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How to assess neurological patients? Dr. Surat Tanprawate, MD, FRCPT Northern Neuroscience Center Chiangmai University

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Page 1: neurological assessment

How to assess neurological patients?

Dr. Surat Tanprawate, MD, FRCPTNorthern Neuroscience Center

Chiangmai University

Page 2: neurological assessment

Assessment

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Assessment

An assessment is a consideration of someone or something

and a judgement about them

= evaluation

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Why neurological patients need special

care?

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The answer is ....

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The answer is ....

• Emergency and life threatening conditions

Page 8: neurological assessment

The answer is ....

• Emergency and life threatening conditions

• Difficult to interpreted

Page 9: neurological assessment

The answer is ....

• Emergency and life threatening conditions

• Difficult to interpreted

• Various conditions

Page 10: neurological assessment

The answer is ....

• Emergency and life threatening conditions

• Difficult to interpreted

• Various conditions

• Complex diseases

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For diagnosis

Page 13: neurological assessment

For diagnosis

For evaluated the prognosis

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For diagnosis

For evaluated the prognosis

For evaluated the response to treatment

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No routine

Routine

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Step to approach

What is the patient’s condition(or diseases)

How we assess?

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Protocol

• Specific disorder

•Goal

• Specific assessment

• Pitfall

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Neurological disorder

• General neurological examination

• Acute stroke

• Seizure

• Coma and alteration of consciousness

• Neuromuscular respiratory failure

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General neurological examination

• Consciousness

• Cranial nerve examination

• Motor system

• Sensory system

• Reflex

• Coordination

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Specific neurological examination

• Depend on specific conditions or diseases

• e.g. COMA: Look “CPOMR”

• Stroke: Look “localizing neurological symptoms”

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Acute stroke

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Acute stroke

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Acute stroke

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Assessment goal

• before IV rtPA use

• progression

• complication from stroke

• complication from thrombolysis

• associated medical condition

• baseline evaluation for follow up

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General evaluation and F/U: use score

• GCS

• general evaluation

• NIHSS

• specific for stroke evaluation

• Barthel index

• disabilities

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GCS

•Don’t appropriated evaluation in stroke patient

Aphasia: problems to evaluate

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• 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

Page 28: neurological assessment

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?

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NIHSS: 11 items

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Brain herniation

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Early detection for brain herniation

•Eyelid apraxia

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

•Change of consciousness

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Disorder of consciousness

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Coma patients

Use CPOMR for evaluate the lesion

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

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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

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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.

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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

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Control of muscle tone

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Different location

Different posture

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Decorticate posturing

Decorticate responseDecorticate rigidityflexor posturing"mummy baby"

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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

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Decerebrate posturing

Decerebrate responseDecerebrate rigidityExtensor posturing

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

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Decerebrate posturing indicates brain stem damage or rather

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

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Pupillary pathway

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Seizure: pitfall

•Seizure VS convulsion

•Epileptic seizure VS non-epileptic seizure

•Status epilepticus

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Convulsion

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Non-convulsive seizure

Temporal lobe epilepsy

Frontal lobe epilepsy

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Massage

•Seizure may be not convulsion

•Convulsion may be not seizure

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Status epilepticus

• มีอาการชักอย่าง

• ต่อเนื่อง

• ยาวนาน

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

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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.

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Observe symptoms of seizure

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Observe symptoms of seizure

• Pitfall

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Observe symptoms of seizure

• Pitfall

• missing of non-convulsive seizure

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Observe symptoms of seizure

• Pitfall

• missing of non-convulsive seizure

• recognized signs of non-convulsive seizure

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Observe symptoms of seizure

• Pitfall

• missing of non-convulsive seizure

• recognized signs of non-convulsive seizure

• prolong SE: brain damage: less motor sign

Page 62: neurological assessment

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)

Page 63: neurological assessment

Neuromuscular respiratory failure

• To detection signs of respiratory failure

• Pitfall

• Deoxygenation: late signs

• Paradoxical abdominal movement: early sign

• Change of Vital capacity: early detection

Page 64: neurological assessment

Thanks U for your attention

SURAT TANPRAWATE, MD, FRCPT

Blog: www.neurologycoffeecup.blogspot.com