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cranial nerves Flashcards

1
Q

which cranial nerves originate from the superior orbital fissure?

A

occulomotor, trochlear, abducens

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2
Q

which cranial nerves originate from the internal auditory meatus?

A

facial and vestibulocochlear

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3
Q

which cranial nerves originate from the jugular foramen?

A

glossopharyngeal, vagus, accessory

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4
Q

which of the cranial nerves are parasympathetic?

A

3,7,9,10

3 = pupillary construction
7 = lacrimation and salivation of sublingual and submandibular glands
9 = salivation of parotid gland
10 = input to organs in thorax and abdomen
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5
Q

which cranial nerves are special sensory?

A

1,2,7,8,9,10

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6
Q

what is the location of the cranial nerve nuclei?

A

3, 4 = midbrain
5, 6, 7 = pons
8 = pontomedullary junction
9, 10, 11, 12 = medulla

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7
Q

combinations of cranial nerve signs: in which region would bilateral III be?

A

midbrain

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8
Q

combinations of cranial nerve signs: in which region would III, IV, VI be?

A

superior orbital fissure

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9
Q

combinations of cranial nerve signs: in which region would VI, VII be?

A

pons

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10
Q

combinations of cranial nerve signs: in which region would V and VIII be?

A

cerebellopontine angle

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11
Q

what would unusual combinations in reference to cranial nerve lesions make you think of?

A

chronic/malignant meningitis

think about crossing sub arachnoid space

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12
Q

what is optic neuritis a sign of?

A

MS

signs of optic neuritis: inflammation of ON, monocular vision loss, pain on eye movement, swollen optic disk

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13
Q

dilated pupil because of loss of parasympathetic nerve input is what disease? (think CN)

A

3rd nerve palsy

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14
Q

a problem where in the sympathetic pathway can lead to a constricted pupil

A

anywhere

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15
Q

what eye drops constrict and dilate pupils?

A

miotic - constrict - remember like my o tic

myDriatic - Dilate

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16
Q

in horners syndrome, first order neurons go to with verterbral level?

A

T1.

First-order preganglionic from hypothalamus -> T1, then second-order preganglionic from T1 through to superior cervical ganglion -> 3rd order neuron (postganglionic) up through internal carotid artery to SOF.

external carotid artery from apex of lungs

can be sign of lung tumour or carotid dissection

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17
Q

what are the two types of isolated third nerve palsy and what are the symptoms/aetiology?

A

microvascular: painless, pupil spared - seen in hypertension and diabetes

compressive - painful, pupil affected - caused by posterior communicating artery aneurysm or raised ICP. the worst headache ever

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18
Q

idiopathic ICP is nerve palsy of which nerve

A

CN VI

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19
Q

nystagmus (butterfly eyes) is most commonly caused by?

A

toxins (e.g. alcohol on a friday night)

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20
Q

what is trigeminal neuralgia defined as clinically

A

paroxsymal attacks of lancinating face pain

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21
Q

what is trigeminal neuralgia commonly caused by and what is the Tx?

A

vascular loop compression in posterior fossa

carbamzepine

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22
Q

what medicine is commonly used to treat trigeminal neuralgia?

A

Carbamazepine

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23
Q

in bells palsy, if facial weakness unilateral or bilateral? + what is the most common indicator
+ how to treat

A

unilateral

first sign: pain behind ear, eye closure affected, treat with steroid

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24
Q

how to tell between UMN or LMN lesion? in terms of wrinkling forehead

A

in UMN, you can wrinkle the whole forehead, in LMN you can only wrinkle on side.

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25
Q

a patient presenting with sudden onset, viral neuritis, vomiting and vertigo would make you think of what?

A

vestibular neuronitis

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26
Q

bulbar palsy and pseudobulbar palsy: which one is LMN and which is UMN?]

A

pseudobulbar palsy is UMN lesion. if bilateral then it is vascular lesions of both internal capsules, indicitave of MND. - brisk jaw jerk and gag reflex.

bulbar palsy = bilateral lesion affects CN 9-12. indicative of MND, syphilis and polio.

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27
Q

what should you be sure not to do if you suspect a patient has bulbar palsy

A

do not feed them!

wasted fasciltating tongue

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28
Q

definition of dementia

A

a PROGRESSIVE syndrome, impairment of MULTIPLE domains of cognitive function in alert patients, leading to LOSS OF ACQUIRED SKILLS and INTERFERENCE in occupational and social roles

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29
Q

treatable causes of dementia are?

