Localization of neurological lesion

Approach to neurological cases

Localization: PNS, spinal cord, brainstem, cerebral cortex, cerebellar, subarachnoid
space
Pathology: congenital, trauma, tumor/paraneoplastic, infection,
inflammatory/demyelinating, toxic/metabolic, vascular, degenerative
Localization of neurological lesion

1.

Cerebral cortex
: lesion cerebral cortex cortical dysfunction

Rt hemiparesis aphasia Lt hemiparesis neglect apraxia

cortical sensory graphesthesia, stereognosia, 2 point discrimination
basic sensation touch, pain sensation

Frontal lobe

motor map

o Primary motor cortex hemiparesis motor map anterior cerebral

distribution weak > middle cerebral distribution weak >

o Premotor cortex (motor program); lesion: apraxia

( learning motor skill ),

deficit fine motor control (serial movement)

o Supplementary motor area ; lesion: mutism, akinesia

o Prefrontal area

; lesion: frontal release signs (palmar grasp reflex, glabellar reflex),

mental disorder
o Brocas area wernickes area (dominant);
(non-dominant); lesion: motor aphasia (-(broc)
), monotone speech

o Frontal eye field (succade); lesion:

lesion (seizure)

Parietal lobe cortical sensation

basic

sensation
lesion 2 point discrimination,

graphesthesia (), stereognosis (), double stimultaneous

stimulation ( pin prick 2 ), abolition of optokinetic

nystagmus, visual inattention; visual pathway: lower quadrant visual field defect
o Dominant parietal lobe: (anomia ,

aphasia , alexia , agraphia ), Gerstmans

syndrome (left-right confusion, finger agnosia, acalculia, agraphia), tactile agnosia, ideational
apraxia
o Non dominant parietal lobe: visuospatial disorder (),
topographic memory loss, anosagnosia (/ ), hemi-neglect (
), dressing apraxia, constructional apraxia (
), confusion, blepharospasm

** Apraxia learning motor skill

Temporal lobe (Auditory cortex)

o Dominant lobe: receptive aphasia (Wernikes aprasia)-were nike

o Nondominant lobe:

o Medial temporal lobe (hippocampal, amygdala): part of limbic system (aggressive

behavior, unable to form memory)-

o Visual pathway: superior quadrant field defect

Occipital lobe: Homonymous hemianopia
o Visual agnosia (), prosopagnosia (), Antons syndrome (
), visual illusion, hallucination, alexia, impaired optokinetic nystagmus

**hemisphere CN facial motor cortex cerebral cortex lesion

CN lesion CN hemisphere CN 3,4,6,lower

part face CN hemisphere 2 forehead, CN 5, 9-12

 lesion hemisphere (

hemisphere transient weakness palatal,

tongue, dysphagia )

Internal capsule pure motor

2.

cortical dysfunction

Thalamus pure sensory hemianesthesia

3.

4.
Cerebellum
o Lateral part: ipsilateral upper extremities dysmetria (FTNTF), dysdiadocholinesia, ataxia,
intention tremor, dysarthria with scanning speech
o Central (metabolic): truncal ataxia, lower extremities ataxia, wide bases gait, nystagmus
5.

Brain stem

: lesion brainstem crossed sign

blood supply brainstem paramedian branches long

circumferential branches (SCA, AICA, PICA) medial

brainstem syndrome lateral brainstem syndrome lesion 4

rules of brainstem lesion medial lateral midbrain,
pons medulla

Medial structure 4 4M Motor pathway (corticospinal tract:

weak ), Medial lemniscus ( vibration, propioception

lesion), Medial longitudinal fascculus (interinclear opthalmoplegia adduction
lesion nystagmus lateral), Motor
nucleus/nerve CN 12 (CN 3, 4, 6, 12)

