Bates Ch 17-Nervous System

Front 1

gray matter vs white matter

Back 1

gray: aggregations of neuronal cell bodies; rims the surfaces of the cerebral hemispheres forming the cerebral cortex
white: neuronal axons that are coated with myelin

Front 2

internal capsule

Back 2

white-matter structure where myelinated fibers converge from all parts of the cerebral cortex and descend into the brainstem

Front 3

reticular activating system

Back 3

in the diencephalon and upper brainstem; consciousness depends on this

Front 4

spinal cord termination

Back 4

L1/L2

Front 5

where are lumbar punctures performed

Back 5

L3/L4 or L4/L5

Front 6

corticospinal (pyramidal) tract

Back 6

mediate voluntary movement and integrate skilled, complicated, or delicate movements by stimulating selected muscular actions and inhibiting others
- carry impulses that inhibit muscle tone
- originate in motor cortex
- travel down into lower medulla where they decussate at pyramids
- cross in medulla and go downward
** tracts that synapse in the brainstem with motor nuclei of cranial nerves= corticobulbar

Front 7

bradykinesia

Back 7

damage to basal ganglia
- slowness or lack of spontaneous and automatic movements

Front 8

pain and temperature

Back 8

pass into the posterior horn of the spinal cord and synapse with secondary neurons

Front 9

crude touch fibers

Back 9

pass into posterior horn and synapse with secondary neurons
-secondary neurons cross to opposite side and pass upward in spinothalamic tract into the thalamus

Front 10

position and vibration fibers

Back 10

pass directly into posterior columns of the cord and travrel up to medulla with fibers of fine touch
-synapse in medulla with secondary neurons
- fibers from secondary neurons cross to opposite side at medullary level and continue on to thalamus

Front 11

thalamic level

Back 11

quality of sensation is perceived but fine distinctions are not made

Front 12

loss of position and vibration sense with preservation of other sensations- where is the lesion?

Back 12

posterior columnstransection of the spinal cord

Front 13

all componenets of a reflex arc

Back 13

sensory nerve fibers
spinal cord synapse
motor nerve fibers
neuromuscular junction
muscle fibers

Front 14

ankle reflex

Back 14

S1

Front 15

knee reflex

Back 15

L2-4

Front 16

brachioradialis reflex

Back 16

C5-6

Front 17

biceps reflex

Back 17

C5-6

Front 18

triceps reflex

Back 18

C6-7

Front 19

abdominal reflex (upper)

Back 19

T8-10

Front 20

abdominal reflex (lower)

Back 20

T10-12

Front 21

plantar reflex

Back 21

L5-S1

Front 22

anal reflex

Back 22

S2-4

Front 23

different presentation of myopathy vs polyneuropathy

Back 23

b/l proximal weakness in myopathy
b/l distal wekaness in polyneuropathy

Front 24

presentation of paresthesias around the mouth and in hands Ddx?

Back 24

hyperventilation

Front 25

dysesthesias

Back 25

distorted sensation in response to a stimulus (light touch or pinprick as burning or tingling sensation)

Front 26

vasovagal syncompe

Back 26

emotional stress and warning symptoms (flushing, warmth, nausea); slow onset, slow offset

Front 27

cardiac syncope

Back 27

arrhythmias, sudden onset/offset

Front 28

presentation of tonic-clonic motor activity, bladder or bowel incontinence, and postictal state

Back 28

generalized seizure; may bite tongue

Front 29

stroke

Back 29

sudden neurologic deficit caused by CV ischemia (80-85%) or hemorrhage (15-20%)

Front 30

hemorrhagic strokes- two types

Back 30

intracerebral (10-15%) or subarachnoid (5%)

Front 31

TIA

Back 31

sudden focal neurologic deficit- lasting less than 24 hours- more recent: less than 1 hour without underlying structural defects

