• The human PNS is composed of 43 pairs of spinal

nerves that issue in orderly sequence from the spinal

cord, and 12 pairs of cranial nerves that emerge
from the base of the brain.

• The peripheral nerves carry input to the CNS via

their sensory afferent fibers and deliver output from
the CNS via the efferent fibers.

• The nervous system is the major controlling,

regulatory and communicating system in the body.

• It accounts for 3% of the total bodyweight, it is the

most complex organ system.

• It is the center of all mental activity, including

thought, learning and memory.

• Together with the endocrine and immune systems,

the nervous system is responsible for regulating and
maintaining homeostasis. NEURONS
• Through its receptors, the nervous system keeps in
• Are specialized cells in the nervous system;
touch with the environment, both external and
each is comprised of a dendrite, cell body
internal.
(soma) and axon.
• The primary functional unit of the nervous
NEUROLOGICAL ANATOMY AND
system.
PHYSIOLOGY
Three characteristics: (1) excitability, or the ability
COMPONENTS OF THE NERVOUS SYSTEM to generate a nerve impulse; (2) conductivity, or the
ability to transmit an impulse; and (3) influence, or
The central nervous system (CNS) consists of the
the ability to influence other neurons, muscle cells, or
spinal cord and the brain and is responsible for
glandular cells by transmitting nerve impulses to
integrating, processing and coordinating sensory
them.
data and motor commands.
• A typical neuron consists of a cell body, multiple
• The CNS is linked to all parts of the body by the
dendrites, and an axon.
PNS which transmits signals to and from the CNS.

Mechaelah Nicole R. Caras

• The cell body containing the nucleus and cytoplasm
is the metabolic center of the neuron.
• Dendrites are short processes extending from the
cell body that receive • impulses from the axons of
other neurons and conduct impulses toward the cell
body.
• The axon projects varying distances from the cell
body, ranging from several micrometers to more
than a meter. The axon carries nerve impulses to
other neurons or to end organs. The end organs are
smooth and striated muscles and glands.
• Many axons in the CNS and PNS are covered by a
myelin sheath, a white, lipid substance that acts as an
insulator for the conduction of impulses.
• Axons may be myelinated or unmyelinated.
Generally, the smaller fibers are unmyelinated
Structural features of neurons:
dendrites, cell body, and axons.
Glial Cells
• Glial cells (glia or neuroglia) provide support,
nourishment, and protection to neurons.
• Constitute almost half of the brain and spinal cord
mass and are 5 to 10 times more numerous than
neurons.
• Glial cells are divided into microglia and
macroglia.
• Microglia, specialized macrophages capable of
phagocytosis, protect the neurons. These cells are
mobile within the brain and multiply when the brain
is damaged.
• Different types of macroglial cells include the
astrocytes (most abundant), oligodendrocytes, and
ependymal cells.
• Astrocytes are found primarily in gray matter and
provide structural support to neurons. Their delicate
processes form the blood-brain barrier with the
endothelium of the blood vessels.
• They also play a role in synaptic transmission
(conduction of impulses between neurons).
• When the brain is injured, astrocytes act as
phagocytes for neuronal debris. They help restore
the neurochemical milieu and provide support for
repair. Proliferation of astrocytes contributes to the
formation of scar tissue (gliosis) in the CNS.
• Oligodendrocytes are specialized cells that produce
the myelin sheath of nerve fibers in the CNS and are
primarily found in the white matter of the CNS.
(Schwann cells myelinat the nerve fibers in the
periphery.)
• Ependymal cells line the brain ventricles and aid in
the secretion of cerebrospinal fluid (CSF).
Mechaelah Nicole R. Caras

