Stroke Examination

Stroke Examination Guide

Credits

  • Dr. Neil Thomas

  • Dr. Patrick Sutton

  • Link to Stroke examination videos on BlackBoard

Learning Outcome

  • Demonstrate a basic examination for stroke (patterns of stroke disease).

Definitions

  • Sensory Ataxia:

    • Definition: Impaired coordination due to loss of proprioceptive input.

    • Notable Effect: Worsens with eyes closed.

  • Sensory Inattention:

    • Definition: Failure to perceive stimuli on one side when both sides are stimulated simultaneously (extinction).

  • Tactile Agnosia:

    • Definition: Inability to recognise objects by touch despite intact sensation.

  • Upper Motor Neuron (UMN):

    • Definition: Neurons originating in the motor cortex or brainstem.

    • Lesion Effects: Cause spasticity, hyperreflexia, and the Babinski sign.

  • Lower Motor Neuron (LMN):

    • Definition: Neurons connecting the spinal cord to muscle.

    • Lesion Effects: Cause flaccid weakness, atrophy, and fasciculations.

  • Monocular:

    • Definition: Involving or seen by one eye only.

    • Example: Monocular vision means using just one eye to see.

  • Dysmetria:

    • Definition: Inability to judge distance or range of movement.

  • Muscle Tone:

    • Definition: The slight, constant tension in muscles that helps keep the body upright, stabilizes joints, and prepares for movement.

  • Nystagmus:

    • Definition: Involuntary rhythmic eye movements.

    • Types: May be horizontal, vertical, or rotatory.

  • Dysdiadochokinesia:

    • Definition: Impaired ability to perform rapid alternating movements, indicating cerebellar dysfunction.

  • Hemiparesis:

    • Definition: Weakness affecting one side of the body, often due to contralateral UMN lesions.

  • Intention Tremor:

    • Definition: Tremor that worsens as a limb approaches a target.

  • Ipsilateral:

    • Definition: Occurring on the same side of the body as the lesion or stimulus.

Examination Preparation

  • Wash your hands.

  • Introduce yourself to the patient.

  • Confirm the patient’s name and date of birth (assess their speech during this process).

  • Explain that the examination will test the nerves of the face, arms, and legs.

  • Obtain consent from the patient.

  • Ask if the patient has any pain.

  • Ensure patient comfort and safety.

  • Check if patient has any walking aids or PEG/RIG tubes with them.

1. Cranial Nerve Examination

  • Initial Observations:

    • Facial symmetry: Look for any unilateral weakness.

    • Eye symmetry.

    • Any involuntary facial muscle contraction (abnormal).

    • Speech: Assess when asking for the patient’s name and D.O.B.

Visual Fields Examination (Cranial Nerve II)

  • Instructions:

    • Sit ~40 cm in front of the patient to establish proper distance for examination.

    • Ask the patient to look into your eyes or nose, reinforcing central gaze throughout.

    • Wiggle fingers in upper and lower quadrants midway between you and the patient (avoid auditory/visual cues to reduce false positives).

  • Purpose:

    • Tests peripheral visual fields in all quadrants.

    • Ask the patient to point to the side(s) where the fingers are moving to confirm detection of movement, ensuring unpredictability.

Monocular Visual Fields

  • Procedure:

    • Repeat with one eye covered (you cover the opposite eye).

    • Isolates monocular visual fields.

    • If defects are suspected, gradually move fingers toward the center until the patient can see it, identifying extent and location of field loss.

Findings

  • Homonymous Hemianopia:

    • Definition: Loss of the same half of the visual field in both eyes.

    • Example: Right homonymous hemianopia.

  • Homonymous Quadrantanopia:

    • Definition: Loss of the same visual field quadrant in both eyes.

  • Visual Inattention:

    • Definition: Ignores one side during simultaneous bilateral stimulation, despite intact unilateral perception.

Eye Movements Examination (Cranial Nerves III, IV, VI)

  • Instructions:

    • Sit ~40 cm from the patient to ensure optimal alignment.

    • Ask patients to follow your finger with their eyes only.

    • Ensure the patient’s head stays still.

  • Movement:

    • Move finger slowly in an “H” pattern starting from the center to test all cardinal directions of gaze.

  • Patient Report:

    • Ask the patient to report any visual changes (e.g., double vision) or pain during movement, which could indicate dysfunction.

Observations

  • Look for:

    • Asymmetry in eye movements.

    • Double vision (Diplopia) – indicates possible cranial nerve III, IV, or VI palsy.

    • Nystagmus – Indicates potential stroke or cerebellar pathology.

Facial Nerve Examination (Cranial Nerve VII)

  • Instructions:

    • Observe facial movements with patient sitting in front of you.

    • Assess facial symmetry at rest and during movement:

      • Raise eyebrows: Check for symmetrical forehead furrowing.

      • Close eyes tightly: Look for eyelash concealment.

      • Smile: Look for asymmetry.

      • Puff out cheeks: Assess lip seal integrity.

    • Gently press on cheeks while patient resists.

  • UMN vs. LMN Lesions:

    • UMN Lesion: Forehead spared; asymmetrical smile.

    • LMN Lesion: Complete unilateral weakness of all facial muscles; forehead not spared.

2. Peripheral Nerve Examination

Sensation Assessment

  • Methods:

    • Assess light touch (using cotton wool) or pain (using neurotip) in all parts of the limbs.

    • Stroke typically causes unilateral sensory loss affecting whole limb areas, not dermatomal patterns.

  • What to Look for:

    • Sensory ataxia

    • Sensory inattention

    • Tactile agnosia

Vibration Sense Assessment

  • Method:

    • Test distal bony prominences and move proximally (e.g. Upper limb: Thumb IP → Olecranon; Lower limb: Hallux IP → Tibial tuberosity).

