Clinical and Identifying Lesions Flashcards
1
Q
Describe the 4 clinical levels of nervous system
A
- Supratentorial - cerebral hemispheres and intracranial portions of CN 1,2
- Infratentorial - brainstem, cerebellum, intracranial portions of CN 3-12
- Spinal: spinal cord
- Peripheral: all CN, ANS, spinal nerves, dorsal and venral roots
2
Q
Describe fnc of Suprtentorial level
A
Segmental: vision olfaction language memory cognition pituitary gland - autonomic funcs
Longitudinal:
S & M in face, trunk, limbs to CONTRALATERAL side
autonomic fncs via hypothalamus
3
Q
Contralateral vs ipsilateal vs bilateral
A
contra: opposite side
ipsi: same side
bi: both sides
4
Q
Describe supratentorial lesion
A
- loss of higher fncs
- increased intracranial pressure: headaches, altered mental state, nausea vomitting, papilledema, diplopia, aphasia, seizures, neglect, apraxia, visual field defects
- CONTRA defecits to face and body
5
Q
Describe fnc of Infratentorial level
A
Segmental: IPSIlateral fncs of CN 3-12 resp, cardiac coordination (cerebellar) postural control consciousness, sleep
Longitudinal:
CONTRA sensory and motor to body
autonomic fncs
6
Q
Describe infratentorial lesion
A
Cross signs: IPSIlateral face but contralateral body affected
7
Q
Describe fnc of spinal level
A
Segmental: sensory, motor, autonomic at that level
Longitudinal: descending motor and autonomic; ascending sensory
8
Q
Describe spinal lesion
A
- loss fnc at level (and below)
- dermatomal/myotomal distribution of loss
- BILATERAL deficits
- radicular pain, incontinence
- no face of CN deficits
9
Q
Describe fnc of peripheral level
A
- sensory, motor, or autonomic of specific nerve
- no longitudinal fncs
10
Q
Describe peripheral lesion
A
- IPSIlateral loss
- usually one side, localized
- pain
- motor weakness to muscles
- dermatomal sensory loss
11
Q
Signs of Epidural hematoma? What type of imaging used?
A
- initially ok, then rapid onset - deteriorates within hours
- common: middle meningeal artery
- blood lentiform shape on imaging, held in place by periosteum and sutures
- CT
12
Q
Signs of subdural hematoma? What type of imaging used?
A
- CT
- acute: acute blood is bright in subdural space, mass effect, midline shift
- subacute: blood broken down so now ISOdense so time has passed
- chronic: blood is darker than tissue
13
Q
What is a coup vs contre-coup injury?
A
cerebral contusions
coup: injury under impact site
conte-coup: injury on opposite side due to motion of brain after impact
14
Q
What is Myasthenia gravis? What are clinical manisfistations? Complications? Tests?
A
- autoimmune disease of NMJ
- IgG antibody binds nicotinic ACh receptor
- maybe due to thymus
- motor weakness due to decreased safety factor for AP threshold
- fatigability - better in morning
- ocular weakness: extraocular movements, ptosis, dipoplia (not pupils)
- bulbar: 9,10,11: disarthria, disphygia, slurred speech
- myasthenic crisis - resp failure
- test for diagnosis: give AChE inhibitor, ice pack on eye > improves symtoms
15
Q
What is Lambert-eaton syndrome
A
-autoimmune - IgG against presynaptic Ca channels
> Ach vesicles not released
-muscle weakness
-gradual proximal > distal leg
-minimal ocular/bulbar symptoms
-Test for Dx: exercise improves symptoms
-Tx: blck Na channels to sustain depolrization > incrase cellular Ca
16
Q
What is ALS? Signs and symptoms?
A
- amyotrophic lateral sclerosis
- degeneration of ant horn cells, cst, corticobulbar neurons
- UMN and LMN signs
- fasiculations, cramps, atrophy, dysarthri, dysphagia
- sensory adn eyes OK
- no cure, supportive therapy
17
Q
What are examples of mononeuropathies?
signs?
A
- Entrapment: Carpal tunnel syndrome, meralgi paresthetica, femoral nerve entrapment
- Bell’s palsy
- CN III palsy
Signs of neuropathy:
- distal weakness
- atrophy
- hyporeflexia
- sensory loss
- normal muscle enzymes
- nerve conduction study slowing
18
Q
What is Guillian Barre Syndrome?
A
- demyleniation due to inflammatin
- ascending weakness from leg, sensory loss, bilateral facial palsies
- Rx: immune globulin
19
Q
What are signs of myopathy? (vs neuropathy)
A
myopathy: weakness proximal (affect larg muscles) atrophy if advanced normal reflexes until advanced normal sensory normal nerve conduction increased muscle enzymes muscle biopsy
20
Q
Pyramidal vs extrapyramidal motor fncs:
A
Pyramidal:
issues with spastic tone, weakness, hyperreflexia
Extrapyramidal:
issues with involuntary movements, rigidity, brdykinesia
(no weakness, reflex issues)
21
Q
What can cause postural instability?
