Clinical Neurology Exam 2 - Cumulative (Tests 1 and 2)

Multiple Sclerosis:

A chronic disease of the central nervous system marked by damage to the myelin sheath. Plaques occur in the brain and spinal cord causing tremor, weakness, incoordination, paresthesia, and disturbances in vision and speech. Can often be indistinguishable from spinal cord compression and progressive cervical myelopathy and needs to have an MRI to distinguish

Which of the sensory neuron fiber types is the fastest?

A-Alpha (largest fiber diameter and myelinated)

Bilateral facial nerve palsy can be caused by: A. Guillain-Barre syndrome B. Streptococcus bacterium C. Clostridium botulinum D. Herpes-zoster infection

A. Guillain-Barre syndrome

Components of the social history section of a complete patient history includes: A. Retired accountant B. Surgeries C. Drinks 4 cups coffee/day D. Allergies include cat and eggs E. Current on all vaccinations

A. Retired accountant C. Drinks 4 cups coffee/day

Dysethesia:

Abnormal or unpleasant sensation

The neurotransmitter released in the Edinger-Westphal nucleus is:

Acetylcholine

Spinal Muscular Atrophy (SMA):

Affects LMN only. A neuromuscular disease characterized by degeneration of motor neurons resulting in progressive muscular atrophy and severe weakness.

Primary Lateral Sclerosis (PLS):

Affects UMN only. A type of motor neuron disease that causes muscle nerve cells to slowly break down overtime causing extreme weakness

Lesions of the cervical spine cause what type of sensory distribution dysfunction?

An electricity-like sensation running down the back and into the extremities upon neck flexion (Myelopathy; Lhermittes sign)

Which of the following are appropriate DDx for clonus being present in the LE? A. Radiculopathy B. Peripheral Nerve lesion C. Cervical myelopathy D. Thoracic myelopathy E. Lumbar myelopathy F. Primary Sensory Cortex G. Primary Motor Cortex

C. Cervical myelopathy D. Thoracic myelopathy G. Primary Motor Cortex Clonus present - think L1 or higher Can't be first two b/c those both produce LMN weakness

During your fundoscopic exam you notice diminished to almost absence of the Red Reflex on that pt's left eye. Which items would help explain this observation? A. CN II lesion B. Chronic hypertension C. Corneal opacity D. CN III lesion E. None of the above

C. Corneal opacity

Which 2 tests are used to access the Trigeminal Nerve (CN V)? A. Able to smile, frown, show their teeth, raise their eyebrows, puff out cheeks B. Hearing test C. Jaw jerk test D. Swallowing E. Corneal reflex

C. Jaw jerk E. Corneal reflex

An 81 year old right-handed M came to the ER d/t right arm numbness and mild language difficulties. His history includes hypertension, DM, and angina. He suddenly became confused and had difficulty combining words properly. He also complained that he could not feel things with his right arm and it felt numb. He had a vague blurring of vision. Mental status was fluent, but occasional paraphasic errors where he substituted letters in words incorrectly. Mild right pronator drift. Diminished bilateral UE pulses and complete loss of bilateral LE pulse sensation. Graphesthesia and stereognosis normal in left hand, absent in right hand. What is the most likely diagnosis? A. Transverse cord lesion B. Right MCA infarct C. Left MCA infarct D. Bilateral medial frontal lesion

C. Left MCA infarct Language affected means the lesion has hit the patient's cortex. It's a left infarct b/c of his right sided effects.

Tic Douloureux is a name describing a pathology in which cranial nerve?

CN V (trigeminal neuralgia)

The typical progression of involvement and symptom presentation in the patient's nervous system for a Cerebellopontine Angle tumor is?

CN VIII --> CN VII --> CN V --> Cerebellum

Cranial Nerves:

CNI - Olfactory CN II - Optic CN III - Oculomotor CN IV - Trochlear CN V - Trigeminal CN VI - Abducens CN VII - Facial CN VIII - Vestibulocochlear CN IX - Glossopharyngeal CN X - Vagus CN XI - Spinal Accessory CN XII - Hypoglossal

Motor pathways can be distinctly categorized within the CNS and PNS by labeling them as?

CNS --> Tracts PNS --> Nerves

A lesion at the optic tract will produce what visual defect?

