1. How to Complete a Clinically Relevant & Directed Neurologic Exam in ED CVA Patients Edward Sloan, MD, MPH Associate Professor Department of Emergency Medicine University of Illinois College of Medicine Chicago, IL 54 1 54

2. Global Objectives Improve pt outcome in stroke
Make consistent and reliable neuro Dx
Provide rationale ED therapies
Maximize ongoing learning
Be comfortable with our clinical skills
Minimize any unnecessary work 54 2 54

3. Session Objectives Present clinical case history
Consider acute stroke for a directed exam
Ask clinically relevant questions
Conduct a directed ED H&P
Examine the NIH Stroke Scale (NIHSS)
Review optimal ED documentation 54 2 54

4. “Real” Session Objectives
State the bare minimum that must be done in order to get the job done.
Allow you to forget about doing the rest. 54 2 54

5. Why Do This Exercise? How to proceed is unclear for many.
A uniformly applied minimal standard is better than a non-uniform approach.
Once achieved, a minimal standard can be enhanced.
This is a standard of care issue. 54 2 54

6. Some Perspective Stroke is a common ED problem.
Outcome from stroke can be devastating.
Use of tPA in stroke is an important issue.
Guidelines are being developed at the local and national level regarding CVA pts.
The cornerstone of this activity remains the front line Emergency Physician. 54 2 54

7. A Disclaimer.
Although I have listened to many lectures on the neurologic exam, I am not fully comfortable with this part of my practice.
What I do in clinical practice may fall below the standard of care.
Others also may fall short of a reasonable standard in doing a stroke neuro exam. 54 2 54

8. A Pledge. I will not simply create controversy.
I will attempt to clarify what are the important clinical questions.
I will attempt to state which physical and neuro exam elements are useful and why.
I will demonstrate a way in which the physical exam findings can be recorded in order to facilitate patient care. 54 2 54

9. A Clinical History
A 62 year old female acutely developed aphasia and right sided weakness while in the grocery store. The store clerk immediately called 911, with the arrival of CFD paramedics within 9 minutes, at 6:43 pm. She arrived at the ED at 7:05 pm, completed her head CT at 7:25 pm, and obtained a neuro consult at 7:35 pm, approximately one hour after the onset of her symptoms. What are the next Rx steps? 54 3 54

10. ED Presentation
What parts of the history and physical exam really matter? Why?
In what way will the neurologic exam direct the ED diagnosis and therapy?
What must be documented? Why? 54 3 54

11. Acute Neurologic Exam Questions
What general exam should be done?
What neuro exam should be done?
What exam findings guide therapy?
What exam findings predict outcome?
What is the NIH stroke scale?
How can documentation be optimized? 54 4 54

12. Acute Ischemic Stroke: Etiology
Thrombotic, embolic, hypoperfusion
Majority are vessel thrombosis
Clot formation on diseased vessel
20% are embolic, from heart, great vessels
Hypoperfusion with cardiogenic shock 5 17

13. Acute Ischemic Stroke: Syndromes
Anterior cerebral
Middle cerebral
Posterior cerebral
Vertebrobasilar
Basilar artery occlusion
Cerebellar
Lacunar
Arterial dissection 5 17

14. Acute Ischemic Stroke H & P: Some Practical Questions
Does the neuro exam tell us anything the CT scan does not?
Do we need to localize the CVA clinically?
Isn’t a large ICH evident most often based on the pt’s mental status and overall appearance?
Who checks for proprioception or a positive Rhomberg in a pt with a CVA? 5 17

15. Acute Ischemic Stroke H & P: Rationale for Exam Findings
To make the correct diagnosis
To identify a stroke syndrome
To identify CVA precipitants/etiology
To determine further diagnostic tests
To determine ED therapies
To allow for proper documentation 5 17

