NEUROLOGY
1.Introduction
Definition:
Nervous system consist of central nervous system(CN) and peripheral
nervous system(PN)
CN divide into_ Brain and Spinal cord
PN divide into_12pair of cranial nerves
_31pair of spinal nerves
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Brain(encephalon)
also divide into: Telencephalon(cerebrum)
Diencephalon
Cerebellum midbrain(mesencephalon) Brainstem pons
medulla oblongate(bulb)
The function of the nervous system is: control and integrate
the
higher cerebral function (including Consciousness,mental activity
speech and intelligence), movements, sensory, reflexes, the function of
the internal organs. the movements are completed by the contract of
skeletal muscles
Neurology is the branch of the clinical medicine, in which we can
study or learn the knowledge about the diseases of the nervous System
and skeletal muscles including the causes(pathogenesis) ，pathology,
clinical feature, investigation, diagnosis, treatment and the Prevention.
The diseases of nervous system are including: congenital or hereditary
diseases,
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inflammation(infection),
wound,
vascular
diseases,
tumour,
degenerative diseases, deficiency diseases, metabolic diseases,
autoimmune disease, the diseases caused by drugs and toxins.
Diagnosis
according to the symptoms, signs and investigation findings to settle the
diagnosis including two steps:
1) determine the location of lesions (topical diagnosis).
2) determine the type of diseases (etiological diagnosis).
2.Simptomatology of the neurological diseases
Higher cerebral function
Cranial nerves
Motor system
Sensory system
Reflexes
 investigations
Higher cerebral function
Consciousness
Somnolence —
The patient is in sleep ,but he can be awakened when
he is stimulated lightly,can make simple conversation. He is orientated
in person, time, and place.
Stupor — The patient is unconscious,in deep sleep, but he can be
awaked when he is stimulated strongly,simple answer with “yes” or
“no”in response,can’t make any conversation,
Coma — The patient is unaware of self and the environment and can
not be awakened
Consciousness
 Confusion
— The patient is lack of attention, disorientation in time,
person and place.
 Delirium
— Delirium is a confusion state characterized by
hyperactivity. The patient may be agitated, excited, anxious, and may
hallucinate.
disorientation in time, person and place.
Cranial nerves
Olfactory nerve(Ⅰ)
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Anatomy: the end-brush of the olfactory nerves distributed in the
mucosa of the nasal cavity,their
fiberes into cranial cavity to be olfactory bulb,tract,
finally stop at the olfactory cortex(temporal lobe)
 Function: receive the sense of smell.
 Examination: a characteristic-smelling object
(e.g. peppermint, clove oil) is held under each nostril in turn while
the other is occluded and the patient keeps the eyes closed .An
individual who has intact olfaction can detect the smell, and
discriminate and name it.)

Optic nerve(Ⅱ)
 Anatomy:optic nerve start from the ritena, gathe- red to optic
disk_optic nerve_optic chiasma_ optic tract_optic radiation_visual
cortex.

function:visual sense.

examination:including four parts_visual acuty,
 visual fields,fundus and color sensation.

Visual acuity ： Visual acuity is tested using a visual acuity chart
in a well-lit room. Seat or stand the patient 5m from the chart. Near
VA is tested using reading charts. If the patient is unable to read
characters of line 60,assess his or her ability to count your fingers at 1 m,
see your hand movements, or perceive a torch light.
Visual field: 1 m distance,face to face with pa- tients,both cover
the eyes with hands the same side,move your another hand in the middle
between
both of you to compare your visual field with patient.
Examination of theFundus :
using a direct ophthalmoscopy,to assess the
shape,color of the optic desk,retina and blood
Vessel.
optic desk swelling(papilledema)
optic desk pallor
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Oculomotor ,Trochlear,Abducens nerves(ⅢⅣⅥ)
Ⅲ and Ⅳ nerves start from the midbrain, Ⅵ nerves start from the
pons,they travel into the eye orbit,control the eye movement,the oculomotor nerve also have a branch-parasympathetic f, control the eyelid
and the pupils .
lesions of them cause the disorders of eye move- ments(ocular
palsy),pupillary abnormality and ptosis (dropping of the upper eyelid).
Eye movements.
you detect the presence of diplopia and nystagmus. Steady the
patient’s head with one of your hands and hold the index finger of your
other hand 40-50 cm in front of the patient’s eyes.Ask the patient to
move his/her eyes follow your finger to look left ，right，up，and down
as quickly as possible
pupils
Assess the size and shape of the pupils
light response — Ask the patient to fixate on a distant target, and
shine the light into the pupil from the lateral side. Observe the direct
and the consensual responses
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—Hold your finger 50-60 cm from the patient and ask
him or her to fixate on it. Bring your finger towards the patient’s
eyes.Observe for the normal reaction of bilateral pupillary constriction
and convergence.
Light response
 Light
(visual pathway)
 retina
optic nerve
 (receptor)
 ( effector)
 pupil
oculomotor nerve
midbrain
Accommodation


pupilary constriction
( reflex center)
Trigeminal nerve (Ⅴ)

