module 9: neurological disorders Flashcards
(105 cards)
1
Q
Define consciousness. What two components comprise consciousness?
A
consciousness = the state of awareness of self and the environment, and of being able to orient to new stimuli
2 components:
- arousal (wakefulness)
- content and cognition
2
Q
What parts of the brain are required for a normal state of arousal (wakefulness)?
A
reticular activating system (RAS)
3
Q
what parts of the brain consists of the RAS?
A
- brainstem
- medulla and thalamus
- functioning cerebral cortex
4
Q
What must be damaged for loss of arousal to occur?
A
- direct injury to the RAS
OR
- both cerebral hemispheres (at the same time)
5
Q
What is included in “awareness”?
A
- selective attention
- ability to select specific information
- memory
- exercutive attention
- maintain sustained attention
6
Q
Describe the levels of consciousness
A
- coma - not arounseable
- stupor - arouseable only to pain
- obtundation - lower level of arousal, sleepy
- delirium - restlessness, hallucinations, delusions
- confusion - disorientation, fuzzy thinking, poor response to current stimuli
7
Q
Name and describe the scale used to commonly assess level of consciousness
A
glasglow coma scale
- categories
- eye opening
- verbal responses
- motor response
- higher the score, the better
8
Q
Define brain death. How is it determined?
A
brain death = no recovery possible and brain cannot maintain internal homeostasis (everything done by machine)
determined by:
- well established underlying pathology
- deep unresponsive coma and absence of motor reflexes
- absent brainstem reflexes
- requires mechanical ventilation- “apnea test”
- lack of other causes (only the brain is the problem)
must be verified by multiple physicians
9
Q
describe cerebral death
A
irreversible come
- brain stem may continue to maintain homeostasis
- individual will never be able to response in any significant way to the environment
10
Q
describe persisitent vegetative state
A
- complete unawreness of self or surrounding environment
- sleep-wake cycles are present
- brain stem reflexes are intact
- bowel and bladder incontinence
11
Q
describe minimally conscious state
A
- individuals may follow simple commands, manipulate objects, gesture, have intelligible speech
12
Q
describe locked-in-syndrome
A
- complete paralysis of voluntary muscles with the exception of eye movement
- individual fully conscious with intact cognitive function, but cannot communicate through speech or body movements
13
Q
Describe Cheyne-Stokes breathing, inclusind the possible location of brain damage that would cause these two patterns of breathing
A
- higher brain injury (ex: cerebral hemisphere)
- alternating periods of apnea (no breathing) and tachypnea (hyperventilation).. no in between
14
Q
describe neurogenic hyperventilation, including the possible location of brain damage that would cause these two patterns fo breathing
A
- injury to midbrain
- > 40 beaths per minute
- stimunlating both extreme inhalation and exhalation
15
Q
What alterations can occur with pupillary response and what information can this yield?
A
pupillary changes
- pupils can range from combinations of fixed, dilated, pinpoint, and unequal when exposed to light
- can help determine location/extent of brain damage
ex: severe hypoxia = dilated, fixed pupils (damage to oculomotor nerve)
16
Q
What is the normal oculomotor “doll’s eye” response in a comatose patient? What are two abnormal oculomotor responses?
A
- doll’s eye response = the oculocephalic reflex is movement opposite from head movement
- abnormal:
- following head movement
- independent movement
assessable only in comatose patients
17
Q
describe decorticate posture and the location of brain damage it indicates
A
- upper extremities flexed at the elbows and held close to the body
- lower extremities that are internally rotated and extended
- may occur with severe cerebral hemisphere damage
18
Q
describe decerebrate posture and the location of brain damage it indicates
A
- increased tone in extensor muscles and trunk muscles (stretched right out)
- clenched jaw
- extended neck
- head in neutral position, all four limbs rigidly extended
- occurs with brain stem lesions
19
Q
Define seizure. What are some causes of seizures?
A
a sudden, explosive, disorderly discharge of cerebral neurons that produces a temporary change in brain function
causes:
- cerebral lesions
- biochemical disorders
- cerebral trauma
- epilepsy
20
Q
Differentiate between a seizure and a convulsion
A
- seizure = electrical disturbance in brain
- convulsions = jerky, muscle contraction - relaxation cycles
21
Q
what is agnosia?
A
failure to recognize the form.nature of objects
- usually only affects once sense
- ex: can recognize a safety pin by touching it, but not when looking at it
- caused by any damage to a specific part of the brain
22
Q
what is hemineglect?
