1	Basic Neurology (Being a quick neuro review for stroke unit nurses)
2	Neurological Exam Mental Status Cranial Nerves Sensory Exam Motor Exam Cerebellar Testing Gait
3	Mental State Level of Consciousness Content of Consciousness Orientation Language function Spontaneous speech Receptive Language Memory Concentration Abstract Reasoning
4	Levels of Consciousness Awake and Alert Lethargic Obtunded Comatose Unarousable unresponsiveness
5	Reticular Activating System
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7	Applying pain
8	Posturing
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11	Decorticate Posturing Decorticate posturing is seen when there is a lesion of the corticospinal tract superior to the level of the brainstem. This is indicated in the comatose patient who responds to a sternal rub by full flexion of the elbows, wrists, and fingers, as well as plantar flexion of the feet with extension and internal rotation of the legs
12	Decerebrate Posturing Decerebrate posturing is seen in patients with lesions of the brainstem itself. These patients will exhibit extension of the arms, flexion of the wrists, jaw-clenching, back-arching, plantar flexion, and neck extension, either spontaneously or in response to a sternal rub.
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14	Doll’s Head Maneuver
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18	Pupil Shape
19	Localization of Responses
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23	Mental Status Exam Orientation Memory Recent Remote Calculation Attention Serial 7’s, 3’s “World” backwards Knowledge Abstraction v. Concrete thought Aphasia, Agnosia, Apraxia
24	Aphasia- language deficit Expressive = “Broca” Decreased speech fluency Inferior left frontal lobe Receptive = “Wernicke” Decreased understanding Posterior left temporal lobe Transcortical: Preserved repetition Conduction: Inability to repeat Distinguish from Dysarthria- problem pronouncing words
25	Aphasia: Things to Check in order of importance Spontaneous speech: Fluency. Motor aphasia Understanding: Reception. Sensory aphasia Ability to repeat: Conduction and transcortical aphasia Naming: anomia isn’t localizing. Partly word-finding Calculation, right-left orientation
26	Cranial Nerves
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28	Uncal herniation
29	Herniation Uncal Tonsillar Subfalcial Shift of intracranial structures due to mass lesion of swelling
30	Herniation Altered level of awareness IIIrd Nerve on side of herniation Pupil is dilated Eye pointed out Upper lid is down (ptosis) May be ipsi or contalateral hemiparesis
31	Herniation Paroxysmal posturing Rapid increase in vital signs Irregular respirations
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35	Disk edema
36	Testing EOM’s
37	Bell’s palsy (VII)
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39	Facial N Palsy Diabetes Lyme Disease Herpes viruses Guillian-Barre (bilateral) Other neuromuscular disease Brainstem or hemispheral stroke
40	Facial Nerve palsy Peripheral Upper and lower face is affected Hyperacusis Loss of taste ant. 2/3 of tongue Chorda tympani Central Only lower face Hemispheral stroke Brainstem Peripheral + opposite hemiparesis VI nerve on same side may be affected (abducent)
41	Accessory Nerve (XI) Sternomastoid and trapezius Shoulder shrug SCM turns head to opposite side Look for atrophy and scapular winging
42	Hypoglossal N (XII)
43	Hypoglossal Nerve Carotid artery surgery Neck dissection Rarely brainstem stroke Motor neuron disease (Lou Gerig) Tongue protrudes toward weak side Be careful diagnosing if facial nerve palsy
44	Brainstem Stroke Dysarthria (not aphasia) Diplopia Dysphagia Dysphonia Ataxia Vertigo Cranial nerve signs: may be opposite to body weakness, numbness May look toward your side of weakness
45	(as opposed to) MCA stroke Everything is on the same side of the body Hemiparesis Hemisensory loss Hemianopsia Neglect Aphasia Look away from the side of weakness
46	Sensory Exam Touch Pin Prick Vibration Proprioception Cortical testing Right v. left - Stroke Proximal v. distal – Guillian-Barre Upper body v. lower body – Spinal cord
47	Lacunar Stroke Weakness alone of entire hemi-body Numbness alone of entire hemi-body No aphasia Small or non-existent CT lesion Hypertension and diabetes Carotid arteries are clean Treat hypertension!!
