1. The document discusses examination of the cranial nerves and neurological system. Key tests described include evaluation of gait, stance, speech, mental status and cranial nerves I-XII. 2. Specific disorders are discussed such as types of dysarthria and dysphasia, optic nerve conditions seen on fundoscopy, and lesions affecting cranial nerves. 3. Examination techniques are provided for assessing conditions of the cranial nerves including testing of smell, hearing, eye movements, facial strength, and vestibular function.

1. ‫الرحمن‬ ‫ال‬ ‫بسم‬
‫الرحيم‬
CNS EXAMINATION
Dr. M.H.F.
Neurosurgeon

2. 2
Consciousness:
1.State(awakefullness): RAS
(lower pons
to thalamus).
2.Content(awareness): cerebral
cortex &
thalamus.
•Evaluation of comatose
pt.:
a.GCS.
b.pupils, fundi & ocular
movements
c.FND

3. 3

4. 4
• Meningism S. & S.
Stance:
1.Stand up straight with feet
close & eye open.
2. Imbalance, with eyes open
suggest cerebellar ataxia, with
eyes closed suggest sensory
ataxia (proprioceptive defect)(+ve
Romberg's test).
Gait:
Ask pt.to walk 10 m. &
return.
Ask the pt. to walk heel to
toe (tandem gait) to identify
gait ataxia.

5. 5
Types of gait:
1. Ataxic gait.
2. Hemiplegic(spastic) gait.
3. Scissoring(paraplegic)gait.
4. Festinant&shuffling gait.
5. Apraxic gait.
6. Steppage gait.
7. Waddling(dystrophic/
myopathic) gait.
8. Antalgic gait.
9. Orthopaedic gait.
10. Bizzare(functional or
hysterical) gait.
11. Choreic gait in
Huntington’s dz.

6. 6
Speech difficulties:Speech difficulties:
1. Mutism: bilateral medial
frontal lobe lesion→no
attempt to speak.
2. Dysphonia: impairment of
voice production from vocal
cord &/or larynx dz.
3. Dysarthria:
disarticulation.
4. Dysphasia: disturb of
understand &/or expression
of words.

7. 7
Examination for Speech
disorder:
Dysarthria & Dysphonia:
1. Listen to pt. volume, rhythm & clarity of
speech.
2. Ask pt. to repeat: (yellow lorry) for lingual
sounds & (baby hippopotamus) for lip (labial)
sounds. Then a tongue twister (e.g. the Leith
Police dismisseth us).
3. Ask pt.to count steadly to 30to asses ms.
Fatique.
4. Ask the pt. to cough & say Aaah to test
dysphonia.

8. • Causes of Dysarthria &
Dysphonia:
1. Spastic (pseudobulbar) dysarth: bilat.UMNL.
(+ve jaw jerk)
2. Bulbar dysarthria: LMNL, pt. has ligual
sounds/nasal speech.
3. Extrapyramidal dysarthria: d.to
parkinsonism, monotonous speech.
4. Cerebellar (ataxic) dysarthria:slow,slurred
speech.
5. Myasthenia gravis speech (fatiguable
speech).
6. Dysphonia c.by laryngitis/vagus n. damage,
cough bovine.

9. 9
Dysphasia:
assess fluency, comprehension,
repetition, naming, dyslexia & agraphia.
1. Listen for fluency, paraphasia (incorrect
words) & neologisms (nonsense words).
2. naming.
3. asses comprehention: give simple 3 command
e.g. pick up the piece of paper, fold it in half &
place it under the book (without visual clues).
4. Repeat a simple sentence (repetition).
5. Ask the pt. to read passage (lyxia).
6. Ask the pt. to write a sentence(graphia).

