Lectures 1 - 5 Flashcards
What does gradual onset make you think?
Inherited or compressive
What does sudden onset make you think?
Ischemic, inflammatory or infectious
What does afferent mean?
Toward the brain
What does efferent mean?
Away from the brain
What age group do you think of when you are considering congenital lesions?
Children
What age group do you think of when you are considering degenerative or vasculopathic lesions?
Older adults
What age groups make you think of neoplastic disorders?
Children (Craniopharyngioma)
Adults (Pituitary Adenoma)
What are the critical components of a neuro-ophthalmic history? (10)
CC Detail the Problem Temporal Profile of Symptoms Associated Symptoms Past Neurological History Neurology Systems Review Past Medical History Family History Social History Special Considerations in Children (Pregnancy, Birth, Milestones)
When detailing the problem for afferent and efferent issues what are some unique questions you would ask to differentiate between the two?
Afferent: nasal, temporal, superior, inferior field of vision. Degree of loss.
Efferent Constant or Variable/Transient
What sort of disease process are you thinking of when the pattern of symptoms are described as acute w/ eventual plateau?
Vascular/Inflammatory
What sorts of disease processes are you thinking of when the pattern of symptoms is described as episodic?
Migraine, carotid disease, seizure disorder
What sort of disease process are you thinking when the degree of recovery is transient
Elevated ICP, vascular
What sort of disease process are you thinking when status gets worse over time then plateaus?
Inflammatory
What kind of recovery do you expect when a patient has a lesion due to ischemia?
Acute loss w/ little recovery
What kind of disease progression do you expect when your patient has a compressive lesion?
Gradual worsening
What are the major functions of the frontal lobe?
Primary motor cortex
Personality, behavior, emotion
Judgement, planning, problem solving
Intelligence, concentration, self-awareness
Broca’s area: expressive language
FEF: saccades, voluntary eye movement; communicates w/ EOMs via PPRF
What are the major functions of the parietal lobe?
Primary sensory cortex
Interpret visual and spatial information
Interpret language and words
Dominant lobe (left): calculation, writing, left-right orientation, finger recognition
Non-dominant lobe: integrates contralateral side of body with environment (left sided neglect)
Connect somatosensory, auditory and visual input
What are the major functions of the temporal lobe?
Understanding language (Wernicke’s speech area), hearing, memory
What is the major function of the occipital lobe?
Vision
What percentage of the total neurons in the brain pass through the cerebellum?
50%
What are the major parts of the diencephalon?
Thalamus & Hypothalamus
& the pineal gland
What nuclei are contained in the midbrain?
CN III and CN IV
What sensory and motor nuclei lie within the pons?
CN V, VI, VII, & VIII
What are the major components of the sympathetic nervous system pertaining to vision?
Any lesion to the sympathetic chain will affect your ability to dilate.
Pre-ganglionic : T1-2
Synapse: Cervical Sympathetic Ganglia
Postganglionics: Peri-arterial plexus along ICA and ECA
What are the major components of the parasympathetic nervous system pertaining to vision?
Preganglionics: CN III, VII (& IX, X)
Synapse: 4 cranial ganglia (ciliary & pterygopalatine) or directly on target glands
Postganglionics (Distributed via branches of CN V)
Describe the anatomy of CN I.
Olfactory Nerve
Not a true nerve
exits cranium via perforation in the cribriform plate
Special afferent fibers only
Describe the anatomy of CN II.
Optic Nerve Not a true nerve Exits cranial cavity via optic canal Carries axons of ganglion cells in the retina Special afferent fibers only
Describe the anatomy of CN III.
Oculomotor Nerve
Exits cranial cavity via superior orbital fissure
Mixed cranial nerve (GE & VE)
Describe the anatomy of CN IV.
Trochlear
Innervates superior oblique
Originates in dorsal aspect of midbrain (on CN to cross over)
Exits cranial cavity via superior orbital fissure
General efferent only
Describe the anatomy of CN V.
Trigeminal
Mostly sensory
Some GSE fibers
Suspends 4 sympathetic ganglia (ciliary, pterygopalatine, otic, submandibular)
Carries hitchhiking fibers
Exits from the Pons
3 Divisions (Ophthalmic, maxillary, mandibular)
Describe the anatomy of CN VI.
Abducens
Innervates lateral rectus
Exits brainstem at junction of pons and medulla
Exits cranial cavity via superior orbital fissure
General efferent only
Describe the anatomy of CN VII.
Facial Nerve
GE, VE, SA (ant. 1/3rd of tongue)
Longest intraosseous course
Describe the anatomy of CN VIII.
Vestibulocochlear
Leaves brainstem lateral to CN VII at CPA
Exits cranial cavity through internal acoustic meatus
Does not leave the skull
Innervates inner ear structures
Special afferent fibers only
Describe the anatomy of CN IX.
