Conducting a Neurological Examination in English

Medical Education de UCD School of Medicine and Medical Science

Bilateral Internuclear Ophthalmoplegia in Multiple Sclerosis

A 45-year-old man with multiple sclerosis presented with worsening weakness in his right leg and double vision. Neurologic examination revealed horizontal diplopia during lateral gaze in both eyes. The patient had an adduction deficit in the right eye and nystagmus in the left eye on leftward gaze (Panel A). He also had an adduction deficit in the left eye and nystagmus in the right eye on rightward gaze (Panel B). Upward gaze (Panel C), downward gaze (Panel D), and normal primary position (Panel E) were unremarkable. Internuclear ophthalmoplegia is characterized by impaired horizontal eye movement that is caused by a lesion in the medial longitudinal fasciculus, a fiber tract that rises from the abducens nucleus in the pons to the contralateral oculomotor nucleus in the midbrain. Lesions in the medial longitudinal fasciculus result in the failure of adduction on attempted lateral gaze. Any brain-stem syndrome can interrupt the medial longitudinal fasciculus and result in impaired horizontal eye movement, but the most frequent underlying cause is multiple sclerosis. This patient had internuclear ophthalmoplegia in both eyes due to demyelinating lesions. Glucocorticoids were administered intravenously, but the deficits did not resolve. On follow-up at 2 months, the patient's gait had improved, but the internuclear ophthalmoplegia remained.

Weber and Rinnè tests

Learn how to assess hearing problems with simple tests 

Chvostek's and Trousseau's Signs

A 38-year-old man presented to the emergency department with facial paresthesias and upper-extremity muscle cramping. His symptoms were progressive, beginning as mild paresthesias on postoperative day 1 by the time he presented, they had been getting worse for about 24 hours. His medical history was noteworthy only for papillary thyroid carcinoma, for which he had undergone a total thyroidectomy 2 days earlier. Physical examination revealed apparent Chvostek's sign (Figure 1A and Video 1) and Trousseau's sign (Figure 1B and Video 2), a result of postsurgical acquired hypoparathyroidism. His total calcium level was 5.8 mg per deciliter (normal range, 8.4 to 10.3) (1.45 mmol per liter [2.1 to 2.6]), his free calcium level was 1.68 mEq per liter (normal range, 2.24 to 2.64) (0.84 mmol per liter [1.12 to 1.32]), and his serum phosphate level was 6.6 mg per deciliter (normal range, 2.7 to 4.5) (2.13 mmol per liter [0.87 to 1.45]). The parathyroid hormone level was 7 pg per milliliter (normal range, 15 to 65).

Gradenigo syndrome

A 28-year-old woman presented with fever, double vision, and facial pain. Neurologic examination showed neck stiffness, pain in the distribution of the right trigeminal nerve, and right abducens palsy (figure 1). Tympanic membranes were normal. MRI revealed sphenoid sinusitis, basilar pachymeningitis, and clivus osteomyelitis (figure 2). CSF analysis showed pleocytosis, increased protein contents, decreased glucose levels, and positive cultures for Staphylococcus aureus. The triad of suppurative otitis media, pain in the distribution of the trigeminal nerve, and abducens palsy is called Gradenigo syndrome.¹ While it most often affects children, it may occur in adults and may rarely present without otitis media.² While bone compromise is usually confined to the petrous apex, it may extend to sphenoid sinuses, clivus, and basal meninges.

Figure 1

Photograph of the patient shows isolated right abducens palsy

Figure 2 Head MRI

Contrast-enhanced T1-weighted MRI of the head shows mucosal thickening of sphenoid sinuses (arrowheads), basilar and right middle fossa pachymeningitis (small arrows), and osteomyelitis of the clivus (large arrow). While the right abducens nerve is not well visualized, it could be inferred in the axial sections (upper row) that it is entrapped throughout the Dorello channel and the cavernous sinus.

 

Acute Adie syndrome

Parasympathetic denervation of the iris sphincter muscle in Adie syndrome results in an enlarged tonic right pupil reacting poorly to light (A, B). Near response was also impaired (C). It is supersensitive to cholinergic agents (pilocarpine 0.1%) (D). Paralysis of the iris results in characteristic segmental vermiform movements. These are visible superolaterally acutely and inferomedially 6 months later