Lecture 7 (Neuro) - Exam 3 Flashcards

Question

Neurological Assessment - Coordination * What is the romberg test?

Answer 1

* Stand with feet together and arms at their side. * Stand nearby, not touching the patient but ready to catch them if they fall. * Observe the patient for 20 seconds. * Tell patient to close their eyes, continue the test for another 30 seconds

Answer 2

Check both sides of the body, at same location – to ensure it is consistent

Answer 3

Can they detect and separate types of sensations * Dull object on their palm vs a sharp object * Remember to tell them what is sharp and dull before doing procedure then perform in different location Abnormal results can indicate spinal cord lesions

Answer 4

* Coordination should be tested in the upper and lower limbs. * In upper limbs, it is best assessed using the "finger to nose" test. * In the lower limbs using the "heel to shin" test.

Answer 5

Abnormal results can be due to defects in * Cerebellar function * Muscular weakness

Answer 6

* Corneal/Blink reflex – test with cotton rubbed over cornea * Babinski/Plantar - stroke sole of the foot, positive means toes flare and big toe goes up * Protective – gag, cough, corneal test

Answer 7

Oculocephalic - "dolls eyes", * Intact brain stem – eyes are fixed on the on the same point in the room as the patient's head is moved * Midbrain damage – eyes will continue to start in whatever direction the head is pointed Deep tendon - biceps, triceps, quadriceps, Achilles

Answer 8

* Easiest way to remember is that dead people's eyes do not move. * Reason for conducting the test is to not determine if there is a brain lesion but to check for brain death.

Answer 9

* Reflexes are automatic responses to stimulation. * These unconscious movements happen quickly, and we do not have time to consciously register what happened. * Reflex actions do not involve the brain. * Simple reflexes are controlled by certain areas of the spinal cord.

Answer 10

* Developed in 1974 as an objective and reliable scale to record the level of consciousness of a person, especially after a head injury. * An accurate neurological examination will help to determine the type and position of the pathological process and provide a baseline for comparison with subsequent examinations.

Answer 11

* Conscious state * Pupillary size and reaction * Focal neurological signs in the limbs

Answer 12

* Eye/facial trauma * Intubation * Damage to the throat or cords * Drugs (both ones the patient took and what we gave them) * Paralytics * Fear or sleep depervation * Deafness or blindness * Etoh and withdrawal * Electrolyte imbalances

Answer 13

Gives a numerical value to the three most important parameters of the level of consciousness: * Opening of eyes * Best verbal response * Best motor response Exact response can be represented on a chart, or the level of consciousness given a numerical score – the sum of the parameters of the Glasgow coma score.

Answer 14

indicates a severe injury

Answer 15

* First sign of depressed conscious state is drowsiness – may be easily arousable and oriented to person, place and time. * As they deteriorate, they become more confused and drowsier. * Coma is restricted to patients who show no response to external stimuli.

Answer 16

* Avoid the terms “semicoma or stuporse" as they convey different meanings to different observers. * Assessment is more accurate and reproducible if either the exact response is described, or the Glasgow coma score is used.

Answer 17

* Using only the motor component of the GCS – if less than 6 is just as predictive for severe injury as using the whole GCS. * Purposeful withdrawal - indicates that the patient is consciously moving towards the source of the pain – suggests higher level of brain function - localizes, crosses the midline

Answer 18

* Non-purposeful withdrawal - can be indicative of a lower level of consciousness or severe brain injury, where movement is more reflexive and not consciously directed * Flexor response - decorticate - suggests damage to cerebral hemispheres * Extensor response – decerebrate - indicates more severe damage involving the brainstem

Answer 19

Often used to describe the patient’s level of consciousness. * A stands for alert * V for responds to verbal stimuli * P for responds to painful stimulus * U for unresponsive.

Answer 20

* This approach, although simple, fails to provide information regarding specifically how the patient responds to either verbal or painful stimuli. * Lack’s precision and has fallen out of favor.

Answer 21

Location of cranial nerves in the brain, help to identify how they are affected during times of trauma, strokes.

Answer 22

* Compression of a brain mass directly on the affected cranial nerve on the same side, produces a deficit on that SAME side, such as hearing loss. * This would not produce upper or lower extremity weakness.

