neurological examination of icu patients -...

NEUROLOGICAL EXAMINATION OF ICU PATIENTS

[email protected] Université de Versailles

Institut Pasteur Hôpital Raymond Poincaré

Garches - France

mailto:[email protected]

NEUROLOGICAL EXAMINATION • Component of the « localizing" approach

– Differentiate central from peripheral nervous disorders

– Spinal cord vs brainstem vs hemisphere – Motoneuron, nerve, NMJ and muscle

• Component of the « diagnosis » approach – Acute vs chronic course – Inflammatory (exacerbation) vs degenerative

(progressive) course – Congenital vs acquired disorders

• Component of the prognosis assessment

NEUROLOGICAL EXAMINATION

It is necessary for indicating and interpreting the complementary biological, neuroradiological and neurophysiological investigations


Admission 1. Neurological disease as cause for admission 2. Preexisting neurological disease (interpretation

of subsequent neurological complication)

Critical illness 1. Detection of ICU-neurological complication 2. Prevention of ICU-neurological complication

Recovery of critical illness

1. Diagnosis of ICU-neurological complication 2. Treatment of ICU-neurological complication

Discharge 1. Follow-up of ICU-neurological complication

CENTRAL NERVOUS SYSTEM

EPIDEMIOLGY

• Present in 25-60% of ICU patients • Leading predictor of

– Death – Length of mechanical ventilation – LOS

• Coma assessment (GCS) is an integral component in the most widely used intensive care scoring systems – APACHE – SAPS – SOFA

Stevens - Crit Care Med - 2006

• Comatose patients are not sleeping • Comatose patients do not speak, do not move spontaneously and do not follow

commands. • When provoked by a noxious stimulus, their eyes remain closed, vocalization is

limited or absent, and motor activity is absent or abnormal and reflexive rather than purposeful or defensive .

IMPAIRMENT OF WAKEFULNESS (absence of arousal) - Lack of eyes opening - Absence sleep-wake cycles IMPAIRMENT OF AWARENESS - Of self - Of environment

DEFINITION

NON-ORGANIC

Presence of avoidance - Blinking to threat - Do not let hand fall on his face

If any doubt, do an EEG

COMATOSE PATIENT

BRAINSTEM RESPONSES 1. Eyes spontaneous movement 2. Eyes position 3. Oculocephalogyre response 4. Oculovestibular response 5. Pupillar size 6. Pupillar light reflex 7. Corneal reflex 8. Grimace 9. Cough reflex 10. Oculocardiac response 11. Respiratory pattern

FOCAL SIGNS Comparison between right and left body 1. Motor responses to order or painful stimulation 2. Limbs tone 3. Tendon reflexes 4. Plantar reflex

Verbal response Eyes response Motor response

SCALE

MYOCLONUS 1. Limbs 2. Lids NECK STIFFNESS

APPROACH

1. Diagnosis 2. Severity 3. Causes 4. Prognosis

FOUR & GLASGOW COMA SCALES

Wijdicks et al – Ann Neurol - 2005

Patients with the lowest GCS score could be further distinguished using the FOUR score.

FOUR COMA SCORE


EYE RESPONSES

MOTOR RESPONSES

FOUR COMA SCORE


RESPIRATION

BRAINSTEM REFLEXES

COMATOSE PATIENT EYES POSITION

Wijdicks E.F.M. Plum and Posner

Skew deviation (Cajal nuclei)

Hemispheric /pons

Thalamus /mesenceph

Bilateral hemispheric

COMATOSE PATIENT

A: roving B: periodic alternating gaze (bi H., cereb.) C: ping pong (bi H., cereb.)

D: convergence nystagmus (mesenceph.) E: bobbing (pons) F: dipping (bi H.)

Wijdicks E.F.M.

PUPILS

Adapted from Plum and Posner's Diagnosis of Stupor and Coma

HERNIATION

CLAUDE BERNARD HORNER

Sympathetic nervous system

Dissection Catheter

Cancer

Spine

Medulla (Wallenberg)

78 years old woman, with hypertension and diabetes, treated by anticoagulant for an atrial fibrillatrion was referred to our ICU for a coma. Neurological examination showed: Glasgow coma scale at 7, myosi,s generalized hypotonia and a bilateral Babinski sign. Biological screening is normal, but PT of 49%.

WHAT IS IT?

