Diagnostics ： the Nervous

System

Huang Li an

1
 Diagnostics: nervous system

1 Preface
Telencephalon: Cerebrum
NS Thalamus
Diencephalons
Brain Hypothalamus
Midbrain
Brain stem Pons
CNS Medulla oblongata
Cerebellum
Spinal cord
PNS Cranial nerves & Spinal nerves
2
1 Preface

Fig 1: Medial
aspects of the
brain in sagittal
section

3
1 Preface

SPINAL CORD

4
1 Preface
 Symptoms, signs and examination of NS
 The contents concerning NS of the textbook you
have in hand: too much for you now.
 only essential parts for generalized clinical
practice be discussed here.
– Disturbance of consciousness
– Headache
– Dizziness
– Tics, twitches, convulsion & seizures
– Examination of NS
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2 Disturbance of consciousness:
Coma and other Alternations of Consciousness
Vegetative
state

Lock in
syndrom

Fig 2: Ascending reticular activating system (ARAS) 6

2 Disturbance of consciousness:
Coma and other Alternations in Consciousness

 Consciousness refers to set of neural processes

that allow an individual to perceive, comprehend,
and act on the internal and external
environments.
 Normal human beings are alert
 Pathophysiology: Two components****
– awareness
– arousal (or wakefulness)

7
2 Disturbance of consciousness:
Coma and other Alternations in Consciousness

 Arousal: describes the degree to which the

individual is able to interact with the
environment; the contrast between waking
and sleeping is a common example of two
different states of arousal. Be wakeful ! ****
 more primitive, “on-off switch” of
awareness via thalamus projecting
diffusely to cortex ****

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2 Disturbance of consciousness:
Coma and other Alternations in Consciousness

 Awareness reflects the depth and content of

the arousal state.
– Its content includes orientation,
attention, memory, thought, perception,
intellect, mood, affect, etc.
– dependent on arousal (switch on-off),
because one who cannot be aroused
appears to lack awareness.

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2 Disturbance of consciousness:
Coma and other Alternations in Consciousness

Mechanisms
A. Bilateral diffuse cerebral cortex failure:
impaired awareness with intact arousal
mechanisms (vegetative state)

B. Brainstem failure: impaired arousal,

undetectable of awareness (ARAS switch off)
Primary & Secondary (herniation)
C. Combined bilateral cortical and brainstem
failure: generalized disorders (non-CNS)

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2 Disturbance of consciousness:
Coma and other Alternations in Consciousness

Etiology
a) Infectious disease: CNS and non-CNS
b) All other CNS diseases
c) Endocrinal and metabolic disorders: i.e. uremia
( dysfunctions of kidney), liver, respiration,
diabetics (ketosis, hyperosmotic coma), etc.
d) Cardiovascular diseases
e) Water electrolyte imbalance
f) Toxicosis (extraneous sources)
g) Physiologic & anoxic injuries:e.g. heatstroke, etc.
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LEVELS of CONSCIOUSNESS DISTURBANCE****

1) Lethargy ( “Shi-Sui 嗜睡” )

 early stage of unconsciousness, permanent sleeping
 able to be waked (ready arousal, responsible
verbally)
 answer simple questions correctly or fulfill simple
tasks
 falls asleep immediately once the stimuli stopped

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LEVELS of CONSCIOUSNESS DISTURBANCE****

2) Stupor “Hun-Shui ( 昏睡 ) ”
 incomplete arousal to painful stimuli, to very loud
verbal.

permanent sleeping, still able to be waked (pain)

 fending-off type motor to pain, eye-open, no verbal
response, no purposeful motor response
 falls asleep immediately once the stimuli stopped

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LEVELS of CONSCIOUSNESS DISTURBANCE****

3) Coma, “Hun-Mi ( 昏迷 )”:

Loss of consciousness ( 意识丧失 )

 Not able to be waked
 No verbal response
 No eye-open response to stimuli

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LEVELS of CONSCIOUSNESS DISTURBANCE****

3-1 Light Coma: “Qian-Hun-Mi, 浅昏迷”

 The features described above
 Primitive & disordered motor response to strong
pain stimuli, not fending-off type, or occasionally
involuntary limbs movement
 Absence of abdominal and cremasteric reflexes
 Presence of other physiological reflexes, or
pyramid signs (if exist)

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LEVELS of CONSCIOUSNESS DISTURBANCE ****

3-2 Deep Coma: “Shen-Hun-Mi, 深昏迷”

 The features described above ， but
 Absence of any response to most painful stimuli
 Absence of abdominal and cremasteric reflexes,
esp. corneal reflex
 Absence of other physiological reflexes, or
disappearance of pyramid signs (if existed before)
 Vital signs changes
3-3 The term of 中度昏迷 （ moderate coma), between light and
deep coma, is used also in the clinical practice.

