Pratap Sagar Tiwari, Lecturer,

Internal Medicine, NGMC

CNS EXAMINATION: HIGHER MENTAL FUNCTION & CRANIAL

NERVES

FOR EG :• Patient is conscious, cooperative and well oriented to person place & time. His/her GCS

is 15/15.

• Patient’s memory and attention is intact and speech and language is normal. His/her MMSE is 28/30

HIGHER MENTAL FUNCTION1. Appearance & Behaviour

2. Level of consciousness :

3. Congnitive functions

• Memory & attention

• Speech & language

• Cortical functions

GCS

MMSE

CORTICAL FUNCTIONExamination of

• Frontal lobe

• Parietal lobe

• Temporal Lobe

• Occipital lobe

GLASCOW COMA SCALE

MEMORY & ATTENTIONMemory

• Remote memory

• Recent memory

Attention

• Serial 7s

• Word backward

SPEECH & LANGUAGE• Dysarthria

• Dysphasia

DYSARTHRIA• Motor inability to speak, abnormality in articulation.

• Could be due to local tongue causes, facial muscles, disruption of neuromusculature etc

DYSPHASIA• Higher order inability to speak, disorder in encoding and decoding the language. Usually

associated to left hemisphere lesion.

• Four components: fluency, comprehension, repetition and naming

• Naming is affected in all forms of dysphasia.

TYPES OF DYSARTHRIA• Flaccid dysarthria

• Spastic dysarthria

• Hypokinetic dysarthria

• Ataxic dysarthria

FLACCID DYSARTHRIA/ BULBAR PALSY• Bulbar refers to medulla oblongata and bulbar palsy denotes any weakness of muscles

that is supplied by 7,9,10,12 th cn from the pons and medulla.

• Dysphagia also occurs.

• Palatal weakness with nasal voice

• Myasthenia gravis and polyneuropathies also cause flaccid dysarthria. In MG ,fatigue becomes evident as the patient talks.

SPASTIC DYSARTHRIA: PSEUDOBULBAR PALSY• UMN disorder affecting tongue, pharynx and facial muscles.

• Jaw jerk may be brisk

• Contracted spastic tongue

• Hot potato voice.

HYPOKINETIC DYSARTHRIA• Hypokinetic dysarthria: as in Parkinsonism

• Monotonous speech , low volume voice

ATAXIC DYSARTHRIA• Ataxic Dysarthria: Cerebellar dysarthria

• Slow,slurred scanning speech

• Ataxic gait

• Other features of Cerebellar dysfunction

DYSPHASIA: TYPES• Broca’s aphasia

• Wernicke’s aphasia

• Global aphasia

• Conduction Aphasia

BROCA’S APHASIA

• (Dominant frontal lobe): Brodmann Area:44,45

• Motor, Expressive, non fluent , agrammatic aphasia with intact comprehension (broken speech)

• Eg for “I take dog for a walk” .patient will say “I.. dog.. walk”

WERNICKES APHASIA

• (posterior superior dominant temporal lobe): Broddmann Area: 22

• Sensory, non expressive/receptive and fluent with loss of comprehension.(wordy)

Conduction Aphasia:

• fluent and intact comprehension but poor repetition and naming

Global Aphasia( large dominant hemispheric lesion involving frontal, temporal and parietal area)

• produce few recognizable words and understand little or no spoken language . Global aphasics can neither read nor write.

• Persons with global aphasia are often mute or reduced to a few stereotyped words or sounds.

SUMMARY

Repetition Naming Fluency

Transcortical motor

Normal mild Non Fluent

Transcortical sensory

Normal mod Fluent

Broca Poor mod Non Fluent

Wernicke Poor mild Fluent

COGNITIVE FUNCTION: MMSE

O Orientation PlaceTime

10

R Registration Name 3 objects 3

A Attention & calculation Serial 7 / Word backward 5

R Registration Recall Recall previously named 3 objects 3

L Language 3 stage commandName two objectsRead and followDraw a pentagonRepititionWrite a sentence

9

MMSETotal score:

• 21-24: mild cognitive dysfunction

• 10-20: moderate

• Less than 10 : Severe

• Eg 26/30 or 24/30 (blind)

LOBAR FUNCTIONS

FRONTAL LOBE:

Functions:

• Executing functions

• Personality (eg apathy)

• High level processing of motor tasks

• Note: Apathy or impassivity is a state of indifference, or the suppression of emotions such as concern, excitement, motivation and passion.

• Apathy Abulia Akinetic mutism

FRONTAL LOBECheck for

• Abstraction :say a proverb and judge for interpretation

• Estimation : ask to estimate a height

• Self cued test: ka baata aaune animal ko names

Praxis:

• Simultaneous simple motor task: fist open and close

• Limb kinetic apraxia: copy finger position like peace sign

• Ideomotor apraxia: ask how you d blow a kiss

Expressive dysphasia, Urinary incontinence, change in personality

Frontal release signs

• Pouting reflex/facial reflex

• Palmomental reflex

• Grasp reflex

PARIETAL LOBE :

• Sensory

• Dominant

• Non dominant

PARIETAL LOBE :

1. Sensory: check for drift, Astereognosis, Agraphesthesia

2. Dominant: RAAF and Language

3. Non dominant: (spatial cognition)

• Hemisensory neglect: anosognosia (left hand doesn’t belong to body)

• Constructional Apraxia :as in MMSE

• Dressing apraxia: doesn’t dress left half of body

• Extinction: ignore stimulus on left side

• (primitive reflex also)

TEMPORAL LOBE :

• Memory

• Seizure: complex partial seizure

• Wernickes aphasia

OCCIPITAL LOBE:

• Visual agnosia: failure to recognize object despite preserved acquity

• Visual anosognosia:( Anton syndrome): denies he is blind but collides while walking.

• Prosopagnosia: inability to recognize similar faces

• Micropsia

• Macropsia

• Visual hallucinations

• Ballint syndrome: oculomotor apraxia: failure to look around the object within the visual field

References:

• Hutchinsons

• Mcleods

• Pictures taken from the internet