Neuropsych unit notes

Assessments, disorders,

1. Developed in 2004 Inspired by Luria’s approach

2. Developed by

   1. Shobini Rao,

   2. Subbakrishna,

   3. Gopakumar

3. It follows international standard using peterson criteria (below 1.5 SD)

4. Aims to map

   1. Cognitive deficits and strengths

   2. Brain structure functionally

   3. Pre and post intervention comparison

5. Battery include 13 subtests standardised to indian population

6. Age range: 16 to 65

7. norms Categorised based on

   1. 3 set of age (16-30, 31-50, 51-65)

   2. 2 set of gender (male Female(

   3. 3 set education (illiterate, school, college)

8. Now 7.5 percentile is taken as significant finding earlier it was 15 percentile

Overview of Nimhans Neuropsych battery (8)

• qualitative analysis of cognitive processes,

• dynamic assessment,

• syndrome analysis based on detailed clinical observations

• not just final score

What is Luria approach compared to traditional psychometric batteries?

1. Sensory deficits which are not corrected

2. Physiological aspects (food, medication etc)

3. Enough time frame to finish

4. Attention

5. Orientation

6. Language comprehension ability

Things to the assured before administering battery? (6)

1. Finger tapping

2. Digit symbol substitution

3. Digit Vigilance

4. Color Trial test 1

5. Color trial 2

6. COVA- Controlled oral Word Association

7. ANT- Animal naming test/ Category /Fluency test

8. Verbal N back test

9. Stroop Test

10. AVLT- Auditory Verbal Learning Task

11. Tower of london

12. Complex figure test (CFT)

13. WCST- Wisconsin Card sorting test

WMS 3

1. Logical memory test

2. Visual Reproduction test

3. Digit Span

4. Spatial Span

which are the 13 subtests in Nimhans neuropsychology battery? (13)

From both Sobini Rao scale and WMS? (17)

1. Assess

   • motor speed

   • sequencing

   • manual dexterity in relation to psychomotor functioning

2. Helps to identify subtle motor deficits and their potential neurological origins in motor areas 

3. material: Equipment and stopwatch

4. Administration

   1. 3 set of 10s finger tapping dominant hand index finger

   2. take 30s break

   3. 2 set of 10s finger tapping of same hand

   4. continue same with other hand

5. Scoring: Average no of taps per hand

6. Helpful in assessing

   1. Parkinson bradykinesia

   2. Upper limb motor deficit in stroke

   3. Psychomotor functioning in TBI

   4. Ataxia or any cerebellar pathology

Finger tapping test over view?

assess?

insight?

administration?

1. To assess (5)

   1. Processing speed

   2. Mental speed

   3. Visual motor coordination

   4. Motor persistence

   5. sustained attention

2. Administration

   1. Demo with 10 trials

   2. Finish all the boxes sequentially as fast as possible

3. Score: time taken to fill all

4. GIve insights into

   1. Visual problems

   2. Perseveration

   3. Spatial neglect

5. Brain area involved

   1. DLPFC (Usually Lt>Rt)

Subtest Digit symbol substitution overview? (12)

Assess?

administration?

scoring?

insights?

1. Mental Speed: Rapid processing to match symbols accurately and quickly.

2. Visual-Motor Coordination: Integrating visual scanning and hand motor responses.

3. Sustained Attention: Maintaining focus and persistence throughout the test.

4. Motor Persistence: Continuously producing rapid motor responses over time

Cognitive Domains Assessed in DSST

Sustained attention

Digit vigilance Assess which domain

1. An alternative of trial making test

2. Aim to assess domain of

   1. Sustained attention

   2. Focused attention

   3. sequencing ability

   4. Cognitive flexibility

3. It has no norm for illiterate population

4. Helps to assess functioning of orbitofrontal cortex in ventral frontal lobe

   • (Important role in flexible thinking, self-monitoring, and adapting behavior based on feedback)

5. There should not be any achromatic and patient should know numbers

6. Score: Time taken to finish

Overview of color trial test (6)

Focused attention

Capacity to focus on tasks when distractions are present?

1. Focused attention

2. Divided attention

3. Flexibility/ Set shifting

4. sequencing ability

What does color trial 2 assess?

