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Localization of CNS Lesions

Jul 15 | 2:00 PM

A traditional and widely used approach for linking neurological symptoms to specific brain regions involves identifying overlap in lesion location across patients with similar symptoms. However, this powerful approach is too complicated and we all have confusion with the tracts. Let's untangle all the tracts and CNS lesions with Dr. Sahay, who has an uncanny ability to make complex concepts simple.

so hi dr welcome you all uh to the second session on in the series of cns localization of legions is kind of very difficult topic we all face issues there we have a lot of confusion but we have dr davin sir here today with us he has uncanny ability to simplify concepts uh and he was a professor and i showed you at js medical college and km hospital right so good evening i have been told to take something about localization of revision neurological actually when we take history or we examine okay so exactly what is it that we are doing while taking string or examining it is all the time we are localizing okay localizing means localized to a system like when you take a history and the chief complaint is weakness or paralysis right so you have localized you have localized this case as a neurological one so from symptoms you localize this system is involved right so that way you go ahead now in cns cases the nervous system disorders from history from examination you are doing exactly the same thing like you have the simplest of neurological case is stroke let me please so patient tells you you ask what is what is your complaint so patience is weakness of paralysis of say right half of the body the right upper lip and lower limb okay is not functioning or is become weak suddenly there is a sudden weakness of my upper lip and right or for that matter which part of the nervous system has got involved so when a person says that suddenly both his upper limb and lower hip or one half of the body is not affected okay the localization is that the corticospinal other than particular spinal tract causing any feature so it is the corticospinal tract that has gone now the corticospinal tract starts from the brain and ends at various points in the spinal cord so it is just a matter that this corticospinal tract has got affected at a certain localization at a certain point and that has caused hemiplegia so basically it is just involvement of the corticospinal tract right but if because it has got involved at a certain point certain anatomical position therefore the manifestation is as heavy okay so we have that's what exactly we do okay you do a neurological examination okay you see for the nutritional status of the muscle tone reflexes all that that you examine in water system is just picking up okay whether it is an upper motor neuron lesion or a lower motor neurologist okay and which parts of the body has got involved in this right so this is hemiplegia right so mdp here corticospinal tract is part of the upper motor neuron okay so therefore will always be upper motor neuron okay there can't be a lower motor neuron hemiplegia okay so you have localized this is localization when you say the patient has got right sided hemiplegia or right half of the body is paralyzed that means you are localizing the lesion to corticospinal tract now we take example of just this right so the corticospinal tract getting involved okay at different places in the central nervous system will cause different manifestation where does the corticospinal tract start from the cortical spinal tract starts from the motor cortex that's the neuron and the corticospinal tract is the exam of all the neurons situated in the motor cortex right so the lesion could occur in the water bottles that's not controversial but the neuron of the cortical spinal tract so if there is a vascular religion a acute concept is a vascular religion so a lesion in the motor cortex is causing an upper motor neuron involvement but it can never cause hemiplegia the lesion in the motor cortex can cause at the most amount of region if a limb is to be involved so a very small group of muscles will get involved because the entire body is spread over a large area if you cut a section of the motor cortex it will be something like this okay the leg is up and the head is down like that so in this entire motor cortex and supplied by various arteries okay the leg area is supplied by anterior cerebral artery the face and the upper limb is supplied by the middle cerebral artery so one of the arteries has got involved so it can never cause any pleasure so if you examine and you have a small muscle paralysis or say while talking of limbs one limb reasonably bone and it is upper motor neuron inclusion the lesion is in the motor cortex right so when you are localizing people don't understand this a cortical legion can never cause any region okay now the next part because from the motor cortex okay the fibers okay the axons of the neurons okay they arise and pass down okay from the motor cortex so the fibers are wide spread like that okay so that's the corona radiator it is fan like corona okay and it's radiating so a lesion in the coronal radiator is the next anatomical place where religion can occur okay involving the corticospinal tract so again in the coronal radiator the fibers are widespread so there also it will cause a very small group of muscles will get involved so at the most amount of region okay so a lesion in the motor cortex next structure corona radiator cannot cause any pressure but before exiting the brain the axons do not cortex so middle central arteries okay in the motor cortex supply face and the upper limb only that much you will get involved okay and the arterial involvement okay if a large artery is involved in the brain they have all got anastomosis okay circular ability of understand are you