CENTRAL NERVOUS SYSTEM

HISTORY
1. Developmental history—GM / FM / PS / Language / Vision /
Hearing
2. Weakness / tightness
a. Duration / onset / progress
b. Distal weakness—difficulty in buttoning / writing /
feeding with spoon / cannot grip the slippers.
c. Proximal weakness—difficulty in combing hair / taking
bath / getting up from squatting position / climbing stairs
d. Associated symptoms
3. Sensory disturbance—superficial / deep, B/B disturbance
4. Cranial nerve involvement
▪ I—h/o smell disturbances
▪ II—h/o visual disturbances
▪ III, IV, VI—h / o diplopia / squint / ptosis
▪ V—h / o difficulty in feeding
▪ VII—h / o dribbling of saliva / deviation of angle of mouth/ inability to
close eyes / loss of taste sensation
▪ VIII—h / o hearing disturbances
▪ XI, X—h / o nasal twang to speech / nasal regurgitation
▪ XI—h / o difficulty is shrugging of shoulders
▪ XII—h / o dysphagia / dysarthria
5. Higher mental function

6. Seizures—type / onset / duration / progress / B / B disturbance /

post-ictal period / episodes.

7. Cerebellar symptoms—h / o swaying / difficulty in taking food to

mouth (coordination), ataxia.

8. Headache / vomiting / blurring of vision (raised ICT), fever, altered

sensorium (meningoencephalitis).
EXAMINATION
CNS EXAMINATION
1. HMF, Gait

2. Cranial nerves

3. Motor system examination

4. Sensory system examination

5. Cerebellar signs

6. ANS examination

7. Skull and spine

HIGHER MENTAL FUNCTION
MNEMONIC (ABCDE MIS OS): Appearance / Behavior / Consciousness Level /
Delusion / Emotional Liability / Memory / Intelligence / Speech / Orientation /
Sleep
i. Appearance—dressing / hygiene / self neglect
ii. Behaviour—normal / hyperactive / docile
iii. Level of consciousness drowsy / delirium / obtundation / stupor / coma-light /
deep / flaccid [DDO SC]
iv. Delusion—(false and firm believe)
Illusion—(false believe with external stimuli, e.g. snake instead of rope)
Hallucination—(false believe without external stimuli, e.g. visual /
olfactory / tactile)
v. Emotional lability
vi. Memory—immediate / recent / remote
vii. Intelligence
viii. Speech—normal / dysphasia / aphasia / dysarthria
▪ BROCA speech—inferior frontal gyrus (understand but cannot write)
▪ WERNICKE speech—superior temporal gyrus (do not understand but
can write)
▪ Bulbar palsy—9, 10, 12 CN—nasal twang
▪ Pseudobulbar palsy—craniospinal—slurred
▪ Cerebellar lesion—scanning
▪ U / L vocal cord palsy—hoarseness of voice
▪ B / L vocal cord palsy—aphasia
ix. Orientation to time / place / person
x. Sleep pattern
2. Optic (II)
Gross vision
Snellen’s chart (distant vision)
Jaeger’s chart (near vision) (keep at 30-40 cm)
Acuity of vision
Finger movement / hand movement / perception (stand at
100 cm)
Field of vision Perimetry (>7 years) or confrontation method (>3 years)
(sit 3 feet away)
Colour vision (Ishihara test) (>3 years)
Fundus Look for optic disc, retina, maculae