Contralateral homonymous hemianopia

You have been asked to examine a patient with an internuclear opthalmoplegia (INO). Given this Dx, a positive finding in which of the following examinations will help you confirm? A. End stage nystagmus assessment B. Palate elevation assessment C. Ptsosis assessment D. Horizontal (R to L and L to R) field of gaze E. Convergence assessment

D. Horizontal (R to L and L to R) field of gaze E. Convergence assessment

Patient presents with acute onset of right scapular pain. You immediately wonder if there is a referred gall bladder pattern. During the history, the pt informs you that she had her gallbladder excised 5 years ago. In which history section should the gallbladder excision be recorded? A. HPI (history of present illness) B. ROS (review of systems) C. Social history D. Past medical history E. Family history

D. Past medical history

A 24 y/o M was drinking heavily whenever he fell from a second-story balcony and immediately noticed complete loss of movement and sensation in his legs. In the ER, he had flaccid tone, 0/5 strength bilateral LE, decreased rectal tone, absent bulbocavernosus reflex, and bilateral T10 sensory level to pinprick, touch, vibration, and joint position sense. What is the most likely diagnosis? A. Left MCA infarct B. Right MCA infarct C. Bilateral medial frontal lesion D. Spinal cord compression

D. Spinal cord compression (myelopathy)

What are Dorsal Root Ganglia and what are they responsible for?

DRGs are sensory neuron cell bodies. Each DRG has a stem axon that bifurcates, resulting in one long sensory message being carried from the periphery and into the spinal cord via a dorsal nerve root.

Hypesthesia:

Decreased pain sensitivity to normally painful stimuli

The most common cause of spinal cord dysfunction:

Degenerative disease, trauma, and metastatic cancer

Intermediate hemispheres of the cerebellum are involved with what:

Distal limb coordination

Smaller diameter and unmyelinated axons carrying information about pain and temperature also enter the spinal cord via what entry zone:

Dorsal root

Pt presents with contralateral homonymous hemaniopsia that spares the macula (central vision). Where do you expect to find the lesion?

Meyer's loop

Acute Transverse Myelitis (ATM):

Most difficult to diagnose of spinal cord de-myelination. Identical to acute cord transection symptomalogy, occurs within 3 days and usually happens in mid-thoracic cord which produces a band of pain around the best which mimics intrathoracic or cardiac disease. *emergency*

The lateral hemispheres of the cerebellum are involved with what:

Motor planning for all extremities

Name the Motor/Descending pathways and name the Sensory/Ascending pathways:

Motor/Descending: - Pyramidal tracts 1. Lateral corticospinal 2. Anterior corticospinal - Extrapyramidal tracts 1. Rubrospinal 2. Reticulospinal 3. Olivospinal 4. Vestibulospinal Sensory/Ascending: - Dorsal column-medial lemniscus 1. Fasiculus gracilis 2. Fasiculus cuneatus - Spinocerebellar 1. Anterior spinocerebellar 2. Posterior spinocerebellar - Anterolateral system 1. Anterior spinothalamic 2. Posterior spinothalamic

Neurogenic claudication vs. Vascular Claudication:

Neurogenic: posture-dependent pain. Occurs d/t spinal canal stenosis causing pressure on spinal nerves Vascular: exertionally-dependent pain. Results from blood flow that cannot match the increased demand. Typically caused by peripheral artery disease (PAD) Use bicycle test for differentiation! flexing forward = reduction in pain = stenosis flexing forward = pain = pad

Dix-Hallpike maneuver is best used to diagnose: A. Cerebellar deficiency B. Syncope C. Vestibular neuritis D. Meniere's disease E. None of the above

E. None of the above

In early stages, the reflexes below the level of the lesion are:

Enhanced

Hyperpathia/Hyperalgesia:

Enhanced pain to normally painful stimuli

The best way to examine the presence of atrophy and fasiculations of the tongue is to examine the tongue by:

Having the tongue remain at rest with mouth open and use a light pen

Brown Sequard syndrome:

Hemi-section / damage to half of the spinal cord - ipsilateral (same side) spastic paralysis and loss of position sense - contralateral (opposite side) loss of pain and thermal sense

Most common worldwide infectious cause of trigeminal neuralgia is:

Herpes-Zoster virus (shingles)

Cervical myelopathy is most often found in the lumbar and cervical regions. Why?

