Neuro Pathology Pt. 1 Flashcards
Stroke, Cerebellum lesions, MS, & Parkinson's Disease (PD)
Define a stroke
- Occurs when the blood supply to the brain is interrupted or reduced
Define an ischemic stroke
- Makes up 80% of cases
- Cerebral thrombosis: formation or development of a blood clot or thrombus within the cerebral arteries or their branches
- Cerebral embolism: traveling bits of matter that produce occlusion & infarction in the cerebral arteries
Define a hemorrhagic stroke
- Abnormal bleeding as a result of rupture of a blood vessel
- Occurs in about 20% of cases
Define a TIA (transient ischemic attack)
- A temporary period of symptoms resulting from decrease blood supply to the brain
- Precursor to major stroke; lasts <24hrs
- No permanent damage
Risk factors for a stroke
- Atherosclerosis
- HTN
- Cardiac disease
- DM, metabolic syndrome
- TIAs
What are the 4 after effects/pathophysiology of a stroke
- Cerebral anoxia: lack of O2 supply to the brain (irreversible damage begins after 4-6 min)
- Cerebral infarction: irreversible cellular damage
- Cerebral edema: accumulation of fluids within brain causes further dysfunction, elevates ICP, can result in herniation & death
- Secondary cell death: death of neurons around the specific area of damage
Characteristics of a MCA stroke
- UEs affected more than LEs
- Contralateral hemiplegia of face
- Contralateral hemisensory loss
- Homonymous hemianopsia
Characteristics of a ICA (internal carotid artery) syndrome stroke
- ICA comes off the common carotid artery and gives off an ophthalmic branch and terminates in the ACA (anterior cerebral artery)
- Has signs and symptoms similar to MCA involvement with reduced levels of consciousness
Characteristics of an ACA stroke
- LEs affected more than UEs
- Contralateral hemiplegia
- Contralateral hemisensory loss
- Urinary incontinence
- Problems with bimanual tasks
- Apraxia (inability to perform particular purposeful actions)
Characteristics of a PCA stroke
- Contralateral sensory loss
- Involuntary movements: choreoathetosis, tremor, hemiballismus
- Transient contralateral hemiparesis
- Homonymous hemianopsia
Characteristics of an internal capsule lesion posterior limb stroke
- Lacunar (pure motor) stroke
- Contralateral hemiplegia UE and LE
Describe the different types of vertebrobasilar artery syndrome
- Medial medullary syndrome: occlusion of the vertebral anterior branch of the lower basilar artery
- Lateral medullary (Wallenberg’s) syndrome: occlusion of vertebral, posterior inferior cerebellar, or basilar artery
- Basilar artery syndrome: occlusion at the level of the pons; locked-in syndrome
- Medial inferior pontine syndrome: occlusion of the paramedic branch of basilar artery
- Lateral inferior pontine syndrome: occlusion of the anterior inferior cerebellar artery (AICA)
Characteristics of a midbrain stroke
- Contralateral hemiplegia
- Possible contralateral CN III palsy
Characteristics of a medial pontine syndrome stroke
- Ipsilateral: nystagmus, cerebellar ataxia, paralysis of conjugate gaze to side of lesion, diplopia
- Contralateral: hemiparesis UE/LE, impaired sensation
Characteristics of a lateral pontine syndrome (AICA) stroke
- Ipsilateral: ataxia, nystagmus, vertigo, facial paralysis, paralysis of conjugate gaze to the side of the lesion, deafness, tinnitus, impaired facial sensation
- Contralateral: impaired pain & temperature sensation half of body
Characteristics of a medial medullary syndrome stroke
- Ipsilateral: paralysis of half of tongue
- Contralateral: hemiplegia UE/LE, impaired sensation
Characteristics of a lateral medullary (Wallenberg’s) syndrome stroke
- Ipsilateral: ataxia, nystagmus, vertigo, loss of pain & temperature to face, sensory loss UE/trunk/LE
- Contralateral: loss of pain & temperature to body & face
What parts of the brain are involved in a pure sensory lacunar stroke
- Involvement of the ventrolateral thalamus or thalamocortical projections
What parts of the brain are involved in a dysrthria/clumsy hand syndrome stroke
- Involving the base of the pons, genu of anterior limb, or the internal capsule
What parts of the brain are involved in a ataxic hemiparesis stroke
- Involving the pons, genu of internal capsule, corona radiata, or cerebellum
What are the 6 sequential recovery stages of a stroke
- Stage 1: initial flaccidity, no voluntary movement
- Stage 2: emergence of spasticity, hyperreflexia, synergies (mass patterns of movement)
- Stage 3: voluntary movement possible, but only in synergies; spasticity strong
- Stage 4: voluntary control in isolated joint movements emerging, corresponding decline of spasticity & synergies
- Stage 5: increasing voluntary control out of synergy; coordination deficits present
- Stage 6: control & coordination near normal