48	Graphesthesia
49	Cortical Sensory Modalities
50	Motor Exam Power Tone Flaccid Spastic Rigid Bulk (atrophy) Fatigue (myasthenia gravis)
51	Grading Strength 5 – full power 4 - Gravity + resistance but still weak 3 - Barely against gravity 2 - Moves limb but not against gravity 1 - Flicker
52	Pronator Drift
53	UE Muscle Testing
54	LE Muscle Testing
55	Deep Tendon Reflexes 4+= Clonus 3+= Hyperactive Crossed Adductor Hoffman Radiation of Reflexes 2+= Normal 1+= Inactive
56	Deep Tendon Reflexes -Findings Hyperactive: spacticity Hypoactive: Peripheral Neuropathy Reflex Loss: Nerve or root disease Increased in LE: spinal Cord Increased on one side: Stroke Babinski sign: Spasticity
57	Frontal Release Signs Grasp Snout Suck Root Glabellar Palmomental Liberation from frontal inhibition
58	Cerebellar Testing Finger to nose: Heel-Knee-Shin Fine movements Handwriting Rapid alternating movement: dysdiadichokinesis Wide based gait Trunkal Titubation Dysarthria nystagmus
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60	Basal Ganglia Striatum Putamen Caudate Globus Pallidus Subthalamic nucleus Substantia nigra
61	Basal ganglia Rigidity: resistance increased in agonist and antagonist throughout whole excursion Tremor: Rest, Action, Sustension, Intention. Rhythmic alternate spont. contraction of agonist Chorea: Dancing movement Dystonia and toritcollis Myoclonus: random rapid contraction Brady/akinesia
62	Gait Hemiparetic Ataxic (lurching): etoh and Cbllm Spastic (scissors): spinal cord Elderly Parkinsonian (festinating, shuffling, stooped) Frontal Lobe Steppage, slapping: peripheral nerve Choreic Veering: vestibular Multi-sensory deficit Astasia-Abasia: fashion model, hysterical
63	“Neuro Check” – Relevant Exam Stroke Weak or numb side Level of awareness Speech, if affected Intracranial catastrophe (SAH, ICH) Level of awareness Pupils and eyes Weakness syndromes:muscle, spine,LGB Increased weakness or incapacity?? Dyspnea
64	Types of Glia
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71	Midline view of Brain
72	NIHSS 1a LOC The investigator must choose a response, even if a full evaluation is prevented by such obstacles as an endotracheal tube, language barrier, orotracheal trauma/bandages. A 3 is scored only if the patient makes no movement (other than reflexive posturing) in response to noxious stimulation. 0 = Alert; keenly responsive.1 = Not alert, but arousable by minor stimulation to obey, answer, or respond. 2 = Not alert, requires repeated stimulation to attend, or is obtunded and requires strong or painful stimulation to make movements (not stereotyped). 3 = Responds only with reflex motor or autonomic effects or totally unresponsive, flaccid, areflexic.
73	NIHSS 1b Questions The patient is asked the month and his/her age. The answer must be correct - there is no partial credit for being close. Aphasic and stuporous patients who do not comprehend the questions will score 2. Patients unable to speak because of endotracheal intubation, orotracheal trauma, severe dysarthria from any cause, language barrier or any other problem not secondary to aphasia are given a 1. It is important that only the initial answer be graded and that the examiner not "help" the patient with verbal or non-verbal cues. 0 = Answers both questions correctly. 1 = Answers one question correctly. 2 = Answers neither question correctly.
