Final Flashcards
are ppl who had TBI more at risk for later cognitive decline?
yes
Sequele Post TBI
Prolonged Post Concussion Syndrome chronic, traumatic encephalopathy- Child abuse: blow to the head Clown shot out of a cannon Personality changes--due to frontal lode Boxer's get PD induced by trauma maybe
Deceleration injury
body moves and rapidly stops
hit FRONTAL LOBE then OCCIPITAL LOBE
multiple site injury: coup contracoup
brain hits front of skull and bounce back and hits back of skull
if there are rotational forces get multiple sites of injury
Whiplash
hit from behind
first hit OCCIPITAL LOBE then hit FRONTAL LOBE
(rule out cervical spine involvement)
Boxing Injury
punched from in front
First hit FRONTAL LOBE then hit OCCIPITAL LOBE
Contusion
**can result in hemorrhage : need to do imaging if there is a bleed can go into a coma from the pressure of blood in brain, need to be observed closely
anatomical structural injury
can be associated with coup and contracoup mechanism of injury
can be severe and extensive
can be mild with just edema and resolve 2-4 days
Sequela to TBI
problems can vary in severity
- anterograde amnesia: amnesia prior to incident will be more common
- retrograde amnesia is more severe: not learning new information
- loss of mental flexibility -more rigid in thinking
- attention and concentration deficits : short attention, impair learning
- rate of new learning impaired
- HIGHER LEVEL THINKING IMPAIRED: problem solving impaired
- Can return to work and social interaction impaired in 50% of severe TBI patients–higher level tasks are difficult
- -FRONTAL LOBE DEFICITS: behavioral issues
Meningitis
signs and sx
CNS infection
caused by bacterial or viral infection of pia and arachnoid
–better to have bacterial for treatment
MEDICAL EMERGENCY: can die
-
signs and sx*
1. headache
2. fever
3. confusion
4. stiff neck
5. sensory changes
6. red spotting on skin, especially extremities (6-12 hours)
Acute Meningitis
if acute: THIS IS AN EMERGENCY: all structures bathed by CSF is exposed to infection –> GO TO THE EMERGENCY ROOM
-college setting common (often give vaccine)
there are flu symptoms, red spots on skin, especially extremities
antibodies build up and lead to severe vascular changes in extremities: ie gangrene
bacterial: take antibiotics (within 6-12 hours)
viral: some medications
Flu symptoms with red spots on skin
GO TO THE EMERGENCY ROOM
SEVERE MENINGITIS
Chronic Meningitis
less severe than acute, pick up what it is: if bacterial use antibiotic, if viral treat the symptoms
slow progression of sx–blood born bacteria
dx: lumbar puncture and CSF analysis and blood cultures
Bacterial causes:
1) CNS trauma or surgery (especially if skull fracture)
2) ear infection
3) Lyme disease
4) HIV
Regional Meninitis
if someone gets flu sx ask if traveled recently
Etiology of sx in Meningitis
response to infection is increase CSF production with obstruction of BF
Results in cerebral edema, inflammation of blood vessels
Can cause hydrocephalus (increased fluid)
MR
CNS involvement
motor deficits and seizures
Encephalitis
brain inflamed–> they need to see the doctor
Can be bacterial or viral, meninges are affected
Sx
1) impaired consciousness, confusion
2) Fever, headache, seizures, weakness
3) Any CNS signs +/or CNS involvement
What causes encephalitits?
- Mumps
- Regional Virus
- Bacteria
Can get proressive neuroloical decline after
- Herpes Simplex Encephalitis: (herpes simplex virus gets into the CNS) headache, personality changes seizures
- St. Louis Encephelitis
- West Nile encephalitis
- Post Infectious Encephalitis: ie had chicken pox/ measles / mumps / german measles / flu
Lyme Disease
cause
Initial Signs (3)
Secondary Signs
Third-Neurological Symptoms (3)
caused by tick bites from mice, deer ticks
**CAN GET PNS AND CNS INVOLVEMENT FROM IT
Initial signs:
1) large circular lesion
2) red rash
3) flu like symptoms
Secondary Signs
1) Arthritis in 2/3 of untreated patients
* *need to be treated to not get this**
Third: Neuro Sx
1) Plexitis (plexopathy, can happen to both plexus)
2) Bell’s Palsy
3) Cardiac Arrhythmia’s
Dx: bloodwork
Tx: Antibiotics early
HIV/AIDS
what it does
sx (6)
sx if untreated
Destroys myelin in CNS (can also have PNS involvement)
-early sx like MS: weakness, sensory disturbances, demyelinating neuropathies, like Meningitis (not AIDS, but a variety of opportunist organisms)
If untreated late onset of symptoms:
- AIDS dementia
- PERIPHERAL neuropathy
- Myopathies
- Cerebrovascular complications
- Seizures
- Encephalopathies (diffuse brain disease)
Toxic and Metabolic
alcohol
Alcohol: CNS depressor: chronic use can cause CNS and PNS involvement
–overdose can cause tremor, respiratory failure, coma, hallucination, ataxia
Etiology:
- Vitamin B (thiamine) needed to synthesize high levels of alcohol
- Causes deficiency: in thiamine and other B vitamins needed for nerve function
Wernicke Korsakof Syndrome
BC deficient in vitamin B
1) eye movement disorders, nystamus
2) ataxic gait
3) mental status changes: quiet confusion, perceptual disorders, selective memory loss
4) inability to learn new information. Short term memory very impaired. Lon term memory is better.
