Exam 1 - Clinical Scenarios Flashcards
1
Q
Branchial Fistula
A
Cyst along the lower mandible that is usually asymptomatic
Caused by lack of obliteration of embryonic structure (pharyngeal pouches that join together to create a cleft)
Treatment: no treatment needed, surgical removal if it’s a problem
2
Q
Great Auricular Nerve
A
Must be careful with this one when performing certain plastic surgical procedures (rhytidectomy or facelift)
3
Q
Thyroidectomy
A
Layers: Thyroid|Trachea|RLN + Thoracic Duct|Esophagus
Careful not to cut the Recurrent Laryngeal Nerve (RLN)
If cut = dysphonia, trouble breathing
Can cut/ligate the inferior laryngeal artery (ILA)
4
Q
Lymphatic Drainage During Surgery
A
Pretracheal and paratracheal nodes drain to the deep cervical nodes
Input MUST EQUAL output; if not, cervical edema
5
Q
Tracheotomy
A
Emergency airway cut through tracheal rings 2-4
6
Q
Cricothyrotomy
A
Emergency airway cut through the cricothyroid membrane - cuts the median cricothyroid ligament
7
Q
Tracheostomy
A
Extensive surgical procedure to open a long-term airway through tracheal rings 2-4 (usually for a vent)
8
Q
Pneumothorax
A
Penetrating wounds to the base of the neck can puncture the pleural cavity and/or lung causing it to collapse
9
Q
Dopamine Pathway Conditions
Parkinson’s
Addictions
Schizophrenia
A
Substantia nigra dopaminergic pathway usually does motor control; damaged here
Mesolimbic pathway usually does pleasure/rewards, altered with various addictions
Mesocortical pathway crucial for attention and higher levels of consciousness, dysfunctional here
10
Q
Serotonin-Induced Depression
A
Caused by disruptions in serotonin delivery by the midline raphe nucleus
11
Q
Alzheimer’s
A
Loss of function in the midbrain due to cortical neurons no longer producing acetylcholine may be one cause
CB-2 agonists (endocannibinoid receptor) causes macrophages to remove beta-amyloid and may be a treatment for Alzheimer’s
12
Q
Denervation Hypersensitivity
A
Caused by the alpha motor neuron innervating skeletal muscle being transected and the muscle continues to respond to Ach
Nicotinic receptors at the motor end-plate will react with free floating Ach and cause random action potentials = fasciculations and twitches
13
Q
Stiff Person Disease
A
Autoimmune response
GABA plays an important role here - without it, you get muscle cramps and tetany
Pancreatic beta cells make GABA too so antibodies may be detected in T1D as well
14
Q
Subclavian Steal Syndrome (Vertebro-Basilar Insufficiency)
A
During exercise, blood is shunted from the brain to the extremities and may cause an occlusion at the vertebral artery
Decrease in blood flow to the brain may lead to a coma, quadriplegia, or cranial nerve abnormalities
This is a type of ischemia - may result in transient or permanent neurological dysfunction
15
Q
Significant Shunting within the Carotids
A
May result in hyperperfusion and cerebral edema due to the Circle of Willis typically being incomplete and asymmetrical
if person has a complete and symmetrical Circle of Willis, they can survive an occlusion of these arteries
Components of the Circle of Willis: Internal Carotid (with anterior cerebral, middle cerebral, posterior cerebral, and branches) and the Vertebral Arteries
- 85% of aneurysms happen here
16
Q
Superficial Temporal Artery
A
Pulse can be readily palpated anterior to the auricle
Sometimes used in neurosurgical procedures to bypass obstructions of the middle cerebral artery
17
Q
Epidural Hematoma
A
Middle meninges like artery can be ruptured with head trauma leading to hemorrhaging and a blood clot in the epidural space
can be fatal if not treated promptly
18
Q
Removal of the Internal Jugular Vein
A
When they remove this vein, they also remove the nearby lymph nodes (deep cervical)
Done in a Neck Dissecetion - usually as a preventative or curative procedure for metastasis of cancer; removes the IJV, CNXI, and SCM along with the lymph nodes
19
Q
Paralysis of the Phrenic Nerve
A
Unilateral paralysis: usually asymptomatic or few symptoms
Bilateral paralysis: exertional dyspnea, scaphoid abdomen, hyperactivity of accessory breathing muscles, difficulty in coughing and sneezing
X-ray will show the diaphragm high in the chest
20
Q
Phrenic Neuralgia
A
