Neuro Block 2 Flashcards
Define Nystagmus
Define Syncope
Rapid involuntary movements of the eyes
LOC from insufficient blood flow to the brain
Define Postictal
Define Oscillopsia
After a sudden attack (epilepsy)
Visual disturbance where objects appear to oscillate
Define Hydrops
Define Dizziness
Edema/distension of a hollow organ w/ fluid
Whirling sensation in head w/ tendency to fall; encompasses vertigo, disequilibrium, light headedness
Define Vertigo
Define Prodrome
Sensation of motion where surroundings seem to whirl; indicative of vestibular pathway dysfunction
Premonitory symptom of a Dz
Define Myelopathy
Define Spacticity
Dz or D/o of the spine
Hypertonicity w/ inc tendon reflexes
Define Parkinsonims
Define Ataxia
Neuro d/o similar to parkinson’s
Inability to coordinate voluntary muscular movements that are Sx in CN D/o and injuries
Define Choreoform
Define Schwannoma
Movement d/o marked by spasmodic movements of limbs/facial muscles
Tumor of the tissue covering nerves, typically benign and most commonly vestibular
Define Labrynthitis
Define Sensorinueral hearing loss
Inflammation of the inner ear and nerves connecting the ears to the brain
Hearing loss due to damage to the inner ear or the nerve from the inner ear to the brain
What are the 3 types of feelings encompassed in the term Dizziness?
What are the 3 categories of Dizziness?
Vertigo
Disequilibrium
Light headed
Faint/Pre-Syncope
Vertigo
Miscellaneous head sensation
What 4 terms can be used semantically for dizziness?
What are 4 misleading words that can be used by PTs to describe dizziness?
Light headed, Faintness, Spinning, Giddiness
Confusion, Blurred vision, HA
Tingling
Define Disequilibrium
Define Light Headed
Describes feeling of being unsteady, about to fall and associated w/ abnormal gait
Sensation one is about to faint
Define Presyncope
Define Multiple Sensory Defect Dizziness
Describes transient cerebral hypoperfusion (orthostatic), usually a prodrome
AKA Benign Disequilibirum of aging
Mild light headed, impaired feet sensation and poor vision
Define Syncope
What are the 3 D/os of vascular tone?
Transient decrease in blood and/or O2 flow to the brain causing LoC
Vasovagal- neural mediated
Postural- OHOTN
Reflex- carotid sinus hypersensitivity, Situational, Glossopharyngeal neuralgia
Neurally mediates syncope includes ? 2
Vasovagal- sympathetic withdrawal (dilation) and inc of PNS activity (bradycardia)
Vasodepressor syndrome- SNS withdrawal alone, “Common Faint”
What are the S/Sxs present during a Neurally Mediated Syncope
How are they Tx?
Pale, Clonic jerks of face, Varied responsiveness, Maintained sphincter maintained, Brief Confusion <30sec
Supine w/ elevated feet, Tx underlying cause
Define OHOTN
Reduced SBP 20mm, DBP by 10mm w/in 3min of standing
Always associated w/ change of position and systematic fall of arterial blood flow while upright
What underlying issues are common causes of OHOTN?
Elderly w/ Poly-pharm- Anti-HTN/Depressants
PNS Dzs- DM, Nutrition deficits, Amyloid polyneuropathy
Define Carotid Sinus Hypersensitivity
Inc pressure on carotid baroreceptors, typically occurs after shaving/combing hair/turning head w/ tight collar on
Afferent nerve fibers activate efferent sympathetic nerve fibers in heart/vessels
Define Reflex Syncope
Abnormal autonomic control that involve cardio-inhibitory/vasodepressor response
SEEING BLOOD
Can be caused by Cough, Deglutition, Micturition, Defecation
Define Glossopharyngeal Neuralgia
Uncommon
Activation of afferent impulse in glossopharyngeal nerves that terminate in nucleus solitarius in medulla
Pain similar to trigeminal neuralgia
How is Glossopharyngeal Neuraliga Tx?
Carbamazepine
If meds fail, microvascular decompression Rhizotomy of CN9/10 (cutting of nerve near brain if PT has continuous pain/syncope)
What are CV D/o syncope usually related to?
CVD alone rarely cause syncope, most PTs also have Sxs of ?
Arrhythmia pre/post exertion without prodromes
Focal neuralgia ischemia Extremety weakness Diplopia Ataxia Dysarthria
What is a rare CV d/o that causes syncope in adolescents?
What does it suggest if a PT passes out while Upright/Sitting, Laying or Exercised induced
Basilar artery migraine
Upright/Sitting= OHOTN Laying= cardiac event, seizure Exercise-induced= CV etiology
What are the Dx Tests for syncope?
