Assessment of brain involvement

When a neurologic disorder is suspected, doctors usually evaluate all of the body
systems during the physical examination, but they focus on the nervous system.
Examination of the nervous system—the neurologic examination—includes
evaluation of the following:

 Mental status
 Cranial nerves
 Motor nerves
 Sensory nerves
 Reflexes
 Coordination and balance
 Walking (gait)
 Regulation of internal body processes (by the autonomic nervous system )
 Blood flow to the brain
Doctors may evaluate some areas more thoroughly than others depending on what
type of disorder they suspect.

The neurologic examination can also help identify the cause of a muscle
malfunction (such as weakness or paralysis) because normal muscle contraction
depends on stimulation by a nerve (see figure Using the Brain to Move a Muscle ).
A neurologic examination differs from a psychiatric examination, which focuses
on a person's behavior. However, the two examinations overlap somewhat
because abnormalities in the brain can cause abnormal behavior. Abnormal
behavior can be a clue to a physical problem in the brain.

Mental Status

Doctors evaluate the following:

 Attention

 Orientation to time, place, and person

 Memory

 Various abilities, such as thinking abstractly, following commands, using

language, and solving math problems
  Mood

The mental status evaluation consists of a series of questions and tasks, such as
naming objects, recalling short lists, writing sentences, and copying shapes. The
person’s answers are recorded and scored for accuracy. If the person reports
feeling depressed, doctors ask if there have been any thoughts of suicide.

Cranial Nerves

There are 12 pairs of cranial nerves, which connect the brain with the eyes, ears,
nose, face, tongue, throat, neck, upper shoulders, and some internal organs (see
table Testing Cranial Nerves ). How many nerves doctors test depends on what
type of disorder they suspect. For example, the 1st cranial nerve (the nerve of
smell) is not usually tested when a muscle disorder is suspected, but it is tested in
people recovering from serious head trauma (because smell is often lost).
A cranial nerve may be damaged anywhere along its length as a result of any of
the following:

 An injury

 Impaired blood flow

 An autoimmune disorder

 A tumor

 An infection

The exact site of the damage can often be identified by testing the functions of a
particular cranial nerve.

Motor Nerves

Motor nerves carry impulses from the brain and spinal cord to voluntary muscles
(muscles controlled by conscious effort), such as muscles of the arms and legs.
Muscle weakness or paralysis of a muscle may indicate damage to any of the
following:

 The muscle itself

 A motor nerve
  The nerve's connection to the muscle (neuromuscular junction)
 The brain

 The spinal cord

Doctors look for abnormalities such as the following:

 A decrease in muscle size (wasting, or atrophy)

 An increase in muscle size

 Tremor (rhythmic shaking of a body part) and other unintended

(involuntary) muscle movements
 Muscle twitching

 An increase (spasticity or rigidity) or a decrease in muscle tone

 Weakness, particularly which body parts are affected (pattern of weakness)

 Loss of dexterity (the ability to use the hands skillfully and nimbly)

The doctor inspects the muscles for size, unusual movements, tone, strength, and
dexterity.

Change in muscle size

A muscle wastes away (atrophies) when the muscle or the nerves supplying it are
damaged or when the muscle has not been used for months for other reasons
(such as being in a cast).

