Diagnostic procedures may be needed to confirm a diagnosis suggested by the medical history Medical History in Neurologic Disorders Before doing a physical examination, doctors interview the person. Doctors ask the person to describe current symptoms, including those related to the nervous system (neurologic symptoms): What... read more and neurologic examination Neurologic Examination When a neurologic disorder is suspected, doctors usually evaluate all of the body systems during the physical examination, but they focus on the nervous system. Examination of the nervous system—the... read more .
Electroencephalography (EEG) is a simple, painless procedure in which the brain’s electrical activity is recorded as wave patterns, printed on paper, and/or recorded in a computer. EEG can help identify the following:
Certain metabolic or structural disorders of the brain
For example, EEG can help identify where a seizure originates and show changes in electrical activity associated with confusion, which may result from disorders such as liver failure (liver encephalopathy Hepatic Encephalopathy Hepatic encephalopathy is deterioration of brain function that occurs in people with severe liver disease because toxic substances normally removed by the liver build up in the blood and reach... read more ) or certain drugs.
For the procedure, an examiner places small, round adhesive sensors (electrodes) on the person’s scalp. The electrodes are connected by wires to a machine, which produces a record (tracing) of small changes in voltage detected by each electrode. These tracings constitute the electroencephalogram (the EEG).
If a seizure disorder is suspected but the initial EEG is normal, another EEG is done after using a tactic that makes seizure activity more likely. For example, the person may be deprived of sleep, be asked to breathe deeply and rapidly (hyperventilate), or be exposed to a flashing light (stroboscope).
Sometimes (for example, when behavior that resembles a seizure is difficult to distinguish from a psychiatric disorder), the brain’s electrical activity is recorded for 24 hours or longer while people are monitored in the hospital by a video camera. This procedure is called video EEG. The camera detects the seizure-like behavior, and by examining the EEG at that moment, doctors can determine whether brain activity indicates a seizure or is normal, suggesting a psychiatric disorder.
Recording Brain Activity
An electroencephalogram (an EEG) is a recording of the brain’s electrical activity. The procedure is simple and painless. About 20 small adhesive electrodes are placed on the scalp, and the brain’s activity is recorded under normal conditions. Sometimes the person is exposed to various stimuli, such as bright or flashing lights, to try to provoke a seizure.
Electromyography and Nerve Conduction Studies
Electromyography and nerve conduction studies help doctors determine whether muscle weakness, sensory loss, or both result from injury to the following:
Spinal nerve root Overview of Spinal Cord Disorders Spinal cord disorders can cause permanent severe problems, such as paralysis or impaired bladder and bowel control (urinary incontinence and fecal incontinence). Sometimes these problems can... read more (for example, due to a ruptured disk in the spine Herniated Disk A herniated disk occurs when the tough covering of a disk in the spine tears or ruptures. The soft, jelly-like interior of the disk may then bulge out (herniate) through the covering. Aging... read more of the neck or lower back)
Peripheral nerve Overview of the Peripheral Nervous System The peripheral nervous system refers to the parts of the nervous system that are outside the central nervous system, that is, those outside the brain and spinal cord. Thus, the peripheral nervous... read more (for example, due to carpal tunnel syndrome Carpal Tunnel Syndrome Carpal tunnel syndrome is a painful compression (pinching) of the median nerve as it passes through the carpal tunnel in the wrist. The cause of most cases of carpal tunnel syndrome is unknown... read more or diabetic neuropathy)
Connections between nerve and muscle (neuromuscular junction Overview of Neuromuscular Junction Disorders Nerves connect with muscles at the neuromuscular junction. There, the ends of nerve fibers connect to special sites on the muscle’s membrane called motor end plates. These plates contain receptors... read more )—for example, due to myasthenia gravis Myasthenia Gravis Myasthenia gravis is an autoimmune disorder that impairs communication between nerves and muscles, resulting in episodes of muscle weakness. Myasthenia gravis results from malfunction of the... read more , botulism Botulism Botulism is an uncommon, life-threatening poisoning caused by toxins produced by the anaerobic bacteria Clostridium botulinum. Botulism toxins, usually consumed in food, can weaken or paralyze... read more , or diphtheria Diphtheria Diphtheria is a contagious, sometimes fatal infection of the upper respiratory tract caused by the gram-positive, rod-shaped bacteria (see figure How Bacteria Shape Up) Corynebacterium diphtheriae... read more
Muscle (for example, due to polymyositis)
In electromyography (EMG), a small needle is inserted into a muscle to record the electrical activity of the muscle when the muscle is at rest and when it is contracting. Normally, resting muscle produces no electrical activity. A slight contraction produces some electrical activity, which increases as the contraction increases.
