Increased reflexes.

Babinski sign (the toe goes up [dorsiflexes] when the lateral border of the foot is slowly stroked with a sharp point).

Spasticity (when the limb is passively moved there is resistance to the movement not due to contracture).

Clonus (e.g., when the ankle is passively dorsiflexed there is a rhythmic dorsiflexion/plantar flexion movement).

Test the patient carefully for aphasia (a disorder of production or comprehension of language). Listen to spontaneous speech. Note any breakdown in fluency. Notice any errors of word or syllable choice (paraphasias). Have the patient name objects (e.g., pen, tie, watch), repeat phrases (e.g., “no ifs, ands, or buts”), and read. Check the patient’s comprehension of commands (e.g., “Touch your left thumb to your right ear. Close your eyes.”). Have the patient write a sentence or two. Is the patient right-handed? Remember, in nearly all right-handed and most left-handed people, the left hemisphere is dominant for language (see Chapter 4).

Check for cortical sensory loss. For example, test position sense, graphesthesia (write numbers on the palm), and stereognosis (have the patient identify objects placed in the hand). Touch the patient on different parts of the arm and leg, and have him or her identify where he or she is touched. Touch both sides at the same time to see if the patient notices one side only (extinction). Remember, primary sensation (pin, touch, temperature) must be intact to do such testing. Cortical sensory loss implies a parietal or subcortical localization on the contralateral side.

Are the face and arm more affected than the leg (suggesting lateral frontal lobe, middle cerebral artery territory in a stroke patient), or is the leg more involved (high frontal lobe or anterior cerebral artery territory)?

Is there eye deviation or a gaze preference? The eyes look toward the hemisphere involved and away from the hemiparesis in a cortical lesion (see Fig. 34.3).

Check carefully for a visual field defect. Ask the patient to identify fingers presented simultaneously in peripheral fields. Note: Field defects and “cortical-type” eye deviation may be found in subcortical lesions, and must be interpreted in the context of other findings. The presence of seizures, cortical sensory loss, or aphasia often will assist in accurate diagnosis, suggesting a cortical location.

Are there seizures? A hemiparesis associated with a seizure suggests a cortical lesion. Has the patient had seizures in the same distribution as the weakness?