Chapter 16 - Concepts of Neurological Dysfunction -
This chapter deals with what happens when there are pathologic changes in the neurologic system such as coma, seizures, and other deficites. Note what happens with increased intracranial pressure leading to herniation of the brain. Alterations in emotions
Alterations in Cognitive Systems - Consciousness
The most critical index of nervous system dysfunction
Alterations in Cognitive Systems - Arousal vs. awareness
State of wakefulness
Mediated by the reticular activating system
Alterations in Cognitive Systems - Awareness
Cognitive functions that embody awareness of self, environment, and affective states (i.e., moods)
Content of thought
Alterations in Arousal
Coma is produced by either:
Bilateral hemisphere damage or suppression
Brainstem lesions or metabolic derangement that damages or suppresses the reticular activating system
Alterations in Arousal - Structural
Supratentorial
Infratentorial
Subdural
Extracerebral
Intracerebral
Alterations in Arousal - Metabolic
...
Alterations in Arousal- Psychogenic
...
Alterations in Arousal - Clinical manifestations - Level of consciousness changes
Most critical index of nervous system
Brain Death (Brainstem Death
+ Body cannot maintain internal homeostasis
+ Brain death criteria
-Completion of all appropriate, therapeutic procedures
-Unresponsive coma (absence of motor and reflex responses)
-No spontaneous respirations (apnea) - Doctors take you off the machine an
Cerebral Death
-Cerebral death (irreversible coma): death of the cerebral hemispheres exclusive of the brainstem and cerebellum
-No behavioral or environmental responses
-The brain can continue to maintain normal respiratory and cardiovascular functions, temperature con
Cerebral Death - Survivors of cerebral death
+Remain in coma
+Emerge into a vegetative state ("wakeful unconscious state")
-Can digest, breath, eye open, no purposeful motor activity
+Progress into a minimal conscious state
-Akinetic mutism (AM)- visual tracking. Lack of motivation.
-Locked-in syndr
what is a Seizures
+Disruption in balance of excitation and inhibition
+Sudden, transient alteration of brain function caused by an abrupt explosive, disorderly discharge of cerebral neurons
+Motor, sensory, autonomic, or psychic
+Convulsion
-Tonic-clonic (jerky, contract-r
What is a Generalized seizure?
Bilat, no focal point, altered Level of conscienceness LOC. A person who shakes on the floor.
Alterations in Arousal - Clinical manifestations - Pupillary changes
Opiates which is your Herione and Morophone will cause your pupils to Pinpoint. Achermine and fetamines Like Meth dilates pupils.
Alterations in Arousal - Clinical manifestations - Oculomotor responses (Doll's eyes)
This where you can check to see if a person is brain dead by turning there head and checking to see if there eyes are fixed to one position. If normal the eyes will move to the corner.
Alterations in Arousal - Clinical manifestations - Motor responses
Placing Ice Cold WAter in the eye for motor response. Patient should be able to squeeze hand, sucking, etc. etc.
Alterations in Arousal - Clinical manifestations - Pattern of breathing
- Posthyperventilation apnea (PHVA)
+respirations stop after hyperventilation
+PCO2 driven
- Cheyne-Stokes respirations (CSR)
+A smooth increase in rate and depth followed by a gradual smooth decrease in rate and depth
Partial (focal) seizures
Unilat, consciousness may or not may not be lost, repetitive movements. A person with seizures in one location and then spreads.
Type of Seizure - Secondary generalization
Starts has a Partial and Spreads to Generalized.
