1. The Neurologic Exam for the Emergency Physician Andy Jagoda, MD, FACEP Mount Sinai School of Medicine Department of Emergency Medicine New York, New York 1 1 1 1

2. Overview
Neuroanatomy
History
Physical
Clinical Scenarios 2 2 2 2

3. Introduction Facilitates Communication Provides Baseline
Directs Testing
Identifies Need For Life-Saving Therapies
Risk Management 3 3 3 3

4. Risk Management: Case #1
A 46 year female with a long history of migraine headaches presented c/o a severe occipital HA that was different form her past headaches in location and intensity. Neuro exam “WNL”. Patient was treated with Compazine, 10 MG IV, with “Resolution of Headache” and discharged home to “Follow-Up With PMD”.
18 Hours later, patient was brought in by EMS comatose. 4 4 4

5. Risk Management: Case #2
A 64 year old male presented with lower back pain which had become progressively worse over the past 2 weeks. The pain was primarily in the lower back without radiation, with nonspecific numbness in the legs. PMH: presently being treated for prostatitis. Exam: “Mild Paralumbar Tenderness”, “SLR -”, “Motor / Sensory Intact”, Knee DTR +2. patient was prescribed Morton and told to follow-up with his PMD.
Patient developed irreversible renal damage. 5 5

6. Neuroanatomy Central versus peripheral If central, what is the level:
symmetrical vs asymmetrical
If central, what is the level:
Cerebrum
Brain Stem
Spinal cord
If peripheral, is it
Nerve
Muscle
NMJ 7 5 6 6

7. Neuroanatomy 8 6 7 7

8. Central Lesions
Lesions in the cerebral cortex result in contralateral deficits of the face and body
Lesions at the midbrain result in contralateral hemiplegia and ipsilateral peripheral paralysis of III and IV
Lesions at the pons result in contralateral hemiplegia and ipsilateral deficits of V, VI, VII, VIII
Lesions at the medulla result in contraleral hemiplegia and ipsilateral deficits of IX, X, XI, XIII 8 8

9. Anatomy of the Spinal Cord
Corticospinal Tracts: motor from cerebral cortex: cross in the lower medulla
Spinothalamic Tracts: pain and temperature: cross 1 or 2 levels above entry
Posterior Column: proprioception and vibration 9 9

10. Spinal Cord : Vascular Supply
Single Anterior
Paired posterior from vertebral arteries (Except in cervical cord)
Radicular Arteries from aorta:
Varying degrees of contribution
Great radicular artery of Adamkiewicz T-10 to L-2 (Major source of blood flow to 50% of anterior cord in 50% of patients)
Anterior perfuses anterior and central cord 10 10

11. UMN vs LMN UMN increased DTR (after SS) LMN decreased DTR
UMN muscle tone increased
LMN tone decreased, atrophy
UMN no fasciculations LMN fasciculations 11 11

12. UMN vs LMN Weakness
Mylopathy = Spinal Cord Process = UMN findings (spasticity, weakness, atrophy, sensory findings, bowel and bladder complaints)
Radiculopathy = Nerve Root Process = LMN findings (Paresthesias, Fasciculations, Weakness, decreased DTR)
Patient may have a radiculopathy with mylopathy below the lesion 12 12

13. The Neuro Exam: History
Neuro complaints may be primary or secondary to other system disease
Infection
Overdose
Metabolic Disorder
History often provides the key since the neuro exam may be normal
Subarachnoid Hemorrhage
Carbon Monoxide Poisoning
Subdural Hematoma
Nonconvulsive Seizures 15 9 13 13

14. The Neuro Exam: History
Time of Onset
Type of Onset
Progression
Trauma
Associated Symptoms
Factors that make it better/worse
Past Symptoms / Events
Past Medical History
Occupational / Environ Exposures 16 10 14 14

15. The Neuro Exam: Physical
Vital Signs
Head: Evidence of Trauma
Neck: Bruits, Rigidity
Heart: Murmurs
Abdomen: Masses / Distention
Skin / Scalp: Lesions / Tenderness 17 11 15 15

16. The Neuro Exam: Physical
Mental Status
Cranial Nerves
Motor
Sensory
Coordination
Reflexes 18 12 16 16

17. The Neuro Exam: Initial Approach
Posture
Decorticate
Decerebrate
Facial or body asymmetry
Hemiparesis results in external rotation of the foot to the affected side 18 13 17 17