Answer 23

In this case, brain mass on left, cranial nerve 8 affected, hearing loss.

Answer 24

* Cranial nerve deficits like loss of vision –compression by a benign brain mass upon the optic chiasm. * This would not produce upper or lower extremity weakness. * In this case, patient may have loss of vision as the mass presses against the nerve junction.

Answer 25

A patient with a stroke or head injury can have deficits on the opposite side of the body due to the way the brain and spinal cord are organized - a process called decussation.

Answer 26

* Primary pathway that carries motor signals from the brain to the spinal cord and then to the muscles. * They originates in the motor cortex of the brain and travels down through the brainstem. * At the level of the medulla/pons region, fibers in the corticospinal tract cross over to the opposite of the body - decussation * As a result, the right side of brain controls muscles on left side of the body, left side of brain controls muscles on the right side.

Answer 27

Like motor pathways, sensory pathways also cross over to the opposite side of the body. (at level of medulla)

Answer 28

* This helps to see the location of cranial nerves and how they are affected by tumors, bleeding, trauma. * This also helps to understand how one hemisphere can cause deficits on the opposite side of the body. * At brainstem

Answer 29

* Frontal Lobe: Executive/Motor and Expressive Function * Parietal Lobe: Somatosensory/Calculating * Temporal Lobe: Comprehension and memory function * Occipital Lobe: Vision

Answer 30

* Refers to identifying locations of a CNS event based on clinical symptoms that are absent or a dysfunction that is present. * The term brain lateralization refers to the fact that the two halves of the human brain are not exactly alike. * Each hemisphere has functional specializations: a theory that different areas of the brain are specialized for different functions.

Answer 31

Damage or activity in this region on the left hemisphere typically affects the **right side of the body**

Answer 32

Dominant hemisphere – left hemisphere is dominant for language and cognitive functions. Nondominant hemisphere – usually the right hemisphere. It is responsible for three-dimensional, or spatial, perception and nonverbal ideation. It also allows for superior recognition of faces.

Answer 33

Knowing a patient’s handedness helps in predicting which hemisphere might be more critical for these functions. * If they have a tumor affecting the left hemisphere, or large tumor, can affect language. * Most people are right-handed, thus left side is dominant. * In left-handed people, 85% still have left side of brain as dominant side.

Answer 34

* Aphasia – impaired expression or comprehension of written or spoken language: * Broca’s Area – located in frontal lobe – receptive aphasia - can understand but cannot speak. * Wernicke Area – located in the temporal lobe – expressive aphasia – patient understands but their responses do not make sense. * Global (all aspects of language involved)->Typically, because of a large stroke

Answer 35

* Primarily reside in the cerebral cortex, specifically within the motor cortex areas such as the precentral gyrus, which is part of the frontal lobe. * The primary motor cortex, located in the precentral gyrus, is the key area where the cell bodies of upper motor neurons are found.

Answer 36

* These neurons then send their axons down through the brainstem and spinal cord, forming the corticospinal and corticobulbar tracts, to synapse on lower motor neurons or interneurons in the spinal cord or brainstem. * Responsible for transmitting motor signals from the brain to the lower motor neurons in the brainstem and spinal cord. * Involved in planning, initiating, and controlling voluntary movements.

Answer 37

* Disuse atrophy * Weakness * Increased reflexes with deep tendon reflex testing – exaggerated reflexed due to loss of inhibitory signals from the brain. * Clonus – repetitive, rhythmic muscle contractions * Babinski sign – abnormal reflex where the big toe extends upward when the sole of the foot is stimulated.

Answer 38

* Amyotrophic Lateral Sclerosis (ALS) – progressive neurodegenerative disease that affects both upper and lower motor neurons – muscle weakness, spasticity and atrophy. * Primary Lateral Sclerosis (PLS) – rare motor neuron disease that primarily affects the UMN. Progresses more slowly than ALS – spasticity, muscle stiffness and weakness in legs.

