CA Neurology

What are the 3 primary sections of the brain?

Cerebrum (cerebral cortex)

Cerebellum

Brain stem

Is the ascending spinal cord tract sensory or motor? Are the nuclei located anterior or posterior?

Sensory; Posterior

Is the descending spinal cord tract sensory or motor? Are the nuclei located anterior or posterior?

Motor; Anterior

How many cranial nerve pairs compose the peripheral nervous system?

12 pairs

How many spinal nerve pairs compose the peripheral nervous system?

31 pairs

What is the function of the Corticospinal (Pyramidal) Tract?

Mediates voluntary movement and inhibits muscle tone

What disease commonly impacts the Corticospinal (Pyramidal) Tract?

ALS

What is the function of the Basal Ganglia System?

Maintains muscle tone and controls body movements

What diseases commonly impact the Basal Ganglia System?

Parkinson's Disease, Huntington's Diseases, Tourette Syndrome

What is the function of the Cerebellar System?

Coordinates motor activity, balance, and posture

What diseases commonly impact the Cerebellar System?

Multiple Sclerosis, Ataxia, Astrocytomas

When upper motor neurons are damaged above the crossover in the medulla, motor impairment develops on the _____________ side of the body

Contralateral

When upper motor neurons are damaged below the crossover in the medulla, motor impairment develops on the _____________ side of the body

Ipsilateral

What are the 3 principle motor pathways?

Corticospinal (Pyramidal) Tract

Basal Ganglia System

Cerebellar System

What are the 2 principle sensory pathways?

Spinothalamic Tract

Posterior Columns

What is the function of the Spinothalamic Tract?

Transmits sensations of pain, temperature, and crude touch

What is the function of the Posterior Columns?

Transmit sensations of proprioception, vibratory sense, and fine touch

True or False: In the corticospinal tract, damage or deficit occurs below the level of injury or lesion

True

Hyperreflexia and increased muscle tone is due to a lesion on an ____________ neuron

Upper Motor Neuron

Hyporeflexia, absent reflexes, weakness, paralysis, and decreased muscle tone are due to a lesion on an ____________ neuron

Lower Motor Neuron

What is a dermatome?

A band of skin innervated by the sensory root of a single spinal nerve; Help to localize lesions to a specific spinal cord segment

______ are the most basic unit of sensory and motor function to determine a neurological response

Deep Tendon Reflexes (DTRs)

Deep Tendon Reflexes: Biceps

C5

Deep Tendon Reflexes: Triceps

C7

Deep Tendon Reflexes: Brachioradialis

C6

Deep Tendon Reflexes: Knee

L4

Deep Tendon Reflexes: Ankle

S1

Superficial (Skin) Reflexes: Upper Abdomen

T8

T9

T10

Superficial (Skin) Reflexes: Lower Abdomen

T10

T11

T12

Superficial (Skin) Reflexes: Plantar

L5

S1

Superficial (Skin) Reflexes: Anal

S2

S3

S4

____________ lie in the motor strip of the cerebral cortex. Their axons synapse with motor nuclei in the brainstem and spinal cord

Upper Motor Neurons

____________ have cell bodies in the spinal cord. Their axons transmit impulses through anterior spinal root and spinal nerves into the periphery

Lower Motor Neurons

In UMN lesions, muscle tone ____________ and deep tendon reflexes ____________

Increase; Increase

In LMN lesions, muscle tone ____________ and deep tendon reflexes ____________

Decrease--> leads to weakness/paralysis; Decrease

True or False: Diseases of the basal ganglia and cerebellar system cause paralysis

False

____________ refers to a patient's capacity for arousal or wakefulness. It is determined by the level that patient can be aroused to perform in response to stimuli from the examiner

Level of Consciousness

____________: using normal tone of voice, patient's arousal intact; responds fully & appropriately

Alert

____________: using loud tone of voice, patient appears drowsy but opens eyes and responds then falls asleep

Lethargic

____________: shake patient gently; patient opens eyes but responds slowly, somewhat confused

Obtunded

____________: apply painful stimulus to arouse patient from sleep, verbal responses slow/absent, unresponsive when stimulus ceases

Stuporous

____________: unarousable with eyes closed after repeated painful stimuli, no response to environment

Comatose

What is the function of the frontal lobe?

