- •Overview
- •Preface
- •Translator’s Note
- •Contents
- •1. Fundamentals
- •Microscopic Anatomy of the Nervous System
- •Elements of Neurophysiology
- •Elements of Neurogenetics
- •General Genetics
- •Neurogenetics
- •Genetic Counseling
- •2. The Clinical Interview in Neurology
- •General Principles of History Taking
- •Special Aspects of History Taking
- •3. The Neurological Examination
- •Basic Principles of the Neurological Examination
- •Stance and Gait
- •Examination of the Head and Cranial Nerves
- •Head and Cervical Spine
- •Cranial Nerves
- •Examination of the Upper Limbs
- •Motor Function and Coordination
- •Muscle Tone and Strength
- •Reflexes
- •Sensation
- •Examination of the Trunk
- •Examination of the Lower Limbs
- •Coordination and Strength
- •Reflexes
- •Sensation
- •Examination of the Autonomic Nervous System
- •Neurologically Relevant Aspects of the General Physical Examination
- •Neuropsychological and Psychiatric Examination
- •Psychopathological Findings
- •Neuropsychological Examination
- •Special Considerations in the Neurological Examination of Infants and Young Children
- •Reflexes
- •4. Ancillary Tests in Neurology
- •Fundamentals
- •Imaging Studies
- •Conventional Skeletal Radiographs
- •Computed Tomography (CT)
- •Magnetic Resonance Imaging (MRI)
- •Angiography with Radiological Contrast Media
- •Myelography and Radiculography
- •Electrophysiological Studies
- •Fundamentals
- •Electroencephalography (EEG)
- •Evoked potentials
- •Electromyography
- •Electroneurography
- •Other Electrophysiological Studies
- •Ultrasonography
- •Other Ancillary Studies
- •Cerebrospinal Fluid Studies
- •Tissue Biopsies
- •Perimetry
- •5. Topical Diagnosis and Differential Diagnosis of Neurological Syndromes
- •Fundamentals
- •Muscle Weakness and Other Motor Disturbances
- •Sensory Disturbances
- •Anatomical Substrate of Sensation
- •Disturbances of Consciousness
- •Dysfunction of Specific Areas of the Brain
- •Thalamic Syndromes
- •Brainstem Syndromes
- •Cerebellar Syndromes
- •6. Diseases of the Brain and Meninges
- •Congenital and Perinatally Acquired Diseases of the Brain
- •Fundamentals
- •Special Clinical Forms
- •Traumatic Brain injury
- •Fundamentals
- •Traumatic Hematomas
- •Complications of Traumatic Brain Injury
- •Intracranial Pressure and Brain Tumors
- •Intracranial Pressure
- •Brain Tumors
- •Cerebral Ischemia
- •Nontraumatic Intracranial Hemorrhage
- •Infectious Diseases of the Brain and Meninges
- •Infections Mainly Involving the Meninges
- •Infections Mainly Involving the Brain
- •Intracranial Abscesses
- •Congenital Metabolic Disorders
- •Acquired Metabolic Disorders
- •Diseases of the Basal Ganglia
- •Fundamentals
- •Diseases Causing Hyperkinesia
- •Other Types of Involuntary Movement
- •Cerebellar Diseases
- •Dementing Diseases
- •The Dementia Syndrome
- •Vascular Dementia
- •7. Diseases of the Spinal Cord
- •Anatomical Fundamentals
- •The Main Spinal Cord Syndromes and Their Anatomical Localization
- •Spinal Cord Trauma
- •Spinal Cord Compression
- •Spinal Cord Tumors
- •Myelopathy Due to Cervical Spondylosis
- •Circulatory Disorders of the Spinal Cord
- •Blood Supply of the Spinal Cord
- •Arterial Hypoperfusion
- •Impaired Venous Drainage
- •Infectious and Inflammatory Diseases of the Spinal Cord
- •Syringomyelia and Syringobulbia
- •Diseases Mainly Affecting the Long Tracts of the Spinal Cord
- •Diseases of the Anterior Horns
- •8. Multiple Sclerosis and Other Myelinopathies
- •Fundamentals
- •Myelin
- •Multiple Sclerosis
- •Other Demyelinating Diseases of Unknown Pathogenesis
