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Sophisticated technology for neurodiagnosis supplements, but does not replace, the neurological examination. Physical examination remains the standard for assessing the normal or abnormal function of the nervous system, the localization of neurological injury, and the severity of impairment. An experienced examiner can rapidly perform this assessment and then exercise the best judgement in selecting laboratory investigations.

Our presentation in this chapter of a general outline by which one might ap­proach the neurologic examination is somewhat artificial in that the, examina­tion is discussed in isolation from the neurologic history. In practice, history and examination are dynamically related. One gets a sense from the clinical history of what might be wrong, and the hierarchy of these possibilities is then measured against the examination. After the examination, the “odds ratios” for various structural and functional abnormalities of the nervous system are adjusted, and further diagnostic testing is selected or postponed. We have cho­sen to focus this chapter on the examination as opposed to the clinical history and interview, because psychiatric clinicians are usually excellent at the latter and clumsy at the former. We have not forgotten, however, that the clinical history directs and focuses the examination, and salient historical issues are discussed in the separate chapters with the various disease syndromes.

We examined 28 male leprosy patients to discover if a more extensive neurological investigation than usual would be worthwhile in diagnosis and/or management. Our findings were fully compatible with what might be expected from a mononeuritis multiplex, either due to leprosy or other causes. The following observations are noteworthy. Changes of position sense and a decrease of some tendon reflexes were present in a minority of the patients. In soles of the feet, considered to be an- or hypaesthetic, some residual pain sensation could occasionally be detected. Functional testing of at least one muscle group (m. triceps surae) appeared to be more reliable than manual testing according to MRC criteria. We concluded that an extensive neurological examination is probably not required for diagnosis. It does provide, however, more accurate information on the extent of damage to the peripheral nervous system, which may be important for management and for assessment of treatment effects. The use of a myometer is advocated.

The neurological examination is a resource used in evaluating patients who are in coma. Anaesthesia can be a factor that exerts an influence on the findings. We evaluated the examination of the comatose patient in the case of patients anaesthetised with propofol in order to define its clinical value.A prospective study was conducted among those who had undergone heart surgery in the intensive care unit of a tertiary hospital during the months of April and May 2011. Aspects that were analysed were the examination of the anaesthetic coma, pharmacological or medical factors that can have an influence and a full neurological examination following recovery. Patients with previous neurological symptoms were excluded.Thirty patients were selected (16 males and 14 females); mean age: 72 ± 10 years. All the patients were sedated with propofol. During sedation, 17 (46.7%) presented unreactive pupils. No spontaneous eye movements were observed in 100% of the sample. Ocular alterations in primary position were observed in 23.3% of them. Oculocephalic reflexes were absent in 93.3% and oculovestibular reflexes, in 100%; the corneal reflex, was absent in 70% (with asymmetry), as was the ciliospinal reflex, in 83.3%. The algesic motor response was absent in 93.3%, as were the cutaneous plantar extensor reflexes, in 20%; and 66.7% were indifferent. Following anaesthesia, the neurological examination was normal in 80%, there were slight orientation impairments in 16.7% and a hemispheric syndrome was found in one patient.Anaesthesia with propofol alters the reversible cutaneous-plantar, pupillary, trunk and motor response reflexes on withdrawing sedation. The alterations may be asymmetrical. Neurological examinations should not be used in the case of patients sedated with propofol in order to make clinical decisions.Exploracion neurologica en pacientes sometidos a sedacion con propofol: estudio descriptivo.Introduccion. La exploracion neurologica es un recurso en la evaluacion de los pacientes en coma. La anestesia puede ser un factor influyente en los hallazgos. Evaluamos la exploracion del paciente en coma en pacientes anestesiados con propofol para definir su valor clinico. Pacientes y metodos. Estudio prospectivo en sometidos a cirugia cardiaca en los cuidados intensivos de un hospital terciario durante los meses de abril y mayo de 2011. Se analiza la exploracion del coma anestesico, factores farmacologicos o medicos que pueden influir y exploracion neurologica completa tras la recuperacion. Se excluyeron pacientes con sintomas neurologicos previos. Resultados. Se seleccionan 30 pacientes (16 hombres y 14 mujeres); edad media: 72 ± 10 años. Todos los pacientes estaban sedados con propofol. Durante la sedacion, 17 (46,7%) presentaban pupilas arreactivas. En el 100% no se observaron movimientos espontaneos de los ojos. El 23,3% presentaba alteracion ocular en posicion primaria. Los reflejos oculocefalicos estaban ausentes en el 93,3%, y los oculovestibulares, en el 100%; el reflejo corneal, en el 70% (con asimetria); el espinociliar, en el 83,3%. La respuesta motora algesica estaba ausente en el 93,3%; en un 20%, los reflejos cutaneoplantares extensores; e indiferentes, en el 66,7%. Tras la anestesia, la exploracion neurologica fue normal en el 80%, hubo leves alteraciones de orientacion en un 16,7% y se encontro un sindrome hemisferico en un paciente. Conclusiones. La anestesia con propofol altera los reflejos pupilares, del tronco, respuestas motoras y reflejo cutaneoplantar reversibles al retirar la sedacion. Las alteraciones pueden ser asimetricas. No se deberia utilizar la exploracion neurologica en el paciente sedado con propofol para la toma de decisiones clinicas.