18. Mental Status Exam AVPU GCS Orientation
Speech (dysarthria vs aphasia)
Comprehension
Confusion assessment method (CAM)
Acute onset / fluctuating course
Inattention
Disorganized thinking
Altered level of consciousness
Mini-mental status exam
Score affected by education and age
<20 = cognitive impairment 19 14 18 18

19. Acute Altered Mental Status
Intracranial lesion
Metabolic disorder
Toxin
Infection
Ictal state
Postictal state
Psychogenic 16 19 19

20. Cranial Nerve Exam Focus exam on II - VIII Symmetrical vs symmetrical23 17 20 20

21. Evaluation of II, III, IV, VI
Visual acuity
Visual fields
Examine the cornea, pupil, fundi
Check afferent function
Extraocular movements
Accentuated when looking in the direction of the paralyzed muscle
Differentiation can be facilitated by placing a colored glass over one eye 24 18 21 21

22. Cranial Nerve II Visual acuity Visual fields Fundoscopy
Swinging flashlight test 25 19 22 22

23. III Nerve Emerges from brainstem next to posterior cerebral artery
May be compressed by herniation
Runs in the lateral wall of the cavernous sinus 27 20 23 23

24. III Cranial Nerve Parasympathetics Levator Palpebrae
Inferior Obliques, Medial, Inferior, and Superior Rectus Muscles SR
IO IO SR LR
MR MR LR
IR SO SO IR 28 21 24 24

25. III Cranial Nerve Paralysis
Ptosis
Dilated Pupil
Paralyzed eye is deviated out and down; SO and LR control eye SR
IO IO SR LR
MR MR LR
IR SO SO IR 29 22 25 25

26. III Cranial Nerve Lesions
Progressive lesions after passage through the dura usually usually causes a ptosis and pupil dilatation first
Lesions in the nucleus cause motor deficits first
Intact pupil indicates a peripheral ischemic lesion 30 23 26 26

27. IV Cranial Nerve Superior oblique Causes eye to turn in and down
When paralyzed, eye can not turn down when it is rotated in SR
IO IO SR LR
MR MR LR
IR SO SO IR 31 24 27 27

28. VI Cranial Nerve Lateral rectus
Long course; goes through the CS, not within the wall
Paralysis impairs abduction SR
IO IO SR LR
MR MR LR
IR SO SO IR 32 25 28 28

29. Conjugate Gaze Controlled by supranuclear connections
Medial longitudinal fasciculus is responsible for coordinating the oculomotor nerves; lesions result in impairment of LR and MR moving in sync, ie, contralateral eye does not pass the midline
Multiple sclerosis 33 26 29 29

30. Causes of III, VI, VI CN paralysis
Isolated cases usually due to vascular causes: HTN, DM, Atherosclerosis
Tumors
Increased intracranial pressure
Colloid cyst of the III ventricle
Wernicke-korsakoff syndrome
Myasthenia, Botulism
Toxic drug reactions 34 27 30 30

31. Cranial Nerve V Sensory: corneal reflexes
Motor: jaw strength and muscle bulk
Corneal reflex may be abnormal in cerebellopontine angle lesions: test in patients with hearing deficits or vertigo 35 28 31 31

32. Cranial Nerve VII Motor smile bury eyelashes nasolabial fold
forehead has bihemispheric innervation centrally
Taste anterior 2/3 36 29 32 32

33. Cranial Nerves VIII - XII
VIII - vestibular function / hearing
IX - taste / sensation posterior pharynx
X - SCM; chin to the opposite side
XII - tongue 37 30 33 33

34. Motor Exam Strength Tone Bulk Fasciculation Tenderness
primary concern: can patient breathe
key test: drift of extremity
Tone
hypertonia: subacute or chronic corticospinal lesion
hypotonia: LMN lesion or acute UMN
rigidity: basal ganglia disease
Bulk
wasting correlates with LMN
Fasciculation
anterior horn cell lesion
Tenderness
metabolic / inflammatory muscle disease 39 31 34 34

35. Motor Exam 0 = no movement 1 = flicker but no movement
2 = movement but can not resist gravity
3 = movement against gravity but can not resist examiner
4 = resists examiner but weak
5 = normal 40 32 35 35

36. Sensory Exam
Pain / Temp - cross at entrance, ascend in spinal thalamic tract
Light touch - ascend in posterior column, cross in the brain stem
Vibration - posterior column, cross in the brain stem

37. Sensory Exam
Dermatomal deficit accompanied with pain suggests peripheral lesion
Central deficits are not dermatomal and usually result in loss of sensation not pain
Thalamic pain syndrome 43 35 37 37