Type of Seizure - Status epilepticus
Experience of a second seizure before the person has fully regained consciousness from the preceding seizure or a single seizure lasting more than 30 minutes. So, One big seizure or multiples. Seizures are very bad because the Cerebral is not getting O2,
Seizures
Resting potential instability
Bursts of action potentials (hypersynchronization)
Epileptogenic focus
Group of neurons that appear to be hypersensitive to paroxysmal depolarization
Tonic phase-
contraction with increase tone
Clonic phase
alternates contraction/relaxation
Postictal state
State that follows the seizure
Seizures: Consequences
+250% increase in adenosine triphosphate (ATP)
+Cerebral oxygen consumption increased by 60%
+Cerebral blood flow also increases approximately 250%
+Available glucose and oxygen are depleted
With severe seizures the brain tissue may require more ATP than
Seizure Syndromes - Epilepsy
+To be seized by a force from without"
+Types
-Idiopathic - more than half the time
-Symptomatic -one third of the time
Cryptogenic
Seizure Syndromes - Aura
gustatory, visual, or auditory experience
Seizure Syndromes - Prodroma
malaise, headache, depression
Alterations in Awareness - Selective attention
+Ability to select from available competing environmental and internal stimuli
+Sensory inattentiveness
Extinction
Neglect syndrome
+Selective attention deficit
Alterations in Awareness - Declarative memory
First Love, graduating high school
Alterations in Awareness - Nondeclarative memory
Skills you know, Like brushing your teeth
Alterations in Awareness - Dysmnesia
-Retrograde amnesia - Forgot things that happened in the past
-Anterograde amnesia - you cant make new memories
Alterations in Awareness -
Vigilance, detection, and working memory deficits
Data Processing Deficits - Agnosia
Tactile, visual, auditory, etc.
Related to injury in the lobe of origin
- Tactile happens in the Parietal lobe because thats were the receptors are for touch.
Data Processing Deficits - Aphasia
A Means No - No written and spoken language
Data Processing Deficits - Dysphasia
Dys means something gone wrong - Most related to CVA of middle cerebral artery
Expressive dysphasia
Receptive dysphasia
Acute Confusional States
+Acquired mental disorder with deficits in attention and coherence of thoughts and action
-Secondary to drug intoxication, metabolic disorder, or nervous system disease
-Disruption of reticular activating system of upper brainstem and its projections to t
Dementia
Progressive failure of cerebral functions not caused by an impaired level of consciousness
Classifications of Dementia - Cortical
Alzheimer and Pick diseases
Loss of memory
Alzehiemer starts mentally and ends Physically
Classifications of Dementia - Subcortical
Parkinson and Huntington diseases.
Parkinsons starts physically and ends mentally.
Classifications of Dementia - Cortical and Subcortical
Infectious and Creutzfeldt-Jakob diseases
This is like human mad cow. Caused by a protein you contract it and causes ditearation of the brain. Very Sad
What is Alzheimer Disease?
+Familial, early and late onset
+Nonhereditary (sporadic, late onset)
+Theories
-Mutation for encoding amyloid precursor protein
-Alteration in apolipoprotein E
-Pathologic activation of N-methyl-D-aspartate (NMDA)
- Linked to Down-Syndrome
What are the effects of Alzheimer Disease?
+Neurofibrillary tangles
+Senile plaques
+Clinical manifestations
-Forgetfulness, emotional upset, disorientation, confusion, lack of concentration, decline in abstraction, problem solving, and judgment
-Insidious onset
+Diagnosis made by ruling out other
What is the Stages and effects fo Increased Intracranial Pressure?
+Normal 5 to 15 mmHg
+Caused by increased intracranial content
-Tumor growth, edema, excessive CSF, or hemorrhage
+Stage one
CSF reduction, vasoconstriction
+Stage two
Increase in systemic pressure
+Stage three
Sluggish pupils, wide pulse pressure, altere
What is 8, 10 ,10
80% of your Skull is full of Brain.
10% is CSF
10% is Blood
Where does CSF Drain?
Aranoid Villi
Where is CSF Produced?
