Neuro Block 3 Flashcards
clostridia
gram positive
spore forming
anaerobes
rods
clostridia tetani
in soil/feces
penetrate wounds and release toxin (tetanospasmin)
spastic paralysis
generalized - most common in US, 3-21 days, muscle rigidity, supportive care (benzos, respirator), give tetanus immune globulin. give tD booster
clostridia botulinum
classic - ingested from canned foods, flaccid paralysis, cook is usually victim, CNS not affected, die from respiratory paralysis, 12-48 hours, antitoxin then supportive care
infants - feed honey, non fatal, infection, constipation/respiratory distress
protozoa
usually ingest cyst
lumen dwelling and blood tissue
naegleria
warm brakish and fresh water
have flagella
Primary Amebic Meningoencephalitis (PAM) - fatal, CNS infection (eat away), CSF cloudy w increased proteins, increased neutrophils, increased pressure, decreased glucose, treat with amphotericin B
acanthamoeba
freshwater and soil
cyst double refraction
granulamtous amebic encephalitis (necrotizing cerebellum, midbrain, brainstem)
develops slowly and leads to confusion, dizziness, hallucinations
keratitis - opaque cornea, usually from rinsing eyes with tap water, treat with intraconeuzole and narcotics for pain
toxoplasma gondii
toxoplasmosis
immunocompromised affected
in outdoor cats feces/tissue cysts in meats
can cross placenta
ring enhancing lesions on CT (AIDS)
infants get hydrocephaly then fluid is absorbed and have microcephaly
tx - pyrimethamine and sulfadiazine
trypanosomes
east African sickness - acute
west african sickness - chronic
from tsese flies
cervical lymphedemopathy
Herpes viridae
exposed by close body contact
goes latent (ganglia for HSV)
no humoral or cell mediated immunity prevent latency
HSV
90% of adults exposed
stomatisis - cold sores
virus replicates at initial site then moves to ganglia, heals without scarring
can get reactivation
treat with acyclovir
ocular herpes
dendritic branching ulcers
HSV1 encephalitis
most common cause of encephalitis in adults
red blood cells in csf
cytomegalovirus
almost all people have it
in US adults get exposed with sexual contact
#1 congenital infection - not affected mother (seronegative) gets exposed in first or second trimester leading to fetal hearing loss and retardation, has owls eye inclusions
tx - gangcyclovir
rhabdovirus
rabies
single stranded negative RNA
in rabid animals and you must be bitten
14-90 days
neurotrophic
negri bodies
post exposure prophylaxis 5 ml rabies antitoxin
can use rabies immune globulin as well
bacterial meningitis
infection, pus (neutrophils) in subarachnoid space
can result in communicating hydrocephalus
cortical vessels engorged and can thrombose
can spread to brain (cerebritis) and ventricals
CSF - high WBC (neutrophils), high protein, low glucose
bacteria - depends on age, S. pneumoniae and N. meningitidis common in children and adults
viral meningitis (aseptic)
mostly viral (enterovirus often)
CSF - high WBC (lymphocytes), moderately elevated protein, normal glucose
focal lesions
abscess in brain
liquefacive necrosis surrounding by granulation tissue and fibrotic rim
edema and possible herniation, seizure focus
often streptococci and staphylococci
CSF - increased pressure, high WBC, normal glucaose
TB
thick exudate in subarachnoid space
granulomatous
worse at base of brain
CSF - moderate WBC, high protein, glucose normal
neurosyphilis
meningovascular - chronic meningitis, cerebral gummas
paretic - spirochetes within brain, dementia
tabes dorsalis - immunologic injury to dorsal root ganglia, degeneration of posterior columns
viral encephalitis
microglial nodules, intracellular inclusions, perivascular cuffing by lymphocytes
arbo virus - arthropod vectors, can cause necrosis and be fatal
herpes - HSV 1 involves temporal and inferior frontal lobes/inflammation/necrosis/neurons with intracellular inclusions, HSV 2 neonatla/extensive necrosis
varicella zoster
latent in ganglia following chickenpox
vesicular eruptions in dermatomal distribution
cytomegalovirus
can cause congenital malformations
affects immunocompromised, large intracellular inclusions, can involve ependymal and paraventricular areas
rabies
via bites and contact with infected animals
retrograde transport in peripheral nerves, slow
encephalitis, negri bodies
spasms of throat, difficulty swallowing, aspiration of fluids (hydrophobia)
fungal
often in inmmunocompromised