A

B12 deficiency, hypothyroidism, HIV/ syphilis

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30
Q

mimics of dementia are?

A

depression, hypdrocephalus, tumour

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31
Q

what are routine tests done to diagnose dementia?

A

bloods, CT, MRI - MRI is good cause it shows atrophy.

other tests are CSF if inflam, EEG, FI, genetics

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32
Q

screening tests for examination of cognitive function:

A

Montreal (MOCA) - BEST
Mini-mental (MMSE)

if unsure or patient has high IQ, you can ask for a neuropsychological assesment

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33
Q

what is the protein involved in lewybody dementia?

A

alpha - synonuclein

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34
Q

common treatments for Alzheimers and lewybody dementia?

A

cholinesterase inhibitors - due to inhibition of choline.

NMDA antagonist.

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35
Q

which version of dementia is associated with B- amyloid plaques and neurofibrillary tangles (tau)
+
Apoliproptein E (APOE)

A

alzheimers

onset is mostly over 70 but 25% of patients have onset before 65 yo

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36
Q

what dementia does this describe? :

visuospatial problems, personality is preserved

A

tempero-parietal dementia

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37
Q 
what dementia does this describe? : 
early personality changes,
 tau body plaque, 
changed eating habits
hypersexuality
A

fronto-temporal dementia

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38
Q

what dementia does this describe? :

early personality changes & parkinsonism

A

lewy body dementia

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39
Q

what protein aggregates in lewy body dementia?

A

alpha-synonuclein

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40
Q

what treatment exists for dementia? (hint: Tx only exists for two types)

A

only treatments exist for LBD and alzheimers

  • cholinesterase inhibitors due to choline inhibition
  • NMDA inhibitors
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41
Q

diagnosing parkinsons: What signs need to be present

A

bradykinesia + at least one of:
rigidity, tremor, instability

slow onset (5-10 years), and must have ruled out other causes

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42
Q

which type of Parkinsons is most common

A

idiopathic

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43
Q

what part of the body does vascular parkinsons affect?

A

lower half

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44
Q

parkinsons plus syndromes

A

multiple system atrophy
progressive supranuclear atrophy
corticobasal degeneration
any sort of basal ganglia disease

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45
Q

is parkinsons more common in males or female?

A

1.5 M: F

2nd most common neuro disease

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46
Q

genetic factors increasing risk of parkinsons:

A

LRRK2 (late onset), Parkin (young onset), GBA (gauchin disease)

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47
Q

most common symptom in parkinsons?

A

unilateral, asymetrical tremmor at rest, slow onset

ONE SIDED and gets better when not at rest

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48
Q

treatment for parkinsons:

A
  1. L-dopa inhibitor - levodopa
  2. decarboxylase inhibitor - carbidopa/ benserazide
  3. COMT inhibitor - entacapone, tolcapone - COMT
  4. dopamine agonist - ropinorole, pramipexole
  5. MAO-B inhibitor - selegiline.

If late treatment, try to treat motor symptoms bc effect of levodopa wears off quickly. increase 1/2 life. can use deep brain stimulation or continuous IV if needed

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49
Q

what two things does consciousness depend on? (RAS)

A
  1. intact ascending reticular activating system - controls arousal/ wakefulness
  2. function cerebral cortex of both hemispheres - awareness
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50
Q

low Respiratory rate when patient is in coma is caused by what?

A

OD/ alcohol/metabolic disturbane

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51
Q

high respiratory rate when patient is in coma is caused by what?

A

hypoxia, hyercapnia, acidosis

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52
Q

a fluctuating respiratory rate when patient is in coma is caused by what?

A

brainstem lesion

53
Q

coma: if there is no meningism or cerebral signs, what sort of causes would you think of?

A

metabolic/toxins/ epilepsy

54
Q

meningism but no laterising cerebral signs in coma make you think of what?

A

subarachnoid haemorrhage/meningitis/ encephalitis

Always rule out meningitis!!

55
Q

first and second step of meningitis investigation?

A

1 - CT head scan
2. lumbar puncture - L4/L5
look for: appearance, cell count, glucose levels, capsular antigen test

56
Q

investigation if there are cerebral signs of a stroke?

A 
1. CT/MRI
if not diagnosed from CT/ MRI then: 
- metabolic screens
- lumbar puncture (looking for meningitis)
- EEG for epilepsy
57
Q

locked in syndrome is total paralysis below the level of which nerve nuclei?

A

3rd - so paralysis from pons and below

58
Q

how to look for locked in syndrome?

