A brain lesion (damage to the brain tissue) that has a clear location of damage (more prescribed damage) would be describe as ______, whilst brain lesions that were spread out affecting many areas of the brain would be described as _____.
Focal - site, determines nature of injury; size, determines severity.
Brain disorders that involve gradual deterioration are considered _____, whilst brain disorders that occur from a single-event (static) are considered _____.
What are the most common causes of traumatic head injuries?
Motor vehicle accidents
Sports (gymnastics, diving, skiing, football, HR)
What are the peak ages for the occurance of traumatic brain injuries? and what are the most likely causes for these ages?
are men or women more likely to have a traumatic brain injury?
15-24 years, car accidents
less than 5 years old, falls
Men are more likely than women to have a traumatic brain injury.
What are the two types of traumatic head injury?
Penetrating head injury
Closed head injury
Describe the neuropathology (usual features) of a penetrating head injury.
An object penetrates the skull and exposes the brain.
- Focal lesions
- Severe brain damage
- high potential for infection when brain is exposed
Describe the neuropathology (usual features) of a closed head injury.
Skull remains intact. Injury occurs when object hits head, head hits object or from whiplash (rapid acceleration/deceleration).
Can result in diffuse or focal lession (or both)
- Diffuse lessions - e.g., damage to bloodvessels and cells
- Focal lessions - coup ("impact injury") and countercoup (opposite side to imapct resulting from pressure) injury.
What is a coup and what is a countercoup injury?
Coup injury describe brain lesions at the site of the impact.
A countercoup injury describes lesions at the exact opposite side of the head to the impact site, it occurs because the pressure from the impact site causes compression on the other side of the brain.
Give some examples of where rapid acceleration and decceleration can result in brain damage.
Acceleration - propelled into motion e.g., hit with a baseball
Decceleration - movement is suddenly stopped e.g., the landing from a fall.
How is the severity of traumatic head injury assessed?
The patient is assessed using the Glasgow Coma Scale, this assesses the depth and duration of their coma
Describe how the Glasgow Coma Scale is used to assess the depth of a patients coma. (describe how and what it measures)
The glasgow coma scale is a brief test of simple visual, verbal and motor abilities.
Visual - does the patient open their eyes? ranked from 1 (not at all) ->2 (to pain) ->3 (to speech)-> 4 (spontaneous)
Verbal - do they respond verbally? ranked from 1-5: none, incomprehensible, inappropriate, confused, orientated.
Motor - Do they respond to a motor command (e.g., can you move X) ranked from 1-6: none, extension, abnormal flexion, withdrawal, localises pain, obeys command
What GCS rating combined with Coma durations suggest Mild, Moderate and Severe traumatic brain injuries, respectively?
What level of disability are each of these categories predictive of?
- GCS: greater than 13
- Duration: less than 30 minutes
- Predicts: good recovary
- GCS: 9-12
- Duration: less than 6 hours
- Predicts: moderate disability
- GCS: less than 8
- Duration: greater than 6 hours after admission
- Predicts: severe disability
What rating on the Glasgow Coma Scale is predictive of greater mortality?
A GCS score of less than 7.
At what score on the Glasgow Coma Scale is the unconsciousness considered to be a "Coma"?
less than or equal to 8.
however it is important to recognise that "coma" is a continuum from no coma -> shallow coma -> deep coma ...and that people come out of coma gradual in stages.
Damage to what structure of the brain results in coma?
What is reterograde amnesia?
Inability to recall events that occured BEFORE the injury (e.g., driving before accident)
What is Anterograde amnesia?
Inability to recall events that occured AFTER injury (e.g., ambulence ride to hospital)
How is reterograde amnesia and anterograde amnesia tested?
It is part of the Galveston Orientation Amnesia Test (GOAT).
asks two questions to assess amnesia
Reterograde: "what is the last thing you remember after the injury?"