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LEVELS of CONSCIOUSNESS DISTURBANCE

 Alert – lethargy -- stupor – light come – deep coma

 An individual patient may have some changes

during a period, even a short time.
 The changes in levels of consciousness may
represent the severity of illness.
 Another method to reflect the disturbance levels of
consciousness is Glasgow Coma Scale

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LEVELS of CONSCIOUSNESS DISTURBANCE
Glasgow Coma Scale
Nil 1 Nil 1
Best Extension 2
Eye-opening To pain 2 Motor (decerebrate) 3
To voice 3 response Flexing (decorticate) 4
Withdrawing 5
Spontaneously (with 4 Localizing 6
blinking) Obeying

Nil 1 Total Best 3; worst 3

Best Verbal Groans (incomprehensible) 2 No coma
response ≥8
Word 3 Coma
(expletive/inappropriate) <8
Disorientated (confused) 4 Concomitantfixed pupils and oculocephalic
Orientated 5 reflex absence suggest worse prognosis
3~5
Special forms of
CONSCIOUSNESS DISTURBANCE **

1) Confusion: “Yi-Shi-Mo-Hu ( 意识模糊 )”

Both arousal and awareness impairments

 Slightly decreased arousal and awareness
(lethargy, or even slighter)
 Orientation-dysfunction

 Incomplete cooperation to the examiner.

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Special forms of
CONSCIOUSNESS DISTURBANCE **

2) Delirium “Zhan-Wang-Zhuang-Tai ( 谵妄状态 )”

Both arousal and awareness impairments
 Slightly decreased arousal and obviously awareness
 Interval drowsiness or pernoctation (not sleep over
night)
 Orientation, intelligence, emotion disorders
 Irritation, anxiety, visual hallucination, fragment
delusion
 Incomplete cooperation to the examination
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Syncope “Yun-Jue ( 晕厥 )”
 A brief loss of consciousness.
– transient diminution of the cerebral circulation
– changes in the composition of the blood, as in
hypoglycemia or hypocapnea.
 Impaired circulation of the brain may occur from
ineffective cardiac action (myocardial insufficiency
or dysrhythmias), loss of peripheral resistance in the
vascular tree producing hypotension, or from
vascular reflexes.

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Syncope “Yun-Jue ( 晕厥 )”
 In the erect position, consciousness is lost when the
mean arterial pressure declines to 20–30 mmHg or
when the heart stops for 4–5 seconds.
 In the horizontal position, more extreme conditions
can be tolerated. The patient may complain of “weak
spells,” “light-headedness,” or “blackouts.”
 A careful history must be obtained from both the
patient and witnesses. The history and initial
physical exam are of the greatest usefulness in
establishing a specific etiology.
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 Syncope “Yun-Jue ( 晕厥 )”
 Themost common cause of syncope is the
vaso-vagal, or vasodepressor, faint.
 Other considerations are cardiac
dysrhythmias (Adams-Stokes attacks, either
tachy-or bradycardia), seizure, anaphylaxis,
autonomic dysfunction with orthostatic
hypotension, pulmonary embolism, aortic
stenosis, and cerebrovascular disease.

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 Basic Principles for Identifying Coma Causes

 History taking and signs

1) Looking for whether evidence exist, that Indicating
primary nervous system disorders
– Local brain damage signs (or symptoms):
– Cervical rigidity (cervical irritation signs)
2) Looking for whether evidence exist, that Indicating
non primary nervous system disorders (generalized)
– Pulmonary, hepatic, metabolic, renal disorders, or
Water electrolyte imbalance, etc.
3) Toxicosis (extraneous sources), or 1), 2) & others
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2. Headache
 Definition:

• refers to pain perceived more than

momentarily in the cranial vault, the orbits,
and the nape of the neck;
• pain elsewhere in the face is not included.
 Most common symptoms

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2. Headache
Mechanisms
 Vascular factor: extra-intracranial vascular
contraction (spasm), dilation or stretch
 Irritation or stretch of meninges

 Irritation, extrusion or stretch of cranial nerve

V, IX, X and cervical nerves
 Head and neck muscles contraction

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2. Headache
Mechanisms (continued)
 Chemical factors, endocrinal disorders and
psychogenic factors: in general via vascular factor
 Ophthalmic, rhinologic, otologic disorders, or even
stomatologic disorders (i.e. temporomandibular
joint disease) may cause headache via different
mechanisms.
 From the mechanisms: evident that all extracranial
and intracranial tissues disorders, including neck,
and non-nervous system, may cause headache.

