1 Flashcards
MRC muscle strength scale
5 - Muscle contracts against full resistance
4 - Strength reduced, but contraction can still
move joint against resistance
3 - Strength further reduced so that joint can be
moved only against gravity with examiner’s resistance completely removed
2 - Muscle can only move if resistance of gravity
is removed.
1 - Only a trace or flicker of movement is seen or
felt, or fasciculations are observed
0 - No movement
Deep Tendon Reflexes scale
0 = no response 1+ = a slight decrease but definitely present response 2+ = a brisk response, normal 3+ = a very brisk response 4+ = a tap elicits a repeating reflex (clonus)
Deep Tendon Reflexes locations - upper limb
Biceps C5-C6
Brachioradialis C5-C6
Triceps C6-C7
Deep Tendon Reflexes locations - lower limb
Patellar L2-L4
Achilles Tendon S1
Superficial Reflexes locations
1) Abdominal
1. upper -> Th8-9
2. medium -> Th10
3. lower Th11-12
2) Cremasteric reflex L1
3) Plantar reflex (if + -> Babinski) S1-S2
4) Perineal/ anal reflex S3-S4
Upper motor neuron lesion
- Muscle weakness (pyramidal weakness)/ paresis
- Spasticity, increased muscle tone -> Clasp-knife response where initial higher resistance to movement is followed by a lesser resistance
- Increased deep tendon reflexes
- Decreased or absence of superficial reflexes
- Pathological reflexes: Babinski sign, pronator drift, Rossolimo sign
Lower motor neuron lesion
- Muscle paresis or paralysis
- Hypotonia or atonia – Tone is not velocity dependent
- Hyporeflexia (decreased or absence of both deep reflexes and cutaneous reflexes)
- Muscle atrophy
- Fibrillations or fasciculations (caused by increased receptor concentration on muscles to compensate for lack of innervation)
Extrapyramidal symptoms
- Altered quantity and velocity of movement (bradykinesia/ hyperkinesia)
- Altered muscle tone (hypotonia/ hypertonia)
- Involuntary movement (tremors, chorea, dystonia, ballismus)
- Akathisia - a feeling of internal motor restlessness that can present as tension, nervousness, or anxiety
- Altered posture reflexes
Cerebellar symptoms
- Ataxia
- Intention tremor
- Dysmetria (undershoot or overshoot of intended position with the hand, arm, leg, or eye)
- Dysdiadochokinesia (impaired ability to perform rapid, alternating movements)
- Dysarthria - speech disorder (motor)
- Nystagmus (involuntary movement of the eye)
- Ataxic Gait -> wide-based gait
- Muscle hypotonia
sensory pathways
- spino-thalamic tract ->
a) anterior -> touch (inconcrete localization), slow transmission of pain
b) lateral -> temprature, fast transmission of pain - spino-bulbar tract -> touch - concrete localization, placing, vibration, proprioception
Horner syndrome
Ptosis - drooping of the upper eyelid Anhidrosis - decreased sweating Miosis - constriction of the pupil Enophthalmos - posterior displacement of the eyebal Loss of ciliospinal reflex
+ Heterochromia iridum -> in congenital Horner syndrome -> difference in coloration of the iris
Bulbar palsy symptoms
-> impairment of function of the cranial nerves 9, 10, 11, 12 -> due to a lower motor neuron lesion in the medulla oblongata or in the cranial nerves outside the brainstem
- dysarthria
- dysphagia (difficulty in swallowing)
- difficulty in chewing
- absent or decreased jaw jerk
- palate paralysis + absent/ decreased gag reflex
- atrophic tongue or its fasciculations or tongue paresis
Pseudobulbar palsy symptoms
-> the result of damage of motor fibers from the cerebral cortex to the lower brain stem
- dysarthria
- dysphagia (difficulty in swallowing)
- difficulty in chewing
- brisk jaw jerk
- Positive primitive (atavistic) reflexes = frontal release signs (ex. snout reflex = Pout)
- Small, stiff and spastic tongue
- Labile affect -> involuntary laugh or cry
Frontal release signs
- > sign of disorders that affect the frontal lobes or piramidal or extrapiramidal tract
1. Palmar grasp - baby naturally grabs objects placed in palm
2. Palmomental reflex - stroking on the thenar eminence of the hand causes contraction of submental muscles
3. Sucking reflex - instinctively sucking anything that touches the roof of their mouth (babies)
4. Snout reflex - pouting or pursing of the lips that is elicited by light tapping of the closed lips near the midline
5. Glabellar reflex - persistent blinking in response to repetitive tapping on the forehead (normally blinking stops after a few secends)
Glasgow scale
A) eye opening 1-none 2-to pain 3-to voice 4-spontaneous
B) best motor response 1-none 2-extensor posturing 3-flexor posturing 4-withdraws to pain 5- localizes to pain 6-obeys commands
C) best verbal response 1-none 2-incomprehensible sounds 3-inappropiate words 4-conversant and disoriented 5-conversant and oriented
