Clinical and Identifying Lesions Flashcards

1
Q

Describe the 4 clinical levels of nervous system

A
  1. Supratentorial - cerebral hemispheres and intracranial portions of CN 1,2
  2. Infratentorial - brainstem, cerebellum, intracranial portions of CN 3-12
  3. Spinal: spinal cord
  4. Peripheral: all CN, ANS, spinal nerves, dorsal and venral roots
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2
Q

Describe fnc of Suprtentorial level

A
Segmental:
vision
olfaction
language
memory
cognition
pituitary gland - autonomic funcs

Longitudinal:
S & M in face, trunk, limbs to CONTRALATERAL side
autonomic fncs via hypothalamus

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3
Q

Contralateral vs ipsilateal vs bilateral

A

contra: opposite side
ipsi: same side
bi: both sides

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4
Q

Describe supratentorial lesion

A
  • loss of higher fncs
  • increased intracranial pressure: headaches, altered mental state, nausea vomitting, papilledema, diplopia, aphasia, seizures, neglect, apraxia, visual field defects
  • CONTRA defecits to face and body
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5
Q

Describe fnc of Infratentorial level

A
Segmental:
IPSIlateral fncs of CN 3-12
resp, cardiac
coordination (cerebellar)
postural control
consciousness, sleep

Longitudinal:
CONTRA sensory and motor to body
autonomic fncs

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6
Q

Describe infratentorial lesion

A

Cross signs: IPSIlateral face but contralateral body affected

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7
Q

Describe fnc of spinal level

A

Segmental: sensory, motor, autonomic at that level
Longitudinal: descending motor and autonomic; ascending sensory

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8
Q

Describe spinal lesion

A
  • loss fnc at level (and below)
  • dermatomal/myotomal distribution of loss
  • BILATERAL deficits
  • radicular pain, incontinence
  • no face of CN deficits
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9
Q

Describe fnc of peripheral level

A
  • sensory, motor, or autonomic of specific nerve

- no longitudinal fncs

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10
Q

Describe peripheral lesion

A
  • IPSIlateral loss
  • usually one side, localized
  • pain
  • motor weakness to muscles
  • dermatomal sensory loss
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11
Q

Signs of Epidural hematoma? What type of imaging used?

A
  • initially ok, then rapid onset - deteriorates within hours
  • common: middle meningeal artery
  • blood lentiform shape on imaging, held in place by periosteum and sutures
  • CT
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12
Q

Signs of subdural hematoma? What type of imaging used?

A
  • CT
  • acute: acute blood is bright in subdural space, mass effect, midline shift
  • subacute: blood broken down so now ISOdense so time has passed
  • chronic: blood is darker than tissue
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13
Q

What is a coup vs contre-coup injury?

A

cerebral contusions
coup: injury under impact site
conte-coup: injury on opposite side due to motion of brain after impact

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14
Q

What is Myasthenia gravis? What are clinical manisfistations? Complications? Tests?

A
  • autoimmune disease of NMJ
  • IgG antibody binds nicotinic ACh receptor
  • maybe due to thymus
  • motor weakness due to decreased safety factor for AP threshold
  • fatigability - better in morning
  • ocular weakness: extraocular movements, ptosis, dipoplia (not pupils)
  • bulbar: 9,10,11: disarthria, disphygia, slurred speech
  • myasthenic crisis - resp failure
  • test for diagnosis: give AChE inhibitor, ice pack on eye > improves symtoms
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15
Q

What is Lambert-eaton syndrome

A

-autoimmune - IgG against presynaptic Ca channels
> Ach vesicles not released
-muscle weakness
-gradual proximal > distal leg
-minimal ocular/bulbar symptoms
-Test for Dx: exercise improves symptoms
-Tx: blck Na channels to sustain depolrization > incrase cellular Ca

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16
Q

What is ALS? Signs and symptoms?

A
  • amyotrophic lateral sclerosis
  • degeneration of ant horn cells, cst, corticobulbar neurons
  • UMN and LMN signs
  • fasiculations, cramps, atrophy, dysarthri, dysphagia
  • sensory adn eyes OK
  • no cure, supportive therapy
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17
Q

What are examples of mononeuropathies?

signs?