A

eye movement but NOT horizontally

59
Q

at what score on the GCS do you need to intubate and vent?

A

GCS > or equal to 8

60
Q

how to treat raised ICP?

  • drug?
  • head tilted at what angle?
A
  • osmotic agent - mannitol - to stop brainstem herniation
  • head angle at 30-45 deg. - to encourage venous return
  • mantain PO2 to reduce PCO2
  • reduce metabolism (to decrease temp), can also use barbituates
61
Q

features of someone having a non-epileptic attack (pseudoseizure)?

A
  • young
  • F>M
  • recent stress
  • Hx of psychiatric issues
62
Q

diagnosis of someone having a non-epileptic attack (pseudoseizure)?

A
  • sinusoidal tremor, NOT jerking
  • pelvic thrusting
  • side to side head movements
  • eyes closed, resisting opening
63
Q

scale used to tell if stroke or not?

A

ROSIER scale

-2 -> 5 scale
>0 = stroke

-1 if loss of consciousness or seizure
+1 for weakness of face, arm or leg, or speech problems

64
Q

glasgow coma scale - full?

A 
EYES
4 - spontaneous
3 - to speech
2 - to pain
1 - no response
SPEECH 
5 - orientated to time, place, person
4 - confused
3 - innapropriate words
2 - incomprehensible sounds
1 - none
MOTOR
6 - obeys commands
5 - moves to localised pain
4 - flexes to withdraw from pain
3 - abnormal flexion
2 - abnormal extension
1 - none
65
Q

glasgow coma scale -

  1. what three things are tested?
  2. considered a coma if GCS is __ or less?
  3. what is the normal score if healthy?
  4. what is the lowest possible score?
A
  1. eye opening, verbal response, motor response
  2. 8
  3. 15
  4. 3

score:
eye opening - 2 or less
verbal response - 2 or less
motor response - 4 or less

66
Q

define stroke

A

A SUDDEN onset of focal or global neuro symptoms caused by ISCHEMIA or HAEMorrhage, lasting more than 24H

67
Q

A stroke where symptoms relieve within 24 hours is known as what?

A

Transient ischaemic stroke

  • 10% stroke likelihood within 2 weeks following TIA
  • treat with antihypertensives, antiplatetets, statins, endartectomy if carotid artery stenosis
68
Q

what is the name for stroke caused by large arteries branching off small arteries?

A

lipohyalinosis - lacunar stroke

common in brainstem, basal ganglia and subcortical areas

69
Q

what is the best type of drug for treating AF so that risk of ischaemic stroke is minimised

A

DOAC (direct oral anticoagulant) such as apixiban - less risk of bleeding than anticoag such as warfarin or an antiplatelet such as aspirin

risk of embolic stroke after AF is 5x

70
Q

where is wernickes area and what does it control

A

speech, temporal lobe

71
Q

A stroke in the anterior cerebral artery would cause weakness in the legs or arm/face?

A

legs> arms/face

72
Q

A stroke in the middle cerebral artery would cause weakness in the legs or arm/face?

A

arm/face UMN > leg

73
Q

Injuries to the pyramidal tract above the medulla generally cause weakness in arm/leg on opposite side as CN problem. This is known as what?

A

Contralateral hemiparesis

74
Q

damage to the optic nerve causes lost vision in one eye, but damage beyon the __ causes vision loss in both eyes

A

optic chiasm

75
Q

what is:

  • PACS
  • TACS
  • POCS
  • LACS
A
  • PACS = partial anterior
  • TACS = total anterior
  • POCS = posterior
  • LACS = lacunar
76
Q

what would a LACS stroke not have using the oxford classification, that other strokes would (think table)

A

LACS would not have any cortical signs - so no hemianopia ( loss of one half of visual field) , dysphasia (LHS) , neglect (RHS)

  • this is because LACS only affects the small perforating arteries, and therefore has no affect on higher function
77
Q

what would POCS have using the oxford classication that no other stroke class does?

A

brainstem/cerebellar signs

78
Q

what one out of the 3 cortical signs does TACS have to have

A

hemianopia (loss of visual field in one eye) plus one other out of dysphasia (LHS) or neglect

79
Q

TACS is often due to a stroke in either of which two arteries?

A

middle cerebral or carotid

80
Q

basilar artery occlusion (type of POCS) causes ischaemia in which area of the brain stem? any clinically identifiable features?

