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Term 3 > CNS Unit 5 Cranium, Ventricles, and Meninges > Flashcards

CNS Unit 5 Cranium, Ventricles, and Meninges Flashcards

1
Q

What are the Meninges?

A

The Meninges are the secondary line of defense in you head behind the skull.
- The Meninges cover both the brain and Spinal Cord forming a tight seal with three membranes
– Dura Mater
– Arachnoid
– Pia Mater

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2
Q

What is the Dura Mater? What do separations of the dura mater create? What do Dura Folds do?

A
  • This is the thickest and toughest membrane; Most outermost layer. This layer is perforated to allow Cranial Nerves and Blood Vessels to pass through
  • Separations of the dura membranes create sinuses. Sinuses are important parts of the Venous Drainage system. Dura Folds form in a few places to form septum’s that separate brain structures
  • One fold of dura extends into the longitudinal fissure separating the Right and Left hemisphere, this is the Falx Cerebri
  • Another fold of dura occurs at the back of the brain and divides the cerebral hemispheres (Primarily occipital lobes) from the cerebellum and is called Tentorium Cerebelli
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3
Q

What structures would the Falx Cerebri and the Tentorium Cerebelli most likely damage during a high speed impact to the head?

A
  • The Falx Cerebri can damage the Corpus Callosum
  • The Tentorium Cerebelli can damage Oculomotor Nerve (CN III) , PCA, and Brainstem
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4
Q

What is the Arachnoid? What are Arachnoid Villa/Granulations?

A

The arachnoid membrane adheres to the dura mater. It is thinner and more delicate than the dura but not as delicate as the Pia mater.
- This is the middle layer of the meninges laying between the dura and pia.
Subarachnoid space is between pia and arachnoid layers and have trabeculae that suspends the brain

Arachnoid Villa/Granulations: serve as one way valves to the dural sinus

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5
Q

What is Pia Mater?

A

The thinnest and most delicate meningeal layer and adheres directly to brain tissue. It follows each gyri and sulci and adheres to the spinal cord.
- There are extensions of the pia that extend out from the spinal cord surface to attach and anchor the spinal cord to the dura called the Dentate Ligaments

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6
Q

What is the Epidural Space?

A

The space that lies above the dura
- This space contains the Middle Meningeal Artery (Branch of the External Carotid Artery)

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7
Q

What is an Epidural Heamtoma?

A
  • Typically traumatic rupture of the Middle Meningeal Artery due to a Temporal Bone Fracture
  • May initially be asymptomatic but within hours have increased intracranial pressure (ICP) Which may shift brain, in left Pic, herniation and death
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8
Q

What is the Subdural Space?

A

This is between the dura and the arachnoid
- This contains bridging veins: These cross the subdural space and drain into the venous sinuses

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9
Q

What is a Subdural Hematoma?

A

A rupture of the bridging veins which are susceptible to shear force
- Two types:
–Chronic (Elderly)
–Acute (due to a lot of force)

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10
Q

What is the Subarachnoid Space?

A

This is between the arachnoid and Pia mater
- This contains major arteries of the brain and contains CSF

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11
Q

What is Subarachnoid Hemorrhage?

A

This can be a Traumatic or Non-traumatic injury
- Bleeding into the CSF
- Headaches are severe

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12
Q

What are the Brain Ventricles and where are they located?

A
  • Lateral Ventricle: Within the cerebral hemisphere (There are 2 of these)
  • Third Ventricle: Within the thalamus and hypothalamus
  • Fourth Ventricle: Within the pons, medulla, and cerebellum

In total of 4 ventricles

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13
Q

What structure connect the Lateral Ventricle to the Third Ventricle?

A

The Interventricular Foramen/Foramen of Monro

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14
Q

What structure connects the Third Ventricle to the Fourth Ventricle?

A

The Cerebral Aqueduct

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15
Q

When CSF is going through the ventricles, where does it go after the Fourth Ventricle?

