WHERES THE

LESION?
Why,. Sign and
Symptom!!!
Neuroscience Core Lecture
Anwar Wardy, MD.Neu
Department of Neurology
FKK UMJ

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ALL OF COMPLAINTS NEUROLOGIC

IN ORIGIN

Wheres the lesion, ????

somewhere in
the neuraxis.

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Divisions of the Neuraxis

Cortical Brain
Subcortical
Brain
Brainstem
Cerebellum
Spinal Cord
Root
Peripheral Nerve
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Neuromuscula
r Junction
Muscle

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Divisi dari Neuraxis

KortikalOtak
SubkortikalOtak
Otak
Otak kecil
Saraf tulang belakang
Akar
PeripheralNerve
NeuromuscularJunction
Otot
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OFF THE TOP OF MY

HEAD . . .
Imbalance = Cerebellum
Pneumonia = Brainstem (related
dysphagia)
Loss of Dexterity = Peripheral Nerve
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 Ketidakseimbangan=Cerebellum
Pneumonia=batang
otak(dysphagiaterkait)
KehilanganDexterity=SarafPeriphe
ral

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Neurologic Examination

Higher Cortical Function

Cranial Nerves
Cerebellar Function
Motor
Sensory
Deep Tendon Reflexes
Pathologic Reflexes

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Pemeriksaan neurologis
FungsikortikalTinggi
Sarafkranial
CerebellarFungsi
Motor
Indrawi
DeepTendonRefleks
Reflekspatologis

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The Neuro Exam Should

Evaluate the Entire Neuraxis

Higher Cortical Function: cortex

Cranial Nerves: subcortex, brainstem
Cerebellar Function: cerebellum
Motor: motor homonculous, subcortical
pyramidal tracts, BS, cord, radicle, PN,
muscle
Sensory: ascending tracts, thalamus,
subcortical tracts, sensory hononculous
Deep Tendon Reflexes: afferent PN, radicle,
cord, efferent PN, muscle
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Pathologic
Reflexes:
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UjianNeuroHarusMengevalua
siSeluruhNeuraxis
CorticalTinggiFungsi:korteks
Sarafkranial:subcortex,batang otak
CerebellarFungsi:otak kecil
Motor:motorhomonculous,saluranpira
midalsubkortikal,BS,kabel,radikula,PN,
otot
Sensorik:ascendingtraktat,talamus,sal
uransubkortikal,sensorikhononculous
DeepTendonRefleks:PNaferen,radikula,
kabel,PNeferen,otot
Reflekspatologis
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SCOTTS EXAM SHOWED:

Higher Cortical Function: normal
Cranial Nerves: oropharyngeal dysarthria
Cerebellar Function: hypotonia, assynergy,
dysmetria, staccato dysarthria, intention
tremor, appendicular ataxia
Motor: hypotonia, normal strength
Sensory: decreased vibration and
temperature
Deep Tendon Reflexes: areflexia
Pathologic Reflexes: plantar flexing
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SCOTTS EXAM SHOWED

CorticalTinggiFungsi:normal
Sarafkranial:dysarthriaorofaringeal
CerebellarFungsi:hypotonia,assyner
gy,dysmetria,staccatodysarthria,tr
emorniat,ataksiaapendikularis
Motor:hypotonia,kekuatannormal
Sensorik:getaranmenurundansuhu
DeepTendonRefleks:areflexia
Reflekspatologis:kelenturanplantar
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SO WHERES THE
LESION?

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Goals of MD Testing
Localization
Muscle

Fiber type

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Severity

NMJ

Nerve

Pathology

Anterior Horn

Temporal course

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Brain component
Cerebral cortex

Cerebral cortex
Basal nuclei
(lateral to thalamus)

Basal nuclei
Thalamus
(medial)

Thalamus

Hypothalamus

Hypothalamus
Cerebellum

Cerebellum

Midbrain
Brain stem

Brain stem
(midbrain, pons,
and medulla)

Pons
Medulla

Spinal cord

BRAIN COMPONENT

Cerebral cortex

MAJOR FUNCTIONS
1. Sensory perception
2. Voluntary control of movement
3. Language
4. Personality traits
5. Sophisticated mental events, such as thinking memory,
decision making, creativity, and self-consciousness

Basal nuclei

1. Inhibition of muscle tone

2. Coordination of slow, sustained movements
3. Suppression of useless patterns of movements

Thalamus

1. Relay station for all synaptic input

2. Crude awareness of sensation
3. Some degree of consciousness
4. Role in motor control

Hypothalamus

1. Regulation of many homeostatic functions, such as temperature

control, thirst, urine output, and food intake
2. Important link between nervous and endocrine systems
3. Extensive involvement with emotion and basic behavioral patterns

Cerebellum

1. Maintenance of balance
2. Enhancement of muscle tone
3. Coordination and planning of skilled voluntary muscle activity

Brain stem
(midbrain, pons,
and medulla)

1. Origin of majority of peripheral cranial nerves

2. Cardiovascular, respiratory, and digestive control centers
3. Regulation of muscle reflexes involved with equilibrium and posture
4. Reception and integration of all synaptic input from spinal cord;
arousal and activation of cerebral cortex
anwar wardy
w in sleep-wake cycle
5. Role

Cortical Brain
Depends upon hemispheric dominance
Non-neurologists generalize:
right: visual/spatial, perception and memory
left: language and language dependent
memory

