Introduction to Clinical Neurology

Prof. Daiva Rastenytė

Department of Neurology

2017/2018
• Overview of neuroanatomy
• Focal neurological symptoms
• Global neurological symptoms
• Topical neurological diagnosis
• Neurological examination
 Functional regions of the cerebral cortex
Lateral left

Speech control

Speech interpretation
 Ist neuron

Tr. corticospinalis
seu pyramidalis IInd neuron
Posterior columns Anterolateral column
(epicritic/lemniscal system) (protopatic system)
ventral spinocerebellar tract dorsal spinocerebellar tract
Cranial nerves
Ascending and descending tracts of the spinal cord
Segmental
innervation
of the skin
Innervation
of the skin
by
peripheral
nerves
Two groups of symptoms:

• Focal neurological symptoms – due to lesion of a

certain part of brain, spinal cord or peripheral
nerve

• Global symptoms – due to diffuse effect on brain

Focal neurological symptoms

- clinical signs of a lesion in the neuroaxis

• Negative symptoms – those in which normal neurological

function is lost (e.g., hemiparesis, muscle weakness,
aphasia, loss of sphincter control, etc.)

• Positive symptoms – novel phenomena due to irritation

or stimulation (e.g., seizures, flashing lights (photopsia),
hallucinations, tingling, etc.)
Global neurological symptoms

• Symptoms
– Impaired consciousness
– Headache
– Nausea, vomiting
– Seizures (generalized)
– Edema p.n. optici

• Causes
– Increased intracranial presure
– Impairment of cerebrospinal fluid circulation
– Meningeal irritation, etc
Neurological examination and history taking:
where? what?

• Is this a neurological disorder?

• If yes, where in the neuraxis is a lesion likely to be?

(history & examinations)

• What is the nature of the lesion? (the mode of illness

presentation)
 Topical neurological diagnosis

• The major part of both the central and the peripheral

nervous system cannot be seen, palpated, percussed or
auscultated

• The location of the lesion is mainly detected based on the

impairment of certain functions - movements, sensations,
mental, etc.
Topical neurological diagnosis – the
correct attribution of symptoms or syndromes to lesions
at specific sites in the nervous system
Findings helpful for localization in the nervous system
Signs
Cerebrum Abnormal mental status or cognitive impairment
Unilateral weakness* and sensory abnormalities
including head and limbs
Visual field abnormalities
Movement abnormalities (diffuse incoordination,
tremor, chorea)
Brainstem Isolated cranial nerve abnormalities (single or multiple)
“crossed weakness”* and sensory abnormalities of
head and limbs (e.g. weakness of right face and left arm
and leg)
* Central (upper) motor neuron pattern
Findings helpful for localization in the nervous system
(cont.)
Signs
Spinal cord Back pain or tenderness
Weakness* and sensory abnormalities sparing the head
Mixed upper and lower motor neuron findings
Sensory level
Sphincter dysfunction
Spinal roots Radiating limb pain
Weakness** or sensory abnormalities following root
distribution
Loss of reflexes

* Central (upper) motor neuron pattern; **Peripheral (lower) motor neuron pattern
Findings helpful for localization in the nervous system
(cont.)

Signs
Peripheral nerve Mid or distal limb pain
Weakness* or sensory abnormalities following
nerve distribution
Stocking or glove distribution of sensory loss
Loss of reflexes

*Peripheral (lower) motor neuron pattern

Findings helpful for localization in the nervous system
(cont.)

signs
Neuromuscular Bilateral weakness including face (ptosis, diplopia,
junction dysphagia) and proximal limbs
Increasing weakness with exertion
Sparing of sensation
Muscle Bilateral proximal or distal weakness
Sparing of sensation
 Neurological examination and history
taking: where? what?
• Is this a neurological disorder?
• If yes, where in the neuraxis is a lesion likely to be?
• What is the nature of the causal lession inferred by the mode of
illness presentation?
– Genetic
– Congenital
– Infection
– Inflammatory
– Neoplastic
– Degenerative
– Metabolic and toxic
– Paroxysmal (including migraine and epilepsy)
– Vascular
Neurological examination and history taiking

• Presenting complaint
• History
• Somatic and neurological examination
• Scales
• Clinical syndrome
• Differentials
• Diagnostic tests
• Clinical diagnosis
Neurological examination: the present complaint

• Time of onset
• Mode (speed) of onset (acute, subacute, chronic, insidious)
• Duration of symptoms
• The time course (progressive, relapsing or remitting, static)
• Associated symptoms and signs
• Specifics about pain:
– Location and iradiation
– Quality, severity, frequency
– Aggravating or relieving factors
• Previous treatments and investigations
Onset Vascular Epileptic Migrainous Inflamatory Infective Neoplastic Degenerative

