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How to assess neurological patients?

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

Assessment
Assessment
Assessment = evaluation
Assessment
= evaluation

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

Why neurological patients need special care?
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 diagnosis
For diagnosis
For evaluated the prognosis
For evaluated the prognosis
For diagnosis
For diagnosis
For evaluated the prognosis
For evaluated the prognosis
For evaluated the response to treatment
For evaluated the response to
treatment

Routine

No routine

Step to approach

What is the patient’s condition (or diseases)

How we assess?

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

Specific disorder

Goal

Specific assessment

Pitfall

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

• 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

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

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

Aphasia:

problems to evaluate

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

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?

Mid-range NIHSS, thrombolysis indicated High NIHSS, thrombolysis less indicated NIHSS 10-20 optimal for thrombolysis?
Mid-range NIHSS, thrombolysis indicated High NIHSS, thrombolysis less indicated NIHSS 10-20 optimal for thrombolysis?

NIHSS 10-20 optimal for thrombolysis?

NIHSS 10-20 optimal for thrombolysis?
NIHSS 10-20 optimal for thrombolysis?

NIHSS: 11 items

Brain herniation

Brain herniation
Brain herniation

Early detection for brain herniation

Eyelid apraxia

Unqual pupil: pupillary constriction(Horner’s syndrome)

Change of consciousness

Disorder of consciousness

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

Control of muscle tone

Different location

Different posture

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

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

Pupillary pathway

Pupillary pathway
Pupillary pathway

Seizure: pitfall

Seizure VS convulsion

Epileptic seizure VS non- 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

Convulsion

Non-convulsive seizure

Non-convulsive seizure Temporal lobe epilepsy Frontal lobe epilepsy

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