Methodical Instruction



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Methodical Instructions

For individual work of students in preparation for practical classes


Subject

Neurology



Topic


Localization of the functions in the brain cortex. The affection syndromes. Cerebrospinal fluid, its changes. Meningeal syndrome.


Year

IV


Faculty

Medical



1. Topicality: The topic is important because of the prevalence of pathology of higher nervous activity, importance of timely diagnostics on early stages of neurological and somatic diseases – brain tumors, intoxications, strokes, encephalitis, meningitis, neurosis, brain traumas etc.
2. Proper purposes:

  1. To be able to reveal abnormalities of cortical functions in patient – agnosia, apraxia, aphasia, localize pathological process, to solve topical tasks.

  2. To be able to examine motor speech, sensory speech, counting, and ability to recognize and name a subject, examine reading, writing, distinguish motor speech and sensor abnormalities.



  1. Basic knowledge, skills and competences: (interdisciplinary integration)




Subject

Information to learn

To be able

1

Anatomy of brain

Anatomy of convexital basal surface of brain

To know definitions of given subjects

2

General physiology (neurophysiology)

Main definitions of neurophysiology, dominant, parabiosis.

To know definitions of given subjects

3

Histology

Cellular structure of neuron, types of neurons

To know definitions of given subjects

4
Nervous diseases – clinical picture, diagnostics

Clinic of focal lesion of brain cortex.

To know definitions of given subjects

4. Tasks for individual work during preparation for classes:

Listening tapes of speech abnormalities - motor aphasia, sensory aphasia, semantic aphasia, dysarthria etc.

Stand - “Localization of the function in brain cortex”, tables “Brain cortex”

Computer program “Neurovisualisation”, computer test program “Test”.

а) The list of the basic terms, characteristic, which students must master in preparation for the class:
а) Theoretical questions for the class:

Structure of cerebral hemisphere.

Cytoarchitecture and myeloarchitectonics of the cortex. Localization of the functions in cerebral cortex. Dynamic localization of the functions. Motor and sensory representations. Functional anatomical asymmetries of the cerebral hemispheres.

Gnostic functions. Kinds of abnormalities of gnostic functions: visual, olfactory, auditory agnosias, tactile amnesia, autotopagnosia, anosognosia.

Praxis. Kinds of apraxias: constructive, ideational, motor.

Speech. Speech disorders: motor, sensory, amnestic aphasias.

Syndromes of affections of segments of cerebral hemispheres: frontal lobe, temporal lobe, parietal lobe, occipital lobe, limbic cortex

Syndromes of irritation of cerebral hemispheres cortex.

Syndromes of affection of the right hemisphere and the left hemisphere

Definition of interhemisphere asymmetry.

Syndrome of chronic vegetative state.

“Locked-in” syndrome.

Brain stem death syndrome.

Spinal puncture.

A rachnoid membrane and a spinal cord membrane. Physiology of liquor formation. Structure of normal liquor, its variety in meningitis, tumors, hemorrhagic stroke, tuberculosis. Cellular-protein dissociation. Pleocytosis.

Meningial symptoms: headache, vomiting, general hyperesthesia, photophobia, neck muscles stiffness, Kernig's symptom, Brudzinski sign (upper, medium, low), trismus, local reaction pain phenomenon, Mendel’s syndrome, Bekhterev’s syndrome, pain in pushing great and small cervical nerve exit points. Meningial position of patient. Lessage's symptom.


1. L. frontalis - Frontal lobe –anatomy, clinical picture of affections.

L. occipitalis –occipital lobe - anatomy, clinical picture of affections

L. temporalis – temporal lobe - anatomy, clinical picture of affections



Left hemisphere – aphasia, apraxia, agraphia, alexia, acalculia, characteristics of symptom complex.

Right hemisphere – autotopagnosia, anosognosia, mind abnormality, symptom complex.

с) Practical works (tasks) made at the class:

1. Examination tests, MMSE, others
Topic contents: semiotics of affection of frontal lobe, occipital lobe, parietal lobe, temporal lobe.