• Neuroglia are mitotic and can replicate.
• In general, when neurons are destroyed, the tissue
is replaced by the proliferation of neuroglial cells.
• Most primary CNS tumors involve glial cells.
• Primary malignancies involving neurons are rare.
NERVE IMPULSE
• The purpose of a neuron is to initiate, receive, and
process messages about events both within and
outside the body.
• The initiation of a neuronal message (nerve
impulse) involves the generation of an action
potential. Once an action potential is initiated, a series
of action potentials travels along the axon.
• When the impulse reaches the end of the nerve
fiber, it is transmitted across the junction between
nerve cells (synapse) by a chemical interaction
involving neurotransmitters.
• This chemical interaction generates another set of
action potentials in the next neuron. These events are
repeated until the nerve impulse reaches its
destination.
• Because of its insulating capacity, myelination of
nerve axons facilitates the conduction of an action
potential. Many peripheral nerve axons have nodes
of Ranvier (gaps in the myelin sheath) that allow an
action potential to travel much faster by jumping
from node to node without traversing the insulated
membrane segment. This is called saltatory
(hopping) conduction.
• In an unmyelinated fiber, the wave of
depolarization travels the entire length of the axon,
with each portion of the membrane becoming
depolarized in turn.
Synapse
• A synapse is the structural and functional
junction between two neurons.
• It is the point at which the nerve impulse
is transmitted from one neuron to another. The
nerve impulse can also be transmitted from neurons
to glands or muscles.
• The essential structures of synaptic transmission
are a presynaptic terminal, a synaptic cleft, and
a receptor site on the postsynaptic cell.
• Two general classes: electrical synapses and
chemical synapses.
• Electrical synapses permit direct, passive flow of
electrical current from one neuron to another in the
form of an action potential. The current flows
through gap junctions, which are specialized
membrane channels that connect the two cells.
• Chemical synapses, in contrast, enable cell-to-
cell communication via the secretion of
Mechaelah Nicole R. Caras
neurotransmitters; the chemical agents released by
the presynaptic neurons produce secondary current
flow in postsynaptic neurons by activating specific
receptor molecules.
– 2. biogenic amines: serotonin, histamine, and
the catecholamines dopamine and noradrenaline
– 3. excitatory amino acids: glutamate and aspartate,
and the inhibitory amino acids gamma-aminobutyric
acid (GABA), glycine and taurine

– 4. neuropeptides: over 50 of which are known,

amino acid neurotransmitters being the most
numerous.

Neurotransmitters
• Neurotransmitters are chemicals that affect Central Nervous System
the transmission of impulses across the synaptic
cleft. • The components of the CNS include the cerebrum
(cerebral hemispheres), brainstem, cerebellum, and
• Chemically, there are four classes spinal cord.
of neurotransmitters:
• The spinal cord is continuous with the brainstem
– 1. acetylcholine (ACh): the dominant and exits from the cranial cavity through the
neurotransmitter in the peripheral nervous system, foramen magnum.
released at neuromuscular junctions and synapses
of the parasympathetic division • A cross section of the spinal cord reveals gray
matter that is centrally located in an H shape and
is surrounded by white matter.

