Herniation & Coma Flashcards by Geun Young Park

What are the 4 main categories of Cognitive Disorders

Delirium
Dementia
Mild Cognitive Impairment
Static Encephalopathy

How well did you know this?

Not at all

Perfectly

Type of Cognitive Disorder; memory loss WORSE than normal age-related decline but patients have NO functional impairment, and therefore don’t meet the criteria for dementia

Mild Cognitive Impairment

How well did you know this?

Not at all

Perfectly

Type of Cognitive Disorder; ACUTE alteration of mental status characterized by abnormal and fluctuating attention; can also have confusion, illusions and hallucinations

Delirium

How well did you know this?

Not at all

Perfectly

Delirium is a (symptom/disease)

Symptom, thus you form a differential from it (drugs, metabolic disorder, infection, etc.)

How well did you know this?

Not at all

Perfectly

Differential Diagnosis for Delirium

Metabolic disorders
Drugs
Infections
Neurologic (stroke, tumor, etc.)
Perioperative (hypoxia, hypotension, etc.)

How well did you know this?

Not at all

Perfectly

Delirium in (old/young) patients is usually due to medications, infection or metabolic disturbances

Old

How well did you know this?

Not at all

Perfectly

Delirium in (old/young) patients is usually due to drug or alcohol intoxication/withdrawal

Young

How well did you know this?

Not at all

Perfectly

What are some tests/procedures you would do to help diagnose a cause of Delirium (remember, a SYMPTOM not a disease)

Neuro exam
Medication History
Electrolytes, Renal and Liver function
CBC
Thyroid and B12
ECG
CXR
Pulse ox
Head CT (then LP or EEG or MRI)

How well did you know this?

Not at all

Perfectly

Type of Cognitive Disorder; an ACQUIRED, persistent and PROGRESSIVE impairment in intellectual function in multiple cognitive domains, usually memory

Dementia

How well did you know this?

Not at all

Perfectly

Type of Neurodegenerative Dementia (3 total)

Alzheimer's
Parkinson's
Frontotemporal ("Pick's Disease")
Lewy Body Dementia
ALS
Huntington's
Friedrich's Ataxia

How well did you know this?

Not at all

Perfectly

What is the central pathology for Neurodegenerative Diseases (Alzheimer’s, Parkinson’s, etc.)

Deposition of abnormal proteins (amyloid, tau, alpha synuclein)

How well did you know this?

Not at all

Perfectly

Which protein is associated with Alzheimer’s Dementia

B-amyloid

How well did you know this?

Not at all

Perfectly

Which protein is associated with Frontotemporal Dementia (“Pick’s Disease”) and also Chronic Traumatic Encephalopathy

Tau

How well did you know this?

Not at all

Perfectly

Which protein is associated with Lewy Body Dementia

Synuclein

How well did you know this?

Not at all

Perfectly

Type of Cognitive Disorder; Neurodegenerative Dementia; MOST COMMON; short term memory loss with many cortical deficits (language, praxis, etc.); atrophy of most lobes of the brain (Occipital usually spared); deposition of “senile plaques” of B-amyloid and neurofibrillary tangles

Alzheimer’s Disease

How well did you know this?

Not at all

Perfectly

Alzheimer’s Disease affects (men/women) twice as much

Women

How well did you know this?

Not at all

Perfectly

Alzheimer’s Disease usually involves atrophy of all cerebral lobes EXCEPT…

Occipital (usually spared)

How well did you know this?

Not at all

Perfectly

Type of Cognitive Disorder; Neurodegenerative Dementia; ASYMMETRIC atrophy of Frontal and Temporal lobes with marked early PERSONALITY CHANGE; see Tau-positive bodies and ballooned neurons with dissolution of chromatin

Frontotemporal Dementia (aka “Pick’s Disease”)

How well did you know this?

Not at all

Perfectly

Histological finding for Frontotemporal Dementia (aka “Pick’s Disease”)

Pick bodies with Tau-positive stain

Ballooned neurons with dissolution of chromatin

How well did you know this?

Not at all

Perfectly

What is Frontotemporal Dementia also known as?

