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Case 20 Flashcards

1
Q

What does the abbreviation FAST stand for?

A

Face, arms, speech, time

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2
Q

In the UK what proportion of strokes are caused by cerebral infarction?

A

80-85%

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3
Q

Which parts of the brain receive their blood supply from the middle cerebral artery?

A

Parietal, frontal, superior and temporal lobes

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4
Q

Which of the following clinical sub types of stroke has the worst prognosis?

A

TACS

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5
Q

What fact would exclude a patient with suspect stroke in the ED from being eligible for thrombolysis?

A

The patients symptoms were present on waking from sleep this morning.

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6
Q

What percentage of patients with ischaemic stroke will treated with alteplase will show clinical improvement?

A

30%

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7
Q

What endocrine structure is associated with body of the sphenoid?

A

Pituitary Gland

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8
Q

What surgical approach would you use to reset a pituitary adenoma?

A

Transsphenoidal - must pass through the sphenoidal sinus via the nasal cavity

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9
Q

What portion fo the temporal bone contains air cells (i.e. pneumatised)?

A

Mastoid portion

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10
Q

What bony structure articulates with the occipital condyles?

A

Atlas (C1`)

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11
Q

What opens into the inferior meatus?

A

Nasolacrimal duct

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12
Q

Through which foramen do the vertebral arteries reach the cranial vault?

A

Magnum

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13
Q

A lacunar stroke will present with higher cerebral dysfunction, true or false?

A

False

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14
Q

Which artery supplies the brainstem?

A

Posterior cerebral artery

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15
Q

What are the 3 components of the Glasgow coma scale?

A

Eyes, Motor and Verbal

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16
Q

What would the Glasgow coma scale top score be?

A

M6V5E4

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17
Q

The knowledge of yourself and your surroundings and ability to respond to it, is the definition of what?

A

Consciousness

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18
Q

In each component of the GCS the best score is what?

A

Spontaneous

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19
Q

If when you approach the patient, they are awake and looking at you, how would you score them on the GCS?

A

E4 - Spontaneous eye opening

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20
Q

You are called to see a patient with swollen eyes which they can not open. How do you record this on the GCS?

A

ENT (eyes not testable)

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21
Q

A 45 year old man called Hamish is admitted to the emergency department on the 1st September, when he is asked to tell you his name, where he is and the date he replied with My name is Hamish, Im at home and it’s December. How do you score this on the GCS?

A

Confused (V4)

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22
Q

You are assessing the motor component of a patient’s GCS. They are unable to obey commands, but bend their elbow when their finger nail bed is stimulated. What do you do next??

A

Apply a trapezius squeeze

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23
Q

A patient reacts to supraorbital pressure by moving their hands to their face. What is this response on the GCS?

A

Localises to pain

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24
Q

Normal flexion, where a patient’s elbow bends and their arms moves outwards and rapidly extends from their body is recorded as what in the GCS?

A

M4

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25
Q

If you were told by a colleague that a patient’s GCS score was E2, V3, M5 what does this mean?

A

The patients eyes open to pressure, they utter some words but do not form sentences and are able to localise to the trapezius pinch.

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26
Q

If a patient doesn’t respond spontaneously or to verbal stimuli, but does respond to pain what score do they get on the AVPU scale?

A

P

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27
Q

When we are asleep what are we?

A

Subconscious

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28
Q

Which cranial nerve is not associated with the ear at all?

A

CN 11 - Accessory

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29
Q

The EJV sits on top of which muscle?

A

Sternocleidomastoid

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30
Q

Which area of the face should you avoid for sensory testing of the trigeminal nerve?

A

Angle of Mandible as supplied by cervical plexus not V3

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31
Q

What cranial nerve is the chorda tympani a branch of?

A

CNVII - facial nerve

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32
Q

Which gland does the facial nerve pass through?

A

Parotid

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33
Q

Examination of a patient shows a uvula deviation. A lesion on which nerve would cause this finding?