Presence of prodromal light headed or clear thinking upon recovery suggests?
Presence of typical aura of postictal state suggests?
ECG, Autonomic, Exercise stress test
Syncope
Seizure
Vertigo is either ? based or ? based and is associated with what S/Sxs?
PT vs Environment
Impulsion- body pulled through space
Oscillopsia- hallucination of moving back/forth or up/down
N/V, Gait ataxia
Vertigo can come from a disturbance from what 3 systems?
What is most often caused by?
Vestibular apparatus
Visual system
Somatosenosry
Asymmetry/imbalance between R/L vestibular systems
Vertigo must be differentiated between a ? or a ? cause
What does Otolith mean and what do they contain?
Central or peripheral
Ear rock- contain calcium carbonate crystal
What is the function of the Otolith organs?
What is the sensory epithelium of the urticle?
Sense static position and linear acceleration
Urticle macula- sense head position vertical to the ground
Sacular macula- vertically orientated
What are the functions of the semicircular canals?
What is the function of the otolith?
Perceiving angular rotation
Otolith- static head tilt and linear movement
What tests are encompassed in a vertigo exam?
Orthostatic vs Nystagmus Bruits Cerebellar- Romberg, Wide gait, Tremor, Finger-Nose, Heel-Shin, RAMs Weber/Rinne Pos Dix-Hallpike maneuver
PT w/ unilateral conduction l deafness will have ? Weber/Rinne result?
PTs w/ unilateral partial deafness will have ? Weber result?
W- vibration in effected ear
R- doesn’t hear air vibrations
W- Vibration in normal ear
R- vibration in air after bone conduction is gone
Nystagmus is characterized by what 3 things?
What are the two types?
Position of gaze
Amplitude
Direction
Pendular- back and forth, slow and fast
Saccade/Pursuits- Fast/Slow
How to differentiate between Presyncope and Vertigo?
Pre: after prolonged standing, improved w/ laying/sitting
Vertigo: after head change, tinnitus, nystagmus, ataxia
What are the 4 types of physiological vertigo?
Intersensory mismatch- car sick
Unfamiliar/unadapted movement- sea sickness
Unusual positions- painting
Post spinning
What are the types of pathologic vertigo?
Lesion on stabilizing sensory systems
Visual vertigo
Peripheral neuropathy/myelopathy
Vestibular dysfunction- most common
Difference between Peripheral and Central vertigo?
Peripheral: Intense short episodes, typically affected by head positions
Horizontal nystagmus is always present, never vertical
Inner ear Sxs
Acoustic Sxs
Central: long episodes of unchanging dizziness, not affected by head position/movement, possible nystagmus of either type Motor sensory deficit Hyperreflexia Extensor plantar response Ataxia Dysarthria
What are examples of Peripheral Vertigo
Benign Paroxysmal positional vertigo Peripheral vestibulopathy Menieres Dz Acoustic Neuroma Gentamycin ototoxicity
What are examples of Central Vertigo
ETOH intoxication Wernicke's encephalopathy MS Alcoholic cerebellar degeneration TIA/Stroke Cerebellar ataxias
Peripheral vertigo d/os involve lesions where?
What are the S/Sxs?
Outside of the brain
Sudden onset of intense vertigo that is worsened by head movement and lasts for days
No findings on PE
Define Vestibular Neuronitis
Paroxysmal vertigo
Usually as a single attack
Pure= preserved auditory*
Labyrinthitis- combined w/ unilateral hearing loss
What will be seen on PE of Vestibular Neuronitis during the acute phase?
How is it Tx?
Nystagmus
Absent response to caloric testing
Diazepam
Meclizine
Vestibular therapy if not completely resolved
ABX- only if fever/infxn
What is the most common cause of vertigo after a head concussion?
What does a chronic post-traumatic form result from?
Labyrinthine Concussion- Traumatic Vertigo
Cupulolithiasis- causes excessive cupular deflection w/ head movement causing episodic position vertigo
What is the triad of Meniere’s Dz?
What other Sxs can be seen?
Unilateral deafness
Episodic/paroxysmal vertigo
Unilateral low freq tinnitus
Vertigo, N/V, Sensorineural hearing loss that gets worse as vertigo gets better
What is the theorized pathology behind that cause of Meniere’s Dz?
How is this Dx?
Secondary to excess fluid in inner ear
Audiometry for all
Vestibular testing
MRI
How is Meniere’s Dz treated?
Diet- avoid salt, caffeine, alcohol, nicotine, MSG Diuretics- HCTZ Meclizine/Scopolomine/Valium Hearing Aid Gentamicin injection into ear
Meniere’s Dz is AKA ?
