Part I: Neurological Exam Part II: Coma Connie Chen Neurology Consultants of Dallas

Part I: Neurological Part I: Neurological ExamExam

Part II: ComaPart II: Coma

Connie ChenConnie Chen

Neurology Consultants of Neurology Consultants of DallasDallas

Part IPart INeurological ExamNeurological Exam

Neurological Exam:Neurological Exam:Some BasicsSome Basics

Purpose of exam: differential Purpose of exam: differential diagnosisdiagnosis

The mantra:The mantra:– History comes first!History comes first!– Exam is next best option.Exam is next best option.– ““Pan-scanning” is a poor substitute for Pan-scanning” is a poor substitute for

exam.exam.– ““Pan-scanning” results in “missing the Pan-scanning” results in “missing the

boat”.boat”.

Neurological Exam:Neurological Exam:More BasicsMore Basics

Lecture goal:Lecture goal:– Moving past medical school --see the Moving past medical school --see the

forests, not the trees.forests, not the trees.– Tailor your exam to meet your needs.Tailor your exam to meet your needs.– Full neurological exams will waste your Full neurological exams will waste your

time?time?

Case exampleCase example

65 yo with low back pain. 65 yo with low back pain. Pain radiates down right leg.Pain radiates down right leg. He notes new acute weakness in He notes new acute weakness in

right leg.right leg.

Differential?Differential? How can the exam support/aid in How can the exam support/aid in

diagnosis?diagnosis?

Exam PurposeExam Purpose Identify the part of the “neuro-axis” involved:Identify the part of the “neuro-axis” involved:

– link link EXAMEXAM with with FUNCTIONFUNCTION Neuro-axis:Neuro-axis:

– CortexCortex– SubcortexSubcortex– Brain stemBrain stem– Spinal cordSpinal cord– Nerve rootNerve root– Peripheral nervePeripheral nerve– Neuromuscular junctionNeuromuscular junction– Muscle.Muscle.

The Exam ItselfThe Exam Itself

Components:Components:– Mental statusMental status– CNCN– Motor Motor (tone, bulk, strength)(tone, bulk, strength)

– Sensation Sensation (soft touch/temp/pinprick vs (soft touch/temp/pinprick vs vib/proprio)vib/proprio)

– ReflexesReflexes– CoordinationCoordination– Gait Gait (stressed gaits, base, arm swing, turn)(stressed gaits, base, arm swing, turn)

Matching Matching Exam to LocationExam to Location– Mental statusMental status– CNCN– MotorMotor– SensationSensation– ReflexesReflexes– CoordinationCoordination– GaitGait

– CortexCortex– SubcortexSubcortex– Brain stemBrain stem– Spinal cordSpinal cord– Nerve rootNerve root– Peripheral Peripheral

nervenerve– Neuromuscular Neuromuscular

junctionjunction– MuscleMuscle

ExamExam Mental statusMental status

– Level of alertnessLevel of alertness– OrientationOrientation– Language (naming, Language (naming,

fluency, repetition, fluency, repetition, comprehension, reading)comprehension, reading)

– CalculationsCalculations– MemoryMemory– Judgement/insightJudgement/insight– Executive Executive

function/Abstract function/Abstract thoughtthought

– Visualspacial abilityVisualspacial ability

Cortex (Frontal, Cortex (Frontal, parietal, parietal, temporal, temporal, occipital)occipital)

Subcortex Subcortex (white matter, (white matter, thalamus)thalamus)

ExamExam Cranial Cranial

NervesNerves

– III/IVIII/IV

– IV-VIIIIV-VIII

– V, IX-XIIV, IX-XII

BrainstemBrainstem

– midbrainmidbrain

– ponspons

– medullamedulla

Motor ExamMotor Exam

PATTERNS:PATTERNS: Corticospinal tract: strength “stroke pattern”Corticospinal tract: strength “stroke pattern”

– tone and bulk change latertone and bulk change later– spinal cord: spinal shockspinal cord: spinal shock

Anterior horn: weakness at level, fasciculationAnterior horn: weakness at level, fasciculation Root: weakness in all muscles involving rootRoot: weakness in all muscles involving root Nerve: weakness in all muscles involving nerveNerve: weakness in all muscles involving nerve Muscle: proximal > distal weaknessMuscle: proximal > distal weakness

0= no movement, 1= f licker, 2= gravity removed,

3= against gravity, 4-/4/4+ = grades of resistance, 5= full

Sensation ExamSensation Exam

Notoriously painful for all involved.Notoriously painful for all involved. Patterns: Central, cord, peripheralPatterns: Central, cord, peripheral Main pointers:Main pointers:

– Dorsal columns: late cross, vib/proprioDorsal columns: late cross, vib/proprio– Spinal thalamic tract: early cross, ST/temp/PPSpinal thalamic tract: early cross, ST/temp/PP

ReflexesReflexes

0: absent0: absent 1: present with distraction1: present with distraction 2: present without distraction2: present without distraction 3: spreads across more than one joint3: spreads across more than one joint 4: Clonus- sustained and non-sustained.4: Clonus- sustained and non-sustained.

