How to Perform a Complete Neurological Examination
The complete neurological examination should systematically assess mental status, brainstem reflexes (pupillary light response, oculocephalic, corneal, and cough/gag reflexes), motor function, sensory function, coordination, gait, and use standardized scoring tools like the NIHSS or Glasgow Coma Scale 1.
Systematic Approach to the Neurological Examination
1. Mental Status Assessment
Begin by evaluating:
- Level of consciousness using standardized scales (Alert, Drowsy, Obtunded, Coma/unresponsive) 2
- Orientation to person, place, and time - ask 2 specific orientation questions 2
- Response to commands - test with 2 specific motor commands 2
- Language function - assess for aphasia (mild, severe, or global/mute) 2
- Use the Confusion Assessment Method for delirium screening 1
2. Cranial Nerve Examination
Gaze and Visual Fields:
- Test horizontal eye movements for gaze palsies (normal, partial, or complete) 2
- Assess visual fields in all four quadrants - document any hemianopia (partial, complete, or bilateral) 2
Facial Function:
- Examine facial movement symmetry, grading from normal to complete unilateral palsy 2
Brainstem Reflexes:
- Pupillary light response - critical for assessing brainstem function 1
- Oculocephalic reflex (doll's eyes)
- Corneal reflex
- Cough and gag reflexes 1
3. Motor Examination
Upper Extremities:
- Test each arm separately (left, then right) 2
- Have patient hold arms extended for 10 seconds
- Score: 0=no drift, 1=drift before 5 seconds, 2=falls before 10 seconds, 3=no effort against gravity, 4=no movement 2
Lower Extremities:
- Test each leg separately using the same scoring system 2
- Assess for pronator drift
Important caveat: Motor examination is only meaningful when sedation and paralytics are lightened or discontinued 1. This is a common pitfall in acute settings.
4. Coordination and Cerebellar Function
- Limb ataxia testing - assess finger-to-nose and heel-to-shin
- Score: 0=no ataxia, 1=ataxia in 1 limb, 2=ataxia in 2 limbs 2
5. Sensory Examination
- Test light touch, pain, temperature, proprioception, and vibration
- Score: 0=no sensory loss, 1=mild sensory loss, 2=severe sensory loss 2
- Note: Sensory exams are often limited in acutely ill patients 1
6. Speech and Articulation
- Articulation (dysarthria): 0=normal, 1=mild, 2=severe 2
- Distinguish from language problems (aphasia)
7. Extinction and Inattention
- Test for neglect using simultaneous bilateral stimulation
- Score: 0=absent, 1=mild (loss in 1 sensory modality), 2=severe (loss in 2 modalities) 2
Key Principles and Common Pitfalls
Standardization is Essential: Using standardized tools like the NIHSS ensures uniform assessment, facilitates communication between providers, helps quantify deficits, identifies vessel occlusion location, provides early prognosis, and guides treatment selection 2.
Serial Examinations: Perform baseline assessment, then serial evaluations throughout the clinical course 1. Daily assessment by a neurologist/neurointensivist improves care, with more frequent nursing assessments every 1-4 hours based on risk 1.
Sedation Considerations: Neurological evaluation is frequently confounded by sedatives and paralytics 1. Use standardized sedation protocols with validated scoring systems like the Richmond Agitation Sedation Scale. Intermittent sedation is preferred over continuous infusion, and daily sedation interruptions improve examination accuracy 1.
Signs of Life: Assess gasping, pupillary light response, and increased consciousness - these signs may be associated with improved neurological outcomes even in critically ill patients 1.
Common Pitfall - Fixed Pupils: Fixed and dilated pupils during resuscitation are frequently seen after epinephrine administration and do not necessarily indicate irreversible brain injury 1. This historical contraindication has been challenged by favorable outcomes despite these findings.