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Clinical Occurrence of headache****
(Etiology)

Too many causes!!

 Chronic or recurrent headaches:
– most vascular, psychogenic or nervous
origins, usually primary headache: without
obviously so called organic dysfunction
 Acute severe headaches
– may ominous prognosis & reflect serious
underlying disease

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Some common Chronic or Recurrent headache

 Migraine  Chronic Generalized disorder

 Cluster headache – Anemia
 Tension-type headache – Liver, kidney, metabolic,
 Trigeminal neuralgia respiratory dysfunctions
 Occipital neuralgia – etc.
 Psychosocial stress
 Arteriovenous
malformations
 Brain tumor

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Other common etiology of headache

 Any causes inducing  Cerebral Vascular

Increase intracranial disorders
pressure  Infections / Inflammatory
 Any intracranial
 Tumor/ occupying
disorders  Demyelinating
 Any cause to induce
 Traumatic
dilation of cerebral
 Hereditary /Congenital
Poisoning, Metabolic &
vessels
nutritional
 Eye, nose, ear, neck, etc. Systematic disorders
(primary disease is non-
nervous / muscle system)
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Evaluation of the patient with
headache****

 An urgent intensive search for serious

pathology is required if the patient
describes:
 A new occurred headache
 A severe headache unlike any experienced
in the past.

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Evaluation of the patient with
headache**** History taking ---- PQRST

Other inquires
 about family members with a headache history
 Identify associated symptoms, such as
• Fever
• Stiff neck
• Nausea and vomiting
• Visual disturbances
• cerebral symptoms
• Dizziness of even vertigo,
• Mood, and sleep disturbances.
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Evaluation of the patient with
headache****

2) Physical examination
careful neurological and general
examination
3) Ancillary tests:
if special symptoms or positive sign of
the nervous system.

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 Evaluation of the patient with
headache****

• Warning signs of possible disorder other than

primary headache are:
• Subacute and/or progressive headaches which
worsen over time (months)
• A new or different headache
• Any headache of maximum severity at onset
• Headache of new onset after age 50
• Persistent headache precipitated by a Valsalva
maneuver
From “Diagnosis and treatment of headache” 2006, Guideline

Jinan University Guangzhou, 暨南大学 34

 Evaluation of the patient with
headache****

• Warning signs of possible disorder other than

primary headache are: (continuing)
• Evidence such as fever, hypertension
myalgias, weight loss, or scalp tenderness
suggesting a systemic disorder
• Presence of neurological signs that may
suggest a secondary cause
• Seizures

From “Diagnosis and treatment of headache” 2006, Guideline

Jinan University Guangzhou, 暨南大学 35

3. Dizziness

36
Introduction
Puzzle ！
• Dizziness
- Dear doctor
• Vertigo ， I am dizzy!
• Lightheadedness- Me, too.
• Giddiness • 头晕
• Disequilibrium • 眩晕
[disikwi’libriėm]
真性，假性
• 头昏
Jinan University Guangzhou, 暨南大学 37
3-1 Classification
• Many disorders in the realms of neurology,
otolaryngology, cardiology, ophthalmology,
psychiatry, and medicine may lead to the
complaint of dizziness ( 头昏 / 头晕 / 眩晕 ).
• Very unpleasant or disabling, and sometimes
heralds the onset of potentially serious diseases:
worry about it! Not only the patients.
• A systematic approach is necessary to reach the
correct diagnosis.
from MA Samuels: Manual of neurologic therapeutics with essentials
of diagnosis, 3rd Edition, Little, Brown and Company 38
3-1-1 Vertigo （眩晕，真性眩晕） ****
 An illusion or movement of the patients or his
or her surroundings
• Rotating, spinning, tilting, or swaying
 Autonomic symptoms (nausea, vomiting,
depression), disequilibrium, and nystagmus (A
rapid, involuntary, oscillatory motion of the
eyeball)
 Implying PNS & CNS pathways of the vestibular
system （ including central & peripheral vertigos)

39
3-1-2 Disequilibrium ****

 A sense of imbalance, unsteadiness, or

“drunkenness” without vertigo.

 Patients usually describe it as 头晕 .

