CA Bates reading Flashcards Preview

Sasha: Module 11 Neurology > CA Bates reading > Flashcards

Flashcards in CA Bates reading Deck (168)

Motor: Chronic contralateral corticospinal-type weakness and spasticity. Flexion is stronger than extension in the arm, plantar flexion is stronger than dorsiflexion in the foot, and the leg is externally rotated at the hip.

Sensory: Contralateral sensory loss in the limbs and trunk on the same side as the motor deficits

DTR: increases

Ex of cause: cortical stroke

Cerebral Cortex (1)

Central Nervous System Disorders


MOtor Weakness and spasticity as above, plus cranial nerve deficits such as diplopia (from weakness of the extraocular muscles) and dysarthria

Sensory: Variable; no typical sensory findings

DTR: increased

ex of cause: Brainstem stroke, acoustic neuroma

Brainstem (2)

Central Nervous System Disorders


MOTor: Weakness and spasticity as above, but often affecting both sides (when cord damage is bilateral), causing paraplegia or quadriplegia depending on the level of injury

Sensory:Dermatomal sensory deficit on the trunk bilaterally at the level of the lesion, and sensory loss from tract damage below the level of the lesion

DTR: increased

ex of cause: Trauma, causing cord compression

Spinal Cord (3)

Central Nervous System Disorders


Motor: Slowness of movement (bradykinesia), rigidity, and tremor

Sensory: Sensation not affected

DTR: normal or decreased

ex of cause: Parkinsonism

Subcortical Gray Matter: Basal Ganglia (4)

Central Nervous System Disorders


Motor: Hypotonia, ataxia, and other abnormal movements, including nystagmus, dysdiadochokinesis, and dysmetria

Sensory: Sensation not affected

DTR: normal or decreased

ex of cause: Cerebellar stroke, brain tumor


Central Nervous System Disorders


Motor: Weakness and atrophy in a segmental or focal pattern; fasciculations

Sensory: Sensation intact

DTR: Decreased

ex of causes: Polio, amyotrophic lateral sclerosis

Anterior Horn Cell (1)

Peripheral Nervous System Disorders


Motor: Weakness and atrophy in a root-innervated pattern; sometimes with fasciculations

Sensory: Corresponding dermatomal sensory deficits

DTR: decreased

examples of cause: Herniated cervical or lumbar disc

Spinal Roots and Nerves (2)

Peripheral Nervous System Disorders


Motor: Weakness and atrophy in a peripheral nerve distribution; sometimes with fasciculations

Sensory: Sensory loss in the pattern of that nerve

DTR: decreased

ex of cause: trauma

Peripheral Nerve—Mononeuropathy (3)

Peripheral Nervous System Disorders


Motor: Weakness and atrophy more distal than proximal; sometimes with fasciculations

Sensory: Sensory deficits, commonly in stocking-glove distribution

DTR: decreased

Ex of cause:Peripheral polyneuropathy of alcoholism, diabetes

Peripheral Nerve—Polyneuropathy (4)

Peripheral Nervous System Disorders


Motor: Fatigability more than weakness

Sensory: Sensation intact

DTR: Normal

ex of cause: Myasthenia gravis

Neuromuscular Junction (5)

Peripheral Nervous System Disorders


Motor: Weakness usually more proximal than distal; fasciculations rare

Sensory: Sensation intact

DTR: Normal or decreased

ex of cause: Muscular dystrophy

Muscle (6)

Peripheral Nervous System Disorders


Although there are many causes of coma, most can be classified as either (2 types)

structural or metabolic


Arousal centers poisoned or critical substrates depleted

Toxic–Metabolic coma


Lesion destroys or compresses brainstem arousal areas, either directly or secondary to more distant expanding mass lesions.

Structural coma


Respiratory pattern:
If regular, may be normal or hyperventilation. If irregular, usually Cheyne-Stokes

Toxic–Metabolic coma


Pupillary size and reaction:
Equal, reactive to light. If pinpoint from opiates or cholinergics, you may need a magnifying glass to see the reaction.

May be unreactive if fixed and dilated from anticholinergics or hypothermia

Toxic–Metabolic coma


Level of consciousness:
Changes after pupils change

Toxic–Metabolic coma


causes: Uremia, hyperglycemia alcohol, drugs, liver failure hypothyroidism, hypoglycemia, anoxia, ischemia meningitis, encephalitis hyperthermia, hypothermia

Toxic–Metabolic coma


respiratory pattern: Irregular, especially Cheyne-Stokes or ataxic breathing. Also with selected stereotypical patterns like “apneustic” respiration (peak inspiratory arrest) or central hyperventilation

Structural coma


pupillary size and reaction: Unequal or unreactive to light (fixed)

Structural coma


Midposition, fixed—suggests

midbrain compression


Dilated, fixed—suggests

compression of CN III from herniation


LOC: changes BEFORE pupils change

Structural coma


Example of cause: Epidural, subdural, or intracerebral hemorrhage; cerebral infarct or embolus; tumor, abscess; brainstem infarct, tumor, or hemorrhage; cerebellar infarct, hemorrhage, tumor, or abscess

structural coma


Pupillary ____, ______, and ______ help to assess the cause of coma and to determine the region of the brain that is impaired.

Remember that unrelated pupillary abnormalities, including miotic drops for glaucoma or mydriatic drops for a better view of the ocular fundi, may have preceded the coma.

size, equality, and light reactions


suggest damage to the sympathetic pathways in the hypothalamus, or metabolic encephalopathy, a diffuse failure of cerebral function that has many causes, including drugs. Light reactions are usually normal.

Bilaterally small pupils (1–2.5 mm)


suggest a hemorrhage in the pons, or the effects of morphine, heroin, or other narcotics. The light reactions may be seen with a magnifying glass.