Glossopharyngeal
Leaves brainstem from lateral aspect of upper medulla
Exits cranial cavity via jugular foramen
VE, VA, GA (post 1/3rd of tongue)
Describe the anatomy of CN X.
Vagus
Leaves brainstem lateral to CN IX in the upper medulla
Exits cranial cavity via jugular foramen
GE, VE (to all organs below neck minus adrenal)
Describe the anatomy of CN XI.
Spinal Accessory Nerve
Innervates trapezius & sternocleidomastoid
GE only
Originates outside the skull in the upper spinal cord between C1 and C5
Enters skull via foramen magnum, exits skull via jugular foramen
Describe the anatomy of CN XII.
Hypoglossal
Innervates the tongue
Leaves the cranial cavity via hypoglossal canal in the occipital bone
GE only
What are the critical components of the neuro-ophthalmic exam for the afferent visual system?
VA
Contrast Sensitivity
Color Vision
VF
What are the critical components of the neuro-ophthalmic exam for the efferent visual system?
Pupils
Eyelids
EOMs
Facial Nerve Function
How do you test CN I (Olfactory Nerve)?
Test each nostril separately with coffee or perfume
How do you test CN II (Optic Nerve)?
VA, color vision, VF, pupils
How do you test CN III (Oculomotor Nerve)?
EOMs (SR, MR, IR, IO, LPS), pupils
How do you test CN IV (Trochlear)?
EOMs (SO)
How do you test CN V (trigeminal)?
Sensory: facial sensation in each area, corneal blink reflex
Motor: ask pt to clench teeth while you palpate master and pterygoid, have patient move jaw against resistance from your hand
How do you test CN VI (Abducens)?
EOMs (LR)
How do you test CN VII (facial)?
Motor: eyelid closure, forehead wrinkling, smiling, cheek puffing, whistling
Lacrimation: Shirmer Testing
Taste
How do you test CN VIII (Vestibulocochlear)?
White Noise Tests (Rinne Test, Weber Test)
How do you test CN XI (Spinal Accessory Nerve)?
Head and shoulder elevation
How do you test CN IX (Glossopharyngeal) and X (Vagus)?
Check gag reflex
How do you test CN XII (Hypoglossal)?
Tongue protrusion (lick the wound)
What are the key components of a neurological exam?
Mental Status Evaluation
Cranial Nerve Assessment
Examination of Arms and Legs
What does the hill of vision?
As you get closer and closer to the fovea from the periphery your sensitivity increases until you reach the peak at the center of the fovea
Where is the physiological blind spot?
15 degrees temporal to point of fixation, 1.5 degrees below the horizontal meridian
In what type of perimetry do patients with neurological diseases tend to do better at?
Kinetic perimetry (octopus)
What other part of the visual pathway will be involved when a pituitary tumor pushes on a pre-fixed chiasm?
Optic tract first
What other part of the visual pathway will be involved when a pituitary tumor pushes on a post-fixed chiasm?
Optic nerve first
What is the visual pathway extending from the retina to the occipital cortex?
Retinal ganglion cells > Optic nerve > Optic chasm > Optic tract > Lateral Geniculate Body > Optic Radiations > Visual Cortex
What does a depression in a VF mean?
Generalized reduction in retinal sensitivity
What does a scotoma mean?
A focal area of reduced sensitivity surrounded by an area of normal sensitivity
What are the patterns of VF loss when there is a lesion to the optic nerve?
Central, centro-cecal, arcuate, altitudinal, enlarged blind spot, diffuse
What kind of VF loss do you expect with Anterior Chiasmal Syndrome?
Ipsilateral central scotoma, contralateral superior temporal defect
What kind of VF loss do you expect with Posterior Chiasmal Syndrome?
Central bitemporal hemianopia defects (nasal macular fibers)
What kind of VF defect do you expect with Middle Chiasmal Syndrome?
Bitemporal hemianopia, bilateral optic atrophy
What kind of VF defect do you expect with Lateral Chiasmal Lesion?
Binasal hemianopia, bilateral optic atrophy
What kind of VF defect do you expect to find with an optic tract lesion?
Congruous hemianopia
What kind of VF defect do you expect to find with a Lesion of the Optic Radiations?
Incomplete incongruous quadranopsia but neurological deficits predominate
What kind of VF defect do you expect to find with a temporal lobe lesion?
Pie in the Sky
What kind of VF defect do you expect to find with a parietal lobe defect?
Pie in the floor
What kind of VF defect do you expect to find with a middle cerebral artery infarct to the visual cortex?
Congruous homonymous hemianopia with macular sparing
What kind of VF defect do you expect to find with a posterior cerebral artery infarct to the visual cortex?
Congruous homonymous macular defect
