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131 Cards in this Set

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What are the criteria for a febrile seizure?
1. age 3 m/o to 6 y/o (most common between 6-18 months)
2. fever > 38.8°C
3. non-CNS infection
Define aphasia.
variety of language disorders
inability to speak, write, or comprehend language
d/t brain disorder
What are the most common causes of febrile seizures?
usually acute respiratory illness
sometimes gastroenteritis (Shigella, Campylobacter), UTI
rarely roseola infantum, immunizations
Define hypersomnia.
excessive daytime sleepiness
FEBRILE SEIZURES:
ETIOLOGY:
Criteria:
1. age 3 m/o to 6 y/o (most common between 6-18 months)
2. fever > 38.8°C
3. non-CNS infection
Causes:
usually d/t acute respiratory illnesses
sometimes d/t gastroenteritis (Shigella, Campylobacter), UTI
rarely d/t Roseola infantum (classic cause), immunizations
occur in 2-3% of children

CLINICAL PRESENTATION:
90% generalized, last <5 min, occur early in illness causing fever

DIAGNOSTIC WORKUP:
evaluate for source of fever and R/O CNS infection (meningitis, encephalitis)
CBCDP and BC
LP → if child < 18 months (since signs unreliable), cause of fever not found, close F/U not possible, or recovery slow (negative finding does not R/O emerging CNS infection)

MANAGEMENT:
1. find source of fever and treat appropriately
2. measures to control fever (tepid baths, antipyretics, antibiotics) are reasonable but unproven to prevent recurrent febrile seizures
3. if complicated seizure or medical reassurance fails to relieve family anxiety → anticonvulsant prophylaxis (phenobarbital, valproic acid)

PATIENT EDUCATION:
1. recurrent febrile seizures occur in 30-50% of cases → expect more seizures
2. simple febrile seizures do not have any long-term adverse outcomes
3. complex febrile seizures may rarely lead to epilepsy (occur in 1-3%; risk increased 2-5 times; risk higher if complex features such as longer than 15 minutes, more than 1 seizure daily, focal features; risk higher if abnormal neurologic status preceding seizure, onset before age 1, FH of epilepsy)
Define hemiplegia.
paralysis of one side of body
Define paraplegia.
paralysis of lower half of body
d/t thoracic spinal cord injury
Define quadriplegia.
partial or total paralysis of entire body from neck down
d/t cervical spinal cord injury
Define decorticate.
abnormal posturing characterized by:
rigidity
adduction of arms
flexion of elbows
clenched fists
extension of legs
plantar flexion
Define decerebrate.
abnormal posturing characterized by:
rigidity
head/neck arched back
arms adducted
elbows extended and pronatated
clenched fists
legs extended
plantar flexion
CLUSTER HEADACHE:
ETIOLOGY:
unknown
PREVALENCE:
Middle-aged men

CLINICAL PRESENTATION:
episodes of severe unilateral periorbital pain occurring daily x several weeks
often accompanied by ipsilateral nasal congestion, rhinorrhea, lacrimation, eye redness, and Horner syndrome
restlessness, agitation during attacks
episodes often occur at night, awaken patient, last 15 min to 3 hours, followed by spontaneous remission that may last weeks to months
triggers include alcohol, stress, glare, specific foods
no signs apart from Horner syndrome

DIAGNOSTIC WORKUP:
none
MANAGEMENT:

PATIENT EDUCATION:
List the different types of seizures.
generalized seizures:
absence (petit mal)
tonic-clinic (grand mal)

partial seizures:
simple partial
complex partial
What is the difference between a simple partial and complex partial seizure
both affect restricted part of one cerebral hemisphere
both may become secondarily generalized leading to a tonic, clonic, or tonic-clonic seizure

consciousness preserved in simple partial

consciousness impaired in complex partial
What is the difference between a partial seizure and a generalized seizure?
partial seizures involve localized are of the brain and only 1 cerebral hemisphere; consciousness may be preserved or impaired