1. Assess Phonemic fluency

   1. Lt Frontal Cortex (DLPFC)

   2. executive functioning

2. test is the ability to spontaneously produce words

controlled oral Word association test (COWA)?

Helps to assess functioning of lateral temporal lobe (Lt generally)

Category Fluency test/ Animal Naming test helps to assess functioning of which brain area?

1. Verbal n back test

2. Digit span

3. Spatial Span

What are tests that assess working memory in Nimhans neuropsych battery?

N back test

A neuropsychological performance test used to assess working memory in which Participants are presented with a sequence of stimuli (such as letters or numbers) and must indicate whether the current stimulus matches the one presented n items ago

Working memory

cognitive manipulation

N back tests assess what in cog neuropsychology

1. Aphasia (if left hem is involved)

2. Dysarthria (motor speech disorder- slurred speech)

3. Apraxia of speech

What are communication Disorders post stroke

Aphasia

What is the language disorder that affects spoken comprehension, expression, reading and writing?

1. Motor speech disorder

2. Caused due to impairment to speech muscles causes reduced intelligebility

3. 42% incidence

Dysarthria?

1. A motor speech disorder

2. Reduced ability to coordinate the gestures used for speech leading to difficulty in producing right sound in right order

3. Often cooccur with aphasia

Apraxia of speech?

Symptom caused by Sudden, unprovoked hyper electric activity of neurons in brain

Seizure?

1. Generalised Seizure

2. Focal Seizure

3. Unknown Seizure

types of seizures according to ILAE?

1. To assess and quantify cognitive deficits reported

2. pre and post intervention comparison

When do we use Neuropsychological assessments

1. Finger tapping (Manual dexterity)

2. Digit substitution (MS,PS, PMA)

3. COWA (phonemic fluency)

4. ANT (Category fluency)

5. Digit span (Verbal working memory)

6. Spatial span (Spatial working memory)

7. Color trial 1 and 2 (attention- sustained, focused and divided)

8. N back 1 and 2 (WM)

9. Stroop test (inhibitory control, flexibility)

10. Complex figure (Visuo spatial, executive)

11. AVLT (Verbal learning memory)

What all test are involved Nimhans Neuropsych battery short version? (11)

1. Neuronal migration disorder

2. resulting in clusters of misplaced neurons (“bands”) under the cortex,

3. disrupting normal cortical architecture and neurocognitive functioning.

What is meant by heterotopia?

Band

Cluster of misplaced neurons in brain are called?

1. Expressive language

2. Problem solving

3. Attention deficit

4. Planning deficit

If left frontal lobe is affected what all cognitive areas can have dysfunction?

1. Episodic memory

2. Deficits in new learnings

If medial (inner) temporal lobe is affected what all cognitive areas can have dysfunction?

Hippocampus

Medial temporal lobe consist of ?

1. Sensory processing (visual and auditory)

2. Semantic memory impairment

3. Language comprehension impairment

If lateral (Outer) temporal lobe is affected what all cognitive areas can have dysfunction?

Reduced blood supply to tissues in brain

Ischaemia?

Decreased Oxygen supply to tissues

Hypoxi

A type of tumor that forms in Glial cells in brain and spinal cord

Glioma?

1. Low grade glioma (slow growing)
   &
   High grade glioma (Fast growing and aggressive)

2. Benign (non-cancerous) o
   &
   malignant (cancerous).

what are two types of glioma?

observed signs and symptoms of a seizure,

including subjective sensations and objective behaviors

Semiology of seizure means what?

Auras (Subjective experiences)

1. Sensory Aura

   1. Visual (flashes of light, colors)

   2. Auditory (buzzing, ringing)

   3. Olfactory (unusual smells)

   4. Gustatory (odd tastes)

   5. Somatosensory (tingling, numbness)

2. Autonomic auras

   1. Feeling of heat

   2. Nausea

   3. Epigastric sensation

   4. palpilation

3. Psychic auras

   1. Fear, panic

   2. De javu

   3. depersonalisation

   4. other emotional experiences

4. Cognitive Aura

   1. Difficulty thinking, speaking clearly

Objective

1. Motor symptoms

   1. Clonic

   2. Tonic

   3. Automatism

   4. Posturing

2. Behavioural changes

   1. Confusion

   2. Staring

   3. Performing repetitive actions

   4. Lack of orientation

What are the semiologies in seizures to check for? (22)

1. Seizure localisation

2. Seizure classification

3. Treatment planning

4. Surgical assessments

Why is seizure semiology important?