She is fine, she is sleeping…

• 27/11/10 : 74 years old and aplasic patient

• 1-2/12/11 : Pneumoniae and shock (Pseudomonas Aeruginosa et Stenotrophomonas Maltophilia)

• 5/12/11 : Non sedated. The patient is sleeping…

She is fine, she is sleeping…

ALGORITHM

Fever

Medical history (Alcohol, Epilepsia…)

Circumstances (CO…) Glycemia

Imaging,

± AB ± CSF

Neck stiffness Focal sign Trauma

Imaging

Seizure

Imaging

± AB ± CSF

Imaging

± CSF

EEG, Imaging

± CSF

OUTCOMES

COMA

BRAIN DEATH

PERSISTENT COMA

VEGETATIVE STATE (VS)

MINIMALLY CONSCIOUS STATE (MCS)

NEUROPSYCHOCOGNITIVE DYSFUNCTIONS

FULL RECOVERY

GLOBAL DISORDERS OF CONSCIOUSNESS

Stevens et al – Crit Care Med - 2006

RELEVANCE FOR DETECTING MCS?

• Errors: 40% ! – Schnakers et al. Diagnostic accuracy of the vegetative and minimally

conscious state: Clinical consensus versus standardized neurobehavioral assessment. BMC Neurology. 2009

• Better prognosis??

– Luauté et al. Long-term outcomes of chronic minimally conscious and vegetative states. Neurology. 2010 juill 20;75(3):246–52.

• Important for the family

VEGETATIVE AND MCS STATUS

1. Use appropriate scale 2. Redo the examination 3. Ask a neurologist to come 4. Usefulness of complementary investigation

PROGNOSIS

Wijdicks et al Crit Care Med 2014

N=1695 ICU patients Admission for coma

Prognosis value of brainstem assessment

Wijdicks et al - Neurology 2006

PREDICTION STudies: 1966-2006 Bad outcomes: at 1 month, death o consciousness impairment or at 6 mois, consciousness impairment or severe sequellae (daily nursing)

A

B

B

B

Am

eric

an A

cade

my

of N

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NEUROLOGICAL ASSESSMENt IN POST-CA COMATOSE PATIENTS

1. Arousal 2. Consciousness 3. Focal Neurological signs 4. Brainstem reflexes 5. Myoclonia

GCS FOUR EEG

Brain death Coma Status epilepticus

Acute stage Prediction phase

Motor response Brainstem reflexes SSEP (N20) EREP (MMN) EEG (Reactivity) ±MRI

Recovery phase

1. Full neurological examination 2. Motor assessment 3. Cognitive function 4. COnfusion

CRS-R CAM-ICU/NINDS MMS Neurocognitive tests Psychological tests

Withdrawal Support Unknown

Vegetative state MCS Lance Adams Sequellae


Booth et al - JAMA 2004

DELIRIUM

DELIRIUM DSM IV A. Alteration of consciousness: decreased interaction with the environment,

attention and concentration difficulties

B. Impairment of one or more cognitive functions: – Speech – Memory – Disorientation in space and time – Thinking/judgement

C. Onset sudden or rapidly progressive, fluctuating symptoms D. Secondary to:

– Medical illness – Drugs toxicity – Withdrawal

DELIRIUM TYPES

Hyperactive delirium: agitation, restlessness, emotional lability Hypoactive delirium: withdrawal, flat affect, lethargy and decreased responsiveness

All agitated patients are not confused All confused patients are not agitated

However, there are common causes and

risk factors between agitation and delirium

DELIRIUM SCALES Sedation/Agitation : - RAMSAY - Richmond Agitation Sedation Scale (RASS) - Adaptation to the Intensive Care Unit

Environment (ATICE) Delirium : - Confusion Assessment Method for the ICU

(CAM-ICU) - Intensive Care Delirium Screening Check-list

(ICDSC)

RA

SS

CAM-ICU FLOW SHEET

Items Altered level of consciousness (if A or B, do not complete patient evaluation for the

period) A: No response, score: none B: Response to intense and repeated stimulation (loud voice and pain), score: none D: Normal wakefulness, score: 0 E: Exaggerated response to normal stimulation, score: 1 Inattention (score: 0 to 1) Disorientation (score: 0 to 1) Hallucination-delusion-psychosis (score: 0 to 1) Psychomotor agitation or retardation (score: 0 to 1) Inappropriate speech or mood (score: 0 to 1) Sleep/wake cycle disturbance (score: 0 to 1) Symptom fluctuation (score: 0 to 1) Total (score: 0 to 8)

