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R E V I E W / Neurological examination – how to get started

A number of non-neurological conditions may mimic a nervous system lesion.


A detailed clinical examination should therefore be performed before embarking on
the neurological examination.

Why attempt to localise should be focused on what you are aiming to


the problem? find out:
✜ Are any neurological abnormalities
Having established that the purpose of the neu- detectable?
rological examination is to determine the neu- ✜ Which part(s) of the nervous system
rological abnormalities and, based on these, the may be involved to explain these
location of the lesion(s) responsible (ie, the neu- abnormalities?
roanatomical diagnosis), why is this important? ✜ Is the lesion localisation focal, multifocal
Narrowing down the focus to the part(s) of or diffuse?
the nervous system that may be affected can The first question does not require any
undeniably present a number of advantages. detailed knowledge of neuroanatomy or neuro-
From a diagnostic point of view, the differential anatomical pathways. By simple observation
diagnosis is entirely dependent on the neuro- and testing of a number of reflexes and
anatomical diagnosis. As well as determining responses (see later sections on hands-on and
which part of the nervous system is affected, hands-off examination), the clinician should
localising the lesion also involves determining be able to determine whether or not the cat is
if the problem is focal, multifocal (ie, affecting neurologically sound.
multiple parts of the nervous system) or diffuse The second and third questions are
(ie, affecting globally and symmetrically one or addressed in the neurological examination by
more parts of the nervous system). Such infor- testing the integrity of the various compo-
mation can then be used to narrow down even nents of the nervous system and detecting any
further the differential list (see later section on functional deficit(s) present. Normal findings
how to establish a differential diagnosis list). are as important as abnormal ones in
Furthermore, as alluded to earlier, a number localising a lesion. Neurological abnormalities
of disease processes may only be diagnosed detected on examination should be added
by exclusion of other causes that have a simi- to the list of abnormal findings collected
lar clinical history and presentation. Only by from the history. Attempts should then
evaluating the correct part of the nervous sys- be made to explain all the abnormal
tem can these mimics be confidently ruled findings by a single lesion within one of the
out. Failure to localise the lesion makes the following specific regions of the nervous
task of interpreting any diagnostic test results system:
very challenging for the clinician; particularly ✜ focal forebrain, brainstem, cerebellum;
in the face of negative findings (as seen with ✜ C1–C5 spinal cord segments;
some vascular or degenerative diseases of the ✜ C6–T2 spinal cord segments;
central nervous system) or findings that do ✜ T3–L3 spinal cord segments;
not match the clinical history. ✜ L4–L6 spinal cord segments;
Finally, running a limited number of inves- ✜ L7–S3 spinal cord segments;
tigations aimed at narrowing down the differ- ✜ peripheral nerve, neuromuscular junction,
ential list to a specific part of the nervous muscle.
system will of course mean less cost for the Lesions within these regions of the nervous
owner and less time spent reaching a diagno- system result in predictable and specific
sis for the clinician (and cat). neurological signs. Note that in localising a
lesion, it is not necessary that all the clinical
What are the principles of signs referable to one location or syndrome are
lesion localisation? present. If a single lesion cannot explain all
the abnormal findings identified, the lesion
Before rushing headlong into the specifics localisation is considered as being multifocal or
of the neurological examination, attention diffuse.

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R E V I E W / Neurological examination – how to get started

