Brain Flashcards

Question

5. In a patient with traumatic brain injury and vertigo, which physical examination finding from a Dix-Hallpike test would encourage you to perform an Epley maneuver? 1. (a) Persistence of responses to repeated provocation 2. (b) Fixed direction of nystagmus with rotary component 3. (c) Nonconcordant or divergent gaze 4. (d) Persistence of nystagmus, 30 seconds for each provocation

Answer 1

20. (b)A positive Dix-Hallpike test definitively establishes the diagnosis of benign paroxysmal positional vertigo (BPPV). The Dix-Hallpike maneuver is performed by quickly dropping a patient backwards from a sitting position so that the head is rotated 45 degrees and hangs over the edge of a mat. Characteristics of BPPV are mixed torsional and vertical nystagmus, which lasts for 10–20 seconds, associated with a sensation of rotational vertigo. Repetition of the test results in a reduction in the intensity of vertigo and nystagmus. The Epley maneuver, which is performed at the bedside, relocates debris from the posterior semicircular canal into the vestibule of the vestibular labyrinth.

Answer 2

21. (b)In communicating post-traumatic hydrocephalus, cerebral spinal fluid (CSF) absorption by the villi is impaired. This occurs with inflammation or subarachnoid hemorrhage.

Answer 3

22. (b)An increase in the diastolic blood pressure is indicative of an unstable cardiac condition. The other choices are normal responses to exercise.

Answer 4

23. (b)Meningiomas are the second most common form of primary tumors. Gliomas are the most common. Glioblastoma multiforme has a median survival rate of less than 1 year. Treatment side effects do affect outcome. Fifty percent of CNS tumors are metastatic.

Answer 5

24. (b)Alcohol is believed to be involved in 60% of traumatic brain injury (TBI) cases. Polymedication is not a common indirect cause of traumatic brain injury. Motor vehicle accidents and falls are direct causes of TBI and not indirect.

Answer 6

25. (d)Divalproex sodium reduces the number and severity of migraine headaches. With 3 migraine-like headaches a week, prophylactic treatment for migraine is indicated. There is concern for developing dependence and abuse potential for butorphanol. Daily use of ibuprofen is more likely to result in rebound headaches when discontinued. There is no evidence that the selective serotonin release inhibitors are effective in the treatment of headache.

Answer 7

26. (d)Hydrocephalus is a well-recognized complication of subarachnoid hemorrhage. The fundamental abnormality in post-traumatic hydrocephalus is an imbalance in the production and absorption of cerebral spinal fluid (CSF). As the blood in the subarachnoid space obstructs the arachnoid villi it impairs absorption of CSF, thus causing hydrocephalus.

Answer 8

27. (c)More than 90% of the primary malignant tumors of the brain in adults are **high-grade astrocytomas and, of these, the most common is glioblastoma multiform.** Meningiomas are tumors that occur in the membranes that cover and protect the brain and spinal cord (the meninges). Meningiomas usually grow slowly. Medulloblastomas are almost always found in children or young adults. Ependymoblastomas are rare cancers that usually occur in children.

Answer 9

28. (a)The Rancho Los Amigos level IV applies to persons who are confused and agitated. The need of a padded floor bed indicates that the patient is restless and agitated.

Answer 10

c)Phenol acts as a neurolytic agent that denatures protein in myelin sheaths and axons. Dantrolene sodium (Dantrium) reduces calcium release from the sarcoplasmic reticulum. Tizanidine (Zanaflex) is an alpha-2 agonist. Botulinum toxin (Botox) inhibits acetylcholine release.

Answer 11

30. (a)The mechanism of brain damage in anoxic brain injury is ischemia due to hypoxemia or decreased cerebral perfusion. Although anoxic brain injury typically causes diffuse neuronal death and injury, there is selective vulnerability of certain neurons. Neurons in parts of the hippocampus appear to be the most vulnerable, **which correlates with the high frequency of amnesia following anoxic brain injury.**

Answer 12

31. (d)Factors associated with poor prognosis in multiple sclerosis are: progressive course at onset, male sex, age at onset \>40 years, cerebellar involvement at onset, and multiple system involvement at onset. A positive Lhermitte sign (shocklike sensation down the spine, often into the limbs on neck flexion) is indicative of cervical myelopathy but has no prognostic significance.

Answer 13

32. (b)Factors associated with poor functional outcome following stroke include a prolonged flaccid period, severe proprioceptive deficits, late return of reflexes, and severe proximal spasticity.

Answer 14

d)Inferior subluxation of the glenohumeral joint occurs frequently following stroke. Pain in the shoulder is often felt in the upright position, since gravity further aggravates the subluxation.

Answer 15

34. (a)The use of metoclopramide (Reglan) should be avoided because it is known to cause sedation and significant cognitive difficulties for individuals with brain injuries, especially for those regaining consciousness. It also has potential side effects of extrapyramidal movements and tardive dyskinesia. The other agents do not have significant cognitive effects on brain-injured individuals.

Answer 16

35. (d)Magnetic resonance imaging (MRI) is considered better than computed tomography (CT) for evaluating diffuse axonal injury (DAI). A CT scan is superior to MRI for the detection of acute extra-axial hematomas, and in the evaluation of acute brain injury.

