Intraobserver and interobserver agreement of 8 segmental reflexes in healthy dogs

BACKGROUND

No available literature supports the claim that the patellar and withdrawal (flexor) reflexes are the only reliable segmental reflexes in dogs.

OBJECTIVE

Measure intra- and interobserver agreement of 8 segmental reflexes in dogs without clinical evidence of orthopedic or neurologic disease.

ANIMALS

One-hundred and one client- or staff-owned dogs between 1 and 10 years of age with no clinical evidence of orthopedic disease, myelopathy, or neuromuscular disease.

METHODS

Descriptive study. The intraobserver proportion of agreement (%) of responses to selected segmental reflexes in right versus left limbs by 3 observers was calculated and reported. The interobserver agreement of 2 observers of responses to selected reflexes was estimated by calculating proportions of agreement, kappa values, and 95% confidence intervals. A segmental reflex with an acceptable agreement was defined as that with a proportion of agreement ≥90% and a Kappa value ≥0.61 in both limbs.

RESULTS

The intraobserver proportion of agreement for all 3 observers was high (≥95%) for the extensor carpi radialis, withdrawal, patellar, and cranial tibial reflexes. Between observers 1 and 3 and observers 2 and 3, the interobserver proportion of agreement was high (≥ 92%) for the extensor carpi radialis (κ 0.66, not determined [ND]), withdrawal (both limbs, κ ND), patellar (κ ND), and cranial tibial reflexes (κ ND).

CONCLUSIONS AND CLINICAL IMPORTANCE

The extensor carpi radialis, withdrawal, patellar, and cranial tibial reflexes had a higher proportion of agreement and kappa values between 2 observers.

Neurological Examination: An Evaluation of Video-Based Learning

Objective This study aimed to systematically review and assess educational YouTube videos on neurological examination. Methods YouTube was screened for educational videos on neurological examination. A scoring system (involving five major and six minor criteria) was used to assess videos. Educationally useful videos were defined as those satisfying all major criteria and at least three minor criteria; 2 points were allocated for each major criterion and 1 point for each minor criterion, thereby using a score of 13 as a threshold. Results A total of 500 videos were screened, and 128 videos were included in the final selection procedure. Only 55 videos were deemed as educationally useful; 13 of these videos focused on the general neurological examination, 10 on cranial nerves, 11 on the upper limb, five on the lower limb, three on reflexes, one on upper and lower limbs, one on gait, and 11 were in the form of lectures. Six (46.15%) of the educationally useful videos about general neurological exams, including the top three videos, were created by academic institutions, and three (23.07%) were book-related. Educationally useful videos were not the most viewed videos. None of the analyzed videos included the evaluation of the autonomic nervous system in the physical examination routine. Conclusions YouTube is an increasingly common source of educational videos for medical students. However, videos found on YouTube are not peer-reviewed and may be inaccurate, and the preponderance of videos available on the platform makes it difficult for students and educators to find good educational material. We provide a list of URLs of educationally useful videos for students and educators in neurology and offer suggestions for the creation of high-quality educational videos.

Large vessel occlusion prediction scale thresholds that are sensitive for DAWN Trial patients

BACKGROUND

Large vessel occlusion (LVO) prediction scales are used to triage prehospital suspected stroke patients with a high probability of LVO stroke to endovascular therapy centers. The sensitivities of these scales in the 6-to-24-h time window are unknown. Higher scale score thresholds are typically less sensitive and more specific. Knowing the highest scale score thresholds that remain sensitive could inform threshold selection for clinical use. Sensitivities may also vary between left and right-sided LVOs.

METHODS

LVO prediction scale scores were retrospectively calculated using the National Institutes of Health Stroke Scale (NIHSS) scores of patients enrolled in the DAWN Trial. All patients had last known well times between 6 and 24 h, NIHSS scores ≥ 10, intracranial internal carotid artery or proximal middle cerebral artery occlusions, and mismatches between their clinical severities and infarct core volumes. Scale thresholds with sensitivities ≥ 85% were identified, along with scores ≥ 5% more sensitive for left or right-sided LVOs. Specificities could not be calculated because all patients had LVOs.

RESULTS

A total of 201 out of 206 patients had the required NIHSS subitem scores. CPSS = 3, C-STAT ≥ 2, FAST-ED ≥ 4, G-FAST ≥ 3, RACE ≥ 5, and SAVE ≥ 3 were the highest thresholds that were still 85% sensitive for DAWN Trial LVO stroke patients. RACE ≥ 5 was the only typically used score threshold more sensitive for right-sided LVOs, though similar small differences were seen for other scales at higher thresholds.

CONCLUSIONS

Our findings likely represent the maximum sensitivities of the LVO prediction scales tested for ideal thrombectomy candidates in the 6-to-24-h time window because NIHSS scores were documented in hospitals during a clinical trial rather than in the prehospital setting. Patients with NIHSS scores < 10 or more distal LVOs would lower sensitivities further. Selecting even higher scale thresholds for LVO triage would lead to many missed LVO strokes.

Structured Manual Muscle Testing of the Lower Limbs

An accurate and reliable neurological examination is pivotal in diagnosing patients with neurological and neurosurgical conditions. Despite the advancement of neuroscientific knowledge and the ever-progressing technologies and modalities that are being adopted to help achieve the challenge of accurate diagnosis, the neurologic examination is still crucial in both ambulatory and emergency settings. It provides the physician a tool to recognise neurologic involvement in certain disease states, and thereby allow proper work-up and treatment for patients. A basic neurologic examination can be performed rapidly with practice. Manual muscle testing of the lower limbs was carried out in accordance with a bedside clinical examination involving a clinical personnel examiner and a patient. This testing was performed in a rostro-caudal manner, starting from the hip and progressing to the toes. The neurological exam can be intimidating to perform for a lot of physicians. Deficiencies in accurate muscle testing have always presented a challenge for medical students and clinicians. By referring to the examination methods mentioned in our text and with the help of related video, it is our aim to improve the quality of neurological examination among medical personnel so that diseases may be recognised and managed earlier in their course.

Neuroworsening in the Emergency Department Is a Predictor of Traumatic Brain Injury Intervention and Outcome: A TRACK-TBI Pilot Study

INTRODUCTION

Neuroworsening may be a sign of progressive brain injury and is a factor for treatment of traumatic brain injury (TBI) in intensive care settings. The implications of neuroworsening for clinical management and long-term sequelae of TBI in the emergency department (ED) require characterization.

METHODS

Adult TBI subjects from the prospective Transforming Research and Clinical Knowledge in Traumatic Brain Injury Pilot Study with ED admission and disposition Glasgow Coma Scale (GCS) scores were extracted. All patients received head computed tomography (CT) scan <24 h post-injury. Neuroworsening was defined as a decline in motor GCS at ED disposition (vs. ED admission). Clinical and CT characteristics, neurosurgical intervention, in-hospital mortality, and 3- and 6-month Glasgow Outcome Scale-Extended (GOS-E) scores were compared by neuroworsening status. Multivariable regressions were performed for neurosurgical intervention and unfavorable outcome (GOS-E ≤ 3). Multivariable odds ratios (mOR) with [95% confidence intervals] were reported.

RESULTS

In 481 subjects, 91.1% had ED admission GCS 13-15 and 3.3% had neuroworsening. All neuroworsening subjects were admitted to intensive care unit (vs. non-neuroworsening: 26.2%) and were CT-positive for structural injury (vs. 45.4%). Neuroworsening was associated with subdural (75.0%/22.2%), subarachnoid (81.3%/31.2%), and intraventricular hemorrhage (18.8%/2.2%), contusion (68.8%/20.4%), midline shift (50.0%/2.6%), cisternal compression (56.3%/5.6%), and cerebral edema (68.8%/12.3%; all p < 0.001). Neuroworsening subjects had higher likelihoods of cranial surgery (56.3%/3.5%), intracranial pressure (ICP) monitoring (62.5%/2.6%), in-hospital mortality (37.5%/0.6%), and unfavorable 3- and 6-month outcome (58.3%/4.9%; 53.8%/6.2%; all p < 0.001). On multivariable analysis, neuroworsening predicted surgery (mOR = 4.65 [1.02-21.19]), ICP monitoring (mOR = 15.48 [2.92-81.85], and unfavorable 3- and 6-month outcome (mOR = 5.36 [1.13-25.36]; mOR = 5.68 [1.18-27.35]).

