The Neurologic Exam for the Emergency Physician Andy Jagoda, MD, FACEP Mount Sinai School of Medicine Department of Emergency Medicine New York, New York 1 1 1 1

Overview Neuroanatomy History Physical Clinical Scenarios 2 2 2 2

Introduction Facilitates Communication Provides Baseline Directs Testing Identifies Need For Life-Saving Therapies Risk Management 3 3 3 3

Risk 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. 4 4 4

Risk 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. 5 5

Neuroanatomy Central versus peripheral If central, what is the level: symmetrical vs asymmetrical If central, what is the level: Cerebrum Brain Stem Spinal cord If peripheral, is it Nerve Muscle NMJ 7 5 6 6

Neuroanatomy 8 6 7 7

Central 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 8 8

Anatomy 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 9 9

Spinal 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 10 10

UMN vs LMN UMN increased DTR (after SS) LMN decreased DTR UMN muscle tone increased LMN tone decreased, atrophy UMN no fasciculations LMN fasciculations 11 11

UMN 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 12 12

The 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 15 9 13 13

The 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 16 10 14 14

The Neuro Exam: Physical Vital Signs Head: Evidence of Trauma Neck: Bruits, Rigidity Heart: Murmurs Abdomen: Masses / Distention Skin / Scalp: Lesions / Tenderness 17 11 15 15

The Neuro Exam: Physical Mental Status Cranial Nerves Motor Sensory Coordination Reflexes 18 12 16 16

The Neuro Exam: Initial Approach Posture Decorticate Decerebrate Facial or body asymmetry Hemiparesis results in external rotation of the foot to the affected side 18 13 17 17

Mental 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 <20 = cognitive impairment 19 14 18 18

Acute Altered Mental Status Intracranial lesion Metabolic disorder Toxin Infection Ictal state Postictal state Psychogenic 16 19 19

Cranial Nerve Exam Focus exam on II - VIII Symmetrical vs symmetrical 23 17 20 20

Evaluation 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 24 18 21 21

Cranial Nerve II Visual acuity Visual fields Fundoscopy Swinging flashlight test 25 19 22 22

III Nerve Emerges from brainstem next to posterior cerebral artery May be compressed by herniation Runs in the lateral wall of the cavernous sinus 27 20 23 23

III Cranial Nerve Parasympathetics Levator Palpebrae Inferior Obliques, Medial, Inferior, and Superior Rectus Muscles SR IO IO SR LR MR MR LR IR SO SO IR 28 21 24 24

III Cranial Nerve Paralysis Ptosis Dilated Pupil Paralyzed eye is deviated out and down; SO and LR control eye SR IO IO SR LR MR MR LR IR SO SO IR 29 22 25 25

III 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 30 23 26 26

IV Cranial Nerve Superior oblique Causes eye to turn in and down When paralyzed, eye can not turn down when it is rotated in SR IO IO SR LR MR MR LR IR SO SO IR 31 24 27 27

VI Cranial Nerve Lateral rectus Long course; goes through the CS, not within the wall Paralysis impairs abduction SR IO IO SR LR MR MR LR IR SO SO IR 32 25 28 28

Conjugate 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 33 26 29 29

Causes 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 34 27 30 30

Cranial 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 35 28 31 31

Cranial Nerve VII Motor smile bury eyelashes nasolabial fold forehead has bihemispheric innervation centrally Taste anterior 2/3 36 29 32 32

Cranial Nerves VIII - XII VIII - vestibular function / hearing IX - taste / sensation posterior pharynx X - SCM; chin to the opposite side XII - tongue 37 30 33 33

Motor Exam Strength Tone Bulk Fasciculation Tenderness 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 39 31 34 34

Motor 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 40 32 35 35

Sensory 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

Sensory 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 43 35 37 37

Sensory Exam Distribution Pinprick versus light touch right vs left vs bilateral dermatomal distal versus proximal stocking glove cape like Pinprick versus light touch 44 36 38 38

Sensory 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 45 37 39 39

Coordination 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 38 40 40

Reflexes 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: 49 39 41 41

Hysteria (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 50 40 42 42

Pitfalls 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 72 41 43 43

Pearls 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 73 42 44 44

The Neurologic Exam Case Scenarios 1 1 45 45

Case 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 patient’s symptoms, which cranial nerve should your exam focus on? A. III B. VI C. VII D. IV II 2 46 46

III 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) 27 25 34 31

Case 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 3 47 47

Lower Extremity Innervation L 3 / L 4 = Patellar reflex L 5 = Big toe extension S 1 = Achilles reflex

Case 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 4 48 48

DISRUPTION OF THE SYMPATHETICS PUPIL CONSTRICTION DISRUPTION OF THE SYMPATHETICS HORNER’S CAROTID ARTERY DISSECTION PONTINE HEMORRHAGE TOXINS NARCOTICS CHOLINERGICS 17 17

Case 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 5 49 49

50% HAVE AN IDENTIFIABLE UNDERLYING ETIOLOGY IDIOPATHIC 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

PAPILLEDEMA VISUAL DISTURBANCE 50 - 80% BLINDNESS IN 10% PHYSICAL 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%

Case 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 6 50 50

CENTRAL CORD SYNDROME HYPEREXTENSION INJURIES, TUMOR, SYRINGOMYELIA M U D PARESIS OR PLEGIA OF ARMS > LEGS POSTERIOR COLUMN SPARED SENSATION UE>LE; SACRAL SPARING PERFORATING BRANCHES OF ANTERIOR SPINAL ARTERY AT GREATEST RISK FOR VASCULAR INSULT GOOD PROGNOSIS

Case 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 7 51 51

GUILLAIN-BARRE ACUTE POLYNEUROPATHY SYMMETRIC ASCENDING WEAKNESS ARRFLEXIA (LMN) NO MENINGEAL SIGNS, FEVER, SIGNS OF SYSTEMIC ILLNESS CSF: INCREASED PROTEIN WITHOUT PLEOCYTOSIS

Case 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 8 52 52

HTLV-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