cerebral hemispheres, or a focal lesion affect-


Normal findings on neurological examination ing the ascending reticular activating system
(ARAS) of the brainstem. The ARAS functions
are as important as abnormal ones to arouse the cerebral cortex and maintain the
state of wakefulness.
in localising a lesion. Common changes in the patient’s level of
awareness and behaviour include disorienta-
tion, aggression, vocalising, circling, compul-
How practically can the problem sive walking or head pressing. Signs such as
be localised within the nervous these reflect disturbances in the ARAS and
system? limbic system components of the cerebrum or
rostral brainstem. Circling can be caused by
The neurological examination can be divided lesions in the vestibular system as well as an
into two main parts – a hands-off examination asymmetrical or focal lesion in the forebrain
and a hands-on examination, which evaluate (see video 1, doi:10.1016/j.jfms.2009.03.002).
and assess the following: The owner is usually the best judge of any
subtle changes in the cat’s behaviour in its
normal environment and should be ques-
Hands-off examination Hands-on examination tioned about this.
✜ State of consciousness ✜ Postural reactions
✜ Awareness and behaviour ✜ Muscle tone and size Posture and body position at rest
✜ Posture and body position ✜ Spinal reflexes Observation of the cat’s posture and body
at rest ✜ Nociception position at rest helps the clinician to appreci-
✜ Gait ✜ Cranial nerves ate the general symmetry of the animal and its
balance at the stance. It can also reveal abnor-
malities such as:
It is often tempting in the face of a neurolog- ✜ head tilt (associated with a vestibular
ical presentation to rush into testing an ani- disorder; see video 2, doi:10.1016/j.jfms.
mal’s spinal reflexes, postural reactions or 2009.03.002);
cranial nerves and neglect the hands-off ele- ✜ head turn (associated with an ipsilateral
ment of the examination. However, given the forebrain lesion);
all-too-common fractious nature of our feline ✜ ventroflexion of the neck (associated with
patients, spending more time simply observ- a neuromuscular disorder or severe
ing the cat clearly makes sense. Not only can cervical spinal cord grey matter lesion);
it prove valuable in its own right, but by ✜ spinal curvature (ie, kyphosis or lordosis).
simplifying the hands-on element, the exami- Attention should also be paid to the position
nation becomes less time consuming, safer for of the joints, limb stance, tail posture and the
the clinician and less upsetting for the animal. presence of voluntary tail movement. Cats often
carry their tail elevated straight dorsally when
Hands-off examination they are suffering a significant loss of balance.

This initial part of the examination can be per- Gait evaluation


formed while collecting historical information A normal gait requires intact function of the
from the owner. The cat is best set free on the brainstem, cerebellum, spinal cord, and senso-
floor of the consultation room (ideally a non- ry and motor peripheral nerves, neuromuscu-
slippery surface), allowing it to adapt to this lar junction and muscles. The cerebrum’s
new environment. This gives the clinician the contribution to the gait is less
opportunity to observe its awareness and important in cats compared
behaviour, posture and gait. with primates.
Evaluation of the
cat’s gait should be
State of consciousness, awareness and Ataxia performed with the aim of
behaviour Ataxia is defined as determining if the patient is ataxic
The first step in the neurological examination an uncoordinated (uncoordinated), paretic (weak) or
should focus on evaluating the animal’s state gait and can arise lame (from either neuromuscular dis-
ease or an orthopaedic disorder), and
of consciousness, awareness to its environ- from a peripheral
identifying which limb(s) are involved.
ment and attitude to being handled. nerve or spinal cord
Disturbances in the state of consciousness lesion (general pro-
are classified in order of severity as depres- prioceptive ataxia; see
sion, lethargy, obtundation, stupor (semi- video 3, doi:10.1016/j.jfms.
coma) and coma. As a rule, altered states of 2009.03.002), a vestibular
consciousness relate either to a diffuse lesion lesion (vestibular ataxia; see
or widespread multifocal lesions of both videos 4 and 5, doi:10.1016/j.jfms.

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R E V I E W / Neurological examination – how to get started