May result from neck tumors, aortic aneurysm, pericardial/mediastinal infections
Most cases, the pain is on the left side
21
Q
Nuchal Rigidity
A
Stiffness occurs with neuralgia, various neck lesions, meningitis, or blood in the CSF (subarachnoid hemorrhage)
22
Q
**Vernet’s Syndrome
A
Basilar skull fracture due to trauma that may involve the jugular foramen and result in ipsilateral IX, X, and XI paralysis
23
Q
**Collet’s/Sicard’s Syndrome
A
May be due to injury in the retroparotid space that involves ipsilateral paralysis of CN IX-XII and the cervical sympathize trunk
24
Q
Sedation by General Anesthesia
A
Two ways to accomplish this relevant to this section:
- Benzodiazepine sites found on GABA receptors to increase inhibition
- Benzodiazepine sites on AMPA subtype of non-NMDA receptors to decrease excitation
25
Rasmussen's Encephalopathy
Rare condition in which severe, intractable seizures develop in child
Antibodies against metabotropic receptors have been found in people suffering with this condition
Causes brain damage, usually destroying a hemisphere
Treatment: surgical removal of damaged hemisphere
26
Excitotoxicity
Caused by over-stimulation of the EAA system following an insult to the brain leading to cell death in neurons
Strong evidence for involvement in: cerebral ischemia, stroke, hypoglycemia, epilepsy
*weird, but can get domoic-acid poisoning after consuming mussels that can cause this*
27
Cerebral Ischemia
Oxygen deprivation causes cells to not be able to meet metabolic demands
Can happen within 4 minutes of deprivation --> ATP levels drop to 0, cells depolarize (NTs are high), and there will be excessive activation of NMDA/non-NMDA receptors
28
Reperfusion Injury
Particularly common in drowning incidents --> slight cerebral edema
Caused by giving oxygen after a traumatic brain injury when the neurons have already been deprived --> O2 becomes a free radical and apoptotic pathway will be activated
Certain chemicals help potentiates further injury: epinephrine (increases K+ but inhibits protein synthesis), WBCs (hallmark of necrosis occurring), growth factors
There are "pre-treatments" available but these injuries are hard to predict; must be treated in the 4 minutes window
29
Lesion of Perivascular Plexuses or SNS Branch to the Ciliary Ganglion
Lose innervations to the eyes - specifically the dilator pupillae and tarsal muscles
30
Lesion to Deep Petrossal Nerve
Fibers travel to the palate, nasal cavity, pharynx, orbit, and lacrimal glands
Lose innervations to the nasal cavity and lacrimal gland specifically
31
Lesion to Carotico-tympanic Nerve
Courses through the middle ear (and the ganglion there) but a lesion here will cut innervation to the parotid gland
32
Horner's Syndrome
Caused by spinal cord and neck trauma, specifically by an interruption to the cervical sympathetic trunk or cervical spinal cord (above the level of T1)
Symptoms: PAMELA'S HORNY
P = ptosis (paralysis of the tarsal muscle)
A = anhidrosis (vasodilation, on the skin of face due to loss of sympathetic innervation to blood vessels)
M = miosis (pupillary constriction due to paralysis of dilator papillae muscle)
E = enopthalamos (paralysis of muscle of Muller)
L = loss of reflex
These can be transient and thus hard to diagnose
33
Sacral Autonomic Plexus Injury
Important to check patients for bowel movements as this would typically innervate the colon, rectum, bladder
34
Hypercalcemia
Alters the permeability of the cell to sodium leading to hyperpolarization and muscle weakness
35
Hyperkalemia
Depolarizes the cells, making them more excitable
36
Changes in Blood Pressure
As blood pressure drops --> decrease in baroreceptor firing --> increase in RAAS systems (activation of nicotinic receptors in adrenal chromaffin)
37
Chronic Hypercapnia
CSF will have high CO2 --> acidosis
Cells making CSF will utilize carbonic anhydrase to add HCO3 to CSF and pump hydrogen ions into the blood to raise the pH
38
Chronic Hypocapnia
CSF will have too little CO2 --> alkalosis
Cells making CSF will move HCO3 out to the blood and keep hydrogen ions in order to lower pH
39
Normal Pressure Hydrocephalus
(based on the case study provided)
Present with neurological symptoms such as unaware, cognitive deficits, gait problems, positive snout and suckling reflex (abnormal in adults), ventriculomegaly