A

The passageway after the Fourth Ventricle are 2 foramen:
- Foramen of Luschka (goes laterally (2 of these)
- Foramen of Magendie (Goes medial to Central canal of spinal cord)

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16
Q

What are the 5 parts of the Lateral Ventricle and where are they located

A
  • Frontal (Anterior) Horn: Begins anterior to the interventricular foramen of Monro and extends to frontal lobe
  • Body: Posterior to the interventricular foramen of Monro, within the frontal and parietal lobes
  • Atrium (Trigone): Area of convergence of the occipital horn, the temporal horn, and the body of the lateral ventricle
  • Occipital (Posterior) Horn: Extends from the atrium posterior into the occipital lobe
  • Temporal (Inferior) Horn: Extends from the atrium inferiorly into the temporal lobe
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17
Q

What is the Choroid Plexus? What is the function?

A

This is the make up of Ependymal cells, these cells produce CSF and assist in circulating it by movement of their cilia.
- The choroids plexuses are constantly producing CSF creating a small pressure gradient

Function:
- Buoyancy, Cushioning, Cleaning, Ionic Balance

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18
Q

What are Cisterns? What are the different types and where are they located?

A

In the Subarchnoid space there are areas where there is large “pocketing”. These areas are called Cisterns
- Cisterna Magna (or Cerebellar Medullary Cistern): This is found between the Cerebellum and the Medulla
- Pontine Cistern and the Interpeduncular Cistern

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19
Q

How does CSF exit?

A

Through Arachnoid Granulations, which then dumps it in the Venous Sinus

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20
Q

What are the 2 disorders of CSF System?

A

Hydrocephalus
Increased ICP

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21
Q

What is Hydrocephalus?

A

This is the dilation of the Ventricles, due to:
- Blocked CSF circulation
- Impeded CSF absorption
- Too much production

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22
Q

Hydrocephalus can result in?

A

Pressure in the Corticobulbar and Corticospinal tracts which results in increased weakness and/or spasticity

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23
Q

With Shunts, what are common complications?

A
  • Malfunction: Partial or complete blockage; disconnection; displacement; migration
  • Infection
  • Over/under drainage
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24
Q

With Disorders of CSF System, what may cause an Increase of ICP?

A

Mass Effect
Any increase in size of any structure can cause an increase of ICP.
Such as:
- Diffuse Cerebral Edema
- Tumors
- Hemorrhage
- Obstruction of CSF flow
- Venous Obstruction

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25
Q

What are common Symptoms and signs of Elevated Intracranial Pressure?

A
  • HA
  • Altered mental status, especially irritability and depressed level of alertness and attention
  • Nausea and vomiting
  • Papilledema (Optic disc swelling)
  • Visual Loss
    -Diplopia
  • Cushing Triad (Hypertension, Bradycardia and irregular respirations)
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26
Q

With elevated ICP, what do you do if ICP is above 20-30mmHG?

A

Notify the nurse/doctor an modify your intervention to avoid spikes

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27
Q

With elevated ICP, what do you do if ICP is above 30-40mmHG?

A

STOP therapy and notify nurse/doctor

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28
Q

How is CSF diffused?

A

The CSF diffuses through the arachnoid granulations and is reabsorbed into the venous system (Venous sinus)

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29
Q

The veins of the brain empty into what? What are they formed by? Where does drainage occur?

A

The veins empty into sinuses.
- The sinuses are formed by the two layers of the Dura Mater. (There are no valves in the sinuses)
- Drainage occurs from the Superior Sagittal Sinus into two Transverse sinuses and into the Sigmoid Sinus.

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30
Q

Where does the Inferior Sagittal Sinus run? What does it later become? What does it join?

A

The Inferior Sagittal Sinus runs along the bottom edge of the Falx Cerebri heading back towards the Tentorium Cerebelli where it becomes the Straight Sinus and then it joins the Superior Sagittal Sinus

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31
Q

What is the Confluence of the Sinuses?

A

The area where the Superior, Inferior and Straight Sinuses converge

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32
Q

What is the Cavernous Sinus? What does it surround?What happens if there is an abnormality?
Where does this Sinus drain?

A

This sinus is inferior and “sits” on the Sella Turcica of the skull.
- It surrounds the pituitary gland and CN (III, IV,Part of V, VI) and the internal carotid artery runs through the sinus

  • If there is an abnormality in venous return it could compress against these CN or artery.
  • This sinus drains posteriorly through the superior and inferior petrosal sinus back to the Transverse sinus
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33
Q

With Herniations, what are the 3 most clinically important herniation syndromes caused by?