 Vestibular, proprioceptive, cerebellar,

visual, or extrapyramidal system disordes

 May termed also 假性眩晕 in Chinese

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3-1-3 Syncope ( 晕厥 ) or

presyncope***
 a sense of impending loss of consciousness
or fainting
 With diaphoresis, nausea, apprehension,
and transient bilateral visual loss
 Insufficient Cerebral blood supply
 Implying vascular or cardiac dysfunction
 Entirely different from vertigo

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3-1-4 ill-defined dizziness****

 A vague, lightheadedness, giddiness, or

fear of falling that is distinct from the

vertigo, presyncope, or disequilibrium,
usually termed in Chinese “ 头昏”
 Occurs in: Anemia, cardiovascular

diseases, metabolic and toxic disorder)

and emotional disorders, or even a
common cold.
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When difficulty to describe dizzy****

Some patients have difficulty in adequately

describe their dizzy sensation. So, to put the
patient through a serious of maneuvers:
a) Checking for orthostatic hypotension.
b) Vigorous hyperventilation for 3 minutes.
c) Sudden turns when walking
d) Spinning the patient while standing
e) The Nylen-Bárány test for position
vertigo (a test for benign position vertigo).

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3-2 Etiology
• Do you worry about that the cause of the
dizziness is due to a a cardiac or
neurologic cause (dysrhythmia,
cerebrovascular ischemia, or brain
tumor) ? too many disorders ！！
• DIZZINESS accounts for an estimated
7,000,000 clinic visits in the United
States each year
44
 Peripheral
3-2 Etiology Vertigo****

3.2.1 Peripheral vestibular causes

 Benign positional vertigo
 Labyrinthitis (or vestibular neuronitis)
 Meniere's disease
 Other less common disorders
drug-related ototoxicity
nonspecific disorders (peripheral
vestibulopathy of uncertain cause).
From Kroenke, et al. HOW COMMON ARE VARIOUS CAUSES OF
DIZZINESS? A CRITICAL REVIEW. South. Med J.2000, 93(2) 45
 Peripheral
3.2 Etiology Vertigo****
3.2.2 Central vestibular causes

 CVD (strokes or TIAs/ PCI or “VBI”);

 Brain tumors

acoustic neuromas
less commonly posterior fossa tumors
 Other central vestibular disorders
MS, migraine, or dizziness with findings indicative of
a central vestibulopathy on neuro-otologic / vestibular
testing.
46
3.2 Etiology 3.2.3 Psychiatric causes

 Absence of evidence of nonpsychiatric

causes
 Hyperventilation test

 Psychiatric manifestations

47
3.2 Etiology 3.2.4 Other causes

 Presyncope comprises dizziness due to

decreased perfusion, typically orthostatic

hypotension, arrhythmias, or other
cardiovascular causes.
 Dysequilibrium refers to unsteadiness or

balance disorders, most commonly in the

elderly as described.

48
3.2 Etiology 3.2.4 Other causes

 anemia, metabolic causes, medication-

related (excluding drug related
vestibulopathy, i.e, SM ), nonvestibular
neurologic causes (i.e. PD).
 Unknown cause refers to those cases of

dizziness in which a cause cannot be

assigned after diagnostic evaluation had
been completed
49
Epidemiologic data

Unknown 13%

others 26%

Psychatric 16%

Central Vertigo 11%

peripheral
Vertigo 44%

0% 10% 20% 30% 40% 50%

From Kroenke, et al. HOW COMMON ARE VARIOUS CAUSES OF

DIZZINESS? A CRITICAL REVIEW. South. Med J.2000, 93(2)
50
 Epidemiologic data
drug-
Non-specific vestibular rare related
others 14%
ototoxicity

Meniere D 5%

Labyrinthitis 9%

BPPV 16%

0% 5% 10% 15% 20%

Peripheral vestibular causes

51
Epidemiologic data
Unknown
Cerebellar atrophy
Migraine
other 3%
Multiple sclerosis
Mo Epilepsy
st Others
ne aco
tumor 0.70% uro us
ma tic
s

1CVD
／ 2 ： TIA ， ＆ 1 ／ 2 VBI
6%

0% 1% 2% 3% 4% 5% 6% 7%

Central vestibular causes

52
Epidemiologic data
14%
12% 11%
10%
8%
6% 5%
4%
2%
0%
Psychiatric hyperventilation
disorder

Psychiatric
53
Epidemiologic data

Arrhythmia unknow 13%

Only 1.6%
other 13%

disequlibrium 5% VBI?
Non-cardiac
presyncope 6%
Ie. orthostatic
hypotension 0% 2% 4% 6% 8% 10% 12% 14%
>4%
No vestibular, non-psychiatric
54
 **** Central Vertigo Peripheral Vertigo
1. Disorder Ischemic stroke Meniere’s D; labyrinthitis
tumor; epilepsy vestibular neuronitis;
etc. otitis media; BPPV $
2. Hearing loss &
Tinnitus Rare@ Common #
3. Features of Moderate, weeks Severe, sudden, minutes
vertigo to months to days, (weeks)
4. Vertigo to
Position Yes or not Yes
5. Romberg Sign
Yes; or ataxia compensated (open eye)
6. Other CNS
signs Yes; No
7. Autonomic NS
$: BPPV: benign proximal
symptoms Moderate Severe positional vertigo
# not incl.: BPPV &
@:not incl.: acoustic neuromas & internal auditory A. stroke vestibular neuronitis
4. Tics, twitches & Convulsions