understand so a vascular event okay which will cause a neurological deficit involves arteries which are terminal branches okay right it's penetrating branch of terminal branch they don't have any anastomosis so very small area will get involved if it is mcs territory involvement in the motor cortex it will cause up either upper limb okay or of the phase what you call as brachiocephalic only involved okay so if it is only length then it is part of the interior circulating all right so if all the upper limb lower limb phase everything cannot be what get involved in a cortical region so very small area will get involved corona radiator now these fibers corticospinal fibers exit the brain anything that exists the brain anything means any conducting pathway which are exons any axons which exists the brain or enters the brain it can do through only one entrance entrance gate in the brain and that is the internal capsule so no other point can exhaust the conducting pathways either descending or ascending can enter the brain okay it's all through the internal capsule so the corticospinal tract exits the brain at the internal capsule the genu and the posterior two-third of the i'm sorry anterior two-third of the posterior limb so mainly posteriorly but anterior part of the posterior limb and that is where the corticospinal tract is situated and it exits the brain right and even it exits so they are all packed very close together so a lesion in the internal capsule will cause whites wide spread destruction because a dining region will involve all the fibers they are all packed there and from internal capsule onwards the corticospinal tracts are packed together again very narrowly like cable and the wire coming which is all the fibers right so internal capsular lesion will cause maximum paralysis that's what's called tense hemiplegia okay so again wrongly thought that then semipregame is degree of paralysis okay zero power it is not that power may be four by five only okay but all that can possibly be involved all the entire one side of the body maximum paralysis that is possible by a single lesion happens it could be far could be four by five but involves everything i'll tell you what is meant by everything but that is the maximum possible beyond that by a single lesion it is not possible right so it is a capsular region internal capsule region right so internal capsule region will cause paralysis of all that is possible to be paralyzed so by a single region what is maximally possible to be paralyzed is lower part of the face the upper limb and the lower hip beyond that a single legion cannot cause paralysis the eye closure of the eye right upper part of the face the other cranial nerves lower part of the face when i am saying that means seven now okay so seven not getting paralyzed in an upper motor neuron that only will cause lower part of the phase paralysis assuming you can understand it so the maximum possibility of paralysis is just this by a single lesion right the others are the training other kenyans will not get involved in an upper motor denomination right because they have bilateral innervation from both sides both motor cortex is supplying that right so therefore an internal capsular region will have this plus there will be associated so associated features okay like there will be we assume hemiplegia to be a motor involvement only when you say hemiplegia using half the body is paralyzed so we assume it is only mode of manifestation it's not true okay there'll be sensory manifestation also there again it depends on what has got involved so what has got involved that is called sensory involvement in this part so nature knows this okay nature know this that this is a vital area so all vital installations are supplied by many phases of electricity are two phases or three phases of electricity same nature as done here this is you know human beings is evolved in neurologically evolved okay therefore the internal capsule has supply blood supply from all three artists okay and branches the anterior cell middle cerebral and also from posterior circular personal communicating branch okay supply the internal capsule so you have all three so depending on which one has got involved okay the manifestations are there but then that is final examination okay for example in hemiplegia what is more paralyzed the lower limb is more paralyzed or upper limb and the face is more paralyzed it is associated with hemi anesthesia or hemianopia so all these extra examinations we just do a hemiplegic motor examination and the okay so if it is a pure internal capsule illusion we are localizing can cause hemi anesthesia what sensation would be lost well that is a big question how do you know hemi anesthesia means what sensitive sensation is lost so for this we have to understand that sensations are perceived in the thalamus okay so it is below the brain so from thalamus most sensations are perceived in the thalamus and from thalamus with the fibers then ascend into the brain as i told you it can anything can enter the brain or exit the brain any of the axons okay through the internal capsule only so only those sensations that are perceived in the sensory cortex in the brain will be lost sensations that are perceived only in the sensory cortex are given that name cortical sensation okay that's why you examine cortical sensitivity what is the part of the touch scale the vibration pain temperature okay but you also examine cortical that's what you were taught okay when this is being taught it would have been better why did you examine this if that was told that would have been better but then that's how we do so only cortical sensations will be lost if the lesion is in the internal capsule okay so that's how you look nice okay you find that there is then semi pleasure that means lower part of the face upper limb and lower limb all on the same side is involved