A
  • Entrapment: Carpal tunnel syndrome, meralgi paresthetica, femoral nerve entrapment
  • Bell’s palsy
  • CN III palsy

Signs of neuropathy:

  • distal weakness
  • atrophy
  • hyporeflexia
  • sensory loss
  • normal muscle enzymes
  • nerve conduction study slowing
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18
Q

What is Guillian Barre Syndrome?

A
  • demyleniation due to inflammatin
  • ascending weakness from leg, sensory loss, bilateral facial palsies
  • Rx: immune globulin
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19
Q

What are signs of myopathy? (vs neuropathy)

A
myopathy: 
weakness proximal (affect larg muscles)
atrophy if advanced
normal reflexes until advanced
normal sensory
normal nerve conduction
increased muscle enzymes
muscle biopsy
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20
Q

Pyramidal vs extrapyramidal motor fncs:

A

Pyramidal:
issues with spastic tone, weakness, hyperreflexia

Extrapyramidal:
issues with involuntary movements, rigidity, brdykinesia
(no weakness, reflex issues)

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21
Q

What can cause postural instability?

A
Basal ganglia - parkinson's
Vestibulocerebellar
Vestibular
Visual
Proprioception
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22
Q

What is criteria for Parkinson’s? for IPD?

A

-Bradykinesia + at least 1 of rigidity, rest tremor, postural instability
-at least 3 of: _ and no exclusions
unilateral first
70-100% response to ldopa
ldopa response more than 5 yrs
ldopa induced chorea
rest tremor
progressive degeneration
disease will last >10 yrs

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23
Q

4 Motor and 6 non-motor features of PD?

A

Motor:

  • TRAP
  • speech and bulbar dysfnc
  • gait difficulties
  • dystonia

Non-motor:

  • sleep disturbances
  • fatigue
  • anxiety/depression
  • cognitive slowing
  • autonomic
  • sensory - pain
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24
Q

What is pathology of parkinson’s?

A
  • dopaminrgic neurons in substantia nigra pars compacta die
  • histo: see lewy bodies
  • low Da > less inhibition on globus pallidus interna > more inhibition effect on thalamus > less activation of cortex
  • this is already at stage 3 of degeneration when we clinical pick it up
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25
Q

What is the genetic link to PD?

A

many
ex: LRRK2 muttion - high in Ash. Jewish popn
Parkin mutation

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26
Q

What are Parkinson Plus disorders?

A
Other neurodegenerative diseses with parkinsonism features:
MSA
PSP
CBD
Wilson's - high Cu
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27
Q

What is MSA? Symptoms? what do we see on MRI?

A
Multi system Atrophy
-rarer than IPD
-type P (striato nigral)
-type C (cerebellar)
-type A (autonomic)
all progress to P
  • orthostatic hyptotnesion
  • urinary impotence
  • rigidity - symmetric
  • postural instability
  • cerebellar issues
  • midline dystonia
  • stridor
  • speech - high pitched
  • swallowing
  • dementia
  • see atrophy of putamen - iron deposits. DARKer
  • Hot cross bun sign on cerebellum - cross is WHITE
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28
Q

What is PSP? symptom? what do we see on imaging?

A

Progressive supranuclear palsy

  • later onset >50yrs
  • early falls
  • symmetric bradykinesia
  • difficulty swallowing, speaking
  • axial rigidity
  • GAZE

MRI: hummingbird sign - atrophy of midbrain

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29
Q

What is CBD?

A

Cortical Basal ganglion degeneration

  • apraxia
  • alien limb
  • usually limb
  • cortical sensory loss
30
Q

What are 2ry causes of parkinsonism?

A
  • Infection: encephalitis
  • Drugs: antipsychotics, lithium
  • infarcts
  • tumours
  • head injury
  • hydrocephalus
31
Q

What are red flags that it’s not IPD?

A
  • early falls (PSP)
  • orthostatic hypotension or incontinence (MSA)
  • apraxia, alien limb (CBD)
  • early hallucination (dementia)
  • symmetry, midline, bulbar signs, cerebellar signs (MSA)
  • gaze palsy (PSP)
  • lower body involved
  • NO RESPONSE TO LDOPA
32
Q

How does ldopa work? side effects?