10. 10
naming repetition comprehen
tion
Fluency
+/-ve -ve +ve -ve Broca's Aphasia
-ve -ve -ve +ve Wernicke's Aphasia:
+ve -ve +ve +ve Conduction Aphasia
-ve +ve +ve +ve Anomic Aphasia
-ve -ve -ve -ve Global Aphasia
-ve +ve -ve +ve Transcorticalsensory
-/+ve +ve +ve -ve Transcortical motor
-ve +ve -ve -ve Mixed transcortical

11. 11
Mental function:
1. Appearance & behaviour: self neglect, Depression,
Dementia, Drinking & Drug abuse. Behavior (frontalism), flat
affect, emotional liability & hysteria.
2. Mood: Depression, Schizophrenia blunting affect.
3.Vegetative symptoms: (wt.loss, sleep disturb, appetite,
constipation & libido).
4. Delusion, Illusion & hallucination:
Delusion: firmly held belief not altered by rational
argument.
Illusion: Miss interpretation of external stimuli.
Hallucination: Perception without external stimuli,

12. 12
Mental assessement:
1. Attention & Orientation:
2. Memory:
3. Calculation:
4. Abstract:
5. Spatial orientation: constructional apraxia.
6. Visual & body perception (Agnosia)
Prosopagnosia: Failure to recognize faces
Hemineglect: One side ignorance
Asomatognosia: Failure to recognize left hand.
Anosagnosia: Unawareness of affected side weakness.
Asteriognosis: Sensory agnosia.
Agraphaesthesia: Failure to recognize shape.
Gerstman's syndrome = Acalculia, finger agnosia, Rt.-
Lt.disorientation & agraphesthesia.
7. Apraxia: a.Ideational apraxia b.Ideomotor apraxia
c. Dressing apraxia d.Constructional apraxia

13. 13

14. 14
Cranial nerves examination:
I. Olfactory nerve:
Close eye & shut one
nostril & use coffee,
chocolate, soap, &
ask pt. to sniff.
Causes of Anosmia:
Bilateral anosmia caused by common cold.
Unilateral anosmia caused by HI & basal skull #, or
brain tumour. Parkinson & Huntington dz.
Paraosmia is perceiving of pleasant odour as
unpleasant & may occur in HI, sinus infection or
drug.

15. 15
Optic nerve:
a. Inspection: ptosis, proptosis,
enophthalamus & lid retraction.
b. Pupil: size, shape, symmetry,
light/accomodation Rx.
c.Visual acuity:Snellen chart.
d.Visual field: perimetry & confrontation test.
e.Colour vision: Ishihara test plates.
f.Fundoscopy:
1.optic disc: papilloedema, papillitis & colloid bodies (drusen).
2. bld vess: A-V nipping, neovascularization & cholesterol
embolous.
3. Retina:
Red lesion: dot & blot hrg, flame hrg., sub hyaloid hrg.
White lesion: hard exudates, cotton wall (soft) exudates.
Black lesion: moles/melanoma, laser burn, Retinitis pigmentosa.

16. 16
Papilloedema

17. 17
Severe papilloedema

18. 18
Pseudopapilledema.The disc margin is blurred but
the n.fiber layer appears clear.

19. 19
Optic disc drusen

20. 20
Anterior optic neuritis in right eye

21. 21
Anterior ischaemic optic neuropathy in right eye

22. 22
Anterior ischemic optic neuropathy

23. 23
Neuroretinitis

24. 24
Optic disc swelling&optociliary shunt vessels

25. 25
Papillophlebitis

26. 26
Optic disc edema&hyperemia(central retinal v.occlusion)

27. 27
Optic disc swelling,hrge&infiltrationin sarcoidosis.

28. 28
Hypcremic disc with telangiectatic vess(Leber's optic npathy)

29. 29
Swollen optic disc in early papilledema

30. 30
Disc edema and hrg.in acute papilledema.

31. 31
Chronic papilledema with pseudodrusen.

32. 32
Chronic papilledema

33. 33
Swollen optic disc in malignant hypertension.

34. 34
Diabetic papillopathy

35. 35
Tilted optic disc.

36. 36
Optic nerve hypoplasia.

37. 37
Optic disc coloboma.

38. 38
Central retinal artery occlusion

39. 39
Central retinal artery thrombosis

40. 40
Multiple cotton-wool spots(SLE)

41. 41
Central retinal vein
occlt

42. 42
Retinitis pigmentosa

43. 43
Retinitis Pegmentosa

44. 44
Astrocytic hamartoma

45. 45
Occlusion of br.of retinal artery from a cholesterol embolus

46. 46
If severely impaired VA (Snellen chart is unuseful), count
fingers. then light percept.
Poor VA with cataracts, ant. optic chamber (glaucoma), retina
(macular degen.) or optic neuritis. ↓ VA (central VF defect) c. by
cataract.
Macular & Optic n.lesion → central scotoma.
Peripheral retina lesion → ring scotoma.
Optic disc lesion → horizontal or arcuate scotoma.
Optic n. damage from photoreceptors to lat.geniculate body →
impaired red-green colour vision.
Congenital red green blindness (X-linked recessive) affect 7% of
male.
Papilloedema→enlarged blind spot due to ↑ ICP.
Functional (hysterical) VF loss is bilateral VF constriction (tubular
constriction).
Bilat. retinal disorder(retinitis pigmentosa)→funnel constriction.

