Neurology W1 Flashcards
stroke, brain injury, concussion
Describe the ABCD rule of stroke prognosis
A = age, B=blood pressure, C=clinical features, D=duration
A clinical prediction tool used to determine the risk of stroke on the days following a TIA
How soon after a thrombotic stroke does tissue plasminogen activator need to be injected
Within first 3 hours of initial symptoms
A stroke in which side of the brain is more likely to cause aphasia?
Left
Wernicke’s aphasia description and location
Receptive/fluent, left temporal lobe
Broca’s aphasia description and location
Expressive/non-fluent, left frontal lobe
A pt’s left side is hemiparretic, which side should you lay them on and why
There left side as long as shoulder is positioned correctly - can decrease tone, prevent subluxation and free the good arm to be able to assist in mobility
What factors can impact prognosis post cva? name 4.
Decreased age, location of stroke, ability to voluntarily move fingers (pyramidal motor output intact), absence of aphasia or other cognitive deficits and absence of incontinence
Describe the penumbra of a stroke
The area of the brain at risk of dying as its located between the site of perfusion and necrosis- it can remain viable for several hours post stroke which is why time is of the essence in ischemic strokes
What is a Lacunar stroke?
Blockage of small deep penetrating arteries of the brain that feed the deep nuclei of the brain
basal ganglia & deep cereballer nuclei
In what area of the brain are hemorrhagic strokes more likely to occur (2)?
Cerebral cortex and basal ganglia
What potential symptoms are associated with a right sided CVA? Name 4
- visual agnosis (objects)
- prospagnosia (faces)
- anosognosia (deny)
- distorted awareness / impression of self (L sided neglect)
- short attention span
- dec musical/artistic abilities
What are some benefits towards performing transfers towards the hemiparetic side?
- retains motor control
- Dec extensor strategy by WB while maintain knee flex
- directs attention and vision to affected side
What is the major function of the frontal lobe
Primary motor cortex, Broca’s area (speaking), and cognition
What is the major function of the parietal lobe?
- Primary sensory cortex,
- short term memory
What is the major function of the occipital lobe?
Primary visual
What is the major function of the temporal lobes?
Primary auditory, wernicke’s area (receptive), long term memory, olfactory area
What things are located medially on the motor and sensory homonculus?
Motor: toes, feet, leg,
Sensory: genitals, feet, legs
An ACA stroke would affect upper or lower extremity more? (Think homonculus)
Legs (ACA supplies frontal lobe)
if a stroke occured in the left ACA, what deficits would be expected?
weakness & sensory loss of right LU
*emotional liability, changes to personality, disinhibition, memory impairment (frontal lobe)
*seizures
Internal carotid artery supplies…
Anterior 2/3 of cerebrum except for temporal and occipital lobes
Where is the most common site for an ischemic strokes?
Middle cerebral artery
if there was a stroke to the right MCA, what deficits would be expected?
weakness and sensory loss of left UE and face, difficulty with ADLS
*left sided homonymous hemianopsia
*left sided neglect
*anaosognosia
*aphasia (could be broca’s or wernickes)
*impaired hearing
a stroke in which areas are likely to cause horners syndrome?
internal carotid artery
*brainstem stroke (PICA, AICA, SCA)
what deficits will a stroke to the left PCA cause?
right sided homonymous hemianopsia, disorders of reading and colour vision
*thalamic pain syndrome
*CN 3 palsy, right sided hemiplegia and hemisensory loss
*chorea, hemiballismus
*memory impairments (temporal lobe)
What are symptoms of horners syndrome?
- Droopy eyelid (ptosis)
- constricted pupil (miosis)
- dry/red face on IL side
Posterior cerebral artery supplies…
Part of temporal and occipital lobes, thalamus and upper brainstem
Vertibrobasilar system supplies…
Posterior 2/5 of the cerebrum, part of the cerebellum and the brainstem
What is “locked in” syndrome and when does it occur?
Pt is aware but can’t move or communicate verbally due to paralysis of all voluntary muscles except for vertical eye mvmts and blinking.
Occurs when there is damage to portions of lower brain/brainstem without damage to upper brain stem
Name the 3 arteries of the cerebellum and where they arise from
- Superior cerebellar artery from basilar
- Anterior inferior cerebellar artery from basilar
3 posterior inferior cerebellar artery from vertebral
What is lateral medullary syndrome or Wallenberg syndrome? And what are s/s?
Damage or clot in PICA, it is the most common brainstem syndrome.
Symptoms include: loss of pain/temp on CL trunk, loss of pain/temp on IL face, IL limb ataxia, horners syndrome, dysphasia, hoarse voice, etc
What differentiated Wallenberg syndrome from damage to AICA?
AICA symptoms include fascial paralysis and hearing loss
Describe a primary traumatic brain injury
Damage that occurs at the moment of trauma when tissues and blood vessels are stretched, compressed or torn.
Coup vs contra coup for brain injury
Coup = damage that occurs on the same side of the brain as the impact
Contra coup= damage to the brain as a result of forces causing it to hit skull on opposite side.
What are some potential causes of secondary brain injury?
