Clinical Neurological Examination and Localization

✍ Scribed by Vinit Suri

• Publisher: Springer
• Year: 2024
• Tongue: English
• Leaves: 473
• Edition: 2
• Category: Library

✦ Table of Contents

Preface
Acknowledgments
Contents
About the Author
Part I: Introduction
Chapter 1: Introduction
Chapter 2: Basic Neuroanatomy
2.1 Anatomy of the Motor System
2.1.1 Upper Motor Neurone
2.1.1.1 Brainstem
2.1.1.2 Midbrain
2.1.1.3 Pons
2.1.1.4 Medulla Oblongata
2.1.1.5 Clinical Features of UMN Involvement at Various Sites
2.1.1.6 Midbrain Syndromes
2.1.1.7 Pons Syndromes
2.1.1.8 Medulla Oblongata Syndromes
2.1.1.9 Spinal Cord
2.1.2 Lower Motor Neurone
2.2 Anatomy of the Sensory System
2.2.1 Spinothalamic Pathway
2.2.2 Posterior Column Pathway
2.3 Anatomy of Reflexes
2.3.1 Superficial and Deep Reflexes
2.3.1.1 Superficial Reflexes
2.3.1.2 Deep Tendon Reflexes
2.3.1.3 Pathological Reflexes (Released Reflexes)
Chapter 3: The Neurological History
3.1 Components of History
3.1.1 Demographics
3.1.2 History of Present Illness
3.1.3 Past Medical History
3.1.4 Family History
3.1.5 Social History
3.2 Summarize the History of the Patient
Chapter 4: The Neurological Kit
Chapter 5: Neurological Examination: The Format
5.1 The Format
Part II: Mental Status Examination and Higher Cortical Functions: Screen and Lobar Function
Chapter 6: Mental Status Examination and Higher Cortical Functions
6.1 Screening Tests for Mental Status Function
6.1.1 Attention Span and Vigilance
6.1.2 Orientation
6.1.3 Memory
6.1.3.1 Types of Memory and Their Substrate (Table 6.1)
Immediate Recall
Short-Term Memory
Long-Term Memory
6.1.4 Calculation
6.1.5 Abstract Thinking and Judgement
6.1.6 Visuospatial Tests
6.1.7 Apraxia
6.1.8 Agnosia
6.1.9 Appearance, Behaviour, Mood, Delusions and Hallucinations
6.2 Cognitive Rating Scales
Chapter 7: Specific Lobar Function
7.1 Neuroanatomy: Lobes
7.2 Brodmann Areas
7.3 Important Brodmann Areas (Fig. 7.9)
7.4 Brodmann Areas: 1–52 Areas (Figs. 7.7 and 7.8)
Chapter 8: Frontal Lobe
8.1 Neuroanatomy
8.2 Functions and Tests According to Functional Regions of the Frontal Lobe
8.3 Tests for the Frontal Lobe
Chapter 9: Parietal Lobe
9.1 Neuroanatomy
9.2 Functions of Parietal Lobe and Tests According to Functional Regions of the Parietal Lobe
Chapter 10: Temporal Lobe
10.1 Neuroanatomy
10.2 Functions and Tests According to Functional Regions of Temporal Lobe
Chapter 11: Occipital Lobe
11.1 Functions and Tests According to Functional Regions of Occipital Lobe
Part III: Language and Speech
Chapter 12: Examination of Speech: Language Disorders, Dysarthria and Dysphonia
12.1 Language Disorders or Aphasia
12.1.1 Spontaneous Speech
12.1.2 Comprehension of Speech
12.1.3 Repetition
12.1.4 Paraphasic Errors
12.1.5 Naming
12.1.6 Reading (Alexia)
12.1.7 Writing (Agraphia)
12.2 Dysarthria
12.2.1 Clinical Evaluation
12.2.2 Types of Dysarthria (Table 12.4)
12.3 Dysphonia
Part IV: Cranial Nerves
Chapter 13: Cranial Nerve Examination
13.1 Cranial Nerve Nuclei
13.2 Cranial Nerve Origin