47. 47

48. 48
III,IV&VI Exam:
1.Look for head turn or tilt.
2.pupil, light & accommodation reflux.
3.Look gaze direction, squint
or diplopia.
4. If squint &/or diplopia, do cover test, squint eye;
absence of outer image mean covered eye is paralytic.
5. Look for nystagmus direction & position.
4 types of eye movement:
1. Saccadic: rapid (frontal lobe).
2. Pursuit: slow (occipital lobe).
3. Vistibular-positional (vistibulo-ocular): cerebellar & vestibular
nuclei.
4. Convergence: midbrain.

49. 49
Internal and external

50. 50

51. 51
The centre for lat. gaze (PPRF) in Pons & for vert.
gaze is in Midbrain. Connection between is MLF.
INO c.by MLF lesion. One & half syndrome c.by
lesion of PPRF. & MLF. IN & supranuclear lesion
rarely c.diplopia.

52. 52
Squint either Paralytic or incomitant
(acquired or congenital) or non paralytic or
concomitant squint.
In acquired paralytic squint diplopia is
greatest direction of paretic ms., in cong.
long standing paralytic squint, the head is
tilted to minimize diplopia.
Concomitant squint are same in all
direction of gaze, it is not associated with
diplopia, because this symptom is
suppressed centrally in young child→
amblyopia (lazy eye).

53. 53
Vn.Exam:
a. Sensory: ophthalmic,
maxillary & mandibular
division.
Light touch,superficial
pain & touch sensation
in the ant. 2/3 of tongue.
b. Motor: inspect mastication ms.,
clench the teeth & feel masseter ms. &
open jaw against resistance
c. Corneal reflux & jaw jerk.

54. 54
VII n.Exam:
a. Inspect face asymmetry,
blinking, eye closure, spontaneous
/involuntary movement.
b. wrinkle forehead, bare teeth,
shut eye tightly & blow out cheecks.
c. Taste from ant. 2/3 of tongue.
d. Schirmer’s test.
e. corneal reflux.
UMN VII weakness spares frontalis so pt. can wrinkle brow.
LMNVIIweakness involves forehead ms. & pt can’t wrinkle brow &
has unilat.
Hyperacusis & loss of taste. Facial diplegia, or bilat. LMN VII
weakness is seen in such conditions as GBS or sarcoidosis.
N.B.: Bell’s phenomena: eyes turn upwards on attempts closure
which indicates VII n. palsy.
Whistle-smile sign (no smile when whistle).

55. 55
Lesions of VII n.:
a.Distal to junction
with corda tympani
=LMNL.
b.Distal to n.to stapedius=above+
tongue ant.2/3taste loss(ageusia).
c.Distal to lacrimal br.GSPN=above
+hyperacusis.
d.Proximal to GSPN.=above+loss of
lacrimation.

56. 56
ExamVIIIn.:
Rinne’s & Weber’s test.
Check gross hearing in each ear by rubbing
fingers about 3 inches from ear, with
contralat. ear covered.
If hearing in one ear impaired, perform Rinne
& Weber tests.
With conductive hearing loss, from middle ear
dz or obstruction of EAM with wax, BC > AC &
Weber test will lateralize to the deaf ear.
With SN hearing loss AC better than BC &
Weber test will lateralize to good ear.

57. 57
Vistibular nerve Exam:
a. Gait & turning test.
b.Nystagmus (Dix-Hallpikes test)
In normal individual, no nystagmus. In peripheral
lesion, vertigo & nystagmus after delay of 5-15
second, decline as the position maintained & fatique
if the test repeated (fatiquable rotary nystagmus
with delay). In central lesion, no latency, no fatique
& less prominent vertigo.
c.Oculocephalic test (Doll’s eye reflux).
d.Oculovistibular reflux: In coma, tonic movement
occurs towards irrigated ear. In canal paresis,
reduced response to cold & warm stimuli.