Hypermobility in those areas = loss of structure = easy degeneration and area susceptibility

Cranial nerve VII (Facial) is derived from the ___________ brachial arch:

I (first)

Transverse myelitis:

Inflammation of the spinal cord Patients usually present with symptoms that develop quickly, over hours or days

A lesion at the optic nerve will result in what visual defect?

Ipsilateral complete blindness

Pyramidal tracts (Corticospinal tracts/Voluntary):

Anterior Corticospinal and Lateral Corticospinal Anterior - voluntary movement of contralateral limbs Lateral - voluntary movement of trunk, neck and shoulders

The spinothalamic tract is responsible for what forms of sensation?

Itch, Tickle, Pain, Temperature, Crude touch

What four sensations fall under Proprioception?

Joint position sense, Kinesthesia (movement), Sense of Force (effort/tension/heaviness), and Sense of Change in Velocity

What is the Spinoreticular tract primarily responsible for?

Known as the "older pain" pathway responsible for conveying the emotional and arousal aspects of pain.

Central cord syndrome (large lesion):

Loss of all motor and sensory function in body except for genital area and face "sacral sparring" -nothing can cross when entire cord is affected

Posterior cord syndrome:

Loss of dorsal columns bilaterally, bilateral loss of proprioception, vibration, pressure, stereognosis, 2 point discrimination; preservation of motor function, pain and light touch; very rare

Central cord syndrome (small lesion):

Loss of pain and temperature in UE Cape-like distribution

The facial nerve nucleus is located in the:

Medulla

A 71 y/o F presents with mild unsteady gait and bilateral leg stiffness. Her left leg gradually became weaker meanwhile, her right leg developed progressive numbness and tingling and she had intermittent left-sided thoracic back pain. She had increased urinary frequency with occasional incontinence and difficulty completing bowel movements. Upon rectal exam, it was noted that she was unable to voluntarily contract her anal sphincter. Increased tone in left leg. Pinpick sensation decreased on the right side below umbilicus. Vibration and joint position sense decreased in the left foot and leg. What is the most likely diagnosis? Choose all that apply. A. UMNL B. LMNL C. Brown Sequard syndrome D. Thoracic tumor E. Transverse cord lesion

B. LMNL C. Brown Sequard syndrome D. Thoracic tumor

You are performing H in space and every time the pt's eyes are pursuing your index finger from their right eye to their left, you noticed the left eye does not abduct, the right eye adducts normally. You also observe consistent normal eye movements when the pt pusuits from their left to their right eye. You now suspect the pt is having: A. Left SO mm palsy B. Left LR mm palsy C. Left IO mm palsy D. Left IR mm palsy

B. Left lateral rectus mm muscle

60 y/o pt presents with bilateral lower leg numbness and pain, insidious onset 12 years ago. For the last 1 year, bilateral hand numbness and tingling. Family hx is positive for DM; you are suspecting her sx may be due to diabetes. Which of the following tests will most likely have a positive finding if the patient had untreated, progressive chronic disease? A. Dix-Hallpike B. Lower extremity sensory exam C. Blood work - elevated ESR D. Head Impulse Test E. Lower extremity dermatological exam F. Fundoscopic exam

B. Lower extremity sensory exam C. Blood work F. Fundoscopic exam

During an extraocular muscle exam, you ask the pt to look as follows: Fully to their right (R eye abducted, L eye adducted) and then fully look up (both eyes towards ceiling) You notice that the left eye fails to elevate and the right eye fully elevates. All other extraocular movements are normal. From this information, you conclude the affected muscle is: A. Rectus femorus B. Superior oblique C. Inferior rectus D. Superior rectus E. Inferior oblique

B. Superior oblique

CN I (olfactory) is a derivative of the: A. Myelencephalon B. Telencephalon C. Diencephalon E. Mesencephalon F. Metencephalon

B. Telencephalon

A lesion at the optic chiasm will produce what visual defect?

Bitemporal hemianopia

Pt presents with a severe and chronic right CN XII LMNL. Which findings will most likely be note during exam?

