Patho Final II Flashcards
Meningitis
Inflammation of the brain and spinal cord meninges
Usually the result of a viral infection or bacterial infection
Inflamm. may involve all three meningeal membranes (dura mater, arachnoid, pia mater)
Acute or chronic
Bacterial Meningitis
Often fatal
Rapidly progressive and affects meninges/subarachnoid space
Acute, may develop in children with CF or severe burns; most common cause is Group B streptococci during first 2 months of life
Clinical Picture of Bacterial Meningitis
High fever, chills, photophobia, severe headache, vomiting, neck stiffness progressing to drowsiness, stupor, seizures, coma
When severe, neck flexion may cause hip or knee flexion - Brudzinski’s sign
May be resistance to passive knee extension while hip is flexed - Kernig’s sign
Tx for Bacterial Meningitis
Responds well to IV antibiotics and corticosteroids
Supportive therapies for dehydration, shock, fever, electrolyte disorders, seizures
Prognosis: Good if recognized early and responds well to treatment, poorer for infants and elderly patients (mortality rate is 70-100%)
Encephalitis
Inflammation of the parenchyma of brain tissue due to direct viral invasion. Often carried by mosquitos
Clinical Picture: fever, headache, stiffness in back and neck
Tx: Supportive antiviral medication
Prognosis: Some forms kill most pts or lead to permanent neurologic impairment
Poliomyelitis
Caused by poliovirus entering via the GI tract and manifesting in the spinal cord
Destroys anterior horn cells of motor neurons causing paralysis
Polio vaccine!
Stroke
(cerebrovascular accident (CVA))
More common in people over age 50
Major cause of sudden death in this age group
A sudden impairment of cerebral circulation in one or more blood vessels interrupting or lessening oxygen supply usually causing serious damage or necrosis of brain tissue.
Effects of CVA depend on its location and extent of ischemia
Cause of Stroke
80% of cases - thrombus or embolus, less often hemorrhage
Third leading cause of death in US
Clinical Manifestations of Stoke
BEFAST
sudden unconsciousness, permanent neurologic disability, death
Common symptoms - dysphagia, confusion, poor cognition, hemiparesis
BEFAST - Balance, Eyes, Face, Arm, Speech, Time
Tx of Stroke
Depends on severity but can included anti-coagulant, hypertensive medication
Long term speech and PT
Changing controllable risk factors: smoking, obesity, inactivity, alcohol use
Prognosis: varies with severity and area of brain affected; disability affects 75% of those who survive stroke
Role of PTA with Stroke
Assist pt in reestablishing body control and movements lost due to CVA
Transient Ischemic Attack (TIA)
An episode of cerebrovascular insufficiency associated with a partial occlusion of a cerebral artery by plaque or an embolus
Clinical Manifestations of TIA
varies - dizziness, weakness of limbs, numbness, slurring of speech, brief or mild loss of consciousness
Tx: surgery if indicated to open vessel, antiplatelet drugs, statins, mod risk factors
Epilepsy
Seizure - abnormal, unregulated electrical discharge occurring in the brain’s gray matter that transiently interrupts normal brain function
60% cases are unknown cause
Tx - anticonvulsive medication
Prognosis - based on effectiveness of medications and severity of condition
Dementia
A loss of mental ability because of the loss of brain cells or neurons. Three different categories: Head Trauma Dementia, Substance-Induced Dementia, and Vascular Dementia
Head Trauma Induced Dementia
Largest rate amongst professional athletes who play football, ice hockey, boxing, rugby, mixed martial arts, wrestling
Trauma causes brain cells to die due to blood flow being impaired or stopping
Substance Induced Dementia
Substance abuse from alcohol or addictive drugs directly affect cells in the frontal portion of the brain. Alcohol as early as 30 but common in people 50-70 years old.
Vascular Dementia
Acute or chronic cognitive degeneration via decreased blood flow due to atrophy and death of brain cells. Usually after age 70 following multiple strokes, Alzheimers
Alzheimer’s Disease
A degenerative disorder of the cerebral cortex, especially the frontal lobe. Accounts for more than half of all cases of dementia. Progressive loss of mental function with pts generally living about 7 yrs following dx.
Characterized by death of neurons and their replacement of microscopic plaques. Affects people 70 or older.
Parkinson’s Disease
One of the most common disabling diseases in the US. Involved slow and progressive brain degeneration. Characteristically produces progressive mm rigidity, akinesia, and involuntary tremor.
Clinical Manifestations of Parkinson’s Disease
Rigid and immobile hands, slow speech, fine tremor of the hands with a “pill rolling” motion of fingers, infrequent eye blinking, expressionless facial appearance, flexed arms, a “bent forward” posture, walking gait that consists of short quick steps
Amyotrophic Lateral Sclerosis (ALS)
Degenerative disease that affects the upper and lower motor neurons. Chronic, progressively debilitating disease that may be fatal in less than 1 year or may continue for 10 years or more depending on affected mms.
