Day 7 - Exam Questions Flashcards
List 3 Modifiable and 3 non-modifiable causes or risk factors for stroke.
MODIFIABLE
- HTN
- Heart Disease (AF)
- DM
- Smoking
- ETOH
- Carotid stenosis
- Hyperlipidemia
- Migraine
- Physical Activity
NONMODIFIABLE
- Age
- Sex
- Race
- Family History of Stroke
Circle of Willis
Describe Artery of Adamkiewics
Major lumbar radicular artery arising from aorta
Level of T10 to L3
Considered watershed area in spinal cord
List 6 Risk factors for DVT
- Immobility
- Obesity
- Pregnancy
- OCP
- Malignancy
- Trauma
- Surgery
- Coagulopathy
What are contraindications to intravenous tissue plasminogen activator?
List 3 anti-platelet with mechanism of action.
Aspirin: Non-selective and irreversibly inhibits both of CO-1 & COX-2
Clopidogrel (Plavix): inhibitor of ADP-induced platelet aggregation
Ticagrelor (Brilinta): Reversibly binds to the ADP P2Y12 receptor and prevents ADP from binding.
Mention the blood supply to the brain lobes 🔑🔑
- The middle cerebral artery (MCA) → lateral aspect of the hemisphere.
- The anterior cerebral artery (ACA) → medial aspect of the hemisphere
- The posterior cerebral artery (PCA) → posterior inferior surface of the temporal lobe
and the visual cortex.
67yo man with right sided third cranial nerve palsy, left hemiparesis. Name the location of the lesion.
Right Midbrain
Brain stem lesion = Ipsillateral CN + Contralateral Body
Midbrain CN 3-4 (Right)
Pons CN 5-8
Medulla 9-12
Weber syndrome vs Millard Gubler ( 5 Marks)
Brainstem lesion
Ipsilateral C.N. + Contralateral Body
Web (3 Letters)
Ipsilateral Oculomotor Palsy
Contralateral Hemiparesis
Millard (7 Letters) Gulber (6 Letters)
Ipsilateral Facial Palsy
Ipsilateral Abducent Palsy
Contralateral Hemiparesis
Name 6 lacunar stroke syndromes
- Pure motor hemiplegia
- Pure sensopry stroke
- Sensorimotor stroke
- Clumsy-hand dysarthria
- Ataxic hemiparesis
- Hemichorea-Hemiballismus
List 8 symptoms of Lateral medullary syndrome.
Ipsilateral side
- Horner’s syndrome (ptosis, anhidrosis, and miosis)
- Decrease in pain and temperature sensation on the ipsilateral face
- Cerebellar signs such as ataxia on ipsilateral extremities (patient falls to side of lesion)
Contralateral side
- Eyes → Nystagmus, diplopia
- Ears → Vertigo, nausea, and vomiting
- Mouth → Dysphagia, dysarthria, hoarseness, vocal cord paralysis
- Hiccups
- Decreased pain and temperature on contralateral body
Note: No facial or extremity muscle weakness seen in this syndrome.
Cuccurollo Chapter 1
List 3 symptoms of Medial medullary syndrome.
- Ipsilateral hypoglossal palsy (with deviation toward the side of the lesion)
- Contralateral hemiparesis
- Contralateral lemniscal sensory loss (proprioception and position sense)
59yo male with sudden quadraplegia, able to blink and move eye vertically. Dx and location.
59yo male with sudden quadraplegia, able to blink and move eye vertically. Dx and location.
Locked in syndrome → bilateral ventral pontine lesion.
List 8 sign and symptoms of brain stem lesions
Crossed symptoms = Ipsilateral C.N + contralateral body hemiparesis
- CN 3, 4, 6 → Diplopia, Gaze palsies, Nystagmus
- CN 5 → Numbness of face
- CN 7 → Horner’s syndrome, Tongue deviation and atrophy
- CN 8 → Vertigo, Nausea/vomiting, Incoordination, Gait imbalance, Hearing loss
- CN 9 & 12 → Hoarseness, Dysphagia, Dysarthria, Dysphonia, Tongue deviation
- Contralateral motor or sensory deficits in the body
What is prosopagnosia? localize the lesion.