Caused by increased pressure due to CSF accumulation because of a mismatch between production and absorption
Intracranial pressure will usually be on the high side of normal - still dangerous
40
Epileptic Seizure due to BBB GLUT Deficiency
Caused by uncontrolled synchronization of neuronal discharges, typically from parts of the brain where cells are hyperexcitable
Can be triggered by reduced CSF glucose causing an unstable membrane potential due to a mutation in the genes coding for GLUT transporters
Treatment: low carb/high fat diet (provides ketone bodies to be used as energy for neurons)
41
Lumbar Puncture Effects
When CSF is taken out, it often causes headaches because of the blood vessels that are well innervated get pulled and causes pain
42
Phases of Swallowing
1. Oral Phase: mastication (chewing)
2. Oropharyngeal Phase: elevation of the floor of the mouth and tongue to push bolus into oropharynx
3. Pharyngo-esophageal Phase: oropharynx elevates and constricts around bolus to push it into esophagus
Caused by the laryngeal aditus sphincter and epiglottis, aryepiglotic fold, thyroepiglottic muscle
43
Airway Protective Cough Reflex
Series of expiratory cough triggered by a noxious stimulus to the supraglottic laryngeal mucosa - VITAL
Example: acid reflux may cause this cough, but treatment of the acid will neutralize the stimulus
If they can't cough, may be due to the abdominal oblique muscles
44
Laryngeal Cough Reflex (Inspiratory and Expiratory)
From infancy to adulthood, the larynx is displaced around months 2-4 to descend further back
Without this process, may have nasalized speech
Caused by the vagus nerve and the internal sphincters of the larynx (vocal folds, adductor muscles, thyroarytenoid)
This airway is protected by the internal branch of superior laryngeal nerve (afferent, sensory component)
45
Piriform Recesses
Secretions may gather here but should disappear when swallowing
When it doesn't, patient is said to have a "pooling" sign which suggests an obstruction or paralysis of the upper esophagus
46
Nasopharynx Development
In infants, if this doesn't close off properly, milk can reflux through to the ear cavity causing otitis media
47
Zenker's Diverticulum
Can form within Killian's Triangle (between the thryopharyngeal and cricopharyngeus muscles) due to it being a vulnerable area
48
Pharyngeal Speech in Total Laryngectomy
Have to learn to use esophageal speech, which is the vibration of the cricopharyngeus muscle by regurgitation of swallowed air
49
Retropharyngeal Space
Between the buccopharyngeal and prevertebral fascia
Can have infections spread to here because it is continuous from the skull to mediastinum (dangerous)
If a surgical fusion of vertebra was needed, they would approach it via this space
50
Gag Reflex
Glosspharyngeal (9) and vagus (10) nerves elicit a gag response when the back of the throat is touched
9 does the sensory portion while 10 mediates the motor response (in by 9, out by 10)
51
Arytenoid Cartilages
*looks like two penguins facing each other*
During phonation: they rotate along a vertical axis to control the tension on the vocal cords
During respiration: they slide laterally to open the rima glottidis (opening formed by the free margin of the vocal folds)
52
Intubation
During intubation, the blade is placed on the valleculae epiglottica to help move the tongue and epiglottis out of the way
Placing an NG tube into the airway can cause a pneumothorax
53
Fracture of the Larynx
May result from blows received during high impact sports or compression of the shoulder strap in MVA
Produces submucosal hemorrhage, edema, respiratory obstruction, hoarseness, and dysarthria
54
Movement of the Vocal Cords
Abduction: posterior cricoarytenoid
Adduction: lateral cricoarytenoid, arytenoideus
Tension: cricothyroid (increases tension) and vocalis (decreases tension)
55
Paralysis of the RLN
Lesions result in hoarseness and dysphagia; there may be coughing and choking due to collapse of the aryepiglottic fold and drainage of fluids into the larynx
56
Delphian Lymph Node
Located at the midline of the thyrohyoid membrane may become enlarged in thyroid carcinoma and subacute thyroiditis
57
