Systematic Neurological Assessment — When, How Often, What Order
Mandatory Indications
- Post-neurosurgery (craniotomy, spinal surgery, VP shunt)
- Head injury — any GCS <15 or loss of consciousness
- Acute stroke or TIA
- Seizure — post-ictal and ongoing monitoring
- Meningitis / encephalitis
- Altered level of consciousness (any cause)
High-Risk Medications
- Opioids — respiratory depression, miosis, reduced GCS
- Sedatives / benzodiazepines — CNS depression
- Anticonvulsants — toxicity can mimic neurological decline
- Osmotic agents (mannitol, hypertonic saline) — monitor neuro response
- Thrombolytics (tPA) — haemorrhagic transformation risk
Post-neurosurgeryEvery 15 min × 2 h → Every 30 min × 2 h → Hourly × 4 h → 2-hourly if stable
Acute stroke (first 24 h)Hourly neuro obs; escalate if any GCS drop or new deficit
Moderate TBI (GCS 9–12)Every 30 min until GCS stable × 4 h, then hourly
Severe TBI / raised ICPContinuous monitoring; neuro obs every 15–30 min; ICP waveform where available
Post-seizureEvery 15 min × 1 h then 30-min until baseline GCS restored
Stable neuro patientMinimum 4-hourly; increase at any change in condition
Escalation Rule Any single GCS drop of 2 or more points from baseline = urgent medical review. New pupil abnormality = emergency.
- Level of consciousness (GCS) — Eye, Verbal, Motor (always in this order and documented as E+V+M)
- Pupils — Size (mm), equality, shape, direct and consensual light reaction (PERRLA or document abnormality)
- Motor function — Upper limb power bilaterally, drift test, lower limb power bilaterally
- Limb movements — Spontaneous movement, purposeful vs reflexive; compare left vs right
- Vital signs — BP (watch for Cushing's triad: HR, RR, BP pattern), SpO2, temperature
- Pain assessment — Use validated scale; pain may elevate BP and confound assessment
Documentation Principle Trend over time is more important than any single reading. Document baseline GCS on admission and flag any change. Use neurological observation chart consistently — do not substitute general nursing notes.
GCS Drop ≥2 Points Urgent medical/neurosurgery review. Do not wait for next scheduled obs.
New Fixed Dilated Pupil Transtentorial herniation until proven otherwise. Call neurosurgeon NOW.
Cushing's Triad Hypertension + bradycardia + irregular breathing = late sign of raised ICP. Emergency.
New Focal Deficit New limb weakness, facial droop, or speech change — notify medical team within minutes.
Glasgow Coma Scale — Interactive Calculator
Select one response in each category. The total and clinical interpretation update automatically.
Select all three categories
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GCS Total
Paediatric GCS Modifications (Children <5 years)
Modified Verbal (V)
- V5 — Smiles, coos, words appropriate for age
- V4 — Cries but consolable; inappropriate words
- V3 — Persistently irritable; crying to stimuli
- V2 — Moaning; agitated to stimuli
- V1 — None
Modified Motor (M, <2 years)
- M6 — Spontaneous normal movements
- M5 — Withdraws to touch (localises)
- M4 — Withdraws to pain
- M3 — Decorticate (abnormal flexion)
- M2 — Decerebrate (extension)
- M1 — None
Eye opening is unchanged in paediatric GCS. Total score interpretation thresholds are the same (severe ≤8, moderate 9–12, mild 13–15).
Neuro Obs Trend Alert — 3 Consecutive GCS Scores
Enter three sequential GCS totals to visualise the trend and receive an alert if deterioration ≥2 points is detected.
GCS Interpretation Reference
| Total Score | Severity | Clinical Meaning | Key Action |
|---|
| 13–15 | Mild | Minor impairment; patient communicable | Monitor; neuroimaging if indicated |
| 9–12 | Moderate | Significant impairment; confusion or limited response | Close monitoring; medical review; consider CT |
| 3–8 | Severe | Coma — unable to follow commands | GCS <8 = consider airway protection / intubation; ICU referral |
| 3 | Minimum | Deeply unresponsive; no eye/verbal/motor | Immediate critical care; assess for brainstem reflexes |
Intubation Threshold GCS ≤8 with inability to protect airway — anaesthetics/ICU review for intubation. This is a guideline, not an absolute rule; clinical context always applies.