2009.03.002) or a cerebellar lesion (cerebellar


ataxia).
Gait generation
Gait generation requires interaction between two motor systems: the upper
Paresis motor neuron (UMN) and lower motor neuron (LMN) systems.
Paresis is defined as a loss of ability to support
✜ UMN system The UMN system is confined to the central nervous system. It
weight (lower motor
is responsible for the initiation and maintenance of normal movements and
Depending neuron disease) or
for the maintenance of tone in the extensor muscles to support the body
on which limbs are inability to generate
affected, paresis/paralysis can against gravity. The cell body of an UMN lies within the cerebral cortex,
a gait (upper motor
be further defined as tetraparesis/ basal nuclei, brainstem or spinal cord. Nerve impulses travel through the
plegia (all four limbs affected), para-
neuron disease).
brain and/or spinal cord white matter and synapse indirectly (via an
paresis/plegia (pelvic limbs affected), The term paresis
interneuron) with a LMN to modulate its activity (essentially inhibitory).
monoparesis/plegia (only one limb implies that some
affected) and hemiparesis/plegia (limbs ✜ LMN system The LMN system connects the central nervous system
voluntary move-
on one side affected). with the muscles to be innervated. The cell body of a LMN lies within the
ment is still
ventral horn of the spinal cord grey matter or within the cranial nerve
present, as com-
nucleus of the brainstem. Its axon leaves the central nervous system
pared with paraly-
by the ventral nerve roots to join successively a spinal nerve and
sis, which refers to a
a peripheral nerve before it synapses with an effector muscle. The LMN
more severe paresis
is the last neuron in the chain of neurons that produces muscular
with complete (-plegia) loss
contraction necessary to maintain posture, support weight and provide
of voluntary movement.
the gait (final common pathway to the effector).
Two qualities of paresis can be distin-
guished: upper motor neuron (UMN) and The UMN pathways are responsible for stimulating the appropriate LMNs
lower motor neuron (LMN) paresis. that induce the postural and protraction phases of locomotion.
✜ UMN paresis causes a delay in the onset
of protraction, which is the swing phase
of the gait (see video 6, doi:10.1016/j.jfms. Hands-on examination
2009.03.002). Lesions at many different levels
of the central nervous system can produce Postural reactions
the same set of UMN clinical signs. Due to The primary aim of testing postural reactions
their close anatomical relationship within is to detect any subtle deficits that were not
the caudal brainstem and spinal cord, obvious on gait evaluation. These reactions
most gait abnormalities involving the reveal the cat’s awareness of the precise posi-
UMN pathways necessary for gait tion and movements of parts of its body (espe-
generation also cause some degree of cially the limbs), as well as the cat’s ability to
general proprioceptive ataxia. From generate movement in the part tested. The
the point of view of lesion localisation, reactions commonly tested are the paw
UMN paresis and general proprioceptive replacement (or ‘knuckling’) response, hop-
ataxia visible in the gait can occur as a ping response, and visual or tactile placing
consequence of a lesion affecting the response. These responses are complex in their
brainstem or spinal cord. By contrast, pathways but generally involve an afferent
lesions affecting the forebrain (aside from FIG 1 Hopping response. arm and an efferent arm (see box below).
The normal cat responds to
those caused by acute disease processes hopping by quickly replacing A lesion affecting any of these components
such as infarct, haemorrhage and head the limb under the body as could potentially result in abnormal postural
it is moved laterally. The
trauma) produce contralateral paresis that hopping movement should be reactions.
is so mild that it is usually not apparent in smooth and fairly rapid, and Paw position testing can be very difficult to
not irregular or excessive.
the gait. The thoracic limbs should be assess in cats. Hopping (Fig 1; also see video 8,
✜ LMN paresis manifests as degrees of carefully compared doi:10.1016/j.jfms.2009.03.002), wheelbarrowing
difficulty in supporting weight, producing
gait abnormalities varying from a short Postural reactions pathways
stride to collapse of the limb whenever
weight is placed on it (see video 7, ✜ Afferent arm components
doi:10.1016/j.jfms.2009.03.002). Lesions may 1 Joint proprioceptor
be localised in the peripheral nerves, 2 Peripheral sensory nerve
neuromuscular junction and/or muscles. 3 Spinal cord and brainstem ascending pathways
Motor deficits observed are ipsilateral 4 Contralateral forebrain
to the lesion. Care must be taken in
interpretation as many cats adopt an ✜ Efferent arm components
apparent plantigrade stance (crouched 1 Contralateral forebrain
posture) in a hostile environment such as 2 Descending motor pathways within the
a consultation room. Contrary to UMN brainstem and spinal cord
paresis, disorders of the LMN do not cause 3 Peripheral motor nerve and skeletal muscle
ataxia, only paresis.