A
Basal ganglia - parkinson's Vestibulocerebellar Vestibular Visual Proprioception
22
Q
What is criteria for Parkinson’s? for IPD?
A
-Bradykinesia + at least 1 of rigidity, rest tremor, postural instability
-at least 3 of: _ and no exclusions
unilateral first
70-100% response to ldopa
ldopa response more than 5 yrs
ldopa induced chorea
rest tremor
progressive degeneration
disease will last >10 yrs
23
Q
4 Motor and 6 non-motor features of PD?
A
Motor:
- TRAP
- speech and bulbar dysfnc
- gait difficulties
- dystonia
Non-motor:
- sleep disturbances
- fatigue
- anxiety/depression
- cognitive slowing
- autonomic
- sensory - pain
24
Q
What is pathology of parkinson’s?
A
- dopaminrgic neurons in substantia nigra pars compacta die
- histo: see lewy bodies
- low Da > less inhibition on globus pallidus interna > more inhibition effect on thalamus > less activation of cortex
- this is already at stage 3 of degeneration when we clinical pick it up
25
What is the genetic link to PD?
many
ex: LRRK2 muttion - high in Ash. Jewish popn
Parkin mutation
26
What are Parkinson Plus disorders?
```
Other neurodegenerative diseses with parkinsonism features:
MSA
PSP
CBD
Wilson's - high Cu
```
27
What is MSA? Symptoms? what do we see on MRI?
```
Multi system Atrophy
-rarer than IPD
-type P (striato nigral)
-type C (cerebellar)
-type A (autonomic)
all progress to P
```
- orthostatic hyptotnesion
- urinary impotence
- rigidity - symmetric
- postural instability
- cerebellar issues
- midline dystonia
- stridor
- speech - high pitched
- swallowing
- dementia
- see atrophy of putamen - iron deposits. DARKer
- Hot cross bun sign on cerebellum - cross is WHITE
28
What is PSP? symptom? what do we see on imaging?
Progressive supranuclear palsy
- later onset >50yrs
- early falls
- symmetric bradykinesia
- difficulty swallowing, speaking
- axial rigidity
- GAZE
MRI: hummingbird sign - atrophy of midbrain
29
What is CBD?
Cortical Basal ganglion degeneration
- apraxia
- alien limb
- usually limb
- cortical sensory loss
30
What are 2ry causes of parkinsonism?
- Infection: encephalitis
- Drugs: antipsychotics, lithium
- infarcts
- tumours
- head injury
- hydrocephalus
31
What are red flags that it's not IPD?
- early falls (PSP)
- orthostatic hypotension or incontinence (MSA)
- apraxia, alien limb (CBD)
- early hallucination (dementia)
- symmetry, midline, bulbar signs, cerebellar signs (MSA)
- gaze palsy (PSP)
- lower body involved
- NO RESPONSE TO LDOPA
32
How does ldopa work? side effects?
- parkinson's
- precursor for dopamine
- side eff: nausea, vomitting, postural hypotension
- complication: motor fluctuations, dyskinesias
33
What is carbidopa?
decarboxylase inhibitor administered with ldopa
34
What are dopamine agonists?
directly stimulate Da receptors
- bypass nigrostriatal neurons
- monotherapy or adjunct with ldopa
- lower incidence of dyskinesia
- BUT problem with impulse control disorders, sleep attacks, orthostatic hypotension
35
What is amantadine?
- antiviral
- release more Da, act as Da agonist, inhibit NMDA receptors
- good for adjunct to ldopa to decrease dyskinesia
36
What are other drugs for PD?
COMT inhibitor - decrease alternative pathway for ldopa
| MAO-B inihibitor - decrease Da degradation
37
What is the ddx for dystonia?
```
INVITED MD
infection
neoplastic; tumour
vascular
inflammation
```
Degeneration: PD, PSP, MSA, CBD
Wilson's disease
etc
38
What is dystonia by distribution? what are causes?
Dystonia - location of muscle involved
- can be brought out by tasks: ex: writing, playing instrument
- idiopathic or genetic cuses
39
What is dystonia? How can it be overcomed?
involuntary sustained contraction of muscles - agonist and antagonist
- mobile, not fixed
- may be task/position specific when it comes out
- may have tremor
- have have athetosis
-change sensory input
40
What are causes of 2ry dystonia?
- parkisons, parkinson's plus
- huntington's
- wilson's
41
Describe Young onset dystonia. Tx?
-late teen onset
-limb first then body
-may be genetic: DYT1
>scoliosis, nerve entrapment, spinal stenosis
Tx: ldopa, deep brain stimulation
42
What are red flags for 2ry dystonia?
- abnormal birth, developmental delay
- drugs
- progressive symptoms
- major bulbar signs
- distribution not following age of onset
43
What is the workup for dystonia?
MRI
gene testing
if young nd gene negative: 24hr Cu, ceruloplasmin, ldopa trial
44
What is tourette syndrome?
- chronic motor and vocal tics
- inherited - young onset
- voluntary, conscious tic to escape unpleasnt feeling
- linked to excess dopamine
- complications are not the tics, but OCD, ADHD, behaviour issues
45
DDx for tics?
