This document discusses various alterations in cognitive systems, cerebral hemodynamics, and motor function. It covers topics like alterations in arousal and consciousness, including coma. It also discusses increased intracranial pressure, herniation syndromes, cerebral edema, hydrocephalus, seizures, alterations in movement such as paresis and paralysis, and disorders of gait and posture. Finally, it briefly mentions reviewing differences in the nervous system of children compared to adults and covers childhood brain tumors.

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Alterations in Cognitive Systems,
Cerebral Hemodynamics and
Motor Function

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Alterations in Cognitive Systems
 Consciousness
 State of awareness of oneself and the
environment
 Arousal
• State of awakeness

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Alterations in Arousal
 Structural
 Divided by location above or below tentorial
plate
 Metabolic
 Psychogenic

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Alterations in Arousal (cont’d)
 Coma is produced by either:
 Bilateral hemisphere damage or suppression
 Brain stem lesions or metabolic derangement
that damages or suppresses the reticular
activating system

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Alterations in Arousal
 Clinical manifestations:
 Level of consciousness changes
 Pattern of breathing
• Posthyperventilation apnea (PHVA)
• Cheyne-Stokes respirations (CSR)
 Pupillary changes
 Oculomotor responses
 Motor responses
 Vomiting, yawning, hiccups

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Clinical Manifestations

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Clinical Manifestations (cont’d)

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Clinical Manifestations (cont’d)

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Clinical Manifestations (cont’d)

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Brain Death (Total Brain Death)
 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)

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Brain Death (Brain Stem Death)
 Brain death criteria:
 No ocular responses
 Isoelectric EEG
 Persistence 6 to 12 hours after onset

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Cerebral Death
 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

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Cerebral Death (cont’d)
 Survivors of cerebral death:
 Remain in coma
 Emerge into a persistent vegetative state
 Progress into a minimal conscious state (MCS)
 Locked-in syndrome

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Alterations in Awareness
 Selective attention:
 Ability to select from available, competing
environmental and internal stimuli
 Sensory inattentiveness
• Extinction
• Neglect syndrome
 Selective attention deficit

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Alterations in Awareness (cont’d)
 Memory
 Amnesia
 Retrograde amnesia
 Anterograde amnesia
 Executive attention deficits
• ADHD
 Image processing

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Seizures
 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

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Seizures (cont’d)
 Convulsion
 Tonic-clonic (jerky, contract-relax) movements
associated with some seizures
 Epilepsy: no underlying cause can be
found

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Seizures (cont’d)
 Etiologic factors:
 Cerebral lesions
 Biochemical disorders
 Cerebral trauma
 Epilepsy

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Seizures (cont’d)
 Partial seizures
 Simple, complex, secondary generalized
 Generalized seizures
 Absent, myoclonic, clonic, tonic-clonic, atonic
 Unclassified epileptic seizure

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Seizures (cont’d)
 Aura
 Prodroma
 Tonic phase
 Contraction
 Clonic phase
 Relaxation
 Postictal phase

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Data Processing Deficits
 Agnosia
 Tactile, visual, auditory, etc.
 Dysphasia
 Expressive dysphasia
 Receptive dysphasia
 Transcortical dysphasia
 Aphasia

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Acute Confusional States (ACS)
 Transient disorders of awareness that
result from cerebral dysfunction
 Secondary to drug intoxication, metabolic
disorder, or nervous system disease
 Delerium
• Hyperkinetic
• Hypokinetic

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

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Alzheimer Disease (AD)
 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

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Alzheimer Disease (AD) (cont’d)
 Neurofibrillary tangles
 Senile plaques
 Clinical manifestations:
 Forgetfulness
 Emotional upset
 Disorientation
 Confusion
 Lack of concentration
 Decline in abstraction, problem solving, and
judgment
 Diagnosis is made by ruling out other
causes of dementia

