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Neurological examination is traditionally divided into examination of the cranial nerves and examination of the peripheral nervous system. In fact the two routines are complementary, and serve a common primary goal: to localise pathology within the nervous system, central and peripheral. Together with an impression of the type of lesion, derived primarily from the history, this localising information is central to correct interpretation of subsequent cross-sectional imaging.
Examination of the cranial nerves
You may need to select appropriate components of the following examination routines according to the clinical scenarios and guidance provided by examiners. This is a test of frontal lobe function.
CN I (olfactory nerve)
• Not routinely tested
CN II (optic nerve)
• Acuity: each eye individually
• Fields: four quadrants to confrontation
• Reflexes: accommodation; direct and consensual light reflex
• Ophthalmoscopy: visualise the disc, exclude papilloedema
CN III, CN IV, CN VI (oculomotor, trochlear, abducens nerves)
• Ask patient to report any double vision during testing.
• Instruct patient to keep the head still.
• Ask patient to follow finger with eyes and report any double vision.
• Move finger to all extremes of gaze in an H-shape, to confirm normal upgaze/downgaze in both eyes, in abduction and adduction.
CN V (trigeminal nerve)
• Assess fine touch sensation in the three divisions:
• ophthalmic (Va) over temple
• maxillary (Vb) over cheek
• mandibular (Vc) over angle of mandible
• Confirm masseter/temporalis contraction on clenching teeth.
• Elicit corneal reflex and jaw jerk.
CN VII (facial nerve)
• Ask patient to:
• raise eyebrows
• close eyes tightly
• puff out cheeks
• show teeth
CN VIII (vestibulocochlear nerve)
• Test recognition of whispered speech in each ear individually.
• Weber's and Rinne's tests.
CN IX (glossopharyngeal nerve)
• Offer to test gag reflex.
• Prompt the patient to cough, looking for a strong cough.
• Prompt the patient to swallow, observing for symmetry.
Gliomas are neoplasms derived from glial cell precursors. Gliomas may present with one or a combination of neurological deficits, symptoms of mass effect and seizures, usually reflecting the anatomical location of the lesion. Seizures in the context of glioma appear to confer a significant prognostic benefit. Epileptic foci are believed to develop within the cortex surrounding tumors, since the lesions themselves have no electroencephalographic (EEG) activity and are not electrically excitable. Diagnosis of a space-occupying lesion as the cause of a seizure is made usually with the aid of cross-sectional imaging. Magnetic resonance imaging (MRI), with and without gadolinium contrast, is the investigation of choice, showing a higher sensitivity and specificity than computed tomography (CT) for detecting glioma. Fractionated focal radiotherapy is a key component of adjuvant treatment, especially in high-grade lesions. Chemotherapy with temozolomide has been shown to be of seizure benefit in approximately 50% of Grade 2 gliomas.
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