Brain Anatomy, Physiology, Stroke & Neurological Assessment

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Brain anatomy,physiology,Stroke&Neurological AssessmentStephanie Drysdale

Stephanie Drysdale

Functions of the BrainPrecentral gyrusPrimary Motor CortexFRONTALFRONTAL Personality/Behaviour Planning Decision making Concentration Voluntary motorfunctions Primary motor cortex(precentral gyrus)PARIETALPARIETALPostcentral gyrusPrimarySomatosensory Cortex Comprehension andlanguage Sensory functions(pain, heat and othersensations) Primary somatosensorycortex (postcentralgyrus)TEMPORALTEMPORAL OCCIPITALOCCIPITAL Understanding speechInterpretation and storage of auditory andolfactory sensations BRAINSTEMBRAINSTEMCEREBELLUMCEREBELLUM(Midbrain, Pons,Medulla(Midbrain,Pons,oblongata)Medulla oblongata) BreathingSwallowingHeart rateArousal andwakefulness Coordination BalanceStores memories ofpreviously learnedmovement patternsPrimary visual cortexProcessing visualinformation Storing visualmemories

Contra-lateral ControlStephanie Drysdale

Speech centres Broca; control themuscles of the larynx,pharynx and mouththat enable us to speak Wernicke’s area, injuryhere may result inreceptive dysphasia.Controls ourunderstanding oflanguage.Stephanie Drysdale

Blood Supply to the BrainStephanie Drysdale

Stephanie Drysdale

Stephanie Drysdale

1. Frontal LobeControls: Behaviour Emotions Organisation Personality Planning Problem solvingArteries: ACA, MCA2. Parietal LobeControls: Judgement ofshape,size,texture,and weight The sensation ofpressure and touch Understanding ofspoken/writtenlanguage Arteries: ACA, MCA3. Occipital LobeControls: Colourrecognition ShaperecognitionArteries:PCAStephanie Drysdale21467345. BrainstemControls: Alertness Blood pressure Digestion Breathing Heart rateArteries: Vertebral Basilar544. CerebellumControls: Balance Muscleco-ordination PosturemaintenanceArteries: BasilarPICA, AICA, SCAACA Anterior Cerebral ArteryMCA Middle Cerebral ArteryPCA Posterior Cerebral ArteryPICA Posterior Inferior Cerebellar ArteryAICA Anterior Inferior Cerebellar ArterySCA Superior Cerebellar Artery6. HippocampusControls: Object recognition Stores meaning ofwords or placesArteries: PCA7. Temporal lobeControls: SmellIdentification SoundIdentification Short-termMemory HearingArteries: MCA, PCA

What is a Stroke? Interruption of blood supply to thebrain, caused by a blocked or burstblood vessel Cuts of the supply ofoxygen and nutrients, causing damageto brain tissue.( World Health Organisation 2010)Stephanie Drysdale

Ischaemic Stroke It an obstruction within the BloodVessels. 84% Strokes are Ischaemic.Stephanie Drysdale

Ischemic stroke (Thrombo/embolicstroke) hypercholesterolemia hypertension Atrial fibrillation Ischaemic heart disease/angina Peripheral vascular disease DiabetesStephanie Drysdale

Previous stroke/TIA Smoking Increased alcohol intake Poor diet/obesity Increasedageatherosclerosis Oral Contraceptive Pill Drug misuseStephanie Drysdale

Haemorrhagic Stroke Chronic high bloodpressure. Amphetamine. Amyloid angiopathy Arterial Venousmalformation (AVM), inflammation of bloodvessels (vasculitis), bleeding disorders, anticoagulants,Stephanie Drysdale

Intracerebral and subarachnoidhaemorrhageStephanie Drysdale

Subdural Haematoma A subdural hematoma (Americanspelling) or subdural haematoma (Britishspelling), also known as a subduralhaemorrhage (SDH), is a type ofhaematoma, usually associated withtraumatic brain injury. Blood gathersbetween the dura mater, and the brain. Usually resulting from tears in bridgingveins which cross the subdural space,subdural hemorrhages may cause anincrease in intracranial pressure (ICP),which can cause compression of anddamage to delicate brain tissue. Subdural hematomas are often lifethreatening when acute. Chronicsubdural hematomas, however, have abetter prognosis if properly managed.Stephanie Drysdale