16. Rationale for a Directed Neuro Exam: To Make the Correct Diagnosis
A complete neuro exam helps when Sx are vague, mild or confusing
TIA, seizure or migraine variant setting
Exam puts a name on non-persistent Sx
Most acute stroke pts have obvious Sx
What else causes L sided paralysis acutely?
Doesn’t the constellation of Sx make the Dx?
Which Dx must be immediately excluded? 5 17

17. To Make the Correct Diagnosis: A Stroke Differential Diagnosis
Hypertensive encephalopathy
Subdural, epidural hematoma
Meningitis, encephalitis, abcess, labarynthitis
Seizure, SE, Todd’s paralysis
Neoplasm
Hypoglycemia, metabolic
Migraine
Peripheral nerve, Bell’s palsy
Multiple sclerosis 5 17

18. Rationale for a Directed Neuro Exam: To Identify a Stroke Syndrome
The neurologic exam must establish:
anterior or posterior circulation location.
if the Dx is cerebellar hemorrhage.
if the lesion is in the brain stem.
if the lesion is in the spinal cord.
There is no other requirement with regards to the acute Dx of the stroke pt. 5 17

19. To Identify a Stroke Syndrome: Anterior vs. Posterior Circulation
Markedly different presentations.
Anterior circulation:
Sx (motor, sensory) on the same body side
Sx contralateral to the side of the CVA
Visual field deficits, gaze abnormalities
Aphasia, dysarthria, apraxia 5 17

20. To Identify a Stroke Syndrome: Anterior vs. Posterior Circulation
Minimal (transient) motor abnormality
Marked sensory (LT, pinprick) abnormality
Visual abn, oculomotor palsy
Ataxia, hemiballism
Vertebrobasilar system:
CN, body motor deficits on alternating sides
Hemiparesis, hemiplegia, dizziness, dim vision, dysarthria, dysphagia, vomiting 5 17

21. Rationale for a Directed Neuro Exam: Cerebellar Hemorrhage
A specific clinical presentation:
Nausea, vomiting, central vertigo
Headache, nuchal rigidity
Syncope, ataxia, inability to ambulate
AMS when brainstem is compressed
Pathologic respiratory pattern
A true surgical emergency (evacuation).
Often difficult to detect on CT. 5 17

22. Rationale for a Directed Neuro Exam: Brain Stem Lesion
A specific clinical presentation:
Markedly abnormal vital signs
Altered mental status, often coma
Pupillary abnormalities
Abnormal respirations
Often with the need for immediate intubation
A picture of critical illness 5 17

23. Rationale for a Directed Neuro Exam: Spinal Cord Lesion
Injury with unilateral or bilateral findings
Complete spinal cord injury
Partial syndromes
Central, anterior, Brown-Sequard
Cauda equina
Tumor, abcess, epidural hematoma
Disc disease/acute herniation
No Hx, Px findings that suggest a CVA 5 17

24. Rationale for a Directed Neuro Exam: To ID Stroke Precipitant/Etiology
What is the etiology of the stroke?
What findings suggest the need for a specific Rx or further Dx testing?
Four stroke etiologies are noted:
Thrombotic (atherosclerosis)
Embolic
Hemorrhage
Subarachnoid hemorrhage 5 17

25. To ID Stroke Precipitant/Etiology: Findings Suggesting Embolic CVA
Most often anterior circulation process
Abrupt Sx onset, worst deficit at onset
Carotid bruit: carotid artery occlusion and source of embolism
A Fib: embolism source of MCA stroke
Heart murmur: valve pathology, embolism 5 17

26. To ID Stroke Precipitant/Etiology: Findings Suggesting Thrombotic CVA
Most often posterior circulation process
Gradual Sx onset, stepwise deficit
Carotid bruit: evidence of atherosclerosis
LV Heave: cardiac hypertrophy
Aorta: AAA indicated vasculopathy
Extremities: poor pulses, atherosclerosis 5 17

