Practical Neurology Neurologic Exam History and Observation
Wendy Blount, DVM Neuro History
• Behavior • Seizures • Tremor • Hearing Loss • Vision Loss • Dysphagia
• Onset & Progression • Videos!! Neuro History
Behavior • Wandering, vocalizing, stuck in corners, inappropriate elimination – forebrain • Increased or decreased appetite – diencephalon • Increased water intake – diencephalon • Any other abnormal behavior – forebrain Neuro History
Seizures • Onset • Frequency – Single or clusters? • Progression • Description – Generalized, partial or behavioral – Duration and character of pre-ictal, seizure and post-ictal phases • Medications and drug monitoring Neuro History
Tremor (4 kinds?)
1. Intention Tremor • Bobble-head type movement • Intensifies when reaching the end of a goal- oriented movement (lesion?) • Cerebellar lesion
2. Postural Tremor - In head or limb when weight supported, due to pain or weakness
3. Myoclonus - Jerking, involuntary muscle contractions
4. Myotonia – muscles that have trouble relaxing Neuro History
Hearing Loss (symptoms?) • Startles easily, Very deep sleep • Chronic, severe, recent ear infection • Failure to respond to commands • Unilateral hearing loss may not be recognized by the owner Vision Loss • Bumps in to things, especially in unfamiliar surroundings • Low light or bright light Neuro History
Dysphagia (symptoms?) • Trouble swallowing (gulping) • Coughing, gagging or regurgitation – Especially after eating or drinking • Voice change (dysphonia) • Inspiratory stridor – Worse in heat or with exercise – Laryngeal paralysis • Can watch eat/drink or get owner video Hx Form Neuro Hx Form Neuro History Onset & Progression
Trauma & Vascular Events • Peracute onset (minutes to hours) • Little to no progression in 24 hours • Gradual improvement begins
Infectious Diseases • Acute onset (hours to days) • Acute to moderate progression if untreated
Neoplasia and Degenerative Disease • gradual to insidious onset (days to weeks to months) • Gradual progression if untreated Neuro History Onset & Progression
Congenital Anomaly • Often evident in young dogs • No progression or gradually progressive
Epileptic Seizure Disorders • Episodic – normal between episodes
Neoplasia that presents acutely • Spinal cord lymphoma in cats • Seizures associated with brain tumors Neuro Exam There is much more to a neurologic exam than flipping the toes and thumping the knees
• Takes 10-15 minutes • Do things first that are least likely to upset the patient • Omit steps that might cause injury • Any sedation can affect gait, posture, ataxia and mentation – Usually does not affect reflexes • Complete the entire exam, as the patient allows – Don’t zero in on obvious abnormalities and miss others Neuro Exam
Assess 6 Things: 1. Mental Status and Behavior 2. Attitude, Gait and Posture 3. Eye & Ear Exam 4. Cranial Nerves 5. Spinal Reflexes 6. Palpation and Pain Perception Neuro Exam
Neuro Assessment Scale: 0 – absent 1 – decreased 2 – normal 3 – increased 4 – clonus Neuro Exam
Tools: 1. Pokers and Prodders – plexor, hemostat, ballpoint pen 2. Tools to Evaluate Eyes & Vision: – Strong light source (transilluminator) – Cotton tipped applicator, saline – Cotton balls – Schirmer Tear Test strips – (Blindfold – muzzle, handkerchief, 8x10 piece of paper) – Drops to dilate eyes – Hand Lens and ophthalmoscope – Topical anesthetic & tonometer 3. Slip free surface 4. Otoscope Neuro Exam
Tips for the feline neurologic exam • Work quickly, before you patient decides he/she is through with you • 0-1 Neuro Scores on myotatics are rarely significant in the cat – Difficult to diagnose LMN conditions • Use a pediatric pleximeter • When in lateral recumbency, stand behind the cat and support the limb – Try both up and down legs on each side Neuro Exam