- •9. Epilepsy and Its Differential Diagnosis
- •Types of Epilepsy
- •Classification of the Epilepsies
- •Generalized Seizures
- •Partial (Focal) Seizures
- •Status Epilepticus
- •Episodic Neurological Disturbances of Nonepileptic Origin
- •Episodic Disturbances with Transient Loss of Consciousness and Falling
- •Episodic Loss of Consciousness without Falling
- •Episodic Movement Disorders without Loss of Consciousness
- •10. Polyradiculopathy and Polyneuropathy
- •Fundamentals
- •Polyradiculitis
- •Cranial Polyradiculitis
- •Polyradiculitis of the Cauda Equina
- •Polyneuropathy
- •Fundamentals
- •11. Diseases of the Cranial Nerves
- •Fundamentals
- •Disturbances of Smell (Olfactory Nerve)
- •Neurological Disturbances of Vision (Optic Nerve)
- •Visual Field Defects
- •Impairment of Visual Acuity
- •Pathological Findings of the Optic Disc
- •Disturbances of Ocular and Pupillary Motility
- •Fundamentals of Eye Movements
- •Oculomotor Disturbances
- •Supranuclear Oculomotor Disturbances
- •Lesions of the Nerves to the Eye Muscles and Their Brainstem Nuclei
- •Ptosis
- •Pupillary Disturbances
- •Lesions of the Trigeminal Nerve
- •Lesions of the Facial Nerve
- •Disturbances of Hearing and Balance; Vertigo
- •Neurological Disturbances of Hearing
- •Disequilibrium and Vertigo
- •The Lower Cranial Nerves
- •Accessory Nerve Palsy
- •Hypoglossal Nerve Palsy
- •Multiple Cranial Nerve Deficits
- •12. Diseases of the Spinal Nerve Roots and Peripheral Nerves
- •Fundamentals
- •Spinal Radicular Syndromes
- •Peripheral Nerve Lesions
- •Fundamentals
- •Diseases of the Brachial Plexus
- •Diseases of the Nerves of the Trunk
- •13. Painful Syndromes
- •Fundamentals
- •Painful Syndromes of the Head And Neck
- •IHS Classification of Headache
- •Approach to the Patient with Headache
- •Migraine
- •Cluster Headache
- •Tension-type Headache
- •Rare Varieties of Primary headache
- •Symptomatic Headache
- •Painful Syndromes of the Face
- •Dangerous Types of Headache
- •“Genuine” Neuralgias in the Face
- •Painful Shoulder−Arm Syndromes (SAS)
- •Neurogenic Arm Pain
- •Vasogenic Arm Pain
- •“Arm Pain of Overuse”
- •Other Types of Arm Pain
- •Pain in the Trunk and Back
- •Thoracic and Abdominal Wall Pain
- •Back Pain
- •Groin Pain
- •Leg Pain
- •Pseudoradicular Pain
- •14. Diseases of Muscle (Myopathies)
- •Structure and Function of Muscle
- •General Symptomatology, Evaluation, and Classification of Muscle Diseases
- •Muscular Dystrophies
- •Autosomal Muscular Dystrophies
- •Myotonic Syndromes and Periodic Paralysis Syndromes
- •Rarer Types of Muscular Dystrophy
- •Diseases Mainly Causing Myotonia
- •Metabolic Myopathies
- •Acute Rhabdomyolysis
- •Mitochondrial Encephalomyopathies
- •Myositis
- •Other Diseases Affecting Muscle
- •Myopathies Due to Systemic Disease
- •Congenital Myopathies
- •Disturbances of Neuromuscular Transmission−Myasthenic Syndromes
- •15. Diseases of the Autonomic Nervous System
- •Anatomy
- •Normal and Pathological Function of the Autonomic Nervous System
- •Sweating
- •Bladder, Bowel, and Sexual Function
- •Generalized Autonomic Dysfunction
- •Index
Special Considerations in the Neurologic Examination of Infants and Young Children 43
Special Considerations in the Neurological Examination of Infants and Young Children
Most of the techniques presented above for the neurological examination of adults cannot be used in infants or small children. In this age group, the important clinical indicators of nervous system function are body posture, spontaneous motor behavior, and the reflex motor responses induced by certain specific stimuli.