cryptococcal - meningitis follows perivascular spaces into brain, prominent cysts in oraganisms in basal ganglia
aspergillus - invades and occludes vessels, causes hemorrhagic infarcts
protozoal
toxoplasmosis - immunocompromised, can infect fetus (cerebritis followed by calcification), areas of necrosis, cysts and free organisms
amebiasis - naegrleria spp. (swimming, rapid fatal encephalitis), acanthamoeba (chronic granulomatous meningoencephalitis)
prion disease
due to abnormal protein (prion protein) that can change normal protein into abnormal form (no nucleic acid)
familial forms exist
difficult to decontaminate - iatrogenic forms occur
creutzfeldt jacob disease
valine at codon 129
spongiform change, neuronal loss, gliosis in cortex
rapidly progressive dementia, motor signs (myoclonus), EEG changes
variant CJD
transmission of bovine spongiform encephalopathy
unusal features - amyloid plaque, younger patients, psychiatric symptoms
fatal familial insomnia
autonomic disturbances, insomnia
methionine at codon 129
thalamus affected more than cortex
gerstmann straussler scheinker
familial
affects cerebellum
amyloid plaques
suicide
men (peak 45) more than women (peak 55)
higher social status higher risk
increases slightly during fall and spring
1/3 see doctor within 6 months of death
95% have mental disorder
bacterial meningitis presentation
fever, headache, nuchal rigidity
rarely present until 12-24 hours after symptom onset
infants - less active, irritable, poor feeding, floppy body, swelling fontanelle
most common causes bacterial meningitis
steptococcus pneumoniae
streptococcus agalactiae (strep B)
neisseria meningitidis
haemophilus influenzae
strep pneumoniae
lancet shaped gram positive diplococci
capsule inhibit phagocytosis
pneumococcal proteins play role in virulence - IgA protease and pneumolysin
strep agalactiae (group B)
gram positive cocci chains
in vagina and GI tract
cause pneumonia, septicemia, meningitis
leading cause meningitis in first week of life
long term neuro probs common
neisseria meningitidis
aerobic or facultative anaerobic gram negative diplococcus
asymptomatic in nasopharynx of 5-30% general pop
invades blood stream and causes robust immune response (primary route to brain)
virulence factors - capsule, pili, opacity proteins, meningococcal seine protease A, lipooligosaccharide, human factor H binding proteins
complications - septic shock, disseminated intravascular coagulation, waterhouse friedrichson syndrome
haemophilus influenzae
facultative anaerobic gram negative coccobacillus
commonly ear infections in kids
virulence factors - lipooligosaccharide, fimbriae, capsule, exoenzymes (IgA protease, beta lactamase)
empiric therapy for bacterial meningitis
less than 1 month - ampicillin and gentamycin
1 month - 50 years ceftriaxone and vancomycin
50 and older - ceftriaxone, vancomycine, ampicillin
chemoprophylaxis
n meningitidis - ceftriaxone
h influenzae - rifampin
definitive therapy h influenzae
ceftriaxone
prophylaxis rifampin
can get vaccine to reduce risk
definitive therapy n meningitidis
ceftriaxone
prophylaxis ceftriaxone as well
meningococcal vaccine
definitive therapy s pneumoniae
ceftriaxone plus vancomycin
if susceptible to cephalosporin just ceftriaxone
pneumococcal vaccine
definitive therapy L monocytogenes
ampicillin
can be ampicillin and gentamicin
definitive therapy S algalactiae
ampicillin or penicillin
if allergic use cephalosporin like cefazolin (mild) or clindamycin (IgA rxn)
parasitic meningitis treatment
N. Fowleri - miltefosine
T. gondii - primethamine + sulfadiazine + leucovorin
Acanthomoeba - Miltefosine
T. brucei - eflornithin and nifurtimox
fungal meningitis
usually immunocompromised
amphotericin B for all
cryptococcus - flucytosine then fluconazole
histoplasma - itraconazole
blastomyces - fluconazole
coccidodes - fluconazole
paracoccidiodes - itraconazole
viral meningitis
HSV and VZV - acyclovir
CMV - gangocyclovir
Rabies - rabies vaccine and human rabies immune globulin
Enterovirus - Pleconaril
causes of viral meningitis
enteroviruses (most common)
herpesviruses
arboviruses
respiratory viruses
measles mump HIV lymphocytic choriomeningitis
parechoviruses
viral meningitis symptoms
fever, headache, photophobia, neck stiffness, nausea/vomiting
infants - fever, irritability, nonspecific symptoms
self limiting with spontaneous recovery
fungal meningitis
coccidiomycosis - dessert areas