A

pons

  • bilateral but can be asymetrical
  • PROGRESSIVE DETERIORATION
81
Q

neglect (one of the 3 cortical signs) in the oxford classification of strokes, is often known as what?

A

agnosia - cant process sensory information

82
Q

test for stroke (newtons third law) involving pushing one leg down and moving one up is known as?

A

hoovers sign

83
Q

what letter of the alphabet is associated with common stroke mimics?

A

S -

Seizures, snycope, sugar, sepsis + previous stroke, severe migraine

84
Q

ischemic and haemorragic stroke, which one: MRI or CT?

A

MRI for infarct

CT for heam - shows up blood and is faster

85
Q

What are the criteria for admisinister tPA in ischeamic stroke?

  • exclusion criteria too
A
  • use within 4.5 hours of symptom onset
  • symptoms need to be present for at least 60 mins
  • consent as there is a disabling neurological affect
86
Q

exclusion criteria when thinking about administering tPA in ischaemic stroke?

A
  • if patient is on anything making haemorrhage more likely
  • blood on CT
  • recent surgery
  • recent bleeding
  • taking anticoag
  • BP over 185 systolic or 110 diastolic
  • sugar too high or low - might be a stroke mimic (think of the S’s)
87
Q

signs of UMN lesion v LMN lesions?

A

UMN: hyper

  • stiffness
  • strong reflex
  • postitive baninski - foot extends
  • can wrinkle all of forehead

LMN:

  • muscle wastage
  • lack of reflexes
  • fasciltations
  • can only wrinkle one side of forehead
88
Q

polyneuropathy, myelopathy and cauda equina: UMN or LMN lesions?

A

polyneuropathy : LMN. peripheral nerve damage, often from diabetes or alcohol. no urinary incontinence

myelopathy: UMN, spinal cord compression, signs in all four limbs

cauda equina: UMN. herniated disk at lumbar spine

89
Q

where to perform a lumbar puncture?

A

L3/4

90
Q

the right middle cerebral artery supplies what functions?

A

left both strength and sensation

91
Q

the left middle cerebral artery supplies what functions?

A

right body strength, sensation and LANGUAGE

92
Q

the posterior cerebral artery supplies what functions?

A

The left cerebral artery supplies the right visual field

right cerebral artery supplies the left visual field

93
Q

most intracranial aneurysms arise from where in the circle of willis?

A

Branch points

94
Q

cerebellum strokes are supplied by which arteries in the circle of willis?

A

Superior, anterior inferior and posterior inferior cerebellar arteries

95
Q

what connects the two lateral ventricles to the third ventricle?

A

Foramina of Munro - also known as interventricular foramina

96
Q

what connects the third ventricle to the 4th?

A

mesencephalic aqueduct (cebrebral aqueduct of sylvius)

97
Q

the 4th ventricle empties into the subarachnoid space through the median and lateral apertures (foramina), what are their names? - clue - median foramina is a colour)

A

median aperture: foramen of magendie

lateral aperture: foramen of luschka

98
Q

what is hydrocephalus?

A

abnormal accumulation of CSF within ventricles of the brain

99
Q

what is hydrocephalus?

A

an abnormal accumulation of CSF within the ventricles of the brain

100
Q

types of hypdrocephalus?

A

Communicating: Defect in CSF reabsorption by the arachnoid granulations.

Obstructive: Block before the arachnoid granulations.

101
Q

Most common cause of hydrocephalus

A

Aqueduct stenosis - usually seen in infancy

102
Q

what is Dandywalker malformation in hydrocephalus?

A

atresia of foramina of luschka and magendie.

signs: small cerebellum, large CSF space in posterior fossa.

103
Q

What are the signs of hydrocephalus?

A

same signs as increase ICP: papillodema, upgaze, gait changes

104
Q

treatment for hydrocephalus

A

communicative - lumbar puncture

obstructive - External ventricular drain or endoscopic third ventriculostomy or ventriculo-peritoneal shunt

105
Q

frontal lobe functions?

A

precentral gyrus - voluntary control of movement
speech
higher order functions - restraint, initiative, order (RIO)

106
Q

frontal lobe examinations?