L. frontalis - frontal lobe - paralysis, paresis

anosmia,


frontal ataxia,

motor aphasia,

agraphia,

paralysis of gaze,

catch phenomena,

jacksonian epilepsy,

syndromes of attention disorders

motor apraxia,

modal non-specific memory disorders,

aspontaneity,

apathy,

abulia,


bulimia,

pseudoagnosias,

pseudoamnesia,

intellectual perseverations,

regulatory apraxias,

(echolalia, echopraxia),

vertical behavior,

emotions disorders (euphoria, moria, explosiveness, aggressiveness)



L. occipitalis – occipital –

visual agnosia,

colour agnosia,

prosopagnosia,

simultaneous agnosia,

apperceptive agnosia,

literal agnosia,

spatial agnosia,

agnostic alexia,

visual hallucinations,

photopsy,
L. parietalis - parietal

astereognosis.

alexia,

agraphia ,

apraxia,

autotopagnosia,

sensitive ataxia,

sensitivity abnormalities,

sensitive jacksonian epilepsy

autotopagnosia,

anosognosia.

L. temporalis – temporal


aphasias – sensory and amnestic

alexia,


cortical ataxia,

hemianopsia,

agnosias – auditory,

olfactory,

gustatory,

vestubular syndrome,

hallucinations – auditory, olfactory, gustatory,

Korsakoff's (amnestic) syndrome,

confabulations,

paramnesia.


Left hemisphere –aphasia, apraxia, agrophia, alexia, acalculia

Right hemisphere autotopagnosia, anosognosia, mind abnormality
Medullispinal fluid

Anatomical and physiological peculiarities of liquor system -

Brain and spinal cord are covered with three membranes: pachymeninx, arachnoid and pia.

There are appendices of pachymeninx:

falx of cerebrum (falx cerebri);

falx of cerebellum (falx cerebelli);

tentorium of cerebellum (tentorium cerebells),

- diaphragm of sella turcica ( diaphragma cella turcicae)

There are sinuses between plates and appendices of pachymeninx :

• superior sagittal sinus (sinus sagittalis superior), that pass into transverse sinus and located along concave side of top edge of of major falcated processus;

• inferior sagittal sinus (sinus sagittalis inferior) is along lower edge of major falcated processus and pass into straight sinus;

transverse sinus (sinus transversus)

sigmoid sinuses(sinus sigmoideus);

straight sinus (sinus rectus) located along the splice line of major falcated processus with tentorium of cerebellum. It passes into transverse sinus with superior sagittal sinus;

cavernous sinus (sinus cavernosus) is on each side of ephippium. There are three walls in it: roof, outer wall and inner wall.

There is internal carotid artery with its sympathetic plexus inside the sinus. Forming the anterior intercavernous sinuses (sinus intercavernosus anterior) and forming posterior intercavernous sinus (sinus intercavernosus posterior) in posterior sections of diaphragm. That’s why major circular sinus takes this name (sinus circularis).

superior petrosal sinus, (sinus petrosus superior) is a sequel of cavernous sinus and it is located along the top edge of temporal pyramid and connected cavernous sinus and transverse sinus;

• inferior petrosal sinus (sinus petrosus inferior) comes out cavernous sinus, located in inferior petrosal sulcus between bend of occipital condyle and pyramid of temporal;

• occipital sinus (sinus occipitalis) is along internal occipital protuberance (crest). It comes from transverse sinus and it is divided into two branches, which wrap round edges of cervical foramen and pass into sigmoid sinus.

Arachnoid membrane of brain surrounds main brain, it is covered with endothelium, and it is connected with dura mater of brain and pia mater of brain, overarachnoidal and subarachnoidal connective tissues partition. There are fissured subdural (subdural) space between archnoid membrane and dura mater of brain. Subdural space has some cerebrospinal fluid.

Cisterns - (cisternae subarachnoideae).

posterior cerebellomedullary cistern (cisterna cerebellomedullaris) is between cerebellum and medulla; (cisterna cerebellomedullaris);

cistern of lateral fossa of great brain (cisterna fossae lateralis cerebri );

• interpeduncular cistern (cisterna interpeduncularis );

•cistern of optic chiasm (cisterna chiasmatica), which is between visual nerves and frontal lobes;

• cistern of corpus callosum (cisterna corporis callosi) which is along top edge and genu of corpus callosum;

• ambience cistern(cisterna ambiens) which is on the bottom of the cleft between occipital lobes of hemispheres and superior surface of cerebellar hemisphere;

• lateral pontine cistern cisterna lateralis pontis);

• medium pontine cistern (cisterna medialis pontis).

Сerebrospinal fluid from different parts of brain gathers in subarachnoidal space.



Pia mater of brain directly covers it and it is formed by gentle plump connective tissue which contains a great amount of vessels and nerves.

Vascular plexes of ventricles connect with pia.