A
inability to attend to and react to stimuli coming from the contralateral side of space
- won’t visually track, orient or reach to the neglected side
- may not use those limbs, or take care of them
23
Q
what is dysphasia?
A
understanding (receptive) and use (expressive) of symbols is disturbed or lost
- ex: cannot find words, or uses words, but are meaningless
- caused by dysfunction in left cerebral hemisphere (stroke, cancer, trauma, etc.)
24
Q
what is aphasia?
A
inability to communicate
25
what is broca's aphasia?
a result of damage to the centre of the brain responsible for the production of language
26
what is wernike's aphasia?
a result of damage to the centre of the brain responsible for the comprehension of language
27
what are the 4 data processing deficits?
1. agnosia
2. hemineglect
3. dysphasia
4. aphasia
28
What does IICP stand for and what does it mean?
increased intracranial pressure
* may result from anything that takes up volume in the brain
* increased pressure in cranium
29
what can cause IICP?
* tumour
* edems
* excess CSF (cerebral spinal fluid)
* hemorrhage
30
What 3 things can be adjusted to compensate for changes in IICP? In what order are these adjusted, if needed?
3 things:
* blood volume
* CSF volume
* tissue volume
* initial loss of CSF since it is the most easily decreased in response to increased intracranial pressure (can reabsorb CSF quickly)
* cerebral blood volume
* tissue volume
31
what is the Monro-Kellie hypothesis?
stages of how body compensates with increased pressure
32
describe stage 1 of intracranial hypertension
* CSF is displaced in to spinal subarachnoid pace = increase reabsorption
* external compression of the venous system occurs to decrease ICP
* may be asymptomatic
* blood is limited in hoe much it can buffer the increased pressure due to increased levels of co2 = vasodilation = hyperventilation sometimes used to decrease ICP
33
describe stage 2 of intracranial hypertension
more pressure still appplied after removing CSF = decrease cerebral blood flow = vasocontriction to force blood into brain
* too much volume = decrease in brain tissue perfusion and oxygenation is compromised
* results in confusion, restlessness, drowsiness due to low o2
* neurons in vasomotor causes systemic vasoconstriction to increase systemic blood pressure
* to overcome decreased flow in brain
AKA Crushing's reflex
34
describe stage 3 of intracranial hypertension
pressure in cranium starts to match systemic blood pressure = no blood up to brain = rapid decrease in functioning (hypoxia and hypercapnia of brain tissue occur)
* at this point, all compensatory mechanisms have been used, so there can now be a dramatic rise in ICP over a very short period of time
35
describe stage 4 of intracranial hypertension
* brain tissue shifts from the compartment of greater pressure to a compartment of elsser pressure
* the increased pressure in the lower pressure compartment also impairs its blood supply
as tissue starts to move, it adds pressure to other regions
36
Describe cerebral edema (definition, be familiar with causes and effects)
* an increase in the fluid content, causing increase in brain tissue volume
* causes:
* trauma
* incfection
* hemorrhage
* tumour
* ischemia
* infarct
* hypoxia
* effects
* distorts blood vessels
* displaces brain tissues
* causes herniation
37
Name and describe the mechanism of the two types of cerebral edema
**vasogenic edema:**
* start at blood vessel
* increased permeability of blood brain barrier
* plasma proteins leak out of capillaries = water drawn to them = increased water content of tissue
* occurs maining in the white matter
**cytotoxic edema:**
* toxins, hypoxia, etc. cause failure of transport mechanism of cells
* more sodium inside cell = ore water inside cell
* occurs mainly in the gray matter
38
What is hydrocephalus and what is its cause?
* excess fluid in ventricles, subarachnoid space, or both
* cause:
* too high production of CSF
* too loe reabsorption of CSF
39
Name and describe the two types of hydrocephalus and give an example of each
* **noncommunicating (obstructive**) = obstruction prevents CSF from reaching arachnoid villi and being reabsorbed
* **communicating** = failure of reapsorption due to too few, or scarring of arachnoid villi
* adenomas of choriod plexus can also cause overproduction of CSF (less common)
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40
Name 3 general alterations that can occur if the neuromotor function of the nervous system is affected.
1. alterations in muscle tone
2. alterations in movement
3. alterations in complex motor performance
41
What is muscle tone and what does it do? How is it controlled?
* muscle tone = the normal state of muscle tension which allows for controlled movement and maintenance of posture
* controlled by stretch reflex
42
What changes in muscle tone are brought about by injuries to the upper motor neurons vs the lower motor neurons?