13.3 Cranial Nerve Exit from the Skull
13.4 Characteristic Features
Chapter 14: Olfactory Nerve: First Cranial Nerve
14.1 Neuroanatomy
14.2 Clinical Testing
14.3 Clinical Interpretation
Chapter 15: Optic Nerve: Second Cranial Nerve
15.1 Neuroanatomy
15.2 Clinical Testing
15.2.1 Visual Acuity
15.2.2 Colour Vision
15.2.3 Visual Field Testing
15.2.3.1 Hemianopia
15.2.3.2 Field Defect at Various Sites of the Optic Pathway (Fig. 15.3, Table 15.1)
15.2.4 Pupil
15.2.4.1 Clinical Testing
15.2.4.2 Abnormal Pupillary Responses (Table 15.2)
15.2.5 Fundus Examination
15.2.5.1 Disc Oedema
15.3 Fluorescein Angiography
15.4 Optical Coherence Tomography (OCT)
Chapter 16: Oculomotor (3rd), Trochlear (4th) and Abducens (6th) Cranial Nerves
16.1 Neuroanatomy
16.2 Supranuclear Ocular Movements
16.2.1 Saccades
16.2.2 Pursuit
16.2.3 Convergence
16.2.4 Vestibular Eye Movements
16.3 Infranuclear Ocular Movements
16.4 Oculomotor or Third Cranial Nerve
16.5 Trochlear Nerve Fourth Cranial Nerve
16.6 Abducens or Sixth Cranial Nerve
16.7 Clinical Evaluation of Third, Fourth and Sixth Nerves and Supranuclear Movements
16.7.1 Ocular Movements
16.7.2 Diplopia Testing
16.7.3 Convergence
16.7.4 Nystagmus—Assessment
16.7.4.1 Nystagmus
16.7.4.2 Non-Nystagmus Ocular Oscillatory Movements
16.8 Clinical Evaluation of Nystagmus
16.9 Clinical Interpretation of Ocular Movement Abnormality
16.9.1 Ophthalmoplegia
16.9.2 Conjugate Gaze Palsies
16.9.2.1 Supranuclear Conjugate Palsy
16.9.2.2 Infranuclear Gaze Palsy
Infranuclear or Nuclear Lesions
16.9.3 Skew Deviation
Chapter 17: Trigeminal: Fifth Cranial Nerve
17.1 Neuroanatomy
17.1.1 Sensory Component
17.1.2 Motor Component
17.2 Clinical Evaluation
17.2.1 Motor Examination
17.2.2 Sensory Testing
17.2.3 Reflex Testing (Table 17.2)
17.3 Fifth Nerve Lesion According to Site of Lesion (Tables 17.3, 17.4, and 17.5)
Chapter 18: Facial Nerve: Seventh Cranial Nerve
18.1 Neuroanatomy
18.1.1 Intracranial Course
18.1.2 Extracranial Course
18.2 Clinical Testing
18.2.1 Upper Motor Facial Palsy (UMN)
18.2.2 Lower Motor Facial Palsy (LMN)
Chapter 19: Vestibulocochlear: Eighth Cranial Nerve
19.1 Neuroanatomy
19.2 Clinical Testing
19.2.1 Tests of Cochlear Function
19.2.2 Tests of Vestibular Function
19.3 Electronystagmography (ENG)
19.4 Summary of Examination: Vestibulo-Cochlear Nerve (Tables 19.3 and 19.4)
Chapter 20: The Glossopharyngeal (Ninth) and Vagus (Tenth) Nerves
20.1 Neuroanatomy
20.1.1 Glossopharyngeal (IX)
20.1.2 Vagus (X)
20.1.2.1 Motor
20.1.2.2 Autonomic
20.1.2.3 Sensory
20.2 Clinical Testing
20.3 Lesions
20.3.1 Unilateral Ninth Nerve Lesion
20.3.2 Unilateral Tenth Nerve Lesion
20.3.3 Lesions of Superior Laryngeal Nerve
20.3.4 Lesion of Recurrent Laryngeal Nerve
20.3.5 Unilateral Lesion of Recurrent Laryngeal Nerve
20.3.6 Bilateral Lesion of Recurrent Laryngeal Nerve
Chapter 21: Spinal Accessory Nerve: Eleventh Cranial Nerve
21.1 Neuroanatomy
21.2 Clinical Testing
21.2.1 Bilateral Sternocleidomastoid Lesion
21.2.2 Bilateral Trapezius Weakness