In taking the clinical history, the examiner must inquire about any problems that may have occurred during the child’s gestation and delivery. In the physical examination, attention should be paid to any constant, fixed postures of the limbs or asymmetry of the skull (plagiocephaly). The tension of the fontanelles should also be assessed by inspection and palpation.
Reflexes
General aspects. The primitive motor functioning of healthy infants and toddlers is mainly controlled by a number of reflex mechanisms. These reflexes can be affected by neurological disease so that they are absent, or exaggerated, or persist beyond the age at which they normally disappear.
Postural reflexes control the posture of the body and its relation to the ground. Positioning reflexes return the body to a “normal” position after a perturbation; the vestibular system plays an important role in these reflexes. Finally, statokinetic reactions and equilibrium reactions provide the body in motion with important protective movements and righting responses.
The manner of eliciting the reflexes described in this section is illustrated in Fig. 3.33.
Reflexes reflecting the state of maturation of the infantile CNS. A wide variety of reflexes can be pathologically altered in developmental disorders of the CNS. We will only present the more important ones here.
The doll’s-eyes phenomenon is induced by turning the head from side to side or up and down, in an awake, supine infant. The eyes make a compensatory movement in the opposite direction and thus stay in their original position with respect to outside space. This vestibular reflex is demonstrable at birth and persists for the first six weeks of life.
The foot placement reflex is elicited by holding the infant upright under the axillae (while supporting the head) and allowing the dorsum of a foot to touch the edge of the table. A normal newborn infant will flex the hip and knee and put the foot on the table. This reflex disappears in the first few weeks of life.
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45°
3
The Neurological Examination
Fig. 3.33 Reflexes in the infant. a Moro reflex: the infant is held by the examiner in a diagonal, half-supine position, with one hand under the trunk and one hand supporting the head. When the examiner suddenly tips the infant toward the horizontal, momentarily reducing the supportive pressure on the occiput, the infant extends its upper and lower limbs. b The same response can be induced in a supine infant if the examiner suddenly strikes and depresses the mattress. c Parachute reflex: the examiner suddenly tips the infant
forward, from a vertical position toward the horizontal. Normally, the arms are extended, as if to break the infant’s fall. d Landau reflex: an infant held around the trunk in a prone position tends to keep the limbs extended and the head tilted upward. When the head is passively tilted downward, the normal response is flexion of the limbs (positive Landau reflex). (Modified from Lietz, R.: Klin- ische-neurologische Untersuchung im Kindesalter, 2nd edn, Deutscher Ärzteverlag, Cologne, 1993).