What causes Perilymphatic Fistula
Endolymphatic Hydrops
Trauma/Pressure that causes leaking perilymphatic fluid from inner ear that drips into tympanic cavity
How is Perilymphatic fistula treated?
What is the most common cause of acuter peripheral vertigo?
Bed rest
Head elevation
Avoid any straining
Persistence= surgery referral
Benign Paroxysmal Positional Vertigo
What causes BPPV?
What PE finding is always present?
Calcium carbonate crystals in the semicircular canal
Positional nystagmus
How can BPPV Sxs be reproduced?
How is it managed/Tx?
Dix-Hallpike Test, AKA Barany Maneuver
Epley reposition maneuver
Meclizine, Valium, Scopolomine patch
Cervical vertigo is AKA ?
This form usually develops when?
Cervical Proprioceptive Dysfunction- causes vertigo w/ certain head positions
Head injury w/ hyperextension or DJD of cervical spine
How is Cervical Vertigo Tx?
PT- neck exercises
Neck collar
Muscle relaxer
Define Vestibular Vertigo
How is it Tx?
Episodic vertigo temporarily related to HA similar to Meniere’s Dz
Migraine Tx/prophylaxis
Diet
Anti-emetics
Central vertigo is due to lesions located ?
How does it present and what is different?
Cerebellum, Pons
Slow onset of Ataxia, Vertigo, Nystagmus w/ little/no change w/ head movement
Central disorders are often associated w/ what other adverse things?
How are central d/os disequilibrium based on location?
Hemorrhage/Ischemia in cerebellum, vestibular nuclei, brain stem
Cerebllum= incoordination
Basal ganglia= impaired posture reflexes
Sensory tract/receptors= impaired proprioception
What can cause acute central vertigo?
What can cause chronic central vertigo?
Infarct, AVM, Tumor
MS, ETOH, Hypothyroid, Genetics
What are 6 common causes of central vertigo?
Vertebrobasilar ischemia Vertebrobasilar TIA/Stroke Acoustic neuroma Toxic vestibulopathies MS Vestibulocerebellum neurodegenerative conditions
When does a Dx of Vertebrobasilar ischemia need to be considered?
What is the vertigo usually accompanied by
Older PT w/ isolated and new onset vertigo w/out obvious cause
Diplopia, Dysarthria, Ataxia, Numbness
Vertebrobasilar TIA/Stroke is usually caused by an infarct in ? branch of the ?
What is a common cause of this?
Medial branch of PICA
DM
When working up a Vertebrobasilar TIA/Stroke, what needs to be rule out?
What is the preferred imaging modality for this?
Anemia, Pregnancy, Glucose derangement
MRI but usually after a CT
How is a Vertebrobasilar TIA from central cause, Wernickes and MS handled?
Central- referral to surgery
Wernicke’s- Thiamine replacement
MS flare- prednisone
Define Acoustic Neruoma
What S/Sxs does it present with?
Benign tumor from the sheath of CN8 in the internal auditory canal
Insidious hearing loss, tinnitus, HA, vertigo and facial weakness/pain
Unilateral sensorineural hearing loss on exam w/ “machine like/hissing” sound
What tumor accounts for 80% of all cerebellopontine angle tumors
Commonly found on CN8, where else can it be found?
Acoustic neruoma
CN5 and CN7
What is the pathology of Acoustic Neuromas?
What PT population are these usually found in?
Spindle cells from palisades called Verocay Bodies
Middle aged female
What image modality is used to search for Acoustic Neuromas?
How are they Tx?
MRI w/ contrast
If <3cm- removal w/ stereotactic radio surgery
What are 4 substances that can cause toxic vestibulopathies?
Gentamycin
Salicylates
Quinine
Cis-Platium
How is Cerebellar Ataxia Dx?
What PT position is a must and what two movements are essential?
Finger to Nose test
Sitting up
Pronation and supination w/ encouragement to go faster
What test is done to test the position sense?
Balance is maintained by what 3 factors?
Romberg- since it takes 2 of the 3 systems for balance, closing eyes limits balance to 1 system
Visual, Proprioception, Vestibular
Define Seizure
Define Epilepsy
D/o characterized by excessive/over synchronized discharges of cerebral neurons
Group of d/os characterized by recurrent seizures
A seizure is defined by ? and whether or not it ?
Define Ictus
Part of brain involved
Affects consciousness or not
Seizure
Define Convulsion
Define provoked seizure
Seizure caused by abnormal muscle contraction
Seizure occuring in otherwise normal brain from alteration of Glucose, Na or Drugs
Define Status Epilepticus
What types of conditions have a high likelihood of resulting in chronic seizures?
