How to Complete a Clinically Relevant & Directed Neurologic Exam in ED CVA Patients Edward Sloan,...

How to Complete a How to Complete a Clinically Relevant & Directed Clinically Relevant & Directed

Neurologic Exam in ED CVA Patients Neurologic Exam in ED CVA Patients

Edward Sloan, MD, MPHEdward Sloan, MD, MPHAssociate ProfessorAssociate Professor

Department of Emergency MedicineDepartment of Emergency MedicineUniversity of Illinois College of MedicineUniversity of Illinois College of Medicine

Chicago, ILChicago, IL

Edward Sloan, MD, MPH

Global ObjectivesGlobal Objectives

• Improve pt outcome in stroke

• Make consistent and reliable neuro Dx

• Provide rationale ED therapies

• Maximize ongoing learning

• Be comfortable with our clinical skills

• Minimize any unnecessary work


Session ObjectivesSession Objectives

• Present clinical case history

• Consider acute stroke for a directed exam

• Ask clinically relevant questions

• Conduct a directed ED H&P

• Examine the NIH Stroke Scale (NIHSS)

• Review optimal ED documentation


““Real” Session ObjectivesReal” Session Objectives

• State the bare minimum that must be done in order to get the job done.

• Allow you to forget about doing the rest.


Why Do This Exercise?Why Do This Exercise?

• How to proceed is unclear for many.

• A uniformly applied minimal standard is better than a non-uniform approach.

• Once achieved, a minimal standard can be enhanced.

• This is a standard of care issue.


Some PerspectiveSome Perspective

• Stroke is a common ED problem.

• Outcome from stroke can be devastating.

• Use of tPA in stroke is an important issue.

• Guidelines are being developed at the local and national level regarding CVA pts.

• The cornerstone of this activity remains the front line Emergency Physician.


A Disclaimer.A Disclaimer.

• Although I have listened to many lectures on the neurologic exam, I am not fully comfortable with this part of my practice.

• What I do in clinical practice may fall below the standard of care.

• Others also may fall short of a reasonable standard in doing a stroke neuro exam.


A Pledge.A Pledge.

• I will not simply create controversy.• I will attempt to clarify what are the

important clinical questions.• I will attempt to state which physical and

neuro exam elements are useful and why.• I will demonstrate a way in which the

physical exam findings can be recorded in order to facilitate patient care.


A Clinical HistoryA Clinical History A 62 year old female acutely developed aphasia

and right sided weakness while in the grocery store. The store clerk immediately called 911, with the arrival of CFD paramedics within 9 minutes, at 6:43 pm. She arrived at the ED at 7:05 pm, completed her head CT at 7:25 pm, and obtained a neuro consult at 7:35 pm, approximately one hour after the onset of her symptoms. What are the next Rx steps?


ED PresentationED PresentationWhat parts of the history and physical

exam really matter? Why?

In what way will the neurologic exam direct the ED diagnosis and therapy?

What must be documented? Why?


Acute Neurologic Exam QuestionsAcute Neurologic Exam Questions

• What general exam should be done?

• What neuro exam should be done?

• What exam findings guide therapy?

• What exam findings predict outcome?

• What is the NIH stroke scale?

• How can documentation be optimized?


Acute Ischemic Stroke:Acute Ischemic Stroke:EtiologyEtiology

• Thrombotic, embolic, hypoperfusion

• Majority are vessel thrombosis

• Clot formation on diseased vessel

• 20% are embolic, from heart, great vessels

• Hypoperfusion with cardiogenic shock


Acute Ischemic Stroke: SyndromesAcute Ischemic Stroke: Syndromes

• Anterior cerebral• Middle cerebral• Posterior cerebral• Vertebrobasilar• Basilar artery occlusion• Cerebellar • Lacunar• Arterial dissection


Acute Ischemic Stroke H & P:Acute Ischemic Stroke H & P:Some Practical QuestionsSome Practical Questions

• Does the neuro exam tell us anything the CT scan does not?

• Do we need to localize the CVA clinically?

• Isn’t a large ICH evident most often based on the pt’s mental status and overall appearance?

• Who checks for proprioception or a positive Rhomberg in a pt with a CVA?


Acute Ischemic Stroke H & P:Acute Ischemic Stroke H & P:Rationale for Exam FindingsRationale for Exam Findings

• To make the correct diagnosis

• To identify a stroke syndrome

• To identify CVA precipitants/etiology

• To determine further diagnostic tests

• To determine ED therapies

• To allow for proper documentation


Rationale for a Directed Neuro Exam:Rationale for a Directed Neuro Exam:To Make the Correct DiagnosisTo Make the Correct Diagnosis

• A complete neuro exam helps when Sx are vague, mild or confusing – TIA, seizure or migraine variant setting– Exam puts a name on non-persistent Sx

• Most acute stroke pts have obvious Sx– What else causes L sided paralysis acutely?– Doesn’t the constellation of Sx make the Dx?

