Pprf

Loss of ipsilateral conjugate movement

Medial and lateral lemniscus

Contralateral impairment of touch, position, and vibration sense

Lateral spinothalamic tract

Contralateral impairment of pain and temperature sensation

Table 6 Medullary syndromes (p. 73) Medial Medullary Lesions

Cause. Occlusion of the anterior spinal artery or vertebral artery.

Table 6 Medullary syndromes (p. 73) Medial Medullary Lesions

Cause. Occlusion of the anterior spinal artery or vertebral artery.

Structures Affected

Symptoms and Signs

Hypoglossal n. nucleus/fibers

Ipsilateral peripheral (nuclear) hypoglossal paralysis

Pyramidal tract

Contralateral central paralysis sparing the face (flaccid, in isolated pyramidal tract lesions)

Medial lemniscus

Contralateral impairment of touch, position, and vibration sense (pain and temperature sensation intact)

Medial longitudinal fasciculus

Upbeat nystagmus

Lateral Medullary Lesions (Dorsolateral Medullary Syndrome, Wallenberg Syndrome)

Cause. Occlusion of posterior inferior cerebellar artery (PICA) or vertebral artery. Less common causes: tumor, metastases, hemorrhage due to vascular malformations, multiple sclerosis, vertebral artery dissection (after chiropractic maneuvers), trauma, gunshot wounds, cocaine intoxication.

Site of Lesion

Symptoms and Signs

Spinal nucleus of trigeminal nerve

Ipsilateral analgesia/thermanesthesia of the face and absence of corneal reflex with or without facial pain

Cochlear nucleus

Ipsilateral hearing loss

Nucleus ambiguus

Ipsilateral paralysis of the pharynx and larynx (hoarseness, paralysis of the soft palate), dysarthria, and dysphagia. Tongue movement remains intact

Solitary nucleus

Ageusia (impaired sense of taste)

Dorsal nucleus of vagus n.

Tachycardia and dyspnea

Inferior vestibular nucleus

Nystagmus away from the side of the lesion, tendency to fall toward the side of the lesion, nausea and vomiting

Central tegmental tract

Ipsilateral myorhythmia of the soft palate and pharynx

Central sympathetic pathway

Ipsilateral Horner syndrome

Reticular formation

Singultus

Inferior cerebellar peduncle

Ipsilateral ataxia and intention tremor

Anterior spinocerebellar tract

Ipsilateral hypotonia

Lateral spinothalamic tract

Contralateral loss of pain and temperature sensation with sparing of touch, position, and vibration sense (sensory dissociation)

Involvement of the lower pons produces diplopia. Occipital pain in Wallenberg syndrome is most commonly due to vertebral artery dissection.

Table 7 Syndromes affecting the facial muscles (p. 98)

Syndrome

Etiology

Hypomimia or amimia

Basal ganglia dysfunction (p. 206), depression

Blepharospasm, Meige syndrome, lid-opening apraxia, oromandibular dystonia, tics (p. 64ff.)

Basal ganglia dysfunction

Melkersson-Rosenthal syndrome (recurrent swelling of face/lips, peripheral facial palsy, and fissured tongue)

Unknown

Heerfordt syndrome (fever, uveitis, parotitis, peripheral facial palsy)

Occasional manifestation of sarcoidosis, lymphoma. Cryptogenic

Bilateral peripheral facial paralysis

Neuroborreliosis, Guillain—Barre syndrome, Fisher syndrome, botulism

Möbius syndrome

Congenital bilateral facial palsy and cranial nerve involvement (bilateral: VI; unilateral: XII, IV, VIII, IX)

Synkinesis (involuntary co-movement of facial muscles, e. g., narrowing of palpebral fissure when the lips are pursed); hemifacial spasm

Faulty regeneration of CN VII after facial palsy. Nerve root compression and segmental demyelination in hemifacial spasm

Pseudobulbar palsy

Multiple bilateral supratentorial or pontine vascular lesions

Myopathic facies

Myopathic disorders (myotonic dystrophy, my-asthenia, facial-scapular-humeral muscular dystrophy)

Gustatory sweating (Frey syndrome) or lacrimation ("crocodile tears")

Faulty regeneration of the auriculotemporal/facial nerve

Progressive facial hemiatrophy

Unknown

Table 8 Neurological Causes of Dysphagia (p. 102)

Symptoms and Signs Site of Lesion

Cause

Oral phase impaired and swallowing reflex delayed (slightly) because of paralysis

Delayed swallowing reflex, aspiration (especially of fluids), prolonged oral phase (pseudobulbar palsy, akinesia, dysarthria, dys-phonia, salivation, oromandibular dystonia)