EEG rhythms
- α=PDR - posterior dominant rhythm
- β
- θ (theta)
- δ
PDR
- Main feature in normal EEG in wakeful adults
- 8-13 Hz (cycle-per-second = cps)
- Best observed in parietal and occipital regions
- Shape: sinusoid -> increasing and decreasing amplitude
- In relaxed individuals manifests with eye closure and attentuates with alerting or eye opening
rhythm β
- In normal EEG in wakeful adults in front-central areas
- 14-30 Hz (cycle-per-second = cps)
- They don’t attentuate with eye opening
- Decrease of amplitude (local) suggest disease spot (ex. tumor, place after a stroke, brain edema)
rhythm θ (theta)
- In normal EEG in wakeful adults there can be a small amount, more seen while sleeping
- 4-7 Hz (cycle-per-second = cps)
- Increase suggests pathology
rhythm δ
- DON’T occur in wakeful adults, only while sleeping -> NREM 3&4
- <4 Hz (cycle-per-second = cps)
- Suggest pathology
Herniation syndromes
- Subfalcine hernation
- Central transtentorial herniation
- Uncal transtentorial herniation
- Tonsillar herniation
- Upward herniation
Epilepsy treatment generalized-onset tonic-clonic
- Lamotrigine
- Valproic acid
- Levetiracetam
- Carbamazepine
- Oxcarbazepine
Epilepsy treatment focal
- Lamotrigine
- Carbamazepine
- Oxcarbazepine
- Phenytoin
- Levetiracetam
- Gabapentin
- Valproic acid
Epilepsy treatment typical absence
- Valproic acid
- Ethosuximide
- Lamotrigine
Epilepsy treatment myoclonic
- Valproic acid
- Lamotrigine
- Topiramate
- Levetiracetam
Epilepsy treatment tonic/ atonic
- Valproic acid
MS McDonald criteria
-> either:
1. Prove 2 or more attacks (dissemination in time) AND
prove 2 or more lesions (dissemination in space)
- 1x objective clinical evidence of attack with reasonable historical evidence of a prior attack
- Insidious neurologic progresion suggestive of PPMS
MS McDonald criteria dissemination in time
- > either:
1) 2x objective clinical evidence of attacks or
2) simultaneous presence of gadolinium-enhancing and nonenhancing lesions at any time
MS McDonald criteria dissemination in space
- > 2 or more lesions on MRI in either:
1. periventricular
2. juxtracortical
3. infratentorial
4. spinal cord
MS McDonald criteria Insidious neurologic progresion suggestive of PPMS
both:
- 1 year of disease progression (retrospectively or prospectively)
- 2 out of the 3 criteria:
1) evidence of at least 1 lesion in MRI in brain
2) evidence of dissemination in space in spinal cord (at least 2 lesions)
3) Positive CSF (isoelectric focusing evidence of oligoclonal bands and/or elevated IgG index)
Drugs frequently used in MS
A) Modestly Effective
- Interferon β -> sc or im
- Glatiramer Acetate -> sc
B) Moderately Effective -> orally
- Fingolimod
- Dimethyl Fumarate (DMF)
C) Highly Effective -> iv
- Natalizumab
- Ocrelizumab
Drugs less commonly used in MS
- Teriflunomide -> modestly effective
- Alemtuzumab -> highly effective
- Mitoxantrone -> highly effective
MS ataxia/ tremor symptomatic therapy
- Clonazepam
- Primidone
- Propranolol
- Ondansetron
MS spasity and spasm symptomatic therapy
- Baclofen
- Diazepam
- Tizanidine
- Dantrolene
- Cyclobenzaprine hydrochloride
- Baclofen pump
- Botulinum toxin
MS weakness symptomatic therapy
- Aminopyridine
2. 3,4-diaminopyridine
MS pain symptomatic therapy
A) Anticonsulvants 1. Carbamazepine 2. Phenytoin 3. Gabapentin 4. pregabalin B) Antidepressants 1. Amitriptyline 2. Nortripyline 3. Desipramine 4. Venlafaxine C) Benzodiazepins D) Baclofen
MS automatic bladder symptomatic therapy
(antimuscarinic)
- Propantheline
- Oxybutynin
- Tolterodine
- Hyoscyamine
MS detrusor sphincter dyssynergia (DSD) symptomatic therapy
- > α1-antagonist
1. Terazosin
2. Phenoxybenzamine
3. Doxazosin
4. Tamsulosin
MS fatique symptomatic therapy
- Amantadine
- Methylphenidate
- Modafinil
- Armodafinil
MS depression symptomatic therapy
- SSRI (Fluoxetine, Sertraline)
- Tricyclic antidepressants (Amitriptyline, Nortripyline, Desipramine)
- Nontricyclic antidepressants (Venlafaxine)
MS sexual dysfunction symptomatic therapy
- Sildenafil
- Tadalafil
- Vardenafil
Initial Symptoms of MS
- Sensory loss
- Optic neuritis
- Weakness/ Paralysis of limbs
- Paresthesias/ transverse myelitis
- Cerebellar syndrome
- Pseudobulbar syndrome
Clinical types of MS
- Relapsing RMS (nawracająco-zwalniający)
- Secondary Progressive SPMS
- Primary Progressive PPMS
- > + postępująco-nawracający
Characteristic syndromes associated with MS
- Lhermitte’s syndrome
- Uhthoff’s syndrome
- Acute Marburg variant of MS
- Balo’s concentric sclerosis
Amyotrophic Lateral Sclerosis treatment
- Riluzole -> NMDA antagonist
2. Edaravone -> antioxidant
