Neuro Block 1 Cram Flashcards
What CNs make up the Branchiomotor Group and Tongue
Function of CN7 and issues with it will cause PT difficulty making ? noise
5 7 9-12
Facial expressions, taste of anterior 2/3
Difficult w/ “ma ma ma” sound
Motor, Sensory, Parasympathetic function of CN9
Motor, Sensory, Parasympathetic function of CN10
Voluntary swallow, phonation
Gag reflex, posterior 1/3 taste
Salivary glands, carotid reflex
Voluntary swallow, phonation
Ear, external auditory canal
Heart, lungs, digest, cartoid reflex
Together, CN9 and 10 do what functions?
Issues w/ these will give the PT difficulty making ? noises
Phonation, Gag reflex, palate elevation
Kuh kuh kuh sound
What 3 nerves make up the special sensory group?
What nerve innervates the tibialis anterior muscle?
What nerve innvervates ankle dorsiflexion
1, 7, 8
L4 via deep peroneal nerve
L4-5 via peroneal nerve
What day of development does the neural tube close?
Why is this time frame a concern?
Day 26-28
Women don’t know they’re pregnant until they’re 1wk late, Day 21
What NTD is a failure of the neuropore to close and causes cranial bones to fail tin development?
Where is this issue more commonly seen?
Anencephaly
1:1000 births
2-4 x F>M
How are NTD avoided?
What puts a PT as a high risk for NTD?
Folic acid
Low risk= .4mg 1mon prior
High risk= 4mg 3mon prior
Prior NTD pregnancy
Mom/Dad have NTDs
Frontal lobe is responsible for ?
What is the anterior 2/3 of the prefrontal cortex in charge of?
SPERM Behavior
Solving, Personality, Emotion, Reasoning, Motor region, Behavior
JOACS
Judgement, Orientation, Abstract, Concentration, Solving problems
What is the temporal lobe responsible for?
What is the parietal lobe responsible for?
SHOL
Short term, Hearing, Olfaction, Languag
HAI
Hemispatial, Asterognosis, Inability to copy
What is the occipital lobe responsible for?
What woul be the different results of a lateral and bilateral lesion in this lobe?
Visual processing and Shape/Color ID
Bilateral= cortical blindness Unilateral= contralateral hemianopia of quadrantopia
Which NT is excitatory at neuromuscular junctions?
How does it do this effect?
ACh
Opens ligand gated cation channels
What does the lack of ACh present as?
What causes these adverse Sxs?
Weakness
Fatigue of skeletal muscles
Abs destroy ACh receptors at junctions
What hallmark of MG presents first?
What is the major inhibitory NT of the brain and spinal cord?
EOMs- diplopia and Ptosis
Brain= GABA Spine= Glycine
UMN begin at ? and end at ?
LMN begin at ? and end at ?
Cortex/brain stem to anterior horn
Anterior horn to muscle fibers
Function of Corticospinal, Spinothalamic and Dorsal Columns
Almost all PTs w/ aphasia will also have ?
Corticospinal- voluntary motor
Spinothalamic- pain/temp
Dorsal- vibration, position, light touch
Agraphia
What is the difference between Brocas and Wernickes
Brocas: broken thoughts
Problem w/ language production, Impaired fluency/repetition, Preserved comprehension, R Hemiparesis
Wernicke- word salad
preserved fluency, problem w/ comprehension
R upper visual defect, PT initially unaware of problem
S/Sxs of compressed radial nerve
What is it AKA and how is it Tx
Wrist drop, weak thumb abduction and finger extension, sensory loss between thumb and index finger
AKA Saturday Night Palsy
Cock-up wrist finger splint
What are the 7 types of Polyneuropathy
B12 deficient Diabetic Lyme Dz Leprous Autonomic Plexopathy
B12 Polyneuropathy
Vegan, Alocholics, IBDz, Post Gastroectomy
Sx: Distal symmetry numbness starting in hands and gait instability
PE: Dec vibration sense, loss of position sense
Dx: smear for macrocytic anemia, macro-ovalocytes, hyper segmented neutrophils
Tx: 1000mcg B12 weekly x 1mon, Qmon
Diabetic Neuropathy
Sensory loss is first from hyperglycemia
TCAs
Gaba/Pregaba
SSRI/SNRI
Capsaicin
HIV Neuropathy
Neuropathy from HIV itself or from anti-viral meds
Secondary neuropathy due to Cytomegalovirus
Most common presentation= Sx encephalopathy
Lyme Dz
Bilateral facial neuropathy
Tx: Doxy or Ceftriaxone if severe
S/e: sunburn easily
Leprous Neuritis
Due to acid bast bacilli in skin
Two forms:
Lepromatous- systemic presentation, spares lungs and CNS
Tuberculoid
Autonomic Neuropathy
Generalized polyneuropathy
Anhydrosis
Tx underlying autonomic issue