Lateral structure 4 4S Spinocerebellar (ataxia

lesion), Spinothalamic tract ( pain, temp lesion),Sympathetic tract (Horner

syndrome lesion), Sensory nucleus of CN 5 ( pain, temp
lesion)

* **Sympathetic system lesion thalamus, medulla, C8T1 root,

sympathetic fiber carotid, carvernous sinus

Cranial nerves

o Midbrain lesion CN 3 (ptosis, dilated pupil, eye turn out + slightly

down, , adduction lesion), CN 4 ( lesion)

o Pons lesion (CN 5-8) CN 5 (unilateral facial numbness lesion),

CN 6 (lateral gaze palsy lesion), CN 7 (facial palsy lesion), CN 8

(unilateral deafness lesion) *** vestibular portion CN 8 (vertigo)

lateral medulla

o Medulla lesion (CN 9-12) CN 9 ( pharyngeal sensation

lesion), CN 10 (palatal weakness lesion), CN 11 (weakness trapezius,

sternocleidomastoid lesion), CN 12 (weakness tongue lesion)

Intraaxial extraaxial lesion CN involvement

long tract involvement intraaxial CN involvement long tract
extraaxial lesion

***lesion brain stem cerebellum

cerebellum dysfunction

*** facial palsy UMN lesion cerebral cortex lesion

(UMN weakness of face) brain stem lesion (nucleus CN

VII pons lesion pons ( cerebral peduncle midbrain)

UMN weakness )

Brain stem syndrome

Medial syndrome

Lateral syndrome

lateral brainstem syndrome

Ventral midbrain syndrome (Webers syndrome)

Contralateral hemiparesis
Ipsilateral third nerve palsy
Dorsal midbrain syndrome (Benedicts syndrome)
Ipsilateral oculomotor paresis
Contralateral involuntary movement: rubral tremor, ataxia
Contralateral hemiparesis
6.

Spinal cord

UMN weakness, increased muscle tone, hyperreflexia, upgoing

plantar response, sensory level, autonomic disturbance

Intrinsic cord
Weakness
ANS
Pain
Sensory

Extrinsic cord

Descending
Ascending
Early autonomic
Late autonomic
involvement
involvement
Funnicular pain
Bone pain, radicular pain
Sacral sparing
Sensory level
Intrinsic cord lesion: acute transverse myelitis, spinal cord ischemia, intrinsic cord
tumor (astrocytoma, ependymoma), syringomyelia
Extrinsic cord lesion: metastatic tumor causing spinal cord compression, epidural
abscess, extrinsic cord tumor (meningioma, schwannoma, lipoma), degenerative spine
disease

7.

Subarachinoid

Localization
Superior orbital
fissure
Cavernous sinus
Retrosphenoid
space
Apex of petrous
bone
(Gradenigro)
Pontocerebellar
angle
Jugular foramen
Posterior
laterocondylar
space
Posterior
retroparotid
space

CN
III, IV, V1, VI
III, IV, V1, V2, VI
II, III, IV, V, VI

Pathology

Tumor

V, VI

tumor of petrous bone,

infection, acoustic neuroma

V, VII, VIII, (IX)

acoustic neuroma,
menigioma
tumor, aneurysm
tumor of parotid gld

IX, X, XI
IX, X, XI, XII
IX, X, XI, XII,
Horners
syndrome

Carvernous sinus lesion

Infection: Carvernous sinus

thrombosis, chronic granulomatous
infection (TB, Fungal)

Trauma: CC fistula

Vascular: aneurysm of
intracarvernous part of carotid a.

Tumor:

Cause of CN III lesion

Diabetes

Posterior
communicating a.
aneurysm

Uncal herniation

Carvernous sinus
lesion

Superior orbital
fissure lesion

Orbital apex lesion

o Direct extension from skull base: CA

nasopharynx
o Metastasis: breast, lung

Inflammation in
o Hematologic: lymphoma, leukemia
subarachnoid space
o Extension from sella tumor

Idiopathic inflammatory (Tolosa

Hunt)

8.