A
  • parkinson’s
  • precursor for dopamine
  • side eff: nausea, vomitting, postural hypotension
  • complication: motor fluctuations, dyskinesias
33
Q

What is carbidopa?

A

decarboxylase inhibitor administered with ldopa

34
Q

What are dopamine agonists?

A

directly stimulate Da receptors

  • bypass nigrostriatal neurons
  • monotherapy or adjunct with ldopa
  • lower incidence of dyskinesia
  • BUT problem with impulse control disorders, sleep attacks, orthostatic hypotension
35
Q

What is amantadine?

A
  • antiviral
  • release more Da, act as Da agonist, inhibit NMDA receptors
  • good for adjunct to ldopa to decrease dyskinesia
36
Q

What are other drugs for PD?

A

COMT inhibitor - decrease alternative pathway for ldopa

MAO-B inihibitor - decrease Da degradation

37
Q

What is the ddx for dystonia?

A
INVITED MD
infection
neoplastic; tumour
vascular
inflammation 

Degeneration: PD, PSP, MSA, CBD
Wilson’s disease
etc

38
Q

What is dystonia by distribution? what are causes?

A

Dystonia - location of muscle involved

  • can be brought out by tasks: ex: writing, playing instrument
  • idiopathic or genetic cuses
39
Q

What is dystonia? How can it be overcomed?

A

involuntary sustained contraction of muscles - agonist and antagonist

  • mobile, not fixed
  • may be task/position specific when it comes out
  • may have tremor
  • have have athetosis

-change sensory input

40
Q

What are causes of 2ry dystonia?

A
  • parkisons, parkinson’s plus
  • huntington’s
  • wilson’s
41
Q

Describe Young onset dystonia. Tx?

A

-late teen onset
-limb first then body
-may be genetic: DYT1
>scoliosis, nerve entrapment, spinal stenosis

Tx: ldopa, deep brain stimulation

42
Q

What are red flags for 2ry dystonia?

A
  • abnormal birth, developmental delay
  • drugs
  • progressive symptoms
  • major bulbar signs
  • distribution not following age of onset
43
Q

What is the workup for dystonia?

A

MRI
gene testing
if young nd gene negative: 24hr Cu, ceruloplasmin, ldopa trial

44
Q

What is tourette syndrome?

A
  • chronic motor and vocal tics
  • inherited - young onset
  • voluntary, conscious tic to escape unpleasnt feeling
  • linked to excess dopamine
  • complications are not the tics, but OCD, ADHD, behaviour issues
45
Q

DDx for tics?

A
  • Tourette’s
  • Down’s
  • Fragile X
  • Autism
  • Lesh Nyhan
  • Caudate lesions: stroke, MS, hypoxic injury, tumours
46
Q

What are red flags for 2ry tourettism?

A
  • adult onset
  • neuro signs
  • progressive
  • drug/illness induced
  • abnormal brith/development
47
Q

What are tx for tics?

A
  • clonidine
  • neuroleptics
  • tetrabenzine
  • desiprimine
  • habit reversal therapy - retrain urge
  • botulin toxin
48
Q

What is the difference bt chorea and akathisia?

A
  • both random additionl invol movements
  • akathisia: internal feeling, can’t sit still. doesn’t know movement is happening
  • ASK ABOUT FEELING
49
Q

what is is Hungtington’s Disease?

A
  • slow saccades
  • chorea (think japanese kibouki”
  • gait issues
  • tics
  • paranoia, disinhibition
  • genetic
  • early onset - 30yrs
  • can induce parkisonism, falls

Tx:

  • supportive: social work, SLP, longterm care
  • psych meds
50
Q

What is myoclonus? 1ry vs 2ry?

A

brief, jerks

  • activation/deact of muscle groups
  • can be illicit voluntarily
  • causes: sensorimotor cortex, caudal brainstem, reticulr formation, spinal, peripheral nerve

1ry: hypnic jerks, jerks during sleep, hiccups
2ry: INVITED MD - lots of things

51
Q

Timeline of gross motor development.