27. To ID Stroke Precipitant/Etiology: Findings Suggesting Hemorrhagic CVA
Impaired consciousness key element
Abrupt Sx onset, usu max deficit early
HTN, bradycardia
Papilledema, hemorrhages 5 17

28. To ID Stroke Precipitant/Etiology: Findings Suggesting Subarachnoid
Impaired consciousness key element
Varied Sx onset and deficit progression
Severe headache, neck stiffness
Retinal hemorrhages
Meningismus 5 17

29. Rationale for a Directed Neuro Exam: To Determine Further Dx Tests
Very few further tests in the ED:
EKG for dysrhythmia
CXR to rule out tumor, CHF
Contrast Head CT for abcess, tumor
Angiography for suspected SAH, aneurysm
CT, US for suspected large AAA
ECHO for suspected acute cardiac lesions
MRI, other tests rarely indicated 5 17

30. Rationale for a Directed Neuro Exam: To Determine ED Therapies
Very few specific ED therapies.
Embolic, thrombotic CVAs:
ASA, Heparin, tPA
Hemorrhagic CVA
Mannitol, decadron, phenytoins
Operative intervention
Subarachnoid hemorrhage
Nimodipine, ?? OR 5 17

31. Rationale for a Directed Neuro Exam: To Allow for Proper Documentation
What was the clinical state of the pt when in our ED, and under our care?
Did we complete exam sufficient to direct Rx that would optimize this pt’s care?
Did our clinical Rx follow our exam?
If necessary, could a NIHSS score be assigned in retrospect 5 17

32. Acute Stroke: Historical Elements
When did symptoms begin? Onset?
Prior history of similar symptoms?
When was the patient last seen normal?
Risk factors?
Medical hx that would preclude tPA use? 5 17

33. Acute Stroke: Physical Exam
Vital signs, pulse ox, accucheck
HEENT: Pupils, papilledema, airway
Neck: Bruits, nuchal rigidity
Chest: Rales (CHF, aspiration)
Cardiac: Gallop, murmur, dysrhythmias, ventricular heave 5 17

34. Acute Stroke: Physical Exam
Abd: Evidence of AAA
Ext: Evidence of CHF, DVT, vascular Dx
Skin: Evidence of infectious etiology
Neuro: Mental status, CN, eye exam, motor, sensory, reflexes, cerebellar, visual, language, neglect 5 17

35. Neurologic Exam: Mental Status
Level of consciousness (AVPU)
Alert
Responds to verbal
Responds to painful
Unresponsive
Glasgow Coma Scale (GCS) score
Designed for trauma, TBI
Still is a reproducible, systematic scale
Delirium: AMS, inappropriate, wax/wane 5 17

36. Neurologic Exam: Cranial Nerves
Cranial Nerves: Anterior vs. posterior?
Anterior: CN, body deficits on same side
Posterior: CN and body deficits are on opposite sides of the body (alternating hemiplegia)
Face motor, sensory (LT) only
Gag reflex (intubation)
Eye Closure (Bell’s palsy) 5 17

37. Neurologic Exam: Eye Exam
Pupils: location of brain stem lesion
EOM: CN palsies, often not due to CVA
Vertigo: assists with DDx of CVA 5 17

38. Neurologic Exam: Motor
Motor: upper & lower extremities
Upper: Pronator drift, hand grasp
Lower: Leg lift, foot push on hand 5 17

39. Neurologic Exam: Sensory
Sensory: Light touch OK, pinprick ??
No other sensory testing is indicated unless a posterior circulation infarct or a spinal cord syndrome is suspected
No heat, vibration, proprioception 5 17

40. Neurologic Exam: Reflexes
Suggest UMN control of LMN
Corneal, gag, DTRs all are normal
Pathologic reflexes
Babinski, Chadduck
Clonus
Unclear whether or not these add to our overall impression of CVA severity 5 17