Pinpoint pupils (


Midposition fixed pupils

Pupils that are in the midposition or slightly dilated (4–6 mm) and are fixed to light suggest structural damage in the midbrain


may be due to severe anoxia and its sympathomimetic effects, as seen after cardiac arrest. They may also result from atropinelike agents, phenothiazines, or tricyclic antidepressants.

Bilaterally fixed and dilated pupils


may be due to cocaine, amphetamine, LSD, or other sympathetic nervous system agonists.

Bilaterally large reactive pupils


warns of herniation of the temporal lobe, causing compression of the oculomotor nerve and midbrain.

A pupil that is fixed and another dilated


is most commonly seen in diabetic patients with infarction of CN III.

A single large pupil


This reflex helps to assess brainstem function in a comatose patient. Holding the upper eyelids open so that you can see the eyes, turn the head quickly, first to one side and then to the other. Make sure the patient has no neck injury before performing this test.

Oculocephalic Reflex (Doll’s Eye Movements)


In irritative lesions from epilepsy or early cerebral hemorrhage, the eyes _________ from the affected hemisphere.

Look away


In structural hemispheric lesions, the eyes _______________ in the affected hemisphere.

“look at the lesion”


In a comatose patient with absence of doll’s eye movements ( the ability to move both eyes to one side) is lost, suggesting a lesion of the

midbrain or pons.


If the _________ reflex is absent and you seek further assessment of brainstem function, test the oculovestibular reflex. Note that this test is almost never performed in an awake patient.



the upper arms are flexed tight to the sides with elbows, wrists, and fingers flexed. The legs are extended and internally rotated. The feet are plantar flexed. This posture implies a destructive lesion of the corticospinal tracts within or very near the cerebral hemispheres. When unilateral, this is the posture of chronic spastic hemiplegia.

Decorticate Rigidity (Abnormal Flexor Response)


Sudden unilateral brain damage involving the corticospinal tract may produce a _________ (one-sided paralysis), which is flaccid early in its course. Spasticity will develop later. The paralyzed arm and leg are slack. They fall loosely and without tone when raised and dropped to the bed. Spontaneous movements or responses to noxious stimuli are limited to the opposite side. The leg may lie externally rotated. One side of the lower face may be paralyzed, and that cheek puffs out on expiration. Both eyes may be turned away from the paralyzed side

hemiplegia (early)


the jaws are clenched and the neck is extended. The arms are adducted and stiffly extended at the elbows, with forearms pronated, wrists and fingers flexed. The legs are stiffly extended at the knees, with the feet plantar flexed. This posture may occur spontaneously or only in response to external stimuli such as light, noise, or pain. It is caused by a lesion in the diencephalon, midbrain, or pons, although severe metabolic disorders such as hypoxia or hypoglycemia may also produce it.

Decerebrate Rigidity (Abnormal Extensor Response)


A gait that lacks coordination, with reeling and instability, is called

may be due to cerebellar disease, loss of position sense, or intoxication



Walk heel-to-toe in a straight line

may reveal an ataxia not previously obvious.

Tandem walking


sensitive tests, respectively, for plantar flexion and dorsiflexion of the ankles, as well as for balance.

may reveal distal muscular weakness in the legs. Inability to heel-walk is a sensitive test for corticospinal tract damage.

Walk on the toes, then on the heels


involves the proximal muscles of the legs as well as the distal ones and requires both good position sense and normal cerebellar function

difficultly may be due to weakness, lack of position sense, or cerebellar dysfunction.

Hop in place on each foot in turn (if the patient is not too ill)


difficulty suggests proximal weakness (extensors of the hip), weakness of the quadriceps (the extensor of the knee), or both.

Difficulty in doing a shallow knee bend:

Do a shallow knee bend, first on one leg, then on the other. Support the patient’s elbow if you think the patient is in danger of falling.


Seen in corticospinal tract lesion in stroke, causing poor control of flexor muscles during swing phase. Affected arm is flexed, immobile, and held close to the side, with elbow, wrists, and interphalangeal joints flexed. Affected leg extensors spastic; ankle plantar-flexed and inverted. Patients may drag toe, circle leg stiffly outward and forward (circumduction), or lean trunk to contralateral side to clear affected leg during walking.

Spastic Hemiparesis


Seen in spinal cord disease, causing bilateral lower extremity spasticity, including adductor spasm, and abnormal proprioception. Gait is stiff. Patients advance each leg slowly, and the thighs tend to cross forward on each other at each step. Steps are short. Patients appear to be walking through water. Scissoring is seen in all spasticity disorders, most commonly cerebral palsy

Scissors Gait


Seen in foot drop, usually secondary to peripheral motor unit disease. Patients either drag the feet or lift them high, with knees flexed, and bring them down with a slap onto the floor, thus appearing to be walking up stairs. They cannot walk on their heels. The steppage gait may involve one or both legs. Tibialis anterior and toe extensors are weak.

Steppage Gait


Seen in the basal-ganglia defects of Parkinson disease. Posture is stooped, with flexion of head, arms, hips, and knees. Patients are slow getting started. Steps are short and shuffling, with involuntary hastening (festination). Arm swings are decreased, and patients turn around stiffly—“all in one piece.” Postural control is poor (retropulsion).

Parkinsonian Gait


Seen in disease of the cerebellum or associated tracts. Gait is staggering, unsteady, and wide based, with exaggerated difficulty on turns. Patients cannot stand steadily with feet together, whether eyes are open or closed. Other cerebellar signs are present such as dysmetria, nystagmus, and intention tremor.