Answer 17

36. (b)Individuals with a history of traumatic brain injury (TBI) and apolipoprotein-E (APOE-4) allele have 10 times the risk of developing Alzheimer’s disease compared with 2 times the risk for APOE-4 allele alone and no increased risk with TBI alone.

Answer 18

38. (d) A series reported by Tribl and Oder found that of 48 patients who underwent ventriculoperitoneal shunting for post-traumatic hydrocephalus slightly more than half experienced significant benefit.

Answer 19

39. (a)In studies by Beaupre and Lew, and Ramnemark et al, the largest change in bone mineral density(BMD) is in the humerus on the paretic side (-17%), the next largest change was -12% in the proximal femur on the paretic side and -9% in the distal radius on the paretic side. No change in BMD was found in the lumbar spine

Answer 20

40. (b) A minimally conscious state is a condition of severely altered consciousness in which minimal but definite behavioral evidence of self, or environmental awareness, is demonstrated by any or all these actions: simple gestures, purposeful behavior, appropriate smile/cry or vocalization to stimulation, reach for object, purposeful visual tracking. The vegetative state is associated with preserved hypothalamic and brainstem autonomic function and the patient exhibits a sleep/wake cycle, but there is an absence of cortical activity, judged behaviorally. The patient may exhibit visual pursuit but not in relation to meaningful behavior. The term persistent vegetative state is confusing and it is suggested that the term be abandoned, since it combines diagnosis (vegetative) with prognosis (persistent). Coma is a transient state after a traumatic brain injury (TBI) of being not awake and not aware of surroundings, and is seen in patients with a severe TBI and a Glasgow coma scale (GCS) of 8 or lower.

Answer 21

41. (b) Early and aggressive therapy addressing the higher level skills of gait, higher order functional skills, and problem solving were associated with better outcomes in a multi-center observational study.

Answer 22

(A)Patients with a first ischemic stroke and a single positive antiphospholipid antibody test result who do not have another indication for anticoagulation may be treated with aspirin (325mg/day) or moderate-intensity warfarin (INR 1.4–2.8).

Answer 23

43. (d) Meningiomas are the most common benign brain tumor, comprising about 15% of all primary brain tumors.

Answer 24

(b) After a traumatic brain injury, the following factors are associated with a better prognosis: younger age, reactive pupils, conjugate eye movement, decorticate posturing, early spontaneous eye opening, absence of ventilatory support, and higher Disability Rating Score on admission. Factors associated with poor prognosis include decerebrate posturing and flaccid muscle tone.

Answer 25

(B) The onset of central pain following a stroke occurs more than 1 month after the stroke in 40% to 60% of all patients. The pathogenesis of central pain is still largely a matter of conjecture and hypothesis. It is generally believed that damage to the spinothalamicocortical sensory pathways plays a significant role in the pathogenesis, but central pain can occur with lesions in any part of the brain. Treatment options are limited and at present amitriptyline is the drug of first choice, other drugs, including antidepressants, anticonvulsants, antiarrhythmics, and opioids may provide relief for some patients who do not respond to amitriptyline.

Answer 26

46. (d) Genu recurvatum is a common atypical gait pattern in patients with upper motor neuron pathology. It may be caused by ankle plantarflexor spasticity, heel cord contracture, quadriceps weakness, or spasticity and a combination of the above impairments. In this case an ankle foot orthosis with 5o of plantarflexion would worsen the gait. A tendon lengthening would be aggressive and more conservative management should be attempted first. A phenol motor point injection to the hamstrings would make knee control more problematic. Botulinim toxin can be very helpful for focal spasticity and can decrease ankle plantarflexor spasticity and decrease the backward force at the knee.

Answer 27

(b) Concussive injuries of the spinal cord are more varied in gradation than injuries to the brain. Seemingly mild spinal concussions, seen most frequently in cervical hyperextension, may lead to complete tetraplegia, even in the absence of penetration of the spinal canal or even vertebral fracture. Mild concussive trauma to the brain results in a more mild brain injury and a more severe concussive trauma to the brain results in a more severe neurologic dysfunction.

Answer 28

48. (b) Impaired bladder control is frequent following stroke with initial hypotonic bladder, but voiding returns very quickly and urine retention is rarely a problem. In the postacute phase of stroke rehabilitation, the problem is not bladder overdistention, but uninhibited bladder with incontinence.

Answer 29

49. (a) Relaxation techniques with slow, rhythmic rotational movements starting with passive range of motion distally and progressing proximally and then adding active range of motion is effective in decreasing rigidity.

Answer 30

50. (a) A defective swallowing mechanism rather than excessive saliva production is the primary cause of drooling and the complaints of excessive drooling in Parkinson’s disease. A behavior modification program with frequent reinforcement may be effective in reducing drooling in Parkinson’s disease and should be used prior to medication or botulinum toxin therapy.

Answer 31

51. (d) Recurrent falls are more common in individuals with Parkinson’s disease who are taking benzodiazepines. Other risk factors are: history of falls, severe disease, poor balance, depression, and loss of arm swing with gait.

