Ch.16

Question 1

ALTERATIONS IN COGNITIVE
SYSTEMS

Answer 1

Consciousness
* State of awareness of oneself and the environment
* Arousal
* State of awakeness

Question 2

ALTERATIONS IN AROUSAL

Answer 2

• Structural
  
  • Divided by location
    above or below
    tentorial plate
• Metabolic
• Psychogenic
• Coma is produced by either:
  
  • Bilateral hemisphere damage or suppression
  • Brain stem lesions or metabolic derangement that
    damages or suppresses the reticular activating system

Question 3

ALTERATIONS IN AROUSAL Clinical manifestations

Answer 3

• Level of consciousness changes
• Pattern of breathing
• Posthyperventilation apnea (PHVA)
• Cheyne-Stokes respirations (CSR)
• Pupillary changes
• Oculomotor responses
• Motor responses
• Vomiting, yawning, hiccups

Question 4

BRAIN DEATH (TOTAL BRAIN
DEATH)

Answer 4

• Body can no longer maintain internal homeostasis
• Brain death criteria:
  
  • Completion of all appropriate and therapeutic procedures
  • Unresponsive coma (absence of motor and reflex
    responses)
  • No spontaneous respirations (apnea)
  • No ocular responses
  • Isoelectric EEG
  • Persistence 6 to 12 hours after onset

Question 5

CEREBRAL DEATH

Answer 5

• Cerebral death (irreversible coma) is death of the cerebral hemispheres exclusive of the brain stem and cerebellum
• No behavioral or environmental responses
• The brain can continue to maintain internal
  homeostasis
• Survivors of cerebral death:
  
  • Remain in coma
  • Emerge into a persistent vegetative state
  • Progress into a minimal conscious state (MCS)
  • Locked-in syndrome

Question 6

ALTERATIONS IN AWARENESS

Answer 6

Selective attention:
* Ability to select from available, competing environmental
and internal stimuli
* Sensory inattentiveness
* Extinction
* Neglect syndrome
* Selective attention deficit
* Memory
* Amnesia
* Retrograde amnesia
* Anterograde amnesia
* Executive attention deficits
* ADHD
* Image processing

Question 7

SEIZURES

Answer 7

• Syndrome versus disease
• Sudden, transient alteration of brain function caused by an abrupt explosive, disorderly
  discharge of cerebral neurons
• Motor, sensory, autonomic, or psychic signs
• Convulsion
  
  • Tonic-clonic (jerky, contract-relax) movements associated
    with some seizures
• Epilepsy: a seizure activity with no underlying
  cause

Question 8

SEIZURES Etiologic Factors

Answer 8

• Cerebral lesions
• Biochemical disorders
• Cerebral trauma
• Epilepsy

Question 9

SEIZURE types

Answer 9

• Partial seizures
  
  • Simple (without impairment of consciousness)
  • Complex (with impairment of consciousness)
  • Secondary generalized (partial onset evolving to
    generalized tonic-clonic seizures)
• Generalized seizures
  
  • Absence
  • Myoclonic
  • Clonic
  • tonic-clonic
  • atonic
• Unclassified epileptic seizure

Question 10

SEIZURES types con.

Answer 10

Aura
* A partial seizure experienced as a peculiar sensation preceding onset of generalized seizure that may take the form of gustatory, visual, or auditory experience or a feeling of dizziness, numbness,
or just “a funny feeling”

Prodroma
* Early clinical manifestations, such as malaise, headache, or sense of depression, that may occur hours to a few days before onset of a seizure

Tonic phase
* State of muscle contraction

Clonic phase
* State of alternating contraction and relaxation of muscles

Postictal phase
* Time period immediately following cessation of seizure activity

Question 11

DATA PROCESSING DEFICITS

Answer 11

• Agnosia
• Dysphasia
• Aphasia

Question 12

Agnosia

Answer 12

Tactile, visual, auditory, etc.