Look for aphasias, apraxias, and agnosias

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Neurologic Examination when

Cortical Brain is Lesioned
Higher Cortical Function: aphasia, apraxia,
agnosia
Cranial Nerves: normal
Cerebellar Function: normal
Motor: weakness if you hit the motor
homonculous
Sensory: sensory abnormalities if you hit the
sensory homonculous
Deep Tendon Reflexes: hemi-hyper-reflexia
Pathologic Reflexes: possibly Babinskis reflex or
frontal release signs
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Neurologic examination
cortical brain is lesioned
CorticalTinggiFungsi:aphasia,apraxia,agno
sia
Sarafkranial:normal
CerebellarFungsi:normal
Motor:Kelemahanjikaanda
menekanmotorhomonculous
Sensorik:kelainansensorikjikaanda
menekansensorikhomonculous
DeepTendonRefleks:hemi-hiper-reflexia
Reflekspatologis:mungkintandatandarefleksataufrontalBabinskirilis
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Primary Somatosensory Cortex

Located in the
postcentral gyrus, this
area:
Receives information from
the skin and skeletal
muscles
Exhibits spatial
discrimination

Somatosensory
homunculus caricature
of relative amounts of
cortical tissue devoted
to each sensory function
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Primary Motor Cortex

Located in the
precentral gyrus
Composed of pyramidal
cells whose axons make
up the corticospinal
tracts
Allows conscious control
of precise, skilled,
voluntary movements
Motor homunculus
caricature of relative
amounts of cortical
tissue devoted to each
motor function
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Neurologic Examination when

Brainstem is Lesioned

Higher Cortical Function: normal

Cranial Nerves:

III, IV, VI: diplopia

V: decreased facial sensation
VII: drooping
VIII: deaf and dizzy
IX, X, XII: dysarthria and dysphagia
XI: decreased strength in neck and shoulders

Cerebellar Function: normal

Motor: hemi-paresis, UMN
Sensory: hemi-dysesthesias
Deep Tendon Reflexes: hemi-hyper-reflexia
Pathologic Reflexes: Babinskis reflex

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Cerebellar Function
Some people believe that one can not test
specifically for cerebellar abnormalities
no one test on examination reliably evaluates the cerebellum

H:
A:
N:
D:
S:
T:

hypotonia
assynergy of (ant)agonist muscles
nystagmus
dysmetria, dysarthria
stance and gait
tremor

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Neurologic Examination when

the Cerebellum is Lesioned

Higher Cortical Function: normal

Cranial Nerves: normal
Cerebellar Function:
nystagmus
staccato dysarthria (abnormality of prosody)

Motor:
hemi-hypotonia
intention > positional tremor
axial instability with dysmetria

Sensory: normal
Deep Tendon Reflexes: normal
Pathologic Reflexes: none

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Spinal Cord
Sensory level (horizontal)
Weakness below the lesion (paraparesis) =
Kelemahanbawah(paraparesis)lesi
UMN signs below the lesion (UMNtandatandadi bawahlesi )
Bowel and bladder incontinence
(Inkontinensiausus dankandung kemih)

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Neurologic Examination when

the Spinal Cord is Lesioned

Higher Cortical Function: normal

Cranial Nerves: normal
Cerebellar Function: normal
Motor: weakness below the lesion
Sensory: horizontal level
Deep Tendon Reflexes: hyper-reflexia
below the lesion
Pathologic Reflexes: Babinskis reflex
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Root/Radiculopathy
Pain is the hallmark of a radiculopathy
(nyeriadalahciri
khassebuahradikulopati)
Sensory abnormalities in a dermatome
provocative maneuvres exacerbate the pain
(manuverprovokatifmemperburukrasa sakit)

Weakness in a myotome (assymetric)

LMN findings
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Neurologic Examination when

a Root is Lesioned

Higher Cortical Function: normal

Cranial Nerves: normal
Cerebellar Function: normal
Motor: assymetric weakness in a myotome
Sensory: pain and dysesthesia confined to
a dermatome (rasa
sakitdandysesthesiaterbataspadadermat
om)
Deep Tendon Reflexes: hypo- to a-reflexia if
the root carries a reflex
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Pathologic
Reflexes:
none

Peripheral Nerve
(presuming nonfocality)
Weakness: distal predominant
Sensory Dysesthesias: distal
predominant

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Neurologic Examination with

Diffuse PN Lesioning

Higher Cortical Function: normal

Cranial Nerves: normal
Cerebellar Function: normal
Motor: weakness is distal predominant
Sensory: dysesthesias are distal
predominant
Deep Tendon Reflexes: loss of distal reflexes
Pathologic Reflexes: mute responses to
plantar stimulation
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Neuromuscular Junction
Fatiguability is the hallmark
Weakness: proximal and symmetric
exacerbated with use, recovers with
rest(diperburukdenganpenggunaan,sem
buhdenganistirahat)
often affects facial muscles (ptosis,
dysconjugate gaze, slack jaw) =
seringmempengaruhiototototwajah(ptosis,dysconjugatetatapan,rahangslack

Sensation: preserved = diawetkan

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Neurologic Examination in
Disorders of the NMJ
Higher Cortical Function: normal
Cranial Nerves: fatiguabile ptosis, dysconjugate
gaze, slack jaw
Cerebellar Function: normal
Motor: fatiguable proximal weakness in both UEs
and LEs
Sensory: normal
Deep Tendon Reflexes: normal
Pathologic Reflexes: none
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Muscle
Weakness of proximal arm and leg
muscles
symmetric

Sensation is normal
though patients complain of cramping
and aching
(meskipunpasienmengeluhkramdans
akit)

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Neurologic Examination in
Disorders of Muscle
Higher Cortical Function: normal
Cranial Nerves: ptosis, dysconjugate gaze,
dysphagia, dysphonia, (dysarthria)
Cerebellar Function: normal
Motor: proximal weakness in both UEs and LEs,
atrophy and fasiculations, hypotonia
Sensory: normal
Deep Tendon Reflexes: preserved until late in the
disease
Pathologic Reflexes: none
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