C8 L3 L4 L5 S1

Diaphragm

Rhomboids, supraspinatus, infraspinatus, deltoid Biceps brachii, brachioradialis

Triceps brachii, extensor carpi radialis, pectoralis major, flexor carpi radialis, pronator teres

Abductor pollicis brevis, abductor digiti quinti, flexor carpi ulnaris, flexor pollicis brevis Quadriceps femoris, iliopsoas; adductor longus, brevis et magnus Quadriceps femoris (vastus medialis m.)

Extensor hallucis longus, tibialis anterior, tibialis posterior, gluteus medius Gastrocnemius, gluteus maximus

Tables 3 Types of tremor (p. 62)

Type

Features

Physiological tremor (PT)

Normal. Discrete, usually asymptomatic tremor of unclear significance. Isometric tremor may occur, e. g., when holding a heavy object.

Exaggerated PT, toxic or drug-induced tremor

Amplitude > PT, frequency = PT. Absent at rest. Mainly PosT.1 Stress (anxiety, fatigue, excitement, cold). Metabolic disturbances (hyperthyroidism, hypoglycemia, pheochromocytoma). Drugs/toxins (alcohol or drug withdrawal; mercury, manganese, lithium, valproic acid, cyclosporine A, amiodarone, flunarizine, cinnarizine, tricyclic antidepressants, neuroleptics o tardive tremor)

Essential tremor (ET)

Classical ET: PosT > KT2. Approx. 60% autosomal dominant, rest sporadic. Hands > head > voice >trunk. Often improved by alcohol. Orthostatic tremor: Occurs only when standing o unsteadiness, hard to stand still. Task-specific tremor

Parkinsonian tremor

RT3 See p. 206. Postural and kinetic tremor may also be present.

Cerebellar tremor

IT4 reflecting cerebellar dysfunction. Postural tremor and head/trunk tremor may be seen when the patient is standing (alcohol intoxication).

Holmes tremor (rubral, mid-brain tremor, myorhythmia)

RT + PosT + IT, mainly proximal, disabling. Associated with lesions of nigro-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 stem infarct) or essential; clicking noise in ear

Psychogenic tremor

Migrates from one part of the body to another. Accompanied by muscle contraction (co-contraction)

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.

Table4 Midbrain syndromes (p. 71)

Anterior Midbrain Lesions (Peduncle, Weber Syndrome)

Cause. Infarct. Less commonly caused by hemorrhage, tumor (germinoma, teratoma, pineocytoma, pineoblas-toma, astrocytoma, tentorial edge meningioma, lymphoma), or multiple sclerosis.

Structure Affected

Symptoms and Signs

Intramesencephalic fibers of oculomotor n.

Ipsilateral oculomotor paralysis + parasympathetic dysfunction (pupil dilated and unreactive to light)

Pyramidal tract

Contralateral central paralysis + face (o supranuclear facial palsy) + spastic-ity. Dysarthria (supranuclear hypoglossal palsy)

Substantia nigra

Rigidity (rare)

Medial Midbrain Lesions (Tegmentum, Benedikt Syndrome) Cause. Same as in anterior lesions.

Structure Affected

Symptoms and Signs

Intramesencephalic fibers of oculomotor n.

Ipsilateral oculomotor paralysis + parasympathetic dysfunction (see above )

Medial lemniscus

Contralateral impairment of touch, position, and vibration sense

Red nucleus

Contralateral tremor (myorhythmia o red nucleus syndrome, Holmes tremor)

Substantia nigra

Rigidity (variable)

Superior cerebellar peduncle

Contralateral ataxia (o Claude syndrome)

Dorsal Midbrain Lesions (Tectum

, Parinaud Syndrome)

Cause. Tumor of third ventricle, infarct, arteriovenous malformation, multiple sclerosis, large aneurysm ol posterior fossa, trauma, shunt malfunction, metabolic diseases (Wilson disease, Niemann-Pick disease), infectious diseases (Whipple disease, AIDS)

Structure Affected

Symptoms and Signs

Oculomotor nuclei

Pathological lid retraction (Collier's sign) due to overactivity of levator palpebrae superioris m. Over the course of the disease, accommodation is impaired; the pupils become moderately dilated and unreactive to light, but they do constrict on convergence (light-near dissociation)

Medial longitudinal fasciculus

Supranuclear palsy of upward conjugate gaze (vertical gaze palsy o the eyes move upward on passive vertical deflection of the head, but not voluntarily). Convergence nystagmus with retraction of the eyeball on upward gaze (retraction-convergence nystagmus)

Trochlear nucleus

Trochlear nerve palsy

Aqueduct (compressed)

Hydrocephalus (headache, papilledema)

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

Unilateral or bilateral vertical gaze palsy; impaired convergence; retraction nystagmus. Sudden oscillations (sensation of movement of surroundings when walking or when moving head). Collier's sign. Strabismus with di-plopia. Pupils may be constricted and responsive or dilated and unresponsive to light.

Thalamus, parts of temporal and occipital lobes

Visual field defects (homonymous hemianopsia, cortical blindness). Variable features: Somnolence, peduncular hallucinations (dreamlike scenic hallucinations), memory impairment, disorientation, psychomotor hyperactivity

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

Intrapontine fibers of trigemi-nal nerve

Middle cerebellar peduncle

Contralateral central paralysis sparing the face

Ipsilateral facial hypesthesia, peripheral-type weakness of muscles of mastication

Ipsilateral ataxia

■ Lacunar Syndromes1

Structures Affected

Symptoms and Signs

Pyramidal tract

Contralateral central paralysis, sometimes more pronounced in legs, with or without facial involvement

Middle cerebellar peduncle

Ipsilateral ataxia, which may be accompanied by dysarthria and dysphagia, depending on the site of the lesion (dysarthria—clumsy hand syndrome)

"'Similar syndromes can also occur in patients with supratentorial lacunas (internal capsule, thalamocortical pathways).

m Locked-in Syndrome (p. 120)

Structures Affected

Symptoms and Signs

Ventral pons (corticobulbar and corticospinal tracts) bilaterally, abducens nucleus, pontine paramedian reticular formation, fibers of trigeminal nerve

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.

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)

Table 5 Pontine syndromes (continued) Dorsal Pontine Lesions (Pontine Tegmentum) Cause. Same as in lesions of ventral pons.

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 formation (PPRF, "pontine gaze center")

Ipsilateral loss of conjugate movement (loss of optokinetic and vestibular nystagmus o PPRF lesion with intact vestibulo-ocular reflex (VOR, p. 84))

Pyramidal tract

Contralateral central paralysis sparing the face

m 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 (o Millard-Gubler syndrome)

Fibers of abducens nerve

Ipsilateral abducens paralysis (o Foville syndrome, eyes drift "away from the lesion"; loss of VOR)

Central sympathetic pathway

Ipsilateral Horner syndrome

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