Color Atlas of Neurology

Segment

Features

Normal. Discrete, usually asymptomatic tremor of unclear significance.

Isometric tremor may occur, e. g., when holding a heavy object.

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 with-

drawal; mercury, manganese, lithium, valproic acid, cyclosporine A, amio-

darone, flunarizine, cinnarizine, tricyclic antidepressants, neuroleptics tar-

dive tremor)

Classical ET: PosT !KT 2. Approx. 60% autosomal dominant, rest sporadic.

Hands !head !voice !trunk. Often improved by alcohol.

Orthostatic tremor: Occurs only when standing unsteadiness, hard to

stand still.

Task-specific tremor

RT 3 See p. 206. Postural and kinetic tremor may also be present.

IT4 reflecting cerebellar dysfunction. Postural tremor and head/trunk tremor

may be seen when the patient is standing (alcohol intoxication).

RT + PosT + IT, mainly proximal, disabling. Associated with lesions of nigro-

striatal and cerebello-thalamic pathways (multiple sclerosis, infarct)

RT, PosT, or IT, predominantly either proximal or distal. 3–10 Hz5

Symptomatic (medullary lesion due to encephalitis, multiple sclerosis, brain

stem infarct) or essential; clicking noise in ear

Migrates from one part of the body to another. Accompanied by muscle

contraction (co-contraction)

Structure Affected

Symptoms and Signs

Intramesencephalic fibers of

Ipsilateral oculomotor paralysis + parasympathetic dysfunction (pupil dilated

oculomotor n.

and unreactive to light)

Pyramidal tract

Contralateral central paralysis + face ( supranuclear facial palsy) + spastic-

ity. Dysarthria (supranuclear hypoglossal palsy)

Substantia nigra

Rigidity (rare)

Structure Affected

Symptoms and Signs

Intramesencephalic fibers of

Ipsilateral oculomotor paralysis + parasympathetic dysfunction (see above )

oculomotor n.

Medial lemniscus

Contralateral impairment of touch, position, and vibration sense

Red nucleus

Contralateral tremor (myorhythmia red nucleus syndrome, Holmes

tremor)

Substantia nigra

Rigidity (variable)

Superior cerebellar peduncle

Contralateral ataxia ( Claude syndrome)

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 the

eyes move upward on passive vertical deflection of the head, but not volun-

tarily). Convergence nystagmus with retraction of the eyeball on upward

gaze (retraction-convergence nystagmus)

Trochlear nucleus

Trochlear nerve palsy

Aqueduct (compressed)

Hydrocephalus (headache, papilledema)

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

Ipsilateral loss of conjugate movement (loss of optokinetic and vestibular

formation (PPRF, “pontine

nystagmus PPRF lesion with intact vestibulo-ocular reflex (VOR, p. 84))

gaze center”)

Pyramidal tract

Contralateral central paralysis sparing the face

Structures Affected

Symptoms and Signs

Pyramidal tract

Contralateral central paralysis sparing the face

Nucleus/fibers of the facial n.

Ipsilateral (nuclear = peripheral) facial palsy ( Millard–Gubler syndrome)

Fibers of abducens nerve

Ipsilateral abducens paralysis ( Foville syndrome, eyes drift “away from

the lesion”; loss of VOR)

Central sympathetic pathway

Ipsilateral Horner syndrome

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

Symptoms and Signs

Ipsilateral peripheral (nuclear) hypoglossal paralysis

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

tract lesions)

Contralateral impairment of touch, position, and vibration sense (pain and

temperature sensation intact)

Upbeat nystagmus

Symptoms and Signs

Ipsilateral analgesia/thermanesthesia of the face and absence of corneal re-

flex with or without facial pain

Ipsilateral hearing loss

Ipsilateral paralysis of the pharynx and larynx (hoarseness, paralysis of the

soft palate), dysarthria, and dysphagia. Tongue movement remains intact

Ageusia (impaired sense of taste)

Tachycardia and dyspnea

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

side of the lesion, nausea and vomiting

Ipsilateral myorhythmia of the soft palate and pharynx

Ipsilateral Horner syndrome

Singultus

Ipsilateral ataxia and intention tremor

Ipsilateral hypotonia

Contralateral loss of pain and temperature sensation with sparing of touch,

position, and vibration sense (sensory dissociation)

Syndrome

Hypomimia or amimia

tongue)

eral facial palsy)

Bilateral peripheral facial paralysis

Möbius syndrome

the lips are pursed); hemifacial spasm

Pseudobulbar palsy

Myopathic facies

(“crocodile tears”)

Table 8 Neurological Causes of Dysphagia (p. 102)

Symptoms and Signs

Site of Lesion

Oral phase impaired and swallow-

Supratentorial

Cerebral infarct, tumor or hemorrhage

ing reflex delayed (slightly) be-

Unilateral

cause of paralysis

Delayed swallowing reflex, aspira-

Supratentorial

Vascular lesions (single or multiple infarcts, hemor-

tion (especially of fluids), pro-

Bilateral

rhage), trauma, tumor, multiple sclerosis, encephali-

longed oral phase (pseudobulbar

tis, parkinsonism, multiple system atrophy, Alzheimer

palsy, akinesia, dysarthria, dys-

disease, Creutzfeldt–Jakob disease, hydrocephalus,

phonia, salivation, oromandibular

dystonia (toxic/drug-induced), chorea, intoxication,

dystonia)

cerebral palsy

Loss of swallowing reflex, im-

Brain stem,

Vascular lesions, multiple sclerosis, tumor, trauma,

paired pharyngeal phase, impaired

cerebellum

amyotrophic lateral sclerosis, syringobulbia, poliomy-

cough reflex (bulbar palsy, dy-

elitis, Arnold–Chiari malformation, central pontine

sarthria, respiratory disturbances),

myelinolysis, listerial meningitis, spinobulbar muscu-

risk of aspiration

lar atrophy, spinocerebellar degeneration

Weakness of muscles of mastica-

Cranial nerves

Facial paralysis, Guillain–Barré syndrome, diabetic

tion, impaired oral phase, im-

neuropathy, amyloidosis, base of skull syndrome

paired lip closure, nasal drip; im-

(p. 74)

paired pharyngeal phase (dy-

sarthria) may occur: depending on

which nerve/muscle is affected

Same as above (generalized my-

Neuromuscular

Myasthenia, amyotrophic lateral sclerosis, Lambert–

opathy, dysphonia)

Eaton syndrome, botulism, polymyositis/dermatomy-

ositis, scleroderma, hyperthyroidism, oculopharyn-

geal muscular dystrophy, myotonic dystrophy, facial–