case studies
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The Johns Hopkins Center for Cerebrovascular Disease. Case Studies. A Practical Approach to the Focused Neurological Examination. Four Questions. Is this a stroke? Where is the stroke? How would you quantify/describe the deficits? Would you give TPA to this person?. Why This Review?. - PowerPoint PPT PresentationTRANSCRIPT
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Case Studies
A Practical Approach to the Focused Neurological
Examination
The Johns Hopkins Center for Cerebrovascular Disease
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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?
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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
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Arjun Chanmugam, MD
The Key Questions
• Is there a lesion?
• Where is the lesion?
• What caused the lesion?
• What interventions are available?
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Arjun Chanmugam, MD
The Nervous System
• The Brain– Cortex– Subcortical Region
– Cerebellum– Brainstem
• The Spinal Cord• Peripheral Nerves
Infra-tentorial
Supra-tentorial
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Arjun Chanmugam, MD
Functional Neuroanatomy
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Arjun Chanmugam, MD
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Arjun Chanmugam, MD
Functional Neuroanatomy
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Arjun Chanmugam, MD
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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)
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Arjun Chanmugam, MD
Spinal cord cross-section
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Arjun Chanmugam, MD
General Approach
• History• Physical • Neurological Evaluation
– Neurological Review of Systems– Neurological Examination
• Localization• Management
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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
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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
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Arjun Chanmugam, MD
Neurological Examination
Mental Status Cranial Nerves Motor and Reflexes Sensory Coordination and Gait
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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
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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
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Arjun Chanmugam, MD
Cranial Nerves
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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,
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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
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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
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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
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Arjun Chanmugam, MD
Glossary- Neuroanatomy• UMN-- Cortex to
the lateral column of the spinal cord
• LMN-- Anterior column to the motor end-plate
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Arjun Chanmugam, MD
UMN verses LMN
• Spastic Paralysis
• Hyperreflexia
• Hypertonicity
• Babinski reflex
• Flaccid Paralysis
• Hyporeflexia
• Hypotonicity
• Muscle atrophy
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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
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Arjun Chanmugam, MD
Sensory Examination
• Touch
• Pinprick (spinothalamic)
• Temperature (spinothalamic)
• Position (posterior column)
• Vibration (posterior column)
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Arjun Chanmugam, MD
Dermatomes
• Figure #7 • Figure #8
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Arjun Chanmugam, MD
Sensory Dermatomes
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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
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Arjun Chanmugam, MD
Localization• Cortical• Subcortical
– Internal capsule– Basal Ganglia– Thalamus
• Brainstem– Midbrain– Pons– Medulla
• Spinal cord
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Arjun Chanmugam, MD
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Arjun Chanmugam, MD
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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
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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
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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 )
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Arjun Chanmugam, MD
Visual Field
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Arjun Chanmugam, MD
Brainstem Lesions
• Crossed hemiplegia (ipsilateral cranial nerves with contralateral
motor)
• Cerebellar signs (ipsilateral)
• Nystagmus (worse on ipsilateral gaze)
• Hearing loss
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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)
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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
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Arjun Chanmugam, MD
Nondominant Hemisphere• Inattention (neglecting left side)
• Extinction (double simultaneous sensory stimulation)
• Denial or unconcern
• Acute confusional state
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Arjun Chanmugam, MD
Nondominant Hemisphere
• Constructional apraxia ( copy a simple diagram)
• Dress apraxia (wrong sleeve)
• Impersistence of a task
• Spatial disorientation
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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)
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Arjun Chanmugam, MD
Brain Arterial SupplyCircle of Willis
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Arjun Chanmugam, MD
Circle of Willis
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Arjun Chanmugam, MD
TIAs Symptomatology Carotid
• Amaurosis fugax
• Aphasia
• Motor paresis
• Motor paralysis
• Slurred speech
Vertebro-basilar
• Ataxia
• Dizziness
• Diplopia
• Motor/sensory deficit
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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)
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Arjun Chanmugam, MD
Arterial Territory
Lateral aspect
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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
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Arjun Chanmugam, MD
Arterial Territory
Medial aspect
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Arjun Chanmugam, MD
Posterior Cerebral Artery Syndrome
• Homonymous hemianopsia (most common)
• Little or no paralysis• No aphasia• Prominent sensory loss• Recent memory loss (hippocampus)
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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
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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
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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
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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
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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