Focal neurologic deficits: Difference between revisions

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*'''Frontal Lobe'''  
*'''Frontal Lobe'''  
**Damage to the frontal lobe can lead to the following signs:
**Damage to the frontal lobe can lead to the following signs:
***Sensorimotor deficit of the contralateral lower extremity
***[[Numbness|Sensory]]/[[weakness|motor]] deficit of the contralateral lower extremity
***Language disturbances
***Language disturbances
***Profound behavioral changes
***Profound behavioral changes
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**Damage to the temporal lobe can lead to the following signs:
**Damage to the temporal lobe can lead to the following signs:
***Upper homonymous quadrantanopsia
***Upper homonymous quadrantanopsia
***Cortical deafness
***Cortical [[hearing loss|deafness]]
***Wernicke’s aphasia (word deafness, auditory verbal agnosia)
***Wernicke’s aphasia (word deafness, auditory verbal agnosia)
***Hallucinations
***[[Hallucinations]]
***Complex partial seizures
***Complex partial [[seizures]]
***Kluver-Bucy syndrome (Bilateral disease. Compulsion to attend all visual stimuli, hyperorality, hypersexuality, blunted emotional reactivity)
***Kluver-Bucy syndrome (Bilateral disease. Compulsion to attend all visual stimuli, hyperorality, hypersexuality, blunted emotional reactivity)


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**Damage to the temporal lobe can lead to the following signs:
**Damage to the temporal lobe can lead to the following signs:
***Contralateral homonymous hemianopia
***Contralateral homonymous hemianopia
***Cortical blindness (bilateral lesions)
***Cortical [[vision loss|blindness]] (bilateral lesions)
***Visual hallucinations
***Visual [[hallucinations]]
***Prosopagnosia
***Prosopagnosia
***Alexia without agraphia
***Alexia without agraphia
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***Cerebellar
***Cerebellar
***Damage to the cerebellum can lead to the following signs:
***Damage to the cerebellum can lead to the following signs:
***Ataxia of voluntary movements
***[[Ataxia]] of voluntary movements
***Intention tremor
***Intention [[tremor]]
***Dysarthria  
***[[Dysarthria]]
***Postural abnormalities
***Postural abnormalities
***Hypotonia
***Hypotonia
***Incoordination
***Incoordination
***Nystagmus, gaze paresis
***[[Nystagmus]], gaze paresis


*'''Brainstem'''
*'''Brainstem'''
**Damage to the brainstem can lead to the following signs:
**Damage to the brainstem can lead to the following signs:
***Crossed deficits – motor or sensory involvement of the face on one side of the body and the arm and leg on the other side  
***Crossed deficits – [[weakness|motor]] or [[numbness|sensory]] involvement of the face on one side of the body and the arm and leg on the other side  
***[[Cranial nerve]] palsies (see below)
***[[Cranial nerve]] palsies (see below)


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{{Spinal cord syndromes DDX}}
{{Spinal cord syndromes DDX}}


===Peripheral Nerves===
{{Peripheral nerve syndromes}}
*See [[Peripheral nerve syndromes]]
 