Paralysis of a Vocal Cord
If one is paralyzed, it will remain fixed while the others move in and out
In elderly patients, vocal folds frequently do not completely adduct during phonation
58
Tumors of the Vocal Folds
Results in dysphonia (hoarseness) which can be detected pretty early and usually have a favorable diagnosis/prognosis
59
Inhalation of Sharp Objections
Results in choking, sharp pain, and progressive obstruction to breathing due to inflammation of the larynx and edema of the glottis
Produces an explosive cough reflex; aspiration into the larynx will cause the muscles there to spasm and close, blocking the airway until the object is removed or bypassed
60
Lemniscus
Definition: bundle or crossed, secondary nerve fibers in a conscious sensory fibers
- Lesion: always results in contralateral deficits
61
Falx Herniation
The falx cerebri splits the two hemispheres of the brain – here, a unilateral separation may cause the cingulate gyrus to herniate across the midline
- Will see a midline shift, ventricles will be asymmetrical, not always clinical signs of herniation (less severe herniation)
62
Epidural Hematoma
Caused by a fracture of the pterion that ruptures a meningeal vessel causing the hematoma
Clinically: patient loses consciousness, rapid recovery, then loses consciousness again
- There is an increase in supratentorial cranial volume that causes herniation
- Can either press against the falx cerebri (falx herniation) or the tentorial notch (tentorial/uncal herniation)
- Can also get a tonsillar herniation of the cerebellum
63
Tentorial Herniation
This can be caused by an epidural hematoma or tumors above the tentorial notch
- This causes an opening in the cranial vault – BIG DEAL
- When volume increases, so does pressure and affects consciousness
64
Subdural Hematoma
Head trauma might cause cerebral veins to rupture as they cross the subdural space
Clinically: onset of symptoms may be delayed for days or weeks – patient will display lethargy, seizures, and headaches
- In children = due to skull fracture
- In the elderly = head trauma due to more fragile blood vessels
- May lead to seizure disorders or cause blood clots in the brain
65
Other Trauma to the Midbrain
Severe blows to the head may cause the incisura to lacerate or contuse the brainstem
- May result in temporary or permanent coma
66
Thrombosis of Venous Sinus
If a blood clot forms in either the straight venous sinus or the left transverse sinus results in ischemia and/or necrosis in the deep cerebrum - FATAL
67
Papilledema
Increased intracranial pressure also increases pressure on the small veins on the optic nerve causing edema of the retina and swelling of the optic disc
68
Subarachnoid Hemorrhage
All of the major blood vessels supplying the CNS pass through the subarachnoid space – rupture of one of these causes the hemorrhage
- Can be detected by blood in a CSF sample
69
Choroid Plexus Ependymomas
One or both of the interventricular foramen may be obstructed by tumors
70
Astrocytomas
Midbrain tumors that obstruct the cerebral aqueduct and causes hypertrophy of the lateral and third ventricles (supratentorial internal hydrocephalus)
71
Syringomyelias
Central canal in the fourth ventricle enlarges and develops a cavity in the center of the cord
72
Hydrocephalus
Symptoms: strabismus (abducens palsy) and papilledema
External Hydrocephalus: excessive of accumulation of CSF in the subarachnoid space
- Supratentorial external hydrocephalus – most common with Alzheimer’s (senile atrophy of the cortex)
- Infratentorial external hydrocephalus – seen with communicating hydrocephalus
Internal Hydrocephalus: noncommunicating hydrocephalus – may be due to obstruction of the interventricular foramen (by ependymoma) or cerebral aqueduct (astrocytoma)
- Results in dilation of the ventricles proximal to the obstruction
Communicating Hydrocephalus: combination of infratentorial external and internal hydrocephalus – space between the tentorial notch and midbrain works as communication for CSF and may become obstructed due to adhesions or fibrosis
- Results in hypertrophy of ventricles and accumulation of CSF in the infratentorial subarachnoid space
- Treatment: shunt or tube is inserted into the cisterna magna
73