Cerebral infarction/ischaemic 84% Intracerebral haemorrhage 13% Subarachnoid haemorrhage 6% Risk of recurrence within 5 years 30-40%(Stroke AssociationStephanie Drysdale

Neurological assessmentWhy perform a neurological assessment?The reasons to perform a neurological assessment include:1. Identify the presence of nervous system dysfunction2. Detect life-threatening situations3. Establish a neurological baseline for the patient4. Compare data to previous assessments to determine change, trendsand necessary interventions5. Determine the effects of nervous system dysfunction on activities ofdaily living and independent function6. Provide a database upon which nursing interventions will beimplemented.Stephanie Drysdale

The Glasgow Coma Scale It provides a practical method for assessment ofimpairment of conscious levelStephanie Drysdale

The Glasgow Coma Scale The GCS evaluates three key categories of behaviour that mostclosely reflect activity in the higher centres of the brain: eyeopening, verbal response and motor response (Waterhouse,2005). These categories enable the MDT to determine whetherthe patient has cerebral dysfunctionStephanie Drysdale

The Glasgow Coma Scale Within each category, each level of response is attributed a numerical value.The lower the value, the greater the neurological deterioration and resultingbrain insult. A Coma Score of 13 or higher correlates with a mild brain injury, 9to 12 is a moderate injury and 8 or less a severe brain injury. The lowestpossible score is 3 which indicates that the patient is completely unresponsive.Stephanie Drysdale

The Glasgow Coma Scale The aim of the GCS, is to get a firm baseline forcomparison. Without this, you will be unable torecognise deterioration in the patient’s neurologicalcondition and will not be able to react appropriately. When used correctly, it alerts medics and nurses to adeterioration in a patient’s neurological statusStephanie Drysdale

Illustration of GCSStephanie Drysdale

Motor response -Abnormal Flexion(3) Elbow bends Shoulder adduction - arm moves towardsthe body Wrist flexion features clearly predominantly abnormalStephanie Drysdale

Motor response – Extension (2) Arm extends at elbow Adduction of the shoulder -arm moves towards the body Wrist flexion Arm rotates internallyStephanie Drysdale

GCS Flow Chart : Eye OpeningDoes patient open eyesspontaneously whenapproachedYesScore 4NoTalk to patient in anormal voice.Call patient’s name.‘Open your eyes’Open EyesScore 3No ResponseSpeak LouderOpen EyesScore 3No ResponseTouch or gently shakepatientOpen EyesScore 2No ResponseApply a central stimulusNo ResponseScore 1Open EyesScore 2

Eye OpeningScoreInterpretation4SpontaneouslyRAS, thalamus andcortex function intactCN3 intact3To speechRAS and cortex functionintactMotor cortex intactCN3 intact2To painReduced function ofRAS and cortex1noneNeurologicaldysfunction in RAS(brainstem)

GCS Flow Chart : Best Verbal responseAsk the patient the following questions:- What is your name? (Person)- Where are you right now? (Place)- What’s the date today? (Time)Do not ask closed endedquestions(yes/No questions)Do not ask the names of relativesNo ResponseScore 1INCOMPREHENSIBLESOUNDSResponds to the questionsbut no clear words.No intelligible words.Often moans, groans ormumbles.Score 2Answers everythingcorrectlyScore 5Not all arecorrectCONFUSEDGives inaccurateresponses but still ableto respond in contextScore 4INAPPROPRIATE WORDSResponds to the questionbut words are random,muddled, or out of context.No complete sentences.Repeats the same words.(Perseveration)Score 3

Verbal ietal,frontal and prefrontalcortex intactCN 5, 7, 8, 9, 124Confused/ sentencesTemporal/parietal,frontal intactReduced activity prefrontal cortex3Inappropriate WordsTemporal/parietal,frontal ntal intact1noneNeurologicaldysfunction in cerebralcortex

Questions used to assess best verbalresponseAsk patient the following questions: Tell me your name? (personal details) Where are you? Or what is this place? What do you think my jobis? (hospital, nurse) Tell me the month and year (the current month, year or season) Do not ask closed questions(i.e. those with yes/no answers) Do not ask the names of relatives Do not ask who the current prime minister is or other irrelevantquestions (these are context specific e.g. if it is a visitor to theUK, they might not be able to answer)