Pick’s disease

How well did you know this?

Not at all

Perfectly

In Pick’s Disease, aka Frontotemporal Dementia, atrophy is (symmetric/asymmetric) and the (occipital/parietal) lobe is usually spared

Asymmetric; Parietal

*Alzheimer’s disease is symmetric and spares occipital

How well did you know this?

Not at all

Perfectly

Type of Cognitive Disorder; Neurodegenerative Dementia; SECOND most common cause of dementia; cognitive impairment, stiffness and slowness often with visual hallucinations; brain is NOT as atrophic, but has SYNUCLEIN proteinopathy and shows Lewy bodies in cortex, limbic system and brainstem

Lewy Body Dementia

How well did you know this?

Not at all

Perfectly

Types of NON-degenerative Dementia

Vascular
Alcoholic
Creutzfeldt-Jakob Disease

How well did you know this?

Not at all

Perfectly

Type of Cognitive Disorder; NON-Degenerative Dementia; step-wise progression of deficits caused by CVD such as numerous microinfarcts

Vascular Dementia

How well did you know this?

Not at all

Perfectly

Type of Cognitive Disorder; NON-Degenerative Dementia; due to the direct toxicity of chronic alcohol exposures to neurons; associated with Wernicke-Korsakoff Syndrome (thiamine deficiency)

Alcoholic Dementia

Encephalopathy associated with chronic alcohol consumption resulting in thiamine deficiency; will experience confusion, ophthalmoplegia (paralysis of eyes) and gait ataxia along with CONFABULATIONS (due to memory disorder); ALWAYS involves lesions in the mammillary bodies

Wernicke-Korsakoff Syndrome

Vitamin deficient in Wernicke-Korsakoff Syndrome

Thiamine (B1)

Classic Triad of Wernicke Encephalopathy

- confusion - opthalmoplegia (eye paralysis) - ataxia *will also see Confabulations due to memory disorder

Why is it dangerous to give glucose to a patient with borderline Wernicke-Korsakoff

WKS is due to thiamine (B1) deficiency, which is required for oxidative metabolism of pyruvate for ATP production. High alcohol consumption use up thiamine. Intravenous glucose administration to a patient with borderline thiamine deficiency may trigger the WKS

Type of Cognitive Disorder; NON-Degenerative Dementia; Prion disease with infectious particles that cause dementia, myoclonus and ataxia; prominent Cortical atrophy and spongiform change on histology; EEG shows Periodic Sharp Wave Complexes

Creutzfeldt-Jakob Disease (CJD)

Examples of Reversible Dementia

``` B12 deficiency Hypothyroidism Syphilis Normal Pressure Hydrocephalus Hematomas Benign Tumors HIV??? ```

Type of Cognitive Disorder; REVERSIBLE Dementia; idiopathic or due to abnormal CSF absorption (meningitis, subarachnoid hemorrhage, etc.); classic triad of dementia, gait instability and urinary incontinence ("Wacky, wobbly and wet") due to compression of premotor and ventromedial cortex; treat with LP or CSF shunt

Normal Pressure Hydrocephalus

Classic traid for the symptoms of Normal Pressure Hydrocephalus

Dementia Gait instability Urinary incontinence ("Wacky, wobbly and wet")

Treatment for Normal Pressure Hydrocephalus

LP | CSF shunt

Portion of cortex associated with emotional meaning, motivation and the initiation of action based on relative emotional importance

Ventromedial cortex

Lesions of the Ventromedial Cortex results in...

Apathy Dec. spontaneous movement Gait disturbance Urinary Incontinence *remember it's the region for motivation and associated with Normal Pressure Hydrocephalus

Post-traumatic cognitive impairment with reversible functional disturbance without structural damage to be brain; is a spectrum from being dazed to persistent neurological abnormalities and potentially Chronic Traumatic Encephalopathy; associated with AXONAL dysfunction and excitotoxic cascade due to release of glutamate

Concussion

Syndrome that follows after years of continuous concussions (especially in atheletes); can lead to full blown dementia and parkinsonism; shows atrophy, ventricular dilatation and thinning of the Corpus Callosum; can see Tau deposition in neurons and astrocytes

Chronic Traumatic Encephalopathy

Key cellular change in Chronic Traumatic Encephalopathy

Tau deposition

Loss of consciousness; unarousable and unresponsive

Coma

State of being awake and aware of one's surroundings

Consciousness

Portions of the brain critical for Consciousness

Cortex | Midbrain (Reticular Activating System)

State of unresponsiveness from which a patient CAN be aroused from momentarily by very vigorous or painful stimuli

Stupor

What Neurological examination should you do for a patient with a coma?

Glasgow Coma Score General exam Cranial Nerves Reflexes

What are the three parts of a Glasgow Coma Scale

Eye opening Verbal Response Motor Response

Minimum and Maximum score on the Glasgow Coma Scale

3-15 *no zeros, so minimum is 3

Difference between localizing vs. withdrawing from pain (Glasgow Coma Scale)

Localizing: "swats your arm away during IV" Withdrawing: "pulls arm away as you put IV in"

What specifically do you do to assess the cranial nerves in a Coma patient

