neuro Flashcards
1
Q
key motor tests
A
Drift of upper extremity (and lower if necessary)
o Have pt. close eyes and hold arms horizontally forward, palm up for
15-30 sec
o If +, hand will drop and rotate in***
*often combined with rhomberg balance test
Hand grasp and toe dorsiflexion
o Weakness is commonly seen in upper motor neuron lesion
o Cross hands, have pt. grasp index and middle fingers
o Move toe and foot against resistance
2
Q
Coordination, stance and gait tests
A
- Finger-to-nose and Heel-to-shin
o Cerebellar lesions: awkwardness of movement - Rapid alternating movements
o Slowness may results from cerebellar lesion,
3
Q
Balance tests
A
- Tandem gait (walk heel to toe) 2. Rhomberg
o We all need 2 out of the following 3 senses to maintain balance • Vision
• Vestibular sense
• Proprioception
o (+) test”pt sways when eyes are closed
• either vestibular or proprioceptive defect
o If pt. sways when eyes are open this is not a positive test and
therefore suspect a cerebellar lesion
4
Q
ROS HEENT
A
- Headache?
- Visual changes?
- dizziness
5
Q
ROS neuro
A
- Tremor?
- Weakness or sensory loss?
- LOC?
- Motordysfunction
6
Q
Mental status FOGS
A
- FamilyStoryofMemoryLoss
- Orientation
o To precise time (month, day, year) - GeneralInformation
o e.g. Who are the president and vice president of the U.S.? 4. Spelling
7
Q
Sensory Testing
A
Pain: Sharp and dull testing Proprioception, stereogenesis, vibration 1. With pts. eyes closed, bend big toe up and down and then test vibration with tuning fork o Decreased proprioception in MS Light touch
8
Q
ReflexTesting
A
- Triceps
- Biceps
- Knee Jerk
- Ankle Jerk
- Babinski
o + (abnormal dorsiflexion of the great toe and fanning of the other toes)” UMN lesion
Normal responses are symmetrical
Asymmetryisgenerallymorereflectiveofpathology
9
Q
Tests for meningeal irritation (r/o meningitis or subarachnoid hemorrhage)
A
- Kernig
o (+)”pain in low back on straightened lower extremity) - Brudzinski
o (+) “ flexion of the head results in marked neck pain and
involuntary flexion of the hip and lower extremities
10
Q
neuro Basic Labs
A
a. CBC
b. CMP
c. TSH
d. Bedside glucose***
consider:
Celiac (anti-gluten Abs, TTG)
Heavy metal testing (whole blood, hair analysis, urine with and without provocation)
Environmental testing for solvents, pesticides, etc
11
Q
Imaging and further studies
A
a. Lumbar Puncture*
b. CT*
c. MRI***
d. MRA
e. MRV
f. Echoencephalography
g. Cerebral Catheter angiography
h. Duplex Doppler Ultrasonography
etc. ..
12
Q
Cerebrovascular Accident (Stroke)
A
Definition: sudden interruption of cerebral blood flow that results in neurologic deficit
i. Causes brain damage
ii. mc cause of neuro disability, 3rd mc cause of death
13
Q
if anterior brain blood supply affected by stroke
A
(2/3 of the brain)
- Internal Carotid
- Strokes involving this blood supply to the brain typically have unilateral sxs
14
Q
if Posterior Supply affected by stroke
A
(posterior portion of temporal and parietal lobes, brainstem, and cerebellum)
- Vertebrobasilar
- Strokes involving this blood supply to the brain can have unilateral or bilateral sxs and is more likely to affect consciousness
15
Q
stroke Risk Factors
A
i. Prior stroke
ii. Older age
iii. family hx
alcohol, male, HTN, cigarettes, cholesterol?, DM…
16
Q
S/SX of stroke
A
Sudden!
