A Neurological Examination

Home , Neurological examination, Pronator drift

THE 3 MINUTE NEUROLOGICAL EXAMINATION DEMYSTIFIED Faculty: W.J. Oczkowski MD, FRCPC Professor and Academic Head, Division of Neurology, Department of Medicine, McMaster University Stroke Neurologist, Hamilton Health Sciences

Relationships with commercial interests: ► Not Applicable

Potential for conflict(s) of interest: ► Not Applicable

Mitigating Potential Bias ► All the recommendations involving clinical medicine are based on evidence that is accepted within the profession. ► All scientific research referred to, reported, or used is in the support or justification of patient care. ► Recommendations conform to the generally accepted standards. ► Independent content validation. ► The presentation will mitigate potential bias by ensuring that data and recommendations are presented in a fair and balanced way. ► Potential bias will be mitigated by presenting a full range of products that can be used in this therapeutic area. ► Information of the history, development, funding, and the sponsoring organizations of the disclosure presented will be discussed. Objectives

► Overview of neurological assessment . It’s all about stroke! . It’s all about the chief complaint and history. ► Overview: . 3 types of clinical exams . Neurological signs . Neurological localization o Pathognomonic signs o Upper versus lower motor neuron signs ► Cases and practice

Bill

► 72 year old male . Hypertension . Smoker ► Stroke call: dizzy, facial droop, slurred speech ► Neurological Exam: . Ptosis and miosis on left . Numb left face . Left palatal weakness . Dysarthria . Ataxic left arm and left leg . Numb right arm and leg NIH Stroke Scale Score ► LOC: a,b,c______0 ► Best gaze______0 0 ► Visual fields______0 ► Facial palsy______0 ► Motor arm and leg______-Left Ptosis 2 -Left miosis ► Limb ataxia______-Weakness of 1 ► Sensory______left palate ► Best Language______0 1 ► Dysarthria______0 ► Extinction and inattention____ - . (tone, reflexes, distal sensation, gait) It’s all about Stroke! Focal Motor or Sensory Presentation

Not Stroke Stroke EKG of Stroke

8 Troponin of Stroke

9 How do doctors make diagnoses?

•Chief complaint 78% 78% •History 16% 94% •Physical exam 4% 98% •Lab studies 2% 100%

Gruppen LD et al. Proceedings Ann Conf Research in Medical Education 27:242-7, 1988 Dooley JM et al. Pediatric Neurology 28(2): 96-9, 2003 .

The upper limb tests with the greatest sensitivities for detecting a focal brain lesion….

► Finger rolling ► Forearm rolling ► Assessment of power ► Rapid alternating movements ► Pronator drift . Detect 50%; specificity of 100% “The” 3 Minute Neurological Exam

► LOC: a,b,c______► Best gaze______► Visual fields______► Facial palsy______► Motor arm and leg______► Limb ataxia______► Sensory______► Best Language______► Dysarthria______► Extinction and inattention____ . (tone, reflexes, distal sensation, gait) A Neurological Examination

► Assess orientation (“How old are you? What month is it?”) ► Assess the ability to describe the picture ► Assess the ability to read the sentences ► Assess visual fields and assess for inattention (4 quadrants) ► Assess the pupillary light reflex ► Assess eye movements following the “H” pattern ► Assess facial sensation (left and right cheek using sharp and dull) ► Assess facial movements (close eyes, smile) ► Assess hearing using finger rub ► Assess palatal and tongue movements (say “ah”, stick out tongue) ► Assess tone in the 4 limbs ► Assess strength using drift and arm rolling tests ► Assess distal sharp-dull and vibration sensation and sensory inattention ► Assess reflexes (biceps, brachioradialis, triceps, quadriceps, achilles, Babinski) ► Assess limb coordination (finger to nose, heel – knee – shin) ► Assess gait and tandem walking (tandem gait, normal gait)