Seconds

Minutes

Hours

Days

Weeks

Months

Years

The mode of different pathological processes

Neurological examination: history

• Prior medical history: neurological disorders, Risk

factors, head trauma, etc.
• Comorbidities
• Family history
• Social history
• Current drugs and allergies
A basic neurological examination

• Mental status
• Meningeal symptoms
• Cognitive function
• Cranial nerve examination
• Motor examination
• Sensory examination
• Coordination
• Stance and gait
Examination before and during history taking

• Gait
• Synkinesia
• Involuntary movements and tremor
• Facial expression
• Speech and cognition
 Cognitive functions

 Memory, recent & remote: asking the patient to recall 5 words after 5 min
 Attention/concentration: orientation, digit span (asking the pt to repeat
number strings), the ability to recite months the year backwards or serial
sevens (asking the pt to subtract 7 from 100 and keep subtracting 7)
 Language: spontaneous speech, naming, comprehension, repetition,
reading & writing
 Calculation: ability to understand or write numbers
 Praxis (ability to perform and control skilled or complex motor
actions)
 Visuo-spatial and perceptual function: drowing a clock face,
overlaping pentagons, three-dimensional cube
Speech and language

• Dysphonia – difficulty in producing sounds

(phonating) (a defect of speech volume)

• Dysarthria – difficulty in articulating the individual

sounds or the units (phonemes) of speech without
disturbance of language function

• Dysphasia – a defect of language function in which

there is difficulty in expressing or understanding
words as the symbols of communication or both
 Cranial nerves
• I, olfactory nerve – olfaction - is rarely tested in clinical
practice
– Performed by ENT specialist
– Anosmia – loss of sense of smell: blocked nasal
passages (e.g. common cold), trauma; a relative loss
occurs with ageing, Parkinson’s disease
– Hallucinations of smell – pathological lesions in
temporal lobe

• II, optic nerve – visual acuity, visual fields, fundoscopy

– Performed by ophtalmologist
– Bedside test – finger movements or red pin
 Fields of vision
1.
Temporal Nasal Nasal Temporal Lesion: right optic nerve
Defect: blidness of right eye

2.
Lesion: optic chiasma in midline
Defect: bitemporal hemianopia

1 3.
2 Lesion: right edge of chiasma
3 Defect: nasal hemianopia, right

4
4.
5 Lesion: right optic tract
Defect: left homonymous
hemianopia

5.
Lesion: right geniculocalcarine tract or visual cortex
Defect: left homonymous hemianopia with sparing
of macular vision
 Cranial nerves (cont.)

• III, IV, VI (oculomotor, trochlear & abducent nerves) –

– ptosis (drooping eyelid),
– pupil size,
– pupil light reaction (II & III),
– lateral & vertical eye movements (double vision,
movement amplitude, conjugate eye movement,
nystagmus)
 oculomotorius

trochlearis abducens
 Cranial nerves (cont.)

• V, trigeminal nerve –
– sensation (light touch, pinprick) in 3 sensory divisions
(ophthalmic V1, maxillary V2, mandibular V3),
– m. masseter, m. temporalis, mm. pterygoideus: look for any
muscle wasting; ask to open the jaw against resistance;
– the jaw jerk;
– corneal reflex (not as a routine): touch the cornea with a wisp
of cotton wool
 Cranial nerves (cont.)
VII, facial nerve – nasolabial folds;
– frontalis “wrinkle the forehead”;
– orbicularis oculi “screw up the eyes”;
– buccinator “blow out the cheeks”; Unilateral peripheral (lower)
– orbicularis oris “show the teeth”, motor neuron facial weakness
– taste (anterior two-thirds of the tongue)

Bilateral lower motor neuron

facial weakness
Unilateral central (upper) (Guillain-Barre s.,Myasthenia
motor neuron facial weakness Gravis, Myopathies, Lyme d., etc.)
 Cranial nerves (cont.)