Ischemic Stroke
85% of strokes, caused by an embolism or large artery stenosis
74
Hemorrhagic Stroke
15% of strokes, caused by parenchymal or subarachnoid hemorrhage
75
Neurohistological Status
Normal regional blood flow: ~53 - hypoxic symptoms appear when this drops below 30
Electrical failure:
76
Watershed Infarction
In global ischemia, distal areas of cerebral arterial circulation are hypoperfused and vulnerable to a watershed infarction
- Causes the tissue to be too ischemic to function but critically viable
77
Thrombosis of Anterior Choroidal Artery
Supplies several structures of the midbrain and prone to thrombosis due to its long course in the subarachnoid space
- This is important in Parkinson’s cases
78
Cerebral Aneurysms
```
Highest incidence (35%) is in the Anterior Cerebral Artery (ACA)
25% of cases in the MCA, 25% in anterior communicating artery, 10% from basilar artery
```
79
Occlusion of ACA
Leads to sensory (dystesia of the *contralateral* leg and foot) and motor (spastic paralysis) deficits
Supplies the middle portion of the brain (in the midline on an angiogram)
80
Occlusion of the MCA
Leads to sensory and motor deficits in the *contralateral* arm, forearm, hand, and head
- Also affects Broca’s, Warnecke’s, and auditory areas
- Temporal branch: difficulty localizing sounds
- Parietal branch: body neglect, agnosia, apraxia
81
Broca’s Aphasia
Thrombosis results in a motor language disorder where patients have cryptic speech, often frustrated because they can’t get the right words out
- Non-fluent aphasia, but can comprehend what they hear
82
Warnecke’s Aphasia
Obstruction of the MCA, patients are fluent (talkative) but lack content or meaning
- Fluent aphasia, but can’t comprehend what they hear/say
83
Central Cord Syndrome
Disruption of blood flow to the anterior spinal artery leading to ischemia in the central region of the spinal cord
84
Compromise of Great Anterior Artery of Adamkiewicz
Compromised secondary to thoracolumbar fracture or surgical repair of an abdominal aortic aneurysm (AAA)
85
Lateral Medullary (Wallenburg) Syndrome
Thrombosis of the PICA
86
Contralateral Homonymous Hemianopsia w/ Macular Sparing
Uncal herniation may compress the PCA (or it may be occluded by thrombosis) causing an ischemic necrosis of the primary visual cortex
87
Coma
Neither awake nor aware
88
Persistent Vegetative State
Identifiable sleep/wake cycles, no evidence of awareness
**thalamus hit the hardest**
89
Minimally Conscious State
Sleep/wake cycles and reproducible awareness as they respond to simple commands
90
Scalp Lacerations
Involves the close, subcutaneous tissue layer and in a deep cut, causes it to bleed profusely because this layer is highly vascular
91
Scalp Avulsions
(Removal of the skin layers of the skull) Superficial temporal artery is the major blood source for the aponeurotic layer of the scalp (sutures are usually done here too)
92
Infections of the Skull
Infections may readily spread via the emissary veins to the venous sinuses in the loose subaponeurotic layer
93
Depressed Skull Fractures
Takes place in the loose subaponeurotic layer layer and includes a scalp hematoma and CSF leakage
Blood may push into the subarachnoid space and describe it as "the worst headache ever"
If the layers tear, may get a secondary chemical-induced meningitis
94
Inflammation of the Parotid Gland
Grossly inflamed in cases of epidemic parotitis (bumps) and hypertrophied in chronic bulimia
95
Face Lift Procedure
Typically operate in the Superficial Musculo-Aponeurotic System (SMAS) - fascia over the parotid gland
Good for a face lift because they can avoid the facial nerve
96
Lesion to the Nerve to the Stapedius Muscle
Causes hyperacusis
97
Temporal Branch Lesion in Frontalis Muscle
Normal: raising the eyebrows
Inability to elevate the eyebrows
98
Temporal and Zygomatic Branch Lesion in Orbicularis Oculi Muscle
Normal: blinking or winking
Drooping of the lower lid, spilling of tears, corneal drying
99
Zygomatic Branch Lesion in Zygomatic Major Muscle
Normal: smiling
Inability to elevate and retract the angle of the mouth (uneven smiling)
100
Bucchal Branch Lesion in Orbicularis Oris Muscle
Normal: puckering the lips
Drooling of saliva from the corner of the mouth
101
