Title: The Neurologic Exam for the Emergency Physician Andy Jagoda, MD, FACEP Mount Sinai School of Medicin
1The Neurologic Exam for the Emergency Physician
Andy Jagoda, MD, FACEPMount Sinai School of
MedicineDepartment of Emergency MedicineNew
York, New York
2Overview
- Neuroanatomy
- History
- Physical
- Clinical Scenarios
3Introduction
- Facilitates Communication
- Provides Baseline
- Directs Testing
- Identifies Need For Life-Saving Therapies
- Risk Management
4Risk 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.
5Risk 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.
6Neuroanatomy
- Central versus peripheral
- symmetrical vs asymmetrical
- If central, what is the level
- Cerebrum
- Brain Stem
- Spinal cord
- If peripheral, is it
- Nerve
- Muscle
- NMJ
7Neuroanatomy
8Central Lesions
- 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
9Anatomy 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
10Spinal 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
11UMN vs LMN
- UMN increased DTR (after SS)
LMN decreased DTR - UMN muscle tone increased
- LMN tone decreased, atrophy
- UMN no fasciculations
LMN fasciculations
12UMN 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
13The 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
14The 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
15The Neuro Exam Physical
- Vital Signs
- Head Evidence of Trauma
- Neck Bruits, Rigidity
- Heart Murmurs
- Abdomen Masses / Distention
- Skin / Scalp Lesions / Tenderness
16The Neuro Exam Physical
- Mental Status
- Cranial Nerves
- Motor
- Sensory
- Coordination
- Reflexes
17The Neuro Exam Initial Approach
- Posture
- Decorticate
- Decerebrate
- Facial or body asymmetry
- Hemiparesis results in external rotation of the
foot to the affected side
18Mental 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
19Acute Altered Mental Status
- Intracranial lesion
- Metabolic disorder
- Toxin
- Infection
- Ictal state
- Postictal state
- Psychogenic
20Cranial Nerve Exam
- Focus exam on II - VIII
- Symmetrical vs symmetrical
21Evaluation 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
22Cranial Nerve II
- Visual acuity
- Visual fields
- Fundoscopy
- Swinging flashlight test
23III Nerve
- Emerges from brainstem next to posterior cerebral
artery - May be compressed by herniation
- Runs in the lateral wall of the cavernous sinus
24III Cranial Nerve
- Parasympathetics
- Levator Palpebrae
- Inferior Obliques, Medial, Inferior, and Superior
Rectus Muscles
IO IO
SR
SR
LR
MR MR
LR
IR SO
SO IR
25III Cranial Nerve Paralysis
- Ptosis
- Dilated Pupil
- Paralyzed eye is deviated out and down SO and LR
control eye
IO IO
SR
SR
LR
MR MR
LR
IR SO
SO IR
26III 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
27IV Cranial Nerve
- Superior oblique
- Causes eye to turn in and down
- When paralyzed, eye can not turn down when it is
rotated in
IO IO
SR
SR
LR
MR MR
LR
IR SO
SO IR
28VI Cranial Nerve
- Lateral rectus
- Long course goes through the CS, not within the
wall - Paralysis impairs abduction
IO IO
SR
SR
LR
MR MR
LR
IR SO
SO IR
29Conjugate 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
30Causes 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
31Cranial 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
32Cranial Nerve VII
- Motor
- smile
- bury eyelashes
- nasolabial fold
- forehead has bihemispheric innervation centrally
- Taste anterior 2/3
33Cranial Nerves VIII - XII
- VIII - vestibular function / hearing
- IX - taste / sensation posterior pharynx
- X - SCM chin to the opposite side
- XII - tongue
34Motor 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
35Motor 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
36Sensory 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
37Sensory 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
38Sensory Exam
- Distribution
- right vs left vs bilateral
- dermatomal
- distal versus proximal
- stocking glove
- cape like
- Pinprick versus light touch
39Sensory 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
40Coordination
- 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
41Reflexes
- 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
42Hysteria (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
43Pitfalls 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
44Pearls
- 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
45The Neurologic Exam Case Scenarios
46Case 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 patients symptoms,
which cranial nerve should your exam focus on? - A. III B. VI C. VII D.
IV II
47III 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)
48Case 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
49Lower Extremity Innervation
- L 3 / L 4 Patellar reflex
- L 5 Big toe extension
- S 1 Achilles reflex
50Case 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
51PUPIL CONSTRICTION
- DISRUPTION OF THE SYMPATHETICS
- HORNERS
- CAROTID ARTERY DISSECTION
- PONTINE HEMORRHAGE
- TOXINS
- NARCOTICS
- CHOLINERGICS
52Case 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
53IDIOPATHIC 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
54PHYSICAL FINDINGS
- PAPILLEDEMA
- VISUAL DISTURBANCE 50 - 80
- BLINDNESS IN 10
- DECREASED VISUAL ACUITY 30
- TRANSIENT VISUAL OBSCURATION 68
- ENLARGED BLIND SPOT
- SCOTOMAS
- VI NERVE PALSY (FALSE LOCALIZING) 38
55Case 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
56CENTRAL CORD SYNDROME
- HYPEREXTENSION INJURIES, TUMOR, SYRINGOMYELIA
- M U D
- PARESIS OR PLEGIA OF ARMS LEGS
- POSTERIOR COLUMN SPARED
- SENSATION UELE SACRAL SPARING
- PERFORATING BRANCHES OF ANTERIOR SPINAL ARTERY AT
GREATEST RISK FOR VASCULAR INSULT - GOOD PROGNOSIS
57Case 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
58GUILLAIN-BARRE
- ACUTE POLYNEUROPATHY
- SYMMETRIC ASCENDING WEAKNESS
- ARRFLEXIA (LMN)
- NO MENINGEAL SIGNS, FEVER, SIGNS OF SYSTEMIC
ILLNESS - CSF INCREASED PROTEIN WITHOUT PLEOCYTOSIS
59Case 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 -
60HTLV-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