Answer 32

52. (d) A systematic program of physical therapy for Parkinson’s disease with repetitive exercise for 1 hour daily, 3 times a week for 4 weeks can significantly improve rigidity, bradykinesia, and activities of daily living, but not tremor. The improvements were not sustained if a regular home program of exercise was not continued.

Answer 33

53. (d) Athetosis is a continuous, slow writhing movement of the limbs or other body parts. It is important to differentiate athetosis from spasticity, because athetosis does not respond to antispasticity treatment. Chorea is characterized by brief, irregular contractions, which affect individual muscles as random events that seem to flow from one muscle to the other. Myoclonus manifests as rapid, shock-like or lightning-like jerks. Dystonia is a syndrome of sustained muscle contraction that frequently causes twisting and repetitive movements or abnormal postures.

Answer 34

54. (c) Essential tremors, as described in this scenario, can develop in adolescence or in the fourth to fifth decades. Essential tremors are distiguished from parkinsonian tremors in that they are faster (7-10 Hertz, versus 4-7 Hertz) have more flexion/extension and less supination/pronation, and are not associated with bradykinesia, cogwheeling, or masked facies. Nonpharmacologic treatment consists of rest, decreasing central nervous system stimulants, and occasional use of situational alcohols. Medication would be started when activity of daily living skills are impaired, as in this case, with beta-noradrenergic blockers such as propranolol. Botulinum toxin would not be the initial treatment.

Answer 35

55. (d) Intrathecal baclofen withdrawal can be very serious and warrants immediate evaluation and management. The signs of baclofen withdrawal can be subtle with an intrathecal baclofen pump, but a sudden increase in spasticity and feeling ill wit**h whole body itching are seen with baclofen withdrawal.** Nausea and emesis is a warning of impending severe withdraw. **Prevention of severe spasticity and the sequelae of rhabdomyolysis** is critical to the health and welfare of the patient. The treatment is to restore intrathecal baclofen.

Answer 36

56. (c) A year out from his injury an aggressive stretching program and occupational therapy (OT) should have already been tried and oral antispasticity medication is managing his lower extremity tone well. Further OT and adjustment of medications are not likely to help. Intrathecal baclofen is more effective for lower extremity spasticity than for upper extremity spasticity. Botulinum toxin intramuscular injections can be quite effective when combined with a therapy program for upper extremity tone and spasticity.

Answer 37

(b) As with all health problems, a workup for dementia must start with a history and physical exam. These findings will direct the rest of your dementia workup and treatment. Erythrocyte sedimentation rate and thyroid function studies should be added to her laboratory workup.

Answer 38

58. (d) Reducing cardiovascular risk factors, especially hypertension and hyperlipidemia, can decrease the risk of recurrent stroke and are important strategies in preventing or slowing the progression of mixed dementia.

Answer 39

59. (d) The only benign brain tumor listed is craniopharyngioma

Answer 40

60. (b) The majority of patients with Parkinson disease experience orthostatic hypotension (OH) as the disease progresses. The patient’s history suggests falls related to postural changes and situations that lower blood pressure. Educating your patient to avoid or mitigate these situations (slow postural changes, small meals, and avoidance of high heat exposure and alcohol) is the best initial treatment.

Answer 41

62. (b) Multiple studies have shown that **age, initial Glasgow Coma Scale (GCS) score, duration of coma, duration of posttraumatic amnesia (PTA), and neuroimaging** findings are correlated with outcome. All provide valuable information that the clinician can use to mark milestones, and help with prognosis, but **the most powerful of these is the duration of PTA.** The longer the duration of the PTA, the worse the outcome. It is unlikely for a person with PTA lasting less than 2 months to have a serious disability; however, the likelihood of a good recovery is poor if the PTA extends beyond 3 months. Length of coma is determined by the time from coma onset to the time when the patient can follow commands. On average only 7%--8% will make a good recovery if the coma lasts longer than 4 weeks, and severe disability is unlikely if the coma lasts less than 2 weeks. Although the GCS score provides a general idea about the severity of the injury, it does not by itself yield a definitive prognosis.

Answer 42

63. (D) After a traumatic brain injury, diffuse axonal injury (DAI) is the leading cause of morbidity, this morbidity includes impairments in cognition, behavior, and arousal

Answer 43

64. (C) The Brunnstrom stages of motor recovery can be used to describe motor recovery following stroke. Brunnstrom classification stage 4 is when the patient begins to activate muscles selectively outside of flexor and extensor synergy. Stage Description 1 Immediately following a stroke there is a period of flaccidity whereby no movement of the limbs on the affected side occurs. 2 Recovery begins with developing spasticity, increased reflexes and synergic movement patterns termed obligatory synergies. These obligatory synergies may manifest with the inclusion of all or only part of the synergic movement pattern and they occur as a result of reactions to stimuli or minimal movement responses. 3 Spasticity becomes more pronounced and obligatory synergies become strong. The patient gains voluntary control through the synergy pattern, but may have a limited range within it. 4 Spasticity and the influence of synergy begins to decline and the patient is able to move with less restrictions. The ease of these movements progresses from difficult to easy within this stage. 5 Spasticity continues to decline, and there is a greater ability for the patient to move freely from the synergy pattern. Here the patient is also able to demonstrate isolated joint movements, and more complex movement combinations. 6 Spasticity is no longer apparent, allowing near-normal to normal movement and coordination.

