part 2 general examination & part 3-A Higher brain functions 2024.pptx

this presentation for young neurosurgeon residents to teach them haw to do neuro examination for a patients (this part include general examination and examination of higher brain functions

1. Mohamed Wael Samir, MD Professor of neurosurgery Ain Shams University Cairo, Egypt Art of History Taking & Neurological Examination Part 2 General Examination

2. ILOs Enumerate different items of the medical history. Discuss the basic principles in taking the medical history. Enumerate different items should be available for ideal neurological examination. Enumerate different items of neurological examination. Acquire the skills of taking a medical history from patients. Acquire the skills of eliciting and interpret different neurological signs

3. "The eyes see what the mind knows." Smart physical examination is based on smart history. Smart physical examination will not replace or substitute poor history and vice versa.

4. Examination: Tools Required Stethoscope Bld. pressure cuff Tongue depressors Ophthalmoscope Reflex Hammer Tuning Forks 126 and 512 (or 256 for both) Hz A Snellen Eye Chart or Pocket Vision Card Pen Light or Otoscope Safety pin. Bottles with essences of familiar odors ( coffee ) Tasty substance ( saline ) & Cotton-tipped swabs Cup of water Newspaper Assorted small objects (coin, key) Tape measure

5. General Examination

6. General Examination (8 items) General look: Body built & State Vital signs: HEENT (Head, ear, eye, nose, throat): Exo, Eno, Ptosis, retraction, ear discharge Neck: scar of previous surgery & planed ACDF surgery Chest examination: Lungs: Clear to auscultation bilaterally Cardiovascular: Regular rate and rhythm, Abdomen: scar of previous surgery & planed V-P shunt surgery Extremities: peripheral pulsation & signs of ischemia (claudication pain)

7. Example of general Examination Report Madam Fatma looks healthy in general examination with no acute distress. She weights 100 kg and her height is 160 cm. Her vital data are as following: Temp. 36.7°C, Bl. P. 130/70 in right arm Pulse: 74 and respiratory rate is 16 HEENT examination are apparently normal with no scars of previous surgeries. Chest and heart examination are within normal. Her abdomen moves freely with respiration with no tenderness or palpable swelling or scars of previous surgeries. There are no skin petechiae, rashes, swelling, ulcers, pigmentations or edema.

8. Signs of trauma, endocrine disturbance, Scars of previous surgeries

9. Neurocutaneous syndromes “ Phakomatosis ” Dysplastic, and neoplastic lesions of skin and nervous system, explained by their common ectoderm origin. Autosomal Dominant Phenotypes Neurofibromatosis type 1 (17) & type 2 (22) Tuberous sclerosis (9 & 16) Osler-Weber- Rendu disease Nevoid basal cell carcinoma syndrome Autosomal Recessive: Ataxia-telangiectasia X-linked, and Congenital Origin Sturge-Weber syndrome

10. Criteria for Diagnosis Patient must have ≥ 2/7 of the following 1 st degree relative with NF1 ≥ 2 neurofibroma of any kind , or one plexiform neurofibroma ≥ 6 café- au-lait macules (>5 mm if prepubertal or >15 mm if postpubertal Axillary /inguinal freckling ≥ 2 iris hamartoma Optic pathway glioma Distinct osseous abnormality (sphenoid wing dysplasia, pseudoarthrosis , thinning of long bone cortex

11. Criteria for Diagnosis Patient must have two or more of the following 1 st degree relative with NF1 ≥ 2 neurofibroma of any kind , or one plexiform neurofibroma ≥ 6 café- au- lait macules (≥ 0.5 cm if prepubertal or larger if postpubertal Axillary /inguinal freckling ≥ 2 iris hamartoma Optic pathway glioma Distinct osseous abnormality (sphenoid wing dysplasia, pseudoarthrosis , thinning of long bone cortex 2

12. Criteria for Diagnosis Patient must have two or more of the following 1 st degree relative with NF1 ≥ 2 neurofibroma of any kind , or one plexiform neurofibroma ≥ 6 café- au-lait macules (>5 mm if prepubertal or >15 mm if postpubertal Axillary /inguinal freckling ≥ 2 iris hamartoma 2