Pupillary / accommodation
Reflexes
(Afferent: CN II; Efferent: CN III)
• Tell child to fix the gaze to examiner eye
7. Facial (VII): Ask in history about deviation of angle of mouth /hyperacusis /
leaking of food and saliva. Look for any facial asymmetry
▪ Sensory: Taste sensation over anterior 2/3rd of tongue (asl the child to
identify the substance by pointing to the words written on the card).
▪ Motor: Forehead furrowing / eyebrow raising (frontalis)
(Keep a hand over the scalp to black occipital head)
♦ Eyes closure: Orbicularis oculi, Bell’s phenomenon
♦ Teeth showing: Depressor anguli oris
♦ Blowing the cheek: Buccinator
♦ Nasolabial fold (Obliterated on the paralysed side) and eversion of lower lip):
Platysma
▪ Secretomotor: Salivation/ lacrimation (Schirmer’s test: Put a piece of
blotting paper under the lower eyelids and remove it after 5 min. Normally
after 5 min blotting paper should be marked with 10 mm of tear secretion)
8. Vestibulo-cochlear (VIII)
▪ Vestibulo (h /o vertigo), nystagmus, Romberg’s sign, doll’s eye (occulo-
cephalic reflex), Fukuda step test
▪ Vestibulo-ocular Reflex—Afferent: CN VII; Efferent: CN 3,4,6
▪ Cochlear (Watch test / Rinne’s test / Weber’s test) (256 or 512Hz)

Conductive hearing Sensori-neural

Test Normal response
loss hearing loss

Rinne AC > BC BC > AC Cannot be tested

Lateralised to Lateralised to normal

Weber No lateralisation
defective ear ear

AC: Air conduction; BC: Bone conduction

9. and 10. Glosso-pharyngel (IX), Vagus (X) (Longest CN)
▪ Sensory: Taste sensation of the posterior 1 / 3rd (IX) of tongue
▪ Motor: H / o dysphagia / dysarthria / nasal regurgitation / nasal twang of voice.
▪ Movement of palate / position of uvula (X) / gag reflex—Afferent: CN IX; Efferent:
CN X
11. Spinal accessory (XI): Shrugging of shoulder (trapezius)—check from behind
Turning the neck against resistance (sterno-cleidomastoid) check from front.
12. Hypoglossal (XII):
▪ H / o dysarthria
▪ Position of tongue / wasting / deviation / fasciculation / movements on protruding out
Remember Rule of 17
10+7=17 (10th and 7th nerve palsy results in deviation to the opposite side)
As in 7th nerve palsy, mouth deviate to the opposite side,
10th nerve palsy uvula deviate to the opposite side
12+5=17 (12th and 5th nerve palsy results in deviation to the same side)
As in 5th nerve palsy, jaw deviate to the same side (healthy lateral pterygoid push it towards
paralysed side), 12th nerve palsy tongue deviate to the same side
(Tongue always tells the truth)
Note: Nerves in the shadows (research going on)
i. Cranial N XIII: Nervus terminalis / zero nerve / nerve N
ii. Cranial N XIV: Nervus intermedius
 MOTOR SYSTEM
MNEMONIC: ABCD MP GST—Attitude / bulk / coordination / DTR / movement
(invol) / power / GAIT / sup reflex / tone.
2. Nutrition (bulk): Comment on size / shape and symmetry
measurement in cm
Right Left

Mid arm

Mid forearm

Mid thigh

Mid calf

3. Coordination of movements: Finger nose test / heel knee test

DTR Root value Reaction noticed Rt Lt
Contraction of the biceps and flexions of the
Bicep C5 C6
forearm
Supinator C5 C6 Flexion of the elbow
Contraction of triceps and extension of
Tricep C6 C7, C8
forearm
Contraction of quadriceps and extension of
Knee L3 L4
the knee
Ankle S1, S2 Contraction of calf muscles
Mnemonic
1, 2: Buckle my shoes (Ankle / Achilles reflex)
3, 4: Kick the door (Knee / patellar)
5, 6: Pick up the sticks (Biceps and supinator / brachioradialis)
7, 8: Lay them straight (Triceps)
Note: Jaw jerk—trigeminal (V) nerve (afferent and efferent both)
Grading of DTR
0 Absent
+ Sluggish or present only with reinforcement
++ Readily elicited (like normal ankle jerk)
+++ Brisk (like normal knee jerk)
++++ With Clonus
• Clonus—patellar / knee, sustained / ill sustained
• Plantar is extensor till 2 years of age.
▪ Reinforcement of reflexes by—Jendrassik manoeuvre
5. Involuntary movement: Mention if any seen fasciculation / tremors / chorea /
athetosis/ hemiballism
6. Power
Grade the power (Medical Research Council Scale)

