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

The Neurologic Exam for the The Neurologic Exam for the Emergency Physician Emergency Physician

Andy Jagoda, MD, FACEPAndy Jagoda, MD, FACEPMount Sinai School of MedicineMount Sinai School of Medicine

Department of Emergency MedicineDepartment of Emergency MedicineNew York, New YorkNew York, New York

Andy Jagoda, MD

OverviewOverview

• Neuroanatomy

• History

• Physical

• Clinical Scenarios

Andy Jagoda, MD

IntroductionIntroduction

• Facilitates Communication

• Provides Baseline

• Directs Testing

• Identifies Need For Life-Saving Therapies

• Risk Management

Andy Jagoda, MD

Risk Management: Case #1Risk 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.

Andy Jagoda, MD

Risk Management: Case #2Risk 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.

Andy Jagoda, MD

NeuroanatomyNeuroanatomy• Central versus peripheral– symmetrical vs asymmetrical

• If central, what is the level:– Cerebrum – Brain Stem– Spinal cord

• If peripheral, is it– Nerve–Muscle– NMJ

Andy Jagoda, MD

NeuroanatomyNeuroanatomy

Andy Jagoda, MD

CentralCentral LesionsLesions

• 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

Andy Jagoda, MD

Anatomy of the Spinal CordAnatomy 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

Andy Jagoda, MD

Spinal Cord : Vascular SupplySpinal 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

Andy Jagoda, MD

UMN vs LMNUMN vs LMN

• UMN increased DTR (after SS) LMN decreased DTR

• UMN muscle tone increased

LMN tone decreased, atrophy

• UMN no fasciculations LMN fasciculations

Andy Jagoda, MD

UMN vs LMN WeaknessUMN 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

Andy Jagoda, MD

The Neuro Exam: HistoryThe 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

Andy Jagoda, MD

The Neuro Exam: HistoryThe 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

Andy Jagoda, MD

The Neuro Exam: PhysicalThe Neuro Exam: Physical

• Vital Signs

• Head: Evidence of Trauma

• Neck: Bruits, Rigidity

• Heart: Murmurs

• Abdomen: Masses / Distention

• Skin / Scalp: Lesions / Tenderness

Andy Jagoda, MD

The Neuro Exam: PhysicalThe Neuro Exam: Physical

• Mental Status

• Cranial Nerves

• Motor

• Sensory

• Coordination

• Reflexes

Andy Jagoda, MD

The Neuro Exam: Initial ApproachThe Neuro Exam: Initial Approach

• Posture

• Decorticate

• Decerebrate

• Facial or body asymmetry

•Hemiparesis results in external rotation of the foot to the affected side

Andy Jagoda, MD

Mental Status ExamMental 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

Andy Jagoda, MD

Acute Altered Mental StatusAcute Altered Mental Status

• Intracranial lesion• Metabolic disorder• Toxin• Infection• Ictal state• Postictal state • Psychogenic

Andy Jagoda, MD

Cranial Nerve ExamCranial Nerve Exam

• Focus exam on II - VIII

• Symmetrical vs symmetrical

Andy Jagoda, MD

Evaluation of II, III, IV, VIEvaluation 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

Andy Jagoda, MD

Cranial Nerve IICranial Nerve II

• Visual acuity

• Visual fields

• Fundoscopy

• Swinging flashlight test

Andy Jagoda, MD

III NerveIII Nerve

• Emerges from brainstem next to posterior cerebral artery

• May be compressed by herniation

• Runs in the lateral wall of the cavernous sinus

Andy Jagoda, MD

III Cranial NerveIII Cranial Nerve

• Parasympathetics• Levator Palpebrae• Inferior Obliques, Medial, Inferior, and Superior

Rectus Muscles

LR MR MR LR

IO IO SRSR

IR SO SO IR

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III Cranial Nerve ParalysisIII Cranial Nerve Paralysis

• Ptosis• Dilated Pupil• Paralyzed eye is deviated out and down; SO

and LR control eye

LR MR MR LR

IO IO SRSR

IR SO SO IR

Andy Jagoda, MD

III Cranial Nerve LesionsIII 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