- ischemic: BF is usually 50% less than pre-injury level
- cerebral edema leading to increased ICP
- release of free radicals
- electrolyte imbalances
- excessive release of glutamate
What is a normal ICP level and what is too high?
Normal = 0-15mmHg
BAD = >20 mmHg
Where is CSF produced?
By the choroid plexus in the ventricles
How much CSF is produced per day and how much is present in subarachnoid space?
500mL, 150mL
What are signs of a basal skull fracture?
Blood/CSF out of nose or ears, raccoon eyes, bruising over mastiod
What are contraindications for basal skull fracture?
Nasal suctioning or NG tube
Interprete scores of Glasgow coma scale
13-15 =mild BI
9-12=moderate BI
<8=severe Bi
How often is coma pt recommended to wear splints?
6-8 hours to prevent contractures
Why is initial nutrition important for coma patients?
Metabolism increases because of
1. Doubled energy expenditure for up to 4weeks
2. Inc brain glucose metabolism due to metabolic cascade
3. Inc muscle tone and issues with temp regulation
What is the prognosis for pts in a vegetative state?
50% of TBI pts in a vegetative state 1 month post trauma will recover consciousness (may have motor/cognitive deficits)
Describe decorticate vs decerebrate posturing.
Decorticate = LE in extension, UE in flexion - damage above red nucleus (cerebral hemisphere or corticospinal tract)
Decerebrate = neck extended, LE IR & extended, UE extended with wrist flex - damage below red nucleus to cerebellum or brainstem
What is a subarachnoid hemorrhage
High pressure art bleed between the arachnoid and pia
What is a sub-dural hematoma
Low pressure bleed with blood collecting between dura and arachnoid
What is an Epidural hematoma
Rapid arterial bleed occurring between crainial vault and dura (outside dura)
Which 2 hemorrhage/hematomas can be fatal and why
Subarachnoid and epidural because they are arterial bleeds
What deficits can be expected with damage to frontal lobe
- poor planning and judgement
- disinhibition
- Broca’s aphasia
- altered manners and moral/emotions
What deficits can be expected with damage to parietal lobe
- somatosensory function alterations in touch, pressure, temp and position awareness, some language comprehension (wernicke’s), apraxia (motor planning issues)
What deficits can be expected with damage to temporal lobe
Broca’s and wernicke’s aphasia, memory impairment, auditory processing, integration and regulation of emotions, motivation and behaviour
What are some symptoms of a concussion
Drowsiness, HA, confusion, vision problems, light/noise sensitivity
What are some signs of a concussion
Vomiting, balance impairment, trouble with memory recall, change in pupil size
How many people are likely to get post concussion syndrome and how is this classified
10-20% of concussions cases, classified by symptoms lasting longer than a month
What are the components of a VOMS screen
- smooth pursuit
- saccades
- convergence
- VOR (vestibular-ocular reflex) test
- VMS (visual motion sensitivity) test
According to the Canadian CT head rule, who is at high risk for neurological intervention?
- GCS score <15 at 2hrs post injury
- suspected open/depressed skull fracture
- any sign of basal skull fracture
- vomiting > 2 episodes
- age > 65years
What is the SCAT 5
Sport concussion Ax tool, used for baseline Ax of suspected concussion, 13+
When can the SCAT 5 be performed
Immediately post injury or within 72 hours
What is the King Devick test? What does it assess?
Sideline concussion screening tool that can be administered in less than 2 minutes
- assess eye mvmt, attention and language
What is second impact syndrome?
Rare, fatal uncontrolled swelling of the brain that occurs when someone suffers a minor 2nd blow before symptoms of prior brain injury are resolved
What is post concussion syndrome?
Persistent concussion symptoms that have lasted longer than 1 month post concussion
What factors increase risk of post concussion syndrome?
- hx of TBI
- female
- inc age
- anxiety/depression
- learning disability
- employment
- access to care
When can a patient progress to the next phase of their concussion return to play?
When they have been symptom free for 24hours, if any symptoms occur - pt must go back to previous asymptomatic level for atleast 24 hours
What is a seizure?
Sudden change in electrical activity in the brain causing changes in behaviour, movement or consciousness
What is epilepsy?
Group of non-communicable neurological disorders characterized by recurrent excessive and synchronized electrical discharge
What is a primary generalized seizure and name the 2 types.
Definition: bilateral and symmetrical w/o local onset
1. Tonic-clonic (grand mal)
2. Absence seizures
What is a grand mal seizure
Bilateral, convulsive stiffening and rhythmic muscle contractions, 2-5min
What is a Petit mal seizure?
Brief LOC and return, generally not followed by a period of lethargy
What are the 3 types of simple partial seizures?
Focal motor, focal motor w/ March (Jacksonian), temporal lobe seizure
Name the 5 neuroanatomy groupings of the brain and what they are made up of
- Telencephalon - cerebral cortex
- Diencephalon - thalamus
- Mesencephalon - midbrain
- Metencephalon - pons + cerebellum
- Myelencephalon - medulla
What are Brunnstrum’s 7 stages of stroke recovery?