A
  • Herniation through tentorial notch (Uncal Transtentorial herniation)
  • Herniation centrally and downward (Central herniation
  • Herniation under the Falx Cerebri (Subfalcine herniation)
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34
Q

What is the Blood Brain Barrier?

A
  • Tight junctions between the endothelial cells the line the capillary walls
  • Astrocytes abutting on the capillaries
  • Basement membranes
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35
Q

Which artery does anterior circulation and which artery does posterior circulation?

A

Anterior Circulation: Internal Carotid Arteries (ICA)

Posterior Circulation: Vertebral Arteries

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36
Q

Where does the Internal Carotid Artery enter the skull? Where does it enter the brain?

A

The Internal Carotid Artery enters the skull through the Carotid Canal in the Temporal Bone.
- This then moves forward through the Cavernous sinus then enters the brain near the Optic Chiasm and it divides to the ACA and MCA

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37
Q

Where in the hemisphere/Lobes does the ACA supply?
Where in the hemisphere/Lobes does the MCA supply?

A
  • The Anterior Cerebral Artery supplies the Medial Surface of the hemisphere, Frontal and Parietal Lobes as well as the Basal Ganglia and Corpus Callosum
  • The Middle Cerebral Artery supplies the lateral surface of the hemisphere, Frontal, Parietal, and Temporal Lobes. (Inferior surface of Frontal and Temporal)
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38
Q

What Lobes/structures does the PCA supply?

A

Medial and Inferior surface of the Temporal and Occipital Lobes as well was the Thalamus and Hypothalamus

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39
Q

With Vascular Territory of Deep Cerebral Structures, where are the Lenticulostriate Arteries a branch from and what do they supply?

A

Branch from MCA

  • Supply Internal Capsule and regions of Basal Ganglia (potions of Putamen and Caudate Nucleus)
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40
Q

With Vascular Territory of Deep Cerebral Structures, Where are the Posterior Choroidal Arteries a branch from and what does it supply?

A

Branch from PCA

  • Supplies the Thalamus
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41
Q

With Vascular Territory of Deep Cerebral Structures, Where are the Anterior Choroidal Arteries from and what do they supply?

A

Branch of Internal Carotid

  • Supplies portions of Globus Pallidus and Putamet
42
Q

With Vascular Territory of Deep Cerebral Structures, where Is the (Recurrent) Artery of Heubner from and what does it supply?

A

Branch of ACA

  • Supplies portions of head of caudate nucleus and anterior Putamen
43
Q

How does the Vertebral Artery enter the skull?
What happens when the 2 Vertebral Arteries converge?
What artery comes off the Vertebral?

A

It enters through the Foramen Magnum and runs along the lateral aspect of the medulla.

  • The 2 vertebral arteries converge to make the Basilar Artery
  • The Posterior Inferior Cerebellar Artery (PICA) is also off the Vertebral A.
44
Q

What arteries are off the Basilar Artery?

A
  • There are several arteries off the Basilar, which includes the Pontine Arteries, these are small arteries that supply the Pons.
  • The Anterior Inferior Cerebellar Artery, branches off the Basilar by the Low Pons. This supplies the anterior and inferior portions of the cerebellum.
    –The Labyrinthine Artery (off the AICA) follows the Facial and Vestibulocochlear Nerve through the Internal Acoustic Meatus to supply the inner ear
  • The Superior Cerebellar Artery, this branches off as the top of the Pons (just below the PCA) and supplies the superior portion of the cerebellum
45
Q

What supplies the Caudate, Putamen, and Internal Capsule?

A

Supplied by the striate branches of the MCA

46
Q

What supplies the Thalamus?

A

Supplied by the Thalamic branches of PCA

47
Q

What supplies the Midbrain?

A

Supplied by the PCA, SCA and Basilar Arteries

48
Q

What supplies the Pons?

A

Supplied by the Basilar Artery, as well as AICA and SCA

49
Q

What supplies the Medulla?