Andy Jagoda, MD

IV Cranial NerveIV Cranial Nerve

• Superior oblique• Causes eye to turn in and down• When paralyzed, eye can not turn down

when it is rotated in

LR MR MR LR

IO IO SRSR

IR SO SO IR

Andy Jagoda, MD

VI Cranial NerveVI Cranial Nerve

• Lateral rectus• Long course; goes through the CS, not

within the wall• Paralysis impairs abduction

LR MR MR LR

IO IO SRSR

IR SO SO IR

Andy Jagoda, MD

Conjugate GazeConjugate 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

Andy Jagoda, MD

Causes of III, VI, VI CN paralysisCauses 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

Andy Jagoda, MD

Cranial Nerve VCranial 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

Andy Jagoda, MD

Cranial Nerve VIICranial Nerve VII

• Motor• smile• bury eyelashes• nasolabial fold• forehead has

bihemispheric innervation centrally

• Taste anterior 2/3

Andy Jagoda, MD

Cranial Nerves VIII - XIICranial Nerves VIII - XII

• VIII - vestibular

function / hearing

• IX - taste / sensation

posterior pharynx

• X - SCM; chin to the

opposite side

• XII - tongue

Andy Jagoda, MD

Motor ExamMotor Exam

• Strength• 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

Andy Jagoda, MD

Motor ExamMotor 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

Andy Jagoda, MD

Sensory ExamSensory 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

Andy Jagoda, MD

Sensory Exam 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

Andy Jagoda, MD

Sensory ExamSensory Exam

• Distribution– right vs left vs bilateral– dermatomal– distal versus proximal• stocking glove• cape like

• Pinprick versus light touch

Andy Jagoda, MD

Sensory ExamSensory 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

Andy Jagoda, MD

CoordinationCoordination

• 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

Andy Jagoda, MD

ReflexesReflexes

• 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:

Andy Jagoda, MD

Hysteria Hysteria (conversion vs malingering)(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

Andy Jagoda, MD

Pitfalls In The Neurologic Exam 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

Andy Jagoda, MD

PearlsPearls

• 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

Andy Jagoda, MD

The Neurologic Exam The Neurologic Exam

Case Scenarios

Andy Jagoda, MD

Case Scenario #1Case Scenario #1

A 46 yo female with a long history of migraine A 46 yo female with a long history of migraine headaches presented c/o a severe occipital HA headaches presented c/o a severe occipital HA that was different from her past headaches in that was different from her past headaches in location and intensity. If an aneurysm is location and intensity. If an aneurysm is suspected to be causing the patient’s suspected to be causing the patient’s symptoms, which cranial nerve should your symptoms, which cranial nerve should your exam focus on?exam focus on?

A. III B. VI C. VII D. IV IIA. III B. VI C. VII D. IV II

Andy Jagoda, MD

III NERVEIII 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 ARTERYPOSTERIOR COMMUNICATING ARTERY

• ICA IN THE CAVERNOUS SINUS (IV, V AND VI NERVES ICA IN THE CAVERNOUS SINUS (IV, V AND VI NERVES ALSO INVOLVED)ALSO INVOLVED)

Andy Jagoda, MD

Case Scenario #2Case Scenario #2

A 64 yo male presented C/0 low back pain which A 64 yo male presented C/0 low back pain which has become progressively worse over the past 2 has become progressively worse over the past 2 weeks. The pain was primarily in the low back weeks. The pain was primarily in the low back without radiation; C/O nonspecific numbness in without radiation; C/O nonspecific numbness in the legs. Which nerve root is responsible for the legs. Which nerve root is responsible for plantar flexion and the ankle jerk? plantar flexion and the ankle jerk?

A. A. L3 L3 B. B. L4 L4 C. C. L5L5 D. D. S1S1 E. E. S2S2

Andy Jagoda, MD

Lower Extremity InnervationLower Extremity Innervation

• L 3 / L 4 = Patellar reflex• L 5 = Big toe extension• S 1 = Achilles reflex

Andy Jagoda, MD

Case Scenario #3Case Scenario #3

AA 30 yo female is in an MVA hitting her head on the dash. 30 yo female is in an MVA hitting her head on the dash. The next day she developed a sudden onset severe right The next day she developed a sudden onset severe right frontal HA, that persisted. One day later she developed left frontal HA, that persisted. One day later she developed left sided arm weakness that lasted 2 hours. In the ED she had an sided arm weakness that lasted 2 hours. In the ED she had an OD ptosis and OD miosis. Her motor / sensory exam was OD ptosis and OD miosis. Her motor / sensory exam was “WNL”. What is your initial impression? “WNL”. What is your initial impression?