i. Numbness,weakness or paralysis of the contralateral limbs, face
ii. Aphasia
iii. Confusion
iv. Visual disturbances in one or both eyes
v. Dizziness or loss of balance and coordination
vi. Headache
17
Q
ischemic stroke
A
80%
1. Thrombosis–sites of turbulent flow, branching
MC• Atherosclerotic plaques
LC vascular inflamm dt infection, hypercoagulable state
2.Emboli
MC: cardiac–atrital fib, post MI, prosthetic valves, etc
LC: fat emboli, air, venus clots thru patent foramen ovale
- Lacunar (small vessel dz)
DM, poorly controled HTN
4. TIA (Transient Ischemic Attack) internal carotid artery dz sx < 1 hr st precede stroke onset by days/months often no brain damave
18
Q
ssx embolic stroke
A
o Quicker onset of neurologic deficit: minutes
o Often during the day
o Headache may precede neurologic deficit
19
Q
ssx thrombotic stroke
A
o Tend to occur during the night and are noticed upon first waking
o May have slower onset of sxs: over 24-48hrs (aka “evolving stroke” or “stroke in evolution”)
• Evolving stroke: Unilateral neurologic dysfunction often
beginning in one arm and then spreading ipsilaterally
• Extends without headache, pain or fever
20
Q
ssx lacunar stroke
A
o Pure motor hemiparesis
o Pure sensory hemianesthesia
o Ataxic hemiparesis
21
Q
dx imaging
A
o CT
• Done first to exclude intracerebral hemorrhage
o MRI
• Generally done 2nd; many smaller infarcts may only be found with MRI
22
Q
stroke ddx
A
- Hypoglycemia
- Postictal paralysis
- Hemorrhagic stroke
- Migraine
- Tumor
- Systemic condition: Guillian Barre, Bell’s Palsy
- syncope
23
Q
Intracerebral Hemorrhage
A
Definition: Focal bleeding from a blood vessel in the brain parenchyma caused by HTN! or...Arteriovenous Malformations (AVMs) • Aneurysm • Trauma • Brain tumor • Bleeding disorder
24
Q
Intracerebral Hemorrhage ssx
A
Focal neuro deficit w/: • Headache • Nausea • Impairment of consciousness o Nausea o Vomiting o Delirium
25
ssx Intracerebral Hemorrhage in hemisphere
hemiparesis
26
ssxIntracerebral Hemorrhage in posterior fossa
Brain stem and cerebellar dysfunction
27
intracerebral hemorrhage ddx
DDX
o Ischemic stroke
o Subarachnoid hemorrhage o Hypoglycemia
o seizure
28
Subarachnoid Hemorrhage (SAH)
Definition: sudden bleeding into the subarachnoid space
29
SAH etiol
mc ruptured aneurysm
30
SAH ssx
Sudden severe headache with LOC
• Headache is severe; peaking within seconds!!!
o Severe neurologic deficits
o Seizures are possible
o No neck stiffness initially but chemical meningismus may appear with
vomiting
31
SAH dx
Non-contrast CT
( if negative, lumbar puncture)
• blood in CSF
32
SAH etiol
mc TRAUMA, or ruptured aneurysm
33
SAH PE
```
mild/moderate BP elev
temp elev
tachycardia
papilledema
retinal hemorrhage
global/focal neurpo ab.
```
34
Intracerebral Hemorrhage
Definition: Focal bleeding from a blood vessel in the brain parenchyma
caused by HTN! or...Arteriovenous Malformations (AVMs)
• Aneurysm
• Trauma
• Brain tumor
• Bleeding disorder
35
Intracerebral Hemorrhage ssx
```
Focal neuro deficit w/:
• Headache
• Nausea
• Impairment of consciousness
o Vomiting
o Delirium
```
36
intracerebral hemorrhage ddx
```
DDX
o Ischemic stroke
o Subarachnoid hemorrhage
o Hypoglycemia
o seizure
```
37
SAH PE
```
mild/moderate BP elev
temp elev
tachycardia
papilledema
retinal hemorrhage
global/focal neuro ab.