A

Supplied by the Vertebral, Anterior and Posterior Spinal Arteries, PICA, and Basilar Arteries

50
Q

What supplies the Cerebellum?

A

Supplied by the SCA, AICA, and PICA

51
Q

What supplies the Spinal Cord?

A
  • 2 Posterior Spinal Arteries
  • 1 Anterior Spinal Artery
52
Q

What forms the Anterior Spinal Artery? Where does this artery run?
How much of the spinal cord does it supply?

A
  • Its formed by the merging of the 2 arteries that branched off the vertebral artery
  • This artery descends down the anterior surface of the spinal cord in the anterior median sulcus (fissure)
  • Supplies 2/3 of the spinal cord
53
Q

What forms the Posterior Spinal Artery? Where does this artery run?
How much of the spinal cord does it supply?

A
  • The 2 Posterior Spinal arteries branch off the vertebral spinal arteries
  • They travel down on the posterior cord near the posterior nerve roots
  • Supplies 1/3 of the Spinal Cord
54
Q

Several Radicular Arteries (off of aorta) assist with supplying the spinal cord, what is this artery? Where does it have blood supply?

A

Great Radicular Artery of Adamkiewicz
- This provides major blood supply to lumbar and sacral cord (Usually between T9-T12)

55
Q

In the Spinal Cord, What is the Vulnerable Zone?

A
  • This is the Mid-Thoracic area (~T4-T8) where there is decreased blood perfusion
  • This area is susceptible to infarct during thoracic surgery or other conditions causing decreased aortic pressure (Anterior Cord Syndrome)
56
Q

What is Infarct?

A

An area of necrosis in a tissue due to local ischemia resulting from obstruction of circulation to the area, most commonly by a thrombus or an embolus

57
Q

What is an Aneurysm?

A

A sac formed by the dilation of the artery or vein

58
Q

recap
What is Aphasia, Apraxia, Agnosia?

A

Aphasia: Loss of language (left cerebral hemisphere)

Apraxia: Difficulty performing certain learned movements without loss of power, sensation or coordination (right hemisphere)

Agnosia: Loss of the ability to recognize the importance of sensory stimuli

59
Q

What are the Mechanisms of Ischemic Stroke? What are the different types/classifications?

A

Infarction to brain tissue
(lack of blood flow to the brain/blockage of blood flow)

Types/Classifications:
- Embolic and ischemic
- Large-vessel vs small vessel infarcts (lacunar infarcts)
- Cortical (brain) vs Subcortical (brainstem) lesions

60
Q

With Ischemic Stroke, what is the source of Embolic Stroke and common sites of occlusion?

A
  • Source is usually cardiac related A-fib or MI
    (has an abrupt onset)
  • Common sites of occlusion:
    Internal Carotid or MCA
61
Q

With Ischemic Stroke, what is the source of Thrombic Stroke and common sites of occlusion?

A
  • Common in patients over 50 usually due to atherosclerosis
    (Onset can be abrupt or slow)
  • Common sites of occlusion:
    Vertebral, Basilar, MCA
    –Less common; ACA or PCA
62
Q

With Ischemic Stroke, what do Emboli usually cause and involve?

A

Large-vessel infarcts involving cerebral or cerebellar cortex, with sudden onset of maximal deficits

63
Q

With Ischemic stroke, what are Lacunes?
What does it usually affect?

A

Small-vessel infarcts usually seen in chronic hypertension, usually affecting deep structures of hemispheres and brainstem

64
Q

With Ischemic stroke, where do Thrombosis occur?

A

Large proximal vessels

65
Q

What is Carotid Stenosis?
What can this cause and where does this typically occur?

A

Atherosclerotic disease that leads to stenosis of Internal Carotid Artery.
- We can get some thrombus that can embolize and cause a TIA or infarct (Typically occurs in MCA, ACA or Ophthalmic arteries)
- Most associated with MCA symptoms (contra weakness, paresthesia, visual deficits, aphasia, neglect)

66
Q

What is Dissection of Carotid or Vertebral Arteries? This is caused by…?

A

Dissection: blood burrows into blood vessel wall that has a small tear of intimal surface

  • Caused by trauma to head or neck
67
Q

With Strokes, what are Hemorrhagic Strokes? What can cause them?
What are the 2 different types?

