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FIrst Aid for the Wards
1.19 Neurology part 1
131
Medical
Professional
01/19/2013

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Term
What Hz tuning fork is used to test hearing?
Definition
512
Term
What Hz turning fork is used to test vibration sense?
Definition
256
Term
What are contraindications to a spinal tap?
Definition
suspected intracranieal mass lesion, local infection, a spinal cord mass, and coagulopathy
Term
What patients should recieve a CT before getting an LP?
Definition
any patient who presents with altered mental status, focal enurologic deficits, or immunosuppression
Term
What are the parts of the neuro exam in order?
Definition
mental status, cranial nerves, motor, sensory, coordination, gait
Term
What are the parts of the mental status exam?
Definition
a/o, attention (digit span), language (repeat, comprehension, fluency, naming), concentration, mood, memory, and higher cognitive function (fund of knowledge, calculations, abstractions, constructions)
Term
How do you test the cranial nerves?
Definition
visual acuity, visual fields, pupillary reaction, fundoscopic exam, extraoccular movements, light touch and masseter strength (corneal reflex if decreased level of consciousness), facial muscles, finger rub in front of ear, gag reflex or palate elevation, trap/SCM, tongue
Term
What would cause ptosis?
Definition
a lesion in the sympathetic nerves (above T1) that innervate the smooth muscle of the eyelid or a CN III palsy or dysfunction of the neuromuscular junction
Term
Difference between spacticity and rigidity=
Definition
spasticity= persistent state of increased involuntary reflex activity in response to a stretch; by contrast, the term rigidity is used to describe an involuntary increase in the resistance of a muscle to a passive stretch that is uniform throughout the range ofmotion NOT velocity dependent
Term
What are the components of the motor portion of the screening neurological exam?
Definition
tone, strength (esp finger extension, index finger abduction, big toe dorsiflexion and plantar flexion); pronator drift, orbit sign, DTRs and plantar response
Term
Biceps reflex=
Definition
C5, C6
Term
Brachioradialis reflex tests=
Definition
C5, C6
Term
Triceps reflex tests=
Definition
C6, C7
Term
Patella reflex tests=
Definition
L2-L4
Term
Achilles reflex tests=
Definition
S1
Term
Nipple dermatome=
Definition
T4
Term
Xiphoid process dermatome=
Definition
T7
Term
Dermatomal pattern of the umbilicus=
Definition
T10
Term
Dermatomal pattern of the inguinal ligament=
Definition
L1
Term
Dermatomal pattern of the penile/anal zone=
Definition
S2-S4
Term
What are the components of the screening exam for sensation=
Definition
pain or temperature sensation in the hands and feet, vibration or joint position sense in the hands and feet, light touch
Term
What is paratonia?
Definition
changes in tone over time/position caused by an inability to relax
Term
What is the orbit sign?
Definition
ask the patient to make fists and revolve them around each other as if boxing a punching bag; cortical spinal tract weakness leads the weak hand to "orbit" around the strong hand
Term
What are two types of rigidity?
Definition
cogwheel or lead pipe
Term
Name some superficial reflexes?
Definition
abdominal, cremasteric
Term
What are frontal release reflexes?
Definition
reflexes that occur when a patient's frontal lobe has been damaged; include lots of neonatal reflexes like rooting, sucking, and palmar reflex; also glabellar reflex seen in parkinson's patients
Term
How do you check coordination?
Definition
finger to nose test; heel to shing test and rapid movements (strength and coordination)
Term
How do you test distal weakness when evaluating gait?
Definition
ask pt to walk on toes and walk on heels
Term
How do you test for proximal weakness?
Definition
have the patient hop on one foot or try a knee bend while standing on one foot; ask the patient to get out of his/her chair without using their arms
Term
0/5 strenght=
Definition
no movement or contraction
Term
1/5 strength=
Definition
flicker of contraction
Term
2/5 strength=
Definition
full range of motion with gravity eliminated
Term
What is 3/5 strength?
Definition
full range of motion against gravity
Term
What is 4/5 strength?
Definition
full range of motion against gravity and some resistance
Term
What is 5/5 strength?
Definition
full power
Term
What are the specific circumstances in which CT is preferred over MRI?
