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  • Localization in neurology

    1. cortex

    56 AF





    1. 56 risk

    cardiovascular cancer

    2. AF cardioembolic stroke

    ischemic stroke warfarin DDx

    intracerebral hemorrhage setting

    3. vascular cause

    etiology localization

    4. global aphasia lesion

    frontotemporal lobe left dominant hemisphere

    80% dominant hemisphere language ability

    frontotemporal lobe Broca's Wernicke's area

  • 5. different

    anatomy motor strip area frontal lobe leg area medial

    parasagittal area supply anterior cerebral artery arm area

    dorsolateral area supply middle cerebral artery vascular cause


    MCA cortex subcortical subcortical area

    internal capsule fiber

    6. focal secondary to GTCs

    lesion cortex lesion arm area

    motor strip area propagate

    7. cortical lesion 1/3 hemisphere

    brain hypoxia

    cortical lobe signs


    2. seizure


    4. aphasia



    7.visual field defect

    basic . Gerstmann syndrome

  • dominant parietal lobe left right confusion, finger agnosia, acalculia,


    2. subcortical lesion

  • 56 underlying disease hypertension 3


    1. hypertension risk cardiovascular risk factor

    stroke MI


    brainstem lesion

    brainstem ipsilateral lesion


    lesion thalamic lesion

    subcortical area right thalamic lesion thalamus

    lesion internal capsule

    lesion subcortical area; internal capsule and thalamic

    lesion right side

    3. vascular cause stroke

    4. cortical involvement

    subcortial area

    1. pure motor weakness contralateral lesion; internal capsule

  • cortical

    lesion leg arm area supply vessel

    ? motor power 1 different

    2. pure sensory loss contralateral lesion; thalamus lesion

    3. dysarthria clumsy hand; internal capsule ; genu

    bulbar involvement corticobulbar tract genu of internal capsule

    lesion motor weakness

    lesion internal capsule

    4. ataxic hemiparesis; pons, corona radiata, internal capsule cerebellar

    signs lesion vertigo ataxia

    5. mixed motor and sensory loss lesion ; subcortial area; internal


    5 lacunar syndrome stroke small vessels

    occlusion long standing hypertension

    2. brainstem

    localization 3 cortical and subcortical lesion

    brainstem lesion

    . brainstem 90% RS

  • CVS . 20

    misconcept brainstem structure

    cranial nucleus, fasicle, cerebellar tract, corticospinal

    tract, spinothalamic tract. RS, CVS lesion

    1 level

    brainstem reticular activating system(RAS), RS, CVS center

    1.cranial nucleus, fasicle involvement; LMN type, ipsilateral lesion

    2. cerebellar signs; ipsilateral lesion

    3. motor weakness; lesion medullar decussation

    contralateral lesion lesion medullar decussation




    . " right pontomedullary lesion CN7

    palsy palsy upper motor neuron lower motor neuron"

    . " uppermotor neuron

    lesion " 90% brainstem cranial nucleus

    fasicle nuclear control muscle lower motor neuron

  • nucleus cranial nerve anterior horn cell control

    level brain stem

    uppermotor neuron anterior

    horn cell cranial nucleus brain stem lower motor

    neuron type lesion fiber

    corticospinal tract motor strip area subcortical internal capsule

    brain stem cross medullar decussation

    spinal cord lesion medullar decussation


    upper motor neuron CN involvement LMN type

    lesion+ lesion+ cerebellar signs lesion

    brain stem lesion !!!

    4. spinal cord lesion

    localization 4 spinal cord lesion

    35 10 5

    spastic tone both legs ,

    motor power grade 0 both legs, DTR 4+ clonus present, BBK dorsiflexion,

  • sensory loss up to T10 level , loose sphincter tone.

