Neuro - Wk 3 Quiz Material Flashcards
What questions do we need to ask ourselves about a lesion?
Where is it? One or multiple? Confined to NS or systemic dz? What part of NS is affected? Is it a tumor, infection, or hemorrhage?
In Past Medical Hx what organ systems do we need to explore?
Cardio (HTN, CVD?), Neuro (Stroke, TIAs, Psychiatric illness?), Endocrine (DM?), Hepatobiliary (Liver dz?), Trauma (TBI, Concussion, MVA?), Overall systemic (CA?)
In Family Hx what diseases should we ask about?
Alzheimer’s, Parkinson, CVD
What should we ask about in ROS?
Any pain. HEENT: Headache, visual changes, dizziness.
Neuro: Tremor, weakness, sensory loss, LOC, motor dysfunction, speech or swallowing concerns.
2 Mental Status Exams
FOGS, Mini mental status exam (MMSE), and Montreal Cognitive Assessment (MoCA)
F- Family Story of Memory Loss
O- Orientation (to precise time month, day, year)
G- General Information (president & vp of the US)
S- Spelling (spell “world” forward & back, if not, then try a 4 letter, then a 3 letter word).
Testing CN 1
Olfactory nerve. Can be helpful if a frontal lobe lesion suspected (personality change, hemiparesis, unexplained visual loss).
Test each side w/a mild agent (soap, coffee, chocolate)
Testing CN 2
Optic nerve. Visual fields near & far, gross fields, opthalmoscopic exam.
Testing CN 3, 4, 6
Oculomotor, Trochlear, Abducens. PERRLA & H + X in space.
Testing CN 5
Trigeminal. Stimulate nerve distribution with light touch.
Testing CN 7
Facial nerve. Smile.
Testing CN 8
Vestibulocochlear. Can they hear your fingertips moving?
Testing CN 9, 10
Glossopharyngeal, Vagus. Gag reflex.
Testing CN 11
Spinal Accessory. Shoulder elevation.
Testing CN 12
Hypoglossal. Stick out the tongue.
Motor System test - pronator drift
Upper extremity drift (pronator drift). Stand with eyes closed & arms forward horizontally, palms up for 15-30 sec. If (+) a hand will drop and rotate in b/c pronators are stronger. Suggests an upper motor neuron lesion.
Coordination test - finger-to-nose, heel-to-shin
Awkwardness of movement in cerebellar lesions.
Balance test - Rhomberg
Everyone needs 2 of vision, vestibular sense, and proprioception to balance. (+) test is that the pt sways when they close their eyes. *Not positive if they sway before they close their eyes.
Babinski reflex
Abnormal dorsiflexion of big toe & fanning of the other toes when the bottom of the foot is stroked. Normal in infants, goes away. (+) indicates upper motor neuron lesion. (UMN lesion)
Meningitis tests
Kernig - pain in low back on straightening lower extremity.
Brudzinski - flexion of head results in neck pain & involuntary flexion of the hip and lower extremities
In general, what 4 labs might we want to run?
CBC (infection, anemia), CMP (electrolyte, kidney, blood sugar), TSH, **Bedside glucose (starred b/c we can do it in office, WHILE waiting for an ambulance if need be)
In general, what are the 3 biggest imaging/procedures we might need?
CT (faster), MRI (smaller bleeds), Lumbar puncture
Stroke - Definition & overview
Sudden interruption of cerebral blood flow that results in neurologic deficit. Third most common cause of death & most common cause of neurologic disability. A stroke involving the internal carotid may affect the anterior 2/3 of the brain and is likely to have unilateral sxs. A stroke involving the vertbrobasilar arteries may affect the posterior portion of the brain (temporal, parietal, brainstem, cerebellum), can have unilateral or bilateral sxs, and is more likely to affect consciousness
Stroke - Risk Factors
Old age, HTN, Cigarette smoking, prior stroke, family hx, alcoholism, male sex, hypercholesterolemia, diabetes, some drugs (cocaine, amphetamines), abdominal obesity, lack of physical activity, hypercoagulability.
Stroke - SSx & FAST
Occur suddenly. HA that is sudden, severe, “different,” Contralateral limbs affected, numbness, weakness, or paralysis of face or contralateral limbs, aphasia (difficulty speaking or understanding), confusion, visual disturbances in one or both eyes, dizziness or loss of balance & coordination.
F- facial asymmetry/drooping. A- arms & arm weakness, S- Speech, T- time (onset & call 911 NOW!)
Etiology of Ischemic Stroke
80% of strokes.
