Neuro Exam III: Cerebellar Coordination & Special Situations Flashcards
Define and differentiate between dizzy and vertigo
Dizzy: vague term; ask pt. to define
Vertigo: false sense of spinning motion
Presyncope: near fainting
Disequlibrium: feeling unsteady/off balance (visual loss, weakness, peripheal neuopathy)
psyhciatric conditions like anxiety and panic attacks can create simialr sensations
3 types of periphearl vertigo
BPPV
acute labryinthitis
meineres disease
Drug Toxicity
Acustic Neuroma
BPPV: triggered by changes in head position, vertigo occurs and lasts < 1 minute
- no hearing loss
- N/V and horizontal nystagus
Acute Labrinthisis: history of preceeding infection with varibale duration in legth (hours to months)
- no hearing loss
- N/V/vertigo
Menire’s Disease
- sudden onset vertigo lasting hours to days
- sensorineuroal hearing loss which progresses to tinnitus
- pressure/fullness in the ear with N/V/nystagumus
Drug Toxicity
- loop diuretics
- aminoglycosides
- ETOH
- salicylates
- +/- hearing loss
Acoustic Neuroma (CN VIII Schawannoma)
- tumor of the nerve sheath; benging
- unliateral sensorineural hearing loss
- tinniuts, HA, numbness of face, vertigo & balance issues
Central Vertigo
due to a brainstem issue
Symptoms
- Vertical nystagumus that is non-fatiguable and continuous
- gait instability
Causes of Central
- cerebellar or pontine tumor
- PCA stroke
- vascular stenosis in the posterior circulation (vertebra or basialr artery)
- MS
Assessing Coordination
ways it is tested
what is balance
Cooridantion invloves many body systems
- motor
- cerebellar
- vestibular
- sensory
Tested through…
- gati
- posture
- balance
- fine motor/sensory awareness
Balance: the ability to maintain the line of gravity in bosy with the base of support with minimum sway
- uses the inner ear vestibu. system
- cerebellum
- vision
- somatoseonsry input
What is Gait: how is it tested
Gait
Normal
- legs narrowly spaced
- symmetrical moving
- moderate arm swing
- no issues turning
Assessing Gait
- observe normal walking without shoes (if safe)
- with eyes open and closed
- observe heel-toe walking (enhances small movements/changes)
- walk on heels: distal muslce weakness
- walk on toes: distal muscle weakness
- hop on each foot: test muscle weakness, cerebellar disaesae or lack of position sense
Hemiplegic Gait
- circumduction of one foot/leg = arc-like movement
- spacticity, flexion hypertonia of the upper limb and extenosry hypertonia of the lower limb (UMN lesions)
- distal (foot) weakness = foot drop
seen in
- MCA strokes of the contralater side as defict
Ataxia
- wide based gait: staggered, clumpsy, unsteady
- pt falls toward the side of teh lesion
- difficult to turn
- unableto stand with feet together (they will sway)
- unable to heel-toe walk
Causes
- cerebellar disorders
- stroke
- cervical myleopathy
Diplegic Gait
scissoring gait
- narrow, stiff gait;hypertonia in the legs
- thigh adductors causing extreme adduction and inability to move hips well
- limbs move slowly
- knees and thighs cross midline each step
- could compenstae with toe walking due tot eh excessive spasticity (hyerptonia)
Causes
- Cerebral palsy
- UMN lesions (stroke, tumor, SC injury)
Parkinsonian Gait
- stooped posture
- shuffling gait
- difficult to initiate step
- slow, short steps that accelerate (falling over)
- unversile flexion of all joints: they will lean forward
- reduced arm swing
Steppage gait
- seen in peripheral motor disease
- foot drop: inability to dorsiflex due to weakness in nerve; so they have to lift up high to compensate
- they will drag foot or lift up high
Causes
- peroneal nerve palsy
- L5 radiulopathy
- ALS
- other peripheraly neuropathies (DM)
- dorsal column isues (nned to eliect pain to feel the step)
Sensory Ataxia
- form of ataxia not due to cerebellar dysfunction
- periphearl nueopathies and dysfunction specifcally in the dorsal column (could be infection or autoimmune pathology)
- lost position sense in legs = wide-based gait & unsteady
- they will double tap the ground to ensure they feel it (cant have proprioception since lost dorsal)
- watch the ground as they walk
+ Rhomberg’s sign: cant stand still; worse coordination when they have eyes closed
PSeudoatheosis: continuous involuntary tapping and moving out outstretched arms/fingers (trying to senes where they are)
Posture Tests for Coordination
rhomberg
pronator drift
Romberg Test
- stand still, eyes closed
- minimal swaying
- arms at sides: 20-30 seconds then eyes closed for 30 more
Outcomes
- maintains posture with eyes open only (not closed) = think dorsal column issue
- unable to maintain posture at all - cerebellar disease
remeber to keep your arms out to catch pt.
(can also assess with hoping on one foot or standing on one foot)
Pronator Drift
- senstive for lesions incorticospinal tract coming from opposite hemisphere & cerebellar dysfunction
- pt. stands with hands out and up : eyes closed
- monitor for a drift down and pronation of the hand
- then quickly tap the arms down: they should return to th orignial location
- drifting instead of returning = lost position sense
- if they go back to position but OVERSHOOT = lost cerebellar function
Rapid Alternation Movement Tests
tests
signs
Hand supanation & pronation on thighs
thumb opposition
ankles (tap ground with foot)
assessing
- speed
- smoothness
- accuracy
dysdiadochokinesia: impaired ability for the rapid alternating movemnets = cerebellary dysfunction
Point to Point tests
- Finger to nose
- Finger to nose to finger
- heel down shin
Suspected Meningitis
Brudzinski
Kernigs
meningitns = fever, neck stiffness & vomiting
test these
Brudzinksi: pt. lays flat
- passive flexion of the neck by provider
- if pt. flexs hip and knees during this thats a + postive sign
- watch neck trauma
Kernig’s Sign
- pt. laying supine
- provider bends knee and slowly lowers it down to extension
- + positive = pain in lowerback with this motion
Neurologic Evaluation in the Unconscious pt.
