NPTE- NEUROANATOMY LEC 2

y

NEUROANATOMY

y

METC

y

Major landmarks, first orientation

y

Major landmarks: The four lobes

y

Primary Areas

y

Divisions of  Primary Motor and Somatic Areas

y

Parieto-occipital sulcus

-

Separates parietal from occipital lobe

* Calcarine sulcus- surounded by visual receptive area y

Blood supply

y

CIRCLE

y

Formed by two internal carotid arteries and 2 ve rtebral arteries at the base of the brain

y

Functions of the Cortex

OF WILLIS

Language

1- Brocas Area   an area of the frontal lobe, usually in the left hemisphere, that directs the m uscle movements involved in speech

2- Wernickes Area   a brain area involved in language comprehension and expression; usually in the left temporal lobe. y

Specialization and Integration in Language

1- Visual cortex  receives written words as visual stimulation. 2- Angular gyrus  transforms visual representations into an auditory code. 3- Wernickes area  interprets auditory code. 4- Brocas area  controls speech muscles via the motor cortex. 5- Motor cortex  word is pronounced. y

Lateralization

Left Hemisphere

Verbal competence Speaking, reading,

thinking & reasoning

Processes info in sequence

One piece of data at a time logical Right Hemisphere

Nonverbal areas Comprehension,

spatial relationships, drawing, music, emotion

Processes info. As a whole

intuitive y

Emotion and Lateralization

Left Hemisphere

y

Important for the

expression of positive emotion

y

Damage to the L.H. leads to loss of the c apacity of joy.

y

Activation in the L.H. leads to tendencies to approach other people.

Right Hemisphere

y

Important for the

expression of negative emotion

y

Damage to the R.H. may make people euphoric.

y

Activation in the R.H. leads to tendencies to withdraw from people.

y

The Homunculus

y

Cerebral Cortex:

Outer layer of neurons (1mm thick) y

The Hind Brain (Rhombencephalon)

y

Medulla  breathing, heart rate

y

Pons  sleeping, walking, dreaming

Left Hemisphere

Verbal competence Speaking, reading,

thinking & reasoning

Processes info in sequence

One piece of data at a time logical Right Hemisphere

Nonverbal areas Comprehension,

spatial relationships, drawing, music, emotion

Processes info. As a whole

intuitive y

Emotion and Lateralization

Left Hemisphere

y

Important for the

expression of positive emotion

y

Damage to the L.H. leads to loss of the c apacity of joy.

y

Activation in the L.H. leads to tendencies to approach other people.

Right Hemisphere

y

Important for the

expression of negative emotion

y

Damage to the R.H. may make people euphoric.

y

Activation in the R.H. leads to tendencies to withdraw from people.

y

The Homunculus

y

Cerebral Cortex:

Outer layer of neurons (1mm thick) y

The Hind Brain (Rhombencephalon)

y

Medulla  breathing, heart rate

y

Pons  sleeping, walking, dreaming

y

Reticular activating system (RAS) y

From stem reticular fibers

y

Modulates consciousness

y

Distributes neuromodulators

  alertness, attention y

Cerebellum 

y

Midbrain / Mesencephalon

y

Extends fr pons to the diencephalon

y

The cerebral aqueduct is its cavity & connects the 3 & 4 ventricles

y

Roof of midbrain called tectum & lies posterior to the cerebral aqueduct

y

Made up of 4 rounded bodies known as Corpora quadrigemina

y

The paired upper bodies serve as visual reflex centers for head & eyeball movements

y

The lower bodies are auditory relay centers

y

The Forebrain ( Prosencephalon)

balance, coordination for the

muscles

rd

th

The Hypothalamus rd

-

Found inferior to the thalamus, forms the floor & part of the lateral walls of 3 ventricle

-

Optic chiasm marks the crossing of the optic nerves

-

Infundibulum connects the pit. gld to the hypothalamus

-

Contains centers for body temp control, appetite & sat iety, & water balance; regulates pituitary gld & links nervous & endocrine systems; helps control autonomic system;

-

It is involved with drives associated with survival such as hunger, thirst, emotion, sex, and reproduction

y

Cerebellum

y

behind the dorsal aspect of the pons and the medulla.