Behaviors of a left hemisphere lesion (right hemiplegia)
- Slow
- Cautious
- Hesitant
- Insecure
- Often aware of their impairments resulting in frustration
- Aphasia
Behaviors of a right hemisphere lesion (left hemiplegia)
- Impulsive
- Quick
- Indifferent
- Often exhibit poor judgement & safety, overestimating their abilities while understanding their problems
- Perceptual deficits
Describe the components of an UE flexion synergy
- Scapular retraction/elevation
- Shoulder abduction, ER
- Elbow flexion
- Forearm supination
- Wrist and finger flexion
Describe the components of an UE extension synergy
- Scapular protraction
- Shoulder adduction, IR
- Elbow extension
- Forearm pronation
- Wrist and finger flexion
Describe the components of an LE flexion synergy
- Hip flexion, abduction, ER
- Knee flexion
- Ankle DF/inversion
Describe the components of an LE extension synergy
- Hip extension, adduction, IR
- Knee extension
- Ankle PF/inversion
What are some typical gait deficits in stroke patients
- Retracted/flexed hip
- Trendelennburg limp
- Scissoring
- Insufficient pelvic rotation during swing
- Circumduction
- Knee hyperextension
- Footdrop
- Unequal step lengths
- Decreased cadence, uneven timing
Key red flags/PT implications for stroke patients
- Avoid traction or overhead activity when pts have flaccid shoulder muscles with risk of subluxation/dislocation
- Emphasize compensation strategies for pts with sensory & perceptual losses to prevent additional injury & functional losses
- Monitor HR and BP closely during exercise or activity training; monitor for signs?symptoms of cardiovascular compromise
Common outcome measures used/specific for stroke patients
- Fugl-Meyer assessment of motor performance
- Functional independence measure (FIM): motor & cognitive tasks
- Postural assessment scale for stroke patients
- Trunk impairment scale
- Stroke impact scale: self report
Interventions for stroke patients
- Promote active problem solving independence
- Focus one goal directed tasks
- Compensatory strategies
- Improve cardiopulmonary endurance & aerobic conditioning
- BWS (body weight support) and motorized treadmill training
- Constraint induced movement therapy (CIMT)
- AFO
- FES (functional electrical stimulation)
Common drugs and their purpose used for strokes
- t-PA: indicated for acute ischemic stroke; monitor BP
- Baclofen, Tizanidine, Dantrolene sodium (anti-spasticity): indicated to relax skeletal muscle/anti-spasticity; fall risk, monitor functional ability & limitations
- Diazepam: indicated for anti-spasticity, seizure prevention; fall risk, reduced psychomotor ability
- Botulinum (botox): indicated for local relief of muscle tone & spasms; rare systemic effects including generalized weakness, flaccidity, difficulty speaking, dysphagia, and/or respiratory distress
How to promote learning in left hemisphere lesions (right hemiplegia)
- Develop an appropriate communication base: words, gestures, pantomime; assess level of understanding
- Give frequent feedback & support
- Do not underestimate ability to learn
How to promote learning in right hemisphere lesson (left hemiplegia)
- Use verbal cues; demonstrations or gestures may confuse pts with visuospatial deficits
- Give frequent feedback: focus on slowing down & controlling movement
- Focus on safety
- Avoid environmental clutter
- Do not overestimate ability to learn
What are the 4 types of primary brain injury for a TBI
- Diffuse axonal injury: disruption/tearing of axons & small blood vessels
- Focal injury: contusions, lacerations, mass effect from hemorrhage, & edema
- Coup-contracoup: injury at point of impact & opposite point of impact
- Closed or open injury: with fracture of the skull
What are the secondary brain damage to TBI
- Hypoxic-ischemic injury: results from systemic problems that compromise cerebral circulation
- Swelling/edema: can cause mass effect with increased ICP, brain herniation, & death
- Electrolyte imbalance and mass release of damaging neurotransmitters
Define a concussion
- Loss of consciousness either temporary or permanent resulting from injury or blow to head with impaired functioning of the brainstem reticular activating system (RAS)
- May see changes in HR, BP, & RR
What re the CPG recommendations for AFO/FES use post-stroke
- Chronic FES: increase tibialis anterior activation, improve dynamic balance, improve walking endurance, improve mobility, improve gait speed
- Acute FES: improve mobility
- Chronic AFO: improve gait speed, mobility, walking endurance, dynamic balance, QoL for footdrop
- Acute AFO: improve gait speed
What are the recovery stages from diffuse axonal injury
- Coma: unable to arouse
- Unresponsive wakefulness syndrome/vegetative state: return of sleep/wake cycles