Answer 44

(d) The casters should lead the rear wheels for the most common direction of travel. This will help reduce the possibility of the user flipping over when hitting an obstacle and will make the chair more directionally stable.

Answer 45

66. (A) Primary cerebral lymphoma presents as multiple tumor deposits in the brain and has an increased incidence in patients infected with human immunodeficiency virus (HIV). Surgical removal does not improve outcome.

Answer 46

67. (d) Botulinum toxins act on the neuromuscular junction where they inhibit the release but not the production of acethylcholine (ACh). Botulinum toxin does not affect the sarcoplasmic reticulum, nor does it work at the troponin-tropomysin complex.

Answer 47

68. (b) Significant risk factors for heterotopic ossification in traumatic brain injury include prolonged coma (\>1 month), increased muscle tone, limited movement in the involved lower extremity, and associated fractures. Late seizures, gender, and diabetes insipidus are not associated with increased risk of heterotopic ossification.

Answer 48

69. (A) A pure motor stroke (hemiplegia and dysarthria without sensory deficits) is caused by a lesion in the posterior limb of the internal capsule.

Answer 49

Commentary: An essential tremor is more prominent with activity (5-8Hz) and is diminished at rest. Stress exacerbates the tremor. The essential tremor can be confused with parkinsonian tremor. Essential tremor is more prominent with activity, while parkinsonian tremor is more prominent at rest, with a 4-5Hz frequency. There is also an absence of the other symptoms of parkinsonism such as loss of postural reflexes, rigidity and bradykinesia. Enhanced physiologic tremor is a high-frequency tremor that is most prominent with posture and action. It is exacerbated by anxiety, fatigue and many drugs. It can be seen with alcohol withdrawal. The cerebellar tremor has a frequency of about 3Hz and is mainly in a horizontal plane. It is most prominent with fine repetitive action of the extremities and is associated with other signs of cerebellar ataxia.

Answer 50

71. Answer: A Commentary: Methylphenidate and dextroamphetamine do not appear to be associated with increased seizure risk among patients with traumatic brain injury. However, **amitriptyline, bupropion and quinolones decrease seizure threshold.**

Answer 51

72. Answer: D Commentary: Favorable electroencephalogram (EEG) patterns after a traumatic brain injury are normal activity, rhythmic theta activity, frontal rhythmic delta activity, and spindle pattern. Poor prognosis is associated with epileptiform activity, nonreactive, low amplitude delta activity and burst suppression patterns with interruption of isoelectricity. Complete isoelectric EEG activity had the highest mortality.

Answer 52

Answer: B Commentary: The present evidence suggests that methylphenidate should be regarded as first-line therapy when an agent from this medication class is used. If methylphenidate proves ineffective Commentary: The present evidence suggests that methylphenidate should be regarded as first-line therapy when an agent from this medication class is used. If methylphenidate proves ineffective or produces intolerable side effects, dextroamphetamine, amantadine, or bromocriptine may be useful alternative stimulant medications. Amantadine’s side effect profile is worse than methylphenidate and there is some evidence of a lowering of the seizure threshold, but this is controversial. There is no support at this time in the literature for the use of modafinil over methylphenidate. Bromocriptine and carbidopa/levodopa both have worse side effects and are not as well studied as methylphenidate or amantadine.

Answer 53

74. Answer: D Commentary: This patient is exhibiting normal bladder emptying with no evidence of a bladder infection. An anticholinergic in a patient with a traumatic brain injury may exacerbate his confusion. A condom catheter in this population will probably not stay in place. It may increase agitation and will not help the patient. Intermittent catheterization and a Foley catheter will increase the patient's infection risk. The best course at this time is frequent bladder emptying and retraining, with the entire rehabilitation team encouraging the new behavioral modification.

Answer 54

75. Answer: B Commentary: Diabetes insipidus after TBI usually has an onset 10 days after trauma when the antidiuretic hormone (ADH) stored in the posterior pituitary is depleted.

Answer 55

Answer: D Commentary: Of the complications listed, aspiration/pneumonia is seen in about 40%, while venous thromboembolism is seen in 6%; falls occur in 16%, musculoskeletal complications in 5%, and reflex sympathetic dystrophy (RSD) in 30 %. Depression affects 30%. Urinary tract infection is just as frequent at 40%, but is not listed.

Answer 56

Answer: C Commentary: A lesion in the lateral medulla causes Wallenberg syndrome and is associated with ipsilateral loss of facial pain- and temperature-sensation and contralateral loss of body pain-and- temperature sensation. Ipsilateral Horner syndrome (ptosis, miosis and anhidrosis) is found, as well as nystagmus, dysphagia and dysphonia

Answer 57

78. Answer: A Commentary: The Western Aphasia Battery measures various parameters of language and provides the aphasia quotient as a measure of aphasic severity. The Boston Diagnostic Aphasia examination produces a classification of the features of a particular patient and a score of severity and is similar to the Western Aphasia battery, but not the aphasia quotient. The Porch Index of Communication Ability (PICA) is different and evaluates verbal, gestural and graphic responses. The Functional Communication profile provides an overall rating of functional communication.

