Stroke 1- Mental Health 2 Flashcards
5 Neurological Tests
Glasgow coma scale: eye opening, motor and verbal. Evaluates severity of TBI.
EEG: Electrical activity of cerebral cortex
VEP: Integrity of visual pathway
Lumbar puncture: Samples CSF fluid and measures pressure.
Other neuro imaging: x ray, angio, CT, MRI, PET
What two diseases could cause increased intracranial pressure?
Idiopathic Intracranial HTN/Pseudotumor cerebrii
OR
Hydrocephalus
Most common cause of papilledema
Pseudotumor cerebrii
Pseudotumor cerebrii
Elevated ICP in absence of known lesion/cause.
Papilladema and HA are most common findings.
Risk factors: Female, overweight.
DX: Papilledema, MRI normal, increased pressure during lumbar puncture.
Hydrocephalus
Abnormal accumulation of CSF.
Signs: scalp veins, increased head circumference, sunset eyes, bossing of forehead.
Tx: Ventricular shunt
3 types: Normal, communicating and non communicating.
Infectious CNS disorders 2 major categories.
Meningitis (bacterial and viral)
and
Encephalitus
Difference between hydrocephalus and encephalitis
Hydro: Abnormal accumulation of CSF.
Encephalitis: Inflamamtion of entire brain, usually along with meningitis.
Meningitis
Signs: Sudden fever, stiff neck, HA, altered mental status (95% have 2)
Most common ocular manifestations (35% have):
pupil changes (80%)
Cranial neve palsies
Fundus changes
Bacterial: Less common, more severe. Strep pneumonia. Hearing loss and brain damage.
Viral: More common, less severe. Enterovirus, HSV2
Encephalitis
Inflammation of the entire brain, usually along with meningitis.
60% idiopathic. When known, viral. Enterovirus or HSV2.
Signs: Seizures, lack of mental function (stupor), coma
2 broad causes of altered mental status
- Psychiatric. mental illness.
- Encephalopathic. OD, dementia.
- Disease in brain. Stroke, tumor.
We talked about seizures and syncope.
What are seizures and what are the types
Synchronous discharge of cortical neurons. Most seizures are epileptic. Anything that injures brain can cause seizure.
Partial (simple vs complex)
OR
Generalized (Absence vs tonic clonic)
___ is the most common seizure disorder
Epilepsy.
Family hx is risk.
60% idiopathic.
Syncope
Brief loss of consciousness due to reduced blood flow to the cerebral tissue.
Types: vasovagal, postural, cariogenic, neurologic.
3 types of demyelinating diseases
MS
NMO
Guilan Barre
MS
T cell mediated disease of CNS- central demyelination.
Idiopathic.
Dx: 2+ attacks + MRI showing lesion.
2/3 have ocular symptoms: optic neuritis, CN palsy, nystagmus.
NMO
Autoimmune disease that attacks ON and spinal cord. Causes demyelination by attacking AQP4.
More severe attacks than MS.
Dx: no brain lesions.
3+ spinal cord enhancements
NMO IgG seropositive
Guillain Barre
Acute idiopathic peripheral NS demyelination
Progressive ascending weakness. Moves up from feet.
Rare.
If eyes are involved, miller fisher.
2 neurological disorders
Myasthenia Gravis
Bells Palsy
DAI Diffuse axonal injury
Microscopic damage to axons after trauma. Found by MRI.
Most important factor in determining mortality after TBI.
caused by accel/deaccel injury. Axons stretch and then lesions develop in white matter axons.
TBI ocular manifestations
30% VF defect 27% CN palsy 24% accom 23% CI 19% vestibular 16% photophobia
Chronic traumatic encephalopathy (CTE)
Progressive deign disease of the brain due to repeated brain injury causing accumulation of tau proteins in neurons and neurofibrillary tangles.
Most common primary and secondary brain tumor
Primary: 34% meningioma
Secondary: 38% lung
Cerebral Palsy
Group of syndromes that are permeant and non-progressive neuronal damage to motor control.
70-90% are congenital.
*Most common motor disability in childhood.
Signs: Spasticity, ataxia, dyskinesia (involuntary movement)
Ocular associations: Strab Ref error Amblyopia Optic atrophy, VF defect, nystagmus.
MD
Genetic defect. Deterioration of striated muscle without inflammation.
Group of more than 30 genetic disorders.
Most common: Duchenne MD. X linked. Early onset. 3-5 years. Absence of dystrophin causes skeletal muscle fibers to be replaced by fat and fibrous CT. Death by 30s due to dilated cardiomyopathy.
What causes death?
- MD
- ALS
- Alzheimers
- Parkinsons
- Hutingtons
- Dilated cardiomyopathy.
- Respiratory failure.