- ABC’s
- Level of Consciousness
- Respirations & vitals = looking for abnormal patterns
- Pupils = size and reactivity
- Brain Stem Reflexes: Pupillar, Corneal & Gag reflex
- DTRs
- posture and muscle tone
Levels of Consciousness
Alert
- eyes open
- fully responds and appropriate responses
Lethargic
- droswy pt, but opens eyes
- responds then falls asleep
Obtunded
- opens eyes to responses slowly
- confused
- alterness and interest significanlt decreased
Stuporous
- arouses only after a painful stmuli
Coma
- unarousable even to pain
Abnormal Respirations
Kussmal Breathing
- deep labored breathing
- a form of hyperventilation
- blow off CO2 (metabolic acidosis, DKA, urema, sepsis, MUDPILES)
Cheyne-Stokes Breathing
- periodic breathing (increase breathing, then periods of apnea)
- strokes, hypoxia (poor perfusion to the respiratory centers) or drugs
what is spinal shock
what is cushings reflex
Spinal Shock
- acute SC injuries
- hyporeflexia then hyperreflexia later on
- flaccid paralysis
- loss of sensation below lesion
- neruogenic shock due to imparied autonomic functions : hypotension, bradycardia, hypothermia, flushing & HA
Cushing’s Reflex
- triad of symptoms during an Acute brain injury
- this indicates BRAIN HERNATION MAY BE OCCURING
- Systolic Hypertension (widened pulse pressue)
- slow, irregular breathing (imparie BS functioning)
- bradycardia
Glasgow Coma Scale
eye opening
- spontaneous
- to speech
- to pain
- no response
Verbal
- oriented to time, place and person
- confsued
- inappropirate words
- incomprehensible sounds
- none
Motor Response
- obeys commands
- moves to localized pain
- flexion wihtdrawal from pain
- abnoraml flex (decoritate)
- abnormal fleion (decerebrate)
- no response
- standard verbal, eye opening and motor responses
- alwasy take note of pt. best response
- document numerically their score
GSC: 14-15 = mild, 13-8 = moderate < 8 = severe
Pupils & what they indicate
bilaterally small
pinpoint
fixed/dialted
reactive/dialted
fixed/midposition
unlateral dialted/fixed
BIlaterally small
- hypothalmus damange, metabolie encephalopathy, diffuse cerebral function failure
Pinpoint
- naroctic use
- pontine hemorrhage
Fixed/dilated
- severe anoxia (caridac arrest)
- drugs
reactive/dilated
- cocaine, LSD, amphetamines
Fixed in midposition
- midbrain lesion
unilateral dialted & fixed
- brain hernation
what are the 3 brainstem reflexs to test in an unconscious pt.
Pupillary Reflex
- afferent CN II
- efferent CN III
Corneal Reflex
Afferent CN V
Efferent CN VII
Gag Reflex
Afferent CN IX
Efferent X
Oculocephalic Reflex (dolls eye)
- holding llids open, rotate head to one side
- if they eyes move in the opposite of the head: that means the brainstem is intact
- if they roll with the head: brainstem defect
Posturing
Decorticate v Decerebrate
- abnormal posturing de to a verity of reasons : but high morbility and mortality if these are seen: cerebrate worse
- Red Nucleus: helps to cooridnate motor control in the midbrain; helps with large movements of the arms and legs ; relay center between teh cortex and cerebellum
Decorticate (flexor response)
- not crossing midline
- suggestive of corticospainl lesions in the hemispheres, internal capsule, thalmus or midbrain
Decerebrate (extensor response)
- also not crossing midline; arms out and extended and felxed
- suggesting diencephalon, midbrain or pons lesion
- severe hypoxia, hypoglycemia
Hemiplegia
- suden unliater damange to the tract (unilateral falccidity)
compare/contrast
toxic-metabolic v strucural coma
respiratory differences
pupils
Toxic-Metabolic
- toxin ingestion, uremia, anoxia, hypothermi
- normal or kussmal breathing: hypervent
- equal pupils +/- dilated
Structural
- hemorrhage, ishcemia, tumor, etc.
- cheyne-Stoke: ataxia breathing
- unequal or unreactive pupillary reaction to light
STrokes
FAST
NIH
FAST
- Face; facial drooping
- A: arm drift
- S: speech slurred
- T : time!!
NIH Stroke Scle
- evaluation to quantifity impairment
- 11 sections to streamline dx. and treatemetn of strokes
aphasia: incomprehensible speech/compresion of speech
dysarthia: cant get the words out, motor issue
Myasthenia Gravis
ALS
Myasthenia Gravis
- a NMJ disorder: muslce weakness and fatigue
- ptosis is a common first sign
- bulbar symptoms (CN deficits)
- facial weakness, neck muscle weakness
- respiratory muslce weakness
Amyotropic Lateral Sclerosis
- impacting motor function only
- hands weakness, weakness of dorsiflexion of ankles
- UMN findings: slow, hyperreflexia and incoordination
- LMN findings: fasciulations, cramps, inability to close eyes
