Pearls for Avoiding Risk in Neurological Emergencies · artery 2. Superior cerebellar artery 3....

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