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The Neurologic Exam for the Emergency Physician Andy Jagoda, MD, FACEP Mount Sinai School of Medicine Department of Emergency Medicine New York, New York PowerPoint PPT Presentation


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The Neurologic Exam for the Emergency Physician Andy Jagoda, MD, FACEP Mount Sinai School of Medicine Department of Emergency Medicine New York, New York. Overview. Neuroanatomy History Physical Clinical Scenarios. Introduction. Facilitates Communication Provides Baseline

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The Neurologic Exam for the Emergency Physician Andy Jagoda, MD, FACEP Mount Sinai School of Medicine Department of Emergency Medicine New York, New York

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The Neurologic Exam for the Emergency Physician Andy Jagoda, MD, FACEPMount Sinai School of MedicineDepartment of Emergency MedicineNew York, New York


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Overview

  • Neuroanatomy

  • History

  • Physical

  • Clinical Scenarios


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Introduction

  • Facilitates Communication

  • Provides Baseline

  • Directs Testing

  • Identifies Need For Life-Saving Therapies

  • Risk Management


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Risk Management: Case #1

  • A 46 year female with a long history of migraine headaches presented c/o a severe occipital HA that was different form her past headaches in location and intensity. Neuro exam “WNL”. Patient was treated with Compazine, 10 MG IV, with “Resolution of Headache” and discharged home to “Follow-Up With PMD”.

  • 18 Hours later, patient was brought in by EMS comatose.


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Risk Management: Case #2

  • A 64 year old male presented with lower back pain which had become progressively worse over the past 2 weeks. The pain was primarily in the lower back without radiation, with nonspecific numbness in the legs. PMH: presently being treated for prostatitis. Exam: “Mild Paralumbar Tenderness”, “SLR -”, “Motor / Sensory Intact”, Knee DTR +2. patient was prescribed Morton and told to follow-up with his PMD.

  • Patient developed irreversible renal damage.


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Neuroanatomy

  • Central versus peripheral

    • symmetrical vs asymmetrical

  • If central, what is the level:

    • Cerebrum

    • Brain Stem

    • Spinal cord

  • If peripheral, is it

    • Nerve

    • Muscle

    • NMJ


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Neuroanatomy


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CentralLesions

  • Lesions in the cerebral cortex result in contralateral deficits of the face and body

  • Lesions at the midbrain result in contralateral hemiplegia and ipsilateral peripheral paralysis of III and IV

  • Lesions at the pons result in contralateral hemiplegia and ipsilateral deficits of V, VI, VII, VIII

  • Lesions at the medulla result in contraleral hemiplegia and ipsilateral deficits of IX, X, XI, XIII


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Anatomy of the Spinal Cord

  • Corticospinal Tracts: motor from cerebral cortex: cross in the lower medulla

  • Spinothalamic Tracts: pain and temperature: cross 1 or 2 levels above entry

  • Posterior Column: proprioception and vibration


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Spinal Cord : Vascular Supply

  • Single Anterior

  • Paired posterior from vertebral arteries (Except in cervical cord)

  • Radicular Arteries from aorta:

    • Varying degrees of contribution

    • Great radicular artery of Adamkiewicz T-10 to L-2 (Major source of blood flow to 50% of anterior cord in 50% of patients)

  • Anterior perfuses anterior and central cord


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UMN vs LMN

  • UMN increased DTR (after SS) LMN decreased DTR

  • UMN muscle tone increased

    LMN tone decreased, atrophy

  • UMN no fasciculations LMN fasciculations


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UMN vs LMN Weakness

  • Mylopathy = Spinal Cord Process = UMN findings (spasticity, weakness, atrophy, sensory findings, bowel and bladder complaints)

  • Radiculopathy= Nerve Root Process = LMN findings (Paresthesias, Fasciculations, Weakness, decreased DTR)

  • Patient may have a radiculopathy with mylopathy below the lesion


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The Neuro Exam: History

  • Neuro complaints may be primary or secondary to other system disease

    • Infection

    • Overdose

    • Metabolic Disorder

  • History often provides the key since the neuro exam may be normal

    • Subarachnoid Hemorrhage

    • Carbon Monoxide Poisoning

    • Subdural Hematoma

    • Nonconvulsive Seizures


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The Neuro Exam: History

  • Time of Onset

  • Type of Onset

  • Progression

  • Trauma

  • Associated Symptoms

  • Factors that make it better/worse

  • Past Symptoms / Events

  • Past Medical History

  • Occupational / Environ Exposures


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The Neuro Exam: Physical

  • Vital Signs

  • Head: Evidence of Trauma

  • Neck: Bruits, Rigidity

  • Heart: Murmurs

  • Abdomen: Masses / Distention

  • Skin / Scalp: Lesions / Tenderness


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The Neuro Exam: Physical

  • Mental Status

  • Cranial Nerves

  • Motor

  • Sensory

  • Coordination

  • Reflexes


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The Neuro Exam: Initial Approach