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FIG 2 Wheelbarrowing is performed with the neck extended FIG 3 Tactile placing. When the carpus makes contact with
and the pelvic limbs elevated the edge of the table, the cat should immediately place its
foot on the surface

(Fig 2; also see video 9, doi:10.1016/j.jfms.2009. Spinal reflex evaluation should be considered
03.002) and tactile placing (Fig 3) are preferred
postural reactions tests in feline patients. If the as a continuation of the gait and postural reactions
cat is reluctant to hop, it should be held with assessments, and not as a sole entity.
three limbs restrained and lowered suddenly to
the ground surface with the limb to be tested
extended. As soon as the paw strikes the
ground the cat should be moved laterally to
TABLE 1 Neuroanatomical diagnosis based on combined
force it to hop on that limb.
evaluation of gait, postural reactions and segmental
spinal reflexes testing
Spinal reflexes, muscle tone and size
Spinal reflex evaluation should be considered Limb(s) presenting with Segmental spinal Likely neuroanatomical
as a continuation of the gait and postural reac- abnormal gait and/or reflexes in affected diagnosis
abnormal postural reactions limbs
tions assessments, and not as a sole entity.
Following gait and postural reactions testing, All four limbs Normal to increased Brainstem or C1–C5 spinal
the clinician should be in a position to narrow in all 4 limbs cord segments
down the lesion localisation to being cranial to Decreased to absent Generalised polyneuropathy/
the T3 spinal cord segments, caudal to the T3 in all 4 limbs junctionopathy/myopathy
spinal cord segments, or within the peripher- Decreased to absent C6–T2 spinal cord segments
in thoracic limbs;
al nervous system (peripheral nerve, neuro- normal to increased
muscular junction or muscles). Spinal reflex in pelvic limbs
evaluation helps to narrow down further the
Bilateral pelvic limbs Normal to increased T3–L3 spinal cord segments
lesion localisation by testing the integrity of
the C6–T2 and L4–S3 intumescences, as well Decreased to absent L4–S3 spinal cord segments,
peripheral nerve roots/nerves
as the respective segmental sensory and of the pelvic limbs
motor nerves that form the peripheral nerve,
and the muscles innervated (Table 1). Thoracic and pelvic limbs on Normal to increased Ipsilateral brainstem or C1–C5
the same side of the body in thoracic and spinal cord segments
Spinal reflexes do not require consciousness pelvic limbs
and are segmental. Testing only evaluates the
Decreased to absent Ipsilateral C6–T2 spinal cord
spinal segment(s) within the intumescences in thoracic limbs; segments
corresponding to the stimulated nerve. normal to increased
Lesions at the level of these intumescences in pelvic limbs
result in loss of segmental spinal reflexes as Unilateral thoracic limb Normal to increased Ipsilateral brainstem or C1–C5
well as reduced muscle tone and size. spinal cord segments
Spinal reflex evaluation in cats is best per- Decreased to absent Ipsilateral C6–T2 spinal cord
formed with the animal positioned in dorsal segments, or the nerve roots,
recumbency between the thighs of the exam- brachial plexus or peripheral
nerves affecting that limb
iner (see video 10, doi:10.1016/j.jfms.2009.03.002).
Although many spinal reflexes are described, Unilateral pelvic limb Normal to increased Ipsilateral T3–L3 spinal cord
the most reliable ones in cats are the withdraw- segments
al reflex and the patellar reflex (see boxes, Decreased to absent Ipsilateral L4–S3 spinal cord
page 345). Other spinal reflexes (triceps, biceps, segments, or the nerve roots
or peripheral nerves affecting
extensor carpal radialis and gastrocnemius) are that limb
more difficult to perform and to interpret.

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W i t h d r a w a l ( f l e x o r ) re f l e x
In the thoracic limb, the withdrawal reflex evaluates the integrity of the
C6–T2 spinal cord segments (and associated nerve roots), brachial plexus,
peripheral nerves (radial, axillary, musculocutaneous, median and ulnar)
and the muscles innervated. In the pelvic limb, this reflex evaluates the
integrity of the L4–S1 spinal cord segments (and associated nerve roots),
the femoral and sciatic nerves, and the muscles innervated.
This test is performed with the cat in dorsal recumbency between the
thighs of the examiner. A noxious stimulus is applied to the tested limb by
pinching the nail bed or digit with the fingers or haemostat forceps. The
stimulus causes a reflex contraction of the flexor muscles and withdrawal
of the tested limb. If this withdrawal reflex is absent, individual toes can be
tested to detect if specific nerve deficits are present.
It should be remembered that the withdrawal reflex in the thoracic or
pelvic limbs does not depend on the animal’s conscious perception of
noxious stimuli (nociceptive function). It is a segmental spinal cord reflex
that only depends on the function of the local spinal cord segments.