We analyzed cases of small brain ischemic lesions found in examinees of a brain dock (neurological health screening center). Small cerebral infarction was found in 17 % of the examinees (733 cases). White matter lesions were found in 24 %. Infarctions were located in the cortex or subcortical white matter in 31 % and in the basal ganglia in 44 % of cases. Infratentorial infarction was found in 1.6 %. We have developed an animal model of small infarction in the cortex or basal ganglia induced by photothrombosis in rodents. Sprague-Dawley rats or Mongolian gerbils were anesthetized and photothrombotic infarction was induced in the left caudate nucleus or parietal cortex by light exposure via an optic fiber and intravenous Rose Bengal dye injection. Histological examination revealed development of a small spherical infarction surrounding the tip of the optic fiber. The lesion turned to a cyst by 6 weeks after lesioning. Neurological deficits were found in animals both with cortical and caudate infarction. Behavioral changes in an open field test differed with the lesion site. Neurological deficits were sustained longer in animals with larger infarctions. Thus, photothrombotic infarction is useful for analyzing location-dependent and size-dependent neurological and neuropathological changes after cerebral infarction.

A thorough but focused history and neurological examination remain the most important initial elements of neurological diagnosis at all ages. Advances over the past two decades in clinical neurophysiology, neuroimaging, genetics, and neuropathological examination of tissue have at times appeared to predominate over traditional history and physical exam, but no laboratory studies can provide the focus and clues to diagnosis that clinical findings offer. History taking and the techniques of neurological examination are skills to be learned by the student, refined by the resident, and practiced and perfected throughout the career of a pediatric neurologist. Examination must be specifically modified to correspond to age and with the expectation of developmental skills achieved at various ages, in addition to the localizing value of particular signs that may apply at all ages. Hypotonia, extensor plantar responses, and lack of visual fixation may be normal in a preterm infant but abnormal at several months of age. "Primitive" reflexes disappear at a certain age, but really are only suppressed or inhibited and may become re-expressed with disinhibition many decades later. Finally, the pediatric neurologist needs to have a firm foundation in normal development, neuroembryology, and changes in the expression of diseases at various stages of maturation of the nervous system.

【Abstract】Objective: To determine the frequency of altered findings on repeat cranial tomography (CT) in patients with mild head injury along with stable neurological examination at tertiary care hospital. Methods: Cross-sectional study was done in the Department of Radiology, Liaquat National Hospital, Karachi from January 2008 to September 2010. All patients with mild head injury in terms of Glasgow Coma Scale (GCS) who underwent repeat scan without clinical or neurological deterioration in the emergency department of a tertiary care centre were included. The collected data were accordingly entered and analyzed by the principal investigator using Statistical Package for Social Sciences (SPSS) version 16.0. Results: In all 275 patients, only 17 (6%) of the patients were found worseing on repeat CT, 120 (43.63%) scans improved, 138 (50.18%) unchanged and 17 (6.18%) worsened. None of these patients showed signs of clinical deterioration. ?Conclusion: Our results suggest that for patients with mild head injury and stable neurological examination, only 6% of them show deterioration on repeat CT, especially when patients?GCS is below 13.?Key words: Brain injuries; Neurologic examination; Glasgow coma scale; Tomography