Peripheral neuvous system

Clinical LMN weakness: decreased muscle tone, muscle atrophy/ fasciculation, muscle
weakness, hyporeflexia, down going plantar response

Approach
Pure motor: anterior horn cell, NMJ, muscle

o Anterior horn cell: atrophy, fasciculation, distal > proximal, DTR decrease (increase in
ALS); eg. polio, ALS
o NMJ: No atrophy, proximal > distal; Bulbar, ocular; Fluctuation, DTR-normal; eg. MG,
Lambert Eaton, botulism
o Muscle: No atrophy, proximal > distal or specific muscle group, muscle pain, DTR-normal;
eg. muscular dystrophy (congenital, infection (viral, pyomyositis, trichinosis), inflammation
(polymyositis, dermatomyositis, inclusion body myositis), toxic/metabolic (thyroid, DM, K, Ca,
PO4, Mg), drug (statin, steroid, alcohol, ARV))
Mixed motor, sensory, autonomic: nerve root, plexus, peripheral nerve
o nerve root, plexus: distal = proximal; peripheral nerve: distal > proximal
o Peripheral nerve: weakness & sensory loss in distribution, decrease DTR

Cause of peripheral neuropathy

Hereditary: Charcot Marie Tooth (HMSN), HNPP,

amyloidosis

Tumor related (paraneoplastic): Lung, breast, ovarian

cancer, hematologic malignancy, multiple myeloma

Infection: HIV, hepatitis B, C, leprosy

Autoimmune/ inflammation: GBS, chronic inflammatory

demyelinating polyneuropathy (CIDP), vasculitis

Metabolic/toxic: Diabetes, thyroid diseases, drugs/toxin

related, alcohol related

Nutritional deficiency: B1 deficiency, B12 deficiency

Basic Neurological localizing signs


1.Lobar localization
1.1 Frontal lobe lesion :
1.1.1 Motor dysfunctions = homunculus at motor area , pyramidal
signs (UMN lesion)

Ex :

1.1.2 Conjugate diviayion of eyes = Area 8

irritative lesion --> conjugate eye movement

lesion

destructive lesion --> conjugate eye movement

lesion

1.1.3 Grasping reflex = lesion

diffuse cerebral
lesion or hydrocephalus
1.1.4 Apathy or Personality change
1.1.5 Motor aphasia (Dysphasia) = lesion at Broca area

1.2 Parietal lobe lesions :

1.2.1 Sensory dysfunction = homunculus at postcentral gyrus

Ex :

1.2.2 Failure to detect simultaneous stimuli =

( parietal lobe )

visual
inattention
1.2.3 Finger agnosia =
1.2.4 Right / Left disorientation =

1.2.5 Astereognosia = ( lesion)

1.2.6 Agraphesthesia = ( lesion)

1.2.7 Acalculia =
1.2.8 Alexia =

1.2.9 Unaware of affected part = lesion

1.2.10 Visual field defect = homonymous lower quadrantanopia (

lesion)
1.2.11 Sensory aphasia = Wernicke's aphasia

1.3 Temporal lobe lesions :

1.3.1 Visual field defect = homonymous upper quadrantanopia (

lesion)
1.3.2 Memory impairment

1.4 Occipital lobe lesions :

1.4.1 Visual field defect = homonymous hemianopia with macular sparing
( lesion)
1.4.2 Cortical blindness = bilateral occipital lesion --> blindness with normal
pupil reflex

2.Cerebellar lesion : lesion

2.1 Nystagmus = rapid phase swing lesion

2.2 Dysarthria (Slurred speech)
2.3 Over shooting =

2.4 Intention tremor (terminal tremor) =

2.5
2.6
2.7
2.8
2.9

Dysdiadokokinesia
Heel to knee test
Ataxic gait = Tandem walking --> swaying
Wide base gait
Truncal ataxia = vermis lesion

