HighYieldNeurologicalExaminationVanjaDouglas,MD

Sara&EvanWilliamsFoundationEndowedNeurohospitalistChair

Director,NeurohospitalistDivisionAssociateProfessorofClinicalNeurology

UCSFDepartmentofNeurology

Disclosures

None

PurposeofNeuroExam

•  Screenasymptomaticpatients•  Screenpatientswithsymptomsthatcouldindicateafocalneurologiclesion(e.g.backpain,headache,seizure)

•  Localizethelesioninpatientswithneurologicdeficits– Generateadifferentialdiagnosis– Decidewhattesttogetnext(e.g.brainMRI,spineMRI,EMG/NCS,CK)

Typical“Screening”NeuroExam•  MentalStatus:Levelofalertness,orientation,attention,

language,memory•  CranialNerves:IIthroughXII•  Motor:Bulk,tone,powerinallmusclesinbotharmsand

legs•  Sensory:Lighttouch,vibration/jointpositionsense,pain/

temperature,Romberg•  Reflexes:Biceps,triceps,brachioradialis,knees,ankles,

plantarresponse•  Coordination:Finger-nose-finger,heel-knee-shin•  Gait:Observegait,includetandem,heel,andtoewalking

HighYieldScreeningNeuroExam

•  MentalStatus•  CranialNerves•  Motor•  Sensory•  Coordination•  Reflexes•  Gait

Language

ReceptiveAphasia

Fluency Intact

Comprehension Impaired

Repetition Impaired

ExpressiveAphasia

Fluency Impaired

Comprehension Intact

Repetition Impaired

ConductionAphasia

Fluency Intact

Comprehension Intact

Repetition Impaired

HighYieldScreeningNeuroExam

•  MentalStatus:language,orientation,andattention

•  CranialNerves•  Motor•  Sensory•  Coordination•  Reflexes•  Gait

ExtraocularMovements

FacialSymmetry

VisualFields

HighYieldScreeningNeuroExam

•  MentalStatus:language,orientation,andattention

•  CranialNerves:visualfields,eyemovements,andfacialsymmetry

•  Motor•  Sensory•  Coordination•  Reflexes•  Gait

MotorSystem2minutescreenforuppermotorneuronweakness:•  PronatorDrift•  Fingertaps&Foottaps•  Distalextensorpower:•  Fingerextensors•  Tibialisanterior

HighYieldScreeningNeuroExam•  MentalStatus:language,orientation,andattention

•  CranialNerves:visualfields,eyemovements,andfacialsymmetry

•  Motor:Pronatordrift,fingerandfoottaps,fingerextensorandextensorhallucislonguspower

•  Sensory•  Coordination•  Reflexes:Biceps,knees,andankles•  Gait

Coordination&Gait

•  Hemispheres:– Finger-nose-finger

– Heel-knee-shin

•  Vermis:– Gait

HighYieldScreeningNeuroExam•  MentalStatus:language,orientation,andattention•  CranialNerves:visualfields,eyemovements,andfacialsymmetry

•  Motor:Pronatordrift,fingerandfoottaps,fingerextensorandextensorhallucislonguspower

•  Sensory•  Coordination:Finger-nose-fingerandheel-knee-shin(canreplaceHKSwithgait)

•  Reflexes:Biceps,knees,andankles•  Gait:Observegait(base,stride,posture,armswing,turn),tandem

WhyDoASensoryExam?

•  Iftherearesensorycomplaints•  Iftherearebalancecomplaintsoragaitdisorder

•  Ifthereisweakness

SensoryTractsVibration&Jointpositionsense

HighYieldScreeningNeuroExam•  MentalStatus:language,orientation,andattention•  CranialNerves:visualfields,eyemovements,andfacialsymmetry

•  Motor:Pronatordrift,fingerandfoottaps,fingerextensorandextensorhallucislonguspower

•  Sensory:(Ifdone,dopainORtemp+vibrationORJPS)•  Coordination:Finger-nose-fingerandheel-knee-shin(canreplaceHKSwithgait)

•  Reflexes:Biceps,knees,andankles•  Gait:Observegait(base,stride,posture,armswing,turn),tandem

LET’SPRACTICE!CaseScenarios

ThinkLikeANeurologist

•  ChiefComplaint:suspectedlocalization•  History:refinethelocalization•  Exam:pickmaneuversthatruleinorruleoutyoursuspicions

Patient#1

•  A23y/owomanwithahistoryofmigraineheadachesisadmittedtothehospitalwithleftlegcellulitis.Onhospitalday2,shecomplainsofanewheadache.Shesaysit’sdifferentfromherpreviousmigrainesbecauseitis“muchworse”andiswonderingifsheneedsanMRI.