``` Fundoscopic exam (papilledema) Pupil size and reflex Corneal reflex EOMS Gag reflex ```

Purpose of Fundoscopic exam in a coma patient

Small, reactive pupils are seen in.

Opioid Intoxication

Unequal pupils (one large) and UNreactive means what?

Oculomotor nerve lesion (CN III) *Uncal herniation?

Unequal pupils (one small) but REACTIVE means what?

Horner's Syndrome *damage to sympathetics

Unequal size of the pupils of >1mm

Anisocoria

PEARLA

Pupils Equal And Reactive to Light and Accommodation

If you have a Coma due to a Frontal Eye Field lesion, the eye points (towards/away) from it

Toward

If you have a Coma due to a Pontine Lesion, the eye points (towards/away) from it

Away

Reflexive eye movement during head movement in order to stabilize images on the retina

Vestibulo-Ocular Reflex (VOR) *can simulate this with cold/warm water in ear

How can you simulate the Vestibulo-Ocular Reflex

Cold/warm water in the ear Warm--> same side Cold--> opposite side *COWS

(Warm/Cold) water irrigation of the ear results in the eyes looking in the same direction (irrigate right ear, eyes look right)

Warm *COWS= Cold Opposite Warm Same

(Warm/Cold) water irrigation of the ear results in the eyes looking in the opposite direction (irrigate right ear, eyes look left)

Cold *COWS= Cold Opposite Warm Same

In the Corneal reflex, the absence of ANY response indicates cranial nerve (V/VII) dysfunction

CN V (Trigeminal)

In the Corneal reflex, the absence of a reflex in ONLY ONE eye indicates cranial nerve (V/VII) dysfunction

CN VII (Facial)

(Decorticate/Decerebrate) posturing involves arms FLEXING and legs EXTENDING

Decorticate

(Decorticate/Decerebrate) posturing involves BOTH arms and legs extended; due to lesion below red nucleus in Midbrain

Decerebrate

(Coma/Locked-In) state is characterized by unconscious, no purposeful movement of face, limbs or eyes; NO sleep cycle; caused by lesion in BOTH hemispheres or RAS

Coma *main characteristic is unconscious and no sleep cycle

(Coma/Locked-In) state is characterized by CONSCIOUS, no purposeful movement of face or limbs, but CAN look up with eyes; NORMAL sleep cycle and due to lesions in Pons (takes out Corticospinal and Corticobulbar tracts but not RAS)

Locked-In

Key differences between Coma and Locked-In state in regards to symptoms

Coma: Unconscious, no eye movements or sleep cycle | Locked-In: Conscious, eyes can look up, normal sleep cycle

Difference between Coma and Locked-In state based on location of Lesion

Coma: Both hemispheres or RAS | Locked in: bilateral Pons (takes out Corticospinal and Corticobulbar tracts, but NOT RAS)

Difference between Coma and Persistent Vegetative State

PVS has: Sleep Wake cycle Auditory/Visual startle reflex Noxious Stimuli reflex