Pupil Assessment — PERRLA and Beyond
Size
2–6 mm in normal lighting. Document in mm — not "normal" or "small".
Equality
Both pupils within 1 mm of each other. Difference >1 mm = anisocoria — assess further.
Reaction
Brisk direct and consensual response to light. Sluggish = impaired; absent = fixed.
PERRLA Pupils Equal, Round, Reactive to Light, and Accommodating. Use pen torch in dimmed room. Assess each eye separately. Document size (mm), shape, direct reaction, and consensual reaction.
| Finding | Likely Cause(s) | Urgency | Action |
|---|
Unilateral fixed dilated pupil ("blown")
One pupil >6mm, no reaction |
Transtentorial (uncal) herniation — CN III compression; ipsilateral mass lesion |
EMERGENCY |
Call neurosurgeon IMMEDIATELY. HOB 30°. Mannitol if prescribed. Emergency CT. |
Bilateral fixed dilated pupils
Both pupils fixed, no reaction |
Bilateral CN III compression, brainstem herniation, severe cerebral anoxia, high-dose atropine |
EMERGENCY |
Check drug history (atropine, mydriatics). If no drug cause: brain herniation — ICU/neurosurgery NOW. |
Pinpoint pupils (miosis)
<2 mm, equal, may still react |
Opioid administration; pontine haemorrhage; organophosphate poisoning |
Urgent |
Check opioid administration history. If no drugs: pontine haemorrhage — urgent CT/neurology review. |
Unequal pupils — anisocoria
Difference >1 mm |
CN III palsy (large); Horner's syndrome (small — miosis, ptosis, anhidrosis); normal variant if <1mm |
Urgent |
Document exact sizes. Assess for ptosis, facial changes. Review baseline. Neurology review if new finding. |
Sluggish / slow reaction
Reacts but delayed (>1 sec) |
Raised ICP (early); metabolic encephalopathy; sedative medication |
Monitor closely |
Increase frequency of neuro obs. Review ICP trends. Compare with previous documentation. |
Context Matters Always interpret pupils alongside GCS and motor findings. Isolated anisocoria <1 mm without other signs is often a normal variant. A new finding in a deteriorating patient is never reassuring.
Select size (mm) and reaction for each eye. The tool provides interpretation and urgency level.
Assessment Technique — Step by Step
- 1Dim the room lighting before assessment
- 2Approach from the side — avoid letting patient fixate on the torch
- 3Shine torch at each eye separately — observe direct reaction (same eye) and consensual reaction (opposite eye)
- 4Use a pupil gauge card to measure size in mm — do not estimate
- 5Document: size (mm) both eyes, shape (round/irregular/oval), reaction (brisk/sluggish/fixed/absent)
- 6Compare to previous documentation — a change is more significant than any single reading
Motor & Limb Assessment — Power, Tone, Coordination, Reflexes
| Grade | Finding | Clinical Meaning |
|---|
| 5/5 | Normal power | Full movement against full resistance — normal |
| 4/5 | Against some resistance | Reduced power but useful movement; compare with contralateral side |
| 3/5 | Against gravity only | Can lift limb off bed but not against any added resistance |
| 2/5 | With gravity eliminated | Movement possible only when gravity is removed (sliding on bed) |
| 1/5 | Flicker of movement | Visible or palpable muscle contraction — no movement produced |
| 0/5 | No movement | Complete paralysis — no contraction detected |
Document Format Record each limb separately: Upper right / Upper left / Lower right / Lower left. Always compare sides. Grade 4 is broad — consider 4-, 4, 4+ to improve precision.