there is cortical sensory loss okay so that determines that the lesion is in the internal capsule okay now corticospinal tract goes beyond the internal capsule so whatever structures are there lesions in those areas will also will manifest and therefore you can diagnose where the lesion is so after the internal capsule as it releases the exit of the brain so after the brain is the brain stem okay the two hemispheres like that and the brainstem here okay and that proceeds that the spinal cord is extracted after the after the skull okay it exits the skull like that so the brainstem is here okay so the corticospinal tract after the internal capsule enters the brain stem right so the first part of the brainstem is the midbrain so the next possible area okay where the lesion can occur after the internal capsule is the midbrain right so how would you make out okay if there is a lesion in the midbrain patient will get same hemiplegia upper part of the phase upper limb lower level on the same side then how is it different from internal capsular region so whatever structure is there apart from the cortical spinal tract in the midbrain would have got affected so the structure you know this is some basic anatomy that you know so midbrain has the cranial nerve nuclear okay majorly the third and fourth we so a midbrain lesion will have destruction or damage to the third nerve nucleus and the corticospinal tract again because both are there and the relationship between third nerve and the particular contract is very close so it passes just existing right so in mid-brain lesion how will it manifest say a right-sided midbrain lesion has occurred okay so it will cause hemiplegia on which side opposite side patient will have opposite side hemiplegia okay just like internal capsular but the third num nucleus on the right will also get affected right the third knob the friction because third knob paralysis but on the same side but that's the lower motor neuron for the third the third nucleus is the lower motor neuron so it will be the same side so if that's why you need to examine all the okay all cranial nerves okay why are you examining other cranial nerves okay theoretically it is not only face okay so this was described about 100 years ago not now so again 100 years ago it has been described okay and person who described went by the name weber therefore it's called paper syndrome okay so a lesion in the midbrain because ipsilateral same side third north paralysis and contralateral hemiplegia okay that's called river syndrome uh so there are two questions i'll discuss reception and kinesthesia sensation will be lost right your precipitation will not be lost in internal absolution okay so in which situation it will be lost but then because the question is that proprioception proprioception is loss of posterior problem sensation procrastinating sense of position and movement okay proprioception all right so so this is perceived in the thalamus so in internal capsulation the artery is applying okay usually branch of the middle cerebral artery supply the internal capsule as well as the thalamus so this is a thalamo capsular you might have heard mris reports okay there is a thalamo capsular region so thalamus is involved as well as the internal capsule if this is the situation then only proprioception will be lost right it's a pure internal capsule lesion only cortical sensation can be involved will be involved but because associated thalamic lesion is there then only other okay just the other modalities of sensation apart from cortical sensation will get involved right so these are final points you can go ahead with this okay how with this when will pain and temperature be lost in hemiplegic so that way so the question put up was proprioception so what happens in your examination of a hemiplegic of all of you all of us have done many examinations sometimes if you found that there is hemianisthesia all modalities like proprioception okay so where is the region so this is a thalamo thalamus and internal capsule both have got important only then okay so after the midbrain again the part of the brain stem is the palms okay so suppose there is the lesion in the pons right which causes heavy vision then how do you know so same thing which neurons which lower motor neurons are located in the past sixth and seventh effect fifth also but the relationship between the jet nerve nucleus okay and the corticospinal tract is quite far so according to the smile right usually will not get involved in fact we don't get involved in a region okay where the fifth number nucleus is important okay because the anatomical distance is quite a lot but sixth and seventh gradient of nucleus and the particular spine tract have close association so a lesion in the pawns where hemiplegia is occurring okay is likely to involve sixth and seventh nuclear okay so if there is a lesion in the palm say right pawns there will be hemipedia on the opposite side okay this is clear because the spine track crosses the lower end of the middle so still it is representing the opposite side so there will be right-sided pontine lesion involving particles contract will cause left-sided limit region but what what will get involved in this the face will not get involved okay do a session now nucleus is in the pawns what is the manchester city upper limb and lower limb but because the nucleus of the seventh and sixth sixth and seventh nerve is in the pawns they will get involved so if the nucleus of the seven nerve and the sixth nerve get involved they will cause paralysis of the facial face and the sixth nerve but on the same side right so a right side is right answering just give me an example it could be left so right sided on time lesion again will cause hemiplegia of the opposite side contralateral limbic region involving upper limb and lower limb but same side hips lateral lower motor neuron