Answer 58

79. Answer: A Commentary: The Bobath technique of therapy focuses on good posture and works on proximal muscle groups first before proceeding to distal muscle groups. Brunnstrom method uses synergistic patterns and focuses on general movement patterns before moving to more isolated movements. Proprioceptive neuromuscular facilitation (PNF) focuses on multijoint movement patterns in a “diagonal” pattern. The Rood approach focuses on specific muscles selected according to the recovery stage of the stroke.

Answer 59

80. Answer: C Commentary: Internuclear ophthalmoplegia (INO) is caused by a lesion in the medial longitudinal fasciculus (MLF) in the paramedian brainstem. It is characterized by impaired adduction of the contralateral eye with gaze toward the side of the lesion. In practice, an isolated case of INO is rare since the 2 sides of the MLF are very near the midline of the brain stem. The two most common causes of INO are multiple sclerosis and paramedian brain stem infarct. The Horner syndrome is due to a superior cervical sympathetic ganglion lesion and causes miosis, ptosis and anhydrosis. Parinaud syndrome causes impaired upward gaze with dilated and nonreactive pupils and is the result of a lesion in the midbrain, usually a pineal tumor. Millard-Gubler syndrome is due to an ipsilateral pons lesion causing ipsilateral palsy of cranial nerve (CN) 6 and CN 7 and a contralateral hemiparesis.

Answer 60

Answer: (d) Commentary: Early feeding of a person who has a traumatic brain injury is associated with fewer infections and a trend towards better outcomes in terms of survival and disability. Two trials reported the effect of route of feeding on the incidence of infection of any type, but both trials showed a trend towards more infection with parenteral nutrition (PN) than with enteral nutrition (EN). This difference might reflect catheter related infection with PN. In 3 trials reporting the effect of route of feeding on the occurrence of pneumonia, a trend towards reduced incidence of pneumonia was found in the PN group. Although it is easier to provide PN than it is to obtain adequate EN access, EN has a decreased incidence of complications and lower cost compared to PN, with no significant differences in measured nutritional parameters. Also, providing nutrition to the intestine can stimulate gut immune function and limit deterioration of the intestinal mucosa characteristic of bacterial translocation and its potential for contributing to sepsis.

Answer 61

Answer: (b) Commentary: Hyperbaric oxygen therapy (HBOT) delivers 100% oxygen under pressure, which increases the amount of oxygen dissolved in the blood, thereby increasing the oxygen delivered to the body tissues. HBOT may also enhance the formation of new blood vessels, decrease inflammation, and increase the volume of blood flow. Treatment sessions occur inside a sealed, pressurized space known as a hyperbaric chamber. The oxygen is delivered either by mask or directly into the chamber. The pressures used are expressed in units of atmospheric pressure and commonly range from 1.5 to 3 atmospheres. The sessions last from 30 to 90 minutes and many practitioners recommend 100 sessions (range, 80-150 sessions). The cost ranges from $200 to $400 per session. HBOT is not FDA approved for treatment of traumatic brain injury. A number of more minor complications may occur due to HBOT. V**isual disturbance, usually a reduction in visual acuity secondary to conformational changes in the lens, is common.** While the great majority of patients recover spontaneously over a period of days to weeks, a small proportion of patients continue to require correction to restore sight to pretreatment levels. **The second most common adverse effect associated with HBOT is aural barotrauma.** Barotrauma can affect any air-filled cavity in the body (including the middle ear, lungs and respiratory sinuses) and occurs as a direct result of compression. There is limited evidence that HBOT reduces the chance of dying following a traumatic brain injury. There is little evidence that more survivors have a good outcome. Thus, the routine adjunctive use of HBOT in these patients cannot be justified. Because evidence of lesion resolution or change in size of persistent defect obtained by magnetic resonance imaging (MRI) or computed tomography (CT) has not been studied, there is no evidence to suggest this occurs.

Answer 62

83. Answer: (d) Commentary: There is no evidence that prophylactic antiepileptic medications, used at any time after head injury, reduce death and disability. Evidence exists that prophylactic antiepileptics reduce early seizures, but there is no clinical evidence that late seizures are reduced, or that treatment has any effect on death or neurological disability.

Answer 63

84. Answer: (a) Commentary: This review of 14 studies with 659 participants looked at whether repeated practice of tasks similar to those commonly performed in daily life could improve functional abilities. In comparison with usual care or placebo groups, people who practiced functional tasks showed modest improvements in walking speed, walking distance and the ability to stand from sitting, but improvements in leg function were not maintained 6 months later. Repetitive task practice had no effect on arm or hand function. There was a small amount of improvement in ability to manage activities of daily living. Training effects were no different for people whether the training was given early or late after stroke

Answer 64

85. Answer: (a) Commentary: The initial computed tomography and magnetic resonance imaging scans taken soon after injury are often normal. Only 10% of patients with diffuse axonal injury (DAI) demonstrate the classic CT findings of DAI. These are hemorrhagic punctate lesions of (1) the corpus callosum, (2) the gray-white matter junction of the cerebrum, and (3) the pontine- mesencephalic junction.

