신경학적 검사 (Neurological Examination) 경희대학교 의과대학 부속병원 신경과학교실 이상훈

병력청취(History Taking) 정신기능검사(Mental Status Examination) 뇌신경검사(Cranial Nerve Examination) 운동계검사(Motor System Examination) 감각계검사(Sensory System Examination) 반사(Reflexes) 운동조화(Coordination) 보행과 자세(Gait and Stance) 뇌막자극징후(Meningeal Irritation Sign)

병력청취(History Taking) 환자의 주소와 현병력 과거력, 가족력, 사회력 계통적 문진과 신경학적 증상의 문진 목표 신경계 질환의 유무 병변의 위치(where is the lesion?) 질환의 병태생리(what is the lesion?) 감별진단(differential diagnosis)

Mental Status & Behavior General appearance and behavior (including level of consciousness & affection) Attention and concentration Memory Orientation Thought process (abstract thought, judgement, insight) Thought content Calculations Language and speech

Functional Anatomy of Brain Cortex Frontal lobe Dominant, Nondominant, Bilateral Parietal lobe Temporal lobe Occipital lobe

Mini-Mental Status Examination 지남력(시간) : 5점 지남력(장소) : 5점 기억등록 : 3점 주의집중 및 계산 : 5점 기억회상 : 3점 언어 및 시공간 구성 : 9점

Speech Examination Fluency of speech Comprehension Naming letters, numbers, and objects Repetition Reading Writing Graphic

Classification of Aphasia Global aphasia Motor aphasia (Broca) Sensory aphasia (Wernicke) Conduction aphasia Transcortical motor aphasia Transcortical sensory aphasia

뇌신경검사(Cranial Nerve Examination) Olfactory nerve Optic nerve Fundus, visual field, visual acuity, color vision Oculomotor, Trochlear, and Abducens nerve Eye lids, pupils, extraocular movement Trigeminal nerve : Facial sensory, corneal reflex Facial nerve : Movement of forehead and cheek, taste Vestibulocochlear nerve : Weber, Rinne test Glossopharyngeal, Vagus nerve Soft palate elevation, gag reflex(CN9 CN10) Spinal Accessory nerve : SCM, Trapezius muscle Hypoglossal nerve : Tongue movement

Olfactory Nerve Aromatic, nonirritative substance Test when The patient complains of loss of smell or taste Suspect frontal pathology Trauma Headache Personality change Dementia

Optic nerve Fundus, visual field, visual acuity, color vision Confrontation Test

Not Cooperated or Stuporous Patient Watch the patient’s eyes to see Starting from behind the patient  Your face or money, no sounds ! Visual Threat (threatening test)

Primary Gaze Red-Glass Test Oculomotor, Trochlear, and Abducens nerve Eye lids, pupils, extraocular movement Primary Gaze Red-Glass Test

Pupillary Reflex Arc Afferent Pupillary Pathway Light  Optic nerve  Optic chiasm  Optic tract  Lateral geniculate body  Pretectal nucleus  Bilateral Edinger-Westphal nucleus Efferent Pupillary Pathway Edinger-Westphal nucleus  Oculomotor nerve  Ciliary ganglion Direct or Indirect Light Reflex

Direct reflex Indirect reflex Optic nerve - - Optic tract + or - + or - Lateral geniculate + + Optic radiation + + Visual cortex + + Oculomotor nerve - +

Pupil Examination “PERRL & A” P : Pupil E : Equal (Symmetricity) R : Round (Shape) R : Reflex to L : Light A : Acommodation

Eye Movement Examination Observe the eyes for their position at rest. Observe the spontaneous movement of the eye. Ask the patient to follow a stimulus, such as penlight. The test for convergence of the eyes. Look for any adventitious (extraneous) movement, such as nystagmus

탐구사항 The pathway of eye movement Frontal eye field PPRF(paramedian pontine reticular formation) MLF(medial longitudinal fasciculus) Internuclear ophthalmoplegia One-and-a-half syndrome

뇌신경검사(Cranial Nerve Examination) Trigeminal nerve : Facial sensory, corneal reflex V1, V2, V3 division of trigeminal nerve

Corneal Reflex Arc Afferent Pupillary Pathway Trigeminal nerve Efferent Pupillary Pathway Facial nerve

Corneal stimulus Right blink Left blink Rt. stimulus - - Lt. stimulus + + Rt. stimulus - + Lt. stimulus - + Right Afferent lesion Normal of Left Afferent and Both efferent Right efferent lesion

뇌신경검사(Cranial Nerve Examination) Facial nerve : Movement of forehead and cheek, taste

탐구사항 Peripheral Facial Palsy Central Facial Paralysis Facial nerve function Nerve to stapedius Chorda tympani Etc…

뇌신경검사(Cranial Nerve Examination) Vestibulocochlear nerve : Weber, Rinne test Weber test Rinne test

탐구사항 Nylen-Balani Test Caloric test

뇌신경검사(Cranial Nerve Examination) Glossopharyngeal, Vagus nerve Soft palate elevation, gag reflex(CN9 CN10)