Cerebellar Ataxia


Seen in loss of position sense in the legs (with polyneuropathy or posterior column damage). Gait is unsteady and wide based (with feet wide apart). Patients throw their feet forward and outward and bring them down, first on the heels and then on the toes, with a double tapping sound. They watch the ground for guidance when walking. With eyes closed, they cannot stand steadily with feet together (positive Romberg sign), and the staggering gait worsens.

Sensory Ataxia


Location of lesion:Upper motor neuron or corticospinal tract systems

Description: Increased muscle tone (hypertonia) that is rate dependent. Tone is greater when passive movement is rapid, and less when passive movement is slow. Tone is also greater at the extremes of the movement arc. During rapid passive movement, initial hypertonia may give way suddenly as the limb relaxes. This spastic “catch” and relaxation is known as “clasp-knife” resistance.

Common Cause: Stroke, especially late or chronic stage



Location of lesion:Basal ganglia system

Description: Increased resistance that persists throughout the movement arc, independent of rate of movement, is called lead-pipe rigidity. With flexion and extension of the wrist or forearm, a superimposed rachetlike jerkiness is called cogwheel rigidity.

Common cause: Parkinsonism



Location of lesion: Lower motor neuron system at any point from the anterior horn cell to the peripheral nerves

Description: Loss of muscle tone (hypotonia), causing the limb to be loose or floppy. The affected limbs may be hyperextensible or even flail-like. Flaccid muscles are also weak.

Common cause: Guillain-Barré syndrome; also initial phase of spinal cord injury (spinal shock) or stroke



Location of lesion: Both hemispheres, usually in the frontal lobes

Description:Sudden changes in tone with passive range of motion. Sudden loss of tone that increases the ease of motion is called mitgehen (moving with). Sudden increase in tone making motion more difficult is called gegenhalten (holding against).

Common cause: Dementia



Marked floppiness indicates muscle ______ or _______ , usually from a disorder of the peripheral motor system.

hypotonia or flaccidity


velocity-dependent increased tone that worsens at the extremes of range.

seen in central corticospinal tract diseases, is rate-dependent, increasing with rapid movement.



is increased resistance throughout the range of movement and in both directions; it is not rate-dependent.



refers to weakness of one-half of the body



to paralysis of one-half of the body.



means paralysis of the legs; quadriplegia means paralysis of all four limbs.



With flexion and extension of the wrist or forearm, a superimposed rachetlike jerkiness is called

cogwheel rigidity


Tremors are rhythmic oscillatory movements, which may be roughly subdivided into three groups:

resting (or static) tremors,

postural tremors, and

intention tremors.


These tremors are most prominent at rest and may decrease or disappear with voluntary movement. Illustrated is the common, relatively slow, fine, pill-rolling tremor of parkinsonism, about 5 per second.

Resting (Static) Tremors


These tremors appear when the affected part is actively maintaining a posture. Examples include the fine rapid tremor of hyperthyroidism, the tremors of anxiety and fatigue, and benign essential (and sometimes familial) tremor.

Postural Tremors


, absent at rest, appear with movement and often get worse as the target gets closer. Causes include disorders of cerebellar pathways, as in multiple sclerosis, or any other disease of the cerebellum.

Intention tremors


are rhythmic, repetitive, bizarre movements that chiefly involve the face, mouth, jaw, and tongue: grimacing, pursing of the lips, protrusions of the tongue, opening and closing of the mouth, and deviations of the jaw.

The limbs and trunk are involved less often.

These movements may be a late complication of psychotropic drugs such as phenothiazines, termed tardive (late) dyskinesias. They also occur in long-standing psychoses, in some elderly individuals, and in some edentulous persons.

Oral–Facial Dyskinesias


brief, repetitive, stereotyped, coordinated movements occurring at irregular intervals. Examples include repetitive winking, grimacing, and shoulder shrugging. Causes include Tourette’s syndrome and drugs such as phenothiazines and amphetamines.



similar to athetoid movements, but often involve larger portions of the body, including the trunk. Grotesque, twisted postures may result. Causes include drugs such as phenothiazines, primary torsion dystonia, and as illustrated, spasmodic torticollis.



slower and more twisting and writhing than choreiform movements, and have a larger amplitude. They most commonly involve the face and the distal extremities. Athetosis is often associated with spasticity. Causes include cerebral palsy.



brief, rapid, jerky, irregular, and unpredictable. They occur at rest or interrupt normal coordinated movements. Unlike tics, they seldom repeat themselves. The face, head, lower arms, and hands are often involved. Causes include Sydenham’s chorea (with rheumatic fever) and Huntington’s disease.



seen in peripheral nerve disease, from radial nerve damage, and in central nervous system disease, producing hemiplegia, seen in stroke or multiple sclerosis.

Weakness of extension


seen in cervical radiculopathy, de Quervain’s tenosynovitis, carpal tunnel syndrome, arthritis, and epicondylitis.

A weak grip


Weak finger abduction occurs in

ulnar nerve disorders.


Look for weak opposition of the thumb in ____________ such as ____________

median nerve disorders such as carpal tunnel syndrome


Symmetric weakness of the proximal muscles suggests a



symmetric weakness of distal muscles suggests a


disorder of peripheral nerves


__________ are seen in central nervous system lesions along the descending corticospinal tract. Look for associated upper motor neuron findings of weakness, spasticity, or a positive Babinski sign.

Hyperactive reflexes (hyperreflexia)


scale for grading redflexes

4+: very brisk, hyperactive, with clonus (rhythmic oscillations between flection and extension)

3+: brisker than average, possibly but not necessarily indicative of disease

2+: average, normal

1+: somewhat diminished, low normal

0: no response


seen in diseases of spinal nerve roots, spinal nerves, plexuses, or peripheral nerves. Look for associated findings of lower motor unit disease, namely weakness, atrophy, and fasciculations.

