Color Atlas of Neurology (Thieme 2004)
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Diagnostic Evaluation
Neurophysiological and Neuropsychological Tests
" Neurophysiological Tests
Test/Purpose |
Risks |
Comments |
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Electroencephalography: To assess elec- |
Surface electrodes: none |
Sphenoid, subdural or depth re- |
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trical activity of the brain1 |
Needle electrodes: infec- |
cording3 for special questions relevant |
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tion |
to the (preoperative) diagnostic eval- |
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Induction of seizures by |
uation of epilepsy |
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provocative methods2 |
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Evoked potentials (EPs): |
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! VEPs4: Study of optic nerve, optic |
! |
None |
! Used mainly to diagnose prechias- |
chiasm and optic tract |
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matic lesions |
! AEPs5: Study of peripheral and cen- |
! |
None |
! Used mainly for diagnosis of multi- |
tral segments of the auditory path- |
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ple sclerosis, tumors of the poste- |
way6 |
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rior cranial fossa, brain stem le- |
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sions causing coma or brain death, |
! SEPs7: Study of somatosensory sys- |
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and intraoperative monitoring |
! |
None |
! Used to assess proximal peripheral |
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tems8 |
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nerve lesions (plexus, roots) and |
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spinal cord or parietal lobe lesions |
! MEPs9: Study of corticospinal |
! |
May induce epileptic |
! Pyramidal tract lesions, motor neu- |
motor pathway |
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seizures. Contraindica- |
ron lesions, root compression, |
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tions: cardiac |
plexus lesions, stimulation of deep |
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pacemakers, metal |
nerves, differential diagnosis of |
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prostheses in the target |
psychogenic paresis |
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area, pregnancy, un- |
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stable fractures |
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Electromyography: Study of electrical |
Contraindication: |
Provides information on motor unit |
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activity in muscle |
coagulopathy. Risk of in- |
disorders in patients with peripheral |
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jury in special studies11 |
nerve lesions or myopathies. Not dis- |
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ease-specific. Disposable needles |
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should be used to prevent spread of |
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infectious disease10 |
Electroneurography: Measurement of |
Needle recordings con- |
Localization (proximal, distal, conduc- |
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motor and sensory conduction veloci- |
traindicated in patients |
tion block) and classification (axonal, |
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ties. |
with coagulopathy |
demyelinating) of peripheral nerve le- |
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sions12 |
Electro-oculography: To record and |
Caloric testing with water |
Diagnosis and localization of periph- |
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assess eye movements and/or nystag- |
contraindicated in patients |
eral and central vestibular lesions. |
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mus |
with perforated eardrums |
Differentiation of saccades |
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1 For assessment of epilepsy, localized pathology (neoplasm, trauma, meningoencephalitis, infarct) or generalized pathology (intoxication, hypoxia, metabolic encephalopathy, Creutzfeldt–Jakob disease, coma, brain death), for sleep analysis (polysomnography), or to monitor the course of such conditions. 2 Photostimulation, hyperventilation, sleep, sleep withdrawal. 3 For diagnostic assessment before epilepsy surgery, in specialized centers.
4 Visual EPs. 5 Acoustic EPs. 6 Peripheral nerve and cochlear lesions are mainly studied audiometrically, and peripheral and central disorders by electro-oculography or posturography. 7 Somatosensory EPs. 8 Functional assessment of sensory pathways (p. 104) by tibial, median, ulnar, and trigeminal nerve stimulation. 9 Motor EPs. 10 Particularly Creutzfeldt–Jakob disease, hepatitis, AIDS. 11 Examples: Pneumothorax in study of the serratus anterior m., perforation of the rectal wall in study of the anal sphincter. 12 F-wave measurement for localization of proximal nerve damage, H-reflex in S1 syndrome.
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" Neuropsychological Tests |
tion suggest the possibility of mental illness or |
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of mental dysfunction due to neurological dis- |
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Comprehensive testing of cognitive function, |
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ease. Objectives: Accurate detection and effec- |
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352 |
behavior, and affective processes, perhaps in |
tive monitoring, prognostication, identification |
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collaboration with a neuropsychologist, is re- |
of etiology, and treatment of mental disorders |
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quired when the history and physical examina- |
(p. 122 ff). |
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Rohkamm, Color Atlas of Neurology © 2004 Thieme
All rights reserved. Usage subject to terms and conditions of license.