- Thrombosis (Atherosclerosis, vascular inflammation, hypercoagulability disorders, older OCPs),
- Emboli (from cardiac thrombi thrown off in fibrilation, RHD, MI, vegetations, prosthetic valves, or rarely fat emboli, air, or venous clots),
- Lacunar (small vessel dz, usu in older pts with DM or poorly controlled HTN),
- *TIA (transient ischemic attack or “mini stroke”
SSx of Ischemic Strokes by type
- Thrombotic: often occur at night, noticed on waking. slower onset of sx 24-48hrs “evolving stroke,” may look like dysfunction beginning in 1 arm & then spreading ipsilaterally. Extends without HA, pain, or fever
- Embolic: Quicker onset occuring in minutes, often during the day, HA may precede neurologic deficit
- Lacunar: she isn’t testing on (and TIAs aren’t mentioned here)
Dx an Ischemic Stroke
Usually Dx is clinical. CT (faster) & MRI (smaller infarcts). Do bedside glucose testing to r/o hypoglycemia!
DDx for Ischemic Stroke
Hypoglycemia, postictal paralysis, hemorrhagic stroke, migraine, tumor, systemic conditions (Guillan Barre, Bell’s Palsy), Syncope
Etiology of Hemorrhagic stroke
20% of strokes - focal bleeding from a blood vessel in the brain parenchya, usually caused by HTN
Less commonly- arteriovenous malformations (AVMs), Aneurysm, Trauma, Brain tumor, Bleeding disorder.
OR Subarachnoid Hemorrhage, usually caused by ruptured aneurysm.
SSx of Hemorrhagic stroke by type
Bleed into Parenchyma: Focal neuro deficit (already concerning) w/HA, Nausea, Impaired consciousness, nausea, vomiting, delirium, focal or generalized seizures, s/t hemiparesis or brain stem/cerebellar dysfunction.
SAH: Severe sudden HA with LOC, severe neurologic deficits, seizure possible, no neck stiffness, m/b vomiting.
Dx of Hemorrhagic stroke
Bleed into Parencyma: (Send to ER immediately…) CT, MRI, Bedside blood glucose (if you don’t do this… she’s gonna get you!)
SAH: Non-contrast CT, if that’s negative, lumbar puncture **blood in the CSF!*
DDx for Hemorrhagic stroke
Ischemic stroke, subarachnoid hemorrhage, hypoglycemia, seizure
Possible PE findings on subarachnoid hemorrhage
temp increase, tachycardia, papilledema, retinal hemorrhage, global or focal neuro abnormalities
Delirium vs Dementia - what does each affect?
Delirium - attention
Dementia - memory
Delirium vs Dementia - Onset
Delirium - Sudden onset w/a definite beginning point
Dementia - Slow & gradual, uncertain beginning point
Delirium vs Dementia - Duration
Delirium - Days to weeks, m/b longer
Dementia - Permanent usually
Delirium vs Dementia - Cause
Delirium - Almost always another condition (infection, dehydration, use or withdrawal of drugs)
Dementia - Usually a chronic brain disorder (Alzheimers, Lewy body dementia, vascular dementia)
Delirium vs Dementia - Course
Delirium - Reversible usually
Dementia - Slowly progressive
Delirium vs Dementia - At night
Delirium - Almost always worse
Dementia - Often worse
Delirium vs Dementia - Attention
Delirium - Greatly impaired
Dementia - Unimpaired until dementia becomes severe
Delirium vs Dementia - Level of Consciousness
Delirium - Variably impaired
Dementia - Unimpaired until dementia becomes severe
Delirium vs Dementia - Orientation to time & place
Delirium - Varies
Dementia - Impaired
Delirium vs Dementia - Use of language
Delirium - Slow, often incoherent, inappropriate
Dementia - Sometimes difficult to find the right word
Delirium vs Dementia - Memory
Delirium - Varies
Dementia - Lost, especially for recent years
Delirium vs Dementia - Need for medical attention
Delirium - Immediate
Dementia - Required, less urgently
SSx of Delirium
Difficulty focusing, maintaining, or shifting attention
Fluctuating consciousness
Disoriented to time & space
M/b hallucinations, delusions, paranoia
Confusion
Changes in personality or affect
Required to Dx Delirium
*Acute change in cognition that fluctuates throughout the day. *Inattention (difficulty focusing or following what is said). *Plus one of: (1) disturbed consciousness (reduced clarity/awareness of the environment) [Diagnostic statistical manual DSM], or (2) altered level of consciousness (hyper-alert, lethargic, stupor, comatose) or disorganized thinking (rambling, irrelevant conversation, illogical flow of ideas) [Clinical Assessment Manual CAM)
PE for Delirium pt
- Vitals (fever, meningismus, Kernig/Brudzinski signs)
- Hydration status
- Foci for infection
- Skin, head, neck (lacerations, bruising, welling, trauma)
- Neurologic exam (focal abnormalities or papilledema)
Labs/Imaging for Delirium
Firstly - CT/MRI, tests for infection, electrolytes, BUN, Creatinine, Glucose, Drug screen (blood & urine)
Second - LFTs, serum calcium, albumin, TSH, bitamin B12, ESR, ANA, and syphilis testing.
