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Case Studies

The Johns Hopkins Center for Cerebrovascular Disease. Case Studies. A Practical Approach to the Focused Neurological Examination. Four Questions. Is this a stroke? Where is the stroke? How would you quantify/describe the deficits? Would you give TPA to this person?. Why This Review?.

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Case Studies

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  1. The Johns Hopkins Center for Cerebrovascular Disease Case Studies 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. 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

  4. The Key Questions • Is there a lesion? • Where is the lesion? • What caused the lesion? • What interventions are available?

  5. The Nervous System • The Brain • Cortex • Subcortical Region • Cerebellum • Brainstem • The Spinal Cord • Peripheral Nerves Supra-tentorial Infra-tentorial

  6. Functional Neuroanatomy

  7. Functional Neuroanatomy

  8. Spinal Cord- 3 Basic Areas Posterior column (sensory, -( proprioception, vibration)) Lateral Column a. cortico-spinal (motor) b. spinothalamic(sensory) Anterior region (Motor)

  9. Spinal cord cross-section

  10. General Approach • History • Physical • Neurological Evaluation • Neurological Review of Systems • Neurological Examination • Localization • Management

  11. 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 Neuro Review of Systems

  12. Sphincter Speech Writing Reading Memory Level of Consciousness Bowel or bladder language vs dysarthia Ability to write Difficulty Forgetfulness Fainting, diminished, sz Neurological Review of Systems

  13. Neurological Examination • Mental Status • Cranial Nerves • Motor and Reflexes • Sensory • Coordination and Gait

  14. Mental Status Cranial Nerves Motor/Reflexes Sensory* Coordination Propioception Cortex Subcortical, Brainstem Upper and Lower Motor Neurons Subcortical, Spinal Cord Cerebellum Spinal Cord Neurological Examination * Isolated lesions in the postcentral gyrus is rare

  15. 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

  16. Cranial Nerves

  17. 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,

  18. 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

  19. 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

  20. 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 Rating Scale for the Motor Exam Response Score

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

  22. Spastic Paralysis Hyperreflexia Hypertonicity Babinski reflex Flaccid Paralysis Hyporeflexia Hypotonicity Muscle atrophy UMN verses LMN

  23. Deep Tendon Reflexes* *Spinal shock can accompany acute cortical stroke

  24. Sensory Examination • Touch • Pinprick (spinothalamic) • Temperature (spinothalamic) • Position (posterior column) • Vibration (posterior column)

  25. Figure #7 Figure #8 Dermatomes

  26. Sensory Dermatomes

  27. Coordination and Gait • Cerebellar • Finger-nose (dysmetria - ataxia) • Heel-shin • Rapid alternate movements (dysdiadochokinesia) • Rhythmic tapping • Romberg’s test • Gait • Normal versus Tandem

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

  29. L A H

  30. Cortical Lesions • Language* • Aphasia ( motor, sensory, global, conduction) • Motor - Which is more involved? • face and arm>leg(MCA) • leg >arm and face(ACA) • Cortical sensory loss (stereognosis, graphesthesia, point localization) * neglect in nondominant hemisphere

  31. Cortical Lesions • Is there eye deviation? (towards the lesion) • Is there field defect? (also with subcortical) • Is there associated seizure activity? Think about blood

  32. 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 )

  33. Visual Field

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

  35. 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)

  36. 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

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

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

  39. 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)

  40. Brain Arterial Supply Circle of Willis

  41. Circle of Willis

  42. Carotid Amaurosis fugax Aphasia Motor paresis Motor paralysis Slurred speech Vertebro-basilar Ataxia Dizziness Diplopia Motor/sensory deficit TIAs Symptomatology

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

  44. Arterial Territory Lateral aspect

  45. Anterior Cerebral Artery Syndrome • Paralysis of the lower extremity • Cortical sensory loss (legs only) • Incontinence • Grasp & suck reflexes (release phenomena) • No hemianopsia or aphasia

  46. Arterial Territory Medial aspect

  47. 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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