P a t e l l a r re f l e x
Nociception testing The patellar reflex is elicited by control in cats with ambiguous
Apart from conscious proprioception and tapping the patellar ligament and patellar reflexes as it involves
evaluation of facial sensation (discussed observing a reflex the same neuro-
later), evaluation of the sensory system in cats contraction of the anatomical compo-
largely relies on tests for pain perception quadriceps muscle nents (femoral nerve
(nociception). The purpose of such testing is and extension of the and quadriceps mus-
to detect and map out any areas of sensory stifle joint. It is like- cle) (see video 11,
loss. Assessment of pain sensation requires a wise performed with doi:10.1016/j.jfms.2009.
noxious stimulus and evaluation of the ani- the cat in dorsal 03.002).
mal’s response. recumbency between A lesion cranial to
Nociception is tested by pinching the digits the thighs of the the L4 spinal cord
with the fingers or with haemostats. Only a examiner. This posi- segment can cause a
behavioural response to this noxious stimulus tion allows the stifle to normal or exaggerat-
(ie, turning of the head and/or attempting to be slightly flexed, and ed reflex. In the
bite) indicates conscious pain perception. If no the two sides of the absence of other neu-
response is elicited when using fingers, the test cat to be compared. rological deficits, an
should be repeated with haemostats to ensure The patellar reflex exaggerated patellar
that the response is absent. Withdrawal of the evaluates the integrity reflex means little and
limb is only the flexor reflex, and should not be of the L4–L6 spinal can be observed in an
interpreted as evidence of pain perception. cord segments excited or nervous
(and associated In the absence of other cat. The patellar
Cranial nerve evaluation (Table 2) nerve roots), as reflex can also
Menace response well as the femoral neurological deficits, appear hyper-
The menace response is elicited by making a nerve. A weak or reflexic in a cat
absent reflex indi-
an exaggerated with a sciatic
threatening gesture towards the eye of the cat
with one hand (Fig 4). The afferent arm of this cates a lesion with- patellar reflex means nerve or L6–S1
in the L4–L6 spinal spinal cord
cord segments or little and can be segment lesion.
the femoral nerve.
observed in an excited This pseudo-
A similarly weak or hyperreflexia is a
absent reflex can or nervous cat. result of de-
on occasion be creased tone in
seen in cats with stifle disease. the muscles that flex the stifle and
Evaluation of the extensor tone on normally counteract stifle extension
the pelvic limb can be used as a during the patellar reflex.

response involves the retina, optic nerve


(cranial nerve [CN] II), contralateral optic
tract and contralateral forebrain. The efferent
FIG 4 Menace response pathway involves the contralateral forebrain,

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Cranial nerve tests commonly used in cats