13. Criteria for Diagnosis Patient must have two or more of the following 1 st degree relative with NF1 ≥ 2 neurofibroma of any kind , or one plexiform neurofibroma ≥ 6 café- au-lait macules (>5 mm if prepubertal or >15 mm if postpubertal Axillary /inguinal freckling ≥ 2 iris hamartoma Optic pathway glioma Distinct osseous abnormality (sphenoid wing dysplasia, pseudoarthrosis , thinning of long bone cortex 2

14. Criteria for Diagnosis Patient must have two or more of the following 1 st degree relative with NF1 ≥ 2 neurofibroma of any kind , or one plexiform neurofibroma ≥ 6 café- au-lait macules (>5 mm if prepubertal or >15 mm if postpubertal Axillary /inguinal freckling ≥ 2 iris hamartoma Optic pathway glioma Distinct osseous abnormality (sphenoid wing dysplasia, pseudoarthrosis , thinning of long bone cortex 2 Bowing Deformity 8 mo. Later

15. Breathing Patterns Bilateral cerebral hemispheric or diencephalic dysfunction→ Cheyne -Stokes respiration Lower midbrain and upper pons dysfunction → Central reflex hyperpnea lower pons dysfunction → Apneustic respiration lower pons or upper medulla dysfunction → Cluster ( Biot's ) breathing Medulla dysfunction → Ataxic respiration

16. Mohamed Wael Samir, MD Professor of neurosurgery Ain Shams University Cairo, Egypt Art of History Taking & Neurological Examination Part 3 Neurological Examination A- Higher Brain Functions

17. Neurological Examination

18. Neurological Examination Higher functions Cranial nerves Sensory system Motor system Reflexes Cerebellum Spine examination Special test

19. Higher Brain Functions Gait Language Cognitive/Mental status الأنسان يفكر يتكلم ويمشي علي قدميه

20. Higher Brain Functions: Gait & Stains Normal gait: Stressed gait: Toes and heels Tandem Quiet stains: Stressed stains: Romberg's Test:

21. Hemiparetic gait: e.g. Unilateral pyramidal lesion Ataxic gait: e.g. Cerebellar or vestibular lesions Shuffling gait & festinating gait: e.g. Parkinsonian gait Steppage gait: e.g. drop foot Scissor gait: e.g. Bilateral pyramidal lesions as CP or cervical or dorsal cord lesions Waddling gait (myopathic gait): e.g. Trendelenburg or gluteal gait: e.g. unilateral waddling in sup. gluteal nerve (L4,L5 & S1) affection Antalgic (painful hip) gait Higher Brain Functions: Gait

22. Trendelenburg or Gluteal Gait Due to Sup. Gluteal Nerve (L4,L5 & S1) Injury

23. Compensated Trendelenburg Gait

24. Trendelenburg or Gluteal Gait Due to Sup. Gluteal Nerve (L4,L5 & S1 ) Injury

25. Higher Brain Functions Gait Language Cognitive/Mental status الأنسان يفكر يتكلم ويمشي علي قدميه

26. Definition of Language The principal method of human communication Consisting of words used in a structured and conventional way and conveyed by speech, writing, or gesture.

27. Higher Brain Functions: Language You should differentiate between Dysphasia: Defect in language process. Dysarthria: Defect in oral language production. Other speech disorders: Mutism Apraxia of speech You should know different types of Dysphasia: 7 types You should know different types of Dysarthria: 7 types

28. To communicate with others you should Tools of communication Receptive Language Expressive

29. If I know the language but the receptive mechanism is damaged. Other mechanisms show sympathy Tools of communication

30. If I know the language but the expressive mechanism is damaged. Other mechanisms show sympathy Tools of communication

31. If I don't know the language or all mechanisms of language are damaged, or in acute presentation of partial damage Tools of communication

32. Higher Brain Functions: Language Oral Language disorders: Speech processing disorders (understanding “comprehend” and expressing) =Aphasia: Speech form disorders (articulation and phonation = Dysartheria ) Writing disorders = Agraphia Reading disorders = Alexia منطوقه مقرؤه مكتوبه

33. If you can’t speak either you have a problem in the language process or a problem in speaking process Tools of communication Receptive Language Expressive Dysarthria Apraxia of speech Motor system Premotor system

