirm that this is if it is thrombotic so you do thrombolysis like like myocardial infarction okay so first four hours a thrombolysis okay we lie the thrombus blood flow will be restored and chances of neurological deficit in being controlled is there okay so that's what the initial manager first attempt is always there to get the patient within four hours and do a imaging and do a thrombolysis if the diagnosis is this is a thrombotic event beyond four hours then neurons cannot be retrieved okay so you do a palliative you reduce the ill effects so as i told you the major reason for neurological deficit is not the lesion itself but the edema surrounding perillusional edema so therefore after that you can give dehydrating agents like manitol is given to reduce edema okay so that neurological deficit recovers faster okay if it is an irritating inflammatory lesion causing edema like bleed so corticosteroid can be given so these two substances okay will reduce the energy right thereafter the management is rehabilitation okay and the restoration of whatever function can be done so physiotherapy is significant right if the patient loses his voice so speech therapy but once speech is lost very difficult for you to come okay so left side that way okay left side lesion is dangerous so right sided me pj is dangerous in that speech may be lost okay so speech therapy can be done then secondary prevention prevent the strokes occurring again therefore the underlying cause has to be treated the hypertension has to be corrected diabetes to be treated correctly okay and adequately hyperlipidemia to be reduced okay and if it is a thrombotic event you give antiplatelet drugs okay so that that it doesn't occur again if a person was getting a stroke hemiplegia is likely to get it again more importantly all these hemiplegics will ultimately die of myocardial infarction okay because there is a thrombotic even thrombotic lesion in the brain that means there is atherosclerosis of the cerebral artery if there is atherosclerosis the cerebral artery there would be atherosclerosis of the coronaries as well thrombotic strokes secondary prevention of thrombotic stroke is not just prevention of thrombotic stroke but also prevention of a cardiac event okay myocardial infarction right that is like you told that if it is hemorrhagic then just correcting the blood pressure is significant okay but hemorrhage may occur without hypertension if there is a anatomical defect like an aneurysm in the brain okay so for that digital subtraction angiography apart from mri okay you have to do a digital subtraction angiography in case it is a bleed to see which vessel had bled and why blood okay whether there is an aneurysm so there is no hypertension and there is a bleed so you suspect like that okay so these are all okay further in management of the hemiplegia and what all you have to see okay thermotic antiplatelets and statins okay absolutely essential to prevent secondary stroke or a myocardial event right so that's it anything else this is the most basic of neurological conditions okay nobody understands it it should be understood well why okay there is now life goes on without understanding it is that you have got imaging from imaging you can know what is wrong okay something is wrong with the nervous system so do mri and you come to it okay so that technicians will take over after some time okay so and the computer can okay there are set patterns of what is the management but then when you are there okay you have to make your presence felt you have to understand this okay what has happened so what what is the scope of learning more here of about strokes so what you have done here is you have learned about lesion of the corticospinal tract okay just that it is a matter of chance that lesion of the particle spinal tract will cause hemiplegia we think that we are doing hemiplegia you have just done lesion of the corticospinal tract but at the specific side you have learned it is in the internal capsule so the manifestations are obvious so you have to know what is the vascular accident what is thrombosis okay the scope of learning more the question was very pertinent okay about antiplatelets okay how to prevent so if you are suspecting in a person who has not had a stroke but is hypertensive okay and it's diabetic and hyperlipidemic the first step is to control these things and you think that this person is vulnerable to it later you must have already had a atherosclerotic plaque so you give the primary prophylaxis for a thrombotic event that means antiplatelet drugs and static that can be given okay the rest of okay where else a lesion of the corticospinal tract will have what kind of manifestation okay so like i told you in mid brain i gave you one example okay it will have facial uh sorry hemiplegia on one side and the third nerve on the same side of the like that so elsewhere also you can do okay and managing we have to if you get to see through hemiplegia you should use your knowledge okay in benefiting the patient or treating that is your job okay so any question any time is welcome so we'll see through it yeah definitely sir they have say thank you and it was a great session you

BEING ATTENDED BY

Dr. Sharad Jadhav & 266 others

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dr. Yogesh Khandagale

Dr. Yogesh Khandagale

Resident Doctor, Seth GSMC & KEM hospital, Mumbai

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dr. Kunal Marathe

Dr. Kunal Marathe

Dr. Kunal is resident doctor at seth GSMC & KEM Hospital, Mumbai. He holds a university gold medal in medicine and is the winner of an international microbiology quiz. He is the recipient of numerous ...

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dr. Ravindra Nath Sahay

Dr. Ravindra Nath Sahay

Professor of Internal Medicine at GSMC & KEMH (Retired) | Professor at DY Patil Medical College | Consultant Physician, Apollo Hopital, Navi Mumbai

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dr. Yogesh Khandagale

Dr. Yogesh Khandagale

Resident Doctor, Seth GSMC & KEM hospital, Mu...

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dr. Kunal Marathe

Dr. Kunal Marathe

Dr. Kunal is resident doctor at seth GSMC & K...

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dr. Ravindra Nath Sahay

Dr. Ravindra Nath Sahay

Professor of Internal Medicine at GSMC & KEMH...

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