histoplasmosis - river valleys, caves, bird/bat droppings
blastomycosis - leaves, decaying wood
inhaled anesthetics
enflurane, sevoflurane, isoflurane, desflurane, halothane, nitrous oxide
IV anesthetics
dexmedetomidine, etomidate, ketamine, propofol, thiopental
anesthetic adjuncts
lidocaine, fentanyl, sufentanil, morphine, midazolam
factors influencing rate of induction with inhaled anesthetics
solubility in blood (less hydrophilic/more lipophilic faster induction)
anesthetic partial pressure (higher partial pressure faster induction)
pulmonary ventilation (hyperventilation increases induction)
pulmonary blood flow (slower cardiac output increases induction)
arteriovenous concentration gradient (higher concentration gradient faster induction)
MOA inhaled anesthetics
target GABAa receptor
nitrous oxide targets NMDA
potent volatile inhalation anesthetics inhibit nicotinic ACh receptors
halothane
can cause arrythmias and hypotension
hepatotoxicity
malignant hyperthermia
isoflurane
lower BP and vascular resistance
increase HR
malignant hyperthermia
high pungency
sevoflurane
most recently used
low pungency
desflurane
most pungent
not used via facemask
malignant hyperthermia
hyperthermia, metabolic acidosis, hypercalcemia, tachycardia, accelerated muscle contractions, myoglobinuria
treated with dantrolene
nitrous oxide
inhibit NMDA
MAC 100% so would cause hypoxia
thiopental
IV - barbiturate
bind GABAa prolonging opening of Cl
not made in US
propofol
IV - phenol
agonize GABAa
ICU and rapid onset, short duration, prolonged sedation
metabolized by liver
etomidate
IV - imidazole
GABAa like mediated
used for serious cardiovascular disease bc respiration, CO and BP maintained
suppressant of adrenal steroidogenesis
dexmedetomidine
IV
alpha 2 receptor agonist inhibiting NE release
sedation without respiratory depression
ketamine
NMDA glutamate receptor blocked
dissociative anesthesia without loss of consciousness
increases HR, CO, BP
increases O2 consumption and intracranial pressure
benzodiazapines
preop sedation, operative sedation not requiring analgesia
GABAa receptor
midazolam
preanesthetic medication - produce anterograde amnesia
opioids (fentanyl, sufentanil, morphine)
postop analgesia
fentanyl and sufentanil more than morphine
naloxone reverse effects
schizophrenia
2 or more core symptoms (1 must be hallucinations, delusions, disoganized speech) must persist for 1 month and have continuous signs lasting at least 6 months
markedly impaired functioning
brief psychotic disorder
duration of episode at least 1 day but less than 1 month with eventual full return to premorbid level of functioning
schizophreniform disorder
episode at least 1 month long but less than 6 months
if dx made without full recoery it is qualified as “provisional”
delusional disorder
1 or more delusions present for more than 1 month
hallucinations would be related to content of delusions
function not markedly impaired and behavior not markedly odd
schizoaffective disorder
core symptoms cooccur with manic or major depressive episode
preceded or followed by 2 weeks of delusions or hallucinations without major mood episode
major mood episodes present for at least half the duration
natural history of schizophrenia
premorbid - no significant signs or symptoms, gross motor milestones occur later
prodromal - attenuated, transient psychotic symptoms the remit spontaneously, widespread cognitive deficits, self reported drug abuse
progression - overt psychotic symptoms, highest risk of suicide, antipsychotics slow progression of brain structural changes, progressive deterioration
chronic/residual - persistence of residual symptoms, treatment resistence, decrease in brain tissue and ventricles
treatment of schizophrenia
pharmacology - antipsychotics
psychosocial
sleep deprivation
increased BP, inreased diabetes risk, obesity, decreased growth hormones, cognitive and emotional disturbances, death
arousal system (staying awake)
locus ceruleus, raphe nuclei, cholinergic projections from rostral reticular formation, basal nuc of meynert, lateral hypothalamus (tuberomammillary nuc, lateral tuberal hypothalamus)
ascending reticular activating system
locus ceruleus - NE to diencephalon and cortex
raphe nuclei - serotonin to diencephalon and cortex
rostral pons/caudal midbrain reticular formation - ACh to thalamus
basal nucleus of meynert
below globus pallidus
ACh to cortex