  • Posture

    • Decorticate

    • Decerebrate

    • Facial or body asymmetry

      • Hemiparesis results in external rotation of the foot to the affected side


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Mental Status Exam

  • AVPU

  • GCS

  • Orientation

    • Speech (dysarthria vs aphasia)

    • Comprehension

  • Confusion assessment method (CAM)

    • Acute onset / fluctuating course

    • Inattention

    • Disorganized thinking

    • Altered level of consciousness

  • Mini-mental status exam

    • Score affected by education and age

    • <20 = cognitive impairment


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Acute Altered Mental Status

  • Intracranial lesion

  • Metabolic disorder

  • Toxin

  • Infection

  • Ictal state

  • Postictal state

  • Psychogenic


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Cranial Nerve Exam

  • Focus exam on II - VIII

  • Symmetrical vs symmetrical


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Evaluation of II, III, IV, VI

  • Visual acuity

  • Visual fields

  • Examine the cornea, pupil, fundi

  • Check afferent function

  • Extraocular movements

    • Accentuated when looking in the direction of the paralyzed muscle

    • Differentiation can be facilitated by placing a colored glass over one eye


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Cranial Nerve II

  • Visual acuity

  • Visual fields

  • Fundoscopy

  • Swinging flashlight test


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III Nerve

  • Emerges from brainstem next to posterior cerebral artery

  • May be compressed by herniation

  • Runs in the lateral wall of the cavernous sinus


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III Cranial Nerve

  • Parasympathetics

  • Levator Palpebrae

  • Inferior Obliques, Medial, Inferior, and Superior Rectus Muscles

SR

IO IO SR

LR

MR MR

LR

IR SO SO IR


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III Cranial Nerve Paralysis

  • Ptosis

  • Dilated Pupil

  • Paralyzed eye is deviated out and down; SO and LR control eye

SR

IO IO SR

LR

MR MR

LR

IR SO SO IR


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III Cranial Nerve Lesions

  • Progressive lesions after passage through the dura usually usually causes a ptosis and pupil dilatation first

  • Lesions in the nucleus cause motor deficits first

  • Intact pupil indicates a peripheral ischemic lesion


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IV Cranial Nerve

  • Superior oblique

  • Causes eye to turn in and down

  • When paralyzed, eye can not turn down when it is rotated in

SR

IO IO SR

LR

MR MR

LR

IR SO SO IR


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VI Cranial Nerve

  • Lateral rectus

  • Long course; goes through the CS, not within the wall

  • Paralysis impairs abduction

SR

IO IO SR

LR

MR MR

LR

IR SO SO IR


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Conjugate Gaze

  • Controlled by supranuclear connections

  • Medial longitudinal fasciculus is responsible for coordinating the oculomotor nerves; lesions result in impairment of LR and MR moving in sync, ie, contralateral eye does not pass the midline

  • Multiple sclerosis


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Causes of III, VI, VI CN paralysis

  • Isolated cases usually due to vascular causes: HTN, DM, Atherosclerosis

  • Tumors

  • Increased intracranial pressure

  • Colloid cyst of the III ventricle

  • Wernicke-korsakoff syndrome

  • Myasthenia, Botulism

  • Toxic drug reactions


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Cranial Nerve V

  • Sensory: corneal reflexes

  • Motor: jaw strength and muscle bulk

  • Corneal reflex may be abnormal in cerebellopontine angle lesions: test in patients with hearing deficits or vertigo


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Cranial Nerve VII

  • Motor

    • smile

    • bury eyelashes

    • nasolabial fold

    • forehead has bihemispheric innervation centrally

  • Taste anterior 2/3


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Cranial Nerves VIII - XII

  • VIII - vestibular function / hearing

  • IX - taste / sensation posterior pharynx

  • X - SCM; chin to the opposite side

  • XII - tongue


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Motor Exam

  • Strength

    • primary concern: can patient breathe

    • key test: drift of extremity

  • Tone

    • hypertonia: subacute or chronic corticospinal lesion

    • hypotonia: LMN lesion or acute UMN

    • rigidity: basal ganglia disease

  • Bulk

    • wasting correlates with LMN

  • Fasciculation

    • anterior horn cell lesion

  • Tenderness

    • metabolic / inflammatory muscle disease


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Motor Exam

  • 0 = no movement

  • 1 = flicker but no movement

  • 2 = movement but can not resist gravity

  • 3 = movement against gravity but can not resist examiner

  • 4 = resists examiner but weak

  • 5 = normal


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Sensory Exam

  • Pain / Temp - cross at entrance, ascend in spinal thalamic tract

  • Light touch - ascend in posterior column, cross in the brain stem

  • Vibration - posterior column, cross in the brain stem


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Sensory Exam

  • Dermatomal deficit accompanied with pain suggests peripheral lesion

  • Central deficits are not dermatomal and usually result in loss of sensation not pain