Mechaelah Nicole R. Caras

• The gray matter contains the cell bodies of
voluntary motor neurons, preganglionic autonomic
motor neurons, and association neurons
(interneurons).
• The white matter contains the axons of the
ascending sensory and the descending
(suprasegmental) motor fibers.
Ascending Tracts
• The ascending tracts carry specific sensory
information to higher levels of the CNS.
• This information comes from special sensory
receptors in the skin, muscles and joints, viscera,
and blood vessels and enters the spinal cord by way
of the dorsal roots of the spinal nerves.
• The fasciculus gracilis and the fasciculus cuneatus
(commonly called the dorsal or posterior columns)
carry information and transmit impulses concerned
with touch, deep pressure, vibration, position sense,
and kinesthesia (appreciation of
movement, volweight, and body parts).
• The spinocerebellar tracts carry information about
muscle tension and body position to the cerebellum
for coordination of movement.
• The spinothalamic tracts carry pain and
temperature sensations. Therefore the ascending
tracts are organized by sensory modality, as well as
by anatomy
Descending Tracts
• Descending tracts carry impulses that are
responsible for muscle movement.
• Among the most important descending tracts are
the corticobulbar and corticospinal tracts, collectively
termed the pyramidal tract.
• These tracts carry volitional (voluntary) impulses
from the cerebral cortex to the cranial and
peripheral nerves.
• Another group of descending motor tracts carries
impulses from the extrapyramidal system (all motor
systems except the pyramidal) concerned with
voluntarymovement. It includes pathways originating
in the brainstem, basal ganglia, and cerebellum. The
motor output exits the spinal cord by way of the
ventral roots of the spinal nerves.
Lower and Upper Motor Neurons
• Lower motor neurons (LMNs) are the final common
pathway through which descending motor tracts
influence skeletal muscle.
• The cell bodies of LMNs, which send axons to
innervate the skeletal muscles of the arms, trunk,
and legs, are located in the anterior horn of the
corresponding segments of the spinal cord (e.g.,
cervical segments contain LMNs for the arms).
• LMNs for skeletal muscles of the eyes, face, mouth,
and throat are located in the corresponding
segments of the brainstem.
• These cell bodies and their axons make up the
somatic motor components of the cranial nerves.
• LMN lesions generally cause weakness or
paralysis, denervation atrophy, hyporeflexia or
areflexia, and
• Upper motor neurons (UMNs) originate in the
cerebral cortex and project downward.
• The corticobulbar tract ends in the brainstem, and
the corticospinal tract descends into the spinal cord.
These neurons influence skeletal muscle movement.
• UMN lesions generally cause weakness or
paralysis, disuse atrophy, hyperreflexia, and
increased muscle tone (spasticity).
Reflex Arc
• A reflex is an involuntary response to stimuli. • In
the spinal cord, reflex arcs play an important role in
Mechaelah Nicole R. Caras
maintaining muscle tone, which is essential for body
posture.
• The components of a monosynaptic reflex arc are
a receptor organ, an afferent neuron, an
effector neuron, and an effector organ (e.g.,
skeletal muscle).
• The afferent neuron synapses with the
efferent neuron in the gray matter of the spinal
cord.
Brain
• The term brain usually refers to the three major
intracranial components: cerebrum, brainstem, and
cerebellum.
Cerebrum.
• The cerebrum is composed of the right and left
cerebral hemispheres and divided into four lobes:
frontal, temporal, parietal, and occipital.
• The frontal lobe controls higher cognitive function,
memory retention, VoLuntary eye movements,
voluntary motor movement, and speech in Broca’s
area.
• The temporal lobe integrates somatic, visual, and
auditory data and contains Wernicke’s speech area.
• The parietal lobe interprets spatial information and
contains the sensory cortex.
• Processing of sight takes place in the occipital lobe.
• The division of the cerebrum into lobes is useful to
delineate portions of the neocortex (gray matter),
which makes up the outer layer of the cerebral
hemispheres. Neurons in specific parts of the
neocortex are essential for various highly complex
and sophisticated aspects of mental function, such
as language, memory, and appreciation of visual-
spatial relationships.
• The basal ganglia, thalamus, hypothalamus, and
limbic system are also located in the cerebrum.
• The basal ganglia are a group of structures located
centrally in the cerebrum and midbrain. The function
of the basal ganglia includes the initiation, execution,
and completion of voluntary movements, learning,
emotional response, and automatic movements
associated with skeletal muscle activity (e.g.,
swinging the arms while walking, swallowing saliva,
and blinking).
• The thalamus (part of the diencephalon) lies
directly above the brainstem and is the major relay
center for afferent inputs to the cerebral cortex.
• The hypothalamus is located just inferior to the
thalamus and slightly in front of the midbrain.
• It regulates the ANS and the endocrine system.
• The limbic system is located near the inner
surfaces of the cerebral hemispheres and is
concerned with emotion, aggression, feeding
behavior, and sexual response.
Mechaelah Nicole R. Caras

Brainstem
• The brainstem includes the midbrain, pons, and
medulla.
• Ascending and descending fibers to and from the
cerebrum and cerebellum pass through the
brainstem.
• The nuclei of cranial nerves III through XII are in
the brainstem.
• The vital centers concerned with respiratory,
vasomotor, and cardiac function are located in the
medulla.
• Also located in the brainstem is the reticular
formation, a diffusely arranged group of neurons
and their axons that extends from the medulla to the
thalamus and hypothalamus. The functions of the
reticular formation include relaying sensory
information, influencing excitatory and inhibitory
control of spinal motor neurons, and controlling
vasomotor and respiratory activity.
• The reticular activating system (RAS) is a complex
system that requires communication among the
brainstem, reticular formation, and cerebral cortex.
The RAS is responsible for regulating arousal and
sleep-wake transitions. The brainstem also contains
the centers for sneezing, coughing, hiccupping,
vomiting, sucking, and swallowing.
Cerebellum
• The cerebellum is located in the posterior part of
the cranial fossa inferior to the occipital lobe.
• The cerebellum coordinates voluntary
movement and maintains trunk stability and
equilibrium.
• The cerebellum receives information from
the cerebral cortex, muscles, joints, and inner ear.
• It influences motor activity through
axonal connections to the motor cortex, the
brainstem nuclei, and their descending pathways.
Mechaelah Nicole R. Caras
Ventricles and Cerebrospinal Fluid.
• The ventricles are four interconnected fluid-filled
cavities. The lower portion of the fourth ventricle
becomes the central canal in the lower part of the
brainstem. The spinal canal extends centrally
through the full length of the spinal cord.
Cerebrospinal fluid (CSF)
• Circulates within the subarachnoid space that
surrounds the brain, brainstem, and spinal cord.
increased CSF pressure, can force
downward (central) herniation of the brain and
brainstem.
Peripheral Nervous System
• The PNS includes all the neuronal structures that
lie outside the CNS. It consists of the spinal and
cranial nerves, their associated ganglia (groupings of
cell bodies), and portions of the ANS.