Hypoactive or absent reflexes (hyporeflexia)


Assessing patients with stroke involves three fundamental questions, based on a careful history and detailed physical examination

What brain area and related vascular territory explain the patient’s findings?
Is the stroke ischemic or hemorrhagic?
If ischemic, is the mechanism thrombus or embolus?


ischemic brain injury begins with a central core of very low perfusion and often irreversible cell death.

acute ischemic stroke


This core is surrounded by an_____________ of metabolically disturbed cells that are still potentially viable, depending on restoration of blood flow and duration of ischemia.

ischemic penumbra

acute ischemic stroke


most irreversible damage occurs in the first __________ after onset of symptoms,

3 to 6 hours


therapies targeted to the ______ window achieve the best outcomes, with recovery in up to 50% of patients in some studies.



Contralateral leg weakness

Vascular Territory: Anterior circulation—anterior cerebral artery (ACA)

Includes stem of Circle of Willis connecting internal carotid artery to ACA, and the segment distal to ACA and its anterior choroidal branch


Contralateral face, arm > leg weakness, sensory loss, field cut, aphasia (left MCA) or neglect, apraxia (right MCA)

Vascular Territory: Anterior circulation—middle cerebral artery (MCA)

Largest vascular bed for stroke


Contralateral motor or sensory deficit without cortical signs

Vascular Territory: Subcortical circulation*—lenticulostriate deep penetrating branches of MCA

Small vessel subcortical lacunar infarcts in internal capsule, thalamus, or brainstem. Four common syndromes: pure motor hemiparesis; pure sensory hemianesthesia; ataxic hemiparesis; clumsy hand—dysarthria syndrome


Contralateral field cut

Vascular Territory: Posterior circulation—posterior cerebral artery (PCA)

Includes paired vertebral and basilar artery, paired posterior cerebral arteries. Bilateral PCA infarction causes cortical blindness but preserved pupillary light reaction.


Dysphagia, dysarthria, tongue/palate deviation and/or ataxia with crossed sensory/motor deficits (= ipsilateral face with contralateral body)

Vascular Territory: Posterior circulation—brainstem, vertebral, or basilar artery branches


Oculomotor deficits and/or ataxia with crossed sensory/motor deficits

Vascular territory: posterior circulation—basilar artery

Complete basilar artery occlusion—“locked-in syndrome” with intact consciousness but with inability to speak and quadriplegia


Mechanism: Sudden peripheral vasodilatation, especially in the skeletal muscles, without a compensatory rise in cardiac output. Heart rate then blood pressure fall. Often slow onset, slow offset.

Precipitating Factors:A strong emotion such as fear or pain

Predisposing Factors: Fatigue, hunger, a hot humid environment

Prodromal Manifestations: Restlessness, weakness, pallor, nausea, salivation, sweating, yawning

Vasodepressor or Vasovagal Syncope (the common faint)


Mechanism: Inadequate vasoconstrictor reflexes in both arterioles and veins, with resultant venous pooling, decreased cardiac output, and low blood pressure

Precipitating Factors: Standing up

Predisposing Factors: Central and peripheral neuropathies: Parkinson disease, Shy-Drager syndrome; Lewy body disease diabetes, amyloidosis; antihypertensive vasodilator drugs; prolonged bed rest

Prodromal Manifestations: Often none

Orthostatic (Postural) Hypotension (orthostatic)


Mechanism: Hypovolemia, a diminished blood volume insufficient to maintain cardiac output and blood pressure, especially in the upright position

Precipitating Factors: Standing up after hemorrhage or dehydration

Predisposing Factors: Central and peripheral neuropathies: Parkinson disease, Shy-Drager syndrome; Lewy body disease diabetes, amyloidosis; antihypertensive vasodilator drugs; prolonged bed rest

Orthostatic (Postural) Hypotension (orthostatic)


Predisposing Factors: Bleeding from the GI tract or trauma, potent diuretics, vomiting, diarrhea, polyuria

Prodromal Manifestations: Light-headedness and palpitations (tachycardia) on standing up

Orthostatic (Postural) Hypotension (orthostatic)


Mechanism:Neurally mediated, possible vagal stimulation

Precipitating Factors: Severe paroxysm of coughing

Predisposing Factors: Chronic bronchitis in a muscular man

Prodromal Manifestations: Often none except for cough

Cough Syncope


Mechanism: Vasovagal stimulation

Precipitating Factors: Emptying the bladder after getting out of bed to void

Predisposing Factors: Nocturia, usually in elderly or adult men

Prodromal Manifestations: Often none

Micturition Syncope


Mechanism: Decreased cardiac output from cardiac ischemia, ventricular arrhythmias, prolonged QT syndrome, persistent bradycardia, infrafascicular block. Often sudden onset; sudden offset.

Precipitating Factors: A sudden change in rhythm

Predisposing Factors: Heart disease, aging decrease tolerance of abnormal rhythms.

Prodromal Manifestations: Often none

Cardiovascular Disorders



Mechanism: Vascular resistance falls with exercise, but cardiac output cannot rise due to outflow obstruction.

Precipitating Factors: Exercise

Predisposing Factors: Cardiac disorders

Prodromal Manifestations: Often none. Onset is sudden.