* upper motor neuron injury = increased tone as the inhibitory effect of the brain on the spinal cord reflexes is removed
* lower motor neuron injury = decreased tone
43
what is hypertonia?
muscle rigidity
44
what is hypotonia?
flaccidity (soft & limb)
45
Distinguish between paresis, paralysis and hyperkinesia
* paresis = weakness of muscle contraction
* paralysis = loss of motor neuron function so that a muscle group is unable to overcome gravity
* hyperkinesia = excessive movement/ loss of control of movements, but more movement uncontrolled
46
Define the terms hemi-, para- and quadri-, as applied to paresis and paralysis
* hemiparesis/hemilagia = full upper/lower body on one side
* paraparesis/paraplagia = lower body on both sides
* quadriparesis/quadriplagia = full body, neck down
47
Describe 3 groups of disorders that are included under the category of alterations in complex motor performance.
1. disorders of posture
2. disorders of gait
3. disorders of expression
48
Name and describe 3 disorders of posture.
* decorticate posture
* decerebrate posture
* basal ganglion posture
49
Define hypermimesis
innappropriate laughter or crying
50
define dyspraxia/apraxia
inability performing tasks that require learned motor skills
* problem is with use of muscles, not with comprehension
51
define dysarthria
muscles not used to perform speech
52
define agraphia
loss of previous ability to write
53
Describe open and closed brain trauma, and what type of action would cause each.
* open = break in the dura membrane
* results in exposure of the cranial contents to the environment
* closed = dura membrane still intact
* may result in both focal brain injuries, or diffuse axonal injuries
54
Describe what is meant by primary and secondary stages of brain trauma
* primary = the damage is caused by impact
* secondary = the damage is caused by subsequent swelling, infection, or hypoxia
55
Define focal brain injury
* specific, grossly observable (can easily see it) brain lesions that occur in a precise location
56
Define contusion and differentiate between coup and contrecoup injury
contusions = bruises in brain tissue (blood leaking from injured blood vessels) ]
* croup injury = impact against the object, causing direct trauma to brain at point of impact
* contrecoup injury = not just impact area damaged, but also brain rebounds from skull on other side
57
Describe the possible sequence of events involved in the occurrence of a contusion
* edema occurs around/in damaged area, as well as infarction, necrosis, and hemorrhage
* effects peak 18-36 hours after injury
* since excess bleeding/swelling can take time to toke over compensatory factors
1. immediate loss of consciousness (no longer than 5 mins)
2. loss of reflexes
3. brief period of no respiration
4. brachycardia
5. decrease in BP
58
what is a hematoma?
bleeding in/beside the brain as a result of trauma can produce an area filled with blood
59
what is an extradural (epidural) hematoma?
injury (usually a fracture) causes bleeding between the dura mater and the skill
* predominantly due to arterial bleeding
60
why is there a delay before symptoms are evident?
* lucid period of 2-3 hours between trauma and clinical signs
* rapid deterioration as intracranial pressure rises
61
what is a subdural hematoma?
* below membrane, towards brain tissue
* can be a very slow bleed
* typically venous, low pressure, slow bleeding
62
what is intracerebral hematomas?
* bleeding within the brain
* penetrating injury or shearing forces traumatize small blood vessels
* may be delayed, appearing 3-10 days after injury
* signs and symptoms depend upon location int he brain
63
Define a diffuse brain injury, its causes, and effect
* diffuse and widespread damage to neural axons in the brain
* can be observed only with microscope
* causes:
* shaking
* rotational and twisting movements
* effect:
* reduces the speed of informational processing
* damage to neuron itself
64
Differentiate between mild concussion and classic cerebral concussion
* mild = no loss of conciousness, but CSF pressure increases, confusion lasts for several minutes, retrograde amnesia
* classic = loss of consciousness for up to 6 hours, confused state lasts for several hours, headache, nausea, retrograde amnesia
65
What determines the category (i.e., mild to severe) of a DAI?
the time
* mild = 6-24 hours
* moderate = over 24 hours
* severe = emerge from coma in first 3 months
66
describe a mild DIA
* 6-24 hour coma
* may display decerebrate or decorticate posturing with extended periods of stupor/restlessness
67
describe moderate DAI
* over 24 hour coma
* may display decerebrate/decorticate with unconsciousness lasting days/weeks
* on awakening, often permanent deficit in memory, reasoning, language, etc.
68
describe a severe DAI
* usually emerge from coma in the first 3 months after injury
* initial injury eventually results in compromised coordinated movements, verbal and written communication skills, inability to learn and reason
69
Describe what is meant by a secondary brain trauma.