Ventricles
Herniation Syndromes - Supratentorial herniation -
Uncal
Uncus or hippocampal gyrus (or both) shifts from the middle fossa through the tentorial notch into the posterior fossa
Herniation Syndromes - Supratentorial herniation
- Central
Downward shift of the diencephalon through the tentorial notch
Herniation Syndromes -Supratentorial herniation - Cingulate
Cingulate gyrus shifts under the falx cerebri
Herniation Syndromes - Infratentorial herniation
Cerebral Edema
...
What is Cerebral Edema
Increase in the fluid (intracellular or extracellular) within the brain
Cerebral Edema -Type
Interstitial
Seen with noncommunicating hydrocephalus
This is when you see the intersitital cerebral edema
Cerebral Edema - Vasogenic
Increased permeability of capillary endothelium - Fancy way of saying pipes are leaky and fluid can flow in.
Cerebral Edema - Cytotoxic
Toxic factors
Cerebral Edema - Ischemic
Follows cerebral infarction - Something that is blocked. Schemia is a blockage
What is Hydrocephalus?
+Variety of conditions
+Excess fluid within the cranial vault, subarachnoid space, or both
+Caused by interference in CSF flow
-Decreased reabsorption -Aranoid villi
-Increased fluid production -Ventricles
-Obstruction within the ventricular system
Explain the communication of the Hydrocephalus?
+Noncommunicating hydrocephalus
+Communicating (extraventricular) hydrocephalus
-Hydrocephalus ex vacuo
-Normal-pressure hydrocephalus
Alterations in Motor Function - Hypotonia
Less Tone
Alterations in Motor Function - Hypertonia
More Tone
Alterations in Motor Function - Spasticity
Being Spastic
Alterations in Motor Function - Gegenhalten (paratonia)
Dont worry about it
Alterations in Motor Function - Rigidity
Being Rigid
Alterations in Movement - Paresis
Weakness
Alterations in Movement - Paralysis
inability to move.
Paraplegia - Two Extremities (superior or inferior)
Quadriplegia - All four extremities
Alterations in Movement - Spinal Shock
CAn be resolved or you can have permanent damage.
Alterations in Movement - Lower motor neuron syndromes
+Flaccid paresis or flaccid paralysis
+Hyporeflexia or areflexia - No reflexes
+Gamma neuropathies
+Fibrillation
Lower Motor Neuron Syndromes - Amyotrophies
+Hard to recognize due to multiple nerve innervation
+Fasciculations and muscle cramps- Fancy way of saying Twitching.
+Paralytic poliomyelitis
+Nuclear palsies
+Progressive spinal muscular atrophy
+Progressive bulbar palsy
+Bulbar palsy
Abnormal Movements - Hyperkinesia
-Excessive movement
-Chorea means huntingsons, wandering, tremor at rest, postural tremor, etc.
Abnormal Movements - Paroxysmal dyskinesias
...
Abnormal Movements - Tardive dyskinesia
-Involuntary movement of face, trunk, and extremities
-Can be caused by antipsychotic drugs
because they mimic an increase in dopamine
Huntington disease
-Also known as chorea
-Autosomal dominant hereditary-degenerative disorder - All it takes is One parent to have a 50/50 chance.
-Severe degeneration of the basal ganglia (caudate and putamen nuclei) and frontal cerebral cortex - This comes from Parkinsons
Hypokinesia
-Decreased movement
-Akinesia - No Movement
-Bradykinesia - Slow
-Loss of associated movement
Parkinson Disease
+Severe degeneration of the basal ganglia (corpus striatum) involving the dopaminergic nigrostriatal pathway
-Parkinsonian rigidity
-Parkinsonian bradykinesia
-Parkinsonian tremor
-Postural abnormalities
-Autonomic and neuroendocrine symptoms
-Cognitive-a
Parkinson and Dementia
50% of persons have depression, an inherent part of the pathologic state and not a situational response
30% treated on outpatient basis have dementia; 80% of persons requiring institutional care have dementia
Disorientation, confusion, memory loss, distra
Disorders of Posture (Stance) - Dysonia
+Dystonic postures and movements
+Decorticate posture - Rembeber your decorating your body with arms.
