1. A Practical Approach to the Focused Neurological Examination
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. Supra-tentorial Infra-tentorial The Nervous System The Brain
Cortex
Subcortical Region
Cerebellum
Brainstem
The Spinal Cord
Peripheral Nerves
Supra-tentorial
Infra-tentorial

6. Functional Neuroanatomy

8. Functional Neuroanatomy

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

11. Spinal cord cross-section

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

13. 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

14. 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

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

16. 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

17. 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

18. Cranial Nerves

19. 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,

20. 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

21. 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

22. Rating Scale for the Motor Exam
Response
Score 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

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

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

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

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

27. Dermatomes
Figure #7
Figure #8

28. Sensory Dermatomes

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

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

32. L A H

33. Cortical Lesions Language* Motor - Which is more involved?
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

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

35. 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 )

36. Visual Field

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

38. 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)

39. 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

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

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

42. 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)

43. Brain Arterial Supply
Circle of Willis

44. Circle of Willis

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

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

47. Arterial Territory
Lateral aspect

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

49. Arterial Territory
Medial aspect

50. Posterior Cerebral Artery Syndrome
Homonymous hemianopsia (most common)
Little or no paralysis
No aphasia
Prominent sensory loss
Recent memory loss (hippocampus)

51. 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
Answers none correctly 3
1c. LOC commands Obeys both correctly 0
Obeys one correctly 1
Obeys none correctly 2

52. NIH Stroke Scale Category Response Score 2. Best gaze Normal 0
Partial gaze palsy
Forced deviation
3. Best visual No visual loss
Partial hemianopsia
Complete hemianopsia
4. Facial palsy Normal
Minor facial weakness
Partial facial weakness
No facial movement

53. NIH Stroke Scale Category Response Score
5. Best motor arm No drift after 10 s
Drift
Some effort (hits bed)
No effort against gravity
No movement
6. Best motor leg No drift after 5s
Drift
Some effort (hits bed)
No effort against gravity
7. Limb ataxia Absent
Present in upper/lower Ex
Present in both upper/lower

54. NIH Stroke Scale Category Response Score 8. Sensory Normal 0
Partial loss
Dense loss
9. Neglect No neglect
Partial neglect
Complete neglect
10. Dysarthria Normal articulation
Mild to moderate dysarthria 1
Near unintelligible or worse 2

55. NIH Stroke Scale Category Response Score
11. Best Language No aphasia
Mild to Moderate aphasia
Severe Aphasia
Mute