Cardiovascular Disorders

Aortic Stenosis and Hypertrophic Cardiomyopathy


Mechanism: Sudden arrhythmia or decreased cardiac output

Precipitating Factors: Variable

Predisposing Factors: Coronary artery disease

Prodromal Manifestations: Ischemic chest pain; often none

Cardiovascular Disorders

Myocardial Infarction


Mechanism: Sudden hypoxia or decreased cardiac output

Precipitating Factors: Variable, including prolonged bed rest and clotting disorders

Predisposing Factors: Deep vein thrombosis, bedrest hypercoagulable states (SLE; cancer), protein S or C deficiency, antithrombin III deficiency. Estrogen therapy

Prodromal Manifestations: Dyspnea, pleuritic chest pain

Cardiovascular Disorders

Massive Pulmonary Embolism


Mechanism: Constriction of cerebral blood vessels secondary to hypocapnia induced by hyperventilation

Precipitating Factors: Anxiety, panic disorder

Predisposing Factors: Anxiety

Prodromal Manifestations: Dyspnea, palpitations, chest discomfort, numbness and tingling of the hands and around the mouth lasting for several minutes. Consciousness is often maintained.

Disorders Resembling Syncope

Hypocapnia due to Hyperventilation


Mechanism: Insufficient glucose to maintain cerebral metabolism; secretion of epinephrine contributes to symptoms. True syncope is uncommon.

Precipitating Factors: Variable, including fasting

Predisposing Factors: Insulin therapy and a variety of metabolic disorders

Prodromal Manifestations: Sweating, tremor, palpitations, hunger, headache, confusion, abnormal behavior, coma

Disorders Resembling Syncope



Mechanism: The symbolic expression of an unacceptable idea through body language. Skin color and vital signs may be normal; sometimes with bizarre and purposive movements; occurrence in the presence of other people.

Precipitating Factors: Stressful situation

Predisposing Factors: Hysterical personality traits

Prodromal Manifestations: Variable

Disorders Resembling Syncope

Hysterical Fainting From Conversion Reaction


Seizures are classified into (2)

focal and generalized


Underlying causes should be identified as (3)

genetic, structural/metabolic, or unknown.


“are conceptualized as originating within networks limited to one hemisphere. They may be discretely localized or more widely distributed. they may originate in subcortical structures.

Focal seizures


for each seizure type waht is consistent from one seizure to another?

ictal onset


some cases though there are more than one network, and more than one seizure type, but each individual seizure type has a consistent

site of onset


Tonic and then clonic movements that start unilaterally in the hand, foot, or face and spread to other body parts on the same side

Normal consciousness

Focal Seizures Without Impairment of Consciousness or Awareness: With observable motor and autonomic symptoms



Turning of the head and eyes to one side, or tonic and clonic movements of an arm or leg without the Jacksonian spread

Normal consciousness

Focal Seizures Without Impairment of Consciousness or Awareness: With observable motor and autonomic symptoms

Other motor


A “funny feeling” in the epigastrium, nausea, pallor, flushing, lightheadedness

Normal consciousness

Focal Seizures Without Impairment of Consciousness or Awareness: With observable motor and autonomic symptoms

with autonomic symptoms


Numbness, tingling; simple visual, auditory, or olfactory hallucinations such as flashing lights, buzzing, or odors

Normal consciousness

Focal Seizures Without Impairment of Consciousness or Awareness: With subjective sensory or psychic phenomena


Anxiety or fear; feelings of familiarity (déjà vu) or unreality; dreamy states; fear or rage; flashback experiences; more complex hallucinations

Normal consciousness

Focal Seizures Without Impairment of Consciousness or Awareness: With subjective sensory or psychic phenomena


The seizure may or may not start with the autonomic or psychic symptoms outlined above. Consciousness is impaired, and the person appears confused. Automatisms include automatic motor behaviors such as chewing, smacking the lips, walking about, and unbuttoning clothes; also more complicated and skilled behaviors such as driving a car.

Postictal state: The patient may remember initial autonomic or psychic symptoms (which are then termed an aura), but is amnesic for the rest of the seizure. Temporary confusion and headache may occur.

Focal Seizures With Impairment of Consciousness


Partial seizures that become generalized resemble tonic–clonic seizures (see next page). Unfortunately, the patient may not recall the focal onset, and observers may overlook it.

Postictal state: As in a tonic–clonic seizure, described on the next page. Two attributes indicate a partial seizure that has become generalized: (1) the recollection of an aura, and (2) a unilateral neurologic deficit during the postictal period.

Focal Seizures That Become Generalized


“are conceptualized as originating as some point within, and rapidly engaging, bilaterally distributed networks….that include cortical and subcortical structures, but do not necessarily include the entire cortex… the location and lateralization are not consistent from one seizure to another.

can be asymmetric.

They may begin with body movements, impaired consciousness, or both.

Generalized seizures


begin after age 30, suspect either a partial seizure that has become generalized or a general seizure caused by a toxic or metabolic disorder. Toxic and metabolic causes include withdrawal from alcohol or other sedative drugs, uremia, hypoglycemia, hyperglycemia, hyponatremia, and bacterial meningitis.

tonic–clonic seizures


The person loses consciousness suddenly, sometimes with a cry, and the body stiffens into tonic extensor rigidity. Breathing stops, and the person becomes cyanotic. A clonic phase of rhythmic muscular contraction follows. Breathing resumes and is often noisy, with excessive salivation. Injury, tongue biting, and urinary incontinence may occur.

Postictal (post seizure) state: Confusion, drowsiness, fatigue, headache, muscular aching, and sometimes the temporary persistence of bilateral neurologic deficits such as hyperactive reflexes and Babinski responses. The person has amnesia for the seizure and recalls no aura.

Generalized Seizures

Tonic–Clonic (grand mal)


A sudden brief lapse of consciousness, with momentary blinking, staring, or movements of the lips and hands but no falling. Two subtypes are recognized. Typical absences last less than 10 second and stop abruptly. Atypical absences may last more than 10 second.