The record produced by EMG is called the electromyogram. It is abnormal if muscle weakness results from a problem with a spinal nerve root, peripheral nerve, muscle, or neuromuscular junction. Each type of problem produces a distinctive pattern of abnormalities, which can be identified based on the person's symptoms and results of the examination and electromyography.
Unlike CT or EEG, which can be done routinely by technicians, EMG requires the expertise of a neurologist, who chooses the appropriate nerves and muscles to test and interprets the results.
Nerve conduction studies
Nerve conduction studies measure the speed at which motor or sensory nerves conduct impulses. A small electrical current stimulates an impulse along the nerve being tested. The current may be delivered by several electrodes placed on the surface of the skin or by several needles inserted along the pathway of the nerve. The impulse moves along the nerve, eventually reaching the muscle and causing it to contract. By measuring the time the impulse takes to reach the muscle and the distance from the stimulating electrode or needle to the muscle, doctors can calculate the speed of nerve conduction. The nerve may be stimulated once or several times (to determine how well the neuromuscular junction is functioning).
Results are abnormal only if the symptom results from a problem with a nerve or neuromuscular junction. For example,
If nerve conduction is slow, the cause may be a disorder that affects one nerve, such as carpal tunnel syndrome Carpal Tunnel Syndrome Carpal tunnel syndrome is a painful compression (pinching) of the median nerve as it passes through the carpal tunnel in the wrist. The cause of most cases of carpal tunnel syndrome is unknown... read more (painful compression of a nerve in the wrist). Or the cause may be a disorder that affects nerves throughout the body (a polyneuropathy Polyneuropathy Polyneuropathy is the simultaneous malfunction of many peripheral nerves throughout the body. Infections, toxins, drugs, cancers, nutritional deficiencies, diabetes, autoimmune disorders, and... read more ), as when diabetes Nerve damage in diabetes People with diabetes mellitus have many serious long-term complications that affect many areas of the body, particularly the blood vessels, nerves, eyes, and kidneys. (See also Diabetes Mellitus... read more damages nerves throughout the body, starting with those in the feet.
If the muscle’s response is progressively weaker after repeated stimulation, a problem with the neuromuscular junction Overview of Neuromuscular Junction Disorders Nerves connect with muscles at the neuromuscular junction. There, the ends of nerve fibers connect to special sites on the muscle’s membrane called motor end plates. These plates contain receptors... read more (as occurs in myasthenia gravis Myasthenia Gravis Myasthenia gravis is an autoimmune disorder that impairs communication between nerves and muscles, resulting in episodes of muscle weakness. Myasthenia gravis results from malfunction of the... read more ) may be the cause.
However, the speed of nerve conduction may be normal if the affected nerves are small and do not have a myelin sheath (the outer layer of tissues that helps nerves conduct impulses faster). Speed is also normal if the disorder involves only the brain, spinal cord, spinal nerve roots, or the muscle. Such disorders do not affect the speed of nerve conduction.
For this test, doctors use stimuli for sight, sound, and touch to activate specific areas of the brain, that is, to evoke responses. EEG is used to detect the response evoked by the stimuli. Based on these responses, doctors can tell how well those areas of the brain are working. For example, a flashing light stimulates the retina of the eye, the optic nerve, and the nerve pathway to the back part of the brain where vision is perceived and interpreted.
Evoked responses are particularly useful in testing how well the senses are functioning in infants and children. For example, doctors can test an infant’s hearing by checking for a response after a clicking sound is made at each ear.
Evoked responses are also useful in identifying the effects of multiple sclerosis Multiple Sclerosis (MS) In multiple sclerosis, patches of myelin (the substance that covers most nerve fibers) and underlying nerve fibers in the brain, optic nerves, and spinal cord are damaged or destroyed. The cause... read more and other disorders on areas of the optic nerve, brain stem, and spinal cord. Such effects may or may not be detected by MRI.
Evoked responses can also help predict the prognosis for people who are in a coma. If stimuli do not evoke typical brain activity, the prognosis is likely to be poor.
Imaging tests commonly used to diagnose nervous system (neurologic) disorders include the following:
In myelography, x-rays of the spinal cord are taken after a radiopaque contrast agent is injected into the subarachnoid space via a spinal tap. Myelography has been largely replaced by MRI, which usually produces more detailed images and is simpler and safer to do.