34. Dysarthria: 7 Types 1& 2) UMN dysartheria : 1) Unilateral UMN: (UMN dysarthria ) 2) Bilateral UMN: Cerebral, Spastic or Pseudo- bulbal dysarthria. 3) LMN dysartheria : Flacid dysarthria: Cranial nuclei, nerves or MNJ lesions VII= Mi-Mi-Mi XII= La-la-la X= Ga-Ga-Ga 4) Cerebellar dysartheria : 4) Ataxic ( scanning or staccato) dysarthria: Cerebellar lesions

35. Dysarthria: 7 Types 5 &6) Basal ganglia dysarthria: 5) Hypokinetic Dysarthria: PD 6) Hyperkinetic Dysarthrias: A) Slow hyperkinetic dysarthria: Dystonia B) Quick hyperkinetic dysarthria: Chorea 7) Mixed dysarthria:

36. Normal Language Process Concept area Arcuate Facsiculus Wernicke’s area Broca’s area Voice Production & articulation Hearing R Understand & respond = comprehension أرفع يدك اليسري لفوق تكلم عن طبيعة عملك كرر ورائي مفيش لو أو لكن Spontaneous speech Motor center Hearing center

37. Motor Dysphasia Concept area Wernicke’s area Broca’s area Voice Production & articulation Understand & respond = comprehension أرفع يدك اليسري لفوق تكلم عن طبيعة عملك Spontaneous speech Motor aphasia Non fluent + NO repetition+ Can comp Arcuate Facsiculus R كرر ورائي مفيش لو أو لكن Hearing Hearing center Motor center

38. Transcortical Motor Dysphasia Concept area Wernicke’s area Broca’s area Understand & respond = comprehension أرفع يدك اليسري لفوق تكلم عن طبيعة عملك Spontaneous speech Transcortical Motor aphasia Hearing Hearing center Arcuate Facsiculus R كرر ورائي مفيش لو أو لكن Non fluent + NO repetition+ Can comp Non fluent + Good Repetition + Can comp

39. Sensory Dysphasia Concept area Wernicke’s area Broca’s area Voice Production & articulation Understand & respond = comprehension أرفع يدك اليسري لفوق تكلم عن طبيعة عملك Spontaneous speech Fluent + NO repetition+ No comp Hearing Hearing center Arcuate Facsiculus R كرر ورائي مفيش لو أو لكن Sensory aphasia

40. Transcortical Sensory Dysphasia Concept area Wernicke’s area Broca’s area Understand & respond = comprehension أرفع يدك اليسري لفوق تكلم عن طبيعة عملك Spontaneous speech Transcortical Sensory aphasia Hearing Hearing center Arcuate Facsiculus R كرر ورائي مفيش لو أو لكن Fluent + NO repetition+ No comp Fluent + Good Repetition + No comp

41. Conductive Aphasia Concept area Wernicke’s area Broca’s area Voice Production & articulation Understand & respond = comprehension أرفع يدك اليسري لفوق تكلم عن طبيعة عملك Fluent + NO repetition+ Can comp Hearing Hearing center Arcuate Facsiculus R كرر ورائي مفيش لو أو لكن Conductive aphasia

42. Global Dysphasia Concept area Wernicke’s area Broca’s area Understand & respond = comprehension أرفع يدك اليسري لفوق تكلم عن طبيعة عملك Hearing Hearing center Arcuate Facsiculus R كرر ورائي مفيش لو أو لكن Global aphasia Fluent + NO repetition+ Can comp Non fluent + NO repetition+ No comp

43. Mixed Transcortical Dysphasia Concept area Wernicke’s area Broca’s area Voice Production & articulation Understand & respond = comprehension أرفع يدك اليسري لفوق تكلم عن طبيعة عملك Non fluent + NO repetition+ No comp Mixed Transcortical aphasia Non fluent + Good Repetition + No comp Hearing Hearing center Arcuate Facsiculus R كرر ورائي مفيش لو أو لكن

44. Fluent = Sensory = Receptive dysphasia Non Fluent = Motor = Expressive dysphasia Global dysphesia

45. Language Deficits Other Than Dysarthria & Dysphasia Apraxia Of Speech (AOS) Lesion mostly in premotor area of the dominant hemisphere. A person with this disorder tends to have periods of fluent, easily understandable speech but other periods of effortful groping to find the correct articulatory postures for speech sounds with numerous speech sound errors