Front 32

predictive value of TIAs

Back 32

15% of patients progress to stroke w/i first 3 months

Front 33

when is risk of stroke highest

Back 33

first 30 days after TIA

Front 34

middle cerebral artery occlusion symptoms

Back 34

visual field cuts and contralateral hemiparesis and sensory deficits

Front 35

MCA occlusion in L hemisphere

Back 35

aphasia

Front 36

MCA occlusion in R hemisphere

Back 36

hemineglect

Front 37

most common cause of hemorrhagic stroke from subarachnoid hemorrhage

Back 37

rupture of saccular aneurysms in circle of Wilils

Front 38

ideal level of HgA1C in diabetics to control risk for stroke

Back 38

< 7.4% so onset of neuropathy drops by 50-60%

Front 39

loss of sense of smell indicates

Back 39

sinus congestion, head trauma, smoking, aging, use of cocaine, parkinsons

Front 40

disc pallor vs disc bulging

Back 40

pallor: optic atrophy
bulging: papilledema

Front 41

prechiasmal, anterior defects (visual)

Back 41

glaucoma, retinal emboli, optic neuritis

Front 42

bitemporal hemianopsias

Back 42

defects at optic chiasm- pituitary

Front 43

homonymous hemianopsias or quadrantanopsia

Back 43

postchiasmal lesions- parietal lobe- acuity normal

Front 44

monocular diplopia

Back 44

local problems with glasses or lenses, cataracts, astigmatism, ptosis

Front 45

binocular diplopia

Back 45

CN III, IV, VI, neuropathy (40%), MG, trauama, thyroid ophthalmopathy, INO (muscle disease)

Front 46

nystagmus (define and when you see it)

Back 46

involuntary jerking movement of the eyes with quick and slow components
- cerebellar disease (increases with retinal fixation), vestibular disorders (decreases with retinal fixation)

Front 47

how is nystagmus named

Back 47

for the direction of the fast component

Front 48

unilateral weakness in CN V pontine lesions

Back 48

b/l weakness in cerebral hemispheric disease because of b/l cortical innervation

Front 49

ipsilateral face but contralateral body sensory loss localizes lesion to?

Back 49

brainstem

Front 50

acoustic neuroma presentation

Back 50

absent blinking and sensorineural hearing loss

Front 51

conductive vs. sensorineural hearing loss

Back 51

conductive: impaired air thorugh ear transmission
sensorineural: damage to chochlear branch of CN VIII

Front 52

Rinne vs Weber test

Back 52

Rinne: air and bone conduction- normal air > bone- conductive- bone longer than air in affected ear- sensorineural- air longer than bone but less than 2:1 ratio
Weber: lateralization- normal NONE- conductive- lateralization of deaf ear
sensorineural- lateralization to better ear

Front 53

causes of conductive hearing loss

Back 53

cerumen, otosclerosis, otitis media

Front 54

b/l lesion of vagus nerve

Back 54

failure of palate to rise

Front 55

u/l lesion of vagus

Back 55

one side doesnt rise and with uvula is pulled toward normal side

Front 56

tongue atrophy and fasciculations

Back 56

amyotrophic lateral sclerosis, polio

Front 57

unilateral cortical lesion

Back 57

protruded tongue deviates transiently in a direction away from the side of cortical lesion, toward side of weakness

Front 58

pseudohypertrophy and when seen

Back 58

increased bulk with diminished strength: DMD

Front 59

sign of atrophy in the hands

Back 59

flattening of thenar and hypothena eminences and furrowing b/w metacarpals; median and ulnar nerve damage, respectively

Front 60

weakness of extension

Back 60

peripheral nerve disease such as radial nerve damage and in CNS disease producing hemiplegia- stroke/MS

Front 61

weak grip (C7-T1)

Back 61

cervical radiculopathy, de Wuervain's tenosynovitis, CTS, arthritis, epicondylitis

Front 62

weak finger abduction

Back 62

ulnar nerve disorders

Front 63

weak opposition of the thumb

Back 63

medial nerve

Front 64

flexion of hip tests

Back 64

L2-L4; iliopsoas

Front 65

signs of cerebellar disease

Back 65

ataxia, nystagmus, dysarthria, hypotonia

Front 66

dysdiadochokinesis

Back 66

when one movement cannot be followed quickly by its opposite; movements are irregular, slow, clumsy- cerebellar disease

Front 67

dysmetria

Back 67

finger initially overshoots but eventually reaches it

Front 68

differentiation of ataxia from dorsal column disease vs cerebellar disease

Back 68

cerebellar: difficulty standing with feet together whether eyes are open or closed
-those with dorsal column problems compensate by eyes then demonstrate (+) romberg sign

Front 69

pronator drift

Back 69

sensitive and specific for corticospinal tract lesion originating in contralateral hemisphere

Front 70

stereognosis, number identification, two-point discrimination impaired in?

