additional neuro system disorders Flashcards
MG what is it
A neuromuscular junction disorder characterized by progressive muscular weakness and fatigability on exertion
Autoimmune disease
Antibody-mediated attack on acetylcholine receptors at neuromuscular junction
mg etiology
unkown maybe thymus dysfx
mg risk factors
Age
Sex
Other
Average age of onset: 59 years
Female: Male = 2:1
Prior autoimmune disorder
mg s/s
Lower motor neuron disorder
Progression typically seen within 18 months of symptom onset
Weakness
Worsens with continuing contraction, improves with rest
Particularly muscles of face and throat – eye lid mm weak
Generalized weakness throughout body
Extremities
Intercostal muscles
Diplopia and ptosis
Laryngeal irritation
mg exacerbating facotrs
Stress
Extreme heat
fatigue
meds BB, CC blockers, some antibiotics
mg subtypes
Ocular myasthenia – most start w/ ocular
Only affects the muscles that move the eyes and eyelids
Double vision, blurry vision, ptosis
Mild generalized myasthenia
Severe generalized myasthenia
Myasthenic Crisis
Myasthenia gravis + respiratory failure
myasthenic crisis what is it
complications of mg characterized by sig mm weakness resulting in respiratory failure -> require incubation
how common in myasthenic crisis
15-20 percent
Median time to first myasthenic crisis from onset of MG ranges from 8-12 months
what can myasthenic crisis involve
Can involve the upper airway muscles, respiratory muscles, or a combination of both muscle groups
Both inspiratory and expiratory respiratory muscles can be affected, manifesting as dyspnea
potential complications of myastheenic crisis
Like other dx
Potential complications: fever, infection, DVT, cardiac complications
tx of myasthenic crisis
ivig
plasmaphoresis
dx testing mg
Edrophonium test – reversable AcH inhib
Blood analysis – abnormal antibodies
Ice Pack Test – cooling may improve NMJ transmitting
Electrodiagnostic Testing
NCV: Repetitive Nerve Stimulation
Pulmonary Function Tests
medical management mg
IVIg – 5days, Plasmapheresis every other day for 10 days
NCV repetitive nerve stim mg
Repetitive supramaximal stimuli
Analyze CMAP amplitude (peak-to-peak)
Normal 5-8% drop
mg = big decline
mg examination Cranial nerves
Examine for diplopia, ptosis, progressive dysarthria or nasal speech, difficulty in chewing and swallowing, difficulties in facial expression, drooping facial muscles
CN II, CN3 4 and 6, CN5 9 and 10, CN7, CN 12
mg examination mm strength
Proximal more involved than distal,
fatigability,
repeated muscle use results in rapid weakness
Endurance typically poor
mg exam functional mobility
Common difficulty with climbing stairs, rising from a chair or lifting
mg exam components
cranial nerves
respiratory function
mm strength
functional mobility
mg prognosis
Even with moderately severe cases, with appropriate treatment people can continue to work and live independently between exacerbations
Life expectancy = normal
hydrocephalus what is it
Abnormal buildup of CSF in the ventricles
Leads to ventricular enlargement places excessive pressure on surrounding brain tissue
Most commonly seen in infants and older adults
hydrocephalus communicating vs non communicating
Communicating Hydrocephalus
CSF flow disrupted after leaving ventricles
However, can still get through
Non-Communicating Hydrocephalus
CSF flow blocked along one or more of the narrow passages connecting the ventricles
clinical triad of s/s for normal pressure hydrocephalus
CLINICAL TRIAD OF SYMPTOMS
Altered mental status
Gait disturbance
Urinary incontinence
clinical triad NPH altered mental status
Mild dementia
Disorientation, confusion, apathy, personality changes, decreased attention span, reduced processing speeds, motor slowing most affected
clinical triad NPH gait distrubance
Shuffling, “magnetic” gait – like festinating/shuffling – really hard to pick their feet off of the ground
clinical triad NPH urinary incontinence
Appears later in disease than gait and cognitive impairments
normal pressure hydrocephalus what is it
Idiopathic or result of bleeding in the brain’s CSF
hydrocephalus dx
neuro exam
MRI
lumbar puncture
ICP monitoring when applicable
medical management surgery for hydrocephalus
Shunt placement – most common – in chest cavity or abdomen
Endoscopic third ventriculostomy
*not used for NPH (normal pressure)
s/s of shunt dysfunction
MEDICAL EMERGECY
S&S of shunt dysfunction:
HA
Diplopia
Photosensitivity
N/V
Neck/shoulder soreness
Seizures
Redness or tenderness along shunt tract
Low-grade fever
Excessive sleepiness or exhaustion
Reoccurrence of hydrocephalus symptoms
prognosis hydrocephalus
If left untreated, can be fatal.
