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Methodology for the neurologic examination in the equine species is described. Information is organized to assist the reader in defining neurologic deficits and in localizing lesions to the major subdivisions within the central or peripheral nervous system. Numerous examples of deficits are presented to assist the reader in recognition of common neurologic disease states.
OBJECTIVES: To assess the utility of neuroimaging in the evaluation of children presenting with two of the most common forms of headache, migraine and chronic daily headache, and to determine the utility and pathological yield of neuroimaging in specific headache syndromes in children whose neurological examinations are normal. METHODS: We retrospectively reviewed the medical records of patients coded for headache (ICD 784) in the Pediatric Neurology Clinic at Children's Hospital of the King's Daughters between 1997 and 1999. The age range considered was between 6 and 18 years. The study focused on the two most common types of headache, uncomplicated migraine and chronic daily headache. Only patients with normal physical and neurological examinations were considered in this analysis. RESULTS: Three hundred two patients were coded for headache within the defined age group. One hundred seven (35.4%) patients fulfilled IHS-R criteria as having uncomplicated migraine with a normal examination, and 30 (9.9%) patients fulfilled criteria for chronic daily headache. Twenty-nine (9.6%) patients presented with migrainelike symptoms, and 6 (2.0%) presented with chronic daily symptoms, but had neurological abnormalities present on examination. The remainder of the patients with headache had the following etiologies: 50 (16.6%) with secondary headache, 22 (7.3%) with complicated migraine, 20 (6.6%) with posttraumatic headache, 13 (4.3%) with seizure-related headache, 11 (3.6%) with brain tumors, 10 (3.3%) with tension-type headache, and 4 (1.3%) with pseudotumor cerebri. Of the 107 patients with migraine, 42 (39.3%) received CT scans; 2 (4.8%) of which were considered "abnormal." One of the abnormalities was an arachnoid cyst and the other was a dilated Virchow-Robin space. Twelve (11.2%) patients with migraine received an MRI, 2 (16.7%) of which were considered abnormal. Both of the abnormal findings were Chiari type I malformations. Of the 30 patients with chronic daily headache, 17 (56.7%) received CT scans, 3 (17.6%) of which were considered abnormal. The abnormalities consisted of a maxillary opacification, a mucous retention cyst, and an occult vascular malformation. Eight (26.7%) of the patients with chronic daily headache had an MRI, 2 (25.0%) of which were abnormal. One of the abnormalities was a Chiari I malformation, and the other was an occult vascular malformation. CONCLUSION: The yield of neuroimaging in children with uncomplicated migraine and normal neurological examination was 3.7%. The yield in children with chronic daily headache and normal neurological examination was higher at 16.6%. The abnormalities discovered included arachnoid cysts, Chiari I malformations, sinus disease, occult vascular malformations and "dilated Virchow-Robin spaces." While none of the neuroimaging findings were apparent clinically, their discovery did not influence the diagnosis, management, or outcome of the patients. None of the abnormalities necessitated surgical intervention or were associated with the headache presentation. Therefore, neuroimaging is not warranted in children and adolescents with defined clinical headache syndrome diagnoses whose neurological examinations are normal.
The degree of agreement between the neonatal neurological examination and a standardized neurobehavioural assessment was investigated in a group of 32 newborns with congenital heart defects. A paediatric neurologist performed a neurological examination, and an occupational therapist administered the Einstein Neonatal Neurobehavioural Assessment Scale on all subjects. Both examiners independently evaluated each subject, and were blinded to the diagnosis, to perinatal status and to each other's clinical findings. Statistical analysis demonstrated a significant association between the overall impression between both examiners (p < .0001), with a crude agreement of 96.9%. Sixteen neonates were determined to be normal and 15 abnormal by both examiners, with disagreement in only one subject. Although two distinct approaches were employed in the neurological assessment of high-risk newborns, both assessments evaluate the maturity and integrity of the immature central nervous system. The results demonstrate a strong agreement between these two approaches, suggesting that the neonatal neurological examination is consistent and valid.