What are the 4 hereditary polyneuropathies
CMT
HSAN
FAP
Refsum Dz
Charcot Marie Tooth Dz
Slow progressive neuropathy High steppage gait, tripping and falling Sensory loos but NO numb/tingling Distal weakness in legs to hands to forearms Inverted champagne bottle legs Tremor= conspicuous finding
Hereditary Sensory and Autonomic Neuropathy
Distal sensory loss
Recurrent osteomyelitis infxns
Familial Amyloid Polyneuropathy
Defected Transthretin gene
Sxs: PHOTN, Constipation/diarrhea, ED, impaired sweating
Cardiomyopathy leads to HF
Refsums Dz
Autosomal RECESSIVE
Earliest Sx= night blindness
Triad- peripheral neuropathy, retinitis pigmentosa, cerebellar ataxia, elevated CSF protein level
Dx- elevated phytanic acid in serum and urine
Tx- avoid lamb, beef, all fish
What are the 5 forms of immunologic polyneuropathy
GBS CIDP MM MG Myasthenic Syndrome
Guillan Barre Syndrome
Follows infection/vaccine, usually Campylobacter infxn
Symmetric weakness of legs w/out pain (rubbery)
Slowed motor/sensory conduction
Inc CSF protein, normal count
Tx: plasmaphoresis, IV IgG
Chronic Inflammatory Demyelinating Polyneuropathy
Gradual onset and undifferentiated from GBS
Consider CIDP if longer than 9wks or > 3 relapses
Multiple Myeloma
Lytic/osteoporotic bone lesions
Sensorimotor polyneuorpathy that doesn’t reverse after Tx
MG Tx
Thymectomy
Pyridostigmine for Sx relief
Myasthenic Syndrome/Lambert Eaton
Associated w/ small cell carcinoma Defected P/Q type voltage gated Ca channel Weakness in proximal limbs Power INC w/ sustained flexion Tx: Prednisone, Azathioprine
What are the 4 toxin polyneuropathies
Botulism
Aminoglycoside use
Tetanus
Nerve agents
Aminoglycoside use is c/i in ? PTs?
What two drugs does this encompass?
MG
Gentamycin
Streptomycin
How does Tetanus poisoning work?
Irreversible binding to cord/stem preventing release of GABA, causing inc tone, spasms and rigidity
Nerve agents in chemical warfare work by ? and are most commonly ?
What 4 nerve agents are similar to insecticdes like Malathion
Cholinesterase inhibition
Organophosphorus compounds
Sarin GB
Tabun GA
Soman GD
VX
What part of the nerve agent effect accounts for the major life-threatening effects?
Acetylcholinesterase inhibition
UMN lesions cause ?
LMN lesions cause ?
Diffuse Weakness Spasticity Increased DTRs Babinski response Little/no muscle atrophy
Wasting/fasciculations
Loss of DTRs
Hypotonia
Define Hemiparetic gait
Define Paraparetic/Diplegic gait
Unilateral weakness and spasticity from UMN lesion, most common impairment after strokes w/ R sided weakness
Scissor gait, spasticity in LE>UP, common in strike/cerebral palsy in kids
Define Steppage Gait
Define Parkinsonian Gait
Most often seen in peripheral nerve dz (L5 if unilateral), distal LE most effected as weak foot dorsiflexors
Stooped posture and shuffling w/ pill rolling tremor, turns En Bloc (as a whole) like a statue
Define Apraxia
Define Choreoathetotic
Similar to Parkinsonian but no pill rolilng, PT appears to be glued to ground w/ difficulty turning/starting, dementia and incontinence
Hyperkinetic gait as lurching and unpredicatble motions, Huntingtons Dz,
Tardive Dyskinesia- cause of many odd stereotype gait d/os
Define Vestibular gait
Define Astasia/Abasia gait
PT falls to one side, asymmetric nystagmus
Psychogenic gait
MS
Autoimmune
Sensory loss, optic neuritis, Weak, Hyper reflexes, + babinksi, Dydiadokinesis
Dx: MRI w/ 2 regions of white matter at different times IgG bands (oligodclonal)
Tx: flares w/ Glucocorticoids
DMARD for long term
Acute Disseminated Encephalomyelitis
Widely scattered small foci of perivenular inflammation and demyelination
(MS has large demyelinatino lesions)
Presents 1st with behavior and cognitive abnormalities
(MS presents with these late in Dz)
ALS
Most common progressive motor neuron Dz
Dx requires simultaneous U/L neuron involvement w/ progressive weakness and all normal: no pain, bowel/bladder, x-rays, CSF
Tx: Riluzole- reduces glutamate to inc short term suvival
Edaracone- free radical scavenger to slow Dz progression in early/mild cases
Poliomyelitis
Entrovirus transmitted through fecal-oral
Destroys anterior horns
Dxs by isolating virus in stool/NP secretions
Poliomyelitis follows a prodromal phase that includes ? 5 things?