responsive to the amount of light entering the
TABLE 2
eye, and the sympathetic system, which is
responsive to the emotional state of the cat.
Cranial Afferent Brain region Efferent cranial Principal effect
nerve test cranial nerve noted
Through the parasympathetic nerve pathways
nerve that innervate the iris, the pupil regulates the
Menace CN I (optic) Forebrain CN VII (facial) Blink elicited by a
amount of light that reaches the retina. The
response Cerebellum menacing gesture parasympathetic component of the oculomo-
Brainstem tor nerve (CN III) is involved in the control of
pupillary constriction while the somatic effer-
Visual CN I (optic) Forebrain None Reaching out
placing for support on ent component of the oculomotor nerve is
response approaching the responsible for the motor innervation of the
table levator palpebrae superioris (elevation of the
Pupillary CN I (optic) Brainstem CN III (oculomotor) Pupillary constriction upper eyelid), ipsilateral dorsal, ventral and
light reflex elicited by shining a medial rectus extraocular muscles as well as
light in the eye the ventral oblique muscle (movement of the
Dark CN I (optic) Hypothalamus Sympathetic Pupillary dilation in eyeball). The tone of the iris dilator muscle is
adaptation Brainstem supply to the eye darkness maintained by the sympathetic system, which
test keeps the pupil partially dilated under normal
Palpebral CN V Brainstem CN VII (facial) Blink elicited conditions and dilates it during periods of
reflex (trigeminal; by touching the stress and fear, and in response to painful
ophthalmic medial or lateral stimuli. The ocular sympathetic nervous sys-
or maxillary) canthus of the eye
tem also innervates and provides tone to the
Response CN V Forebrain None Withdrawal of the smooth muscle of the periorbita and eyelids.
to nasal (trigeminal; Brainstem head elicited by This tone keeps the eyeball protruded, the
stimulation maxillary) touching the nostril
palpebral fissure widened and
Oculo- CN VIII Brainstem CN III (oculomotor) Nystagmus induced the third eyelid retracted.
vestibular (vestibular) CN IV (trochlear) by moving the head Assessment of pupil-
reflex CN VI (abducens)
lary size and equality
should be determined
in ambient light as Cats with pupils of unequal size
well as in darkness. (anisocoria) or shape (dyscoria) must be
ipsilateral cerebellum and facial nerve (CN Normally, the pupils found to be free of primary or secondary
VII). The expected response is a blink. of the eyes should be anatomical or mechanical abnormalities
The contralateral eye must be covered with symmetrically shaped (eg, iris atrophy, uveitis or glauco-
the other hand to assess each eye separately and equal to each other ma) before a neurological
(see video 12, doi:10.1016/j.jfms.2009.03.002). Care in size. In cats with aniso- dysfunction is assumed.
must be taken not to touch the cat’s eyelashes coria or dyscoria, determin-
or to create air currents that might stimulate ing which pupil is abnormal is
sensation of the face (trigeminal nerve, CN V) achieved by checking the pupillary light reflex
and elicit a palpebral or corneal reflex. (PLR) and assessing if the asymmetry in pupil
The menace response can be particularly size increases in bright light or in complete
difficult to elicit in a normal cat and its darkness (dark adaptation test).
absence should be interpreted with caution. The PLR involves an afferent arm and an
It may be helpful to tap the cat lightly a few efferent arm. The afferent arm shares some
times to get its attention before evaluating common pathways (ipsilateral retina, optic
this response. nerve, optic chiasm and contralateral optic
tract) with part of the afferent arm of the
Visual placing response menace response and visual placing response.
Carrying a cat towards a table top tests These tests use different integration centres
the visual placing response (see video 13, within the brain and different efferent path-
doi:10.1016/j.jfms.2009.03.002). On approaching the ways. The PLR does not test the animal’s
surface the cat will reach out to support itself vision and the cerebrum is not involved in the
on the table before the paw touches the table. PLR pathway. The efferent arm of the PLR
This response requires intact visual and motor reflex is mediated by the parasympathetic
pathways and can be useful in assessing visu- portion of CN III. Combining the results of the
al function in a cat where the menace response menace response, visual placing response and
is ambiguous. PLR testing helps to determine whether or not
the lesion is localised within this common
Pupil size and symmetry, pupillary light reflex pathway. The dark adaptation test allows the
and dark adaptation test eyes to dark-adapt in complete darkness for a
The size of the pupils represents a balance couple of minutes to allow complete relax-
between the parasympathetic system, which is ation of the pupillary sphincter muscle.

