Miscellaneous Flashcards
1
Q
Aphasia vs dysarthria
A
Aphasia is higher order inability to speak (language deficit)
Dysarthria is motor inability to speak (movement deficit)
2
Q
Where are broca’s and wernicke’s?
A
In dominant hemisphere (if R handed, your dom hemisphere is L)
Motor speech is Broca - Frontal lobe above sylvian fissure
Associative auditory cortex is Wernicke - temporal below sylvian. Borders parietal too. Behind primary auditory cortex.
3
Q
Broca’s aphasia
A
1) No fluency
2) Yes comprehension
3) No repetition
Inferior frontal gyrus
Broca is Broken Boca
4
Q
Wernicke aphasia
A
1) Yes fluency
2) No comprehension
3) No repetition
Superior temporal gyrus
Wernicke is Wordy but makes not sense. Wernicke is What???
5
Q
Conduction aphasia
A
1) Yes fluency
2) Yes comprehension
3) No repetition
Arcuate fasciculus
Can’t repeat phrases such as No ifs, ands, or buts
6
Q
Global aphasia
A
1) No fluency
2) No comprehension
3) No repetition
AF, Brocas and Wernicke affected
7
Q
Transcortical motor aphasia
A
1) No fluency
2) Yes comprehension
3) Yes repetition
8
Q
Transcortical sensory aphasia
A
1) Yes fluency
2) No comprehension
3) Yes repetition
9
Q
Mixed transcortical aphasia
A
1) No fluency
2) No comprehension
3) Yes repetition
Broca and Wernicke involved. AF spared.
10
Q
Kluver-Bucy Syndrome
A
Bilateral amygdala lesion
disinhibited behavior (hyperphagia, hypersexuality, hyperorality)
Associated with HSV1
11
Q
Frontal lobe lesion
A
Disinhibition and deficits in concentration, orientation, judgment. May have reemergence of primitive reflexes
12
Q
Nondominant parietal-temporal cortex lesion
A
Hemispatial neglect syndrome (agnosia of contralateral side of the world)
13
Q
lesion to dominant parietal-temporal cortex
A
Agraphia, acalculia, finger agnosia, L-R disorientation
Gerstmann Syndrome
14
Q
Lesion to reticular activation system (midbrain)
A
Reduced levels of arousal and wakefulness (coma)
15
Q
Mammilary body lesion bilateral
A
WKS - confusion, ophthalmoplegia, ataxia; memory loss (anterograde and retrograde amnesia), confabulation, personality changes
Associated with thiamine deficiency and excessive EtOH use. Can be precipitated by giving glucose without B1 to a B1 deficient patient
CAN of beer - Confusion, Ataxia, Nystagmus
16
Q
Basal ganglia lesion
A
May cause tremor at rest, chorea, athetosis
PD, HD
17
Q
Cerebellar hemisphere lesion
A
Intention tremor, limb ataxia, loss of balance; damage to cerebellum leading to ipsilateral deficits. Fall toward side of lesion
Cerebellar hemispheres are laterally located - affect lateral limbs
18
Q
Cerebellar vermis lesion
A
Trunctal ataxia, dysarthria
Vermis is centrally located - affected central body
19
Q
STN lesion
A
Contralateral hemiballismus
20
Q
Hippocampus lesion bilateral
A
Anterograde amnesia - inability to make new memories
21
Q
Paramedian pontine reticular formation lesion
A
Eyes look away from side of lesion
22
Q
Frontal eye field lesion
A
Eyes look towards lesion
23
Q
MCA stroke
A
1) Motor cortex - upper limb and face: Contralateral paralysis of upper limb and face
2) Sensory cortex - upper limb and face: Contralateral loss of sensation of upper limb and face
3) Temporal lobe (Wernicke), Frontal lobe (Broca): Aphasia if in dominant (usually left) hemisphere. Hemineglect if lesion affects nondominant (usually Right) hemisphere
24
Q
ACA stroke
A
1) Motor cortex - lower limb: Contralateral paralysis of lower limb
2) Sensory cortex - lower limb: Contralateral loss of sensation of lower limb
25
Lenticulo-striate artery stroke
Striatum, internal capsule: Contralateral hemiparesis/hemiplegia
Common location of lacunar infarcts secondary to unmanaged HTN
