Neuro exam

Universal Exams Non-intubated exams Intubated Exams NPI Cranial Nerves CN I CN II (Optic Nerve)CN III, CN IV, CN VI CN VII (Facial Nerve)CN VIII (Vestibulocochlear Nerve)Motor Exam (Dermatome / Myotome)Cervical Lumbar Long Tract Signs Comatose Exams Specialty Exam Components Relative afferent Pupillary defects EEA / Skull Base Cerebellar Rectal Cervical (Trauma)Stroke Gaze & Frontal Eye Fields (FEF)Subarachnoid Hemorrhage Cranial Oncology Bulbo-cavernous Reflex Anal Wink Reflex Gait Patterns Neurovascular Exam Pediatric Neuro Exams Miscellaneous

Universal Exams

Non-intubated exams

EOS
Ox3
PERRL, EOMI, FS, TML
55555/55555
55555/55555
No drift
SILT
No Hoffman’s hyperreflexia, clonus

Eyes	EOS
Orientation	Ox3
Cranial nerves	PERRL, EOMI, FS, TML
Motor exam	see below
Pronator Drift	1) Generally, this is useful for detecting subtle weakness not picked up on confrontational testing (e.g. someone can be 55555 in RUE but have a RUE drift). 2) NOTE: it should not be assumed that everyone with proximal UE weakness is going to have a pronator drift.
Sensation	SILT
Long-tract signs	No Hoffman / clonus / hyperreflexia

Notes:

do not put FC x 4 if a patient has a motor exam (that's implied).

for spine patients, always put full muscle groups, even if intact. For cranial patients, ok to put a lumped limb rating.

However if you are the consult resident seeing the patient for the first time, document full muscle group breakdown on every single patient.

Do not document things you didn’t test, like cranial nerves on a spine patient.

Intubated Exams

Component	Example
TOF	TOF 4/4
Sedation	prop at 75 held > 20 min
Ventilation	Int AC 40/5 TV (trach vent) AC 40/5
Eyes	ETP
Pupils (OD/OS) NPI (OD/OS)	5R/4NR 4.2/0.3
Protectives	+ cough/+gag/+corneal
Motor exam	Loc / Loc Wd / Wd

Notes:

don't forget to document ethanol level if it's high

HHFNC = heated high flow nasal cannula, include liters and percent

NPI

Neurological pupillary index is a quantitative measure of the pupillary light reflex.

The neuroptics device we use at PUH creates a waveform of pupil size over time and takes the measurements diagrammed below.

See more here: https://neuroptics.com/clinical-publications-critical-care/

How medications affect NPI

Cranial Nerves

CN I

generally not applicable

CN II (Optic Nerve)

Acuity (Snellen)

Fields

CN III, CN IV, CN VI

Recall the motor extraocular muscles and their nerve supply:

CN 3

Compressive third nerve palsy

Pupil: fixed and dilated (sphincter pupillae paralysed)
Ptosis (levator paleprae superioris muscle paralysis)
Down and out

do not be confused by diabetic (pupil-sparing) 3rd nerve palsies

Feature	Pupil-Sparing Third Nerve Palsy	Pupil-Involving Third Nerve Palsy
Typical Cause	Microvascular ischemia (e.g., diabetes, hypertension)	Compressive lesion (e.g., posterior communicating artery aneurysm, tumor, uncal herniation)
Mechanism	Ischemia affects central fibers of CN III (motor to extraocular muscles), sparing superficial parasympathetic fibers	Compression affects superficial parasympathetic fibers on the nerve surface, leading to pupil involvement
Pupil Findings	Normal or minimally affected pupil (reactive to light)	Dilated, poorly reactive or fixed pupil
Extraocular Muscle Weakness	Present (ptosis, “down and out” eye)	Present (same pattern: ptosis, “down and out” eye)
Pain	Often mild or absent	Often severe (especially in aneurysm)
Urgency	Usually less urgent; observe and manage vascular risk factors	Neurosurgical emergency — requires urgent imaging (CTA/MRA) to rule out aneurysm
Recovery	Typically spontaneous over weeks	Depends on underlying cause and intervention

CN VII (Facial Nerve)

Describe as peripheral or central facial palsy and use House-Brackmann scale if relevant.

