Lecture 52: ANS

Question 1

Central autonomic network: cortical

Answer 1

Insular, amygdala, anterior cingulate (goal-directed behavior)

Question 2

Central autonomic network: subcortical

Answer 2

Hypothalamus/pre-optic area, brainstem nuclei

Question 3

Central autonomic network: brainstem

Answer 3

AFFERENT: nucleus of solitary tract (visceral afferents/medullary reflexes); EFFERENT: ventrolateral medulla (nucleus ambiguus, dorsal motor nucleus of vagus)

Question 4

Sympathetic chain ganglia runs through what levels?

Answer 4

T1 - L3

Question 5

Parasympathetic outflow is divided into what two regions?

Answer 5

Cranial (vagus) and sacral (pelvic/distal GI)

Question 6

Sympathetics of the eye: general description of tract

Answer 6

From midbrain–> exit in upper thoracic –> rise with chain ganglia –> carotid plexus –> lesser ciliary nerve

Question 7

Parasympathetic control of the eye travel with which CN? Nucleus?

Answer 7

III; Edinger-Westphal

Question 8

Horner’s syndrome: lesion, symptoms (3), classical lesions (2)

Answer 8

Lesion of sympathetic innervation; mild ptosis, meiosis, anhidrosis; lesion of apex of lung (Pancoast tumror) or dissection of carotid artery

Question 9

CN III Palsy symptoms (3)

Answer 9

Down and out, ptosis, mydriais

Question 10

ANS control of blood pressure regulates slow/rapid changes

Answer 10

Rapid (response to changes in position)

Question 11

Afferent BP signal (receptors, nerves, nucleus)

Answer 11

Baroreceptors and chemoreceptors; CN IX and X; solitary nucleus

Question 12

Efferent BP signal (para and sympha)

Answer 12

Parasympathetic to heart via vagus and sympathetic to heart/arterioles

Question 13

What are two symptoms of dysfunction of BP control?

Answer 13

Hypotension and syncope (brief)

Question 14

Where is body temperature regulated?

Answer 14

Preoptic area and anterior hypothalamus

Question 15

Sweating is under para/sympa control? What are these nerves called? Special fact about them?

Answer 15

Sympathetic control; sudomotor fibers; terminal NT is ACh

Question 16

Two disorders of sweating

Answer 16

Hyperhidrosis and hypohidrpsis

Question 17

Which sweating disorder is related to lesions/neurodegenerative disorders?

Answer 17

Hypohidrosis

Question 18

Pelvic innervation (level/type of innervation)

Answer 18

F

Question 19

Overflow incontinence

Answer 19

Atonic bladder: bladder fails to empty

Question 20

What is the most common cause of overflow incontnence

Answer 20

Outflow obstruction

Question 21

Neurological causes of overflow incontinence

Answer 21

Most common: small fiber neuropathy (diabetes); cauda equina/conus medullaris; mononeuropathies

Question 22

Detrusor hyperreflexia

Answer 22

Spastic bladder: bladder contracts when not trying to urinate

Question 23

Detrusor dyssnergia

Answer 23

Contraction of sphincter is not coordinated with that of the detrusor due to disconnection from pontine center

Question 24

What is a first-line test for ANS function?

Answer 24

Continuous BP/HR/respiration monitoring

Question 25

What are the provocative maneuvers to test ANS function?

Answer 25

Tilt table, sinus arrhythmia, valsalva maneuver

Question 26

Describe tilt table and normal findings

Answer 26

Patients go from lying down –> 70 degrees to test BP; HR and BP does not change upon tilt

Question 27

Describe sinus arrhythmia

Answer 27

Test HR variability as we breathe in and out

Question 28

Describe the Valsalva maneuver and normal findings

Answer 28

Monitors BP response to during continued expiration; BP should initially increase (due to force of breathing), decrease (due to decreased venous return because of increased thoracic pressure), then recover (due to vasoconstriction and HR increase), then drop (due to end of exhale), then increase (due to compensatory mechanisms described above), then return to normal

Question 29

How do we test sweating (name of two tests, descriptions)?

Answer 29

1. Thermoregulatory sweat test: cover body in powder that changes color during sweating and place in hot box; 2. Quantitative Sudomotor Axon Reflex: give sweat gland ACh and see if they respond by sweating

Question 30

Approach to syncope: 3 realms of differential

Answer 30

1. Cardiac; 2. Neurodegenerative (central vs peripheral); 3. “Benign” (vasovagal, POTS)

Question 31

When orthostatic hypotension is caused by a neuro problem, what is this problem? HR/MAP tilt signs?

Answer 31

Neurodegenerative; increase in HR, decrease in MAP

Question 32

Vasovagal syncope is what? What brings it on and what are the HR/MAP tilt signs?

Answer 32

“Common faint,” brought on by sudden increase in vagal tone, bradycardia and hypotension

Question 33

Postural orthostatic tachycardia syndrome (POTS) HR/MAP tilt signs. What can this be associated with (3)?

Answer 33

Increase in HR, no change in MAP; post-viral, migraine, fibromyalgia

Question 34

What Parkinson’s disease has a large ANS component?

Answer 34

Multiple systems atrophy

Question 35

What do we call the peripheral counterpart of ANS disorder? Name four causes for long-term neuropathy

Answer 35

Autonomic neuropathy; most common: DM, amyloid (uncommon), hereditary, connective tissue disease

Question 36

Four causes of acute/subacute autonomic neuropathy

Answer 36

Toxic (chemotherapy), G-B, immune-mediated/post-viral, paraneoplastic

Question 37

Steps of treatment for orthostatic intolerance

Answer 37

1. Review meds; 2. Life style factors: salt + water/stockings/head of bed/strength training; 3. Meds (to increase BP): florineft, midodrine, droxidropa

Question 38

What medication can be helpful for POTS

Answer 38

Pyridostigmine (ACHE inhibitor)