Numerous physiological changes occur in the nervous system with increasing age. On clinical neurological examination, such changes may be misinterpreted as pathology in the nervous system. The objective of this article is to provide a review of the clinical neurological findings that may be caused by normal ageing.The present manuscript is based on a non-systematic search in PubMed as well as on the clinical experience of the authors.Cognitive functions are usually fairly well preserved in old age, apart from executive functioning, psychomotor speed and episodic memory, which are reduced with increasing age. Physiological changes related to increasing age include, in particular, vertical eye movements (upwards), vibration sense, Achilles reflexes, primitive reflexes and motor speed. Muscle power is reduced by 20-40% in healthy individuals aged over 70 years.A correct diagnosis based on findings in the neurological examination cannot be made without knowledge of how ageing affects the physiology of the nervous system. However, the evidence regarding physiological changes in the nervous system is limited, and more research is needed in this field.

The clinical and electrographic signs of hypoxic-ischaemic encephalopathy (HIE) evolve over the first days of life. We examined the evolution of neurological signs over the first 3 days of life, and determined whether serial administration of the Amiel-Tison Neurological Assessment at Term (ATNAT) would predict neurodevelopmental outcome at 24 months.Term (37 wks' gestation) neonates born with suspected HIE between May 2003 and May 2005 in a Cork maternity unit were recruited prospectively. Modified Sarnat grading was assigned. The ATNAT was administered on days 1, 2, and 3 of life and a discharge neurological examination. Time to oral feeding and demographic variables were recorded. Developmental status was assessed using the revised Griffiths Mental Development Scales at 6, 12, and 24 months.Fifty-seven infants were recruited, with 51 (31 males, 20 females) included for follow-up. Neurological examination evolved and normalized over the first 3 days of life in many cases. At 24 months, 21 children had an adverse outcome, including six deaths. Examination at all time points correlated significantly with neurological outcome at 24 months. The best correlations were found to be (1) neurological examination at discharge (r=0.65, p0.001), (2) Sarnat grading (r=0.64, p0.001), and (3) ATNAT on day 3 (r=0.46, p0.001). The best predictive value was seen with neurological examination at discharge (positive and negative predictive values of 86% and 72% respectively).Persistence of abnormal neurological signs correlates significantly with adverse outcome. The later a neonatal neurological examination was performed, the better its predictive ability.

The aim of the study was to evaluate prevalence of cervical spine inflammatory changes, especially atlantoaxial pathology, and their possible relation to subjective and objective neurological symptoms in rheumatoid arthritis patients. 100 patients (88 female and 12 male) aged 23 to 85 (61.4 +/- 12.9), with the mean disease duration of 12.5 +/- 9.5 years were included in the study. According to radiological examination (lateral and antero-posterior X-ray of the cervical spine) supplemented by MR of the cervical spine or CT of the atlanto-axial joint in suspected cases, 26% of patients had only inflammation, next 15% of patients presented with instability of the atlanto-axial joint and 9% developed basilar invagination of the dens of axis. 18% of patients presented subaxial cervical instability. Neurological examitation was performed by independent neurologist in 99 patients, only 14 presented abnormalities suggesting cervical myelopathy. Two of them showed no patology of the cervical spine. Remaining patients presented: C1/C2 inflammation in 4 cases, anterior atlanto-axial subluxation (AAS) in two cases, basilar invagination in 4 cases and instability with medullary compression on lower cervical levels only--in two cases. There were 4 cases of coexisting C1/C2 changes with medullary compression due to discopathy and (in 3 of them) instability on lower cervical levels. In 6 cases surgical stabilisation was proposed (5 patients with basilar invagination and 1 patient with AAS and myelopathy). There was statistically significant correlation between symptoms (like: paraesthesiae, intermittent problems with hearing and seeing), neurological examination and degree of radiological damage of atlanto-axial joint. The authors concluded that careful medical history and neurological examination can be useful in making decision of further radiological diagnostic procedures of the cervical spine in rheumatoid arthritis.

The neurological examination is a challenge for both the physician as well as the patient. Its goal is the formation of a syndrome--but not the diagnosis--with the tools of the case history and the neurological examination, which are presented coarsely, weighted, ostentatious, and provocative at times.