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44 3 The Neurological Examination
The stepping reflex is seen when the examiner holds |
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In the Landau reflex, the examiner first lifts the infant |
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the infant under the axillae so that the soles of the feet |
into the air in a prone position; the infant will respond |
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just touch the surface of the examining table and then |
by extending the limbs and head. The examiner then |
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slowly moves the infant forward. The infant will then |
flexes the infant’s head, and the infant flexes the limbs |
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make stepping movements with the feet. This reflex, |
as well (Fig. 3.33d). This reflex should be demonstrable |
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too, is elicitable only in the first few weeks of life. |
from the fourth to the 18th month. In infants with cere- |
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In the tonic hand-grasp reflex, the infant forcefully |
bral damage, the Landau reflex appears late or not at all, |
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grasps the examiner’s index finger when it is placed in the |
or else it persists longer than normal. |
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palm of the hand. The grasp is so tight that the infant can |
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To elicit the asymmetric tonic neck reflex (nuchal re- |
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even be held up by the examiner’s finger. In the analogous |
flex), the examiner slowly turns the supine infant’s head |
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foot-grasp reflex, there is tonic flexion of the toes on |
to one side, while preventing any movement of the |
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stimulation of the sole of the foot. The tonic hand-grasp |
shoulders. The arm and leg are then extended on the |
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reflex is present in the first two months of life, then |
side to which the head is turned and flexed on the other |
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gradually diminishes till it totally disappears, usually in |
side (fencing posture). This reflex is present in new- |
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the third month of life, and no later than the fourth. |
borns and disappears at the age of four months. Per- |
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To elicit the Moro reflex, the examiner holds the infant |
sistence after the sixth month is pathological. |
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in a diagonal, half-supine position, with one hand under |
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The Babinski sign (p. 38) is normally present in infants |
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the trunk and one hand supporting the head. The infant is |
and usually disappears when the child learns to walk. It |
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then suddenly tipped toward the horizontal, while the |
is absent in all healthy children from the age of two |
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support under the occiput is momentarily released. The |
years onward. |
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body flexes as if in fright and the arms are first extended |
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The diagram in Fig. 3.34 represents the stages of nor- |
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and then brought forward as if in a hug (Fig. 3.33a). A sim- |
mal motor development in infancy and early childhood. |
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ilar response can be elicited in a supine infant by sud- |
Some abnormal findings that may suggest a cerebral |
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denly striking and depressing the mattress (Fig. 3.33b). |
motor disorder at different times in the first year of life |
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The Moro reflex is no longer seen after the third or fourth |
are listed in Table 3.11. |
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month of life. Its absence in the first few months of life is |
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usually associated with severe brain damage. |
Table 3.11 Findings suggesting a cerebral motor disorder in |
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Support reactions are tested by pressing on the infant’s |
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palms or soles. The infant extends the corresponding |
the first year of life |
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limb as if to support its weight with it. Support reactions |
High-risk birth (prematurity, cyanosis at birth, abnormal Apgar |
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are present at birth in the legs and develop in the arms |
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scores) |
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over the first four or five months of life. Cerebral lesions |
Abnormal flaccidity or fixed lumbar lordosis |
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make these reactions abnormally intense. |
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Tendency to opisthotonus |
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Feeding difficulties |
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The positioning reflexes are evoked by a combination |
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Spasticity with resulting difficulty in changing diapers |
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of afferent input from the vestibular system and from re- |
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Squint |
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ceptors in the skin, joints, and muscles. In the parachute |
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No head lifting in the prone position at age three months or |
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reflex, the vestibular system plays the most important |
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older |
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role: the examiner holds the infant around the trunk with |
No head control in the sitting position at age four months or |
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both hands, lifts it off the examining table, holds it at |
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older |
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Persistence of certain reflexes |
about a 60° angle, and then suddenly tips the infant for- |
No free sitting or flattening of the lumbar kyphosis at age |
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ward into a horizontal position, near the surface of the |
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nine months or older |
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table (or crib). Infants aged about four months or older |
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will extend their arms, downward and in mild abduction, |
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and open their hands, as if to break the fall (Fig. 3.33c). |
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Months 1 |
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3 |
4 |
5 |
6 |
7 |
8 |
9 |
10 |
15 |
Fig. 3.34 Stages of normal motor |
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development in infancy and early |
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childhood. |
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Head, |
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spine |
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Crawling, |
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standing, walking |
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Mumenthaler / Mattle, Fundamentals of Neurology © 2006 Thieme All rights reserved. Usage subject to terms and conditions of license.