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A Practical Approach to the Focused Neurological Examination

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Presentation on theme: "A Practical Approach to the Focused Neurological Examination"— Presentation transcript:

1 A Practical Approach to the Focused Neurological Examination
The Johns Hopkins Center for Cerebrovascular Disease Case Studies A Practical Approach to the Focused Neurological Examination

2 Four Questions Is this a stroke? Where is the stroke?
How would you quantify/describe the deficits? Would you give TPA to this person?

3 Why This Review? Patients with neurological complaints are often difficult to manage Not everyone remembers their neuroanatomy (or wants to) Not enough time President Ford We can now do something about Strokes* * Thrombolytic Therapy For CVA , NEJM 1998

4 The Key Questions Is there a lesion? Where is the lesion?
What caused the lesion? What interventions are available?

5 Supra-tentorial Infra-tentorial The Nervous System The Brain
Cortex Subcortical Region Cerebellum Brainstem The Spinal Cord Peripheral Nerves Supra-tentorial Infra-tentorial

6 Functional Neuroanatomy


8 Functional Neuroanatomy


10 Spinal Cord- 3 Basic Areas
Posterior column (sensory, -( proprioception, vibration)) Lateral Column a. cortico-spinal (motor) b. spinothalamic(sensory) Anterior region (Motor)

11 Spinal cord cross-section

12 General Approach History Physical Neurological Evaluation Localization
Neurological Review of Systems Neurological Examination Localization Management

13 Neuro Review of Systems
Headaches Visual Symptoms Hearing Vertigo Ataxia Focal Weakness Paresthesia Quality, duration, pattern loss, diminished change spinning sensation imbalance(hands/feet) unilateral -arm, hand ,leg focal numbness, tingling

14 Neurological Review of Systems
Sphincter Speech Writing Reading Memory Level of Consciousness Bowel or bladder language vs dysarthia Ability to write Difficulty Forgetfulness Fainting, diminished, sz

15 Neurological Examination
Mental Status Cranial Nerves Motor and Reflexes Sensory Coordination and Gait

16 Neurological Examination
Mental Status Cranial Nerves Motor/Reflexes Sensory* Coordination Propioception Cortex Subcortical, Brainstem Upper and Lower Motor Neurons Subcortical, Spinal Cord Cerebellum Spinal Cord * Isolated lesions in the postcentral gyrus is rare

17 Mental Status I. Consciousness & Orientation PPT
II. Concentration and Attention Spell a five letter word, Clock draw III. Language Fluency, Comprehension, Naming, Repetition IV. Memory Immediate, Recent, Remote

18 Cranial Nerves

19 Testing Cranial Nerves
I. Olfaction (usually not tested) II. Optic -- visual acuity, peripheral vision, funduscopy III, IV Extraocular movements, VI pupillary reaction V. Sensory: Corneal reflex, sensation of the face, scalp Motor: mastication,

20 Testing Cranial Nerves
VII. Sensory: taste in anterior 2/3 of the tongue Motor: Close eyes, Show some teeth (facial expression) VIII. Hearing, equilibrium IX, X. Palate and pharynx motor, “AHHH”, Gag, taste posterior 1/3 tongue XI. Shrug shoulders, head turn against resistance XII. Move the tongue

21 Motor Examination 1. Strength (rating scale, bulk)
2. Tonicity (UMN verses LMN) 3. Posture (decorticate, decerebrate) 4. Involuntary Movements (tremor, dystonia, chorea, fasiculations, etc.) 5. Reflexes

22 Rating Scale for the Motor Exam
Response Score 1 2 3 4 5 No muscle contraction Trace contraction Movement in the absence of gravity Movement against gravity Movement against moderate resistance Normal strength

23 Glossary- Neuroanatomy
UMN-- Cortex to the lateral column of the spinal cord LMN-- Anterior column to the motor end-plate

24 UMN verses LMN Spastic Paralysis Hyperreflexia Hypertonicity
Babinski reflex Flaccid Paralysis Hyporeflexia Hypotonicity Muscle atrophy

25 Deep Tendon Reflexes* *Spinal shock can accompany acute cortical stroke

26 Sensory Examination Touch Pinprick (spinothalamic)
Temperature (spinothalamic) Position (posterior column) Vibration (posterior column)

27 Dermatomes Figure #7 Figure #8

28 Sensory Dermatomes

29 Coordination and Gait Cerebellar Gait Finger-nose (dysmetria - ataxia)
Heel-shin Rapid alternate movements (dysdiadochokinesia) Rhythmic tapping Romberg’s test Gait Normal versus Tandem