• This fluid provides cushioning for the brain and the Spinal Nerves
spinal cord, allows fluid shifts from the cranial cavity
• The spinal cord can be seen as a series of
to the spinal cavity, and carries nutrients.
spinal segments, one on top of another.
• The formation of CSF in the choroid plexus in the
• Each segment contains a pair of dorsal
ventricles involves both passive diffusion and active
(afferent) sensory nerve fibers or roots and ventral
transport of substances. CSF resembles an
(efferent) motor fibers or roots, which innervate a
ultrafiltrate of blood.
specific region of the body.
• CSF is produced at an average rate of about 500
• This combined motor-sensory nerve is called a
mL/day, many factors influence CSF production and
spinal nerve.
absorption. The ventricles and central canal are
normally filled with an average of 135 mL of CSF.

• Changes in the rate of production or absorption will

result in a change in the volume of CSF that remains
in the ventricles and central canal.

• Excessive buildup of CSF results in a condition

known as hydrocephalus. • The CSF circulates
throughout the ventricles and seeps into the
subarachnoid space surrounding the brain and
spinal cord.

• It is absorbed primarily through the arachnoid villi

(tiny projections into the subarachnoid space), into the
intradural venous sinuses, and eventually into
the venous system.
• The analysis of CSF composition provides useful
diagnostic information related to certain nervous
system diseases. CSF pressure is often measured in
patients with actual or suspected intracranial injury.
Increased intracranial pressure, indicated by
• The cell bodies of the voluntary motor system are
located in the anterior horn of the spinal cord
gray matter.
• The cell bodies of the autonomic (involuntary)
motor system are located in the anterolateral portion
of the spinal cord gray matter.