A

CNX vagus

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34
Q

A uvula deviation to the left shows the lesion is on which side?

A

Left sided lesion

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35
Q

Examination of a patient shows symmetrical eyebrow raising but an asymmetric smile (no raised upper lip on the left). Where is the lesion?

A

Right sided upper motor neurone lesion

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36
Q

The patient sticks their tongue out and there is a deviation to the left. What nerve is affected?

A

CNXII - hypoglossal

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37
Q

A left sided tongue deviation, shows a lesion is where?

A

Left sided lesion

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38
Q

What is clinically important about the pterion?

A

Site of many sutures - extremely susceptible to fracture - may rupture the middle meningeal artery

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39
Q

What is the bregma?

A

Site of anterior fontanelle in neonates - closes at 18 months when the frontal and parietal bones fuse

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40
Q

What is the lambda?

A

Site of posterior fontanelle in neonates - closes at 2 months (up to 6 months)

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41
Q

What is the function of flat bones of the skull?

A

Provide protection or a broad surface for muscle attachment

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42
Q

What bone is associated with the pituitary gland and where is it located?

A

Sphenoid bone - the pituitary glands sits behind the sphenoid sinus

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43
Q

What are complications of a pituitary adenoma?

A

It can push on the optic chiasm causing vision problems. It is resected via a transphenoidal approach via the nasal cavity.

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44
Q

What bone are the pterygoid plates (lateral and medial) part of?

A

Sphenoid bone

The lateral plate is the site of attachment for the muscles of mastication.

45
Q

Describe the squamous portion of the temporal bone

A

Flat lateral wall - site of Temporalis muscle attachment

46
Q

Describe the tympanic portion of the temporal bone

A

Associated with the external acoustic meatus

47
Q

Describe the mastoid portion of the temporal bone

A

Forms the Mastoid process and part of the middle ear - contains air cells which have some role in protection against trauma, regulating middle ear pressure, and sound conduction

48
Q

Failure to pneumatic the mastoid portion of the temporal causes what?

A

Auditory tube dysfunction

Site of potential secondary infections especially otitis media

49
Q

Describe the petrous portion of the temporal bone

A

Thick slab of bones containing the inner ear (ossicles) and may foramina

50
Q

Describe the squamous portion of the occipital bone

A

Forms the flat posterior wall
External occipital protuberance
Nuchal line - important site of muscle attachment

51
Q

Which muscles attach to the nuchal line?

A

Trapezius

Sternocleidomastoid

52
Q

Describe the basilar portion of the occipital bone

A

Forms most of the base

Contains the foramen magnum and occipital condyles (lies lateral to the Foramem magnum

53
Q

What articulates with the occipital condyles?

A

C1

54
Q

What articulates with the cloves portion of the basilar portion of the occipital bone?

A

Sphenoid bone

Close association with the brainstem

55
Q

What bones does the medial wall consist of and what is its function?

A

The ethmoid and vomer bones
Divides the nasal cavity into the left and right side.
Smooth wall

56
Q

What is the superior boundary of the nasal cavity?

A

Anterior to posterior order = nasal, frontal, ethmoid and sphenoid bones

57
Q

What is the inferior boundary of the nasal cavity?

A

Anterior to posterior order - maxilla and palatine bones forming the hard palate

58
Q

What is the anterior boundary of the nasal cavity?

A

cartilaginous portion of the nose

59
Q

What is the posterior boundary of the nasal cavity?

A

The nasopharynx which connects the nasal and oral cavities

60
Q

What is the lateral boundary of the nasal cavity?

A

Lateral wall

61
Q

What is the medial boundary of the nasal cavity?

A

Medial wall

62
Q

What does the lateral wall consist of?

A

The superior, middle and inferior nasal conchae

63
Q

What is the function of the conchae?

A 
covered in a mucosal layer - they increase the surface area of the nasal cavity. 
The meati (spaces between the
64
Q

What are the meati?