generalized seizures involve diffuse area of the brain and both cerebral hemispheres; consciousness may be impaired or lost
Define seizure.
abnormal paroxysmal neuronal discharge in the brain causing transient disturbance in cerebral function
Define epilespy.
recurrent unprovoked seizures
What is a complex seizure?
restricted part of one cerebral hemisphere affected
may become secondarily generalized leading to a tonic, clonic, or tonic-clonic seizure
consciousness impaired (may be preceded by illusions, hallucinations, automatisms)
What is a partial seizure?
restricted part of one cerebral hemisphere affected
may become secondarily generalized leading to a tonic, clonic, or tonic-clonic seizure
consciousness preserved
may manifest as focal motor symtoms (convulsive jerking), somatosensory symptoms (paresthesias), special sensory symptoms (light flashes, buzzing), autonomic symptoms (abnormal epigastric sensations, sweating, flushing, pupillary dilation), dysphasia, déjà vu , illusions or hallucinations
What are the causes of seizures?
idiopathic → usually occurs between 5-20y/o
congenital abnormalities
perinatal injuries
trauma
vascular → usually occur >60y/o
metabolic disorders → hypo/hyperglycemia, uremia
infectious disease → meningitis, encephalitis, neurosyphilis
neoplasm → usually occur >30y/o
degenerative
drug withdrawal
LACUNAR INFARCT:
small lesions (usually < 5 mm in diameter)
occur in the distribution of short penetrating arterioles in the basal ganglia, pons, cerebellum, anterior limb of the internal capsule, and, less commonly, the deep cerebral white matter
associated with poorly controlled HTN or DM,
associated with several clinical syndromes → contralateral pure motor or pure sensory deficit, ipsilateral ataxia with crural paresis, and dysarthria with clumsiness of the hand
neurologic deficit may progress over 24–36 hours before stabilizing
sometimes visible on CT scans → small, punched-out, hypodense areas
prognosis good, often with partial or complete recovery within 4-6 weeks
Which is more sensitive for detecting acute blood, CT or MRI?
CT
Which should be ordered for suspected hemorrhagic stroke?
CT
What is a subarachnoid hemorrhage?
leakage of blood into subarachnoid space
What is the diagnostic workup of subarachnoid hemorrhage?
non-contrast CT
LP if CT negative but still highly suspicious
Worst HA of your life describes?
subarachnoid hemorrhage?
What is the most common cause of subarachnoid hemorrhage?
70% caused by aneurysm
Subarachnoid hemmorhage is indicated by what LP results?
presence of RBCs and xanthochromia
What are the risk factors of subarachnoid hemorrhage?
smoking
HTN
FH
Where do saccular aneurysms tend to occur?
arterial bifurcations
usually anterior Circle of Willis
specifically anterior or posterior communicating arteries, bifurcation of the middle cerebral artery, or bifurcation of the internal carotid artery
INTRACRANIAL ANEURYSM:
ETIOLOGY:
may be associated with polycystic kidney disease, coarctation of the aorta

RISK FACTORS:
smoking, HTN, hypercholesterolemia
increased risk of subarchnoid hemorrhage associated with older age, female, non-white, HTN, hypercholesterolemia, high alcohol consumption (>150g/week), tobacco smoking, previous sxs, posterior circulation aneurysms, larger aneurysms

CLINICAL PRESENTATION:
usually asymptomatic
possible focal neurologic deficit d/t compression on adjacent structures

DIAGNOSTIC WORKUP:
angiography → bilateral carotid and vertebral studies

INITIAL MANAGEMENT:
prevent hemorrhages
prompt tx if symptomatic or large → surgery or endovascular
observation with arteriography if asymptomatic and small (<10mm)

PREVENTION:
PROGNOSIS:
may rupture producing subarachnoid hemorrhage
What are AV malformations?
congenital vascular malformations consisting of abnormal arteriovenous communications without intervening capillaries
What is the etiology of Tourette's syndrome?
autosomal dominant genetic disorder
What is the Rx management of Tourette's syndrome?
haloperidol
What is oculogyric crisis?
type of ocular dystonic reaction
What are the characteristics of an oculogyric crisis?
onset may be paroxysmal or stuttering over several hours
initial symptoms include malaise, restlessness, agitation, or fixed stared
usually SUSTAINED MAXIMAL UPWARD DEVIATION OF EYES BILATERALLY
occasionally eyes may deviated upward and laterally, deviated downward, or converge
protracted staring episodes
periorbital twitches
blepharospasm
ocular pain
widely opened mouth
tongue protrusion
extension or lateral flexion of neck
wave of exhaustion following episode
eye blinking, lacrimation, pupil dilation, drooling, facial flushing, vertigo
What is ddx for oculogyric crisis?
usually d/t neuroleptic drugs
other drugs (benzodiazepines, lithium, carbamazepine, levodopa, metoclopramide, nifedipine, cetirizine, amantadine, chloroquine)
head trauma
meningitis
encephalitis
focal seizures
conversion reaction
other movement disorders
MYASTHENIA GRAVIS:
ETIOLOGY:
often associated with autoantibodies but not always
autoantibodies bind to Ach receptors → blocking neuromuscular transmission to variable degree → inducing immune-mediated destruction of endplate → reducing number of functioning Ach receptors → weakness
associated with HLA-DR3, hyperthyroidism, thymoma, RA, SLE