• Which Dx must be immediately excluded?


To Make the Correct Diagnosis: To Make the Correct Diagnosis: A Stroke Differential DiagnosisA Stroke Differential Diagnosis

• Hypertensive encephalopathy• Subdural, epidural hematoma• Meningitis, encephalitis, abcess, labarynthitis• Seizure, SE, Todd’s paralysis• Neoplasm• Hypoglycemia, metabolic• Migraine• Peripheral nerve, Bell’s palsy• Multiple sclerosis


Rationale for a Directed Neuro Exam:Rationale for a Directed Neuro Exam:To Identify a Stroke SyndromeTo Identify a Stroke Syndrome

• The neurologic exam must establish:– anterior or posterior circulation location.

– if the Dx is cerebellar hemorrhage.

– if the lesion is in the brain stem.

– if the lesion is in the spinal cord.

• There is no other requirement with regards to the acute Dx of the stroke pt.


To Identify a Stroke Syndrome:To Identify a Stroke Syndrome:Anterior vs. Posterior CirculationAnterior vs. Posterior Circulation

• Markedly different presentations.

• Anterior circulation:– Sx (motor, sensory) on the same body side

– Sx contralateral to the side of the CVA

– Visual field deficits, gaze abnormalities

– Aphasia, dysarthria, apraxia


To Identify a Stroke Syndrome:To Identify a Stroke Syndrome:Anterior vs. Posterior CirculationAnterior vs. Posterior Circulation

• Posterior circulation:– Minimal (transient) motor abnormality– Marked sensory (LT, pinprick) abnormality– Visual abn, oculomotor palsy– Ataxia, hemiballism

• Vertebrobasilar system:– CN, body motor deficits on alternating sides– Hemiparesis, hemiplegia, dizziness, dim vision,

dysarthria, dysphagia, vomiting


Rationale for a Directed Neuro Exam:Rationale for a Directed Neuro Exam:Cerebellar HemorrhageCerebellar Hemorrhage

• A specific clinical presentation:– Nausea, vomiting, central vertigo– Headache, nuchal rigidity– Syncope, ataxia, inability to ambulate– AMS when brainstem is compressed– Pathologic respiratory pattern

• A true surgical emergency (evacuation).

• Often difficult to detect on CT.


Rationale for a Directed Neuro Exam:Rationale for a Directed Neuro Exam:Brain Stem LesionBrain Stem Lesion

• A specific clinical presentation:– Markedly abnormal vital signs

– Altered mental status, often coma

– Pupillary abnormalities

– Abnormal respirations

– Often with the need for immediate intubation

• A picture of critical illness


Rationale for a Directed Neuro Exam:Rationale for a Directed Neuro Exam:Spinal Cord LesionSpinal Cord Lesion

• Injury with unilateral or bilateral findings– Complete spinal cord injury– Partial syndromes

• Central, anterior, Brown-Sequard• Cauda equina

• Tumor, abcess, epidural hematoma

• Disc disease/acute herniation

• No Hx, Px findings that suggest a CVA


Rationale for a Directed Neuro Exam:Rationale for a Directed Neuro Exam:To ID Stroke Precipitant/EtiologyTo ID Stroke Precipitant/Etiology

• What is the etiology of the stroke?

• What findings suggest the need for a specific Rx or further Dx testing?

• Four stroke etiologies are noted:– Thrombotic (atherosclerosis)– Embolic – Hemorrhage– Subarachnoid hemorrhage


To ID Stroke Precipitant/Etiology:To ID Stroke Precipitant/Etiology:Findings Suggesting Embolic CVA Findings Suggesting Embolic CVA

• Most often anterior circulation process

• Abrupt Sx onset, worst deficit at onset

• Carotid bruit: carotid artery occlusion and source of embolism

• A Fib: embolism source of MCA stroke

• Heart murmur: valve pathology, embolism


To ID Stroke Precipitant/Etiology:To ID Stroke Precipitant/Etiology:Findings Suggesting Thrombotic CVA Findings Suggesting Thrombotic CVA