74	NIHSS 1c Commands The patient is asked to open and close the eyes and then to grip and release the non-paretic hand. Substitute another one step command if the hands cannot be used. Credit is given if an unequivocal attempt is made but not completed due to weakness. If the patient does not respond to command, the task should be demonstrated to them (pantomime) and score the result (i.e., follows none, one or two commands). Patients with trauma, amputation, or other physical impediments should be given suitable one-step commands. Only the first attempt is scored. 0 = Performs both tasks correctly 1 = Performs one task correctly 2 = Performs neither task correctly
75	NIHSS 2. best gaze Only horizontal eye movements will be tested. Voluntary or reflexive (oculocephalic) eye movements will be scored but caloric testing is not done. If the patient has a conjugate deviation of the eyes that can be overcome by voluntary or reflexive activity, the score will be 1. If a patient has an isolated peripheral nerve paresis (CN III, IV or VI) score a 1. Gaze is testable in all aphasic patients. Patients with ocular trauma, bandages, pre-existing blindness or other disorder of visual acuity or fields should be tested with reflexive movements and a choice made by the investigator. Establishing eye contact and then moving about the patient from side to side will occasionally clarify the presence of a partial gaze palsy. 0 = Normal 1 = Partial gaze palsy. This score is given when gaze is abnormal in one or both eyes, but where forced deviation or total gaze paresis are not present. 2 = Forced deviation, or total gaze paresis not overcome by the oculocephalic maneuver.
76	NIHSS 3. visual Visual fields (upper and lower quadrants) are tested by confrontation, using finger counting or visual threat as appropriate. Patient must be encouraged, but if they look at the side of the moving fingers appropriately, this can be scored as normal. If there is unilateral blindness or enucleation, visual fields in the remaining eye are scored. Score 1 only if a clear-cut asymmetry, including quadrantanopia is found. If patient is blind from any cause score 3. Double simultaneous stimulation is performed at this point. If there is extinction patient receives a 1 and the results are used to answer question 11. 0 = No visual loss 1 = Partial hemianopia 2 = Complete hemianopia 3 = Bilateral hemianopia (blind including cortical blindness)
77	NIHSS 4. Facial palsy Ask, or use pantomime to encourage the patient to show teeth or raise eyebrows and close eyes. Score symmetry of grimace in response to noxious stimuli in the poorly responsive or non-comprehending patient. If facial trauma/bandages, orotracheal tube, tape or other physical barrier obscures the face, these should be removed to the extent possible. 0 = Normal symmetrical movement 1 = Minor paralysis (flattened nasolabial fold, asymmetry on smiling) 2 = Partial paralysis (total or near total paralysis of lower face) 3 = Complete paralysis of one or both sides (absence of facial movement in the upper and lower face)
78	NIHSS 5&6 arm & leg The limb is placed in the appropriate position: extend the arms (palms down) 90 degrees (if sitting) or 45 degrees (if supine) and the leg 30 degrees (always tested supine). Drift is scored if the arm falls before 10 seconds or the leg before 5 seconds. The aphasic patient is encouraged using urgency in the voice and pantomime but not noxious stimulation. Each limb is tested in turn, beginning with the non-paretic arm. Only in the case of amputation or joint fusion at the shoulder or hip may the score be "9" and the examiner must clearly write the explanation for scoring as a "9". 0 = No drift, limb holds 90 (or 45) degrees for full 10 seconds1 = Drift, Limb holds 90 (or 45) degrees, but drifts down before full 10 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 gravity3 = No effort against gravity, limb falls4 = No movement 9 = Amputation, joint fusion explain:
79	NIHSS 7 Ataxia This item is aimed at finding evidence of a unilateral cerebellar lesion. Test with eyes open. In case of visual defect, insure testing is done in intact visual field. The finger-nose-finger and heel-shin tests are performed on both sides, and ataxia is scored only if present out of proportion to weakness. Ataxia is absent in the patient who cannot understand or is paralyzed. Only in the case of amputation or joint fusion may the item be scored "9", and the examiner must clearly write the explanation for not scoring. In case of blindness test by touching nose from extended arm position. 0 = Absent 1 = Present in one limb 2 = Present in two limbs If present, is ataxia in?
80	NIHSS 8 Sensory Sensation or grimace to pin prick when tested, or withdrawal from noxious stimulus in the obtunded or aphasic patient. Only sensory loss attributed to stroke is scored as abnormal and the examiner should test as many body areas [arms (not hands), legs, trunk, face] as needed to accurately check for hemisensory loss. A score of 2, "severe or total," should only be given when a severe or total loss of sensation can be clearly demonstrated. Stuporous and aphasic patients will therefore probably score 1 or 0. The patient with brain stem stroke who has bilateral loss of sensation is scored 2. If the patient does not respond and is quadriplegic score 2. Patients in coma (item 1a=3) are arbitrarily given a 2 on this item.