Headache

Suspectedlocalization•  Focalbrainlesion

Otherpotentialpresentingsymptoms

•  Seizure•  Unilateralweakness•  Unilateralnumbness•  Dysarthria

Hypothesis-DrivenNeuroExam

Patient#2

•  57y/omanhospitalizedwithMIisalteredafterhiscardiaccath.Heissomnolentbutarousable,mumblingincoherently.Hisfamilyisveryconcernedthathehashadastroke.

AlteredMentalStatus

Suspectedlocalization•  Bilateralhemispheres•  Brainstem

Patient#2Exam

•  Arousestotouch•  Namessimpleobjects,repeatsshortphrases,followssimplecommands

•  Disorientedandunabletotestattention•  EOMI;facesymmetric;blinkstothreatbilaterally•  Leftarmdriftsandhandisclumsy•  Withdrawslessbrisklytopainintheleftleg•  HeadCTisnormal

MultifocalStrokes

Patient#3

•  A65y/omanwithprostatecancerpresentswithbilaterallegweaknessandurinaryurgency.

BilateralLegWeakness

Suspectedlocalization•  Spinalcord•  Caudaequina

Otherpotentialpresentingsymptoms

•  Urinaryorbowelincontinence

•  Gaitdifficulty•  Backpain

UMN LMN

Pattern of Weakness Pyramidal Variable

Function/Dexterity Slow alternate motion rate Impairment of function is mostly due to weakness

Tone Increased Decreased

Tendon Reflex Increased Decreased, absent or normal

Other signs Babinski sign, other CNS signs (e.g. aphasia, visual field cut)

Atrophy (except with problem of neuromuscular junction)

SpinalCordCross-Section

Patient#3:Exam

•  DecreasedEHLpowerbilaterally•  Slowfoottaps•  Briskkneejerkandanklejerkreflexes•  Reducedjointpositionsenseintoes•  SensoryleveltopinprickatT5

MetastasticSpinalCordCompression

Patient#4

•  A30y/owomanwithlupus,APLAS,andhistoryofendocarditisongentamycinpresentswithacutevertigo.

Vertigo

Suspectedlocalization•  Brainstem•  Cerebellum•  Innerear

Otherpotentialpresentingsymptoms

•  Imbalance

Hypothesis-DrivenNeuroExam

HINTS

•  HeadImpulseTest– Abnormal=peripheral

•  Nystagmus– Unidirectional=peripheral– Direction-changing=central

•  TestofSkew– Skewdeviation=central

•  https://youtu.be/1q-VTKPweuk

Patient#4:Exam

•  Leftbeatingnystagmusinleft-gazeonly•  Positiveheadthrusttesttotheright

GentamycinToxicity

Summary

•  Highyieldscreeningexam•  Hypothesisdrivenapproachto:– Suspectedfocalbrainlesion– Alteredmentalstatus– Suspectedspinalcordlesion– Vertigo

BonusCase

•  A32y/owomanpresentswithtinglinginthehandsandfeetthatprogressedtodiffuseweaknessinthearmsandlegsoverfourdays.Sheisnowsoweakshecannolongersitup.

DiffuseWeakness

Suspectedlocalization•  Highspinalcord•  Neuropathy•  Neuromuscularjunction•  Myopathy

Otherpotentialpresentingsymptoms

•  Diplopia•  Dysarthria•  Dysphagia•  Respiratoryfailure

LocalizationofWeaknessPattern of weakness

Tone Bulk Reflexes Sensory Loss

Other

Upper Motor Neuron

Pyramidal Spastic Normal Increased Varies

Anterior Horn Cell

Pyramidal or myotomal

Spastic or normal

Atrophy Increased or decreased

None Fascic-ulations

Peripheral Nerve

In distribution of root or nerve

Normal or reduced

Atrophy Decreased Prominent

Neuro-muscular Junction

Diffuse Normal Normal Normal (myasthenia) or Absent (botulism)

None Ptosis and ophthalmo-paresis

Muscle Proximal > Distal

Normal Normal or patterned atrophy

Normal None

BonusCase

•  Diffuseweaknessthroughoutbotharmsandlegsinbothflexorsandextensors

•  Nosensorylevel•  Decreasedpinpricksensationinthefeet•  Diffuselyabsentreflexes

NextStep?

•  Lumbarpuncture:– Protein143– WBC2

•  Guillain-BarreSyndrome

Acknowledgements

•  HoomanKamel•  AndyJosephson•  DanLowenstein•  AnnPoncelet•  Kameletal,Arandomizedtrialofhypothesis-drivenvsscreeningneurologicexamination.NeurologyOct2011,77(14)1395-1401.