* indirect result of primary trauma
* mechanisms:
* cerebral edema
* IICP
* decreased cerebral perfusion pressure
* ischemia
* brain herniartion
* brain damage occurs hours to days after primary trauma
70
Define cerebrovascular disease and be familiar with examples of causes
* problem with blood vessels through your brain
* any abnormality of the brain caused by a pathologic process in the blood vessels
* causes:
* ischemia
* hemorrhage
* ex: cerebrovascular accident (CVA)
* AKA stroke
71
What are the two possible results of cerebrovascular disease?
* ischemia
* hemorrhage
72
Define CVA/stroke
* CVA = cerebrovascular accident
* AKA stroke
* an acute focal neurological deficit from a vascular disorder, that injures brain tissue
73
Describe risk factors for a CVA and related long-term deficits
risk factors:
* age, sex, race
* family history
* hypertension
* smoking
* diabetes mellitus
* asymptomatic carotid stenosis
* hyperlipidemia
* atrial fibrillation
stroke- related long-term deficits:
* motor deficits
* dysarthria
* aphasia
* congnitve and other deficits
74
what are the types of ischemic strokes?
* thrombotic (large vessel)
* lacunar (small vessel)
* TIA (transient ischemic attack)
* embolic
75
describe a thrombotic stroke
* large vessel
* occlusions formed by thrombi developing in arteries within the brain
* thrombi develop often as a result of atherosclerosis
* usually a single cerebral artery is affected, often affecting the cortex
* symptoms:
* aphasia
* neglet
* visual field defects
* usually seen in older persons
* not associated with activity
76
describe lacunar stroke
* small vessel
* very small infarctions deep in the brain
* can be due to emboli, small hemorrhages, vasospasm, etc.
* due to location, effects are different than large vessel strokes
* sensory or motor hemiplegia, dysarthria
* risk factors: chronic hypertension, diabetes
77
What does TIA stand for? Describe a TIA, its likely cause, and what it will likely lead to with no treatment. What manifestations are associated with a TIA?
* TIA = transient ichemic attack
* cause:
* platelet clumps
* vessel narrowing with spasm
* lead to w/ no treatment = high risk of repeat occurrence and eventual stroke
* manifestations:
* numbness in face, arm or leg
* trouble speaking or understanding
* poor vision in one or both eyes
* confusion
78
Differentiate between a thrombotic and an embolic stroke as to nature of blockage and timing.
* thrombotic:
* blockage of single cerebral artery
* acute
* embolic:
* blockage is middle cerebral artery
* sudden onset with immediate maximum deficit
79
What is the most frequent site for embolic stroke? What conditions can lead to formation of an embolus.
* middle cerebral artery
* conditions:
* rhematic heart disease
* atrial fibrillation
* recent heart attack
80
Describe a hemorrhagic stroke as to causes, timing, manifestations, and why it is the most frequently fatal type of stroke
* causes:
* hypertension
* ruptured aneuysms
* trauma
* timing:
* occurs suddenly with activity
* manifestations:
* vomiting at outset
* headache
* most fatal because great danger is increased intracranial pressure, which could lead to coma and death
81
What is the most common manifestation of a stroke? Describe some of the additional manifestations that can occur
* most common = contrlateral weakness of arm and face, sometimes leg
* symptoms sudden and usually one sided
* initial flaccidity replaced by spasticity after 6-8 weeks
* loss of vision in one eye (monocular blindness)
* hemianopia
* aphasia
* dysarthria
* ataxia
* lack of motor defects
* deficits of language, sensation and cognition
82
define hemianopia
lose sight in half of your visual field
83
define ataxia
the presence of abnormal, uncoordinated movements
84
Describe intracranial aneurisms to include size/shape, manifestations, complications, and treatment
* size/shape:
* 2mm - 2-3cms
* fusiform or berry shape
* manifestations:
* acute subarachnoid hemorrhage
* intracerebral hemorrhage
* excruciating hedache
* vomiting
* motor and sensory deficits
* complications:
* vasospasm in area od aneurysm
* hydrocephalus caused by plugging of the arachnoid villi
* treatment:
* surgery to insert a metal clip around the neck of the aneurysm that protects from rebleeding
85
Describe the pathophysiology of Parkinson’s disease, its 3 cardinal symptoms, and the basis for using levodopa for treatment
* pathophysiology:
* degeneration of the basal ganglia and loss of dopamine producing cells
* 3 cardinal symptoms:
* resting tremor
* bradykinesia
* muscle rigidity
* treatment:
* levodopa to metabolize to dopamine in the brain
86
Describe the mechanism behind neuron death in Alzheimer Disease, progression of disease symptoms and treatment
* most common type = late-onset AD
* mechanisms of neuron death:
* protein containing structures called plaques form between neurons
* protein containing tangles form inside neurons
* progression of disease symptoms:
* memory loss increases over time
* confusion increases
* problem solving, language, and math skills decrease
* behavioural changes occur
* treatment:
* using devices to compensate for impaired cognitive function
* no cure
87
Lisa L. (57 yrs) was discovered unconscious in the bathtub by her husband. She appeared to have slipped and fallen while taking a shower. Her husband immediately called 911 and an emergency response team quickly arrived. By the time that the ambulance arrived, Lisa had regained consciousness and while she was able to speak easily with a paramedic and readily touch her nose with her right hand, she remained confused as to the date and where she had had her accident. Her vitals at this time were: BP 138/79, pulse 78, respiratory rate 14 and temperature 36.8°C. Her pupils were equal in size, round and reactive to light. The rest of a physical examination revealed no injuries, other than a large hematoma on the right temporal area of her skull. On the way to the hospital, she complains of a headache and vomits once
What is Lisa’s initial Glasgow coma scale score? Justify your answer.