Answer 65

86. Answer: (b) Commentary: Presenting symptoms at the time of diagnosis with brain metastasis, in order of decreasing frequency, are as follows: (patients can have more than a single symptom): headache, 49%; mental disturbance, 32%; focal weakness, 30 %; gait ataxia, 21 %; seizures, 18%; speech difficulty, 12%, visual disturbance, 6%; sensory disturbance, 6%; and limb ataxia, 6%.

Answer 66

87. Answer: (b) Commentary: Hypertension, defined as a systolic pressure greater than 165mmHg, or a diastolic pressure greater than 95mmHg, increases the relative risk of stroke by a factor of 6. The Framingham study has confirmed that smoking is independently associated with stroke. The relative risk for heavy smokers (more than 40 cigarettes a day) is twice that of light smokers (fewer than 10 cigarettes a day). Cessation of smoking reverses the risk to that of nonsmokers within 5 years of quitting. Hypercholesterolemia has not been epidemiologically linked to increased stroke incidence, but its strong influence on atherosclerosis makes it an indirect risk factor. Diabetes mellitus increases the relative risk of stroke by 3 to 6 times the general population.

Answer 67

88. Answer: (c) Commentary: The American Academy of Physical Medicine and Rehabilitation and the American Association of Neurological Surgeons recommend seizure prophylaxis after a traumatic brain injury as standard treatment. All patients with postresuscitation Glasgow Coma Score (GCS) below 12 require 7 days of therapeutic phenytoin sodium. Immediate posttraumatic seizures (defined as those occurring within 24 hours postinjury) do not require any additional prophylaxis after 7 days. Early (more than 24 hours but less than7 days) seizures should be treated with at least 12 months of an antiepileptic medication, unless a time-limited intracranial abnormality such as hydrocephalus, infection, or active hemorrhage, etc., was the cause. Late seizures -- those occurring more than 7 days postinjury -- should be treated with an antiepileptic medication for at least 12 months. Any seizure that lasts longer than 2 minutes is defined as “status epilepticus” and warrants treatment with an antiepileptic medication for at least 12 months.

Answer 68

89. Answer: (a) Commentary: Distinguishing dementia from pseudodementia (which is really depression) is important, in order to provide appropriate treatment to your patient with memory problems. Pseudodementia’s onset is fairly well demarcated with a short history and is rapidly progressive in nature. These patients usually have a history of a previous psychiatric difficulty or a recent life crisis. Their complaints of cognitive dysfunction are detailed and elaborate with an affective change and the patients expend little effort on examination items. Nocturnal exacerbations are rare and memory loss is inconsistent in recall of recent and remote items. Dementia’s onset, in contrast, is indistinct with a history of problems long before they seek clinical help and early deficits often go unnoticed. A history of previous psychiatric problems or emotional crisis is uncommon. These patients struggle with cognitive tasks but usually put forth good effort. Nocturnal dysfunction is common. The memory loss on recent items is worse than for remote items and there is a consistent impairment of performance.

Answer 69

90. Answer: (d) Commentary: Prophylaxis for deep vein thrombosis (DVT) should be considered in all patients with a traumatic brain injury after acute admission to the hospital. Graded compression stockings are of little benefit. Thigh high intermittent compression devices help reduce DVT risk but are not an appropriate primary prophylaxis. A vena cava filter is not appropriate prophylaxis and chemical prophylaxis is needed as soon as feasible. In patients who are not fully ambulatory in 24 hours unfractionated heparin sodium is adequate and can be used 12 hours after surgery. However, in all patients who have long-bone fractures, prior DVT, or more than 4 total risk factors, low molecular weight heparin sodium should be used until the patient is fully mobilized.

Answer 70

91. Answer: (a) Commentary: Neuromuscular electrical stimulation (NMES) to the deltoid (mainly posterior) and the supraspinatus can decrease subluxation and reduce shoulder pain. It is required for several hours daily over several weeks to achieve clinical benefits.

Answer 71

Answer: (b) Commentary: Of the options listed, transcutaneous electrical nerve stimulation (TENS) is the modality that may be useful in treating phantom limb pain. Iontophoresis is generally used for dispersion of medications. Short wave diathermy is a method of deep heat. Paraffin bath is a superficial heat modality.

Answer 72

Answer: A The pituitary gland rests in the sella turcica. With involvement of the sella, diabetes insipidus can occur from damage to the posterior pituitary with interruption of ADH secretion. Other complications from damage to the pituitary gland include impotentence, reduced libido, and amenorrhea.