    1. characteristic spinal cord lesion 3

    1.1 motor weakness; quadri, paraparesis level

    hemiparesis, monoparesis Brown-Sequad syndrome

    C or T

    1.2 sensory loss; sensory loss dermatome

    extrinsic cord level dermatome intrinsic

    cord lesion Hanging or cape like pattern

    complete cord dermatome level

    1.3 autonomic involvement; bowel bladder involvement, anhidrosis, loss of

    hair, loss of morning erection

    set cord lesion exclude


    2. 35 CNT dz

    sexual active life risk HIV demyelinating

    disease multiple sclerosis .

    requirement resident med diag


    3. 10 post viral

    syndrome transverse myelitis

  • 4. sensory loss up to T10 level , level of

    lesion T10 dermatome MRI level

    whole spine

    5. loose sphincter tone. autonomic


    6.spastic tone both legs , DTR 4+ clonus present, BBK dorsiflexion,

    upper motor neuron weakness

    lesion corticospinal tract involvement

    brain, brain stem, spinal cord brainstem is

    upper motor neuron corticospinal tract

    intrinsic VS extrinsic cord lesion resident


    5. polyneuropathy

    localization 5 nerves lesion; polyneuropathy

    polyneuropathy symmetry , asymmetry

    4,5,6 symmetric lesion

    asymmetric lesion mononeuritis multiplex nerve

  • entrapment resident . Guillain Barre

    syndrome(GBS) focus resident

    symmetry GBS and its variant(MFS, overlaping, AMAN,AMSAN,

    pandysautonomia, pure sensory, oropharyngeal type, Bickerstaff's encephalitis)

    . hiso



    nerve characteristics lower motor neuron lesion

    1. flaccid tone

    2. areflexia ( nerve lesion )

    3. sensory involvement( pure motor involvement

    motor nerve)

    4. muscle atrophy( acute atrophy)

    5. muscle fasiculation

    exclude GBS Myasthenia

    gravis MG neuromuscular junction disease

  • 40 10 5

    dysarthria, nasal voice,

    motor weakness grade 3 all, decrease sensation at both palms and feet, facial

    diplegia. DTR 0 all

    1. 40 active sexual life risk HIV asso. GBS

    Hx of CNT dz

    2. infectious diarrhea

    degree of dehydration

    GBS most common organism asso

    campylobacter jejuni diarrhea metabolic

    disturbances ; hypokalemia, hyponatremia

    ..... cranial nerve

  • 3. decrease sensation at both palms and feet sensory

    involvement sensory dermatome spinal cord lesion

    nerve lesion

    4. motor weakness grade 3 all

    generalized muscle weakness with gradually progressive course

    vascular cause vascular cause sudden

    onset fluctuation

    neuromuscular disease (MG)

    5.dysarthria, nasal voice bulbar

    involvement(lower CN )

    6. facial diplegia

    facial nerve bilateral lesion lower motor neuron type

    7. DTR 0 areflexia nerve lesion

    8. respiratory involvement

    typical GBS sensory and motor involvement

    key nerve areflexia, sensory impaired, motor

    weakness without fluctuation GBS investigation

    LP cell protein albuminocytologic dissociation

    nerve conduction


  • IVIG,

    plasma exchange

    6. neuromuscular junction

    localization 6 neuromuscular junction

    Myasthenia gravis Lambert

    Eaton myasthnia gravis characteristic

    1. pure motor proximal weakness

    2. normoreflexia

    3. fluctuation/fatiquability



    facial diplegia, partial ptosis both eyes, proximal muscle weakness grade3,

    DTR 2+, limited EOM, sensory; intact, dyspnea,

  • .....