```
38
Delirium
```
Typically caused by acute illness or drug toxicity
. Often reversible
any age, elderly more common
Worse at night***
mc causes:
1. Drugs, particularly anticholinergics, psychoactive drugs, and opioids
2. Dehydration
3. Infection
```
39
delerium S/Sx
```
difficulty focusing
variable conscioussness
confusion
changes in personality/affect
disorientation
hallucinations
```
40
delerium DX
```
Required for Dx
1. Acute change in cognition
2.inattention/ focus problem
3. Plus one of the following:
o Disturbance of consciousness
o An altered level of consciousness (eg, hyperalert, lethargic, stuporous, comatose) or disorganized thinking
```
41
delerium PEs
```
Vitals
hydration status
potential infection
tremor/myoclonus (uremia, liver,drugs)
skin
Head and neck
Neuro
```
42
delerium labs
```
First line :
CT/MRI
CBC, UA,
CXR
electrolytes
CMP
drug screen
```
```
SECOND line:
LFTs,
thyroid and ANAs
B12
syphilis
```
THIRD line:
CSF, serum ammonia, heavy metals
43
Dementia
a. Typically caused by anatomic changes in the brain
b. Slower onset
c. Typically irreversible
44
MC causes of dementia
1. Alzheimer’s Dementia
2. Vascular Dementia
3. Lewy Body Dementia and Parkinson Disease Dementia
4. HIV-associated Dementia
5. Frontotemoral Dementia
45
reversible dementia conditions
```
o Structural Brain Disorders
• Normal Pressure Hydrocephalus
o Metabolic Disorders
• Hypothyroidism • B12 deficiency
o Toxins
• Lead
```
46
Dementia
a. Typically caused by anatomic changes in the brain
b. Slower onset
c. Typically irreversible
* **short term memory loss mc first sign
47
dementia stages
1. short term memory loss, difficulty withb ADL, may have apraxia, aphasia, may have personality changes
2. inability to learn, recall new info, remote event memory impaired, loss of sense of time and place, need help with ADL
3. cant walk, feed themselves, or do ADLS, incontinence, complete aphasia, death usually dt infection after become debilitated
48
dementia labs
```
TSH
B12
CBC
LFTs
HIV/ RPR?
and
CT or MRI
```
49
distinguish dementia from the following:
1. Delirium
2. Age-associated memory impairment
3. Mild cognitive impairment
4. Cognitive sxs related to depression
50
Dx of dementia
requires:
Cognitive or behavioral symptoms interfere with ADL
o These symptoms represent a decline from previous levels of functioning.
o symptoms not explained by delirium or a major psychiatric disorder.
> 2 of the following:
Impaired ability to acquire and remember new information (amnesia)
o Language dysfunction (aphasia)
o Visuospatial dysfunction
o Impaired executive function, including reasoning, handling ofcomplex tasks, and/or judgment (apraxia)
o Changes in personality, behavior, or comportment.
51
Alzheimers Dz
Progressive cognitive deterioration caused by β-amyloid deposits and neurofibrillary tangles in the cerebral cortex and subcortical gray matter.
β-amyloid is formed during the processing of amyloid precursor protein (APP) (extracellularly)
2 known membrane-bound proteins called presenilins also contribute to APP processing: presenilin 1 and presenilin
MC cause of dementia
52
Neurofibrillary tangles
Number and distribution of tangles is directly related to the
severity of the dementia
Consist of a microtubule-associated protein, tau (maintains neuronal cytoskeleton) and is change din AD
53
Alzheimers DX criteria
* Dementia established clinically and documented by
a formal mental status examination
*Deficits in ≥ 2 areas of cognition
*Gradual onset and progressive worsening of memory and other cognitive functions
*No disturbance of consciousness
*Onset after age 40, most often after age 65
*No systemic or brain disorders that could account for the progressive deficits in memory and cognition
54
Vascular Dementia
Acute or chronic cognitive deterioration due to diffuse or focalcerebral infarction most often related to cerebrovascular disease (CVD)
2nd mc dementia type
```
exaggerated DTRs UMN!
gait
weakness
hemipelagias
pseudobulbar palsy
```
55
vascular dementia risk factos
```
HTN
• DM
• Hyperlipidemia
• Smoking
• Hx of Several strokes
```
56
types of vascular dementia
Multiple lacunar infarction
o Multi-infarct dementia
o Strategic single-infarct dementia
o Binswanger dementia (subcortical arteriosclerotic encephalopathy)
57
Lewy Body dementia and ssx
characterized by cellular inclusions, called
Lewy bodies, in the cytoplasm of cortical neurons
Cognitive and extrapyramidal sxs usually begin within 1 year of each other (unlike Parkinson Dementia).
Fluctuating cognitive function
deficits summetric
58
Parkinson dz dementia
Parkinson Disease (PD) is typically characterized as a movement disorder but dementia can form late in the disease.