Postictal (post seizure) state: No aura recalled. In petit mal absences, a prompt return to normal; in atypical absences, some postictal confusion

Generalized Seizures:



Sudden, brief, rapid jerks, involving the trunk or limbs. Associated with a variety of disorders

Postictal (post seizure) state: Variable

Generalized Seizures:



Sudden loss of consciousness with falling but no movements. Injury may occur.

Postictal (post seizure) state: Either a prompt return to normal or a brief period of confusion

Generalized Seizures:

Myoclonic Atonic (drop attack)


The movements may have personally symbolic significance and often do not follow a neuroanatomic pattern. Injury is uncommon.

Postictal (post seizure) state: Variable


May mimic seizures but are due to a conversion reaction (a psychological disorder)


Disorders of speech fall into three groups affecting:

(1) the voice,
(2) the articulation of words, and
(3) the production and comprehension of language.


refers to a loss of voice that accompanies disease affecting the larynx or its nerve supply.



refers to less severe impairment in the volume, quality, or pitch of the voice. For example, a person may be hoarse or only able to speak in a whisper. Causes include laryngitis, laryngeal tumors, and a unilateral vocal cord paralysis (CN X).



refers to a defect in the muscular control of the speech apparatus (lips, tongue, palate, or pharynx). Words may be nasal, slurred, or indistinct, but the central symbolic aspect of language remains intact. Causes include motor lesions of the central or peripheral nervous system, parkinsonism, and cerebellar disease.



refers to a disorder in producing or understanding language. It is often caused by lesions in the dominant cerebral hemisphere, usually the left.



(1) Wernicke’s, a fluent (receptive) aphasia, and (2) Broca’s, a nonfluent (or expressive) aphasia.

There are other less-common kinds of aphasia, which are distinguished by differing responses on the specific tests listed. Neurologic consultation is usually indicated.

two common types of aphasia


Qualities of Spontaneous Speech: Fluent; often rapid, voluble, and effortless. Inflection and articulation are good, but sentences lack meaning and words are malformed (paraphasias) or invented (neologisms). Speech may be totally incomprehensible

Word Comprehension: Impaired

Reputation: Impaired

Naming: Impaired

Reading Comprehension: Impaired

Writing: Impaired

Location of Lesion: Posterior superior temporal lobe

Wernicke’s Aphasia


Qualities of Spontaneous Speech: Nonfluent; slow, with few words and laborious effort. Inflection and articulation are impaired but words are meaningful, with nouns, transitive verbs, and important adjectives. Small grammatical words are often dropped.

Word Comprehension: Fair to good

Reputation: Impaired

Naming: Impaired, though the patient recognizes objects

Reading Comprehension: Fair to good

Writing: Impaired

Location of Lesion: Posterior inferior frontal lobe

Broca’s Aphasia


rhythmic oscillation of the eyes, analogous to a tremor in other parts of the body.

It has multiple causes, including impairment of vision in early life, disorders of the labyrinth and the cerebellar system, and drug toxicity.

occurs normally when a person watches a rapidly moving object (e.g., a passing train).



observe for nystagmus only within the field of

full binocular vision.


** picture of both eyes looking to the PATIENTS right ***

Nystagmus on Right Lateral Gaze
Nystagmus Present (Right Lateral Gaze)


Left-Beating Nystagmus—a Quick Jerk to the Left in Each Eye, Then a Slow Drift to the Right

Direction of the Quick and Slow Phases


Nystagmus usually has both slow and fast movements, but is defined by its

fast phase


if the eyes jerk quickly to the patient’s left and drift back slowly to the right, the patient is said to have

left-beating nystagmus.


Occasionally, nystagmus consists only of coarse oscillations without quick and slow components. It is then said to be



3 planes of movements for nystagmus

1. Horizontal Nystagmus
2. Vertical
3. Rotary


It is the ____ of the movements, not the direction of the gaze, that defines this variable.



Facial weakness or paralysis may result either from (2)

(1) a peripheral lesion of CN VII, the facial nerve, anywhere from its origin in the pons to its periphery in the face, or

(2) a central lesion involving the upper motor neuron system between the cortex and the pons.


A peripheral lesion of CN VII, exemplified here by a Bell’s palsy, is compared with a central lesion, exemplified by a left hemispheric cerebrovascular accident. These can be distinguished by their

different effects on the upper part of the face.

go to page 757 in BATES... great pictures of this! :)


The lower part of the face normally is controlled by _______________ located on only one side of the cortex—the opposite side.

Left hemispheric damage to these pathways, as in a stroke, paralyzes the right lower face.

upper motor neurons


he upper face, however, is controlled by ______________

Even though the upper motor neurons on the left are destroyed, others on the right remain, and the right upper face continues to function fairly well.

pathways from both sides of the cortex.


____________ nerve damage to CN VII paralyzes the entire right side of the face, including the forehead.



other symptoms with Peripheral Nerve damage of CN VII

Closing eyes: right eye does not close; eyeball rolls up

flat nasolabial fold on pts right side

Raising eyebrows: forehead not wrinkled on pts right; eyebrow not raised on right

paralysis of lower face on right


CN VII—Central Lesion

Closing eyes: right eye closes with slight weakness

flat right nasolabial fold

Raising eyebrows: right forehead wrinkled, eyebrow raised

right paralysis of lower face


mediate voluntary movement and integrate skilled, complicated, or delicate movements by stimulating selected muscular actions and inhibiting others.

They also carry impulses that inhibit muscle tone, the slight tension maintained by normal muscle even when it is relaxed.

originate in the motor cortex of the brain. Motor fibers travel down into the lower medulla, where they form an anatomical structure resembling a pyramid. There, most of these fibers cross to the opposite or contralateral side of the medulla, continue downward, and synapse with anterior horn cells or with intermediate neurons. Tracts synapsing in the brainstem with motor nuclei of the cranial nerves are termed corticobulbar.