ICU Delirium Screening Checklist

RISK FACTORS

HOST FACTORS FACTORS OF CRITICAL ILLNESS IATROGENIC FACTORS Age (older) Acidosis Immobilization Alcoholism Anemia SEDATION (opioids, bzd)

APOE4 Fever/infection/SEPSIS Sleep disturbances

(Pre) Dementia Hypotension Dehydration, dyspnea

Depression Metabolic disturbances (for example, sodium, calcium, BUN, bilirubin) Drugs toxicity

Hypertension Withdrawal syndrome

Smoking Respiratory disease/ congestive heart failure

Vision/hearing impairment High severity of illness

A 55 years old man was hospitalised for a septic shock. Blood culture were positive to Staphylococcus aureus and CSF analysis showed an aseptic meningitis. At admission, neurological examination was normal as well as MRI of the brain and spine. Transoesophageal cardiac ultrasound only showed a thrombus in the left atria. He also underwent surgery for a septic arthritis of the right knee. A right jugular catheter could not be put. A goitre was also noticed. Vasopressor and mechanical ventilation were discontinued the 3rd and 5th days from admission. The patient was treated with methicillin and heparin. Day 8, the patient developed agitation and delirium. Neurological examination showed a weakness of the right arm and slight right central facial palsy as well a ptosis and miosis of the right eye. The right arm was also oedematous. The brain CT scan and CSF analysis were normal. EEG showed a slow cortical activity. Biochemical screening showed a moderate renal insufficiency. Blood culture were negative.

CASE REPORT 2

CASE REPORT 2

1. Left pre-rolandic lesion 2. Thrombosis of right jugular vein 3. Orbenin overdose

CASE REPORT

• Mme X…, 53 years old, traited with CS et I- for LED, is admitted for ARF related to a thrombotic microangiopathy. Occurrence of a hyperactive delirium: « on me vole mon enfant, les médecins me vole mon enfant… »

NEUROLOGICAL EXAMINATION OF SEDATED

PATIENTS

EFFECTS OF SEDATION

• Most severe critically ill patients often require sedation

• Sedation is a risk factor for brain dysfunction (delirium or delayed awakening) and can mask the occurrence of a brain dysfunction

• How to detect acute brain dysfunction in sedated critically ill patients?

DESIGN

[12-24h] Every day Discontinuation of sedation

1st N.E N.E Coma/Delirium

Within 3 days

Reproducibility of neurological examination was satisfactory

Sharshar et al – Crit Care Med – 2011

Non brain injured critical ill patients

NEUROLOGICAL ASSESSMENT

BRAINSTEM RESPONSES 1. Eyes spontaneous movement 2. Eyes position 3. Oculocephalogyre response 4. Pupillar size 5. Pupillar light reflex 6. Corneal reflex 7. Grimace 8. Cough reflex

FOCAL SIGNS Comparison between right and left body 1. Motor responses to order or painful stimulation 2. Limbs tone 3. Tendon reflexes 4. Plantar reflex

Verbal response Eyes response Motor response

GLASGOW COMA SCALE

NEUROLOGICAL EXAMINATION 12-24H OF SEDATION Fitting set Validation set Number of patients 72 72 Midazolam (mg/kg) 0.9 (0.6 to 1.8) 1.3 (0.8 to 2.0) Subfentanyl (µg/kg) 2.0. (0.8 to 4.0) 2.0 (0.7 to 4.6) sedation to inclusion (hours) 12 (12-24) 12 (12-24) ATICE (from 0 to 20) 9 (9 to 10) 9 (9 to 10) RASS Not tested -4 (-4 to -2) Blinking to strong light (%) 31 (43) 28 (39) Absent eye movement (%) 66 (93) 67 (93) Myosis (%) 45 (63) 38 (54) Pupillary light response (%) 51 (71) 58 (82) Corneal reflex (%) 65 (90) 66 (92) Oculocephalic response (%) 32 (47) 33 (46) Cough response (%) 36 (51) 60 (83) Grimacing (%) 41 (57) 48 (69)