y

A midline portion, the vermis, separates two lateral lobes, or cerebellar hemispheres.

y

consists of the cerebellar cortex & underlying cerebellar white matter 

y

4 deep cerebellar nuclei are located within the white matter of the cerebellum

Because of the location of the fourth ventricle, ventral to the cerebellum, mass lesions or swelling of the

cerebellum can cause obstructive hydrocephalus. y

Cerebellum

A. Paleocerebellum- consists of anterior lobe; controls gross movement of head & body B.

Nepcerebellum- middle lobe; fine voluntary movements

C. Archicerebellum- flocullonodular lobe; vestibular system y

Cerebellar functions (CBP) 1. coordinating skilled voluntary movements by influencing muscle activity, 2. controlling equilibrium and muscle tone through connections with the vestibular system and the spinal cord and its gamma motor neurons. 3. There is a somatotopic organization of body parts within the cere bellar cortex. 4.

In

addition, the cerebellum receives collateral input from the sen sory and special sensory 

systems. y

Damage to the cerebellum

y

Causes a lack of co-ordination: 1. Speaking 2. Walking 3. Tremour

y

Damage can result in ataxic or uncoordinated movement because of errors in the direction,

range, & rate of movement y

Characteristic drunken or staggering gait

y

Speech slurred & theres dysmetria (overshooting)

y

Clinical dxtic test; ask pt to place a finger on his / her own nose.

y

(+) will miss mark & may miss several times before finding the target

y

Cerebellar Stroke

y

Dizziness, vomiting

y

Unsteady so that walking is impossible

y

Power, tone and reflexes normal

y

Area of blood in the cerebellum would show on a CT scan

y

The Nervous System

1. The spinal cord communicates with the sense organs and muscles bel ow the level of the head y

Bell-Magendie Law- entering dorsal roots carry sensory information and the exiting ventral roots carry motor information to the m uscles and glands

y y

Dorsal Root Ganglia- clusters of neurons outside the spinal cord

The Spinal Cord, Spinal

Nerves,

and Spinal Reflexes y

Spinal Cord

y

Extends from foramen magnum to second lumbar vertebra

y

Segmented 1. Cervical 2. Thoracic 3. Lumbar 4. Sacral

y

Gives rise to 31 pairs of spinal nerves

y

Not uniform in diameter throughout length

y

Blood Supply

y

Two posterior spinal arteries- supply the posterior 1/3 of the SC

y

Anterior spinal artery- anterior 2/3 of SC

y

Segmental arteries

y

Feeder arteries

y

CSF



Shock absorbing fluid that fills ventricles, cavities within the brain & subarachnoid spaces around the brain & SC



Most produced by cluster of capillaries known as CHOROI D plexuses (projects fr pia matter into ventricles)

y

Cross Section of Spinal Cord

y

Cross Section of Spinal Cord

y

White matter:

y

Myelinated axons forming nerve tracts

y

Fissure and sulcus

y

Three columns: y

Ventral

y

Dorsal

y

Lateral

y

Gray matter:

y

Neuron cell cell bodies, dendrites, axons

y

Horns:

y

y

Posterior (dorsal)

y

Anterior (ventral)

y

Lateral

Commissures: y

Gray: Central canal

y

White

y

Gray Matter: Organization

y

Dorsal half   sensory roots and ganglia

y

Ventral half   motor roots

y

Dorsal and ventral roots fuse laterally to form spinal nerves

y

Four zones are evident within the gray matter  somatic sensory (SS), visceral sensory (VS),

visceral motor (VM), and somatic motor (SM) y

White Matter in the Spinal Cord

y

Fibers run in three directions  ascending, descending, and transversely

y

Divided into three funiculi (columns)   posterior, lateral, and anterior 

y

Each funiculus contains several fiber tracts y

Fiber tract names reveal their origin and destination

y

Fiber tracts are composed of axons with simi lar functions

y

White Matter in the Spinal Cord

y

Pathways decussate (cross-over)

y

Most consist of two or three neurons

y

Most exhibit somatotopy (precise spatial relationships)

y

Pathways are paired (one on each side of the spinal co rd or brain)

y

W hite Matter:

y

Spinal

y

31 pairs: 8 cervical, 12 thoracic, 5 lumbar, 5 sacral, and 1 coccygeal

Pathway Generalizations

Nerves

- each peripheral nerve has 3 layers of CT y

Epineurium  outer tough fibrous sheath - dense irregular CT, 1° of collagen fibers and fibrocytes - forms the blood-nerve barrier

y

Perineurium  composed of collagenous fibers, elastic fibers, and fibrocytes

- divides the nerve into fascicles (bundle of axons) y

Endoneurium  loose irregular CT - capillaries from the perineurium provide oxygen and nutrients ot the axons and Schwann cells

of the nerve

Anatomy of a Peripheral Nerve

y

Peripheral Distribution of Spinal Nerves

y

Each spinal nerve forms through fusion of dorsal and ventral nerve roots

y

Distally all spinal nerves form 2 branches

- a dorsal ramus and a ventral ramus y

Spinal nerves T1 to L2 contain 4 branches - a dorsal ramus and a ventral ramus - a white ramus and a gray ramus known as rami communicantes ( communicating branches)

y

Rami Communicantes

y

Carry visceral motor fibers to and from a nearby autonomic ganglion associated with the sympathetic division of the ANS

y

White ramus  carries fibers to the ganglion - contains preganglionic myelinated axons

y

Gray ramus  innervate glands and smooth muscles - 2 groups of unmyelinated postganglionic fibers that leave the ganglion

y

Dorsal and Ventral Rami

y

Dorsal ramus provides sensory innervation from, and motor innervation to, a specific segm ent

of the skin and muscles of the neck and back y

Ventral ramus supplies the ventrolateral body surface, structures in the body wall, and the limbs

y

Distribution of sensory fibers within these rami illustrates the segmental division of labor

- each pair of spinal nerves monitors a specific region of the body surface known as a dermatome Peripheral Distribution of Spinal Nerves (Motor Fibers)

Peripheral Distribution of Spinal Nerves (Sensory Fibers) y

Dermatomal Map

y

Skin area supplied with sensory innervation by spinal nerves

y

Dermatomes

y

Area of skin innervated by the cutaneous branches of a single spinal nerve.

y

All segments except C1 have dermotomal distribution

y

UE typically from C5-T1

y

LE typically

y

Clinically important -damage to a spinal nerve or dorsal root ganglion produces a loss of 

from L1-S1

sensation y

Sensory Nerve Tracts

y

Transmit action potentials from periphery to brain

y

Each pathway involved with specific modalities

y

1 half of word indicates origin,

y

2nd half indicates termination

y

Pain

y

Types

st

y

Referred:

y

Phantom: Occurs in people who have appendage amputated or structure removed as

Sensation in one region of body that is not source of stimulus

tooth y y

Chronic:

Not a response to immediate direct tissue injury

Peripheral Nervous System (PNS)

y

All nerves that leave the CNS

y

Two Modalities:

y

Peripheral Nervous System

y

Sensory Nerves

(to the brain) Carry messages from special reporters in the skin, muscles, and other internal and external sense organs to the spinal cord and then to the brain

y

Motor Nerves

(from the brain) Carry orders from CNS to muscles, glands to contract and produce chemical messengers y

Peripheral Nervous System

y

Somatic

NS

Consists of nerves connected to sensory receptors and skeletal muscles Permits voluntary action (writing your name) y

Autonomic NS

Permits the involuntary functioning of blood vessels, glands, and internal organs such as the bladder,

stomach and heart y

Summary of Function of Cranial Nerves

y

Cranial Nerve I:

y

Arises from the olfactory epithelium

y

Passes through the cribriform plate of the ethmoid bone

y

Fibers run through the olfactory bulb and terminate in the primary olfactory cortex

y

Functions solely by carrying afferent impulses for the sense of smell

y

Cranial Nerve I:

y

Cranial Nerve II: Optic

y

Arises from the retina of the eye

y

Optic nerves pass through the optic canals and converge at the optic chiasm

y

They continue to the thalamus where they synapse

y

From there, the optic radiation fibers run to the visual cortex

y

Functions solely by carrying afferent impulses for vision

y

Cranial Nerve II:

y

Cranial Nerve III: Oculomotor

Olf actory

Olf actory

Optic

y

Fibers extend from the ventral midbrain, pass through the superior orbital fissure, and go to the