CONCLUSIONS

Neuroworsening in the ED is an early indicator of TBI severity, and a predictor of neurosurgical intervention and unfavorable outcome. Clinicians must be vigilant in detecting neuroworsening, as affected patients are at increased risk for poor outcomes and may benefit from immediate therapeutic interventions.

Does Your Bedside Neurological Examination for Suspected Peripheral Neuropathies Measure Up?

SYNOPSIS: Neurological testing is essential for screening and diagnosing suspected peripheral neuropathies. Detecting changes in somatosensory and motor nerve function can also have direct implications for management decisions. Nevertheless, there is considerable variation in what is included in a bedside neurological examination and how it is performed. Neurological examinations are often used as screening tools to detect neurological deficits but not used to their full potential for monitoring progress or deterioration. Here, we advocate for better use of the neurological examination within a clinical reasoning framework. Constrained by the lack of research in this field, our Viewpoint is based on neuroscientific principles. We highlight 6 challenges for clinicians when conducting neurological examinations and propose ways to overcome these challenges in clinical practice. We challenge widely held ideas about how the results of neurological examinations for peripheral neuropathies are interpreted and how the examinations are performed in practice. J Orthop Sports Phys Ther 2023;53(3):107-112. Epub: 28 October 2022. doi:10.2519/jospt.2022.11281.

Pattern and implications of neurological examination findings in autosomal dominant Alzheimer disease

INTRODUCTION

As knowledge about neurological examination findings in autosomal dominant Alzheimer disease (ADAD) is incomplete, we aimed to determine the frequency and significance of neurological examination findings in ADAD.

METHODS

Frequencies of neurological examination findings were compared between symptomatic mutation carriers and non mutation carriers from the Dominantly Inherited Alzheimer Network (DIAN) to define AD neurological examination findings. AD neurological examination findings were analyzed regarding frequency, association with and predictive value regarding cognitive decline, and association with brain atrophy in symptomatic mutation carriers.

RESULTS

AD neurological examination findings included abnormal deep tendon reflexes, gait disturbance, pathological cranial nerve examination findings, tremor, abnormal finger to nose and heel to shin testing, and compromised motor strength. The frequency of AD neurological examination findings was 65.1%. Cross-sectionally, mutation carriers with AD neurological examination findings showed a more than two-fold faster cognitive decline and had greater parieto-temporal atrophy, including hippocampal atrophy. Longitudinally, AD neurological examination findings predicted a significantly greater decline over time.

DISCUSSION

ADAD features a distinct pattern of neurological examination findings that is useful to estimate prognosis and may inform clinical care and therapeutic trial designs.

Associations between neurological examination at term-equivalent age and cerebral hemodynamics and oxygen metabolism in infants born preterm

Background

Infants born at 29-36 weeks gestational age (GA) are at risk of experiencing neurodevelopmental challenges. We hypothesize that cerebral hemodynamics and oxygen metabolism measured by bedside optical brain monitoring are potential biomarkers of brain development and are associated with neurological examination at term-equivalent age (TEA).

Methods

Preterm infants (N = 133) born 29-36 weeks GA and admitted in the neonatal intensive care unit were enrolled in this prospective cohort study. Combined frequency-domain near infrared spectroscopy (FDNIRS) and diffuse correlation spectroscopy (DCS) were used from birth to TEA to measure cerebral hemoglobin oxygen saturation and an index of microvascular cerebral blood flow (CBF _i ) along with peripheral arterial oxygen saturation (SpO₂). In combination with hemoglobin concentration in the blood, these parameters were used to derive cerebral oxygen extraction fraction (OEF) and an index of cerebral oxygen metabolism (CMRO_2i ). The Amiel-Tison and Gosselin Neurological Assessment was performed at TEA. Linear regression models were used to assess the associations between changes in FDNIRS-DCS parameters from birth to TEA and GA at birth. Logistic regression models were used to assess the associations between changes in FDNIRS-DCS parameters from birth to TEA and neurological examination at TEA.

Results

Steeper increases in CBF _i (p < 0.0001) and CMRO_2i (p = 0.0003) were associated with higher GA at birth. Changes in OEF, CBF _i , and CMRO_2i from birth to TEA were not associated with neurological examination at TEA.

Conclusion

In this population, cerebral FDNIRS-DCS parameters were not associated with neurological examination at TEA. Larger increases in CBF _i and CMRO_2i from birth to TEA were associated with higher GA. Non-invasive bedside FDNIRS-DCS monitoring provides cerebral hemodynamic and metabolic parameters that may complement neurological examination to assess brain development in preterm infants.

Psychometric Properties of a New Measure of Upper Limb Performance in Post-Stroke Individuals: Trunk-Based Index of Performance

BACKGROUND

Several measures of upper limb (UL) motor tasks have been developed to characterize recovery. However, UL performance and movement quality measures in isolation may not provide a true profile of functional recovery.

OBJECTIVE

To investigate the measurement properties of a new trunk-based Index of Performance (IPt) of the UL combining endpoint performance (accuracy and speed) and movement quality (trunk displacement) in stroke.

METHODS

Participants with stroke (n = 25, mean time since stroke: 18.7 ± 17.2 months) performed a reaching task over 3 evaluation sessions. The IPt was computed based on Fitts' Law that incorporated endpoint accuracy and speed corrected by the amount of trunk displacement. Test-retest reliability was analyzed using intraclass correlation coefficient (ICC) and Bland-Altman plots. Standard error of measurement (SEM) and Minimal Detectable Change (MDC) were determined. Validity was investigated through the relationship between IPt, Fugl-Meyer Assessment (FMA-UE), and Action Research Arm Test (ARAT), as well as the ability of IPt to distinguish between levels of UL motor impairment severity.

RESULTS

Test-retest reliability was excellent (ICC = .908, 95% CI: 0.807-0.96). Bland-Altman did not show systematic differences. SEM and MDC₉₅ were 14% and 39%, respectively. Construct validity was satisfactory. The IPt showed low-to-moderate relationships with FMA-UE (R² ranged from .236 to .428) and ARAT (R² ranged from .277 to .306). IPt scores distinguished between different levels of UL severity.

CONCLUSIONS

The IPt showed evidence of good reliability, and initial validity. The IPt may be a promising tool for research and clinical settings. Further research is warranted to investigate its validity with additional comparator instruments.

Assessment of the cutaneous trunci muscle reflex in healthy cats: comparison of results acquired by clinicians and cat owners

OBJECTIVES

The study aimed to evaluate the cutaneous trunci muscle reflex (CTMR) in healthy cats using methods performed by the clinician and the cat's owner at home.

METHODS

A total of 55 healthy cats without neurological abnormalities were included in this study. CTMR evaluation was performed sequentially in each cat using three methods by a clinician: method A, pinch skin with a straight 14 cm Crile haemostat forceps; method B, displace fur with the tip of a pen or haemostat forceps; and method C, poke skin with the tip of a straightened paper clip. The normal response rates for each method were obtained and compared. A 'CTMR performance score' was assigned for each cat, reflecting the presence of a normal CTMR response using one or more of the three methods. An 'owner performance score' was also obtained, reflecting the response of the CTMR when performed at home by the cat owner. The two scores were compared as paired data for each cat.

RESULTS

The CTMR was elicited normally in 17 (31%), 27 (49%) and 16 (29%) cats using methods A, B and C, respectively. Method B delivered a significantly higher percentage of normal responses. When comparing the 'CTMR performance score' and 'owner performance score', the percentage of normal responses was 60% and 100%, respectively, which was significantly different.