GCS Flow Chart : Best Motor ResponseAsk patient to follow 2 simple commands. Give verbalcommands only.(eg. Lift up both of your arms, bend both of your knees)Avoid asking to squeeze your hands. If you ask patient tosqueeze your hand, make sure the patient releases yourhand on command too.No commandsobeyedApply a centralstimulusNoresponseScore 1EXTENSIONIn response to the painful stimulus,straightens arm at the elbow androtates the arm inwards. Legs areoften extended and the feet areplantarflexed.Score 2ABNORMAL FLEXIONIn response to painful stimulus,flexes the arm and rotates the wrist.Score 3ObeyscommandsScore 6Does not obey command buttries to remove an oxygenmask or a nasogastric tubeScore 5LOCALISES TO PAINTries to remove stimulus.Arm moves across the midlinetowards the level of the chin.Score 5NORMAL FLEXIONIn response to the painfulstimulus, flexes the armtowards the source of pain butfails to localise or remove thesource/stimulus.Score 4

Motor responsesScoreInterpretation6Obeys commandsNeurologically intact5Localising painSensory and motorcortex and pathwaysintact4Flexion to painReduced sensory andmotor processing3Abnormal flexionBlocked motor pathwaybetween cortex andbrainstem2ExtensionBlocked motor pathwaywithin brainstem1noneGross neurologicaldysfunction

Physical stimulusCentral Stimulus Can be used to assess eye opening response and motor response If the patient does not obey commands or is not trying to pull ofoxygen facemask or nasogastric tube (if applicable)- central painfulstimulus needs to be applied Trapezius squeezeAlways explain to the patient and relatives what you are about todo and why

Trapezius Squeeze The trapezius squeeze targets the spinal accessory nerve(cranial nerve XI) and is documented as the most suitablemethod. Apply pressure by grasping approximately 3 cm of themuscle between the thumb and forefingers and squeezingwith gradually increasing intensity for up to 15 seconds Do not squeeze for more than 15 seconds even if thepatient does not react This method could be difficult on a large or obese patientbut can be done.

Pupillary Responses Estimate the size in mm using pupil scale and recordthe size numerically on the chart Move the torch from the outer aspect of the eyetowards the pupil, the pupil should constrict quickly(direct light response) Repeat the previous procedure but observe thereaction of the opposite eye( consensual lightresponse) Repeat point 3 and 4 for the opposite eye

Pupillary ResponsesfeatureactioninterpretationSizeEquality Normal pupils areround, equal andreact briskly andsimultaneously tolightResting assessmentequalityNormal 2-6mm,Pinpoint- opiatesLarge- atropineFixed Dilated- suddenCN3 compression,rising ICPshapeOvoidKeyholeIrregular/ jaggedRising ICPCataractOrbital injuriesReaction to lightSluggishNoneConsensual responserising intracranialpressurecompression of CN3 atbrainstemCoordination of CN3,unilateral compression

Assessing the pupilsAcutely widely dilated pupil on one sidemay be due to a unilateral spaceoccupying lesionBilateral abnormally constricted pupils maybe due to opiatesBilaterally dilated pupils could be anintracranial catastrophe or due tosympathetic over activity i.e fear

Limb assessment Evaluation of the limbs provides the nurse with detail of the geographicaldistribution of dysfunction and is important when performing a fullneurological assessment of the patient. A difference in responsiveness in one limb compared to another indicatesfocal brain damage. Hemiparesis or hemiplegia usually occurs in the limbson the opposite side to the lesion (due to the crossing over of nerve fibresin the medulla). However, it may also affect the limbs on the same side asthe lesion due to the pressure on the contra lateral hemisphereStephanie Drysdale

How to test limbs Each limb should be assessed separately. The patient should be awake,able to co-operate and understand what you are asking them to do. Have the patient flex and extend their arm against your hand, squeeze yourfingers, lift their leg while you press down on their thigh, hold her legstraight and lift it against gravity, and flex and extend her foot against yourhand. A peripheral stimulus needs to be applied to limbs that you have notseen move. As part of the motor assessment, also check for arm pronation or drift.Have the patient hold her arms out in front of her with her palms facing theceiling, eyes closed. If you observe pronation—a turning inward—of thepalm or the arm or the arm drifts downward, it means the limb is weak.Stephanie Drysdale