38. Sensory Exam Distribution Pinprick versus light touch
right vs left vs bilateral
dermatomal
distal versus proximal
stocking glove
cape like
Pinprick versus light touch 44 36 38 38

39. Sensory Exam Double simultaneous testing Establish sharp / dull
Check cheek, dorsum of hands, dorsum of feet
Test both sides simultaneously with pin
lateralizes pain, significant sensory deficit
initially no lateralization but on repeat 15 sec later, lateralization suggests subtle deficit 45 37 39 39

40. Coordination
Requires integration of cerebellar, motor, and sensory functions
Balance requires (2 of 3)
vision
vestibular sense
proprioception
Falling with eyes open or closed = cerebellar
Falling only with eyes closed = posterior column or vestibular 38 40 40

41. Reflexes Symmetry / upper vs lower
0 = absent
1 = hyporeflexia
2 = normal
3 = hyperreflexia
4 = clonus (usually indicates organic disease)
Superficial reflexes (corneal, pharyngeal, pharyngeal, abdominal, anal, cremasteric, bulbocavernosus)
Pathologic reflexes: babinski: 49 39 41 41

42. Hysteria (conversion vs malingering)
Blindness: opticokinetic test
Hand drop on face test for coma or UE weakness
Hemianesthesia: if real, patient cannot perform finger-to nose with eyes closed; vibration remains intact (if bony skeleton intact)
Weakness: elbow extension or flexor test; wrist extensor test
Unilateral LE weakness: thigh abduction test, hoover test 50 40 42 42

43. Pitfalls In The Neurologic Exam
Not getting a complete history utilizing family or observers
Not performing a systematic exam
Jumping to conclusions before gathering all the data
Misinterpreting old lesions for new
Misinterpreting limitations from pain as neurologic deficits 72 41 43 43

44. Pearls
Lesions of the cerebral cortex result in sensory and motor defects confined to the contralateral side of the body
Brain stem and spinal cord lesions result in ipsilateral as well as contralateral defects due to varying patterns of crossover
Unilateral pain syndromes without motor deficits suggest possible thalamic pathology
A careful exam of CN II, III, IV, and IV is indicated in patients with headache or suspected processes that cause increased ICP
Testing for pronator drift is the best screen for muscle weakness of central origin 73 42 44 44

45. The Neurologic Exam Case Scenarios1 1 45 45

46. Case Scenario #1
A 46 yo female with a long history of migraine headaches presented c/o a severe occipital HA that was different from her past headaches in location and intensity. If an aneurysm is suspected to be causing the patient’s symptoms, which cranial nerve should your exam focus on?
A. III B. VI C. VII D. IV II 2 46 46

47. III NERVE EMERGES FROM BRAINSTEM NEXT TO POSTERIOR CEREBRAL ARTERY
RUNS IN THE LATERAL WALL OF THE CAVERNOUS SINUS
MAY BE COMPRESSED:
HERNIATION
ANEURYSM
POSTERIOR COMMUNICATING ARTERY
ICA IN THE CAVERNOUS SINUS (IV, V AND VI NERVES ALSO INVOLVED) 27 25 34 31

48. Case Scenario #2
A 64 yo male presented C/0 low back pain which has become progressively worse over the past 2 weeks. The pain was primarily in the low back without radiation; C/O nonspecific numbness in the legs. Which nerve root is responsible for plantar flexion and the ankle jerk?
A. L3 B. L4 C. L5 D. S1 E. S2 3 47 47

49. Lower Extremity Innervation
L 3 / L 4 = Patellar reflex
L 5 = Big toe extension
S 1 = Achilles reflex

50. Case Scenario #3
A 30 yo female is in an MVA hitting her head on the dash. The next day she developed a sudden onset severe right frontal HA, that persisted. One day later she developed left sided arm weakness that lasted 2 hours. In the ED she had an OD ptosis and OD miosis. Her motor / sensory exam was “WNL”. What is your initial impression?
A. Hysteria B. Subarachnoid bleed C. Epidural hematoma
D. Carotid artery dissection E. Entrapment syndrome 4 48 48

51. DISRUPTION OF THE SYMPATHETICS
PUPIL CONSTRICTION
DISRUPTION OF THE SYMPATHETICS
HORNER’S
CAROTID ARTERY DISSECTION
PONTINE HEMORRHAGE
TOXINS
NARCOTICS
CHOLINERGICS 17 17