Fever
Myalgia, Malaise, URI/GI, Weakness lasting days
What CNs are Sensory, Motor an Both
S- 1 2 8
M- 3 4 6 11 12
B- 5 7 9 10
How does Amaurosis Fugax
present and what causes it?
PTs with this need to be treated as ?
Transient monocular blindness, “curtain coming down over an eye”
Dec blood to retina
TIA/Stroke
S/Sxs of Optic neuritis
What is it associated w/
More severe Sxs are due to ?
Why is Dx usually delayed and how is it treated?
Unilateral vision loss over days and retrobulbar pain w/ EOMs
MS
Vit D
Disc looks normal, IV Methylpredinsolone
How is GCA treated?
What type of vision loss is typical for non function pituitary tumor
Prednisone and Biopsy ASAP
Bitemporal hemianopsia from tumor pressing on optic chiasm
S/Sxs of Argyll Robertson pupil
What is this Dz related w/?
+ accomodation w/ near vision
- reaction at all to light
Syphilis or MS
What are the 3 most common causes of CN6 Palsy
What 3 things can also, less frequently, cause this?
Bilateral CN6 Palsy are all treated as ? until disproven
Trauma, Microvascular Dz, Basal intracranial neoplasms
Basal meningitis, clivus lesions and posterior fossa lesions
Inc ICP
What is the most common cause of isolated 6th Palsy in elderly PTs?
What is the more common cause in kids/young adults and what steps need to be taken?
Microvascular infarction
Tumor
Order MRI
Elderly PT presenting with CN6 Palsy regardless of DM/HTN Hx needs to have what work up done?
ESR, Glucose, Anti-nuclear Abs, Fluroescent treponemal Abs and Lyme Titer
No improvement in months= MRI
Lesions of the abducens nucleus in the brainstem often produces a ?
But not always ?
Conjugate gaze palsy to ipsilateral side
True abduction weakness
CN5 Trigeminal Neuralgia is AKA ?
Definition
What causes pain?
Tic Douloreux
Compression of sensory fibers on root by Superior Cerebellar Artery
Triggered by touch, eating, wind
How does CN 5 Trigeminal Neuralgia seen on imaging?
How is it treated?
Exam, CT, MRI and arteriography are all normal
Carbemazepine (monitor LFTs and CBC for development of agranulocytosis),
Oscarbazepine- less bone marrow toxicity
Phenytoin, Baclofen
CN8 Cochlear portion issues are seen how by Rinne ad Weber?
Conductive: external canal or middle ear affected
Weber lateralizes to lesion
Rinne BC>AC on side of lesion
Sensorineural- lesion in inner ear/CN8
Weber lateralizes away from lesion
Rinne- AC>BC on side of lesion, both are not good
Pure CN9 issue is seen as ?
CN10 issue is seen as ?
CN 11 issue is seen as ?
CN12 issue is seen as ?
Diminished gag, difficult swallowing
Asymmetric rise of uvula
Paralyzed SCM and Trap
Tongue paralysis w/ atrophy and speech issues
idiopathic facial paresis of the LMN is seen in ?
Who is this seen more commonly in?
Bells Palsy
Women and DM
How is Bells Palsy Tx
Define Ramasy Hunt Syndrome
Prednisone 60mg x 5 days, followed by 5 day taper and eye protection
HSV infection as vesicular rash in ear w/ pain prodrome, loss of hearing, balance and nausea
Tx: anti-virals (Acyclovir or Famciclovir) and steroid
Retina receive blood from retinal artery which is a branch of ?
Visual cortex is supplied by the ? which is a branch of the ?
Ophthalmic artery
PCA, branch of basilar artery
If blindness onset is rapid, slow or transient then what is the cause?
Rapid= vascular Slow= inflammation, neoplastic Transient= MS, MG, Ischemia
How do afferent signals travel to the brain?
How are efferent signal sent for action?