46. Language Deficits Other Than Dysarthria & Dysphasia Mutism: It is absence of speech output Causes: Cerebellar mutism: rare, following midline cerebellar surgery in children Akinetic mutism Bilateral thalamic damage Bilateral vocal cord paralysis (although this may be better termed aphonia ) Psychogenic, as in schizophrenia or affective disorders, with or without catatonia

47. Language Examination (8 items) Spoken language: “Aphasia” Comprehension to what is said: Repetition: Fluent or not: Obey = Intact comprehension أرفع يدك اليسري Don't = Sensory dysphasia or transcortical Obey = Intact repetition = transcortical sensory قل الحمد لله Don't = Sensory dysphasia Obey = Intact expression أذكر طبيعة عملك Don't = Motor dysphasia or transcortical motor

48. Language Examination (8 items) Reading: “Alexia” Can read loudly Comprehension to what is read Writing: “ agraphia ” إقرأ ما هو مكتوب بصوت عالي ونفذه ” أكتب أسمك في تلك الورقه“ Identifying: Names “nominal aphasia” Faces “ prosopagnosia ”

49. Higher Brain Functions Gait Language Cognitive/Mental status الأنسان يفكر يتكلم ويمشي علي قدميه

50. Higher Brain Functions: Mental State C onsciousness & Orientation: A ttention & Concentration: T hought: M ood & Behavior: I ntegrative Sensory: M emory: I ntegrative Motor: CAT MIMI قطة ميمي

51. Higher Brain Functions: Mental State Consciousness & Orientation: Attention & Concentration: Thought Mood & Behaviour Memory Integrative Sensory: Integrative Motor: Level of consciousness should be documented by a written description of the patient’s response to a specific stimuli rather than by the use of nonspecific imprecise terms such as “lethargy,” “stupor,” or “semi-coma”. “Mr. Mohamed is wakeful and responding normally to stimulus” You may use Glasgow coma scale.

52. Assessment of level of consciousness

53. Level of consciousness Assessment Original GCS (1974): 14 points Modified GCS (1976): 15 points Glasgow Coma Scale-Pupils Score (GCS-P) (2018) Pediatric GCS (PGCS):

54. Glasgow Coma Scale GCS Glasgow Coma Scale 1974 (14-point scale) Glasgow Coma Scale 1976 (15-point scale) 1 2 3 4 5 Eye opening None To pain To sound Spontaneous Verbal response None Incomprehensible inappropriate Confused Oriented Motor response None Extending Flexing Localizing Obeying

55. Glasgow Coma Scale GCS Glasgow Coma Scale 2014 (update to terminology & non-testable aspect) To sound To pain Incomprehensible inappropriate

56. Glasgow Coma Scale GCS 42 year old man, intubated after traumatic brain injury (TBI) for decreasing GCS. Currently, he opens his eyes to pressure, is intubated, and withdraws his left arm and leg to pain. 1976  – GCS: E 2, V 1t, M 4. Combined GCS: 7t 2014  – GCS: E 2, V NT , M 4. = 6 + V NT It is no longer recommend to assign 1 point to non-testable elements , therefore a combined score should not be used here as it would imply that the patient is more unwell than they really are. Any element that cannot be tested should be marked as NT, for “not testable” 4 .

57. Glasgow Coma Scale GCS Glasgow Coma Scale-Pupils Score (GCS-P) (2018) 37 year old female with a traumatic subarachnoid hemorrhage (SAH). On presentation to the ED, she does not open her eyes, she moans, and displays abnormal flexion in her limbs to pain. On examination of her pupils they are both fixed and dilated. Her GCS is 6. Her GCS-P is 6-2 = 4.