26
Anterior Spinal Artery stroke
1) Lateral corticospinal tract - Contralateral hemiapresis of upper and lower limbs
2) Medial lemniscus - reduced contralateral proprioception
3) Caudal medulla, hypoglossal nerve - ipsilateral hypoglossal dysfunction (tongue deviates ipsilaterally)
Stroke is commonly bilateral
Medial Medullary Syndrome - Caused by infarct of paramedian branches of ASA and vertebral arteries
27
PICA stroke
Lateral medulla - vestibular nuclei, lateral spinothalamic tract, spinal trigeminal nucleus, nucleus ambiguus, sympathetic fibers, inferior cerebellar peduncle
Vomiting, vertigo, nystagmus; reduced pain and temp senseation from ipsilateral face and contralateral body; DYSPHAGIA, HOARSENESS, lower gag reflex; ipsilateral Horner; ataxia, dysmetria
Lateral Medullary (Wallenburg) Syndrome - Nucleus Ambiguus effects are specific to PICA. Don't PICK A (PICA) HORSE (horseness) that CANT EAT (dysphagia)
28
AICA stroke
1) Lateral pons - cranial nerve nuclei; vestibular nuclei, facial nucleus, spinal trigeminal nucleus, cochlear nuclei, sympathetic fibers
Vomiting, vertigo, nystagmus. PARALYSIS OF FACE. reduced lacrimation, salivation. Reduced taste from anterior two thirds of tongue
Ipsilateral reduced pain and temp of the face, contralateral loss of pain and temp of body
2) Middle and inferior cerebellar peduncles - ataxia, dysmetria
Lateral Pontine Syndrome - facial nucleus effects are specific to AICA lesions. Facial droop means AICA's pooped.
29
PCA stroke
Occipital cortex, visual cortex - Contralateral hemianopia with macular sparing
30
Basilar stroke
Pons, medulla, lower midbrain, corticospinal and corticobulbar tracts, ocular cranial nerve nuclei, PPRF
Preserved consciousness and blinking, quadriplegia, loss of voluntary facial, mouth, and tongue movements
"locked in"
31
ACom lesion
Most common lesion is aneurysm. Can lead to stroke. Saccular (berry) aneurysm can impinge cranial nerves
Visual field defects
Lesions are typically aneurysms not strokes
32
PCom lesion
Common site of saccular aneurysm
CN3 palsy - eye is down and out with ptosis and mydriasis
Lesions are typically aneurysms not strokes
33
Where does most CSF drain?
Superior sagittal sinus via arachnoid granulations
34
CSF route
Lateral ventricle to 3rd ventricle via R and L interventricular foramina of Monro
3rd to 4th via cerebral aqueduct of Sylvius
4th to subarachnoid space via Foramina of Luschka (lateral) and Magendie (medial)
35
Communicating hydrocephalus
Lower CSF absorption by arachnoid granulations leads to higher ICP, papilledema, herniation (think arachnoid scar post meningitis)
36
NPH
Type of communicating hydrocephalus
Affects the elderly; idiopathic; CSF pressure elevated only episodically; does not result in increased subarachnoid space volume.
Expansion of ventricles distorts the fibers of the corona radiata (nerve fibers running along ventricles) leading to triad of urinary incontinence, ataxia and cognitive dysfunction (sometimes reversible)
LP improves symptoms
Tx = VP Shunt (shunt CSF from ventricles into peritoneum)
37
Noncommunicating (obstructive) hydrocephalus
Caused by structural blockage of CSF circulation within ventricular system (stenosis of aqueduct of Sylvius; colloid cyst blocking foramen of Monro)
38
Ex vacuo ventriculomegaly
Appearance of increased CSF on imaging, is actually due to decreased brain tissue (neuronal atrophy)
Ex = AD, advanced HIV, Pick Disease
ICP normal. Triad not seen.
39
ALS lesion pattern
Coritcospinal (UMN signs) and ant motor horn (LMN signs)
No sensory (distinguishes from syringomyelia) or oculomotor deficits. Can be caused by defect in superoxide dismutase I.
