Beyond Stroke Scales: The Expanded Neurological Assessment

EMS providers often use stroke scales to assess patients with potential neurological abnormalities. Unfortunately, stroke scales are not effective at identifying anything but major neurological abnormalities. Many patients who pass the basic components of a stroke scale may still be suffering neurological emergencies.

To address the gap between stroke scales and other neurological abnormalities, this article will introduce readers to a rapid expanded neurological assessment.

Beyond Standard Scales

As most EMS providers are aware, basic stroke scales revolve around identifying facial droop, arm drift, and slurred speech. The components of stroke scale assessments are highly sensitive tests.

This means if a patient fails any component of a basic stroke scale, there is a high probability they are suffering a stroke or some other neurological abnormality. On the other hand, patients who pass all the components of a basic stroke scale may still be suffering from a stroke.

A comprehensive neurological assessment is helpful in identifying patients with less-obvious neurological abnormalities, but performing one can be difficult in the typical EMS environment. A true comprehensive evaluation takes 10–20 minutes and typically includes:

• Basic stroke scale;
• Mental status;
• Cranial nerve assessment;
• Strength and sensory function;
• Coordination;
• Balance and gait. 

This doesn’t mean EMS providers should avoid assessing patients beyond basic stroke scales. This is where the expanded neurological assessment can be utilized.

The expanded aspect begins after the EMS provider completes a basic stroke scale. This assessment evaluates all the components of a comprehensive evaluation while considering the time constraints associated with EMS scenes. This expanded neurological assessment takes between 2–3 minutes to perform.

Assessment Components

Here are the components to the expanded neurological exam.

1. Basic stroke scale—Start by having the patient smile. The patient then holds their arms out for 10 seconds with palms upward and eyes closed. It’s completed by having the patient repeat a statement with multiple consonants. If the patient fails any component, there is up to an 89% probability of a stroke or some other neurological abnormality.

2. Mental orientation—This is assessed by establishing patient orientation to person, place, time, and event. The patient passes if they correctly answer these questions. 

3. Mental cognition—This is assessed by asking the patient to spell a simple word backward, such as dog. The patient is also asked to name a presented object and then later recall that object. The patient passes if they perform these tasks correctly.

4. Cranial nerve assessment

• Visual acuity—Have the patient read something with printed text. The patient passes if they can read the text. 
• Pupil reactions—Determine direct pupillary reaction and accommodation. Direct pupillary reaction is pupil constriction when a light is directed on the cornea of the eye. Accommodation is pupil constriction in the opposite eye. 
• Eye movement—Hold a finger in front of the patient’s face, in line with the nose. The patient holds their head in place while the provider moves his/her finger up, down, and side to side. The patient passes if they can smoothly track without moving their head. They fail if either eye is unable to track or they must move their head.
• Facial sensation—Determine bilateral sensation along the forehead, cheek bones, and jawbone. The patient passes if they possess bilateral sensation along all three points. 
• Raise eyebrows—Have the patient raise their eyebrows. The patient passes if there is facial symmetry. 
• Puff cheeks—Have the patient puff their cheeks while holding their lips tightly closed. The patient passes if they can symmetrically puff their cheeks. 
• Clench teeth—Ask the patient to show their teeth. The patient passes if their mouth is symmetrical.
• Tongue out—Have the patient stick their tongue out. The patient passes if their tongue sticks straight out. They fail if their tongue sticks out asymmetrically.
• Say “a-a-ah”—Have the patient say, “A-a-ah.” The patient passes if their uvula elevates symmetrically. 
• Shoulders and head—Have the patient turn their head right and left, then shrug their shoulders against provider resistance. The patient passes if there is bilateral and equal resistance.

5. Upper extremity strength—Have the patient hold their arms as if they are in a boxing match while the provider applies resistance to each arm. The patient passes if there is equal and bilateral resistance.

6. Upper extremity sensation—Lightly touch the backs of the patient’s hands. The patient passes if they have equal bilateral sensation.

7. Finger, then nose—Point your index finger and having the patient move their index finger back and forth between your finger and their nose. The patient passes if they can coordinate between these locations with each hand.

8. Lower extremity strength—Place the hands to the soles of the feet to check plantar flexion, then to the tops of the feet to check dorsiflexion. The patient passes if strength is symmetrical.

9. Lower extremity sensation—Lightly touch the tops of the patient’s feet. The patient passes if they have equal bilateral sensation.

10. Heels to shins—Have the patient run their heel up and down the top of their shin. The patient passes if they can move their heel straight up and down along their shin. 

11. Heels to toes—Have the patient walk heel to toe. The patient passes if they can do this without stumbling.

12. Romberg test—Have the patient stand with their feet together and head upward. The patient passes if they can stand upright with their eyes open as well as closed. Remain near the patient in case of stumbles or falls.

13. Recall object—Complete the assessment by asking the patient to recall the item that was shown during the mental cognition assessment.

Summary

Basic stroke scales are good for identifying major neurological abnormalities. If your patient passes a basic stroke scale, an expanded neurological assessment will help identify more subtle neurologic problems.

Failure of an individual or combination of expanded neurological assessment tests indicates your patient may be suffering from a neurologic abnormality. 

Failing one or more of these tests typically does not necessitate a stroke alert or transport to a stroke center. What failure does warrant is a strong recommendation for transport and further assessment at a medical facility.   

Resources

Brooker C. The Neurological Exam…Made Simple, www.neurologyexam.com/.

Fuller G. Neurological Examination Made Easy, 6th ed. Elsevier, 2019.

Murray ED, Price BH. The Neurological Examination. In: Rosenbaum JF, Fava M, Rauch S, Biederman J. Comprehensive Clinical Psychiatry, 1st ed. Philadelphia: Mosby/Elsevier, 2008.

Nicholl DJ, Appleton JP. Clinical neurology: Why this still matters in the 21st century. J Neurol Neurosurg Psychiatry, 2015 Feb; 86(2): 229–33.

Rank W. Simplifying neurologic assessment. Nursing Made Incredibly Easy!, 2010 Mar–Apr; 8(2): 15–19.

Zohrevandi B, Kasmaie VM, Asadi P, Tajik H, Roodpishi NA. Diagnostic accuracy of Cincinnati pre-hospital stroke scale. Emerg (Tehran), 2015 Summer; 3(3): 95–8.

Bob Matoba is lead instructor for the St. Anthony Paramedic Academy in Lakewood, Colo. He has been involved in EMS for more than 37 years.