Clinical Assessment of the Neurosurgical Patient Flashcards
What is the point of doing a history/examination?
- Make a diagnosis
- Determine anatomical location of pathology
- Determine causative agent
- Effect on daily life
- Use SOCRATES and ICE
What type of neuro patients may you come across?
- Obtunded patient (history from paramedics, bystanders etc.)
- Confused/dysphasic/preverbal patient (History from notes and family)
- Awake and alert patient (history from patient)
How should an obtunded patient be assessed?
- ABC
- GCS
- Pupils
What pathology may there be in an obtunded patient?
- Cerebral perfusion/metabolic issue
- Cerebral herniation
What are the components that make up the volume of intracranial space?
- CSF volume
- Blood volume
- Brain volume
- Other volume
What is the cerebral perfusion pressure equal to?
Mean arterial pressure - intracranial pressure
CPP=MAP-ICP
How can you assess if a patient has experienced brain herniation?
- Pupillary response
- If herniated, fixed dilated pupils
How should the non-communicative patient be assessed?
- Observation – posturing, focal lack of movement, neglect, eye movements
- Assess speech
- Mini-mental score
How should the communicating patient be assessed?
- Cranial – which lobe, cerebellar, CN?
- Spinal – which level, myelopathy, radiculopathy,
- Peripheral nerve
What are the functions of the frontal lobe?
- Voluntary control of movement
- Speech
- Saccadic eye movements
- Bladder control
- Gait
- Higher order
What part of the frontal lobe is for voluntary control of movement?
Precentral gyrus
What part of the frontal lobe is responsible for speech?
- Pars opercularis
- Pars triangularis
What part of the frontal lobe is responsible for saccadic eye movements?
Frontal eye field
What part of the frontal lobe is responsible for gait?
Periventricular
What part of the frontal lobe is responsible for bladder control?
Paracentral lobule
How should the frontal lobe be examined?
-Inspection (Decorticate posture, ‘Magnetic gait’, Urinary catheter, Abulia)
-Pyramidal weakness (UMN signs – weakness, increased tone, brisk reflexes, up-going plantar
Pronator drift)
-Saccadic eye movement
-Primitive reflexes
-Speech
What is the function of the orbitofrontal cortex?
- Restraint
- Mediates empathic, civil and socially appropriate behaviour
How can the orbitofrontal cortex be examined?
- Is speech and behaviour socially appropriate?
- Go/no-go tests
- Stroop test
What is the function of the supplementary motor cortex/anterior cingulate?
Initiative
What may indicate a problem with initiative?
- Lack of motivation
- Apathy
- Abulia
- Depression
What is the function of the dorsolateral prefrontal cortex?
Order
Executive function
The integration of sensory information, the generation of a range of response alternatives to environmental challenges, the selection of the most appropriate response, maintenance of task set, sequential ordering of data, self-evaluation of performance and the selection of a replacement responses if the first applied response fails.
How can the dorsolateral prefrontal cortex be tested?
- Ability to make an appointment and keep to time
- Ability to give coherent account of history
- Spell WORLD backwards
- Say as many words as possible with a particular letter
How can language be examined?
- Fluency – Broca’s
- Nominal aphasia
- Repetition – arcuate fasciculus
- 3 step command – Wernicke’s
- ‘Baby hippopotamus’ – cerebellar speech
- Orofacial movement – ppp, ttt, mmm
- Reading
- Writing
What should you ensure before examining language ?
- Hearing is intact
- First language is English
- Determine handedness
What are the functions of the parietal lobe?
- Body image representation – primary somatosensory area
- Multimodality assimilation
- Visuospatial coordination
- Language
- Numeracy
What cortical sensory syndrome can occur as a result of parietal lobe pathology?
- Sensory inattention
- Astereoagnosia
- Dysgraphasthesia
- Two point discrimination
What syndrome can affect the dominant parietal lobe?
Gerstman’s syndrome
How can Gerstman’s syndrome present?
- Dyscalculia
- Finger anomia
- Left/right disorientation
- Agraphia
How may pathology in the non-deominant parietal lobe present?
-Ideomotor apraxia
-‘How to do’ – light a match
-Ideational apraxia
‘What to do’ – loss of understanding of the purpose of objects – what is a comb for?
-Constructional apraxia
-Dressing apraxia
-Hemineglect
-Loss of spatial awareness
What are the functions of the temporal lobe?
- Processes auditory input (Heschl gyrus)
- Language
- Encoding declarative long-term memory (hippocampus) – semantic/episodic
- Emotion (amygdala)
- Visual fields (Meyer’s loop)
How may pathology in the cerebellum present?
DANISH P
- Dysdiadochokinesia
- Ataxia
- Nystagmus
- Intention tremor
- Slurred Speech
- Hypotonia
- Past pointing
- Lower CN signs
- Hydrocephalus
What types of pathology can occur in the spine?
- Nerve root (radiculopathy)
- Peripheral nerve
- Cord (myelopathy)
- Peripheral neuropathy
What would suggest a radiculopathy (nerve root)?
- Unilateral
- Single myotome
- Single dermatome, -(reflex),
- LMN
What would suggest pathology with a peripheral nerve?
-Unilateral
-Motor and sensory deficits
LMN
What would suggest a myelopathy (cord)?
- Bilateral
- Motor and sensory level
- UMN (long tract signs)
What would suggest a peripheral neuropathy?
Glove and stocking
What type of signs would occur with a myelopathy?
Long tract signs
- Clonus
- Upgoing plantars
- increased tone
- Hoffman sign
- brisk reflexes
- Proprioception impairment Romberg’s test
- Tandem walking
Where is the pathology in myelopathy?
Cervical or thoracic
What does the location of pathology in myelopathy determine?
- UMN below the lesion
- Motor and sensory level
What does radiculopathy present with?
- Pain in single dermatome
- Dermatomal sensory disturbance
- Weakness in myotome
- Loss of reflex