* eyes – 4 – assume she can open them spontaneously
* verbal – 4 – speaks easily with attendant, but is confused as to date and place
* motor – 6 – can touch nose with hand, when asked
= 14
88
Lisa L. (57 yrs) was discovered unconscious in the bathtub by her husband. She appeared to have slipped and fallen while taking a shower. Her husband immediately called 911 and an emergency response team quickly arrived. By the time that the ambulance arrived, Lisa had regained consciousness and while she was able to speak easily with a paramedic and readily touch her nose with her right hand, she remained confused as to the date and where she had had her accident. Her vitals at this time were: BP 138/79, pulse 78, respiratory rate 14 and temperature 36.8°C. Her pupils were equal in size, round and reactive to light. The rest of a physical examination revealed no injuries, other than a large hematoma on the right temporal area of her skull. On the way to the hospital, she complains of a headache and vomits once.
Suggest four categories of brain trauma that Lisa is likely experiencing. Justify your choices with facts from the case as presented so far.)
* Primary – at point of injury.
* Closed – dura is intact
* Diffuse - Classic concussion – loss of consciousness of less than 6 hrs, confusion, retrograde amnesia, headache and nausea.
* Focal – very likely, due to appearance of hematoma on her head
89
Lisa L. (57 yrs) was discovered unconscious in the bathtub by her husband. She appeared to have slipped and fallen while taking a shower. Her husband immediately called 911 and an emergency response team quickly arrived. By the time that the ambulance arrived, Lisa had regained consciousness and while she was able to speak easily with a paramedic and readily touch her nose with her right hand, she remained confused as to the date and where she had had her accident. Her vitals at this time were: BP 138/79, pulse 78, respiratory rate 14 and temperature 36.8°C. Her pupils were equal in size, round and reactive to light. The rest of a physical examination revealed no injuries, other than a large hematoma on the right temporal area of her skull. On the way to the hospital, she complains of a headache and vomits once.
Disruption of what structure(s) must have occurred to cause Lisa’s initial loss of consciousness?
Either both cerebral hemispheres or the reticular activating system.
90
Lisa is examined in the emergency department and then held for observation. After a couple of hours, she becomes increasingly sleepy and has difficulty holding an extended conversation without nodding off. Assessment for a Glasgow coma scale score shows that she will open her eyes only if verbally prodded, thinks she is at home, and will not respond to requests for simple motor actions, but will attempt to push a hand away that is putting pressure on her supraorbital groove. Her pupillary responses remain within normal limits. However, her BP is now 160/82, with a pulse rate of 60. A CT scan is ordered.
Suggest a possible reason for Lisa’s deteriorating condition.
She is developing a hematoma within her skull that is causing increased intracranial pressure (IICP).
91
Lisa is examined in the emergency department and then held for observation. After a couple of hours, she becomes increasingly sleepy and has difficulty holding an extended conversation without nodding off. Assessment for a Glasgow coma scale score shows that she will open her eyes only if verbally prodded, thinks she is at home, and will not respond to requests for simple motor actions, but will attempt to push a hand away that is putting pressure on her supraorbital groove. Her pupillary responses remain within normal limits. However, her BP is now 160/82, with a pulse rate of 60. A CT scan is ordered.
Why didn’t the present problems show up immediately after her accident? In your explanation, describe two compensations that have probably occurred in Lisa’s brain prior to the appearance of these latest signs/symptoms and state the purpose of these compensations.
Stage 1 - Her brain is compensating for the increase in pressure by:
* Movement of CSF down into spinal cord.