뇌신경검사(Cranial Nerve Examination) Spinal Accessory nerve : SCM, Trapezius muscle Shoulder Elevation Power Check

뇌신경검사(Cranial Nerve Examination) Hypoglossal nerve : Tongue movement Tongue Deviate or Not

운동계검사(Motor System Examination) 시진(Inspection) Muscle bulk Abnormal movement 근긴장도(Muscle tone) : spasticity, rigidity, hypotonia 근력(Muscle power) Screening tests for hemiparesis Pronator drift Rapid finger taps Arm-rolling test

Functional Anatomy of Motor System

Abnormal Movements Fasciculation Tremor Myoclonus Asterixis(Negative myoclonus) Chorea Athetosis Ballism

Abnormal Movements Fasciculation

Abnormal Movements Tremor

Abnormal Movements Myoclonus

Abnormal Movements Asterixis(Negative myoclonus)

Abnormal Movements Choreoathetosis

Abnormal Movements Ballism

근긴장도(Muscle Tone) Spasticity

근긴장도(Muscle Tone) Rigidity

근긴장도(Muscle Tone) Hypotonia

근력(Muscle Power) 0 No muscle contraction detected 1 A barely detectable flicker or trace of contraction 2 Movement occurs only in the plane of gravity 3 Active movement against gravity but not against resistance 4 Active movement against resistancebut less than normal strength (may be graded as 4+, 4, or 4-) 5 Normal strength

Screening Tests for Hemiparesis Pronator drift

Screening Tests for Hemiparesis Rapid finger taps

Screening Tests for Hemiparesis Arm-rolling test

감각계검사(Sensory System Examination) Primary sensory modalities Light touch Pinprick, Temperature Vibration Joint position(proprioception) Cortical sensory modalities Simultanagnosia Graphesthesia Stereognosis Two-point discrimination Baresthesia

Functional Anatomy of Sensory System

Cortical Sensory Modalities Graphesthesia

Cortical Sensory Modalities Stereognosis

Cortical Sensory Modalities Two-point discrimination

Cortical Sensory Modalities Baresthesia

반사(Reflexes) 심부건반사(Deep tendon reflexes) 족부반사(Plantar reflexes) 피부반사(Cutaneous reflexes) 전두엽 해체징후(Frontal releasing signs)

심부건반사(Deep tendon reflexes) Jaw jerk

심부건반사(Deep tendon reflexes) Biceps

심부건반사(Deep tendon reflexes) Triceps

심부건반사(Deep tendon reflexes) Finger flexion (Hoffman’s) reflex

심부건반사(Deep tendon reflexes) Knee jerk

심부건반사(Deep tendon reflexes) Ankle jerk

족부반사(Plantar reflexes) Babinski’s sign Chaddock’s sign Oppenheim’s sign Gordon’s sign

족부반사(Plantar reflexes) Babinski’s sign

족부반사(Plantar reflexes) Chaddock’s sign

족부반사(Plantar reflexes) Oppenheim’s sign

족부반사(Plantar reflexes) Gordon’s sign

피부반사(Cutaneous reflexes) 복부반사(Abdominal reflexes) T8-9 T11-12 고환올림근반사(Cremasteric reflex) L1-2 S1 구해면체근반사(Bulbocavenous reflex and anal wink) S2-4 S3-4

전두엽 해체징후(Frontal releasing signs) Snout, suck, and root reflexes Palmomental reflex Grasp reflex Glabellar reflex

전두엽 해체징후(Frontal releasing signs) Snout reflex

전두엽 해체징후(Frontal releasing signs) Palmomental reflex

전두엽 해체징후(Frontal releasing signs) Grasp reflex

전두엽 해체징후(Frontal releasing signs) Glabellar reflex

운동조화(Coordination) Coordination of movement Maintenance of muscle tone Dysmetria : finger-to-nose test, heel-to-shin test Dysdiadochokinesia : rapid alternating movement Maintenance of muscle tone Hypotonia : pendular knee jerk Equilibrium Gait and Stance ataxia : tandem gait

Functional Anatomy of Cerebellum Embryologic classification of cerebellum Archcerebellum, Paleocerebellum, Neocerebellum Functional classification of cerebellum Vestibulocerebellum, spinocerebellum, cerebrocerebellum Deep nuclei of cerebellum Dentate, Interposed(emboliform, globose), fastigial

Coordination of Movement Dysmetria finger-to-nose test heel-to-shin test

Coordination of Movement Dysdiadochokinesia Rapid alternating movement

Maintenance of Muscle Tone Hypotonia Pendular knee jerk

Equilibrium Gait and Stance ataxia Tandem gait

Abnormal Gait Cerebellar gait Gait of sensory ataxia Hemiplegic gait Festinating gait Steppage gait Waddling gait Staggering or Drunken gait Hysteric gait (Astasia-abasia) Gait in Normal Pressure Hydrocephalus

Meningeal Irritation Signs Neck stiffness Kernig sign Brudzinski sign