• VIII, auditory and vestibular nerves – any problems with

hearing (auditory);
– gait,
– nystagmus,
– caloric testing (vestibular)
 Cranial nerves (VI)
• IX, glossopharyngeal; X, vagus n. –
– IX – sensation on the posterior wall of the tonsillar fossa,
taste (the posterior one-third of the tongue)
– X – articulation, cough, ability to elevate the soft palate
(“Ah”); gag reflex

• XI, accessory nerve – m. trapezius & m.

sternocleidomastoideus (shrug the shoulders, turn the head
against resistance)

• XII, hypoglossal nerve – (stick out the tongue) tongue

movements, wasting, fibrillation
Bulbar palsy – due to lesion of n.n. IX, X, XII
(peripheral type)

• Dysphagia
• Dysphonia
• Dysarthria
• Diminished reflexes of soft palate and of posterior
wall of pharynx
• Descended arcs of palate
• Tongue wasting and fasciculations
Pseudobulbar palsy – due to central lesion of
n. IX, X, XII

• Involuntary cry and laugh

• Dysphonia
• Dysarthria
• primitive reflexes, brisk jaw jerk
• Descended arcs of palate with retained reflexes of
soft palate and of posterior wall of pharynx
 Motor examination

• Involuntary movements, e.g. extrapyramidal disease,

fasciculation, myokymia (a fine twitching motion of the
face)
• Muscle symetry (wasting)
• Muscle tone
• Muscle strength: proximal/dystal, sin/dex, upper
limbs/lower limbs
• Bare s.
• Muscle stretch (deep tendon) reflexes
 Muscle tone
- certain resistance to passive movement through certain
joints

1 – pronate and supinate the forearm

2 – roll the hand round at the wrist
3 – full range of flexion and extension at the elbow
4 – roll the knee rapidly
5 – lift the knee rapidly (watch the heel)
6 – flex and extend the knee
7 – flex and dorsiflex the foot
 Muscle tone
• Normal: slight resistance through whole range of
movements
• Decreased tone: loss of resistance through movement.
Marked loss of tone = flaccid (lower motor neuron or
cerebellar lesion, ‘spinal shock”)
• Increased tone:
– Spasticity
– Lead pipe & Cogweel rigidity
• Myotonia
• Dystonia
• Percussion myotonia
 Muscle tone: increased tone

Spasticity – velocity dependent (may be absent with slow

speed of displacement). Predominates in flexors of upper
limbs and extensors of lower limbs and in pronators
compared to supinators. Fades as stretch continues
(clasp-knife effect) (upper motor neuron lesion)

Rigidity – not velocity dependent. Increased through

whole range, as if bending a lead pipe: lead pipe rigidity.
Regular intermittent break in tone through whole range:
cogwhell rigidity (extrapyramidal syndromes)
Muscle tone

• Myotonia – impaired relaxation of skeletal muscle after

contraction: “make a fist and then release it suddenly”

• Dystonia – abnormal postures caused by the contraction

of antagonistic muscle groups

• Percussion myotonia – abnormal contraction triggered by

percussing the muscle
 Muscle strength
• Shoulder elevation
• Shoulder abduction
• Elbow flexion & extension
• The first dorsal interosseous & abductor pollicis brevis
• Hip flexion & extension
• Knee flexion & extension
• Feet plantar flexion & dorsiflexion

Compare one limb with the other

Compare proximal muscle groups with the distal ones (the overall
distribution), flexors with extensors (the pattern), muscle groups
innervated by a single root vs multiple roots vs plexus vs single
nerve vs multiple nerves (the grouping)
Grading of motor strength

0 No muscle movement

1 visible muscle movement but nor movements at the joint

2 movement at the joint, but not against gravity

3 movement against gravity, but not against added resistance

4 movement against resistance, but less than normal

5 normal strength

UK Medical Research Council scale, 1995

Bare’ symptom
Muscle stretch reflexes (deep tendon reflexes)
Abdominal reflexes

• Triceps (C6,) C7, C8 roots 7,8

• Biceps C5, C6
5,6
• Brachioradialis C5, C6
• Abdominal T8, T9, T10, T11, T12
• Knee (L2,) L3, L4 3,4
• Ankle (L5,) S1, S2 1,2

• Look at
– Symmetry
– Amplitude
– Additional beats (clonus)
Reflexes
Grading of reflexes

• Absent Lower motor neurone lesion

Neuropathy
• Present only with reinforcement Cerebellar syndrome
• Present but depressed (hypoactive) Muscle disease
• Normal
• Increased (hyperactive)
Upper motor neurone lesion above the root of that level
• Clonus (if together with decreased strength and other symptoms)

• Compare one limb with another

 Plantar response (Babinski’s sign)

• Drawing a stick up a lateral border of the

foot and across the foot pad:
– The toes all flex – flexor plantar
response: negative Babinski’s sign –
normal
– Hallux extends (goes up), the other
toes flex or spread: extensor plantar
response: positive Babinski’s sign
– Hallux extends (goes up), the other Babinski’s sign
toes extend and ankle dorsiflexes:
withdrawal response
– No movement of the hallux (even if the
other toes flex): no response
– A positive test should be reproducible
 Differential diagnosis of weakness