Dura mater of spinal cord forms wide prolonged cylindrical bag

( ). Upper border of hard cerebrospinal membrane is on the level of occipital foramen and knits with periosteum in inner surface of occipital foramen. Moreover it connects with surface membrane ( ), with posterior atlanto-occipital membrane (ligament) and it is fixed to posterior longitudinal ligament ( ) by short connective tissue membranes. Underneath the bag of hard cerebrospinal membrane forms terminal cistern ( ) which is filled with cerebrospinal fluid. Dura mater of spinal cord covers radices, nodes and nerves which come from spinal cord, as vagines which spread to intervertebral foramen. Корінці, вузли та нерви, що відходять від спинного мозку, тверда оболон­ка вкриває у вигляді піхв, які поширюються у напрямку до міжхребцевих отворів.

Memraneous branches of spinal nerves ( ) innervate dura mater of spinal cord. Branches of vertebral arteries (аа.vertebralis) and parietal arteries of thoracic aorta and abdominal aorta provide bloodsupply. Venous blood gathers in venous spinal plexus.

Archnoidal membrane of spinal cord as dura mater of spinal cord is a bag which covers spinal cord quite loosely. There are subdural spaces ( ) as capillary clefts between archnoidal membrane and dura mater of spinal. Subarchnoidal spaces ( ) look like cavities filled with cerebrospinal fluid.

Archnoidal membrane connects with dura mater of spinal cord in section of radices of spinal nerves. It connects with pia mater of brain with numerous thin connective tissue membranes, which form posterior subarchnoid membrane. In addition, archnoidal membrane connects with dura mater of brain and pia meter of brain with ligaments called denticulate ligaments ( ).

Pia mater of spinal cord is stronger than pia mater of brain. It closely leans against outer surface of brain and enters its front medium cleft. Denticulate ligaments which start from pia mater between front and posterior radices and fix to dura spinal membrane, fix both membranes.


Physiological significance of cerebrospinal fluid: it carries out the function of mechanical protection of brain; regulate intracranial pressure, excretory function and transport function, function of immunologic border etc.

Examination of cerebrospinal fluid

The most available way is lumbar puncture

In proper cases suboccipital puncture is done, but this manipulation needs conditions of neurosurgery department.

It is not recommended lumber puncture when there is a suspicion of volume process in posterior cranial fossa or temporal region of hemisphere of great brain. The puncture is counter-indicative when there are inflammatory impairments of skin and ossa in lumbar region.



Methods – to know

Cerebrospinal fluid

- Taking its pressure, in lying position in healthy person is 1—2 kPa (100—200 millimeter of water)in sitting position — 2,5 kPa (250 millimeter of water) and more, and in children — 0,4—0,9 kPa (45—90 millimeter of water).



Queckenstedt's test gives an opportunity to estimate permeability subarachnoid space. This test is done with energetic compression of jugular vein during 10 sec. – increases and gets the level in 1—3 kPa (100—300 millimeter of water) — higher than normal.

Stookey test: energetic compression at the stomach predetermines fast increasing of pressure of cerebrospinal fluid.

Characteristics of syndromes of intracranial pressure abnormalities are given in the table 3.



Protein-cellular dissociation is a sign of presence of brain and spinal cord tumors

Cellular-protein dissociation is a sign of inflammation of meninx. Basic showings of cerebrospinal fluid are normal and in some pathological states – to know.

Increasing of cell number in cerebrospinal fluid (pleocytosis) is a sign of irritation of meninx by pathological process or development of inflammatory processes in them.



Symptom complex of meninx irritation. Meninx irritation can be predetermined by their inflammation, intoxication and hemorrhage in subarachnoid space. There is meningeal syndrome (membranous) which includes:

General cerebral syndrome with special characteristics – bad stable headache, often with nausea and spouting vomiting, hypertension of skin, increasing of sensitivity to visual and auditory stimuli (is met in liquor hypertension)

Meningeal syndrome is characterized by presence of meningial symptoms:

rigidity of occipitals,

Mendel sign, Kernig's symptom, Brudzinski’s sign, Bechterew's symptom

Position of patient in bed is rather typical: lying with overturned head and pulled legs to the stomach (position of “setter dog”)



Rigidity of occipitals results from rapid increasing of tone of the muscles which unbend head.
Table 3. Basic findings of cerebrospinal fluid normally and in different pathological conditions.