A

Spaces underlying the mucosal layer where the paranasal sinuses and nasolacriminal ducts drain.

65
Q

What part of the ethmoid bone forms the roof of the nasal cavity?

A

Cribriform plate

66
Q

What bone facilitates the passage of the olfactory nerve?

A

Cribriform plate of the ethmoid bone

67
Q

What does the ethmoid bone form?

A

Part of the eye socket and a portion of the metal and lateral wall of the nasal cavity

68
Q

What bone is an unpaired midline bone?

A

Ethmoid bone

69
Q

Where do all the sinuses drain into?

A

The lateral wall of the nasal cavity -> meati

70
Q

Name the 4 sinuses and describe their location

A

Maxillary – sits above the upper dentition and lies lateral to the nasal cavity
Sphenoidal – below the sella turcia which houses the pituitary glands and lies superoposteriorly to the nasal cavity
Frontal – anterior and lies between the 2 glabellae (between the eyebrows) on top of the nasal cavity
Ethmoidal – relatively small and also called the anterior, middle and posterior ethmoidal air cells and sits on top of the nasal cavity.

71
Q

What drains into the superior meatus?

A

Posterior ethmoid air cells and sphenoid sinus

72
Q

Where else other than the superior meatus can the sphenoid sinus drain?

A

Sphenoethmoidal recess

73
Q

Where does the ethmoidal bulla lie?

A

Middle meatus

74
Q

What do the middle ethmoidal air cells drain into?

A

Middle Meatus and ethmoidal bulla

75
Q

What do the anterior ethmoidal air cells drain into?

A

Middle Meatus and semilunar hiatus

76
Q

What does the nasolacrimal duct drain into?

A

Inferior Meatus

77
Q

What drains into the semilunar hiatus?

A

Anterior ethmoidal air cells, Maxillary sinus and frontal sinus

78
Q

What drains into the middle meatus?

A

Anterior and middle ethmoidal air cells, maxillary sinus and frontal sinus

79
Q

What is indicated by a non intact orbital floor?

A

Blow out fracture

80
Q

What blood vessels enter through the Foramen magnum?

A

Vertebral arteries

81
Q

How do the internal carotid arteries enter the the skull?

A

Internal carotid arteries enter the carotid canal and then enter the upper portion of the foramen lacerum

82
Q

What bone is the foramen lacerum associated with?

A

The sphenoid bone

83
Q

Which upper motor neurone sign relates most with disruption to control of spinal circuitry?

A

Hypereflexia

84
Q

Which lower motor neurone sign realties most with disruption to control of spinal circuitry?

A

Fasiculations

85
Q

The withdrawal reflex activates local reflex pathways to withdraw limbs from painful stimuli. Which pathway alerts the brain to painful stimuli?

A

Spinothalamic

86
Q

Which component of the stretch reflex pathway does the Ia sensory neurone inhibit via interneurones and motor neurones to facilitate this reflex?

A

Antagonist muscles

87
Q

What is the anterior circulation of the brain and what is it supplied by?

A

Circle of Willis supplied by the internal carotid artery (via the common carotid, right brachiocephalic, aorta)
70% of blood supply to the brain

88
Q

Which is the largest terminal branch of the internal carotid artery and describe it’s course and the territory which it supplies?

A

Middle cerebral artery

Passes within the lateral fissure of Sylvian between the temporal and occipital lobes.

Supplies the majority of the lateral cerebrum
Territories:
Brain stem – orbital surface of Frontal lobe, anterior temporal cortex
Upper division – motor and sensory gyri, parietal cortex
Lower division – temporal and occipital cortices

89
Q

What artery connects the anterior and posterior circulation of the brain?

A

Posterior communicating artery

90
Q

Describe the connections, course and territories of the anterior cerebral artery?

