Advanced Neuro II

Question 1

Hemineglect

Answer 1

Hemineglect is an abnormality in attention to one side of the universe that is not due to a primary sensory or motor disturbance. Patients ignore visual, somatosensory, or auditory stimuli on the affected side, despite intact primary sensation.

Below are reference MiniCog tasks on the left and the corresponding hemineglect responses on the right.

Question 2

Anosognosia

Answer 2

Unawareness of functional deficits following neural injury.

A patient may be completely paralyzed on one side and not notice.

Question 3

Hemi-asomatognosia

Answer 3

When patients do not comprehend that parts of their body belong to them

Question 4

Tests for neglect

Answer 4

Copy drawing test, construction tasks (like draw a clock, etc)

Question 5

Presence of the grasp reflex on exam often indicates . . .

Answer 5

. . . frontal lobe dysfunction

Question 6

The frontal release reflexes

Answer 6

Frontal lobe lesions in adults can cause the reemergence of certain primitive reflexes that are normally present in infants.

These are collectively called “frontal release reflexes,” and include the grasp, snout, root, and suck reflexes. The grasp and Babinski reflexes are evaluated clinically when patients are suspectedd of frontal lobe dysfunction.

Question 7

Written alternating sequence tasks

Answer 7

Ex, draw alternating square and triangles, or the trail-making test on the MOCA

Patients with frontal lobe deficits have trouble with these tasks.

Preservation may be observed on these tasks when patients, for example, keep drawing squares or keep connecting letters.

Question 8

Auditory Go-No-Go test

Answer 8

Another simple test for frontal lobe dysfunction, specifically for motor impersistence, a form of distractibility in which patients only briefly sustain a motor action in response to a command such as “Raise your arms” or “Look to the right.”

Ability to suppress inappropriate behaviors can be tested by the auditory Go-No-Go test, in which the patient moves a finger in response to one sound, but must keep it still in response to two sounds.

Question 9

When evaluating for CN I function, you should have the patient. . .

Answer 9

. . . cover one nostril at a time and close their eyes. You should also use a different scent for each nostril so the patient cannot simply guess or repeat their answer.

Question 10

“Blink to threat” test

Answer 10

May be used to evaluate visual fields in a patient with impaired mental status.

Have the patient sit still and move your finger quickly toward their eye from an angle that approximates a visual field. Stop before touching their eyelash.

If their fields are intact, they should reflexively blink at each angle of approach.

Question 11

Test for optokinetic nystagmus

Answer 11

Test by moving a strip with parallel stripes on it in front of the patient’s eyes and asking them to watch the stripes go by.

Normally, rhythmic eye movements called nystagmus occur consisting of an alternating slow phase with slow pursuit movements in the direction of strip movement, and a rapid phase with quick refixations back to midline.

Question 12

In comatose or severely lethargic patients, the ___ can be used to test whether brainstem eye movement pathways are intact.

Answer 12

In comatose or severely lethargic patients, the vestibulo-ocular reflex can be used to test whether brainstem eye movement pathways are intact.

The oculocephalic reflex, a form of the vestibulo-ocular reflex, is tested by holding the eyes open and rotating the head from side to side or up and down. The reflex is present if the eyes move in the opposite direction of the head movements, and it is therefore sometimes called doll’s eyes.

In awake patients, doll’s eyes are usually not present because voluntary eye movements mask the reflex. Thus, the absence of doll’s eyes suggests brainstem dysfunction in the comatose patient but can be normal in the awake patient.

Question 13

Corneal reflex

Answer 13

Have the patient look up and gently graze the patient’s eye with the tip of a cotton tipped swave.

The reflexive blink should be symmetrical, and involves both CN V and CN VII.

Question 14

Jaw Jerk reflex

Answer 14

Elicited by gently tapping on the jaw with the mouth slightly open.

Question 15

Testing taste

Answer 15

Can be done by brushing one side of a patient’s tongue with a cotton-tipped swave dipped in a solution of sugar, salt, or lemon juice.

Question 16

Saccades

Answer 16

Eye movements used to rapidly refixate from one object to another without moving the head.

The examiner can test saccades by holding two widely spaced targets in front of the patient (such as the examiner’s thumb on one hand and index finger on the other) and asking the patient to look back and forth between the targets.

Question 17

Test for peripheral vertigo

Answer 17

Have the patient sit up on the exam table. Then, while supporting the patient’s head, have them relatively swiftly, but not too fast, lie back and turn their head to one side. Let them sit here for a moment and examine the eyes for nystagmus.

Then, reverse the maneuver and sit the patient back up with their head straight and again sit here for a moment and watch for nystagmus.