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Trigeminal and facial nerve function Oculovestibular reflex and nystagmus


The trigeminal nerve (CN V) provides sensory Observation of the animal’s body and head
innervation to the face (skin, cornea, and posture at rest, and evaluation of its gait, can
mucosae of the nasal septum and oral provide a lot of information about the
cavity) and motor innervation to the vestibular function of CN VIII. This
masticatory muscles (temporalis, function can also be more specifically
masseter, medial and lateral ptery- assessed by testing the oculovestibu-
goid and rostral part of the digastric lar reflex and looking for pathologi-
muscles). The motor function of CN V cal nystagmus. Nystagmus is an
is assessed by evaluating the size and involuntary rhythmic movement of
symmetry of the masticatory muscles the eyeballs. Physiological (or
and testing the resistance of the jaw vestibular) nystagmus is a nystag-
to opening the mouth. The sensory mus that occurs in normal animals
function can be assessed by individu- (to stabilise images on the retina dur-
ally testing the corneal reflex (oph- ing head movement), while patho-
thalmic branch), the palpebral reflex logical nystagmus reflects an under-
(ophthalmic or maxillary branch lying vestibular disorder. In both
when touching the medial or lateral types of nystagmus there is a slow
canthus of the eye, respectively), and fast phase (ie, jerk nystagmus).
the response to nasal stimulation A physiological nystagmus can be
(ophthalmic branch) (see below), induced in normal individuals by
and by pinching the skin of the face rotating the head from side to side
with haemostat forceps and observ- (oculovestibular reflex). With a feline
ing an ipsilateral blink or facial FIG 5 Assessing the response to patient, this is best done by holding
nasal stimulation
twitch. the animal at arm’s length and rotat-
The facial nerve (CN VII) provides ing it from side to side. The nystag-
motor innervation to the muscles of mus is always observed in the plane
facial expression. This motor function of rotation of the head and consists
is primarily assessed by observing for of a slow phase away from the direc-
movement of the ears, eyelids, lips tion of head rotation, and a fast
and nostrils, and for symmetry of the phase in the same direction as the
lips. The facial nerve is also involved head rotation. In the absence of
in the motor response (efferent part) any head movement, nystagmus
of the following tests: palpebral reflex should never be present in a normal
(CN V and VII; see video 14, animal.
doi:10.1016/j.jfms.2009.03.002); corneal Two types of pathological nystag-
reflex (CN V and VII); menace mus can be observed in cats with
response (CN II and VII); and pinch- vestibular disorders: spontaneous,
ing of the face (CN V and VII). The which occurs when the head is in a
Schirmer tear test can evaluate the normal position at rest; and/or posi-
parasympathetic supply to the tional, which is seen when the head
lacrimal gland associated with CN VII. is held in different positions (eg, to
either side, dorsally or by placing the
Response to nasal stimulation animal upside down on its back – Fig
As with the menace response, the 6). Nystagmus is usually classified
response to nasal stimulation requires on the basis of its direction (the fast
an intact contralateral forebrain. One of movement) and may be horizontal,
the two nostrils is stimulated using a vertical or rotatory. In disorders of
pair of forceps or a pen while the cat’s the peripheral components of the
eyes are masked, or while making sure vestibular system in the inner ear, the
the animal is not able to see the stimu- direction of the nystagmus is always
lus, to prevent any visual input (Fig 5). opposite to the side of the lesion and
The afferent arm involves the sensory is usually horizontal or rotatory.
component of the trigeminal nerve, Lesions of the central components of
which conducts the information to the the vestibular system can cause
brainstem, from where it continues to pathological nystagmus in any direc-
the contralateral forebrain. The expect- tion, and occasionally it changes
ed response is a withdrawal move- FIG 6 Testing for positional direction with different positions
ment of the head and neck. Like the nystagmus. Extending the of the head (see video 15,
head and neck while the cat
menace response, this response might is in dorsal recumbency can doi:10.1016/j.jfms.2009.03.002). A vertical
be abnormal in a cat with a structural help in detecting a positional nystagmus is most commonly due to
nystagmus by challenging
contralateral forebrain lesion. the vestibular system a central lesion.