Anterograde: "what is the first thing you remember after the injury?
participants must give details
Post-traumatic amnesia severity can be categorised based on it's duration.
at what duration would PTA be considered:
- very mild
- very severe
- extremely severe
very mild < 5 mins
mild 5-60 mins
moderate 1-24 hours
severe 1-7 days
very severe 1-4 weeks
extremely severe > 4 weeks
What are the four main complications of a closed head injury?
Oedema (accumulation of fluid, not enough space for brain to swell into)
Haemorrhage (bleeding) and resulting hematoma (accumulation of blood)
Skull fractures (protrude into the brain and can result in infection)
Post-traumatic epilepsy (due to scar tissue)
What extreneous factors can affect the severity of a traumatic brain injury?
History of head injury
History of alcohol abuse
What are (or can be) the cognitive symptoms of traumatic head injury? (its neuropsychological profile)
What personality changes can result from traumatic brain injury?
Lack of initiative & loss of spontaneity
Temper outbursts & mood alterations
poor self-awarenss (of deficits)
deppression (usually after 6 months post-injury)
What is another name for a mild closed head injury?
Describe the duration of loss of consciousness(LOC) post-traumatic amnesia (PTA) and 'complaints' consistent with a mild traumatic head injury (i.e., concussion)
LOC: less than or equal to 30 mins
PTA: less than or equal to 24 hours
Complaints: less than or equal to 3 months (changes in the brain are microscopic)
What are the common complaints of a mild traumatic head injury (i.e., a concussion)?
How long does it usually take complaints to emerge?
How long does recovary usually take?
- Dizziness, headaches, noise sensitivity, vision (e.g., blurred)
- Orientation (initial person/time/place), Attention (concentrating) and Memory
- Patience/temper, anxiety and deppression.
Symptoms/complaints emerge a few days after injury (When people attempt to resume regular activity)
Recovary can take 3 months and symptoms tend to disappear gradually.
What is the neuropsychologists role in the case of a traumatic brain injury?
Initial brief evaluation at hospital - orientation, attention & memory.
This proves a baseline, information about the patients tolerance for further tests and is usefull for outcome prediction
- Subsequent comprehensive formal evaulation
- Aids in detection of brain injury
- outlines deficits & residual stengths
- Documents individual features of disabilities
- Predict outcome and prognosis
- Monitor recovery
- Evalutate effectiveness of rehabilitation
What is the timeline of recovery for traumatic brain injuries?
During what time period are the most recovery gains made?
Max level of recovery reached around 2 years post-THI
Most gains made during the first 6 months.
What are the 3 types of Cerebro Vascular Disorders (CVAs)?
Transient Ischemic Attack (TIA)
Obstructive Ischemic Stroke
Why are CerebroVascular accidents so devastating?
Because the brain CANNOT store oxygen yet uses 20% of oxygen it requires a constant supply of oxygen (carried in blood).
CVAs result in a lack of oxygen to areas of the brain.
What is a Cerebrovascular accident?
When there is an obstruction or a rupture in a blood vessle/artery resulting in hypoxia and subsequent necrosis.
What is hypoxia?
Insufficient supply of oxygen.
What is necrosis?
Death of brain cells
What is a Transient Ischemic Attack (TIA)?
What risk does a TIA present?
When a temporary obstruction occurs in an artery, resulting in temporary hypoxia.
It is short-lasting and results in transient deficits.
If you have a TIA you have a 20-30% of latter stroke.
What are the symtoms of a Transient Ischemic Attack (TIA)?
Physical - dizziness
Cognitive - orientation, sensation & perception, language, motor skills (weakness)
What is a Obstructive Ischemic Stroke?
What are the two types of Obstructive Ischemic Stroke?
When there is an permanent obstruction in a blood vessel resulting in prolonged hypoxia resulting in necrosis (i.e., an infarction)
- Thrombotic - when fatty desposits built up in vessle walls and block/narrow blood vessles in the brain. The accident occurs over 30mins.
- Embolic - Plague forms elsewhere and travels to the brain where it blocks a blood vessle.
Thrombotic Obstructive Ischemic Strokes occur more in what age group?
Embolic Obstructive Ischemic Strokes occur more in what age group?
Which is more common in general?