extrinsic eye muscles y

Functions in raising the eyelid, directing the eyeball, constricting the iris, and controlling lens

shape y

The latter 2 functions are parasympathetically controlled

y

Parasympathetic cell bodies are in the ciliary ganglia

y

Cranial Nerve III: Oculomotor

y

Cranial Nerve IV: Trochlear

y

Fibers emerge from the dorsal midbrain and enter the orbits via the superior orbital fissures;

innervate the superior oblique muscle y

Primarily a motor nerve that directs the eyeball

y

Cranial Nerve IV: Trochlear

y

Cranial Nerve V: Trigeminal

y

Composed of three divisions

y

y

Ophthalmic (V1)

y

Maxillary (V2)

y

Mandibular (V3)

Fibers run from the face to the pons via the superior orbital fissure (V1), the foramen rotundum

(V2), and the foramen ovale (V3) y

Conveys sensory impulses from various areas of the face (V 1) and (V2), and supplies motor fibers (V3) for mastication

y

T ic douloureux or trigeminal

neuralgia

- Most excruciating pain known (?) - Caused by inflammation of nerve - In severe cases, nerve is cut; relieves agony but results in loss face y

Cranial Nerve

V: Trigeminal

y

Cranial Nerve

VI: Abducens

of sensation on that side of the

y

Fibers leave the inferior pons and enter the orbit vi a the superior orbital fissure

y

Primarily a motor nerve innervating the lateral r ectus muscle (abducts the eye; thus the name

abducens) y

Cranial Nerve

VII: Facial

y

Fibers leave the pons, travel through the internal acou stic meatus, and emerge through the

stylomastoid foramen to the lateral aspect of the face y

Motor functions include; y

Facial expression

y

Transmittal of parasympathetic impulses to lacrimal and salivary glands (submandibular and sublingual glands)

y

Sensory function is taste from taste buds of anterior two-thirds of the tongue

y

Cranial Nerve

y

Facial Nerve (CN VII)

VII: Facial

pal sy : paralysis of facial muscles on affected side and loss of taste sensation



Bell s



Caused by herpes simplex I virus



Lower eyelid droops



Corner of mouth sags



Tears drip continuously and eye cannot be completely closed (dry eye may occur)



Condition my disappear spontaneously without treatment

y

Cranial Nerve

VIII: Vestibulocochlear

y

Fibers arise from the hearing and equilibrium apparatus of the inner ear, pass through the

internal acoustic meatus, and enter the brainstem at the pons-medulla border y

Two divisions  cochlear (heari ng) and vestibular (balance)

y

Functions are solely sensory  equilibrium and hearing

y

Cranial Nerve

y

Cranial Nerve IX:

y

Fibers emerge from the medulla, leave the skull via the jugular foramen, and run to the throat

VIII: Vestibulocochlear Glossopharyngeal

y

Nerve IX is a mixed nerve with motor and sensory functions

y

Motor  innervates part of the tongue and pharynx, and provides motor fibers to the parotid salivary gland

y

Sensory  fibers conduct taste and general sensory impulses from the tongue and pharynx

y

Cranial Nerve IX:

y

Cranial Nerve X:

y

T he only cranial nerve that extend s

y

Fibers emerge from the medulla via the jugular foramen

y

The vagus is a mixed nerve

y

Most motor fibers are parasympathetic fibers to the heart, lungs, and visceral organs

y

Its sensory function is in taste

y

Paralysis leads to hoarseness

y

Total destruction incompatible with life

y

Cranial Nerve X:

Glossopharyngeal

Vagus beyond the head and neck 

Vagus y

Cranial Nerve XI: Accessory

y

Formed from a cranial root emerging from the medulla and a spinal root arising from the

superior region of the spinal cord y

The spinal root passes upward into the cranium via the foramen m agnum

y

The accessory nerve leaves the cranium via the jugular foramen

y

Primarily a motor nerve y

Supplies fibers to the larynx, pharynx, and soft palate

y

Innervates the trapezius and sternocleidomastoid, which move the head and neck

y

Cranial Nerve XI: Accessory

y

Cranial Nerve XII: Hypoglossal

y

Fibers arise from the medulla and exit the skull via the hypoglossal canal

y

Innervates both extrinsic and intrinsic muscles of the t ongue, which contribute to swallowing and speech

y

If damaged, difficulties in speech and swallowing; inability to protrude tongue

y

Cranial Nerve XII:

Hypoglossal

y

Peripheral Distribution of Spinal Nerves

y

Each spinal nerve connects to the spinal cord via tw o medial roots

y

Each root forms a series of rootlets tha t attach to the spinal cord

y

V entral root s

y

Dor sal

ari se from the anterior horn and contain motor (efferent) fibers

root s ari se from sensory neurons in the dor sal root ganglion and contain sensory

(afferent) fibers y

Spinal

Nerves: Rami

y

The short spinal nerves branch into three or four mixed, distal rami y

Small dorsal ramus  to back

y

Larger ventral ramus  to plexuses/intercostals

y

Tiny meningeal branch  to meninges

y

Rami communicantes at the base of the ventral rami in the thoracic region  to/from ANS

y

Spinal

Nerve Innervation:

Back, Anterolateral Thorax, and Abdominal Wall y

The back is innervated by dor sal rami via several branches

y

The thorax is innervated by ventral rami T 1-T12 as intercostal nerves

y

Intercostal nerves supply muscles of the ribs, anterolateral thorax, and abdominal wall

y

Nerve Plexus

y

Complex interwoven network of nerves

y

Occurs in segments that control skeletal musculature of the neck and limbs - peripheral distribution of the ventral rami do not directly proceed to their peripheral targets

y

Ventral rami of adjacent spinal nerves blend their fibers to produce compound nerve trunks

- formed during development when small skeletal muscles fuse to form larger muscles with compound origins - compound muscles contain sensory and motor fibers - ventral rami converge and branch to form compound nerves 4 Ma jor Ner ve Plexuses y

Cervical

plexus

y

Brachial plexus

y

Lumbar plexus

y

Sacral plexus

y

Cervical

Plexus

y

Consists of cutaneous and muscular branches in the ventral rami of spinal nerv es C1-C4, some C5

y

The cutaneous branches innervate areas on the head, neck, and chest

y

The muscular branches innervate muscles of the neck and shoulder

y

Major nerve of this plexus the phrenic nerve provides the entire nerve supply to the diaphragm

Cervical

Plexus

y

Brachial Plexus

y

Formed by C5-C8 and T1 (C4 and T2 may also contribute to this plexus)

y

It gives rise to the nerves that innervate the upper limb

y

Trunks and Cords of Brachial Plexus



Nerves that form brachial plexus originate from:

y

 ±

superior, middle, and inferior trunks

 ±

large bundles of axons from several spinal nerves

 ±

lateral, medial, and posterior cords

 ±

smaller branches that originate at trunks

Brachial Plexus: Nerves

y

 A xillary  

innervates the deltoid and teres minor

y

Musculocutaneous  sends fibers to the biceps brachii and brachialis

y

Median  branches to most of the flexor muscles of forearm

y

U lnar 

y

Radial  

supplies the flexor carpi ulnaris and part of the flexor digitorum profundus innervates essentially all extensor muscles

The Trunks and Cords of the Br achial Plexus y

Brachial Plexus Organization

y

Flow chart summarizing relationships within the brachial plexus - dashed lines to the posterior cord merely indicate that the posterior division lie posterior to the anterior divisions

y

Lumbar

Plexus

y

Arises from (T12) L1-L4 and innervates the thigh, abdominal wall, and psoas muscle

y

The major nerves are the femoral and the obturator 

y

Sacral

y

Arises from L4-S4 and serves the buttock, lower limb, pelvic structures, and the per ineum

y

The major nerve is the sciatic , the longest and thickest nerve of the body

y

The sciatic is actually composed of two nerves: the tibial and the common fibular (peroneal)

Plexus

nerves y

Nerve plexuses - Summary

y

Cervical

y y

Phrenic nerve

Brachial  C5  T1 (roots/trunks/divisions/cords) y

y

Axillary, MC, median, ulnar, radial

Lumbar

y y

 C1-C4

Sacral

y

 L1-L4 Femoral, obturator

 L4-S4 Sciatic (common peroneal/tibial), pudendal

y

Reflexes

y

A reflex is an immediate involuntary response to a specific stimulus

y

The neural writing of a single reflex is referred to as a reflex arc

Reflexes

are classified according to :