Myelography with computed tomography (CT) is used when doctors need more detail of the spinal cord and surrounding bone than MRI can provide. Myelography with CT is also used when MRI is not available or cannot be done safely (for example, when a person has a heart pacemaker).
Cerebrospinal fluid flows through a channel (the subarachnoid space) between the layers of tissue (meninges) that cover the brain and spinal cord. This fluid, which surrounds the brain and spinal cord, helps cushion them against sudden jarring and minor injury.
For a spinal tap (lumbar puncture), a sample of cerebrospinal fluid is withdrawn with a needle and sent to a laboratory for examination.
The cerebrospinal fluid is checked for evidence of infections, tumors, and bleeding in the brain and spinal cord. These disorders may change the content and appearance of the cerebrospinal fluid, which normally contains few red and white blood cells and is clear and colorless. For example, the following findings suggest certain disorders:
An increase in the number of white blood cells in the cerebrospinal fluid suggests an infection or inflammation of the brain and spinal cord.
Cloudy fluid, due to the presence of many white blood cells, suggests meningitis Introduction to Meningitis Meningitis is inflammation of the layers of tissue that cover the brain and spinal cord (meninges) and of the fluid-filled space between the meninges (subarachnoid space). Meningitis can be... read more (infection and inflammation of the tissues covering the brain and spinal cord) or sometimes encephalitis Encephalitis Encephalitis is inflammation of the brain that occurs when a virus directly infects the brain or when a virus, vaccine, or something else triggers inflammation. The spinal cord may also be involved... read more (infection and inflammation of the brain).
High protein levels in the fluid may result from any injury of the brain, the spinal cord, or a spinal nerve root (the part of a spinal nerve next to the spinal cord).
Abnormal antibodies in the fluid suggest multiple sclerosis Multiple Sclerosis (MS) In multiple sclerosis, patches of myelin (the substance that covers most nerve fibers) and underlying nerve fibers in the brain, optic nerves, and spinal cord are damaged or destroyed. The cause... read more or an infection.
Low sugar (glucose) levels suggest meningitis or cancer.
Blood in the fluid may indicate a brain hemorrhage Overview of Hemorrhagic Stroke Hemorrhagic strokes include bleeding within the brain (intracerebral hemorrhage) and bleeding between the inner and outer layers of the tissue covering the brain (subarachnoid hemorrhage). ... read more —for example, when a bulge in a weakened artery in the brain (aneurysm) bursts (ruptures).
An increase in the fluid’s pressure can result from many disorders, including brain tumors Overview of Brain Tumors A brain tumor can be a noncancerous (benign) or cancerous (malignant) growth in the brain. It may originate in the brain or have spread (metastasized) to the brain from another part of the body... read more and meningitis.
Doctors do not do a spinal tap when the pressure within the skull is increased, for example, when there is a mass (such as a tumor or abscess) in the brain. In such cases, a spinal tap may suddenly reduce pressure below the brain. As a result, the brain may shift and be pressed through one of the small openings in the relatively rigid tissues that separate the brain into compartments (called herniation Herniation: The Brain Under Pressure Head injuries that involve the brain are particularly concerning. Common causes of head injuries include falls, motor vehicle crashes, assaults, and mishaps during sports and recreational activities... read more ). Herniation puts pressure on the brain and may be fatal. The medical history and neurologic examination help doctors determine whether herniation is a risk. For example, doctors use an ophthalmoscope Ophthalmoscopy A person who has eye symptoms should be checked by a doctor. However, some eye disorders cause few or no symptoms in their early stages, so the eyes should be checked regularly (every 1 to 2... read more to examine the optic nerve, which bulges when the pressure within the skull is increased. As another precaution before a spinal tap is done, CT or MRI of the head is often done to check for masses.
How a Spinal Tap Is Done
Cerebrospinal fluid flows through a channel (called the subarachnoid space) between the middle and inner layers of tissue (meninges) that cover the brain and spinal cord. To remove a sample of this fluid, a doctor inserts a small, hollow needle between two bones (vertebrae) in the lower spine, usually the 3rd and 4th or the 4th and 5th lumbar vertebrae, below the point where the spinal cord ends, and then into the subarachnoid space—the space between the layers of tissue (meninges) that cover the spinal cord (and brain). Usually, people lie on their side with their knees curled to their chest. This position widens the space between the vertebrae, so that the doctor can avoid hitting the bones when the needle is inserted.