52. Case Scenario #4
A 50 yo female c/o a diffuse headache for two months that is constant. There is no past HA history. She claims that intermittently her vision seems blurred but otherwise denies symtoms. On exam: VSS; VA: 20/40. CN: diplopia on far lateral gaze bilaterally. Which of the following is the most likely diagnosis.
A. Occipital Lobe Stroke B. Pituitary Adenoma
C. Multiple Sclerosis D. Myasthenia Gravis
E. Intracranial Hypertension 5 49 49

53. 50% HAVE AN IDENTIFIABLE UNDERLYING ETIOLOGY
IDIOPATHIC INTRACRANIAL HYPERTENSION (BENIGN INTRACRANIAL HYPERTENSION, PSEUDOTUMOR CEREBRI)
SYNDROME DEFINED BY SIGNS AND SYMPTOMS OF HIGH ICP WITHOUT APPARENT INTRACRANIAL MASS
50% HAVE AN IDENTIFIABLE UNDERLYING ETIOLOGY
ALTERED ABSORPTION OF CSF AT THE ARACHNOID VILLUS
ALTERATION DUE TO EITHER:
ELEVATED PRESSURE WITHIN THE SAGITTAL SINUS
INCREASED RESISTANCE TO DRAINAGE OF CSF WITHIN THE VILLUS

54. PAPILLEDEMA VISUAL DISTURBANCE 50 - 80% BLINDNESS IN 10%
PHYSICAL FINDINGS
PAPILLEDEMA
VISUAL DISTURBANCE %
BLINDNESS IN %
DECREASED VISUAL ACUITY 30%
TRANSIENT VISUAL OBSCURATION 68%
ENLARGED BLIND SPOT
SCOTOMAS
VI NERVE PALSY (FALSE LOCALIZING) 38%

55. Case Scenario #5
A 20 yo college student flips his car, hitting head on the dash. He arrives in the ED in full spinal immobilization. On exam he has 2/5 strength in his wrists, 3/5 strength in his deltoids, 5/5 strength in his LE. He complains of numbness in his arms but is able to distinguish sharp from dull. DTRs intact. What is your leading diagnosis?
A. Central Cord Syndrome B. Anterior Cord Syndrome
C. Spinal Epidural Hemorrhage D. Subdural Hemorrhage
E. Brown - Sequard Syndrome 6 50 50

56. CENTRAL CORD SYNDROME HYPEREXTENSION INJURIES, TUMOR, SYRINGOMYELIA
M U D
PARESIS OR PLEGIA OF ARMS > LEGS
POSTERIOR COLUMN SPARED
SENSATION UE>LE; SACRAL SPARING
PERFORATING BRANCHES OF ANTERIOR SPINAL ARTERY AT GREATEST RISK FOR VASCULAR INSULT
GOOD PROGNOSIS

57. Case Scenario #6
A 23 yo female presents complaining of feeling generally weak with the sensation that she is dragging her feet when she walks. On exam her sensation is intact; motor strength is 5/5 in all major muscle groups; deep tendon reflexes are 2/2 in the UE, 2/2 at the knees, and and 0/2 at the ankles. What is your major concern?
A. Spinal Stenosis B. Conus Medularis C. Guillian Barre
D. Polymyalgia Rheumatica E. Myasthenia Gravis 7 51 51

58. GUILLAIN-BARRE
ACUTE POLYNEUROPATHY
SYMMETRIC ASCENDING WEAKNESS
ARRFLEXIA (LMN)
NO MENINGEAL SIGNS, FEVER, SIGNS OF SYSTEMIC ILLNESS
CSF: INCREASED PROTEIN WITHOUT PLEOCYTOSIS

59. Case Scenario #7
A 30 yo male with AIDS complains of diffuse weakness that is progressive in the LE associated with paresthesias; there is no back pain. On exam he has 4/5 upper extremity strength, 2/5 lower extremity strength; DTRs are 2/2 in the UE and 4/2 in the LE. His plantar reflexes are upgoing upgoing bilaterally.
Which of the following is the most likely diagnosis?
A. Myelopathy B. Neuropathy C. Myopathy
D. Neuromuscular Junction Disease E. Radiculopathy 8 52 52

60. HTLV-1 ASSOCIATED MYELOPATHY
PROGRESSIVE LOWER EXTREMITY WEAKNESS (ARMS MORE THAN LEGS)
SPASTICITY
PARESTHESIAS ARE COMMON; SENSORY DEFICITS ARE RARE
SYMMETRIC UPPER MOTOR NEURON PARAPARESIS
SPHINCTER DISTURBANCES