A

15-20% of strokes
- Vessel rupture

  • Intracerebral Hemorrhage
  • Subarachnoid Hemorrhage

Can be caused by:
Aneurysm, AV malformation or HT, trauma to the head or a bleeding disorder

(Hemorrhagic strokes have better outcomes than ischemic)

68
Q

Which stroke has the highest mortality, which one has the lowest?

A

Hemorrhagic strokes have a higher mortality rate than embolic or thrombic stroke

  • Lowest mortality are seen with smaller lacunar infarcts

When a patient has had a stroke, they have a higher risk sustaining a subsequent stroke

69
Q

What are the Cortical Stroke Syndromes?

A

Occlusions of the MCA, ACA, and PCA

70
Q

What is the most common source of Infarct?
What lobes are associated with this?

A

MCA

With the MCA we have:

  • Superior Division (Anterior Parietal Lobe)
  • Inferior Division
    (Temporal Lobe)
  • Deep Territory (Lenticulostriate Arteries)
71
Q

With MCA, what are Stem Infarcts?

A

This is when there a is Proximal Occlusion that affects all 3 regions
(Superior Div., Inferior Div., and Deep Territory)

  • Infarct that occurs right after it leaves the internal carotids
72
Q

What would be the Deficits if there is an Infarct in the Left MCA Superior Division?

A
73
Q

What would be the Deficits if there is an Infarct in the Left MCA Inferior Division?

A
74
Q

What would be the Deficits if there is an Infarct in the Right MCA Superior Division?

A
75
Q

What would be the Deficits if there is an Infarct in the Right MCA Inferior Division?

A
76
Q

What would be the Deficits if there is an Infarct in the Left MCA Deep Territory?

A
77
Q

What would be the Deficits if there is an Infarct in the Left MCA Stem?

A
78
Q

What would be the Deficits if there is an Infarct in the Right MCA Deep Territory?

A
79
Q

What would be the Deficits if there is an Infarct in the Right MCA Stem?

A
80
Q

What is Common with ACA stroke? What is Dominant/Non-Dominant hemisphere ACA Stroke? Which lobe is typically affected?

A
  • UMN weakness and cortical-types sensory loss affecting contralateral LE
  • Dominant Hemisphere ACA stroke: Transcortical Motor Aphasia
  • Non-Dominant Hemisphere ACA: Contralateral Neglect
  • Variabel Frontal Lobe dysfunction
81
Q

What would be the defects if there is a L ACA stroke?

A
82
Q

What would be the defects is there is a R ACA stroke?

A
83
Q

What is Common with PCA stroke?

A
  • Contralateral Homonymous Hemianopia (Visual deficit)
  • If smaller vessels are involved:
    Contralateral sensory loss, contralateral hemiparesis, (May see damage to the thalamus or posterior limb of internal capsule, with much larger infarcts)

Also:
- Left occipital cortex-alexia w/o agraphia
- Left thalamus and internal capsule-aphasia

84
Q

What would be the defects with a L PCA stroke

A
85
Q

What would be the defects with a R PCA stroke?

A
86
Q

With Watershed Infarcts, what are Watershed Zones?

A

When blood supply to 2 adjacent cerebral arteries are compromised, regions between 2 vessels are most susceptible to ischemia and infarction.

87
Q

With Watershed Infarcts, what happens if there is an occlusion of Internal Carotid or a Drop in BP with a patient with Carotid Stenosis?

A

This can cause ACA-MCA Watershed Infarct
- In Dominant Hemisphere we’ll see Transcortical Aphasia Syndromes

If MCA-PCA are involved we’ll see disturbances of higher order visual processing

88
Q

What is the prognosis for Brainstem Stroke? What can this involve?

A
  • Usually a worse prognosis for survival or recovery
  • Prognosis will depend on the location and size of lesion and amount of collateral blood flow and early medical care
  • May involve coma, lesions of CN, lesions of descending motor or ascending sensory pathways
89
Q

What are the 4 Ds with Vertebral-Basilar Artery syndromes?
What can be other signs of this?