* External compression of venous sinuses.
* These compensations result in no actual increase in pressure, therefore in Stage 1, there are no manifestations.
92
Lisa is examined in the emergency department and then held for observation. After a couple of hours, she becomes increasingly sleepy and has difficulty holding an extended conversation without nodding off. Assessment for a Glasgow coma scale score shows that she will open her eyes only if verbally prodded, thinks she is at home, and will not respond to requests for simple motor actions, but will attempt to push a hand away that is putting pressure on her supraorbital groove. Her pupillary responses remain within normal limits. However, her BP is now 160/82, with a pulse rate of 60. A CT scan is ordered.
What is a probable cause for her increased systolic BP at this point in time?
Cushing’s reflex – an attempt to force more blood into the brain
93
While waiting for the CT scan, assessment for a further GCS shows that Lisa will now only open her eyes to pain, and her verbal responses are limited to moaning when pain is applied. Pressing on her fingernail bed causes her to pull her hand away. Her right pupil constricts slowly with either direct light or when light is shined in other eye. Her left pupil is quickly reactive in both situations.
Name and describe the lesion that the CT scan will likely show. (Be as specific as possible.)
Likely an epidural hematoma at the point of the blow. A mass of blood between the dura and the skull, due to arterial bleed
94
Would the cause of Lisa’s initial loss of consciousness (i.e., at the time of her fall) be able to be seen on the CT scan? Explain your answer.
She probably lost consciousness due to tearing of axons, which cannot be seen on a CT scan.
95
Mrs. R., an overweight 75 yr old female with type 2 diabetes mellitus, has been brought to the emergency department by her son, who says that his mother began to exhibit several very alarming signs 40 minutes ago: she can no longer see articles on the right side of her vision (although she still has some vision out of her right eye), the right side of her face and right eyelid are drooping, and she has trouble raising her right arm, in which she is also experiencing numbness. Although her speech is fairly clear, she appears frustrated in speaking and has difficulty naming objects. Her temperature and respirations are normal, but her blood pressure is 160/95 mmHg. Electrocardiogram results were normal. A CT scan of her brain (performed immediately upon her arrival in hospital) did not reveal any abnormal signs (however, a subsequent scan performed 36 hours later did show increased density in an area within the brain). A history taken of the patient reveals a lifetime smoking habit (50 yrs), as well as two previous TIA’s within the past year, involving right-sided weakness that completely resolved within an hour.
What is the most likely event that has occurred to Mrs. R.? Support your conclusion with her initial abnormal signs and symptoms.
Ishemic stroke – due to no initial CT result
* Loss of right side of vision
* Drooping right eyelid
* Paresis and numbness in right arm
* Aphasia (trouble thinking of words)
* No blood in first CT scan, so not hemorrhagic - (can’t see blocked artery on CT scan without using contrast dye, but can see blood).
* Change in density in brain shown in CT scan after 36 hours (so not TIA)
96
Mrs. R., an overweight 75 yr old female with type 2 diabetes mellitus, has been brought to the emergency department by her son, who says that his mother began to exhibit several very alarming signs 40 minutes ago: she can no longer see articles on the right side of her vision (although she still has some vision out of her right eye), the right side of her face and right eyelid are drooping, and she has trouble raising her right arm, in which she is also experiencing numbness. Although her speech is fairly clear, she appears frustrated in speaking and has difficulty naming objects. Her temperature and respirations are normal, but her blood pressure is 160/95 mmHg. Electrocardiogram results were normal. A CT scan of her brain (performed immediately upon her arrival in hospital) did not reveal any abnormal signs (however, a subsequent scan performed 36 hours later did show increased density in an area within the brain). A history taken of the patient reveals a lifetime smoking habit (50 yrs), as well as two previous TIA’s within the past year, involving right-sided weakness that completely resolved within an hour.
Could this possibly be classified as a TIA? Explain your reasoning.
No, because the CT scan at 36 hrs showed that there had been damage.
97
Mrs. R., an overweight 75 yr old female with type 2 diabetes mellitus, has been brought to the emergency department by her son, who says that his mother began to exhibit several very alarming signs 40 minutes ago: she can no longer see articles on the right side of her vision (although she still has some vision out of her right eye), the right side of her face and right eyelid are drooping, and she has trouble raising her right arm, in which she is also experiencing numbness. Although her speech is fairly clear, she appears frustrated in speaking and has difficulty naming objects. Her temperature and respirations are normal, but her blood pressure is 160/95 mmHg. Electrocardiogram results were normal. A CT scan of her brain (performed immediately upon her arrival in hospital) did not reveal any abnormal signs (however, a subsequent scan performed 36 hours later did show increased density in an area within the brain). A history taken of the patient reveals a lifetime smoking habit (50 yrs), as well as two previous TIA’s within the past year, involving right-sided weakness that completely resolved within an hour.