41. Neurologic Exam: Cerebellar
Truncal ataxia perhaps useful
Ataxic gait, Rhomberg: No
Extremity tests not useful in paralysis
Past-pointing
Hand alternating movements 5 17

42. Neurologic Exam: Visual
Visual field deficit
Homonomous hemianopsia
Neglect of one side
Preferential gaze 5 17

43. Neurologic Exam: Language
Dysarthria: Poor speech, motor dysfunction
Aphasia: Disturbed language processing
Expressive: can’t speak
Receptive: can’t process the spoken word 5 17

44. Acute Neurologic Exam Answers
The Hx should lead to a provisional Dx.
The Px exam should detect co-morbidity and suggest the stroke etiology.
The neuro exam should confirm the Dx.
Few exam findings specifically direct Rx or direct outcome.
AMS, coma are the most important findings.
The NIHSS directs your neuro exam.
Standardization of your document is key. 54 4 54

45. Acute Ischemic Stroke H & P: Some Practical Answers
The exam directs us to a provisional Dx.
We do localize the lesion by identifying the provisional stroke syndrome.
The CT will identify a large ICH or ischemic stroke, but many times the CT is negative, in which case the exam is key.
Completing all parts of the neuro exam is not necessary, use it to confirm your Dx. 5 17

46. Neuro Exam: Internet Sites
Search engine: Google
Key words: Neurologic Exam
Some web sites:
medicine/StrokeSSM/ClinExamNeuro.htm 5 17

47. Neurologic Exam: NIH Stroke Scale
13 item scoring system, 7 minute exam
Integrates neurologic exam components
CN, motor, sensory, cerebellar, visual, language, LOC
Maximum score is 42, signifying severe stroke
Minimum score is 0, a normal exam
Scores greater than are more severe 5 17

48. NIH Stroke Scale: Important Questions
Which elements are consistently collected?
Which correlate with outcome?
Which improve with tPA?
Which suggest a complicated tPA course?
Which parts overlap with one another? 5 17

49. NIH Stroke Scale: Practical Suggestions
Know the general categories of the NIHSS
Let these 7 areas guide your exam
Know how to score an approximate NIHSS
Go to the web to score your exam fully 5 17

50. NIH Stroke Scale: Internet Calculator
Allows calculation on-line
Will add values, provide total
neurol/Residency/nihss.htm
Other sites: 5 17

51. Neuro Exam in Stroke: Documentation
Know the key elements of provisional Dx
Use Hx and Px to support your Dx
Document pertinent positives, negatives
State neuro exam in terms of the NIHSS 7 5 17

52. Neuro Exam in Stroke: Documentation
State exactly what you did
CN: face motor- ok eye closure, mouth, tongue
Cerebellar: no truncal ataxia with sitting
State findings in terms of a clinical entity
Weakness, aphasia c/w L anterior circ CVA
Cerebellar findings not c/w cerebellar CVA 5 17

53. Neuro Exam Documentation: An Example from a Real Case (Hx)
Date: XXXX exam
57 yo male
Per CFD, thru interpreter
Pt was at friend’s house, attempted to stand up, could not due to weakness
C/o mild headache now
No trauma 5 17

54. Neuro Exam Documentation: An Example from a Real Case (Hx)
? Hx HTN ? Meds ? compliance
No recent illness
No other c/os
The exact time of these events is not as of yet determined 5 17

55. Neuro Exam Documentation: An Example from a Real Case (Px)
Pt alert, NAD, VS noted
Head: pup EOM OK
+ neglect of L visual field
+ mouth droop L
+ tongue dev to L
+ slurred speech
Airway OK 5 17

56. Neuro Exam Documentation: An Example from a Real Case (Px)
Neck: supple, - bruit
Chest: clear BSBE
Cor: reg s
Abd: soft, nt
Ext: nt
Neuro: 5 17