A muscle may increase in size (hypertrophy) because it is working harder to

compensate for the weakness of another muscle. Muscles can appear to increase
is size when normal muscle tissue is replaced by abnormal tissue, as occurs
in amyloidosis and some inherited muscle disorders (such as Duchenne muscular
dystrophy). The abnormal tissue increases the apparent size but not the strength
of the muscle.
Involuntary movements
Muscles may move without the person meaning them to (involuntarily). The
following are examples of involuntary movements:
 Fasciculations are tiny, subtle muscle twitches, which may look ripples
under the skin. Fasciculations may indicate nerve damage to the affected
muscle.
  Myoclonus refers to sudden jerking (contractions) of a muscle or a group of
muscles, such as those in the hand, arm, or leg. The muscles move as if the
person had just received an electric shock. Myoclonus may occur normally,
as when people are falling asleep, or may be caused by a disorder that
affects the spinal cord or brain.
 Tics are purposeless, repetitive but not rhythmic involuntary movements,
such as blinking or jerking the head. Tics often also include involuntary,
abrupt, often repetitive sounds and/or words.
 Hemiballismus usually involves the sudden involuntary flinging of one arm
and/or one leg.
 Chorea refers to quick fidgety involuntary movements that start in one part
of the body and often move abruptly and unpredictably to another part.
 Athetosis refers to continuous slow, writhing involuntary movements.
 Dystonia refers to long-lasting (sustained) involuntary muscle contractions
that may force people into abnormal, sometimes painful positions.
Involuntary movements may indicate damage in the areas of the brain (basal
ganglia) that control motor coordination.

Muscle tone
To evaluate muscle tone, doctors first ask the person to completely relax muscles
in a limb. Then doctors move the person’s limb to determine how much the
relaxed muscle involuntarily resists being moved—called muscle tone. How
muscle tone reacts to being moved suggests possible causes, as follows:

 Uneven muscle tone that suddenly increases as the relaxed muscle is moved
(spasticity): Possibly due to a stroke or spinal cord injury
 Evenly increased muscle tone: Possibly due to a disorder of the basal
ganglia, such as Parkinson disease
 Severely reduced muscle tone (flaccidity): Possibly due to a disorder of the
nerves outside of the brain and spinal cord (peripheral nerves), such
a polyneuropathy (a disorder that affects many nerves throughout the body)
Flaccidity may be present for a short time after an injury that causes paralysis,
such as a spinal cord injury. When flaccidity results from such a spinal cord
injury, muscle tone often gradually increases over days to weeks, eventually
resulting in spasticity.

If people are afraid or confused during the examination, they may not be able to
relax the muscles. In such cases, muscle tone may vary, making it hard for
doctors to evaluate.
Muscle strength
Doctors test muscle strength by asking the person to push or pull against
resistance or to do maneuvers that require strength, such as walking on the heels
and tiptoes or rising from a chair. Doctors then rate muscle strength from 0 (no
muscle contraction) to 5 (full strength).

Sometimes muscle weakness is evident when a person uses one limb more than
another. For example, a right-handed person may gesture mostly with the left
hand during a conversation. A weak arm may swing less while walking or drift
downward when the arms are held up and the eyes are closed.
Knowing which body parts are weak (the pattern of weakness) can help doctors
identify what the problem is, as in the following cases:

 The shoulders and hips are weaker than the hands and feet: The cause may
be a disorder that affects muscles (myopathy). Myopathies tend to affect the
largest muscles first. People may have difficulty raising their arms to comb
their hair, climbing stairs, or getting up from a seated position.

 The hands and feet are weaker than the shoulders, arms, and thighs: The
problem is often a polyneuropathy (the malfunction of many peripheral
nerves throughout the body). Polyneuropathies tend to affect the longest
nerves first (those going to the hands and feet). People may have a weak
grip and have trouble with fine finger movements (dexterity). People may
have difficulty fastening a button, opening a safety pin, or tying their shoes.
 Weakness is limited to one side of the body: Doctors suspect a disorder
affecting the opposite side of the brain, such as a stroke.
 Weakness occurs below a certain level of the body: The cause may be
a spinal cord disorder. For example, an injury to the part of the spine in the
chest (thoracic spine) causes the legs but not the arms to be paralyzed. An
injury in or above the neck causes paralysis of all four limbs.
Muscle weakness may also occur in other patterns, such as the following:

 Weakness occurs in only one relatively small area: This type of weakness
suggests that only one or a few peripheral nerves are damaged. In such
cases, weakness may also impair dexterity.