0 Absent voluntary contraction

1 Feeble contraction on manoeuvre

2 Movement with gravity eliminated

3 Movement against gravity

4 Movement against partial resistance

5 Normal
Check for movement bilaterally and grade the power
Neck Extension / flexion
Shoulder Abduction / adduction / extension / flexion / elevation
Elbow Extension / flexion / supination / pronation
Wrist Extension / flexion
Grip
Intercostal muscle Splinting of diaphragm
Diaphragm Splinting of chest (intercostal muscle)
Abdomen Beevor sign
Abduction / adduction / extension / flexion / internal rotation / external
HIP
rotation
Knee Extension / flexion
Or you can test the muscle power individually
Muscle Instruction to the child Examiner action
Latissimus dorsi Clasp your hands behind your back Resist downward back-ward movement
Serratus anterior Push forwards against the wall Observe winging of scapula
Pectoralis major Stretch your arms in front and clap your hands Try to hold the hands apart
Deltoid Supraspinatus Lift the arm away from the chest Resist abduction
Flex the forearm first. Now try to straighten
Try to keep the forearm flexed while the
Triceps out the forearm against the resistance offered
child tries to straighten it.
by the examiner.
Holding your forearm against your side, bend Grasp the wrist and offer resistance to
Biceps
it flexion.
Place the arm between the prone and supine Grasp the wrist and offer resistance to
Brachioradialis
position, now bend the forearm flexion.
Grasp the wrist and offer resistance to
Extensors of wrist Extension of the hand at the wrist dorsiflexion / extension of the hand at the
wrist
Flexors of wrist Flexion of the hand at the wrist Resist flexion of the hand

Contd.
Muscle Instruction to the child Examiner action

Present index and middle fingers to the

Flexors of the fingers Squeeze my fingers
child to squeeze

Keep leg straight and abduct it fully now bring

Adductors of the thigh Offer resistance to adduction
the leg back to the midline against resistance

Abductors of the thigh Move the leg out against resistance Offer resistance to abduction

Flexors of the thigh

Keep knee extended lift leg off the bed Offer resistance to flexion of the thigh
(Psoas)

Keep knee extended lift leg off the bed now

Extensors of the thigh Offer resistance to extension of the thigh
push the leg down against resistance

Offer resistance to internal rotation of the

Internal rotation at hip Put child in prone, Keep knee flexed now try to
thigh
joint abduct the legs fully

External rotation at hip Put child in prone, Keep knee flexed now try to Offer resistance to external rotation of the
joint cross the legs fully thigh
7. Gait: Hemiparetic / ataxic / shuffling / high stepping / wadding / spastic.
8. Superficial reflexes: Glabellar: Afferent V, Efferent VII
Root value Right Left
Corneal Afferent V / efferent (VII) CN
Abdominal (Stroke towards
T6 to T12 Epigastric – T6 to T9 (Absent in UMN lesion)
umbilicus)
Cremasteric (stroke towards
L1 (Absent in UMN lesion)
upper inner aspect of thigh)
Plantar S1 (Babinski / extensor response in UMN lesion)
Anal S1 and S4
9. Tone: UL and LL (Ask the patient to relax and go floppy)