- Mute responsiveness/minimally responsive: pt shows signs of fluctuating awareness
- Confusional state: all cognitive operations are affected; pt is unable to form new memories
- Emerging independence: some memory possible, frequently uninhibited social behaviors
- Intellectual/social competence: increasing independence although cognitive difficulties persist along with behavior/social problems
Describe a signs/symptoms of a mild TBI
- LOC ≤30 min
- Alteration of consciousness is brief; >24hrs
- Posttraumatic amnesia <1 day
- Glasgow Coma Scale 13-15
- Imaging is normal
Describe a signs/symptoms of a moderate TBI
- LOC >30 min but <24hrs
- Alteration of consciousness >24hrs
- Posttraumatic amnesia 1-7 days
- Glasgow coma scale 9-12
- Imaging can be normal or abnormal
Describe a signs/symptoms of a severe TBI
- LOC >24hrs
- Alteration of consciousness >24hrs
- Posttraumatic amnesia >7 days
- Glasgow coma scale <9
- Imaging can be normal or abnormal
Outcome measures recommended for TBI
- Functional Independence Measure (FIM)
- Rancho’s Levels of Cognitive Functioning (LOCF)
- Coma Recovery Scale
- Agitated Behavior Scale
- Mass Attention Rating Scale
- Modified Ashworth Scale
- Action Research Arm Test (ARAT)
- High Level Mobility Assessment (Hi-mat)
- Community Balance & Mobility Scale
- Dizziness Handicap Inventory (DHI)
- Community Integration Questionnaire
What are the levels of the Rancho’s Levels of Cognitive Function (LOCF)
- I: no response
- II: Generalized response
- III: Localized response
- IV: confused, agitated response
- V: confused, inappropriate, non agitated response
- VI: confused, appropriate response
- VII: automatic, appropriate response
- VIII: purposeful, appropriate response
Define sympathetic storming and what to examine for
- The result of hypothalamic stimulation of the SNS with an increase in circulating corticoids & catecholamines (stress response)
- Examine for alterations in LOC, increased posturing, dystonia, HTN, hyperthermia, tachycardia, tachypnea, diaphoresis, & agitation
Common drugs used for TBI/SCI management
- Baclofen, Tizanidine, Dantrolene sodium: relax skeletal muscle, anti-spasticity
- Diazepam: anti-spasticity, seizure prevention
- Botulinum toxin (Botox): local relief of muscle tone & spasms
- Carbamazepine, Gabapentin, Pregabalin: seizure prevention, spasticity (gabapentin); fall risk, monitor seizure Hx, functional ability, & limitations
Concussion signs observed
- Appears dazed or stunned
- Can’t recall events prior to or after a hit/fall
- Forgets an instruction, appears confused
- Moves clumsily
- Answers questions slowly
- Loses consciousness
- Shows mood, behavior, or personality changes
Concussion symptoms reported
- HA or pressure in head
- Nausea or vomiting
- Balance problems, dizziness, blurry vision
- Bothered by light or noise
- Feeling sluggish, hazy, foggy, or groggy
- Confusion, concentration or memory problems
- Just not “feeling right” or “feeling down”
Seek immediate emergency care if the adult or child experiences any of the following after a blow/hit to the head (possible TBI)
- Drowsiness or inability to wake up
- One pupil larger than the other
- Repeat vomiting or nausea, convulsions, or seizures
- LOC lasting longer than 30 secs
- HA that gets worse over time
- Slurred speech, numbness, or decreased coordination
- Changes in behavior: irritability, restlessness, agitation
- Confusion, disorientation, or amnesia
Describe second impact syndrome
- A 2nd concussion is experienced before the brain has a chance to heal from the first event
Describe post concussion syndrome
- Persistent post concussion symptoms lasting ≥3 months
- Symptoms may include post-traumatic seizures, increased risk of depression, and mild-cognitive impairment later in life
Define chronic traumatic encephalopathy (CTE)
- A progressive neurodegenerative brain disease resulting form repetitive head trauma
- Seen in athletes & boxers with a Hx of multiple concussions & repeated head injury
Level A evidence for examination and treatment of concussion/mild TBI
- Assess Dix-Hallpike test or other appropriate positional test(s)
- Use carnality repositioning intervention for vestibulo-oculomotor impairments
- Provide symptom guided, progressive, aerobic exercise training program
Typical signs and symptoms of chronic traumatic encephalopathy (CTE)
- Recurrent HA and dizziness
- Cognitive impairments: memory loss, difficulty thinking, planning, & carrying out tasks eventually progressing to dementia
- Mood or behavioral disturbances
- Impaired judgement & impulse control, aggression, irritability, anger
- Movement disorders (late)
Signs and symptoms of epilepsy
-Altered consciousness
