Localizing the Lesion

G E R SO N SUA R E Z MD
MOD I FIE D FR O M DAVID HUNT ER , MD AND CASES ADAPT ED
F R O M T U L A N E UNI VE R SIT Y D E PA R T MENT O F NE U R O LOGY
Localize the Lesion

CNS PNS
Brain Cord Nerve Muscle

Muscle
Root Plexus Nerve(s) NM Jxn
Tissue
Case 1
• 26 year-old female graduate student was conducting a philosophy
seminar when she suddenly started stuttering and then became
incoherent. She seemed confused, and her mouth was twisted. One
arm hung limply and she walked unsteadily.
• She had a past history of rheumatic heart disease and took no meds
except for birth control pills.
Case 1: L MCA Infarct
Case 2
• 68 year-old white female presents with CC of inability to walk. Upon
further questioning you find that this has progressed over a month or
two and is not associated with back pain.
• On exam she is slightly inattentive and sometimes inappropriate.
Language is intact. She has no CN deficits, and good strength of the
UE's. Her legs are diffusely weak, 3 to 4 over 5, proximally and
distally. Sensory exam reveals questionable mild loss of LT/PP distally
of LE's, with no demarcated level. Reflexes are brisk in the legs and
she has bilateral Babinski's.
Case 2: Parasagittal Lesion
Case 3
• 55 year-old black female with a history of DM and HTN states that,
while drinking her morning coffee, she suddenly experienced
"heaviness" of the right arm. She fumbled with the cup until she
spilled the coffee, and when the symptoms did not resolve within a
half hour she reported to the ER.
• Examination reveals an alert woman with normal mental status,
decreased LT, PP, Vibration over the right arm and leg. Strength is
objectively normal.
Case 3: Pure
sensory stroke
Thalamic Infarct
Case 4
• Your friend, who is a body builder, complains of sudden back pain and
the inability to walk.
• Your exam reveals bilateral leg weakness, with absent ankle reflexes,
decreased tone in legs. He feels paresthesias running down the back
of both legs, and didn't notice you sticking him with a pin until you
got to the mid-thigh. Pressure on the lumbar spine causes pain, and
he has paralumbar spasm.
Case 4: Cauda Equina
Case 5
• A 35 year-old black male is seen in clinic with 3 month history of
weakness and muscle cramps, first felt in the left arm but progressing
to both legs. His voice is not as loud as it used to be, and is a little
hoarse. Sometimes food gets "stuck" on one side of his mouth and he
has to move it with his finger.
• He has no sensory loss. Reflexes are brisk, including a jaw jerk. The
toes are equivocal. Fasciculations are present in the tongue at rest,
and all four proximal extremities. One year later he has difficulty
swallowing, is short of breath and appears emaciated.
Case 5: ALS
Case 6
• A 62 year-old woman complains of pain and numbness of the right
hand. She has been dropping objects from the hand and the
discomfort is worse at night.
• Exam reveals reduced pinprick sensation on the R palm and mild
atrophy of the thenar eminence.
Case 6: Carpal Tunnel Syndrome
Case 7
• A 30 year-old white female has difficulty climbing stairs. She cannot
lift objects but has no problems writing or buttoning her shirt. Her
gait is waddling. She has been followed for 8 months in the
rheumatology clinic for "arthritis". A visit to the walk-in clinic
prompted her appointment with neurology.
• Her joints have good range of motion and are nonfluctuant. Her
muscles are tender to palpation.
Case 7: Polymyositis
Case 8
• A 28 year-old white female complains of headaches for 1 year, recently
daily. They are often throbbing, usually bitemporal and do not usually cause
too much nausea, although she has vomited once or twice. She also says
her vision has changed, but she went to get her glasses checked and they
told her they were fine. Other pertinent history is obtained that she had a
child 9 months ago, and gained 80 pounds during pregnancy. She has lost
30.
• On physical exam, she is obese. Vital signs are normal. Funduscopic exam
shows bilateral disc margin blurring with a flame hemorrhage in the right.
Pupils are equally reactive. Visual fields are full on finger confrontation.
There is a question of mild lateral rectus weakness on the right. The rest of
the cranial nerves are normal as is her strength, sensation, and reflexes.
There is no Babinski. Coordination and gait are intact.
Case 8: Pseudotumor
Case 9
• A 31 y/o woman presents to you clinic complaining of double vision
and a “droopy eyelid.” Her vision is normal when she wakes in the
morning, but worsens throughout the day. She also reports that she
has to take lengthy breaks while doing housework, because she
becomes so weak.
• Exam reveals ptosis of the left eye greater than the right. Extraocular
movements are intact and visual fields are full. Denies double vision
at this time. Patient has full strength on normal motor testing and
remainder of exam is normal.
Case 9: Myasthenia Gravis
Case 10
• An 18 y/o man is brought to the trauma bay following multiple stab
wounds to the abdomen. On further questioning, he complains he
cannot feel his legs.
• Secondary survey reveals plegia of the LLE. Patient could not feel
vibration in the left great toe but this was intact on the right.
However, the entire RLE was numb to pinprick compared to the left,
with a sensory level at the umbilicus.
Case 10: Brown-Sequard Syndrome
Case 11
• A 21 y/o woman presents to ER after being found down by her
roommate. No one saw the fall. She was confused and had R sided
weakness when EMS arrived at the scene.
• On arrival to the ER, the patient was fully oriented and had normal
exam. The last thing she remembers is an unpleasant odor prior to
losing consciousness and waking up on the floor. She has never had
LOC before but has been noticing the same odor for several months –
for a few seconds at a time. In the same period, she complains of
experiencing déjà vu more than usual.
Case 11: Temporal Lobe Epilepsy
Case 12
• A 53 y/o man presents to the ER with rapid onset of paraplegia. Two
days ago, he noted tingling in his toes and soon had bilateral foot
drop. The weakness progressed to involve the legs and then the
thighs. His family called EMS once he couldn’t walk. Now, he says the
tingling has moved to his fingers. He is usually very healthy but did
have a “stomach bug” a few weeks ago.
• Exam shows flaccid paralysis below the waist with diffuse mild
sensory loss to all modalities. There is no clear sensory level. Reflexes
are absent in BLE and reduced in the BUE.
Case 12:
Gullian-Barre
(AIDP)
Case 13
• A 16 year-old girl is referred to you by her pediatrician. For the last
year, she has complained of global muscle weakness, which seems to
come and go. She also complains of a vague tightness of her throat,
leg aching and frequent headaches. Sometimes she is fine, and other
times she just lies on the couch, or will suddenly fall walking off a
curb.
• On exam, the patient seems sleepy and gives poor effort on strength
testing but no obvious deficits are detected. Reflexes are 2+. Her
mother is very anxious about the patient’s situation but the patient
seems unconcerned by her symptoms.
The End