A
  • rostral>cadual
  • proximal>distal
  • invol> vol motor movements

1mon: chin up
2mon: chest up
15mon: walk
18mon: run, throw
3yr: bike

52
Q

What is cerebral palsy?

A
  • 2-3/1000
  • syndrome of motor disorders
  • movement/posture abnormality causing activity limitation
  • brain abnormality but not progressive
53
Q

Diagnosis of CP?

A
  • clinical signs
  • risk factors: hx
  • delayed motor milestones
  • primitive reflexes stay
  • abnormal posture
54
Q

Classification of CP?

A
  1. Spastic - resistance to movements
  2. Dyskinetic - invol movements
  3. Ataxia
55
Q

Describe spastic CP - what are the subtypes?

A

Resistance to movement. Velocity dependent.

  1. Hemiplegia:
    - caused by MCA ischemic stroke or periventricular venous infarction pre/perinatally
    - arm > leg in MCA
    - leg > arm in periventricular
  2. Quadriplegia:
    - bilateral, cortical/subcortical infarcts
    - ex: bt ACA and MCA watershed
  3. Diplegia:
    ex: periventricular leukomalacia - white matter injury next to ventricles. oligodendrocytes vulnerable to injuries
    - leg >arm
    - learning is spared b/c grey matter not damaged
56
Q

What are primitive reflexes. normal timelines?

A

Moro - drop baby back, arms abduct to midline: birth = 4mon
ATNR - fencing reflex: 2wk - 6 mon
Palmar grasp - birth - 3mon
Plantar grasp - birth - 8-15 mon

57
Q

Timeline for fine motor development

A

1mon: hands fisted, palmar grasp
3mon: opening hands
5mon: grab things with palm
12mon: pincer grasp
15mon: stack blocks
3 yrs: draw circles, stack bridge

58
Q

What are red flags for motor development?

A
  • delays: no hand opening @ 3 mon, head control @ 4mon; no sitting @9min, no walking @ 18mon
  • too early: hand dominance <3 mon
  • primitive relflexes stay
  • tone
59
Q

What are perinatal risk factors of CP?

A
  • early gestational age
  • ischemic stroke
  • hypoxia
  • neonatal encephalopathy
  • infection
60
Q

What are prenatal risk factors of CP?

A
  • mom: thyroid, vascular, htn, dm, epilepsy
  • multiple gestation (twins)
  • infection
  • congenital abnomlities: too small/big
  • placental abnomilities
61
Q

What are postnatal risk factors of CP?

A
  • infection
  • injuries
  • stroke
  • hyperbilirubinemia
  • metabolic issues
  • don’t know…
62
Q

Audiograph indicating sensorimotor hearing loss?

A

Rt and Lt symmetrical, air and bone conduction same level. All decreasing slope because need higher intensity to hear at higher f.
Not in normal range

63
Q

Audiograph for conductive hearing loss?

A

Bone and air conductance separated

64
Q

Distinguish 4 types of hearing loss

A

Conductive loss: outer/middle ear affected

Sensorineural loss: cochlea, sense organs or CNVIII, damage hair cells

Cortical: higher than cochlear nuclei. rare b/c bilateral innervation

Mixed: conductive and sensorineural

65
Q

What type of hearing loss does drugs cause? ex:

A
  • ASA, loop diuretics, aminoglycoside antibiotics, anti-cancer
  • sensoryneural
66
Q

Distinguish 4 types of hearing loss

A

Conductive loss: outer/middle ear affected

Sensorineural loss: cochlea, sense organs or CNVIII

Cortical: higher than cochlear nuclei. rare b/c bilateral innervation

Mixed: conductive and sensorineural

67
Q

What type of loss is ototoxic drugs?

A

sensorineural

68
Q

What type of loss is ear infection? tympanic membrane perforation?

A

conductive

69
Q

What type of loss is tumour?

A

sensorineural/cortical depends

70
Q

What type of loss is stroke?

A

cortical

71
Q

What type of loss is ear wax and noise damage

A

mixed

  • ear wax: conductive
  • noise damage: sensorineural