BACKGROUND: Progress in early surgery and intensive care have enhanced survival for more individuals with serious cyanotic congenital heart disease (CHD). Parents are understandably concerned about patients' brain function. Therefore, a study was undertaken of brain magnetic resonance images (MRI) in infants and children with cyanotic CHD, stressing the correlation between clinical neurological examination and brain MRI findings. METHODS: Sixteen infants and children with cyanotic CHD, 6 males and 10 females, were selected randomly from June 1991 to June 1993. Their ages ranged from 1 to 10 years, with a mean of 4.4 years. All patients underwent brain MRI and thorough clinical neurological examinations. RESULTS: Prominent and tortuous vessels over the Willis circle and basal ganglia were the most common brain MRI findings among patients with normal neurological examination (7/9), while ventriculomegaly (5/7) was the common findings for patients with abnormal neurological examination. Two patients who presented with low-grade fever and Babinski sign were found incidentally to have brain abscesses. CONCLUSIONS: It is not possible to make a conclusion from this preliminary report about the role which cyanotic CHD may play in the pathogenesis of brain insult, but the clinical neurological findings may provide guidance for the arrangement of brain MRI in infants and children with cyanotic CHD. Further larger scale, case-controlled study is needed to answer the controversial question whether cyanotic CHD per se causes brain insult.
Sixteen males, formerly exposed to carbon disulfide (CS2) for at least 10 years (mean 20 years), were administered a neurological examination, cerebral computerized tomography (CT), regional cerebral blood flow (rCBF) examination and neuropsychological examination. The clinical neurological examination revealed abnormalities in 15; cerebral CT showed signs of atrophy in 13; and neuropsychological examination indicated brain organic changes in 13. With the rCBF examination, slight abnormalities were found in 8. The findings indicate that long-term exposure to CS2 involves a risk of developing toxic encephalopathy, demonstrable on both neurological and neuropsychological examination. Furthermore, structural changes in the brain may be demonstrable by cerebral CT.
Indications for head computed tomography (CT) scans are unclear in patients with nonpenetrating head injury and Glasgow Coma Scale (GCS) scores of 15. We performed a prospective study to determine if significant intracranial injury could be excluded in patients with GCS-15 and a normal complete neurological examination. A prospective trial of clinically sober adult patients with GCS = 15 on emergency department (ED) presentation after closed head injury with loss of consciousness or amnesia was conducted from May 1996 through April 1997. All subjects underwent a standardized neurological examination including mental status evaluation, and assessment of motor, sensory, cerebellar and reflex function before CT scan. During the study period, 58 patients met inclusion criteria. Fifty-five patients (95%) had normal CT scans and 23 (42%) had focal neurological abnormalities. Three patients (5%) had CT scan findings of acute intracranial injury, two of whom had normal neurological examinations. One patient had an acute subdural hematoma requiring emergent surgical decompression; the other had both an epidural hematoma and pneumocephalus that did not require surgery. Significant brain injury and need for CT scanning cannot be excluded in patients with minor head injury despite a GCS = 15 and normal complete neurological examination on presentation.
Fifty-one extremely preterm infants were studied to ascertain whether there is an association between sonographic abnormalities and neurological examination at term, controlling for factors such as low birthweight and chronic lung-disease. Their mean birthweight was 956g and mean gestational age was 27.9 weeks. Sonography was performed at least once during the first week, twice within the first month, and once within a month of term-corrected age. Neurological assessment was used to classify the infants as normal, suspect or abnormal at term. Infants were divided into three groups, based on sonographic findings: group 1 (no hemorrhage), group 2 (grade 1 to 3 hemorrhage but normal sonogram or unilateral ventriculomegaly at term) and group 3 (periventricular leukomalacia, grade 4 hemorrhage or ventriculomegaly at term). On neurological examination, 23 infants were found to be normal, 15 suspect and 13 abnormal. On sonography, 27 infants were placed in group 1, 12 in group 2 and 12 in group 3. Sonographic findings and birthweight were the best predictors of the infant's performance on the neurological examination at term.