Fasciculations with eventual atrophy and weakness of hands; fatal
Riluzole modestly increases survival by lowering presynaptic glutamate release (it's a glut antag)
40
Complete occlusion of ASA
Spares dorsal column and Lissauer tract; upper thoracic ASA territory is watershed area as artery of Adamkiewicz supplies ASA below T8
41
Tabes Dorsalis
Caused by tertiary syphilis. From degeneration (demyelination) of dorsal columns and roots leading to impaired sensation and proprioception, progressive sensory ataxia (inability to sense or feel the legs leading to poor coordination)
Associated with Charcot joints, shooting pain, Argyll pupils
Exam shows no DTRs and positive Romberg
42
Syringomyelia
Syrinx expands and damages anterior white commissure of spinothalamic tract (second order neurons) leading to bilateral loss of pain and temperature sensation (C8-T1)
Seen with Chiari I malformation
Can expand and affect other tracts
43
Brown Sequard
Hemisection of spinal cord
1) Ipsilateral UMN signs below level of lesion (due to corticospinal tract damage)
2) Ipsilateral loss of tactile, vibration, proprioception sense below level of lesion (dorsal column damage)
3) Contralateral pain and temp loss below level of lesion (spinothalamic lesion)
4) Ipsilateral loss of all sensation at level of lesion
5) Ipsilateral LMN signs (flaccid paralysis) at level of lesion
If lesion is above T1 you might see Horner due to damage of oculosympathetic pathway
44
Friedreich Ataxia
Auto recessive GAA repeat disorder on chromosome 9 in gene that encodes frataxin (iron binding protein)
Leads to impairment in mitochondrial functioning. Degeneration of multiple spinal cord tracts leads to muscle weakness and loss of DTRs, vibratory sense, proprioception
Staggering gait, frequent falling, nystagmus, dysarthria, pes cavus, hammer toes, diabetes mellitus, hypertrophic cardiomyopathy (cause of death). Present in childhood with kyphoscoliosis
If you cant regulate Fe right you get more ROS due to Fentin reaction
Friedrich is Fratastic (frataxin); he's your favorite frat brother, always staggering and falling but he as a sweet, big heart.
45
Dermatome landmarks
C2 - posterior half of a skull cap
C3 - high turtleneck shirt
C4 - low collar shirt
T4 - at nipple
T7 - xyphoid
T10 - umbilicus
L1 - inguinal ligament
L4 - includes kneecaps
S2,3,4 - erection and sensation of penile and anal zones
46
Clinical reflexes
Biceps - C5 nerve root
Triceps - C7 nerve root
Patella - L4 nerve root
Achilles - S1 nerve root
S1,2 - buckle my shoe (Achilles)
L3,4 - kick the door (patellar)
C5,6 - pick up sticks (biceps)
C7,8 - lay them straight (triceps)
L1,L2 testicles move (cremaster)
S3,S4 winks galore (anal wink)
47
Cranial nerve nuclei locations
Midbrain - 3,4
Pons - 5,6,7,8
Medulla - 9,10,12
Spinal cord - 11
Lateral nuclei are sensory (alar plate). Medial are motor (basal plate)
48
CN 1 exit
Cribiform plate
49
CN 2-6 exit
Middle cranial fossa through sphenoid bone
Optic canal = 2
Superior orbital fissure = 3, 4, V1, 6
Foramen Rotundum = V2
Foramen Ovale = V3
Foramen spinosum = middle meningeal artery
50
CN 7-12 exit
Posterior cranial fossa through temporal or occipital bone
Internal auditory meatus = 7, 8
Jugular foramen = 9, 10, 11, jugular vein
Hypoglossal canal = 12
Foramen magnum = spinal roots of 11, brain stem, vertebral arteries
51
Vagal nuclei
1) Nucleus Solitarius - Visceral sensory information (taste, baroreceptors, gut distention) 7, 9, 10
2) Nucleus ambiguus - Motor innervation of pharynx, larynx, upper esophagus (swallowing, palate elevation) 9, 10, 11 (cranial portion)
3) Dorsal motor nucleus - sends autonomic (parasympathetic) fibers to heart, lungs, upper GI - 10 only
52
CN V lesion
Jaw deviates toward side of lesion due to unopposed force from the opposite pterygoid muscle
53
CN X lesion
Uvula deviates away from side of lesion. Weak side collapses and uvula pulls away
54
CN XI lesion
Weakness turning head to contralateral side of lesion (SCM). Shoulder drop on side of lesion (trap).
Left SCM contracts to help turn the head to the right.
55
CN XII lesion (LMN)
Tongue deviates toward side of lesion ("lick your wounds") due to weakened tongue muscles on affected side
56
Cavernous Sinus Syndrome
Presents with variable ophthalmoplegia, lower corneal sensation, Horner and occasional decreased maxillary sensation. Secondary to pit tumor mass effect, carotid-cavernous fistula, or cavernous sinus thrombosis related to infection.
CN 6 is most susceptible to injury
57
Cavernous sinus
Collection of venous sinuses on either side of pit. Blood from eye and superficial cortex leads to cavernous sinus then IJ vein
CN 3, 4, V1, 6 and sometimes V2 plus postganglionic sympathetic pupillary fibers enroute to orbit all pass through it
Cavernous portion of internal carotid is here too.