Chapter 22: The Hypoglossal Nerve: Twelfth Cranial Nerve
22.1 Neuroanatomy
22.2 Clinical Testing (Tables 22.1 and 22.2)
Part V: Motor, Sensory System and Reflexes
Chapter 23: Motor System Examination
23.1 Neuroanatomy
23.1.1 Upper Motor Neuron Lesion
23.1.2 Lower Motor Neuron Lesions
23.1.3 Mixed UMN and LMN Involvement Is Seen in the Following
23.1.4 Neuromuscular Junction
23.1.5 Muscle Disorders
23.2 Clinical Assessment of the Motor System Includes the Following
23.2.1 Inspection
23.2.2 Tone
23.2.2.1 Upper Limb
23.2.2.2 Lower Limbs
23.2.2.3 Disorders of Tone
23.2.3 Motor Power
23.2.3.1 Muscles of the Head, Neck and Face
23.2.3.2 Muscles of the Upper Limb
23.2.4 C5 Dominant Innervated Muscles
23.2.5 C6 Dominant Innervated Muscles
23.2.6 C7 Dominant Innervated Muscles
23.2.7 C8 Dominant Innervated Muscles
23.2.8 T1 Dominant Muscles
23.2.8.1 Muscles of the Trunk
23.2.8.2 Muscles of the Lower Limb
23.3 Summary of Examination—Motor System
Chapter 24: The Reflexes
24.1 Superficial Reflexes
24.1.1 Abdominal Reflex (T1–T12)
24.1.2 Cremasteric Reflex (L1)
24.1.2.1 Segment Innovation L1
24.1.3 Anal Reflex (S4/5)
24.1.4 Bulbocavernosus (S3/S4)
24.1.5 Plantar Response or Babinski Response (S1)
24.1.6 Segmental Innervation
24.1.7 The Hoffman Reflex
24.2 Deep Tendon Reflexes
24.2.1 Reinforcement of Reflex (Fig. 24.7)
24.2.2 Grading of Deep Tendon Reflex
24.2.3 Components of a Brisk Reflex
24.2.4 Inverted Reflex
24.2.5 Hung-Up Reflex
24.2.6 Pendular Jerk
24.2.6.1 Biceps Jerk (C5/C6, Through the Musculocutaneous Nerve) (Fig. 24.8)
24.2.6.2 Supinator Reflex (C6 and C5, Through Radial Nerve) (Fig. 24.9)
24.2.6.3 Triceps Reflex (C7, Through Radial Nerve) (Fig. 24.10)
24.2.6.4 Finger Flexion (C8 Through Ulnar and Median Nerve)
24.2.6.5 Knee Reflex (L3 and L4 Through Femoral Nerve) (Figs. 24.11 and 24.12)
24.2.6.6 Ankle Reflex (S1 and S2, Through Posterior Tibial Nerve) (Fig. 24.13)
24.3 Summary of Examination: Reflexes (Tables 24.6 and 24.7)
Chapter 25: Sensory System Examination
25.1 Exteroceptive Sensations
25.2 Proprioceptive Sensations
25.2.1 Segmental Sensory Dermatomes
Part VI: Cerebellar, Movement Disorders, Skull and Spine
Chapter 26: Cerebellar Examination and Examination of Posture and Gait
26.1 Neuroanatomy
26.2 Anatomical Subdivisions
26.3 Morphological Subdivisions
26.4 Intracerebellar Nuclei
26.4.1 Dentate Nucleus
26.4.2 Emboliform Nucleus
26.4.3 Globose Nucleus
26.4.4 Fastigial Nucleus
26.5 Cerebellar Signs
26.6 Clinical Tests
26.6.1 Dysmetria
26.6.1.1 Finger-Nose Test (Fig. 26.5)
26.6.1.2 Knee-Shin-Heel Test (Fig. 26.6)
26.6.2 Dysdiadokokinesia
26.6.3 Nystagmus
26.6.4 Titubation
26.6.5 Intention Tremor
26.6.6 Truncal Ataxia (Fig. 26.7)
26.6.7 Pendular Knee Jerk
26.6.8 Holmes Rebound Phenomenon (Fig. 26.8)
26.6.9 Hypotonia
26.6.10 Speech
26.7 Examination of Posture and Gait
26.7.1 Posture
26.7.1.1 Clinical Assessment
26.7.2 Gait
26.8 Common Gait Disorders
26.8.1 Asymmetrical Gait
26.8.2 Symmetrical Gait
Chapter 27: Involuntary Movements
27.1 Neuroanatomy