CONCLUSIONS AND RELEVANCE

The overall normal response rate of the CTMR in healthy feline subjects was low when performed by a clinician, regardless of the method applied. Conversely, a high percentage of normal responses was obtained by cat owners performing CTMR at home, potentially indicating the impact of stress on the CTMR performance.

Accuracy of the Hammersmith infant neurological examination for the early detection of neurological changes in infants exposed to Zika virus: A case-cohort study

The Hammersmith infant neurological examination (HINE) is a highly predictive tool for the easy and low-cost detection of cerebral palsy. Between 2015 and 2016, the rapid spread of the Zika virus (ZIKV) in Brazil was responsible for an increase in microcephaly cases. This study aimed to verify the accuracy of the HINE for the early detection of neurological problems in Brazilian babies exposed to ZIKV.This was a cross sectional case-control study of children exposed to ZIKV. This study was part of the Jundiaí ZIKV Cohort. Of a total sample of 782 children, 98 were evaluated (26 in the exposed group and 63 in the control group). We included late preterm infants and term infants who were exposed to the ZIKV and were participants in the ZIKV Cohort study. Student's t-test and stepwise multivariate logistic regression were used to compare groups.Of the 26 items evaluated in the five scored categories of the HINE (cranial nerve function, posture, movements, tone, reflexes, and reactions), only the difference in ankle dorsiflexion between the exposed and the control groups was statistically significant. However, some items showed a significant trend in relation to the control group.Our results demonstrated the importance of early neurological assessment of infants exposed to ZIKV, even in those without a microcephaly diagnosis.

Suspected Pituitary Apoplexy: Clinical Presentation, Diagnostic Imaging Findings and Outcome in 19 Dogs

In human medicine, pituitary apoplexy (PA) is a clinical syndrome characterised by the sudden onset of neurological signs because of haemorrhage or infarction occurring within a normal or tumoral pituitary gland. The diagnosis is usually performed combining neurological signs and imaging findings. The aim of the present study is to describe the abnormal neurological signs, the diagnostic imaging findings, based on Computed Tomography (CT) and/or Magnetic Resonance Imaging (MRI), and the outcome in a population of dogs with suspected PA. Clinical cases were retrospectively reviewed. Nineteen cases of suspected PA were included. The majority of dogs showed behavioural abnormalities (11/19). Neurological signs more frequently identified were obtundation (7/19), vestibular signs (7/19) and epileptic seizures (6/19). The onset of neurological signs was per-acute in 14 out of 19 cases. Data regarding CT and MRI were available in 18 and 9 cases, respectively. Neurological signs resolved in less than 24 h in seven patients. The short-term prognosis was defined as favourable in the majority of our study population. The median survival time was of 7 months from the time of PA diagnosis. This is the first description of neurological signs, imaging findings and outcome in a large group of dogs with PA.

Practical guidance for telemedicine use in neuro-oncology

While the COVID-19 pandemic has catalyzed the expansion of telemedicine into nearly every specialty of medicine, few articles have summarized current practices and recommendations for integrating virtual care in the practice of neuro-oncology. This article identifies current telemedicine practice, provides practical guidance for conducting telemedicine visits, and generates recommendations for integrating virtual care into neuro-oncology practice. Practical aspects of telemedicine are summarized including when to use and not use telemedicine, how to conduct a virtual visit, who to include in the virtual encounter, unique aspects of telehealth in neuro-oncology, and emerging innovations.

"The Value of Clinical Examination in Preterm Newborns after Neonatal Sepsis: A Cross-sectional Observational Study."

BACKGROUND

Neonatal sepsis is an important risk factor for lesions in the brain of preterm newborns (PTNB) and the most effective strategies to minimize its deleterious effects are early detection and intervention.

AIM

To investigate the presence of neurological abnormalities in PTNBs after neonatal sepsis.

METHODS

This was a prospective cross-sectional study with 100 PTNBs selected at random, 50 of the study group (sepsis) and 50 of the control group (non-sepsis). The neurological evaluation protocol adopted was the Hammersmith Neonatal Neurological Examination (HNNE).

RESULTS

The PTNBs of the sepsis group had total HNNE scores lower than expected for normality in 86% of the cases, and the non-sepsis group in 26% (p < .001). Higher prevalence levels of altered scores in tone category (p < .001), tone patterns (p = .026), reflexes (p = .002), movements (p < .001), abnormal signs (p < .001) and behavior (p < .001).

CONCLUSION

The neurological dysfunctions after neonatal sepsis could be identified by clinical neonatal neurological evaluation.

Description of neurological mimics presented to the neurology service of a small animal referral hospital

BACKGROUND

Clinicians observe that cats and dogs referred to neurology services often do not have an underlying neurological disorder. There has been no analysis of the frequency or categorisation of these neurological mimics.

METHODS

Retrospective study of 520 cases was carried out. Data on signalment, presenting clinical signs, neurological examination findings and final diagnosis were collected. Final diagnoses were classified as primary neurological, non-neurological in origin but with neurological clinical manifestation, completely non-neurological (neurological mimics) or undiagnosed. Presenting clinical signs and neurological examination results were compared between neurological mimics and primary neurological cases using Chi-square or Fischer exact test. Relative risk (RR) was calculated for significant associations.

RESULTS

A total of 74% were primary neurological conditions, 8% neurological mimics, 3% non-neurological with neurological manifestation and 15% undiagnosed. An animal referred for lameness was approximately five times more likely to be diagnosed as a neurological mimic than as a primary neurological disorder (RR = 5.42, p < 0.001). Cases with a normal neurological examination were approximately 15 times more likely to be a neurological mimic (RR = 14.97, p < 0.001).

CONCLUSION

Thorough examination with consideration of alternative diagnoses is important when a neurological condition is suspected in an animal that presents with lameness or normal neurological examination.

Challenges in developing therapeutic strategies for mild neonatal encephalopathy

There is increasing evidence that infants with mild neonatal encephalopathy (NE) have significant risks of mortality, brain injury and adverse neurodevelopmental outcomes. In the era of therapeutic hypothermia, infants need to be diagnosed within 6 hours of birth, corresponding with the window of opportunity for treatment of moderate to severe NE, compared to the retrospective grading over 2 to 3 days, typically with imaging and formal electroencephalographic assessment in the pre-hypothermia era. This shift in diagnosis may have increased the apparent prevalence of brain damage and poor neurological outcomes seen in infants with mild NE in the era of hypothermia. Abnormal short term outcomes observed in infants with mild NE include seizures, abnormal neurologic examination at discharge, abnormal brain magnetic resonance imaging and difficulty feeding. At 2 to 3 years of age, mild NE has been associated with an increased risk of autism, language and cognitive deficits. There are no approved treatment strategies for these infants as they were not included in the initial randomized controlled trials for therapeutic hypothermia. However, there is already therapeutic creep, with many centers treating infants with mild NE despite the limited evidence for its safety and efficacy. The optimal duration of treatment and therapeutic window of opportunity for effective treatment need to be specifically established for mild NE as the evolution of injury is likely to be slower, based on preclinical data. Randomized controlled trials of therapeutic hypothermia for infants with mild NE are urgently required to establish the safety and efficacy of treatment. This review will examine the evidence for adverse outcomes after mild NE and dissect some of the challenges in developing therapeutic strategies for mild NE, before analyzing the evidence for therapeutic hypothermia and other strategies for treatment of these infants.

Assessing Cranial Nerves in Physical Therapy Practice: Findings from a Cross-Sectional Survey and Implication for Clinical Practice

BACKGROUND AND OBJECTIVE

Serious pathologies of the neck can potentially result in cranial nerve palsy. Knowledge about cranial nerve examination (CNE) seems sparse, and its use is still unknown. We aim to investigate the knowledge, skills, and utilization of CNE of Italian physiotherapists.

MATERIALS AND METHODS

An online cross-sectional survey.

