neurological assessment

How to assess neurological patients?

Dr. Surat Tanprawate, MD, FRCPTNorthern Neuroscience Center

Chiangmai University

Assessment

Assessment

An assessment is a consideration of someone or something

and a judgement about them

= evaluation

Why neurological patients need special

care?

The answer is ....

The answer is ....

• Emergency and life threatening conditions

The answer is ....

• Emergency and life threatening conditions

• Difficult to interpreted

The answer is ....

• Emergency and life threatening conditions

• Difficult to interpreted

• Various conditions

The answer is ....

• Emergency and life threatening conditions

• Difficult to interpreted

• Various conditions

• Complex diseases

For diagnosis

For diagnosis

For evaluated the prognosis

For diagnosis

For evaluated the prognosis

For evaluated the response to treatment

No routine

Routine

Step to approach

What is the patient’s condition(or diseases)

How we assess?

Protocol

• Specific disorder

•Goal

• Specific assessment

• Pitfall

Neurological disorder

• General neurological examination

• Acute stroke

• Seizure

• Coma and alteration of consciousness

• Neuromuscular respiratory failure

General neurological examination

• Consciousness

• Cranial nerve examination

• Motor system

• Sensory system

• Reflex

• Coordination

Specific neurological examination

• Depend on specific conditions or diseases

• e.g. COMA: Look “CPOMR”

• Stroke: Look “localizing neurological symptoms”

Acute stroke

Acute stroke

Acute stroke

Assessment goal

• before IV rtPA use

• progression

• complication from stroke

• complication from thrombolysis

• associated medical condition

• baseline evaluation for follow up

General evaluation and F/U: use score

• GCS

• general evaluation

• NIHSS

• specific for stroke evaluation

• Barthel index

• disabilities

GCS

•Don’t appropriated evaluation in stroke patient

Aphasia: problems to evaluate

• Prehospital stroke assessment

• Cincinnati Stroke Scale

• Los Angeles Prehospital Stroke Screen(LAPSS)

• ABCD Score

• Acute Assessment Scale

• Canadian Neurological scale

• European Stroke Scale

• Glasgow Coma Scale(GCS)

• NIH Stroke Scale(NIHSS)

• Scandinavian Stroke Scale

• Functional assessment

• Berg Balance Scale

• Lawton IADL Scale

• Modified Rankin Scale

• Stroke Impact Scale

• Outcome assessment

• Barthel Index

• American Heart Association Stroke Outcome Classification

• Glasgow Outcome Scale

NIHSS Estimation: The Procedure

Helps to categorize patients

Low NIHSS, thrombolysis less indicatedMid-range NIHSS, thrombolysis indicatedHigh NIHSS, thrombolysis less indicatedNIHSS 10-20 optimal for thrombolysis?

Quantification directs therapies

NIHSS 10-20 optimal for thrombolysis?

NIHSS: 11 items

Brain herniation

Early detection for brain herniation

•Eyelid apraxia

•Unqual pupil: pupillary constriction(Horner’s syndrome)

•Change of consciousness

Disorder of consciousness

Coma patients

Use CPOMR for evaluate the lesion

C: ConsciousP: PupilO: Ocular movementM: Motor responseR: Respiratory pattern

Glasgow Coma Scale

• 1974:

• Graham Teasdale and Bryan J. Jennett(Neurosurgery at University of Glasgow)

• Initially used to assess level of consciousness after head injury

Individual elements as well as the sum of the score are important.

Generally, comas are classified as: ▪ Severe, with GCS ≤ 8 ▪ Moderate, GCS 9 - 12

▪ Minor, GCS ≥ 13.

Confusing point

1. No motor response 2. Extension to pain 3. Abnormal flexion to pain 4. Flexion/Withdrawal to pain 5. Localizes to pain 6. Obeys commands

Control of muscle tone

Different location

Different posture

Decorticate posturing

Decorticate responseDecorticate rigidityflexor posturing"mummy baby"

Arms flexed, or bent inward on the chest, the hands are clenched into fists, and the

legs extended

Decorticate posturingdamage to the mesencephalic region

the corticospinal tract

Decerebrate posturing

Decerebrate responseDecerebrate rigidityExtensor posturing

the head is arched back, the arms are extended by the sides, and the legs are extended.

Decerebrate posturing indicates brain stem damage or rather

damage below the level of the red nucleus (eg. mid-collicular lesion)

Pupillary pathway

Seizure: pitfall

•Seizure VS convulsion

•Epileptic seizure VS non-epileptic seizure

•Status epilepticus

Seizure

• Temporary abnormal electro-physiologic phenomenon of the brain

• It can manifest as

• an alteration in mental state

• tonic or clonic movements

• psychic symptoms (such as déjà vu or jamais vu)

Convulsion

Non-convulsive seizure

Temporal lobe epilepsy

Frontal lobe epilepsy

Massage

•Seizure may be not convulsion

•Convulsion may be not seizure

Status epilepticus

• มีอาการชักอย่าง

• ต่อเนื่อง

• ยาวนาน

life-threatening condition in which the brain is in a state of persistent seizure

Definition

Defined as one continuous unremitting seizure lasting longer than 5-10 minutes

OR

Recurrent seizures without regaining consciousness between seizures for greater than 30 minutes.

Observe symptoms of seizure

Observe symptoms of seizure

• Pitfall

Observe symptoms of seizure

• Pitfall

• missing of non-convulsive seizure

Observe symptoms of seizure

• Pitfall

• missing of non-convulsive seizure

• recognized signs of non-convulsive seizure

Observe symptoms of seizure

• Pitfall

• missing of non-convulsive seizure

• recognized signs of non-convulsive seizure

• prolong SE: brain damage: less motor sign

Observe symptoms of seizure

• Pitfall

• missing of non-convulsive seizure

• recognized signs of non-convulsive seizure

• prolong SE: brain damage: less motor sign

• Look silence area: eye, small motor groups(fingers)

Neuromuscular respiratory failure

• To detection signs of respiratory failure

• Pitfall

• Deoxygenation: late signs

• Paradoxical abdominal movement: early sign

• Change of Vital capacity: early detection

Thanks U for your attention

SURAT TANPRAWATE, MD, FRCPT

Blog: www.neurologycoffeecup.blogspot.com