Cerebrovascular Ultrasonography, Diagnostic Imaging, and Biopsy Procedures
Aspect To Be Tested |
Questions/Tests |
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! |
Attention (p. 116) |
! Awake, somnolent, stuporous, comatose? Arousability, attention |
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span, perception |
! |
Orientation |
! Personal data (name, age, date/place of birth), orientation (“where |
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are we?”, place of residence); time (day of the week, date, month, |
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year); situation (reason for consultation, nature of symptoms) |
! |
Memory, recall |
! The patient should be able to name the months of the year back- |
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ward, spell a word backward, repeat random series of numbers be- |
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tween 1 and 9. Can the patient recall 3 objects mentioned 3 |
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minutes ago, recall figures, name famous people? Tests of general |
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knowledge |
! |
Serial subtraction |
! Serial subtraction of 3s (or 7s), starting from 100 |
! |
Frontal lobe function |
! Perseveration1; hand sequence test2; proverb interpretation |
! |
Language (pp. 124, 128) |
! Following commands, naming, repetition, writing, reading aloud, |
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simple arithmetic |
! |
Praxis |
! See p. 128 |
!Spatial orientation, visual percep- ! See p. 132. Naming of colors and objects tion
(After Schnider, 1997) 1 Drawing of simple figures (Luria’s loops). 2 Command sequence: “Make a fist—open the hand to the side—open the hand flat.”
" Cerebrovascular Ultrasonography
Ultrasound can be used to assess the extracranial and intracranial arteries. The transmitter emits ultrasonic waves in two modes, continuous wave (CW; cross-sectional data, but no depth information) and pulse wave (PW; flow information at different levels). The reflected waves are recorded (echo impulse signal) and analyzed (frequency spectrum analysis, color coding). The flow velocity of blood particles can be determined according to the Doppler principle. As the flow velocity is correlated with the diameter of a blood vessel, its measurement reveals whether a vessel is stenotic. In direct vessel recordings, CW Doppler can be used to determine the direction of flow and the presence or absence of stenosis or occlusion. In duplex sonography, the PW Doppler and ultrasound images (echo impulse) are combined for simultaneous demonstration of blood flow (color-coded flow image) and tissue structures (tissue image). This permits visualization and
quantitation of stenosis, dissection, extracranial vasculitis, and vascular anomalies. Transcranial Doppler (TCD) and duplex sonography are used to study the intracranial arteries, e. g., for stenosis, occlusion, collateral flow, vasospasm (after subarachnoid hemorrhage), shunting (arteriovenous malformation or fistula), and hemodynamic reserve.
" Neuroimaging
The neuroradiologist can demonstrate structural changes associated with neurological disease with a number of different imaging techniques. When a patient is sent for a neuroimaging study, the reason for ordering the study and the question(s) to be answered by it must be clearly stated. Interventional procedures in the neuroradiology suite are mainly performed to treat vascular lesions (embolization of an arteriovenous malformation, fistula, or aneurysm; thrombolysis; angioplasty; devascularization of neoplasms; stent implantation).
Diagnostic Evaluation
353
Rohkamm, Color Atlas of Neurology © 2004 Thieme
All rights reserved. Usage subject to terms and conditions of license.