Answer 73

Answer: A Lacunar infarcts are small subcortical infarcts caused by the occlusion of a single deep penetrating artery. Lacunes make up 15-25% of all ischemic strokes in the U.S. Incidence increased with age with the mean age of 65 years. Risk factors include hypertension and diabetes mellitus. Lacunes have a more favorable prognosis than nonlacunar strokes. There are 5 lacunar syndromes. Pure Motor Stroke • most common lacunar syndrome (33-50%) • located in the posterior limb of internal capsule, basis pontis, pyramyids • usually affects face, arm, and leg equally • transient sensory symptoms (but not signs) may be present • may have dysarthria and/or dysphagia Pure Sensory Stroke • located in thalamus • persistent or transient numbness and/or tingling on one side of body • occasional complain of burning or pain Ataxic Hemiparesis • second most common lacunar syndrome • located in the posterior limb of internal capsule, basis pontis, corona radiata, cerebellum • weakness and clumsiness on one side of body • affects leg \> arm Dysarthria-Clumsy Hand • located in anterior limb of internal capsule, pons • dysarthria and clumsiness and/or weakness of the hand Mixed Sensorimotor Stroke • located in thalamaus, posterior limb internal capsule • hemiparesis with ipsilateral sensory involvement Ref: www.emedicine.com: Lacunar Stroke; PM&R Secrets: p 168; Braddom 2nd Edition: p 1131

Answer 74

Answer: B Serotonin syndrome typically develops within hours or days of the addition of a new serotonergic agent (i.e. TCA) to a medication regimen that already includes serotonin-enhancing drugs (i.e. SSRI). It may also develop when a new serotonergic agent is started following the recent discontinuation of another serotonergic drug without allowing an adequate washout period. Isolated overdoses of SSRIs can also cause the syndrome. Symptoms attributed to serotonin excess may include restlessness, hallucinations, shivering, diaphoresis, shivering, nausea, diarrhea, HA. Signs of serotonin excess are variable and can be subdivided into the following 3 categories: o Mental status changes - Confusion, agitation, coma o Neuromuscular findings - Myoclonus, rigidity, tremors, hyperreflexia (tends to be more prominent in the lower than the upper extremities), clonus, ataxia o Autonomic instability - Hyperthermia (excessive heat generation may develop secondary to prolonged seizure activity, rigidity, or muscular hyperactivity), mydriasis, tachycardia, blood pressure alterations (hypertension, hypotension) SS produces a clinical picture that is very similar to neuroleptic malignant syndrome (NMS). Both syndromes are associated with autonomic dysfunction, alteration of mental status, rigidity, and hyperthermia. Clinical differentiation between these syndromes is very important because management may differ. For example, chlorpromazine may be of some benefit in SS, whereas it may cause further deterioration in NMS. Distinctions between the two syndromes include the following: o NMS develops in association with neuroleptics, whereas SS develops in association with serotonergic agents. o NMS has a slow onset (days to weeks) and a slow progression of 24-72 hours, whereas SS has a more rapid onset and progression. o NMS is associated with bradykinesia and lead pipe rigidity, whereas SS is associated with hyperkinesia and less rigidity. o NMS is an idiosyncratic reaction to therapeutic doses, whereas SS is a manifestation of toxicity, frequently generated from the combination of two drugs with serotonergic activity Ref: www.emedicine.com: Serotonin Syndrome

Answer 75

Answer: B FIM is a functional assessment tool used to evaluate both physical (ADL, transfers, mobility) and cognitive (communication, social cognition) disabilities which are often present in stroke patients. The Barthel Index only examines physical components and is not as sensitive as the FIM to minor changes at higher levels of functioning (i.e. cooking, housekeeping, socialization). The Glasgow Outcome Scale is the most commonly used measure of outcome in brain injury research. (sorry, I couldn’t figure out what the Rappaport is) ## Footnote Ref: Braddom 2nd Edition: p 155-158, 1081; Practical Manual of PM&R (Tan): p 95

Answer 76

Answer: A Third nerve palsy (ptsosis, diplopia, dilatation of pupil, and divergent strabismus) usually indicates an aneurysm at the junction of the posterior communicating artery (PComA)-ICA junction and less often an aneursym at the PComA-posterior cerebral artery junction. CN III passes immediately lateral to the PComA-ICA junction (see Netter plate 132) Ref: Adams Principles of Neurology 7th Edition: p 890-891; Netter p 132

Answer 77

Answer: A Coma and unconsciousness are caused by the disruption of input to surface brain structures from deeper structures that subserve arousal and wakefulness. Diffuse axonal injury (DAI) is the hallmark lesion of TBI and typically a result of acceleration-deceleration and rotational forces. DAI is primarily responsible for initial LOC and preferentially disrupts fiber at the junction of the gray and white matter in the cortex, and in the corpus callosum, corona radiata, and cerebral and cerebellar peduncles. Epidural hematoma occurs secondary to a temporal or parietal skull fracture with laceration of the middle meningeal artery or vein. The injury may not produce coma initially but a few hours to a day later (longer if venous bleeding), severe headaches, vomiting, confusion, neurology deficits, and eventually coma ensues. The time between the initial injury and delayed coma is called the “lucid interval”. Ref: Pocketpaedia: p 54; Braddom 2nd Edition: p 1085; Adams Principles of Neurology 7th Edition: p 937

Answer 78

Answer: A Contusions typically occur in the inferior frontal and anterior temporal lobes where the adjacent skull surfaces are irregular. (I chose answer A because it gives a specific location in the frontal lobe whereas answer B does not specify where (i.e. anterior) in the temporal lobe). Ref: PM&R Secrets: p 195; Pocketpaedia: p 54; Braddom 2nd Edition: p 1074