1. Their development (innate and acquired) 2. The site where information processing occurs (spinal and cranial) 3. The nature of resulting motor response (somatic and visceral or autonomic) 4. The complexity of the neural circuit (monosynaptic and polysynaptic) Neural Organization- Monosynaptic and Polysynaptic Reflexes y

5

Patterns of Neural Circuits in Neuronal Pools

1. Divergence: y

2.

spreads stimulation to many neurons or neuronal pools in CNS

Convergence:

y

brings input from many sources to single neuron

Patterns of Neural Circuits in Neuronal Pools

y

5

3.

Serial processing:

y

moves information in single line

y

Parallel processing:

y

moves same information along seve ral paths simultaneously

Patterns of Neural Circuits in Neuronal Pools

y

5

5.

Reverberation:

y

positive feedback mechanism

y

functions until inhibited

y

Reflex

activity

y

5 components of a reflex arc

y

Receptor

y

Sensory neuron

y

Integration center (CNS)

y

Motor neuron

y

Effector

y

Spinal Reflexes

y

Range in increasing order of complexity: y

monosynaptic reflexes

y

polysynaptic reflexes

y

intersegmental reflex arcs: y

many segments interact

y

produce highly variable motor response

y

Monosynaptic Reflexes

y

Have least delay between sensory input and motor output: y

e.g., stretch reflex (such as patellar reflex)

y

Completed in 2040 msec

y

Muscle Spindles

y

The receptors in stretch reflexes

y

Bundles of small, specialized intrafusal muscle fibers: y

y

innervated by sensory and motor neurons

Surrounded by extrafusal muscle fibers: y

which maintain tone and contract muscle

y

Postural Reflexes

y

Postural reflexes: y

stretch reflexes

y y

maintain normal upright posture

Stretched muscle responds by contracting: y

automatically maintain balance

y

Polysynaptic Reflexes

y

More complicated than monosynaptic reflexes

y

Interneurons control more than 1 muscle group

y

Produce either EPSPs or IPSPs

y

The Tendon Reflex

y

Prevents skeletal muscles from: y

developing too much tension

y

tearing or breaking tendons

y

Sensory receptors unlike muscle spindles or proprioceptors

y

Withdrawal Reflexes

y

Move body part away from stimulus (pain or pressure): y

e.g., flexor reflex: y

y

pulls hand away from hot stove

Strength and extent of response: y

depends on intensity and location of stimulus

y

Reciprocal Inhibition

y

For flexor reflex to work: y

the stretch reflex of antagoni stic (extensor) muscle must be inhibited (reciprocal inhibition) by interneurons in spinal cord

y

Crossed Extensor Reflexes

y

Occur simultaneously, coordinated with flexor reflex

y

e.g., flexor reflex causes leg to pull up:

y

crossed extensor reflex straightens other leg

y

to receive body weight

y

maintained by reverberating circuits

y

Integration and Control of Spinal Reflexes

y

Though reflex behaviors are automatic: y

processing centers in brain can facilitate or inhibit reflex motor patterns based in spinal cord

y

Higher centers of brain incorporate lower, reflexive motor patterns

y

Automatic reflexes: y

can be activated by brain as needed

y

use few nerve impulses to control complex motor functions

y

walking, running, jumping

y

Superficial reflexes

y

Stroking of the skin elicits muscle contraction y

y

Plantar reflex (L4-S2)Babinski is normal in infants y

y

Involves functional upper motor pathways as well as cord level reflex arcs

Usually indicative of CNS damage in adults

Abdominal reflex (T8-T12) y

Absent with corticospinal lesion

y

Spinal Reflexes

y

Spinal Reflexes

y

Spinal Reflexes

y

Spinal Reflexes

y

Spinal Reflexes

y

Spinal

y

Diseases Affecting the Motor System

Motor Programs

y

Spinal Cord Trauma: Transection

y

Cross sectioning of the spinal cord at any level results in total motor and sensory loss in regions inferior to the cut