Disease

Colour

Clarity

Pressure

Cytosis in 1 mm3, formula

Protein content,

g per L


Glucose content,

mmol per L



Chloride content,

mmol per L



Normal

Non colour

Clear

1-2 kPa

0-3

0,12-0,45

2,5-4,4

120-130







(100-















200mm of water )


























Purulent

Yellowish-

Troubled

Elevated

Thousands – ten thousands

1-3

1-2,4

A little low

meningitis

green







(70-90% neutrophils,
















10—30% lymphocytes)







Tuberculous

Colourless or

Clear,

Те саме

200-800 (20-30% neutrophils,

0,33-1,65

1-2

90-100




mild

opalescent



65—80% lymphocytes,

and higher







xanthochromic






1—5% plasma cells)

























Serous

Colourless

Clear

— « —

50-1500 (1-4% neutrophils,

0,33-1

Normal or a little reduced

Normal









90—95% lymphocytes,






or a little reduced









1—3% plasma cells)



























Brain tumour

same

same

— « —

0-3

0,6-0,9

Normal

Normal


















Spinal cord tumour

xanthochromic

«

Reduced

0-3

0,6-35

same

same



















Subarachnoid hemorrhage

Pink

Troubled

Normal

Mild pleocytosis,

Elevated pro rata quantity of erythrocytes

— « —

— « —




Or




Or little

Many erythrocytes










red



elevated




























Materials for self-control:

А. Tasks for self-control (tables, schemes, drawings, diagram):

Б. Tasks for self-control:

Variants of test tasks –




  1. There are high brain functions of human being. Odd one or more out:

1. thinking

2. speaking

3. praxis

4. hearing

5. gnosis


  1. There are basic kinds of aphasias. Odd one or more out:

1. dysarthria

2. sensory

3. semantic

4. motor


5. amnestic


  1. Tick the abnormality which appears in impairment of left frontal lobe

  1. mutism

  2. motor aphasia

  3. aphonia

  4. sensory aphasia

  5. semantic aphasia




  1. Tick the abnormality which appears in impairment of left temporal region:

  1. autotopagnosia

  2. motor aphasia

  3. sensory aphasia

  4. aphonia

  5. scanning speech




  1. Tick signs of impairments of parietal cortex of right hemisphere of the brain:

  1. apraxia

  2. alexia

  3. agraphia

  4. autotopagnosia

  5. aphasia




  1. Name signs of impairment of parietal cortex of left hemisphere of the brain:

  1. amusia

  2. motor aphasia

  3. agraphia

  4. apraxia

  5. anosmia




  1. Tick what appears in impairment of left supramarginal gyrus:

  1. motor aphasia

  2. sensory aphasia

  3. anosopagnosia

  4. agraphia

  5. apraxia




  1. Tick signs of impairment of the left temporal region:

  1. motor aphasia

  2. sensory aphasia

  3. anosoagnosia

  4. amusia

  5. autopagnosia




  1. Tick clinical signs of impairment of front of right hemisphere of brain (in lefthander):

  1. aculculia

  2. motor aphasia

  3. sensory aphasia

  4. abnormality of body scheme

  5. amnestic aphasia



  1. There are some kinds of aphasia. Odd one or more out:

  1. motor

  2. visual

  3. acoustic

  4. olfactory

  5. gustatory




  1. There are signs of impairments of front of brain. Odd one or more out:

  1. central paresis

  2. hemianopsia

  3. frontal ataxia

  4. motor aphasia

  5. mind abnormality




  1. There are signs of impairment of left parietal region of brain:

  1. monoplegia

  2. monoanesthesia

  3. apraxia

  4. alexia

  5. tactile amnesia




  1. There are impairments of temporal region of brain. Odd one or more out:

  1. olfactory agnosia

  2. auditory agnosia

  3. quadrantic hemianopsia

  4. sensory aphasia

  5. tactile amnesia


Literature. Basic :

  1. Shcrobot S.I., Hara I.I. Neurology in lecture (Selected lectures) . Ternopil, TSMU, «Ukrmedknyha», 2008. 319 p.

  2. Reinhard Rohkamm. Color Atlas of Neurology © 2004 Thieme. 440 p.

  3. Crash course Neurology by Anish Bahra and Katia Cikurel. Copyright 2006, Elsevier, Inc. 244 p.

  4. Adams and Victors. Principles of neurology. © 2005 McGraw-Hill . Medical Publishing Division.

  5. Mayo Clinic Internal Medicine Review 2006-2007. Chapter 18. Editor-in-Chief Thomas M. Habermann, MD




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