-Upper extremity flexion
-Damage above midbrain
+Decerebrate posture - Remember Celebrate and everything is extended
-Extensor responses in upper and low
Disorders of Gait - Spastic gait
upper motor neuron dysfunction
Disorders of Gait - Scissors gait
upper motor neuron dysfunction
Disorders of Gait - Cerebellar (ataxic)gait
a wide-based gait with feet apart and often turned outward or inward for stability; pelvis is stiff, individual staggers
Disorders of Gait - Basal ganglion gait
individual walks with small steps and decreased arm swing. the head and body are flexed and the arms semi flexed and abducted while the legs are flexed and rigid in more advanceed states.
Disorders of Gait - Senile gait
individual walks with small steps and decreased arm swing. the head and body are flexed and the arms semi flexed and abducted while the legs are flexed and rigid in more advanceed states.
Extrapyramidal Motor Syndromes
+Basal ganglia motor syndromes
+Cerebellar motor syndromes
-Rostral vermis
-Caudal vermis
-Neocerebellar syndrome
Which of the following is NOT a basic neural system essential for the cognitive sphere?
A. Attentional systems
B. Memory and language systems
C. Affective or emotive systems
D. Sensory systems
D. The three basic (core) neural systems to the cognitive sphere include attentional systems that provide arousal and maintenance of attention over time, memory and language systems by which information is communicated, and affective or emotive systems th
A person has a structural problem that is located within the brain tissue, and it is causing a decreased level of consciousness. Which of the following terms BEST describes this location?
A. Infratentorial
B. Intracerebral
C. Extracerebral
D. Subdural
B. Intracerebral is a term that means "within the brain tissue." Intracerebral disorders function primarily as masses. Infratentorial is below the tentorium cerebelli. Subdural is located below the dura mater. Extracerebral is outside the brain tissue.
Which of the following is NOT one of the five categories of neurologic function that are classified as critical for evaluation?
A. Level of consciousness
B. Pattern of breathing
C. Heart rate
D. Eye position
C. The five categories that are critical for the evaluation process for neurologic function include (1) level of consciousness (LOC), (2) pattern of breathing, (3) size and reactivity of pupils, (4) eye position and reflexive response, and (5) skeletal mu
A person is diagnosed with Cheyne-Stokes respirations (CSR). Which of the following is a TRUE statement?
A. Pathophysiology involves an increased ventilatory response.
B. There is hypocapnia and increased ventilatory stimulus.
C. Changes in PaO2 produce i
A. The pathophysiology of CSR includes an increased ventilatory response to carbon dioxide stimulation. This causes hypercapnia and diminished ventilatory stimulus. Changes in PaCO2 produce irregular breathing, not changes in PaO2. The PaCO2 level decreas
An individual experiences significant vomiting with a CNS injury. Which of the following is TRUE regarding CNS injury and vomiting?
A. Impinges directly on the floor of the third ventricle
B. Causes a decrease in intracranial pressure
C. Involves the vest
C. Vomiting associated with CNS injuries involves the vestibular nuclei. It can be caused by impingement on the fourth ventricle. It can cause an increase in intracranial pressure. Vomiting with no associated nausea indicates direct involvement of the cen
An individual in a coma presents with pinhole-sized pupils. Which medication would produce this size pupil?
A. Atropine
B. Scopolamine
C. Opiates
D. Amphetamines
C. Opiates (heroin and morphine) cause pinhole pupils. The other choices cause large, dilated pupils.
Which of the following is NOT a criterion when determining brain death?
A. Unresponsive coma
B. No spontaneous respiration
C. Isoelectric EEG
D. Ocular response to head turning
D.There is no ocular response to head turning, and pupils are often fixed and dilated. The following criteria determine brain death:
1. Completion of all appropriate therapeutic procedures
2. Unresponsive coma
3. No spontaneous respiration (apnea)
4. Abse
A woman has sustained a traumatic brain injury. She is able to follow simple commands and can manipulate objects. Which of the following terms BEST describes this state?
