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Signs and Symptoms of Neurological Diseases. Berrin Aktekin Department of Neurology. Anatomy - CNS. Cerebral Circulation. Originates from carotid and vertebral arteries. Blood Brain Barrier: Prevents diffusion of toxic substances and large molecules. Neurological Conditions. - PowerPoint PPT Presentation
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Signs and Symptoms of Neurological Diseases
Berrin AktekinDepartment of Neurology
Anatomy - CNS
Cerebral Circulation
Originates from carotid and vertebral arteries.
Blood Brain Barrier: Prevents diffusion of toxic substances and large molecules.
Neurological Conditions Cardiovascular event – stroke, aneurysm Encephalitis/ Meningitis Subdural or Epidural Hematoma Post-concussion syndrome Headaches Seizure/ Epilepsy Cerebral palsy Neurodegenerative diseases
Dementia Parkinson
Demyelinating diseases Multiple Sclerosis – MS
Amyotrophic Lateral Sclerosis - ALS Peripheral Neuropathy
Guillain-Barre Syndrome Muscle Disease Cerebellar Disease
Neurological ExaminationWhat are the components?
Mental Status Language, Speech Cognitive assessment
Meningeal irritationCranial NervesMotor FunctionsReflexes
Deep Tendon reflexes Superficial cutaneous reflexes Pathologic reflexes
Sensory FunctionCerebellar FunctionGait
Mental Status
Level of alertness, awarenessDegree of interactionOrientationFollowing commandsOlder children: naming objects, simple calculations, extinction, neglect, fund of knowledge
Difference from baseline
Mental Status AssessmentLevel of Consciousness (LOC)
alert, somnolent, stuporous, comatose.
Orientation: person, place, time
Memory:Immediate, recent remote
Language, SpeechLanguage
comprehension spontaneous, fluent appropriate content other things you should check: repetition, naming objects,
reading, writingSpeech
prosody volume rate dysarthria
Cognitive AssessmentThought processCalculationsCurrent eventsResponse to proverbsJudgment & problem solving abilityCommunication abilitiesEmotion- Mood and affect
MeninigesCoverings of the Brain & Spinal cord
Meninges: 3 layers tissueDura materArachnoid layerPia mater
Spaces: EpiduralSubduralSubarahnoid
Cerebrospinal fluid:
Contains: no RBC’s, few WBC’s,Glucose 45-75mg/dl,
Protein 15-45 mg/dl.
Cranial Nerves CN 1: Olfactory…yeah, we don’t check that either CN 2: Optic
Visual acuity Visual fields Fundus
CN 3: Oculomotor Pupil reactivity to light (direct and consensual) and accomadation Extraocular eye movements (superior, medial and inferior recti; inferior
oblique) CN 4: Trochlear
Extraocular eye movements (superior oblique) CN 5: Trigeminal
Muscles of mastication Facial sensation (V1, 2, 3 divisions)
CN 6: Abducens Extraocular eye movements (lateral rectus)
Cranial Nerves, continued CN 7: Facial
Facial muscles Taste (anterior 2/3)
CN 8: Vestibulocochlear Hearing Vestibular function
CN 9: Glossopharyngeal Taste (posterior 1/3) Uvula
CN 10: Vagus Phonation Palate elevation
CN 11: Spinal accessory Head turn Shoulder shrug
CN 12: Hypoglossal Tongue protrusion
Motor SystemVoluntary movementI. motor neuron- upper motor neuronExtrapyramidal systemCerebellar systemII. motor neuron- lower motor neuronMuscular system
Motor Pathways
Final Common Pathway
Motor System
StrengthToneMuscle bulk- TrophyReflexesDeep tendon reflexesPathologic reflexesSuperficial cutaneous reflexes
Involuntary movements
StrenghtCheck agonist/antagonist pairs
Grading system0: no movement1: can see muscle contraction but no movement
2: can move with gravity eliminated3: can move against gravity4: can resist opposition to some extent, but not full (+, - also)
5: full strengthPronator drift: correct position!