On protrusion, tongue deviates; on observation, there is tongue atrophy; tongue muscle weakness is noted when pushing against cheek

What is the Spinomesencephalic tract primarily responsible for?

Pain modulation. Projects to the midbrain perioaqueductal gray matter and superior colliculi.

Lesions of peripheral nerves cause what type of sensory distribution dysfunction?

Pain, numbness, tingling

Allodynia:

Painful sensations provoked by non-painful stimuli

In addition to sensory loss, lesions of the somatosensory pathways can cause abnormal positive sensory phenomena called:

Paresthesias

Somatosensory tests are associated with what lobe of the brain?

Parietal lobe

What are some distinct differences between the Posterior Column-Medial Lemniscal pathway and the Anterolateral Pathway?

Posterior Column-Medial Lemniscal: - Ascends up entire SC until it hits the caudal medulla - stays medial through brainstem, crossing over last Anterorlateral Pathway: - crosses over immediately* - stays lateral in brainstem - Syringomyelia or other obstruction can often block and cause impairment

Match the following: Primary motor cortex Vision Memory/hearing Temporal Parietal Occiput

Primary motor cortex --> Parietal Lobe Vision --> Occiput Temporal --> Memory/hearing

Most common form of spinal cord compression:

Progressive Cervical Myelopathy - ages 30 and 70 - years to develop - coexists with degenerative spondylosis - hallmark wasting away and weakness - all reflexes are brisk (+) and both plantar responses are in extension

Amyotrophic Lateral Sclerosis (ALS) (Lou Gehrig's Disease):

Progressive degeneration of BOTH upper and lower motor neurons. Eventually causes death via respiratory failure. Primarily affects 50-60s

While performing a fundoscopic exam you notice the pt's retina has AV nicking. From this you conclude:

Pt has hypertension

If you suspect the pt is only experiencing denervation of the levator palpebrae muscle, the clinical finding you expect to observe is:

Ptosis

Motor damage is the most easily recognized feature of spinal cord damage. Clinically, these are known as:

Pyramidal signs or UMNL signs. *although, many of the typical findings are produced d/t damage to non-pyramidal motor pathways (reticulospinal, rubrospinal, tectospinal)

Lesions of nerve roots cause what type of sensory distribution dysfunction?

Radicular pain (burning, tingling, numbness) that radiates down affected limb via dermatomal pattern, often provoked by movements that stretch the nerve root

Extrapyramidal tracts (Involuntary):

Rubrospinal - unconscious control of flexor muscles Vestibulospinal - unconscious control of extensor muscles, cervical/upper thoracic stability Reticulospinal tract - unconscious postural control, movement preparation

The fasiculus gracilis is responsible for?

Sensation from our lower body - legs and trunk. More medial portion. It includes proprioception, vibration, two-point discrimination, and graphesthesia. (gracilis = graceful = legs)

The fasciculus cuneatus is responsible for?

Sensation from our upper body - T6 and up to the arms and neck. More lateral portion. It includes proprioception, vibration, two-point discrimination, and graphesthesia. (cuneatus = arms)

Lesions of the thalamus cause what type of sensory distribution dysfunction?

Severe* contralateral pain - Dejerine-Roussy syndrome

Lesions of the anterorlateral pathways cause what type of sensory distribution dysfunction?

Sharp, burning, searing pain

You just stepped on a nail! What 3 anterolateral pathway tracts are involved and what are they telling you?

Spinothalamic tract --> (remember this crosses over immediately) "Something sharp is puncturing the sole of my root foot." Spinoreticular (travels up the SC, synapses--> "Ouch! WTF!" Spinomesencephalic (pain modulation) --> eventually says "Ah, that feels better" once a resolution is set in

Damage to the descending corticospinal tract is usually responsible for the first symptoms of a spinal cord lesion, specifically spinal cord compression. The first symptom is commonly:

Subtle stiffening of the legs of causing difficulty walking

Special skin landmarks that mark sensory areas are as follows:

T4 - Nipple T7 - Xiphoid T10 - Umbilicus T12 - Groin

What part of the brain is considered to be the "processing station" located in the center of the brain?