Diagnostic Evaluation
Cerebrovascular Ultrasonography, Diagnostic Imaging, and Biopsy Procedures
Imaging Study |
Indication/Objective1 |
Conventional radiography2
Skull, spine
Computed tomography (CT)
Head, spine, spinal canal, CT-guided diagnostic interventions, 3-D reconstruction
Magnetic resonance imaging (MRI)4
!Head, spine, spinal canal
!Skeletal muscle
Angiography3,5
Cerebral, spinal; preinterventional or preoperative study6
Myelography3,7
Diagnostic nuclear medicine
!Skeletal scintigraphy (“bone scan”)
!CSF scintigraphy
!Emission tomography8
Metallic foreign bodies, air-filled cavities, fractures, skull defects, bony anomalies, osteolysis, spinal degenerative disease
Assessment of skeleton (anomalies, fractures, osteolysis, degenerative changes, spinal canal stenosis), metastases, trauma, intracranial hemorrhage, cerebral ischemia, hydrocephalus, calcification, intervertebral disk disease, contrast studies3 (brain, spinal canal, CT angiography)
!Tumors (brain, spine, spinal cord), infection (encephalitis, myelitis, abscess, AIDS, multiple sclerosis), structural anomalies of the brain (epilepsy), leukodystrophy, MR angiography (aneurysm, vascular malformation), ischemia of the brain or spinal cord, spinal trauma, hydrocephalus, myelopathy, intervertebral disk disease
!Muscular atrophy, myositis
High-grade arterial stenosis, aneurysm, arteriovenous malformation/ fistula, sinus thrombosis, vasculitis
Largely replaced by CT and, especially, MRI. Used to clarify special diagnostic questions in spinal lesions
!Tumor metastasis, spondylodiscitis
!Intradural catheter function test, CSF leak
!Cerebral perfusion, cerebral metabolic disorders, degenerative diseases, diagnosis of epilepsy
1 Examples. 2 Plain radiographs, X-ray tomography. 3 Risks: allergy ( intolerance), latent hyperthyroidism ( thyrotoxicosis), thyroid carcinoma ( radioiodine therapy cannot be performed for a long time afterward), renal failure, left heart failure ( pulmonary edema), plasmacytoma ( renal failure). 4 Gadolinium contrast agent can be used to show blood–brain barrier lesions (e. g., acute multiple sclerosis plaques). T1-weighted scans: CSF/ edema dark (hypointense), diploe/fat light (hyperintense), white matter light; gray matter dark. T2-weighted scans: CSF/edema light, scalp dark, diploe/fat light, muscle dark, white matter dark; gray matter light. Contraindications: Cardiac pacemaker, mobile ferromagnetic material. 5 Contraindicated in patients with coagulopathy. 6 Endovascular or surgical therapy. 7 Rare complications: generalized epileptic seizures, meningitis, post–lumbar puncture headache; acute transverse cord syndrome possible in patients with spinal tumors. Coagulopathy is a contraindication. 8 SPECT = single-photon emission computed tomography, PET = positron emission tomography.
" Tissue Biopsy |
vessels (e. g., the temporal artery in suspected |
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temporal arteritis). These biopsies can usually |
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In certain cases, the provision of a definitive di- |
be carried out under local anesthesia. Spinal |
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agnosis requires biopsy of nerve (usually the |
tumors can be biopsied under CT or MRI |
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sural nerve, p. 391), muscle (a moderately af- |
guidance, and brain tumors and abscesses can |
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fected muscle in myopathy, p. 399), or blood |
be biopsied with stereotactic technique. |
354
Rohkamm, Color Atlas of Neurology © 2004 Thieme
All rights reserved. Usage subject to terms and conditions of license.
5 Appendix
!Supplementary tables
!Detailed information
!Outlines
!Working aids
Rohkamm, Color Atlas of Neurology © 2004 Thieme
All rights reserved. Usage subject to terms and conditions of license.