58
Hearing loss types
1) Conductive - Rinne is abnormal ( bone is more than air). Weber localizes to affected ear
2) Sensorineural - Normal rinne (air is more than bone). Weber localizes to unaffected ear.
59
UMN facial lesion
Lesions of motor cortex or connection btw cortex and facial nucleus .
Contralateral paralysis of lower face
Forehead spared due to bilateral UMN innervation
60
LMN facial lesion
Ipsilateral paralysis of upper AND lower face
61
Facial nerve palsy
Complete destruction of the facial nucleus itself or its branchial efferent fibers (facial nerve proper)
Peripheral ipsilateral facial paralysis (absent forehead creases and drooping smile) with inability to close eye on involved side
Can occur idiopathically (bell's) - gradual recovery in most cases
Associated with Lyme, herpes simplex and zoster (Ramsay Hunt), sarcoid, tumors, diabetes
Tx = steroids
62
Conditions associated with facial nerve palsy
Lyme
herpes
Zoster
Sarcoid
Tumors
Diabetes
Bells
63
Familial AD altered proteins
ApoE2 - lower risk
ApoE4 - higher risk
APP, Presenilin1, presenilin2 - higher risk of early onset
64
FTD
AKA Pick Disease
Dementia, aphasia, parkinsonian aspects; change in personality
Spares parietal lobe and posterior two thirds of superior temporal gyrus (AD is diffuse cortex)
Pick Bodies - silver staining spherical tau protein (round not neurofibrillary) aggregates
65
AD pathology
Widespread cortical atrophy. Narrow gyri, wider sulci
Less ACh
Seniles plaques in gray matter. Extracellular B-amyloid core. May cause amyloid angipathy (weakens vessels) leading to intracranial hemorrhage.
AB made by cleaving APP
Neurofibrillary tangles intracellularly
Hyperphosphorylated tau - insoluble cytoskeletal elements. Number of tangles correlates with degree of dementia
Confirmed with pathology at autopsy
66
CJD
Rapidly progressive (wks to months) dementia with myoclonus (startle myoclonus)
Spongiform cortex
Prions (PrPc becomes PrPsc which is a B pleated sheet resistant to proteases)
Ataxia. Spike complexes on EEG.
67
PML
Demyelination of CNS due to destruction of oligodendrocytes. Associated with JC virus. Seen in 2-4% of AIDS patients (reactivation of latent virus). Rapidly progressive, usually fatal.
Increased risk with natalizumab and rituximab
68
Charcot-Marie-Tooth Disease
AKA hereditary motor and sensory neuropathy (HMSN)
Group of progressive hereditary nerve disorders related to defective production of proteins involved in structure and function of peripheral nerves or myelin sheath
Autosomal dominant.
Scoliosis and foot deformities (high or flat arches)
69
Metachromatic leukodystrophy
Auto recessive lysosomal storage disease (myelin built up in lysosomes)
Arylsulfatase A deficiency
Buildup of sulfatides leads to impaired production and destruction of myelin sheath
Central/peripheral demyelination with ataxia, dementia
70
Krabbe Disease
Auto recessive LSD from def in galactocerebrosidase
Buildup of galactocerebroside and psychosine in macrophages destroys myelin sheath
Peripheral neuropathy, developmental delay, optic atrophy, globoid cells
71
What vaccines most associated with ADEM?
smallpox and rabies
72
Subacute sclerosing panencephalitis
Gray AND white matter
Slowly progressing, persistent infection of brain by measles virus.
Infection in infancy leads to neuro signs years later
Viral inclusion bodies within neurons (gray matter) and oligodendrocytes (white matter)
Leads to death
73
Adrenoleukodystrophy
X-linked - affects males usually
Disrupted metabolism of VLC fatty acids
Buildup in nervous system, adrenal gland, testes
Progressive disease that can lead to long-term coma/death and adrenal gland crisis
74
Sturge-Weber Syndrome
Neurocutaneous disorder
Congenital, non-inherited, developmental anomaly of neural crest derivatives (mesoderm/ectoderm) due to activating mutation of GNAQ gene.