Answer 39

* Multiple Sclerosis (MS) – autoimmune disease that targets the myelin sheath of neurons in CNS – affecting UMN and other pathways – spasticity, muscle weakness, vision problems. * Spinal cord injury – can damage the UMN running through it – depending on the level of injury, spasticity, paralysis and loss of voluntary control of lower extremities.

Answer 40

* Located in the anterior portion of the spinal cord and in the brainstem. * Lower motor neuros are the final common pathway for motor signals from the central nervous system to the muscles – directly innervate skeletal muscles. * When these neurons or axons are damaged, it results in lower motor neuron signs which can manifest in any muscle group – including upper extremities.

Answer 41

* Typically lead to muscle weakness. * Hyporeflexia. * No myelopathy * Flaccid paralysis

Answer 42

* Spinal Muscular Atrophy (SMA) – genetic disorder, destroys the anterior horn cells in the spinal cord – muscle weakness, reduced reflexes. * Peripheral Neuropathy – damage to multiple peripheral nerves – such as from diabetes, infections, toxins – symmetric muscle weakness, atrophy, sensory disturbances (numbness, hyporeflexia)

Answer 43

Myasthenia Gravis (MS) – autoimmune disorder characterized by weakness and rapid fatigue of voluntary muscles – targets neuromuscular junction – muscle weakness that worsens with exertion and improves with rest.

Answer 44

* CT scan of the head without contrast – most common-initial exam to look for cerebral bleeding, edema, masses. * CT Angiogram of the head and neck – identify source of bleed, aneurysms, arterial venous malformations. * CT Perfusion of the head – generally done for stroke patients, helps to tell if there is a perfusion deficit to parts of the brain such as from a stroke where a clot causes obstruction of cerebral arteries.

Answer 45

* MRI angiography generally does not use radiation but high frequency waves, and a non-allergic type of contrast if needed - not used as much when speed of identification and direction of treatment is important. Great for measuring and examining blood vessels of the brain * MRIs are generally ordered after a patient has had a stroke or suspected, will help identify areas damaged by the stroke. * MRIs of the head, with and without contrast, with stealth – used for mapping of a tumor so that it can be surgically removed.

Answer 46

* Carotid ultrasound – can tell if there is carotid stenosis, generally will tell the percentage of suspected blockage in the carotid arteries – evaluating the speed, of velocity of flow is important, when compared to previous studies can tell if stenosis is developing. * Transcranial Doppler – used to evaluate for increased velocities in the cerebral arteries – vasospasms develop after a subarachnoid bleed – can lead to reduced blood flow and strokes – this helps to identify if that is developing.

Answer 47

Cardiac studies: EKG, Cardiac Monitoring, Echocardiogram, TEE Neurocognitive testing Electrophysiological studies: * EEG, Video EEG monitoring for determination if seizure activity is present – difficult to determine when sedated and unconsciousness. * EMG nerve conduction study

Answer 48

* Can be caused by a peripheral or central etiology, or both. * It is the cardinal symptom of vestibular disease that affects your sense of balance. * Experienced as a distinct “spinning” sensation or a sense of tumbling or of falling forward or backward.

Answer 49

Should be distinguished from light-headedness, and syncope which are nonvestibular in origin. * may be a cardiac problem

Answer 50

Vertigo: false sensation of movement; spinning * Can either be central or peripheral related Presyncope: “lightheadedness” * Often a cardiovascular problem

Answer 51

* Sudden transient loss of consciousness and postural tone due to decreased cerebral perfusion * Prognosis often benign unless cardiac cause (vasovagal syncope)

Answer 52

Disequilibrium: “bad balance”, “poor equilibrium” * Multifocal causation, loss of motor function, visual * Signs and symptoms occur w/ standing or walking and abate when seated/supine * Continuous

Answer 53

disease in the vestibular system

Answer 54

Peripheral disease (ear related) * Onset is sudden, often associated with tinnitus and hearing loss

Answer 55

Central disease (nervous system related) * Develops gradually and then becomes progressively more severe and debilitating * Not associated with auditory symptoms * Ataxia is associated – such as gait abnormality, speech changes, abnormal eye movements

Answer 56

* Benign paroxysmal positional vertigo – most common * Ménière’s Disease * Acute Peripheral Vestibulopathy * Vestibular schwannoma (acoustic neuroma)

Answer 57

* Migraine * Vertebrobasilar Disease * Multiple Sclerosis * Cerebellar infarction or hemorrhage

Answer 58

* Nystagmus is unidirectional (primarily horizontal) * The fast phase usually beats towards the normal ear.