**'''Upper extremity'''
==Evaluation==
***'''Ulnar'''
[[File:Spinal cord tracts.svg|thumb|Spinal cord tracts]]
****Cause of Injury: [[Elbow diagnoses | Elbow]] injury.
[[File:Dermatomes and cutaneous nerves - anterior.png|thumb|Dermatomes and cutaneous nerves - anterior]]
****Sensory changes in the 5th and medial half of 4th digits, weak wrist flexors,  “claw hand”
[[File:Dermatomes and cutaneous nerves - posterior.png|thumb|Dermatomes and cutaneous nerves - posterior]]
***'''Radial'''
[[File:Cutaneous innervation of the upper limb.svg|thumb|Cutaneous innervation of the upper limb]]
****Cause of Injury: Distal humeral shaft fracture, anterior shoulder dislocation, supra-condylar fracture, [[Radial neuropathy at the spiral groove]], [[Posterior interosseous neuropathy]]
[[File:Lower limb peripheral innervation.png|thumb|Lower limb peripheral innervation]]
****“Wrist drop,” weakness of finger extensors. +/- sensory loss over the dorsum of the hand, weak thumb adduction
*Rule out acute causes of focal neurologic signs: [[Stroke (main)|stroke]], [[hemorrhagic stroke]], [[intracranial hemorrhage]], [[meningitis]]
***'''Median, distal'''
****Cause of Injury: Wrist dislocation, laceration, [[Median Mononeuropathy (Carpal Tunnel Syndrome)|Carpal Tunnel Syndrome]]
****Weak flexion of radial half of digits and thumb, loss of abduction and opposition of thumb. Ape hand deformity, benediction sign. Loss of sensation of lateral three and one-half digits and nail beds
***'''Median, proximal'''
****Cause of Injury:  Supracondylar humeral fracture, [[Pronator teres syndrome]], [[Anterior interosseous neuropathy]], tight cast
****See Median, distal above, loss of forearm pronation, loss of radial half digits and thumb flexion
***'''Musculocutaneous'''
****Cause of Injury: [[Anterior shoulder dislocation]], entrapment due to hypertrophy
****Elbow flexion and supination weakness, radial forearm sensory deficits
***'''Axillary'''
****Cause of Injury: [[Anterior shoulder dislocation]], [[inferior shoulder dislocation]], [[proximal humerus fracture]]
****Weak arm abduction (from 15 to 90 degrees), weak shoulder flexion, extension and rotation of shoulder, loss of sensation of upper lateral arm
**'''Lower extremity'''
***'''Femoral'''
****Cause of Injury: Pubic rami fracture, [[pelvic fractures]]
****Weak knee extension, anterior knee sensory deficits
***'''Obturator'''
****Cause of Injury:  Obturator ring fracture, [[obturator nerve entrapment]]
****Weak hip adduction, medial thigh sensory deficit
***'''Posterior tibial'''
****Cause of Injury: [[Knee dislocation]]
****Weak toe flexion, plantar foot sensory deficit
***'''Superficial peroneal'''
****Cause of Injury:  Fibular neck fracture, [[knee dislocation]]
****Weak ankle eversion, lateral dorsal foot sensory deficits
***'''Deep peroneal'''
****Cause of Injury: Fibular neck fracture, [[compartment syndrome]]
****Sensory deficit at dorsal 1st web space, weak ankle and toe dorsiflexion
***'''Sciatic'''
****Cause of Injury:  Posterior [[hip dislocation]]  
****Lower leg weakness, foot drop, leg sensory deficits
***'''Superior gluteal'''
****Cause of Injury: [[Acetabular pelvic fracture]]
****Trendelenburg’s gait, Trendelenburg’s sign
***'''Inferior gluteal'''
****Cause of Injury: [[Acetabular pelvic fracture]], s/p hip replacement
****Abnormal gait, gluteus maximus weakness resulting in gluteus maximus lurch


==Management==
==Management==
*Rule out acute causes of focal neurologic signs: [[Stroke (main)|stroke]], [[hemorrhagic stroke]], [[intracranial hemorrhage]], [[meningitis]]
*Treat underlying condition
 
==Disposition==
*Depending on cause


==See Also==
==See Also==
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[[Category:Neurology]]
[[Category:Neurology]]
[[Category:Symptoms]]

Latest revision as of 02:32, 3 October 2019

Background

  • Also known as focal neurologic signs
  • Refer to objective abnormalities of a specific region of the body detected on the neurologic examination