- Altered motor activity (convulsion): tonic - stiffening & rigidity or muscles; clonic - rhythmic jerking or extremities
- Sensory phenomena
- Autonomic phenomena: sudden attack of anxiety, tachycardia, sweating, abnormal sensation rising up in upper abdomen & chest
- Cognitive phenomena: sudden failure of comprehension, inability to communicate, hallucinations
Describe a grand mal/generalized seizure
- All areas of brain are involved
- Dramatic LOC with stiffening then rhythmic movements of arms/legs
- Eyes are generally open
- Altered breathing
- Loos of urine
- Typically lasts 2-5 minutes
Describe an absence/petit mal seizure
- Posture is maintained
- Repetitive blinking or other small movements may be present
- Typically brief only lasts a few seconds
- Can occur multiple times throughout the day
Describe a partial/focal seizure
- Only one part of the brain is involved
- Symptoms are focal (specific are of the body)
Define status epilepticus
- Prolonged seizure or a series of seizures (lasting >30 minutes) with very little recovery between attacks
- May be life threatening
- Medical emergency
Signs and symptoms of a vestibulocerebellar/flocculonodular lobe (archicerebellum) lesion
- Ocular dysmetria
- Poor smooth pursuit
- Dysfunctional vestibulo-ocular reflex (VOR)
- Impaired eye/hand coordination
- Gait/trunk ataxia
- Little change in tone or dyssynergia or extremity movements
Signs and symptoms of a spinocerebellum/rostral cerebellum/anterior lobe (paleocerebellum) lesion
- Hypotonia with weakness/fatigue
- Truncal ataxia: dysequilibrium, static postural tremor, high guard arm position
- Ataxic gait: unsteady, increased falls
Signs and symptoms of a hemisphere/posterior lobe (neocerebellum) lesion
- Intention tremor
- Dysdiadochokinesia: impaired RAM
- Dysmetria: overshooting, errors of force, direction, amplitude
- Dyssynergia: abnormal timing of movement (errors in onset, stop, and velocity)
General signs and symptoms of a cerebellum lesion
- Asthenia: generalized weakness (3-4/5 MMT)
- Hypotonia: difficulty with postural control of proximal (axial) muscles
- Motor learning impairments: decreased anticipatory control, feedback, & learning delays
- Cognition deficits in info procession, attention deficits
- Emotional dysregulation: changes in emotional behaviors
What kind of motor learning strategy is useful in treatment of patients with a cerebellum lesion
- Low-stimulus environment (closed environment) ideal
- Focus on practice & repetition
- Distributed practice (endurance may be low)
Describe multiple sclerosis (MS)
- Chronic, progressive, demyelinating disease of the CNS affecting mostly young adults (20-50 yrs)
- Female affected more than males
- Characterized by demyelinating lesions (plaques) with variable symptoms
- Exacerbating factors include infections, trauma, pregnancy, and stress
Things that cause transient worsening of MS symptoms
- Adverse reactions to heat
- Hyperventilation
- Dehydration
- Fatigue
What re the 4 types of MS
- Relapsing remitting: discrete attacks of neurological deficits with either full/partial recovery (85% of cases); lack of disease progression when in remission
- Primary progressive: disease progression & a deterioration in function from onset
- Secondary progressive: initial relapsing-remitting course followed by a change to a progressive course with a steady decline in function
- Progressive relapsing: steady deterioration in disease from onset but with occasional acute attacks; continuation of disease progression when in remission
Define clinically isolated syndrome (CIS) for MS
- 1st episode of inflammatory demyelination in the CNS that could become MS if additional activity occurs; can progress to relapse remitting MS
What re 2 common causes of death in MS patients
- Urinary tract infection (UTI)
- Respiratory infection
Classic signs and symptoms of Parkinson’s disease (PD)
- Rigidity (leadpipe or cogwheel)
- Bradykinesia (hypokinesia/slow movements)
- Resting tremor
- Impaired postural reflexes
What are the 5 stages of PD (Hoehn and Yahr classification)
- I: minimal or absent disability, unilateral symptoms
- II: minimal bilateral or midline involvement, no balance involvement
- III: impaired balance, some restrictions in activity
- IV: all sx present & severe, stands & walks only with assistance
- V: confinement to bed or wheelchair
Pharmacology for Parkinson’s disease
- Levodopa & Carbidopa: help with PD motor sx
- COMT inhibitors (Catecholo-Methyl Transferase): prolongs levodopa effects
- Dopamine agonists: may slow early disease progression
- Anticholinergics: help control tremors, rigidity, & dystonia
- Amantadine: enhances dopamine release
- Monoamine Oxidase inhibitor (MAO)/Selegiline: increases dopamine; used during early disease to slow progression