Tips for the feline neurologic exam • Priorities: 1. Watch gait, jumping up/down, while you take a history 2. check placing and CPs 3. Postural reflexes – wheelbarrow, hopping, hemiwalking 4. Perineal reflex 5. Patellar, withdrawal in hind limbs 6. Withdrawal in front limbs 7. Cranial nerves 8. Deep pain if not ambulatory Neuro Exam
Mental Status and Behavior • Abnormal Behavior most often revealed in the history • Observe while taking a history, prior to handling • Let the patient have run of the exam room • Level of consciousness (0-4) – Excited (3-4) – Alert – Normal (2) – Depressed/obtunded – drowsy but arousable (1) – Stuporous – sleeps if left alone, arousable (1) – Comatose – no response to pain (0) • Quality of Consciousness – Normal – Demented – responds inappropriately Bob Stout – Nacogdoches, TX
Free PowerPoint Templates Neuro Exam
Mental Status and Behavior Lesion Localization • dull, wandering, vocalizing, getting stuck in corners, large circles – Cerebral lesion • Stupor, obtunded – Brain Lesion – Cerebral lesion – Can be more severe with brain stem lesions • Demented – Cerebral lesion Neuro Exam
Mental Status and Behavior
Jeane Parent, VMD Neuro Exam
Attitude, Posture and Gait
Attitude • position of the eyes and head with respect to the body Posture • position of the body with respect to gravity Gait • Movements when walking or running Neuro Exam
Attitude – Lesion Localization • Head tilt (one ear lower) – Unilateral vestibular lesion • Head turn (yaw) – Ipsilateral forebrain lesion Neuro Exam
Attitude – Lesion Localization • Head tilt (one ear lower) – Unilateral vestibular lesion • Head turn (yaw) – Ipsilateral forebrain lesion • Head Press – Or gets stuck in corners, or behind doors (behavior) – Forebrain lesion • Dropped eye when head raised – ipsilateral vestibular disease Neuro Exam
Gait (4 parts) 1. Lameness & Stride Length 2. Ataxia 3. Paresis/paralysis 4. Abnormal movements – Unconscious - tremors defined previously, and covered in more detail later – Conscious – Hypermetria, Dysmetria
Also assess vision and hearing while pet is wandering around the room Take Videos of pet moving around the room!! (document R and L) Neuro Exam
Gait – Lameness
Grading system • Grade 1 – barely noticeable • Grade 2 – weight bearing, noticeable • Grade 3 – sometimes skips • Grade 4 – often carries • Grade 5 – always carries Neuro Exam
Gait – Lameness & Stride Length Short, Choppy Strides: • Limb pain – Musculoskeletal pain – Root signature (DDx) • IVDDz, spinal arthritis, nerve sheath tumor • Weakness – LMN lesions, MNJ lesions, muscle weakness, general weakness Long, Swinging Strides: • UMN lesions, cerebellar lesions Neuro Exam Gait – Lameness & Stride Length All 4 Limbs short, choppy, weak, CPs difficult to assess • Generalized muscle pain or weakness • Polyarthritis • Generalized MNJ disease or peripheral neuropathy All 4 long/stiff/CP deficits – rear worse • Brain or upper-mid cervical SC (check mentation) Front short, rear long, may limp on front, CP deficits all 4 • Lower Cervical SC Neuro Exam Gait – Lameness & Stride Length Front normal, rear long/stiff/CP deficits • Thoracolumbar SC Front normal, rear short/weak/CP deficits, may limp on rear • Lower lumbar SC Front normal, rear long/weak/CP? • Lumbosacral SC Gait normal, + flaccid tail, + urinary incontinence, + fecal incontinence • SacroCoccygeal SC Gait normal, CP deficits all 4 – rear worse • Brain lesion Neuro Exam
Gait – Lameness & Stride Length
Painful Limbs are carried