Face blindness, patient cannot recognize people’s faces.
Lesion inferior occipital region, fusiform gyrus, and temporal cortex.
Posterior cerebral arteries (posterior cerebral circulation) affecting inferior occipital region and temporal cortex.
Mention 10 Predictor of Poor functional outcome after stroke.
Present Hx
- Coma at onset
- Large lesion
- Dense hemiplegia
- Delayed acute medical care
- Aphasia
- Old age
- Homonymous hemianopsia
- Visuospatial perceptual deficits
Functional Hx
- Delayed rehabilitation
- Low FIM on admission to rehab
- Inability to perform ADL
- Poor sitting balance
- Bowel incontinence
- Urinary incontinence
PMHx
- Prior stroke
- Medical comorbidity
PSHx
- Poor social support
- Unmarried
- Unemployed
- Cognitive deficits
- Depression
Mention 10 Predictor of Poor functional outcome after stroke.
Present Hx
- Coma at onset
- Large lesion
- Dense hemiplegia
- Delayed acute medical care
- Aphasia
- Old age
- Homonymous hemianopsia
- Visuospatial perceptual deficits
Functional Hx
- Delayed rehabilitation
- Low FIM on admission to rehab
- Inability to perform ADL
- Poor sitting balance
- Bowel incontinence
- Urinary incontinence
PMHx
- Prior stroke
- Medical comorbidity
PSHx
- Poor social support
- Unmarried
- Unemployed
- Cognitive deficits
- Depression
List 8 DDx for hemiplegic shoulder pain.
Muscle & Tendons
- Impingement syndrome
- Rotator cuff injury
- Bicipital tendonitis
- Myofascial pain
Joints
- Capsulitis
- Subluxation
- Soft tissue contracture
Nerves
- Spasticity
- CRPS type 1
- Suprascapular neuropathy
- Brachial plexopathy
- Axillary neuropathy
Braddom ,3rd edition, P1193, P1199
List 8 DDx for hemiplegic shoulder pain.
Muscle & Tendons
- Impingement syndrome
- Rotator cuff injury
- Bicipital tendonitis
- Myofascial pain
Joints
- Capsulitis
- Subluxation
- Soft tissue contracture
Nerves
- Spasticity
- CRPS type 1
- Suprascapular neuropathy
- Brachial plexopathy
- Axillary neuropathy
Braddom ,3rd edition, P1193, P1199
List 5 types of apraxia
LEft MCA “dominant”
- Ideomotor
- Ideational
- Speech
Right MCA “non-dominant”
- Constructional
- Dressing
ACA
- Gait
Mention 4 benefits of AFO in stroke patient.
- Prevent foot drop in swing phase
- Easy to negotiate stairs
- Reduce energy cost
- Increase walking speed
PMR Secrets
Six months post stroke, patient become emotionally liable. Which medication would like to start?
SSRI (Cipralex) 5-10mg
TCA (Amitriptyline) 10-25mg
Patient has a stoke with depression what is the first line management.
Selective serotonin reuptake inhibitors (SSRIs)
Escitalopram (Cipralex)
5-10mg up to 20mg once daily.
Serotonin–norepinephrine reuptake inhibitor (SNRI)
Duloxetine (Cymbalta)
Start at 30 mg once daily for 1 week, increasing to 60 mg once daily.
Tricyclic antidepressants (TCA)
Amitriptyline
Start 25-50 mg PO qHS initially; increase by 25 mg every 5-7 days to 100-200 mg/day
Hemiplegic patient is being evaluated for dysphagia. What would like to examine first? If patient have difficulty swallowing and require feeding tube, where would be the infarct be? What is the most common phase of dysphagia?
- Cognitive function
- Facial nerve (CN VII)
Infarction: Brain stem (medulla > pons)
Pharyngeal phase
3 weeks post stroke, patient left lower limb increased with DTR 3+ and flexor synergy. Which stage of Brunnstrom?
Stage 2
- Spasticity appears, and weak basic flexor and extensor synergies are present.
Define Spasticity & Modified Ashworth Scale
Spasticity
- A motor disorder
- Abnormal, velocity-dependent increase in the tonic stretch reflexes (muscle tone)
- Exaggerated phasic stretch reflexes (tendon jerks, clonus)
- Resulting from hyperexcitability of the stretch reflex.