    1. 38 asso CNT dz, HIV

    2. facial diplegia facial palsy lower motor neuron

    3. limited EOm, ptosis(CN3) Cranial nerve

    involvement 3,4,6

    4. fatiquability

    NMJ lesion

    5. proximal muscle weakness grade3,

    generalized proximal weakness

    6. bulbar involvement

    7. dyspnea respiratory involvement MG

    diaphragmatic muscle weakness

    8. DTR 2+ normoreflexia

    9. sensory intact pure motor weakness

    neuromuscular junction clue

    NMJ lesion myasthenia gravis

    multiple cranial nerves involvement, RS involvement

    brain stem level cranial nerve lesion

    brain stem cerebellar


  • 7. muscle

    localization 7 basic neurology

    muscle core feature muscle disorder

    1. muscle pain exclude

    2. pure motor weakness

    3. normoreflexia severe muscle destruction


    4. proximal muscle weakness proximal part

    muscle mass select distal part

    . common

    proximal muscle

    5. creatinine phosphokinase early

    very chronic CPK

    6. EMG; myopathic pattern resident neuro

    newbie 5


  • 63 HCTZ,

    simvastatin, fenofibrate, glipizide

    1 proximal muscle

    weakness grade 2, DTR 2+ , sensory; intact, CN; intact, generalized muscle

    tenderness, CPK 5,678 mg/dl

    1. 63

    cardiovascular disease

    2. HCTZ, simvastatin, fenofibrate, glipizide ;

    side effect drug interaction


    hypokalemia, hyponatremia proximal part


    fenofibrate group simvastatin drug interaction




    proximal muscle weakness grade 2 generalized muscle

    tenderness generalized proximal muscle weakness with muscle

    pain proximal pain muscle disorder

  • 4.; fluctuation or fatique NMJ

    5. sensory; intact ; pure motor weakness muscle

    6.CN; intact; cranial nerve involvement

    nerve or NMJ

    7. 1 ; etiology progressive

    ongoing destruction

    8.DTR 2+ ; normoreflexia muscle/NMJ


    9. CPK 5,678 mg/dl active muscle injury lesion


    rhabdomyolysis drugs interaction

    inflammatory myopathy ; polymyositis DDx

    3-5 CPK

    resident long case short case

    dermatomyositis polymyositis inclusion body myositis

    basic localization in neurology


    neuro point basic

  • resident neuro deep


    reference 5555



    . resident .

    goodnight la

  • How to approach acute ischemic stroke version;

    Happy New Year !! .

    approach stroke

    . "

    " .

    approach approach

    TOAST classification google

    trial stroke

    mechanism . ischemic stroke

    localization ( )

  • approach etiology

    1. Infection

    2. Trauma

    3. Tumors/ neoplasm

    4. Metabolic

    5. Toxin/ drugs

    6. Vascular

    7. Demyelinating

    8. Neurodegenerative

    9. Congenital

    10. Inflammatory

    1. etiology sudden focal neurodeficits

    vascular cause key sudden

    2. ischemia or hemorrhage ischemia brain

    edema develop increased intracranial pressure

    symptoms 48-72 . stroke large area

    infarcts observe neurosigns NPO complication brain

    herniation, hemorrhagic transformation tube aspirate

    hemorrhage space occupying lesion expand

    increased intracranial pressure small

    hemorrhage ischemic stroke

  • 3. vessel territory

    - anterior circulation : internal carotid a. > MCA , ACA

    - posterior circulation: vertebrobasilar system: PCA

    vessel basic anatomy motor strip area

    parasagittal area dorsolateral supply ACA supply MCA

    1 motor grading MCA get

    subcortical MCA

    lenticulostriate a. lacunar infarcts proximal MCA

    PCA visula field defect homonymous hemianopia with macular

    sparing( macular supply MCA ) vertebrobasilar

    brain stem lesion

    4. resident venous infarcts arterial infarcts

    .... iphone

    5. TOAST classification

    TOAST classification

    1. cardioembolism

    2. Large vessel atherosclerosis subtype arterial to arterial

    emboli fixed intracranial stenosis

    3. lacunar infarction or small vessel occlusion

    4. determined cause

    5. undetermined cause

  • 1. cardioembolism source emboli heart proximal source emboli

    clot emboli anterior

    posterior circulation emboli

    multiple site brain

    infarcts involve anterior territory posterior



    high risk factor mechanical valve, AF, SSS, MS, LA clot

    2. Large vessels atherosclerosis plaque

    atherosclerosis risk factor DM, HT, DLP, obesity, old age , smoking

    metabolic syndrome subtype 2

    2.1 arterial to arterial emboli vessel carotid artery

    internal carotid

    ACA, MCA

    circle of Willis carotid system anterior circulation

    structure supply vertebrobasillar system

    occipital lobe ( macular supply MCA), brain stem

    anterior posterior circulation anterior

    communication artery posterior communication artery circle of

    Willis MCA, ACA, PCA

  • emboli

    Indiana Jones





    embolism heart artery wedge


    a. to a. emboli carotid system

    left internal carotid stenosis flow

    turbulent flow plaque plaque rupture

    vessel brain

    emboli P. com A. com

    posterior cir. ?


    " "

    repeated stroke

    carotid bruit

    carotid stenosis

    transient monocular

  • blindness or amarousis fugax

    *** characteristics a. to a. emboli

    1. metabolic syndrome

    2. transient monocular blindness or amarousis fugax

    3. carotid bruit

    4. repeated stroke; same side ACA or MCA

    posterior circulation carotid bruit

    2.2 fixed intracranial stenosis; fixed lesion vessel brain

    MCA left

    brain neurodef

    diarrhea with

    shock ( ) BP drop

    vessel constrict BP cerebral blood flow

    extern ( extern on

    duty ) low knowledge treat shock staff


    resuscitate volume TIA

    !!! vessel


  • **** characteristics fixed intracranial stenosis

    1. associated with hemodynamic change

    2. repeated stroke; same side and same artery. STEREOTYPE!!