facial pulsey entire face will get fertilized not only lower part even the upper part of the face because it will be a lower motor neuron facial policy because facial nerve nucleus is getting involved and the sixth blood also on the same thing so ipsilateral six nerve seven now and contralateral hemiplegia but this hemiplegia doesn't involve the face of that side only the left side is upper limb and lowers him this kind of manifestation so when you examine you find just this you find that facial nerve paralysis is not on the side of mppg but on this other side and the facial paralysis is lower motor okay that means the upper part and the lower part of the face entire face is paralyzed [Music] for us it is contralateral hemiplegia and ipsilateral sixth and seventh policy would indicate upon timeless easy right so we proceed okay this is how you localize you do localize it so you have to examine first the examination should be good okay that's why it is taught that you have to do gradient level examination you have to do motor system then you have to do sensory system in all patients okay so as you learn how to do it you can do it very fast okay all patients you need not do all the tests okay but then for a beginner you will miss it okay because you're not anticipating it okay so therefore so next is what is known as lower brain stem lesions okay lesions in the middle so here also there will be contralateral hemiplegia but lower cranial nerves will get involved okay lower cranial 11th and twelfth of the movement of the head okay movement is trying to get affected so these can get affected only in lower motor neuron regions okay so these are called lower brain stem signs and in hemiplegia okay so that's so that takes care of the brain but corticospinal drag is not confined to the brain it'll cross over at the lower end of the middle and come into the spinal cord right so there are two corticospinal tracts in the spinal cord spinal cord is a very narrow area anatomically very small area okay so usually in this spinal cord lesion hemiplegia is unlikely right so what is likely is to get a paraplegia or a quadriplegia both sides go to the smile track getting involved you are localizing like we are talking of contiguous smile cartilage okay but cap only which is unusual usually in particular spine both particular spine tracks will get involved okay because they're situated very close together and will cause quadriplegia or paraplegia depending on where it is quadriplegian parabolic same things because the difference of the side so you look like again you're localizing but here we are talking a first particle spinal tract lesion and unilateral single particle spinal tract lesion so a single corticospinal tract can get damaged sometimes in spanish coordination how so the region was very precise very small it causing any section of the spinal cord only half the spinal cord has got damaged generally it is it will happen in space of the time lesions or sometimes traumatic right so hemisection of the spinal cord this you would have heard so if there is any section of the spinal cord means when you're talking upper limb and lower limb okay it's involved so upper limb is supplied by the cervical fix c5 to t1 right so if the legion any section is above c5 right then it will cause hemiplegia it will involve upper limb as well as lower limit okay so this upper limb and lower limb involvement now this time fibers or small tractors already crossed therefore hemisection in the spinal cord will cause hemiplegia on the same side if selector will be richer so that's localization okay so okay so it will involve on the same side you don't know you have examined and found mvpj on one side so how you know this legion is on the same side so therefore hemisection half the the spinal cord getting damaged why the conduit spine track has got damaged in his hemisection of the spinal cord is because the corticospinal tract is passing through this spinal cord but corticospinal tract is not the only tract passing through the spinal cord okay significant tracts okay from examination point that are passing through the spinal cord are the sensory tracts the posterior column okay sensory tract both the dorsal column people call it in humans you can't hold dorsal anterior and posterior okay in animals like this so it is dorsal elementary right it looks like it is something new the person is saying it actually anterior and posterior but then many people by convention still called posterior as dorsal so a dorsal column for the posterior column is passing and the lateral spinothalamic tract so you have to know what sensations are being carried in that i'm assuming that you know the posterior column is carrying touch vibration proprioception we just talked proprioception and all the cortical sensations they are passing through the posterior column so all of it will be lost okay now later spinothalamic tract is carrying pain and temperature so that will also be lost so that how do you make out okay where the lesion is so how you are localizing in a spinal cord lesion the corticospinal tract has got damage say if it is above cervical fib segment so it will cause hemiplegia same as lesion in the palms or in the mid brain i'm not saying so how do you know so the sensory tracks will also get damaged therefore if the posterior column is getting damaged on one side there will be loss of posterior column sensation touch vibration proprioception and cortical sensation on the same side okay and latent spinothalamic tract is a cause tract it has crossed from the opposite side so pain and temperature will be lost on the opposite side so if you but this is a very strange finding okay so many times patient is not cooperating is not telling correctly okay what is having for what is passing with that only is going to tell you okay so take for example a right-sided hemisection of the