GCS
TBI
Bleeds & SOL
Stroke & TIA
Epilepsy
Headache
Infection
Coma
Motor & Movement Disorders
Neuropathies
Spinal
Glasgow Coma Scale
Modality Options
Motor 6 – Obeys commands
5 – Localises to pain (to supraorbital pressure)
, 4 – Withdraws from pain (normal flexion – flexion with
supination)
3 – Abnormal flexion to pain (decorticate posture –
with pronation)
2 – Extending to pain (decerebrate posture)
1 - None
Verbal 5 – Orientated
4 – Confused
3 – Inappropriate words
2 – Incomprehensible sounds
1 - None
Eye opening 4 – Spontaneous
3 – To speech
2 – To pain (fingernail squeeze)
1 – None
Use best score.
Express in format ‘GCS = 15, M6 V5 E4’
Generally, brain injury is:
- Severe 8-9 – below 8 is considered coma; E2 V2 M4
- Moderate 9-12
- Minor >13
Decorticate/flexion (3): indicates cerebral damage/IC/thalamus → rubrospinal tract and red nucleus still
functioning (midbrain), hence the upper extremity flexion.
Decerebrate/extension (2): indicates brain stem damage → below red nucleus (now vestibulospinal tract
acting)
Pronated with extension and fist. May see back arching.
Most important prognostic factor if present. Commonly seen in pontine strokes.
There are 6 tests to confirm brain death; pupillary reflex, corneal reflex, VOR, cough reflex, absent
response to supraorbital pressure, and no spontaneous respiratory effort.
Cranial nerves
Pupils
Relative afferent pupillary defect (Marcus Gunn)
Light shone in normal eye causes normal constriction of both eyes (normal afferents)
Light shone in affected eye causes mild constriction of both eyes (abnormal afferent)
→ Swinging light from normal eye to affected eye causes pupil dilation
Causes: glaucoma, MS/demyelination, ischaemia (GCA), retinal disease (ischaemia, detachment).
,Argyll Robertson pupils
Bilateral small pupils which accommodate (constrict) but do not react to light.
Affects efferent’s of EW nucleus (light).
Causes: neurosyphilis, diabetic neuropathy
Miosis
Excessive constriction of the pupil - parasympathetic
Causes:
- Horner’s, ICH affecting pons
- Uveitis → hence give atropine
- Drugs: opioids, APs, cholinergic drugs, antihistamines, 5HT antagonists (ondansetron)
Mydriasis
Excessive dilation of the pupil - sympathetic
Causes:
- TBI
- Glaucoma → hence avoid anticholinergics and give prostaglandin
- Drugs: stimulants, anticholinergics, SSRIs/serotonin agonists
Fixed and dilated pupil
Supratentorial mass lesion causing uncal herniation hence neurosurgical emergency.
UMN
Supranuclear gaze palsy (cortex, BG, SC, thalamus).
Loss of vertical &/or horizontal gaze.
Distinguish from III, IV and VI palsies by:
• Both eyes affected, but usually no diplopia
• Pupils may be fixed and are often unequal
• Reflex eye movements (e.g. on flexing/extending neck) usually intact
Causes
• Progressive supranuclear palsy (Steele-Richardson Olszewski syndrome) – loss of vertical, later horizontal gaze; assoc
extrapyramidal signs, neck rigidity and dementia
• Oculogyric crisis (involuntary upwards deviation of eyes) with post-encephalitic Parkinson’s disease and pts sensitive to
phenothiazines or those on levodopa therapy
Pseudobulbar dysarthria – UMN, corticobulbar pathways (vascular, PSP, ALS, PD, MND).
Slow speech (Donald duck speech), dysphagia. Brisk jaw jerk. Labile affect.
LMN
Nuclear gaze palsy (brainstem, ocular nerve nuclei). Affects eyes differently.
Bulbar palsy – LMN in CN 9-12 (vascular, ALS, GBS).
Dysphagia, difficulty chewing, aspirations.
Hot potato speech with tongue fasciculations. Normal jaw jerk and absent gag reflex.
CN III
• Unilateral complete ptosis (paralysis of levator palpebrae superioris secondary to lack of 70% skeletal muscle control via
IIIrd nerve)
• Pupil dilated and unresponsive to light (paralysis of constrictor muscle sphincter pupillae due to parasymp loss,
unopposed symp activity)
• Eye abducted and looking down – IV and VI intact (lateral rectus stronger than superior oblique)
• Impairment of eye movements in most gaze directions
Causes
• Medical – pupil sparing (i.e. not dilated; reacts to light); HTN, DM, Vasculitides
• Surgical – pupil dilated and fixed to light; SOL (posterior communicating aneurysm)
, CN IV
Features
• Eye appears conjugate in midline position
• Unable to look down and in, e.g. difficulty going down stairs
Causes: Rare in isolation; usually idiopathic/related to trauma
CN VI
Features
• Eye may appear conjugate in midline OR deviated medially due to unopposed action of medial rectus
Causes: raised ICP, trauma
TBI
Bleeds & SOL
Stroke & TIA
Epilepsy
Headache
Infection
Coma
Motor & Movement Disorders
Neuropathies
Spinal
Glasgow Coma Scale
Modality Options
Motor 6 – Obeys commands
5 – Localises to pain (to supraorbital pressure)
, 4 – Withdraws from pain (normal flexion – flexion with
supination)
3 – Abnormal flexion to pain (decorticate posture –
with pronation)
2 – Extending to pain (decerebrate posture)
1 - None
Verbal 5 – Orientated
4 – Confused
3 – Inappropriate words
2 – Incomprehensible sounds
1 - None
Eye opening 4 – Spontaneous
3 – To speech
2 – To pain (fingernail squeeze)
1 – None
Use best score.