GENETIC PREDISPOSITION:
most common in young women with

RISK FACTORS:
most common in young women with HLA-DR3
most common in older men if thymoma is cause

CLINICAL PRESENTATION:
usually insidious onset but may be exacerbated by infection, before menstrual period, pregnancy, postpartum
fluctuating weakness of commonly used voluntary muscles → cranial muscles (ocular, masticatory, facial, pharyngeal), respiratory, limb → ptosis, ocular palsies, diplopia, difficulty chewing or swallowing, respiratory difficulties, limb weakness
sustained activity increases weakness of affected muscles but improves after brief rest
sensation and DTRs normal
symptoms fluctuate throughout day
weakness may be localized or become generalized
slowly progressive

DIAGNOSTIC WORKUP:
Ach receptor antibody assay
AP and lateral CXR and CT to search for thymoma
electromyography
short-acting anticholinesterases transiently improve weakness

COMPLICATIONS:
myasthenia crisis → acute exacerbation, may lead to respiratory weakness requiring admission to ICU
MULTIPLE SCLEROSIS:
ETIOLOGY:
probably autoimmune
genetic components

GENETIC PREDISPOSITION:
HLA antigens (HLA-DR2)
alleles IL2RA and IL7RA

RISK FACTORS:
usually <55y/o
greatest incidence in young adults
more common if western European lineage + living in temperate zone

CLINICAL PRESENTATION:
episodic neurologic symptoms
single pathologic lesion can’t explain clinical findings
initially presents as fatigue, weakness, numbness, tingling or unsteadiness in a limb; spastic paraparesis; retrobulbar optic neuritis; diplopia; disequilibrium; sphincter disturbance such as urinary urgency or hesitancy
may be interval of months or years after initial episode before recurrent/new symptoms
may be relapse-remission episodes or steady decline
diagnosis requires involvement of different parts of the central nervous system at different times
definitive diagnosis if relapsing-remitting course and evidence of ≥2 two lesions involving different regions of central white matter
probable diagnosis if only 1 clinical attack + multiple white matter lesions or ≥2 clinical attacks + 1 white matter lesion

DIAGNOSTIC WORKUP:
MRI of brain or spinal cord to visualize multiple lesions → areas of demylelination scattered in white matter of brain and spinal cord

COMPLICATIONS:
some disability eventually but 50% of patients do not have significant disability 10 years after onset
List the cranial nerves.
I olfactory
II optic
III oculomotor
IV trochlear
V trigeminal
VI abducens
VII facial
VIII vestibulocochlear
IX glossopharyngeal
X vagus
XI accessory
XII hypoglossal
List the cranial nerves and their corresponding cranial exam components.
I olfactory → none
II optic → visual acuity → snellen, rosenbaum, fundoscopy
III oculomotor → inspect for ptosis, EOMs, convergence; inspect pupillary size/shape, corneal light reflex, accomodation
IV trochlear → superior oblique m. → EOMs, corneal light reflex
V trigeminal → inspect face for muscle atrophy, deviation of jaw to one side, fasciculations; clench teeth, move jaw side to side; soft, sharp, dull
VI abducens → laterla rectus m. → EOM, corneal light reflex
VII facial → raise eyebrows, close eyes and resist opening, puff cheeks and resist popping, smile, show teeth
VIII vestibulocochlear → gross hearing
IX glossopharyngal → stick out tongue, stay ah, gag reflex
X vagus
XI accessory → testing sternocleidomastoid and trapezius
XII hypoglossal → stick tongue out
What are the layers of the meninges?
(skin)
(muscle)
(periosteum)
(skull)
(epidural space)
dura mater
subdural space
arachnoid mater
subarachnoid space
pia mater
Mosbys p760
What arteries supply the brain?
two internal carotid arteries
two vertebral arteries → basilar artery
Mosbys p761
What are the parts of the cerebrum?
cerebrum divides into 2 cerebral hemispheres that each contain frontal lobe, temporal lobe, parietal lobe, and occipital lobe