Multiple logistic model

28-DAYS MORTALITY

Sharshar et al – Crit Care Med - 2011

Fitting set Validation set

OR (95%CI) P OR (95%CI) P SAPS-II at inclusion 1.06 (1.02 to 1.09) 0.003 1.03 (1.00 to 1.07) 0.051 Absent cough response 7.80 (2.00 to 30.4) 0.003 5.44 (1.35 to 22.0) 0.017 C-index (SE) 0.836 (0.055) 0.743 (0.067)

RESPONSES ASSESSED BETWEEN THE 12Th AND 24th H OF SEDATION

ALTERED MENTAL STATUS (after discontinuation of sedation)

Fitting set Validation set

Criteria Confusion or coma Delirium or coma OR (95%CI) P OR (95%CI) P

SAPS-II at inclusion 1.04 (1.00 to 1.07) 0.058 1.03 (0.99 to 1.08) 0.10

Absent oculocephalic response 4.49 (1.34 to 15.1) 0.015 5.64 (1.63 to 19.5) 0.006

RESPONSES ASSESSED BETWEEN THE 12Th AND 24th hours of sedation

Multiple logistic model



1. Feasible, reproducible and interpretable 2. Enables to detect focal neurological sign 3. Enables to estimate critical illness severity (cough

reflex) 4. Enables to identify patient at risk to develop

delirium after sedation discontinuation (Oculocephalogyre response) – Titration of sedation?


SYNDROMIC APPROACH

0

20

40

60

80

100GCS Eyes response

GCS Motorresponse

Myosis

Pupillar lightreflex

Corneal reflex

Oculocephalogyrereflex

Grimace

Cough reflex

Class AClass B

Abolition of brainstem reflexes is not at random Do not correpond to: 1. Particular lesion of the BT 2. To a reported BT syndrome Do not in agreement with 1. Jacksonian paradigm

Rohaut et al - Submitted

Abolition of oculocephalic response

Neuronal apoptosis of LC

Multifocal necrotizing leukoencephalopathy

Death

Abolition of cough reflex

Impaired HR/BP variability

Neuronal apoptosis

RAAS dysfunction Delirium

Maladaptative immune response

Autonomic dysfunction Hemodynamic

failure

CONCEPT OF BRAINSTEM DYSFUNCTION

Sharshar et al – CCM – 2002; Sharshar et al – Lancet – 2004; Pandharipande et al – CC -2011; Annane et al – AJRCCM – 1999; Tracey et al – Nature Review Neuroci

Inf cerebellar peduncle

XII nerves Vestibular n.

Spinothalamic tract

Noyau ambiguus IX/X

Sympathetic fibers

Corticospinal tract

- Medial Lemniscus

- Sympathetic fibers - Facial nerve

- Nerve VIII

- Spinothalamic tract

- Trigeminal Nerve

- Medial longitudinal fascilulus

- Cortico spinal tract - Cerebellar connections

Red nucleus

Medial lemniscus

Spinothalamic tract

Cortico spinal tract

BRAINSTEM SYNDROMES

Pons

Midbrain

Medulla

CASE REPORT A 65 years old man was hospitalised for

an acute respiratory failure that required invasive mechanical ventilation and sedation. Respiratory failure was ascribed to amiodarone interstitial pneumonia, which was given with anticoagulant a month ago for an atrial fibrillation. He had also a severe arteritis and coronary disease.

A week later, while the patient was

ventilated and lightly sedated, neurological examination showed no response of the left arm to painful stimulation, a greater hypotonia of the left arm and leg but also a decreased contraction of the right face to painful stimulation and right ptosis with small pupil.

Weakness

Facial palsy

CASE REPORT

Three days after discontinuation of sedation, the patient developed agitation and delirium. General and neurological examination was not changed. EEG was normal. Agitation and delirium was ascribed to discontinuation of sedation. Three days later, patient complained of pain of the legs and ankles that turned to be due to bacterial and ischemic myositis.

DELIRIUM WITHOUT (new) FOCAL NEUROLOGICAL SIGN IN A RECENTLY NON SEDATED PATIENT

CASE REPORT

Abolition of the left patellar reflex in 72 years old man who needed to be sedated for a very severe ARDS

Non sedated

EXAMINATION Normal

Focal sign

Delirium Agitation

Coma

Myoclonus

Brain imaging

EEG - Biochemistry - Drugs Brain imaging

EEG - Biochemistry - Drugs Brain imaging

Biochemistry - Drugs Brain imaging EEG

LUMBAR PUNCTURE IF ANY DOUBT

UNCONTROLLED SEPSIS?