y

Paraplegia  transection between T1 and L1

y

Q uadriplegia  transection in the cervical region

y

THE NEUROLOGICAL EXAMINATION

y

NEUROLOGICAL EXAM

y

MENTAL STATUS

y

CRANIAL NERVES

y

MOTOR EXAM y

STRENGTH

y

GAIT

y

CEREBELLAR

y

REFLEXES

y

SENSATION

y

MENTAL STATUS

y

Level

y

Awake and alert

y

Agitated

y

Lethargic y

of Consciousness

Arousable with

y

Comatose

y

LANGUAGE

y

Voice

y

Gentle stimulation

y

Painful/vigorous stimulation

y

FLUENCY

y

NAMING

y

REPETITION

y

READING

y

WRITING

y

COMPREHENSION

Aphasia vs. dysarthria y

MEMORY

y

IMMEDIATE

y

REALLY A

MEASURE OF ATTENTION RATHER THAN MEMORY

y

REMOTE

y

3 OBJECTS AT 0/3/5 MINUTES

y

HISTORICAL EVENTS

y

PERSONAL EVENTS

y

ORIENTATION

y

PERSON y

NOT WHO THEY ARE BUT WHO YOU ARE

y

PLACE

y

TIME

y

OTHER COGNITIVE FUNCTIONS

y

CALCULATION

y

ABSTRACTION

y

SIMILARITIES/DIFFERENCES

y

JUDGEMENT

y

PERSONALITY/BEHAVIOR

y

CRANIAL NERVES

y

CRANIAL NERVE EXAM

y

I

y

y

- OLFACTORY

II

y

DONT USE A NOXIOUS STIMULUS

y

COFFEE, LEMON EXTRACT

- OPTIC y

VISUAL ACUITY

y

VISUAL FIELDS

y

FUNDOSCOPIC EXAM

y

CRANIAL

III/IV/VI OCULMOTOR, TROCHLEAR,

y

PUPILLARY RESPONSE

y

EYE MOVEMENTS

y

OBSERVE LIDS FOR PTOSIS

V - TRIGEMINAL y

MOTOR - JAW STRENGTH

y

SENS

- ALL 3 DIVISIONS

y

CRANIAL NERVES

y

VII - FACIAL

y

ABDUCENS

9 CARDINAL POSITIONS

y

y

NERVE EXAM

y

OBSERVE FOR FACIAL ASYMMETRY

y

FOREHEAD WRINKLING, EYELID CLOSURE, WHISTLE/PUCKER

VIII - VESTIBULAR y

ACUITY

y

RINNE,

WEBER

y y

IX/X

y

XI

NERVES

- GLOSSOPHARYNGEAL, VAGUS

y y

CRANIAL

GAG

- SPINAL ACCESSORY

XII -

y

STERNOCLEIDOMASTOID

y

TRAPEZIUS MUSCLE

M.

