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| If this were a CNS problem, which would you expect of the reflexes? |
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Sudden Onset
1. Diminished sensation bilaterally lower limb
2. Diminished reflexes lower limb
3. Weakness bilaterally lower limb
4. Unilateral facial weakness
Is this likely a CNS or a PNS problem? |
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| Guillain-Barre Syndrome—peripheral demyelinating disease |
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| Why can a child's head increase in size and an adult's cannot? |
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| The fontanelles allow for the skull to expand. |
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| Which of these sites might be involved in hydrocephalus? |
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Any of these:
Medial aperture
Medial and lateral aperture
Cerebral aqueduct
Interventricular foramen |
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| You are seeing a child for a check-up. You are charting his head circumference (stars)- above normal. What are your concerns? |
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So what do you think the consequence then of blockage of these arachnoid granulations? An example might be a sub-arachnoid hemorrhage clotting up these granulations.
And the answer, of course, would be hydrocephalus. |
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| What are the two major categories of hydrocephalus? |
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Definition
1. Communicating (non-obstructive) hydrocephalus caused by blockage of the arachnoid granulations
2. Non-communicating (obstructive) hydrocephalus caused by blockage of the CSF flow. |
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| How can obstructive hydrocephalus be treated? |
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Classic Treatment
A ventriculoperitoneal shunt. Cannula in the lateral ventricle led subcutaneously into the abdominal cavity.
Third Ventriculostomy |
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Case:
76 yo man with uncontrolled blood pressure.
Weakness in the face and hands on the right.
Global aphasia - cannot speak or understand complex phrases
CT shows lateral infarct
Angiogram shows blockage of some of the cerebral vessels.
Question: Based on the above, is this a right side or left side stroke?
Why is language affected?
Over the course of time you would expect the patient to have: |
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Left
The language hemisphere is on the left
Spastic paralysis |
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• Non-fluent aphasia
• Difficulty speaking
• Short phrases |
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• Fluent aphasia
• Inability to grasp meaning of words |
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Why is the weakness most pronounced in the face and hand?
What do you remember of the motor homunculus? (left sided stroke) |
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| The face and hand are lateral in the territory of the middle cerebral artery. |
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| What does loss of sensation on strip of right lateral thigh suggest? |
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| Damage to dorsal roots producing a dermatomal loss |
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| What does loss of proprioception and two point discrimination on the right below the injury suggest? |
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| What do we conclude from an intact ankle jerk but absent knee jerk? |
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| The reflex arc at the ankle (S1, 2) is functional but the patellar tendon reflex (L3, 4) is not. |
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| The ventral spinal cord seems to be intact. |
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loss of proprioception on the right below
Dorsal horn at L3, 4: loss of patellar tendon reflex and loss of sensation on dermatomes |
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Later in the ER:
1. Sensation on the right remains the same but pain is lost on the left.
2. Position sense on the left is intact.
3. Knee jerk on the right remains absent, but ankle jerk is now hyperactive.
4. Babinski sign is on the right.
How has the injury progressed? Why is pain lost on the left?
Why is the ankle jerk hyperactive? |
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Definition
Loss of pain means the spinothalamic tract is involved. It carries pain and temperature from the opposite side of the body. Recall that it runs in the ventrolateral cord.
The ankle jerk is now hyperactive (spastic). This is an upper motor neuron sign resulting from the interruption of the corticospinal tract.
These, taken with the original finding, are the presentation of the classic Brown-Sequard syndrome. |
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brown sequard syndrome
Taken together with the original findings, this is a classic presentation of what's called a Brown-Sequard syndrome. And what this shows then is that if the initial damage is right here, the spinal cord will be injured at that level. And there will be a total sensory loss, because of damage to the dorsal roots coming in. And as a consequence of that, there will be areflexia, and likely also if the ventral horn is damaged, that there is no motor component.
And then inferior to the injury, then, we have loss of position sense, because of damage to-- the dorsal columns will have hypereflexia because of damage here to the corticospinal tract, which means it can't have its effect on the reflex activity. And we'll have loss of pain from the contralateral side, because we recall that the pain fibers come in, synapse in the dorsal horn, cross to the other side, and run in the spinothalamic tract. So this complicated set of syndromes-- Brown-Sequard syndrome-- is the result of a spinal cord hemisection. |
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