    3. metabolic syndrome

    3. Lacunar infarction or small vessel occlusion

    longstanding hypertension evidence long standing

    hypertension LVH common basal ganglia, thalamus , pons,

    cerebellum vessel cortex

    lacunar syndrome

    *** characteristics lacunar infarction or small vessel occlusion

    1. involve cortex

    2. area CT

    3. lacunar syndrome

    4. asso. long stnading hypertension

    4. determined cause rare cause arterial dissection, vasculitis,

    hypercoagulability stroke in the young

    5. undetermined cause work up

    cryptogenic, mechanism work up

  • How to approach Headache step by step

    line approach

    100% approach


    1. identify primary secondary headache


    special condition

    workup new onset headache in immunocompromised host HIV,

    awakening pain

    - primary headache overactivity of

    pain-sensitive structures underlying disease

    common Migraine, tension type headache, cluster headache and others

    trigeminal autonomic cephalgia (SUNCT,cluster, paroxysmal hemicrania)

    Chronic daily headaches, hypnic

    headache common neurologist

    - secondary headache disease

    pain sensitive structure encephalitis, aneurysm, tumor

    primary brain secondary brain

  • secondary headache infection, trauma, tumor ,metabolic, toxin

    ,drugs, vascular, demyelination

    2. primary pattern


    headache society classification !!!! criteria

    cluster, tension, migraine classification link


    secondary headache


    focal diffuse

    focal localization structure

    lesion temporal area meninges, bone, sinus, vessel,

    brain parenchyma localization

    step etiology

    etiology key .......


    2.1 infection exclude CNS infection

    secondary headache

    cns infection

    cns infection stiffness of

    neck , signs of increased intracranial pressure (. signs

  • symptoms of increased intracranial pressure !!!)

    approach CNS infection


    2.2 trauma head injury exclude EDH, SDH, ICH

    increased intracranial pressure focal neurological

    deficits epidural hematoma lucid interval

    day3-5 focal neurodef

    increased intracranial pressure

    subdural hematoma bleeding tendency



    secondary headache ??


    pep !!!

    2.3 tumor primary brain tumor common

    Astrocytomas, Oligodendrogliomas, Ependymomas , Meningiomas,

    Craniopharyngiomas neurosurgery

    metastatic CA common

  • Lung ,Breast ,Genitourinary tract cancer, Melanoma,Head and neck cancer

    Gastrointestinal cancers, Lymphoma,

    CA origin primary source

    CA breast abnormal discharge, breast mass CA lung smoking, chronic

    cough , wt loss, lung mass

    2.4 metabolic cause ;



    hypoglycemia http://ihs-


    2.5 toxin, drugs; common nitric oxide

    , carbonmonoxide, alcohol, drugs abuse, medication overuse headache

    (), tropine, digitalis, disulfiram, hydralazine, imipramine,

    nicotine, nifedipine, nimodipine



    2.6 vascular cause; stroke ischemia hemorrhage AVM

    arterial hypertension dialysis hypotension

    ... subarachnoid hemorrhage (SAH)


    - worst headache

    - sudden headache vascular cause sudden

  • - meningism; stiffness of neck, Kernig positive

    subarachnoid hemorrhage irritate meninges

    -signs and symptoms of increased intracranial pressure;

    papilledema, enlarged blind spot

    -subhyaloid hemorrhage

    - three tube/glass test positive LP CSF

    traumatic tap

    - CSF xanthochrome positive

    2.7 demyelination focal neurodef

    multiple sclerosis

    Lhermitte's sign

    approach etiology infection , trauma, tumor etc...