A

Anterior circulation
Connected to the anterior communicating artery
Passes within the longitudinal fissure, along the corpus Callum and to the cingulate gyrus

o Anastomoses with PCA on medial surface at the end arteries

o Supplies medial surfaces of cerebral hemisphere

o Territories = Orbital surface of frontal lobe, frontal pole, cingulate gyrus, corpus callosum

91
Q

What is the posterior circulation and what is it supplied by?

A

30% blood supply to brain – cerebellum, brainstem

Supplied by vertebral arteries (Aorta > subclavian > vertebral (1st branch))

92
Q

What branches does the vertebral artery give rise to?

A

o Ant. Spinal Artery (ASA)
o Post. Spinal Artery
o Post. Inf. Cerebellar Artery (PICA)

93
Q

Which artery unites the anterior and posterior circulation? What branches does it give rise to?

A

Basilar artery

o Ant. Inf. Cerebellar Artery (AICA)
o Sup. Cerebellar Artery (SCA)
o Pontine Arteries

94
Q

What is the course of the posterior cerebral artery?

A

o Branches off basilar artery and arches around the cerebral peduncle supplies the occipital the brainstem.
o Also passes along the corpus callosum and extends laterally to supply the occipital and temporal lobe

95
Q

What are the territories supplied by the posterior cerebral artery?

A

Lateral – parietal and temporal cortices, Medial – calcarine sulcus, splenium of corpus callosum

96
Q

What field of vision may be spared despite occlusion of what artery, and why?

A

Macula (responsible for focusing on a specific point) may be spared.

Artery occluded is the Posterior cererbral artery.

Posterior cerebral supplies the visual area for the contralateral field - however middle cerebral branches often sufficiently innervate the macular part of the viral area.

97
Q

What are the effects of occlusion of the posterior cerebral artery?

A

Contralateral hemianopia

98
Q

What are the effects of occlusion of the middle cerebral artery?

A

contralateral hemiplegia and hemianaesthesia (with expressive or receptive aphasia in the majority if the lesion is left-sided)

99
Q

What are the effects of occlusion of the anterior cerebral artery?

A

Contralateral weakness and sensory loss

100
Q

What arteries are associated with the basal ganglia and what will their occlusion result in?

A

Lateral lenticulostriate arteries

Occlusion of the arteries causes a lacunar stroke which presents with lower cerebral dysfunction (motor impairment)

101
Q

A lacunar stroke in the deee nuclei would result in what?

A

Variable complicated motor deficits

102
Q

A lacunar stroke in the internal capsule would result in what?

A

Contralateral, unilateral motor and sensory deficits - hemiplegia (unilateral paralysis)

103
Q

What 3 main arteries supply the hindbrain and what are their branches?

A

Vertebral Artery (supplies spinal artery alongside intercostal arteries)
o Ant. Spinal Artery (ASA) closely associated with PSA
o Post. Spinal Artery (PSA -not shown)
o Post. Inf. Cerebellar Artery (PICA)

Basilar Artery – runs along brainstem
o Ant. Inf. Cerebellar Artery (AICA)
o Sup. Cerebellar Artery (SCA)
o Pontine Arteries

Posterior Cerebral Artery (PCA)

104
Q

What are the main symptoms of cardinal dysfunction?

A 
Dysdiadochokinesia 
Ataxia 
Nystagmus 
Intention tremor 
Slurred speech 
Hypotonia
105
Q

What is the area postrema (medulla) responsible for?

A

Senses toxins/controls vomiting

106
Q

What is the pineal gland responsible for?

A

Melatonin release

107
Q

What is the posterior pituitary gland responsible for?

A

Hormone release

108
Q

What is the median eminence of hypothalamus responsible for?

A

Hormone release

109
Q

What features of the blood brain barrier protect the internal environment of neural tissue?

A

Lack of fenestrations in capillaries
Abundant tight junctions between endothelial cells
Thicker basil lamina
Enveloping foot processes of astrocytes

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