Weak limbs are dragged Neuro Exam
Gait – Ataxia Sensory Ataxia (cause?) • Caused by loss of CP • Signs of CP loss & Sensory Ataxia: – Clumsiness, incoordination, lazy gait – Wide based stance & swaying gait – Increased or decreased stride length – Dragging/knuckling the toes • Lesion Localization: – UMN or LMN – BOTH or EITHER – Forebrain, Brainstem, Spinal Cord, Peripheral Nerve – 1, 2 (front, back, L, R) or all 4 limbs Neuro Exam
Gait – Ataxia Sensory Ataxia
Identifying generalized Sensory Ataxia Doesn’t help much with lesion localization, unless only one limb
But it tells you that there is indeed neurologic disease present
Sensory Ataxia is the only ataxia with CP deficits and the only ataxia which shows paresis or weakness Neuro Exam
Gait – Ataxia Cerebellar Ataxia • Inability to regulate unconscious proprioreception – Rate and range of movement • Signs of cerebellar ataxia: – Dysmetria, hypermetria – Dysmetric ipsilateral placing & postural responses (paw placing off) – Broad based stance – Intention tremor or head bobble – NO CP DEFICITS!! – Retention of normal strength – Normal spinal nerve reflexes Neuro Exam
Gait – Ataxia Cerebellar Ataxia • Lesion localization – Cerebellum – Rare - spinocerebellar tracts • Lateral spinal cord • Hypermetria can resemble myotonia – Muscles are stiff and even dimpling with myotonia Neuro Exam
Gait – Ataxia Vestibular Ataxia • Inability to tell up from down (assess and respond to gravity) • Signs of unilateral vestibular ataxia: – Head tilt (ipsilateral or contralateral)*** – Abnormal nystagmus – Walking in tight circles to ipsilateral side – Nausea and vomiting – Falling to the ipsilateral side – hugs the wall or floor – NO CP DEFICITS! – Normal strength is preserved Neuro Exam
Normal Gaits - Canine
See Spot Run Rehabilitation Neuro Exam
Normal Gait - Feline
Care Animal Clinic Brookfield Neuro Exam
Gait – Lameness & Stride Length Short Strides All 4 - Peripheral Neuropathy
Dr. Joane Parent Neuro Exam
Gait – Ataxia Vestibular Ataxia
Dr. Joane Parent Neuro Exam
Gait – Ataxia Cerebellar Ataxia – Moderate to Severe
Dr. Joane Parent Neuro Exam
Gait – Ataxia Sensory Ataxia – All 4 Limbs UMN – Cervical SC lesion – limp on LF
Dr. Joane Parent Neuro Exam Brittany King Gait – Ataxia Cerebellar Ataxia - Mild Neuro Exam
Gait – Ataxia Sensory Ataxia – All 4 Limbs UMN – Cervical SC lesion
Dr. Joane Parent Neuro Exam
Gait – Ataxia Cerebellar Ataxia – Moderate
Dr. Joane Parent Brian Hafernick – Lufkin, TX
Free PowerPoint Templates Neuro Exam
Gait – Ataxia Sensory Ataxia – Rear Limbs Weak with long stride – LS Spinal Cord Lesion
Dr. Joane Parent Neuro Exam Gait – Sensory Ataxia gait nearly normal, except crouched and unsteady - CPs all 4 – mentation dull, blind, circles left – cerebral lesion
Dr. Joane Parent Neuro Exam
Gait – Ataxia Vestibular Ataxia - Bilateral
Dr. Joane Parent Neuro Exam
Gait – Ataxia Vestibular Ataxia - Bilateral • Crouched position with wide based stance • May be reluctant to move • Side to side pendular head movement** • Can look very much like cerebellar disease, but not hypermetric & no intention tremor • Rarely has head tilt or nystagmus Neuro Exam Gait – Ataxia Abnormal Nystagmus - horizontal, rotary, vertical Peripheral Vestibular Disease • Outside the brain stem • Inner ear, CN8 • Horizontal or rotary nystagmus • “fast away” – fast phase contralateral • No CP deficits, but will have postural deficits • No CN or SN reflex abnormalities • If middle ear disease – + facial paralysis, + Horner’s Syndrome Neuro Exam