81	NIHSS 9 language A great deal of information about comprehension will be obtained during the preceding sections of the examination. The patient is asked to describe what is happening in the attached picture, to name the items on the attached naming sheet, and to read from the attached list of sentences. Comprehension is judged from responses here as well as to all of the commands in the preceding general neurological exam. If visual loss interferes with the tests, ask the patient to identify objects placed in the hand, repeat, and produce speech. The intubated patient should be asked to write. The patient in coma (question 1a=3) will arbitrarily score 3 on this item. The examiner must choose a score in the patient with stupor or limited cooperation but a score of 3 should be used only if the patient is mute and follows no one step commands.
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84	NIHSS 10 dysarthria If patient is thought to be normal an adequate sample of speech must be obtained by asking patient to read or repeat words from the attached list. If the patient has severe aphasia, the clarity of articulation of spontaneous speech can be rated. Only if the patient is intubated or has other physical barrier to producing speech, may the item be scored "9", and the examiner must clearly write an explanation for not scoring. Do not tell the patient why he/she is being tested.
85	NIHSS 11 Neglect Sufficient information to identify neglect may be obtained during the prior testing. If the patient has a severe visual loss preventing visual double simultaneous stimulation, and the cutaneous stimuli are normal, the score is normal. If the patient has aphasia but does appear to attend to both sides, the score is normal. The presence of visual spatial neglect or anosagnosia may also be taken as evidence of abnormality. Since the abnormality is scored only if present, the item is never untestable
86	Barthel Index Feeding 0 = unable 5 = needs help cutting, spreading butter, etc., or requires modified diet 10 = independent Bathing 0 = dependent 5 = independent (or in shower) Grooming 0 = needs to help with personal care 5 = independent face/hair/teeth/shaving (implements provided) Dressing 0 = dependent 5 = needs help but can do about half unaided 10 = independent (including buttons, zips, laces, etc.) Bowels 0 = incontinent (or needs to be given enemas) 5 = occasional accident 10 = continent Bladder 0 = incontinent, or catheterized and unable to manage alone 5 = occasional accident 10 = continent
87	Barthel (cont’d) Toilet Use 0 = dependent 5 = needs some help, but can do something alone 10 = independent (on and off, dressing, wiping) Transfers (bed to chair, and back)) 0 = unable, no sitting balance 5 = major help (one or two people, physical), can sit 10 = minor help (verbal or physical) 15 = independent Mobility (on level surfaces) 0 = immobile or < 50 yards 5 = wheelchair independent, including corners, > 50 yards 10 = walks with help of one person (verbal or physical) > 50 yards 15 = independent (but may use any aid; for example, stick) > 50 yards Stairs 0 = unable 5 = needs help (verbal, physical, carrying aid) 10 = independent TOTAL (0–100): The Barthel ADL Index: Guidelines The index should be used as a record of what a patient does, not as a record of what a patient could do.
88	Modified Rankin Scale SCORE DESCRIPTION 0 No symptoms at all 1 No significant disability despite symptoms; able to carry out all usual duties and activities 2 Slight disability; unable to carry out all previous activities, but able to look after own affairs without assistance 3 Moderate disability; requiring some help, but able to walk without assistance 4 Moderately severe disability; unable to walk without assistance and unable to attend to own bodily needs without assistance 5 Severe disability; bedridden, incontinent and requiring constant nursing care and attention 6 Dead TOTAL (0–6): ____
89	Hunt and Hess (SAH) DESCRIPTION GRADE Asymptomatic, mild headache, slight nuchal rigidity = 1 Moderate to severe headache, nuchal rigidity , no neurologic deficit other than cranial nerve palsy = 2 Drowsiness / confusion, mild focal neurologic deficit = 3 Stupor, moderate-severe hemiparesis = 4 Coma, decerebrate posturing = 5
90	Homunculus
91	Dermatomes
92	Brain Circulation
93	Meninges