Case Studies

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Case Studies
The Johns Hopkins Center for Cerebrovascular
Disease

• A Practical Approach to the Focused Neurological
  Examination

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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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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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The Key Questions

• Is there a lesion?
• Where is the lesion?
• What caused the lesion?
• What interventions are available?

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The Nervous System

• The Brain
• Cortex
• Subcortical Region
• Cerebellum
• Brainstem
• The Spinal Cord
• Peripheral Nerves

Supra-tentorial
Infra-tentorial
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Functional Neuroanatomy
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Functional Neuroanatomy
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Spinal Cord- 3 Basic Areas
Posterior column (sensory, -( proprioception,
vibration))
Lateral Column a. cortico-spinal (motor)
b. spinothalamic(sensory)
Anterior region (Motor)
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Spinal cord cross-section
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General Approach

• History
• Physical
• Neurological Evaluation
• Neurological Review of Systems
• Neurological Examination
• Localization
• Management

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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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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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Neurological Examination

• Mental Status
• Cranial Nerves
• Motor and Reflexes
• Sensory
• Coordination and Gait

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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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Mental Status
I. Consciousness Orientation PPT II.
Concentration and Attention Spell a five letter
word, Clock draw III. Language Fluency,
Comprehension, Naming, Repetition IV.
Memory Immediate, Recent, Remote
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Cranial Nerves
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Testing Cranial Nerves
I. Olfaction (usually not tested) II. Optic
-- visual acuity, peripheral vision,
funduscopy III, IV Extraocular movements,
VI pupillary reaction V. Sensory
Corneal reflex, sensation of the face, scalp
Motor mastication,
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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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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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Rating Scale for the Motor Exam
Response
Score

• 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

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Glossary- Neuroanatomy

• UMN-- Cortex to the lateral column of the spinal
  cord
• LMN-- Anterior column to the motor end-plate

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UMN verses LMN

• Spastic Paralysis
• Hyperreflexia
• Hypertonicity
• Babinski reflex

• Flaccid Paralysis
• Hyporeflexia
• Hypotonicity
• Muscle atrophy

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Deep Tendon Reflexes
Spinal shock can accompany acute cortical stroke
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Sensory Examination

• Touch
• Pinprick (spinothalamic)
• Temperature (spinothalamic)
• Position (posterior column)
• Vibration (posterior column)

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Dermatomes

• Figure 7

• Figure 8

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Sensory Dermatomes
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Coordination and Gait

• Cerebellar
• Finger-nose (dysmetria - ataxia)
• Heel-shin
• Rapid alternate movements (dysdiadochokinesia)
• Rhythmic tapping
• Rombergs test
• Gait
• Normal versus Tandem

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Localization

• Cortical
• Subcortical
• Internal capsule
• Basal Ganglia
• Thalamus
• Brainstem
• Midbrain
• Pons
• Medulla
• Spinal cord

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L A H
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Cortical Lesions

• Language
• Aphasia ( motor, sensory, global, conduction)
• Motor - Which is more involved?
• face and armgtleg (MCA)
• leg gtarm and face (ACA)
• Cortical sensory loss (stereognosis,
  graphesthesia, point localization)

neglect in nondominant hemisphere
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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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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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Visual Field
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Brainstem Lesions

• Crossed hemiplegia (ipsilateral cranial
  nerves with contralateral motor)
• Cerebellar signs (ipsilateral)
• Nystagmus (worse on ipsilateral gaze)
• Hearing loss

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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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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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Nondominant Hemisphere

• Inattention (neglecting left side)
• Extinction (double simultaneous sensory
  stimulation)
• Denial or unconcern
• Acute confusional state

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Nondominant Hemisphere

• Constructional apraxia ( copy a simple diagram)
• Dress apraxia (wrong sleeve)
• Impersistence of a task
• Spatial disorientation

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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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Brain Arterial Supply
Circle of Willis
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Circle of Willis
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TIAs Symptomatology

• Carotid
• Amaurosis fugax
• Aphasia
• Motor paresis
• Motor paralysis
• Slurred speech

• Vertebro-basilar
• Ataxia
• Dizziness
• Diplopia
• Motor/sensory deficit

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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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Arterial Territory
Lateral aspect
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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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Arterial Territory
Medial aspect
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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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NIH Stroke Scale
Category Response Score 1a.
LOC Alert 0 Drowsy 1 Stuporous 2
Coma 3 1b. LOC questions Answers both
correctly 0 Answers one correctly 1 Answ
ers none correctly 3 1c. LOC commands Obeys
both correctly 0 Obeys one
correctly 1 Obeys none correctly 2

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NIH Stroke Scale
Category Response
Score 2. Best gaze Normal
0 Partial gaze palsy
1 Forced deviation 2 3. Best
visual No visual loss 0 Partial
hemianopsia 1 Complete hemianopsia
2 4. Facial palsy Normal
0 Minor facial weakness 1 Partial
facial weakness 2 No facial movement
3
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NIH Stroke Scale
Category Response Score 5. Best motor
arm No drift after 10 s
0 Drift 1 Some effort (hits
bed) 2 No effort against gravity
3 No movement 4 6. Best
motor leg No drift after 5s
0 Drift 1 Some effort
(hits bed) 2 No effort against
gravity 3 7. Limb ataxia
Absent 0 Present in
upper/lower Ex. 1 Present in both
upper/lower 2
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NIH Stroke Scale
Category Response Score 8.
Sensory Normal 0 Partial
loss 1 Dense loss
2 9. Neglect No neglect
1 Partial neglect 2 Complete
neglect 3 10. Dysarthria Normal
articulation 0 Mild to moderate
dysarthria 1 Near unintelligible or worse
2
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NIH Stroke Scale
Category Response Score 11.
Best Language No aphasia
0 Mild to
Moderate aphasia 1 Severe
Aphasia 2 Mute
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