Pronator Drift Test
- Ask patient to extend both arms, palms up, eyes closed
- Hold for 10–20 seconds
- Positive: one arm drifts downward and forearm pronates = upper motor neurone weakness (contralateral hemisphere lesion)
- Subtle weakness may only show as drift — may be missed at bedside power testing
Grip Strength Comparison
- Ask patient to squeeze two fingers on each hand simultaneously
- Compare symmetry of grip force
- Asymmetric grip with normal-looking arms = early pyramidal weakness
- Combine with arm drift for sensitivity
Foot Plantar Flexion / Dorsiflexion
- Ask patient to push foot down against resistance (S1) and pull foot up (L4–L5)
- Dorsiflexion weakness (foot drop) = common L4–L5 or peroneal nerve lesion
- Compare both sides simultaneously for subtle differences
Facial Symmetry
- Ask patient to show teeth, raise eyebrows, puff cheeks
- Lower face weakness only = UMN lesion (stroke) — forehead sparing (bilateral UMN supply)
- Whole face weakness = LMN lesion (Bell's palsy, pontine lesion)
Tone Assessment
Spasticity (UMN)
Velocity-dependent resistance. "Clasp-knife" — initial resistance then sudden release. Stroke, TBI, spinal cord injury.
Rigidity (Basal Ganglia)
Constant resistance throughout range. "Lead-pipe" or "cogwheel" (Parkinson's). Not velocity-dependent.
Flaccidity (LMN)
No resistance — floppy limb. LMN lesion (peripheral nerve, anterior horn cell) or acute spinal shock phase.
Coordination Tests
- Finger-nose test: patient touches own nose then examiner's finger, repeatedly — assesses cerebellar function (ipsilateral hemisphere). Dysmetria = past-pointing.
- Heel-shin test: heel of one foot runs down the opposite shin — assesses lower limb cerebellar coordination
- Rapid alternating movements (RAM): rapidly alternating pronation-supination. Impaired = dysdiadochokinesia — cerebellar lesion
- Gait assessment: tandem (heel-to-toe) gait, wide-based gait suggests cerebellar ataxia
Deep Tendon Reflexes
| Reflex | Level | Technique | Increased = UMN; Decreased = LMN |
|---|
| Biceps | C5–C6 | Tap biceps tendon with thumb on tendon | UMN: brisk; LMN: absent |
| Triceps | C7–C8 | Tap triceps tendon directly above olecranon | UMN: brisk; LMN: absent |
| Knee (patellar) | L3–L4 | Tap patellar tendon below kneecap; leg relaxed | UMN: clonus possible; LMN: absent |
| Ankle (Achilles) | S1–S2 | Tap Achilles tendon in slight dorsiflexion | UMN: brisk; LMN/S1 radiculopathy: absent |
| Plantar (Babinski) | Corticospinal | Stroke lateral sole heel to toes | Upgoing toe = UMN lesion (normal in infants <18 months) |
Sensory Assessment
- Light touch: use cotton wool; start distally; compare sides; map any deficit
- Pin prick: use disposable pin; dermatomal distribution if cord injury suspected; glove-and-stocking pattern = peripheral neuropathy
- Vibration: 128 Hz tuning fork at bony prominences (hallux, malleoli, patella) — posterior column function
- Proprioception (joint position sense): hold sides of distal phalanx; move up/down; ask patient to identify position with eyes closed — posterior column
Critical Neuro Emergencies — Recognise and Respond
These are time-critical situations. Know the signs and act within minutes, not hours. In all emergencies: call for help first, then act. Do not manage these alone.
🔴 Cushing's Triad — Raised ICP Late Sign
Hypertension +
Bradycardia +
Irregular Respirations
(Cheyne-Stokes or slow/deep)
This is a LATE sign — brain herniation is imminent. Patient may have already deteriorated significantly.
- Call neurosurgeon and ICU IMMEDIATELY
- Elevate head of bed 30 degrees (not more — affects CPP)
- Avoid Valsalva (no coughing, straining, suctioning without pre-oxygenation)
- Maintain MAP 80–100 mmHg — do NOT reduce BP aggressively (need CPP = MAP - ICP)
- Avoid hypotonic fluids; maintain normonatraemia
- If mannitol 20% is prescribed: 0.25–0.5 g/kg IV over 20 min
- Prepare for emergency CT and possible theatre
🔴 Transtentorial (Uncal) Herniation
Unilateral blown pupil +
Contralateral hemiplegia +
Decreasing GCS
Uncal herniation through tentorium cerebelli — compresses ipsilateral CN III first (pupil), then cerebral peduncle (contralateral motor).
