Acute Stroke Management Resource: Neurological Assessment 2007

Neurological Assessment: Objectives  To present the rationale for a focused neurological assessment  To present the components of a two minute neurological assessment  To present the components of a focused neurological assessment  To review three assessment scales used in stroke

Focused Neurological Assessment  History  Stroke onset, risk factors and symptoms  General Medical Assessment  Associated conditions, etiology, additional investigations  Neurological Examination  Localizes the lesion, exclusion of other symptoms  Rules out stroke mimics  Suggests provisional diagnosis  Determines additional investigations  Determines management care plan

Localization  Hemisphere  Anterior circulation  Posterior circulation  Cerebellum  Brain Stem  Spinal Cord  Peripheral Neuropathy  Muscle

History  History  Time of symptom onset o Accurate time of symptom onset is critical o Obtain from patient or person present when the patient was last seen normal  Associated features o Seizure, loss of consciousness

General Medical Assessment  ABC: airway, breathing, circulation  Blood Pressure  tPA candidates: <185/110mmHg  Non tPA candidates: 220/120mmHg  Pulse: irregularity may indicate atrial fibrillation  Temperature: >37.5°C is an independent predictor of poor outcome  Blood glucose: hyperglycemia associated with worse stroke outcomes  General system screen

2 Minute Neurological Examination  Assess:  Pupils, fundi, visual fields, extraocular movements  Ask patient to:  Show me your teeth, say “ah” and stick out your tongue  Assess:  Facial sensation  Muscle tone and strength  Sensory function  Reflexes  Coordination

Neurological Assessment  Level of consciousness  Screening for aphasia  Cranial Nerve assessment  Motor function  Coordination and gait  Reflexes  Sensory function

Level of Consciousness  Most ischemic stroke patients are conscious  Assessment of level of consciousness  Ask the patient: o What month is it? o How old are you?  Response to commands: o Ask patient to open and close their fist o Ask patient to open and close their eyes

Screening for Aphasia  Aphasia: loss of ability to use written and oral language  25% of stroke survivors  50% of individuals with left hemisphere strokes  Bedside screening includes:  Comprehension  Expression & naming  Repetition  Reading  Dysarthria

Cranial Nerves Funduscopic Examination: Optic (II) Identify disk, sharpness of margins Examine macular area for anterior lesions Follow vessels emerging from disk

Cranial Nerves Visual Fields: Optic (II)

Cranial Nerves Pupillary Response: Optic (ll) and Oculomotor (lll)  Assess size prior to light  Elevation of eyelid

Cranial Nerves: Extraocular Movements Oculomotor (III), Trochlear (IV), Abducens (VI)

Cranial Nerves Facial Sensation: Trigeminal (V)

Cranial Nerves Facial Strength: Facial (VII) Smile, show your teeth, lift your eyebrows

Cranial Nerves Palate and Tongue: Glossopharyngeal (IX),Vagus (X) Ask patient to say “ah”

Motor Function Tone and Strength Ask patient to close eyes, arms extended with palms upward

Neurological Assessment: Coordination and Gait Heel-to-shin testFinger-Nose-Finger test

Neurological Assessment: Reflexes Plantar reflex exam Deep tendon reflex exam

Stroke Scales: National Institute of Health Stroke Scale  Measures  11 items  Physiological deficits  Does not measure activity, ADL or participation abilities  Scoring  Quantitative, weighted to severity  0-42, higher score indicative of greater neurological deficits  Characteristics  Reflects comprehensive neurological exam  Results correlate with presenting symptoms  Primarily suited to acute care  Accurate, reliable and well validated  Training required to ensure accuracy in use

Stroke Scales: Canadian Neurological Scale  Measures  6 items  Impairment or physiological deficit  Scoring  , lower score indicative of greater neurological deficit  Characteristics  Reflects common areas related to stroke presentation  Primarily used in acute care  Used in conjunction with Glasgow Coma Scale  Accurate, reliable, sensitive to change, predictive of death, reinfarction and functional independence at 6 months  Training resources available from HSFO

Stroke Scales: Glasgow Coma Scale (GCS)  Measures  3 items  Level of consciousness or coma  Scoring  3-15 with lower score indicative of greater neurological deficit  Characteristics  Developed as a standardized and valid tool for assessing level of consciousness  Not felt to be sensitive enough for stroke patients who do not have impaired level of consciousness  Used in conjunction with CNS if level of consciousness is impaired

Conclusions  Rapid assessment and triage key to optimal treatment  CT scan required to exclude hemorrhage  Knowledge of typical stroke symptoms key  Anatomical and etiological diagnosis necessary  Exclusion of stroke mimics vital

Resources  American Association of Neuroscience Nurses  American Stroke Association  Brain Attack Coalition  Canadian Hypertension Education Program  Canadian Stroke Strategy  European Stroke Initiative

Resources  Heart and Stroke Foundation Prof Ed  Heart and Stroke Foundation of Canada  Internet Stroke Centre  National Institute of Neurological Disorders and Stroke  National Stroke Association  Scottish Intercollegiate Guidelines Network  StrokeEngine