RESULTS

396 completed the survey, reaching the required sample size. Although Italian physiotherapists consider CNE relevant (mean ± SD = 7.6/10 ± 2.0), over half of all responders (n = 229 (57.8%)) were not trained in the fundamentals and around a third did not use it in their daily practice (n = 138 (34.8%)). Additionally, participants were unconfident and insecure in conducting (n = 152 (38.4%) and n = 147 (37.1%)), interpreting (n = 140 (35.4%) and n = 164 (41.4%)), and managing the CNE (n = 141 (35.6%) and n = 154 (38.9%)). Possessing a musculoskeletal specialization was associated with an increased value attributed to clinical practice guidelines and reduced the lack of confidence in conducting, interpreting, and managing the CNE (respectively, n = 35 (25.5%), p = 0.0001; n = 32 (23.4%) p = 0.0002; n = 32 (23.4%) p = 0.0002). Working in a direct access setting significantly increased the considered relevance of guidelines and the concerns about arterial (p = 0.004) and other serious pathologies (p = 0.021). Pain and visual disturbances were considered the main indicators to CNE, demonstrating limited knowledge of signs and symptoms' indicating CNE. Participants considered specific training in CNE as relevant (mean ± SD = 7.6/10 = 2.1).

CONCLUSIONS

a substantial proportion of Italian physiotherapists are not schooled in the fundamentals of cranial nerve examination. Given the number of physiotherapists who work in first contact roles, this is a professional concern.

Practices and Patterns of Hourly Neurochecks: Analysis of 8,936 Patients With Neurological Injury

BACKGROUND

Patients experiencing acute neurological injury often receive hourly neurological assessments ("neurochecks") to capture signs of deterioration. While commonly utilized in the intensive care unit (ICU) setting, little is known regarding practices (i.e., variations by age and ordering services) and patterns (i.e., duration and post-discontinuation plans) of hourly neurochecks. To inform future quality improvement intervention efforts, we performed an analysis of hourly neurochecks using an electronic health record-based dataset.

STUDY DESIGN AND METHODS

Our 75-month retrospective dataset consisted of all health system ICU patients who received hourly neurochecks. Variables included age, admission diagnosis category, ordering provider, post-discontinuation order, and discharge destination. Multivariable Cox regression was used to evaluate factors associated with hourly neurocheck duration.

RESULTS

We evaluated 9,513 first admission hourly neurocheck orders in 8,936 patients. The trauma, neurosurgery, and neurocritical care services were responsible for 4,067 (43%), 2,071 (22%) and 1,697 (18%) hourly neurocheck orders, respectively. Median (interquartile range) hourly neurocheck duration was 1.09 (0.69, 2.35) days, and was greater than 3 and 7 days, respectively, for 1,773 (19%) and 640 (7%) patients. Median hourly neurocheck duration ranged from 0.87 (0.65, 1.68) to 1.60 (0.83, 2.97) days for neurosurgical and non-neurological ICU services, respectively. Upon discontinuation, 2,225 (23%) of hourly neurochecks were transitioned to no neurochecks.

CONCLUSION

Substantial differences exist between ICU services and practice patterns surrounding hourly neurochecks. Understanding these differences will help inform intervention efforts aimed at streamlining hourly neurocheck practices and outcomes for patients with acute neurological injury.

Revisiting the Examination of Sharp/Dull Discrimination as Clinical Measure of Spinothalamic Tract Integrity

Objective: Revisiting the sharp/dull discrimination as clinical measure of spinothalamic tract function considering the International Standards for Neurological Classification of Spinal Cord Injury (ISNCSCI). Three clinically relevant factors were evaluated as to their impact on reliability: (1) the localization of dermatomes in relation to the sensory level, (2) the examination tool, and (3) the threshold of correct answers for grading of a preserved sharp/dull discrimination.

Design: Prospective monocentric psychometric study.

Setting: Spinal Cord Injury Center, Heidelberg University Hospital, Germany.

Participants: Convenient sample of 21 individuals with subacute spinal cord injury (age: 31–82 years) and 20 individuals without spinal cord injury (age: 24–63 years).

Assessment: All participants underwent three assessments for sharp/dull discrimination, applying five commonly used examination tools in seven dermatomes, performed by three trained examiners under conditions in accordance with ISNCSCI.

Main Outcome Measures: Assessment of interrater reliability by determining both the Fleiss kappa (κ) coefficient and the percentage agreement between raters. Data were dichotomized regarding the ISNCSCI threshold.

Results: Interrater reliability in individuals with SCI was overall substantial (κ = 0.68; CI 0.679–0.681) and moderate (κ = 0.54; CI 0.539–0.543) in dermatomes below the sensory level. All applied tools led to at least moderate reliability below the sensory level (lowest κ = 0.44; CI 0.432–0.440), with the officially endorsed safety pin achieving the highest (substantial) reliability (κ = 0.64; CI 0.638–0.646). Percentage agreement differed between non-SCI (97.3%) and formally intact above level dermatomes in SCI (89.2%).

Conclusions: Sharp/dull discrimination as a common clinical examination technique for spinothalamic tract function is a reliable assessment. Independent from the used examination tools, reliability was substantial, with the medium-sized safety pin delivering the most favorable results. Notwithstanding this, all other tools could be considered if a safety pin is not available. Regarding interrater reliability and guessing probability, a threshold of 80% correct responses for preserved sharp/dull discrimination appears to be most suitable, which is in line with current clinical approaches and ISNCSCI. The causal attribution of the identified differences in sharp/dull discrimination between clinically intact dermatomes of individuals with SCI and unaffected dermatomes of individuals without SCI requires future work.

Clinical Trial Registration Number (German Clinical Trials Register): DRKS00015334 (https://www.drks.de).

Diagnosing small fiber neuropathy in clinical practice: a deep phenotyping study

Background and aims

Small fiber neuropathy (SFN) is increasingly suspected in patients with pain of uncertain origin, and making the diagnosis remains a challenge lacking a diagnostic gold standard.

Methods

In this case-control study, we prospectively recruited 86 patients with a medical history and clinical phenotype suggestive of SFN. Patients underwent neurological examination, quantitative sensory testing (QST), and distal and proximal skin punch biopsy, and were tested for pain-associated gene loci. Fifty-five of these patients additionally underwent pain-related evoked potentials (PREP), corneal confocal microscopy (CCM), and a quantitative sudomotor axon reflex test (QSART).

Results

Abnormal distal intraepidermal nerve fiber density (IENFD) (60/86, 70%) and neurological examination (53/86, 62%) most frequently reflected small fiber disease. Adding CCM and/or PREP further increased the number of patients with small fiber impairment to 47/55 (85%). Genetic testing revealed potentially pathogenic gene variants in 14/86 (16%) index patients. QST, QSART, and proximal IENFD were of lower impact.

Conclusion

We propose to diagnose SFN primarily based on the results of neurological examination and distal IENFD, with more detailed phenotyping in specialized centers.

Development of a Comprehensive Outcome Measure for Motor Coordination; Step 1: Three-Phase Content Validity Process

BACKGROUND

Motor coordination, the ability to produce context-dependent organized movements in spatial and temporal domains, is impaired after neurological injuries. Outcome measures assessing coordination mostly quantify endpoint performance variables (ie, temporal qualities of whole arm movement) but not movement quality (ie, trunk and arm joint displacements).

OBJECTIVE

To develop an outcome measure to assess coordination of multiple body segments at both endpoint trajectory and movement quality levels, based on observational kinematics, in adults with neurological injuries.

METHODS

A 3-phase study was used to develop the Comprehensive Coordination Scale (CCS): instrument development, Delphi process, and focus group meeting. The CCS was constructed from common tests used in clinical practice and research. Rating scales for different behavioral elements were developed to guide analysis. For content validation, 8 experts (ie, neurological clinicians/researchers) answered questionnaires about relevance, comprehension, and feasibility of each test and rating scale. A focus group conducted with 6 of 8 experts obtained consensus on rating scale and instruction wording, and identified gaps. Three additional experts reviewed the revised CCS content to obtain a final version.

RESULTS

Experts identified a gap regarding assessment of hand/finger coordination. The CCS final version is composed of 6 complementary tests of coordination: finger-to-nose, arm-trunk, finger, lower extremity, and 2- and 4-limb interlimb coordination. Constructs include spatial and temporal variables totaling 69 points. Higher scores indicate better performance.