27.1.1 Types of Movement Disorders
27.1.1.1 Hyperkinetic Disorders
27.1.1.2 Hypokinetic Disorders
27.1.2 Hyperkinetic Movement Disorders
27.1.2.1 Tremor
Clinical Testing of Tremor
Postural Tremor
Action Tremor
Intention Tremor
Rest Tremor
Certain Other Tremors
27.1.2.2 Chorea
27.1.2.3 Athetosis
27.1.2.4 Tics
27.1.2.5 Hemi-Ballismus
27.1.2.6 Dystonia
27.1.2.7 Asterixis
27.1.2.8 Myoclonus
Approach to Patient with Myoclonus
27.1.2.9 Tardive Dyskinesias
27.1.2.10 Stereotypes
27.2 Hypokinetic Movement Disorders
Chapter 28: Examination of Skull, Spine, Nerves and Neuro-Cutaneous Markers
28.1 Skull
28.1.1 Clinical Evaluation
28.1.1.1 Abnormality of the Skull (Fig. 28.1, Table 28.1)
28.2 Spine
28.2.1 Clinical Evaluation
28.3 Thickened Nerves
28.4 Neurocutaneous Markers
28.4.1 Neurofibroma
28.4.1.1 Diagnostic Criteria of Neurofibromatosis Type 1 (NF1)
28.4.1.2 Diagnostic Criteria of Neurofibromatosis Type 2 (NF2)
28.4.2 Sturge Weber Syndrome
28.4.3 Tuberous Sclerosis or Bourneville Syndrome
28.4.4 Ataxia Telangiectasia or Louis-bar Syndrome
28.4.5 Hypo-Melanosis of Ito or Incontinentia Pigmenti Achromians
28.4.6 Von-Hippel-Lindau Disease
28.4.7 Rarer Forms of Phakomatosis
Part VII: Examination of Autonomic Nervous System and the Peripheral Nervous System
Chapter 29: Automatic Nervous System Examination
29.1 Neuroanatomy
29.1.1 History
29.2 Tests for Automatic Nervous System
29.2.1 Prerequisite for Testing for Autonomic Nervous System
29.2.2 Tests for Autonomic Nervous System
29.2.2.1 Inspection of Skin
29.2.2.2 Cardiovascular Reflexes
Postural Hypotension
BP Response
Heart Rate Response or Cardiovagal Tests
29.2.2.3 Sweating Tests or Sudomotor Tests
Thermoregulatory Sweat Test
QSART (Quantitative Sudomotor Axon Reflex Test)
Skin Sympathetic Response (SSR)
29.2.2.4 Rectum
29.2.2.5 Bladder
Higher Cortical and Pontine Innervation of the Bladder
Sensory Innervation of the Bladder
Central Integration
The Muscles
The Reflex
Storage Phase—Sympathetic System Dominant
Emptying Phase—Parasympathetic System Dominant
29.2.2.6 Pupillary Signs
29.2.2.7 Lab Tests for Autonomic Nervous System
Measurements of Neurotransmitter Levels
29.3 Points to Remember
Chapter 30: Peripheral Nerve Examination
30.1 Inspection and Palpation for Thickened Nerves
30.2 Nerves of Upper Limb (Fig. 30.1)
30.2.1 Axillary Nerve (C6)
30.2.2 Musculocutaneous Nerve (C5, C6, C7)
30.2.3 Median Nerve (C6, T1) (Figs. 30.2 and 30.3)
30.2.4 Ulnar Nerve (C7T1) (Figs. 30.4 and 30.5)
30.2.5 Radial Merve (C5–C8) (Figs. 30.6 and 30.7)
30.3 Nerves of the Lower Limb (Fig. 30.8)
30.3.1 Ilio Hypogastric (T12–L1)
30.3.2 Ilioinguinal (L1)
30.3.3 Genitofemoral Nerves (L1–L2)
30.3.4 Femoral Nerves (L2–L4)
30.3.5 Obturator Nerves (L2–L4)
30.3.6 Lateral Cutaneous Nerve of the Thigh (L2–L3)
30.3.7 Gluteal Nerves (L4–S2)
30.3.8 Pudendal Nerves (S1–S4)
30.3.9 Sciatic Nerves (L4–S3)
30.3.10 Tibial Nerve (Fig. 30.9)
30.3.11 Common Peroneal Nerve (Fig. 30.10)
Part VIII: Examination of the Unconscious Patient and Miscellaneous Neurological Signs