Cervical Branch Lesion in Platysma Muscle
Normal: flaring of neck
Flaring of anterior neck
102
Bell's or Facial Palsy
May be idiopathic, surgical, traumatic, or due to a tumor of the parotid gland (look for large mass on the cheek)
Symptoms: ectropion, spilling of tears, drying of cornea, inability to wink, unequal smile, drooling, hyperacusis
Usually one sided with the compression/lesion of the facial nerve
103
Infections in the Nose
May spread to the veins and sinuses, which drain the brain via the anastomoses between the angular and opthalmic veins
104
Trigeminal Neuralgia
Intractable pain of the face, usually associated with the dermatomes of the trigeminal nerve
Pain may be due to abnormal seizure-like activity in the trigeminal sensory nucleus
105
Calcification of the Pterygospinous Ligament
Ligament may become calcified and obstruct the needle in a maxillary needle block
106
Fracture/Dislocation of the Mandible
Neck of mandible fracture: middle meningeal artery and auriculotemporal nerve
Ramus fracture: lingual nerve and inferior alveolar nerve
Body fracture: only the inferior alveolar nerve
107
Jaw Jerk Reflex
Used to test the status of a patient's trigeminal nerve and to help distinguish an upper cervical cord compression from lesions that are above the foramen magnum
Monosynaptic reflex, usually absent or very slight, pathological if strongly present
Stimulus: rapid depression of chin
Afferent: masseteric nerve
Efferent: masseteric nerve
Response: contraction of masseter muscle
108
Age Changes in the Mandible
```
Mental angles:
Newborn - 175 degrees
Child - 140 degrees
Adult - 110-120 degrees
Elderly - 140 degrees
```
109
Biting Your Cheek
Pain comes from the long bucchal branch of the mandibular nerve
110
Cutting the Temporo-Buccinator Band
The distal portion of the long bucchal branch courses deep to this band so if it's cut, the nerve will also be cut
111
Deep Cut in the Retromandibular Region
May cut the spinal accessory nerve
112
Dental and Lingual Referred Pain
Because of sensory distribution of the trigeminal nerve, pain from these regions may be perceived as originating from other sensory branches
i.e. infection of the tooth (inferior alveolar nerve) may cause pain that is referred to the ear (auriculotemporal)
113
Nose Bleeds
2/3 of the nasal cavity supplied by the third portion of the maxillary artery (sphenopalatine portion)
114
Artery Ruptured with an Epidural Hematoma
Middle Meningeal Artery
115
Internal Branch of the Superior Laryngeal Nerve
**chief sensory nerve to the interior of larynx**
If this nerve is not functional, neuroprotection of the LCR is compromised and there is an increased risk for developing aspiration pneumonia.
116
Branchial Arches (1, 2, and 3)
Arch 1: mastication
Arch 2: facial expression
Arch 3: pharynx and larynx
117
Transient Hydrocephalus
Secondary to subarachnoid hemorrhage, arachnoid villi become temporarily blocked by RBCs causing this
118
Great Vein of Galen
Since it drains most of the cerebrum, obstruction is usually fatal
119
Types of Chief Complaints
```
Abrupt = vascular, trauma, infectious
Progressive = neoplasms and degenerative diseases
Episodic = demyelinating diseases such as MS
```
120
Babinski Reflex
Run monofilament along bottom of foot to see the toes stretch out (pathological except in infants)
Normally, in adults, should see the toes curl
121
Ankle Clonus
Actively dorsiflex the ankle - pathological if there are involuntary waves of muscle contractions
122
Glabellar Reflex
Tap on the forehead to see if the patient also blinks - pathological
123
Vestibular System Symptoms
Nystagmus, vertigo, vomiting, postural impairment
124
Cerebellar System Symptoms
Dysmetria, dysdiadochokinesia, ataxia, slurred speech
| ...may be mistaken for alcoholism lol
125
Pyramidal System Symptoms
Spastic paralysis, hyperreflexia, hypertonia
126
Type of Traumatic Brain Injury
Group 1: no external signs of injury
Group 2: external signs, no focal Neuro signs
Group 3: disorientation, loss of consciousness, trauma, change in vitals
127
What is needed to go from coma to arousal/wakefulness?
EAA and acetylcholine
128
What is needed to go from arousal/wakefulness to awareness?
Norepinephrine and serotonin
129
What is needed to go from awareness to alertness?