Back 70

posterior column disease

Front 71

astereognosis

Back 71

inability to recognize objects placed in hand
-suggest lesion in sensory cortex

Front 72

what presents with lesions in sensory cortex

Back 72

astereognosis, inability to recognize numbers (graphesthesia), increase distance between two recognizable points, impairs ability to localize points accurately

-only one stimulus will be recognized--sensation on opposite side of the damaged cortex is gone

Front 73

neck stiffness and resistance to flexion in what perfect of pts with acute bacterial meningitis vs subarachnoid hemorrhage

Back 73

90%- meningitis
20-85%- subarachnoid hemorrhage

Front 74

Brudzinski's Sign

Back 74

flex the neck; watch the hips and knees- positive when hips and knees flex

Front 75

Kernig's Sign

Back 75

flex the leg at both hip and knee then straighten- pain and increased resistance to extending the knee- (+) Kernig's sign- b/l indicates meningeal irritation

Front 76

positive straight leg test?

Back 76

pain radiating into ipsilateral leg indicating lumbosacral radiculopathy, sciatic neuropathy, or both

Front 77

sensitivity and specificity of straight leg raise for disc herniation vs crossed straight-leg raise

Back 77

95% and 25%
40% and 90%

Front 78

asterixis

Back 78

sudden, brief, nonrhythmic flexion of hands and fingers- liver disease, uremia, hypercapnia

Front 79

winging of scapula

Back 79

weakness of serratus anterior (seen in MD) / long thoracic nerve

Front 80

*Five clinical signs that stronly predict death in coma

Back 80

absent corneal response, absent pupillary response, absent withdrawal response to pain, no motor response; at 72 hours-no motor response

Front 81

DONTS when assessing comatose patient

Back 81

1.) don't dilate the pupils! (most important clue to underlying cause of coma [structural vs. metabolic])
2.) don't flex the neck if there is any question of trauma to the head or neck
-immobilize C-spine and get an x-ray first

Front 82

structural hemispheric lesions (eye direction)

Back 82

look at the lesion in the affected hemisphere

Front 83

comatose pt with lack of doll's eye movements

Back 83

-ability to move both eyes to one side is lost--> lesion of midbrain or pons

Front 84

hemiplegia of sudden cerebral accidents

Back 84

flaccid at first causing limp hand drops to form a right angle with the wrist

Front 85

movement of flaccid leg in acute hemiplegia

Back 85

falls fast into extension with external rotation at hip

Front 86

mechanism of acute ischemic stroke

Back 86

-ischemic brain injury begins with a central core of very low perfusion and often irreversible cell death
-core surrounded by ischemic penumbra of cells that could be salvaged

Front 87

most irreversible damage occurs when

Back 87

3-6 hrs after onset of symptoms

Front 88

NAME THAT STROKE! contralateral leg weakness

Back 88

ACA

Front 89

NAME THAT STROKE! contralateral face, arm>leg weakness, sensory loss, field cut, aphasia (L lesion), neglect/apraxia (R lesion)

Back 89

anterior circulation of MCA

Front 90

NAME THAT STROKE! contralateral motor or sensory deficit without cortical signs

Back 90

subcortical circulation- leticulostriate deep penetrating branches of MCA

Front 91

four common syndromes of lacunar infarcts

Back 91

1.) pure motor hemiparesis
2.) pure sensory hemianesthesia
3.) ataxic hemiparesis
4.) clumsy hand-dysarthria syndrome

Front 92

NAME THAT STROKE! contralateral field cut

Back 92

posterior ciruclation- PCA

Front 93

NAME THAT STROKE! cortical blindness but preserved pupillary light reaction

Back 93

b/l PCA infarction

Front 94

NAME THAT STROKE! dysphagia, dysarthria, tongue/palate deviation and/or ataxia with crossed sensory/motor deficits (ipsilateral face/contralateral body)