Sensory:start from trigeminal ganglion as the three
branch,distributed to face, nasal cavity, oral cavity ,cornea,anterior two
thirds of tongue and receive the sensory from that area,transmit it to
pons(trigeminal nucleus)

motor:control the chew muscle including
masseter,temporalis,medial and lateral pterygoid muscles,the function
of them is chew the food.
— Ask the patient to clench his or her teeth together while the
masseter and temporalis muscles are palpated bilaterally, please notice
weakness.
Jaw jerk — Ask the patient to open his or her mouth slightly, Rest your
index finger on the apex of the jaw and tap it with the patella hammer .the
normal response, mouth closure is due to reflex contraction of the pterygoid
muscles.
Corneal response — Elicited by lightly touching the cornea with a wisp
of cotton wool.
Facial sensory — Test light touch, pin prick ,and temperature over the
forehead, the medial aspects of the cheeks, and the chin.
Motor
Facial nerve(Ⅶ)
Facial nerve start from the pons,including the motor and sensory
nerves, after left the cranial cavity,the motor fiber distribute to the
facial muscles (except the chew muscles_masseter, temporalis, medial
and lateral pterygoid muscles) including orbicularis oculi and
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orismuscles.
 the sensory is the special sensory that,receive the
taste on the anterior two thirds of the tongue.
Examination
Motor — Inspect
the patient’s face. looking for asymmetry of the
nasolabial folds and the position of the two angles of the mouth
palpebral fissures, asking the patient to elevate his or her eyebrows,
close his or her eyes tightly and resist your attempt to open them, blow
out his or her cheeks with air, show his or her teeth, whistle.
Sensory — Taste is examined by applying cotton bud of salt, sweet ,or
sour to the anterior two thirds of the tongue and comparing the
response on the two sides.
Vestibulocochlear nerve(Ⅷ)
Vestibulocochelear nerve consist of the vestibulo
 nerve
and cochlear nerve,they start from the internal
ear_semecircular canal and cochlear, the first receive the sensory of the
position of the body,the second receive the sensory of sound.they inter
the cranial cavity to the pons,connect with their cranial nucleus

Examination:
 rubbing the thumb and fore finger.
 tuning fork test _ Weber test and Rinne test.
 vestibular function.

(you will study this content detailed later)

lesions of vestibular nerve cause:
 vertigo, balance disturbance, nystagmus and
 vomit.
Glossopharyngeal and vagus nerves (ⅨⅩ)
Bos of the two nerves left from the medulla
 oblongate(bulb),separate to the muscles and mucosa of the pharynx
larynx and tongue, control the create of sounds, swallow,special (taste)
and general sensory of the lateral one thirds of tongue.
Accessory nerve(Ⅺ)
Accessory nerve left from the medulla
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 oblongate(bulb),separate to the sternocLeidomastoid muscle and trapezius muscle.the function of them are
that rotate the neck and shrug the shoulders
The
strength of the sternocleidomastoid muscles is assessed by asking
the patient to turn his or her head to each side against the resistance of
the examiner’s hand. The strength of the trapezis muscles is assessed by
asking the patient to shrug his or her shoulders upwards against
resistance.
Hypoglossal nerve(Ⅻ)
 hypoglossal nerve is pure motor nerve,
 left from the medulla oblongate(bulb),
 separate to the tongue,control tongue
 muscle, the function of that muscle is
 protrude the tongue.
Examination:
Ask the patient
to the mouth and stick out the tongue. Normally, the
tongue is protruded and lies in the midline.
 Inspect the tongue as it lies in the floor of the mouth for evidence of
wasting fasciculations or other involuntary movements.
sensory
Sensory is the response at the brain from the stimulation.
 including:
 special sensory_smell,taste,visiun,hear
 superficial sensation
 general sensory
 deep sensation
 compound sensation
 superficial sensation
 (pin prick,light touch, temperature)
general sensory deep sensation
 (joint position sense,vibration sense)



compound sensation
(stereognosis, two-point discrimination graphesthesia)
sensory
sensory
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Sensory pathway