CONCLUSIONS

The CCS may be an important, understandable and feasible outcome measure to assess spatial and temporal coordination. CCS measurement properties are presented in the companion article.

Early Neurological Assessment and Long-Term Neuromotor Outcomes in Late Preterm Infants: A Critical Review

Background and Objectives: Late preterm (LP) infants (born between 34 and 36 weeks of gestational age) are considered at higher risk of neonatal morbidities, mortality, and neurological impairments than full-term born infants (FT). The aim of this study was to provide a critical review of the literature outlining the different aspects of neurological function reported both in the neonatal period and in the follow up of late preterm infants. Materials and Methods: A comprehensive search of the MEDLINE, Embase, PsycINFO, and CINAHL electronic databases was made, using the following search terms: ‘Late preterm infants’, ‘Near term infants’, ‘neurological assessment’, ‘neurological outcome’, ‘neuromotor outcome’, cerebral palsy’, ‘CP’, ‘motor impairment’, including all the studies reporting clinical neurological assessment of LP (including both neonatal period and subsequent ages). Results: A total of 35 articles, comprising 301,495 children, were included as fulfilling the inclusion criteria: ten reported neonatal neurological findings, seven reported data about the first two years after birth, eighteen reported data about incidence of CP and motor disorder during the infancy. Results showed a more immature neurological profile, explored with structured neurological assessments, in LP infants compared with FT infants. The LP population also had a higher risk of developing cerebral palsy, motor delay, and coordination disorder. Conclusion: LP had a higher risk of neurological impairments than FT infants, due to a brain immaturity and an increased vulnerability to injury, as the last weeks of gestational age are crucial for the development of the brain.

Accuracy of selected neurological clinical tests in diagnosing MRI-detectable forebrain lesion in dogs

This retrospective case study aims to evaluate the accuracy of menace response, response to nasal stimulation and proprioceptive placing in diagnosing forebrain lesion in dogs. A total of 145 client-owned dogs investigated by magnetic resonance imaging study of the brain between December 2017 and June 2019 were evaluated. Seventy-one dogs with no magnetic resonance imaging-detectable intracranial and significant cerebrospinal fluid abnormality or recent history of seizure (<48 h) served as controls. Binary regression analysis was performed to determine the sensitivity, specificity and likelihood ratios of each selected test. Older age at presentation was a significant risk factor for the presence of a forebrain lesion. Menace (62.5%) and proprioceptive deficits (40.5%) were common findings in all dogs. They were also significantly associated with the presence of forebrain abnormality. Moreover, they were more sensitive (77.3% and 82.2%, respectively) and specific (50.0% and 62.5%, respectively) when applied to dogs aged 6 years or older. Nonetheless, all of these tests' likelihood ratios, and thus reliability are poor. These neurological tests are commonly employed for diagnosing forebrain disease in dogs, yet are not highly accurate in diagnosing forebrain abnormality. Clinicians should interpret these clinical test results along with the patient history when designing a diagnostic plan.

Neurology and the clinical anatomist

Clinical examination allows the neurologist to test hypotheses generated by their interpretation of the patient's story. By eliciting abnormal clinical signs, the examining doctor works out a differential diagnosis for the part of the nervous system affected and, using information from the clinical history, a differential diagnosis of the pathology. Clinical examination also allows the clinician to observe and quantify function, hear more story and provide reassurance. The focus of the examination should be dictated by the hypothesis being tested, the patient's clinical state and the situation. Examination of the different parts of the nervous system remains very important in all clinical situations as the best available index of function of the nervous system as a whole.

The Importance of Neurological Examination for the Indication of Computed Tomography of the Brain in Pediatric Emergency Room

Objectives:

In this study, records of the children who underwent Computed Tomography of the Brain (CTB) were reviewed to increase the awareness of pediatricians to protect patients from radiation, whether CTB was used with right indications or if it was determinative for diagnosis.

Methods:

In total, in this study, 342 cases applied to our Pediatric Emergency Polyclinic between January 2005-December 2010 were retrospectively evaluated regarding complaints at admission, neurological examination and CTB results. The sensitivity and specificity of the neurological examination in detecting the CTB pathology was determined.

Results:

The results were normal in 319 of the 342 cases with CBT and abnormal in 23, out of which abnormal CTB results were only in three (0.99%) of the 301 patients with normal neurological examination results and in 20 (48.8%) of 41 patients with abnormal neurological examination results. The difference between the two groups was statistically significant (p=0.001). The sensitivity and specificity of the neurological examination in detecting CTB pathology were 87% and 94%, respectively.

Conclusion:

Detailed neurological examination of the patients in the pediatric emergency department has a key role in determining the indications for CTB. Clinical follow-up should guide neuroradiological imaging in children with normal results of the neurological examination.

Under-Recognition of Cervical Dystonia: An Essential Tremor Patient with Numerous Textbook Features of Cervical Dystonia

Background

Physical examination findings of dystonia are often underrecognized, especially in the setting of other movement disorders such as essential tremor (ET).

Phenomenology Shown

A patient with ET exhibited numerous textbook features of cervical dystonia, which were misattributed to ET by a primary care physician and two neurologists.

Educational Value

To provide a clear and unmistakable visual example of the clinically significant characteristics of cervical dystonia in the setting of concomitant ET.

Essential tremor: a nuanced approach to the clinical features

Click here to listen to the Podcast Essential tremor is the most common form of tremor in humans. Given neurologists' high exposure to this condition, and its seemingly straightforward phenotype, it might seem easy to diagnose. However, 30%-50 % of patients labelled as having 'essential tremor' have other diagnoses, mostly Parkinson's disease and dystonia. The tremor of essential tremor is neither non-descript nor featureless but is multifaceted and highly patterned. This review focuses on its clinical features, beginning with a discussion of tremors and then briefly discussing its additional motor features, and presents several aids to help distinguish essential tremor from Parkinson's disease and dystonia. Careful attention to certain clinical nuances will aid the diagnosis and care of patients with essential tremor.

[The Russian version of Coma Recovery Scale-revised - a standardized method for assessment of patients with disorders of consciousness]

The authors officially present for the first time the Russian version of Coma Recovery Scale-Revised (CRS-R). Today CRS-R is the only validated scale in Russian for assessment of patients with chronic disorders of consciousness (DOC). The study showed high consistency for different researchers, high sensitivity in the evaluation of patients over time as well as high concurrent validity. This article contains the text of the scale and recommendations how to use CRS-R and interpret the data. Presented version of the CRS-R is recommended for use in DOC patients. Russian version of the CRS-R is a standardized, comprehensive and systematic approach to the examination and assessment of patients with chronic DOS. It ensures the standard approach to examination and assessment that warrants the accuracy and homogeneity of the obtained results.

Conjugate Eye Deviation in Unilateral Lateral Medullary Infarction

Background and Purpose

The initial diagnosis of medullary infarction can be challenging since CT and even MRI results in the very acute phase are often negative.

Methods

A retrospective, observer-blinded study of horizontal conjugate eye deviation was performed in 1) 50 consecutive patients [age 58±15 years (mean±SD), 74% male, National Institutes of Health Stroke Scale 2±1] with acute unilateral lateral medullary infarction as seen in MRI (infarction group), 2) 54 patients with transient brainstem symptoms [transient ischemic attack of brainstem (TIA) group; age 69±16 years, 59% male], and 3) 53 patients (age 59±20 years, 49% male) with diagnoses other than stroke (control group).

Results

Conjugate eye deviation was found in all patients in the infarction group [n=47 (94%) with ipsilesional deviation and n=3 (6%) with contralesional deviation] compared to 41% (n=22) in the brainstem TIA group and 15% (n=8) in the control group (p<0.0001). Within all groups mean deviation and range were similar for both sides (to the right vs. to the left side 26.6°±12.3 vs. 26.1°±12.3 in the infarction group, 10.5°±5.8 vs. 8.4°±6.3 in the brainstem TIA group and 4.5°±3.2 vs. 7.5°±3.2 in the control group). The extent of eye deviation was significantly greater in the infarction group (p<0.05).