Grading of motor functionGrade each extremity using a motor scale like the one below. 5 - full ROM, full strength 4 - full ROM, less than normal strength 3 - can raise extremity but not against resistance 2 - can move extremity but not lift it 1 - slight movement 0 - no movementStephanie Drysdale

Vital signsTemperature Regulation may be disrupted due to damage to the hypothalamus In the acute phase of brain injury hyperthermia should be treated as it will exacerbatecerebral ischaemia and adversely affect outcomeHeart rate ECG changes may occur in the acute stage following cerebral insult as a result ofcatecholamine release These can include peaked P waves, prolonged QT interval, heightened T waves, STsegment elevation or depression Bradycardia is present in the later stages of raised ICP (compensatory phase –Cushing’s response) or when there is an associated cervical spine injury. Tachycardia is present in the terminal stage of raised ICP Arrhythmias are seen in posterior fossa lesions or when there is blood in the CSFStephanie Drysdale

Vital signsBlood pressure In a normal brain a fall in blood pressure does not cause a drop in cerebralperfusion pressure since autoregulation results in cerebral vasodilation to protectbrain tissue. However, following cerebral insult/injury, when autoregulation may be impaired,hypotension may lead to brain ischaemia. Hypotension (systolic BP 90mmHg) has been identified as a predominant factor insecondary brain injury and is related to morbidity and mortality. Hypotension is associated with a rising ICP and is part of the Cushing’s response –rising BP with a widening pulse pressure, bradycardia and decreasing respirations. This is a late response and may not appear in some patients and is invariablypreceded by a drop in GCS.Stephanie Drysdale

Vital signsRespiration Changes in the respiratory pattern are common following cerebral insult and patientsoften require advanced respiratory support in the acute stage. Initially an acute rise inICP will cause slowing of the respiratory rate indicating loss of all cerebral and cerebellarcontrol of breathing, with respiratory function at only brain stem level As ICP continues to rise the rate becomes rapid indicating that the brain stem is affectedtoo.A decreased level of consciousness may compromise respiratory function, thereforeobserve for potential airway problems Irregular pattern Noisy or snoring respirations Use of accessory muscles Tacypnoea/dyspnoea/apnoeaStephanie Drysdale

Raised Intracranial PressureEarly SignsLater Signs Agitation Increased systolic bloodpressure Vomiting Bradicardia Headache Dilated pupilsStephanie Drysdale Abnormal respiratorypattern

Causes and TreatmentCausesTreatment Oedema Steroids Haemorrhage Manitol Tumour Hyperventilation Encephalopathy HemicraniectomyStephanie Drysdale

HemicraniectomyStephanie Drysdale

GCS .DONT FORGET Score the patient as you see them – noguessing or backdating the results If they do not meet one criteria move downthe score to the next one Always start the assessment with the patientas awake as possible (even at 2am)Stephanie Drysdale

GCS .DONT FORGET If patient looks different to the GCS scoring do a setof obs together at hand over Consistency with using the neuro. Obs is vital todetecting changes in the patients Don’t forget to spot other changes likeincreasing confusion even if the GCS hasn’t yet changedStephanie Drysdale

GCS .DONT FORGET Patterns of change in GCS Dropping obviously! Fluctuating widely – could it represent seizure(sub-clinically) Increasing difficulty in obtaining the same GCS Small changes within the category – e.g.confused but worsening confusion, obeyssome commands but not othersStephanie Drysdale

http://www.glasgowcomascale.org/Stephanie Drysdale

References Care of the neurological patient. Caroline Pollington, 2013 Glasgow coma scale flow chart: a beginner’s guide. K. Okamura, 2014 National Institution for Health and Care Excellence (NICE) (2014) Headinjury: Triage, assessment, investigation and early management of headinjury in children, young people and adults.http://www.nice.org.uk/guidance/cg176 (accessed 24 October 2014) Assessment of altered conscious level in clinical practice (2006) Palmer& Knight

Brain anatomy, physiology, Stroke & Neurological Assessment Stephanie Drysdale. Stephanie Drysdale. Functions of the Brain FRONTAL PARIETAL OCCIPITAL Personality/Behaviour Planning Decision making Concentration Voluntary motor functions Primary motor cortex (precentral gyrus) Comprehension and language Sensory functions (pain, heat and other sensations .

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