Definition
suspected skull fracture, suspected intracranial bleeds, trauma, monitoring hydrocephalus
Term
How long does it take for a bleed to show up on imaging?
Definition
within 20 minutes will appear white on CT scans; takes hours to appear on MRI
Term
Why is CT preferred over MRI to eval head trauma?
Definition
CT is faster and you don't have to worry about issues with metallic foriegn bodies causing more damage like if you did an MRI
Term
Why is CT preferred for monitoring hydrocephalus?
Definition
high resolution isn't needed to monitor increasing ventricular size; CT is faster and cheaper
Term
How do you test higher sensory function?
Definition
graphesthesias, point localization, extinction
Term
0 reflex=
Definition
absent
Term
reflex +1=
Definition
hypoactive
Term
reflex +2=
Definition
normal
Term
reflex +3=
Definition
hyperactive with spread across a joint
Term
+ 4 reflex=
Definition
hyperactive with clonus
Term
T1 images are used for looking at...
Definition
anatomy
Term
How do things look on T1 MRI?
Definition
grey matter is darker, white matter is lighter, CSF is black, bone doesn't produce an MRI signal
Term
Very bright areas on T1 MRI=
Definition
high degree of protein, fat, subacute blood, or contrast agent
Term
What is the perpose of using contrast with MRI?
Definition
gadolinium enhancement can be used to increase the resolution of certain pathologic processes
Term
What do things look like on T2 weighted imaging?
Definition
gray matter is lighter, white matter is darker, and CSF appears white
Term
What are T2 images used to evaluate?
Definition
pathology which appears white owing to edema
Term
What does FLAIR imaging stand for?
Definition
fluid attenuation inversion recovery
Term
What is the purpose of FLAIR imaging?
Definition
a flair image is similar to a T2 image except that the bright CSF has been subtracted away; thus one's eye is drawn to areas of abnormal signal, making th esignal easier to recognize
Term
What does DWI stand for?
Definition
diffusion-weighted imaging
Term
What is the purpose of DWI?
Definition
a specific T2 sequence; DWI is used in suspected cases of acute stroke to determine if an ischemic event is occurring in the brain. as expected the ischemic area appears white; DWI is especially useful because it reveals ischemic areas within minutes of onset
Term
What is the purpose of adding contrast to a study?
Definition
elucidates vascular anatomy (can show occlusion or blood brain barrier leak), this tells the clinician about th eseverity of the condition and can also increase the resolution of the study
Term
What contrast agents are used for CT vs MRI?
Definition
CT= iodinated contrast; MRI= gadolinium
Term
On rare occasions gadolinium can cause what disease?
Definition
nephrogenic fibrosing dermopathy or nephrogenic systemic fibrosis, a syndrome that clnically resembles slceroderma and eosinophilic fasciitis
Term
Which patients are at increased risk of getting nephrogenic fibrosing dermopathy with gadolinium use?
Definition
those with renal insufficiency
Term
An LP is performed between which vertebrae?
Definition
between L4 and L5 (the level of the iliac crests)
Term
Normal LP RBCs=
Definition
<10
Term
Normal LP WBCs=
Definition
<5
Term
Normal LP glucose=
Definition
approx 2/3rds of serum
Term
Normal LP protein=
Definition
15-45
Term
Normal LP opening pressure=
Definition
10-20 mmH2O
Term
Normal LP % gamma globulin of total protein=
Definition
3-12%
Term
What are the findings on LP of SAH?
Definition
increased RBCs, increased WBCs and protein and maybe increased opening pressure or gamma globulin
Term
What percent of stroke is hemorrhagic vs ischemic?
Definition
85% ischemic; 15% hemorrhagic
Term
What does an LP of GBS show?
Definition
increased protein; normal or increased glucose
Term
What does an LP of MS show?
Definition
increased gamma globulin % and normal or increased WBCs
Term
What are the LP findings of pseudotumor cerebri?
Definition
very high opening pressure
Term
What is a CVA?
Definition
a stroke that does not resolve symptomatically
Term
What is a TIA?
Definition
focal neurologic deficit resulting from a disturbance in blood flow that reverses within 24 hours
Term
What are the categories of etiologies of ischemic stroke?