30 Localization Cortical Subcortical Brainstem Spinal cord
Internal capsule Basal Ganglia Thalamus Brainstem Midbrain Pons Medulla Spinal cord


32 L A H

33 Cortical Lesions Language* Motor - Which is more involved?
Aphasia ( motor, sensory, global, conduction) Motor Which is more involved? face and arm>leg (MCA) leg >arm and face (ACA) Cortical sensory loss (stereognosis, graphesthesia, point localization) * neglect in nondominant hemisphere

34 Cortical Lesions Is there eye deviation? (towards the lesion)
Is there field defect? (also with subcortical) Is there associated seizure activity? Think about blood

35 Subcortical Lesions Are face, arm, and leg equally involved? (internal capsule) Are there dystonic posture? (basal ganglia) Is there a dense sensory loss? (thalamic) Is there eye deviation or field defect? (also in cortical )

36 Visual Field

37 Brainstem Lesions Crossed hemiplegia (ipsilateral cranial nerves with contralateral motor) Cerebellar signs (ipsilateral) Nystagmus (worse on ipsilateral gaze) Hearing loss

38 Brainstem Lesions Check for sensory findings (ipsilateral pain, temp, and corneal) Check for dysarthria and dysphagia Check for gaze palsy (ipsilateral INO and MLF syndrome) Check for tongue deviation (ipsilateral)

39 Spinal Cord Lesions Intact cranial nerves and speech
Paralysis is ipsilateral to the lesion Sensation (pain & temp) are contralateral Sensory level may be present Sphincteric incontinence is common

40 Nondominant Hemisphere
Inattention (neglecting left side) Extinction (double simultaneous sensory stimulation) Denial or unconcern Acute confusional state

41 Nondominant Hemisphere
Constructional apraxia ( copy a simple diagram) Dress apraxia (wrong sleeve) Impersistence of a task Spatial disorientation

42 Stroke Where is the stroke? (cortical, subcortical, brainstem, or spinal cord) What is the vascular anatomy? (carotid versus vertebro-basillar territory) How did the stroke develop? (thrombosis, emboli, or intracranial hemorrhage)

43 Brain Arterial Supply Circle of Willis

44 Circle of Willis

45 TIAs Symptomatology Amaurosis fugax Aphasia Motor paresis
Carotid Amaurosis fugax Aphasia Motor paresis Motor paralysis Slurred speech Vertebro-basilar Ataxia Dizziness Diplopia Motor/sensory deficit

46 Middle Cerebral Artery Syndrome
Aphasia or non-dominant findings Hemiparesis (greater in face and arm) Cortical sensory loss Homonymous hemianopsia Conjugate eye deviation (ipsilateral)

47 Arterial Territory Lateral aspect

48 Anterior Cerebral Artery Syndrome
Paralysis of the lower extremity Cortical sensory loss (legs only) Incontinence Grasp & suck reflexes (release phenomena) No hemianopsia or aphasia

49 Arterial Territory Medial aspect

50 Posterior Cerebral Artery Syndrome
Homonymous hemianopsia (most common) Little or no paralysis No aphasia Prominent sensory loss Recent memory loss (hippocampus)

51 NIH Stroke Scale Category Response Score 1a. LOC Alert 0 Drowsy 1
Stuporous 2 Coma 3 1b. LOC questions Answers both correctly 0 Answers one correctly 1 Answers none correctly 3 1c. LOC commands Obeys both correctly 0 Obeys one correctly 1 Obeys none correctly 2

52 NIH Stroke Scale Category Response Score 2. Best gaze Normal 0
Partial gaze palsy Forced deviation 3. Best visual No visual loss Partial hemianopsia Complete hemianopsia 4. Facial palsy Normal Minor facial weakness Partial facial weakness No facial movement

53 NIH Stroke Scale Category Response Score
5. Best motor arm No drift after 10 s Drift Some effort (hits bed) No effort against gravity No movement 6. Best motor leg No drift after 5s Drift Some effort (hits bed) No effort against gravity 7. Limb ataxia Absent Present in upper/lower Ex Present in both upper/lower

54 NIH Stroke Scale Category Response Score 8. Sensory Normal 0
Partial loss Dense loss 9. Neglect No neglect Partial neglect Complete neglect 10. Dysarthria Normal articulation Mild to moderate dysarthria 1 Near unintelligible or worse 2

55 NIH Stroke Scale Category Response Score
11. Best Language No aphasia Mild to Moderate aphasia Severe Aphasia Mute

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