  • Thalamic pain syndrome


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Sensory Exam

  • Distribution

    • right vs left vs bilateral

    • dermatomal

    • distal versus proximal

      • stocking glove

      • cape like

  • Pinprick versus light touch


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Sensory Exam

  • Double simultaneous testing

    • Establish sharp / dull

    • Check cheek, dorsum of hands, dorsum of feet

    • Test both sides simultaneously with pin

      • lateralizes pain, significant sensory deficit

      • initially no lateralization but on repeat 15 sec later, lateralization suggests subtle deficit


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Coordination

  • Requires integration of cerebellar, motor, and sensory functions

  • Balance requires (2 of 3)

    • vision

    • vestibular sense

    • proprioception

  • Falling with eyes open or closed = cerebellar

  • Falling only with eyes closed = posterior column or vestibular


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Reflexes

  • Symmetry / upper vs lower

    • 0 = absent

    • 1 = hyporeflexia

    • 2 = normal

    • 3 = hyperreflexia

    • 4 = clonus (usually indicates organic disease)

  • Superficial reflexes (corneal, pharyngeal, pharyngeal, abdominal, anal, cremasteric, bulbocavernosus)

  • Pathologic reflexes: babinski:


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Hysteria (conversion vs malingering)

  • Blindness: opticokinetic test

  • Hand drop on face test for coma or UE weakness

  • Hemianesthesia: if real, patient cannot perform finger-to nose with eyes closed; vibration remains intact (if bony skeleton intact)

  • Weakness: elbow extension or flexor test; wrist extensor test

  • Unilateral LE weakness: thigh abduction test, hoover test


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Pitfalls In The Neurologic Exam

  • Not getting a complete history utilizing family or observers

  • Not performing a systematic exam

  • Jumping to conclusions before gathering all the data

  • Misinterpreting old lesions for new

  • Misinterpreting limitations from pain as neurologic deficits


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Pearls

  • Lesions of the cerebral cortex result in sensory and motor defects confined to the contralateral side of the body

  • Brain stem and spinal cord lesions result in ipsilateral as well as contralateral defects due to varying patterns of crossover

  • Unilateral pain syndromes without motor deficits suggest possible thalamic pathology

  • A careful exam of CN II, III, IV, and IV is indicated in patients with headache or suspected processes that cause increased ICP

  • Testing for pronator drift is the best screen for muscle weakness of central origin


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The Neurologic Exam Case Scenarios


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Case Scenario #1

A 46 yo female with a long history of migraine headaches presented c/o a severe occipital HA that was different from her past headaches in location and intensity. If an aneurysm is suspected to be causing the patient’s symptoms, which cranial nerve should your exam focus on?

A. III B. VI C. VII D. IV II


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III NERVE

  • EMERGES FROM BRAINSTEM NEXT TO POSTERIOR CEREBRAL ARTERY

  • RUNS IN THE LATERAL WALL OF THE CAVERNOUS SINUS

  • MAY BE COMPRESSED:

    • HERNIATION

    • ANEURYSM

      • POSTERIOR COMMUNICATING ARTERY

      • ICA IN THE CAVERNOUS SINUS (IV, V AND VI NERVES ALSO INVOLVED)


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Case Scenario #2

A 64 yo male presented C/0 low back pain which has become progressively worse over the past 2 weeks. The pain was primarily in the low back without radiation; C/O nonspecific numbness in the legs. Which nerve root is responsible for plantar flexion and the ankle jerk?

A. L3 B. L4 C. L5 D. S1 E. S2


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Lower Extremity Innervation

  • L 3 / L 4 = Patellar reflex

  • L 5 = Big toe extension

  • S 1 = Achilles reflex


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Case Scenario #3

A 30 yo female is in an MVA hitting her head on the dash. The next day she developed a sudden onset severe right frontal HA, that persisted. One day later she developed left sided arm weakness that lasted 2 hours. In the ED she had an OD ptosis and OD miosis. Her motor / sensory exam was “WNL”. What is your initial impression?