To underscore the importance of the pediatric neurological examination for the diagnosis, treatment and prognosis of nervous system disorders in children. For that, we reviewed the research carried out by our group in the past 40 years.Knowing the semiology of neurological development is essential for the neurological, psychological and motor follow-up of children. On their own, neuroimaging techniques are not sufficient to predict the long-term neurological and psychomotor consequences of perinatal events. On the other hand, the neurological examination is a sensitive method with good prognostic value, which facilitates a timely and appropriate treatment intervention. This observation has been confirmed by our research focused on the neurological examination, including the study of the developmental neurological examination in preschoolers, assessment of the psychological and neurological maturity in school age children, development of preterm-born school age children, limb-trunk coordination in premature newborns and their development, relationship between higher brain function, learning to read and write and improving the diagnosis of attention deficit/hyperactivity disorder in school children, neurological disorders in newborns, birth trauma, jaw opening reflex to appendicular compression, parachute and lateral propping reactions in newborns, neurological and psychomotor development at 6 months of corrected age in premature babies with neonatal crises and/or intracranial hemorrhage, and neurological examination in healthy newborns.The neuropediatrician must be aware of the importance of a comprehensive neurological history and consistent semiology to be able to request and correctly evaluate the results of ancillary tests, and thus make adequate treatment decisions.

Dissociative and conversion disorders are classified together according to ICD-10 as states that are not confirmed by the presence of somatic diseases, which they suggest. According to the DSM-IV, both disorders are classified separately. Conversion disorders are a group of psychiatric disorders whose symptoms mimic the presence of malfunction or loss of motor or sensory function, whereas the nature and dynamics of the observed symptoms is not fully explained by the results of objective assessments and consultations, nor is the direct effect of a psychoactive substance. Impaired mental integration of different functions which normally interact simultaneously in the perception of reality and inner experience of the individual is found in dissociative disorders.The article describes the case of 25-year old man, in whom after initial suspicion of myasthenia gravis and its exclusion, a diagnosis of conversion disorder was made on the basis of the clinical picture and treatment with an SSRI antidepressant and individual psychotherapy were recommended. No improvement in mental and neurological status after six month therapy resulted in an in-depth diagnostics in a clinical setting and diagnosis of brain stem tumor (aastrocytoma fibrillare).(a) Neuroimaging is a source of important clinical data and in many cases should constitute an inherent element of a psychiatric diagnosis. (b) Diagnosis of conversion (dissociative) disorders requires a precise differential diagnosis, excluding the somatic causes of observed neurological ailments. (c) A late diagnosis of neurological or somatic causes of symptoms which arouse a suspicion of conversion (dissociative) disorders may make a radical treatment impossible or may considerably aggravate the remote prognosis and quality of the patients' life.

We describe the construction of a scored form for the neurological examination of the full-term neonate. Extensive data analyses were obtained from a large sample of neonatal neurological examinations performed by one examiner (MSP). Examinations were used from neonates with ages less than or equal to 48 hours (n = 727) and 72 hours to 1 week (n = 510) with gestational ages greater than or equal to 37 weeks. Forty-four items from several neonatal assessments were used in these neurological examinations. Further subdivision yielded a total of 65 items. Correlations were obtained for the 65 items. We factored the matrix of these correlations, using several solutions of factor analysis. Thirty-two items were thus grouped and pruned into seven dimensions (factors) to provide a scorable neonatal neurological examination (Neoneuro) with an internal consistency or reliability of 0.80. From the total scores, cut points are recommended for categories of normality/abnormality: normal, mildly abnormal, moderately abnormal, and severely abnormal. This scoring system is well-based both theoretically and psychometrically. The quantified computer-compatible scoring system permits evaluation of individual neonates, as well as comparison of samples of neonates on item scores, subscores (factor scores), and total scores. Such quantification will permit documentation of the natural history of specific abnormalities and the evaluation of various therapies.

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.