Focal Neurologic Signs Organized by Region

Brain

  • Frontal Lobe
    • Damage to the frontal lobe can lead to the following signs:
      • Sensory/motor deficit of the contralateral lower extremity
      • Language disturbances
      • Profound behavioral changes
      • Indifference, apathy
      • Disinhibition (labile and irritable)
      • Impaired judgement, decreased social graces
      • Akinesia (lack of spontaneous movements)
      • Impairment of memory
  • Parietal Lobe
    • Damage to the parietal lobe can lead to the following signs:
      • Agnosia
      • Anosognosia – Unawareness of a deficit
      • Unilateral spatial neglect (hemineglect)
      • Dyslexia, dysgraphia, dyscalculia
      • Impairment of tactile sensation
  • Temporal Lobe
    • Damage to the temporal lobe can lead to the following signs:
      • Upper homonymous quadrantanopsia
      • Cortical deafness
      • Wernicke’s aphasia (word deafness, auditory verbal agnosia)
      • Hallucinations
      • Complex partial seizures
      • Kluver-Bucy syndrome (Bilateral disease. Compulsion to attend all visual stimuli, hyperorality, hypersexuality, blunted emotional reactivity)
  • Occipital Lobe
    • Damage to the temporal lobe can lead to the following signs:
      • Contralateral homonymous hemianopia
      • Cortical blindness (bilateral lesions)
      • Visual hallucinations
      • Prosopagnosia
      • Alexia without agraphia
      • Loss of topographic memory and visual orientation
  • Limbic System
    • Damage to the limbic system can lead to the following signs:
      • Retrograde amnesia (long-term memory loss)
      • Anterograde amnesia (inability to form new memories)
      • Apathy
      • Loss of olfactory functions
      • Cerebellar
      • Damage to the cerebellum can lead to the following signs:
      • Ataxia of voluntary movements
      • Intention tremor
      • Dysarthria
      • Postural abnormalities
      • Hypotonia
      • Incoordination
      • Nystagmus, gaze paresis
  • Brainstem
    • Damage to the brainstem can lead to the following signs:
      • Crossed deficits – motor or sensory involvement of the face on one side of the body and the arm and leg on the other side
      • Cranial nerve palsies (see below)

Cranial nerves

Tongue deviation from unilateral hypoglossal nerve injury (CN XII).
  • CN I (Olfactory)
    • Anosmia + perceived change in taste of food
    • Deficit caused by shearing of the nerve ending passing through the cribriform plate usually by closed head trauma
  • CN II (Optic)
    • Monocular and binocular visual field defects
    • Monocular: Giant cell arteritis, anterior ischemic optic neuropathy, glaucoma, optic neuritis, trauma, increased ICP, emboli/arteritis/stenosis leading to retinal ischemia, ophthalmic artery or vein occlusion
    • Binocular - Hemianopsia due to bilateral optic nerve disease.
  • CN III (Oculomotor) –See Third Nerve Palsy
  • CN IV (Trochlear)- See Trochlear nerve palsy
  • CN VI (Abducens)- See Abducens nerve palsy
  • Internuclear ophthalmoplegia - Lesion in medial longitudinal fasciculus, cannot adduct in horizontal lateral gaze, but normal convergence. Caused by multiple sclerosis or stroke
  • CN V (Trigeminal)
    • Jaw weakness and spasm. Jaw closure may be weak and/or asymmetric. +/- Trismus if irritative lesion to motor root.
    • See trigeminal neuralgia
  • CN VII (Facial)
  • CN VIII (Vestibular)
  • CN IX (Glossopharyngeal)
  • CN X (Vagus)
    • Dysfunction may be characterized by: hoarseness (unilateral vocal cord paralysis), dyspnea and inspiratory stridor (bilateral). Dysarthria, dysphagia.
  • CN XI (Accessory)
    • Dysfunction may be characterized by: Sternocleidomastoid and trapezius weakness leads to weak head rotation and shoulder shrug
  • CN XII (Hypoglossal)
    • Dysfunction may be characterized by: tongue deviation and wasting

