From the Guidelines
A comprehensive neurological examination for stroke or neurological emergencies should follow a systematic approach beginning with the NIHSS (National Institutes of Health Stroke Scale) assessment, as recommended by the most recent guidelines 1.
Step-by-Step Neuro Exam Approach
The approach should start with level of consciousness by checking alertness, orientation, and ability to follow commands.
- Assess cranial nerves by examining pupillary responses, extraocular movements, facial symmetry, and swallowing function.
- Test motor function by evaluating strength in all extremities using the 5-point scale (0-5), noting any weakness, drift, or asymmetry.
- Sensory examination should include light touch, pinprick, proprioception, and temperature sensation.
- Assess coordination with finger-to-nose and heel-to-shin tests, looking for ataxia or dysmetria.
- Check reflexes in all extremities and evaluate for pathological reflexes like Babinski sign.
- Gait assessment, if possible, can reveal hemiparesis or ataxia.
- Language function evaluation should include comprehension, fluency, repetition, and naming abilities.
Importance of Time and Documentation
Throughout the exam, document the time of symptom onset precisely, as this determines eligibility for time-sensitive interventions like thrombolysis (tPA within 4.5 hours) or thrombectomy, as emphasized in the guidelines 1, 2. This systematic approach allows for rapid identification of neurological deficits, localization of the lesion, and guides immediate management decisions in acute neurological emergencies. The use of a standardized stroke scale, such as the NIHSS, is crucial for assessing stroke severity and guiding treatment decisions, as highlighted in the guidelines 3, 4.
Additional Considerations
Additional diagnostic tests, including brain imaging with NCCT or MRI, should be performed promptly to determine eligibility for thrombolysis or endovascular therapy, as recommended in the guidelines 2. Seizure assessment and management are also critical components of acute stroke care, with guidelines recommending the use of short-acting medications for new-onset seizures 1. Overall, a comprehensive and systematic approach to the neurological examination is essential for providing high-quality care to patients with stroke or neurological emergencies.
From the Research
Step-by-Step Neuro Exam Approach
The step-by-step approach for a neuro exam in cases of stroke or neuro emergencies involves several key components:
- Initial Assessment: Evaluate the patient's airway, breathing, and circulation (ABCs) and ensure stability before proceeding with the neuro exam 5, 6.
- History Taking: Gather information about the patient's symptoms, medical history, and timeline of events leading up to the stroke or neuro emergency 7, 8.
- Physical Exam: Perform a comprehensive physical exam, including: + Neurological Exam: Assess the patient's mental status, cranial nerves, motor function, sensory function, and reflexes 5, 6. + Vital Signs: Monitor the patient's vital signs, including blood pressure, heart rate, and oxygen saturation 7, 8.
- Diagnostic Tests: Order diagnostic tests as needed, such as: + Imaging Studies: CT or MRI scans to evaluate the brain and identify any areas of damage or bleeding 5, 6. + Laboratory Tests: Blood tests to evaluate the patient's blood chemistry and identify any underlying conditions that may be contributing to the stroke or neuro emergency 7, 8.
Key Components of the Neuro Exam
The neuro exam should include the following key components:
- Mental Status Exam: Assess the patient's level of consciousness, orientation, and cognitive function 5, 6.
- Cranial Nerve Exam: Evaluate the patient's cranial nerves, including the optic, oculomotor, trochlear, trigeminal, facial, vestibulocochlear, glossopharyngeal, vagus, spinal accessory, and hypoglossal nerves 5, 6.
- Motor Exam: Assess the patient's motor function, including strength, tone, and reflexes 7, 8.
- Sensory Exam: Evaluate the patient's sensory function, including pain, temperature, touch, and proprioception 7, 8.
Importance of Timely Intervention
Timely intervention is critical in cases of stroke or neuro emergencies, as it can significantly impact patient outcomes 5, 6, 7, 8, 9. The use of tissue plasminogen activator (tPA) has been shown to be effective in improving outcomes in patients with acute ischemic stroke, but it must be administered within a specific time frame (typically within 4.5 hours of symptom onset) 5, 6, 7.