Brain metastases occur in 17 to 40% of lung carcinoma and 30 to 60% of brain metastases originate from a lung carcinoma. Brain metastasis directly influences prognosis and treatment of lung cancer. The aim of this study was to prospectively compare the findings of the neurological examination performed by a neurologist and results of double dose delayed computed tomography (CT DDD). The neurologist and radiologist were blinded to each other's results. Patients included had non-small-cell lung cancer (NSCLC) and were neurologically asymptomatic with no other cancer. From November 1993 to May 1996, 135 patients were included (126 men and 9 women). Ninety neurological examinations were normal, 34 suggested brain metastasis and 11 were abnormal but did not suggest brain metastasis. One hundred thirteen CTs were normal, 1 showed a brain metastasis and 11 were abnormal but did not evidence brain metastasis. The sensitivity, specificity, positive predictive value and negative predictive value of the neurological examination were 73, 79, 23 and 97% respectively. The presence of brain metastasis was directly related to tumor stage but not to age or histology. We suggest that brain CT DDD should be performed in stage IIIA, IIIB, IV whereas in stage I or II, the neurological examination is sufficient. However, a larger number of patients would be required to confirm these findings.
The direct physical examination of psychiatric patients is underutilized by clinicians and underinvestigated by researchers. Both clinicians and researchers thus bypass important information. The authors review the literature on physical and neurologic examinations, with attention to aspects of these examinations that might specifically enhance the understanding of the psychiatric patient. Coverage includes the "minor" physical anomalies and "soft" neurologic signs. Findings related to the psychiatric conditions themselves are given precedence over findings of general medical importance. Some of the available physical and neurologic examination schedules are reviewed. A unified examination protocol is presented, incorporating physical and neurologic examinations pertinent to both general medical and specifically psychiatric assessment.
Abnormal findings on a standardized neurologic examination were compared between patients with a clinical diagnosis of probable Alzheimer's disease (AD) and healthy control subjects. Aside from mental status findings, the most useful examination findings for differentiating AD from control subjects were the presence of release signs, olfactory deficit, impaired stereognosis or graphesthesia, gait disorder, tremor, and abnormalities on cerebellar testing. These abnormalities probably reflect the different areas of the central nervous system that are affected pathologically in AD. In the clinical diagnosis of AD, particular attention should be given to these aspects of the neurologic examination.
Perinatal mortality and the incidence of neurological sequelae in preterm infants have diminished owing to advances in perinatology. The accurate assessment of gestational age is a very important component of the medical practice and for the newborn's management. Herein we provide a study to evaluate the neurological examination in comparison to the obstetrics dating criteria and pediatrics scales (Dubowitz and Capurro) to determine the gestational age as well as to compare the gestational age obtained with the different methods. We studied 35 preterm newborns leaving out those ones with any pathologies. The different scales to determine the gestational age were administered to each infant, beyond the neurological examination. We conclude that André-Thomas method is an appropriate clinical tool for reliable determining for gestational age in preterm newborns.
OBJECTIVE: The current investigation examines the impact of a past history of alcoholism on neurologic examination abnormalities in schizophrenia (SZ). BACKGROUND: Individuals with SZ have a high rate of comorbid alcohol use disorders (AUDs), but relatively little is known about the potential adverse consequences of alcoholism for neuropsychological and neurologic functioning in SZ. Recent evidence suggests consistent but subtle neurocognitive differences between groups, with more prominent differences in neurologic examination abnormalities. METHOD: Thirty-three male patients with SZ or SZ/AUDs were evaluated using a modified Neurologic Evaluation Scale (NES) and ratings for positive and negative symptoms. RESULTS: The SZ/AUD group exhibited a greater impairment in the Cognitive-Perceptual factor of the Neurologic Evaluation Scale. Greater impairment in the tandem-Romberg factor or in motor items was not found, nor were groups different based on positive or negative symptoms. CONCLUSIONS: A history of alcoholism in SZ is associated with greater overall neurologic impairment, particularly in the area of cognitive-perceptual dysfunction, an area often found to be impaired in patients with schizophrenia without alcoholism.
Recent studies suggest the occurrence of a neurological dysfunction in Obsessive-Compulsive Disorder (OCD). The purpose of the present study was to verify the clinical value of a neurological evaluation in patients with the disease. We submitted 15 patients with OCD (five of whom were under clomipramine) and 15 controls in a detailed neurological examination, including assessment of the neurological soft-signs. Eleven patients (73.3 percent) and four controls (26.7 percent) presented abnormalities on examination. The main findings among the patients were: palmomental reflex (six cases); mirror movements (five cases); agraphestesia and dysdiadochokinesia (three cases). Three out of the four patients who had a normal examination were on clomipramine. Palmomental reflex was the main finding among the controls. These results, although preliminary, stress the interest and usefulness of performing a detailed neurological examination in OCD.