Conclusions

All patients with MRI-demonstrated unilateral medullary infarction showed conjugate eye deviation. Therefore, conjugate eye deviation in patients with suspected acute lateral medullary infarction is a helpful sensitive sign for supporting the diagnosis, particularly if the deviation is >20°.

Identifying and Quantifying Neurological Disability via Smartphone

Embedded sensors of the smartphones offer opportunities for granular, patient-autonomous measurements of neurological dysfunctions for disease identification, management, and for drug development. We hypothesized that aggregating data from two simple smartphone tests of fine finger movements with differing contribution of specific neurological domains (i.e., strength & cerebellar functions, vision, and reaction time) will allow establishment of secondary outcomes that reflect domain-specific deficit. This hypothesis was tested by assessing correlations of smartphone-derived outcomes with relevant parts of neurological examination in multiple sclerosis (MS) patients. We developed MS test suite on Android platform, consisting of several simple functional tests. This paper compares cross-sectional and longitudinal performance of Finger tapping and Balloon popping tests by 76 MS patients and 19 healthy volunteers (HV). The primary outcomes of smartphone tests, the average number of taps (per two 10-s intervals) and the average number of pops (per two 26-s intervals) differentiated MS from HV with similar power to traditional, investigator-administered test of fine finger movements, 9-hole peg test (9HPT). Additionally, the secondary outcomes identified patients with predominant cerebellar dysfunction, motor fatigue and poor eye-hand coordination and/or reaction time, as evidenced by significant correlations between these derived outcomes and relevant parts of neurological examination. The intra-individual variance in longitudinal sampling was low. In the time necessary for performing 9HPT, smartphone tests provide much richer and reliable measurements of several distinct neurological functions. These data suggest that combing more creatively-construed smartphone apps may one day recreate the entire neurological examination.

The essential neurological examination of the unconscious patient in the emergency room

OBJECTIVE

To determine whether neurologists with long-term experience in the emergency room are in general agreement about the essential components of the neurological examination (NE) used on unconscious patients in whom an obvious cause for coma is lacking.

METHODS

We surveyed 31 board-certified practicing neurologists who regularly examine unconscious patients in the emergency room and asked them to list the specific components of the NE that they would normally choose to apply in at least 80% of cases.

RESULTS

Twenty-seven neurologists rated 24 of 38 items as essential steps of the neurological examination of the unconscious patient, with a high level of agreement amongst survey participants.

CONCLUSIONS

There was a high degree of consensus amongst the neurologists surveyed about which steps are essential for the NE of the unconscious patient. These findings provide an important source of validation for teaching this particular NE to medical students, as well as nonneurologists working in an emergency setting.

Index Finger Pointing (Likely a Subtle Form of Hand Dystonia): Prevalence Across Movement Disorders

Objective: To investigate the prevalence of index finger pointing (IFP) while walking, which is likely a subtle form of hand dystonia, in cranio-cervical focal dystonia syndromes, Parkinson's disease (PD), essential tremor (ET), and controls. Methods: We recruited patients with an established diagnosis of PD, dystonia, or ET and healthy controls. All participants were videotaped while walking. Videotapes were evaluated by the authors, blinded to diagnosis, to assess the presence or absence of IFP. Results: Two-hundred-fifty participants included 50 dystonia, 50 PD, 80 ET and 70 controls. IFP was present in 29/250 (11.6%) participants: 10 dystonia (20.0%), 8 PD (16.0%), 8 ET (10.0%), and 3 controls (3.8%) (p = 0.03). There was a significant evidence of a trend in the odds of having this sign among disorders with higher risk of dystonic features (dystonia>PD>ET>control; test for trend = 0.004). Among the 180 patients (dystonia, PD, and ET, i.e., excluding the 70 controls), IFP was present in 26 (14.4% prevalence). Conclusion: IFP during gait, likely a subtle form of hand dystonia, was observed in 14.4% of movement disorder patients. The highest prevalence was in dystonia, the second highest in a disease that is often accompanied by dystonia (PD), a lower prevalence among individuals with a disease that is rarely accompanied by dystonia (ET), and the lowest in controls.

The neurological examination adapted for neuropsychiatry

The neuropsychiatric examination includes standard neurological and cognitive examination techniques with several additional observations and tasks designed to capture abnormalities common among patients with neuropsychiatric disorders or neurocognitive complaints. Although useful as a screening tool, a single standardized rating scale such as the Mini Mental State Examination (MMSE) or the Montreal Cognitive Assessment (MoCA) is insufficient to establish a neuropsychiatric diagnosis. Extra attention is paid to findings commonly seen in the setting of psychiatric disorders, dementias, movement disorders, or dysfunction of cortical or subcortical structures. Dysmorphic features, dermatologic findings, neurodevelopmental signs, signs of embellishment, and expanded neurocognitive testing are included. The neuropsychiatric clinician utilizes the techniques described in this article to adapt the examination to each patient's situation, choosing the most appropriate techniques to supplement the basic neurological and psychiatric examinations in support of diagnostic hypotheses being considered. The added examination techniques facilitate diagnosis of neurocognitive disorders and enable neuropsychiatric formulation.

Neurological Soft Signs, Spontaneous and Treatment Emergent Extrapyramidal Syndromes in Black Africans With First Episode Schizophrenia

Background: Very little is known about the relationship between spontaneous and treatment-induced motor syndromes in Africans with first episode schizophrenia. Objective: We investigated the association between spontaneous NSS and EPS, with treatment-induced EPS in a homogenous sample of Black Africans with first episode schizophrenia. Methods: We examined Xhosa (South Africa) and Yoruba (Nigeria) patients, using the Neurological Evaluation Scale and extrapyramidal symptoms scale before and at 3 months after exposure to low dose flupenthixol decanoate. Pearson's correlations and Linear regression models, controlling for duration of untreated psychosis (D.U.P) and premorbid adjustments, were used in examining associations. Results: Among 99 participants in the baseline sample, 91 (91.8%) and 20 (20.2%) had at least one definite NSS and EPS, respectively, before exposure to antipsychotics. Treatment-induced EPS were recorded in 34 (38.6%). Spontaneous EPS was associated with treatment-emergent Akathisia in participants with a longer D.U.P (r = 0.75, β = 0.70, p = 0.008). This association was specific for Parkinsonism (r = 0.75, β = 0.85, p = 0.008) and dyskinesia (r = 0.75, β = 1.70, p = 0.008). Conclusion: Similar to previous findings for tardive dyskinesia in studies implementing longer-term follow-up, spontaneous EPS may also predict short-term antipsychotic-induced EPS such as akathisia. These results may be important for early identification of patients at risk of treatment-induced Akathisia-linked psychomotor agitation in first episode schizophrenia.

Use of Machine Learning Classifiers and Sensor Data to Detect Neurological Deficit in Stroke Patients

Background

The pronator drift test (PDT), a neurological examination, is widely used in clinics to measure motor weakness of stroke patients.

Objective

The aim of this study was to develop a PDT tool with machine learning classifiers to detect stroke symptoms based on quantification of proximal arm weakness using inertial sensors and signal processing.

Methods

We extracted features of drift and pronation from accelerometer signals of wearable devices on the inner wrists of 16 stroke patients and 10 healthy controls. Signal processing and feature selection approach were applied to discriminate PDT features used to classify stroke patients. A series of machine learning techniques, namely support vector machine (SVM), radial basis function network (RBFN), and random forest (RF), were implemented to discriminate stroke patients from controls with leave-one-out cross-validation.

Results

Signal processing by the PDT tool extracted a total of 12 PDT features from sensors. Feature selection abstracted the major attributes from the 12 PDT features to elucidate the dominant characteristics of proximal weakness of stroke patients using machine learning classification. Our proposed PDT classifiers had an area under the receiver operating characteristic curve (AUC) of .806 (SVM), .769 (RBFN), and .900 (RF) without feature selection, and feature selection improves the AUCs to .913 (SVM), .956 (RBFN), and .975 (RF), representing an average performance enhancement of 15.3%.