A. Hysteria B. Subarachnoid bleed C. Epidural hematoma

D. Carotid artery dissection E. Entrapment syndrome


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PUPIL CONSTRICTION

  • DISRUPTION OF THE SYMPATHETICS

    • HORNER’S

    • CAROTID ARTERY DISSECTION

    • PONTINE HEMORRHAGE

  • TOXINS

    • NARCOTICS

    • CHOLINERGICS


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Case Scenario #4

A 50 yo female c/o a diffuse headache for two months that is constant. There is no past HA history. She claims that intermittently her vision seems blurred but otherwise denies symtoms. On exam: VSS; VA: 20/40. CN: diplopia on far lateral gaze bilaterally. Which of the following is the most likely diagnosis.

A. Occipital Lobe Stroke B. Pituitary Adenoma

C. Multiple Sclerosis D. Myasthenia Gravis

E. Intracranial Hypertension


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IDIOPATHIC INTRACRANIAL HYPERTENSION (BENIGN INTRACRANIAL HYPERTENSION, PSEUDOTUMOR CEREBRI)

  • SYNDROME DEFINED BY SIGNS AND SYMPTOMS OF HIGH ICP WITHOUT APPARENT INTRACRANIAL MASS

  • 50% HAVE AN IDENTIFIABLE UNDERLYING ETIOLOGY

  • ALTERED ABSORPTION OF CSF AT THE ARACHNOID VILLUS

  • ALTERATION DUE TO EITHER:

    • ELEVATED PRESSURE WITHIN THE SAGITTAL SINUS

    • INCREASED RESISTANCE TO DRAINAGE OF CSF WITHIN THE VILLUS


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PHYSICAL FINDINGS

  • PAPILLEDEMA

  • VISUAL DISTURBANCE 50 - 80%

    • BLINDNESS IN 10%

    • DECREASED VISUAL ACUITY30%

    • TRANSIENT VISUAL OBSCURATION68%

    • ENLARGED BLIND SPOT

    • SCOTOMAS

    • VI NERVE PALSY (FALSE LOCALIZING) 38%


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Case Scenario #5

A 20 yo college student flips his car, hitting head on the dash. He arrives in the ED in full spinal immobilization. On exam he has 2/5 strength in his wrists, 3/5 strength in his deltoids, 5/5 strength in his LE. He complains of numbness in his arms but is able to distinguish sharp from dull. DTRs intact. What is your leading diagnosis?

A. Central Cord Syndrome B. Anterior Cord Syndrome

C. Spinal Epidural Hemorrhage D. Subdural Hemorrhage

E. Brown - Sequard Syndrome


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CENTRAL CORD SYNDROME

  • HYPEREXTENSION INJURIES, TUMOR, SYRINGOMYELIA

  • M U D

  • PARESIS OR PLEGIA OF ARMS > LEGS

  • POSTERIOR COLUMN SPARED

  • SENSATION UE>LE; SACRAL SPARING

  • PERFORATING BRANCHES OF ANTERIOR SPINAL ARTERY AT GREATEST RISK FOR VASCULAR INSULT

  • GOOD PROGNOSIS


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Case Scenario #6

A 23 yo female presents complaining of feeling generally weak with the sensation that she is dragging her feet when she walks. On exam her sensation is intact; motor strength is 5/5 in all major muscle groups; deep tendon reflexes are 2/2 in the UE, 2/2 at the knees, and and 0/2 at the ankles. What is your major concern?

A. Spinal Stenosis B. Conus Medularis C. Guillian Barre

D. Polymyalgia Rheumatica E. Myasthenia Gravis


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GUILLAIN-BARRE

  • ACUTE POLYNEUROPATHY

  • SYMMETRIC ASCENDING WEAKNESS

  • ARRFLEXIA (LMN)

  • NO MENINGEAL SIGNS, FEVER, SIGNS OF SYSTEMIC ILLNESS

  • CSF: INCREASED PROTEIN WITHOUT PLEOCYTOSIS


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Case Scenario #7

A 30 yo male with AIDS complains of diffuse weakness that is progressive in the LE associated with paresthesias; there is no back pain. On exam he has 4/5 upper extremity strength, 2/5 lower extremity strength; DTRs are 2/2 in the UE and 4/2 in the LE. His plantar reflexes are upgoing upgoing bilaterally.

Which of the following is the most likely diagnosis?

A. Myelopathy B. Neuropathy C. Myopathy

D. Neuromuscular Junction Disease E. Radiculopathy


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HTLV-1 ASSOCIATED MYELOPATHY

  • PROGRESSIVE LOWER EXTREMITY WEAKNESS (ARMS MORE THAN LEGS)

  • SPASTICITY

  • PARESTHESIAS ARE COMMON; SENSORY DEFICITS ARE RARE

  • SYMMETRIC UPPER MOTOR NEURON PARAPARESIS

  • SPHINCTER DISTURBANCES


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