This paper provides an overview of the value of a structured neonatal neurological examination that may be performed in different settings, from routine examination to research settings. We will report how a structured neurological examination can help to identify infants with central and peripheral nervous system involvement. We also describe a short but structured proforma to be used for the routine examination of full-term infants. We will finally describe a quantitative assessment to be used in research settings.
The Hammersmith Infant Neurological Examination was performed in 24 infants with cystic periventricular leukomalacia whose gestational age ranged between 26-38 weeks. The infants were examined between 6 and 9.5 months corrected age. The aim of the study was to establish the different patterns of neurological abnormality as well as the optimality scores that predict the severity of motor sequelae at 2 years. Increased neck and trunk extensor tone, and a posture of flexed arms and extended legs between 6 and 9 months were always associated with the inability to sit unsupported at 2 years, whilst truncal hypotonia and extended arms and legs were associated with unsupported sitting but not walking. Optimality scores between 41 and 60 were generally associated with sitting but not walking at 2 years whilst scores below 40 were always associated with the inability to sit independently at 2 years. All infants who did not develop cerebral palsy at 2 years had scores > 60. Our results suggest that the pattern of findings on neurological examination performed between 6 and 9 months as well as the calculated optimality score helps to predict motor impairment in infants with PVL.
Twenty-one children, mean age of 8 years, were each examined on separate occasions by two pediatric residents, blind to diagnosis, using the neurological examination (PANESS) included in the group of instruments recommended by the National Institute of Mental Health for psychotropic drug studies in children. Half the children were hyperactive/aggressive, one quarter were normal, and one quarter had histories or signs strongly presumptive of brain damage. Many of the signs, though reliable, did not occur in the majority of children. Examiners did achieve a high level of agreement about global neurological status. It was concluded that the neurological examination probably contains a substantial number of non-contributory items and should be regarded as experimental rather than definitive.
PURPOSE: To develop a neurologic assessment tool, the Premie-Neuro, for very low birth weight (VLBW) infants. INSTRUMENT DEVELOPMENT: Neurologic data were collected during the coursc of the NICU stay. Factor analysis was utilized to determine the strength of relationships between items and to reduce the initial number of test items. SAMPLE: An NICU cohort of 86 preterm infants was enrolled. Mean birth weight was 1165.8 +/- 446.7 grams, and mean gestational age at birth was 28.8 +/- 3.2 weeks. METHOD: Seventy-five neurologic and behavioral characteristics were assessed in week 1 of life and every 2 weeks thereafter until 38 weeks posreonceprional age. MAIN OUTCOME VARIABLE: Three factors, the Neurologic Scale, the Movement Scale, and the Responsiveness Scale, described the neurologic examination. RESULTS: Factor reliability was calculated for internal consistency (Cronbach alpha coefficient) and ranged from .73 to .82. The Premie-Neuro can be utilized with VLBW infants to monitor neurologic development during NICU care.
As is true of animals with diseases of other organ systems, cats with neurologic disease should be approached in a systematic, problem-oriented manner (Table 1-1). The neurologic examination and process of lesion localization are the principal components of the evaluation. Lesions involving specific areas of the nervous system cause predictable neurologic deficits or problems ranging from monoparesis to seizures. By recognizing one of these problems and relating it to a particular anatomic region of the nervous system, a differential diagnosis of diseases that typically involve this area can be established. Although the neurologic examination and process of lesion localization are essential to developing the differential diagnosis, results of the history are equally important in predicting which disease or group of diseases is most likely present (Table 1-2). Identification of problems related to other organ systems on the physical examination, furthermore, should suggest that polysystemic diseases, such as infectious conditions, are potentially involved. After the differential diagnosis has been developed and the relative likelihood of each individual disease or group of diseases has been established, appropriate diagnostic procedures may be done. This should allow identification of the underlying cause and initiation of treatment, when indicated.