House-Brackmann	Description	Eye Closure	Forehead Movement	Mouth Movement
1	Normal function	Complete	Normal	Normal
2	Mild dysfunction – slight weakness noticeable only on close inspection	Complete with minimal effort	Slight weakness	Slight asymmetry
3	Moderate dysfunction – obvious but not disfiguring	Complete with effort	Obvious weakness	Noticeable asymmetry
4	Moderately severe dysfunction – obvious disfigurement	Incomplete	None	Asymmetric at rest
5	Severe dysfunction – barely perceptible movement	Incomplete	None	Barely perceptible
6	Total paralysis	None	None	None

CN VIII (Vestibulocochlear Nerve)

hearing grossly intact to finger rub

formal audiogram if indicated

Motor Exam (Dermatome / Myotome)

Cervical

Disc	C4-5	C5-6	C6-7	C7-C8	C8-T1
Root	C5	C6	C7	C8	T1
Pitt syntax	D	WrE	T	HI
ASIA syntax	B	WrE	T	Finger flexor	finger ABd
Muscle	Deltoid Biceps Brachialis (elbow flexion)	Long extensor	Triceps (elbow extension)	FDP	Abdudctor digiti minimi
Nerve	Axillary Musculocutaneous	Radial (posterior interosseous)	Radial	Median (1-3) Ulnar (4-5)	Ulnar
Sensory-arm	lateral arm	lateral forearm			medial forearm
Sensory-fingers		1-2 thumb, index	3 middle	4-5 ring pinky

Lumbar

Disc	L1-L2	L2-3	L3-4	L4-5	L5-S1	S1-S2
Nerve Root	L1	L2	L3	L4	L5	S1
PITT	HF (hip flexor)	KE (knee extensor)	ㅤ	DF	EHL	PF
Muscle	Iliopsoas	Iliopsoas	Quads	Quads	ㅤ	gastrocnemius
Nerve	Femoral N.	Femoral N.	ㅤ	ㅤ	ㅤ	ㅤ
Reflex	ㅤ	ㅤ	ㅤ	ㅤ	ㅤ	Achilles (stretch)
Parasthesia	anterior upper thigh medial thigh	lower thigh crossing knee medial thigh	medial shin	lateral shin	calf	ㅤ
Foot	ㅤ	ㅤ	ㅤ	dorsum and medial	lateral and back	ㅤ

Other lumbar plexus nerves not tested on everyday examination

genitofemoral nerve: sensation to genitalia and central portion of the inguinal ligament.

lateral femoral cutaneous nerve: sensation to the anterolateral thigh

obturator nerve: adductor muscles of the leg

lumbar plexus nerve branches: iliohypogastric, ilioinguinal, genitofemoral, lateral femoral cutaneous obturator, and femoral nerves

Nerves and roots

Femoral: L2-4

Long Tract Signs

Hoffman’s

Babinski (Plantar) reflex

stroke lateral foot from bottom to top in a ‘J” pattern and watch the toes

physiology:

afferent limb originates in cutaneous receptors in S1 dermatome and travel proximally via tibial nerve

normal response: plantar flexion (downward toes)

pathologic response: dorsiflexion (extension) of great toe (hallux), fanning of other toes

Clonus

Comatose Exams

Big picture, motor exams on the comatose are all about establishing symmetry.

The most meaningful exam changes to neurosurgeon nare:

Following commands --> Localize/withdrawing --> Posturing --> Flicker --> Flaccid

localize/withdraw is actually a very good exam in the comatose, it means motor function is intact, they just don't have the cognition to be following commands be that because of a brain injury or from sedation or critical illiness/infection/etc. The point is all of that is reversible/may get better with improved level of arousal.

Localizing - this is generally a motor response we use to describe in UEs. Technically people can localize in lowers if you apply stim on thigh and they kick their other leg up but this is very unlikely.

Withdrawing - this can happen in any four extremities, it's just waht it sounds like. The patient withdraws from peripheral stimulation (i.e. on their fingers/toes) but does not cross midline in UEs enough to call it a localize.

