Title text

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Neurological Assessment Objectives

• To present the rationale for a focused
  neurological assessment
• To present the components of a two minute
  neurological assessment
• To present the components of a focused
  neurological assessment
• To review three assessment scales used in stroke

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Focused Neurological Assessment

• History
• Stroke onset, risk factors and symptoms
• General Medical Assessment
• Associated conditions, etiology, additional
  investigations
• Neurological Examination
• Localizes the lesion, exclusion of other symptoms
• Rules out stroke mimics
• Suggests provisional diagnosis
• Determines additional investigations
• Determines management care plan

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Localization

• Hemisphere
• Anterior circulation
• Posterior circulation
• Cerebellum
• Brain Stem
• Spinal Cord
• Peripheral Neuropathy
• Muscle

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History

• History
• Time of symptom onset
• Accurate time of symptom onset is critical
• Obtain from patient or person present when the
  patient was last seen normal
• Associated features
• Seizure, loss of consciousness

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General Medical Assessment

• ABC airway, breathing, circulation
• Blood Pressure
• tPA candidates lt185/110mmHg
• Non tPA candidates 220/120mmHg
• Pulse irregularity may indicate atrial
  fibrillation
• Temperature gt37.5C is an independent predictor
  of poor outcome
• Blood glucose hyperglycemia associated with
  worse stroke outcomes
• General system screen

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2 Minute Neurological Examination

• Assess
• Pupils, fundi, visual fields, extraocular
  movements
• Ask patient to
• Show me your teeth, say ah and stick out your
  tongue
• Assess
• Facial sensation
• Muscle tone and strength
• Sensory function
• Reflexes
• Coordination

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Neurological Assessment

• Level of consciousness
• Screening for aphasia
• Cranial Nerve assessment
• Motor function
• Coordination and gait
• Reflexes
• Sensory function

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Level of Consciousness

• Most ischemic stroke patients are conscious
• Assessment of level of consciousness
• Ask the patient
• What month is it?
• How old are you?
• Response to commands
• Ask patient to open and close their fist
• Ask patient to open and close their eyes

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Screening for Aphasia

• Aphasia loss of ability to use written and oral
  language
• 25 of stroke survivors
• 50 of individuals with left hemisphere strokes
• Bedside screening includes
• Comprehension
• Expression naming
• Repetition
• Reading
• Dysarthria

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Cranial Nerves Funduscopic Examination Optic (II)
www.heartandstroke.ca/profed
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Cranial Nerves Visual Fields Optic (II)
www.heartandstroke.ca/profed
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Cranial Nerves Pupillary Response Optic (ll)
and Oculomotor (lll)

• Assess size prior to light
• Elevation of eyelid

www.heartandstroke.ca/profed
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Cranial Nerves Extraocular Movements Oculomotor
(III), Trochlear (IV), Abducens (VI)
www.heartandstroke.ca/profed
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Cranial Nerves Facial Sensation Trigeminal (V)
www.heartandstroke.ca/profed
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Cranial Nerves Facial Strength Facial (VII)
Smile, show your teeth, lift your eyebrows
www.heartandstroke.ca/profed
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Cranial Nerves Palate and Tongue
Glossopharyngeal (IX),Vagus (X)
Ask patient to say ah
www.heartandstroke.ca/profed
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Motor Function Tone and Strength
Ask patient to close eyes, arms extended with
palms upward
www.heartandstroke.ca/profed
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Neurological Assessment Coordination and Gait
Heel-to-shin test
Finger-Nose-Finger test
www.heartandstroke.ca/profed
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Neurological Assessment Reflexes
Deep tendon reflex exam
Plantar reflex exam
www.heartandstroke.ca/profed
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Stroke ScalesNational Institute of Health
Stroke Scale

• Measures
• 11 items
• Physiological deficits
• Does not measure activity, ADL or participation
  abilities
• Scoring
• Quantitative, weighted to severity
• 0-42, higher score indicative of greater
  neurological deficits
• Characteristics
• Reflects comprehensive neurological exam
• Results correlate with presenting symptoms
• Primarily suited to acute care
• Accurate, reliable and well validated
• Training required to ensure accuracy in use

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Stroke ScalesCanadian Neurological Scale

• Measures
• 6 items
• Impairment or physiological deficit
• Scoring
• 0-11.5, lower score indicative of greater
  neurological deficit
• Characteristics
• Reflects common areas related to stroke
  presentation
• Primarily used in acute care
• Used in conjunction with Glasgow Coma Scale
• Accurate, reliable, sensitive to change,
  predictive of death, reinfarction and functional
  independence at 6 months
• Training resources available from HSFO

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Stroke Scales Glasgow Coma Scale (GCS)

• Measures
• 3 items
• Level of consciousness or coma
• Scoring
• 3-15 with lower score indicative of greater
  neurological deficit
• Characteristics
• Developed as a standardized and valid tool for
  assessing level of consciousness
• Not felt to be sensitive enough for stroke
  patients who do not have impaired level of
  consciousness
• Used in conjunction with CNS if level of
  consciousness is impaired

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Conclusions

• Rapid assessment and triage key to optimal
  treatment
• CT scan required to exclude hemorrhage
• Knowledge of typical stroke symptoms key
• Anatomical and etiological diagnosis necessary
• Exclusion of stroke mimics vital

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Resources

• American Association of Neuroscience Nurses
• www.aann.org
• American Stroke Association
• www.strokeassociation.org
• Brain Attack Coalition
• www.stroke-site.org
• Canadian Hypertension Education Program
• www.hypertension.ca/chep/en/default.asp
• Canadian Stroke Strategy
• www.canadianstrokestrategy.ca
• European Stroke Initiative
• www.eusi-stroke.com

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Resources

• Heart and Stroke Foundation Prof Ed
• www.heartandstroke.ca/profed
• Heart and Stroke Foundation of Canada
• www.heartandstroke.ca
• Internet Stroke Centre
• www.strokecenter.org
• National Institute of Neurological Disorders and
  Stroke
• www.ninds.nih.gov
• National Stroke Association
• www.stroke.org/site/PageServer?pagenameHOME
• Scottish Intercollegiate Guidelines Network
• www.sign.ac.uk
• StrokeEngine
• www.medicine.mcgill.ca/strokengine

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