neuro i exam 1

where is cerebrospinal fluid produced

lateral ventricles of brain in chord plexus

purpose of cerebrospinal fluid

• shock absorption

• transports nutrients & wastes

three major arteries of brain

• anterior cerebral artery

• middle cerebral

• posterior cerebral

types of ischemic strokes

• transient ischemic attack (TIA)

• ischemic (infarct)

types of hemorrhagic strokes

• intracerebral hemorrhage (ICH)

• subarachnoid hemorrhage (SAH)

• arteriovenous malformation (AVM)

which ischemic hemorrhage is NOT associated with permanent brain damage

TIA

symptoms of TIA

• sudden symptoms that go away

• negative MRI

causes of ischemic stroke

• thrombosis (localized clot)

• embolism (clot from another part of body)

• systemic hypoperfusion (BF to body decreases) → watershed zones @ risk

• cerebral venous sinus thrombosis (clot of sinuses)

classifications of ischemic strokes

• large artery atherosclerosis

• cardio embolism

• small vessel occlusion

• other determined etiology

• undetermined etiology

penumbra

salvageable brain area

ischaemic core

brain tissue destined to die

subarachnoid hemorrhage (SAH) vs intracerebral hemorrhage (ICH)

• SAH: bleeding btw pia matter and arachnoid membrane

• ICH: bleeding into the brain parenchyma

physical differences btw left hemisphere stroke vs right hemisphere stroke

left

• right side weakness, sensory loss, and right eye vision loss

• communication barriers arise

right

• left side weakness, sensory loss, and right eye vision loss

• fall risk from neglect, impulse AF

language differences btw left hemisphere stroke vs right hemisphere stroke

left

• aphasia (unable to comprehend language), apraxia (unable to coordinate muscles for language), dysarthria

right

• intact language but dysarthria present (loss of emotional tone)

perception and attention differences btw left hemisphere stroke vs right hemisphere stroke

left

• normal spatial awareness

• attention issues secondary to language

right

• left side neglect/inattention

• visual-spatial defects

memory differences btw left hemisphere stroke vs right hemisphere stroke

• left: impaired verbal

• right: impaired visual/spatial

behavior & awareness differences btw left hemisphere stroke vs right hemisphere stroke

left: aware of deficits, cautious, slow, which may lead to depression

right: unaware and impulsive, POOR JUDGEMENT

difference btw broca’s and wenicke’s aphasia

• broca’s: speech is not fluent. person can comprehend messages but unable to repeat phrases

• wernicke’s: speech is fluent but cannot comprehend or repeat phrases

which body parts are enlarged in homunculus

• motor: fingers (anything needed for fine motor execution)

• sensory: lips, mouth

ataxia

• a lack of voluntary coordination of muscle movements

• PCA affected!

apraxia

inability to perform learned movements or coordinate speech on command

hemiplegia

partial weakness or reduced muscle strength on one side of the body

types of tbi

• penetrating

• non-penetrating

penetrating tbi

• “open”

• objects pierce skull or by a weapon and enters brain tissue

• damage only part of the brain

• more rare

non-penetrating tbi

• “closed head injury/blunt tbi”

• external forces move the brain within the skull

• MOIs: falls, vechicle crashes, sports injuries, blast injuries, being struck by object (shear forces)

what events can cause either types of tbis

• explosions

• natural disasters

• extreme events

penetrating tbi MOIs

• focal brain injury

• skull Fx w/ brain tissue damage

• high velocity (bullets)

• low velocity (knife/sharp items)

which tbi is more severe

penetrating/open

is penetration across midline/penetrate ventricles more or less severe in open tbi

more

coup-countercoup injury

• Coup (Primary Impact): The initial hit where the brain hits the front/side of the skull directly at the point of impact.