- It is a component of the UMNS.
Modified Ashworth Scale:
0 No increase in tone
1 Slight increase in muscle tone, manifested by a catch and release or minimal resistance at the end of the ROM when the affected part(s) is moved in flexion and extension
1+ Slight increase in muscle tone, manifested by a catch, followed by minimal resistance throughout the remainder (less than half) of the ROM
2 More marked increase in muscle tone through most of the ROM, but affected part(s) easily moved
3 Considerable increase in muscle tone, passive movement difficult
4 Affected part(s) rigid in flexion or extension
List 5 management options for spasticity.
Prevention first (non-pharmacological)
- Remove factors or noxious stimuli that may increase spasticity (UTI, etc).
- Exercises: positioning, stretching/ROM.
- Bracing: splinting (static vs dynamic), Serial casting.
- Modalities: cold, electrical stim, FES
Treating second (pharmacological)
- oral medications → Baclofen
- focal treatments → BotoX
- intrathecal baclofen.
- surgical options (selective dorsal rhizotomy)..
Postural abnormalities in upper limb and where to inject. (Bonus Question)
Postural abnormalities in wrist and where to inject. (Bonus Question)
Postural abnormalities in hip & knee and where to inject. (Bonus Question)
Postural abnormalities in ankle and where to inject. (Bonus Question)
What is the mechanism of botulinum toxin? 1 Mark
Inhibition of acetylcholine release at the neuromuscular junction
List 6 reasons why you wouldn’t give Botox in this situation.🔑
- patient refusal
- interferes with functional goals (eg. Quads used for standing).
- contractures instead of spasticity.
- BoNT in last 3 months (risk of antibody formation).
- previous poor results from BoNT.
- adverse events or hypersensitivity.
- NMJ disorder (ALS, motor neuron disease, LEMS, MG).
- borderline breathing or swallowing dysfunction.
- contraindicated medications (eg. Aminoglycosides, spectinomycin).
- anticoagulants or bleeding diathesis
- Sensitivity to Botox
- Infection
How much Botox will you inject per muscle and per session? What is the effectiveness timeline of Botox? (Bonus Question)
- Usual dosage of onabotulinumtoxinA (Botox) is 25 to 200 units per muscle
- Initial safe dose for first treatment is likely 400 units total or 6 units per kg for an adult.
- Reinjections should occur after 3 months
“3 days for initial effect, 3 weeks for peak effect, and 3 months duration.”
Cuccurollo
List 4 side effects of Botox. (Bonus Question)
- Pain/soreness
- Nerve trauma
- Hematoma/bruising/local erythema or swelling
- Flu-like syndrome with headache, nausea, fatigue, general malaise
- Dysphagia may occur from cervical injection (short-lived)
Mention 4 drugs (different classes) treating spasticity and what is the maximum dose per day.
Clonidine (Catapres) Central acting alpha2-adrenergic agonist → 0.4 mg/day
Baclofen (Lioresal) GABAb receptors agonist → 80 mg/day
Diazepam (Valium) GABAa receptor agonist → 60 mg/day
Dantrolene sodium (Dantrium) blocking the release of Ca++ → 400 mg/day
Mention 4 drugs (different classes) treating spasticity and what is the maximum dose per day.
Clonidine (Catapres) Central acting alpha2-adrenergic agonist → 0.4 mg/day
Baclofen (Lioresal) GABAb receptors agonist → 80 mg/day
Diazepam (Valium) GABAa receptor agonist → 60 mg/day
Dantrolene sodium (Dantrium) blocking the release of Ca++ → 400 mg/day
List 4 conditions for which botulinum toxin could be used other than spasticity.
- Chronic migraine headache prophylaxis
- Blepharospasm
- Strabismus
- Primary axillary hyperhydrosis
- Cervical dystonia
- Detrusor overactivity
List 10 side effects of baclofen.
- Brain : Depression - Confusion - Headache - Hallucinations
- Cerebellum : Coordination disorder - Tremor - Ataxia - Nystagmus
- Basal Ganglia : Dystonia
- Brainstem : Blurred vision - Slurred speech - Tinnitus - Diplopia - Dysarthria
- Cardiorespiratory : Hypotension - Dyspnea - Palpitation - Chest pain - Syncope.