cerbral cortex = outer layer
Mosbys p762
What is the function of the frontal lobe?
contain motor cortex associated with voluntary skeletal movement, fine repetitive motor movement, eye movement
Mosbys p762
What is the function of the parietal lobe?
processing sensory data → visual, auditory, olfactory, gustatory, and tactile sensation; propioception
Mosbys p762
What is the function of the temporal lobe?
perception and interpretation of sound, smell, taste, and balance
Mosbys p762
What is the function of the occipital lobe?
contains primary vision center → interpretation of visual data
Mosbys p762
What is the function of the cerebellum?
assists motor cortex of cerebrum in integration of voluntary movement; processes sensory data from eyes, ears, touch receptors, and musculoskeleton → altering muscle tone, equilibrium, and posture
Mosbys p762
What structures comprise the brainstem?
medulla oblongata, pons, midbrain, diencephalon
Mosbys p763
What is the brainstem?
pathway between cerebral cortex and spinal cord; contains nuclei of CNs
Mosbys p763
What are cranial nerves?
peripheral nerves that arise from the brain (not the spinal cord)
Mosbys p763
What is the function of the pituitary gland?
hormonal control of metabolism, vasoconstriction, growth, and lactation
Mosbys p764
What is the function of the hypothalamus?
processing of internal stimuli for ANS; maintains temperature control, water metabolism, body fluid osmolarity, feeding behavior, and neuroendocrine activity
Mosbys p764
What is the function of the epithalamus?
house pineal body
sexual development and behavior
Mosbys p764
What is the function of the olfactory nerve (CN I)?
sensory → smell
What is the function of the optic nerve (CN II)?
sensory → vision
What is the function of the oculomotor nerve (CN III)?
motor → raise eyelids, most EOMs
parasympathetic → constrict pupils, alter lens shape
What is the function of the trochlear nerve (CN IV)?
motor → EOM of the superior oblique muscle → eyes move medially and inferiorly
What is the function of the abducens nerve (CN VI)?
motor → EOM of the lateral rectus muscle → eyes move laterally
What is the function of the trigeminal nerve (CN V)?
motor → clench teeth, open jaw, mastication
sensory → sensation to facial skin, forehead, eyelids, lacrimal gland, conjunctiva, cornea, iris, ear, nose, nasal mucosa, mouth mucosa, teeth, tongue
What is the function of the facial nerve (CN VII)?
motor → close eyelids, movement of facial expression muscles except jaw, labial speech sounds (b, m, w, and rounded vowel sounds)
sensory → taste (anterior 2/3rds of tongue), sensation to pharynx
parasympathetic → secretion of tears and saliva
What is the function of the vestibulocochlear nerve (CN VIII)?
sensory → hearing, balance
What is the function of the glossopharyngeal nerve (CN IX)?
motor → voluntary muscles for swallowing and phonation (gutteral speech sounds)
sensory → sensation of nasopharynx, taste (posterior 1/3rd), gag reflex
parasympathetic → secretion of salivary glands , carotid reflex
What is the function of the vagus nerve (CN X)?
sensory → sensation behind ear and part of external ear canal
parasympathetic → secretion of digestive enzymes, peristalsis, carotid reflex, involuntary action of heart, lungs, and GI tract
What is the function of the function of the acessory nerve (CN XI)?
motor → turn head, shrug shoulders, some phonation
What is the function of the hypoglossal nerve (CN XII)?
motor → tongue movement for sound articulation (l, t, d, n), swallowing
Describe the neurological exam.
Cerebral Function:
1. check altertness and orientation → document as A&O x 4
-name
-date → day, month, year, season
-place
-purpose
2. test memory
-recent memory → ask patient to remember 3 simple words, ask to repeat, then ask to repeat later on in exam → ball, cat, apple
-remote memory → ask president
3. test graphesthesia → ask patient to close eyes, draw letter in hand, bilaterally
4. test stereognosis → ask patient to keep eyes closed, place object in hand, use different object for other hand
5. ask patient to recall words