- Respiratory disease (55%) or cardiovascular (22%)
- Pneumonia
- Pneumonia
Two broad groups of neurodegenerative diseases
- Without dementia: ALS
2. With dementia: Alzheimers, Parkinsons, Huntingtons.
ALS (amyotrophic lateral sclerosis)
Progressive neurodegen of motor neurons.
Most common motor neuron disease.
Affects upper and lower motor neurons- central and peripheral.
Does not affect personality, eyesight and EOMs.
Dx: MRI
Death within 3-5 years. Usually due to respiratory failure- impaired speech, swallowing, respiration. Eventual paralysis.
Most common motor disability in childhood.
Most common motor neuron disease.
Cerebral palsy
ALS
60% of dementia cases and #6 cause of death
Alzheimers.
Alzheimers
Cerebral degeneration and atrophy.
Toxic buildup of abnormal folding proteins: amyloid plaques and neurofibrillary tangles/tau proteins.
Death in 10 years due to respiratory disease (55%) or heart disease (22%)
Diseases that involve abnormal folding proteins- amyloid plaques, tau proteins and neurofib tangles.
Alzheimers
CTE
Huntingtons
Parkinsons
Degen of substantiated nigra due to reduction of dopamine. Causes reduction in muscle control.
Idiopathic.
Death due to pneumonia.
Ocular manifestations: Decreased blink rate, spasms, decreased convergence and diplopia.
Huntingtons
Autosomal dominant.
Basal ganglia neuronal degeneration.
Due to amyloid protein deposition.
Fatal in 10-20 years due to increased size of lateral ventricles/pneumonia.
Symptoms: hallucinations, dementia, involvuntary movements.
Leukodystrophies (LD)
Genetic defect. Progressive deterioration of myelin due to defective myelin production.
34 rare disorders affecting the CNS.
Most manifest early in life and are rapidly fatal.
One example of LD
Adrenoleukodystrophy. MOA very long FA chain buildup.
X linked.
Impairs adrenal function, decreasing cortisol levels.
Signs: optic atrophy, EOM, cranial nerve palsy.
3 types of lysosomal storage diseases
Tay Sachs:
Autosomal recessive
manifests at 6 months
Cherry red spot in macula.
Neimann pick:
Autosomal recessive
Onset at 1 year
Cherry red spot in macula.
Fabrys:
X linked
3-10 year onset
whorl keratopahy without taking amiodarone.
What are lysosomal storage diseases
Genetic. Buildup of metabolic debris in cells due to enzyme defects= metabolic byproduct build up= cell dysfunction.
Mood disorders (3)
Major depressive disorder
Dysthymia - Persistent depressive disorder
Bipolar
5 types of anxiety disorders
Generalized Panic OCD PTSD Phobias
Which type of mood disorder is most common?
Major depressive disorder (6.7%)
Bipolar only 2.6%
Anxiety disorder prevalence in order from most to least
PTSD 3.5%
Generalized 3%
Panic 2.7%
OCD 1%
Major depressive disorder dx and tx
Dx: 6 symptoms (5+ decreased mood/decreased interest)
Tx: Meds, CBT, exercise.
Bipolar
- onset
- men vs female?
- Genetic component?
- Manic episode requirements
- Tx
Onset at 25 years
Male= female
Genetic component. Most if identical twin has it (70%). If both parents have it, 50-75%.
Manic episodes must have 3+ symptoms lasting more than 1 week.
Tx: Meds by mood stabilizer or electroconvulsive therapy. Hospitalization.
Generalized anxiety disorder
- requirements
- men vs female
- tx
Excessive worry about everyday problems for more than 6 months. They are AWARE of excessive worry.
Women 2x more likely than men
Tx best with CBT. Then meds.
Panic disorder
- acute or long term
- Women vs men
- 1/3 develop
- tx
Acute, unexpected and repeated episodes.
women 2x more likely than men.
1/3 develop agoraphobia
tx: meds and behavior therapy
OCD 2 portions
- Obsessions are recurrent thoughts or images that cause anxiety.
- Compulsions are repeated behaviors that are done to decrease the anxiety created by the obsession. People will spend hours doing these. Handwashing, checking, counting.
OCD might be due to heightened neural activity where
male vs female?
In the caudate nucleus
male = female
Leading cause of disability in the US for ages 15-44
Major depressive disorder
Most severe mental illness
Schizo
Schizo What is it? Onset % of pop men vs women? How many commit suicide
Split mind- separation from reality. 1/3 homeless population is thought to have. Onset age 16-30 1% of population affected men= women 10-15% commit suicide
Borderline personality disorder. What is it? % of pop Onset men vs women? How many commit suicide Tx Dx
Widely unstable moods 1-2% of pop Onset 18-22 Women= men 9% commit suicide Tx: Psychotherapy Dx: 5+ symptoms
Child abuse. 80% are ages less than
- 18 months is the highest risk.