Clinical manifestations of ALS
weak and wasted mms with stiff, awkward, clumsy movements, decreased mm strength usually starting in hands, mm cramps, loss of weight and feeling unusually tired, twitch in mms and increase in tone, control of facial expressions difficult, slurred speech
Huntington’s Chorea
Genetic disease affecting half of children in families in which one parent has the dominant gene. Does not appear until middle age.
Symptoms include: progressive brain deterioration, loss of mm control
Chorea - involuntary, irregular, unpredictable mm movements
Multiple Sclerosis (MS)
Progressive autoimmune disease characterized by inflammation, selective demyelination, and gliosis. Affects approx. 400,000 people in the US
Clinical and pathological characteristics of MS
Paralysis, Intention tremor, scanning speech, nystagmus
Incidence of MS
Onset of MS typically between 20-50 years old.
Affects predominantly white populations
MS Pathophysiology
Acute inflammatory attack on myelin gradually subsides, contributing to pattern of fluctuations in function that characterize disease:
Notes as relapses (periods of acute worsening of neurological function) and remissions (periods without disease progression and partial or complete abatement of s/s)
Disease course of MS
- Relapsing-Remitting Disease (RRMS): periods of active and non active. Most common course (85% of pts)
- Primary Progressive (PPMS) (15% of pts)
- Secondary-Progressive (SPMS)
Exacerbating Factors of MS
Relapses are defined by new and recurrent MS symptoms lasting more than 24 hrs, but generally of longer duration
Sensory symptoms of MS
Complete loss of any single sensation is rare
Altered sensations far more common (pins and needles) numbness of face, body, and extremities
LE impairments
Pain symptoms of MS
80% of pts experience pain
Significant pain occurring in 55% of individuals - half with chronic pain
Symptoms include:
Trigeminal neuralgia - pain with eating, shaving
Paroxysmal limb pain (abnormal burning, aching pain) - often worse at night and after exercise
Lhermitte’s sign - posterior column damage in SC where flexion of neck causes electric shock-like sensation running down spine and into LEs
Visual symptoms of MS
80% pf pts will have involvement of the optic nerve, producing altered visual acuity
Optic neuritis
Diplopia (double vision)
Motor Symptoms of MS
S/S of upper motor neuron syndrome:
Paresis
Spasticity
Brisk tendon reflexes
Clonus
Babinski’s sign
Weakness - movements that are slow, stiff, weak
Ataxia
Reduced strength, power, endurance
Coordination and Balance symptoms of MS
Demyelinating lesions in the cerebellum and cerebellar tracts are common:
Ataxia (general uncoordinated movements)
Postural and intention tremors
Hypotonia
Traumatic Brain Injury (TBI)
Trauma to the brain, neck, and spinal cord causing many types of disabilities and even death.
Head trauma can lead to edema, increased ICP, hemorrhage, infection.
Severe brain injury: loss of consciousness for more than 30 min and memory loss after injury for longer than 24 hrs
Contact injuries TBI
From contusions, lacerations, intracerebral hematomas. Focal and Coup-contracoup
What is the difference between a concussion and contusion?
A concussion is head trauma that does not physically bruise the brain. A contusion is more serious and is defined as physical bruising of the brain tissue. Often occurs when the skull is fractured.
Concussion Incidence - 70-90% of head injuries
Contusion Incidence - 20-30% of head injuries
Clinical Manifestations of Concussion and Contusion
Main symptom of both - unconsciousness!
Amnesia
Blurred vision, headache, irritability, sudden vomiting
Contusion can lead to hematoma of the brain, increased ICP, brain damage
What is an area of bruised lesion called?
Coup lesion. If an injury occurs on the opposite side of the brain it is considered a contracoup lesion.
What is post concussion syndrome?
Symptoms that may occur for weeks following a concussion including headache, difficulty sleeping, fatigue, short-term memory problems, difficulty concentrating, sensitivity to light/noise, personality changes
How are concussions and contusions diagnosed?
Hx of injury, cranial x-rays, neuro exam, CT/MRI
Glasgow Coma Scale and Rancho Los Amigos Scale to assess head injuries/prognosis
Behavior control is imperative
Better outcomes achieved when PT occurs in familiar settings
Tx for Concussions and Contusions
Concussion - Rest quietly in bed under supervision, waking them q 2-4 hrs to check for changes
Contusion - hospitalized and continually monitored
Head injuries should not receive any pain relief medicine as to not mask in any bad symptoms
What is an epidural hematoma?
Collection of blood between the skull and dura mater. Pt may present with dilated pupils, headache, nausea, vomiting, dizziness, potentially increased ICP, loss of consciousness.
What is a subdural hematoma?
Collection of blood between the dura mater layer and the arachnoid layer (2x as common as epidural). Symptoms related to increased ICP including hemiparesis, nausea, vomiting, convulsions, dizziness, loss of consciousness
What is a subarachnoid hematoma?
Bleeding into the subarachnoid space between the pia mater and arachnoid mater of the meninges. Usually caused by rupture of an aneurysm in an artery. Life threatening.
What are two types of Stroke (CVA)?