Cerebellar Function
1. finger-nose touch → eyes open, faster, moving, eyes closed, bilaterally
2. rapid alternating movements
-upper extremities
-lower extremities
3. shin-scrape
Define graphesthesia.
ability to recognized writing on the skin by the sensation of touch
List the deep tendon reflexes and the associated spinal roots being tested.
biceps→ C5
brachioradialis → C6
triceps → C7
patellar → L4
achilles → S1, S2
Describe the grading scale for tendon reflexes.
0 = absent
1+ = trace
2+ = normal
3+ = hyperactive without clonus
4+ = hyperactive with clonus
List the superficial reflexes and the associated spinal roots being tested.
abdominal →
cremasteric →
plantar →
Define anosmia.
loss of sense of smell or inability to discriminate odors
Mosbys p776
What is the ddx for anosmia?
trauma to cribiform plate
olfactory tract lesion
Mosbys p776
What is the ddx for reduced sense of smell?
inflammation of mucous membranes
allergic rhinitis
smoking
Mosbys p776
How is normal alertness and orientation documented?
A&O x 4
How are normal pupils documented?
PERRLA
If patient complains of severe constant headaches, what should you look for?
impaired extraocular movement in lateral direction → suggests impaired lateral rectus muscle → suggests impaired abducens nerve

*abducens nerve usually loses function first in presence of increased ICP
Mosbys p777
Which cranial nerve usually loses function first with increased ICP?
abducens (CN VI) → loss visible when evaluting lateral rectus muscle (EOMs impaired in lateral direction)
Mosbys p777
How do you perform the corneal reflex test?
1. if present, ask patient to remove contact lenses
2. ask patient to look up and away
3. approach patient from side
4. touch cornea with cotton, avoiding eyelashes and conjunctiva
5. if corneal reflex present, patient should blink bilaterally
Mosbys p777
What is the ddx for absent corneal reflex?
use of contact lenses (may be diminished or absent)
damage to opthalmic branch (V1) of trigeminal nerve (CN V)
Mosbys p777
How do you evaluate nasopharyngeal sensation?
gag reflex → palate should move upward, pharnygeal muscles should contraction, uvula should remain midline
Mosbys p778
What cranial nerves are responsible for nasopharyngeal sensation?
glossopharyngeal
vagus
Mosbys p778
Failure of palate to rise + deviation of uvula from midline may indicate?
glossopharyngeal or vagus nerve damage
Mosbys p778
Deviation of tongue from midline may indicate?
hypoglossal nerve damage
Mosbys p779
What is past pointing?
occurs during finger-nose test
patient consistently misses touching examiners finger
may indicate cerebellar disease
Mosbys p781
Past pointing may indicate?
cerebellar disease
Mosbys p781
Define ataxia.
gross lack of muscle coordination
What is the ddx for positive Romberg sign (i.e. loss of balance)?
cerebellar ataxia
vestibular dysfunction
sensory loss
Mosbys p781
What evaluating gait, what are you looking for?
normally smooth, symmetric with regular rhythm

shuffling, widely placed feet, walking on toes, drop foot, leg lag, scissoring, loss of arm swing, staggering, reeling
Mosbys p783
Deviation of the tongue to the left may indicate?
left hypoglossal (CN XII) palsy
Define stereognosis.
ability to recognize an object by touch
What must you remember when evaluating a musculoskeletal complaint?
1. examine joint above and below complaint
2. examine contralateral side
Define gait cycle.
interval from heelstike to heelstrike of same foot
What percentages do the stance and swing phases comprise of the gait cycle?
stance = 60%
swing = 40%
Where is the visual cortex located?
near calcarine sulcus of occipital lobe of cerebral cortex
The primary visual cortex receives info from?
ipsilateral lateral geniculate nucleus (LGN)
List the EOMs involved in eye movement.
CN III, IV, V
What CN is involved in focusing the lens of the eye?
CN III (visceral motor)
What CN is involved in constricting the pupil?
CN III (visceral motor)
What CN is involved in raising the eyelids?
CN III (somatic motor)
Where is the center for lateral gaze located?
paramedian pontine reticular formation (PPRF) of pons
Is pupillary constriction controlled by the parasympathetic or sympathetic nervous system?
parasympathetic
Is pupillary dilation controlled by the parasympathetic or sympathetic nervous system?
sympathetic
Is lens thickening and near vision controlled by the parasympathetic or sympathetic nervous system?
parasympathetic
Paralysis of lower half of face indicates?
UMN lesion (lesion to primary motor cortex)

