SITE LOCALISATION

Dr Manish Mittal
SRHU
 LEVEL OF LESION IN NEUROLOGY
• Cortical
• Subcortical- corona radiata
• Internal capsule
• Brainstem
• Cerebellum
• Spinal cord
• Anterior horn cell
• Root
• Plexus
• Nerve
• Neuromuscular Junction
• Muscle
 Differences between UMN and LMN lesions
FEATURES UMN lesion SIGNS
Pattern Of weakness Usually whole limb involved.
Weakness more in extensor
group in UL and more in
flexor group in LL
LMN lesion SIGNS
Weakness in distribution of a root
or nerve(Selected muscles may be
involved)

Fine Motor control Loss of fine motor May be preserved

control(loss of dexterity)
TONE SPASTICITY FLACCIDITY
REFLEXES DTR 3+, Sup. reflexes- DTR -
Diminished (Abdominal)
PLANTARS EXTENSOR FLEXOR
WASTING / ATROPHY ABSENT OFTEN SEVERE
FASCICULATIONS ABSENT PRESENT
BLADDER / BOWEL INVOVLVED NOT INVOLVED(UNLESS CAUDA
EQUINA IS INVOLVED)
 Cerebrum
• Abnormal mental status or cognitive
impairment
• Seizures
• Contralateral weakness and sensory loss over
face and limbs
• Visual field abnormalities
• Involuntary movements like- Tremors, Chorea,
Athetosis and Dystonia.
 CORTICAL AND SUBCORTICAL LESIONS
FEATURES CORTICAL SUBCORTICAL
APHASIA PRESENT LESS COMMON
SEIZURES PRESENT ABSENT
WEAKNESS USUALLY MONOPLEGIA (Face WEAKNESS(Face=Arm =Leg).
and Arm weakness more than Weakness can be subtle in
Leg weakness or vice versa) corona radiata lesion or it can be
dense in Internal capsule lesion
VISUAL LOSS ABSENT(Occipital cortical PRESENT(Field defect may be
lesion may have field defect) present)
HEMIANAESTHESIA CORTICAL SENSORY LOSS PRESENT- primary sensation may
be affected
MOVEMENT ABSENT MAY BE PRESENT[BG – chorea,
DISORDER parkinsonism, hemibalallismus]

LEFT CORTICAL LESION – APHASIA

RIGHT CORTICAL LESION – VISUOSPATIAL DISORIENTATION AND
NEGLECT
 Extra Pyramidal System
 Difficulty to initiate movements
 Hypertonia – rigidity [cog wheel or
lead pipe]
 No loss of power of muscles and
wasting
 Bradykinesia or akinesia
 Involuntary movement
 Plantar response – Flexor
 Sensations
Cortical sensations Elementary Sensation
• Stereognosis • Pain
• Graphesthesia • Temperature
• Tactile extinction • Touch
• Position sense
• Vibration
• Tactile localisation
• Two point
discrimination(1mm-tip of
tongue, 2mm-lips, 2to4mm-
fingertips, 1cm- palm, 2to3cm- back
of hand, 3to4cm-dorsum of foot)
Thalamic Lesion- Contralateral Sensory loss
over face and body with Thalamic pain
Internal capsule lesion
• Dense Hemiplegia with
or without sensory loss
on contralateral side of
body
• Normal sensorium
• No aphasia or seizures
 CEREBELLAR LESION
• IPSILATERAL ATAXIA AND ATAXIC GAIT
 Clinical Features of Cerebellar Lesion
• Ipsilateral limb ataxia
• Truncal ataxia
• Gaze evoked nystagmus
• Scanning speech
• Intention tremors
• Dysdiadochokinesia
• Dysmetria- Finger nose finger test
• Limb incodination-Knee heel shin test
• Rebound
• Pendular knee jerk
Brainstem Lesion
• Ipsilateral cranial nerve
involvement and contralateral
long tract signs(Hemiplegia or
sensory loss)
• Crossed Hemiplegia: Cranial
nerve involvement on one side
and hemiplegia on other
side(Ex- Facial weakness on Rt
side and upper limb and lower
limb weakness on left side).
• D’s- Dizziness, Diplopia,
Dysarthria and Dysphagia
Cord Lesions- Myelopathy
• Paraplegia or Quadriplegia
with UMN lesion signs with
sensory level and bowel and
bladder involvement.
• Head is spared
• Patient complain of
localised girdle pain or band
like sensation or tightness.
• Back pain and spinal
tenderness
Anterior Horn cell diseases- Poliomyelitis,
Motor neuron disease
• Anterior horn cell can
also get involved in
Syringomyelia
• Features: Asymmetrical
weakness, Muscle
atrophy, Fasciculation's,
Hypotonia, sensations
are normal and reflexes
are absent.
Radiculopathy
• TYPICAL ROOT PAIN
 SHARP
 SHOOTING
 STABBING
 ELECTRIC LIKE
 RADIATING
 WORSEN BY STRETCHING THE ROOT

• ON EXAMINATION – ALL DEFICITS

LOCALISED TO ROOT
 MYOTOMAL WEAKNESS
 DERMATOMAL SENSORY LOSS
 LOCALISED REFLEX CHANGES
 WEAKNESS IS LMN type
Brachial plexus lesion- compression, traction
or viral infection
• Lower motor neuron type
of weakness with sensory
features in one arm which
can’t be explained by
radiculopathy or
neuropathy.
• Shoulder and brachial pain
• Sparing of rhomboids,
serratus anterior and
paraspinal muscles in
upper brachial plexus injury
Neuropathy
• Glove and stocking sensory loss
• Distal weakness and sensory loss
• Distal pain, burning and tingling.
• Sensory loss and weakness in
distribution of a nerve.
• Autonomic involvement
• Depressed reflexes
• Decreased tone
• Muscle wasting
Neuromuscular Junction Disorders-
Myasthenia gravis
• Asymmetrical proximal weakness
• Tone, sensation, bulk and reflexes
are normal.
• Diurnal variation- weakness more
in evening after work.
• Easy Fatigability
• Waxing and waning weakness.
(Worsen with exercise and better
with rest)
• Diplopia, ptosis, facial weakness,
dysarthria and dysphagia are
common.
• Most signs of myopathy present
and signs of neuropathy absent
Myopathy- Muscle Disease
• Proximal symmetrical
weakness- Difficulty in getting
up from squatting or in
climbing stairs
• Can not pick things from shelf.
• Tone, Reflexes, sensation and
bulk are normal.
• Gower’s sign positive
• Pseudohypertrophy may be
present in muscular
dystrophy.