A. Coma
B. Vegetative
C. Minimally conscious
D. Locked-in syndrome
C. The term minimally conscious applies to a severely altered consciousness in which the person demonstrates minimal but defined behavioral evidence of self or environmental awareness. The clinical features include following simple commands, manipulation
Which of the following is the BEST definition of a person with akinetic mutism?
A. Has severe disturbance in motivation
B. Can follow simple commands and manipulate objects
C. Is in a wakeful unconsciousness
D. Is unarousable and unresponsive
A. The definition of akinetic mutism is a state characterized by a severe disturbance in behavioral drive. Unarousable and unresponsive describes coma. Wakeful unconsciousness is the vegetative state. The ability to follow simple commands and manipulate o
A 19-year-old woman sustains a nontraumatic brain injury. Which of the following is a TRUE statement regarding prognostic indicators?
A. She has a 91% death rate if pupils are nonreactive at 24 hours.
B. She has a 95% death rate when pupillary reflexes ar
The absence of eye opening at 24 hours predicts death or severe disability. Choices A and B are true for traumatic brain injury. Prognosis for nontraumatic brain injury is established earlier than for traumatic brain injury.
Which of the following is NOT a means of classifying a seizure?
A. Clinical manifestations
B. Site of origin
C. Length of activity
D. EEG correlates
C. The following are ways to classify seizures: (1) clinical manifestations, (2) site or origin, (3) EEG correlates, and (4) response to therapy.
A person experiences a unilateral, focal seizure and maintains consciousness. Which of the following is the appropriate term for this type of seizure?
A. Generalized
B. Partial
C. Secondary
D. Status epilepticus
B. Partial seizures involve neurons only unilaterally. They often have a local (focal) onset. Consciousness may be maintained. In generalized seizures consciousness is almost always impaired. When partial seizures become generalized to involve neurons of
A person is in status epilepticus. What is the greatest concern when treating these individuals?
A. Cerebral hypoxia
B. Aspiration
C. Bleeding of the tongue
D. Musculoskeletal trauma
A. Cerebral hypoxia is of critical importance; if not corrected, mental retardation, dementia, and further brain damage may result.
A person is having a seizure and is currently in the tonic phase. Which of the following BEST describes this phase of a seizure?
A. Phase of muscle contraction with increased muscle tone
B. Phase of alternating contraction and relaxation of muscle
C. Phas
A. The phase of muscle contraction with increased muscle tone is the tonic phase. Alternating contraction and muscle relaxation represents the clonic phase. The postictal phase immediately follows the seizure. There is no phase of complete paralysis in a
A person is describing a loss of past memories. For which of the following disorders is this a characteristic?
A. Extinction
B. Dysmnesia
C. Sensory inattentiveness
D. Nondeclarative memory
B. Dysmnesia is a disorder of the declarative memory network. This disorder is a loss of past memories with an inability to form new memories. Nondeclarative memory is memory involved in how to carry out activities. Sensory inattentiveness is a form of ne
A person is experiencing difficulty in recognizing a pattern. He cannot recognize the form and nature of objects. Which of the following is the term that describes this condition?
A. Agnosia
B. Aphasia
C. Dysphasia
D. Alzheimer
A. Agnosia is a defect of pattern recognition. Aphasia is the complete absence of speech. Dysphasia is impairment of comprehension or production of language. Alzheimer is a disease of dementia.
Which term describes a person who is experiencing a loss of comprehension or production of language?
A. Dysphasia
B. Aphasia
C. Expressive dysphasia
D. Transcortical dysphasia
B. Aphasia is complete inability to speak or to comprehend language. Dysphasia is impairment in comprehension or production of language. Expressive dysphasia is characterized primarily by expressive deficits, but comprehension may be present. Transcortica
A man has a contusion that has developed over 2 to 3 days. He is restless and irritable. He is brought to the physician's office. Which of the following best describes this condition?