Affects small (capillary sized) blood vessels leading to port wine stain of the face (nevus flammeus, non-neoplastic birthmark in V1, V2 distribution)
Ipsilateral leptomeningeal angioma leading to seizures/epilepsy
Intellectual disability
Episcleral hemangioma leading to increased IOP leading to early-onset glaucoma
SSTURGGE: Sporadic, port wine Stain, Tram track calcifications (opposing gyri), Unilateral; Retarded; Glaucoma; GNAQ: Epilepsy
75
Tuberous Sclerosis
neurocutaneous
HAMARTOMAS:
```
Hamartomas in CNS and skin
Angiofibromas
Mitral Regurg
Ash-leaf spots
Rhabdo
Tuberous sclerosis
autosomal dOminant
Mental retardation
renal Angiomyolipoma
Seizures
Shagreen patches
```
Increased incidence of subependymal astrocytoma and ungual fibromas
76
NF1
Von Recklinghausen Disease
```
Cafe-au-lait spots
Lisch nodules (pigmented iris hamartomas)
Cutaneous neurofibromas
Optic gliomas
Pheochromocytoma
```
Mutated NF1 tumor suppressor gene (neurofibromin is a negative regulator of RAS) on chromosome 17
Skin tumors of NF1 are derived from neural crest cells
77
Von Hippel Lindau Disease
neurocutaneous
Hamangioblastomas (high vascularity with hyperchromatic nuclei) in retina, brain stem, cerebellum, spine
Angiomatosis (cavernous hemangiomas in skin, mucosa, organs)
Bilateral renal cell carcinomas
Pheochromocytomas
78
Peripheral vertigo
More common. Inner ear etiology (semicircular canal debris, vestibular nerve infection, meniere disease)
Positional testing leads to delayed horizontal nystagmus
79
Central vertigo
Brain stem or cerebellar lesion (stroke affecting vestibular nuclei or posterior fossa tumor)
Findings: directional change of nystagmus, skew deviation, diplopia, dysmetria. Positional testing leads to immediate nystagmus in any direction; may change directions
Focal neuro findings
80
GBM
AKA Grade 4 astrocytoma
Common. Most common CNS tumor in adults. Highly malignant primary brain tumor with 1 year median survival.
Found in cerebral hemispheres. Can cross corpus (butterfly)
Stain astrocytes for GFAP
Histo: Pseudopalisading pleomorphic tumor cells - border central areas of necrosis and hemorrhage
81
Meningioma
Females more than Males
Common. Usually benign primary brain tumor
Most often in convexities of hemispheres (near surfaces of brain) and parasagital region
Arises from arachnoid cells, is extra-axial (external to brain parenchyma) and may have a dural attachment (tail)
often asymptomatic
May present with seizures or focal neuro signs
Resection and/or radiosurgery
Histo: Spindle cells in a whorled pattern with psammoma bodies
Expresses estrogen receptor
82
Hemangioblastoma
Most often cerebellar
Associated with von-hippel lindau when found with retinal angiomas.
Can produce EPO causing secondary polycythemia
Histo: Close, thin walled capillaries with little intervening parenchyma
83
Schwannoma
Classically at cerebellopontine angle, but can be along any peripheral nerve. Benign
Schwann cell origin. S-100 positive.
Often localized to CN8 leading to vestibular schwannoma.
Resectable or treated with stereotactic radiosurgery
Bilateral vestibular schwannomas are found in NF2
84
Oligodendroglioma
malignant
Rare. Slow growing. Frontal lobes. Chicken wire capillary pattern
Histo: oligodendrocytes = fried egg cells. they're often calcified here.
85
Low grade (pilocytic) astrocytoma
Kid brain tumor. #1 in kids.
Usually well circumscribed. In children, most often found in posterior fossa/cerebellum. May be supratentorial. GFAP positive.
Benign with good prognosis.
Rosenthal fibers - eosinophils, corkscrew fibers
86
Medulloblastoma
Kids
Highly malignant. A form of primitive neuroectodermal tumor. Can compress 4th ventricle, causing hydro.
Can send "drop mets" to spinal cord
Homer-Wright rosettes. Solid. small blue cells.
87
Ependymoma
Ependymal cell tumors most commonly found in 4th ventricle. Can cause hydro. Poor prognosis
Perivascular rosettes. Rod-shaped blepharoplasts found near nucleus.
Kids
88
Craniopharyngioma
Benign kid tumor that may be confused for pit adenoma (can both cause bitemporal hemianopsia). Most common kid supratentorial tumor.
Can recur after resection
From epithelial remnants of Rathke's pouch.
89
Polymyalgia rheumatica
Does NOT cause weakness
Pain and stiffness in shoulders and hips
Often with fever and malaise and weight loss
More in women over 50.
