Essential Elements of the Neuro Exam Your Guide: JJ Baumann, MS, RN,CNS The brain is the last and grandest biological frontier, the most complex thing we have yet discovered in our universe. It contains hundreds of billions of cells interlinked through trillions of connections. The brain boggles the mind. ~ James D. Watson (from Discovering the Brain, National Academy Press, 1992) Why know what’s inside? • Direct what to look for in the neuro exam • Impact be on the patient’s life • Location of lesion • Type of lesion – Anatomical: trauma – Physiologic: metabolic, infectious – Conductive: epileptic The Hard Candy Shell Meninges • Collective term for covering of brain • Attached brain to bony structures • Supports • Protects • Encloses Name this tumor! • Dura Mater – covers all of brain • Arachnoid Mater – thin, clear, avascular, houses CSF • Pia Mater – gives brain shape, forms sulci and gyri Name that bleed! Usually caused by a blow to the temporal area Caused by tearing of arteries (esp medial meningial) Bleeds fast Pt has labile alertness Above the dura Name this bleed! Can by sudden or gradual Caused from the break in bridging veins Seen in very young and very old Bleed is under the dura Name that bleed! Usually occurs while straining on the toilet or post coital 75% caused from a cerebral aneurysm Pt complains of the worst HA of their entire life Bleed is below the arachnoid space The Soft Center Frontal Lobe • • • • • • Extends all the way to the central sulcus Judgment, personality, and reasoning Initiates motor function Bowel and bladder Broca’s speech Long term memory (phone #s) Summary – this lobe makes you acceptable to be in public. Temporal Lobe • • • • • Lobe sits in sphenoid bone Wernickes speech area 1º hearing - listening to voice 2º hearing - interpretation of voice Short term memory Summary: Husbands have temporal lobe damage. Parietal Lobe • Posterior central sulcus • Processes tactile stimulation to modulate movement • Stereognosis (recognize object by feeling size and shape) • Two point discrimination Summary: Robots do not have parietal lobes! Occipital Lobe • 1º vision – see object • 2º vision – interpret / relate to previous experience Summary: Mom does see out the back of her head! Cerebellum Helps provide smooth, coordinated body movements. • Tremors. • Nystagmus (Involuntary movement of the eye). • Ataxia, lack of coordination. Brain Stem • Midbrain – CN 3 & 4 • Pons – Pontine pupils, respiratory drive CN 5 - 8 • Medulla - Crossing of motor tracts. Cardiac and Vasomotor Center Respiratory Center CN 9-12 Alzheimer’s Progressive memory loss. Declining interest in people and environment. Episodic bouts of irritability. Neglects personal hygiene. What lobes are effected? Michael J. Fox, actor (quoted in People magazine, December 7, 1998, p. 135; talking about his surgery for Parkinson's disease) They did something once that slurred my speech, and I thought, "Oh, man, you're messing with my brain. It's freaking me out." What part of the brain did they mess with? Infratentorial Infratentorial: Infratentorial Hernations. From Betz et al., 1994. No Fat, Just Brain ICA – Big Time • Contralaterial sensory and motor • Aphasia – if dominant hemisphere involved • Agnosia, unilateral neglect – if non dominant hemisphere is involved • Contralateral visual field deficit / eye deviation ACA – Crazy Legs • • • • • • Paralysis of contralateral foot and leg Sensory loss –toes, foot, leg Impaired gait Abulia (slow to respond) Flat affect Urinary incontinence MCA – The Drift • Motor and sensory of face and arm on contralateral side • Global aphasia if dominant hemisphere involved • Neglect if non-dominant hemisphere involved • Homonymous hemianopsia PCA / Pcom • Contralateral visual field deficit, impaired depth perception, nystagmus, sensory loss • Ipsilateral 3rd nerve palsy Big Bad Basilar • Quadriplegia • ‘locked-in’ • Weakness of facial, lingual, and pharyngeal muscles Name that vessel. Pt presents with: • L facial droop • L sided arm weakness • Aphasic Drainage Frontal and parietal veins drain to superior sagittal sinus. Inferomedial veins drain to straight sinus. Then drain to large venous sinus and to jugular veins. Traveling with CSF Choroid plexus and ependymal cells – lateral ventricles – foramen of Monroe – 3rd – aqueduct of sylvius – 4th then absorbed by arachnoid villi meets with sag sinus and into venous Monro-Kellie Doctrine Increasing ICP • • • • Headache Nausea ALOC, lethargy Cushing’s Triad – Widening pulse pressure – Bradycardia – Irregular respirations EVD • • • • Drain blood and CSF Monitor ICP (<20) Monitor CPP (70-90) HOB >30 What in the brain is going on here? • • • • Ischemic? Hemorrhagic? Seizure? Other neuro problems? • Onset? • Changes in neuro status? • Level of consciousness? • Numbness / tingling? • Focal weakness? • Coordination? • Trouble speaking or understanding others? The Neuro Physical Exam • • • • • • Mental status Cranial nerves Motor system Sensory system Coordination Deep tendon reflexes Glasgow Coma Scale Intro – Survey the Scene Full consciousness