58. 58
IX & Xn.:
a. assess speech for
dysarthria & dysphonia,
swallowing, coughing&
laryngoscopy.
b. Pt.says Aaah & look
moving Palate & uvula.
c. Test sensation of pharynx,
larynx, post. 1/3 of tongue
& parotid gland.
d. Gag reflux.
e. Ask the pt. to puff out cheeks
with lips closed, look & feel air
escaping from nose.

59. 59
Deviation of uvula
to one side implies
LMNL of X n. contralat.
to side the uvula is
deviating to normal.
UMNL of X n. present
with uvula deviating
toward the side of lesion.
N.B.: Damage to IX &/or X n.→deviation of the
uvula to normal side.
Damage to recurrent laryngeal nerve cause
dysphonia & bovine cough. Bilateral vagus
nerve damage cause dysphagia.

60. 60
XI n. Exam: a. Inspect scm & trapezius for wasting
& fasciculation.
b. Elevate&turn head against resistance.
c. Shrug shoulder against resistance.
N.B.: ipsilat.cerebral 1/2 supply contralat.
Trapezius & ipsilateral scm. ms. Weakness of both
ms.on same side means peripheral accessory n.
palsy (LMNL.).
Weakness of ipsilateral st.cl.m & contralat.
trapezius means UMNL. ipsilateraly. Unilateral
delayed shoulder shrug means contralat. UMNL.
Bilateral weakness & wasting of scm.ms. means
myopathy (dystrophia myotonica & Mgravis).
Head tilt means cervical dystonia.

61. 61
XII Exam.:
a. Open the mouth &
inspect the tongue for
wasting, fasciculation &
involuntary movement.
b. Protrude tongue &
look for deviation
ipsilateraly.
c. Move tongue & press
against cheek to assess
power.
d. Assess speech &
say yellow lorry.

62. 62
N.B.:LMNL. unilaterally
c. deviation of tongue
to affected side. LMNL.
bilaterally
c. wasting & shrunken
tongue&in severe weakness
there is dysarthria & dysphagia. UMNL.
Bilaterally (pseudobulbar palsy) cause
spastic conical tongue & result from
vascular dz., MND. & MS.
Resting tongue tremor=parkinson dz.
Orolingual dyskinesia is drug induced
(antiparkinson & neuroleptics).

63. 63
Motor system exam:
a.Weakness b.Hyperreflexia.
c.Hypertonia d.Spasticit
Examination:
1. Inspection.
2. Tone.
3. Power & movement.
4. coordination.
5. Refluxes.

64. 64

65. 65
Cortico-Bulbar Tracts.Nuclei of Brainstem

66. 66
Ms. weakness in: UMNL., LMNL., ms. dz. (wasting, hypotonia &
hyporeflexia), NMJ, fatique weakness (normal/hypotonia &
normo refluxia) & functional weakness (normal tone &
refluxes & no wasting).
In ms. disorder, ms. Wasting & myopathy u. occure proximaly
except in dystonia myotonica myopathy occurs distally.
Hyperreflexia = UMNL., Hyporflexia = LMNL. & myopathy.
In Holmis Adies syndrome myotonic pupil, there is loss of deep
tendon reflexes.
In Hypothyroidism, normal refluxes with delayed (slow)
relaxation. +ve Hoffman’s = hypertonia & UMNL.
In cerebellar damage, pendular reflux.
Inverted reflux = tapping biceps tendon → triceps contraction
indicate combined spinal cord&root pathology.

67. 67
•Superficial refluxes:
1.Abdominal reflux (T8-12):
light & brisk stroke medialy across upper & lower
1/4 of abdomen.
This reflux is lost in UMNL. & affected by LMNL.
Affect T8-T12. It is difficult to elicit in obese &
elderly & abdomen sx, frequent pregnancy,
pyramidal tract lesion above & peripheral nerve
abnormality.
2. Planter reflux(S1&2): stroke planter aspect of the
foot,or lateral aspect of the foot (Chaddock’s
reflux),or move down the medial aspect of the tibia
by the thumb & index finger (Oppenheim’s
reflux),Upward movement means UMNL.
3. Cremasteric reflux (L1&2): stroke the upper
medial aspect of adducted& externally rotated
thigh cause brisk rise testis.