The concept of the NHS as a natural experiment isn’t new. Neither is the sense that evaluation of major NHS reforms has barely been attempted and might even be considered undesirable by politicians. Why ask a question that might lose you a general election? The power of the NHS is the public’s emotional attachment to it. Failures of the NHS may not be viewed as unfortunate flaws in the system of care but as political misjudgements. In politics, misjudgement has a high attrition rate. NHS campaigners have picked off politicians in constituencies where voters have been upset by changes to local services. At the next election, David Cameron, Nick Clegg, and Jeremy Hunt will all be challenged by doctors. Other high-profile politicians may also be targeted by the National Health Action party, who will achieve a publicity triumph if nothing else. The hurt from the 2012 Health and Social Care Act remains. Questions are unanswered. Has the Health and Social Care Act achieved its objectives? How would we know if it did? Katikireddi et al.1 believe that four methodological challenges must be overcome to evaluate the Health and Social Care Act. First, we need to know what are the reforms to be evaluated. What, then, are the outcomes that are likely to change? When will the reforms have an effect? And, finally, what would have happened if the reforms had not been introduced? All questions are important, although the last one seems the most fascinating. The authors believe that, even at this late stage and with ingenuity, some valuable information can be gathered. Regrettably, we may never know the true impacts of the NHS reforms. Mexico, Brazil, and China are finding ways to evaluate their major health reforms, yet it remains a task that is beyond us, the nation with a health service that has been a natural experiment since its inception. JRSM encourages further discussion, debate, and research assessing the outcomes of the Health and Social Care Act. Health policy is important, as are clinical skills. When I mastered the full neurological examination as a medical student it was a major landmark. Now O’Brien2 tells us that there is no such thing, at least in the course of a clinical encounter, as it would take all day and more, waste a considerable amount of time, and achieve very little. Bartholomew3 believes many open access journals also achieve next to nothing except buffering the cash reserves of publishers. He has a point but it would be wrong to damn all open access publications, plenty of whom, like JRSM Open, offer authors a low-cost route to publication of their work with free dissemination. Others believe, with some good reason, that peer review is a broken system and that publication with minimal or no peer review is preferable. The purpose of peer review at JRSM and JRSM Open is to improve the quality of articles between submission and publication. The decision to publish, whether on health service reforms, the neurological examination, or predatory journals, rests with the editor. All three subjects, I propose in the best tradition of articles in medical journals, require further evaluation.

We studied reports of clinical neurological status in patients referred from primary and secondary health service to a neurological department.We evaluated referrals consecutively during 6 months. By using parametric and categorical statistical methods, we studied characteristics in examined patients compared with others.Of a total of 912 patients, 431 (47%) had been examined neurologically. Among the women, 267 women (51%) had been examined; among the 164 men (43%). Patients with musculoskeletal disorders were more often examined, p = 0.0001, while those with faint or seizure disorders were significantly less frequently examined compared with other patients, p = 0.009. Clinical neurological examinations were performed more often in women compared with men, p = 0.03. The mean age was higher in the examined group (49.7 years) compared with others (46.5 years), p = 0.006.Clinical neurological examination in patients referred to a neurological department had more often been performed in women, in higher age groups, and in those with musculoskeletal symptoms. In more than half of the patients, the decision of referring patients to the department of neurology was not based on results obtained from clinical neurological examination.

Vertigo is caused by disturbance of the input or central processing of sensory signals from the vestibular apparatus that provide information regarding the position of the body in space. It is caused either by asymmetric disruption of sensory input from the vestibular organs or asymmetric integration of vestibular input into the central nervous system. Vertigo is readily differentiated from other causes of dizziness by a sensation of motion. A crucial aspect of the management of the emergency department patient with vertigo is the differentiation of vertigo associated with acute stroke syndromes from vertigo due to peripheral causes. Routine computerized axial tomography imaging is insensitive for posterior circulation strokes, so for emergency physicians, the history and neurological examination remain the most useful diagnostic tools. This article emphasizes the history and physical examination in the localization of the lesion in patients with vertigo and offers a rational basis for decisions regarding the need for special neurological imaging and consultation. It also emphasizes subtle findings that may prevent the erroneous diagnosis of peripheral vertigo in the presence of an acute stroke syndrome.

This chapter covers the purposes for which a neurological examination of a neonate may be performed. A brief description is given, of assessments currently in use. More extensive information is provided on the elements of the Neurobehavioral Assessment of the Preterm Infant (NAPI), an assessment which has been used extensively by this author and others (see references at www-med.stanford.edu/school/pediatrics/NAPI/index). Medical and environmental factors that impact on the neurobehavioral performance of an infant are outlined. Two detailed case studies give insight to the complexity of the initial hospital stay of extremely low birth weight infants of short gestational age. The results of NAPIs for each of these cases are explained and the relation to long term outcome at 18 months is presented.

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.

