- The neurological examination
- Medical history
- Physical examination
- Localization of neurological disease
- Diseases and disorders
- The meninges and cerebrospinal fluid
- The peripheral system
- The spinal cord
- Cranial nerves
- The cerebellum
- The cerebrum
- Unlocalized or multifocal disorders
- Metabolic disease
The raphe nuclei of the pons and the locus ceruleus, which mediate sleep, are situated in the brainstem. Sleep consists of two phases: rapid eye movement (REM) sleep and non-REM, or slow-wave, sleep. During non-REM sleep an individual progresses from drowsiness through deeper and deeper levels of relaxation, with decreasing ability to be aroused; progressively slower waveforms appear on an electroencephalogram (EEG) during this phase. Periods of REM sleep, during which dreaming occurs, punctuate slow-wave sleep. Paradoxically, although the individual appears deeply asleep, fast activity occurs on an EEG during this phase, and numerous brief, small-amplitude movements are made by the eyes and the muscles.
Narcolepsy is a genetic disorder in which, with little warning, irresistible sleepiness overcomes a person during the day. One form includes vivid hallucinations on awaking or falling asleep, temporary but profound sleep paralysis on awakening that does not affect breathing, and sudden, brief loss of muscle power in the limbs and trunk during emotional moments such as laughter (cataplexy). Increased sleepiness, or hypersomnia, may be the cause of drowsiness or narcolepsy. Narcolepsy may be described as an intrusion of REM sleep into the waking hours. Treatment of the disorder with stimulants and tricyclic medications is often effective.
Brain death is synonymous with brainstem death, since the control centres for essential functions such as consciousness, respiration, and blood pressure are located within the brainstem. In many countries strict criteria for diagnosis of brain death have been established by common consent among medical, religious, ethical, and legal experts. Signs of brain death include the presence of deep coma with an established cause and the absence of any brainstem functions, such as spontaneous respiration, pupillary reactions, eye movements, and gag and cough reflexes. EEG may be a useful confirmatory test. When brainstem death is confirmed, the heart usually stops beating within a day or two, even when other vital functions are artificially maintained.
Spinocerebellar degenerations are a group of inherited disorders characterized by atrophy of the central nervous system and of peripheral nerves. They commonly affect the cerebellum and its connections, as well as the nuclei in the medulla known as the olives, the centres for control of eye movements, the optic nerves, the dorsal columns of the spinal cord, and the corticospinal tracts. Onset is usually in the first two decades of life. Some patients show only minimal signs, although most conditions are slowly progressive. Friedreich ataxia, the prototypical spinocerebellar degeneration disorder, affects the optic nerves, dorsal columns, corticospinal tracts, and cerebellum. Peripheral neuropathy, skeletal deformities, high-arched feet, and rotation of the spine (scoliosis) also may occur.
Inflammatory diseases affecting the cerebellum comprise abscesses, which usually complicate chronic infections of the middle ear through the spread of infection along the veins draining back into the posterior fossa, cerebellitis, associated with some viral infections in children, and tuberculomas, inflammatory masses that act as tumours, raising intracranial pressure and causing cerebellar dysfunction.
Cerebellar hemorrhage may occur with high blood pressure, causing sudden headache, neck stiffness, and cerebellar signs, often with evidence of compression of the brainstem on the side of the bleeding. Prompt surgical evacuation of the blood clot is necessary, and the availability of computed tomography (CT) scanning aids in diagnosis. Infarcts of the cerebellar arteries may also affect part of the medulla oblongata or pons.
Demyelination frequently affects the cerebellum and its connections. The primary signs of cerebellar disease are nystagmus, ataxia, and scanning speech. (See Unlocalized or multifocal disorders: Demyelinating diseases.)
Chronic alcoholism, toxicity of diphenylhydantoin (an antiepileptic medication), thiamine and nicotinic acid deficiencies, and hypothyroidism may all cause cerebellar dysfunction. In all of these disorders, typical signs of truncal and limb incoordination, or ataxia, are detectable; treatment usually reverses the deficits. Numerous inherited metabolic defects of metal, lipid, or amino acid metabolism (see below Unlocalized or multifocal disorders) and some serum protein abnormalities also cause signs of cerebellar disease.
Benign tumours, usually schwannomas on the vestibulocochlear nerve, may compress the cerebellum and lead to dysfunction on one side, but malignant astrocytomas and metastases from cancers are more common. In children, medulloblastomas are fast-growing malignant tumours that destroy the central part of the cerebellum and cause severe gait ataxia. Astrocytomas grow much more slowly and can often be completely removed.
The basal ganglia
Parkinson disease is a progressive disorder caused by degeneration of the cells of the substantia nigra and locus ceruleus (both pigmented nuclei in the brainstem) and of their connections with the basal ganglia. The basal ganglia are nuclear masses situated above the brainstem that are involved with the initiation and patterning of voluntary movements. This motor control system uses the neurotransmitters dopamine and acetylcholine; in parkinsonism there is a deficiency of dopamine as a result of the degeneration of neurons in the substantia nigra. This leads to inhibition of activity within the basal ganglia. Most cases of parkinsonism occur in late middle age. Slowness of movement, muscle rigidity, stooped and flexed posture, and repetitive tremor of the limbs are the main symptoms of Parkinson disease. Depression and loss of intellectual agility are also common. The cause of Parkinson disease is unknown, although encephalitis in early life, many drugs and toxic chemicals, brain trauma, cerebral anoxia, and other degenerative diseases of the nervous system (e.g., progressive supranuclear palsy) cause similar or identical symptoms.
The medication levodopa, or l-dopa, a precursor of dopamine that crosses the blood-brain barrier into the brain, where it encourages the synthesis of the deficient neurotransmitter, is the primary treatment. Other treatment approaches include anticholinergic medications, which reduce activity in the basal ganglia; medications such as bromocriptine and pergolide, which augment the responsiveness of the receptor sites where dopamine normally exerts its effect; amantidine, which increases dopamine release; and selective inhibitor medications such as deprenyl, which block the action of the enzyme that breaks down dopamine. If treatment with medication is not successful, surgery may be performed to destroy the area of the brain that produces tremors.