Case Studies

A Practical Approach to the Focused Neurological

Examination

The Johns Hopkins Center for Cerebrovascular Disease

Arjun Chanmugam, MD

Four Questions

• Is this a stroke?

• Where is the stroke?

• How would you quantify/describe the deficits?

• Would you give TPA to this person?

Arjun Chanmugam, MD

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

Arjun Chanmugam, MD

The Key Questions

• Is there a lesion?

• Where is the lesion?

• What caused the lesion?

• What interventions are available?

Arjun Chanmugam, MD

The Nervous System

• The Brain– Cortex– Subcortical Region

– Cerebellum– Brainstem

• The Spinal Cord• Peripheral Nerves

Infra-tentorial

Supra-tentorial

Arjun Chanmugam, MD

Functional Neuroanatomy

Arjun Chanmugam, MD

Arjun Chanmugam, MD

Functional Neuroanatomy

Arjun Chanmugam, MD

Arjun Chanmugam, MD

Spinal Cord- 3 Basic Areas

Lateral Column a. cortico-spinal (motor) b. spinothalamic(sensory)

Posterior column (sensory, -( proprioception, vibration))

Anterior region (Motor)

Arjun Chanmugam, MD

Spinal cord cross-section

Arjun Chanmugam, MD

General Approach

• History• Physical • Neurological Evaluation

– Neurological Review of Systems– Neurological Examination

• Localization• Management

Arjun Chanmugam, MD

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

Arjun Chanmugam, MD

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

Arjun Chanmugam, MD

Neurological Examination

Mental Status Cranial Nerves Motor and Reflexes Sensory Coordination and Gait

Arjun Chanmugam, MD

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

Arjun Chanmugam, MD

Mental StatusI. Consciousness & Orientation

PPT

II. Concentration and AttentionSpell a five letter word, Clock draw

III. Language

Fluency, Comprehension, Naming, Repetition

IV. MemoryImmediate, Recent, Remote

Arjun Chanmugam, MD

Cranial Nerves

Arjun Chanmugam, MD

Testing Cranial NervesI. Olfaction (usually not tested)

II. Optic -- visual acuity, peripheral vision, funduscopy

III, IV Extraocular movements, VIpupillary reaction

V. Sensory: Corneal reflex, sensation of the face, scalp

Motor: mastication,

Arjun Chanmugam, MD

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

Arjun Chanmugam, MD

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

Arjun Chanmugam, MD

Rating Scale for the Motor Exam

• 0• 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

Score Response

Arjun Chanmugam, MD

Glossary- Neuroanatomy• UMN-- Cortex to

the lateral column of the spinal cord

• LMN-- Anterior column to the motor end-plate

Arjun Chanmugam, MD

UMN verses LMN

• Spastic Paralysis

• Hyperreflexia

• Hypertonicity

• Babinski reflex

• Flaccid Paralysis

• Hyporeflexia

• Hypotonicity

• Muscle atrophy

Arjun Chanmugam, MD

Deep Tendon Reflexes*Reflex Roots Nerve Biceps C5-C6 Musculocutaneous

Brachioradialis C5-C6 RadialTriceps C7-C8 RadialKnee L2-L3-L4 Femoral

Hamstring L5-S1-S2 Sciatic

Ankle S1-S2 Tibial*Spinal shock can accompany acute cortical stroke

Arjun Chanmugam, MD

Sensory Examination

• Touch

• Pinprick (spinothalamic)

• Temperature (spinothalamic)

• Position (posterior column)

• Vibration (posterior column)

Arjun Chanmugam, MD

Dermatomes

• Figure #7 • Figure #8

Arjun Chanmugam, MD

Sensory Dermatomes

Arjun Chanmugam, MD

Coordination and Gait• Cerebellar

– Finger-nose (dysmetria - ataxia)– Heel-shin

– Rapid alternate movements (dysdiadochokinesia)

– Rhythmic tapping– Romberg’s test

• Gait– Normal versus Tandem

Arjun Chanmugam, MD

Localization• Cortical• Subcortical

– Internal capsule– Basal Ganglia– Thalamus

• Brainstem– Midbrain– Pons– Medulla

• Spinal cord

Arjun Chanmugam, MD

Arjun Chanmugam, MD

Arjun Chanmugam, MD

Cortical Lesions• Language*

– 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

Arjun Chanmugam, MD

Cortical Lesions

• Is there eye deviation? (towards the lesion)

• Is there field defect? (also with subcortical)

• Is there associated seizure activity?

