The Rapid Neuro Exam

The Rapid Neuro Exam

Scott Kobner and Anand Swaminathan

• A rapid stroke exam is a screening tool used to make initial decisions about code stroke activation in a time-limited clinical encounter. It is not the final neuro exam, and it should not replace NIH Stroke Scale/Score (NIHSS) and a comprehensive diagnostic exam.
  • A rapid stroke exam is used to quickly screen patients with neurological complaints that might benefit from a code stroke activation. The exam should answer 2 questions:

• Is there a reasonable chance this patient’s complaint can be explained by an acute lesion in their brain that requires further imaging and neurologic evaluation?
• Does this patient qualify for any urgent interventions as defined by current guidelines (time, contraindications)?

• If the answer to both of these questions is yes, then preceding with a code stroke evaluation is a reasonable next step. 

• Components of the exam: We want to identify patients who have symptoms that can be explained by a lesion in the brain, so our exam begins with signs that localize to the brain, then ultimately includes higher sensitivity motor and sensory findings that are less specific.
  • Cortical signs:
    • Aphasia: name 2 objects, repeat a phrase, follow a command
    • Vision: gaze deviation, confrontational testing
    • Neglect: interact with the patient on both sides, is there a clear preference?
  • Motor signs:
    • Lateralization is most concerning
    • Pronator drift: arms up, palms up, eyes closed
    • Finger roll: point index fingers at each other, rotate them around each other
  • Sensory exam:
    • Light touch across large representative dermatomes (face, arms, legs)
    • Subjective exam, but don’t forget lateralized, isolated sensory findings can be a thalamic stroke
  • Interpret the exam:
    • Is there a classic pattern of disability?
      • Think about stroke syndrome patterns (middle cerebral artery [MCA], anterior cerebral artery [ACA], etc)
      • Brainstem syndromes with crossed findings
    • What about isolated motor or sensory findings?
      • Isolated motor or sensory findings are poor localizers. However, at this stage, we are not pushing thrombolytics or performing endovascular interventions based on your exam. We just want to know if we should activate a code stroke and do a further, expedited workup.
    • Could this be a large vessel occlusion?
      • Consider the vision, aphasia, neglect (VAN) assessment tool (you’ve already done the steps).
      • Visual cut, aphasia, or neglect + upper extremity weakness = high likelihood of a large vessel occlusion.

What about the posterior circulation, the brainstem and cerebellum?

• Posterior strokes represent the majority of missed strokes, so we have to have a high index of suspicion.
• Brainstem syndromes are helpful to raise your level of suspicion but these are not generally the strokes you will miss.
• Dizziness and giddiness are the strokes we miss, so slow down a second:
  • Take a thorough history and understand the acute, spontaneous vestibular syndrome.
  • Appropriately apply the HINTS (Head Impulse-Nystagmus-Test of Skew) exam.
    1. We can be just as good as neurologists if we study it, practice it, and know when to apply it).
  • Consider calling it the N-S-HIT exam to help you remember that nystagmus is a key part of when it is appropriate to use.
  • Use the penlight cover test to assess for nystagmus, not just your finger.
  • Maintain a low threshold to image and call for a consult.

CorePendium: Transient Ischemic Attack and Acute Ischemic Stroke

References:

Penlight-cover test: a new bedside method to unmask nystagmus
Newman-Toker DE, Sharma P, Chowdhury M, et al. J Neurol Neurosurg Psychiatry. 2009;80(8):900-903. doi: 10.1136/jnnp.2009.174128. PMID: 19336432.

Stroke vision, aphasia, neglect (VAN) assessment–a novel emergent large vessel occlusion screening tool: pilot study and comparison with current clinical severity indices
Teleb MS, Ver Hage A, Carter J, et al. J Neurointerv Surg. 2017;9(2):122-126. doi: 10.1136/neurintsurg-2015-012131. PMID: 26891627

The forearm and finger rolling tests
Anderson NE. Pract Neurol. 2010;10(1):39-42. doi: 10.1136/jnnp.2009.200121. PMID: 20130296