Answer 59

* Purely vertical, does not fatigue, keeps going. * May not be present all the time * VERTICAL WITHOUT vertigo always indicates a lesion in the brain.

Answer 60

* Most common cause of recurrent vertigo. * Rotatory nystagmus is a classic sign. * Caused by crystals trapped in semicircular canals. * Vertigo that lasts 10 to 30 seconds and that recurs every time the patient assumes a particular position, such as rolling to one side while lying in bed.

Answer 61

* Not associated with hearing loss, tinnitus, aural pressure or headache. * Occur in clusters that persist for several days. * Dix-Hallpike maneuver reveals a delayed onset fatigable nystagmus-> Reproduces symptoms

Answer 62

Epley-reposition maneuver of crystals * The theory behind the Epley Maneuver is that through sequential head movements, crystals are transferred from the posterior semi-circular canal back to the vestibule of the inner ear. Medications * (Antivert) meclizine – manages symptoms only

Answer 63

* Characterized by sensorineural hearing loss, tinnitus, and vertigo. * Results in accumulation of endolymph in the inner ear, with distortion and distention of the membranous, endolymph-containing portions of the labyrinthine system.

Answer 64

* Two or more episodes of vertigo * Fluctuating aural fullness * Tinnitus * Hearing loss in the affected ear that is not better explained by another disorder * Low to mid frequency hearing loss demonstrated by audiometry

Answer 65

* Tinnitus is often described as a low frequency roaring. * Aural fullness may be triggered by high salt meals or caffeine – may not have recognized the connection. * Classic tetrad does not always exist at initial presentation.

Answer 66

* fluctuating hearing loss * episodic vertigo typically lasting up to 5 hours * tinnitus, and aural fullness

Answer 67

horizontal nystagmus during vertigo Dix-Hallpike Maneuver reveals fatigable nystagmus Romberg test positive during acute attacks – assesses your ability to stay balanced hearing evaluation by way of the finger rub, Weber, Rinne * hearing loss is sensorineural, not conductive – its not a blockage in the ear canal ## Footnote Imaging/ labs unnecessary if history is convincing that it is Meniere’s.

Answer 68

Treatment primarily prophylactic * elimination of alcohol and caffeinated products – including chocolate * 80% of patients respond to conservative therapy with salt restriction (1-2g/day) and diuretics * medications are aimed at symptom reduction: Meclizine (Antivert), Diazepam (Valium) * steroids may reduce endolymphatic pressure – but for more persistent cases

Answer 69

* Ménière’s disease, vertigo seems to occur unprovoked * Benign positional vertigo, it tends to be brought on by rolling over in bed, lifting dishes to the top shelf, turning to check traffic

Answer 70

* Ménière’s disease or benign positional vertigo, room spins fast * Migraines and anxiety, room spins slow

Answer 71

* Vestibular neuritis – inflammation of the inner ear * Uncertain pathophysiology (could be a post-viral cause)

Answer 72

Clinical picture: * vertigo gradual onset; resolves in 24-48 hours, but may last for weeks * incapacitating nausea, vomiting and ataxia * peripheral nystagmus Treatment: * supportive care * Diazepam or Antivert

Answer 73

* Are those associated with SAH, cerebral hemorrhages. * Consider if persistent vertigo with vascular risk factors (HTN, DM etc.) or in any elderly patient.

Answer 74

* includes vertebral artery occlusion/dissection, cerebellar hemorrhage/stroke * can have sudden, severe headaches, dizziness * physical examination may review nuchal rigidity, AMS, focal neurological deficits

Answer 75

* Headache is the subjective feeling of pain referable to a variety of intracranial & extracranial structures * It is the most common reason for neurological consultation. * Tension type headache is the most prevalent type of primary headaches in the general population

Answer 76

* Tension Type Headache * Cluster Headache * Migraine

Answer 77

* Medication Overuse Headache (MOH) * Brain Tumor Headache * Sinus Headache * Hangover Headache * Pseudotumor cerebri, also known as idiopathic intracranial hypertension.