• Contrecoup (Secondary Impact): The secondary hit where the brain sloshes backward and strikes the opposite side of the skull.

diffused axonal injury (DAI)

• rotational acceleration/deceleration that causes shear-forces that result in widespread disruption of axonal fibers (white matter) and myelin sheaths

acceleration injury vs deceleration injury (closed)

• acceleration: head put into motion from stand still position

• deceleration: head brought to a stand still position from a moving position (falls)

MOIs for closed/blunt tbi

• coup-contrecoup

• DAI

primary injury

• happens @ time of impact

• immediate damage to brain tissue

• contusion (vessel bleed)

• laceration (mechanical tear in brain tissue)

• intracranial hemorrhage

• skull fx

secondary injury

• timing: changes that occur over the hours to days after injury

• mechanism: cellular, chemical, tissue, or blood vessel changes contribute to damage

• trigger: initial blow causes release of chemicals that cause further damage

cushing triad

• hypertension

• bradycardia

• respiratory depression: slow and irregular

intracranial pressure

diagnosed using cushing triad

decorticate vs decerebrate

• decerebrate: lesion below red nucleus

  • more severe damage to rubrospinal tract & RN

• decorticate: lesion above red nucleus

tests to look at tbi severity

• glasgow coma scale

• post-traumatic amnesia

• imaging

glasgow coma scale (GCS)

• Measures depth and duration of coma

• mild: 13-15

• moderate 9-12

• severe 3-8

post traumatic amnesia (PTA)

• period from accident until the person is oriented to their surroundings

which is a better predictor

PTA

imaging for tbis

• CT: hematomas, contusions, skull Fx

• MRI: subtle contusions, DIA, brainstem injury

• Functional MRI: vegetative state v minimally conscious, BF changes

mild tbi severity

• loss of consciousness: up to 30 mins

• alteration of consciousness: up to 24 hrs

• PTA: 0-1 day

moderate tbi severity

• loss of consciousness: >30 mins and <24 hrs

• alteration of consciousness: >24 hrs

• PTA: 1-7 day

severe tbi severity

• loss of consciousness: >24 hrs

• alteration of consciousness: >24 hrs

• PTA: >7 days

coma (braintree)

• rancho i

• deep state of unconsciousness

• no signs of being awake or aware

• No eye opening, no response to environment/voices/pain, no purposeful movement

• frontal cerebral blood flow is reduced

vegetative state (braintree)

• Return of sleep-wake cycle (noted on EEG)

• Eye opening and closing

  • no awareness of self and environment i.e unconscious

• Preserved capacity for spontaneous (cry/smile) or stimulus induced arousal (startle), may move eyes towards person/object in room

• No Purposeful movement

• No speech/other form of communication

• “wakeful unconsciousness”

• racho ii

minimally conscious state (braintree)

• Severely altered consciousness with minimal but definite behavioral evidence of self or environmental awareness

• May follow simple commands, gesture yes/no responses

• Intelligible verbalizations (language disorder dependent)

• Movement occurs in relation to environment, not reflexive

• rancho iii

RLA i

no response

disability rating scale

• tracks recovery of individual from coma to community

JFK coma recovery scale R

• eval instrument

• useful to guide Tx

• lowest item = reflexive activity

• highest item = cognitively mediated behaviors

clinical outcome measures

• disability rating scale (DRS)

• JFK coma recovery scale - R (CRS-R)

• extended glasgow outcome scale (GOSE)

pusher syndrome

• also known as lateropulsion, contraversive pushing

• altered perception of the body’s orientation to gravity

• more common w R sided strokes

what in the brain is affected by pusher’s

• thalamus (PL, VPL, VPM)

• cortex (inferior parietal lobe, parieto-insular vestibular cortex)

signs/symptoms of pusher’s

• spontaneous body posture

• active pushing w/ nonparetic extremities to lean toward hemiplegic side

• resistance to passive correction of posture

assessments for pusher’s

• scale for contraversive pushing (SCP)

• modified scale for contraversive pushing (m-SCP)

• bruke lateropulsion scale (BLS)

• all of these assessments = higher score is worse pushing behavior

difference btw pusher assessments

• SCP: easiest and used as screen.