Back 94

posterior circulation- brainstem, vertebral, basilar artery branches

Front 95

NAME THAT STROKE! oculomotor deficits and/or ataxia with crossed sensory/motor deficits

Back 95

posterior circulation- basilar artery

Front 96

decerebrate rigidity (abnormal extensor response)

Back 96

-jaws clenched, neck extended, arms adducted and stiffly extended at elbows, forearms protonated, wrists/fingers flexed
- legs extended at the knees, feet plantar flexed
- may occur spontaneously
**lesion in diencephalon, midbrain, or pons
**also from severe metabolic disorders- hypoxia or hypoglycemia

Front 97

hemiplegia (early)

Back 97

-flaccid (later spastic)
- paralyzed arm and leg slack- fall loosely
- leg may lie externally rotated
- if lower face paralyzed, cheek puffs out with exhalation
- both eyes away from paralyzed side

Front 98

decorticate rigidity (abnormal flexor response)

Back 98

- upper arms flexed tight to the sides with elbows, wrists, fingers flexed
- legs extended and internally rotated
- feet are plantar flexed
- lesion of corticospinal tracts w/i or near cerebral hemispheres

Front 99

bilaterally small pupils

Back 99

1.) damage to sympathetic pathways in hypothalamus
2.) metabolic encephalopathy
- light rxns normal

Front 100

pinpoint pupils (<1 mm)

Back 100

1.) hemorrhage in pons
2.) morphine, heroin, narcotics

Front 101

midposition fixed pupils

Back 101

midposition of slightly dilated (4-6mm)- damage in midbrain

Front 102

b/l fixed and dilated pupils

Back 102

severe anoxia and its sympathomimetic effects
- atropinelike agents, phenothiazines, TCAs

Front 103

b/l large reactive pupils

Back 103

cocaine, amphetamine, LSD, sympathomimetics

Front 104

one large pupil (fixed and dilated)

Back 104

herniation of the temporal lobe (compression of CN III and midbrain)

Front 105

features of toxic-metabolic coma

Back 105

*arousal centers poisoned or critical substrates depleted*
- regular respiration: normal or fast; irregular: Cheyne-Stokes
-pupils: equal, reactive- may be unreactive if fixed and dilated from anticholinergics/hypothermia
- level of consciousness changes after pupils change

Front 106

causes of toxic-metabolic coma

Back 106

uremia, hyperglycemia, alcohol, drugs, liver failure, hypothyroidism, hypoglycemia, anoxia, ischemia, meningitis, encephalitis, hyperthermia, hypothermia

Front 107

features of structural coma

Back 107

*lesion destroys or compresses brainstem arousal areas*
- irregular respiration (Cheyne-Stokes or ataxic)
- pupils: unequal or unreactive- midbrain compression if midposition and fixed
- if dilated and fixed- compression of CN III
- level of consciousness changes before pupils change

Front 108

causes of structural coma

Back 108

epidural, subdural, intracerebral hemorrhage, cerebral infarct or embolus, tumor, abscess, brainstem infarct, tumor, hemorrhage, cerebellar infarct, hemorrhage, tumor or abscess

Front 109

steppage gait

Back 109

- foot drop
- cannot walk on heels
- tibialis anterior and toe extensors are weak

Front 110

parkinsonian gait

Back 110

- basal-ganglia defects
- posture is stopped (flexion of head, arms, hips, knees(
- fenestrating
- poor postural control (retropulsion)

Front 111

cerebellar ataxic gait

Back 111

staggering, unsteady, wide based
- cannot stand with feet together regardless of eyes

Front 112

sensory ataxia

Back 112

- gait unsteady, wide based
- pts throw feet forward and outward and bring them down, first on heels then toes

Front 113

this suggests progressive subacute onset of distal lower extremity weakness

Back 113

guillan barre syndrome

Front 114

what indicates an abrupt onset of motor and sesory deficitis

Back 114

TIA or stroke

Front 115

ataxia, diplipa, and dysarthria indicate

Back 115

vertebrobasilar TIA or stroke also consider posterior fossa tumor and vertebrobasial or hemicranial migraine