Early diagnosis and successful treatment greatly ↑ chance of good recovery
Life expectancy = normal
Many patients make close to or full recovery from shunt placements
↑ chance of lingering symptoms with ↑ age, and as time progresses with disease
NPH prognosis
NPH: When gait disturbance precedes mental deterioration = more favorable outcome is expected
_____ may be needed for hydrocephalus through a person’s life
Multiple surgeries may be needed to repair or replace a shunt
brain absesss what is it
Pus-filled swelling in brain
Cause: bacteria or fungi
Typically preceded by infection or severe TBI
s/s of brain absess
Symptoms: location-dependent
HA, Altered mental status, focal weakness, seizures, visual disturbances
tx for brain absess
Treatment: antibiotics/antifungals, drainage
complications of brain absess
Complications: recurrence, brain damage, seizures, meningitis
encephalitis what is it
Inflammation of brain tissue cause by viral infection – herpes
s/s ecephalitis
Symptoms: Flu-like signs and symptoms that last for 2-3 weeks + neuro signs – usually tx viral and encephalitis will go away
more severe s/s mor difficult to tx encephalitis
muscle weakness, paralysis, memory loss, sudden impaired judgment, poor responsivenessVary from mild to life threatening
despite mild s/s for encephalitis
can be life threatening if undx
meningitis s/s
Inflammation of meninges in brain or spinal cord
cause meningitis
Cause: bacterial, viral,
fungal, parasitic, amebic
s/s fo meningitis
Hallmark signs: headache, fever and neck stiffness
prevention meningitis
and treatemnt
Prevention: Childhood vaccinations, hygeine
Treatment: Antibiotics, antifungals, steroids
kkernigs sign
neck regidity/brudinksis neck sign
pt supine w/ hip fl 90 knee can be fully ext
fl neck causes knee fl
CNS infection gen tx guidelines
patients may fully recover without need for PT or
tx symptom management
seizure what is it
Sudden, uncontrolled electrical disturbance in the brain
May or may not have preceding aura (more common with epilepsy)
causes of seizures
primary and secondary
Primary: Epilepsy
Secondary: 2/2 trauma, infection, inflammation, certain medications
seizure can result in
Result in motor, cognitive, and autonomic manifestations
Can lead to alterations in consciousness
seizure is followed by
What is it
How long
Characterized by
a “postictal state”
Lasts 5-30 minutes, but can last longer with more severe seizure episodes
Characterized by drowsiness, confusion, nausea, HA, HTN
Monitor vitals closely
types of seizure
focal
absence - petit mal
tonic
atonic - drop
clonic
myoclonic
tonic clonic - grand mal
Focal
Can occur with or without LOC
Absence (“Petit mal” seizures)
Common in children
Characterized by staring off into space, or by subtle body movements
Tonic
Characterized by muscle stiffening
Atonic (“Drop seizures)
Sudden loss of muscle tone/control, often causing patient to drop to the ground
Clonic
Characterized by repeated or rhythmic, jerking muscle movements
Myoclonic
Sudden, brief jerks or twitches of arms and legs
Tonic-clonic (“Grand mal seizures”)
Body stiffening, shaking, abrupt LOC
Often with bladder incontinence and/or biting of tongue
seizure last longer than __ medical emergency
5 min
medications seizures
AE
Medications - Anticonvulsants
AE - drowsiness, ataxia, vertigo, cognitive dysfunction
what to do if seizure
stay calm
call for help
ensure pt safe position away from anything they might hurt themselves with
adequate vent
DONT put hands in mouth
eval for postictal s/s
tx guidelines for seizure
General rule of thumb for generalized seizures: 🚫 PT for 24 hours
pt often asymptomatic between seizure
pt edu seizure
Auras, postictal state
Triggering factors
brain tumor incidence age and gender
Children 0-15 years old
Adults in 5th-7th decades of life
Caucasian > Black and Hispanic Americans
Males > Females
eitology brain tumor
phones, occupational/industrial hazards, radiation exposure
Grade I brain tumor
The tissue is benign. The cells look nearly like normal brain cells, and they grow slowly.