A
  • wernickes area by giving three commands
  • brocas by testing fluency
  • look for decorticate posture and altered behaviour
  • UMN pyramidal signs - weakness, hyper, up going
  • plantar reflex
  • pronator drift
  • speech
107
Q

parietal lobe functions

A

body image representation - primary somatosensory area in postcentral gyrus - think of the formative q when guy didnt recognise himself or his surroundings

visuospatial coordination
numeracy
language

108
Q

parietal lobe examination

A

tests of the non dominant side -

  • hemineglect - lack of awareness of self
  • constructional apraxia - cant copy drawing
109
Q

temporal lobe functions

A
  • processing auditory input (heschl gyrus)
  • long term memory
  • emotion (amygdala)
  • visual fields ( myers loop)
110
Q

pneumonic for testing cerebellum problem. (hint - guy in our year)

A

DANISH P

Disdiachokinesia - cant rapidly move muscles eg finger tapping
Ataxia
N
I
S
H
P
111
Q

pneumonic for testing cerebellum problem. (hint - guy in our year

A

DANISH P

Disdiachokinesia - cant rapidly move muscles eg finger tapping
Ataxia - cant coordinate basic muscle movements
Nystagmus
Intention tremor - rhythmic muscle movements during voluntary movement
Slurred speech
Hypotonia
Past pointing

vertigo too

112
Q

gerstmanns syndrome makes you think of a problem in which lobe?

A

Parietal

gerstmanns syndrome: acalculia, agraphia, right left confusion, finger agnosia

cant do math,s cant draw, forgetting himself

113
Q

ataxia and poor coordination - which part of the brain is the problem?

A

CEREBELLUM

remember danish P

Dydiakochinesa
Ataxia
Nystagmus 
Intention tremor
Slurred speech 
Hypotonia 
Past pointing
Vertigo
114
Q

what are the long tract signs seen in myelopathy?

A

think of LMN signs

clonus, increased tone, proprioception impairment, hoffman sign, upgoing plantar (positive babinski test)

115
Q

what are myelopathy and radiculopathy

A

MYELOPATHY

spinal cord problems
UMN long tract signs
bilateral

RADICULOPATHY

nerve root problem 
slipped disk 
unilateral 
LMN signs 
can be localised to specific dermatome
pain in dermatome and weakness in corresponding myotome
116
Q

what are the dermatomes for the toe, knee and achiles?

A

Knee - L3/4
achiles - S1
Big toe - L5

117
Q

symptoms of cauda equina?

A 
Bilateral leg pain
numbness around stomach
pins and needles senstion
bladder disturbance 
LMN signs
118
Q

if there are UMN signs but only problems with the lower limbs not upper, which level of the spinal cord is the problem likely to be in?

A

Thoracic level, if pain was in upper and lower limbs and there were UMN signs = cervical

119
Q

full GCS scale?

A 
EYES
4 - spontaneous
3 - open to speech
2 - open to pain
1 - NR
SPEECH 
5 - orientated to person, place
4 - confused
3 - innapropriate words
2 - incomprehensible sounds
1 - nr
MOTOR
6 - obeys commands 
5 - localised to pain 
4 - flexion in response to pain
3 - abnormal flexion
2 - abnormal extension
1 - none
120
Q

how much CSF is there in the brain at any one time (in ml)?

how much CSF is produced per day (in cc) ?

A

150ml

production: 400-450 cc/day

121
Q

what is the blood volume in the brain?

what is the paranchyme volume in the brain?

A

blood volume: 150 ml
paranchyme volume: 1400ml

total volume in the brain: 1700 ml

122
Q

Monroe kelly doctrine

A

CPP = MAP - ICP

123
Q

cerebral blood flow

A

14% of cardiac output
50ml / 100g / min
or 700ml / min
more in grey matter

124
Q

how much water is in CSF

A

Normal ICP 5 to 15 cm of water

125
Q

Sustained increase beyond __ of water in the CSF indicates pathological problem

A

20cm

126
Q

Mean arterial pressure – (MAP) is the ___ pressure plus ___ of the pulse pressure (difference between the systolic and diastolic)

A

MAP = Diastolic pressure + 1/3rd of pulse pressure

127
Q

What age of patients is cerebral ischaemia common in?

A

Younger

raised ICP = decreased CPP

128
Q

what things are low density on a CT and what colour do they show up as

A

Low density = CSF, air, chronic old blood - shows up black

High density = bone, acte new blood - shows up white

129
Q

Extradural haemorrhage vs subdural -

what are the differences

A

EDH

  • unlikely in extremes of age
  • peels dura off skull
  • lense or egg shaped
  • from direct impact
  • find fracture in squamous temporal bone or middle meningeal artery
  • P will have lucid interval and then deterioration

SDH

  • common in elderly
  • crescent shaped
  • not from direct impact, from tearing of bridging veins

systems - neuro (1 decks)

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