How to assess neurological patients?

Dr. Surat Tanprawate, MD, FRCPT Northern Neuroscience Center Chiangmai University

Assessment

Assessment
An assessment is a consideration of someone or something and a judgement about them

= evaluation

Why neurological patients need special care?

The answer is ....

The answer is ....
• Emergency and life threatening
conditions

The answer is ....
• Emergency and life threatening
conditions

• Difficult to

interpreted

The answer is ....
• Emergency and life threatening
conditions

• Difficult to interpreted • Various conditions

The answer is ....
• Emergency and life threatening
conditions

• Difficult to interpreted • Various conditions • Complex diseases

For diagnosis

For diagnosis
For evaluated the prognosis

For diagnosis
For evaluated the prognosis

For evaluated the response to treatment

Routine

No routine

Step to approach
What is the patient’s condition (or diseases) How we assess?

Protocol

• • Goal Specific assessment • • Pitfall
Specific disorder

Neurological disorder

• General neurological examination • Acute stroke • Seizure • Coma and alteration of consciousness • Neuromuscular respiratory failure

General neurological examination
• Consciousness • Cranial nerve
examination

• Motor system • Sensory system • Reflex • Coordination

Specific neurological examination

• Depend on specific conditions or
diseases

• e.g. COMA: Look “CPOMR” • Stroke: Look “localizing
neurological symptoms”

Acute stroke

Acute stroke

Acute stroke

Assessment goal

• before IV rtPA use • progression • complication from stroke • complication from thrombolysis • associated medical condition • baseline evaluation for follow up

General evaluation and F/U: use score
• GCS • general evaluation • NIHSS • specific for stroke evaluation • Barthel index • disabilities

GCS

• Don’t appropriated evaluation in
stroke patient
Aphasia: problems to evaluate

Prehospital stroke assessment


• • • •

Functional assessment
Berg Balance Scale Lawton IADL Scale Modified Rankin Scale Stroke Impact Scale

• • •

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


• • •

Outcome assessment
Barthel Index American Heart Association Stroke Outcome Classification Glasgow Outcome Scale

NIHSS Estimation: The Procedure
Quantification directs therapies

Helps to categorize patients
Low NIHSS, thrombolysis less indicated Mid-range NIHSS, thrombolysis indicated High NIHSS, thrombolysis less indicated NIHSS 10-20 optimal for thrombolysis? NIHSS 10-20 optimal for thrombolysis?

NIHSS: 11 items

Brain herniation

Early detection for brain herniation

• Eyelid apraxia Unqual pupil: pupillary • • Change of consciousness
constriction(Horner’s syndrome)

Disorder of consciousness

Coma patients
Use CPOMR for evaluate the lesion

C: Conscious P: Pupil O: Ocular movement M: Motor response R: Respiratory pattern

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

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.

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

Control of muscle tone

Different location Different posture

Decorticate posturing
Decorticate response Decorticate rigidity flexor posturing "mummy baby"

Arms flexed, or bent inward on the chest, the hands are clenched into fists, and the legs extended
Decorticate posturing damage to the mesencephalic region the corticospinal tract

Decerebrate posturing
Decerebrate response Decerebrate rigidity Extensor posturing
the head is arched back, the arms are extended by the sides, and the legs are extended.

Decerebrate posturing indicates brain stem damage or rather damage below the level of the red nucleus (eg. mid-collicular lesion)

Pupillary pathway

Seizure: pitfall

• • Epileptic seizure VS nonSeizure VS convulsion epileptic seizure

Status epilepticus

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)

Convulsion

Non-convulsive seizure
Temporal lobe epilepsy

Frontal lobe epilepsy

Massage

• •

Seizure may be not convulsion Convulsion may be not seizure

Status epilepticus
• มีอาการชักอย่าง • ต่อเนื่อง • ยาวนาน
life-threatening condition in which the brain is in a state of persistent seizure

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.

Observe symptoms of seizure

Observe symptoms of seizure
• Pitfall

Observe symptoms of seizure
• Pitfall • missing of non-convulsive seizure

Observe symptoms of seizure
• Pitfall • missing of non-convulsive seizure • recognized signs of non-convulsive
seizure

Observe symptoms of seizure
• Pitfall • missing of non-convulsive seizure • recognized signs of non-convulsive
seizure

• prolong SE: brain damage: less motor sign

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)

Neuromuscular respiratory failure
• To detection signs of respiratory failure • Pitfall • Deoxygenation: late signs • Paradoxical abdominal movement: early
sign

• Change of Vital capacity: early detection

Thanks U for your attention
SURAT TANPRAWATE, MD, FRCPT Blog: www.neurologycoffeecup.blogspot.com

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