    approach long case

    infection trauma bla bla

    step step how

    to approach headache

    1. identify ; primary or secondary headache characteristic of

    secondary headache

    2. if it is primary; pattern primary headache

    migraine, tension , cluster, other trigeminal

  • autonomic cephalgia

    3. if it is secondary ; focal or diffuse focal localization

    pain sensitive structure meningeal

    irritation signs eyeground ********

    sinus diffuse

    localization non specifics

    4. approach etiology




    review paper

    standard textbook


    admit point goodnight

  • Vertigo

    vertigo neuro ENT approach vertigo

    true vertigo

    dizziness chief complaint

    vertigo true

    vertigo component retropulsion, spinning sensation true

    vertigo vertigo sensory ataxia

    1. identify true vertigo dizziness ataxia

    2. true vertigo peripheral central vertigo

    anatomy peripheral vertigo ENT


    central vertigo cerebellar tracts and its pathway cerebellum

    tract brain stem central cerebellum

    and brainstem

    IT (


  • 3. peripheral vertigo central vertigo

    3.1 nystagmus nystagmus

    quick and slow phase

    ( horizontal) (vertical)

    (rotatory) (multidirectional)

    nystagmus google lets say


    eye deviate nystagmus


    nystagmus nystagmus

    peripheral vertigo nystagmus horizontal rotatory

    vertical nystagmus central vertigo nystagmus

    specific central vertigo vertical

    nystagmus*** multidirectional nystagmus

    vertigo nystagmus exclude

    3.2 peripheral central

    3.3 postural related vertigo

    peripheral central central

  • orthostatic hypotension


    3.4 hearing problem

    vertigo peripheral central

    3.5 neurologic deficits central vertigo

    cerebellar signs


    scanning speech



    overshooting reflex

    neuro .


    3.6 Dik- Hallpike maneuver



    -peripheral vertigo ( BPPV benign paraxysmal

    positional vertigo) nystagmus

  • latency 5-20 seconds central

    - maneuver peripheral vertigo fatiquability/habituation

    nystagmus central

    3.7 duration peripheral central

  • How to approach transient loss of consciousness (TLOC)

    Hello 555

    AEC extern intern

    . .

    elective seniority


    555 ( )

    transient loss of consciousness syncope vs non syncope


    1. Neurally-mediated reflex dysautonomia rare

    autonomic involvement reflex

    2. Orthostatic hypotension .


    3. Cardiac arrhythmia VT, AF with RVR, sick sinus

    syndrome , SVT , heart block syncope

    4. Structural cardiac or pulmonary disease O2

    hypoxia COPD exacerbation , TOF common


    5.cerebrovascular disease minor stroke : lacunar infarction or TIA

  • non syncope

    1. Disorders resembling syncope without any impairment of consciousness

    . Pseudoseizure , psychogenic

    witness hypoxia bizarre pattern

    stereotype secondary gain


    ??? !!

    2. Epileptic syndrome generalized seizure complex partial


    common disease transient loss of

    consciousness syncope seizure TIA

    TIA focal neurodef

    impaired conscious lesion brain bilateral lesion

    seizure vs syncope

    Step 1

    Pre symptomatic phase



    SNSD one direction

  • ( ) syncope


    ( senario 555 )


    Seizure aura lobe

    Occipital lobe

    Temporal lobe

    (de ja vu)

    Parietal lobe paresthesia

    Frontal lobe orbitofrontal

    Step 2

    Symptomatic phase


  • 1. Duration

    absence seizure

    complex partial seizure

    versive seizure lesion frontal lobe extremely

    away from lesion deviate lesion

    Syncope seconds

    2. Abnormal movement syncope loss of tone or brief muscle

    contraction seizure

    - stereotype pattern

    -rhythmic movement

    - jerky component seizure

    3. Eye deviation syncope eye deviate nystagmus


    4. Self injury head injury seizure

    5. Incontinence loose sphincter seizure

    6. Frothing , drooling seizure

    7. Hypoxic feature cyanosis seizure syncope

  • Step 3

    Post symptomatic phase

    hypoxia seizure 3-4

    brain hypoxia syncope hypoxia

    1. Post ictal confusion

    2. Post ictal aphasia language deficit primary lesion

    dominant hemisphere

    3. Todd's paralysis primary lesion

    frontal lobe

    step localization

    1. Aura lobe

    2. Abnormal movement focal secondary to GTCs

    primary lesion

    3. Eye deviation imply frontal eye field *** remember seizure: look away from

    lesion (irritative lesion) stroke: look into the lesion( destructive lesion)

    pathway basic eye movement

    4. Post ictal aphasia; dominant hemisphere

    5. Todd's paralysis

  • neuro good night good morning