Think about blood

Arjun Chanmugam, MD

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 )

Arjun Chanmugam, MD

Visual Field

Arjun Chanmugam, MD

Brainstem Lesions

• Crossed hemiplegia (ipsilateral cranial nerves with contralateral

motor)

• Cerebellar signs (ipsilateral)

• Nystagmus (worse on ipsilateral gaze)

• Hearing loss

Arjun Chanmugam, MD

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)

Arjun Chanmugam, MD

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

Arjun Chanmugam, MD

Nondominant Hemisphere• Inattention (neglecting left side)

• Extinction (double simultaneous sensory stimulation)

• Denial or unconcern

• Acute confusional state

Arjun Chanmugam, MD

Nondominant Hemisphere

• Constructional apraxia ( copy a simple diagram)

• Dress apraxia (wrong sleeve)

• Impersistence of a task

• Spatial disorientation

Arjun Chanmugam, MD

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)

Arjun Chanmugam, MD

Brain Arterial SupplyCircle of Willis

Arjun Chanmugam, MD

Circle of Willis

Arjun Chanmugam, MD

TIAs Symptomatology Carotid

• Amaurosis fugax

• Aphasia

• Motor paresis

• Motor paralysis

• Slurred speech

Vertebro-basilar

• Ataxia

• Dizziness

• Diplopia

• Motor/sensory deficit

Arjun Chanmugam, MD

Middle Cerebral Artery Syndrome

• Aphasia or non-dominant findings

• Hemiparesis (greater in face and arm)

• Cortical sensory loss

• Homonymous hemianopsia

• Conjugate eye deviation (ipsilateral)

Arjun Chanmugam, MD

Arterial Territory

Lateral aspect

Arjun Chanmugam, MD

Anterior Cerebral Artery Syndrome

• Paralysis of the lower extremity• Cortical sensory loss (legs only)• Incontinence• Grasp & suck reflexes (release

phenomena)• No hemianopsia or aphasia

Arjun Chanmugam, MD

Arterial Territory

Medial aspect

Arjun Chanmugam, MD

Posterior Cerebral Artery Syndrome

• Homonymous hemianopsia (most common)

• Little or no paralysis• No aphasia• Prominent sensory loss• Recent memory loss (hippocampus)

Arjun Chanmugam, MD

NIH Stroke ScaleCategory Response Score1a. LOC Alert 0

Drowsy 1Stuporous 2Coma 3

1b. LOC questions Answers both correctly 0Answers one correctly 1Answers none correctly 3

1c. LOC commands Obeys both correctly 0Obeys one correctly 1Obeys none correctly 2

Arjun Chanmugam, MD

NIH Stroke ScaleCategory Response Score2. Best gaze Normal 0

Partial gaze palsy 1Forced deviation 2

3. Best visual No visual loss 0Partial hemianopsia 1Complete hemianopsia 2

4. Facial palsy Normal 0Minor facial weakness 1Partial facial weakness 2No facial movement 3

Arjun Chanmugam, MD

NIH Stroke ScaleCategory Response Score5. Best motor arm No drift after 10 s 0

Drift 1Some effort (hits bed) 2No effort against gravity 3No movement 4

6. Best motor leg No drift after 5s 0Drift 1Some effort (hits bed) 2No effort against gravity 3

7. Limb ataxia Absent 0Present in upper/lower Ex. 1Present in both upper/lower 2

Arjun Chanmugam, MD

NIH Stroke ScaleCategory Response Score8. Sensory Normal 0

Partial loss 1Dense loss 2

9. Neglect No neglect 1Partial neglect 2Complete neglect 3

10. Dysarthria Normal articulation 0Mild to moderate dysarthria 1Near unintelligible or worse 2

Arjun Chanmugam, MD

NIH Stroke Scale

Category Response Score

11. Best Language No aphasia 0

Mild to Moderate aphasia 1

Severe Aphasia 2

Mute 3