Express in format ‘GCS = 15, M6 V5 E4’
Generally, brain injury is:
- Severe 8-9 – below 8 is considered coma; E2 V2 M4
- Moderate 9-12
- Minor >13
Decorticate/flexion (3): indicates cerebral damage/IC/thalamus → rubrospinal tract and red nucleus still
functioning (midbrain), hence the upper extremity flexion.
Decerebrate/extension (2): indicates brain stem damage → below red nucleus (now vestibulospinal tract
acting)
Pronated with extension and fist. May see back arching.
Most important prognostic factor if present. Commonly seen in pontine strokes.
There are 6 tests to confirm brain death; pupillary reflex, corneal reflex, VOR, cough reflex, absent
response to supraorbital pressure, and no spontaneous respiratory effort.
Cranial nerves
Pupils
Relative afferent pupillary defect (Marcus Gunn)
Light shone in normal eye causes normal constriction of both eyes (normal afferents)
Light shone in affected eye causes mild constriction of both eyes (abnormal afferent)
→ Swinging light from normal eye to affected eye causes pupil dilation
Causes: glaucoma, MS/demyelination, ischaemia (GCA), retinal disease (ischaemia, detachment).
,Argyll Robertson pupils
Bilateral small pupils which accommodate (constrict) but do not react to light.
Affects efferent’s of EW nucleus (light).
Causes: neurosyphilis, diabetic neuropathy
Miosis
Excessive constriction of the pupil - parasympathetic
Causes:
- Horner’s, ICH affecting pons
- Uveitis → hence give atropine
- Drugs: opioids, APs, cholinergic drugs, antihistamines, 5HT antagonists (ondansetron)
Mydriasis
Excessive dilation of the pupil - sympathetic
Causes:
- TBI
- Glaucoma → hence avoid anticholinergics and give prostaglandin
- Drugs: stimulants, anticholinergics, SSRIs/serotonin agonists
Fixed and dilated pupil
Supratentorial mass lesion causing uncal herniation hence neurosurgical emergency.
UMN
Supranuclear gaze palsy (cortex, BG, SC, thalamus).
Loss of vertical &/or horizontal gaze.
Distinguish from III, IV and VI palsies by:
• Both eyes affected, but usually no diplopia
• Pupils may be fixed and are often unequal
• Reflex eye movements (e.g. on flexing/extending neck) usually intact
Causes
• Progressive supranuclear palsy (Steele-Richardson Olszewski syndrome) – loss of vertical, later horizontal gaze; assoc
extrapyramidal signs, neck rigidity and dementia
• Oculogyric crisis (involuntary upwards deviation of eyes) with post-encephalitic Parkinson’s disease and pts sensitive to
phenothiazines or those on levodopa therapy
Pseudobulbar dysarthria – UMN, corticobulbar pathways (vascular, PSP, ALS, PD, MND).
Slow speech (Donald duck speech), dysphagia. Brisk jaw jerk. Labile affect.
LMN
Nuclear gaze palsy (brainstem, ocular nerve nuclei). Affects eyes differently.
Bulbar palsy – LMN in CN 9-12 (vascular, ALS, GBS).
Dysphagia, difficulty chewing, aspirations.
Hot potato speech with tongue fasciculations. Normal jaw jerk and absent gag reflex.
CN III
• Unilateral complete ptosis (paralysis of levator palpebrae superioris secondary to lack of 70% skeletal muscle control via
IIIrd nerve)
• Pupil dilated and unresponsive to light (paralysis of constrictor muscle sphincter pupillae due to parasymp loss,
unopposed symp activity)
• Eye abducted and looking down – IV and VI intact (lateral rectus stronger than superior oblique)
• Impairment of eye movements in most gaze directions
Causes
• Medical – pupil sparing (i.e. not dilated; reacts to light); HTN, DM, Vasculitides
• Surgical – pupil dilated and fixed to light; SOL (posterior communicating aneurysm)
, CN IV
Features
• Eye appears conjugate in midline position
• Unable to look down and in, e.g. difficulty going down stairs
Causes: Rare in isolation; usually idiopathic/related to trauma
CN VI
Features
• Eye may appear conjugate in midline OR deviated medially due to unopposed action of medial rectus
Causes: raised ICP, trauma