The corticospinal tracts


his exceedingly complex system includes motor pathways between the cerebral cortex, basal ganglia, brainstem, and spinal cord. It helps to maintain muscle tone and to control body movements, especially gross automatic movements such as walking.

basal ganglia system


receives both sensory and motor input and coordinates motor activity, maintains equilibrium, and helps to control posture.

cerebellar system.


Stroke at a Glance: Key Facts for Prevention and Patient Education

--> Stroke affects 7,000,000 Americans at a cost of $40 billion annually.

--> Stroke prevalence and mortality are disproportionately higher in African Americans, compared to whites:

--> Prevalence, black vs. white men: 4.5% vs. 2.4%; black vs. white women 4.4% vs. 3.3%

--> Mortality per 100,000, black vs. white men—67 vs. 40; black vs. white women—55 vs. 40

(Cardiovascular disease, including stroke, is the greatest contributor to the 6-year disparity in life expectancy for African Americans compared to whites. Other contributing factors include a higher prevalence of hypertension, diabetes, left ventricular hypertrophy, and income and insurance gaps.)

--> The prevalence of silent stroke increases progressively from 11% between ages 55 and 64 to 43% after age 85.

--> Individuals with TIA have a 1-year mortality of ~12%, and a 10-year risk of stroke and death from cardiovascular disease of 19% and 43%.

--> Women ages 45 to 54 are twice as likely as men to report previous stroke. Midlife risk factors now include autoimmune collagen vascular disease and history of preeclampsia, gestational diabetes, and pregnancy-induced hypertension.

--> Public awareness of stroke warning signs is improving, but only 17% of the U. S. population are aware of correct warning signs and would call 911 if they thought someone was having a stroke.

--> Stroke outcomes markedly improve if therapy is given within 3 hours of onset of symptoms; however, the median emergency room arrival time from symptom onset is 3 to 6 hours.

--> Physician awareness of warning signs, risk factors, and prevention remains insufficient.

i know it is long.. but it is just for reading purposes


1. Sudden numbness or weakness of the face, arm, or leg

2. Sudden confusion, trouble speaking or understanding

3. Sudden trouble seeing in one or both eyes

4. Sudden trouble walking, dizziness, or loss of balance or coordination

5. Sudden severe headache

AHA/ASA Stroke Attack Warning Signs


Hypertension: Hypertension is the leading risk factor for both ischemic and hemorrhagic stroke. Individuals with blood pressure

Behavioral Risk Factors
for stokes

Primary Prevention for Ischemic Stoke

.... again i know it is long.... just read it


Atrial fibrillation:
Valvular (rheumatic) and nonvalvular atrial fibrillation increases risk of stroke 5- and 17-fold, respectively, compared to controls. Risk for ischemic stroke with warfarin therapy and aspirin therapy are ~68% and ~20%, but individual risk levels are variable. When considering antithrombotic therapy, experts recommend individual risk stratification into high-, moderate-, and low-risk groups to balance risk of stroke against risk of bleeding. CHADS2 is a commonly used scoring system based on Congestive heart failure, Hypertension, Age >75 years, Diabetes, and prior Stroke/TIA. Patients with atrial fibrillation at highest risk are those with additional stroke risk factors: prior TIA or stroke, hypertension, diabetes, poor left ventricular function, rheumatic mitral valve disease, and women over age 75.

Carotid artery disease:
The prevalence of atherosclerotic carotid artery disease of the extracranial carotid arteries in the U.S. population over age 65 is 1%. Medical therapy in individuals with asymptomatic carotid artery stenosis of 60% to 70% has improved, with an annual stroke rate of 1% annually. Experts recommend risk factor reduction and medical therapy, reserving endarterectomy and stenting for highly selected individuals. In 2007, the U.S. Preventive Services Task Force recommended against screening the general population due to lack of evidence that use of duplex ultrasonography reduces stroke

Disease-Specific Risk Factors for strokes

Primary Prevention for Ischemic Stoke

.... again i know it is long.... just read it


Don’t dilate the pupils, the single most important clue to the underlying cause of coma (structural vs. metabolic), and

Don’t flex the neck if there is any question of trauma to the head or neck. Immobilize the cervical spine and get an x-ray first to rule out fractures of the cervical vertebrae that could compress and damage the spinal cord.

Don’ts” When Assessing the Comatose Patient


Process: Neuronal dysfunction, possibly of brainstem origin, involving low serotonin, spreading cortical depression and trigemino-vascular activation. Types: with aura; without aura; variants.

Location: Unilateral in ~70%; bifrontal or global in ~30%

Quality/Severity: Throbbing or aching, variable in severity.

Onset: Fairly rapid, reaching a peak in 1–2 hours

Duration: 4–72 hours

Course: Peak incidence early to mid-adolescence; prevalence is ~6% in men and ~15% in women. Recurrent—usually monthly, but weekly in ~10%

Associated Factors: Nausea, vomiting, photophobia, phonophobia, aura in 30%, either visual (flickering, zig-zagging lines), motor (paresthesias of hand, arm, or face, or language dysfunction).

Aggregate or provoke: Alcohol, certain foods, or stress may provoke; also menses, high altitude; aggravated by noise and bright light

Relieving Factors: Quiet, dark room; sleep; sometimes transient relief from pressure on the involved arter

Mirgaines primary Headache


Process: Unclear—possibly heightened CNS pain sensitivity. Involves pericranial muscle tenderness. Etiology also unclear.