Definition
cardiac,large vessel atherothrombosis, small vessel atherothrombosis, hematologic disorders including hypercoagulable states, fibromuscular dysplasia, inflammatory diseases, arterial dissection, migraine venous thrombosis
Term
What is the most common cardiac cause of stroke? other causes?
Definition
afib; mural thrombi, thrombi from diseased or prosthetic valves, other arrhythmias, endocarditis, and paradoxic or venous emboli in patients with right to left shunt in the heart
Term
Nonmodifiable stroke risk factors=
Definition
age, male gender, ethnicity (african american, hispanic, asian) genetics
Term
What are some modifiable risk factors for stroke?
Definition
hypertension, DM, smoking, heavy alcohol intake, cocaine use, obesity, hypercholesterolemia, carotid stenosis, AF
Term
Pts with Afib have how much a greater risk of stroke than the general population?
Definition
5-6x
Term
What percent of strokes are due to large vessel atherothrombosis?
Definition
35% of all strokes; and roughly 40% of all ischemic strokes
Term
Describe the course of a stroke due to large vessel atherothrombosis?
Definition
symptoms maximal at onset and roughly 40% of ischemic strokes
Term
What causes strokes due to small vessel atherothrombosis?
Definition
lacunar infarcts occur in regions supplied by small perforating vessels and results from either atherosclerotic or hypertensive occlusion
Term
What percent of strokes are ccaused by lacunar infarcts?
Definition
20%
Term
Where do small vessel atherothrombosis strokes typically occur?
Definition
basal ganglia, brain stem, and internal capsules (due to small vessel disease)
Term
What hypercoagulable states can cause strokes?
Definition
sickle cell disease, polycythemia, thrombocytosis, leukocytosis, malignancy, hereditary coagulopathies, and collagen vascular disease
Term
What causes hemorrhagic strokes?
Definition
hypertensive rupture of small vessels, AVMs, hemorrhagic conversion of ischemic strokes, amyloid angiopathy, cocaine use, and/or bleeding diatheses
Term
What is the time course for thrombotic strokes?
Definition
evolve in minutes to hours and may follow a TIA
Term
What is the time course for an embolic stroke?
Definition
often present with the full deficit acutely and do not evolve
Term
What is the time course of a hemorrhagic stroke?
Definition
onset can include headache and/or altered mental status; deficits may not strictly follow vascular territories due to hematoma expansion and edema surrounding the bleed
Term
What is Todd's paralysis?
Definition
postictal paralysis
Term
Trunk/arm/face paralysis=
Definition
contralateral MCA
Term
Wernicke's aphasea=
Definition
dominant MCA
Term
Broca's aphasia=
Definition
MCA (dominant)
Term
hemineglect=
Definition
MCA, nondominant
Term
Leg/foot paralysis=
Definition
ACA
Term
stroke with cognitive changes=
Definition
ACA
Term
stroke with bladder incontinence=
Definition
aca
Term
Stroke with vision changes=
Definition
PCA
Term
Stroke with reading/writing deficits=
Definition
PCA
Term
stroke with coma=
Definition
basilar
Term
"locked in" syndrome stroke=
Definition
basilar
Term
stroke with cranial nerve palsies=
Definition
basilar
Term
stroke with drop attacks=
Definition
basilar
Term
What is the goal of stroke workup?
Definition
1) urgently determine whether the stroke is ischemic or hemorrhagic; 2) if the stroke is ischemic, to ascertain whether it can be reversed within a three-hour window using tPA both to salvage ischemic brain and to prevent further strokes
Term
region supplied by the MCA=
Definition
lateral cerebral hemispheres; deep subcortical structures
Term
MCA stroke=
Definition
combined deficits of superior/inferior divisions; may see coma an dincreased intracranial pressure
Term
region supplied by superior division of MCA=
Definition
motor/sensory areas of the face,arm hand; broca's area
Term
Stroke of superior division of the MCA=
Definition
contralateral hemiparesis of face, arm and hand, expressive aphasia if dominant hemisphere
Term
REgion supplied by inferior division of the MCA?