Cerebrospinal fluid is then allowed to drip into test tubes, and the samples are sent to a laboratory for examination.
For a spinal tap, people typically lie on their side in a bed and draw their knees to their chest. A local anesthetic is used to numb the insertion site. Then, a needle is inserted between two vertebrae in the lower spine below the end of the spinal cord.
During a spinal tap, doctors can measure the pressure within the skull. Pressure can be higher than normal in people with idiopathic intracranial hypertension Idiopathic Intracranial Hypertension Idiopathic intracranial hypertension is characterized by increased pressure within the skull (intracranial pressure). What triggers the disorder is unknown. People have daily or near daily headaches... read more and certain other disorders of the brain and surrounding structures. Pressure is measured by attaching a gauge (manometer) to the needle used for the spinal tap and noting the height of the cerebrospinal fluid in the gauge.
A spinal tap may be done for other reasons:
To reduce pressure within the skull (intracranial pressure) in people with idiopathic intracranial hypertension Idiopathic Intracranial Hypertension Idiopathic intracranial hypertension is characterized by increased pressure within the skull (intracranial pressure). What triggers the disorder is unknown. People have daily or near daily headaches... read more
To give drugs when they are needed to work quickly or to target a specific area of the brain, spinal cord, or meninges—for example, to treat infections or cancer affecting these structures
A spinal tap usually takes no more than 15 minutes.
About 1 of 10 people develops a headache when standing up after a spinal tap (called a low-pressure headache Low-Pressure Headache Low-pressure headaches result when cerebrospinal fluid is removed during a spinal tap (lumbar puncture) or leaks out because of a cyst or tear in one of the layers of tissues that cover the... read more ). The headache usually disappears after a few days to weeks. However, if the headache is still troublesome after a few days, doctors may inject a small amount of the person's blood into the area around where the spinal tap was done. This procedure, called a blood patch, slows the leakage of cerebrospinal fluid and may relieve the headache. Other problems are very rare.
Other Tests for Brain, Spinal Cord, and Nerve Disorders
Muscle and nerve
Occasionally, doctors cannot determine the cause of the nerve damage or muscle weakness based on results of blood tests, imaging tests, electromyography (EMG), or nerve conduction studies. In such cases, doctors typically refer the person to a specialist, who may remove a small sample of muscle tissue and sometimes a nerve to examine under a microscope (biopsy). The sample is removed from an area of the body where symptoms occur. The sample is stained to help doctors identify the pattern of muscle or nerve damage and to determine whether white blood cells (which indicate inflammation) are present.
Often, the sensory nerve examination and EMG do not detect damage of the nerves that sense pain or that automatically regulate body processes (called autonomic nerves Autonomic Nervous System Disorders read more ). Doctors may suspect such damage if people have less sensitivity to pain, have burning pain in their feet, feel dizzy or light-headed when they stand up, or sweat too much or too little. To check for this damage, doctors may use a small round cutter to remove a sample of skin (punch skin biopsy) and send it to a laboratory to be examined under a microscope.
If the nerve endings in the skin sample have been destroyed, the cause may be a disorder (such as vasculitis Overview of Vasculitis Vasculitic disorders are caused by inflammation of the blood vessels (vasculitis). Vasculitis can be triggered by certain infections or drugs or can occur for unknown reasons. People may have... read more ) that affects small nerve fibers, including pain-sensing and autonomic nerves fibers.
Echoencephalography uses ultrasound waves to produce an image of the brain. This simple, painless, and relatively inexpensive procedure can be used in children younger than 2 years because their skull is thin enough for ultrasound waves to pass through. It can be done quickly at the bedside to detect hydrocephalus Hydrocephalus Hydrocephalus is an accumulation of extra fluid in the normal spaces within the brain (ventricles) and/or between the inner and middle layers of tissues that cover the brain (the subarachnoid... read more (previously called water on the brain) or bleeding.
CT and MRI have largely replaced echoencephalography in older children and adults because they produce much better images in these age groups.
Genetic abnormalities cause many neurologic disorders—particularly movement disorders Overview of Movement Disorders Every body movement, from raising a hand to smiling, involves a complex interaction between the central nervous system (brain and spinal cord), nerves, and muscles. Damage to or malfunction... read more , including those that cause tremor or problems walking. Genetic tests can sometimes help doctors diagnose certain nerve and muscle disorders.
When genetic testing is recommended, people are usually referred to a genetic counselor. If they are not, people may request an appointment with one.