Handsurgeons are normally more interested in clinical tests evaluating sensory and movement disorders of hand. Since these are often unprecise and require a cooperative (and intelligent) patient, neurologists and neurosurgeons prefer precise diagnostic procedures. For this reason they use electrophysiological techniques to evaluate and localize peripheral nerve lesions, i.e. electromyography, sensory and motor nerve conduction velocity and somatosensory-evoked potentials (SEP), by which most nerves of the arm and hand (median, ulnar and radial nerves including their major branches) can be easily assessed. Insufficient technique (submaximal stimulation, no temperature control, stimulation of a neighbouring nerve) and mis- or overinterpretation are sources of error, which can best be avoided when the diagnosis is made in context with the clinical picture--especially when the surgeon is familiar with electrophysiological techniques.

Bilateral absence of cortical N20 responses of median nerve somatosensory evoked potentials (SEP) predicts poor neurological outcome in postanoxic coma after cardiopulmonary resuscitation (CPR). Although SEP is easy to perform and available in most hospitals, it is worthwhile to know how neurological signs are associated with SEP results. The aim of this study was to investigate whether specific clinical neurological signs are associated with either an absent or a present median nerve SEP in patients after CPR. Data from the previously published multicenter prospective cohort study PROPAC (prognosis in postanoxic coma, 2000–2003) were used. Neurological examination, consisting of Glasgow Coma Score (GCS) and brain stem reflexes, and SEP were performed 24, 48, and 72 h after CPR. Positive predictive values for predicting absent and present SEP, as well as diagnostic accuracy were calculated. Data of 407 patients were included. Of the 781 SEPs performed, N20 s were present in 401, bilaterally absent in 299, and 81 SEPs were technically undeterminable. The highest positive predictive values (0.63–0.91) for an absent SEP were found for absent pupillary light responses. The highest positive predictive values (0.71–0.83) for a present SEP were found for motor scores of withdrawal to painful stimuli or better. Multivariate analyses showed a fair diagnostic accuracy (0.78) for neurological examination in predicting an absent or present SEP at 48 or 72 h after CPR. This study shows that neurological examination cannot reliably predict absent or present cortical N20 responses in median nerve SEPs in patients after CPR.

This review is an attempt to evaluate critically some of the recent literature on the clinical utility of the neurological examination in child psychiatric practice. Three separate but related issues are discussed; the accuracy of the examination in assessing cerebral dysfunction, the strength of the association between neurological signs and behaviour disorders and finally the clinical significance of this association. It is pointed out that not all neurological signs are of equal significance, but that developmental neurological signs which indicate cerebral immaturity are weakly associated not only with hyperactivity, but possibly with other behaviour disorders as well. Some of the methodological weaknesses in this literature are pointed out. Recent studies of children with motor impairment (clumsiness) are briefly mentioned as a potentially more fruitful avenue of research. It is concluded that the neurological examination may be useful in identifying sub-groups of behaviourally disturbed children who differ from other children with behaviour disorders in terms of etiology, prognosis or treatment needs. Unfortunately, little work has been done in this specific area and further research is needed.

Sixteen males, formerly exposed to carbon disulfide (CS 2 ) 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. WitrCrCBF examination, slight abnormalities were found in 8. The findings indicate that long-term exposure to CS 2 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.

A modified Prechtl neurological examination and the Brazelton Neonatal Behavioural Assessment Scale (BNBAS) were used on days 1 and 5 in 78 healthy newborn infants. Correlations between variables in the neurological examination and the behavioural items and subscales in the BNBAS were calculated. Especially the total neurological score and optimality score were significantly correlated to motor performance (days 1 and 5) and to orienting responses to animate and inanimate stimuli (day 1) in the BNBAS. The neurological variables showed poor or no correlation to the habituation items and to certain items concerned with changes of behavioural state in the BNBAS.

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.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.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.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.

A young woman presented to neurology with a 1 month history of progressive diplopia on lateral gaze and a 1 week history of headaches. On examination she was found to have complex ophthalmoparesis with binocular horizontal diplopia, failure of abduction bilaterally and limited upgaze with convergence-retraction nystagmus. The rest of the neurological examination was normal. She was admitted for investigations: blood, CT brain, MR brain and lumbar puncture results were normal. Anti-GD1a antibodies were strongly positive; anti-GM1, anti-GM2 and anti-GD1b were also positive. On follow-up 3 weeks later, the complex ophthalmoplegia persisted. It was decided to treat with intravenous immunoglobulins (IVIgs) with good response but recurrence at 2 weeks post infusion. She was treated with 4 weekly IVIg courses and remains responsive and controlled over 1 year since presentation but becomes symptomatic in the week running up to each dose; thus, disease modifying treatment is currently being considered.