Answer 79

Answer: A There was no LOC and symptoms lasted for less than 15 minutes so the athlete has suffered a grade I concussion. According to the American Academy of Neurology (AAN) guidelines, after a single grade I concussion, the athlete may return to play after being asymptomatic with normal neurologic exam at rest and with exercise after 15 minutes (i.e. now). AAN Return to Play Guidelines Grade Criteria Return to Play \*\* I No LOC Transient confusion Symptoms \< 15 minutes 15 minutes (single) 1 week (multiple) II No LOC Transient confusion Symptoms ≥ 15 minutes 1 week (single) 2 weeks (multiple) III Any LOC, either brief (seconds) or prolonged (minutes) 1 week (brief LOC) 2 weeks (prolonged LOC) ≥ 1 month (multiple) \*\* after being asymptomatic with normal neurologic exam at rest and with exercise Ref: Braddom 2nd Edition: p 1107

Answer 80

Answer: A Baseline evaluation for dementia should include a CBC, standard chemistries, VDRL, TSH, and vitamin B12 level. Syphilis, vitamin B12 deficiency, and thyroid disease are potentially treatable causes of dementia. ## Footnote Ref: Cecils Essentials of Medicine 4th Edition: p 800

Answer 81

``` Answer: B Etidronate disodium (Didronel) is a bisphosphonate which inhibits growth of hydroxyapatite crystals by preventing the precipitation of calcium phosphate. It also slows the rate of osteoclastic and osteoblastic activity. It cannot dissolve any bone already formed by HO; however, may prevent recurrence of HO after resection (no good studies; radiation and NSAIDs more effective?). Didronel carries a potential risk of bone fracture secondary to osteomalacia when used for prolonged periods. It can also inhibit mineralization of bone after surgery. ``` ## Footnote Ref: PDR 2002: p 2888; Essentials of PM&R: p 574; PM&R Clinics of North America 1992: 3(2) p 411-413; Pocketpaedia: p 88

Answer 82

Answer: A Reglan should be avoided in the TBI population because it can impair cognition. Other classes of medications to be avoided include benzodiazepines, phenothiazines / neuroleptics (i.e. Haldol), central sympathetic inhibitors / centrally acting antihypertensives (i.e. clonidine), and anticonvulsants (i.e. Dilantin) as they may limit the recovery of the brain-injured patient or induce mental status changes. ## Footnote Ref: PM&R Secrets: p 434, 502

Answer 83

Answer: B A patient with a Ranchos score of 3 has exhibits localized responses. The patient has spontaneous, purposeful movements but follows commands only inconsistently. Ranchos Los Amigos Medical Center Level of Cognitive Functioning Level Name Description I No response Deep sleep; no response to any stimulation II Generalized response Gross movements in response to noxious stimulation III Localized response Spontaneous, purposeful movements; follows commands inconsistently IV Confused-agitated Confused, amnestic, inattentive; may be aggressive V Confused-inappropriate Confused and amnestic but not agitated VI Confused-appropriate ↓ initiative and problem solving; functions with structure and supervision VII Automatic-appropriate Follows daily routines; need supervision for home and community skills VIII Purposeful-appropriate Independent with home/community skills; may have cognitive deficits Ref: Braddom 2nd Edition: p 1086

Answer 84

Answer: B A patient with a Ranchos score of 5 is confused and inappropriate. The patient is amnestic but not agitated. See answer to Question 63.

Answer 85

Answer: A The Rood method (sensorimotor approach) relies on peripheral input of cutaneous sensory stimulation in the form of superficial brushing and tendon tapping, to facilitate or inhibit motor activity. The Bobath method (neurodevelopemental technique (NDT)) emphasizes inhibition of abnormal tone, postures, and reflex patterns while facilitating automatic motor responses that will eventually allow the performance of skilled voluntary movements. Patients are taught “reflex inhibiting patterns” and are guided by therapists from “key points of control” (proximal areas such as shoulder, pelvic girdles) to inhibit abnormal motor activity. Kabat and Voss method (proprioceptive neuromuscular facilitation(PNF)) uses spiral and diagonal movement patterns (as opposed to traditional movement in the cardinal planes) with the goal of facilitating movements that have more functional relevance than those achieved through traditional techniques of strengthening individual muscle groups. The movement patterns do not inhibit abnormal reflex activities. Brunnstrom method utilizes limb synergy patterns and primitive reflexes that are present during the recovery process after a CNS insult. Patients are taught to voluntarily control the motor patterns available to them and these are incorporated into simple to complex movements with functional relevance. Ref: PM&R Secrets: 171-172; Tan: p 172-173

Answer 86

Answer- Detrusor Hypereflexia ## Footnote Lesions above the pontine micturition center (head injury, MS, CVA, brain tumor) would lead to detrusor hyperreflexia because of the lack inhibitory effect of the cerebral cortex on the sacral (parasympathetic) micturition center. There would be no sphincter dyssynergic because of the intact pontine micturition center. Reference: Kessler Notes 2003, Lecture 43, Neuroanatomy, Physiology, Treatment of the Bladder

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