stimulation
Receptor


peripheral nerve
grocile
 (internal capsule)
cortex
dorsal root ganglion
dorsal horn,
thalamus
and cuneate nucleus
sensation
sensory
 superficial sensation
 the first nerve cell(dorsal ganglion) receive the
 temperature,pain impulse by the receptor of the
 end brush and send it to the dorsal horn-second
 nerve cell,the fibre from it cross to the other side
 of the spinal cord at grey matter and travel to the
 thalamus as the spinathalamic tract, the cell in
 thalamus(third nerve) send fibre through out the
 internal capsule, finally stop at the sensory cortex
 (parietal lobe-primary sensory cortex) .
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sensory
the first nerve cell(dorsal ganglion) receive the deep sensation by the
receptor of the end brush at the joint, muscle, tendon and muscle thin,
and into spinal cord, travel at the back of the spinal cord as the
posterior column to the medulla, send it to the gracile cuneate nucleus
–second nerve cell, the fibre from it cross to the other side of the
medulla and travel to the thalamus as the medial lemniscus tract. the
cell in thalamus (third nerve) send fibre through out the internal
capsule, finally as the thalamic radi ation stop at the sensory cortex
(parietal lobe_ primary sensory cortex) .
sensory
 general sensation divide into the superficial
 sensation and deep sensation according to
 the location of the receptor is in deep or shallow. Light touch is superficial sensation, but
it travel with the deep sensation line(pathway)
sensory
 distribution of sensory dermatomes

(segmental control pattern)

neck
____
cervix3 (C3)

papilla___
thorax4 (T4)
umbilicus___ thorax10 (T10)
groin ____
lumbar1 (L1)
Disorders of somatic sensation
 Lesions of the sensory pathway cause the
 disorders of the sensation including:

hyperesthesia____increased sensitivity

dysethesia
___ one stimulus cause another

paresthesia ____ spontaneous sensation

anesthesia
____completely loss

hypesthesia
___ partially loss
Sensory examination
Tools:

cotton, pink, tuning fork

bottles of water in different

temperature.
Method :use the tools to stimulate to one

point of the body, assess the response,
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



compare with the another side,compare
upper part with the lower part,compare
one upper part with another down part
of the body.
Clinical feature of sensory disorders in disturbance of different level
( Localization diagnosis of Sensory disorder)
Cortex form
Internal capsule form
Thalamus form
Brain stem form
Spinal cord form
Clinical feature of sensory disorders in disturbance of different level
peripheral nerve lesions
polyneuropathy (end brush): the sensory loss is generally symmetric
(four limbs) and grater distally than proximally_as the suggested by
the term___stocking-and- glove sensory loss.
mononeuropathy (nerve stem): the sensory loss is in a single
peripheral nerve area.

root involvement(post_ root): impairment

of cutaneous sensation in segmental pat
tern.often occur the spontaneity pain(the

pain without stimulation).
Spinal cord
dorsal horn : impairment of cutaneous sensa
tion in segmental pattern but deep sensation

is intact.
 cord lesion :

spinothalamic tract lesion cause the impair
ment of the superficial sensation at the oppo
site side blow the lesion level.
posterior column lesion cause the impair
ment of the deep sensation at the same side

blow the lesion level.
Spinal cord
cord hemisection : blow the lesion leveldeep sensation impairment at the same side,
superficial sensation impairment at the oppo11
site saide,combinated with limb weakness at
the same side. It is also called as :
brown__ sequard’s syndrome .
complete transection: all the sensation are
lose bilaterally blow the lesion level.
Brain











lesion of the brain stem cause the crossed
sensory deficit .
lesion at the thalamus cause impairment of
all the sensory on the contralateral side of the
body with spontaneous(thalamic) pain.
lesion at the internal capsule cause impairment of all the sensory on the contralateral
side of the body .
lesion at the sensory cortex cause impairment
of all the sensory on the contralateral side of
the limb , sometime occure the seizure.
NEUROLOGY
The department of Neurology
Xinjiang Medical University
Tursun
The Examination of motor function
corteconuclear tract
Cortex
(upper neuron)

cortecosipinal tract

(cross at bulbar)


brain stem
( nucleus lower neuron)
spinal cord(frontal horn-lower neuron)


peripheral nerve

limb muscle
Lesion of the motor pathway _paralysis; palsy; weakness
 lesion of the upper neuron cause the spastic