Mechaelah Nicole R. Caras

• The cell bodies of sensory fibers are located in
the dorsal root ganglia just outside the spinal cord.
• A dermatome is the area of skin innervated by
the sensory fibers of a single dorsal root of a
spinal nerve.
• The dermatomes give a general picture of
somatic sensory innervation by spinal segments.
• A myotome is a muscle group innervated by the
primary motor neurons of a single ventral root.
Dermatomes of the Body
Cranial Nerves
• The cranial nerves (CNs) are the 12 paired nerves
composed of cell bodies with fibers that exit from the
cranial cavity.
• Just as the cell bodies of the spinal nerves are
located in specific segments of the spinal cord, so
are the cell bodies (nuclei) of the CNs located in
specific segments of the brain.
• Exceptions are the nuclei of the olfactory and optic
nerves. The primary cell bodies of the olfactory
nerve are located in the nasal epithelium, and those
of the optic nerve are in the retina.
Autonomic Nervous System.
• The autonomic nervous system (ANS) is divided into
the sympathetic and parasympathetic systems.
• The ANS governs involuntary functions of cardiac
muscle, smooth muscle, and glands through both
efferent and afferent pathways.
• The preganglionic cell bodies of the sympathetic
nervous system (SNS) are located in spinal segments
T1 through L2. The major neurotransmitter released
by the postganglionic fibers of the SNS is
norepinephrine, and the neurotransmitter released
by the preganglionic fibers is acetylcholine.
• The preganglionic cell bodies of the
parasympathetic nervous system (PSNS) are located
in the brainstem and the sacral spinal segments (S2
through S4). Acetylcholine is the neurotransmitter
released at both preganglionic and postganglionic
nerve endings.
• SNS stimulation activates the mechanisms required
for the “fight-or-flight“ response that occurs
throughout the body.
• The PSNS is geared to act in localized and discrete
regions
Mechaelah Nicole R. Caras
Cerebral Circulation
• The brain’s blood supply arises from the
internal carotid arteries (anterior circulation) and
the vertebral arteries (posterior circulation).
• The internal carotid arteries provide blood flow to
the anterior and middle portions of the cerebrum.
• The vertebral arteries join to form the basilar
artery and provide blood flow to the brainstem,
cerebellum, and posterior cerebrum.
• The circle of Willis is formed by communicating
arteries that join the basilar and internal carotid
arteries.
• The circle of Willis is a safety valve for regulating
cerebral blood flow when differential pressures or
vascular occlusions are present.
• Superior to the circle of Willis, three pairs of
arteries supply blood to the left and right
hemispheres.
• The anterior cerebra artery feeds the medial and
anterior portions of the frontal lobes.
• The middle cerebral artery feeds the outer portions
of the frontal, parietal, and superior temporal lobes.
• The posterior cerebral artery feeds the medial
portions of the occipital an inferior temporal lobes.
• Venous blood drains from the brain through the
dural sinuses, which form channels that drain into the
two jugular veins.
• The blood-brain barrier is a physiologic barrier
between blood capillaries and brain tissue.
• This barrier protects the brain from harmful
agents, while allowing nutrients and gases to enter.
• Lipid-soluble compounds enter the brain easily,
whereas water-soluble and ionized drugs enter the
brain and the spinal cord slowly.
• Thus the blood-brain barrier affects the
penetration of drugs.
Protective Structures
• The meninges consist of three protective
membranes that surround the brain and spinal cord:
dura mater, arachnoid, and pia mater .
• The thick dura mater forms the outermost layer. •
The falx cerebri is a fold of the dura that separates
the two cerebral hemispheres and slows expansion
of brain tissue in conditions such as a rapidly
growing tumor or acute hemorrhage.
• The tentorium cerebelli is a fold of dura that
separates the cerebral hemispheres from the
posterior fossa (which contains the brainstem and
cerebellum).
• Expansion of mass lesions in the cerebrum forces
the brain to herniate through the opening created by
the brainstem. This is termed infratentorial
herniation.
• The arachnoid layer is a delicate membrane that
lies between the dura mater and the pia mater (the
delicate innermost layer of the meninges).
• The area between the arachnoid layer and the pia
mater is the subarachnoid space and is filled with
CSF.
• Structures such as arteries, veins, and cranial
nerves passing to and from the brain and the skull
must pass through the subarachnoid space.
• A larger subarachnoid space in the region of the
third and fourth lumbar vertebrae is the area used to
obtain CS during a lumbar puncture.
• Skull. The skull protects the brain from external
trauma. It is composed of eight cranial bones and 14
facial bones.
• Vertebral Column. The vertebral column protects
the spinal cord, supports the head, and provides
Mechaelah Nicole R. Caras
flexibility. The vertebral column is made up of 33
individual vertebrae: 7 cervical, 12 thoracic, 5
lumbar, 5 sacral (fused into one), and 4 coccygeal
ASSESSMENT OF NERVOUS SYSTEM
Subjective Data
• Important Health Information
• Past Health History. Consider three points when
taking a history of a patient with neurologic
problems.
• First, avoid suggesting symptoms or asking leading
questions. • Second, the mode of onset and the
course of the illness are especially important aspects
of the history. Obtain all pertinent data in the history
of the present illness, especially data related to the
characteristics and progression of the symptoms.
• Third, if the patient is not considered a reliable
historian, confirm or obtain the history from someone
with firsthand knowledge of the patient.
• Medications. Obtain a careful medication history,
especially the use of sedatives, opioids, tranquilizers,
and mood elevating drugs. Many other drugs can
also cause neurologic side effects.
• Surgery or Other Treatments. Inquire about any
surgery involving any part of the nervous system,
such as head, spine, or sensory organs. If a patient
had surgery, determine the date, cause,
procedure, recovery, and current status.
• Growth and developmental history can be important