  • score of at least 1 in each of the 3 components is pusher Dx

• m-SCP: focuses on functional movements and has 4 postures/activities

  • score of 3 is pusher Dx

• BLS: more comprehensive than SCP and more sensitive

  • score of 3 is pusher Dx

PT implications for pusher syndrome

treat in vertical (unless pushing in supine)

extended glasgow outcome scale (GOSE)

• used for functional outcome

• looks @ good v. bad prognosis

two models for Tx of TBIs

• crash

• impact

crash model

• corticosteroid randomized after significant head injury

• predicts unfavorable outcomes at 6 months and mortality at 14 days

two types of crash model

• basic

• CT: look to see if traumatic SAH is present

impact model

• internation mission on prognosis and analysis of clinical trials in TBI

• predicts unfavorable outcome and mortality at 6 months

• NOT AS ACCURATE

types of impact model

• core: basics

• extended: CT classification

• lab: extended model + looking @ glucose, hemoglobin

what indicates poor prognosis for TBI

• hypotension (lack of BF)

• elevated ICP (>20 bad)

• hyperthermia

• anoxia/hypoxia

• imaging abnormalities

when is severe disability unlikely

• time to follow commands < 2 wks

OR

• duration of PTA < 2 months

when is good recovery unlikely

• time to follow commands > 1 month

• duration of PTA > 3 months

• age > 65

OR

• MRI indicates bilat. brainstem injury

craniotomy

• skull is cut to each brain

• bone flat is screwed back in

craniectomy

• removal of skull flap and area is left open

• flap stored somewhere else (abdomen)

cranioplasty

• follow up reconstructive Sx

• bone flap placed back on (or an implant)

aerobic training and TBI effects on…

• cardiorespiratory fitness

• cognition

• cardiorespiratory fitness - increased cardioresp fitness

• cognition - increased cognition

principles of neuro rehab

• icf

• teamwork

• person-centered care

• prognosis

• neural plasticity

• motor control

• functional movement re-ed

• skill acquisition

• exercise prescription

• health promotion

• self management

• mindset

• behavior changes

bbs cut off

<40/56

how should interventions prioritize active engagement

have repetitive, task -specific training at appropriate intensities

when should i use stim intervention

racho i-iii

when should i use a structure orientation program

rancho iv-vi

when should i use specific skill/community oriented program

rancho vii-x

tolerance definition (according to tilt table)

being able to maintain all physiologic and objective measures of tolerance @ at least 60° for greater than 5 mins

evidence for music and attention/arousal

music enhanced attention/arousal compared to white noise/disliked music

evidence for salient voices (family voice) in rehab

salient auditory stimuli enhanced likelihood to see brain and behavioral activities

theory for stimulated programs

• Sensory stimulation may stimulate affected neural networks → accelerate brain plasticity

• Sensory deprivation → slow down recovery

FAST study results

FAST improves arousal, awareness, and brain response in ppl w/ disorders of consciousness after TBI

agitated behavior scale

• looks @ agitation during acute recovery after TBI

• good tool for rancho iv-vi

rla grade ii

2: Generalized Response – responses are inconsistent and non-purposefu

rla grade iii

3: Localized Response – responses are inconsistent and specific to external stimul

rla grade iv

4: Confused and Agitated – bizarre and non-purposeful behavior, agitation originated primarily from internal confusion

rla grade v

5: Confused and Inappropriate (non-agitated) – responds inaccurately to commands

rla grade vi

6: Confused and Appropriate – responds accurately to commands

rla grade vii

7: Automatic and Appropriate – poor insight to deficits, requires supervision

rla grade viii

8: Purposeful and Appropriate – improving awareness of deficits, stand by assist

rla grade ix

9: Purposeful and Appropriate – stand by assist by request

rla grade x

10: Purposeful and Appropriate – modified independence

agitated behavior scale components

• aggression: physical and verbal hostility or violence towards ppl

• disinhibition: impulsive, socially inappropriate, or uncooperative actions w/o regarding safety

• lability: rapid, unpredictable shifts in mood or emotional state (ex: crying, laughin)

what does praxis include

• ideation

• planning

• execution

ideational apraxia

• breakdown is knowing what is to be done

• lack of an idea

• poor initiation, poor organization and sequencing

motor apraxia

• loss of kinesthetic memory patterns thats leaves the person unable to perform purposeful tasks

spatial relations syndrome

brain struggles to interpret and organize visual info about how objects and bodies exist in space

unilat spatial neglect

inattention to or neglect of multi-sensory stimuli in peri-personal or extra-personal space CL to lesion

preseveration

difficulty shifting from one pattern of response to another