Gait – Ataxia Central Vestibular Disease • Inside the brain stem • Nystagmus can be horizontal, rotary or vertical • Vertical nystagmus is always central • Positional nystagmus while in dorsal recumbency usually central • May have CP deficits, will have postural deficits • More likely to show other CN deficits – + facial nerve Neuro Exam
Gait – Ataxia
It can sometimes be difficult to tell Cerebellar Ataxia from Vestibular Ataxia There are direct communications from the cerebellum to the vestibular system, so cerebellar disease may be accompanied by vestibular signs • Animals with cerebellar disease can also have nystagmus (often rotary) • Head tilt is the most common vestibular symptom – not seen with cerebellar disease • Intention tremor only with cerebellar dz Neuro Exam
Gait – Ataxia Replacing otoliths to proper place in the semicircular canals • BPPV in people – Benign Paroxysmal Positional Vertigo • The Epley Maneuver can resolve • If symptoms are consistent with right peripheral vestibular disease, start maneuver on the right • If symptoms are consistent with left peripheral vestibular disease, start maneuver on the left Neuro Exam
https://www.youtube.com/watch?v=BtT2PDJVXlk Neuro Exam
https://www.youtube.com/watch?v=i61ZqdtYK9Y Neuro Exam
Gait – Paresis/Paralysis • Bilateral musculoskeletal disease can mimic neurologic weakness/paralysis – Bilateral cruciates – Bilateral coxofemoral luxations – Bilateral severe hip dysplasia – Severe spinal arthritis
Evaluate gait on different surfaces • Slick floor • Throw rug or grass Neuro Exam
Gait – Paresis/Paralysis
Paresis =/ Weakness • Partial loss of voluntary movement • May be flaccid or spastic
Paralysis (plegia) • Total loss of voluntary movement
Paresis/Paralysis can be UMN or LMN Neuro Exam Gait – Paresis/Paralysis Monoparesis/Monoplegia • Partial/total loss of voluntary movement in one limb • Caused by peripheral nerve disease, or lateralized lower cervical or lower lumbar disease Hemiparesis/Hemiplegia • Partial/total loss of voluntary movement in both limbs on the same side (R or L) • Caused by lateralized disease in the brain, lower brain stem or nick Neuro Exam Gait – Paresis/Paralysis Paraparesis/Paraplegia • Partial/total loss of voluntary movement in both rear limbs • Caused by thoracolumbar spinal cord disease Quadriparesis/Quadriplegia=Tetraparesis/ Tetraplegia • Partial/total loss of voluntary movement in all 4 limbs • Caused by disease in the brain, brain stem, neck or thoracolumbar spinal cord disease – Decerebrate rigidity – Decerebellate rigidity – Severe cervical spinal cord disease – Schiff-Sherrington posture Neuro Exam
Gait – Paresis/Paralysis Signs of Paresis • Abnormal rate or range of motion • Short or long strides in affected limbs • More rapid fatigue • Loss of muscle mass (atrophy), with either increased or decreased muscle tone Neuro Exam
Gait – Paresis/Paralysis Assessing Strength – All 4 limbs
Dr. Joane Parent Neuro Exam
Gait – Paresis/Paralysis Left Hemiplegia – LF monoparesis, LR monoplegia Neuro Exam
Gait – Paresis/Paralysis Paraplegia – UMN (spastic) Neuro Exam
Gait – Paresis/Paralysis Monoplegia – LR Nerve Sheath Tumor Neuro Exam
Gait – Paresis/Paralysis Paraplegia – LMN 9 (flaccid) Neuro Exam
Posture & Attitude Neck Pain
Dr. Joane Parent Neuro Exam
Posture & Attitude Neck Pain • Reluctance to move, but will usually eat and drink when food/drink brought to them • Head, neck and body move as a block as the dog turns, rather than leading with the head • Head carriage is low, and posture might be hunched to keep the head low • Neck Muscles Tense, may quiver • Looks around by moving the eyes only, without turning or tilting the head Neuro Exam
Posture Unilateral TL SC Lesion (FCE or inflammatory disease)