• A rare progressive cerebro-vascular condition affecting arteries in the bottom of brain

• Characterised by narrowing and blockage of internal blood flow

• common symptoms

  • TIA

  • Headache

  • hemiparesis

  • numbness

  • vision problems

  • Cog symtoms

What is moya moya disorder?

Children

1. Transient ischemic attack/Stroke

2. cog developmental delay if there was repeated ischemic events

3. Sudden weakness or numbness in one side (hemiparesis)

4. Hypertension

5. blindness

6. Seizures

7. Severe headache

Adults

1. Hemorrhagic Stroke (bleeding in brain)

   • often associated with sudden, severe headache, loss of consciousness, or acute neurological decline

1. focal neurologic deficits (such as hemiparesis, aphasia, or visual disturbances),

2. progressive cognitive decline and personality changes that can sometimes be mistaken for psychiatric illnesses.

What are symptoms of moyamoya, Children and adult? (10)

1. Absence seizure

2. Tonic Seizure

3. Clonic seizure

4. Tonic Clonic seizure

5. Myoclonic seizure

6. Atonic Seizure

what are different types of generalised seizure? (6)

Memory deficits (episodic and working memory)

• Lt TLE - verbal memory

• Rt TLE - visuospatial memory

A hallmark symptom of temporal lobe epilepsy

An acute injury to internal brain structures due to any external physical force

Traumatic brain Injury? 

1. Closed injury (non penetrative)

2. Open injury (penetrating)

Types of TBI?

1. Altered consciousness

2. Loss of memory

3. Disorientation

What are possible symptoms of TBI?

1. Source of external physical source (accident, fall)

2. Any LOC

3. Type of wound

   • Any ENT bleed (help to assess open or closed wound)

4. Any vomiting episode (in brainstem involved)

5. Any seizure (physiological dysruption)

6. Any amnesia of event?

7. Disorientation

8. All investigation findings (CT, MRI etc)

9. Intervention administered

10. Status at the time of discharge

11. Course from discharge till day

12. Current complaints

What all things to be added in history in a TBI intake? (12)

1. Traumatic brain injury

2. Non traumatic brain injury ( not due to external physical force)

What are types of acquired brain injury (2)

Immediate physical damage caused to the brain at the moment of traumatic event,

which is non reversible

What is mean by primary TBI

1. Contusion (injury)

2. Lacerations (wound)

3. Intracranial hemorrhages

4. Axonal shearing

example of Primary TBI? (4)

Injury happens gradually over time (hours or days) after traumatic brain injury as a result of biological or physiological responses

reversible

What is mean by secondary TBI

1. Cerebral Edema

2. Ischemia

3. Hypoxia/Anoxia

4. Chronic sub hemorrhage

5. Chemical toxicity

Eg of Secondary TBI? (5)

A neck injury caused by a sudden, forceful back-and-forth movement of the head and neck

Whiplash injury

Physical

1. Headache

2. Dizziness

3. Nausea and vomiting

4. Clear fluid draining from EN

5. Unequal eye pupil size

6. Neurological problems like slurred speech, weakness of limbs
   

Cognitive behavioral change

1. LOC from sec to hours

2. decreased level of consciousness

3. Confusion/ disorientation

4. Problem remembering

Perceptual/ sensory

1. increased sensitivity to light and sound

2. lack of sensation in body parts

What are the consequences of TBI? (10)

• A numerical rating used to assess a person's level of consciousness after a head injury,

• Ranging from 3 (deeply unconscious) to 15 (fully awake)

• Includes

  • Eye opening

  • Verbal responses

  • Motor responses

What is Glasgow coma scale? GCS?

1. Gelastic seizure (laughint type)

2. Dacrystic seizure(crying type)

3. Aphasic seizure

What are special and rare type of seizurs?

A neurological brain disorder

1. at least 2 episodes of seizure 24 hour apart

Epileptic Seizure?