A. A. Hysteria Hysteria B. SubarachnoidB. Subarachnoid bleed bleed C. Epidural hematoma C. Epidural hematoma

D. Carotid artery D. Carotid artery dissection dissection E. EntrapmentE. Entrapment syndrome syndrome

Andy Jagoda, MD

PUPIL CONSTRICTIONPUPIL CONSTRICTION

• DISRUPTION OF THE SYMPATHETICSDISRUPTION OF THE SYMPATHETICS• HORNER’SHORNER’S

• CAROTID ARTERY DISSECTIONCAROTID ARTERY DISSECTION

• PONTINE HEMORRHAGEPONTINE HEMORRHAGE

• TOXINSTOXINS• NARCOTICSNARCOTICS

• CHOLINERGICSCHOLINERGICS

Andy Jagoda, MD

Case Scenario #4Case Scenario #4

AA 50 yo female c/o a diffuse headache for two months 50 yo female c/o a diffuse headache for two months that is constant. There is no past HA history. She claims that is constant. There is no past HA history. She claims that intermittently her vision seems blurred but otherwise that intermittently her vision seems blurred but otherwise denies symtoms. On exam: VSS; VA: 20/40. CN: diplopia denies symtoms. On exam: VSS; VA: 20/40. CN: diplopia on far lateral gaze bilaterally. Which of the following is on far lateral gaze bilaterally. Which of the following is the most likely diagnosis. the most likely diagnosis.

A. Occipital Lobe Stroke B. Pituitary AdenomaA. Occipital Lobe Stroke B. Pituitary AdenomaC. Multiple Sclerosis D. Myasthenia GravisC. Multiple Sclerosis D. Myasthenia GravisE. Intracranial HypertensionE. Intracranial Hypertension

Andy Jagoda, MD

IDIOPATHIC INTRACRANIAL HYPERTENSION IDIOPATHIC INTRACRANIAL HYPERTENSION (BENIGN INTRACRANIAL HYPERTENSION, PSEUDOTUMOR CEREBRI)(BENIGN INTRACRANIAL HYPERTENSION, PSEUDOTUMOR CEREBRI)

• SYNDROME DEFINED BY SIGNS AND SYMPTOMS OF SYNDROME DEFINED BY SIGNS AND SYMPTOMS OF HIGH ICP WITHOUT APPARENT INTRACRANIAL MASSHIGH ICP WITHOUT APPARENT INTRACRANIAL MASS

• 50% HAVE AN IDENTIFIABLE UNDERLYING ETIOLOGY50% HAVE AN IDENTIFIABLE UNDERLYING ETIOLOGY• ALTERED ABSORPTION OF CSF AT THE ARACHNOID ALTERED ABSORPTION OF CSF AT THE ARACHNOID

VILLUSVILLUS• ALTERATION DUE TO EITHER:ALTERATION DUE TO EITHER:

• ELEVATED PRESSURE WITHIN THE SAGITTAL SINUSELEVATED PRESSURE WITHIN THE SAGITTAL SINUS• INCREASED RESISTANCE TO DRAINAGE OF CSF INCREASED RESISTANCE TO DRAINAGE OF CSF

WITHIN THE VILLUSWITHIN THE VILLUS

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PHYSICAL FINDINGSPHYSICAL FINDINGS

• PAPILLEDEMAPAPILLEDEMA• VISUAL DISTURBANCE VISUAL DISTURBANCE 50 - 80%50 - 80%• BLINDNESS IN BLINDNESS IN 10%10%• DECREASED VISUAL ACUITYDECREASED VISUAL ACUITY 30%30%• TRANSIENT VISUAL OBSCURATIONTRANSIENT VISUAL OBSCURATION 68%68%• ENLARGED BLIND SPOTENLARGED BLIND SPOT• SCOTOMASSCOTOMAS• VI NERVE PALSY (FALSE LOCALIZING) 38%VI NERVE PALSY (FALSE LOCALIZING) 38%

Andy Jagoda, MD

Case Scenario #5Case Scenario #5

A 20 yo college student flips his car, hitting head on the dash. 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 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 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 strength in his LE. He complains of numbness in his arms but is able to distinguish sharp from dull. DTRs intact. What is is able to distinguish sharp from dull. DTRs intact. What is your leading diagnosis?your leading diagnosis?