in ascertaining whether nervous system dysfunction
was present at an early age. Specifically inquire
about major developmental tasks such as walking
and talking.
• Functional Health Patterns. Key questions to ask a
patient with a neurologic problem are presented in
Table 56-5.
Objective Data
• Physical Examination. The standard neurologic
examination helps determine the presence, location,
and nature of disease of the nervous system.
• The examination assesses six categories of
functions: mental status, cranial nerve function,
motor function, sensory function, cerebellar function,
and reflexes..
• Mental Status. Assessment of mental status
(cerebral function) gives a general impression of
how the patient is functioning.
• It involves determining complex and high-level
cerebral functions that are governed by many
areas of the cerebral cortex.
The components of the mental status
examination include:
• • General appearance and behavior: This
component includes level of consciousness (awake,
asleep, comatose), motor activity, body posture, dress
and hygiene, facial expression, and speech pattern.
• • Cognition: Note orientation to time, place, person,
and situation, as well as memory, general
knowledge, insight, judgment, problem solving,
and calculation. Common questions are “Who were
the last three presidents?“ “Does a rock float on
water?“ “How much money is a quarter, two dimes,
and a nickel?“ Consider whether the patient’s plans
and goals match the physical and mental capabilities.
Note the presence of factors affecting intellectual
capacity such as cognitive impairment,
hallucinations, delusions, and dementia.
• • Mood and affect: Note any agitation, anger,
depression, or euphoria and the appropriateness of
these states. Use suitable questions to bring out the
patient’s feelings.
Mechaelah Nicole R. Caras
• Conscious State . Arousal and awareness are the
fundamental constituents of consciousness and
should be evaluated and documented repeatedly for
trend analysis. Changes in the conscious state are the
first to change in deterioration.
• Arousal assessment. The evaluation of arousal
focuses on the ability to be able to respond to a
variety of stimuli and can be described using the
AVPU scale or disorientated, lethargic, or obtunded.
• The advanced trauma life support course
recommends an initial assessment during initial
resuscitation based on the response to stimulation:
Awake, Verbal, Pain, Unresponsive (AVPU).
• Observe the patient’s response (verbal or motor). If
there is no response to voice or light touch, painful
stimulus is needed to assess neurological status.
• Assessment of awareness . If arousable, progress
to assessment of awareness using the Glasgow Coma
Scale (GCS).
• Teasdale and Jennett designed the GCS to establish
an objective, quantifiable measure to describe the
prognosis of a patient with a brain injury and include
scoring of separate subscales related to eye
opening, verbal response and motor response.
• Eye and pupil assessment. Pupillary responses,
including pupil size and reaction to light, are
important neurological observations and localize
cerebral disease to a specific area of the brain.
• The immediate constriction of the pupil when light is
shone into the eye is referred to as the direct light
reflex. • Withdrawal of the light should produce an
immediate and brisk dilation of the pupil.
• Introduction of the light into one eye should cause a
similar constriction to occur in the other pupil
(consensual light reaction).
Other points to consider when conducting pupillary
observations include the following:
• pinpoint non-reactive pupils are associated with
opiate overdose
• non-reactive pupils may also be caused by local
damage • atropine will cause dilated pupils
• one dilated or fixed pupil may be indicative of an
expanding or developing intracranial lesion,
compressing the oculomotor nerve on the same side
of the brain as the affected pupil
• A sluggish pupil may be difficult to distinguish from
a fixed pupil and may be an early focal sign of an
expanding intracranial lesion and raised
intracranialpressure. A sluggish response to light in a
previously reacting pupil must be reported
immediately.
Assessment of pupillary function focuses on
three areas:
• (1) estimation of pupil size and shape;
• (2) evaluation of pupillary reaction to light;
• (3) assessment of eye movements.
• Eye and eyelid movements. Patients who are
comatose will exhibit no eye opening.
• In patients with bilateral thalamic damage, there
may be normal consciousness, but an eye opening
apraxia may mimic coma. If the patient’s eyes are
closed, the clinician should gently raise and release
the eyelids. Brisk opening and closing of the eyes
indicates that the pons is grossly intact.
• If the pons is impaired, one or both eyelids may
close slowly or not at all. • In the patient with intact
frontal lobe and brainstem functioning, the eyes,
when opened, should be pointed straight ahead and
at equal height. If there is awareness, the patient
should look towards stimuli after eye opening.
Mechaelah Nicole R. Caras
• Eye deviation indicates either a unilateral cerebral
or brainstem lesion. If the eyes deviate laterally,
gently turn the head to see if the eyes will cross the
midline to the other side. A pattern of spontaneous,
slow and random movements (usually laterally) is
termed roving-eye movements. This indicates that the
brainstem oculomotor control is intact but awareness
is significantly impaired.

• Limb movement. Assessment of extremities and

body movement (or motor response) provides
valuable information about the patient with a
decreased level of

• Decorticate (flexor) posturing is seen when there is

involvement of a cerebral hemisphere and the brain
stem. • It is characterised by adduction of the
shoulder and arm, elbow flexion, and pronation and
flexion of the wrist while the legs extend. In terms of
the GCS motor score, the withdrawal flexor scores a
higher (4/6) than a spastic flexor movement (3/6).

• Decerebrate (extensor) posturing is seen with

severe metabolic disturbances or upper brainstem
lesions. It is characterised by extension and
pronation of the arm(s) and extension of the legs.
Patients may have an asymmetrical response and
may posture spontaneously or to stimuli.

Mechaelah Nicole R. Caras