Sedated

Discontinuation of sedation

What strategy?

Sedation necessary

Monitoring

Antagonist?

SPINAL CORD SYNDROMES

Syringomyelic

Complete transection

Brown Séquard Anterior spinal artery

Posterior spinal artery

Subacute combined degeneration

ALS

Poliomyelitis

PERIPHERAL NERVOUS SYSTEM

PERIPHERAL NERVOUS SYSTEM Neurono -

neuropathy Neuropathy Myasthenic

syndrome Myopathy

Symmetry Bilateral ± symmetrical

Variable MM: asymmetrical

PN: symmetrical PRN: symmetrical

Bilateral and symmetrical

Bilateral and symmetrical

Proximal vs distal

Proximal or distal

MM: distal PN: distal

PRN: proximal

Proximal ++

Proximal ++

Topography

Limbs, Bulbar,

respiratory

MM: ≥ 1 nerve PN: limbs ± respiratory

PRN: limbs, trunk, bulbar, facial,

respiratory

Variable Limbs, facial,

bulbar, trunk or respiratory Ptosis (often

unilateral) and diplopia

Variable

Limbs, facial, bulbar, trunk,

respiratory

MM: mononeuropathy multiplex; PN: polyneuropathy; polyradiculoneuropathy


Neurono- Neuropathy

Neuropathy Myasthenic syndrome Myopathy

Tone flaccidity flaccidity flaccidity flaccidity

Tendon reflexes Lost or

pyramidal signs (ALS)

Lost or decreased Preserved Preserved

Idio-muscular response Preserved Preserved Preserved Absent

Atrophy Pronounced Pronounced No Variable

Other motor signs Fasiculation - Fatigability Fluctuation

Myalgia Myotonia

Other neurological signs Cramps

± sensory loss ± dysautonomia

No sensory loss (except L.

Eaton) No sensory loss


A 67 years old man, without pre-existing neurological disease and who was referred to our ICU for a severe ARDS and septic shock complicated by multiple organ failure developed a flaccid quadriplegia. There was no Babinski sign, fasiculations or evidence for a sensory deficit. Tendon reflexes were abolished. Examination of cranial nerves was normal. There was diffuse edema. The patient had been treated by steroids and neuromuscular blocking agent.

?

MRC SUM SCORE

Kleyweg et al. - Muscle Nerve - 1991 0

60

48

36

Pare

sis

Nor

mal

Se

vere

DETECTION Advantages Inconvenients

CLINICAL EXAMINATION

(ICU-AP)

Simple Relevant

Due to CINM

Awareness Delayed

diagnosis

ENMG (CIP/CIM/CINM)

Neuropathy Myopathy

Early detection

Availability Artefacts

Correlation?

Muscle biopsy (CIM)

Myopathy Physiopathology

Invasive

Other techniques: ultasound, MRI

SEMIOLOGY

• Weakness – Bilateral et symmetric – Four limbs – Essentially proximal – Sparing the face

• ± sensory deficit • ± Areflexia • ± Amyotrophic

RIGHT LEFT

SHOULDER

ELBOW

WRIST

HIP

KNEE ANKLE

0,0 0,5 1,0

1,5 2,0

2,5

3,0

3,5

4,0

4,5

5,0

NM score

De Jonghe et al JAMA 2002

CSF: not helpful CK: normal, slightly or highly increased (Status asthmaticus)

ICU-ACQUIRED PARESIS

Frequent and severe complication associated with 1. Increased mortality 2. Prolonged weaning and reintubation 3. Increased length of stay in ICU 4. Disability

ENTRAPMENT NEUROPATHY

Peroneal nerve

Radial nerve

Hypoesthesia in green area

Hypoesthesia

University of Versailles Raymond Poincaré

Service de Réanimation Pr Djillali Annane

MERCI

Institut Pasteur Fabrice Chrétien

Human Histopathology and Animal Models

DIFFERENTIAL DIAGNOSIS OF PARAPLEGIA

Areflexic and flaccid paraplegia

Think about injury of the spinal cord, conus medullaris syndrome or a cauda equina syndrome, especially if there is a sensory level, urinary retention or pelvic hypoesthesia

Doubt: usefulness of MRI, electrophysiological testing

neurological examination of icu patients -...

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