- Tourette's
- Down's
- Fragile X
- Autism
- Lesh Nyhan
- Caudate lesions: stroke, MS, hypoxic injury, tumours
46
What are red flags for 2ry tourettism?
- adult onset
- neuro signs
- progressive
- drug/illness induced
- abnormal brith/development
47
What are tx for tics?
- clonidine
- neuroleptics
- tetrabenzine
- desiprimine
- habit reversal therapy - retrain urge
- botulin toxin
48
What is the difference bt chorea and akathisia?
- both random additionl invol movements
- akathisia: internal feeling, can't sit still. doesn't know movement is happening
- ASK ABOUT FEELING
49
what is is Hungtington's Disease?
- slow saccades
- chorea (think japanese kibouki"
- gait issues
- tics
- paranoia, disinhibition
- genetic
- early onset - 30yrs
- can induce parkisonism, falls
Tx:
- supportive: social work, SLP, longterm care
- psych meds
50
What is myoclonus? 1ry vs 2ry?
brief, jerks
- activation/deact of muscle groups
- can be illicit voluntarily
- causes: sensorimotor cortex, caudal brainstem, reticulr formation, spinal, peripheral nerve
1ry: hypnic jerks, jerks during sleep, hiccups
2ry: INVITED MD - lots of things
51
Timeline of gross motor development.
- rostral>cadual
- proximal>distal
- invol> vol motor movements
1mon: chin up
2mon: chest up
15mon: walk
18mon: run, throw
3yr: bike
52
What is cerebral palsy?
- 2-3/1000
- syndrome of motor disorders
- movement/posture abnormality causing activity limitation
- brain abnormality but not progressive
53
Diagnosis of CP?
- clinical signs
- risk factors: hx
- delayed motor milestones
- primitive reflexes stay
- abnormal posture
54
Classification of CP?
1. Spastic - resistance to movements
2. Dyskinetic - invol movements
3. Ataxia
55
Describe spastic CP - what are the subtypes?
Resistance to movement. Velocity dependent.
1. Hemiplegia:
- caused by MCA ischemic stroke or periventricular venous infarction pre/perinatally
- arm > leg in MCA
- leg > arm in periventricular
2. Quadriplegia:
- bilateral, cortical/subcortical infarcts
- ex: bt ACA and MCA watershed
3. Diplegia:
ex: periventricular leukomalacia - white matter injury next to ventricles. oligodendrocytes vulnerable to injuries
- leg >arm
- learning is spared b/c grey matter not damaged
56
What are primitive reflexes. normal timelines?
Moro - drop baby back, arms abduct to midline: birth = 4mon
ATNR - fencing reflex: 2wk - 6 mon
Palmar grasp - birth - 3mon
Plantar grasp - birth - 8-15 mon
57
Timeline for fine motor development
1mon: hands fisted, palmar grasp
3mon: opening hands
5mon: grab things with palm
12mon: pincer grasp
15mon: stack blocks
3 yrs: draw circles, stack bridge
58
What are red flags for motor development?
- delays: no hand opening @ 3 mon, head control @ 4mon; no sitting @9min, no walking @ 18mon
- too early: hand dominance <3 mon
- primitive relflexes stay
- tone
59
What are perinatal risk factors of CP?
- early gestational age
- ischemic stroke
- hypoxia
- neonatal encephalopathy
- infection
60
What are prenatal risk factors of CP?
- mom: thyroid, vascular, htn, dm, epilepsy
- multiple gestation (twins)
- infection
- congenital abnomlities: too small/big
- placental abnomilities
61
What are postnatal risk factors of CP?
- infection
- injuries
- stroke
- hyperbilirubinemia
- metabolic issues
- don't know...
62
Audiograph indicating sensorimotor hearing loss?
Rt and Lt symmetrical, air and bone conduction same level. All decreasing slope because need higher intensity to hear at higher f.
Not in normal range
63
Audiograph for conductive hearing loss?
Bone and air conductance separated
64
Distinguish 4 types of hearing loss
Conductive loss: outer/middle ear affected
Sensorineural loss: cochlea, sense organs or CNVIII, damage hair cells
Cortical: higher than cochlear nuclei. rare b/c bilateral innervation
Mixed: conductive and sensorineural
65
What type of hearing loss does drugs cause? ex:
- ASA, loop diuretics, aminoglycoside antibiotics, anti-cancer
- sensoryneural
66
Distinguish 4 types of hearing loss
Conductive loss: outer/middle ear affected
Sensorineural loss: cochlea, sense organs or CNVIII
Cortical: higher than cochlear nuclei. rare b/c bilateral innervation
Mixed: conductive and sensorineural
67
What type of loss is ototoxic drugs?
sensorineural
68
What type of loss is ear infection? tympanic membrane perforation?
conductive
69
What type of loss is tumour?
sensorineural/cortical depends
70
What type of loss is stroke?
cortical
71
What type of loss is ear wax and noise damage
mixed
- ear wax: conductive
- noise damage: sensorineural