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Diagnostic tests should be TABLE 3 Disease processes that can affect the nervous system:
performed solely to confirm or mode of onset, pattern of development and expected
distribution within the nervous system
exclude the differentials in the list,
Pathological Mode of onset Pattern of development Distribution
and not in place of process
Vascular Peracute or acute Non-progressive or Focal and often
the clinical evaluation. (haemorrhage regressive (haemorrhage asymmetrical
may cause may cause progression
subacute onset) over a very short period)
Inflammatory/ Acute, subacute Progressive (waxes and Focal or multifocal
How to establish a infectious or insidious wanes in some early cases) Asymmetrical or symmetrical
differential diagnostic list
Toxic Acute Progressive Diffuse and bilaterally
Determination of a list of differential diag- symmetrical
noses should be directed entirely by the Traumatic Peracute or acute Static or improves Often focal
neuroanatomical diagnosis, and is essential over time Asymmetrical or symmetrical
in choosing and interpreting any diagnostic Anomalous Chronic Non-progressive or slowly Variable
tests, however sophisticated they may be. (occasionally acute) progressive early in life
Diagnostic tests should be performed solely to
confirm or exclude the differentials in the list, Metabolic Variable Waxes and wanes Diffuse and bilaterally
(often acute) or progressive symmetrical
and not in place of the clinical evaluation.
The differential diagnosis list can be devel- Idiopathic Acute Non-progressive Specific to each syndrome
oped by taking into account: or regressive
✜ Patient signalment Neoplastic Chronic Progressive Often focal
✜ Historical data Questioning of the owner (occasionally acute) Asymmetrical or symmetrical
should aim to define the mode of onset
Nutritional Variable (acute Progressive Diffuse and bilaterally
(peracute, acute, subacute, chronic or or insidious) symmetrical
episodic) and pattern of development of the
Degenerative Chronic Progressive Often diffuse and
condition. Historical data can also provide symmetrical
clues as to how widespread or focal the
disease process is in the nervous system,
whether there is evidence of asymmetry, Acknowledgements
and how severe the signs have been.
✜ Neurological findings As has been The author is grateful to Dr Alexander de Lahunta for reviewing this
discussed in this article, the aim of the article and offering his comments.
neurological evaluation is to define the
lesion localisation (forebrain, brainstem, Further reading
cerebellum, spinal cord segments, KEY POINTS
peripheral nerve, neuromuscular junction 1 de Lahunta A, Glass E. Vet-
✜ The neurological examination aims
and muscle) and distribution of the disease erinary neuroanatomy and clini-
to determine if a clinical problem is
(focal, multifocal, diffuse) within the cal neurology. 3rd edn. St Louis,
neurological in origin and which part(s)
nervous system. Missouri: WB Saunders Co, 2008.
of the nervous system may be involved
Disease processes that can affect the nervous 2 Dewey CW. A practical guide
to explain the abnormalities.
system are traditionally classified according to canine and feline neurology.
to the ‘VITAMIN D’ mnenomic (Vascular, Ames, Iowa: Iowa State Press, ✜ Adherence to a systematic stepwise
Inflammatory/Infectious, Toxic/Traumatic, 2003. approach to the neurological examination
Anomalous, Metabolic, Idiopathic, Neoplastic/ 3 Garosi LS. The neurological is essential to confidently make an
Nutritional, Degenerative). Each category has a examination. In: Platt SR, Olby accurate neuroanatomical diagnosis.
typical signalment, onset and progression, and NJ, eds. BSAVA manual of canine
✜ Precise localisation of the causative
distribution within the nervous system (Table 3). and feline neurology. Quedgeley,
disorder within the nervous system
UK, BSAVA, 2004: 1–23.
(neuroanatomical diagnosis) and an
What next? 4 Garosi LS. Lesion localization
understanding of the suspected disease
and differential diagnosis. In:
processes (differential diagnosis) are the
With, by this stage, a clear knowledge of the Platt SR and Olby NJ, eds.
keys to an accurate neurological diagnosis.
region of the nervous system involved, and a BSAVA manual of canine and
differential list reduced to no more than three feline neurology. Quedgeley, ✜ Determination of a differential
or four disease processes, consideration UK, BSAVA, 2004: 24–34. diagnosis list is essential in
should be given only to those diagnostic tests 5 King AS. Physiological and choosing and interpreting any
that will help to narrow down the list further, clinical anatomy of domestic diagnostic tests – however
and that can be afforded by the client. These mammals. Volume 1. Central sophisticated they may be.
tests should ideally be run in succession from nervous system. Oxford:
least invasive through to more invasive. Oxford University Press, 1987.

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