Dementia is from Lewy bodies in the substantia nigra
3rd mc dementia, >60 yo
59
parkinson dz ssx
Cognitive sxs don’t begin until 10-15 years after motor sxs
• Psychiatric sxs (hallucinations, delusions) less frequent than
Lewy Body dementia
60
Lewy Body Probable if 2 of 3 are present:
* Fluctuations in cognition
* Visual hallucinations
* Parkinsonism
61
parkinson dz demenita more probable if
motor sxs are more severe and precede
| cognitive sxs
62
parkinson dz ssx
Cognitive sxs don’t begin until 10-15 years after motor sxs
| • Psychiatric sxs (hallucinations, delusions) less frequent than Lewy Body dementia
63
parkinson dz demenita more probable if
motor sxs are more severe and precede
cognitive sxs
Definitive Diagnosis requires autopsy samples of brain tissue
64
HIV associated dementia
Chronic cognitive deterioration due to brain infection by HIV
affects younger people***
can be causes by opportunistic infection seocndary to HIV
65
Frontotemporal Dementia
poradic, hereditary disorders that affect the frontal and temporal lobes, including Pick Disease
66
frontotemporal dementia etiol
10% of all dementias
o Typically younger (avg. 55-65)
o Affects men and women equally o Family hx present in 50% of cases
67
frontotemporal dementia pathophys
gliosis. neuronal loss, spongioform degeneration in the
superficial layers of the frontal and temporal lobes
Pick cells (large ballooned neurons) in
68
Pick cells/bodies
• Pick bodies are round cytoplasmic inclusions that form in small neurons and are pathognomonic for Pick Disease if found in the dentate gyrus
***usu seen in frontotemporal dementia
69
frontotemporal dementia ssx
Affects personality, behavior, and usually language function more and memory less than AD (striking behavioral and personality changes)
• Major breakdown in social behavior, personal hygiene and affect
MRI
• May show severely thin atrophy in frontal and temporal lobes
70
Normal pressure hydrocephalus
defect in CSF resorption by arachnoid granulations
71
frontotemporal dementia ssx
Affects personality, behavior, and usually language function more and memory less than AD (striking behavioral and personality changes)
• Major breakdown in social behavior, personal hygiene and affect
MRI
• May show severely thin atrophy in frontal and temporal lobes (late in dz)
72
normal pressure hydrocephalus ssx
Gait disturbance (Magnetic gait (feet appear stuck to the floor is consideredcharacteristic)
o Urinary incontinence
o Dementia
o Enlarged brain ventricles
o Normal or slightly elevated CSF pressure
CSF
• Reveals normal to slightly elevated pressure
73
normal pressure hydrocephalus ssx
Gait disturbance (Magnetic gait (feet appear stuck to the floor is consideredcharacteristic)
o Urinary incontinence
o Dementia
o Enlarged brain ventricles
o Normal or slightly elevated CSF pressure
CSF
• Reveals normal to slightly elevated pressure
super enlarged ventricles
74
Spinocerebellar tract:
receives afferent info from the periphery
| o Tracts come from the same side and do not cross
75
Ascending Tracts (Sensory)
3 main sensory systems entering the spinal cord
• Pain-temperature
• Proprioception—stereognosis
• Light Touch
76
Spinothalamic Tract (Pain-temperature, some light touch)
Crosses over to other side of spinal cord almost immediately and then ascends to thalamus and cerebral cortex on that opposite side
a lesion in the spinothalamic tract will result in loss of pain-temperature sensation contralaterally, below the level of the lesion
77
Posterior Columns (conscious Proprioception—stereognosis, vibration, and some light touch)
2 columns:
! fasciculus gracilis
! fasciculus cuneatus
• Initially remains on same side of spinal cord
• Crosses over at junction of spinal cord and brain stem
78
o Spinocerebellar (unconscious proprioception)
Does not cross spinal cord
| • Ipsilateral sxs
79
Descending Tracts (Motor)
Corticospinal Pathway
• Extends from motor area of cerebral cortex down through the brain stem, crossing over at medial lemniscus (junction between brain and spinal cord
80
Upper Motor Neuron (UMN):
pathway from brain to spinal cord before synapse
81
Lower Motor Neuron (LMN)
postsynaptic pathway from spinal cord to periphery (peripheral nerve)