Appendix
Appendix
Table 1 Cranial nerves (p. 28)
Pathway |
Cranial Nerve (CN)/Nucleus |
Functions |
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Somatosensory |
II |
Retina |
Vision |
(afferent) |
III |
Proprioceptors of extraocular mm.1 |
Proprioception2 |
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IV |
Proprioceptors of extraocular mm. |
Proprioception |
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V |
Semilunar ganglion, proprioceptors |
Sensation in face, nose, nasal cavity, oral |
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of masticatory, tensor veli palatini, |
cavity; proprioception, dura mater (pp. 6, |
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and tensor tympani muscles |
94) |
|
VI |
Proprioceptors of extraocular mm. |
Proprioception |
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VII |
Geniculate ganglion |
External ear, parts of auditory canal, outer |
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surface of eardrum (sensation) |
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VIII |
Vestibular ganglion; spiral ganglion |
Balance/equilibrium; hearing |
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IX |
Superior ganglion |
Middle ear, auditory tube (sensation) |
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X |
Superior ganglion |
External auditory canal/dura mater of |
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posterior fossa (p. 5) |
Visceral (afferent) |
I |
Olfactory cells of nasal mucosa |
Smell |
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VII |
Geniculate ganglion |
Taste on anterior 2/3 of tongue (chorda |
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tympani), taste on inferior surface of soft |
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palate (greater petrosal n.) |
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IX |
Inferior and superior ganglia |
Taste/sensation on posterior 1/3 of |
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tongue, pharyngeal mucosa, tonsils, audi- |
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tory tube (sensation) |
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X |
Inferior ganglion |
Abdominal cavity (sensation), epiglottis |
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(taste) |
Motor (efferent) |
III |
Oculomotor nucleus3 |
Extraocular mm. (except those supplied |
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by CN IV, VI), raise eyelid (levator palpe- |
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brae superioris m.) |
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IV |
Trochlear nucleus |
Oblique eye movements (superior oblique |
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m.) |
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V |
Motor nucleus of trigeminal n. |
Mastication,4 tensing of palate5 and tym- |
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panic membrane6 |
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VI |
Abducens nucleus |
Lateral eye movements (lateral rectus m.) |
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VII |
Facial nucleus |
Facial muscles, platysma, stylohyoid and |
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digastric muscles |
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IX |
Nucleus ambiguus |
Pharyngeal mm., stylopharyngeus m. |
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X |
Nucleus ambiguus |
Swallowing (pharyngeal mm.), speech |
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(superior laryngeal nerve) |
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XI |
Nucleus ambiguus, motor cells of |
Muscles of pharynx and larynx, sternoclei- |
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anterior horn of cervical spinal cord |
domastoid m.7 trapezius m.8 |
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XII |
Hypoglossal nucleus |
Muscles of tongue |
Visceral (efferent) |
III |
Parasympathetic, Edinger–Westphal |
Pupillary constriction (sphincter pupillae |
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nucleus |
m.), accommodation (ciliary m.) |
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VII |
Parasympathetic, superior salivatory |
Secretion of mucus, tears, and saliva (sub- |
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nucleus |
lingual and submandibular glands) |
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IX |
Parasympathetic, inferior salivatory |
Secretion of saliva (parotid gland) |
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nucleus |
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X |
Parasympathetic, dorsal nucleus of |
Lungs, heart, intestine to left colonic |
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vagus nerve |
flexure (motor); glandular secretion (res- |
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piratory tract, intestine) |
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1 Eye muscles. 2 See p. 104. 3 Nucleus. 4 Masseter, temporalis, lateral pterygoid, and medial pterygoid muscles. 5 Tensor veli palatini m. 6 Tensor tympani m. 7 Shoulder elevation, scapular fixation, accompanying movements of cervical spine. 8 Neck flexion and extension, head rotation.