Ischemic Stroke - most common (80%) from thrombosis, embolism, hypoperfusion
Hemorrhagic Stroke - occurs when blood vessels rupture causing leakage of blood
Motor deficits from Strokes (CVA)
Paralysis (hemiplegia)
Weakness (hemiparesis)
Typically on side OPPOSITE of the lesion
What are clinical manifestations of Anterior Cerebral Artery Syndrome?
Contralateral hemiparesis and sensory loss (greater involvement of the LE rather than UE)
Urinary incontinence
Apraxia
Abulia (akinetic mutism)
Contralateral grasp reflex
What are clinical manifestations of Anterior Cerebral Artery Syndrome?
Contralateral spastic hemiparesis and sensory loss of face, UE, LE with face and UE more involved than LE
Aphasia
Perceptual deficits
MCA (middle cerebral artery) is the most common site of occlusion of a stroke!
What is Internal Carotid Artery Syndrome?
It is a massive infarction of the region of the brain supplied by the MCA. Can cause obstruction of blood in both MCA and ACA if circle of Willis is absent.
Significant edema with uncal herniation, coma, death
What are clinical manifestations of Posterior Cerebral Artery Syndrome?
Contralateral hemianesthesia (sensory loss)
Central poststroke thalamic pain
Vision issues such as impairment in recognizing objects, language, memory
Bilateral, cortical blindness
What are lacunar strokes?
Caused by small vessel disease deep in the cerebral white matter. Strongly associated with hypertensive hemorrhage and diabetic microvascular disease.
What is Vertebrobasilar Artery Syndrome?
Variety of symptoms both contralaterally and ipsilaterally. Locked-in syndrome (LIS) - sudden onset of acute hemiparesis rapidly progressing to tetraplegia.
Pt cannot move or speak but remains alert and oriented.
What are hemispheric behavioral differences?
L hemisphere lesions (R hemiplegia) demonstrate difficulty in communications and processing info in a sequential, linear manner, cautious, anxious, disorganized
R hemisphere lesions (L hemiplegia) difficulty in spatial-perceptual tasks and grasping the whole idea of a task or activity, quick and impulsive
PT for stroke entalls what?
Stroke Impact Scale
Postural Control and Balance - active pushing with stronger extremities toward hemiparetic side
Gait and Locomotion - balance work
Upper Limb Use - avoid contracture in paretic limbs
What is Cerebral Palsy?
A persistent disorder of posture and movement caused by non progressive defects of lesions of the immature brain. Symptoms appear before age 5. Can include: ataxia (poor coordination) and involuntary movements
Tx of Cerebral Palsy
PT and OT for good movement patterns, strengthening, and stretching. Bracing, drug therapy, surgery for Spasticity. Speech therapy. AD
Traumatic Spinal Cord Injuries can happen from:
MVA, Falls, Violence, Sports-related injuries
Nontraumatic Spinal Cord Injuries can happen from:
Vascular dysfunction, spinal stenosis, spinal neoplasms, syringomyelia, infection, MS or ALS
What are the two categories of classification for SCI?
Tetraplegia - motor and/or sensory impairment of all four extremities and trunk including respiratory mm
Paraplegia - motor and/or sensory impairment of all or part of the trunk and both lower extremities (lesions from thoracic or lumbar sc or cauda equina)
How is motor level determined based on the American Spinal Injury Association (ASIA)?
Determined by testing the strength of 10 key mms on the R and L (MMT)
How is sensory level determined based on ASIA?
Determined by testing the pts sensitivity to light touch and pinprink on L and R side o the body at key dermatomes. Scoring based on a 3 point ordinal scale: 0 - absent, 1 - impaired, 2 - normal.
People may have mixed presentations of intact motor/sensory function below the neuro level assignment.
What is a complete injury to the spinal cord?
No sensory or motor function in the lowest sacral segments with no sacral sparing (determined by sensory function at S4-S5 dermatome, ability to feel anal pressure, or anal sphincter contraction)
What is an incomplete injury of the spinal cord?
Having motor and/or sensory function below the neurological level that includes sensory and/or motor function at S4 and S5, with presence of sacral sparing.
What is it called when there is motor and/or sensory function below neurological level but no sacral sparing?
These are called zones of partial preservation.
What is Brown-Sequard Syndrome?
It occurs from hemisection of the spinal cord (damage to one side). Typically caused by penetration wounds - gunshot or stab. Partial lesions occur more frequently.
Clinical features are asymmetrical. Ipsilateral side as lesion there is paralysis and sensory loss.
Loss of sense of pain and temperature on the contralateral side beginning several dermatome segments below the level of injury
What is Anterior Cord Syndrome?
Related to flexion injuries of the cervical region with resultant damage to the anterior portion of the cord and/or its vascular supply from the anterior spinal artery.
What is Central Cord Syndrome?
Most common SCI syndrome. Occurs from hyperextension injuries to the cervical region. Also associated with congenital or degenerative narrowing of spinal canal.
More severe neuro involvement of UEs than LEs. Sensory impairment tends to be less severe than motor.
Cauda Equina Injuries
LE paralysis and paresis is variable. Lesions are peripheral nerve injuries (lower motor neuron) injuries.