Associated with temporal arteritis
High ESR, High CRP, normal CK
Tx = steroids
90
Axillary nerve
C5-C6
Injury from: Fractured surgical neck of humerus; anterior dislocation of humerus
Flattened deltoid
Loss of arm abduction at shoulder
Loss of sensation over deltoid muscle and lateral arm
91
Musculocutaneous nerve
C5-C7
Injury: Upper trunk compression
Loss of forearm flexion and supination
Loss of sensation over lateral forearm
92
Radial nerve
C5-T1
Injury: Midshaft fracture of humerus, compression of axilla (crutches or sleeping with arm over chair)
Wrist drop: loss of elbow, wrist and finger extension
Reduced grip strength (wrist extension necessary for maximal action of flexors)
Loss of sensation over posterior arm/forearm and dorsal hand
93
Median nerve
C5-T1
Injury: Supracondylar fracture of humerus (prox lesion); carpel tunnel and wrist laceration (distal lesions)
"Ape Hand" and "pope blessing"
Loss of wrist flexion, flexion of lateral fingers, thumb opposition, lumbricals of 2nd and 3rd digits
Loss of sensation over thenar eminance and dorsal and palmar aspects of lateral 3.5 fingers with prox lesion
Tinel sign (tingling on percussion) in carpal tunnel syndrome
94
Ulnar nerve
C8-T1
Injury: Fracture of medial epicondyle of humerus (proximal lesion) or fractured hook of hamate (distal lesion)
"Ulnar claw" on digit extension
Radial deviation of wrist upon flexion (prox)
Loss of wrist flexion, flexion of medial fingers, abduction and adduction of fingers (interossei), actions of medial 2 lumbrical muscles
Loss of sensation over medial 1.5 fingers including hypothenar eminence
95
Recurrent branch of median nerve
C5-T1
Injury: Superficial laceration of palm
"Ape hand"
Loss of thenar muscle group: opposition, abduction, and flexion of thumb
No loss of sensation
96
Erb Palsy
"waiter tip"
Injury: Traction or tear of upper trunk c5-c6 roots
Causes: infants - lateral traction on neck during delivery. Adults - trauma
Deltoid, supraspinatus - abduction (arm hangs by side)
Infraspinatus - lateral rotation (arm is medially rotated)
Biceps brachii - flexion, supination (arm extended and pronated)
97
Klumpke palsy
Injury: Traction or tear of lower trunk C8-T1 root
Infants - upward force on arm during delivery. Adults - trauma like grabbing tree branch to break a fall
Intrinsic hand muscles: Lumbricals, interossei, thenar, hypothenar - total claw hand: lumbricals normally flex MCP joints and extend DIP and PIP joints
98
Thoracic outlet syndrome
Injury: Compression of lower trunk and subclavian vessels
Causes: cervical rib, pancoast tumor
Same as Klumpke palsy - atrophy of intrinsic hand muscles, ischemia, pain, edema due to vascular compression
99
Winged scapula
Lesion of long thoracic nerve
Axillary node dissection after mastectomy, stab wounds
Serratus anterior - inability to anchor scapula to thoracic cage leading to inability to abduct arm above horizontal position
100
Ulnar claw vs pope blessing
Look the same. Context is different.
Extending fingers/at rest - distal ulnar nerve, ulnar claw
While making a fist - prox median nerve, pope blessing
101
Median claw vs OK gesture
Look the same. Context is different
Extending fingers/at rest - distal median nerve, median claw
While making a fist - prox ulnar nerve, OK gesture (digits 1-3 flexed)
102
Interossei muscles
DAB and PAD
Dorsals ABduct the fingers
Palmars ADduct the fingers
103
Hand muscles
Thanar - Opponens, Abductor pollicis brevis, Flexor pollicis brevis (deep head of ulnar nerve)
Oppose, Abduct, Flex (OAF) - same for hypothenar
Hypothenar - Opponens digiti minimi, Abductor digiti minimi, Flexor digiti minimi
104
Obturator nerve
L2-L4
Cause of injury: pelvic surgery
Reduced thigh sensation (medial) and reduced adduction
105
Femoral nerve
L2-L4
Cause of injury: Pelvic fracture
Reduced thigh flexion and leg extension
106
Common peroneal nerve
L4-S2
Cause of injury: Trauma or compression of lateral aspect of leg, fibular neck fracture
Foot drop - inverted and plantarflexed at rest, loss of eversion and dorsiflection.