356
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Appendix
Table 2 Segment-indicating muscles (p. 32)
Segment |
Segment-indicating Muscle(s) |
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C4 |
Diaphragm |
C5 |
Rhomboids, supraspinatus, infraspinatus, deltoid |
C6 |
Biceps brachii, brachioradialis |
C7 |
Triceps brachii, extensor carpi radialis, pectoralis major, flexor carpi radialis, pronator |
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teres |
C8 |
Abductor pollicis brevis, abductor digiti quinti, flexor carpi ulnaris, flexor pollicis brevis |
L3 |
Quadriceps femoris, iliopsoas; adductor longus, brevis et magnus |
L4 |
Quadriceps femoris (vastus medialis m.) |
L5 |
Extensor hallucis longus, tibialis anterior, tibialis posterior, gluteus medius |
S1 |
Gastrocnemius, gluteus maximus |
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Tables 3 Types of tremor (p. 62)
Type |
Features |
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Physiological tremor (PT) |
Normal. Discrete, usually asymptomatic tremor of unclear significance. |
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Isometric tremor may occur, e. g., when holding a heavy object. |
Exaggerated PT, toxic or drug- |
Amplitude !PT, frequency = PT. Absent at rest. Mainly PosT.1 Stress |
induced tremor |
(anxiety, fatigue, excitement, cold). Metabolic disturbances (hyperthyroidism, |
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hypoglycemia, pheochromocytoma). Drugs/toxins (alcohol or drug with- |
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drawal; mercury, manganese, lithium, valproic acid, cyclosporine A, amio- |
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darone, flunarizine, cinnarizine, tricyclic antidepressants, neuroleptics tar- |
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dive tremor) |
Essential tremor (ET) |
Classical ET: PosT !KT 2. Approx. 60% autosomal dominant, rest sporadic. |
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Hands !head !voice !trunk. Often improved by alcohol. |
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Orthostatic tremor: Occurs only when standing unsteadiness, hard to |
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stand still. |
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Task-specific tremor |
Parkinsonian tremor |
RT 3 See p. 206. Postural and kinetic tremor may also be present. |
Cerebellar tremor |
IT4 reflecting cerebellar dysfunction. Postural tremor and head/trunk tremor |
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may be seen when the patient is standing (alcohol intoxication). |
Holmes tremor (rubral, mid- |
RT + PosT + IT, mainly proximal, disabling. Associated with lesions of nigro- |
brain tremor, myorhythmia) |
striatal and cerebello-thalamic pathways (multiple sclerosis, infarct) |
(Poly-)neuropathic tremor |
RT, PosT, or IT, predominantly either proximal or distal. 3–10 Hz5 |
Palatal tremor |
Symptomatic (medullary lesion due to encephalitis, multiple sclerosis, brain |
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stem infarct) or essential; clicking noise in ear |
Psychogenic tremor |
Migrates from one part of the body to another. Accompanied by muscle |
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contraction (co-contraction) |
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1 PosT = postural tremor. 2 KT = kinetic tremor. 3 RT = resting tremor. 4 IT = intention tremor. 5 Occurs in hereditary sensorimotor neuropathy type I, chronic demyelinating polyradiculitis, paraproteinemic neuropathy, diabetic neuropathy, and uremic neuropathy.
Appendix
357
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Appendix
358
Appendix
Table 4 Midbrain syndromes (p. 71)
Anterior Midbrain Lesions (Peduncle, Weber Syndrome)
Cause. Infarct. Less commonly caused by hemorrhage, tumor (germinoma, teratoma, pineocytoma, pineoblastoma, astrocytoma, tentorial edge meningioma, lymphoma), or multiple sclerosis.
Structure Affected |
Symptoms and Signs |
|
|
Intramesencephalic fibers of |
Ipsilateral oculomotor paralysis + parasympathetic dysfunction (pupil dilated |
oculomotor n. |
and unreactive to light) |
Pyramidal tract |
Contralateral central paralysis + face ( supranuclear facial palsy) + spastic- |
|
ity. Dysarthria (supranuclear hypoglossal palsy) |
Substantia nigra |
Rigidity (rare) |
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Medial Midbrain Lesions (Tegmentum, Benedikt Syndrome)
Cause. Same as in anterior lesions.