Conclusions

Sensors and machine learning methods can reliably detect stroke signs and quantify proximal arm weakness. Our proposed solution will facilitate pervasive monitoring of stroke patients.

Leptomeningeal metastases: a RANO proposal for response criteria

Leptomeningeal metastases (LM) currently lack standardization with respect to response assessment. A Response Assessment in Neuro-Oncology (RANO) working group with expertise in LM developed a consensus proposal for evaluating patients treated for this disease. Three basic elements in assessing response in LM are proposed: a standardized neurological examination, cerebral spinal fluid (CSF) cytology or flow cytometry, and radiographic evaluation. The group recommends that all patients enrolling in clinical trials undergo CSF analysis (cytology in all cancers; flow cytometry in hematologic cancers), complete contrast-enhanced neuraxis MRI, and in instances of planned intra-CSF therapy, radioisotope CSF flow studies. In conjunction with the RANO Neurological Assessment working group, a standardized instrument was created for assessing the neurological exam in patients with LM. Considering that most lesions in LM are nonmeasurable and that assessment of neuroimaging in LM is subjective, neuroimaging is graded as stable, progressive, or improved using a novel radiological LM response scorecard. Radiographic disease progression in isolation (ie, negative CSF cytology/flow cytometry and stable neurological assessment) would be defined as LM disease progression. The RANO LM working group has proposed a method of response evaluation for patients with LM that will require further testing, validation, and likely refinement with use.

A neurologic dysfunction scoring protocol for jaundiced neonates requiring exchange transfusion

AIM

To evaluate the performance of a neurologic assessment protocol among jaundiced infants requiring exchange transfusion (ET).

METHODS

We identified infants in a referral children's hospital who received ET and those who met the American Academy of Pediatrics (AAP) criteria for ET based on total serum bilirubin (TSB) levels. The performance of a bilirubin-induced neurologic dysfunction (BIND-M) scoring protocol for acute bilirubin encephalopathy (ABE) in detecting infants treated with ET in both groups was investigated by logistic regression analysis and c-statistic.

RESULTS

A total of 438 late-preterm and term infants were enrolled, out of which 141 (32.2%) received ET, and 155 (35.4%) met AAP criteria for ET. Infants with BIND-M scores of 3-6 (intermediate ABE) or 7-12 (advanced ABE) were significantly associated with ET in both groups, but not scores of 1-2 (mild ABE), with or without adjustment for confounding neurotoxicity risk factors. However, the discriminatory ability of BIND-M regression models was modestly satisfactory (c-statistic range: 0.693-0.791).

CONCLUSIONS

Our findings suggest that BIND-M is a potentially useful decision-making tool for ET and support current recommendation for immediate ET for infants with intermediate-to-advanced stages of ABE regardless of the TSB levels.

The comparison of general movements assessment and neurological examination during early infancy

This prospective single-blinded study was performed to evaluate general movements (GMs) in group of high-risk, low-birth-weight and preterm infants and to compare results with neurologic examination. All infants' neurologic examinations, Gross Motor Function Measurement (GMFM) and Bayley-III Scale were performed at the corrected age of 12 months. A total of 22 infants were included. Eight infants (group-1) (mean: 31.6±3.29 weeks, range: 25-36 weeks) had normal GMs in all recordings and were ultimately evaluated as "normal"; 12 (group-2) (mean: 31.6±3.29 weeks, range:2 5-35 weeks) had abnormal GMs during writhing movements period but had normal GMs in subsequent recordings and were evaluated as "normal"; and 2 infants (group-3) (mean:29.5±7.78 weeks, range:24-35 weeks) with consistent abnormal GMs who were evaluated as "abnormal." Complete agreement (kappa=1) was found between GMs and neurologic examination and significant agreement between GMs and cranial ultrasonography (kappa=0.76). When results of GMFM and Bayley-III were compared; statistically significant differences were found between group-1 and group-2 in "standing" parameter of GMFM (p < 0.05) and "cognitive" parameter of Bayley-III (p < 0.05). GMs assessment can help determine neurologic disorders in high-risk infant populations as an adjunct to other diagnostic techniques.

A station-based concept for teaching the neurological examination: A prospective quasi-experimental study

Background: The neurological examination is considered to be complex and contributes to the phenomenon of "neurophobia". It is traditionally taught in small groups by residents ("traditional concept"), making the learning success partially dependent on the resident's level of clinical training, didactic education and personal motivation. Aim of this study was to examine the effects of a newly developed concept ("station concept") for teaching the neurological examination on achieving an improved and more equal transfer of knowledge and practical skills. Methods: A prospective quasi-experimental design was used to compare the traditional concept with the newly developed station concept, in which the teaching content was divided in eight subdivisions (stations) with one resident being assigned to one station. The primary endpoints of the study were the differences in students' self-assessments of learning success in the different subdomains of the neurological examination, and secondary analyses focused on evaluation results of students and residents. Results: 144 students and 28 residents participated in the traditional concept (summer semester 2012) and 151 students and 28 residents in the station concept (winter semester 2012/13). In the station-concept students' self-assessment significantly improved in the domains "Motor System", "Coordination" and "Mental Status" compared to the traditional concept. Students' evaluation showed significant improvement in five out of eight points. Fifty percent of residents rated the new approach superior to the traditional approach, ten percent as inferior. Conclusion: The station concept improved students' self-assessed learning success as well as evaluation results while simultaneously achieving high acceptance in residents.

Baseline neurological evaluations in a hyperbaric trial of post-concussive syndrome

Standard neurologic examinations may not detect abnormalities in U.S. military service members with persistent post-concussive symptoms following mild traumatic brain injury. The Brain Injury and Mechanisms of Action of Hyperbaric Oxygen for Persistent Post-Concussive Symptoms after Mild Traumatic Brain Injury Study (BIMA) enrolled 71 participants September 2012-May 2014. Participants received: comprehensive neurological and oculomotor exam; balance testing (Berg Balance Scale-BBS; Romberg Test-RT, Sharpened Romberg Test-SRT); olfactory function (Brief Smell Identification Test-BSIT). Two trained neurologists conducted the examinations at a central facility in Colorado Springs. Median age was 32 years (range 21-53), 99% male, 82% Caucasian, 49% PTSD, 28% most recent qualifying injury three months to one year prior to enrollment, 32% blast injuries only, and 73% multiple injuries. Some participants presented with abnormal facial sensation (15%), abnormal tandem gait (13%), and tremor (11%). 54% had abnormal near point of convergence (abnormal range 13-80 cm). 86% scored ≥ 55 on the BBS, with no participant scoring ⟨ 50. 49% scored ⟨ 30 seconds on the best trial of the SRT. RT was abnormal in 10%. 15% of participants scored ≤ 9 (out of 12) on BSIT, about twice what is expected in a normal population. The neurological examination found abnormalities across a range of testing, with convergence insufficiency and SRT having the most sensitivity.

TRIAL REGISTRATION

ClinicalTrials.gov Identifier: NCT01611194; https://clinicaltrials.gov/show/NCT01611194.

Systematic analysis of clinical deficits in unilateral hypoglossal nerve palsy

INTRODUCTION

The clinical characteristics of unilateral hypoglossal neuropathy have not been systematically analyzed.

METHODS

We documented subjective abnormalities of speech and swallowing, and photographed 9 specific tongue movements and positions. Objective deficits were scored independently by 2 examiners.

RESULTS

Eight patients were analyzed. Some degree of dysarthria and dysphagia was noticed by 7 and 8 patients, respectively, mostly resolving within a few months. In all subjects, there was contralateral deviation of the tongue at rest and ipsilateral deviation upon forward protrusion. Furthermore, 7 of 8 patients had deficits in using the tongue to indent the ipsilateral cheek and cover the upper lip.

CONCLUSIONS

Unilateral hypoglossal nerve palsy produces mostly subtle and transient patient symptoms, even when complete. Beyond the classic sign of ipsilateral deviation on protrusion, reliable signs are contralateral deviation at rest, paresis of ipsilateral movement inside the mouth, and paresis of elevation of the tongue tip. Muscle Nerve 54: 1055-1058, 2016.

