pearls for avoiding risk in neurological emergencies · artery 2. superior cerebellar artery 3....
TRANSCRIPT
Pearls for Avoiding Risk in
Neurological Emergencies
Andrew W. Asimos, MDMedical Director, Carolinas Stroke Network
Professor, Department of Emergency Medicine
Carolinas Medical Center
Charlotte, NC
Carolinas Stroke Network
• Research• Penumbra Inc.
• Consultant• Medtronic®
• Royalty payments• Wolters Kluwer Health | UpToDate Inc.
Disclosures
The Posterior Fossa Poses the Greatest Diagnostic Challenge
Arch et al. Stroke 2016;47:668-673.
Essential Exam Elements to Exclude Posterior Circulation Pathology
• Visual Fields• Cranial Nerves• Cerebellar testing
ED Documentation
ED Documentation
Neuro consult exam note on return visit 3 days later
TemporalNasal
Cranial Nerves
Testing Cranial NervesI Smells
II Sees (fundoscopy, acuity, pupillary response)
III-IV Move eyes; CNIII constricts pupils
V Chews & feels the front of the head
VII Moves the face, tastes, salivates, cries
VIII Hears, regulates balance
Testing Cranial NervesIX Tastes, salivates, swallows, monitors
carotid body and sinus
X Tastes, swallows, lifts palate, talks, communication to and from thoraco-abdominal viscera
XI Turns head, lifts shoulders
XII Moves tongue
Cerebellum
• Superior lateral - Limb movement• Superior midline (vermis) - Trunk movements and motor control of
speech articulation (paravermal area)• Inferior – Oculomotor control and vestibular adaptation
Essential Elements of a Thorough Cerebellar Exam
• Assess for limb ataxia• Assess for truncal ataxia• Assess oculomotor control (“eye ataxia”)
• Describe and interpret nystagmus correctly• Listen to articulation and prosody (“ataxic
dysarthria”)
Documentation of my Posterior Fossa Neuro Exam
• Visual fields full to confrontation all four quadrants
• CN – PERL, EOMI, masseter muscles strong bilaterally, face symmetric, hearing intact to finger rub, palate moves symmetrically, shoulder shrug strong and equal bilaterally, tongue midline
• Cerebellum – no dysmetria with FTN testing, steady standing and gait, no disconjugate gaze or direction changing nystagmus, articulation and rhythm of speech normal
Limitations of the NIH Stroke Scale• Should not be the “default exam” for any
suspected stroke patient
• Weighted to detecting anterior circulation pathology• Does not include gait testing
1. Posterior cerebral artery2. Superior cerebellar artery3. Pontine branches of the basilar artery4. Anterior inferior cerebellar artery5. Internal auditory artery6. Vertebral artery7. Posterior inferior cerebellar artery8. Anterior spinal artery9. Basilar artery
Vertigo: The Big Three• BPPV• Vestibular neuritis• Cerebellar/brainstem stroke
Differentiating the Big ThreeBPPV Vestibular Neuritis Cerebellar Stroke
Vertigo when still No Yes YesAble to stand unaided
Yes (but not when vertiginous)
Maybe Maybe
Spontaneous and/or gaze evoked nystagmus
No Unidirectional horizontorotary (not
purely vertical)
Various, including bidirectional
horizontorotary, sometimes vertical
Worse with head movement
Yes Yes Yes
Other neurologic symptoms or findings
No No Often, but not always
Differentiating the Big ThreeBPPV Vestibular Neuritis Cerebellar Stroke
New hearing loss No No RarelyAppropriate forDix-Hallpike
Yes No No
Appropriate for HINTS plus
No Yes Yes
Results from HINTS plus
All four of the following:• Unidirectional
nystagmus• No vertical Skew• Abnormal HIT• No hearing loss
Any of the following:• Birectional
nystagmus• Vertical skew• Normal HIT• New hearing loss
Brain Stem Arteries - Anterior View 1. Posterior cerebral
artery2. Superior
cerebellar artery3. Pontine branches
of the basilar artery
4. Anterior inferior cerebellar artery
5. Internal auditory artery
6. Vertebral artery7. Posterior inferior
cerebellar artery8. Anterior spinal
artery9. Basilar artery
Components of Language Testing• Comprehension• Naming• Fluency• Repetition
Speech Disturbance:Factors Favoring Conversion vs Organic Pathology
CONVERSION➢ Antecedent stress➢ Psychiatric history➢ Stuttering
ORGANIC PATHOLOGY➢ Anomia➢ Paraphasic error➢ Perseveration
OVERLAY
Schuster JP et al. Encephale 2011;37(5):339-44.Mahr G and Leith W. Journal of Speech & Hearing Research 1992;35(2):283-6.
Acute “Numb and Tingly” M&M• Guillain-Barre Syndrome• Spinal Cord Process• Stroke• Heavy Metal Poisoning• Marine Toxins• Tick-Borne Diseases
Sensory Exam - GBS• Despite a frequent history of paresthesias
of the hands and feet, usually minimal objective sensory loss
• Deficits in position and vibratory sense
• 25 / 3,628 first-time patients included in the Lausanne Stroke Registry
• 18 with contralateral paresthesias
• Sensory symptoms or signs were the only clinical abnormality
Motor Neuron Neuroanatomy
• UMN - Cortex to the lateral column of the spinal cord
• LMN - Anterior column to the motor end-plate
Upper vs Lower Motor Neuron Weakness
Clinical UMN LMN Reflexes Muscle tone Fasciculation None Present Atrophy None Severe Babinski sign Present Absent
Core Concepts• Essential exam elements to exclude posterior circulation
pathology• Visual Fields• Cranial Nerves• Cerebellar Testing
• Assess for limb, truncal, eye, and speech ataxia
• Assess comprehension, naming, fluency, and repetition to thoroughly assess speech
• If bilateral paresthesias, test reflexes
• Document meaningfully
Questions