Light through CN2, divides at chiasm and arrives at pretectal nucleus
Signal sent via CN3 to cause direct and consensual constriction
Diplopia is the inability to maintain ?
What are the three CN2 monocular vision D/os
Conjugate gaze
Transient Monocular blindness
Optic neuritis
GCA
Define the Marcus Gun Pupil
Afferent pupil defect from retina/optic nerve Dz
Pupil dilates to light, + consensual reflex
What are the 3 CN2 Binocular Vision D/os
What are the 5 grades of papilledema
Papilledema
Pituitary tumor
Occipital cortex lesion
1- C shaped halo w/ temporal gap 2- circumferential halo 3- loss of vessels leaving disc 4- loss of vessels on disc 5- 4 criteria and loss of all disc vessels
What are the two types of pituitary tumors?
Functioning- HA, galactorrhea, amenorrhea, acromegaly
Prolactoma- most common
Non-Functioning- tumor presses on chiasm causing gradual bitemporal hemianopsia
How are pituitary tumors treated?
What can cause occipital cortex lesions?
Prolactoma- Bromocriptine or Carberogline
All others= surgery
Trauma, Tumor, PCA infarct leading to subtle homonymous hemianopia
Define CN3 Palsy
What are 4 things that can cause it
“Down and Out”
Diplopia, Ptosis and pupil w/ down/out deviation and dilation
Aneurysm
Trauma/Tumor
Menigitis
Ophthalmoplegic migraine
How do you reach Horners Syndrome Anisocoria
Anisocoria more in dark, small pupil abnormal
Dilation lag, Ptosis
10% cocaine, small pupil doesn’t dilate= Horners
If both pupils dilate symmetricaly= physiologic anisocoria
How do you reach Adies Tonic pupil with Anisocoria
More in light, large pupil abnormal
Sluggish to light
0.1% Pilocarpine
Large pupil constricts= Adies
How do you get to 3rd Nerve Palsy w. Anisocoria
More in light, large pupil abnormal
Ptosis/Ophthalmoplegia
How is Horners Syndrome evaluated?
Preganglionic:
No brainstem Sxs= CT or MRi of neck and chest
+ Brainstem Sxs= Neuroimage head
Postganglionic- head andneck MRI
When evaluating Horner’s Syndrome, think of what two causes?
Lung tumor or cartoid artery aneurysm
If there is Ptsosis of eyelid on side of small pupil, PT has ?
If there is ptosis of eyelid on side of large pupil, PT has ?
Horners on that side
Partial 3rd nerve lesion on that side
Define Adie’s Pupil
Parasympathetic denervation that poorly constricts to light but reacts better to accommodation
Define CN4 Palsy
Diplopia
Common cause of vertical diplopia
What is the most common cause of superior oblique palsy?
What does the eye look like?
Head trauma related w/ CN4 palsy
Deviates up and medially
Who is Bells palsy seen most common in?
What preceding Sxs can hint of issue?
Female, DM
Max onset of paralysis in 48hrs, preceded by pain behind ears and loss of taste
What nerve is affected by Bells Palsy?
If forehead muscles are preserved then think ?
CN7
Central lesion instead (stroke in cerebral hemisphere)
Loss of ssensation of hot peppers = ?
What 3 nerves taste?
CN5 somatosensory sensation
7 9 10
Bells palsy will affect taste ?
Define Paresis
Loss of anterior 2/3
Incomplete paralysis
“less severe weakness”
Hypertonia means ? issue
Hypotonia means ? issue
Hyper= spastic- UNM lesion; rigid- extrapyramidal dysfunction
Hypo- LMN lesion or myopathy
Corticospinal tract is AKA ?
What does this tract supply to the body?
Pyramidal system
Inhibition to muscle contraction
An issue at any of what 4 locations can disturb PNS function
JR PAP Anterior Horn Nerve Root Limb Plexus Peripheral Nerve Junction
Polyneuropathies/DM usually have what type of DTR reflexes?
All levels of ? contribute to gait
Loss of distal, preserved proximal
Neuroaxis
What are three causes of Steppage/Neuropathic gait?
What causes waddle gait?
Sensory Neuropathy, b12, Tabe Dorsales- degeneration of dorsal columns causing interfered reflexes/movements
Myopathy, NMJ Dz, Proximal Symmetrical spinal weakness
What PTs commonly have Tardive Dyskinesia
PTs with B12 deficiency can develop sensory ataxia and have what finding during a PE?
Chronic anti-psychotics
D2 dopamine blocking meds
+ Romberg
What are 4 RFs of MS?
What are the top 3 initial Sxs of MS?
