CNS Pathology Flashcards
What are the goals for pts with brain tumors?
Goals are quality of life and to return home; Centered around functional limitations but allowing for changes in patient status
- limited survival
What are the most common primary brain tumors (40-45%)?
Gliomas:
- Astrocytoma (4 grades) – includes glioblastoma (worst)
- Oligodendroglioma
- Ependymoma
What are the types of brain tumor?
- Glioma
- Meningioma
- Medulloblastoma
- Metastatic brain tumor (can be primary or secondary)
What are the signs and symptoms of a brain tumor?
- Headache
- Visual changes*
- Nausea/vomiting
- Lethargy
- Seizures*
- Syncope
- Weakness*
- Cognitive changes*
- Behavioral changes
What are the behavioral changes seen with a brain tumor?
- Irritability
- Flat affect
- Emotional lability
- Lack of initiative
What are symptoms of a brain tumor headache?
- Unilateral or focal followed by generalized
- Pain described as dull, aching, throbbing
- Interrupts sleep or is worse upon awakening
- Elicited by postural changes (especially lying down*), coughing, or sneezing
- Associated with nausea/vomiting or focal neurological signs
- Recent onset - different than usual headaches
- Become more frequent and severe over time
What is the key to differentiate between a CVA and TIA?
TIA (transient ischemic attack aka mini stroke) symptoms resolve completely within 24 hours
What are the types of stroke?
- Ischemic - blood clots and blocks blood flow - embolus (traveled to stroke area) and thrombus (stays where it strokes)
- Hemorrhagic - Intracerebral (within cerebrum) and Subarachnoid (in subarachnoid space)
What is the most common artery to have stroke?
Middle cerebral artery
The following are all risk factors for:
- Age over 65
- Men > women
- Hypertension
- High cholesterol
- Adult onset diabetes (type II)
- Cigarette smoking
- Heavy consumption of alcohol/drugs
- Obesity
Stroke
Velocity dependent increase in muscle tone; Resistance to stretch/passive movement
spasticity
- passive movement increases spasticity as speed increases
What causes spasticity?
injury to descending motor tracts producing hyperactive stretch reflexes (UMN loss)
What are the clinical findings in stroke patients?
- Depends on location
- Sensory, motor, and cognitive dysfunction
- Initial flaccidity then spasticity
- Difficulties with communication (Aphasia – receptive, expressive, global)
- Negative, anxious, depressed, slower, cautious, uncertain, insecure
- More realistic about their problems, very aware of impairments
are behavioral differences seen in patients with stroke involvement of the ____ side of the brain
Left (left hemiparesis)
- patients are fearful and need to be pushed by PTs to do more
- Unilateral neglect - completely ignoring/ not paying attention to affected side of the body and environment
- Indifferent, quick, impulsive, euphoric, poor judgment
- Overestimate their abilities, often unaware of impairments
are behavioral differences seen in patients with stroke involvement of the ____ side of the brain
Right (right hemiparesis)
What is the main issue for patients with a right sided injury of the brain?
safety
What behaviors are affected during stroke that occur with either side?
- Short attention span
- Emotional lability
- Irritability, confusion, restlessness
- Psychosis, delusions, or hallucinations
What age groups are most likely to have a TBI?
- 0-4 = big falls, shaken baby syndrome
- 15-24 = motor vehicle accidents
- 65+ = falls
- incidence greater in males in all age groups
Why are TBIs the most difficult to treat?
Behavioral difficulties make it challenging
What are primary issues with head trauma?
- Skull fractures
- Contusions of gray matter
- Diffuse white matter damage
What are the secondary issues with head trauma?
- Anoxia
- Ischemia
- Swelling/Increased intracranial pressure (ICP)
- Hematoma
What is an open head injury? closed head injury?
Open: Penetrating injury, Dura compromised
Closed: Nonpenetrating injury, Dura uncompromised
Tear in the meningeal artery between skull and dura; Fast bleed, and will show up right away; Usually from a focused blow to the head
Acute epidural hematoma
Venous rupture between dura and the arachnoid; Slower bleed, but continues to bleed over time; High mortality rate
Acute subdural hematoma
What are the types of hematoma?
- Acute epidural hematoma
- Acute subdural hematoma
- these are emergencies; surgery is typically needed
What is used to prognose the severity and duration of a coma from a head injury?
Glasgow coma scale
What is used to score a glasgow coma scale? what do the scores indicate?
EVM: - Eye opening - Verbal response - Best motor response (in upper limbs) Scores: - 3-8 = Severe head injury (coma, poor prognosis) - 9-12 = Moderate head injury - 13-15 = mild head injury
What is used to prognose the cognitive and behavioral changes from a head injury?
Rancho Los Amigos Scale for cognitive functioning
Chronic inflammatory demyelinating [autoimmune] disease of the CNS white matter in the cerebrum, cerebellum, brainstem, and spinal cord; Severing of axons in acute plaques; Results in conduction block and loss of function; Multifocal disease
Multiple Sclerosis
- nerves fatigue quickly due to demyelination
- one of the most common debilitating neurological diseases of YOUNG people
- Caucasians, Females (2-3:1), Young adults
- possibly trigger by virus or infection, linked to genes, linked to environment (geographical pattern)
What are the types of MS? what is the most common?