Loss of swallowing reflex, impaired pharyngeal phase, impaired cough reflex (bulbar palsy, dy-sarthria, respiratory disturbances), risk of aspiration

Weakness of muscles of mastication, impaired oral phase, impaired lip closure, nasal drip; impaired pharyngeal phase (dy-sarthria) may occur: depending on which nerve/muscle is affected

Same as above (generalized my-opathy, dysphonia)

Supratentorial Cerebral infarct, tumor or hemorrhage Unilateral

Supratentorial Vascular lesions (single or multiple infarcts, hemor-Bilateral rhage), trauma, tumor, multiple sclerosis, encephali tis, parkinsonism, multiple system atrophy, Alzheimer disease, Creutzfeldt-Jakob disease, hydrocephalus, dystonia (toxic/drug-induced), chorea, intoxication, cerebral palsy

Brain stem, Vascular lesions, multiple sclerosis, tumor, trauma, cerebellum amyotrophic lateral sclerosis, syringobulbia, poliomy elitis, Arnold-Chiari malformation, central pontine myelinolysis, listerial meningitis, spinobulbar muscular atrophy, spinocerebellar degeneration

Cranial nerves Facial paralysis, Guillain-Barré syndrome, diabetic neuropathy, amyloidosis, base of skull syndrome (p. 74)

Neuromuscular Myasthenia, amyotrophic lateral sclerosis, Lambert-Eaton syndrome, botulism, polymyositis/dermatomy-ositis, scleroderma, hyperthyroidism, oculopharyn-geal muscular dystrophy, myotonic dystrophy, facial-scapular-humeral muscular dystrophy, nemaline my-opathy, inclusion-body myositis

Table 9 Classification of pain1,2 (p. 108)

Type

Clinical Features

Etiology (examples)

Nociceptive pain (somatic, p. 110)3

Paresthesia, allodynia,4 loss of sensation, readily localizable

Meralgia paresthetica, carpal tunnel syndrome, skin lesion

Neuropathic pain, neuralgia (pp. 186, 318 ff.)

Severe pain in nerve distribution, paresthesiae, allodynia, sensory loss, pain on nerve pressure, readily localiz-able

Mononeuritis, polyneuropathy, trauma, nerve compression, trigemi-nal neuralgia, neuroma

Radicular pain (p. 319 f)

Same as above + aggravated by stretching (e. g., Lasegue sign) or movement

Herniated intervertebral disk, poly-radiculitis, leptomeningeal metastases, neurofibroma/schwan-noma

Referred pain

See p. 110

See p. 110

Deafferentation pain, anesthesia dolorosa

Pain in an anesthetic or analgesic nerve territory

Plexus lesion, radicular lesion, trigemi-nal nerve lesion

Phantom limb pain

Pain felt in an amputated limb

Limb amputation

Central pain

Burning, piercing pain in the region of a neurological deficit; imprecisely localizable; frequently accompanied by sensory dissociation, dysesthesia, paresthesia; triggered by stimuli

Cerebral infarct, hemorrhage, or tumor (cortex, thalamus, white matter, internal capsule), brain stem, spinal cord; syrinx, trauma, multiple sclerosis (brain stem, spinal cord)

Chronic pain ("pain disease")

Pain that lasts >6 months, impairs social contacts, emotional state, and physical activity

Sensitization of nociceptors? Transsy-naptic neuropeptide induction (calcitonin gene-related peptide = CGRP, substance P = SP, neurokinin A = NKA)?

Psychogenic pain

Discrepancy between symptoms and organ findings and/or syndrome classification

Mental illness

1 Selected types. 2 Features may overlap. 3 = nociceptor pain. 4 Pain evoked by a normally nonpainful stimulus.

1 Selected types. 2 Features may overlap. 3 = nociceptor pain. 4 Pain evoked by a normally nonpainful stimulus.

Table 10 Sleep Characteristics Observed in Sleep Studies (p. 112)

Stage

EEG1

EOG2

EMG3

Awake

a activity (8-13 Hz)

Blinks, saccades

High muscle tone, movement artifact

NREM stage 1

Increasing 0 activity (2-7 Hz), vertex waves4

Slow eye movements5

Slight decrease in muscle tone

NREM stage 2

0 activity, sleep spindles,6 K-complexes7

No eye movement until stage 4, EEG artifact

Further decrease in muscle tone until stage 4

NREM stage 3

Groups of high-amplitude 5 waves (0.5-2 Hz, amplitude > 0.75 ^V)

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