- Gastrointestinal : Nausea - Constipation
- Genitourinary: Urinary retention - Inability to ejaculate
List 4 signs of abrupt drug withdrawal of baclofen
- seizures.
- rebound spasticity.
- fever.
- hallucinations.
- altered mental status.
- malignant hyperthermia.
- death.
- tachycardia.
- restlessness.
List 10 surgical operations for treatment of spasticity.
Tendon: Release, Transfer, Lengthening
Muscle: Myotomy
Nerve: Peripheral neurectomy → Cordectomy → Dorsal Rhizotomy → Myelotomy
Devices: ITB Pump, Deep brain stimulator
List 4 positive and 4 negative of UMN syndrome.🔑
POSITIVE SIGNS
- Spasticity
- Rigidity
- Spastic dystonia
- Hyperreflexia
- Clonus
- Persistence or re-appearance of primitive reflexes (e.g., positive Babinski response)
NEGATIVE SIGNS:
- Muscle weakness
- Paralysis/paresis
- Muscle atrophy/wasting
- Decreased dexterity
- Loss of voluntary movement
- Loss of coordination
- Fatigue
Counsel a mother on how to prevent spasticity. (Bonus Question)
Prevention first (non-pharmacological)
- Remove factors or noxious stimuli that may increase spasticity (UTI, etc).
- Exercises: positioning, stretching/ROM.
- Bracing: splinting (static vs dynamic), Serial casting.
- Modalities: cold, electrical stim, FES
Treating second (pharmacological)
- oral medications → Baclofen
- focal treatments → BotoX
- intrathecal baclofen.
- surgical options (selective dorsal rhizotomy)..
List 4 triggers of spasticity.
List 4 positive and negative effects of spasticity (Bonus Question)
List 4 reasons for poor outcome of Botox (Bonus Question)
- Inactive medication
- Incorrect dose
- Incorrect diagnosis
- Incorrect muscle selection
- Unrealistic goals
- Disease condition
Braddom
Conduction aphasia - location of the lesion
Wernicke aphasia - location and characteristics.
Wernicke aphasia - location and characteristics.
Broca’s aphasia - location and characteristics.
2-months history of expressive aphasia. No weakness but with memory and cognitive problem. Word finding difficulty. Parietal lobe is normal.
Anomic Aphasia
Palilalia vs Echolalia
Involuntary repetition of own word or phrases with increased speed and decreased volume.
Echolalia is the repetition of words spoken by others.
Phases of swallowing, problem seen with each phase & most important one 🔑Oral Preparatory Phase → Drooling and pocketing
- Oral Preparatory Phase → Drooling and pocketing
- Oral Propulsive Phase → Drooling and pocketing
- Pharyngeal Phase → Aspiration
- Esophageal Phase → heartburn and food sticking
Mention 3 methods to assess swallowing
- Bedside swallowing evaluation
- Videofluorographic swallowing evaluation (VFSS) / modified barium swallow (MBS)
- Fiberoptic endoscopic evaluation of swallowing (FEES)
Predictors of aspiration on “bedside swallowing exam”
- Abnormal gag reflex
- Cough after swallow
- Dysphonia
- Voice change after swallow (wet voice)
Cuccurollo
Risk factors for development of aspiration pneumonia. (Bonus)
Think of bed ridden patient on multi devices and tissue under his chin:
- Decreased level of consciousness
- Tracheostomy
- Emesis
- Reflux
- Nasogastric tube (NGT) feeding
- Dysphagia
Cuccurollo
List 6 Compensatory Strategies.
- Chin tuck
- Chin up
- Head rotation
- Head tilt
- Supraglottic swallow
- Super supraglottic swallow
- Mendelsohn maneuver
Dysphagia. 3 structural causes? 3 peripheral nervous system causes? 3 myopathic?
PNS
- MS
- GBS
- Polio
- ALS
- Parkinson
Myopathic
- Dermatomyositis
- Polymyositis
- MG
Structural Causes
- Tumors
- Congenital malformation
- Cervical Web