3.Cranial nerves lesion :

3.1 Olfactory nerve lesion :

3.2 Optic nerve lesion

: VA , , visual field defect , papilledema

3.3 Occulomotor nerve lesion : medial rectus palsy , ptosis, pupil dilate
3.4 Troclear nerve lesion
: diplopia ,
3.5 Trigeminal nerve lesion : facial pain (trigeminal neuralgia) , sensation
dysturbance (dermatome)
3.6 Abducens nerve lesion : lateral rectus palsy
3.7 Facial nerve lesion : facial palsy ,
3.8 Acoustic nerve lesion : coclear division --> hearing loss
vestibular lesion --> vertigo
3.9 Glossopharyngeal nerve lesion : loss of gag reflex , dysphagia , aspiration
3.10 Vagus nerve lesion :
3.11 Accessory nerve lesion : weakness of stenocleidomastoid , trapezius
3.12 Hypoglossal nerve lesion : tongue deviated to lesion side, fasciculation ,
atrophy

4.Brainstem lesion :
4.1 polycranial nerves involvement
4.2 loss of Doll's eye phenomenon ( good conscious)
4.3 Coma
4.4 Respiration point --> to lesion
4.4.1 Cheyne stoke breathing

----- upper brainstem lesion

4.4.2 Central neurogenic hyperventilation ----- midbrain and upper pons

4.4.3 Apneustic breathing ----- lower pons
4.4.4 Ataxic breathing ----- medulla
4.5 cranial nerves piont ---> to lesion
4.5.1 midbrain --- CN 3 4
4.5.2 pons
--- CN 5 6 7 8
4.5.3 medulla --- CN 9 10 11 12

5. Spinal cord lesion :

Tract spinal cord
5.1
5.2
5.3
5.4

Dorsal column (fasciculus gracilis , cuneatus ) --- vibration, proprioception

Corticospinal tract (Pyramidal tract) ---motor
Lateral spinothalamic tract ---sensory
Intermediolateral (ANS)

Lesion of posterior column : joint position sense (JPS) ,position sense ,

vibratory sense

lesion lesion

Lesion of corticospinal tract : weakness lesion lesion

Lesion of spinothalamic tract : pinprick sensation ,temperature

sensation lesion

lesion
nerve fibers --> tract fiber
Posterior column --> S-L-Th-C (sacrum-lumbarthoracic-cervical)
Lateral column

--> C_Th_L_S (cervical-thoracic-

lumbar-sacrum)
spinal cord sacral segment
cervical segment

--> (lateral column)

6. Reflexes :

LOCALIZING LESIONS IN NEUROLOGY

 lesion

investigation

1. lesion ?
2. nature ?

localized lesion
diagnosis

work up concept lesion

1. Intracranial compartment : supretentorial & infratentorial
2. Spinal cord : CTLS level
3. Peripheral nerves : plexus, cranial nerves, spinal nerves
4. Neuromuscular junction : NMJ
5. Muscles

LOCALIZING INDICATORS

 indicators

A. Intracranial lesion

1.

higher
cortical functions
2. cranial nerves deficit
3. Neurological deficit hemiplegia / hemianesthesia
4. signs of cortical lesion grasping reflex

B. Spinal level lesion

1.
2. paraplegia, suspended
sensory loss,
sensory loss below level ,
3. spinal cord syndrome ;central cord syndrome, BrownSequard syndrome, anterior cord syndrome, posterior cord
syndrome, conus medullaris syndrome
4. involve bowel bladder function

C. Peripheral nerve lesion

1. anatomy
2. motor &
sensory
3. hyporeflexia
4. diatal weakness
5. marked atrophy
6. fibrillation

Motor Weakness predominantly distal

Hypotonia
Glove and stocking sensory loss
Diminished reflexes-Hyporeflexia
Pan-sensory modalities affected
Guillain- Barre syndrome, Diabetic neuropathy

D. Muscles & Neuromuscular junction disease :

1.