Third - CSF, serum ammonia, heavy metals
Prognosis for Delirium
Hospitalized pts have higher morbidity & mortality. Some resolve with tx, may be slow. Risk of further decline is increased for up to 2 years after the event.
Most common diseases that cause Dementia
Alzheimer’s, Vascular Dementia, Lewy Body Dementia & Parkinson Disease, HIV-associated Dementia, and Frontotemoral Dementia.
Not-the-most-common-diseases that can cause dementia
Parkinson’s, Huntington, Progressive supranuclear palsy, Prion disorders, Neurosyphilis, and some others I don’t recognize.
Causes of “Dementia” that may be reversible
Normal Pressure Hydrocephalus, Hypothyroidism, B12 deficiency, Lead toxicity
SSx of Dementia
*Short term memory loss m/b first sign. Globally impaired cognition. Slow onset. Personality/behavioral disturbances. Motor/neuro deficits. Increased incidence of seizure. Psychosis in 10%
Early Stage Dementia
Recent memory impaired. M/b difficulty with ADLs. M/b agnosia (lose recognition of common objects), apraxia (difficulty performing a task when asked), and aphasia (difficulty with language). M/b personality changes begin.
Intermediate Stage Dementia
Inability to learn/recall new things. Reduced memory of remote events. M/b needs help with ADLs (toiled, clothes) Loss of sense of time & place.
Late Stage Dementia
Can’t walk, feed self, or other ADLs. M/b incontinent. M/b unable to swallow. End-stage is coma or death often from infection.
Dx Dementia
*History (with pt and someone who knows them) & Mental status exam.
*Physical w/complete Neuro exam.
*Labs: TSH, B12, CBC, LFTs, Consider HIV or RPR.
Imaging: *CT or MRI
Dx REQUIRES- All of: sx that interfere with ADLs, sx are a decline from previous state, sx are not explained by delirium or psychiatric disorder. AND 2 or more of: amnesia, aphasia, agnosia, apraxia, change in personality, behavior, or comportment.
DDx for Dementia
Delirium, Age-associated memory impairment (forget part of a memory & get it back later), Mild cognitive impairment, Cognitive sxs related to depression.
Alzheimer’s Disease (AD)
60-80% of dementia in the elderly. Neurodegeneration from inappropriate deposition of beta-amyloid protein in the brain (which is formed during processing of amyloid precursor protein which is encoded on chromosome 21 & accounts for younger AD in ppl with trisomy 21). Severity of dementia is directly related to the number & distribution of *neurofibrillary tangles, which are associated with tau protein (does maintenance of cytoskeletons). Gradual loss of neurotransmitters occurs - *Acetylcholine is the first and most important. *Advanced age is the biggest risk factor, and *Loss of short term memory is typically the first sign.
Risk Factors for Alzheimer’s
*Advanced age. Family Hx (1st degree relatives especially). ApoE genotype. Trisomy 21. HTN, Stroke, increased fasting homocysteine levels.
SSx of Alzheimer’s
*Loss of short term memory (typically first sign). Increasing forgetfulness, increasing repetitiveness, behavioral sx (suspicion, paranoia, agitation, yelling, wandering)
Differentiating Alzheimer’s from other dementia
Absence of motor deficits makes Alzheimer’s stand out from other dementias. However, as it progresses Parkinsonism can arise, making it more difficult to tell from Lewy body dementia. Use of Modified Hachinski Score can help differentiate AD from Vascular dementia.
Alzheimer’s Dx
Dementia established by a mental status exam, deficits in 2+ areas of cognition, gradual onset with progressive worsening, no disturbance of consciousness, onset after 40 (most after 65), no systemic or brain disorders that could account for the deficits.
Labs/Imaging for Alzheimer’s
Run the Dementia ones, and maybe look for beta-amyloid or tau protein in the CSF. MRI or CT may show loss of volume.
Prognosis for Alzheimer’s
Average is 7 years after dx but varies widely!
Vascular Dementia
Acute or chronic cognitive deterioration due to diffuse or local cerebral infarction usually related to CVD. May be single or multiple episodes. *Second most common dementia among the elderly.
Risk Factors for Vascular Dementia
HTN, DM, Hyperlipidemia, Smoking, *Several Strokes
SSx of Vascular Dementia
Typical dementia things & possible focal neurological deficits as dz progresses: exaggerated DTRs, extensor plantar response, gair abnormalities, weakness of an extremity, hemiplegias, pseudobulbar palsy w/pathologic laughing & crying (emotional incontinence), signs of extrapyramidal dysfunction.
Dx-ing Vascular Dementia
*History revealing a stroke is a big clue. Hachinski Ischemic score can help differentiate from AD. CT/MRI may show multiple bilateral infarcts.
Vascular Dementia Prognosis
5 year mortality rate is 61%
