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37 - Global neurological examination
- from Section 9 - Neurosurgery
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- By Harry Bulstrode, University College London, Yezen Sheena, Plastic Surgery, Health Education East of England, Cambridge, UK, Diederik O. Bulters, Honorary Senior Clinical Lecturer, Wessex Neurological Centre, Southampton, UK
- Edited by Petrut Gogalniceanu, James Pegrum, William Lynn
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- Book:
- Physical Examination for Surgeons
- Published online:
- 05 July 2015
- Print publication:
- 25 June 2015, pp 319-331
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38 - Focal neurological examination
- from Section 9 - Neurosurgery
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- By Harry Bulstrode, University College London, Yezen Sheena, Plastic Surgery, Health Education East of England, Cambridge, UK, Diederik O. Bulters, Honorary Senior Clinical Lecturer, Wessex Neurological Centre, Southampton, UK
- Edited by Petrut Gogalniceanu, James Pegrum, William Lynn
-
- Book:
- Physical Examination for Surgeons
- Published online:
- 05 July 2015
- Print publication:
- 25 June 2015, pp 332-352
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Summary
Neurological examination is traditionally divided into examination of the cranial nerves and examination of the peripheral nervous system. In fact the two routines are complementary, and serve a common primary goal: to localise pathology within the nervous system, central and peripheral. Together with an impression of the type of lesion, derived primarily from the history, this localising information is central to correct interpretation of subsequent cross-sectional imaging.
Examination of the cranial nerves
You may need to select appropriate components of the following examination routines according to the clinical scenarios and guidance provided by examiners. This is a test of frontal lobe function.
Checklist
CN I (olfactory nerve)
• Not routinely tested
CN II (optic nerve)
• Acuity: each eye individually
• Fields: four quadrants to confrontation
• Reflexes: accommodation; direct and consensual light reflex
• Ophthalmoscopy: visualise the disc, exclude papilloedema
CN III, CN IV, CN VI (oculomotor, trochlear, abducens nerves)
• Ask patient to report any double vision during testing.
• Instruct patient to keep the head still.
• Ask patient to follow finger with eyes and report any double vision.
• Move finger to all extremes of gaze in an H-shape, to confirm normal upgaze/downgaze in both eyes, in abduction and adduction.
CN V (trigeminal nerve)
• Assess fine touch sensation in the three divisions:
• ophthalmic (Va) over temple
• maxillary (Vb) over cheek
• mandibular (Vc) over angle of mandible
• Confirm masseter/temporalis contraction on clenching teeth.
• Elicit corneal reflex and jaw jerk.
CN VII (facial nerve)
• Ask patient to:
• raise eyebrows
• close eyes tightly
• puff out cheeks
• show teeth
CN VIII (vestibulocochlear nerve)
• Test recognition of whispered speech in each ear individually.
• Weber's and Rinne's tests.
CN IX (glossopharyngeal nerve)
• Offer to test gag reflex.
• Prompt the patient to cough, looking for a strong cough.
• Prompt the patient to swallow, observing for symmetry.
Contributors
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- By Jane E. Adcock, Yahya Aghakhani, A. Anand, Eva Andermann, Frederick Andermann, Alexis Arzimanoglou, Sandrine Aubert, Nadia Bahi-Buisson, Carman Barba, Agatino Battaglia, Geneviève Bernard, Nadir E. Bharucha, Laurence A. Bindoff, William Bingaman, Francesca Bisulli, Thomas P. Bleck, Stewart G. Boyd, Andreas Brunklaus, Harry Bulstrode, Jorge G. Burneo, Laura Canafoglia, Laura Cantonetti, Roberto H. Caraballo, Fernando Cendes, Kevin E. Chapman, Patrick Chauvel, Richard F. M. Chin, H. T. Chong, Fahmida A. Chowdhury, Catherine J. Chu-Shore, Rolando Cimaz, Andrew J. Cole, Bernard Dan, Geoffrey Dean, Alessio De Ciantis, Fernando