Most common form of child abuse
Neglect
Sexual abusers are usually what gender
Physical abusers are usually what gender
Male
Female/caregiver
Child abuse risk factors
Child abuse complications in the future
Single parent with live in partner x8
Parental unemployment x2
Low SES x3
Criminal behavior x9
Intimate partner abuse
__% of women’s rapist are their partner.
__% domestic violence occurs at home
Highest risk of violence at what age
51
60
20-24
Elder/disabled abuse
- likely to occur where and by who
- types
Occur at home by family member
Types: neglect and abandonment* abuse, emotional, physical
Substance abuse Dx 3 stages High risk population Most common drug abused Most deadliest drug abused How OD's help- 5As
Dx: Must meet 2-3 critera
Stages: Binge, withdrawal, anticipation
High risk: Young adults, over 65 with mental illness, men
Weed most common
Opioids deadliest
5As: Assess, advise, Agree, Assist, Arrange.
Two broad categories of stroke
TIA
Stroke (Ischemic vs hemorrhagic)
Ischemic vs hemorrhagic stroke
Ischemic more common, less fatal. Due to blood vessel occlusion (bc thrombus) or systemic hypoperfusion (bc pump failure)
watershed/boarder zones in most danger. Ischemic core is most severe, penumbra is area surrounding. Trying to save that area with tx.
Hemorrhagic is less common, more fatal. Due to HTN. Could be extra axial or intraaxial.
What are these hemorrhages caused by?
Epidural
Subdural
Subarachnoid
Epidural: Middle meningeal artery
Subdural: Acceleration/deacceleration, veins.
Subarachnoid: Trauma or Saccular aneurysm.
In general, 50-75% of strokes occur in ___ artery
Middle cerebral artery
Epidural hemorrhage usually due to middle meningeal.
Pay attention to these symptoms for young adults (less than 50) with strokes
Migraine, trauma, substance abuse, pregnancy, oral contraceptives, cardiac embolism, vascular abnormalities, clotting disorders.
3 ways the brain shows injury
Loss of consciousness
Seizures
Localized loss of function
Stroke signs
Sudden onset of VF, EOM, or sensory defect. Sudden hemiplegia (weakness on 1 side of body)
Left Hemi stroke results
Weakness/numb on right side of body
Problems with: Speech- aphasia and dysarthria, sequencing, math,
right semi stroke results
Weakness/numb on left side of the body
Problems with: Speaking- dysarthria, creativity, faces, spacial ability.
3 tests to ask patient to see if they have had a stroke
- Have them speak
- Have them smile and look for symmetry
- Have them close their eyes and hold arms out. Look for symmetry.
If one is abnormal, there is 72% of stroke!
Frontal lobe
Paralysis/motor defects
Personality
Eye movements- saccades
Brocas (Expressive language)
Parietal lobe
Spatial ability
Inferior VF defect
Temporal lobe
Hearing
Wenicke’s area (receptive language)
Superior VF defect
Facial recognition (prosopagnosia)
Occipital lobe
VF defects- central scotoma Color vision defects Motion perception (akinetopsia)
If neglect occurs, where is the lesion likely?
Right hemisphere parietal lobe responsible for spacial ability. Must occur here and causes left side neglect.
If left partial lobe lesion occurs, right lobe can make up for defect.
neglect can occur with or without VF defect. Not a vision problem. Inability to attend to one side of the world.
Results of cerebellar stroke
Ataxia- coordination problems. Vertigo HA vomiting Diplopia
Results of brain stem stroke
Cranial nerve damage/loss of function
If on pure motor track- weakness of half body
If on pure sensory track- decreased sensation on half of body
Dysarthria
Speech impairment due to tongue muscles not working. Imperfect articulation. Due to damage to motor cortex. Coherent, but broken up. Stutter.
Aphasia
Language impairment. Due to damage on left side of brain in the frontal or temporal lobe. Inability to comprehend, integrate and express language
Two forms of aphasia
Receptive Aphasia: Lesion in Brocas area of frontal lobe left hemisphere. Poor comprehension, word salad. Nonsense. but fluent.
Expressive aphasia: Lesion in Wernike’s area of temporal lobe in left hemisphere. Normal comprehension, poor production of words. Labored speech. Not fluent.
Aphasia affects how many stroke patients
1/3
Order from ear to speech
- ear
- Wernicke’s in temporal lobe. Receptive aphasia.
- Brocas area in frontal lobe. Expressive aphasia.
- Motor cortex. Dysarthria.
- Speech
Difference between extinction and neglect
Extinction is a milder form of neglect. Unsure.
