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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

•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
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
• Cincinnati Stroke Scale • Berg Balance Scale

• Los Angeles Prehospital Stroke • Lawton IADL Scale


Screen(LAPSS)
• Modified Rankin Scale
• ABCD Score
• Stroke Impact Scale

• Acute Assessment Scale • Outcome assessment


• Canadian Neurological scale • Barthel Index

• European Stroke Scale • American Heart Association


Stroke Outcome Classification
• Glasgow Coma Scale(GCS)
• Glasgow Outcome Scale
• NIH Stroke Scale(NIHSS)

• Scandinavian Stroke 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
constriction(Horner’s
syndrome)
• Change 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
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

• 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
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