- Neurosurgeon and anaesthetics IMMEDIATELY
- Mannitol 0.25–0.5 g/kg IV (if not contraindicated) while awaiting neurosurgery
- HOB 30 degrees, head midline
- Emergency CT head — do not delay for imaging if clinical herniation
- Prepare for emergency decompression craniotomy
🔴 Status Epilepticus — Seizure >5 Minutes
Ongoing convulsive activity >5 min or No recovery between seizures
- Protect airway — lateral position if safe; suction if needed
- O2 15L via non-rebreather mask; IV access ×2
- BGL immediately — correct hypoglycaemia if present (50 mL of 50% dextrose)
- First-line: Lorazepam 0.1 mg/kg IV (max 4 mg) OR Midazolam 10 mg buccal/IM
- If no IV access: Diazepam 10–20 mg PR or Midazolam IM/buccal
- If still seizing at 10 min: Phenytoin 20 mg/kg IV (cardiac monitoring) or Levetiracetam 60 mg/kg IV
- Refractory at 20–30 min: anaesthetics / RSI / general anaesthesia
- See full protocol in Neurology Guide
⚠ Acute Hydrocephalus — EVD Malfunction
Headache Nausea/Vomiting Decreasing GCS Blown pupil (late)
- Check EVD system: transducer level at foramen of Monro (tragus of ear), no kinks, drainage bag below transducer
- Check for blood clot or debris in tubing — do NOT flush without neurosurgery instruction
- Urgent neurosurgery review — EVD revision or insertion of second drain
- Monitor and document ICP waveform and pressure continuously
- Normal ICP: <15 mmHg; treat if >20–22 mmHg sustained
⚠ Post-Craniotomy Haematoma
Sudden neuro deterioration within hours of craniotomy
Extradural, subdural or intracerebral haematoma can expand rapidly in the post-operative period.
- Rapid neuro assessment — compare to last documented baseline
- Call neurosurgeon IMMEDIATELY
- Emergency CT head (bedside or scanner depending on stability)
- Prepare for emergency return to theatre — theatre team and anaesthetics on standby
- Ensure IV access, blood group and screen, coagulation studies sent
⚠ Acute Spinal Cord Compression
Acute back/neck pain +
Bilateral leg weakness or numbness +
Urinary retention
- Strict spinal precautions — do not move patient without log-roll; collar if cervical
- Urgent MRI spine (within hours for complete compression)
- Neurosurgical and spinal surgery review
- IV dexamethasone if metastatic cord compression (discuss with oncology/neurosurgery)
- Catheterise if urinary retention; strict fluid balance
- Monitor motor and sensory levels serially — document dermatomal level
🔴 Autonomic Dysreflexia — SCI T6 and Above
Sudden severe headache
Acute hypertension (SBP >150)
Flushing/sweating ABOVE lesion
Bradycardia
Life-threatening hypertensive crisis triggered by noxious stimulus below the level of injury. Can cause stroke, MI, death.
- Sit patient upright immediately — this alone reduces BP via orthostasis
- Remove any tight clothing, elastic stockings, abdominal binders
- Find and remove the stimulus: most common = urinary bladder (kinked catheter, blocked catheter, full bladder — decompress NOW)
- Check for faecal impaction (second most common) — consider manual evacuation with topical lignocaine gel
- If BP remains >150: GTN spray 400 mcg sublingual or nifedipine 10 mg bite-and-swallow (hospital protocol dependent)
- Monitor BP every 2–5 minutes until resolved
- Document trigger, response, and medications given
Quick Reference — Neuro Emergency Summary
| Emergency | Key Signs | First Response |
|---|
| Cushing's Triad | HTN + bradycardia + irregular RR | Neurosurgery/ICU; HOB 30°; mannitol if prescribed |
| Blown pupil + hemiplegia | Unilateral fixed dilated + contralateral weakness | Neurosurgeon NOW; mannitol; emergency CT |
| Status epilepticus | Seizure >5 min | Airway, O2, BGL, lorazepam/midazolam |
| EVD malfunction | Headache + decreasing GCS | Check system; neurosurgery; do not flush |
| Post-craniotomy bleed | Sudden deterioration post-op | Neurosurgeon; emergency CT; prepare theatre |
| Cord compression | Bilateral weakness + urinary retention | Spinal precautions; urgent MRI; neurosurgery |
| Autonomic dysreflexia | Severe headache + hypertension + SCI T6+ | Sit up; catheterise; find stimulus; GTN if needed |