Front 116

this suggests chronic more graduate, onset of weakness in lower extremities

Back 116

metastatic cord lesions and lumbar disc disease

Front 117

central focal or asymmetric weakness suggest

Back 117

ischemic, thrombotic, or mass lesions

Front 118

peripher focal or asymmetric weakness sugest

Back 118

nerve injury to the NMJ, to myopathies or intrinsic muscle diseases

Front 119

proximal limb weakness usually symmetric and without sensory loss suggests

Back 119

myopthaties from alcohol, drugs like glucocorticoids, and inflammatory muscle disorders (myosities and dermatomyositis)

Front 120

proximal typically asymmetric weakness that gets worse with effort and associated with bulbar symptoms lke diplipa, ptosis, and dysarthria, and dysphagia suggest..

Back 120

myasthenia graves

Front 121

sensory changes that arise from local nerve compression or entrapment in hand numbness suggests a problem with..

Back 121

medial, ulnar, or radial nerve

Front 122

sensory changes in nerve root compression suggest..

Back 122

issues with dermatomal sensory loss from vertebral bone spurs or herniated discs or central lesions from stroke or MS

Front 123

diabetic with burning pain suggests..

Back 123

sensory neuropathies

Front 124

behavioral risk factors for ischemic stroke

Back 124

1. hypertension

2. dislipedemia

3. weight

4. exercise

5. smoking

6. alcohol use

Front 125

top contributing factors for stroke

Back 125

1. AA

2. HTN

3. diabetes

4. left ventricular hypertrophy

5. income and insurance gaps

Front 126

what are stroke warning signs

Back 126

numbness/weakness; confusion/trouble speaking; trouble seeing and walking; dizziness; balance problems; severe headache

Front 127

early predictions of stroke

Back 127

ABCD2

a=age >60

b=BP >140/90

c=clinical features--focal weakness or impaired speech

d=duration--up to >60min

d=diabetes

Front 128

common causes of acute symptomatic seizures

Back 128

1. head trauma

2. alcohol

3. cocaine

4. w/drawal from alcohol, benzos, and barbs

5. metabolic issues like low gluc, low Ca, low Na

6. stroke

7. meningitis

8. encephalitis

Front 129

what suggests parkinsons disease

Back 129

-low frequency unilateral resting tremor

-rigidity

-bradykinesia (slow movement)

Front 130

this is high-frequency, bilateral, upper extremity tremor, with both limb movement, and sustained posture, w/ possible head, voice, and leg tremors present

Back 130

essential tremors

Front 131

what are disease specific risk factors for stroke

Back 131

1. atrial fib

-CHADS2

--c=CHF

--h=HTN

--a=age >75

--d=diabetes

--s=prior stroke or TIA

2.carotid artery disease

Front 132

categories for ischemic stroke

Back 132

-large artery atherosclerotic infarction

-cardiac embolism

-small vessel lacunar disease

-dissection

-hypercoagulable states

-paradocial embolism through foramen ovale

Front 133

most comon diabetes peripheral neuropathy

Back 133

distal symmetric sensorimotor polyneuropathy

(burning electrical pain in lower extremities at night)

Front 134

five categories for a comprehensive or screening neuro exam

Back 134

1. mental status, speech, language

2. CN

3. motor-coordination, gait, and strength

4. sensory-light, temp, touch, vibrations, discrimination

5. reflexes-DTR and plantar responses

Front 135

loss of smell can occur in..

Back 135

sinus conditions, head trauma, smoking, aging, cocaine use, and PD

Front 136

large pupil reacts poorly to light or aniscoria worsens in light and large pupil has abnormal pupillary constriction..this is seen in..

Back 136

CN 3 palsy

Front 137

if pt awake and if ptosis and opthalmoplegia also present with anisocoria then consider...

Back 137

intracranial aneurysm

Front 138

if pt in coma, with ptosis and opthalmoplegia also present with anisocoria then consider...

Back 138

transtentorial herniation

Front 139

binocular diplopia suggests...