spinal cord so that will damage the corticospinal tract so you'll be an upper motor neutron paralysis of all structures below the lesion so assuming it is above cervical section five fifth segment will cause hemiplegia on the same side of the lesion there will be loss of posterior column sensations touch vibration proprioception and cortical sensation also on the right side but pain and temperature surprisingly will be lost on the left side so if you get this kind of manifestation then it is hemisection of the spinal cord which is also associated with hemophilia so therefore what is the d what are the parts of the body that are involved so when you say upper limb and lower limbs got involved right see both are involved the upper limit is supplied by the cervical segment c5 to t1 okay so this is above c5 only then you'll get this kind of manifestation but if there is any section of the spine anywhere below so whatever wherever it is below that there is upper motor neuron transit right and the steel column sensation lost also on the same side but pain and temperature is lost on the opposite side right so this again many years ago some people okay describe this and it's named after them the brown squad syndrome word this is brown second center we described it right so this is unusual to get a unilateral paralysis in spinal cord division because both particular spine tracks are very close together because both would usually get involved but sometimes if only half of it which is for convenience we are calling hemisection half the spinal cord has got damaged so this is the manifestation right put it simply again it is as i told you it is to do with what has got involved site so at the level where there is damage okay of the spinal cord the anterior horn cells will get affected so at that level there will be a lower motor involved involved very small but everything below that will have upper motor neuron so at the site of lesion lower motor neuron okay like it is given in books below that so now you have understood so below that is all upper motor neuron lesion and posterior column sensation loss on the same side but pain and temperature lost on the opposite side okay so this is wrong so this is how that's that's why you need to you know very unlikely to encounter but the day you encounter the way you're going to miss it if you are not aware of this so this is localization so this was localization of upper motor neutron it is just a matter of chance that we are talking about a lesion in the of the particular spine in the internal capsule so we say this is hemiplegia because that is the communist therefore we assume that okay hemiplegia okay only particular spanish getting damaged but corticospinal tract can get damaged anywhere in its pathway with various manifestation and that's how you it is actually localization of the corticospinal tract lesion okay and when you're saying then semi-pj you're talking about you're localized the internal capsule syndrome all modalities of sensations will be lost okay on the opposite side right so usual in association with the cortical spinal tract lesion okay it usually occurs with an intercapsular region where one branch of the middle cerebral artery okay this all arterial you can keep one session thalamic syndrome is branch of the middle cerebral artery supply the internal capsule as well as the thalamus if both areas have got involved so therefore there will be hemiplegia with all modalities of sensational also on the opposite side just like hemiplegia is in the opposite side so that's the limit syndrome okay then so don't go by names okay you can add a syndrome below c5 okay okay is there any more question yeah yeah we'll take that first question suppose there is a tumor okay at c5 c6 c7 okay on one side the tumor will slowly grow so it will occupy half so initially it is causing damage to only one half of the spinal cord and the lesion is that c is 5 c 6 c 7 so because the upper limit is c by c 6 okay c 7 c 8 t 1 involvement so the upper limit on that same side would be involved in a lower motor neuron paralysis so upper limb will show that atrophy again hypotonia loss of reflexes okay but the corticospinal tract also gets damaged so the lower limb on the same side suppose it is right side we are always giving right side legion the right side lower limb will have upper motor neutral findings so if lesion at that point okay you have to take if the lesion is at this point so what will happen so in the survival 567 that area there is so patient upper limb on the right will be lower motor neuron lower limb on the right will be involved in upper motor neuron region there will be loss of posterior column sensations okay arm downwards on the same side and pain and temperature lost on the opposite side okay so now if it is below entire survival areas is somewhere in the thoracic area okay hemisection so below that that only lower lip is left so right side and say region is that t6 d7 okay t6 so right side lower limb will be involved in upper motor neutron region upper lip will escape there will loss of posterior column sensation of the right lower limb okay and the lower left lower limb there will be pain in temperature loss okay so that okay so this is manifestation so you have to make use of the sensory system here to localize where the lesion is for example if the lesion is actually t6 the two mother t6 so posterior column sensation below t6 will be lost okay when you go up to t6 okay it will be lost above d6 every all in sensations are in time okay like that so that was about localizing a corticospinal tract lesion which leads to hemiplegia right so now like okay if you have say parapj lower limbs okay so that's why you do the motor examination right so only the lower limbs the two lower limbs are involved so by examination you will know okay it is upper motor or the lower motor if it is an upper