A. Central Cord Syndrome B. Anterior Cord SyndromeA. Central Cord Syndrome B. Anterior Cord SyndromeC. Spinal Epidural Hemorrhage D. Subdural HemorrhageC. Spinal Epidural Hemorrhage D. Subdural HemorrhageE. Brown - Sequard SyndromeE. Brown - Sequard Syndrome

Andy Jagoda, MD

CENTRAL CORD SYNDROMECENTRAL CORD SYNDROME

• HYPEREXTENSION INJURIES, TUMOR, HYPEREXTENSION INJURIES, TUMOR, SYRINGOMYELIASYRINGOMYELIA

• M U DM U D• PARESIS OR PLEGIA OF ARMS > LEGSPARESIS OR PLEGIA OF ARMS > LEGS• POSTERIOR COLUMN SPAREDPOSTERIOR COLUMN SPARED• SENSATION UE>LE; SACRAL SPARINGSENSATION UE>LE; SACRAL SPARING• PERFORATING BRANCHES OF ANTERIOR SPINAL PERFORATING BRANCHES OF ANTERIOR SPINAL

ARTERY AT GREATEST RISK FOR VASCULAR ARTERY AT GREATEST RISK FOR VASCULAR INSULTINSULT

• GOOD PROGNOSISGOOD PROGNOSIS

Andy Jagoda, MD

Case Scenario #6Case Scenario #6

A 23 yo female presents complaining of feeling generally weak A 23 yo female presents complaining of feeling generally weak

with the sensation that she is dragging her feet when she with the sensation that she is dragging her feet when she

walks. On exam her sensation is intact; motor strength is 5/5 walks. On exam her sensation is intact; motor strength is 5/5

in all major muscle groups; deep tendon reflexes are 2/2 in 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 the UE, 2/2 at the knees, and and 0/2 at the ankles. What is

your major concern?your major concern?

A. Spinal Stenosis B. Conus Medularis C. Guillian BarreA. Spinal Stenosis B. Conus Medularis C. Guillian Barre

D. Polymyalgia Rheumatica E. Myasthenia GravisD. Polymyalgia Rheumatica E. Myasthenia Gravis

Andy Jagoda, MD

GUILLAIN-BARREGUILLAIN-BARRE

• ACUTE POLYNEUROPATHYACUTE POLYNEUROPATHY

• SYMMETRIC ASCENDING WEAKNESSSYMMETRIC ASCENDING WEAKNESS

• ARRFLEXIA (LMN)ARRFLEXIA (LMN)

• NO MENINGEAL SIGNS, FEVER, SIGNS NO MENINGEAL SIGNS, FEVER, SIGNS OF SYSTEMIC ILLNESSOF SYSTEMIC ILLNESS

• CSF: INCREASED PROTEIN WITHOUT CSF: INCREASED PROTEIN WITHOUT PLEOCYTOSISPLEOCYTOSIS

Andy Jagoda, MD

Case Scenario #7Case Scenario #7

A 30 yo male with AIDS complains of diffuse weakness that is A 30 yo male with AIDS complains of diffuse weakness that is progressive in the LE associated with paresthesias; there is no progressive in the LE associated with paresthesias; there is no back pain. On exam he has 4/5 upper extremity strength, 2/5 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 lower extremity strength; DTRs are 2/2 in the UE and 4/2 in the LE. His plantar reflexes are upgoing upgoing bilaterally. LE. His plantar reflexes are upgoing upgoing bilaterally.

Which of the following is the most likely diagnosis?Which of the following is the most likely diagnosis?

A. Myelopathy B. Neuropathy C. MyopathyA. Myelopathy B. Neuropathy C. MyopathyD. Neuromuscular Junction Disease E. RadiculopathyD. Neuromuscular Junction Disease E. Radiculopathy

Andy Jagoda, MD

HTLV-1 ASSOCIATED MYELOPATHYHTLV-1 ASSOCIATED MYELOPATHY

• PROGRESSIVE LOWER EXTREMITY PROGRESSIVE LOWER EXTREMITY WEAKNESS (ARMS MORE THAN LEGS)WEAKNESS (ARMS MORE THAN LEGS)

• SPASTICITYSPASTICITY• PARESTHESIAS ARE COMMON; SENSORY PARESTHESIAS ARE COMMON; SENSORY

DEFICITS ARE RAREDEFICITS ARE RARE• SYMMETRIC UPPER MOTOR NEURON SYMMETRIC UPPER MOTOR NEURON

PARAPARESISPARAPARESIS• SPHINCTER DISTURBANCESSPHINCTER DISTURBANCES