Spinal Cord Syndromes

Peripheral nerve syndromes

  • Upper extremity
    • Ulnar
      • Cause of Injury: Elbow injury.
      • Sensory changes in the 5th and medial half of 4th digits, weak wrist flexors, “claw hand”
    • Radial
    • Median, distal
      • Cause of Injury: Wrist dislocation, laceration, Carpal Tunnel Syndrome
      • Weak flexion of radial half of digits and thumb, loss of abduction and opposition of thumb. Ape hand deformity, benediction sign. Loss of sensation of lateral three and one-half digits and nail beds
    • Median, proximal
    • Musculocutaneous
      • Cause of Injury: Anterior shoulder dislocation, entrapment due to hypertrophy
      • Elbow flexion and supination weakness, radial forearm sensory deficits
    • Axillary
    • Suprascapular
      • Cause of Injury: Paralabral cyst, bone/soft tissue tumor, Scapular fracture, traction injury, Parsonage-Turner syndrome
      • Weak arm abduction to 90 degrees, weak shoulder flexion to 30 degrees, weak internal rotation
  • Lower extremity
    • Femoral
      • Cause of Injury: Pubic rami fracture, pelvic fractures
      • Weak knee extension, anterior knee sensory deficits
    • Obturator
    • Posterior tibial
      • Cause of Injury: Knee dislocation
      • Weak toe flexion, plantar foot sensory deficit
    • Superficial peroneal
      • Cause of Injury: Fibular neck fracture, knee dislocation
      • Weak ankle eversion, lateral dorsal foot sensory deficits
    • Deep peroneal
      • Cause of Injury: Fibular neck fracture, compartment syndrome
      • Sensory deficit at dorsal 1st web space, weak ankle and toe dorsiflexion
    • Sciatic
      • Cause of Injury: Posterior hip dislocation
      • Lower leg weakness, foot drop, leg sensory deficits
    • Superior gluteal
    • Inferior gluteal
      • Cause of Injury: Acetabular pelvic fracture, s/p hip replacement
      • Abnormal gait, gluteus maximus weakness resulting in gluteus maximus lurch

Evaluation

Spinal cord tracts
Dermatomes and cutaneous nerves - anterior
Dermatomes and cutaneous nerves - posterior
Cutaneous innervation of the upper limb
Lower limb peripheral innervation

Management

  • Treat underlying condition

Disposition

  • Depending on cause

See Also

References

  1. LeBlond RF, Brown DD, Suneja M, Szot JF. LeBlond R.F., Brown D.D., Suneja M, Szot J.F. LeBlond, Richard F., et al. DeGowin’s Diagnostic Examination, 10e. New York, NY: McGraw-Hill; 2015. http://accessmedicine.mhmedical.com.foyer.swmed.edu/content.aspx?bookid=1192&Sectionid=68670445. Accessed September 11, 2015.
  2. Waxman SG. Clinical Neuroanatomy, 27e. New York, NY: McGraw-Hill; 2013. http://accessmedicine.mhmedical.com.foyer.swmed.edu/content.aspx?bookid=673&Sectionid=45395961. Accessed September 07, 2015.
  3. Ropper AH, Samuels MA, Klein JP. Adams & Victor's Principles of Neurology, 10e. New York, NY: McGraw-Hill; 2014. http://accessmedicine.mhmedical.com.foyer.swmed.edu/content.aspx?bookid=690&Sectionid=50910870. Accessed September 07, 2015.
  4. Aminoff MJ, Greenberg DA, Simon RP. Disorders of Equilibrium. In: Aminoff MJ, Greenberg DA, Simon RP. eds. Clinical Neurology, 9e. New York, NY: McGraw-Hill; 2015. http://accessmedicine.mhmedical.com.foyer.swmed.edu/content.aspx?bookid=1194&Sectionid=68656660. Accessed September 08, 2015.
  5. Stone C, Humphries RL. eds. CURRENT Diagnosis & Treatment Emergency Medicine, 7e. New York, NY: McGraw-Hill; 2011. http://accessmedicine.mhmedical.com.foyer.swmed.edu/content.aspx?bookid=385&Sectionid=40357242. Accessed September 15, 2015.