Dopamine
130
EAA: Reticular Activating System and Parabrachial Nuclei
RAS: dorsal and central pathways, medulla
PN: only ventral pathways, pons
MAJOR NT HERE: EAA/glutamate
Problems here = persistent vegetative state
131
Cholinergic System
Location: PPT and LDT
Major NT: acetylcholine
Problems here: Alzheimer's
132
Noradrenergic System
Location: locus ceruleus
Major NT: norepinephrine
Responsible for the startle and alerting responses (can see this on an EEG)
133
Serotonergic System
Location: raphe nuclei
Responsible for quiet awareness, paying attention, mood, pain
During release = euphoria
During depletion = dysphoria
134
Dopaminergic System
Location: ventral tegmental area and substantia nigra
Responsible for alertness, cognitive functions, emotions
Might be able to give levadopa to people in vegetative state
135
Lesion to the Greater Superficial Petrosal Nerve
Decreased lacrimation
136
Lesion to Chorda Tympani
Loss of taste sensation from the anterior 2/3's of the tongue and decreased salivation
137
Bucchal Branch Lesion to Buccinator Muscle
Normal: manipulation of food in the mouth and sucking or blowing actions
138
Great Vein of Galen
Since it drains most of the cerebrum, obstruction is usually fatal
139
Types of Chief Complaints
```
Abrupt = vascular, trauma, infectious
Progressive = neoplasms and degenerative diseases
Episodic = demyelinating diseases such as MS
```
140
Babinski Reflex
Run monofilament along bottom of foot to see the toes stretch out (pathological except in infants)
Normally, in adults, should see the toes curl
141
Ankle Clonus
Actively dorsiflex the ankle - pathological if there are involuntary waves of muscle contractions
142
Glabellar Reflex
Tap on the forehead to see if the patient also blinks - pathological
143
Vestibular System Symptoms
Nystagmus, vertigo, vomiting, postural impairment
144
Cerebellar System Symptoms
Dysmetria, dysdiadochokinesia, ataxia, slurred speech
| ...may be mistaken for alcoholism lol
145
Pyramidal System Symptoms
Spastic paralysis, hyperreflexia, hypertonia
146
Type of Traumatic Brain Injury
Group 1: no external signs of injury
Group 2: external signs, no focal Neuro signs
Group 3: disorientation, loss of consciousness, trauma, change in vitals
147
What is needed to go from coma to arousal/wakefulness?
EAA and acetylcholine
148
What is needed to go from arousal/wakefulness to awareness?
Norepinephrine and serotonin
149
What is needed to go from awareness to alertness?
Dopamine
150
EAA: Reticular Activating System and Parabrachial Nuclei
RAS: dorsal and central pathways, medulla
PN: only ventral pathways, pons
MAJOR NT HERE: EAA/glutamate
Problems here = persistent vegetative state
151
Cholinergic System
Location: PPT and LDT
Major NT: acetylcholine
Problems here: Alzheimer's
152
Noradrenergic System
Location: locus ceruleus
Major NT: norepinephrine
Responsible for the startle and alerting responses (can see this on an EEG)
153
Bucchal Branch Lesion to Buccinator Muscle
Normal: manipulation of food in the mouth and sucking or blowing actions
154
Lesion to Chorda Tympani
Loss of taste sensation from the anterior 2/3's of the tongue and decreased salivation
155
Lesion to the Greater Superficial Petrosal Nerve
Decreased lacrimation
156
Dopaminergic System
Location: ventral tegmental area and substantia nigra
Responsible for alertness, cognitive functions, emotions
Might be able to give levadopa to people in vegetative state
157
Serotonergic System
Location: raphe nuclei
Responsible for quiet awareness, paying attention, mood, pain
During release = euphoria
During depletion = dysphoria
158
Oligodendrocytes
Myelinate the CNS only! (brain and spinal cord)
Covers multiple axons at once, opposite to Schwann Cels
159
Microglia
Act like monocytes/macrophages = do phagocytosis
160
Ependymal Cells
Outline the choroid plexus and produces the CSF
Also broken down into ependymal cells vs tanycytes which also make CSF
161
Dural Venous Sinus Blood Flow
Goes from the brain to the heart
162
Landmarks of the Neck
Greater cornu of the hyoid bone
Cervical vertebra 6
Anterior scalene muscle
163
VNM ANM
```
V = subclavian vein
N = phrenic nerve
M = anterior scalene muscle
```
```
A = subclavian artery
N = brachial plexus
M = middle scalene muscle
```
164
1/6 of the time...