This study examined the role of cranial sonography and neurological examination in the prediction of developmental progress during the first 19 months of life in extremely preterm infants. Forty-seven infants with mean birth weight 993 +/- 197 g and gestational age 27.9 +/- 1.9 weeks were studied. Each infant was classified as normal, suspect, or abnormal using cranial sonography and a structured neurological examination. Developmental outcome was assessed using the Infant Neurological International Battery (INFANIB) at 4, 8, and 14 months and the Rockford Infant Developmental Evaluation Skills (RIDES) at 19 months. Sonographic classification was the best predictor of outcome through 14 months, F(2.72) = 12.4, p.001. The neurological examination predicted performance only at 4 months. No infant classified as normal on both examinations was abnormal on follow-up. Infants with suspect or abnormal neurological examinations had normal outcomes if their sonographic findings were normal.

Thirty-six patients admitted with severe head injury and various degrees of systemic hypotension were studied to determine the effect of hypotension on the validity of the neurological examination in reflecting mechanical brain compression. All patients had clinical signs of transtentorial herniation or upper brainstem compression and underwent immediate bilateral placement of exploratory burr holes for the diagnosis and removal of intracranial hematomas. All patients were initially hypotensive: 10 were in cardiac arrest, 7 had a systolic blood pressure (SBP) less than 60 torr, and 19 had SBP of 60-90 torr. The median score on the Glascow coma scale was 3 (range 3-8). Although 4 of the 10 cardiac arrest patients had anisocoria, only one (10%) had an intracranial hematoma. Among the seven patients with severe hypotension, only two had anisocoria and neither had and intracranial hematoma; one patient in this group (14%) had a hematoma that was diagnosed at autopsy. In contrast, intracranial hematomas were discovered by burr-hole placement and evacuated in 13 (68%) of 19 patients with initially moderate hypotension, including seven (78%) of nine patients with anisocoria. Anisocoria was associated with mechanical brain compression from an intracranial hematoma significantly more often in patients with an initial SBP of 60-90 torr than in those with initial cardiac arrest or SBP less than 60 torr (chi-square p less than 0.05). Intracranial hematomas were significantly more frequent among patients with SBP of 60-90 torr than among those with a lower SBP or initial cardiac arrest (P less than 0.01). Thirty-three of 36 patients died; each of the three survivors had an initial SBP of 60-90 torr, and hematomas were removed in two. In head-injured patients with SBP greater than 60 torr, clinical signs of tentorial herniation or upper brainstem dysfunction remain valid indicators of possible mechanical compression; the high percentage of patients with acute intracranial hematomas in this group warrants immediate diagnostic burr-hole exploration. In patients with severe initial hypotension (SBP less than 60 torr) or cardiac arrest, clinical findings of brainstem dysfunction cannot be relied upon to indicate mechanical compression, and computed tomography scanning should be done immediately after resuscitation to determine the need for surgical exploration.

A display system using multivariate analysis and signal compression methods is described; it serves for the analysis of complex dynamic phenomena via curves in a 2-dimensional coordinate system. Differential diagnosis is then possible, simply by comparing visually the relative variations and differences of shape for these curves. Two major applications are given: (a) 2-dimensional display of hand tremor, for reference testing in relation to the positive diagnosis of ataxia and the differential diagnosis of extrapyramidal syndrome, including the Parkinson syndrome. (b) Visual feedback to the patient when performing tracking tasks in relation to the differential diagnosis of tremor or in training for the use of limbs.

Six hundred newborn babies were examined by the author in the first 4 days of life. 77% were at term, 6% postmature and 17% premature. The biceps reflex was obtained in 89%, triceps jerk in 85%, supinator jerk in 87%, knee and ankle jerks in 99%. A flexor plantar response with lateral plantar stimulation occurred in 2.8% of babies, in 2 of whom the response appeared indicative of pathological change. An increase in the frequency of elicitation of the abdominal reflexes occurred when these reflexes were tested immediately after the initial inspection and not during the course of the routine examination. Tonal fluctuation is seen after the first 6 h of life, usually mild in degree, but it may be more pronounced and then probably represents a delay of the post partum transition period. Comparison between the head and chest circumferences may provide an additional means of differentiating dysmaturity from prematurity.