Posturing- these are descriptions of upper extremities.

1. Flexing:

2. Withdrawing:

Triple Flex: this is a spinal reflex of LEs and the way to differentiate it from withdraw is that a person will continue to withdraw as you continue stimulation (i.e. if you keep pinching them they keep moving and feeling it) while in the TF, it is just a transient flexion of ankle, knee, hip, and it will not persist as you continue pinching, i.e. it is temporary and they are not really feeling you.

Flaccid vs. Flicker

frankly the actual motor response between flaccid and flicker is academic, both generally do not move. The more important distinction is that flaccid people both don't move and have zero tone with

Specialty Exam Components

Relative afferent Pupillary defects

How to test for a relative afferent pupillary defect (RAPD) - PMC

Normal test (no RAPD): pupils constrict equally regardless of which eye is stimulated.

Abnormal test (positive RAPD): less constriction in affected eye

positive RAPD means afferent pathway pathology due to retinal or optic nerve disease.

EEA / Skull Base

Document/present this entire blue box for every single EEA patient every single day.

	OD	OS
Field	Full to confrontation	Full to confrontation
Acuity	20/25	20/25
Pupils	mm, reactive	mm, reactive
EOM	intact, w/o diplopia/nystagmus	intact, w/o diplopia/nystagmus

Remember to test each eye separately!

Subjective vision

Denies blurry vision

Denies double vision at rest

Denies pain with extra-ocular movement

CSF Leak negative on chin-to-chest provocation for 30 seconds

Ask for positional headaches

For acuity, use MDCalc Snellen chart, stand 4 feet away (measure how far this is on your own wingspan).

Cerebellar

dysdiadochokinesia

intention tremor (cerebellar tremor) = worsens as you get closer to target

Romberg test: close eyes and see if patient can maintain a standing posture

positive if start swaying, means they rely on vision to maintain balance

Rectal

Intact perianal sensation, intact rectal tone, intact deep anal sensation, intact voluntary anal contraction

Cervical (Trauma)

No cervical TTP, pain with passive ROM

Stroke

Test Naming 3/3, Repeats 2/2

Gaze & Frontal Eye Fields (FEF)

🧠 “Seizures look away, strokes look toward.”

FEF is found in posterior part of the middle frontal gyrus (Brodmann area 8)

Controls contralateral horizontal gaze — moves eyes to the opposite side

FEF sends signals to the contralateral paramedian pontine reticular formation (PPRF) in the brainstem.

Feature	Seizure	Stroke
Type of FEF involvement	Irritative (overactive)	Destructive (inactive)
Eye deviation	Away from lesion	Toward lesion
Mechanism	Excess stimulation of contralateral gaze pathway	Loss of drive from one FEF → opposite FEF dominates
Example (Left Hemisphere)	Eyes deviate right	Eyes deviate left
Body movement (in focal seizure)	Often contralateral clonic movements	Contralateral weakness (hemiparesis)

Subarachnoid Hemorrhage

check for neck pain / meningismus

Cranial Oncology

Every exam needs to test visual fields

Bulbo-cavernous Reflex

tests the integrity of the S2–S4 spinal segments and the pudendal nerve

Component	Structure
Afferent limb	Pudendal nerve (sensory fibers from genitalia)
Spinal integration	S2–S4 spinal cord segments
Efferent limb	Pudendal nerve (motor fibers to external anal sphincter and bulbocavernosus muscle)

Normal reflex:

when squeezing glans penis (in males) or clitoris (in females) or pulls on an indwelling Foley catheter → brief contraction of the anal sphincter.

pathologic reflex: no contraction

Clinical significance in spinal cord injury

if a person does not have this reflex, it technically means they are in spinal shock and strictly speaking the ASIA exam is not applicable until you’ve proven they are out of spinal shock.

Anal Wink Reflex

anal wink and bulbocavernous reflexes are commonly used synonymously but they are most certainly not the same, as summarized below.