motor neuron region okay then what has got damaged is the portable spine track we have already done or in the motor cortex right if it is a lower motor neuron so you localize it as a lower motor neuron region so parts of the lower motor neuron is the anterior horn cell in the spinal cord from there the axon starts the root anterior a motor root or radical okay it joins with the posterior root to form the peripheral now okay so either the anterior horn cell is involved or the root is involved or the peripheral nerve is involved or at the neuromuscular junction so if the lesion is at this place then there will be a lower motor neuron region so you examine and find your conclusions that's why you have to do motor examination first and conclude this is a lower motor neuron paralysis therefore your localization is to be anterior horn cell root peripheral knob or neuromuscular junction if you are finding that this is an upper motor design region so it is not involved in the lower motor the lesion is of the corticospinal tract okay what forms the upper motor neuron is the cells neurons in the motor cortex precentral gyrus and the corticospinal tract which we followed for hemiplegia okay right so this you localize that it is corticospinal tract lesion or it is part of the lower water by knowing its upper motor neuron paralysis or lower if it is paraplegia that means upper limb has not got involved just now somebody had asked if the lesion is below cervical or cervical segments what will be the male system only lower limb will get involved in paralysis okay it is bilateral involvement right so if upper motor neuron paraplegia okay the legion is in the spinal cord right that's okay spinal cord paralysis but then the name is spinal cord paraplegia therefore there must be some other kind of paraplegia promoter spinal cord upper motor neuron paraplegia so that is also said cerebral palsy and that is possible how okay you another motor cortex like this the right and left motor cortex together okay the upper part upper most part is the lower leg and the head is down okay like this right now the leg area is medial most uppermost and medial moves like that okay the brain is here the brainstem is just like this brainstem and the motor protection okay this is the three central guys okay so we are interested in that because it is a motor manifestation right there so if there is a region in the midline here okay it can involve both the leg areas are very close together here only thing separating is the fox are agreed okay superior central sinus is in between and the two cortex okay just adjacent to each other so a midline lesion in the fat celebrity okay like meningioma of the fat celebrity can cause compression of both leg areas and cause an upper motor neuron paraplegic rest of the power play escapes right so there could be a cerebral palativisia upper mode upper motor neuron paraplegia could be cerebral cause of paraplegia okay this can occur only in a midline lesion which will affect both both leg areas on either side clinically the best example is it looks hypothetical but the clinically the best example for this is the meningioma so it may cause affection of both the leg areas so then how do you localize so this will have upper motor so a cerebral cause of paraplegia for motor neuron so first you have to distinguish if you are getting paraplegics worked on this for 100 years right anatomical liberation sometimes a single anterior branch of the entire several arteries either from the right or left supply both the leg areas okay so such unpaired branch of anterior cerebral artery supplying both leg areas if that has got composed okay that may cause okay upper motor neuron parallel that person was very lucky unlucky okay unpaired and did a several anatomical aberration and that artery also got through right but then hypothetically yes it can fall in that situation the commoner example is superior circular sinus thrombosis or a meningioma of the fox cerebri okay so how do you localize it then this is paraplegic okay why it is not spinal cord white is not spinal cord with very relevant question right so paraplegia will be what upper motor neuron in type the other involvement like spinal cord is just adjacent to the leg area is the bladder area so patient will have a may have automotive neuron bladder okay which will look like a spinal cord illusion but then there will be no sensory involvement as we did just now and ground sequel sensations will be lost okay the here sensation will not be lost it will be pure motor what i'm saying is incorrect so i'm going to add there may be upper motor neural bladder involvement no sensory involvement but then there can be sensory involvement because these central virus and post central values very close together so a superior circle sinus thrombosis or if meningema of the fat cell agree will affect the post central virus also so the leg will have sensory involvement but what sensation will be lost cortical sensations only particle sensation will get lost because this sensation has been perceived in the thalamus right so in a midline vision called cerebral upper motor neurone paraplegia there will be upper motor neuron paraplegia bladder involvement maybe there may be cortical sensory loss other sensations being intact on both the lower lips right so that's how you localize that this is but then apart from it there are other helpful things that come into play okay because it is a server religion so you will have cerebral signs patients okay projectile vomiting all that will occur so these are called other signs of cerebral illusion that will be absolutely so this is how you understand right so how do you localize it to the spinal cord we have done just now the spinal cord lesion so this one is not is hemisection both the spinal cords are good both the corticospinal tracts are getting involved which is commoner