Question 13

Dysphasia

Answer 13

• Expressive dysphasia
  
  • Nonfluent; cannot find words, difficulty writing
  • Occlusion of one or several branches of left middle cerebral
    artery supplying inferior frontal gyrus
    *Receptive dysphasia
  • Fluent; can produce verbal language but it is meaningless, with inappropriate words, similar sounds or meaning substituted for correct words
  • Occlusion of inferior division of left middle cerebral artery
• Transcortical dysphasia
  
  • Ability to repeat and to recite. Speech is fluent but the words make no sense. The individual cannot read or write and has impaired comprehension.
  • Occlusion of left middle cerebral artery of left internal carotid
    artery

Question 14

Aphasia

Answer 14

Inability to communicate (more severe form of dysphasia)

Question 15

ACUTE CONFUSIONAL STATES (ACS)

Answer 15

• Transient disorders of awareness that result from
  cerebral dysfunction
  
  • Secondary to drug intoxication, metabolic disorder, or nervous
    system disease
  • Delirium

Question 16

Delirium

Answer 16

• Hyperkinetic-acute state of brain dysfunction associated with right upper middle temporal gyrus or left temporal occipital junction disruption and several neurotransmitters are involved
• Difficulty in concentrating, restlessness, irritability, insomnia, tremulousness, and poor appetites. Completely inattentive and perceptions are grossly altered in full state.
• Hypokinetic-More likely to be associated with right sided frontal basal ganglion disruption
• Associated with under activity, (fevers or metabolic disorders), or under the influence of depressants. Decrease mental function, specifically alertness, attention span, accurate perception, interpretation of the environment and reaction to the
  environment. Forgetfulness is prominent and the individual
  dozes frequently.

Question 17

DEMENTIA

Answer 17

• Progressive failure of cerebral functions that is not
  caused by an impaired level of consciousness
• Losses:
  – Orientation
  – Memory
  – Language
  – Judgment
  – Decision making

Question 18

ALZHEIMER DISEASE (AD)

Answer 18

• Familial, early and late onset
• Nonhereditary (sporadic, late onset)
  Theories:
• Mutation for encoding amyloid precursor protein
• Alteration in apolipoprotein E
• Loss of neurotransmitter stimulation of choline
  acetyltransferase
• Neurofibrillary tangles
• Senile plaques
• Diagnosis is made by
  ruling out other causes of
  dementia

Question 19

ALZHEIMER DISEASE (AD) Clinical Manifestations

Answer 19

– Forgetfulness
– Emotional upset
– Disorientation
– Confusion
– Lack of concentration
– Decline in abstraction,
problem solving, and
judgment

Question 20

CEREBRAL HEMODYNAMICS

Answer 20

• CBF-Cerebral blood flow
  
  • The brain is normally maintained at ta rate that matches local metabolic needs of the brain
• CPP-Cerebral perfusion pressure (70-90mm hg)
  is the pressure required to perfuse the cells of the
  brain
• CBV-Cerebral blood volume is the amount of blood in the intracranial vault at a give time
• Cerebral oxygenation-is the critical factor and is measured by oxygen saturation in the internal jugular vein

Question 21

INCREASED INTRACRANIAL
PRESSURE (IICP)

Answer 21

• Normal 1to 15 mm Hg
• Caused by an increase in intracranial content
  – Tumor growth, edema, excessive CSF, or hemorrhage
  Stage 1
• Attempt to further decrease IICP
  Stage 2
• Continued expansion of intracranial content. May see episodes of confusion, restlessness, drowsiness, and slight pupillary and breathing changes
  Stage 3
• Brain tissues being to experience hypoxia and hypercapnia, condition rapidly deteriorates.
  Stage 4
• Brain tissue shifts (herniates) form the compartment of greater pressure to a compartment of lesser pressure. Causing further ischemia and hypoxia in the herniating tissues.

Question 22

CEREBRAL EDEMA

Answer 22

• Increase in the fluid (intracellular or extracellular)
  within the brain
• Types:
• Vasogenic
• Cytotoxic
• Interstitial

Question 23

Vasogenic

Answer 23

• The blood brain barrier is disrupted and plasma proteins leak into the extracellular spaces, drawing water to them and increasing the water content of the brain parenchyma.
• Starts in area of injury an spreads

Question 24

Cytotoxic

Answer 24

• Toxic factors directly affect the cellular elements of the brain
  parenchyma, causing failure of the active transport systems
• Cells lose potassium and gain larger amounts of sodium. Water follows by osmosis and the cells swell

Question 25

Interstitial

Answer 25

Seen with noncommunicating hydrocephalus. Caused by transependymal movement of CSF from the ventricles in the extracellular spaces of the brain tissues. Brain fluid volume increases around the ventricles

Question 26

HYDROCEPHALUS

Answer 26

* Excess fluid within the cranial vault, subarachnoid space, or both * Caused by interference in CSF flow * Decreased reabsorption * Increased fluid production * Obstruction within the ventricular system