Myastinia
gravis
2. motor ( sensory intact)
3. absent / hyporeflexia

4. marked atrophy
5. pain & tenderness

Proximal greater than distal muscle weakness

Neck muscles often affected
Sensations are intact
Muscle stretch reflexes are normal
Duchenne muscular dystrophy, polymyositis

A1. supratentorial or Infratentorial lesion

Supratentorial lesion

1. higher cortical functions aphasia

2. Deficit of CN I, II
3. conjugate eye deviation
4. Neurological deficit facial

palsy UMNs

5. reflexes lobar lesion

Infratentorial lesion
1. Infratentorial compartment cross
paralysis

()

2. cerebellum

cerebellar signs

3. Brainstem

 (
brainstem long

tract (corticospinal, spinothalamic tract, etc) nuclei cranial

nerves 7-8-9-10-11-12 cranial

nerves

long tract signs & symptoms

4. cranial nerves deficit ; CN 5,6,7,8,9,10,11

infratentorial lesion
midbrain : CN 3,4 deficit
Pons
: CN 5,6,7,8 deficit
Medulla : CN 9,10,11,12 deficit
5. pinpoint pupils, abnormal

respiration
pattern brainstem

CHARACTERISTICS OF NEURAXIS LESIONS

INTRACRANIAL COMPARTMENT
I. SUPRATENTORIAL LESION SIGNS & SYMPTOMS
Supratentorial compartment :

cortex, subcortical, deep nuclei

CORTEX : frontal, temporal, parietal, occipital lobe

Frontal lobe lesion :

Symptoms : frontal lobe lesion

aphasia,
homanculus

Signs : hemiparesis / hemiplegia , conjugate eye deviation,

Grasping reflex, Brocas aphasia

Parietal lobe lesion:

Symptoms :

Signs : sensory disfunction ( lesion)

finger agnosia ( )
Right/Left disorientation ( )

Astereognosia (
)

Agraphestesia (

Acalculia ( )
Alexia ( )

VF defect (homonymus lower quadrantanopia

Wernickes aphasia

Temporal lobe lesion :

Signs : VF defect (homonymus upper quadrantanipia)

Occipital lobe lesion :

Signs : VF defect (Homonymus hemianopia with macular

sparing)

Cortical blindness ( fundi & pupil

reflex )

Parasagittal lesion : Homunculus parasagittal lesion

paraparesis / paraplegia

spinal cord

lesion parasagittal meningioma

spinal cord

lesion

work up MRI spine lesion

Anterior skull base lesion :

(anosmia) optic nerve

atrophy

papilledema olfactory groove

meningioma

Foster-Kenedy syndrome

SUBCORTICAL LESION
Internal capsule : lesion IC

lesion IC
paraplegia gr
0

 Thalamic lesion / Basal ganglia lesion :

structures nerve fiber internal
capsule

- contralateral loos of dorsal column sensations, contralateral

spastic paresis, contralateral facial weakness UMNs, dysarthria,
thalamic syndrome
Basal nuclei : lesion deep nuclei involuntary
movement (Chorea, athetoid, ballistic), Parkinsonism

II. INFRATENTORIAL LESIONS

Brainstem lesions : neurological deficit

1. polycranial nerves involvement :CN 5,7,8,9,10,11,12
2. loss of Dolls eye phenomenon : Dolls eye

good conscious, unconscious

Dolls eye phenomenon

brainstem

Dolls eye brainstem lesion

3. coma
4. pinpoint pupils
5. abnormal respiratory pattern eg: central neurogenic hyperventilation,
ataxic of breathing
6. Nystagmus, Hornors syndrome, vertigo

7. internuclear ophthalmoplegia (INO)

