Case Studies

1
Case Studies
The Johns Hopkins Center for Cerebrovascular
Disease

• A Practical Approach to the Focused Neurological
  Examination

2
Four Questions

• Is this a stroke?
• Where is the stroke?
• How would you quantify/describe the deficits?
• Would you give TPA to this person?

3
Case I S.V

• 65 yo wm with h/o of DM and prior CVA (residual L
  hemiparesis)
• Presents to the ED with c/o two episodes of
  double vision each lasting 10-15 minutes.
• Last spell occurred 3 hours prior to evaluation
• H/o trigeminal neuralgia, txd with tegretol
• On coumadin, but d/cd 5 days ago for planned
  surgery
• Labs were sent. CT scan obtained
• INR 1. Labs normal (glu 284)

4
(No Transcript)
5
Case I Continued

• 3 am - R sided weakness, slurred speech
• Pt arrives at 11 am, BAT called
• Repeat head CT and labs
• PE --- awake and alert, follows commands,
  asymmetric smile, flattened NL fold
• raise his eyebrows
• Raise his R arm, but it drifts, and its ataxic
• Raise his R leg but it hits the bed within 5 sec

6
Case I Continued

• No sensory loss
• No neglect
• He answers questions easily, it makes sense, but
  he is hard to understand.

Should he get TPA?
7
Case II SPC

• 52 yo female HTN and DM with sudden onset of R
  sided weakness _at_ 12 noon
• 1230 in the ED - she is awake and alert
• R sided weakness
• BAT
• CBC, M7, coags -- no abnormalities
• Head CT is obtained

8
SPC CT 6/16/00
9
Case II SPC

• A A
• answers questions, follows commands, follow you
  with her eyes on either side
• no visual loss, no face involvement
• some sensory loss on R
• R arm leg has some movement, not against
  gravity

10
Case 3 PL

• 72 yo obese f found in toilet by family at
  900am - pt does not move R side
• EMS reports some shaking activity on the R side.
  T100.5, R20, BP 150/95, HR 100
• 930 am- She is unresponsive, groaning. Cannot
  follow commands.
• Eyes are conjugate
• Responds to noxious stimuli by withdrawing her L
  arm and leg

11
Case 3 PL

• Cannot elicit DTRs
• Face symmetric
• No movement in RUE and RLE
• Some movement in LUE and LLE
• Head CT is obtained
• Labs obtained

12
PL CT 9/23/00
13
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
14
The Key Questions

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

15
The Nervous System

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

Supra-tentorial
Infra-tentorial
16
Functional Neuroanatomy
17
(No Transcript)
18
Functional Neuroanatomy
19
(No Transcript)
20
Spinal Cord- 3 Basic Areas
Posterior column (sensory, -( proprioception,
vibration))
Lateral Column a. cortico-spinal (motor)
b. spinothalamic(sensory)
Anterior region (Motor)
21
Spinal cord cross-section
22
General Approach

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

23
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

24
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

25
Neurological Examination

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

26
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
27
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
28
Cranial Nerves
29
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,
30
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
31
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
32
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

33
Glossary- Neuroanatomy

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

34
UMN verses LMN

• Spastic Paralysis
• Hyperreflexia
• Hypertonicity
• Babinski reflex

• Flaccid Paralysis
• Hyporeflexia
• Hypotonicity
• Muscle atrophy

35
Deep Tendon Reflexes
Spinal shock can accompany acute cortical stroke
36
Sensory Examination

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

37
Dermatomes

• Figure 7

• Figure 8

38
Sensory Dermatomes
39
Coordination and Gait

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

40
Localization

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

41
(No Transcript)
42
L A H
43
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
44
Cortical Lesions

• Is there eye deviation? (towards the lesion)
• Is there field defect? (also with subcortical)
• Is there associated seizure activity?

Think about blood
45
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 )

46
Visual Field
47
Brainstem Lesions

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

48
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)

49
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

50
Nondominant Hemisphere

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

51
Nondominant Hemisphere

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

52
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)

53
Brain Arterial Supply
Circle of Willis
54
Circle of Willis
55
TIAs Symptomatology

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

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

56
Middle Cerebral Artery Syndrome

• Aphasia or non-dominant findings
• Hemiparesis (greater in face and arm)
• Cortical sensory loss
• Homonymous hemianopsia
• Conjugate eye deviation (ipsilateral)

57
Arterial Territory
Lateral aspect
58
Anterior Cerebral Artery Syndrome

• Paralysis of the lower extremity
• Cortical sensory loss (legs only)
• Incontinence
• Grasp suck reflexes (release phenomena)
• No hemianopsia or aphasia

59
Arterial Territory
Medial aspect
60
Posterior Cerebral Artery Syndrome

• Homonymous hemianopsia (most common)
• Little or no paralysis
• No aphasia
• Prominent sensory loss
• Recent memory loss (hippocampus)

61
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

62
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
63
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
64
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
65
NIH Stroke Scale
Category Response Score 11.
Best Language No aphasia
0 Mild to
Moderate aphasia 1 Severe
Aphasia 2 Mute
3