Definition
parietal lobe (vvisual radiations, wernicke's area), macular visual cortex
Term
Stroke of inferior division of MCA=
Definition
homonymous hemianopia, receptive aphasia (dominant), impaired cortical sensory functions, gaze preference apraxias and neglect (nondominant)
Term
Region supplied by ACA=
Definition
parasaittal cerebral cortex
Term
stroke of ACA=
Definition
contralateral leg paresis and sensory loss
Term
REgion of the brain supplied by opthalmic artery=
Definition
retina
Term
Neurologic deficit caused by opthalmic arter stroke=
Definition
monocular blindness
Term
Area supplied by the PCA=
Definition
occipital lobe, thalamus, rostral midbrain, medial temporal lobes
Term
Symptoms of PCA stroke=
Definition
contralateral homonymous hemanopia, memory or sensory disturbances
Term
Area of the brain supplied by the basilar artery=
Definition
ventral midbrain, brain stem, posterior limb of the internal capsule, cerebellum, PCA distribution
Term
Basilar artery stroke=
Definition
coma, cranial nerve palsies, apnea, cardiovascular instability
Term
Name some arteries of deep circulation in the brain:
Definition
lenticulostriate, paramedian, thalamoperforate, circumferential arteries
Term
What areas of the brain are supplied by the lenticulostriate, paramedian, thalamoperforate, and circumferential arteries?
Definition
basal ganglia, pons, thalamus, internal capsule, cerebellum
Term
Stroke of the lenticulostriate, paramedian, thalamoperforate, and circumferential arteries=
Definition
"lacunes" pure motor or sensory deficits, ataxic hemiparesis, "dysarthria-clumsy hand" syndrome
Term
What tests should you get for suspected stroke?
Definition
CT withotut contrast to distinguish ischemic from hemorrhagic stroke; MRI, CBC, coagulation panel, lipid panel, ESR, CRP, TSH RPR, B12/folate, glucose and HBA1c, ECG, echo, perhaps carotid ultrasound, blood cultures, screen for hypercoagulable states
Term
What do ischemic strokes look like on CT and how long does it take for changes to show up?
Definition
loss of gray-white differentiation or as a hypodensity, and are generally not visible for at least 3-6 hours after symptom onset
Term
Why might you get an MRI to evaluate a stroke?
Definition
MRI can identify early ischemic changes (DWI to see new ischemia; flair to see old ischemic regions) to identify neoplasms and to adequately image the brain stem and posterior fossa
Term
What tests might be involved in a hypercoaguable workup for stroke?
Definition
INR, aPTT, antithrombin III, protein C/S, antiphospholipid/anticardiolipin antibody, sickle cell trait)
Term
What are major contraindications to tPA therapy for stroke=
Definition
SBP>185 or DBP >110 despite aggressive treatment; prior intracranial hemorrhagic, stroke, or head trauma in the past 3 months; recent MI; current anticoagulant therapy with an INR >1.7, use of heparin in the last 48 hours with prolonged PTT; platelet count <100,000; major surgery in the past 14 days or GI/urinary bleeding in the past 21 days; seizures present at the onset of stroke; blood glucose <50 or >400; age <18
Term
What is the time frame in which tpa can be administered to stroke victims?
Definition
victims must have been confirmed to have been well within three hours of ischemic onset
Term
IF you are past the three hour window to give tPA what can you give ischemic stroke patients instead?
Definition
aspirin has been shown to decrease morbidity and mortality in acute ischemic stroke presenting less than 48 hours from onset
Term
How can you treat small vessel strokes?
Definition
antiplatelet agents such as aspirin, clopidogrel, and dipyridamole/aspirin for small vessel strokes and when anticoagulation is either not indicated or contraindicated
Term
What complications should you be on the lookout for in stroke pts?
Definition
brain swelling, increased intracranial pressure, or herniation
Term
When is carotid endarterectomy indicated?
Definition
in the setting of asymptomatic stenosis > 60% or symptomatic/asymptomatic stenosis > 70%; do not use in 100% blockage
Term
In treating stroke, what "hypo"
s shoudl you avoid?
Definition
hypotension, hypoxemia and hypoglycemia; maintain SBP approximately 20 mmHg above pts baseline to ensure adequate cerebral perfusion and do not lower unless it is >220/>130
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