PATTERNS:PATTERNS: Up: Cortical, spinal Up: Cortical, spinal (before anterior horn)(before anterior horn)

Down: Root, (nerve, muscle)Down: Root, (nerve, muscle)

Coordination=CerebellumCoordination=Cerebellum

Rapid alternating movements Rapid alternating movements (dysdiadokinesia)(dysdiadokinesia)

Past pointingPast pointing Dysmetria: finger nose/heel to shinDysmetria: finger nose/heel to shin ??romberg-- not really??romberg-- not really Wide based stanceWide based stance (nystagmus at primary gaze)(nystagmus at primary gaze)

***Pre-existing weakness can fool you***Pre-existing weakness can fool you

GaitGait

The best part of examThe best part of exam Evaluates strength, coordination, Evaluates strength, coordination,

sensationsensation look at arm swing, base of stance, look at arm swing, base of stance,

steps, turn, steps, turn, stressed gaits will bring out stressed gaits will bring out

subtleties.subtleties.

Case RevisitedCase Revisited

65 yo with low back pain. 65 yo with low back pain. Pain radiates down right leg.Pain radiates down right leg. He notes new acute weakness in He notes new acute weakness in

right leg.right leg.

Differential?Differential? Exam expectations?Exam expectations?

Case SeriesCase Series

67 yo fell off of a horse and has 67 yo fell off of a horse and has developed bilateral LE weakness developed bilateral LE weakness over the course of days.over the course of days.

Differential?Differential? Exam findings?Exam findings? What other pertinent HPI questions What other pertinent HPI questions

would have helped?would have helped?

Case seriesCase series

25 yo notes water feels “funny” on 25 yo notes water feels “funny” on right hand, and then his right leg felt right hand, and then his right leg felt strange.strange.

Differential?Differential? Exam findings?Exam findings?

Case SeriesCase Series

40 yo notes left face and arm feels 40 yo notes left face and arm feels funny since last night and notes left funny since last night and notes left arm and leg weakness.arm and leg weakness.

Differential?Differential? Exam findings?Exam findings?

Case SeriesCase Series

78yo fell and couldn’t get up. “I knew 78yo fell and couldn’t get up. “I knew I was going to get stuck [on the floor] I was going to get stuck [on the floor] for weeks now.” Why is he weak?for weeks now.” Why is he weak?

Differential?Differential? Exam findings?Exam findings?

Case SeriesCase Series

26 yo notes stumbling when walking 26 yo notes stumbling when walking and an inability to make his jump and an inability to make his jump shots with basketball over the course shots with basketball over the course of 2 days. His toes tingle.of 2 days. His toes tingle.

Differential?Differential? Exam findings?Exam findings?

Case seriesCase series

74 yo wm notes left face and arm weakness 74 yo wm notes left face and arm weakness that lasts only 30 minutes. Later that day that lasts only 30 minutes. Later that day she develops vertigo, slurred speech, and she develops vertigo, slurred speech, and diplopia. She can’t walk because she feels diplopia. She can’t walk because she feels “like I’m drunk.” She has right carotid “like I’m drunk.” She has right carotid stenosis.stenosis.

Differential?Differential? Exam findings?Exam findings? Right carotid stenosis relevance? Right carotid stenosis relevance?

Part II: ComaPart II: Coma

Coma DefinitionComa Definition

State of sustained unconsciousness State of sustained unconsciousness Ascertained by examAscertained by exam

How Coma HappensHow Coma Happens

Structural causes:Structural causes:– Bilateral supratentorial disruptionBilateral supratentorial disruption– Disruption of the RAS of the brainstemDisruption of the RAS of the brainstem

Practical thoughts (linking history, Practical thoughts (linking history, exam, and structure):exam, and structure):– ““metabolic”causes affect brain globallymetabolic”causes affect brain globally– ““Vascular” causes are not equal: unilateral Vascular” causes are not equal: unilateral

carotid artery vs. vertebral artery vs. basilar carotid artery vs. vertebral artery vs. basilar artery.artery.

Coma PrognosticationComa Prognostication

Gauging coma:Gauging coma:– HistoryHistory– ExamExam– Ancillary studiesAncillary studies

History cannot accurately predict History cannot accurately predict outcome of coma.outcome of coma.

Coma PrognosticationComa Prognostication

Ancillary studies cannot accurately Ancillary studies cannot accurately ascertain coma emergenceascertain coma emergence

Exception: Exception: – SSEP’s performed days 1-3 after coma.SSEP’s performed days 1-3 after coma.– Absence of cortical response shows poor Absence of cortical response shows poor

prognosis.prognosis.

Coma PrognosisComa Prognosis

ExamExam– Glascow coma score (eye opening, motor Glascow coma score (eye opening, motor

response, verbal response) response, verbal response)

rather uselessrather useless– Motor: Motor:

Command>purposeful>flexor>extensor>fCommand>purposeful>flexor>extensor>flaccidlaccid

– Cranial nerves: present>absentCranial nerves: present>absent– Roving eye movements > no spontaneousRoving eye movements > no spontaneous

Coma Prognosis: Take HomeComa Prognosis: Take Home(it’s bad when…)(it’s bad when…)

First 24hr post First 24hr post circulatory circulatory arrest: arrest: myoclonus status epilepticusmyoclonus status epilepticus

Or by day 3:Or by day 3:– no corneals, orno corneals, or– absent pupillary reaction, orabsent pupillary reaction, or– motor response is extensor or worsemotor response is extensor or worse