think stroke!!!
weakness in contralateral lower half of face
Paralysis of entire half of face indicates?
LMN lesion (lesion to nerve)

think bell's palsy!!!
weakness in contralateral upper and lower halve of face
What are UMNs?
motor neurons that originate in the cerebrum and terminate in the brainstem or spinal cord
What are LMNs?
motor neurons that originate in the brainstem (cranial nerves) or spinal cord (spinal nerves) and terminate at the neuromuscular junction (muscles)
Are descending motor pathways found in the ventral horn or the dorsal horn?
ventral
Are ascending sensory pathways found in the ventral horn or the dorsal horn?
dorsal
Posterior spinal artery infarct causes?
effects ipsilateral DCML
causing ipsilateral loss of proprioception and vibratory sensation
List LMN signs.
weakness
hypotonia
hyporeflexia
marked muscle atrophy
fasciculations
flaccid paresis (or paralysis)
List UMN signs.
weakness
hypertonia
hyperreflexia
Babinski
disuses muscle atrophy
spastic rigidity
What is the corticospinal tract?
descending motor pathway

collection of axons that travel between the cerebral cortex and the spinal cord

fibers separate into:
lateral corticospinal tract
anterior corticospinal tract
Anterior cerebral artery supplies blood to?
medial frontal lobes
superior medial parietal lobes
Anterior cerebral artery infarct manifests as?
contralateral UMN signs
weakness in contralateral leg
somatosensory deficits in contralateral leg

no visual, auditory, or language deficits

*legs are most medial (think FATL)
Posterior cerebral artery supplies blood to?
occipital lobes
Posterior cerebral artery infarct manifests as?
contralateral homonymous hemianopsia

no motor, somatosensory, auditory, or language deficits
Middle cerebral artery supplies?
lateral cerebral cortex
anterior temporal lobes
insular lobes
Middle cerebral artery infarction manifests as?
ipsilateral somatosensory deficits (entire face, upper limb, maybe lower limb)
ipsilateral motor deficits (lower face, upper limb > lower limb)
language deficits (if RT handed + LT MCA infarct then global aphasia; if RT handed + RT MCA infarct then aprosody i.e. lack of variation in speed tone inflexion

no visual or auditory deficits (getting info from both ears)
Lesions in the RT primary visual cortex manifest as?
LT homonymous hemianopia with macular sparing
What are the watershed stroke?
stroke affecting areas of brain farthest away from direct perfusion by major cerebral arteries

d/t hypoperfusion (ex: hypotension, CHF, atherosclerosis of carotid arteries
What is a watershed area?
region that receives blood supply from the distal branches of 2 large arteries

*if atherosclerosis occurs, region is spared from ischemia d/t dual blood supply
*if hypoperfusion occurs, region is particularly vunerable
Deficits affecting one side of face and opposite side of body indicates?
unilateral damage to brainstem
Posterior spinal artery infarct manifests as?
effects DCML
ipsilateral proprioception deficit
Posterior inferior cerebral artery infarct manifests as?
infarct of lateral medulla
ipsilateral deficit in pain/temp for face (trigeminal nucleus)
ipsilateral hearing loss (cochlear nucleus)
vertigo, nystagmus (drift to impaired side and beat back to contralateral side), leaning to ipsilateral side (vestibular nucleus)
contralateral deficit of pain/temp for body
Where is the primary visual cortex located?
occipital lobe
A lesion or infarct in primary visual cortex manifests as?
homonymous hemianopsia with macular sparing
What are the reversible causes of dementia?
neurosyphilis
B12 deficiency
hypothyroidism
normal pressure hydrocephalus
intercranial mass lesion
What is pseudodementia?
depression
What is normal pressure hydrocephalus?
abnormal accumulation of CSF in ventricles - increased ICP - ICP eventually falls back to normal but ventricles enlarge putting pressure on adjacent cortical tissue - resulting in dementia, urinary incontinence and gait disturbance