Thrombotic - Older people
Embolic - Younger people
Thrombotic is more common.
What is a Haemorrhagic Stroke? (+ 3 types of damage)
When there is a rupture in a blood vessel such that oxygen rich blood doesn't make it to the brain, resulting in three types of damage:
- Disrupted blood flow -> hypoxia -> necrosis
- Hematoma -> ICP -> displacement/deformation
- Intoxication/infection (naturally occuring in blood, go into brain)
BURST BLOOD VESSLE
The location of a haemorragic strokes in the brain are divided into two types - what are they?
Intracerebral (in the brain)
Subarachnoid ( surface of the brain, leaks blood between brain and skull)
What is the most common type of brain disorder?
3rd most common cause of death
What is the average of onset for cerebrovascular accidents?
+/- 70 years
What are the risk factors of cerebrovascular accidents?
Hypertension - particularly chronic, can weaken and burst vessles and can dislodge plague.
High cholesterol - clot formation, build up of plague
Cigarette smoking - narrows blood vessles
Past of history of stroke - repeated strokes have cumulative effects
Age - older (less elastic weaker blood vessles)
Gender - men
How is a cerebrovascular accident diagnosed?
what information does it/do they yield?
CT scan (computer transaxial tomography) to visualise bran structures.
- Type of stroke
- site & size of the lesion
Angiogram - visualise blood systems of the brain
- more specific site
What are the common cognitive symptoms of a CVA?
Orientation - self, place, time
Motor function - slowing, paralysis, unsteady, coordination
Executive function - trouble planning, organising, responding to novel situations
Memory - mostly STM (LTM usually alright) misplace things, getting lost, struggle to live independently - structure is important
Do strokes normally occur in one hempisphere or both?
One, very unusual for it to be both.
How do the symptoms of a left hemisphere stroke differ from those of a right hemisphere stroke?
for the 98% of people with left language lateralisation:
- damage to the left hemisphere affects receptive and expressive language.
- damage to the right hemisphere affects visual-spatial ability (perceptual, estimating distances between points)
What personality changes can result from a CVA?
(and the hemisphere where possible)
Depression (left hemisphere stroke)
Apathy/indifference (right hemisphere)[tone expression]
Euphoria (right hemisphere stroke)
Emotional lability - exagerrated or incongruent responses
Lack of initiation - not being able to start a behaviour
Perseveration - Not being able to stop a behaviour
Poor judgement - leading to inappropriate or dangerous behaviour
What are Lack of initiation and
Not being able to start a behaviour
Not being able to stop a behaviour
What is the neuropsychologists role in the case of a CVA?
Track recovery (monthly)
Recommendations about return to work/school
Assit family/caregivers with planning home management
What is the recovary timeline for CVAs?
When does most of the recovery occur?
Plateau at 6 months
Improve most rapidly for the first few weeks
(i.e., quicker initial recovery and quicker plateau than brain injury patients.)
epilepsy is the __th most common neurologica disorder.
what is "epilepsy"?
A cluster of symptoms
- Recurring seizures (reversable alterations of consciousness) [ arousal alertness, awareness
Briefly describe the neuropathology of a seizure
Abnormal electrical activity disrupts normal chemical
What are the two etilogys (causes) of seizures?
Symptomoatic (known cause) - e.g., intoxication, brain infection, brain injury, tumour, surgery, stroke
Idiopathic (unknown cause)
Describe the 3 stages that occur in the course of a seizure.
Prodromal phase - i.e., strange pre-seizure symptoms
Ictal phase - temporary change in consciousness
Post-ictal phase - regain consciousness minutes/hours
Describe some of the strange pre-seizure symptoms that occur in the prodromol phase
what are the features of these pre-seizure symptoms?
AURA - dizzy, nauseous, metallic taste, smells, mood changes, deja-vu, stomach butterflies
Idiosyncratic - they differ from patient to patient
Consistent - consisten in patient
What are the two major categories of seizures?
which is more common?
Generalised - whole brain involved and affected
Partial (focal) - localised (can later evolve into generalised seizures)
Partial are more common
What are the two types of generalised seizures?