68. 68
•Primitive refluxes:
in adult = frontal lesion.
1.Snout reflux: lightly tab lips→protrusion
mouth.
2. Grasp reflux: firmly stroke the palm from
radial side cause gripping of the pt. hand.
3. Palmomental reflux: firm pressure to the
palm next to thenar eminence with tongue
depressor cause puckering of the chin.
4. Glabellar tap: tapping on the glabella
with index finger causing blinking response
which normaly stop after 3-4 tap. If it
continue&not stop,it means parkinsonism.

69. 69
Sensory system exam:
5 modalities:
Vibration, j.position & light touch(post.
column, large fibers).
Pain & temp. sensation (spinothalamic
tract, small fibers).
To test vibration,128Hz fork, start distally
& ↑proximaly
Test sacral sensation in:
1.Urinary/bowel symptoms.
2.Bilateral leg weakness.
3. Sensory loss in both legs.
4. Conus medullaris/cauda equina lesion.

70. 70
Dorsal Column,Medial Lemniscus,Discriminative Touch,Joint Position&Vibration

71. 71
Anterolateral System
— Pain, Temperature, and Crude Touch
Anterolateral System,Pain, Temperature, and Crude Touch

72. 72
V Pathways,Discriminative Touch,Pain &Temperature

73. 73

74. 74
Examine:
1.Light touch.
2.Superficial pain.
3.Deep pain.
4.Temperature.
5.Vibration.
6.Joint position sensation.
7.2point discrimination.
8.Point localization.
9.Steriognosis &graphesthesia.
10. Sensory inattention: recognize one
side,u.rt,when both stimulated, parietal
lobe lesion.

75. • Grades of sensory recovery:
S0 = Absence of all modalities of
sensation.
S1 = only deep cutaneous pain.
S2 = some superfiscial cutaneous
pain.
S3 = superfiscial cutaneous pain&
tactile sensation with disappear of
previous over response.
S3+=as S3 with recovery of 2 point
discrimination.
S4 = normal sensation.

76. 76
Extrapyramidal System Exam:
hypokinetic or hyperkinetic.
•Hypokinetic disorders are: rigidity,
bradykinesia & tremor (Parkinson’s
syndrome).
There is ↑ flexor tone → stooped posture with
head, neck, trunk, arms& legs flexed.
Tremor& slowness of movement & cogwheel
rigidity.
The pt has festinating gait&no motor
weakness.
• Hyperkinetic disorders are excessive motor
activity(chorea,athetosis,dystonia or
hemiballismus).

77. 77
LV LV
GP
(thalamus)
P
Caudate tail

78. 78
Rubro-Spinal Tract

79. 79
Pontine (Medial) Reticulo-Spinal Tract

80. 80
Medullary (Lateral) Reticulo-Spinal Tract

81. 81
Lateral Vestibulo-Spinal Tract

82. 82
Vestibular Nuclei and Eye Movements
Interstitial n. of Cajal
(MLF)
Superior vestibular n.
Lateral vestibular n.
Inferior vestibular n.
Medial vestibular n.
Oculomotor n.
Trochlear n.
Abducens n.
Medial vestibulo-spinal
tract(within MLF)
Lateral vestibulo-spinal
tract

83. 83
Cerebellar signs: DANISH
Assesement of cerebellar
function,ms.weakness, proprioceptive loss
& extrapyramidal dysfunction. We should
test for:
1. Stance & Gait.
2. Speech (dysarthria).
3. Nystagmus.
4. Tone (hypotonia) & Refluxes(pendular).
5. Rebound phenomina.
6. Finger-nose or Heel-Shin test, dysmetria &
dyssynergia.
7. Intentional tremor.
8. Dysdiadochokinesis.

84. 84
Examination of brain stem death:
1.Confirm cause of irreversible brain stem
damage.
2. Exclude reversible causes of
coma(hypothermia, hypoglycaemia,drug
overdose).
3. Confirm ventilator dependency(disconnection
cause rise of arterial PCO2 >7kpa with no
spontaneous respiration.
4. The pupil is fixed&dilated with no light
reflux.
5. Corneal reflux is absent.
6. Oculovestibular reflux absent with no
nystagmus.
7. Gag reflux is absent.
8. The pt.examined by 2 experienced clinician on
2 occasions,24 hrs apart.