Question 18

Dysarthria vs aphasia

Answer 18

Dysarthria is inability to coordinate the muscle movements to form words.

Aphasia is a deficit in generalized language production and comprehension.

Question 19

Testing for dysarthria

Answer 19

A simple test is to have the patient repeat:

Pa pa pa pa pa pa pa

Ta ta ta ta ta ta ta

Ga ga ga ga ga ga ga

Question 20

Quick tests for CN XI function

Answer 20

CN XI innervates the sternocleodioastmoid and trapezius muscles

Ask the patient to shrug their shoulders, turn their head in both directions, and raise their head from the bed, all against the force of your hands.

Question 21

Unilateral tongue weakness causes the tongue to deviate toward the ___ side.

Answer 21

Unilateral tongue weakness causes the tongue to deviate toward the weak side.

Question 22

Rapid alternating movement test

Answer 22

Tap the front of your hand on your leg, then the back, and then repeat as fast as possible.

(This is the test Dr. Housman always does)

Question 23

Heel-shin test

Answer 23

Should be done with the patient lying down or otherwise with their leg raise so you are not just witnessing the effects of gravity

Test for motor coordination of the lower limb

Question 24

Testing for overshoot

Answer 24

Have the patient lay their hands on their lap.

Then hold out your hand flat and say “When I say go, raise your hands up to the level of mine as fast as you can”

Then, perform the same test with bringing hands down from above the patient’s head.

Question 25

“Stance”

Answer 25

How far apart the feet are

Question 26

Tandem gait

Answer 26

Walk in a straight line heel-to-toe

Particularly difficult for patients with truncal ataxia

Question 27

Forced gait test

Answer 27

To bring out subtle gait abnormalities or asymmetries, it may be appropriate in some cases to ask the patient to walk on their heels, their toes, or the insides or outsides of their feet, to stand or hop on one leg, or to walk up stairs.

Question 28

Tests for the various cranial nerves

Answer 28

Question 29

CN reflex summary

Answer 29

Question 30

Grading of muscle strength

Answer 30

Question 31

Deep tendon reflex summary

Answer 31

Question 32

Grading of deep tendon reflexes

Answer 32

Question 33

Upper motor pattern (UMN) of weakness

Answer 33

A pattern of weakness that signifies a lesion in the central nervous system (above the anterior horn cells of the spinal cord, or the motor nuclei of the cranial nerves).

The pattern is most notable in the muscle groups used to lift limbs against gravity. It is common to see weakness (without atrophy), increased muscle tone, hyperreflexia, clonus, and spasticity. It is often more severe distally compared with proximally

Question 34

Lower motor neuron (LMN) pattern of weakness

Answer 34

A pattern of weakness that affects the peripheral nervous system (nerve fibers traveling from the ventral horn or anterior gray of the spinal cord to the relevant muscle groups).

It causes weakness, atrophy will occur with chronic lesions, decreased muscle tone, decreased or absent reflexes, and fasciculations may be visible

Question 35

Fasciculation

Answer 35

A brief, spontaneous contraction of a few muscle fibers, often appearing as a flickering under the skin, and can be due to loss of nerve function to those muscles

Question 36

Pronator drift

Answer 36

An often-subtle proximal limb weakness from a corticospinal tract lesion. An examiner will see a slow turning of the palm toward the floor and downward drift if an outstretched supinated arm

Question 37

Cogwheeling

Answer 37

A form of rigidity in which a tremor is detected through the rigidity causing a ratchet-like start and stop motion

Question 38

Action tremor

Answer 38

A type of tremor that occurs with muscle contraction

Question 39

Dysdiadochokinesia

Answer 39

Lack of ability to perform rapid alternating movements – a feature of cerebellar ataxia or frontal lobe lesions, or both. An inability to switch off antagonizing muscle groups in a coordinated fashion often due to hypotonia.

Question 40

Hyperesthesia

Answer 40

Abnormally increased sensitivity to sensory stimuli

Question 41

Graphesthesia

Answer 41

The inability to identify letters or shapes when drawn on a body part, such as the palm of the hand

Question 42

Festinating gait

Answer 42

A gait in which a person involuntarily moves with short, accelerating steps, with the trunk flexed forward

Question 43

“Cerebellar” gait

Answer 43

Wide-based stance

Clumsy/unsteady

Unable to perform tandem gait

Patient reels towards the affected side (in unilateral side of cerebellar lesion)

Question 44

If someone has a unilateral cerebellar lesion, their ataxia will be on the ___ side.

Answer 44

If someone has a unilateral cerebellar lesion, their ataxia will be on the ipsilateral side.