Petit Mal/ Absense Seizure (when kids have these, they often grow out of them)
What are the features of a grand mal seizure (2-phases)?
Tonic phase - let out a cry, crumple, face goes blue, stop breathing, tense/rigid (30 secs)
Clonic phase - Rhythmic jerking of limbs (30 secs)
What is the main features of a petit mal/absense seizure?
Inattention - starting into space, eyelids fluttering
What are the 3 types of Partial Seizures?
Simple seizure - 1 mode of expression e.g., occipital lobe -> visual disturbances
Complex partial seizures - most often in the temporal lobe (temporal lobe epilepsy) but can be in frontal love; resultings in automatisms.
Jacksonian seizure - motor cortex, "marching" seizures
What are automatisms?
automatisms are a symptom of what type of seizure?
Repeatedly doing the same behaviour ('stuck') e.g., doing up and undoing a button.
Complex partial seizures
Describe the nature Jacksonian Seizures (What happens!)
Seizures of the motor cortex.
They start with muscle contractions in just one area (e.g., moving one finger) then the seizure progresses across the motor cortex.
They are also known as "marching seizures"
What are the risk factors for epilepsy?
Traumatic head injury (and resulting scar tissue)
What are the precipitating factor for seizures? (i.e., trigger)
Drugs (particularly alcohol)
How is epilepsy diagnosed?
Try to induce a seizure and then record with EEG (Electroencephelogram)
records brain activity and pin points type and location of seizure
What techniques are used to induce seizures?
What is the neuropsychological profile of epilepsy? (cognitive and personality symptoms)
- memory and learning
Reduced quality of life -> : limitations in driving, swimming, jobs, reduced social interaction (no late nights or alcohol.
Personality changes: anxiety, deppression, tension, stress, psychotic. (high than in the general population)
Severity of seizures/epilepsy corresponds to...... (list)
Age of onset (younger = more severe)
Seizure frequency (more frequent)
EEG abnormality (more abnormal)
Seizure type (generalised)
Personality are most common in what kind of epilepsy?
Most common in temporal lobe epilepsy (mood, detail obsessed)
What are the treatments for epilepsy?
What are the benifits and disadvantages to seizure medications?
- 75% of epileptics can control with these
- Does not cure epilepsy, just helps prevent seizures
- Side-effects of long-term use
What is a WADA test?
A test done prior to surgery for epilepsy whereby a barbituate is injected at the base of the brain which causes 6-8 minutes of half-brain paralysis.
This enables the neuropsychologist to ensure that the other side of the brain can compensate, thus it is highly useful for partial sezures, specifically temporal lobe seizures.
What are the to surgical procedures used to treat epilepsy?
Removal of seizure focus site
Commissurotomy - split-brain surgery
What is a commissurotomy?
Split-brain surgery, whereby the corpus-collosom is cut.
How can behavioural management be utilised to treat epilepsy?
Patient is counselled of situations that stimulate seizures and what to do to reduce them.
What is "Seizure control" and how can it help manage seizures?
Recognising the signs of an impending seizure and counteracting them
e.g., a patient with a specific smell aura, may purposefully smell something different.
A patient with a specific taste aura, may purposefully eat somehing pleasant
What role does the Neuropsychologist have in Evaluation in the case of epilepsy?
Functional asessment during WADA test (brief assessment of language and memory function)
Determine prescense and extent of cognitive & personality disturbances
Rudimentry assessment of cerebral organisation for speech.
What is a neoplasm?
Abnormal growth of brain tissue
i.e., a brain tumour
What is another name for a brain tumour?
What are the features of a neoplasm?
Progressive - uncontrolled and progressive multiplication of tumour cells
Reversible - can be treated and sometimes 'cured'
Focal damage (usually) - a specific location
What is the incidence of brain tumours (i.e., neoplasms)?
(% of cancers, ages?, men or women?
5% of cancer
most common in young-middle adulthood, but can happen at any age
men and women are equally affected.