than hemisection okay any lesion of the spinal transverse myelitis will not have affect half of it the entire both side will get fit yeah so there will be upper motor neutron paraplegia again spinal cord illusion there will be loss of all modalities of sensation here because both sides is there so not one side and opposite side between richard this will be so complete loss of sensation below the level of vision so you have to commit this okay this complete loss of sensation below that definite level with a level if you can mark up below t10 everything is lost suppose that you are marking the level okay if i give an example of t6 so below t6 all modalities of sensation are lost if you are like that all modern is not portable all modalities pain temperature breathing so then this is a spinal collision plus you have upper motor neuron bladder bowel vowel you cannot make out because person may pass motion once in 24 hours or may not and two three days so different bladder so upper motor neuron bladder right so that muscle so you localize it in the spinal cord now where in the spinal cord again in this if there is sensory loss complete loss of sensation you know t6 so you know the segment okay spinal segments supplying big part so that below that everything is lost say below i'm like us everything is lost um like us is detailed therefore okay so dermatomes okay you need to know yeah some posters below t8 so realize complete loss of sensation okay below the coastal margin so it is lesion is at t8 so that's how you look nice okay within the in the thorax you have to make use of because no motor manifestation would be there specifying where the losses therefore you have to take help of the sensory vision but then patient will have upper motor neurone paraplegia okay so this is localization for paraplegia okay if you're it's the final okay final bit so if then you say this is lower motor neuron palpation okay so that means the lower motors are involved so there the possibilities are anterior on cell lesion root the referral now or neuromuscular junction okay so each of them will have its own right if in the clinical example of lesions okay if there is an anterior horn cell religion causing paraplegic or paralysis lower motor neuron in type and then there will be features of anterior horn cell lesions okay so there are very few diseases which are confined to that one cell motor neuron disease okay therefore this is a chronic condition so there you will have fasciculations so if there is lower motor neuron paralysis just in case okay and there are fascinations so this is anterior hormone solution but some regions like interventional disc prolapse okay that may involve both anterior and posterior so that is very helpful okay there will be root science of root involvement okay so that pain will be radiating in the distribution of the now right but if it is pure anterior root involvement okay can there be just i'll tell you pure motor root involvement then patient will have pure motor lower motor paralysis okay no sensory involvement no fasciculation the best example is gps get the root involved right if it is a after that the anterior root joins with the posterior root and causes to form the peripheral nerve so peripheral now vision very easy if peripheral now legion is there there will be lower motor paralysis associated with sensory loss in the distribution of that nerve so if they both are there okay there are other features of peripheral nerve involvement but if you get motor and sensory both okay and the motor is lower motor if and the sensory sensory loss is confined to distribution of some area then that means in the distribution of the nerve you are localized then there you shall now again and the last part is the neuromuscular junction there are very few diseases involving okay so characteristics of those appeared there you know sensitive manifestation that confines the lesion to the neuromuscular junction so that's how you do it again if in your motor system examination you find that there is attacking that means loss of coordination of movement so then here lesion again is confined with some other areas okay you localize very unknown there is cerebellum illusion what's so difficult patient is the taxes so you have to do the full motor examination right the final points to it okay like involuntary movements then somehow athetosis okay aquaria so your lesion gets localized to the extra pyramidal system so basically the cell lesions in the basal ganglia will cause that kind of involuntary movements so depending on which involuntary movement is there you can also confine which part of the basal ganglia so that another stupid okay so those things some other time so simply okay how you when you examine when you take history actually what you're doing is you're trying to localize it right you are examining you are trying to diagnose a nervous system disorder which consists of brain spinal cord and the peripheral nerve just by examining the muscle so what a great technique okay present day physicians neurologist okay they would not know for them to localize their mri scan of the brain and you know the lesion is in the thalamus absolutely here why you don't do so many examinations to know that but our relevance is still that we know this and we want to impart that okay but then you are training to be master of medicine master physician master of neurology so you have to understand everything you can't talk like current present day neurologist okay i can diagnose only by doing investigation here you just will do a clinical examination and you're localizing so this is localizing deletions right so i think i'll take some more questions okay motor okay so this is this very quickly i'm telling you okay this is supposed to ah most of you will tell okay that's why you give a hammer when you do is examine okay what are we doing why are you