A Neurological Examination

► Assess orientation (“How old are you? What month is it?”) ► Assess the ability to describe the picture ► Assess the ability to read the sentences and name the objects ► Assess visual fields and assess for inattention (4 quadrants) ► Assess the pupillary light reflex ► Assess eye movements following the “H” pattern ► Assess facial sensation (left and right cheek using sharp and dull) ► Assess facial movements (close eyes, smile) ► Assess hearing using finger rub ► Assess palatal and tongue movements (say “ah”, stick out tongue) ► Assess tone in the 4 limbs ► Assess strength using drift and arm rolling tests ► Assess distal sharp-dull and vibration sensation and sensory inattention ► Assess reflexes (biceps, brachioradialis, triceps, quadriceps, achilles, Babinski) ► Assess limb coordination (finger to nose, heel – knee – shin) ► Assess gait and tandem walking (tandem gait, normal gait)

A Neurological Examination

“THE EXAM”

► Diagnostic . localization ► Screening or “Once Over” Examination ► Measuring and monitoring

A “Screening” / “Once Over” Neurological Examination

► Pre-test probability of abnormality is low ► “May” identify non-obvious abnormalities ► Is not a diagnostic exam A Screening or “Once Over” Neurological Examination

§NIH Stroke Scale §Canadian Neurological Scale A Measuring and Monitoring Score Neurological Examination ► LOC: a,b,c______► Best gaze______► Visual fields______► Facial palsy______► Motor arm and leg______► Limb ataxia______► Sensory______► Best Language______► Dysarthria______► Extinction and inattention____ . (tone, reflexes, distal sensation, gait) Examination that I do all the time…..

► The neurological examination has many pieces

► Everyone has been taught a different examination

► We need to speak the same language NIH Stroke Scale Training – You Should Do This! A Diagnostic Neurological Examination

► Identifies the neuro-anatomical diagnosis . “Where is the lesion?” ► May help identify a possible non-stroke etiology . “What is the lesion?” Top - Down

Left - Right

Patient - Examiner Hemispheres

Brainstem

Spinal Cord

Nerves

Muscles

Neuromuscular Junction The Diagnostic Neurological Exam

Assess the ability to read the sentences

Assess visual fields and assess for inattention (4 quadrants) Assess the pupillary light reflex

Assess eye movements following the “H” pattern Assess facial sensation (left and right cheek using sharp and dull) Assess facial movements (close eyes, smile) Assess palatal and tongue movements (say “ah”, stick out tongue) Assess tone in the 4 limbs Assess strength using drift and arm rolling tests Assess distal sharp-dull and vibration sensation and sensory inattention Assess reflexes (biceps, brachioradialis, triceps, quadriceps, Achilles and Babinski) Assess limb coordination (finger to nose, heel – knee – shin) Assess gait and tandem walking (tandem gait, normal gait) The Diagnostic Neurological Exam

► Upper ► Lower . Weakness . Weakness . Tone increased . Tone normal . Hyper-reflexia . Hypo-reflexia . Minimal wasting . Fasiculations . Babinski and wasting . No Babinski Neuro - Anatomical Localization

► Brain ► Brainstem Upper Motor Neuron ► Spinal cord

► Peripheral nerve ► Muscle Lower Motor Neuron ► Neuromuscular junction Neuro - Anatomical Localization For Stroke……

► Brain ► Brainstem ► Other ► Spinal cord ► Peripheral nerve ► Muscle ► Neuromuscular junction Examination of the Patient with Focal Weakness

 Brain vs brainstem vs spine vs nerve vs muscle vs neuromuscular junction

 Pattern of weakness and other signs

 Are there pathognomonic signs?

 Is it upper or lower motor neuron?  Tone, reflexes

Roger

► 57 year old male . Atrial fibrillation . CAD, CHF . Pacemaker . DM2 . HTN, DL

► Presented with sudden left sided weakness NIH Stroke Scale + Score

► LOC: a,b,c______0 ► Best gaze______1 ► Visual fields______2 ► Facial palsy______2 ► Motor arm and leg______8 ► Limb ataxia______0 ► Sensory______2 ► Best Language______0 ► Dysarthria______0 ► Extinction and inattention____ 2 ► (tone, reflexes, distal sensation, gait)- Where is the Lesion?