Sign Upper motor Lower motor Myopathic

neuron neuron
Atrophy none severe mild
Fasciculations none common none
Tone spastic decreased normal/decreas
ed
Distribution of pyramidal/regio distal/segmental proximal
weakness nal
Tendon reflexes hyperactive hypoactive/abse normal/hypoacti
nt ve
Babinski’ sign present absent absent
 Special signs
• Primitive reflexes (“frontal release reflexes”)
– Snout Frontal pathology
– Palmo-mental Diffuse encephalopathy
If unilateral – contralateral frontal lobe
– Grasp
pathology
• Superficial
– Abdominal – Th7, Th8, Th9, Th10, Th11, Th12
– Cremasteric
– Anal
• Tests for meningeal irritation
– Neck stiffness
– Brudzinski’s sign
– Kernig’s sign
Neck stiffness Kernig’s sign

N.B.! Not to be performed if

there could be cervical
instability
Sensation: general

• Vibration sense Posterior column

• Joint position sense
• Light touch
Spinothalamic tract
• Pin prick (pain)
• Temperature
• Romberg test (test of proprioception)
– Positive if sways or falls with the eyes closed while
is still with the eyes open
 Sensation: contralateral parietal lobe
sensory integration function

• Graphestesia (identifying numbers written on the palm using a dull

pointed object)

• Stereognosis (identifying common objects such as a quarter or

dime when placed in the palm and then felt with the fingers)

• Double simultaneous stimulation (touching homologous parts of

the body on one side, the other side, or both sides at once with the
patient identifying which side or if both sides are touched while their
eyes are closed)
 Sensation

• Compare (look for patterns seen with disorders of different

levels of neuroaxis):
– Neuropathy: compare proximal to distal sensation
– Dermatomal and single peripheral nerves
– Brain dysfunction: compare left to right
– Upper limbs/lower limbs & “sensory level” over the trunk
(spinal cord)
Sensation: special

• Smell
• Vision
• Hearing
• Vestibular
• Taste
 Clinical features of cerebellar dysfunction

• Ataxia (incoordination) of limbs and gait

• Dysarthria
• Nystagmus
• Dysdiadochokinesis (impaired rapid alternating
movements)
• Pendular reflexes and the rebound phenomenon
 Testing coordination
• Finger-nose test,
• repeated movements,
• heel—knee-shin test
– Finger overshoots its target: dysmetria (past pointing)
– Intention tremor
– Disorganisation of tapping the hand and the turning it
over: dysdiadochokinesia
– In the presence of weakness, test for coordination
must be interpreted with caution
Testing coordination

The finger-nose test

The heel-knee-shin test

 Differential diagnosis of cerebellar ataxia,
sensory ataxia and frontal gait disorders

Cerebellar Sensory Frontal gait

Base of support Wide-based Narrow base, looks down Wide-based
Velocity Variable Slow Very slow
Stride Irregular Regular with path deviation Short, shuffling
Romberg +/- Unsteady, falls +/-
Heel-shin Abnormal +/- Normal
Initiation Normal Normal Hesitant
Turns Unsteady +/- Hesitant, multistep
Postural instability + +++ ++++
Falls Late event Frequent Frequent
 Stance and gait (I)
Examine:
• Simple gait
• As if on a tight-rope (tandem gait)
• On his toes (S1)
• On his heels (L5)

Look at:
• The posture
• Arm swing
• Lateral distance between the feet
• The knees (the knees lifted high: high-stepping)
• Pelvis and shoulders
• Whole movement
• Etc.
Hemiplegic gait Parkinsonian gait Wide-based gait High stepping
Normal

Ataxia

Parkinsonism

Frontal gait disorder

Hemiplegia

Spastic paraparesis
 Stance and gait (II)
• Romberg’s test (primarily of joint position sense): standing with
feet together
– Stands with eyes open, falls with eyes closed = positive
Romberg’s test: loss of joint position sense (impaired
proprioception)
• Posterior column lesion
• Peripheral neuropathy
– Unable to stand with eyes open and feet together = severe
unsteadness
• Cerebellar syndromes
• Central and peripheral vestibular syndromes
– Stands withs eyes open, rocks backwards and forwards with
eyes closed
• Cerebellar syndromes
 Main neurological syndromes

• Syndrome of central spastic paresis

• Syndrome of peripheral flaccid paresis
• Anterior horn syndrome
• Nerve root syndromes (Radicular)
• Polyradicular syndrome
• Polyneuropathies
• Plexus syndromes
• Peripheral nerve syndromes
• Syndrome of neuromuscular junction
• Syndrome of myopathy
Good luck!