8. Cross paralysis ()

Cerebellar lesion : neurological deficit lesion

1. Nystagmus :
2. Dysarthria (slurred speech)
3. over shooting (Rebound phenomenon)
4. intention tremor (terminal tremor) : ( )
5. Dysdiadokokinesia (impaired rapid alternate movement of hands)
6. Impaired HTK test
7. Ataxic gait (wide base gait, Tandem walking)
8. Truncal ataxia (vermis lesion)
9. Scanning speech (Staccato)
10. Dysmetria, hypotonia

No 1 : Cortical lesion = lobar, seizure,

homunculus lesion Rt.

frontal lobe

homunculus arm

focal seizure

hyperreflexia

lesion fiber area

loss of

conscious herniation

No 2 : Corona radiate / Internal capsule =

lesion

 fiber
3 (internal

capsule) lesion

dense

fiber

conscious

grade 0-I
lesion Rt.internal

capsule

UMN lesion

No 4 : Brainstem lesion = Crossed paralysis

lower

LMN lesion

cranial nerves (CN 5,6,7,8,9,10,11,12)

No 5 : Spinal cord lesion =

level

pattern spinal cord syndrome

No 6,7,8 : Peripheral nerves, NMJ, muscular lesions =

CASE STUDY

1
42

6



PE : vital signs are normal
GA : normal all
NS : hyperreflexia of right arm, other WNL

Case discussion : focal seizure

hyperreflexia

lesion motor cortex

brain

homunculus left cerebral cortex MRI

Confirm diagnosis

2
56

PE : BP 210/120 HR 64 RR 16 BT 36.8 C
GA : obesity woman
NS : good conscious, pupil R3 L3 RTLBE
Left hemiplegia grade I, Lt. BBK dorsiflexion
Left facial palsy (UMNs type)

Case discussion =

UMNs BBK +ve

lesion

Right

internal capsule fiber

vascular cause

 HT and poor
compliance hypertensive putamen hemorrhage
CT brain

3
32 6

PE : normal vital signs

GA : looked sick young man , not coorperation
NS : E3M5V3, pupil R1.5 L1.5 mm SRTLBE, nystagmus
motor, sensory can not evaluation
Reflexes : hyperreflexia both arms & legs
BBK : dorsiflexion bilaterally
Stiff neck ve

Case discussion = localization

lesion brainstem

lower cranial nerves deficit long

tract

signs MRI

4
36

carpal tunnel syndrome

PE : normal vital signs

GA : looked normal woman
NS : good conscious, normal all CNs, Downbeat nystagmus
Suspended sensory loss both arms, muscle atrophy of both
thenas, hyporeflexia both biceps, triceps
motor power both arm Gr III, both legs Gr V

Case Analysis : (problem lists)

1. ()
2. suspended sensory loss
3. downbeat nystagmus

CN lesion

cord involve
lesion cord central

canal downbeat nystagmus (

) Chiari malformation (

tonsil cerebellum upper cervical) case

typical .. ? MRI cervical spine ()

5
32

PE : normal vital signs

GA : alert, coorperative
NS : good conscious, Rt. facial palsy LMN type, poor gag reflex,
Motor :
Deltoid R4 L4
Biceps R4 L4
Triceps R4 L4
Wrist extensor R3 L3
Hand grip

R2 L2

Hip flexor

R4 L4

Quadriceps

R4 L4

Hamstring

R3 L3

DTR absent , PPS decrease both hand & feet

Case discussion :

progressive from

distal to proximal involve brainstem and

spinal cord nuclei
facial palsy LMN type, absent DTR, distal
muscle weakness, motor & sensory lesion
nerve roots brainstem spinal nerve roots

polyradiculoneuritis or Guillain Barre

syndrome
confirm diagnosis by CSF profile.

6
24

PE : normal vital signs

GA : alert, coorperative woman
NS : good conscious, bilateral ptosis, diplopia R>L
Weakness of all extraoccular muscles
ptosis

Other WNL
Case discussion : NMJ

myastinia gravis