A

These are ipsilateral issues
Diplopia
Dysarthria
Dysphasia
Dizziness

Other signs:
- Contralateral weakness/Sensory loss
- Cerebellar signs

90
Q

What is AICA/Lateral Pontine Syndrome or Marie-Foix Syndrome?

A

This is damage to AICA and the Basilar Artery
Damage to Lateral Pons

Can cause:
- Ataxia of UE and LE (Damage to cerebellar tracts)
- Contralateral weakness (Damage to corticospinal tract)
- Contralateral sensory loss, pain and temp. (Damage to Spinothalamic tract)

91
Q

With Basilar Artery Syndromes, what is affected with Locked In Syndrome?

A
  • Bilateral weakness of UE, LE and face (Tetraplegia) Corticospinal tract damage
  • They have Vertical Gaze (weakness of lateral gaze) * Damage to bilateral fascicles of CN VI*
  • Dysarthria Bilateral corticobulbar tract damage
92
Q

With Basilar Artery Syndromes, what is affected with Ventral Pontine Syndrome/Raymond Syndrome?

A
  • Ipsilateral lateral gaze weakness (CN 6 damage)
  • Contralateral weakness of UE and LE
    (Pyramidal tract damage)
93
Q

With Basilar Artery Syndrome, what is affected with Ventral Pontine Syndrome/Millard-Gubler Syndrome?

A
  • Contralateral weakness UE and LE
  • Ipsilateral lateral gaze weakness (CN 6 damage)
  • Ipsilateral weakness of face (CN 7 damage)
94
Q

With Basilar Artery Syndromes, what is affected with Inferior Medial Pontine Syndrome/Foville Syndrome?

A
  • Contralateral weakness of UE and LE
  • Ipsilateral lateral gaze weakness (CN 6 damage)
  • Ipsilateral weakness of face (CN 7 damage)
95
Q

With Basilar Artery Syndrome, what is affected with Medial Medullary Syndrome?

A
  • Contralateral weakness UE and LE
  • Contralateral sensory loss
    –(Vibration and proprioception) DMCL damage
  • Ipsilateral tongue weakness (CN 12 damage)
96
Q

With stroke syndromes, What is Lateral Medullary Syndrome or Wallenberg Syndrome? What will be affected?

A

Damage to Pica and Vertebral Artery (Distal branch)

  • Ipsilateral sensory loss of face and face pain
    (CN 5 nucleus damage)
  • Contralateral sensory loss, Pain/temp.
    (Spinothalamic tract)
  • Ipsilateral ataxia of arm and leg
    (Resitform body and cerebellum damage)
  • Gait ataxia
  • Nystagmus (Vestibular nucleus damage)
  • Nausea/Vomiting/Vertigo
    (Vestibular nucleus damage)
  • Horseness (Nucleus ambiguus damage)
  • Dysphagia (Nucleus ambiguus damage)
  • Horner’s Syndrome (Damage to descending sympathetics)
97
Q

What are Lacunar Strokes?

A
  • Occlusions to small penetrating arteries
    (From any of the cerebral arteries or basilar)
  • Infarcts are subcortical and usually less than 1.5cm in diameter
98
Q

With Lacunar Syndromes, what is Pure Motor Syndrome?

A
  • Lacune (small artery occlusion) in the posterior limb of the Internal Capsule or the basis pontis or the pyramids
  • Contralateral weakness of face, UE, and LE (can be with dysarthria)
99
Q

With Lacunar Syndromes, what is Pure Sensory Syndrome?

A
  • Lacune (small artery occlusion) in the sensory thalamic nuclei (VPL, VPM)
  • Contralateral sensory loss of face, UE, and LE
100
Q

With Lacunar Syndromes, what is Ataxic Hemiparesis Syndrome?

A
  • Lacune (small artery occlusion) of the Internal capsule, basis pontis, red nucleus into cerebral peduncles
  • Contralateral weakness
  • Ataxia
101
Q

With Lacunar Syndromes, what is Dysarthria Clumsy Hand Syndrome?

A
  • Lacune (small artery occlusion) in gnu of internal capsule or in basis pontis
  • Dysarthria
  • Dysphagia
  • Hand paresis and clumsiness

Term 3 (50 decks)

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