HYPOGLOSSAL y

TONGUE STRENGTH

y

RIGHT XII THRUSTS TONGUE TO LEFT

y

MOTOR EXAMINATION

y

STRENGTH

y

STRENGTH

y

GRADED 0 - 5

y

0 - NO MOVEMENT

y

1 - FLICKER

y

2 - MOVEMENT WITH GRAVITY REMOVED

y

3 - MOVEMENT AGAINST GRAVITY

y

4 - MOVEMENT AGAINST RESISTANCE

y

5

- NORMAL STRENGTH

y

STRENGTH EXAM

y

UPPER AND LOWER EXTREMITIES

y

DISTAL AND PROXIMAL MUSCLES

y

GRIP STRENGTH IS A POOR SCREENING TOOL FOR STRENGTH

y

SUBTLE WEAKNESS

y

TOE WALK, HEEL WALK

y

OUT OF CHAIR

y

DEEP KNEE BEND

y

Motor exam, cont

y

Subtle

signs of weakness on a cortical/subcortical basis

y

Pronator drift

y

Orbiting

y

Gait evaluation

y

Include

y

Examples of abnormal

walking and turning

y

High steppage

y

Waddling

y

Hemiparetic

y

Shuffling

y

Turns en bloc

gait

y

MUSCLE OBSERVATION

y

ATROPHY

y

FASCIULATIONS

y

ABNORMAL MOVEMENTS

y

TREMOR y

REST

y

WITH ARMS OUTSTRETCHED

y

INTENTION

y

CHOREA

y

ATHETOSIS

y

ABNORMAL POSTURES

y

CEREBELLAR

FUNCTION

y

RAPID

y

FINGER TO FINGER TO NOSE TESTING

y

HEEL TO SHIN

y

GAIT

ALTERNATING MOVEMENTS

y

TANDEM

y

Romberg Sign

y

Stand with feet together - assure patient stable - have them close eyes

y

Romberg is positive if they do worse with eyes closed

y

Measures y

Cerebellar function y

y

Frequently poor balance with eyes open and closed

Proprioception y

Frequently do worse with eyes closed

y

Vestibular system

y

REFLEXES

y

MUSCLE STRETCH REFLEXES (DEEP TENDON REFLEXES)

y

GRADED 0 - 5

y

y

0 - ABSENT

y

1 - PRESENT WITH REINFORCEMENT

y

2 - NORMAL

y

3 - ENHANCED

y

4 - UNSUSTAINED CLONUS

y

5

- SUSTAINED CLONUS

MSR / DTR

y

BICEPS

y

BRACHIORADIALIS

y

TRICEPS

y

KNEE

y

ANKLE

y

OTHER REFLEXES

y

Upper motor neuron dysfunction y

y

BABINSKI y

present or absent

y

toes downgoing/ flexor plantar response

y

HOFMANS

y

JAW JERK

Frontal release signs y

GRASP

y

SNOUT

y

SUCK

y

PALMOMENTAL

y

TONE

y

INCREASED, DECREASED,

y

COGWHEELING

y

CLASP KNIFE

y

SENSORY EXAM

y

SENSORY EXAM

y

VIBRATION y

NORMAL

128 hz tuning fork

y

JOINT POSITION SENSE

y

PIN PRICK

y

TEMPERATURE

Start

distally and move proximally

y

HIGHER CORTICAL SENSATIONS

y

GRAPHESTHESIA

y

STEREOGNOSIS

y

DOUBLE SIMULTANEOUS STIMULATION

y

BAROSTHESIA

y

TEXTURES

y

Glasgow Coma Scale:

What is it? y

Developed by neurosurgeons in 1974

y

Q uantifies level of consciousness y

 Acute

brain damage: traumatic and/or vascular injuries

or infections y

Metabolic disorders :

hepatic or renal failure, hypoglycemia, diabetic ketosis, toxic

ingestion y

Assess initial level of consciousness

y

Assess changes in level of consciousness

y

Helps guide treatment and predict outcome

y

Glasgow scoring

y

Verbal response in children

y

Posturing

y

Decorticate y

Upper extremity flexion with lower extremity extension

y y

y

Mesencephalic region or corticospinal tract damage

Decerebrate y

Upper and lower extremity extension

y

Brainstem damage below the red nucleus

Progressive y

Uncal or tonsilar herniation

y

Stimulation

y

Eye opening y

y

Verbal response y

y

Name spoken loudly

Person, place, time

Motor response y

Fingernail bed pressure

y

Supraorbital pressure y

y

Sternal rub

y

Glasgow score

y

Score range

y

y

Hand crosses midline and above clavicle

y

Extubated:

y

Intubated:

3  15 3  11T

Clinical presentation y

Normal:

GCS = 15

y

Comatose:

GCS  8

y

Dead:

Grading of head injury

GCS = 3

y

y

Minor:

y

Moderate:

y

Severe:

GCS 9  12 GCS  8

Example report y

GCS 9 = E2 V4 M3 at 07:35

y

Prognosis

y

Prognosis variability

y

Past medical history y

y

GCS  13

Age, previous neurological problems

Injury y

Type and location, depth, duration of coma, presence of low blood pressure, oxyg en levels

after the injury y

Current findings y

Physical examinations, radiological studies of 

the brain y

Clinical correlate (revisited)

y

The patients eyes, initially closed, opened to the sound of his name.

y

y

y

Eye opening

y

3

When asked where he was, the patient said my shoes to change. y

Verbal response

y

3

The patient moved all of his fingers and toes when prompted. y

Motor response

y

6