58. Glasgow Coma Scale GCS Glasgow Coma Scale (4-15 years) Child’s Coma Scale (<5 Years) Eye opening response Eye opening response Spontaneous 4 Spontaneous 4 To verbal stimuli 3 To verbal stimuli 3 To pain 2 To pain 2 No response to pain 1 No response to pain 1 Best motor response Best motor response Obeys verbal command 6 Obeys verbal command or performs normal spontaneous movements 6 Localizes 5 Localizes to pain or withdraws to touch 5 Withdrawal 4 Withdrawal from pain 4 Abnormal flexion (decorticated) 3 Abnormal flexion (decorticated) 3 Abnormal extension (decerebrate) 2 Abnormal extension (decerebrate) 2 No response 1 No response 1 Best verbal response Best verbal response Converses & Oriented 5 Alert, babbles, coos, words 5 Converses & disoriented 4 Less than usual ability and/or spontaneous irritable cry 4 Inappropriate words 3 Cries inappropriately 3 Incomprehensible sounds 2 Occasionally whispers and/or moans 2 No response to pain 1 No response to pain 1

59. AVPU (for children under 2 years old) A lert Responds to V oice Responds to P ain Purposeful – localizes Non-purposeful – withdrawal, abnormal flexion or extension U nresponsive

60. Leveling According to Motor Response Dysfunction Response to Noxious Stimuli Both cortices Normal flexion (flexion withdrawal) Diencephalon till above red nucleus Decorticate posturing (abnormal flexion) Midbrain below red nucleus Decerebrate posturing (Extension) Pontine tegmentum Abnormal extension of the arms with weak flexion of the legs Medulla Weak leg flexion (or none)

61. D.D. of Coma locked-in syndrome: Vegetative state: Persistence” 1 months Permenant : 1year Global aphasia: Akinetic mutism: Abulia : Pseudocoma (hysterical): Brain death:

62. Higher Brain Functions: Mental State Consciousness & Orientation: Attention & Concentration: Thought Mood & Behaviour Memory Integrative Sensory: Integrative Motor:

63. Higher Brain Functions: Mental State Consciousness & Orientation: Attention & Concentration : Thought Mood & Behaviour Memory Integrative Sensory: Integrative Motor: or working memory

64. Higher Brain Functions: Mental State Consciousness & Orientation: Attention & Concentration : Thought Mood & Behaviour Memory Integrative Sensory: Integrative Motor: For attention: Working memory: 2591 كرر ورائي الأرقام التاليه بنفس الترتيب For concentration (Thinking): Abstraction: ما معني اللي بيته من زجاج لايحدف الناس بالطوب Judgment ما أوجه التشابه بين الطبيب والحكيمه والدواء : Planning: ماذا تفعل لو توقفت السياره بك في منتصف الطريق ماذا تفعل لو صحيت الصبح وجدت أرضك الزراعيه غارقه بالماء Set Generation: أ ذكر كلمات تبدأ بحرف السين (بدون أسماء أشخاص أو إعاده) المعدل المقبول 10 كلمات في الدقيقه

65. Higher Brain Functions: Mental State Consciousness & Orientation: Attention & Concentration: Thought Mood & Behaviour Memory Integrative Sensory: Integrative Motor: Hallucination Delusions

66. Higher Brain Functions: Mental State Consciousness & Orientation: Attention & Concentration: Thought Mood & Behaviour Memory Integrative Sensory: Integrative Motor: Apathetic Inappropriately elated mood Depressed mood Agitated Anxious

67. Higher Brain Functions: Mental State Consciousness & Orientation: Attention & Concentration: Thought Mood & Behaviour Memory Integrative Sensory: Integrative Motor: Immediate recall= attention: Recent memory: Remote memory:

68. Higher Brain Functions: Mental State Consciousness & Orientation: Attention & Concentration:: Thought Mood & Behaviour Memory Integrative Sensory: Integrative Motor: Astereognosis : Agraphesthesia : Absence of two-point discrimination: Allesthesia : Disorder of visuo -spatial and perceptual function Sensory inattention Unilateral neglect & anosognosia :: Constructional apraxia Right/left disorientation Finger agnosia

69. Higher Brain Functions: Mental State Consciousness & Orientation: Attention & Concentration:: Thought Mood & Behaviour Memory Integrative Sensory: Integrative Motor: Apraxia: Pretend to comb your hair. Pretend to strike a match and blow it out. Sequencing Tasks write a letter and put it in the envelop written alternating sequence. Manual alternating sequence.

70. Higher Brain Functions: Mental State Mr. Mohamed is fully conscious oriented X3 with normal attention span. He shows normal thinking process (judgment, abstraction. and can recall 2/3 words with clue. He looks depressed with normal sensory & motor high integrative brain functions

71. Mini-Mental Status Examination