Neurological Development of Children With Isolated Robin Sequence Treated With Nasopharyngeal Intubation in Early Infancy

The study assessed the neurodevelopment of children with isolated Robin sequence (IRS) and evaluated if children treated exclusively with nasopharyngeal intubation (NPI) present delay in neurological development. The prospective and cross-sectional study was conducted at the Hospital for Rehabilitation of Craniofacial Anomalies, Brazil. Children with IRS were divided into two groups according to the type of treatment in early infancy: 38 were treated with NPI (more severe cases) and 24 with postural treatment (less severe cases). Regarding interventions, children were assessed at 2 to 6 years of age using the Denver II Developmental Screening Test (Denver II) and Neurological Evolutionary Examination (NEE). According to Denver II, 73.7% in the NPI group and 79.2% in the postural group presented normal development. This result was similar to the results of different studies in the literature with typical population. Considering all areas of development, there were no significant differences in Denver II between the NPI and postural groups (P = .854). In the NPI group, 89.5% of children and 87.5% in the postural group presented normal development in NEE. Language was the most affected area, as 18.4% and 20.8% of children in NPI and postural group, respectively, presented risk for delay in the Denver II. The increased risk for delay in language area was probably due to anatomical conditions of the muscles involved in speech, and to hearing oscillations, as 47.4% in NPI group and 58.3% in postural group underwent myringotomy. IRS treated with NPI had neurological development similar to those in less severe cases. Children treated exclusively with NPI did not present delay in neurological development.

Prenatal ultrasound evaluation of segmental level of neurological lesion in fetuses with myelomeningocele: development of a new technique

OBJECTIVES

To report our preliminary experience in the use of prenatal ultrasound examination to assess lower-limb movements in fetuses with myelomeningocele. We aimed to determine the accuracy of this method to establish the segmental level of neurological lesion, as this is the best known predictor of the future ability to walk.

METHODS

This was a preliminary, observational study including fetuses with myelomeningocele operated on prenatally. The patterns of movements present and absent in the affected fetuses' lower limbs were evaluated systematically by ultrasound examination. According to the known nerve function associated with each muscle group, the segmental level of neurological lesion was established before birth. The agreement for the segmental levels assigned, between the prenatal ultrasound technique and the classical neurological clinical examination after birth (gold standard), was tested using the weighed kappa (wκ) index.

RESULTS

Seventy-one fetuses with myelomeningocele were evaluated at the Hospital Universitari Vall d'Hebron. After counseling, the parents opted for prenatal surgery (26 cases), termination of pregnancy (43 cases) or postnatal repair (two cases). Five patients did not fulfil the inclusion criteria for prenatal surgery and three were excluded after birth. In the 18 fetuses that underwent surgery and were analyzed, the agreement between prenatal and postnatal segmental levels assigned was 91.7% for the right limb (wκ = 0.80) and 88.9% for the left limb (wκ = 0.73).

CONCLUSIONS

The agreement found between prenatal and postnatal assignment of level of lesion in this preliminary study suggests that neurological sonographic evaluation is feasible before birth. This may provide accurate individualized information about the motor function and future ambulation prognosis of fetuses with myelomeningocele.

The Under-Utilization of the Head Impulse Test in the Emergency Department

BACKGROUND

The head impulse test (HIT) is an evidenced based clinical tool to differentiate between peripheral and central causes of vertigo. Our objective was to determine the rate of utilization of the HIT in the emergency room (ER).

METHODS

A retrospective chart review of patients presenting to the ER over one year who received a final diagnosis of dizziness or vertigo. Details of clinical examinations, investigations, and diagnosis were recorded. Patients were grouped into episodic, acute constant, and chronic vertigo groups.

RESULTS

HIT was performed in only 31 of 642 (5%) patients with vertigo. In the acute constant group it was negative in 6 of 6 patients ultimately diagnosed with stroke and positive in 6 of 13 cases of peripheral vertigo.

DISCUSSION

Despite good published evidence regarding its use the HIT is under-utilized in the ER. Physicians need to be aware of the HIT and newer video HITs and make use of them in practice.

Neglect and extinction in kinesthesia and thesesthesia: understanding proprioceptive inattention

This paper describes a new observation of neglect and extinction of kinesthesia and thesesthesia (movement and position imperception), jointly reflecting proprioceptive inattention, in a series of patients with parietal lesions. A prototypical case is discussed in detail and unaddressed aspects of proprioceptive inattention are discussed through findings from four additional cases. Thesesthetic and kinesthetic extinction were tested through simultaneous antidromic vertical displacement of index fingers, while having patients report on finger proprioceptive perception with eyes closed. Patients had variable degrees of proprioceptive inattention affecting a specific limb, but without pallesthetic inattention or somatoagnosia, whereas symptoms often resolved with visual feedback or active limb movements. Findings support that kinesthesia and thesesthesia (a) are subserved by near-identical brain networks, (b) relate more to tactile perception than pallesthesia in higher order cortical areas, and (c) have a somatotopic cortical organization even in association brain areas. Furthermore, proprioceptive extinction and neglect involve (i) "attention network" structures, (ii) either hemisphere, (iii) gray or subcortical white matter damage, (iv) defective vigilance mechanisms possibly through premature habituation of spatiotemporally saturated neural capacitor circuits, and (v) are not the result of somatoagnosia, while (vi) their resolution is observed through reafferent motor-sensory or visual feedback.

National survey of UK medical students on the perception of neurology

BACKGROUND

Medical students perceive neurology to be a difficult subject, a phenomenon described as "neurophobia". Studies investigating student attitudes towards neurology have so far been limited by small sample sizes as a consequence of being conducted within a single medical school or region. We aimed to conduct the first national survey of the perception of neurology among UK medical students.

METHODS

A 24 question online survey was designed and distributed in the form of a web-link to all UK medical schools. Responses were collected for 10 weeks with reminders sent at 3 and 6 weeks. A prize-draw of £300 was offered upon completion of the survey.

RESULTS

2877 medical students from 25 of 31 medical schools responded. Students found neurology to be significantly more difficult than other specialties and were least comfortable drawing up a neurological differential diagnosis compared to other specialties (p < 0.0001 for neurology vs. each of the other specialties). Neuroanatomy was regarded as the most important factor contributing to neurology being perceived as difficult.

CONCLUSIONS

The findings of the first national survey addressing this issue are consistent with previous research. The perception of neurology remains unchanged, in contrast to the rapidly changing demands of neurological care in an ageing population. Neurological examination and formulating a differential diagnosis are important skills in any medical specialty, and combatting "neurophobia" in medical students is therefore essential.

Abnormal downward gaze and cold caloric examination due to propofol: a case study

BACKGROUND

An adolescent girl had isolated abnormal downward gaze and oculovestibular (cold caloric) testing during propofol administration, prompting concern for brainstem abnormality.

PATIENT

An otherwise healthy 16-year-old girl presented after an intentional hanging. Brainstem reflexes were normal except that both eyes exhibited tonic downward gaze on initial examination. After propofol was suspended for 30 minutes in order to evaluate her level of responsiveness, her eyes normalized to midposition from tonic downward gaze. With reinitiation of propofol, the eyes returned to the former downward position. C-collar stabilization prohibited the usual oculocephalic (doll's eyes) evaluation. Right-sided cold water instillation resulted in right eye exodeviation to the right with minimal medial movement of the left eye to the right. After left-sided cold water instillation, the left eye deviated downward with minimal medial deviation of the right eye. She was extubated and off sedatives within 48 hours of admission, and normal ocular motility returned.

CONCLUSION

This patient exhibited abnormal ocular motility and cold caloric response with single-agent propofol exposure. The remainder of her cranial nerve examination was normal, and her normal imaging studies and prompt resolution led us to suspect a propofol effect. Physicians should be aware of the pharmacologic alterations of ocular motility and cold caloric testing when propofol is administered.