Jinan University Guangzhou, 暨南大学 56

4.1 Introduction ****
• Common neurological symptoms
• Belong to involuntary skeletal muscles
movement.
• Generalized or local involuntary repeated
skeletal muscles contractions, usually
induce motional and tonic joints.

Jinan University Guangzhou, 暨南大学 57

4.1 Introduction ****
• Convulsion, generalized, tonic, clonic
twitches, are usually symmetric, with or
without loss of consciousness.
• Differences between seizures and
convulsion:
• Generalized tonic-clonic seizure (GTCS) may
be considered as convulsion, while partial
seizure should not be refereed to convulsion.

Jinan University Guangzhou, 暨南大学 58

4.1 Introduction ****
• Epilepsy: a name of disease;
• Seizure: attack of EP, symptoms of epilepsy
caused by disordered electrical activity in
the brain
Classified as generalized or partial.
Partial seizures are defined as those with a
focal onset, regardless of whether they
generalize later in their course.

Jinan University Guangzhou, 暨南大学 59

4.1 Introduction ****
Tics:
• Normal movements of muscle groups, such
as grimacing, winking, or shoulder
shrugging, are repeated at inappropriate
times.
• May be
• acquired behavioral habits
• or a sign of organic disease, for example,
Tourette syndrome.
• abolished by diverting the patient’s attention
and they disappear during sleep
Jinan University Guangzhou, 暨南大学 60
4.2 Pathophysiology

• The mechanism is not completely understood,

but the abnormal discharge of
neurons**** is considered as the main
mechanism, which may be divided into two
types:
• Brain disorders
• Non-brain disorders (i.e. tetanus,
hypercalcemia).

Jinan University Guangzhou, 暨南大学 61

4. 3 Etiology
• The etiologies include
- Idiopathic causes (i.e. congenital brain disorders)
- Symptomatic.
• Brain disorders:
- Infections;
- Trauma (common cause of epilepsy);
- Brain tumor;
- Cerebral vascular disorders;
- Congenital brain injuries (i.e. sclerosis tuberose,
nuclear icterus),
- Idiopathic causes (i.e. congenital brain disorders)
- Others
Jinan University Guangzhou, 暨南大学 62
4. 3 Etiology
• Generalized disorders
- Infections (acute gastroenteritis, toxic bacillary
dysentery, septicemia, tympanitis, pertussis,
rabies, tetanus, etc.);
- Intoxications (alcohol, drugs, organic
phosphorus, metals, etc.);
- Adms-Stoke syndrome and hypertensive
encephalopathy;
- Metabolic disorders (hypoglycemia,
hypocalcemia, hypomagnesemia, uraemia,
hepatic encephalopathy, eclampsia, ischemia or
anoxia, and many others.
Jinan University Guangzhou, 暨南大学 63
4. 3 Etiology
• Others:
- Drug withdrawal (alcohol, barbiturates,
sedamine, anticonvulsant medications);
- Electric shock,
- Febrile convulsion;
- Hysteria, etc.

Jinan University Guangzhou, 暨南大学 64

4. 4 History and physical examination****

• Inquire carefully for the attributes of

onset:
• provocative and palliative factors
• quality (local local or generalized,
prolonged tonic or intermitted clonic)
and timing.

Jinan University Guangzhou, 暨南大学 65

4. 4 History and physical examination****

• Other inquires about past history, identify

associated symptoms & signs.
• Fever in infectious disease or febrile
convulsion;
• Stiff neck and sharp headache in meningitis,
encephalitis and intracranial hemorrhage;
• Loss of consciousness in epilepsy and severe
intracranial disorders.
• Bilateral pupil dilatation is a characteristic of
epileptic seizure.
Jinan University Guangzhou, 暨南大学 66
4. 4 History and physical examination****

• When the patient has twitches, convulsion or seizure,

the immediate approach is to prevent injury and support
cardiorespiratory function if necessary.
• However, the physician rarely observes the event, so a
thorough history and examination are essential to
identify the cause and to exclude other causes of
impaired consciousness.
• For patients with new onset, seek the cause,
supplementing your neurological examination with
appropriate imaging and laboratory studies.
Jinan University Guangzhou, 暨南大学 67