Continuous/recurring seizures without return of normal consciousness
Penetrating head wounds
Blasts
What are the 2 key features of seizure d/os?
What are the 3 etiologies of seizure disorders?
Aura and Postical confusional state
CNS dysfunction, Underlying systemic dz
Drug induced
The risk for a seizure from low glucose increases if levels are below ?
The risk for a seizure from low Na increases if levels are below ?
30mg
120meq
What are two hyperosmolar states that can lead to seizures?
When Ca levels are below ? the chance of seizures are increased
Non-ketotic hyperglycemia
Hypernatremia
<9.2
What use does an EEG have in a seizure work up?
EEG must be done under what conditions?
Confirms if pos, does not rule out if neg
Physiological stress/sleep deprivation
Imaging is a must for initial seizures, which modality is preferred?
Why is the second modality ordered?
MRI
In the ER- non contrast CT
R/o infection, mass and bleeds
How to tell between a focal or a generalized seizure has occurred?
Focal- one hemisphere, consciousness is preserved
Generalized- both hemispheres, consciousness is lost
What are the 4 types of generalized seizures?
How are focal seizures further broken down?
Myloclonic/Minor motor
Absence
Tonic-Clonic
Atonic
W/ or w/out dyscognitive features
Define Absence Seizure
Petit Mal, short periods of staring/zoning out usually in kids
Define Focal Seizure w/out Dyscognitive features
No LoC
Abnormal sensation- aura, smell, clonic movement
Define Focal Seizure w/ Dyscognitive features
Loss of awareness with confusion and staring
Motor:
Hand rubbing, lip smacking, arm positioning, uncontrolled shouting, swallowing
Olfactory hallucination
Deja vu sensation- usually w/ origin in temporal lobe
Define Tonic Clonic Seizure
Grand mal seizure
PT falls to ground and jerks, loses awareness and possibly loses bowel/bladder function
What are the 3 phases of a Tonic Clonic seizure and what happens during each phase
Tonic/Opisthotonos- 10-20sec w possible apnea, tongue biting
Clonic- muscle contraction/relaxation, lasts 1min w/ sphincter relaxation
Recovery- normal neuro exam w/ postictal confusion, HA, fatigue and Todd Paraylsis- transient unilateral weakness in postictal period
Define Myoclonic seizure
Sudden muscle jerk in part or whole body
Is a common occurrence when falling asleep
Pathologic when associated w/ metabolic d/o, degenerative CNS dz or anoxic brain injury (hanging attempt)
Normal seizure threshold is at ?
PTs w/ epilepsy have a threshold at ?
- 55 mV
- 60 mV
PTs w/ epilepsy may be required to have a seizure free period of how long prior to being able to drive again?
What is the mainstay of seizure Tx?
3-18mon
Antiepileptic meds
A side effect of antiepileptic meds is that all anti-convulsants can lead to ? or ?
What monitoring is needed for PTs on these drugs?
Hematologic or Hepatic toxicity
CBC, LFTs @ 2wks, 1mon, 3mon, 6mon and Q6mon
What derm issue must be watched for in PTs taking anti-convulsant meds?
What meds can be used in the acute setting for post-seizures?
New rash from Stevens-Johnson Syndrome
Carbamazepine
Phenytoin
Valproic acid
What drug can be used in absence seizures?
What are the Tx options for Focal Seizures?
Valproic acid
Ethosuximide- may cause marrow suppression
First: Lamotrigine Carbamazepine Oxcarbazepine Phenytoin Levetiracetam
Second:
Valproic acid
Topiramate
Gabapentin
What meds are used in Generalized Tonic-Clonic serizures?
First:
Lamotrigine
Valproic acid
Second: Carbamazepine Phenytoin Topiramate Zonisamide Oxcarbazepine
Define Status Epilepticus
What 3 issues can develop?
Continuous seizure lasting 5min or more
Cardiorespiratory dysfunction, hyperthermia, metabolic derangement
What are common causes of Status Epilepticus?
Anti-convulsant withdrawal Metabolic- hypoglycemia Drug toxicity CNS infection/tumor Refractory epilepsy Head trauma
What is the medical therapy for Status Epilepticus?
If a first drug achieves partial control, but recurrent seizures continue, what is the next step?
1st= Lorazepam/Diazepam
Phenytoin w/ ECG
No anesthesia, use Midazolam, Propofol or Ketamine
Topiramate
Zonisamide
Lacosamide
Tigabine
Confusion can be branched out into what 3 issues?
A mini mental status exam can be done and test what things?
Derlirium
Dementia
Amnestic d/o
LoC, Orientation, Speech/Language, Memory
What score on a mini mental status exam is concerning?
Define Global Aphasia
Max of 30, 23 or less is concerning
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Lect 2