Toxic Metabolic disorders
Alcohol is CNS depressant and chronic use cause CNS/PNS involve
Wernicke Korsakoff Syndrome–deficient in vitamin B
Polyneuropathy–sensory and motor demyelination and or degeneration
Optic Neuropathy
Cerebellar Ataxias
Concussion –when go back to activity
make sure no residual sins before go back to activity
Hepatic encephalopathy
lead to acute hepatic coma
acute hepatic failure–failure to detoxify metabolites, which have strong effect on many cerebral metabolic processes
–PNS and CNS (bc not able to break down the toxins)
-usually due to dialysis
Heavy Metals
- lead, mercury, arsenic
- all areas of CNS can be affected (where heavy metals collect)
- can result in optic atrophy, mental retardation, learning disabilities
Depression vs Dementia vs Delirium
Depression: mood disorder–depressed mood and low E
Dementia: global decline intellectual function that cant tx with a medication
Delirium: REVERSIBLE, disturbance of consciousness and cognition due to metabolic, infectious, or toxic factors (including medication)
Depression
at least 2 week period of depressed mood or loss of interest in normal activities
+ 4 other related sx
1) change appetite +/or sleep, fatigue
2) psychomotor agitation or retardation
3) worthless of guilt feelings
4) suicide thouhts
5) cognitive disturbances –difficult to concentrate and/or impaired memory , may seem confused
subacute or gradual onset (depend on cause)
Improve in cognitive sx with tx*
How does Dementia present clinically
Dementia clinically presents as a progressive decline in intellectual and cognitive function
—Occurs in 5-10% of people above 65 years
What is the most common form of Dementia
AD is the most common cause of dementia among people 65 and older
Estimates indicate 4.5 million people have AD and rates increase with increasing age
Does dementia have to progress to AD?
Dementia, a loss of intellectual capacity and memory can be nonprogressive and without progressing to AD
5 Signs of Dementia
1) Getting lost when walking
2) Cant fill out checks or balance check books
3) Forget common names, things to do
4) Cannot find bathroom-“incontinent”—deemed incontinent because they couldn’t remember where the bathroom is and had an accident
5) Blank stare –truly blank secondary to loss of associated areas: they are not visually processing with the higher cortical function association area (first memory in temporal lobe but then other areas are affected too)
Presentation and Progression of Dementia
1) Memory loss/difficulty with complicated intellectual function.
* Especially short term memory loss (temporal lobe is the area first involved)
2) Later presents with increased general confusion and speech deficits. Progress to severe difficulty in reading, writing, following directions and engaging in simple conversations.
3) Motor function decline is usually at the end stage of Alzheimers disease. Motor function decline does NOT occur with dementia. (motor units the last involved, closely monitor AD patient because they may wander and don’t remember who they are and how to get back)
Does motor function decline with dementia?
NO
Motor function decline is usually at the end stage of Alzheimers disease. Motor function decline does NOT occur with dementia. (motor units the last involved, closely monitor AD patient because they may wander and don’t remember who they are and how to get back)
Assessment of Dementia: Mini Mental State Exam
–Is patient A&O x 3? (person, place and time)
–Can patient count by 3, 7’s backwards?
–Can patient follow 2 step commands?
–Can patient remember 4 objects?
First tell them that you will have them remember it so they notice it first
Functional Assessment Staging Tool: FAST
Stage 1: no functional loss
Stage 2: subjective loss ie world difficulties only
Stage 3: impairment in demanding situations ie employment
Stage 4: mild AD: ie difficulty with everyday tasks
Stage 5: moderate AD: requires prompting/assistance with ADL
Stage 6: moderate AD: requires prompting/assistance with ADL
Stage 7: ie incontinence, difficulty walking, unable to speak, smile, and swallow
Why do you need to do a CAT scan on a patient with dementia?
to rule out a TREATABLE cause of the cognitive or intellectual decline
—Stroke, tumor, something pathological that is treatable
—Cerebral atrophy also occurs in healthy elderly
—Help to rule out tumor, CVA
—Enlarged cortical sulci
—Enlarged ventricles (ie CSF, atrophy, it is abnormal can be different causes)
—Neuronal loss in association areas (cell loss indicates pathalogy)
—Better to do a clinical assessment for diagnosis, CAT scan is used for ruling out
When a patient has dementia, what do we need to assess for?
1) Stroke, tumor, something pathological that is treatable
2) Cerebral atrophy occurs in healthy elderly
3) Tumor, CVA etiologies
4) Enlarged cortical sulci
5) Enlarged ventricles
(ie CSF, atrophy, it is abnormal can be different causes)
6) Neuronal loss in association areas
(cell loss indicates pathalogy)
7) Better to do a clinical assessment for diagnosis, CAT scan is used for ruling out
What are causes of Dementia (5)
1) AD accounts for 65% of dementia.