The ECG results were normal, however, could you suggest anything more specific about the cause of Mrs. R.’s condition if an ECG actually revealed atrial fibrillation? Explain your answer.
Embolic stroke, due to embolus from left atrium (due to turbulent blood flow).
98
Mrs. R., an overweight 75 yr old female with type 2 diabetes mellitus, has been brought to the emergency department by her son, who says that his mother began to exhibit several very alarming signs 40 minutes ago: she can no longer see articles on the right side of her vision (although she still has some vision out of her right eye), the right side of her face and right eyelid are drooping, and she has trouble raising her right arm, in which she is also experiencing numbness. Although her speech is fairly clear, she appears frustrated in speaking and has difficulty naming objects. Her temperature and respirations are normal, but her blood pressure is 160/95 mmHg. Electrocardiogram results were normal. A CT scan of her brain (performed immediately upon her arrival in hospital) did not reveal any abnormal signs (however, a subsequent scan performed 36 hours later did show increased density in an area within the brain). A history taken of the patient reveals a lifetime smoking habit (50 yrs), as well as two previous TIA’s within the past year, involving right-sided weakness that completely resolved within an hour.
If her signs and symptoms were different and she was actually experiencing only motor hemiplegia accompanied by dysarthria, would your diagnosis change? If it does change, what would it be?
Lacunar stroke – affects basal ganglia, so would see motor effects and dysarthria
99
Mrs. R., an overweight 75 yr old female with type 2 diabetes mellitus, has been brought to the emergency department by her son, who says that his mother began to exhibit several very alarming signs 40 minutes ago: she can no longer see articles on the right side of her vision (although she still has some vision out of her right eye), the right side of her face and right eyelid are drooping, and she has trouble raising her right arm, in which she is also experiencing numbness. Although her speech is fairly clear, she appears frustrated in speaking and has difficulty naming objects. Her temperature and respirations are normal, but her blood pressure is 160/95 mmHg. Electrocardiogram results were normal. A CT scan of her brain (performed immediately upon her arrival in hospital) did not reveal any abnormal signs (however, a subsequent scan performed 36 hours later did show increased density in an area within the brain). A history taken of the patient reveals a lifetime smoking habit (50 yrs), as well as two previous TIA’s within the past year, involving right-sided weakness that completely resolved within an hour.
Would your diagnosis change if the first CT scan had actually shown an abnormal result? Why/why not?
Hemorrhagic stroke, due to presence of blood, which can be seen with CT scan.
100
Mrs. R., an overweight 75 yr old female with type 2 diabetes mellitus, has been brought to the emergency department by her son, who says that his mother began to exhibit several very alarming signs 40 minutes ago: she can no longer see articles on the right side of her vision (although she still has some vision out of her right eye), the right side of her face and right eyelid are drooping, and she has trouble raising her right arm, in which she is also experiencing numbness. Although her speech is fairly clear, she appears frustrated in speaking and has difficulty naming objects. Her temperature and respirations are normal, but her blood pressure is 160/95 mmHg. Electrocardiogram results were normal. A CT scan of her brain (performed immediately upon her arrival in hospital) did not reveal any abnormal signs (however, a subsequent scan performed 36 hours later did show increased density in an area within the brain). A history taken of the patient reveals a lifetime smoking habit (50 yrs), as well as two previous TIA’s within the past year, involving right-sided weakness that completely resolved within an hour.
Why is a CT scan of vital importance in the diagnosis of a stroke? (Hint: consider a main difference in treatment between the two main categories of stroke.)
A thrombolytic drug (clot-buster) would be used with an ischemic stroke, but this would increase the bleeding in a hemorrhagic stroke and make the situation worse.
101
Mrs. R., an overweight 75 yr old female with type 2 diabetes mellitus, has been brought to the emergency department by her son, who says that his mother began to exhibit several very alarming signs 40 minutes ago: she can no longer see articles on the right side of her vision (although she still has some vision out of her right eye), the right side of her face and right eyelid are drooping, and she has trouble raising her right arm, in which she is also experiencing numbness. Although her speech is fairly clear, she appears frustrated in speaking and has difficulty naming objects. Her temperature and respirations are normal, but her blood pressure is 160/95 mmHg. Electrocardiogram results were normal. A CT scan of her brain (performed immediately upon her arrival in hospital) did not reveal any abnormal signs (however, a subsequent scan performed 36 hours later did show increased density in an area within the brain). A history taken of the patient reveals a lifetime smoking habit (50 yrs), as well as two previous TIA’s within the past year, involving right-sided weakness that completely resolved within an hour
. Based on Mrs. R.’s manifestations, which cerebral artery (anterior, middle, posterior) was probably affected?