Personality characteristics

Decision-making

Movement

Recognition of smell

Speech ability-> Broca's area

What is the function of the parietal lobe?

Identify objects

Spatial awareness

Interpretation of pain/touch

Understanding language-> Wernicke's area

What is the function of the occipital lobe?

Visual processing

What is the function of the temporal lobe?

Short-term memory

Speech

Musical rhythm

What is Broca's area?

An area in the posterior left frontal lobe-> critical for speech production

What is Wernicke's area?

An area in the posterior left temporal lobe-> critical for understanding speech

What are the points of the Glasgow Coma Scale?

What is decerebrate posturing?

Extensor response: Hands pushed to sides and body hyper-extended. Arms are stiffly extended, adducted & hyperpronated. Hyperextension of the legs with plantar flexion of the feet.

"extensor = All E's"

What is decorticate posturing?

Flexion response: Hands pulled to chest. Internal rotation and adduction of the arms with flexion of the elbows, wrists & fingers.

"flexor - toward the cord"

What can small or pinpoint pupils indicate?

Response to morphine, heroin, or other narcotics; Pontine lesion

What can fixed, midposition pupils indicate?

Structural damage in the midbrain

What can large pupils indicate?

Response to cocaine, amphetamine, LSD, or other sympathetic nervous system antagonists

What can a unilateral, large pupil indicate?

Herniation of the temporal lobe or CN III infarction

What is Brudzinski sign?

Severe neck stiffness causes a patient's hips and knees to flex when the neck is flexed

*Sign of meningitis

What is Kernig sign?

Patient lies supine, thigh is flexed at right angle, and it hurts to extend leg

*Sign of meningitis

What is asterixis and what does it indicate?

Sudden, brief, nonrhythmic flexion of hands and fingers after asking patient to "stop traffic"

Can indicate hepatic failure encephalopathy, uremic syndrome, or barbiturate overdose

What is Broca's aphasia?

Damage to left frontal lobe; speech is nonfluent but meaningful, patient aware of their difficulty

What is Wernicke's aphasia?

Damage to left temporal lobe; speech is fluent but words are jumbled, obscuring all meaning; patient unaware of their deficit

What is dysarthria?

Difficulty speaking due to weakened or paralyzed muscles of speech

What is aphonia?

Loss of voice

What is dysdiadochokinesis and how is it tested?

Inability to arrest one motion and initiate the opposite

Tested by rapid alternating movements (flip flopping hands against thigh or tapping foot quickly)

What is dysmetria and how is it tested?

The inability to control the distance, speed, and range of motion necessary to perform smoothly coordinated movements

Tested by point-to-point movements (finger to nose or heel to shin)

What is ataxia and how is it tested?

Loss of coordination

Tested with gait assessments

What is the Romberg Test?

Patient stands with feet together and their eyes open, then closes their eyes for 30-60 seconds

What is Pronator Drift?

Patient stands or sits for 30 seconds with arms straight forward, palms up, and eyes closed. Their arms are then tapped briskly downward

In ataxia from ____________ and loss of position sense, vision compensates for sensory loss. During the Romberg test, patients will stand okay with theirs eyes open but will lose balance with eyes closed

Posterior (Dorsal) Column Disease

In ____________ ataxia, patients will have difficulty standing whether eyes are open or closed during the Romberg test

Cerebellar

In ____________, patient will pronate the contralateral forearm and have downward drift with flexion of fingers

Corticospinal Tract (UMN) Lesion

In ____________, patient will have upward drift and overshoots and bounces to correct it (d/t loss of position sense)

Cerebellar Disease

What is spastic hemiparesis?

Flexed arm held close to body while client drags toe of leg or circles it stiffly outward and forward

Due to corticospinal tract lesion in stroke

What causes a scissor gait?

Spinal cord disease causing bilateral lower extremity spasticity (eg, cerebral palsy)

What is a Parkinsonian (propulsive) gait?