1. Brain 2. Brainstem 3. Other 1. Spinal cord 2. Peripheral nerve 3. Muscle 4. Neuromuscular junction Pathognomonic Signs

► Hemispheric . Aphasia . Neglect / agnosia / apraxia . Visual field loss . Behaviour . Memory . LOC, attention

Maria

► 66 year old female . HTN . DL . Depression

► Found at home on the floor unable to talk and with right sided weakness NIH Stroke Scale + Score

► LOC: a,b,c______4 ► Best gaze______0 ► Visual fields______2 ► Facial palsy______3 ► Motor arm and leg______8 ► Limb ataxia______0 ► Sensory______1 ► Best Language______3 ► Dysarthria______0 ► Extinction and inattention____ 0 ► (tone, reflexes, distal sensation, gait) Where is the Lesion?

1. Brain 2. Brainstem 3. Other 1. Spinal cord 2. Peripheral nerve 3. Muscle 4. Neuromuscular junction Pathognomonic Signs

► Hemispheric . Aphasia . Neglect / agnosia / apraxia . Visual field loss . Behaviour . Memory . LOC, attention

Gladys

► 85 year old female . Hypertension . Dyslipidemia

► Found on the floor with a decreased LOC ► Slurred speech, vomiting, and right arm weakness NIH Stroke Scale + Score

► LOC: a,b,c______1 0 ► Best gaze______► Visual fields______0 ► Facial palsy______0 ► Motor arm and leg______0 ► Limb ataxia______2 ► Sensory______0 ► Best Language______0 ► Dysarthria______0 ► Extinction and inattention____ 0 ► (tone, reflexes, distal sensation, gait) - Where is the Lesion?

1. Brain 2. Brainstem 3. Other 1. Spinal cord 2. Peripheral nerve 3. Muscle 4. Neuromuscular junction Pathognomonic Signs

► Brainstem . Cranial Nerve Abnormality with…. . Limb motor sign . Limb sensory sign . Crossed motor signs . Crossed sensory signs . Limb ataxia

______♥ W. J. Oczkowski, MD, McMaster University, [email protected]

Virginia

► 91 year old female . Atrial flutter . CHADS = 1 ► Medications: ASA

► Presented with sudden onset of inability to speak NIH Stroke Scale + Score

► LOC: a,b,c______1 ► Best gaze______0 ► Visual fields______0 ► Facial palsy______2 ► Motor arm and leg______0 ► Limb ataxia______0 ► Sensory______0 ► Best Language______2 ► Dysarthria______0 ► Extinction and inattention____ 0 ► (tone, reflexes, distal sensation, gait) Where is the Lesion?

1. Brain 2. Brainstem 3. Other 1. Spinal cord 2. Peripheral nerve 3. Muscle 4. Neuromuscular junction Pathognomonic Signs

► Hemispheric . Aphasia . Neglect / agnosia / apraxia . Visual field loss . Behaviour . Memory . LOC, attention

Diana

► 74 year old woman . Poorly controlled DM . Hypertension . Dyslipidemia ► Facial droop, ► Acute MI, primary PCI ► Rapidly resolving right weakness and inability to understand NIH Stroke Scale + Score

3 ► LOC: a,b,c______0 ► Best gaze______► Visual fields______0 ► Facial palsy______1 ► Motor arm and leg______0 ► Limb ataxia______0 ► Sensory______1 ► Best Language______2 ► Dysarthria______0 ► Extinction and inattention____ 0 ► (tone, reflexes, distal sensation, gait) - Where is the Lesion?

1. Brain 2. Brainstem 3. Other 1. Spinal cord 2. Peripheral nerve 3. Muscle 4. Neuromuscular junction Pathognomonic Signs

► Hemispheric . Aphasia . Neglect / agnosia / apraxia . Visual field loss . Behaviour . Memory . LOC, attention

Wayne

► 68 year old male . Atrial fibrillation . Previous TIA . Hypertension

► Hiking with his wife ► Dizziness, loss of balance, double vision, left weakness NIH Stroke Scale + Score

► LOC: a,b,c______0 2 ► Best gaze______► Visual fields______0 ► Facial palsy______2 ► Motor arm and leg______2 ► Limb ataxia______0 ► Sensory______0 ► Best Language______0 ► Dysarthria______1 ► Extinction and inattention____ 0 ► (tone, reflexes, distal sensation, gait) - Where is the Lesion?