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muscle



paralysis
lesion of the lower neuron cause the flaccid
paralysis
Discrimination of central nervous paralysis
and peripheral nervous
paralysis
Examination including :
Gait
Muscle shape
Muscle tone
Muscle power
Ataxia
Abnormal movements
Gait
Steppage gait(foot drop): inablity to dorsiflex

the foot,walking by the exaggrated elevation

of the flexed hip and knee. the result of the

peripheral nerve disorder such as the pero
neal palsy.
Cerebellar gait: wide-based, irregular staggering,

or reelling gait,as if drunk.
Hemiplegic gait: walking with the flexed arm and

spastic leg rotated internally.
Gait
Paraplegic gait: spastic legs bilateral rotated

internally called the “scissoring” gait.
Dystrophic gait: waddling and lordotic posture

result from pelvic muscle weakness.
Parkinsonian gait: this consists of slow-starting,

short shuffling steps with a tendency toacce
lerate as if chasing the center of gravity.


Muscle shape:
detect the muscle athrophy
Muscle tone

Muscle tone is defined as resistance of muscle

to passive movement at a joint while the pa
tient in relax position, it can be described as

the decreased, normal and increased.
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The grade of muscle strength
Grade
Response
0 Absent no contraction detected
1 Trace Slight contraction detected
2 Weak Movement against gravity eliminated
3 Fair Movement against gravity
4 Good Movement against gravity with some
resistance
5 Normal Movement against gravity with full
resistance
Localization diagnosis
Motor cortex : monoplegia and seizure
Internal capsule : hemiplegia(hemiparesis)
Brain stem : impairment of cranial nerve at the

lesion side and limb weakness opposite side.
Spinal cord :cervix _ tetraparesis(four limb)

thorax _ paraparesis(two limbs)

lumbar _ paraparesis(two limbs)
Upper motor neuron facial,tongue weakness and pseudobulbar palsy
Corticonuclear tract control the cranial motor
 nucleus bilaterally,except the seventh and twel- veth nerve, so
unilateral lesion is not to cause the disorders of those cranial nerves,
the part of facial nucleus control facial muscle blow the eye fissure and
the hypoglossal nucleus only re-ceive the control from
contralateral(opposite side) corteconuclear tract.
upper neuron facial weakness: the face above the eye fissure is
intact ,weekness involve to the blow the eye fissure.
upper neuron tongue weakness:
tongue deviate to the weakness side without muscle atrophy.
pseudobulbar palsy: bilateral lesion of the
cortecobulbar tract cause the impairment of the ⅨⅩ ( Glossopharyngeal and vagus) function
cause disorders of the create sounds and swallow, same as the
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bulbar lesions but not is the bulbar leision.
Abnormal movements
Tremor
static tremor
postural tremor
intentional tremor
Choreic moement
reflex
Reflex is the basic work pattern of the nervous function.
 receptor
send in

center

effector
send out

reflex
superficial reflex


deep tendon reflex

abnormal (pathologic) reflex
Superficial Reflex
Abdominal reflex: stimulate on the abdominal skin

to three aspect, the response is the contraction of

the abdominis.
Cremasteric reflex: stimulate on the thign from the

groin to down,the response is that the testis move

upward.
Plantar reflex: stimulate lateral sole, the response is

the great toe flex downward.
Anal reflex: pin prick to the edge of anus, the res
ponse is the contraction of the anal muscle.
Deep tendon reflex
Biceps reflex:strike the biceps tendon with percussion hammer,the
response is the bi- ceps contract(C5-6)
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Deep tendon reflex
Triceps reflex : strike the triceps tendon with percussion hammer,the
response is the contraction of the triceps muscle(C7-8)
Deep tendon reflex
Supinator reflex : strike the lower part of the radius bone with
percussion hammer,the res- ponse is the contraction of the
brachioradialis muscle and pronate the hand(C7-8).
Deep tendon reflex
Quadriceps(patellar, knee jerk) reflex: feel for the bottom edge of the
patella, strike just below it, the response is the contraction of the quadriceps and extension at the knee(L3-4)
Deep tendon reflex
Achilles(ankle jerk) reflex : support the sole with your hand,strike to
the tendon of the tri ceps surae(gastrocnemius), the response is the
extension at the ankle(S1-2)
Abnormal reflex
Babinski sign: stimulate at the lateral sole from the bottom to the
toes root and turn to the great toe, the result of the pyramidal tract
damage is the extension upward of the great toe.
Abnormal reflex
Hoffmann sign: pick up the patient’s middle finger with your middle
and forefinger, snap the nail with your thumbnail,the abnormal
response is the flexion of the fingers,some time strike the patient’s
fingers with your fingers can cause same result-called Rossolimo sign
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