Question 27

Noncommunicating hydrocephalus

Answer 27

* Internal * Intraventricular * Obstruction iwthin the ventricular system * More common in children

Question 28

Communicating (extraventricular) hydrocephalus

Answer 28

* Defective resorption of CSF * More common in adults

Question 29

Acute hydrocephalus

Answer 29

* Develop in a couple of hours in a person who has sustained head injury

Question 30

Normal-pressure hydrocephalus

Answer 30

* Dilation of the ventricles without increased pressure develops slowly with the individual or family noting declining memory and cognitive function. * Symptoms of an unsteady, broad-based gait with a history of falling; incontinences; and dementia

Question 31

ALTERATIONS IN NEUROMUSCULAR FUNCTION

Answer 31

* Muscle tone * Hypotonia * Decreased muscle tone * Hypertonia * Increased muscle tone * Spasticity * Gegenhalten (paratonia) * attempting to move the limb of a person with paratonia will result in that person involuntarily resisting the movement. * Dystonia * Rigidity

Question 32

ALTERATIONS IN MOVEMENT

Answer 32

Paresis and paralysis * Upper motor neuron syndromes: * Hemiparesis or hemiplegia * Diplegia * Paraparesis or paraplegia * Quadriparesis or quadriplegia * Pyramidal motor syndromes * Spinal shock Lower motor neuron syndromes: * Flaccid paresis or flaccid paralysis * Hyporeflexia or areflexia * Fibrillation * Hyperkinesia * Paroxysmal dyskinesias * Tardive dyskinesia * Huntington disease * Hypokinesia

Question 33

LOWER MOTOR NEURON SYNDROMES

Answer 33

Amyotrophies: * Paralytic poliomyelitis * Nuclear palsies * Guillain-Barré syndrome * Progressive spinal muscular atrophy * Progressive bulbar palsy * Bulbar palsy

Question 34

Hyperkinesia

Answer 34

* Excessive movement * Chorea, wandering, tremor at rest, postural tremor, etc.

Question 35

Huntington disease

Answer 35

* Also known as chorea * Autosomal dominant hereditary degenerative disorder * Severe degeneration of the basal ganglia (caudate nucleus) and frontal cerebral atrophy * Depletion of gamma aminobutyric acid (GABA)

Question 36

Hypokinesia

Answer 36

* Decreased movement * Akinesia * Bradykinesia * Loss of associated movement

Question 37

PARKINSON DISEASE

Answer 37

* Severe degeneration of the basal ganglia (corpus striatum) involving the dopaminergic nigrostriatal pathway * Parkinsonian tremor, rigidity, bradykinesia * Postural disturbances * Autonomic and neuroendocrine symptoms * Cognitive-affective symptoms * Secondary parkinsonism

Question 38

DISORDERS OF POSTURE (STANCE)

Answer 38

* Dystonia * Dystonic postures and movements * Decorticate posture * Decerebrate posture * Basal ganglion posture * Senile posture

Question 39

DISORDERS OF GAIT

Answer 39

* Spastic gait * Scissors gait * Cerebellar gait (ataxic) * Basal ganglion gait * Senile gait (pseudoparkinsonian gait)

Question 40

DISORDERS OF EXPRESSION

Answer 40

* Hypermimesis * Hypomimesis * Dyspraxias and apraxias

Question 41

Hypermimesis

Answer 41

Manifests as pathologic laughter or crying, laughter is associated with right hemisphere injury and crying is associated with left hemisphere injury

Question 42

Hypomimesis

Answer 42

Manifests as the loss of emotional language (aprosody) and is associated with right hemisphere damage

Question 43

Dyspraxias and apraxias

Answer 43

Difficulty in performing tasks requiring motor skills including speaking, writing, using tools or utensils, playing sports, following instructions, and focusing

Question 44

EXTRAPYRAMIDAL MOTOR SYNDROMES

Answer 44

* Basal ganglia motor syndromes * Cerebellar motor syndromes

Question 45

Basal ganglia motor syndromes

Answer 45

* An imbalance of dopaminergic and cholinergic activity in the corpus striatum. * Excess cholinergic activity produces akinesia and hypertonia. * Excess of dopaminergic activity produces hyperkinesia and hypotonia * Example Parkinson and Huntington

Question 46

Cerebellar motor syndromes

Answer 46

* Associated with ataxia and other symptoms affecting coordinated movement * Primarily influence the same side of the body, so that damage to the right cerebellum generally causes symptoms on the right side of the body