De Paolis, Rolando F. Del Maestro, Irissa M. Devine, Carlo Di Bonaventura, Concezio Di Rocco, Henry B. Dinsdale, Maria Alice Donati, François Dubeau, Michael Duchowny, Olivier Dulac, Monika Eisermann, Brent Elliott, Bernt A. Engelsen, Kevin Farrell, Natalio Fejerman, Rosalie E. Ferner, Silvana Franceschetti, Robert Friedlander, Antonio Gambardella, Hector H. Garcia, Serena Gasperini, Lorenzo Genitori, Gioia Gioi, Flavio Giordano, Leif Gjerstad, Daniel G. Glaze, Howard P. Goodkin, Sidney M. Gospe, Andrea Grassi, William P. Gray, Renzo Guerrini, Marie-Christine Guiot, William Harkness, Andrew G. Herzog, Linda Huh, Margaret J. Jackson, Thomas S. Jacques, Anna C. Jansen, Sigmund Jenssen, Michael R. Johnson, Dorothy Jones-Davis, Reetta Kälviäinen, Peter W. Kaplan, John F. Kerrigan, Autumn Marie Klein, Matthias Koepp, Edwin H. Kolodny, Kandan Kulandaivel, Ruben I. Kuzniecky, Ahmed Lary, Yolanda Lau, Anna-Elina Lehesjoki, Maria K. Lehtinen, Holger Lerche, Michael P. T. Lunn, Snezana Maljevic, Mark R. Manford, Carla Marini, Bindu Menon, Giulia Milioli, Eli M. Mizrahi, Manish Modi, Márcia Elisabete Morita, Manuel Murie-Fernandez, Vivek Nambiar, Lina Nashef, Vincent Navarro, Aidan Neligan, Ruth E. Nemire, Charles R. J. C. Newton, John O'Donavan, Hirokazu Oguni, Teiichi Onuma, Andre Palmini, Eleni Panagiotakaki, Pasquale Parisi, Elena Parrini, Liborio Parrino, Ignacio Pascual-Castroviejo, M. Scott Perry, Perrine Plouin, Charles E. Polkey, Suresh S. Pujar, Karthik Rajasekaran, R. Eugene Ramsey, Rahul Rathakrishnan, Roberta H. Raven, Guy M. Rémillard, David Rosenblatt, M. Elizabeth Ross, Abdulrahman Sabbagh, P. Satishchandra, Swati Sathe, Ingrid E. Scheffer, Philip A. Schwartzkroin, Rod C. Scott, Frédéric Sedel, Michelle J. Shapiro, Elliott H. Sherr, Michael Shevell, Simon D. Shorvon, Adrian M. Siegel, Gagandeep Singh, S. Sinha, Barbara Spacca, Waney Squier, Carl E. Stafstrom, Bernhard J. Steinhoff, Andrea Taddio, Gianpiero Tamburrini, C. T. Tan, Raymond Y. L. Tan, Erik Taubøll, Robert W. Teasell, Mario Giovanni Terzano, Federica Teutonico, Suzanne A. Tharin, Elizabeth A. Thiele, Pierre Thomas, Paolo Tinuper, Dorothée Kasteleijn-Nolst Trenité, Sumeet Vadera, Pierangelo Veggiotti, Jean-Pierre Vignal, J. M. Walshe, Elizabeth J. Waterhouse, David Watkins, Ruth E. Williams, Yue-Hua Zhang, Benjamin Zifkin, Sameer M. Zuberi
- Edited by Simon D. Shorvon, Frederick Andermann, Renzo Guerrini
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- Book:
- The Causes of Epilepsy
- Published online:
- 05 March 2012
- Print publication:
- 14 April 2011, pp ix-xvi
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Chapter 62 - Glioma
- from Section 3 - Symptomatic epilepsy
- Edited by Simon D. Shorvon, Frederick Andermann, Renzo Guerrini
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- Book:
- The Causes of Epilepsy
- Published online:
- 05 March 2012
- Print publication:
- 14 April 2011, pp 433-440
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Summary
Gliomas are neoplasms derived from glial cell precursors. Gliomas may present with one or a combination of neurological deficits, symptoms of mass effect and seizures, usually reflecting the anatomical location of the lesion. Seizures in the context of glioma appear to confer a significant prognostic benefit. Epileptic foci are believed to develop within the cortex surrounding tumors, since the lesions themselves have no electroencephalographic (EEG) activity and are not electrically excitable. Diagnosis of a space-occupying lesion as the cause of a seizure is made usually with the aid of cross-sectional imaging. Magnetic resonance imaging (MRI), with and without gadolinium contrast, is the investigation of choice, showing a higher sensitivity and specificity than computed tomography (CT) for detecting glioma. Fractionated focal radiotherapy is a key component of adjuvant treatment, especially in high-grade lesions. Chemotherapy with temozolomide has been shown to be of seizure benefit in approximately 50% of Grade 2 gliomas.