57. Neuro Exam Documentation: An Example from a Real Case (Px)
LOC: alert, responds to verbal stim
Visual: L visual field neglect, dec EOM to L
Motor: flaccid L arm, no use of L hand
Cerebellar: no truncal ataxia
Sensation: ? grossly nml to light touch except affected extremity
Language: Dysarthria, slurred speech
CN: mouth droop/tongue/loss of L sh shrug c/w CN motor weakness 5 17

58. Neuro Exam Documentation: An Example from a Real Case (Px)
Approx NIHSS:
LOC 0 visual 2
CN 2 motor 3
Sens 1 neglect 1
Dysarthria 1 language 1
Approx total: 11 5 17

59. Neuro Exam Documentation: An Example from a Real Case (MDM)
Plan:
w/u, including CT
Neuro consult
Contact witness to det exact time of sx onset
Imp: Acute CVA with L sided sx
Dx: CT shows parietal bleed
Will Rx per neurosurg, admit ICU, stable 5 17

62. tPA in Acute Ischemic Stroke: Clinical & Documentation Issues
Document that tPA was considered
If not used, state explicitly why the pt did not meet criteria or why it was deferred
When explaining, tell the four key points:
30% greater chance of good outcome
10 fold greater risk of bleeding
Same mortality rate, despite bleeding risk
Explain why mortality is comparable 54 44 54

63. Clinical Case: Physical Exam
On exam, BP 116/63, P 90, RR 16, T 98, and pulse oximetry showed 99% saturation.  The patient appeared alert, and was able to slowly respond to simple commands.  The patient had a patent airway, no carotid bruits, clear lungs, and a regular cardiac rate and rhythm. The pupils were pinpoint, and there was neglect of the R visual field. There was facial weakness of the R mouth, and R upper and lower extremity motor paralysis.  DTRs were 2/2 on the left and 0/2 on the right.  Planter reflex was upgoing on the right and downgoing on the left. The patient’s estimated weight was 50 kg. 54 3 54

64. Acute Ischemic Stroke: Case Management
Complete directed H&P, with neuro exam
Get the CT scan ASAP
Call PMD, family, neurologist
Find out the CT results
Decide risk/benefit
Discuss with pertinent decision makers 54 44 54

65. Acute Ischemic Stroke: Clinical Case: CT Results54 44 54

66. Acute Ischemic Stroke: Clinical Case: CT Results54 44 54

67. Acute Ischemic Stroke: Clinical Case: ED Management
CT: no low density areas or bleed
No clear contra-indications to tPA
NIH stroke scale:
Neurologist said OK to treat
No family to defer tPA use
tPA administered without comp 54 44 54

68. Acute Ischemic Stroke: Clinical Case: tPA & Repeat Exam
tPA dosing:
8:21 pm, approx 1’45” after CVA sx onset
Initial bolus: 5 mg slow IVP over 2 minutes
Follow-up infusion: 40 mg infusion over 1 hour
Repeat exam at 90 minutes:
Repeat Px Exam: Increased speech & use of R arm, decreased mouth droop & visual neglect
Repeat NIH stroke scale: 14-20 54 44 54

69. Acute Ischemic Stroke: Hospital Course & Disposition
Hospital Course: No hemorrhage, improved neurologic function
Disposition: Rehab hospital
Deficit: Near complete use of RUE, speech & vision improved, some residual gait deficit

70. Neurologic Exam in Stroke: Conclusions
The exam can and should be streamlined
Focus on the provisional Dx
Attempt to determine etiology, Dx, Rx
Document in a brief, systematic manner
State exactly what you did, how the findings relate to your provisional Dx and Rx 54 45 54

71. Neurologic Exam in Stroke: Recommendations
Know syndromes, focus neuro exam
Learn to calculate an approximate NIHSS
Document completely, but streamline
Generalize this to process to your care of patients with other neuro emergencies
Optimize outcome and your practice 54 46 54

72. Questions?? Edward Sloan, MD, MPH edsloan@uic.edu 312 413 749054 1 54