This article will review age-related changes in the neurological examination. The involutional process is a diffuse one, affecting all levels of the neuraxis simultaneously. Most of the numerous little manifestations distinguishing them so sharply from the youthful are really features of the neurology of the elderly. Some signs are characteristic: attitude of general flexion, general poverty of movement, gait, minor extrapyramidal signs, primitive reflexes. However, these features may also be caused by neurological diseases common in the elderly, such as dementia or cervical myelopathy, which is very common after 75 years.

Sixty-seven patients with different stages of human immunodeficiency virus (HIV) infection (47 CDC group IV, 20 CDC groups II or III) were followed prospectively for a median of 18 months with neurological examination, magnetic resonance imaging (MRI), and computerized tomography (CT) to evaluate the incidence of the AIDS dementia complex (CDC definition) and other neurological complications. Ten patients developed CNS opportunistic infection or malignancy. Among the remaining 57 patients, 12 of 37 (32%) belonging to CDC group IV, and 1 of 20 (5%) belonging to CDC groups II/III developed the AIDS dementia complex (p = 0.03). MRI white matter lesions occurred in 32% of CDC group IV patients and 5% of CDC groups II/III patients (p = 0.03). The corresponding figures for brain atrophy at CT were 71% and 30% (p less than 0.01) and for neurologic signs 49% and 20% (p = 0.06). The development of the AIDS dementia complex was significantly associated with the occurrence of MRI white matter lesions and a CD4 cell count of less than 200 x 10(6)/l, whereas it was not statistical significantly associated with brain atrophy at baseline. It is concluded that the AIDS dementia complex is a common feature of late stage HIV infection. Brain atrophy occurs in a large percentage of HIV infected patients, but the clinical significance of this atrophy is not clear.

The data of topographic EEG brain mapping were compared to neurological evidence and CT data in 6 patients with organic lesions (sequelae of vertebrobasilar ischemic stroke, brain atrophy, brain tumor). Cortical activity typical for these nosological entities appeared on the EEG maps. In 5 out of 6 patients foci of alpha- and delta-activity indicated the location of the lesion. The authors suggest that EEG brain mapping of the large number of patients with neural and mental diseases will provide insight into pathogenetic mechanisms of these diseases. The authors also think it necessary for patients undergoing EEG brain mapping to be examined neurologically.

Objective The aim of this paper is to describe a low-cost and readily accessed Manual Aspiration Reduction System (MARS) for use treating ping-pong fractures in three patients. Methods The MARS is composed of a pediatric anesthesia mask, part of a macro dripper, a 3-way stopcock, and two 60-ml syringes. Prior to its use in our patient, the system was tested on five adult volunteers to maximum negative pressure, and none reported pain during the procedure or experienced any other complication. We present three clinical cases of patients with depressed ping-pong fracture who were treated with the MARS at the bedside without anesthesia. The patients were monitored by the neonatology team throughout the procedure. Results Skull radiography revealed reduction of the fracture after the procedure performed with the MARS in all patients. The transfontanellar ultrasound and follow-up neurological examination were normal. The patient progressed favorably and was discharged from our service after 24 h. Conclusions Due to its components, the MARS is a low-cost and readily accessed system. In this case, it permitted satisfactory reduction of a ping-pong fracture in all patients. This system should greatly simplify the treatment of such fractures.

A 52-year-old male patient with polyarthritis nodosa (PAN) was referred to our neurology outpatient clinic. His main symptom was paroxysmal alternating bilateral blindness. Subsequently, he developed retro-orbital pain. Neurological examination including funduscopy was normal and laboratory tests showed no relevant abnormalities. MRI orbits showed remarkable perineural thickening and contrast enhancement of the optic nerve sheaths with sparing of the central optic nerve. These findings are pathognomonic for the clinical-radiological diagnosis of optic perineuritis (OPN). The patient was treated with high-dose immunosuppressants and had a good clinical outcome. Rapid diagnosis of OPN is important because early treatment is associated with a better outcome.