Stooped, shuffled, involuntary hastening (festination), arm swing decreased

Seen in basal ganglia defects of Parkinson disease

What is a Steppage gait?

The hip and knee are elevated excessively high to lift the plantar flexed foot off the ground

Seen in foot drop, usually secondary to a LMN lesion causing anterior tibialis weakness

What gait occurs with Cerebellar Ataxia?

Staggering, unsteady, wide based gait

What gait occurs with Sensory Ataxia?

Unsteady, wide based gait with double tapping sound (throwing heels then toes forward)

Seen in loss of position sense in legs (w/ polyneuropathy or posterior column disease)

What may cause abnormal function of Cranial Nerve I?

Sinusitis, smoking, aging, cocaine use, Parkinson disease

What may cause abnormal function of Cranial Nerve II?

Papilloedema, glaucoma, stroke, retinal emboli, optic neuritis, pituitary tumor

What may cause abnormal function of Cranial Nerve II + III?

Anisocoria (unequal pupils) d/t intracranial hemorrhage, transtentorial herniation (if comatose), Horner syndrome

What may cause abnormal function of Cranial Nerve III, IV, + VI?

Nystagmus, ptosis (drooping of upper eyelids), diplopia, astigmatism, myasthenia gravis, graves disease, Horner syndrome, cerebellar disease

What may cause abnormal function of Cranial Nerve V?

Stroke, CNS lesions, trigeminal neuralgia, acoustic neuroma

What may cause abnormal function of Cranial Nerve VII?

Stroke, bells palsy

What may cause abnormal function of Cranial Nerve VIII?

Cerumen impaction, otitis media, Meniere's disease, aging

What may cause abnormal function of Cranial Nerve IX + X?

Pharyngeal weakness

What may cause abnormal function of Cranial Nerve V, VII, X, + XII?

Aphonia (loss of voice) d/t vocal cord paralysis, dysarthria (poor articulation) d/t cerebellar disease, aphasia

What may cause abnormal function of Cranial Nerve XI?

Trapezius atrophy d/t peripheral nerve disorder, bilateral weakness of sternocleidomastoids

What may cause abnormal function of Cranial Nerve XII?

Cortical lesion, amyotrophic lateral sclerosis (ALS), polio

What is a nystagmus?

Involuntary eye movement that may be horizontal, vertical (midbrain), rotary, or mixed

Can be a sign of CNS disease such as MS, encephalitis, head trauma, brain tumor, or cerebellar disease

True or False: Nystagmus usually occurs in the direction of the diseases side

True

What are the 3 types of tremors and what causes them?

Resting (eg, pill-rolling tremor of parkinson disease)

Postural (eg, benign essential/familial tremor)

Intention (eg, cerebellar disease, multiple sclerosis)

What 5 involuntary movements might occur with neurological disease?

Oral-facial dyskinesias (eg, tardive dyskinesia)

Tics (eg, tourette syndrome)

Dystonia (eg, torticollis)

Athetosis (eg, cerebral palsy)

Chorea (eg, huntington disease)

What is atrophy?

Loss of muscle bulk or wasting; results from disease of PNS (eg, DM neuropathy) or diseases of muscles themselves

Fasciculation with atrophy results from a ___________

LMN lesion

What is Pseudohypertrophy?

Increased bulk with diminished strength (eg, Duchenne muscular dystrophy)

What is spasticity? What is it caused by?

Increased tone--> rate-dependent, greater with rapid movement

Caused by UMN lesion or corticospinal tract lesion

What is rigidity? What is it caused by?

Increased resistance--> not rate-dependent

Caused by lesion in the basal ganglia

What is flaccidity? What is it caused by?

Marked floppiness

Caused by LMN lesion

What is paratonia? What is it caused by?

Sudden changes in tone with passive ROM

Caused by lesion in both hemispheres, usually frontal lobes

What is the scale for grading muscle strength?

0 = No contraction noted

1 = Barely detectable contraction

2 = Active movement w/ gravity eliminated

3 = Active movement against gravity

4 = Active mvmt against gravity & some resistance

5 = Active movement against full resistance w/o evident fatigue - This is NORMAL strength