Middle cerebral artery
102
Mrs. R., an overweight 75 yr old female with type 2 diabetes mellitus, has been brought to the emergency department by her son, who says that his mother began to exhibit several very alarming signs 40 minutes ago: she can no longer see articles on the right side of her vision (although she still has some vision out of her right eye), the right side of her face and right eyelid are drooping, and she has trouble raising her right arm, in which she is also experiencing numbness. Although her speech is fairly clear, she appears frustrated in speaking and has difficulty naming objects. Her temperature and respirations are normal, but her blood pressure is 160/95 mmHg. Electrocardiogram results were normal. A CT scan of her brain (performed immediately upon her arrival in hospital) did not reveal any abnormal signs (however, a subsequent scan performed 36 hours later did show increased density in an area within the brain). A history taken of the patient reveals a lifetime smoking habit (50 yrs), as well as two previous TIA’s within the past year, involving right-sided weakness that completely resolved within an hour
What are the risk factors present in this case?
* Diabetes mellitus
* Age
* High BP
* Smoking
* Previous TIA’s
* Obesity
* Female
103
Mrs. R., an overweight 75 yr old female with type 2 diabetes mellitus, has been brought to the emergency department by her son, who says that his mother began to exhibit several very alarming signs 40 minutes ago: she can no longer see articles on the right side of her vision (although she still has some vision out of her right eye), the right side of her face and right eyelid are drooping, and she has trouble raising her right arm, in which she is also experiencing numbness. Although her speech is fairly clear, she appears frustrated in speaking and has difficulty naming objects. Her temperature and respirations are normal, but her blood pressure is 160/95 mmHg. Electrocardiogram results were normal. A CT scan of her brain (performed immediately upon her arrival in hospital) did not reveal any abnormal signs (however, a subsequent scan performed 36 hours later did show increased density in an area within the brain). A history taken of the patient reveals a lifetime smoking habit (50 yrs), as well as two previous TIA’s within the past year, involving right-sided weakness that completely resolved within an hour.
Propose in which side of the brain the later CT scan showed a change in density. Support your conclusion.
Left side of brain.
* Manifestations were on the right side.
* Aphasia is due to damage to speech center, which is on the left side.
104
Mrs. R., an overweight 75 yr old female with type 2 diabetes mellitus, has been brought to the emergency department by her son, who says that his mother began to exhibit several very alarming signs 40 minutes ago: she can no longer see articles on the right side of her vision (although she still has some vision out of her right eye), the right side of her face and right eyelid are drooping, and she has trouble raising her right arm, in which she is also experiencing numbness. Although her speech is fairly clear, she appears frustrated in speaking and has difficulty naming objects. Her temperature and respirations are normal, but her blood pressure is 160/95 mmHg. Electrocardiogram results were normal. A CT scan of her brain (performed immediately upon her arrival in hospital) did not reveal any abnormal signs (however, a subsequent scan performed 36 hours later did show increased density in an area within the brain). A history taken of the patient reveals a lifetime smoking habit (50 yrs), as well as two previous TIA’s within the past year, involving right-sided weakness that completely resolved within an hour
What is the medical term for loss of the same side of vision in both eyes?
Homonymous hemianopia
105
Mrs. R., an overweight 75 yr old female with type 2 diabetes mellitus, has been brought to the emergency department by her son, who says that his mother began to exhibit several very alarming signs 40 minutes ago: she can no longer see articles on the right side of her vision (although she still has some vision out of her right eye), the right side of her face and right eyelid are drooping, and she has trouble raising her right arm, in which she is also experiencing numbness. Although her speech is fairly clear, she appears frustrated in speaking and has difficulty naming objects. Her temperature and respirations are normal, but her blood pressure is 160/95 mmHg. Electrocardiogram results were normal. A CT scan of her brain (performed immediately upon her arrival in hospital) did not reveal any abnormal signs (however, a subsequent scan performed 36 hours later did show increased density in an area within the brain). A history taken of the patient reveals a lifetime smoking habit (50 yrs), as well as two previous TIA’s within the past year, involving right-sided weakness that completely resolved within an hour.
What is the medical term for Mrs. R.’s speech impairment?
Broca’s aphasia