1. High fever

2. Brain infections (Encephalitis, meningitis, parasitic infections etc)

3. TBI

4. Glioma

5. Strokes

6. Electrolyte disturbances/ Metabolic disturbances

What are the possible reasons why seizure happens? (min 6)

1. Also known as primary epilepsy

2. Any epilepsy in which the reason is not identifiable through Brain imagings (MRI).

3. Caused by genetic factors

4. Often manifest in Generalised Seizures

5. Diagnosis usually based on EEG findings

6. **Idiopathic: there is no clear structural abnormality, injury, infection, or other obvious reason for the seizures.

Idiopathic epilepsy? (5)

1. Happen in Children

2. characterized by brief, involuntary muscle jerks (myoclonic seizures),

3. often upon waking,

4. which can affect the arms, shoulders, or legs

Juvenile myoclonic Epilepsy? (JME)

1. Rare type of epilepsy usually begins in early childhood

2. Characterised by frequent and diverse seizures (shifting semiology)

   1. Atonic

   2. Tonic

   3. absent

   4. myoclonic

   5. GCTS

3. It can have comorbid moderate IDD

4. Usually drug resistant

5. EEG: slow spike-and-wave discharges during wakefulness and generalized paroxysmal fast activity during sleep

Lennox-Gastaut syndrome (LGS)?

1. Primary/ Idiopathic

2. Secondary/ symptomatic

Types of epilepsy based on etiology (origin)?

1. Tonic

2. Clonic (tongue bite)

   1. Grunting sound

3. suspended breathing

   1. Body turns bluish due to hypoxia

4. pupil dilation

   1. last for 10-20s

5. Head turning

What are motor symtoms in Generalised seizure? (5)

1. Common among children

2. some fine movement of facial muscles and eye can happen

3. EEG: spiked wave 3/second

4. Brief lapses in awareness with staring

5. minimal motor signs.

Absence seizures?

1. A severe form of epilepsy that develops during infancy (3-12m)

2. Characterised by classic triad

   1. infantile spasm

   2. Developmental delay

   3. Abnormal EEG

West Syndrome/ Infantile Spasm?

How quickly a person can think and perform basic cognitive tasks like decision making, calculation etc

Mental speed?

1. how quickly one can perceiving, interpreting, and acting on sensory input.

2. Function is to quickly recognise and respond to a stimuli

Processing speed?

The ability to focus on one specific stimulus while ignoring other distractions in the environment.

For example, listening to a friend in a noisy room

Sustained attention

The ability to attend to multiple tasks at a time, often referred to as multitasking,

like talking on the phone while cooking

Divided attention?

Ability to respond to a specific task when it captures your attention, often quickly orienting to something new or important in the environment.

focused attention

the ability to concentrate on one specific task over a longer period while actively filtering out other irrelevant or distracting stimuli.

Selective attention

1. Rey Auditory verbal learning test (AVLT)- Learning, IR, DR

2. CFT for visual memory

3. LM- IR and DR

4. Verbal paired associates - Learning, recall

5. Faces in WMS - Rt medial TL

involvement of medial temporal lobe can be assessed using which subtest?

Medial/inner temporal lobe dysfunction

Impaired performance in delayed recall of AVLT and CFT is suggestive of involvement of ?

1. Color trial

Which all subtests has no norms for illiterates in nimhans battery?

>137 - very superior

125 - 136 = Superior

110 to 119 - above average

90 to 109 - average

80 to 89 - below average

70 to 79 - boarderline

50 to 69 - mild

35 to 49 - moderate

20 to 34 - Severe

<20 - profound

WHO IQ ranges?

750ml/ minute

Amount of cerebral blood flow?

1. Internal carotid system/ Anterior circulation

2. Vertebral basilar system/ posterior circulation

What are major arterial systems in cerebral blood flow?

1. supplied by internal carotid arteries

2. Include

   1. ACA- Anterior Cerebral artery

   2. MCA- Middle cerebral artery

3. Supplies most of the

   1. cerebral hemispheres

   2. parts of the frontal lobes,

   3. Parts of parietal lobes,

   4. parts of deep brain structures.

Anterior circulation in cerebral blood flow?