Answer 78

* Systemic symptoms (fever/weight loss/HTN/stiff stiffness, intolerance of light) * Neurologic symptoms (focal or LOC change, thunder-clap) * Onset (sudden) * Older age(without history of prior headaches) * Progression of previous headache – keeps getting worse, medication is not helping reduce symptoms requiring more

Answer 79

* The attack of a tension headache is mild to moderate intensity bilateral non-throbbing headache without other associated features. * Current theory relates tension headaches to abnormal, heightened sensitivity. * The most important finding in patients with tension headache is increased head, neck and shoulder muscle tenderness.

Answer 80

* Tension headaches are typified by a band-like pain around the head or generalized head pain without nausea or vomiting. * Tenderness of the temporalis, masseter, posterior/cervical muscles but physical exam is generally normal.

Answer 81

* Not associated with focal neurological deficits. * Can be episodic or chronic. Stress, sleep deprivation, hunger and eyestrain are typical causes.

Answer 82

Requires at least 10 episodes of headache each lasting 30 minutes to 7 days Fulfill at least two of the following conditions; * occurs bilaterally * pressing or tightening * mild to moderate intensity * not aggravated by routine physical activities Fulfill both of the following: * no nausea or vomiting * may be associated with sensitivity to bright lights, loud sounds

Answer 83

Recommended acute treatment is simple analgesic * Aspirin, Ibuprofen, Naproxen, Acetaminophen * Combination of caffeine, acetaminophen and aspirin or ibuprofen (Fioricet)

Answer 84

* Treatment of comorbid anxiety and depression is important. * Amitriptyline is preferred for preventative therapy as well. * Avoid narcotics. Medication overuse is the major goal for therapy in treating tension type headache.

Answer 85

One of the most painful types of headaches, often described as causing excruciating pain on one side of the head, usually around the eye.

Answer 86

* Hypothalamic dysfunction – regulation of biological clock – maybe why they occur same time each day * Vascular changes – abnormalities in the blood vessels * Neurochemical imbalances – fluctuations in serotonin – brain’s pathways and contribute to severe pain * Genetic predisposition * Environmental triggers – strong smells, bright lights, alcohol * Smoking and alcohol

Answer 87

* exclusively a clinical diagnosis from the history and physical * attacks are severe, unilateral orbital, and/or temporal that lasts 15 to 180 minutes

Answer 88

* red or pink colored eyes due to dilated vessels, watery eyes * nasal congestion * eyelid edema * forehead and facial sweating * constricted pupil (miosis) and/or droopy eyelid (ptosis)

Answer 89

* a sense of restlessness or agitation * frequency of attacks between one every other day and up to eight (8) per day * imaging studies or lumbar puncture is indicated only in specific clinical settings and to rule out other causes of acute headaches.

Answer 90

**Oxygen 100% at 15L/min for 15 mins should be tried first.** Triptans (Sumatriptan) subcutaneously or intranasally, helps to change how blood circulates in the brain and how the brain processes pain signals. * serves as first line treatment, does NOT prevent but CAN stop them during an attack other medications can include Ergotamine * neurotransmitter that acts like a vasoconstrictor

Answer 91

prophylactic therapy of choice for cluster headaches is verapamil. Valproate and oral corticosteroids are other options

Answer 92

* Migraine headaches more typically present unilateral, with throbbing or pulsating discomfort. * Usually located in the periorbital region and can extend to the cheek and ear.

Answer 93

Typical migraine attack progress is through four phases * the prodrome, the aura, the headache, and the postdrome Can often identify triggers as chocolate, red wine, hard cheeses, hormonal changes, exertion and dehydration.

Answer 94

* Patients often relate a family history of migraine headaches. Women are affected more than men; migraines often follow the menstrual cycle pattern. * Pathophysiology of migraines classically has been attributed to intracranial vasospasm followed by extracranial vasodilation. * Migraines can be associated with other diseases such as seizure disorders.