Grade II brian tumor
The tissue is malignant. The cells look less like normal cells than do the cells in a Grade I tumor.
grade III brain tumor
The malignant tissue has cells that look very different from normal cells. The abnormal cells are actively growing
grade IV brain tumor
The malignant tissue has cells that look most abnormal and tend to grow quickly.
brain tumor medical managemnet
radiation vs radiosurgery
Radiation
Can be focused on one specific location or the entire brain
Radiosurgery
Utilizes multiple beams of radiation to give a highly focused form of protons to kill tumor cells
Gliomas what is it
onset
most common site
form from glial cells
Onset > 45 years
Most common site: frontal lobes
most common glioma
astrocytomas
treatment gliomas
Treatment: surgery, radiation, chemo
prognosis gliomas
mild grade I = high survival rate
severe Grade 3-4 = min-mod survival rate
glioblastoma what is it
Glioblastoma: most aggressive form of primary brain CA, mean survival rate 5 years post-diagnosis – AUTO STAGE 4
glioblastoma survival rate
40% survival at 1 year
5.5% survival at 5 years
oligodendodroglioma what is it
Common site
start in oligodendricites
Slow-growing, progressive tumor, typically develop over several years
Common site: frontal and temporal lobes
oligodendodroglioma onset
4-6th decade
oligodendodroglioma gender
male
oligodendodroglioma tx
s/s dependent
Observation, seizure control –> surgery, radiation, chemo
oligodendodroglioma prog
5
10
81% 5-year survival
65% 10-year survival
epnedymomas what is it
Most common site
Grow into ventricles or adjacent brain tissue
Most common site: 4th ventricle
tx ependymomas
Treatment: primarily surgical followed by radiation
common complications ependymomas
Common complication: ↑ ICP, hydrocephalus
Shunt placement
common complications ependymomas
Common complication: ↑ ICP, hydrocephalus
Shunt placement
frequent recurrence
prognosis ependymomas
5
Prognosis:
Frequent recurrence
85% 5-year survival
medullobastoma what is it
complications
Typically grow into 4th ventricle, blocking CSF flow
Hydrocephalus, ↑ ICP common sequelae
medulloblastoma onset and gender
> 45
male
tx medulloblastoma
Treatment: surgery followed by radiation. chemo
prog medulloblastoma
75% 5-year survival
meningiomas wht is it
Slow growing, originate in dura matter or arachnoid membrane. Can be benign or malignant
meningiomas clinical s/s
Clinical symptoms often do not manifest until tumor compresses adjacent structures
Most common symptoms: HA, weakness.
Seizures, personality changes, visual deficits
meningiomas tx
Treatment: surgical resection vs observation – usually wait until neuro s/s
prognosis meningiomas
Prognosis: 82% 10-year survival
pituitary adenomas
what is it
Benign epithelial tumors
Frequently encroach optic chiasm
s/s pituitary adenomas
Cause either hyper- or hyposecretion of hormones
tx and prognosis pituitary adenomas
Treatment: surgical resection, drug therapy
Prognosis: 96% 5-year survival
metastatic brain tumor
general
common clinical manifestations
Originate from malignancies outside of the the CNS and spread to the brain
Common clinical manifestations:
Seizures, HA, focal weakness, mental and behavioral changes, ataxia, aphasia, ↑ ICP
metastatic brain tumors prognosis
w/ tx 6 mo
brain tumor s/s
Could present as anything…depends on where the tumor is.
HA
seizure
altered mental status
brain tumor HA - characteristics
Interrupts sleep or is worse on waking and improves throughout the day
Is elicited by postural changes, coughing, or exercises - any inc ICP
More severe or much different than usual
Associated with nausea and vomiting, papilledema, or focal neurological signs
A ____ during adulthood is suggestive of a ______
A first seizure during adulthood is suggestive of a brain tumor
altered mental status brain tumor range from….
Range from decreased concentration, memory, affect all the way to severe cognitive deficits and confusion
pt management brain tumor
Early mobilization helps to prevent or lessen the incidence of pulmonary embolism and/or ventilator acquired pneumonia
Address any pulmonary hygiene issues
Be aware of intracranial pressure (ICP)
Monitor cognitive status closely
tx impairments that arose from the tumor
Grade 1-2 = pt management
grad 3-4 = pt management
Grade I-II: If surgery was successful these patients can do REALLY well
Grade III-IV: Patients still can make excellent gains initially, but decline is inevitable