A. Alzheimer
B. Dementia
C. Delirium
D. Coma
C. Delirium is an acute state of confusion. It is abrupt in its onset (over 2 to 3 days). The person may have difficulty in concentration, restlessness, irritability, tremulousness, insomnia, and poor appetite. Dementia is a more chronic problem in which
Which of the following is NOT one of the mechanisms in the dementing process?
A. Degeneration possibly caused by genetics
B. Atherosclerosis
C. Trauma
D. Decreased intracranial pressure
D. An increase in intracranial pressure is a mechanism in the dementing process. All the other choices are correct.
Which of the following is TRUE regarding Alzheimer disease?
A. Uncommon neurologic disorder
B. No genetic relationship
C. Associated with Down syndrome
D. Plaques increase nerve impulse transmission
C. Alzheimer disease is associated with Down syndrome. There is a genetic relationship in late-onset familial Alzheimer dementia. It is a common neurologic disorder; nearly 5 million Americans had the disease in 2006 With the formation of plaques, there i
Which of the following is NOT a characteristic of Alzheimer disease?
A. Rapid onset
B. Memory loss
C. Increased irritability
D. Anxiety and depression
A. Alzheimer and other forms of dementia have a slow onset. The other choices are all correct.
A person experiences a traumatic brain injury and has herniation of the brain that is straight downward through the tentorial notch. Which of the following types of herniation is this?
A. Supratentorial
B. Central
C. Cingulate
D. Uncal
B. Central herniation is the straight downward shift of the diencephalon through the tentorial notch. Uncal herniation occurs when the hippocampal gyrus shifts from the middle fossa through the tentorial notch into the posterior fossa. Supratentorial hern
A person experiences edema in the brain caused by movement of CSF from the ventricles into the extracellular space. What type of edema does this describe?
A. Vasogenic
B. Cytotoxic
C. Ischemic
D. Interstitial
D. Interstitial edema is caused by transependymal movement of CSF from the ventricles into the extracellular spaces of the brain tissues. Vasogenic edema is caused by the increased permeability of the capillary endothelium. Cytotoxic edema occurs when tox
A person experiences clonus. Which of the following BEST describes this?
A. Spreading of spasticity accompanied by increased deep tendon reflexes
B. Resistance to passive movement
C. Tonic reflex activity
D. Weakness with impairment of motor function
A. Clonus is spasticity accompanied by increased deep tendon reflexes that spread. Gegenhalten or paratonia is the resistance to passive movement that varies in direct proportion to the force applied. It is also associated with frontal lobe injury. Rigidi
A woman sustains a CVA. She has paralysis on the left side. Which of the following BEST describes this condition?
A. Hemiplegia
B. Paraplegia
C. Diplegia
D. Quadriplegia
A. Hemiplegia means loss of motor function on one side of the body. Paraplegia refers to loss of motor function of the lower extremities. Diplegia is the paralysis of both upper or both lower extremities as a result of cerebral hemisphere injuries. Quadri
A person is diagnosed with Huntington disease. Which of the following is TRUE?
A. Occurs commonly
B. Is a nonhereditary disease
C. Is also known as chorea
D. Onset usually between the ages of 50 and 70 years
C. Huntington disease is also called chorea. It is relatively rare and is a hereditary degenerative disorder. It most commonly affects those between the ages of 25 and 45.
A man is diagnosed with Parkinson disease. Which of the following symptoms would he expect to appear first in the course of his illness?
A. Inability to walk
B. Tremor
C. Postural instability
D. Rigidity
B. Tremor is often the first symptom to appear. This progresses to include gait, postural instability, and inability to walk. The symptoms are often unilateral and then become bilateral.