"steppage gait"
Loss of sensation on dorsum of foot
107
Tibial nerve
L4-S3
Cause of injury: Knee trauma, Baker cyst (prox lesion); tarsal tunnel syndrome (distal lesion)
Inability to curl toes and loss of sensation on sole of foot
In prox lesions, foot everted at rest with loss of inversion and plantarflexion
108
Superior gluteal nerve
L4-S1
Cause of injury: Iatrogenic injury during intramuscular injection to upper medial gluteal region
Trandelenburg gait - pelvis tilts bc weight-bearing leg cannot maintain alignment of pelvis through hip abduction (superior nerve leads to medius and minimus)
Lesion is contralateral to side of the hip that drops, ipsilateral to extremity on which the patient stands
109
Inferior gluteal nerve
L5-S2
Cause of injury: Posterior hip dislocation
Difficulty climbing stairs, rising from seated position
Loss of hip extension (inferior nerve is to maximus)
110
Peroneal vs Tibial
PED TIP
Peroneal Everts and Dorsiflexes. If injured, foot DropPED
Tibial Inverts and Plantarflexes. If injured, cant stand on TIP toes.
111
Branches of sciatic nerve
Sciatic nerve (L4-S3) branches into common peroneal and tibial nerves
112
Signs of L3-L4 disc level radiculopathy
Affects L4 spinal nerve
Weakness of knee extension. Reduced patellar reflex.
113
Signs of L4-L5 disc level radiculopathy
Affects L5
Weakness of dorsiflexion, difficulty in heel-walking
114
Signs of L5-S1 disc level radiculopathy
Affects S1
Weakness of plantarflexion, difficulty in toe walking. Reduced achilles reflex.
115
Ddx of vertigo (9)
1) BPPV
2) Vestibular migraine
3) Vestibular epilepsy
4) Vertebrobasilar insufficiency
5) Meniere Disease
6) Viral vestibular neuronitis
7) Acute suppurative labyrinthitis
8) Acute serous labyrinthitis
9) Herpes zoster oticus (Ramsay Hunt)
116
BPPV
Duration of vertigo attacks: 5-30s
Duration of Symptoms: Repeated attacks over weeks, months, or even years
Associated Symptoms: None
Principle Physical finding: Latent**, geotropic nystagmus with reversibility and fatigue*** on Dix-Hallpike
Tx: Canalith repositioning procedure, Brandt-Daroff exercises
117
Vestibular migraine
Duration of vertigo attacks: Seconds - minutes
Duration of Symptoms: Minutes - hours, recurrent attacks
Associated Symptoms: HA, scintillations, other neurologic symptoms (weakness or numbness of extremity), changes in speech, etc
Principle Physical finding: Usually normal physical exam
Tx: Either suppressive or abortive tx for migraines, refer to neurologist
118
Vestibular epilepsy
Duration of vertigo attacks: Seconds - minutes
Duration of Symptoms: Minutes, recurrent episodes
Associated Symptoms: Loss of consciousness, other neuro symptoms
Principle Physical finding: Usually normal PE
Tx: AEDs, refer to neuro
119
Vertebrobasilar insufficiency
Duration of vertigo attacks: Seconds to minutes
Duration of Symptoms: Repeated episodes or evolving symptoms over weeks
Associated Symptoms: Changes in speech or swallowing, cerebellar symptoms, history consistent with atherosclerosis
Principle Physical finding: Can be normal, might have cranial nerve findings, cerebellar signs, or carotid bruit
Tx: Antiplatelet therapy, management of risk factors
120
Meniere Disease
Duration of vertigo attacks: 20mins to 24h
Duration of Symptoms: Repeated episodes over weeks to months to years
Associated Symptoms: Aural pressure, low pitch (roaring) tinnitus, low frequency hearing loss
Principle Physical finding: Nystagmus during an attack, normal ear exam, might have hearing loss on audiogram, vestibular weakness on ENG
Tx: Low salt diet and diuretic therapy. Might need vestibular suppressants, might need vestibular ablative therapy or nerve section
121
Viral vestibular neuritis
Duration of vertigo attacks: 24h or more
Duration of Symptoms: Several days, resolving over a few weeks as vestibular compensation occurs
Associated Symptoms: n/v
Principle Physical finding: horizontal nystagmus when patient is seen early in course, otherwise normal exam, vestibular weakness on ENG
Tx: Supportive care, anti-emetics, possibly vestibular suppressants, might need vestibular rehab therapy
122
Acute suppurative labyrinthitis
Duration of vertigo attacks: 2-3d
Duration of Symptoms: Several days, resolving over a few weeks as vestibular compensation occurs
Associated Symptoms: Severely ill with nausea and vomiting, hearing loss, tinnitus, otorrhea