1. Brain 2. Brainstem 3. Other 1. Spinal cord 2. Peripheral nerve 3. Muscle 4. Neuromuscular junction Pathognomonic Signs

► Brainstem . Cranial Nerve Abnormality with…. . Limb motor sign . Limb sensory sign . Crossed motor signs . Crossed sensory signs . Limb ataxia

______♥ W. J. Oczkowski, MD, McMaster University, [email protected]

Livia

► 70 year old female . Hypertension . Dyslipidemia . Anxiety and depression ► Coronary angiography ► Post angiogram headache ► “unable to see”

NIH Stroke Scale + Score

0 ► LOC: a,b,c______0 ► Best gaze______► Visual fields______2 ► Facial palsy______0 ► Motor arm and leg______0 ► Limb ataxia______0 ► Sensory______0 ► Best Language______0 ► Dysarthria______0 ► Extinction and inattention____ 0 ► (tone, reflexes, distal sensation, gait) - Where is the Lesion?

1. Brain 2. Brainstem 3. Other 1. Spinal cord 2. Peripheral nerve 3. Muscle 4. Neuromuscular junction Pathognomonic Signs

► Hemispheric . Aphasia . Neglect / agnosia / apraxia . Visual field loss . Behaviour . Memory . LOC, attention

Christinia

► 82 year old female . Hypertension . Diabetes . Dyslipidemia ► Collapse with sudden right leg weakness NIH Stroke Scale + Score

0 ► LOC: a,b,c______0 ► Best gaze______► Visual fields______0 ► Facial palsy______0 ► Motor arm and leg______4 ► Limb ataxia______0 ► Sensory______1 ► Best Language______0 ► Dysarthria______0 ► Extinction and inattention____ 0 ► (tone, reflexes, distal sensation, gait) - Where is the Lesion?

1. Brain 2. Brainstem 3. Other 1. Spinal cord 2. Peripheral nerve 3. Muscle 4. Neuromuscular junction Pathognomonic Signs

► Hemispheric . Aphasia . Neglect / agnosia / apraxia . Visual field loss . Behaviour . Memory . LOC, attention Pathognomonic Signs

► Brainstem . Cranial Nerve Abnormality with…. . Limb motor sign . Limb sensory sign . Crossed motor signs . Crossed sensory signs . Limb ataxia

______♥ W. J. Oczkowski, MD, McMaster University, [email protected]

June

► 88 year old female . CAD . Aortic stenosis ► Acute MI ► Triple vessel bypass ► Aortic valve replacement ► Awoke confused and with left arm weakness

NIH Stroke Scale + Score

3 ► LOC: a,b,c______0 ► Best gaze______0 ► Visual fields______► Facial palsy______0 ► Motor arm and leg______0 ► Limb ataxia______0 ► Sensory______0 ► Best Language______1 ► Dysarthria______0 ► Extinction and inattention____ 0 ► (tone, reflexes, distal sensation, gait) - Where is the Lesion?

1. Brain 2. Brainstem 3. Other 1. Spinal cord 2. Peripheral nerve 3. Muscle 4. Neuromuscular junction Pathognomonic Signs

► Hemispheric . Aphasia . Neglect / agnosia / apraxia . Visual field loss . Behaviour . Memory . LOC, attention

Greg

► 31 year old male . Well

► Collapsed ► Brought to ER with left weakness NIH Stroke Scale + Score

► LOC: a,b,c______0 ► Best gaze______2 ► Visual fields______0 ► Facial palsy______3 ► Motor arm and leg______4 ► Limb ataxia______2 ► Sensory______0 ► Best Language______0 ► Dysarthria______1 ► Extinction and inattention____ 0 ► (tone, reflexes, distal sensation, gait) -

______♥ W. J. Oczkowski, MD, McMaster University, [email protected] Where is the Lesion?

1. Brain 2. Brainstem 3. Other 1. Spinal cord 2. Peripheral nerve 3. Muscle 4. Neuromuscular junction Pathognomonic Signs

► Brainstem . Cranial Nerve Abnormality with…. . Limb motor sign . Limb sensory sign . Crossed motor signs . Crossed sensory signs . Limb ataxia

______♥ W. J. Oczkowski, MD, McMaster University, [email protected]

Harry

► 65 year old male . Smoker . COPD ► Difficulty walking ► Difficulty breathing ► Admitted to stepdown and then ward ► Unable to urinate and ambulate NIH Stroke Scale + Score

0 ► LOC: a,b,c______0 ► Best gaze______0 ► Visual fields______► Facial palsy______0 ► Motor arm and leg______6 ► Limb ataxia______0 ► Sensory______1 Sensory level at T4 ► Best Language______0 ► Dysarthria______0 ► Extinction and inattention____ 0 ► (tone, reflexes, distal sensation, gait) - Where is the Lesion?