Answer 95

* Patients also exhibit irritability and fatigue. * Migraine patients often retreat to quiet, dark rooms and prefer to lie quietly

Answer 96

* migraine with aura (formally called classic migraine) presents with an aura commonly involving visual changes, field cuts, or flashing lights and partial alteration of visual field * can also be auditory, smell, or taste disturbances

Answer 97

* occur 5-30 minutes before pain onset * visual auras are the most common * sensory auras such as numbness and tingling in a limb are second most common

Answer 98

at least 2 attacks with at least 1 of the following aura’s: * visual, sensory, speech/language, motor has at least 3 of the following 6 characteristics: * at least one aura symptom spreads gradually over or equal to 5 minutes, * 2 or more symptoms occur in succession * each individual aura symptom lasts 5-60 minutes * at least one aura symptom is unilateral * at least one aura symptom is positive * aura is accompanied or followed by a headache

Answer 99

Migraine without aura (formally called common migraine) frequently is accompanied by nausea, vomiting, photophobia. * can be more disabling to the patient than the actual head pain Headache lasts 4 to 72 hours

Answer 100

at least five attacks headache attacks last 4-72 hours headache has at least 2 of the following characteristics: * unilateral, pulsating, moderate or severe pain, aggravation by or causing avoidance of physical activity during headache, at least one of the following: * Nausea, vomiting, or both photophobia and phonophobia

Answer 101

* Routine laboratory tests are done only to help rule out other concurrent disorders such as infections, stroke, seizures, or toxins. * Imaging studies such as a head CT with and without contrast, or a lumbar puncture is done only in selected clinical settings and then only to rule out causes of acute secondary headache. * simple procedures such as an fundoscopic exam can identify intracranial pathology

Answer 102

Initially treat with IV anti-emetics and pain control; NSIAD’s such as Toradol and hydration. Abortive therapy may include aspirin, acetaminophen, NSAIDs. Migraine with aura that no longer responds to NSIADs, guidelines recommend the use of Triptans. * Triptan can shrink swollen blood vessels in the brain and quieting down overactive pain nerves

Answer 103

* medical prophylaxis for migraine might include beta blockers, tricyclic antidepressants, calcium channel blockers, NSAIDs. * biofeedback therapy is often employed to help reduce number of headaches * botox injections may be helpful for severe, intractable migraines.

Answer 104

* Migraine – Unilateral, often around the temples, forehead, or eye, intense, throbbing pain, often associated with nausea and sensitivity to light/sound, lasting hours to days, with potential aura. * Cluster –Unilateral, often around the eye or temple, excruciating, short-lived pain around one eye, occurring in clusters, with eye/nasal symptoms and restlessness. * Tension –Bilateral, often around the forehead or temples, mild to moderate, constant pressure or tightness around the head, often related to stress or muscle tension, lasting from 30 minutes to days.

Answer 105

may develop from any primary headache * over-the-counter combination analgesics should be limited to ≤ 9 days a month on average * Nonsteroidal anti-inflammatory drugs (NSAIDs) should be limited to ≤ 15 days a month

Answer 106

Post-traumatic headache * begins within 3 months of TBI Subarachnoid Hemorrhage Headache * sudden onset “worst headache of my life” (80% due to ruptured aneurism)

Answer 107

Temporal Arteritis ( AKA giant cell arteritis, inflammation of the temporal arteries) * UNILATERAL jaw pain, discomfort and scalp tenderness with reduced vision * ESR is high but biopsy is diagnostic * treatment (prednisone) should not be delayed until biopsy * headache patients who are older than 60 yoa, temporal arteritis should be considered

Answer 108

* Neoplasm Headache: Change in pattern or new onset headache (especially in elderly) * Sinus Headache: Facial distribution with sinus symptoms * Trigeminal Neuralgia : Distribution of CN V; typically, maxillary (V2) and mandibular (V3)

Answer 109

* Elevated ICP w/o focal lesion or hydrocephalus * Common in young, obese women, poorly understand MOA * Aggravated by Valsalva * Sxs: Papilledema and increased opening pressure on lumbar puncture * Tx: Loop diuretics, conservative treatment

Lecture 7 (Neuro) - Exam 3 Flashcards

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