Dr. Joane Parent Cheryl Russell – Nacogdoches, TX
Free PowerPoint Templates Neuro Exam Posture TL Back Pain • Hunched posture is common • Less commonly, “C shaped” posture of the spine (to L or R) can indicate lateralized TL SC disease – Vestibulospinal tracts in the ventral funiculus, throughout the spinal cord – Usually FCE or inflammatory disease – Concavity toward the lesion side • C shape while walking or running may or may not be abnormal – Can be a greeting behavior, if the rest of the body language agrees with that Neuro Exam Posture TL Back Pain • Rear legs running at a faster rate than the front – Rear end swings to the side as they run – May or may not be abnormal – Some think that a dog has a dominant side just like a person • the dominant side is stronger, so the rear end will swing to the opposite side • Most obvious at a trot or a canter • Usually straightens out at a gallop – Can also be caused by UMN to the rear legs, so rear legs have a longer stride than the front, so they gain on the front legs Neuro Exam
Posture Wide based stance • Common in neurologic disease • Especially cerebellum and vestibular Schiff Sherrington posture • Extension of the thoracic limbs • Flaccid paralysis of pelvic limbs • Due to removal of retrograde UMN relaxation of front limbs (border cells) • Best appreciated in lateral recumbency
Soroush Moghaddam Jafari • Lesion – L2-L4 (L1-L7) spinal cord Neuro Exam
Posture Decerebrate Rigidity • Extension of all limbs Soren Boyson • Sometimes opisthotonus • Often stupor or coma • Lesion – brainstem • Worse prognosis than decerebellate rigidity
Soroush Moghaddam Jafari Decerebellate Rigidity • opisthotonus • Extension of thoracic limbs • Flexion of the hips • Consciousness not impaired • Lesion – acute cerebellar (herniation) • Resembles Schiff-Scherrington, but with the
Soren Boyson head thrown back Summary
PowerPoints: • .pptx • .pdf 1 slide per page • .pdf 6 slides per page Vet Handouts: • Blount – Internal Medicine History Form • Blount – Neuro History Form Acknowledgements
Anne Katherman, ACVIM (Neurology) • VIN (Veterinary Information Network) Joane Parent, ACVIM (Neurology) • The Canine and feline neurological examination CD-ROM [electronic resource]: a comprehensive approach to the neurological examination. 2001. Curtis Dewey, ACVIM (Neurology) Ronaldo C de Costa • Practical Guide to Canine and Feline Neurology, 3rd ed. 2016. Acknowledgements
See Spot Run Rehabilitation • Normal gaits in the dog • https://www.youtube.com/watch?v=hgF 5YEIdmRg Care Animal Clinic Brookfield • Cat Walking • https://www.youtube.com/watch?v=Hzt 18V3Uaxc Brittany King • Cerebellar ataxia in a dog: hypermetria • https://www.youtube.com/watch?v=PlN a1wQFiyg Acknowledgements
Kristen Janky, AuD, PhD , CCC-A • Boystown National Research Hospital • Treating BPPV: The Epley Maneuver • https://www.youtube.com/watch?v=BtT 2PDJVXlk Exercises For Idiopathic Vestibular Disease • https://www.youtube.com/watch?v=i61Z qdtYK9Y Dipartimento Clinico Veterinario – Universita de Bologna • Videos of dog gait Acknowledgements
Warning Signs of Back Problem in Dachshunds • https://barkhow.com/signs-back- problem-dachshunds/
Soroush Moghaddam Jafari • Department of Clinical Science, Faculty of Veterinary Medicine, Babol Branch, Islamic Azad University, Babol, Iran • Schiff-Sherrington Phenomenon in Dog • ECronicon – Jul 30, 2019 Acknowledgements
Soren Boyson, DACVECC • An overview of the evaluation and treatment of head trauma in small animal patients • Faculty of Veterinary Medicine, University of Calgary, Canada
Andrew Isaacs, ACVIM (Neurology) • Dogwood Veterinary Referral Center, Farmington, MI