1. Supplied by the vertebral arteries which fuse to form the basilar artery.

2. Supplies to

   1. Brain stem

   2. Cerebellum

   3. Occipital lobe

3. two vertebral arteries join to form BASILAR ARTERY which further get divided into PCA

   1. PCA supplies to occipital and posterior temporal lobes

Vertebral basilar system/ posterior circulation?

1. medial of frontal and parietal lobe,

2. corpus callosum,

3. anterior region of basilar membrane (caudate and putamen)

Anterior Cerebral Artery supplies to?

1. Lateral cerebral hemisphere (convex shaped)

2. lateral surface of frontal- temporal-parietal

Middle Cerebral artery/ MCA supplies to?

1. Part of vertebral artery system

2. Supplies to inferior(bottom) and medial aspects of temporal and occipital lobe

Posterior cerebral artery? PCA

An alternative or backup route for blood to reach a part of the brain if the main route is blocked or narrowed.

What are collateral cerebral circulation?

The junction of joining of two blood vessels (vein, artery or both)

Anastomosis?

1. A circular arterial anastomosis at the brain base

2. connecting anterior and posterior circulations.

3. Providing collateral circulation (if one artery is blocked other can backup

Circle of Willis/ Arterial circle?

1. cerebral veins that helps to drain deoxygenated blood and CFS

2. Drains into dural venous sinuses

3. Then direct it out of cranium through jugular veins

4. Affect intracranial pressure and brain metabolism

5. 2 main components

   1. Superficial venous system

   2. Deep venous system

Venous system/ Venous drainage?

superficial venous system + deep venous system → Dural sinuses → Internal Jugular Vein → Heart to purify

route of how cerebral venous system works?

1. A selective semipermeable between blood and brain

2. protect brain from toxins

3. it has physical and enzymatic barrier system

4. consist of tight junction between endothelial cells, astrocytes

Brain Blood barrier

1. Basal Energy

   1. Maintain cell integrity

2. Functional energy

   1. To actively use parts of brain

What are energy requirement of brain?

As it has organelles for metabolism

Why grey matter has higher cerebral blood flow than white matter?

1. A pressure that drives blood through brain’s circulation to push blood

2. It can be calculated by

   1. mean arterial pressure - intracranial pressure

What is cerebral perfusion pressure/ CPP ?

The doctrine saying the total pressure inside cranium is stable and constant and it is not an expandable structure

Monro Kellie Doctrine?

Flow metabolism coupling

1. A phenomenon which is used in FMRI

2. blood flow increases where metabolism and neuronal activity increases 

3. When a brain region becomes more active, it uses more oxygen and glucose and the body responds by sending more blood to that area.

What is the foundation principle in FMRI?

1. Stroke

2. Moya moya

3. TIA

4. Cerebral venous thrombosis

5. Arterio venous malformation

6. Aneurysm

What are different disorders of cerebral circulation? (6)

1. Rapidly developed clinical sign of focal/ global disruption of cerebral function

2. lasting more than 24 hour lead to death

3. 2 types

   1. Ischemic

   2. Hemorrhagic

Stroke/ Cerebrovascular Accident (CVA)?

1. A sudden neurological deficit/ Stroke happen due to blockage of artery to brain area

2. Most frequent

3. Caused by

   1. Thrombosis

   2. Embolism

   3. Systemic hyperfusion

   4. Smoking

Ischemic Stroke?

A stroke caused by internal bleeding causing lack of blood supply to brain areas

more in younge people

Hemorrhagic stroke?

1. Thrombotic: clot forms in situ (usually in atherosclerotic artery)

2. Embolic: clot or debris travels from another site (e.g., heart → brain).

Ischemic stroke is caused by?

1. High BP

2. Aneurysm Rupture (ballooning of a blood vessel)

3. AVM (Arteriovenous Malformation)

4. Trauma

Causes of Hemorrhagic Stroke?

F - Face drooping

A- Arms weakness

S- speaking difficulty such as slurred speech

T- act fast

Easy clinical tool used to recognize the early warning signs of a stroke.

non Modifiable

1. age

2. Family history

3. TIA h/o

4. Race

5. Gender

Modifiable

1. smoking

2. Obesity

3. Unhealthy diet

Risk factors for stroke?

CT scan

Gold standard diagnosis measure for stroke?