- Relapsing Remitting – most common (85%); symptoms almost completely resolve after an attack (pts often become secondary progressive after many years)
- Secondary Progressive
- Primary Progressive (worst prognosis)
- Progressive Relapsing
What are clinical characteristics of MS?
- Motor - Paresis, spasticity, fatigue, impaired balance and gait
- Sensory
- Paresthesias, numbness (one of the first symptoms
- Pain
- Vision (most often first symptom)
- Speech (dysarthria) and Swallowing (dysphagia)
- Cognitive
- Depression
- Bladder, Bowel, and Sexual Dysfunction
How is MS diagnosed?
Made by a neurologist Based on: - History (family, geographical) - Clinical findings - Clinical tests - MRI, CT – 2 or more distinct lesions - CSF – elevated immunoglobulin - Evoked potentials – slowed or abnormal conduction
Disease that affects the basal ganglia; Very common neurodegenerative disorder; 2% of the population older than 65; Incidence increases dramatically with age; Average age of onset is 60 years; Occurs 1.5 times more frequently in men
Parkinson’s disease
What is the pathophysiology of parkinson’s disease?
Cells in the substantia nigra stop producing dopamine
- Brain doesn’t receive messages about how and when to move
What is the role of basal ganglia?
- Planning and programming of movement
- Willed movements, muscle tone, and muscle force
- Cognitive processes – awareness of body in space, ability to adapt behavior, and motivation
What are the 4 cardinal features of parkinson’s disease?
- Rigidity
- Bradykinesia - slowness and difficulty continuing movement (along with akinesia freezing episode)
- Tremor - resting; disappears with sleep and dissipates voluntary movement (pill-rolling)
- Postural instability - narrow base of support, stooped posture; frequent falls
What are the atypical gait patterns seen in parkinson’s
- Reduced stride length
- Reduced speed
- Shuffling steps
- Insufficient heel strike
- Reduced trunk rotation
- Decreased arm swing
- Festinating gait (small quick steps)
- Freezing of gait
- Difficulty turning
- Difficulty with dual tasking (micrographia,
Where are the most common sites of spinal cord injury?
C5-C7;
T12-L2
- transitional vertebrae give up stability for increased mobility
What is the percentage of men to women with SCI? what is the percentage of SCIs are traumatic
Male = 80%
female = 20%
- 90% traumatic (10% non traumatic)
When documenting neurological level of a SCI, you document sensory level and motor level, on each side. Where would you document those levels? How do you classify it into a single neurological level?
Sensory level = last normal dermatome
Motor level = last normal myotome with a 3/5
- lowest segment where motor and sensory function is normal on both sides
Where is the injury if it follows a dermatome/ myotome pattern? where is the injury if it follows a body region? where is the injury if it follows a nerve distribution?
SC or nerve root;
Stroke;
Peripheral nerve
What are the types of incomplete SCIs?
- Brown-sequard syndrome (hemisection) - usually caused by violence
- Anterior cord syndrome - hyeperflexion injury (fall or diving)
- Central cord syndrome - hyperextension injury, edema/hemorrage around the cord squeezes in (sever spinal stenosis)
- Cauda equina
Pathological autonomic reflex occurring in SCI in lesions above T6 (but can be as low as T8); A sudden increase in blood pressure in response to a noxious stimuli (most commonly precipitated by bladder distension); No vasodilation below the level of the lesion so above the level of lesion BP gets very high
Autonomic dysreflexia
- rate of this is higher right after SCI occurs
What are the symptoms of autonomic dysreflexia?
- Hypertension
- Bradycardia - vagus nerve is trying to bring HR down to lower BP
- Severe, pounding headache
- Increased spasticity
- Flushing and sweating above the level of lesion
What should you do in case of autonomic dysreflexia?
- MEDICAL EMERGENCY
1. SIT PATIENT UP!!!
2. Check catheter and other irritants
3. If symptoms don’t subside get help
Upper AND Lower Motor Neuron Disease:
LMN – anterior horn cells of spinal cord
UMN - degeneration of corticospinal tracts, neurons in motor cortex and brainstem
Amyotrophic Lateral Sclerosis (ALS)
AKA Lou Gehrig’s Disease
- death in 2-5 years
What are the S and S of ALS?
- Relentlessly progressive** (quickly) asymmetrical weakness leading to muscle atrophy/wasting
- Hyperreflexia and spasticity
- Fasciculations
- Eventual respiratory failure
- EMG findings - decrease in muscle electrical activity
Involuntary movement disorder; Results in twisting/writhing repetitive movements and abnormal postures; Increased muscle tone; Thought to be caused by altered nerve cell communication in several regions of the brain commonly the basal ganglia; Common symptoms are pain and fatigue due to the constant muscle contractions
Dystonia
Hereditary disease that causes progressive degeneration of nerve cells in the brain; Results in movement, cognitive, and psychiatric impairments (impulsive, inflexible, inappropriate behavior; depression); Common symptoms – dystonia (see previous slide), impaired gait and balance
Huntington’s Disease
Avg age = 30-50
Progressive dementia characterized by slow decline in memory, thinking and reasoning, making judgments and decisions, planning and performing familiar tasks, and hanges in personality and behavior; Most common form of dementia; Nonreversible; 20% of people over 85, 5% of people over 65; Higher incidence in women
Alzheimer’s disease
- see plaques and tangles
Collection of protein on the outside of brain cells
Plaques
Protein twists into abnormal tangles inside brain cells
Tangles