Confusion Lethargy Obtunded Stupor Coma Can we talk? • Oriented to person, place, time, and event? • Rate, rhythm , and articulation of speech? • Expressive or receptive aphasia? • Intact memory? (Remember three simple words) Facing Cranial Nerve Assessment, Barbara Bolek, American Nurse Today, November 2006 Cranial Nerve Function CN I Olfactory Close eyes, close one nostril at a time, smell, identify CN II Optic Read newspaper Close one eye, move finger, "tell me when you see it" Copyright Nursing Brains, LLC Cranial Nerve - Midbrain CN III Oculomotor Pupil size, shape, react to light Assess eye lid (ptosis) CN IV Trochlear CN VI Abducens Move finger in "H" Copyright Nursing Brains, LLC Cranial Nerves - Pons CN V Trigeminal Separate clenched jaw Corneal reflex Assess touch of forehead, cheek, chin CN VII Facial Show teeth, puff out cheeks Identify sugar on tongue CN VIII Acoustic Rub strands of hair together Whisper at foot of bed Copyright Nursing Brains, LLC Cranial Nerves - Medulla CN IX Glossopharyngeal Say "AAH", check symmetrical CN X Vagus elevation of uvula Check gag, both sides of uvula CN XI Spinal Accessory Push head against hand, both sides Shrug shoulders against resistance CN XII Hypoglossal "Stick out your tongue", check midline placement Copyright Nursing Brains, LLC Motor Function • Assess for muscle size and tone bilaterally. – Spasticity (Upper motor neuron injury) – Rigidity – Flaccidity (Lower motor neuron injury) • Assess gait and posture • Look for involuntary movements. • Assess muscle strength. Muscle Strength Grading 0 = No movement 1 = Trace of muscle contraction 2 = Active movement without gravity 3 = Active movement against gravity 4 = Active movement against gravity / resistance 5 = Normal NIH SS 0 = No drift; limb holds 90 (or 45) degrees for full 10 / 5 seconds. 1 = Drift; limb holds 90 (or 45) degrees, but drifts down before full 10 / 5 seconds; does not hit bed or other support. 2 = Some effort against gravity; limb cannot get to or maintain (if cued) 90 (or 45) degrees, drifts down to bed, but has some effort against gravity. 3 = No effort against gravity; limb falls. 4 = No movement. Lyden P, BrottT,Tilley B, et al; Group NTSS. Improved reliability of the NIH stroke scale using video training. Stroke. 1994;25:22202226. Sensory Function • Assess touch – soft and sharp – in each of the dermatomes. • Assess temperature and vibration bilaterally. • Proprioception – thumb or big toe are moved up and down. Patient able to state correct location without looking. Discriminative Sensation • Two-point discrimination – part of body is touched with two sharp objects simultaneously and asked if can feel one or two picks. • Stereognosis – ability to identify a familiar object in hand (no peeking!) • Graphesthesia – draw # or letter in patients hand and have them correctly identify it. Coordination DTRs Biceps – C5 • The biceps reflex is elicited by placing your thumb on the biceps tendon and striking your thumb with the reflex hammer and observing the arm movement. Brachioradialis – C6 • The brachioradialis reflex is observed by striking the brachioradialis tendon directly with the hammer when the patient's arm is resting. Strike the tendon roughly 3 inches above the wrist. Note the reflex supination. Repeat and compare to the other arm. Triceps – C7, 8 • The triceps reflex is measured by striking the triceps tendon directly with the hammer while holding the patient's arm with your other hand. Patellar – L3,4 • With the lower leg hanging freely off the edge of the bench, the knee jerk is tested by striking the quadriceps tendon directly with the reflex hammer. Achilles – S1,2 • The ankle reflex is elicited by holding the relaxed foot with one hand and striking the Achilles tendon with the hammer and noting plantar flexion. Babinski Reflex • The plantar reflex (Babinski) is tested by coarsely running a key or the end of the reflex hammer up the lateral aspect of the foot from heel to big toe. The normal reflex is toe flexion. If the toes extend and separate, this is an abnormal finding called a positive Babinski's sign. Reflexes • Deep Tendon Reflexes – Biceps, triceps, brachioradialis, patellar, achilles • Superficial Reflexes – Epigastric, abdominal, cremasteric, gluteal, plantal, bulbocavernous, superficial anal • Brain Stem Reflexes – Pupillary reaction, corneal, oculocephalic, oculovestibular, gag • Pathological Reflexes – Babinski, grasp Copyright Nursing Brains, LLC DTR Reflex Scale 0 : absent reflex 1+: trace, or seen only with reinforcement 2+: normal 3+: brisk 4+: nonsustained clonus (i.e., repetitive vibratory movements) 5+: sustained clonus As we begin the 21st century, the Hubble space telescope is providing us with information about as yet uncharted regions of the universe and the promise that we may learn something about the origin of the cosmos. This same spirit of adventure is also being directed to the most complex structure that exists in the universe - the human brain. Floyd E. Bloom (in Fundamental Neuroscience edited by L.R. Squire et al., 2003) Questions?