Principle Physical finding: Otitis media or cholesteatoma, nystagmus early in presentation, possible facial paralysis from cholesteatoma
Tx: IV ABx and possibly surgery
123
Acute serous labyrinthitis
Duration of vertigo attacks: 2-3d
Duration of Symptoms: Several days, resolving over a few weeks as vestibular compensation occurs
Associated Symptoms: Hearing loss, tinnitus, nausea and vomiting
Principle Physical finding: History of past otologic surgery, nystagmus early in presentation
Tx: Supportive care with anti-emetics, possible vestibular suppressants, might need vestibular rehab, use steroids if hearing loss is present
124
Herpes zoster oticus (Ramsay Hunt)
Duration: 2-3d
Duration of symptoms: Acute illness lasts approx 7-10d, residual symptoms can be long lasting
Associated symptoms: Herpetic rash in ear, retro-auricular pain, hearing loss
Principle Physical finding: Facial paralysis, hearing loss
Tx: Antiviral medications, steroids, might need vestibular rehab
125
NE anomalies
High in anxiety
Low in depression
Made in locus ceruleus (pons)
126
Dopamine anomalies
High in HD
Low in PD
Low in Depression
Made in ventral tegmentum and substantia nigra pars compacta (midbrain)
127
5-HT anomalies
Low in anxiety and depression
Made in Raphe nucleus (pons, medulla, midbrain)
128
ACh anomalies
High in PD
Low in AD
Low in HD
Made in basal nucleus of meynert
129
GABA anomalies
Low in anxiety and HD
Made in nucleus accumbens
130
ADH and oxytocin source
hypothalamus to posterior pit
ADH - supraoptic nucleus
Oxytocin - Paraventricular nucleus
131
Lateral hypo
Hunger. Destruction leads to anorexia, failure to thrive (infants)
Inhibited by leptin
132
Ventromedial hypo
Satiety. Destruction (craniopharyngioma) leads to hyperphagia
Stimulated by leptin
133
Anterior hypo
Cooling, parasympathetic
Think AC. Ant Cool
134
Posterior hypo
Heating, sympathetic
Lesion makes you cold
135
Suprachiasmatic nucleus of hypo
Circadian rhythm
136
Circadian rhythm
Driven by SCN. Controls nocturnal release of ACTH, prolactin, melatonin, NE
SCN releases NE causing pineal gland to release melatonin. SCN is regulated by environment (light)
137
Stages of sleep
Awake (eyes open) - alert, active mental concentration - Beta (highest freq, low amp) waves on EEG
Awake (eyes closed) - Alpha waves
Non-REM
1) Stage N1 (5%) - light sleep - Theta waves
2) Stage N2 (45%) - deeper sleep, when bruxism occurs - Sleep spindles and K complexes
3) N3 (25%) - Deepest non-REM (slow wave sleep). When sleepwalking, night terrors, and bedwetting occur. Delta waves (lowest freq, highest Amp)
REM - loss of motor tone. Increased brain O2. Increased and variable pulse and blood pressure. When dreaming and penile/clit tumescence occur. May serve memory processing function. beta waves (like being awake and eyes open)
At night BATS Drink Blood (Beta, Alpha, Theta, Spindles, Delta, Beta)
138
Bedwetting
Treat with oral desmopressin (ADH). Preferred over imipramine bc of side effects
139
Night terrors and sleepwalking
Treat with benzos
140
Benzos and sleep
Benzos, alcohol, and barbs reduce REM sleep and delta wave sleep. NE also lowers REM sleep.
141
REM frequency
Every 90 minutes. Duration of each time increases throughout the night.
142
Osmotic demyelination syndrome
Acute paralysis, dysarthria, dysphagia, diplopia, LOC
Can cause locked in syndrome.
Massive axonal demyelination in pontine white matter secondary to osmotic changes. Commonly iatrogenic, caused by overly rapid correction of hypoNa
Correcting hyperNa too quickly causes cerebral edema/herniation
ODS can also occur in severely malnourished patients (alocholic or liver disease)
Correcting Na: From low to high your pons will die. From high to low your brain will blow.
143
VPL nuc of thalamus
Gets input from spinothalamic and dorsal column/ML pathways.
Pain, temp, pressure, touch, vibration, proprioception.
Destination to primary somatosensory cortex
144
VPM nuc of thalamus
From trigeminal and gustatory pathway
Face sensation, taste
Goes to primary somatosensory cortex
"M-akeup goes on the Face"
145
LGN of thalamus
From CN2
To Calcarine sulcus
Vision
L-ateral = Light
146
MGN of thalamus
From superior olive and inferior colliculus of tectum
To Auditory cortex of temporal lobe
Hearing
M-edial = Music
147
VL nuc of thalamus
From basal ganglia and cerebellum
To motor cortex
Motor