Thalamus Nearly all pathways project to the cerebral cortex via synaptic relays in the thalamus. the MAJOR SENSORY RELAY STATION

Ascending pathways:

The systems of neurons that bring information up to the brain from the spinal cord. afferent = sensory Ex: Spinothalamic tract

Descending pathways:

The systems of neurons that bring motor information from the brain down to the appropriate spinal level. Efferent = motor Ex: Corticospinal tract.

Lesions of the posterior column-medial lemniscal pathway cause what type of sensory distribution dysfunction?

Tight bandlike sensation around trunk or limbs, commonly associated with tingling and numbness

T/F. Pt presents with a severe right sided CN VII UMNL (right cortex has a lesion). Given this, you'd expect the pt will have difficulty saying the letter "C" in "cat":

True

T/F. The pathophysiology that causes hyposomia d/t chronic smoking is inflammation.

True

Anterior cord syndrome:

Typically caused by flexion injuries - occurs when 2/3 of the anterior cord is lost - *motor function, pain, and temperature sensation lost bilaterally below the lesion, flaccidity below the lesion

What is considered the best test to RULE OUT cervical radiculopathy?

ULTT

With Chronic Myelopathy you will see all classic signs of what?

UMNL lesion

Cerebellar tracts are also known as:

Unconscious proprioception

Where does the UMN become the LMN?

Ventral (anterior) horn in gray matter

Parasympathetic innervation:

Via the vagus nerve; conveyed to the spinal cord by sacral nerve roots S2-S4

The dorsal columns are responsible for what forms of sensation?

Vibration, Proprioception and Fine touch

Which of the following components listed is NOT a part of a neurological examination? CN I-XII Posture Cognitive abilitiy Gait Blood pressure Reflexes

blood pressure

Transverse cord lesion:

everything below the lesion is affected: vibration/position-sense (dorsal), motor, and pain/temperature (spinothalamic)

Spinal cord shock is characterized by?

- Flaccid paralysis below the level of the lesion - Loss of tendon reflexes - *hallmark* = decreased BP - decreased sympathetic output to vascular smooth muscle (causing decreased BP), and sphincteric and erectile dysfunction *hospital immediately

What are the 4 types of sensory neuron fibers as they are classified by their axon diameter and sensory function?

1. A-alpha (I) - myelinated - largest diameter 13-20 - proprioception 2. A-beta (II) - myelinated - second largest diameter at 6 -12 - proprioception. Responsible for touch, vibration 3. A-delta (III) - myelinated - 1-5 diameter - pain, temperature (cool), itch. Bare nerve endings and slower fibers 4. C (IV) - not myelinated - classic pain fibers - slowest - temperature (warm), pain, itch

Within the multimodel sensory system, there are 5 systems and 1 extra system that is often considered our "sixth sense". Name all 6 and what they are responsible for.

1. Gustation (taste) 2. Ocular (vision) 3. Olfaction (smell) 4. Vestibular (balance) 5. Auditory (hearing) 6. Somatosensory ("sixth" sense") --> Thermoception (temp), Nociception (pain), Equillibrioception (balance), Mechanoreception (vibration/discriminatory touch), Proprioception (position in space/movement).

Match the somatosensory tract with its appropriate function (motor or sensory) and level of decussation: 1. Lateral corticospinal 2. Posterior column-Medial lemniscal 3. Anterolateral

1. Lateral corticospinal: Motor --> Cervico-medullary junction 2. Posterior column-Medial lemniscal: Sensory (vibration, joint position, fine touch) --> Lower medulla 3. Anterolateral: Sensory (pain, temperature, crude touch) --> Anterior commissure of the spinal cord

Somatosensory pathways refer to bodily sensations such as touch, pain, temperature, vibration and proprioception. What are the two main somatosensory pathways?

1. Posterior column (Medial Lemniscal Pathway) Dorsal columns 2. Anterolateral pathway (Spinothalamic tract) Spinothalamic

What are the non-pyramidal pathways and their respective functions?

1. Reticulospinal --> unconscious motor planning, postural control 2. Rubrospinal --> Flexor activity in UE 3. Tectospinal --> Visual

Anterolateral pathway consists of 3 tracts:

1. Spinothalamic 2. Spinoreticular 3. Spinomesencepthalic

Typically, literature states that 4 or 5 beats of clonus is abnormal but clinically _______ may also be abnormal.

2-3