2) Dementia is related to TBI
BUT: AD is not related to TBI
3) Dementia is not part of normal aging being accelerated, incidence
- -INCREASE between 65-80
- -DECREASE in ppl over 90
4) Incidence: FEMALES more than males
5) LOW EDUCATION reveals higher incidence compared to someone with a college education
Is AD related to TBI?
Dementia is related to TBI
BUT AD is not related to TBI
What pathologies can cause Dementia?
1) MULTI-INFARCT dementia:
presents with a segmental decline in intellectual ability with each new lesion: lacunar strokes –do a CT scan
2) Chronic infectious processes:
hypoglycemia, AIDs
3) can develop in later stages of PD
4) dementia with LEWY BODIES:
PD like presentation with early onset of dementia
5) NEUROTOXIC AGENTS:
heavy metals, aluminum, drugs
6) ACUTE ONSET:
reversible (cardiac arrhythmia, post anesthesia-temporary, depression-can present
like dementia)
Can acute onset dementia
be reversed?
YES
cardiac arrhythmia
post anesthesia-temporary,
depression-can present
like dementia
Normal pressure hydrocephalus
- mechanism
- cause
1) due to blockage of CSF flow, ventricles enlarge and produce CNS decline.
2) Due to TBI, meningitis, hemorrhage.
–>restriction in flow of CSF and uptake of CSF, if in a kid, skull enlarges and not increase pressure. If fused skull the ventricles enlarge more and more. Spinal tap and measure pressure considered normal, they are increasing ventricle size, brain is declining in size.
***SURGICAL PLACEMENT OF SHUNT
Normal pressure hydrocephalus
presentation
diff dx
PRESENTATION
1) Gait apraxia as 1st sign, initiation severely affected
2) Dementia
3) Incontinance
4) Possible LE spasticity (wont see this in PD)
DIFFERENTIAL DIAGNOSIS
- fast onset
- no tremor
- no rigidity
- Lumbar puncture→normal CSF pressure!!
***SURGICAL PLACEMENT OF SHUNT
–>restriction flow/uptake CSF,
if kid, skull enlarges not increase pressure.
If fused skull ventricles enlarge more and more.
Spinal tap and measure pressure considered normal, they are increasing ventricle size
BRAIN IS DECLINING IN SIZE
Which is most to least common form of Dementia
AD, Mixed vascular AD, vascular ADm others
AD–> Mixed vascular AD –> Vascular Dementia –> other types
Gait apraxia is the first sign of what condition?
Normal pressure hydrocephalus
How is Normal pressure hydrocephalus treated?
Surgical placement of shunt
5 frequent sx when patient dx with AD?
1) Apathetic Syndrome:
s unique syndrome
Was the most frequent
2) Affective Syndrome: there will be anxiety and depression—will see one, will see the other: very agitated vs quiet and withdrawn
3) Psychomotor: agitation, irritability and aberrant motor behavior: they need good structure and consistency because they cannot deal with the change of anything being different, there is consistent staffing, consistent schedule,
4) Psychotic: delusions and hallucinations
5) Manic: dis-inhibition and euphoria
Preclinical AD:
Where first signs of AD are noticed
Signs of AD are first noticed in the
1) ENTORHINAL CORTEX, –> then proceed to the
2) HIPPOCAMPUS –>Hippocampus and then
3) TEMPORAL LOBE
These changes before see symptoms
Affected regions begin to shrink as nerve cells die
Changes can begin 10-20 years before symptoms appear
How long does it take after brain changes for sx to appear?
Changes can begin 10-20 years before symptoms appear
brain changes before see symptoms
Affected regions begin to shrink as nerve cells die
Mild to moderate AD:
AD spreads through the brain. The CEREBRAL CORTEX begins to shrink as more and more neurons stop working and die
1) Mild AD signs: can include memory loss, confusion, trouble handling money, poor judgment, mood changes and increased anxiety
2) Moderate AD signs: can include increased memory loss and confusion, problems recognizing people, difficulty with language and thoughts, restlessness, agitation, wandering, and repetitive statements
3) In severe AD, extreme shrinkage occurs in the brain. Patients are completely dependent on others for care
4) If bed-bound they are susceptible to skin breakdown, contractures, often go into fetal position
–Symptoms can include weight loss, seizures, skin infections, groaning, moaning, grunting, increased sleeping, loss of bladder and bowel control
5) Death usually occurs from aspiration pneumonia or other infections
- –Caregivers can turn to a hospice for help and palliative care
What causes:
AD spreads through the brain. The CEREBRAL CORTEX begins to shrink as more and more neurons stop working and die
higher cortical function involvement, decline in function, some degree of cell death leads to this: difficulty in understanding and in memory. Some frontal lobe: restlessness, how they interact with people
Mild AD signs
Mild AD signs: can include
memory loss
confusion
trouble handling money
poor judgment
mood changes
increased anxiety