Back 139

CN3, 4, and 6 neuropathies (40% of patients) and eye muscle diseases (MG, trauma, thyroid opthalmopathy, and internuclear opthalmoplegia)

Front 140

involuntary jerking movements of the eyes with quick and slow components

Back 140

nystagmus

Front 141

how is nystagmus named

Back 141

for the direction of the quick component (horizontal, vertical, mixed, or rotary)

Front 142

nystagmus presents in what kind of diseases

Back 142

Cerebellar disease, like gait ataxia and dysarthria and vestibular disorders and internuclear opthalmoplegia

Front 143

CN 5 carries which blinking reflex

Back 143

sensory limb

Front 144

CN 7 carries which blinking reflex

Back 144

motor response

Front 145

what portion of face does a peripheral injury (CN7) affect and an example

Back 145

Bells palsy

-both upper and lower face

Front 146

what portion of face does a central lesion affect

Back 146

mainly lower b/c upper face will receive upper motor neurons from opposite side of face

Front 147

loss of taste, hyperacusis, and increased or decreased tearing is seen in...

Back 147

bells palsy

Front 148

hypertrophy

Back 148

increased muscle bulk with proportionate strength

Front 149

lesion to corticospinal tract causes and what is a common cause

Back 149

-spascity (hypertonia=increased muscle tone)

--common cause: stroke

Front 150

basal ganglia

Back 150

-controls muscle tone and controlled body movements (walking)

Front 151

lesion to basal ganglia would result in and a common cause

Back 151

-rigidity (increased resistance, esp during ROM)

--common cause=parkinsons

Front 152

lead pipe rigidity

Back 152

-increased resistance that persists throughout the movement arc and independ of rate of movement

Front 153

cogwheel rigidity

Back 153

with flexion and extension of the wrist or forearm, a superimposed ratchetlike jerkiness

Front 154

paresis

Back 154

impaired strength (weakness)

Front 155

paralysis or plegia

Back 155

absence of strength

Front 156

hemiparesis

Back 156

weakness to one half of the body

Front 157

paraplegia

Back 157

paralysis of the legs

Front 158

quadriplegia

Back 158

paralysis of all four limbs

Front 159

what is a grade 0 on the muscle strength scale

Back 159

no muscular contractions detected

Front 160

what is a grade 5 on the muscle strength scale

Back 160

normal muscle strength

Front 161

inability to heel walk is a sensitive test for...

Back 161

corticospinal tract damage

Front 162

disease example of loss of vibration sense in posterior column disease

Back 162

tertiary syph and vit B 12 deficiency

Front 163

disease examples of loss of position sense in posterior column disease

Back 163

MS, tabes dorsalis, vit B 12 deficiency, and peripheral neuropathy from DM

Front 164

reflex

Back 164

involuntary sterotypical response that involves at least one afferent and one efferent across a single synapse

Front 165

all componenets of a reflex arc

Back 165

sensory nerve fibers
spinal cord synapse
motor nerve fibers
neuromuscular junction
muscle fibers

Front 166

CNS lesion along descending corticospinal tract is..

Back 166

hyperactive reflexes (hyperflexia)

Front 167

other associated upper motor neuron findings of hyperactive reflexes are...

Back 167

weakness, spasticity, or a positive Babinski

Front 168

hypothyroidism is seen and felt where..

Back 168

ankle reflexes

Front 169

what does sustained clonus indicate

Back 169

CNS disease

Front 170

abdominal reflexes are absent in....

Back 170

CNS and PNS disorders

Front 171

loss of S2-4 anal reflex suggests..

Back 171

cauda equina lesion

Front 172

subarachnoid space inflammation will cause resistance in....

Back 172

-nuchal flexion (neck); brudzinski (femoral n.); and kernigs signs (sciatic n.)

Front 173

sciatica is 5x more likely when...

Back 173

-confirm ipsilateral calf wasting

-weak ankle dorsiflexion

Front 174

how does lethargic pt look

Back 174

-drowsy, opens eyes and responds, falls back to sleep

Front 175

how does obtunded pt look

Back 175

-opens eyes, responds slowly, somewhat confused

-alertness and interest in environment decreased

Front 176

how does a stuporous pt look

Back 176

-painful stimuli needed

-verbal response slow or absent

-unresponsive when stimuli ceases

-minimum awareness of self or environment

Front 177

how does comatose pt look

Back 177

-unarousable and eyes closed