 Weakness becomes apparent only when muscles that are used to do the same
activity over and over become weak more quickly than usual. For example,
people who once could use a hammer well become weak after hammering
for several minutes. Myasthenia gravis can cause this type of weakness
Sensory Nerves

Sensory nerves carry information from the body to the brain about such things as
touch, pain, heat and cold (temperature), vibration, the position of body parts, and
the shape of objects. Each of these senses can be tested. Abnormal sensations or
reduced perception of sensations may indicate damage to a sensory nerve, the
spinal cord, or certain parts of the brain.

Information from specific areas on the body’s surface, called dermatomes, is

carried to a specific location (level) in the spinal cord, then to the brain. Thus,
doctors may be able to pinpoint the specific level of damage to the spinal cord by
identifying the areas where sensation is abnormal or lost.
The surface of the skin is divided into specific
areas, called dermatomes. A dermatome is an area
of skin whose sensory nerves all come from a single
spinal nerve root. (Sensory nerves carry information
about such things as touch, pain, temperature, and
vibration from the skin to the spinal cord.)

Spinal roots come in pairs—one of each pair on

each side of the body. There are 31 pairs:

 There are 8 pairs of sensory nerve roots for the

7 cervical vertebrae.

 Each of the 12 thoracic, 5 lumbar, and 5 sacral

vertebrae has one pair of spinal nerve roots.

 In addition, at the end of the spinal cord, there

is a pair of coccygeal nerve roots, which
supply a small area of the skin around the
tailbone (coccyx).

There are dermatomes for each of these nerve roots.

Sensory information from a specific dermatome is

carried by sensory nerve fibers to the spinal nerve
root of a specific vertebra. For example, sensory
information from a strip of skin along the back of
the thigh, is carried by sensory nerve fibers to the
2nd sacral vertebra (S2) nerve root.

Sensation in the skin is tested. Usually, doctors concentrate on the area where the
person feels numbness, tingling, or pain. The best screening test for loss of
sensation involves touching the skin of the face, body, and all four limbs with a
pin and a blunt object (such as the head of a safety pin) to see if the person can
feel them and tell the difference between sharp and dull. Doctors test both sides
of the body. If doctors detect loss of sensation in a specific area, they test nearby
areas to estimate the extent of the loss. This approach enables them to determine
the abnormality's location in the brain, spinal cord, or peripheral nervous system.
Gentle (light) touch is tested with a cotton wisp.
Temperature sense (the ability to feel hot and cold) is tested with a tuning fork.
Both prongs are cold, so the examiner warms one of them slightly by rubbing it.
Then each of the prongs is touched to the person's skin.
Vibration sense is also tested with a tuning fork. The fork is lightly tapped to
make it vibrate. It is then placed on the joint of a finger to determine whether and
how long the person feels the vibration.
To test position sense, doctors move the person’s finger or toe up or down and
ask the person to describe its position without looking.
The ability to identify the shape of an object is tested by placing a familiar
object, such as a key or safety pin, in a person's hand and asking the person to
identify it without looking. Or doctors may trace letters or numbers on the palm
of the person's hand and ask the person to identify them. If a person cannot
identify them, the cortex of the brain (the outer layer of the cerebrum, the largest
part of the brain) may be damaged. This part of the brain integrates and interprets
sensory information from different sources.
Reflexes

A reflex is an automatic response to a stimulus. For example, the lower leg jerks
when the tendon below the kneecap is gently tapped with a small rubber hammer.
The pathway that a reflex follows (reflex arc) does not directly involve the brain.
The pathway consists of the sensory nerve to the spinal cord, the nerve
connections in the spinal cord, and the motor nerves back to the muscle.

Doctors test reflexes to determine whether all parts of this pathway are
functioning. The reflexes most commonly tested are the knee jerk and similar
reflexes at the elbow and ankle.

The plantar reflex may help doctors diagnose abnormalities in the nerve pathways
involved in the voluntary control of muscles. It is tested by firmly stroking the
outer border of the sole of the foot with a key or other object that causes minor
discomfort. Normally, the toes curl downward, except in infants aged 6 months or
younger. Having the big toe go upward and the other toes spread out is a sign of
an abnormality in the brain or spinal cord.