going with the hammer and hitting the patient everywhere you're trying to find out just find out okay what type of parenthesis is there in this whole universe world there is only two types of paralysis whenever you are asked your put this challenge what kind of paralysis what kind of motor involvement there are just upper motor and lower motor that can makes it very simple for you so how do you make out motor that's why you do motor system examination right so in is a tone and there is hypertonia okay then what is hypertonia though basic things you want that also can be done sometimes okay you have to ask her to do it okay so what does it indicate so hypotony has plasticity in type okay so is indicative of upper motor resonation why that is another story so if you get hypotonia and then you examine with hyper reflexia reflexes are exaggerated the plantar is going so all this suggesting upper motor neuron region a patient has lower motor neuron lesion there reflexes will be absent okay so this suggests that there is no motive okay so first localization is this thereafter okay you also localize the site you know upper motor network region but if the bicep jerk is also exaggerated that means the lesion is above c5 you like that bicep is normal only major is exaggerated lesion is above l2 but below t1 okay so that much of localization but final localization i already told you you have to take help of this sensory system right how to distinguish muscular dystrophy yeah okay within 24 to 48 hours whereas motor neuron disease also involves the motor neuron okay like polio will involve antioxidant motor neuron disease will not involve only anterior on cell okay we'll involve all motor neurons the upper motor neuron as well as lower motor neuron so in motor neuron disease you will have a usually you have a combination of upper motor neuron as well as lower motor neuron lesions it is slow progressive disease okay so if you just want to distinguish this anterior saw on cell is involved in polio or motor neuron disease the fasciculation if the fasciculation association indicates slow ongoing degeneration of the interior harm cells okay muscular dystrophy has nothing to do with muscular dystrophy is a muscle disorder okay it's not in your neurological condition point of time it is difficult okay when patient presents okay findings will be same okay so therefore before you commit that this is a low motor okay you have to do the electrolyte and see patients usually give history if they give okay that he had similar incidents in the past so this kind of help you have to take uh right so yes yes it will cause paraplegia okay right so the protocol is that first okay you have to consider this patient as a paralyzed patient so what is whatever is the treatment for the general treatment for any paraplegic okay like you have to take care of his bladder bowel initial features okay you prevent bed source you prevent deep thrombosis the lymph is not moving so it is prone to that okay so you may have to anticoagulate right but transgender small light is as such okay depends on what is called mostly it is autoimmune so best treatment is inflammation the spinal cord you take care of the inflammation so steroids are the backbone of therapy anti-inflammatory okay but you also prevent any complication of a paralyzed patient so what i told you okay prevent make sure deeply you may have treated the inflammation but patient will get a deep anthropomorphism and may get a pulmonary embolism and may die of that so that part has to be taken care of the bladder power and all that so it is when you are treating it okay where there is system of managing it so successful treatment of a paraplegic it will come in that okay if you treat well the information patient will recover right recover fast to develop obligations like you've catheterized the patient so complications of catheterization okay all that can occur so all that has to be managed but so far as transverse myelitis is concerned if you're you're diagnosing that this is an autoimmune what it usually is so you just give anti-inflammatory form of steroids it can't cause that widespread analysis a lesion in the cortex motor cortex is going to cause small group of muscle paralysis this is what bothers most of the people as i told you okay when teachers and all that they think so the concept cortical vision is there okay everybody is responsible okay about 70 people will say cortical right so this should these things should actually have been well explained i don't know how it has lingered so long so that was a good question so cortical lesions cannot cause and just what we are focusing on the one thing that is said is quite the significance that it is mathematical of all the medical medicine topics and medical systems in medicine cns is the easiest one your just once understand the concept basic and i mean physiology so it is mathematical okay so if one person understand the other person will understand to the same extent but what he asked about his patient that i could not follow okay yeah it can occur but it has to be okay usually if it is involvement if it is an up after the coronal radiator if monoplegia is occurring then that's what you have to decide okay very unlikely for monoprision upper motor neuron type to develop because the fibers are very close together okay so any lesion will cause the effect all or most of the fibers so you can get monomedia but then that will be lower motor neuron type okay upper motor neuron okay so so for some other time what what can be but for localization general thank you concepts much thanks a lot thanks so much [Music]

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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. Ravindra Nath Sahay

Dr. Ravindra Nath Sahay

Professor of Internal Medicine at GSMC & KEMH...

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