The suprascapular comes off of the transverse cervical artery instead of the thyrocervical trunk
165
Innervation of Submandibular Gland
Parasympathetic: Superior salivatory nucleus --> (CN7) --> chorda tympani --> joins with the lingual nerve --> submandibular ganglion --> glands
Sympathetic: facial plexus delivers postganglionic fibers
166
GSE Fibers to ALL Intrinsic Muscles of the Tongue
Hypoglossal Nerve (CN 12)
167
Thyroid Arteries
Superior: comes from the common or external carotids
Inferior: comes from thyrocervical trunk
168
Surgical access to the esophagus is easier from the ____ side
LEFT
169
NE and Epi Receptors
Alpha 1: Gq
Alpha 2: Gi
Beta: Gs
(metabotropic)
170
Dopamine Receptors
D1-like (D1 and D5): Gs
D2-like (D2, 3, 4): Gi
(metabotropic)
171
Serotonin Receptors
```
5HT1 - Gi
5HT2 - Gq
5HT3 - vomiting (ionotropic)
5HT6 - anti-depressants
5HT2c - normal body weight/prevent seizures
```
172
Histamine Receptors and Location
Location: hypothalamus
H1 and H2: neuronal effects (metabotropic)
H3: inhibits release of histamine
173
Acetylcholine Receptors
```
Muscarinic (metabotropic)
M1 - neuronal - Gq
M2 - cardiac - Gi
M3 - smooth muscle - Gq
M4 - glands - Gi
```
Nicotinic: all ionotropic for sodium
174
GABA Receptors and Location
Location: higher CNS
GABA-A: ionotropic for chloride
GABA-B: metabotropic, Gi and Gq (Gi wins though)
175
Glycine Receptor and Location
Location: Lower CNS
| *only one receptor, ionotropic for chloride*
176
Opioid Precursors
Proenkephalins, POMCs, prodynorphins, orphanin Q
177
Opioid Receptors
Metabotropic: Mu, Kappa, and Delta
*Delta important for treating only pain!*
178
Endocannabinoid Receptors
Metabotropic:
CB-1: reduces NT release, Gi
CB-2: anti-inflammatory
179
Ascending Cervical Artery runs with ____
Phrenic Nerve
180
Inferior Laryngeal Artery runs with ____
Recurrent Laryngeal Nerve
181
Common Carotids bifurcate at the level of ____
The Hyoid
182
Which vein primarily drains the brain?
Internal Jugular Vein
183
Solitary Nucleus deals with ____
sensory innervation from the posterior 1/3 of the tongue all the way down to the transverse colon
184
EAA (glutamate/aspartate) Receptors and Location
Location: widespread
Receptors: ionotropic - NMDA and non-NMDA
185
Sympathetics to the Head
Comes from T1 mostly
186
Innervation to the Parotid Gland
Parasympathetic: inferior salivatory nucleus --> (CN9) --> lesser petrosal nerve --> otic ganglion --> auriculotemporal nerve --> parotid gland
Sympathetic: carotico-tympanic nerve from the SCG/internal carotid plexus
187
Innervation to the Lacrimal Gland
Parasympathetic: superior salivatory nucleus --> (CN7) --> greater petrosal nerve --> vidian nerve --> sphenopalatine ganglion --> zygomatic nerve --> lacrimal gland
Sympathetic: deep petrosal nerve from internal carotid plexus forms the vidian nerve
188
Innervation to the Eye
Parasympathetic: Edinger-Westphal nucleus --> (CN3) --> ciliary ganglion --> ciliary muscle + sphincter pupillae
Sympathetic: SNS branch to the ciliary ganglion from the internal carotid plexus
189
Circumventricular Organs (those not covered by the BBB)
1. Posterior Pituitary
2. Area Postrema
3. Organum Vasculosum of the Lamina Terminalis (OVLT)
4. Subfornical Organ
190
Larynx stretches from which vertebra?
CV4-6
191
Name for "Adam's Apple"
Laryngeal Prominence
192
Where does the recurrent laryngeal nerve come from?
VAGUS NERVE!
193
GSE Nerve Fibers
Innervate voluntary skeletal muscles
CN 3, 4, 6, 12 (eyes and tongue)
194
GSA Nerve Fibers
Innervates skin, oral/nasal cavity, sensory
CN 5, 7, 9, 10
195
GVE Nerve Fibers
CN 3, 7, 9, 10 and their respective innervations (both parasympathetic and sympathetic)
196
GVA Nerve Fibers
CN 7, 9, 10 (both parasympathetic and sympathetic)
197
SSA Nerve Fibers
Seeing and hearing
CN 2 and 8
198
SVA Nerve Fibers
Smell and taste
CN 1 and 7, 9, 10
199
SVE Nerve Fibers
Motor to muscles of the face
CN 5, 7, 9, 10, 11
200
Anastomoses Around the Orbit
Includes the facial artery and vein, supratrochlear artery and vein, and the supraorbital artery and vein
201
Retromandibular Vein Drains ____
The temporal and cheek regions.
Important for dissection of the facial artery
202
What passes between the sphenomandibular ligament?
Maxillary artery and auriculotemporal nerve
203
Importance of the Stylomandibular Ligament
Biomechanically makes it much easier to open the mouth