Testing other reflexes can provide important information. For example, doctors
learn the extent of injury in a comatose person by noting the following:

 Whether the pupils constrict when light is shined on them (pupillary light
reflex)
  Whether the eyes blink when the cornea is touched with a wisp of cotton
(corneal reflex)

 How the eyes move when the person’s head is turned or when water is
flushed into the ear canal (caloric testing)

 Whether the person gags when the back of the throat is touched, for
example, with a tongue depressor (gag reflex)

Doctors also check whether the anus tightens (contracts) when it is lightly
touched (called the anal wink). If this reflex is present in a person paralyzed after
a spinal cord injury, the injury may be incomplete, and the chance of recovery is
better than if the reflex were absent.

Reflex Arc: A No-Brainer

A reflex arc is the pathway that a nerve reflex, such as the knee jerk reflex, follows.

1. A tap on the knee stimulates sensory receptors, generating a nerve signal.

2. The signal travels along a nerve to the spinal cord.

3. In the spinal cord, the signal is transmitted from the sensory nerve to a motor nerve.

4. The motor nerve sends the signal back to a muscle in the thigh.

5. The muscle contracts, causing the lower leg to jerk upward. The entire reflex occurs
involving the brain.

Coordination, Balance, and Gait

Coordination and walking (gait) require integration of signals from sensory and
motor nerves by the brain and spinal cord.
To test walking, doctors ask a person to walk normally and in a straight line,
placing one foot in front of the other. Abnormalities may help identify which part
of the nervous system is not functioning normally. For example, if a person takes
wide, unsteady steps (called ataxia), the cerebellum may be damaged or
malfunctioning. (The cerebellum is the part of the brain that coordinates
voluntary movements and controls balance.)
To test coordination, doctors may ask the person to use the forefinger to reach out
and touch the doctor’s finger, then the person’s own nose, and then to repeat
these actions rapidly. The person may be asked to do these actions first with the
eyes open, then with the eyes closed.

The Romberg test is done to test position sense. The person stands still with both
feet together as close as possible without losing balance. Then the eyes are
closed. If balance is lost, information about position from the legs may not be
reaching the brain, usually because the nerves or spinal cord is injured. However,
abnormalities may also result from malfunction of the cerebellum or the balance
system in the inner ears or its connections with the brain

Autonomic Nervous System

The autonomic (involuntary) nervous system regulates internal body processes

that require no conscious effort, such as blood pressure, heart rate, breathing, and
temperature regulation through sweating or shivering. An abnormality of this
system may cause problems such as the following:
 A fall in blood pressure when a person stands up (orthostatic hypotension )
 Reduction or absence of sweating
 Sexual problems such as difficulty initiating or maintaining an erection
(erectile dysfunction)
 A pupil that does not widen or narrow in response to changes in light

Doctors may do a variety of tests, such as the following:

 Measuring blood pressure and heart rate while the person is lying down,
sitting, and standing

 Examining the pupils for abnormal responses or lack of response to changes

in light

 Doing sweat testing

 Removing and examining a small sample of skin (skin punch biopsy) to see
whether the number of nerve endings has decreased, as occurs in some
polyneuropathies that affect small nerves, including autonomic nerves

Blood Flow to the Brain

A severe narrowing of the arteries to the brain reduces blood flow and increases
the risk of stroke. The risk is higher for people who are older, who smoke
cigarettes, or who have high blood pressure, high cholesterol levels, diabetes, or
disorders of the arteries or heart.
To check for problems with blood flow to the brain, doctors place a stethoscope
on the neck (over the carotid artery) and listen for turbulent blood flow through a
narrowed or irregular artery (the sound of turbulent blow flow is called a bruit).
However, the best way to diagnose disorders of the arteries is to do an imaging
test such as ultrasonography, magnetic resonance angiography (MRA), computed
tomography angiography (CTA), or cerebral angiography.
Blood pressure may be measured in both arms to check for blockages in the large
arteries that branch off from the aorta. Such blockages sometimes result in stroke.