Tests Normal Hypotonia Hypertonia

Posture of the limb Normal Limp Extended / stiff
Palpation of muscle Normal Flappability Rigid
Resistance to passive
Normal Decreased Increased
movements
Range of passive movements Normal Increased Decreased
Hypertonia (spasticity/rigidity)
▪ Clasp knife, spasticity—pyramidal
▪ Cog-wheel, lead pipe—rigidity—extrapyramidal
In newborn tone is assessed by scarf sign/heel to ear manoeuvre/adductor angle.
SENSORY SYSTEM
Check for each dermatomes bilaterally, distal to proximal. Tell child to
close the eyes and tell him to respond verbally to appreciation of
sensation. [Required tools—tuning fork 128Hz, 2 test tube, safety pin,
coin, cotton, wooden tongue depressor, blocks, compass]
Antero Lateral Spinothalamic Tract Column Sensation
• Crude touch (ANT STT)
• Temperature (use two test tubes of worm and cold water)
• Pain (use pin head)
Posterior or Dorsal Column Tract Sensation (PCT)
• Light touch (use cotton wisp)
• Vibration (128Hz) (Check on bony points B/L-medial malleoli / tibial tuberosity /
iliac spine / head of ulna / elbow / mastoid)
• Joint sense—upper limb / lower limb
• Position sense (proprioception): Ability to determine the direction of movement of
the great toe or fingers of hand—upward and downward with closed eye.
• Romberg’s sign (inability to stand with feel together and eyes closed) two senses:
▪ Proprioception (PCT) (the ability to know one’s body position in space) and
▪ Vestibular function (VII CN) (The ability to know one’s head position in space
Note: Romberg test is not a sign of cerebellar lesion it is positive in disturbance of
PCT and vestibular lesion
• Pressure sense (use wooden tongue depressor)
Note: PCT does not carry PCT (pain, crude touch, temp)
Cortical Sensation
• Tactile localization
• Tactile discrimination
• Two-point discrimination (use compass)
• Sensory inattention / dissociation (pain and temp lost, crude touch present)
• Stereognosis (give familiar objects, e.g. coin / keys)
• Graphaesthesia (write numbers by your finger on child’s palm)
• Extinction (double simultaneous stimulation)
• Construction and dressing apraxia (give him blocks to make, clothes to wear)
Dermatomes
Remember
• Thumb—C6 • Big toe—L4 • Nipple—T4 • Umbilicus—T10 • Anus—S3 , S4
CEREBELLAR SIGNS (MNEUMONIC: ANS DTR)
• Ataxia
• Atonia (hypotonia)
• Ataxic gait
• Nystagmus
• Scanning speech
• Dysmetria / past pointing (finger-finger-nose test)
• Dyssynergia (knee heel test)
• Dysdiadochokinesia (rapid alternating movements)
• Dysarthria
• DTR—(pendular knee jerk)
• Tandem walking
• Tremors intention (essential tremors—senile)
• Rebound phenomenon
Autonomic Nervous System (Head Ganglion of ANS Hypothalamus)
• Sympathetic: (Fight and flight) thoracolumbar outflow (T1-L2)
• Parasympathetic: (Rest and digest) craniosacral outflow (3,7,9,10 cranial nerve
and S2-S4)
1. Look for sweating after hot bath
2. Variation in HR during Valsalva maneuver
3. Fall in BP>20 mm Hg from supine to standing indicates autonomic
neuropathy (normal variation is <10 mm Hg)
SKULL AND SPINE
Meningeal Signs
• Neck rigidity: Flexion of head causes spasm in the extensor muscles of neck
• Kernig’s sign: Painful restriction of extension of leg when the hip is flexed (due to spasm of the
hamstring muscles)
• Brudzinski’s: Neck sign—flexion of knee and hip following flexion of the neck (better elicited
in the sitting posture)
• Brudzinski’s le sign: Flexion of knee and hip of opposite side following flexion
of other limb
• Straight leg raising test

Note: Meningeal signs in-meningeal irritation are due to stretching of spinal nerve roots
causing reflex muscle spasm