Based on what 3 catergories is the severity/type of a tumour assessed on?
Nature - infiltrating/non-infiltrating
Malignancy - rate of growth (graded 1-4)
Origin - intracerebral, between brain and skull, metastatic.
In terms of the nature of brain tumours, what is the different between infiltrating and non infiltrating tumours?
Infiltrating - tumour is spread out, invades and destroys other areas of the brain, consumes healthy tissue
Non-infiltrating - noninvading, encapsulated growth, growing within itself, does NOT 'take-over'
What is the 'malignancy' of a tumour? and how is it graded?
The tumours rate of growth and the degree of symptoms it is causing
it is graded from 1-4
- Slow growth, minimal symptoms
- low-Intermediate growth, low-moderate symptoms
- Intermediate growth, moderate symptoms
- Fast growth, severe symptoms
What are the three 'origins' of brain tumours?
Intracerebral - within the brain tissue
Subarchnoid space - cavity between the brain and skull
Metastatic - "Secondary brain tumour" whereby tumour ceels brak of from a primary cancer elsewhere in the body (e.g., lungs) and travel through the blood to the brain.
What does it mean to say: "the origin of the tumour is metastatic" ?
The tumour is a "Secondary brain tumour", whereby tumour cells have broken off from a primary cancer elsewhere in the body (e.g., lungs) and traveled through the blood to the brain.
How does the damages caused by an infiltrating tumour differ from that caused by a non-infiltrating tumour?
Infiltrating tumours - invade and destroy healthy brain tissue, directly damaging the brain tissues.
Non-infiltrating tumours - are encapsulated, but as they grow they cause intracranial pressure (ICP) which displacees and compresses the healthy brain tissue causing damage.
What are the (behavioural/sickness) symptoms of a brain tumour?
Headaches (pressure as tumour grows)
Nausea and vomiting
How is a brain tumour diagnosed?
Brain imaging techniques (both are similar, but MRI is more detailed) - locates tumour
CT - visualise structure of cells
MRI - differentiate between brain cells and tumour cells
Brain biopsy - determines the type of tumour
How are brain tumours treated?
Surgical removal of tumour
Radiation therapy (when tumour is inoperable)
Is the prognosis usually better for non-infiltrating or infiltrating tumours? why?
Prognosise is usually better for non-infiltrating than for infiltrating because the former usually progresses slower and is easier to remove. While the latter is usually a higher grade tumour that is difficult to remove.
What is cortical stimulation?
A procedure by which a neuropsychologist works out what areas around a tumour 'do' and thus what will be affected by the removal of a tumour and nearby tissues. i.e., mapping out brain functions.
It helps the surgeon determine the "balancing act" between removing tumour cells and protecting brain cells. If the area contains important function, the surgeon may choose to be more conservative (at the risk of tumour reoccurance). Surgery is often followed by radiation.
- Local anestetic and the skull is opened, exposing the brain
- Low voltage electrode directly stimulates the brain area
- patient responds e.g., touch motor cotex and they move their hand, or they are asked to count etc.
Because, for example, a motor cortex tumour could cause motor trouble and a tumour in the basal ganglia could cause tremours.
What is the neuropsychological profile of brain tumours? (there cognitive and personality symptoms)
Idiosyncractic - depends on the size, site & grade of brain tumour, as well as the direction of tumour growth
- Loss of spontaneity
What role does the neuropsychologist have in evaluation in the case of brain tumour (and surgery/treatment)?
Evaluate baseline (which areas are most affected by the tumour)
Patient has surgery or treatment
Follow-up (hopefully documents improvement)
Risk factors for cerebrovascular disorders include:
B. High cholesterol
C. History of traumatic head injury
D. Both A and B
D: both A and B (Gender and High cholesterol)
The cognitive symptoms associated with temporal love epilepsy include...
A. Visual-spatial deficits
B. Memory impairments
C. Executive dysfunction
D. All of the above
B. Memory impairments
_________ is the loss of memory for events following injury or illness.
The rey figure test is an assessment instrument used to measure the cogntive functioning of ______
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