Structure Affected |
Symptoms and Signs |
|
|
Intramesencephalic fibers of |
Ipsilateral oculomotor paralysis + parasympathetic dysfunction (see above ) |
oculomotor n. |
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Medial lemniscus |
Contralateral impairment of touch, position, and vibration sense |
Red nucleus |
Contralateral tremor (myorhythmia red nucleus syndrome, Holmes |
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tremor) |
Substantia nigra |
Rigidity (variable) |
Superior cerebellar peduncle |
Contralateral ataxia ( Claude syndrome) |
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Dorsal Midbrain Lesions (Tectum, Parinaud Syndrome)
Cause. Tumor of third ventricle, infarct, arteriovenous malformation, multiple sclerosis, large aneurysm of posterior fossa, trauma, shunt malfunction, metabolic diseases (Wilson disease, Niemann–Pick disease), infectious diseases (Whipple disease, AIDS)
Structure Affected |
Symptoms and Signs |
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Oculomotor nuclei |
Pathological lid retraction (Collier’s sign) due to overactivity of levator |
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palpebrae superioris m. Over the course of the disease, accommodation is |
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impaired; the pupils become moderately dilated and unreactive to light, but |
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they do constrict on convergence (light-near dissociation) |
Medial longitudinal fasciculus |
Supranuclear palsy of upward conjugate gaze (vertical gaze palsy the |
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eyes move upward on passive vertical deflection of the head, but not volun- |
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tarily). Convergence nystagmus with retraction of the eyeball on upward |
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gaze (retraction-convergence nystagmus) |
Trochlear nucleus |
Trochlear nerve palsy |
Aqueduct (compressed) |
Hydrocephalus (headache, papilledema) |
|
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Rohkamm, Color Atlas of Neurology © 2004 Thieme
All rights reserved. Usage subject to terms and conditions of license.
Appendix
Table 4 Midbrain syndromes (continued)
Top of the Basilar Artery Syndrome
Cause. Large aneurysm of the basilar tip, thromboembolism in the upper basilar territory, vasculitis, complication of angiography. (Central paralysis is not found.)
Site of Lesion |
Symptoms and Signs |
|
|
Midbrain |
Unilateral or bilateral vertical gaze palsy; impaired convergence; retraction |
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nystagmus. Sudden oscillations (sensation of movement of surroundings |
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when walking or when moving head). Collier’s sign. Strabismus with di- |
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plopia. Pupils may be constricted and responsive or dilated and unrespon- |
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sive to light. |
Thalamus, parts of temporal |
Visual field defects (homonymous hemianopsia, cortical blindness). Variable |
and occipital lobes |
features: Somnolence, peduncular hallucinations (dreamlike scenic halluci- |
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nations), memory impairment, disorientation, psychomotor hyperactivity |
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Table 5 Pontine syndromes (p. 72)
Anterior Pontine Lesions (Ventral Pons)
Cause. Basilar artery thrombosis, hemorrhage, central pontine myelinolysis, brain stem encephalitis, tumors, trauma. Arterial hypertension (lacunar infarct).
! Mid Ventral Pons
Structures Affected |
Symptoms and Signs |
|
|
Pyramidal tract |
Contralateral central paralysis sparing the face |
Intrapontine fibers of trigemi- |
Ipsilateral facial hypesthesia, peripheral-type weakness of muscles of mas- |
nal nerve |
tication |
Middle cerebellar peduncle |
Ipsilateral ataxia |
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! Lacunar Syndromes1
Structures Affected |
Symptoms and Signs |
|
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Pyramidal tract |
Contralateral central paralysis, sometimes more pronounced in legs, with or |
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without facial involvement |
Middle cerebellar peduncle |
Ipsilateral ataxia, which may be accompanied by dysarthria and dysphagia, |
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depending on the site of the lesion (dysarthria—clumsy hand syndrome) |
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1Similar syndromes can also occur in patients with supratentorial lacunas (internal capsule, thalamocortical pathways).
! Locked-in Syndrome (p. 120)
Structures Affected
Ventral pons (corticobulbar and corticospinal tracts) bilaterally, abducens nucleus, pontine paramedian reticular formation, fibers of trigeminal nerve
Symptoms and Signs
Quadriplegia, aphonia, inability to swallow, horizontal gaze palsy (including absence of caloric response), absence of corneal reflex (risk of corneal ulceration)
Eyelid and vertical eye movements (supranuclear oculomotor tracts), sensation, wakefulness (reticular ascending system), and spontaneous breathing remain intact.
Appendix
359
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Appendix
360
Appendix
Table 5 Pontine syndromes (continued)
Dorsal Pontine Lesions (Pontine Tegmentum)
Cause. Same as in lesions of ventral pons.