Chapter 31: Examination of the Unconscious Patient
31.1 Q1. What Is the Level of Consciousness?
31.2 Q2. Is the Neurological Examination Focal or Generalized?
31.2.1 Meningeal Signs
31.3 Q3. What Is the Possible Site and Aetiology of the Lesion?
31.4 Signs of Meningeal Irritation
31.5 Ear Examination
31.6 Tongue Examination
31.7 Fundus Examination
Chapter 32: Miscellaneous Neurological Signs
32.1 Signs of Meningeal Irritation
32.2 Signs of Lumbar Root Irritation
32.3 Signs of Tetany
32.4 Signs of Vestibular Dysfunction
Part IX: Summary of Localization
Chapter 33: Summary of Localization
33.1 UMN Lesion and Sites
33.1.1 Approach to Hemiplegia
33.1.2 Approach to Quadriplegia/Paraplegia
33.1.3 Clinical Features According to Site of Lesion
33.2 LMN Lesions
33.3 Summary of Neurological Examination
33.3.1 Demographics
33.3.2 Mental Status and Higher Cortical Functions
33.3.2.1 Frontal Lobe
33.3.2.2 Tests for Frontal Lobe
33.3.2.3 Parietal Lobe
33.3.2.4 Tests for Parietal Lobe
33.3.2.5 Temporal Lobe
33.3.2.6 Tests for Temporal Lobe
33.3.2.7 Occipital Lobe
33.3.2.8 Tests for Occipital Lobe
33.3.3 Speech, Language and Dysarthria
33.3.4 Cranial Nerve Examination
33.3.5 Motor System Examination
33.3.5.1 Attitude
33.3.5.2 Bulk
33.3.5.3 Tone
33.3.5.4 Power
33.3.6 Reflexes
33.3.6.1 Superficial Reflexes
33.3.6.2 Deep Tendon Reflexes
33.3.6.3 Other Reflexes
33.3.7 Sensory System
33.3.8 Cerebellar Signs
33.3.9 Gait
33.3.10 Autonomic Nervous System
33.3.11 Signs of Meningeal Irritation
33.3.12 Skull and Spine
33.4 Investigations
Part X: Investigations
Chapter 34: Lumbar Puncture
34.1 Lumbar Puncture
34.2 Contraindication for Lumbar Puncture
34.3 Technique of Lumbar Puncture
34.4 Interpretation of the CSF Findings
34.5 CSF Pressure Measurement
34.6 Blood Patch for Post LP Low-Pressure Headache
Chapter 35: Nerve Conduction, Electromyography and Evoked Potentials
35.1 Motor Nerve Conduction Studies
35.2 Sensory Conduction Studies
35.3 Late responses
35.3.1 F Waves
35.3.2 H-Reflex or The Hoffmann Reflex
35.3.3 A Wave or Axon Reflex
35.4 Repetitive Nerve Stimulation (RNS)
35.4.1 RNS Technique
35.5 EMG (Electromyography)
35.5.1 Technique
35.5.2 Normal
35.5.2.1 Insertional Activity
35.5.2.2 Spontaneous Activity
35.5.2.3 Motor Unit Potential
35.5.2.4 Recruitment
35.6 Single-Fibre Electromyography (SFEMG)
35.7 Evoked Potentials
35.7.1 VER: The Visual Evoked Potential
35.7.1.1 Technique
Stimulation
35.7.1.2 Abnormality
35.7.2 Brainstem Auditory-Evoked Response (BAER)
35.7.2.1 Technique
35.7.2.2 Abnormality
35.7.3 Somatosensory-Evoked Potentials (SSEPs)
35.7.3.1 Technique
SSEP
35.7.3.2 For Median Nerve
35.7.3.3 For Tibial Nerve
35.7.3.4 SSEP Waveforms
Normal
Chapter 36: Electroencephalogram (EEG)
36.1 Technique
36.2 Localization
36.3 Abnormalities in EEG
36.3.1 Background
36.3.2 Interictal Epileptiform Discharges (IED)
36.3.3 Non-epileptiform Abnormalities
36.4 Reporting of EEG
36.4.1 Clinical Utility of EEG
Chapter 37: Transcranial Doppler (TCD)
37.1 Technique
37.2 TCD Windows
37.2.1 Trans-temporal Window
37.2.2 Transorbital Window
37.2.3 Suboccipital Window
37.2.4 Transforaminal Window
37.2.5 Submandibular Window
37.3 Normal Spectral Waveform
37.4 Clinical Application of TCD
Chapter 38: Magnetoencephalography (MEG)
38.1 Technique
Chapter 39: Biopsy
39.1 Peripheral Nerve Biopsy
39.1.1 Indications for Nerve Biopsy
39.2 Epidermal Nerve Biopsy
39.3 Muscle Biopsy
39.4 Brain Biopsy