Genetics
Vit D deficient
EBV after early childhood
Smoking
Sensory loss
Optic neuritis
Weakness
Define Internuclear Ophthalmoplegia and who is it seen in
MS Pts w/ impaired adduction of eye due to lesion in ipsilateral medial longitudinal fasciculus
What are the 4 eye problems MS PTs can develop
How is MS and Bells palsy differentiated?
Optic neuritis
Diplopia
Internuclear Opthalmoplegia
CN6 Palsy
MS not associated w/ ipsilateral loss of taste or retroauricular pain
What is the most common reason for work related disability in MS PTs?
What are the 3 parts of the Dz course?
Fatigue
Relapse/Remitting Dz- most common
Secondary progressive- begins as RMS then steadily deteriorates
Primary progressive- steady progression from onset
Since there is no definitive Dx test for MS, what is the most useful tool for confirming Dx?
What is the hallmark for the Dx
MRI w/ contrast for enhancement
2 or more episodes of Sxs and 2 or more signs
(Sxs longer than 24hrs, white matter tracts of CNS, episodes spread by a month or longer)
How is MS treated?
Acute: Glucocorticoids Methyprednisone 1g/day IV x 3 days PO Prednisone 60-80mg/day x 1wk then taper Long term= B-interfeon (Avonex 30 mcg IM/wk) Glatiramer 20mg SQ/day
What meds are used for primary and secondary progressive MS?
Primary- Ocrelizumab
Secondary- little evidence for immuno suppression
When does a MS Dx have favorable prognosis
How is this prognosis info gathered?
Optic neuritis/sensory Sxs at onset
<2 relapses in 1st year
Minimal impairment @ 5yrs
First demyelinating event w/ MRI
3 or more atypical T2 weighted lesions= 80% risk of developing after 20yrs
Normal MRI= <20% chance of developing MS
Define ADEM
What is it’s key presenting Sx
Monophasic illness leading to CNS demyelination
Mild HA and drowsiness to Irritable Sxs like MS
Major Sx- optic neuritis
How is ADEM seen on imaging?
What will lab work show?
MRI w/ gadolinium
Lymphocytic pleocytosis
Elevated protein
Rarely seen oligoclonal bands
What is the prognosis and Tx for ADEM
IV corticosteroids shorten and lessen severity of Dz
Recovery is usually complete
What does ALS stand for?
What do the words mean?
Amyotrophic Lateral Sclerosis
Amyotrophy= no muscle nourishment, atrophy
Lateral
Sclerosis- loss of fibers in lateral columns resulting in fibrillary gliosis impart a partiuclar firmness
Who does ALS impact more and what is the median survival?
3-5yrs, respiratory paralysis
10% autosomal dominant
1-3/100,000
M>F
Traumatic damage above C5 results in ?
Damage below T6 results in ?
Bowel and bladder dysfunction occurs w/ lesions above ? level
Respiratory insufficiency
Abdominal reflexes
Sacral
Define High Quadriplegia
Define Low quadriplegia
Define Paraplegia
C1-4: Dependent for movement, wheelchair and breathing
C5-8
Partially independent
May self-transfer
Manual wheelchair and driving ability
Below T1
Independent and may be able to self ambulate short distances w/ assistance
Where does the motor pathway cross at?
Where does sensations like pain and temp cross?
Medulla, goes down lateral corticospinal tract, lesions cause ipsilateral Sxs
Immediatley cross, goes up spinothalamic tract, lesions cause contralateral Sxs
What are the two types of cord tumors?
Intramedullary- mostly Ependymomas, Gliomas
Extramedullary- majority of all, neurofibromas, meningiomas
What will lab results show in PTs with spinal tumors?
Xanthochromatic Elevated proteins N/Elevated WBC N/Dec glucose Quenckenstedt test- shows partial/complete block
What causes Neurogenic Shock
Acute cord injury
Loss of sympathetic tone, reduced vascular resistance, HOTN, no tachy reflex
What Dx is made via nerve and muscle biopsy?
Fasciculus gracilis belongs to what tract and only exists below what level?
Vasculitic
AKA Polyarteritis nodosa
Dorsal column
T6
Define Central Cord Syndrome
Define Hemicord?Brown Sequard Syndrome w/ R sided injury
Absence of pain and temp in both UE
No Dorsal column in R leg
No Corticospinal in R leg
Retained Spinothalamic in L leg
Define Posterior Cord Syndrome
Define Anterior Cord Syndrome
Bilateral loss of dorsal column sensations
Corticospinal and Spinothalamic tracts severed
Dorsal tract retained