1. Brain 2. Brainstem 3. Other 1. Spinal cord 2. Peripheral nerve 3. Muscle 4. Neuromuscular junction Pathognomonic Signs

► Spinal cord . Nothing above the neck . Bladder and Bowel trouble . Bilateral leg . Spinal sensory level

Linda

► 63 female . Previous stroke with “complete” recovery . Atrial fibrillation . Diabetes type 2

► Presented with severe dysarthria, and left weakness NIH Stroke Scale + Score

0 ► LOC: a,b,c______0 ► Best gaze______► Visual fields______0 ► Facial palsy______0 ► Motor arm and leg______6 ► Limb ataxia______0 ► Sensory______0 0 ► Best Language______Tongue ► Dysarthria______2 weak ► Extinction and inattention____ 0 ► (tone, reflexes, distal sensation, gait) - Where is the Lesion?

1. Brain 2. Brainstem 3. Other 1. Spinal cord 2. Peripheral nerve 3. Muscle 4. Neuromuscular junction Pathognomonic Signs

► Brainstem . Cranial Nerve Abnormality with…. . Limb motor sign . Limb sensory sign . Crossed motor signs . Crossed sensory signs . Limb ataxia

Shelly

► 32 year old female . Healthy ► Difficulty walking up stairs ► Tingling in her feet ► Minor bladder symptoms NIH Stroke Scale + Score

0 ► LOC: a,b,c______0 ► Best gaze______0 ► Visual fields______► Facial palsy______2 ► Motor arm and leg______4 ► Limb ataxia______0 ► Sensory______0 Areflexic ► Best Language______0 ► Dysarthria______1 ► Extinction and inattention____ 0 ► (tone, reflexes, distal sensation, gait) - Where is the Lesion?

1. Brain 2. Brainstem 3. Other 1. Spinal cord 2. Peripheral nerve 3. Muscle 4. Neuromuscular junction Pathognomonic Signs

► Absent Reflex (es) . Lower motor neuron . Nerve Bill

0 ► LOC: a,b,c______0 ► Best gaze______► Visual fields______0 ► Facial palsy______0 ► Motor arm and leg______0 ► Limb ataxia______2 -Left Ptosis -Left miosis 1 ► Sensory______-Weakness of ► Best Language______0 left palate ► Dysarthria______1 ► Extinction and inattention____ 0 ► (tone, reflexes, distal sensation, gait) -

______♥ W. J. Oczkowski, MD, McMaster University, [email protected] Where is the Lesion?

1. Brain 2. Brainstem 3. Other 1. Spinal cord 2. Peripheral nerve 3. Muscle 4. Neuromuscular junction Pathognomonic Signs

► Brainstem . Cranial Nerve Abnormality with…. . Limb motor sign . Limb sensory sign . Crossed motor signs . Crossed sensory signs . Limb ataxia

______♥ W. J. Oczkowski, MD, McMaster University, [email protected]

Pathognomonic Signs

► Nerve . In distribution of… . Lower motor neuron – absent reflexes . Pain . Wasting . Fasciculation

______♥ W. J. Oczkowski, MD, McMaster University, [email protected] Pathognomonic Signs

► Muscle . Normal sensation . Normal reflexes . Wasting . Proximal symmetric weakness

______♥ W. J. Oczkowski, MD, McMaster University, [email protected] Pathognomonic Signs

► Neuromuscular Junction . Fatiguability . Normal sensation . Normal reflexes

______♥ W. J. Oczkowski, MD, McMaster University, [email protected] A “Once Over” Examination Measuring and Monitoring Examination Diagnostic Examination

Ask “Why am I doing this examination?”

1.Is the pre-test probability of an abnormality low and a “once over” examination is needed?

2. Do I need to measure an impairment and a measuring and monitoring examination is needed?

3. Do I need to localize the lesion and a diagnostic examination is needed?

The 3 Minute Neurological Examination Demystified