neurological assessment
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How to assess neurological patients?
Dr. Surat Tanprawate, MD, FRCPTNorthern Neuroscience Center
Chiangmai University
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Assessment
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Assessment
An assessment is a consideration of someone or something
and a judgement about them
= evaluation
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Why neurological patients need special
care?
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The answer is ....
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The answer is ....
• Emergency and life threatening conditions
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The answer is ....
• Emergency and life threatening conditions
• Difficult to interpreted
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The answer is ....
• Emergency and life threatening conditions
• Difficult to interpreted
• Various conditions
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The answer is ....
• Emergency and life threatening conditions
• Difficult to interpreted
• Various conditions
• Complex diseases
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For diagnosis
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For diagnosis
For evaluated the prognosis
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For diagnosis
For evaluated the prognosis
For evaluated the response to treatment
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No routine
Routine
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Step to approach
What is the patient’s condition(or diseases)
How we assess?
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Protocol
• Specific disorder
•Goal
• Specific assessment
• Pitfall
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Neurological disorder
• General neurological examination
• Acute stroke
• Seizure
• Coma and alteration of consciousness
• Neuromuscular respiratory failure
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General neurological examination
• Consciousness
• Cranial nerve examination
• Motor system
• Sensory system
• Reflex
• Coordination
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Specific neurological examination
• Depend on specific conditions or diseases
• e.g. COMA: Look “CPOMR”
• Stroke: Look “localizing neurological symptoms”
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Acute stroke
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Acute stroke
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Acute stroke
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Assessment goal
• before IV rtPA use
• progression
• complication from stroke
• complication from thrombolysis
• associated medical condition
• baseline evaluation for follow up
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General evaluation and F/U: use score
• GCS
• general evaluation
• NIHSS
• specific for stroke evaluation
• Barthel index
• disabilities
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GCS
•Don’t appropriated evaluation in stroke patient
Aphasia: problems to evaluate
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• Prehospital stroke assessment
• Cincinnati Stroke Scale
• Los Angeles Prehospital Stroke Screen(LAPSS)
• ABCD Score
• Acute Assessment Scale
• Canadian Neurological scale
• European Stroke Scale
• Glasgow Coma Scale(GCS)
• NIH Stroke Scale(NIHSS)
• Scandinavian Stroke Scale
• Functional assessment
• Berg Balance Scale
• Lawton IADL Scale
• Modified Rankin Scale
• Stroke Impact Scale
• Outcome assessment
• Barthel Index
• American Heart Association Stroke Outcome Classification
• Glasgow Outcome Scale
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NIHSS Estimation: The Procedure
Helps to categorize patients
Low NIHSS, thrombolysis less indicatedMid-range NIHSS, thrombolysis indicatedHigh NIHSS, thrombolysis less indicatedNIHSS 10-20 optimal for thrombolysis?
Quantification directs therapies
NIHSS 10-20 optimal for thrombolysis?
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NIHSS: 11 items
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Brain herniation
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Early detection for brain herniation
•Eyelid apraxia
•Unqual pupil: pupillary constriction(Horner’s syndrome)
•Change of consciousness
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Disorder of consciousness
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Coma patients
Use CPOMR for evaluate the lesion
C: ConsciousP: PupilO: Ocular movementM: Motor responseR: Respiratory pattern
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Glasgow Coma Scale
• 1974:
• Graham Teasdale and Bryan J. Jennett(Neurosurgery at University of Glasgow)
• Initially used to assess level of consciousness after head injury
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Individual elements as well as the sum of the score are important.
Generally, comas are classified as: ▪ Severe, with GCS ≤ 8 ▪ Moderate, GCS 9 - 12
▪ Minor, GCS ≥ 13.
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Confusing point
1. No motor response 2. Extension to pain 3. Abnormal flexion to pain 4. Flexion/Withdrawal to pain 5. Localizes to pain 6. Obeys commands
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Control of muscle tone
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Different location
Different posture
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Decorticate posturing
Decorticate responseDecorticate rigidityflexor posturing"mummy baby"
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Arms flexed, or bent inward on the chest, the hands are clenched into fists, and the
legs extended
Decorticate posturingdamage to the mesencephalic region
the corticospinal tract
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Decerebrate posturing
Decerebrate responseDecerebrate rigidityExtensor posturing
the head is arched back, the arms are extended by the sides, and the legs are extended.
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Decerebrate posturing indicates brain stem damage or rather
damage below the level of the red nucleus (eg. mid-collicular lesion)
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Pupillary pathway
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Seizure: pitfall
•Seizure VS convulsion
•Epileptic seizure VS non-epileptic seizure
•Status epilepticus
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Seizure
• Temporary abnormal electro-physiologic phenomenon of the brain
• It can manifest as
• an alteration in mental state
• tonic or clonic movements
• psychic symptoms (such as déjà vu or jamais vu)
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Convulsion
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Non-convulsive seizure
Temporal lobe epilepsy
Frontal lobe epilepsy
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Massage
•Seizure may be not convulsion
•Convulsion may be not seizure
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Status epilepticus
• มีอาการชักอย่าง
• ต่อเนื่อง
• ยาวนาน
life-threatening condition in which the brain is in a state of persistent seizure
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Definition
Defined as one continuous unremitting seizure lasting longer than 5-10 minutes
OR
Recurrent seizures without regaining consciousness between seizures for greater than 30 minutes.
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Observe symptoms of seizure
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Observe symptoms of seizure
• Pitfall
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Observe symptoms of seizure
• Pitfall
• missing of non-convulsive seizure
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Observe symptoms of seizure
• Pitfall
• missing of non-convulsive seizure
• recognized signs of non-convulsive seizure
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Observe symptoms of seizure
• Pitfall
• missing of non-convulsive seizure
• recognized signs of non-convulsive seizure
• prolong SE: brain damage: less motor sign
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Observe symptoms of seizure
• Pitfall
• missing of non-convulsive seizure
• recognized signs of non-convulsive seizure
• prolong SE: brain damage: less motor sign
• Look silence area: eye, small motor groups(fingers)
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Neuromuscular respiratory failure
• To detection signs of respiratory failure
• Pitfall
• Deoxygenation: late signs
• Paradoxical abdominal movement: early sign
• Change of Vital capacity: early detection
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Thanks U for your attention
SURAT TANPRAWATE, MD, FRCPT
Blog: www.neurologycoffeecup.blogspot.com