• Most often posterior circulation process

• Gradual Sx onset, stepwise deficit

• Carotid bruit: evidence of atherosclerosis

• LV Heave: cardiac hypertrophy

• Aorta: AAA indicated vasculopathy

• Extremities: poor pulses, atherosclerosis


To ID Stroke Precipitant/Etiology:To ID Stroke Precipitant/Etiology:Findings Suggesting Hemorrhagic CVA Findings Suggesting Hemorrhagic CVA

• Impaired consciousness key element

• Abrupt Sx onset, usu max deficit early

• HTN, bradycardia

• Papilledema, hemorrhages


To ID Stroke Precipitant/Etiology:To ID Stroke Precipitant/Etiology:Findings Suggesting Subarachnoid Findings Suggesting Subarachnoid

• Impaired consciousness key element

• Varied Sx onset and deficit progression

• Severe headache, neck stiffness

• Retinal hemorrhages

• Meningismus


Rationale for a Directed Neuro Exam:Rationale for a Directed Neuro Exam:To Determine Further Dx TestsTo Determine Further Dx Tests

• Very few further tests in the ED:– EKG for dysrhythmia– CXR to rule out tumor, CHF– Contrast Head CT for abcess, tumor– Angiography for suspected SAH, aneurysm– CT, US for suspected large AAA– ECHO for suspected acute cardiac lesions

• MRI, other tests rarely indicated


Rationale for a Directed Neuro Exam:Rationale for a Directed Neuro Exam:To Determine ED TherapiesTo Determine ED Therapies

• Very few specific ED therapies.

• Embolic, thrombotic CVAs:– ASA, Heparin, tPA

• Hemorrhagic CVA– Mannitol, decadron, phenytoins

– Operative intervention

• Subarachnoid hemorrhage– Nimodipine, ?? OR


Rationale for a Directed Neuro Exam:Rationale for a Directed Neuro Exam:To Allow for Proper DocumentationTo Allow for Proper Documentation

• What was the clinical state of the pt when in our ED, and under our care?

• Did we complete exam sufficient to direct Rx that would optimize this pt’s care?

• Did our clinical Rx follow our exam?

• If necessary, could a NIHSS score be assigned in retrospect


Acute Stroke: Historical ElementsAcute Stroke: Historical Elements

• When did symptoms begin? Onset?

• Prior history of similar symptoms?

• When was the patient last seen normal?

• Risk factors?

• Medical hx that would preclude tPA use?


Acute Stroke: Physical ExamAcute Stroke: Physical Exam

• Vital signs, pulse ox, accucheck

• HEENT: Pupils, papilledema, airway

• Neck: Bruits, nuchal rigidity

• Chest: Rales (CHF, aspiration)

• Cardiac: Gallop, murmur, dysrhythmias, ventricular heave


Acute Stroke: Physical ExamAcute Stroke: Physical Exam

• Abd: Evidence of AAA• Ext: Evidence of CHF, DVT, vascular Dx• Skin: Evidence of infectious etiology• Neuro: Mental status, CN, eye exam,

motor, sensory, reflexes, cerebellar, visual, language,

neglect


Neurologic Exam: Mental StatusNeurologic Exam: Mental Status

• Level of consciousness (AVPU)– Alert– Responds to verbal– Responds to painful– Unresponsive

• Glasgow Coma Scale (GCS) score– Designed for trauma, TBI– Still is a reproducible, systematic scale

• Delirium: AMS, inappropriate, wax/wane


Neurologic Exam: Cranial NervesNeurologic Exam: Cranial Nerves

• Cranial Nerves: Anterior vs. posterior?– Anterior: CN, body deficits on same side– Posterior: CN and body deficits are on

opposite sides of the body (alternating hemiplegia)

• Face motor, sensory (LT) only• Gag reflex (intubation)• Eye Closure (Bell’s palsy)


Neurologic Exam: Eye ExamNeurologic Exam: Eye Exam

• Pupils: location of brain stem lesion

• EOM: CN palsies, often not due to CVA

• Vertigo: assists with DDx of CVA


Neurologic Exam: MotorNeurologic Exam: Motor

• Motor: upper & lower extremities– Upper: Pronator drift, hand grasp

– Lower: Leg lift, foot push on hand


Neurologic Exam: SensoryNeurologic Exam: Sensory

• Sensory: Light touch OK, pinprick ??