Location: Usually bilateral; may be generalized or localized to the back of the head and upper neck or to the frontotemporal area

Quality/Severity: Steady; pressing or tightening;nonthrobbing. Mild to moderate intensity

Onset: Gradual

Duration: 30 minutes to 7 days

Course: Episodic; may be chronic; Annual prevalence ~40%

Associated Factors: Sometimes photophobia, phonophobia; nausea absent

Aggregate or provoke: Sustained muscle tension, as in driving or typing

Relieving Factors: Possibly massage, relaxation

tension primary headache


Process: Unclear—possibly hypothalamic then trigemino-autonomic activation.

Location: Unilateral, usually behind or around the eye or temple

Quality/Severity: Deep, continuous, severe

Onset: Abrupt; peaks within minutes

Duration: Up to 3 hours

Course: Episodic, clustered in time, with several each day for 4–8 weeks and then relief for 6–12 months; prevalence

Cluster Primary Headache


Process: Withdrawal of medication

Location: Previous headache pattern


Onset: Variable

Duration: Variable

Course: Depends on frequency of “mini-withdrawals”

Associated factors: Depends on prior headache pattern

Factors that aggravate or provoke: Fever, carbon monoxide, hypoxia, withdrawal of caffeine, other headache triggers

Factors that relieve: Depends on cause

Secondary Headaches:

Analgesic Rebound


Process: Probably the sustained contraction of the extraocular muscles, and possibly of the frontal, temporal, and occipital muscles

Location: Around and over the eyes; may radiate to the occipital area

Quality/Severity: Steady, aching, dull

Onset: gradual


Course: Variable

Associated factors: Eye fatigue, “sandy” sensations in the eyes, redness of the conjunctiva

Factors that aggravate or provoke: Prolonged use of the eyes, particularly for close work

Factors that relieve: Rest of the eyes

Headaches From Eye Disorders:

Errors of Refraction (farsightedness and astigmatism, but not nearsightedness)


Process: Sudden increase in intraocular pressure

Location: In and around one eye

Quality/Severity: Steady, aching, often severe

Onset: Often rapid

Duration: Variable, may depend on treatment

Course: Variable, may depend on treatment

Associated factors: Diminished vision, sometimes nausea and vomiting

Factors that aggravate or provoke: Sometimes provoked by drops that dilate the pupils

Headaches From Eye Disorders

Acute Glaucoma


Process: Mucosal inflammation of the paranasal sinuses

Location: Usually above the eye (frontal sinus) or over the maxillary sinus

Quality/Severity: Aching or throbbing, variable in severity; consider possible migraine

Onset: Variable

Duration: Often several hours at a time, recurring over days or longer

Course: Often recurrent in a repetitive daily pattern

Associated factors: Local tenderness, nasal congestion, discharge, and fever

Factors that aggravate or provoke: May be aggravated by coughing, sneezing, or jarring the head

Factors that relieve: Nasal decongestants, antibiotics

Headache From Sinusitis


Process: Infection of the meninges surrounding the brain and spinal cord

Location: Generalized

Quality/Severity: Steady or throbbing, very severe

Onset: Fairly rapid, usually



Process: Bleeding, most often from a ruptured intracranial aneurysm

Location: Generalized

Quality/Severity: Very severe, “the worst of my life”

Onset: Usually abrupt, severe with prodromal symptoms

Duration: Variable, usually days

Course: A persistent headache in an acute illness

Associated factors: Nausea, vomiting, possibly loss of consciousness, neck pain

Factors that relieve: Subspecialty treatments

Subarachnoid Hemorrhage


Process: Displacement of or traction on pain-sensitive arteries and veins or pressure on nerves

Location: Varies with the location of the tumor

Quality/Severity: Aching, steady, variable in intensity

Onset: Variable

Duration: Often brief

Course: Often intermittent but progressive

Factors that aggravate or provoke: May be aggravated by coughing, sneezing, or sudden movements of the head

Factors that relieve: Subspecialty treatments

Brain Tumor


Process: Vasculitis from cell-mediated immune response to elastic lamina of artery

Location: Localized near the involved artery, most often the temporal, but also the occipital; age related

Quality/Severity: Throbbing, generalized, persistent; often severe

Onset: Gradual or rapid

Duration: Variable

Course: Recurrent or persistent over weeks to months

Associated factors: Tenderness of the adjacent scalp; fever (in ~50%), fatigue, weight loss; new headache (~60%), jaw claudication (~50%), visual loss or blindness (~15%–20%), polymyalgia rheumatica (~50%)

Factors that aggravate or provoke: Movement of neck and shoulders

Giant Cell (Temporal) Arteritis


Process: Follows acceleration-deceleration traumatic brain injury

Location: May be localized to the injured area, but not necessarily

Quality/Severity: Generalized, dull, aching, constant; may have features of tension and migraine headaches

Onset: Within 7 days of the injury up to 3 months

Duration: Weeks, months, or even years

Course: Tends to diminish over time

Associated factors: Poor concentration, problems with memory, vertigo, irritability, restlessness, fatigue

Factors that aggravate or provoke: Mental and physical exertion, straining, stooping, emotional excitement, alcohol

Factors that relieve: Rest; medication

Postconcussion Headache


Process: Compression of CN V, often by aberrant loop of artery or vein, usually near entry to pons

Location: Cheek, jaws, lips, or gums; trigeminal nerve divisions 2 and 3 > 1

Quality/Severity: Shocklike, stabbing, burning; severe

Onset: Abrupt, paroxysmal

Duration: Each jab lasts seconds but recurs at intervals of seconds or minutes

Course: May last for months, then disappear for months, but often recurs. It is uncommon at night.

Associated factors: Exhaustion from recurrent pain

Factors that aggravate or provoke: Touching certain areas of the lower face or mouth; chewing, talking, brushing teeth

Factors that relieve: Medication; neurovascular decompression

Cranial Neuralgias :

Trigeminal Neuralgia (CNV)