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Cerebral Hemodynamics
 CBF
 CPP
 CBV
 Cerebral oxygenation

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Increased Intracranial Pressure
(IICP)
 Normal 5 to 15 mm Hg
 Caused by an increase in intracranial
content
 Tumor growth, edema, excessive CSF, or
hemorrhage
 Stage 1
 Stage 2
 Stage 3
 Stage 4

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Herniation Syndromes
 Supratentorial herniation
 Uncal
• Uncus or hippocampal gyrus (or both) shifts from the
middle fossa through the tentorial notch into the
posterior fossa
 Central
• Downward shift of the diencephalon through the
tentorial notch
 Cingulate
• Cingulate gyrus shifts under the falx cerebri

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Herniation Syndromes (cont’d)
 Infratentorial herniation
 Cerebellar tonsil shifts through foramen
magnum

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Cerebral Edema
 Increase in the fluid (intracellular or
extracellular) within the brain
 Types:
 Vasogenic
 Cytotoxic
 Interstitial

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Hydrocephalus
 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

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Hydrocephalus (cont’d)
 Noncommunicating hydrocephalus
 Internal
 Intraventricular
 Communicating (extraventricular)
hydrocephalus
 Acute hydrocephalus
 Normal-pressure hydrocephalus

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Alterations in Neuromuscular
Function
 Muscle tone
 Hypotonia
 Hypertonia
• Spasticity
• Gegenhalten (paratonia)
• Dystonia
• Rigidity

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Alterations in Movement
 Paresis and paralysis
 Upper motor neuron syndromes:
• Hemiparesis or hemiplegia
• Diplegia
• Paraparesis or paraplegia
• Quadriparesis or quadriplegia
• Pyramidal motor syndromes
• Spinal shock

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Alterations in Movement (cont’d)

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Alterations in Movement (cont’d)

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Alterations in Movement (cont’d)
 Lower motor neuron syndromes:
 Flaccid paresis or flaccid paralysis
 Hyporeflexia or areflexia
 Fibrillation

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Lower Motor Neuron Syndromes

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Lower Motor Neuron Syndromes
(cont’d)
 Amyotrophies:
 Paralytic poliomyelitis
 Nuclear palsies
 Guillain-Barré syndrome
 Progressive spinal muscular atrophy
 Progressive bulbar palsy
 Bulbar palsy

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Alterations in Movement
 Hyperkinesia
 Excessive movement
 Chorea, wandering, tremor at rest, postural
tremor, etc.
 Paroxysmal dyskinesias
 Tardive dyskinesia

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Alterations in Movement (cont’d)
 Huntington disease
 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)

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Alterations in Movement (cont’d)
 Hypokinesia
 Decreased movement
 Akinesia
 Bradykinesia
 Loss of associated movement

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Parkinson Disease
 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

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Disorders of Posture (Stance)
 Dystonia
 Dystonic postures and movements
 Decorticate posture
 Decerebrate posture
 Basal ganglion posture
 Senile posture

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Disorders of Posture (Stance)
(cont’d)

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Disorders of Gait
 Spastic gait
 Scissors gait
 Cerebellar gait
 Basal ganglion gait
 Senile gait

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Disorders of Expression
 Hypermimesis
 Hypomimesis
 Dyspraxias and apraxias

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Disorders of Expression (cont’d)

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Extrapyramidal Motor Syndromes
 Basal ganglia motor syndromes
 Cerebellar motor syndromes

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Alterations of
Neurologic Function in
Children

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Review
 Remember there are many differences in
the nervous system with children:
 Do you remember the following:
 *Fontanels
 *Sutures
 *Reflexes
 We Will explore one major area in children,
in this weeks notes

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Childhood Brain Tumors
 Brain tumors:
 Medulloblastoma
 Ependymoma
 Cerebellar astrocytoma
 Brain stem glioma
• Craniopharyngioma
 Optic glioma

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Childhood Brain Tumors