• No other sensory testing is indicated unless a posterior circulation infarct or a spinal cord syndrome is suspected

• No heat, vibration, proprioception


Neurologic Exam: ReflexesNeurologic Exam: Reflexes

• Suggest UMN control of LMN – Corneal, gag, DTRs all are normal

– Pathologic reflexes• Babinski, Chadduck• Clonus

• Unclear whether or not these add to our overall impression of CVA severity


Neurologic Exam: CerebellarNeurologic Exam: Cerebellar

• Truncal ataxia perhaps useful

• Ataxic gait, Rhomberg: No

• Extremity tests not useful in paralysis– Past-pointing

– Hand alternating movements


Neurologic Exam: VisualNeurologic Exam: Visual

• Visual field deficit

• Homonomous hemianopsia– Neglect of one side

– Preferential gaze


Neurologic Exam: LanguageNeurologic Exam: Language

• Dysarthria: Poor speech, motor dysfunction

• Aphasia: Disturbed language processing– Expressive: can’t speak– Receptive: can’t process the spoken word


Acute Neurologic Exam AnswersAcute Neurologic Exam Answers• The Hx should lead to a provisional Dx.• The Px exam should detect co-morbidity and

suggest the stroke etiology. • The neuro exam should confirm the Dx. • Few exam findings specifically direct Rx or direct

outcome.• AMS, coma are the most important findings. • The NIHSS directs your neuro exam. • Standardization of your document is key.


Acute Ischemic Stroke H & P:Acute Ischemic Stroke H & P:Some Practical AnswersSome Practical Answers

• The exam directs us to a provisional Dx.

• We do localize the lesion by identifying the provisional stroke syndrome.

• The CT will identify a large ICH or ischemic stroke, but many times the CT is negative, in which case the exam is key.

• Completing all parts of the neuro exam is not necessary, use it to confirm your Dx.


Neuro Exam: Internet SitesNeuro Exam: Internet Sites

• Search engine: Google

• Key words: Neurologic Exam

• Some web sites:– www.medinfo.ufl.edu/year1/bcs/clist/neuro.html

– www.dundee.ac.uk/medicine/StrokeSSM/ClinExamNeuro.htm


Neurologic Exam: NIH Stroke ScaleNeurologic Exam: NIH Stroke Scale

• 13 item scoring system, 7 minute exam • Integrates neurologic exam components• CN, motor, sensory, cerebellar, visual,

language, LOC• Maximum score is 42, signifying severe stroke• Minimum score is 0, a normal exam• Scores greater than 15-20 are more severe


NIH Stroke Scale: Important QuestionsNIH Stroke Scale: Important Questions

• Which elements are consistently collected?

• Which correlate with outcome?

• Which improve with tPA?

• Which suggest a complicated tPA course?

• Which parts overlap with one another?


NIH Stroke Scale: Practical SuggestionsNIH Stroke Scale: Practical Suggestions

• Know the general categories of the NIHSS

• Let these 7 areas guide your exam

• Know how to score an approximate NIHSS

• Go to the web to score your exam fully


NIH Stroke Scale: Internet CalculatorNIH Stroke Scale: Internet Calculator

• Allows calculation on-line • Will add values, provide total• http://info.med.yale.edu/

neurol/Residency/nihss.htm• Other sites:

– www.stanford.eud/group/neurologystroke.nihss.html– www.thebraincentre.org/NIHSS/NIHSS.htm


Neuro Exam in Stroke: DocumentationNeuro Exam in Stroke: Documentation

• Know the key elements of provisional Dx

• Use Hx and Px to support your Dx

• Document pertinent positives, negatives

• State neuro exam in terms of the NIHSS 7


Neuro Exam in Stroke: DocumentationNeuro Exam in Stroke: Documentation

• State exactly what you did– CN: face motor- ok eye closure, mouth, tongue– Cerebellar: no truncal ataxia with sitting

• State findings in terms of a clinical entity– Weakness, aphasia c/w L anterior circ CVA– Cerebellar findings not c/w cerebellar CVA


Neuro Exam Documentation: Neuro Exam Documentation: An Example from a Real Case (Hx)An Example from a Real Case (Hx)

• Date: XXXX 530 exam• 57 yo male• Per CFD, thru interpreter• Pt was at friend’s house, attempted to stand

up, could not due to weakness• C/o mild headache now• No trauma


Neuro Exam Documentation: Neuro Exam Documentation: An Example from a Real Case (Hx)An Example from a Real Case (Hx)

• ? Hx HTN ? Meds ? compliance

• No recent illness

• No other c/os

• The exact time of these events is not as of yet determined


Neuro Exam Documentation: Neuro Exam Documentation: An Example from a Real Case (Px)An Example from a Real Case (Px)

• Pt alert, NAD, VS noted

• Head: pup EOM OK– + neglect of L visual field

– + mouth droop L

– + tongue dev to L

– + slurred speech

– Airway OK



• Neck: supple, - bruit

• Chest: clear BSBE

• Cor: reg s

• Abd: soft, nt

• Ext: nt

• Neuro:



• LOC: alert, responds to verbal stim • Visual: L visual field neglect, dec EOM to L• Motor: flaccid L arm, no use of L hand• Cerebellar: no truncal ataxia• Sensation: ? grossly nml to light touch

except affected extremity• Language: Dysarthria, slurred speech• CN: mouth droop/tongue/loss of L sh shrug

c/w CN motor weakness



• Approx NIHSS:– LOC 0 visual 2

– CN 2 motor 3

– Sens 1 neglect 1

– Dysarthria 1 language 1

• Approx total: 11


Neuro Exam Documentation: Neuro Exam Documentation: An Example from a Real Case (MDM)An Example from a Real Case (MDM)

• Plan: – w/u, including CT– Neuro consult– Contact witness to det exact time of sx onset

• Imp: Acute CVA with L sided sx• Dx: CT shows parietal bleed• Will Rx per neurosurg, admit ICU, stable


tPA in Acute Ischemic Stroke:tPA in Acute Ischemic Stroke:Clinical & Documentation IssuesClinical & Documentation Issues

• Document that tPA was considered• If not used, state explicitly why the pt did

not meet criteria or why it was deferred• When explaining, tell the four key points:

– 30% greater chance of good outcome– 10 fold greater risk of bleeding– Same mortality rate, despite bleeding risk– Explain why mortality is comparable


Clinical Case: Physical ExamClinical Case: Physical Exam On exam, BP 116/63, P 90, RR 16, T 98, and pulse oximetry

showed 99% saturation. The patient appeared alert, and was able to slowly respond to simple commands. The patient had a patent airway, no carotid bruits, clear lungs, and a regular cardiac rate and rhythm. The pupils were pinpoint, and there was neglect of the R visual field. There was facial weakness of the R mouth, and R upper and lower extremity motor paralysis. DTRs were 2/2 on the left and 0/2 on the right. Planter reflex was upgoing on the right and downgoing on the left. The patient’s estimated weight was 50 kg.


Acute Ischemic Stroke:Acute Ischemic Stroke:Case ManagementCase Management

• Complete directed H&P, with neuro exam

• Get the CT scan ASAP

• Call PMD, family, neurologist

• Find out the CT results

• Decide risk/benefit

• Discuss with pertinent decision makers


Acute Ischemic Stroke:Acute Ischemic Stroke:Clinical Case: CT ResultsClinical Case: CT Results


Acute Ischemic Stroke:Acute Ischemic Stroke:Clinical Case: ED ManagementClinical Case: ED Management

• CT: no low density areas or bleed

• No clear contra-indications to tPA

• NIH stroke scale: 20-26

• Neurologist said OK to treat

• No family to defer tPA use

• tPA administered without comp


Acute Ischemic Stroke:Acute Ischemic Stroke:Clinical Case: tPA & Repeat ExamClinical Case: tPA & Repeat Exam

• tPA dosing:– 8:21 pm, approx 1’45” after CVA sx onset– Initial bolus: 5 mg slow IVP over 2 minutes– Follow-up infusion: 40 mg infusion over 1 hour

• Repeat exam at 90 minutes:– Repeat Px Exam: Increased speech & use of

R arm, decreased mouth droop & visual neglect– Repeat NIH stroke scale: 14-20


Acute Ischemic Stroke: Acute Ischemic Stroke: Hospital Course & DispositionHospital Course & Disposition

• Hospital Course: No hemorrhage, improved neurologic function

• Disposition: Rehab hospital• Deficit: Near complete use of RUE,

speech & vision improved, some residual gait deficit


Neurologic Exam in Stroke: Neurologic Exam in Stroke: ConclusionsConclusions

• The exam can and should be streamlined• Focus on the provisional Dx• Attempt to determine etiology, Dx, Rx• Document in a brief, systematic manner• State exactly what you did, how the

findings relate to your provisional Dx and Rx


Neurologic Exam in Stroke: Neurologic Exam in Stroke: RecommendationsRecommendations

• Know syndromes, focus neuro exam

• Learn to calculate an approximate NIHSS

• Document completely, but streamline

• Generalize this to process to your care of patients with other neuro emergencies

• Optimize outcome and your practice

QuestionsQuestions?? ??

Edward Sloan, MD, MPHEdward Sloan, MD, MPH

[email protected] 413 7490312 413 7490

How to Complete a Clinically Relevant & Directed Neurologic Exam in ED CVA Patients Edward Sloan,...

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