Example:_______ years old male / female child suspected to have TB meningitis

with right hemiplegic / convulsion + / cranial nerve palsies of __________
Features s/o increased ICT with grade III PEM with normal / abnormal
development, immunized for age
Differences between UMN and LMN Lesion
Features Upper motor neuron lesion Lower motor neuron lesion
Power Reduced Markedly reduced
Distribution of muscle
Diffuse and symmetrical Patchy and asymmetrical
weakness
Muscle tone Spasticity Hypotonia / atonia
Muscle wasting Minimal / absent Significant
DTR Brisk + clonus Sluggish / absent
Plantar Extensor Flexor / absent
Fasciculation / fibrillation Absent Seen
Reaction of degeneration Absent Seen
In UMN facial nerve palsy forehead is spared.
Differences between Cerebellar and Extrapyramidal Dysfunction

Features Cerebellar dysfunction Extrapyramidal dysfunction

Power Normal Normal

Muscle tone Hypotonia Cog-wheel / dystonia

Muscle wasting Absent Absent

Speech Scanning Slurred

Gait Reeling / ataxic Shuffling

Tremors Intention Pill rolling / resting tremors

 GLASSGOW COMA SCALE (GCS)
Eye opening Verbal response Motor response
4 Spontaneous 5 Oriented 6 Obeys commands
3 To voice 4 Confused 5 Localizes to pain
2 To pain 3 Inappropriate words 4 Withdraws
1 None 2 Incomprehensible sounds 3 Flexion response to pain
1 No response to pain (decorticate)
2 Extension response to pain
(decerebrate)
1 No response to pain

Score <7 indicates coma, max score = 15, min score = 3

CRITERIA FOR SIMPLE FEBRILE SEIZURE
1 6 months to 5 years
2 Neurologically normal child
3 Absence of CNS infection
4 Family history
5 Within 24 hours of fever
6 Single episode
7 Generalised tonic clonic seizure (GTCS)
8 <10 minutes
9 No post neurological deficit
10 EEG normal, CT normal
Cerebral Palsy
Nonprogressive, nondegenerative neuromuscular disorder often associated with epilepsy,
abnormalities of speech, vision and intellect due to defect or lesion in the developing brain.
Types—spastic / ataxic / dyskinetic / atonic / dystonic / mixed.
Acute Flaccid Paralysis
Onset of paralysis (<4 weeks) in a child < 15 years of age for which no obvious cause has been
found.
Common causes are—polio / GBS / Transverse myelitis and traumatic neuritis
Acute Encephalitis Syndrome (AES)
A person of any age, at any time of year with the acute onset of fever and a change in mental
status (including symptoms such as confusion, disorientation, coma, or inability to talk) and/ or
new onset of seizures (excluding simple febrile seizures)
Involuntary Movements
1. Ballismus: Throwing movement, rapid, forceful, flingy (disappear in sleep,
spare face and trunk)
2. TICS: Throat clearing, shrugging of shoulders, eye blinking, increase during
stress, can suppress voluntarily
3. Tremors: Purposeless rhythmic movement
4. Athetoid movement: Stiffening and loosening of the body (rhythmic, irregular,
disappear in sleep, increase with activity)
5. Chorea = nonrhythmic, fast abrupt, brief jerky, milk maid grip, darting tongue,
piano playing, disappear in sleep, [Sydenham’s chorea (St Vitus’ dance) seen in
Rh fever)
GAIT
• Circumduction gait → Hemiplegia
• High stepping gait → Polio, peripheral neuropathy
• Ataxic / drunken gait → Cerebellar lesion
• Wadding gait → Myopathic gait
U/L → Trendelenburg
B/L → Hip girdle muscle weakness
• Diplegic / spastic gait → Cerebral palsy
• Parkinsonian gait → Walk of little steps
Specific Investigation to Diagnose CNS Diseases
• Lumbar puncture
• Cranial ultrasonography or neurosonogram (NSG)
• Computed tomography scan (CT scan)
• Magnetic resonance imaging (MRI)
• Electroencephalogram (EEG)