    • Use a C-128 tuning fork and ask the patient to identify when vibration stops with eyes closed.

Muscle Tone Assessment

  • Method:

    • Assess passive upper and lower limb movements for increased tone.

    • Perform slow passive flexion and extension of joints (e.g., elbow, knee).

  • Post-Stroke Tone:

    • May start normal or low and increase over time (hypertonia).

    • Commonly affected muscles become hypertonic:

      • Upper limb: Flexors (biceps, wrist flexors)

      • Lower limb: Extensors (quadriceps, plantarflexors)

  • Clasp-knife spasticity:

    • Classic pattern of stroke where resistance increases during passive movement followed by a sudden release of resistance mid-range, resembling a clasp knife snapping open.

Power Assessment

  • Method:

    • Assess resisted upper and lower limb movements to grade strength on a scale from 0-5.

  • Unilateral Pyramidal Weakness in Stroke:

    • Upper Limb: Flexors stronger than extensors.

    • Lower Limb: Extensors stronger than flexors.

Grade

Description

0

No movement

1

Flicker of movement

2

Movement possible only if gravity is eliminated

3

Active movement against gravity

4

Active movement against gravity and some resistance

4+

Active movement against gravity and moderate resistance

5

Normal power

Reflexes Assessment

  • Position the patient comfortably: seated for upper limb reflexes, lying on the bed for lower limb reflexes.

  • Upper Limb Reflexes:

    • Supinator:

    • Biceps:

    • Triceps:

  • Lower Limb Reflexes:

    • Knee jerk:

    • Ankle jerk:

    • Plantar:

  • Method:

    • Use gravity-assisted tendon hammer swings.

    • If reflexes are hard to elicit, use reinforcement by asking the patient to grit their teeth or clasp their hands together and pull outwards.

UMN vs. LMN Lesions Comparison

Feature

UMN Lesion

LMN Lesion

Tone

Increased (Hypertonia)

Decreased

Power

Pyramidal pattern

Myotomal pattern

Reflexes

Increased (hyperreflexia)

Reduced

Plantar reflex

Upgoing (Babinski sign)

Downgoing

  • Examples:

    • UMN: Stroke, CNS tumour, Myelopathy, Multiple sclerosis, Todd’s Paresis.

    • LMN: Bell’s palsy, Nerve root impingement, Peripheral neuropathy, Guillain-Barré syndrome, Spinal Muscular Atrophy (SMA).

3. Cerebellar Function (Coordination)

  • Observations:

    • Note any walking aids, tremors, scars, or muscle wasting.

  • Tests:

    • Finger-nose test:

    • Ask the patient to alternate touching their nose and your moving finger.

    • Look for dysmetria (intention tremor or past pointing).

    • Perform the same for the other hand.

    • Dysdiadochokinesia test:

    • Performance of rapid alternating hand turns.

    • Foot tapping if upper limb is not feasible.

Heel-Shin Test

  • Ask the patient to slide their heel down the opposite shin to the ankle and back up to the opposite knee while maintaining contact.

  • Repeat for the other side.

  • Cerebellar Lesions Results:

    • Cause ipsilateral motor coordination deficits.

    • Signs include intention tremor, past pointing, impaired heel-shin test, impaired heel-toe walking, dysdiadochokinesis, broad standing base, and gait.

Other Cerebellar Signs

  • Nystagmus: Observed when asking the patient to follow your fingers with their eyes.

  • Dysarthria: Slurred speech assessed by having the patient repeat words like “British constitution” or “sixty-six”.

  • Poor Sitting Balance: Important to note before proceeding.

Gait Examination

Safety First

  • Check sitting balance. If impaired, do not proceed; remain near the bedside while attempting any test.

Progression of Gait Examination

  1. Stand still

  2. Feet together

  3. Feet together, eyes closed (Romberg’s test)

  4. Walk a short distance, possibly heel-to-toe if tolerated

  • Observations:

    • Assess balance, stance, and walking pattern.

Common Gait Findings

  • Hemiparetic Gait:

    • Unilateral leg weakness

    • Hypertonia: Stiff, extended leg

    • Semicircular leg swing

  • Cerebellar Gait:

    • Broad-based, unsteady, and veering pattern.

4. Higher Cerebral Function

Speech Assessment

  • Initial Assessment:

    • Done while asking the patient for their name and D.O.B. as well as obtaining consent.

  • Aphasia Types:

    • Expressive Aphasia (Broca’s area):

    • Ask the patient to repeat a couple of words (e.g., "Thirty-three", "Tip-top", "Baseball player").

    • Receptive Aphasia (Wernicke’s area):

    • Show an object and ask them what it is.

Dysarthria Assessment

  • Definition: Slurred articulation indicating potential cerebellar or pseudobulbar involvement.

Dysphonia Assessment

  • Definition: Altered voice quality indicating possible underlying neurological issues.

Apraxia Assessment

  • Definition: Difficulty initiating or coordinating speech, observed during patient interaction.

Other Higher Cognitive Functions

  • Cognition:

    • Abbreviated Mental Test Score (AMTS) assesses orientation, memory, and concentration (score of <8/10 = impaired).

  • Mood:

    • Observe for signs of depression or agitation.

Complete Examination

After-Examination Protocol

  1. Inform the patient that the examination is finished and thank them for their cooperation.

  2. Wash hands and remove PPE.

  3. Summarize findings on inspection (look), palpation (feel), and movement as well as coordination of patient responses.

Interpretation of Findings

  • Bamford Classification of Stroke:

    • A system used to classify the type of stroke and determine appropriate care and treatment strategies based on the observed symptoms and examination results.