! Oral (Superior) Pontine Tegmentum (Raymond–Céstan Syndrome)
Structures Affected |
Symptoms and Signs |
|
|
Trigeminal nucleus/fibers |
Ipsilateral facial hypesthesia, peripheral paralysis of muscles of mastication |
Superior cerebellar peduncle |
Ipsilateral ataxia, intention tremor |
Medial lemniscus |
Contralateral impairment of touch, position, and vibration sense |
Spinothalamic tract |
Contralateral loss of pain and temperature sensation |
Paramedian pontine reticular |
Ipsilateral loss of conjugate movement (loss of optokinetic and vestibular |
formation (PPRF, “pontine |
nystagmus PPRF lesion with intact vestibulo-ocular reflex (VOR, p. 84)) |
gaze center”) |
|
Pyramidal tract |
Contralateral central paralysis sparing the face |
|
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! Caudal Pontine Tegmentum
Structures Affected |
Symptoms and Signs |
|
|
Pyramidal tract |
Contralateral central paralysis sparing the face |
Nucleus/fibers of the facial n. |
Ipsilateral (nuclear = peripheral) facial palsy ( Millard–Gubler syndrome) |
Fibers of abducens nerve |
Ipsilateral abducens paralysis ( Foville syndrome, eyes drift “away from |
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the lesion”; loss of VOR) |
Central sympathetic pathway |
Ipsilateral Horner syndrome |
PPRF |
Loss of ipsilateral conjugate movement |
Medial and lateral lemniscus |
Contralateral impairment of touch, position, and vibration sense |
Lateral spinothalamic tract |
Contralateral impairment of pain and temperature sensation |
|
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Rohkamm, Color Atlas of Neurology © 2004 Thieme
All rights reserved. Usage subject to terms and conditions of license.
Appendix
Table 6 Medullary syndromes (p. 73)
Medial Medullary Lesions
Cause. Occlusion of the anterior spinal artery or vertebral artery.
Structures Affected |
Symptoms and Signs |
|
|
Hypoglossal n. nucleus/fibers |
Ipsilateral peripheral (nuclear) hypoglossal paralysis |
Pyramidal tract |
Contralateral central paralysis sparing the face (flaccid, in isolated pyramidal |
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tract lesions) |
Medial lemniscus |
Contralateral impairment of touch, position, and vibration sense (pain and |
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temperature sensation intact) |
Medial longitudinal fasciculus |
Upbeat nystagmus |
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Lateral Medullary Lesions (Dorsolateral Medullary Syndrome, Wallenberg Syndrome)
Cause. Occlusion of posterior inferior cerebellar artery (PICA) or vertebral artery. Less common causes: tumor, metastases, hemorrhage due to vascular malformations, multiple sclerosis, vertebral artery dissection (after chiropractic maneuvers), trauma, gunshot wounds, cocaine intoxication.
Site of Lesion |
Symptoms and Signs |
|
|
Spinal nucleus of trigeminal |
Ipsilateral analgesia/thermanesthesia of the face and absence of corneal re- |
nerve |
flex with or without facial pain |
Cochlear nucleus |
Ipsilateral hearing loss |
Nucleus ambiguus |
Ipsilateral paralysis of the pharynx and larynx (hoarseness, paralysis of the |
|
soft palate), dysarthria, and dysphagia. Tongue movement remains intact |
Solitary nucleus |
Ageusia (impaired sense of taste) |
Dorsal nucleus of vagus n. |
Tachycardia and dyspnea |
Inferior vestibular nucleus |
Nystagmus away from the side of the lesion, tendency to fall toward the |
|
side of the lesion, nausea and vomiting |
Central tegmental tract |
Ipsilateral myorhythmia of the soft palate and pharynx |
Central sympathetic pathway |
Ipsilateral Horner syndrome |
Reticular formation |
Singultus |
Inferior cerebellar peduncle |
Ipsilateral ataxia and intention tremor |
Anterior spinocerebellar tract |
Ipsilateral hypotonia |
Lateral spinothalamic tract |
Contralateral loss of pain and temperature sensation with sparing of touch, |
|
position, and vibration sense (sensory dissociation) |
|
|
Involvement of the lower pons produces diplopia. Occipital pain in Wallenberg syndrome is most commonly due to vertebral artery dissection.
Appendix
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Rohkamm, Color Atlas of Neurology © 2004 Thieme
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