Muscle Tone AssessmentMuscle Tone- ranges from flaccid to tautAtonia - no muscle tone, no resistanceHypotonia-slight muscle tone, little resistance
Hypertonia- too much resistanceSpasticity- stiff, awkward movements Rigidity- tightness, inability to bend
Muscle bulk-trophyAtrophy
Early II. motor neuron
Late I. motor neuron
HypertrophyPhysiologicPathologicMuscular dystrophy
Reflexes
Deep tendon reflexesPathologic reflexesSuperficial cutaneous reflexes
Deep Tendon Reflexes Assessment
Deep tendon reflexes- Have pt. in relaxed position, with joint supported.
DTR – compare L to RShort blow with reflex hammer to the muscle’s insertion tendon (wrist action)
Reinforcement – Have pt. contract muscles not being tested this aids in relaxing muscles to be tested
DTR GradingScale 0 - 4+
0 = absent,1+ = diminished 2+ = average 3+ = brisk 4+ = hyperactive, clonus
More pathologic descriptors: crossed, spreading
Pathologic reflexes
HoffmanPalmomentalClonus
Sustained Unsustained
Other grasp, suck, moro, jaw jerk
Plantar response
Clonus TestingPerform clonus testing if previous reflex testing reveals Hyperactivity
Relax muscle of calfBriskly dorsiflex foot and hold stretch
Clonus = rapid rhythmic contractions
NO CLONUS ( no movement) = normal
Superficial Cutaneous Reflex Assessment
Abdominal - Umbilicus shifts toward stimulus.
Cremasteric – Testicle on same side of stimulation rises.
Babisnki (Plantar) – Toes flex.
Involuntary movements:
Tics, Fasciculations (fine tremors)Tremors (resting or intentional)ChoreaBallismusAthetosis
Lower vs. UpperMotor Neuron Weakness
Upper Motor Neuron
(Brain to corticospinal tract)
Lower Motor Neuron
(Anterior horn cells to peripheral nerves)
Reflexes Hyperactive+/- clonus
Diminished or absent
Atrophy Absent* PresentFasciculatio
nsAbsent Present
Tone Increased (spasticity) Decreased or absentToes Up-going (Babinski’s sign) Down-going
*Disuse atrophy can develop after initial presentation
Distinguishing Lower Motor Weakness from Muscle Weakness
Neuropathy MyopathyDistribution Distal > proximal Proximal > distal
Fasciculations May be present AbsentReflexes Diminished Often preservedSensory
signs/symptoms
May be present Absent
• Weakness due to neuropathy: lower motor neuron disease.
• Weakness due to myopathy: nerve function intact.
Sensory SystemFive sense !!!Peripheral Sensory System
SpinothalamicDorsal Column
Cortical-integrative Sensory System
Visceral Sensory System
Peripheral Sensory System
Spinothalamic system-Cutaneous Pain- Temperature Light touch/pressure
Dorsal Column-Medial Lemniscal System-Proprioception
Vibration Position
Spinothalamic system
Dorsal Column-Medial Lemniscal System-
GraphestesiaStereognosisBarognosisTopognosisTwo point discrimination
Cortical SensoryIntegrative sensation
Sensory FunctionPerform all sensory testing with
the patient’s eyes closed and test bilaterally.
Components Light touch Pinprick Temperature Vibration Joint position sense Cortical-integrative
Compare sides Proximal/distal Right / left Dermatome Individual peripheral nerves Checking a level
Romberg- correct positioning!
Cerebellar Functions
Coordination -Corrections of the voluntary motor out-put Rapid alternating
movements Target finding
Tonus Hipotonia
Balance Ataxia
Posture and gait – steady gait with arm swing, balance maintained.
Romberg test – Have pt. stand, feet together, arms side, eyes closed.
Heel to toe gait – tandem walk
Cerebellar Function AssessmentRapid Alternating Movements (RAM)Hand movements- Tap finger to thumb, rapidly. Tap each finger to thumb rapidly.Pronate and supinate hands rapidly on knees
Finger to nose test – Eyes closed touch finger to nose alternating and increasing speed
Finger to finger test - Have pt. touch his fingertip to your fingertip, alter position.
Heel to shin test – While supine or sitting, have pt run heel of one foot over the shin of opposite leg
Rebound Phenomen
GaitPosture of body and limbsLength, speed and rhythm of steps
Symmetry and base of gaitSteadinessArm swingTurns Test with normal gait, toe walking, heel walking, tandem walking
CasualToe HeelTandemWhat are those last 3 testing?
Gait