Feature	Anal Wink Reflex	Bulbocavernosus Reflex (BCR)
Also called	Superficial anal reflex	Bulbospongiosus reflex
Stimulus (afferent limb)	Lightly stroking or pinpricking the perianal skin	Squeezing the glans penis or clitoris, or tugging on a Foley catheter
Response (efferent limb)	Visible contraction of the external anal sphincter	Palpable or visible contraction of the anal sphincter and bulbocavernosus muscle
Afferent nerve	Pudendal nerve (perineal sensory branches)	Pudendal nerve (dorsal nerve of penis/clitoris)
Efferent nerve	Pudendal nerve (motor fibers to external anal sphincter)	Pudendal nerve (motor fibers to bulbocavernosus and anal sphincter)
Spinal segments tested	S2–S4	S2–S4
Reflex type	Superficial (cutaneous) reflex	Deep (visceral–somatic) reflex
Clinical significance	Absence → possible S2–S4 lesion or cauda equina injury	Absence → same, but used to determine end of spinal shock
Ease of testing	Simple bedside test	Requires genital stimulation or catheter tug; slightly less convenient
Common uses	Assess perineal sensation and sacral integrity in suspected cauda equina	Determine end of spinal shock, assess sacral cord function

Gait Patterns

Gait Type	Anatomic Localization	Key Features / Description	Typical Neurosurgical Causes
Myelopathic Gait	Cervical or thoracic spinal cord (upper motor neuron involvement)	Stiff, unsteady, wide-based gait; spasticity; difficulty with tandem walking; may show foot drag	Cervical spondylotic myelopathy, thoracic cord compression, intradural extramedullary tumor
Frontal / Magnetic	Frontal lobes (esp. SMA, prefrontal)	Difficulty initiating steps; short shuffling steps; “feet stuck to floor”	Normal pressure hydrocephalus, frontal tumor
Antalgic	Pain-related (any level)	Short stance phase on painful side	Radiculopathy, post-op pain
Cerebellar (Ataxic)	Cerebellar hemispheres	Wide-based, irregular steps; veers to lesion side	Cerebellar tumor, stroke, metastasis
Hemiparetic (Circumduction)	Contralateral motor cortex or internal capsule	Stiff leg extended at knee; swings outward in semicircle; flexed arm	Stroke, tumor, post-op motor deficit
Apraxic	Bifrontal / parietal lobes	Normal strength but inability to coordinate walking	Hydrocephalus, bilateral ACA infarcts
Truncal Ataxic	Cerebellar vermis (midline)	Broad-based staggering, instability while sitting/standing	Midline tumor (e.g. medulloblastoma), post-fossa surgery
Parkinsonian	Basal ganglia	Stooped posture, shuffling, festination, en bloc turning	Parkinson’s disease, NPH, midbrain compression
Choreiform	Striatum / subthalamic nucleus	Irregular, dance-like involuntary steps	Huntington’s disease, hemiballismus
Spastic (Scissoring)	Corticospinal tracts (bilateral)	Stiff legs, thighs adducted, narrow base	Cervical / thoracic myelopathy, spinal tumor
Sensory Ataxic	Posterior columns	Stamping gait; loss of joint position sense; worse in dark	Dorsal column tumor, B12 deficiency
Steppage	Peripheral nerve / L5 root	Foot drop → exaggerated hip flexion, foot slap	Lumbar disc herniation, peroneal palsy
Waddling (Myopathic)	Proximal muscles (pelvic girdle)	Pelvic drop, trunk sway; difficulty climbing stairs	Chronic steroid myopathy, muscular dystrophy
Functional / Psychogenic	No organic lesion	Dramatic, inconsistent, non-anatomic gait	Conversion disorder

Neurovascular Exam

Check puncture site (femoral vs. wrist)

Check to make sure no hematoma / pseudoaneurysm (hard to distinguish in reality on exam, just make sure soft tissue is compressible, has no lump or active signs of bleeding)

Check to make sure have distal pulses

Location of pulses

Pediatric Neuro Exams

Vocabulary:

Sutures can be "splayed"

Fontanelles can be "bulging"

Miscellaneous

Akinetic Mutism: unresponsiveness with superficial appearance of alertness

occurs 2/2 bilat lesions caudate w/ destruction of medial putamen, septum, medial frontal cortex, cingulate cortex