lateral hypothalamus
tuberomammillary nucleus - histamine to thalamus and cortex
lateral tuberal hypothalamus - orexin/hypocretin to thalamus and cortex
narcolepsy
deficient in orexin/hypocretin
possible autoimmune
initiation of sleep
adenosine accumulates in EC space and binds adenosine receptors and inhibit basal nucleus of meynert
caffeine inhibits adenosine receptor
retinohypothalamic pineal pathway
retinal gang cells send axons to suprachiasmatic nucleus
suprachiasmatic nucleus inhibits or excites neurons in paraventricular nucleus
paraventricular nucleus sends axons to IML
IML preganglionic axons stimulates superior cervical ganglion
postganglionic axons stimulate pineal gland to secrete melatonin
light on
activated suprachiasmatic nuc
GABA inhibits paraventricular nucleus
no activation of sup cervical gang/pineal gland/ no secretion melatonin
light off
no ganglionic input to suprachiasmatic nucleas
suprachiasmatic nuclease releases glutamate to increase paraventricular nucleus
increased stimulation superior servical ganglion and pineal gland
more melatoning secretion
initiating sleep
neurons in ventrolateral preoptic hypothalamus formation activated and inhibit ascending reticular activating system
stages of sleep
awake eyes closed - alpha waves
awake eyes opened - beta waves
NREM 1 - theta
NREM 2 - theta and sleep spindles (beta)
NREM 3 - delta
REM - beta
NREM sleep
some muscle activity retained
increased parasympathetic activation
memory consolidation
REM sleep
LMN and dorsal column inhibited
rapid eye movements
body temp reptilian
increased sympathatic activation
memory consolidation
COMA
lesion of midbrain pontine reticular formation
insomnia
inadequate, disturbed, insufficient, nonrestorative sleep
types - falling asleep, frequent or sustained awakenings, early morning awakenings, persistent sleepiness/fatigue
tx - good sleep hygeine, treat medical disorders, behavior therapy, pharm therapy for psych disorders or sedatives
central sleep apnea
cessation of ventilation from lack of respiratory drive
obstructive sleep apnea
cessation of ventilation despite respiratory efforts
snoring frequent and prominent
apneahypopnea index of five or more per hour
treat with CPAP or BiPAP
circadian rhythm sleep disorders
delayed phase sleep - go to sleep and wake up late, treat with melatonin at night and light exposure in morning
advanced sleep phase syndrome - sleep moved earlier with earlier wakings, treat with blue light in evening
non 24 hour sleep wake rhythm disorder (blind)
parasomnias
abnormal behaviors or experiences that arise from or occur during sleep
NREM - confusing arousals to sleep walking to night terrors
REM - REM sleep behavior disorder and nightmares
REM sleep behavior disorder
vigorous motor activity in response to dream content, high percent have underlying neuro disorder
treat with melatonin and clonazapam/clonazapam
nightmare disorder
recurrent highly dysphoric or anxiety laden dreams that are clearly recalled upon awakening
other NREM parasomnias
exploding head syndrome, sleep related hallucinations, sleep enuresis, parasomnia associated with medical disorders, unspecified parasomnias
sleep walking
sleep terrors
sleep bruxism (grinding teeth)
sleep related eating disorder
restless leg syndrome
intense urge to move leg
worsens or begins in inactivity
partially or totally relieved by movements
worse or only occur at night
treat with dopaminergic agonists
periodic limb movement disorders
periodic episodes or repetitive and stereotypic limb movements in lower extremities that associate with sleep disturbance
COMA
deep sleep like state with eyes closed, cannot be aroused
due to damage or metabolic derangements
treatment - prevent further CNS damage
alzheimers
tau neurofibrillary tangles
beta amyloid plaques
amyloid angiopathy
cholinergic deficit
genetics - presenilins (chromosome 1 and 14) and apolipoprotein E (chromosome 19), increased amyloid precursor protein
use anticholinesterase agonist
picks disease/frontotemporal dementia
atrophy or neuronal loss in frontal or temporal lobes
personality/language symptoms, can have extrapyramidal
pick bodies (round inclusions) and pick cells (enlarged neurons)
genetic ateration FTD TDP
dementia with lewy bodies
deficit in attention/visuospacial function, fluctuating cognition, recurrent visual hallucinations
lewy bodies present and dementia present before parkinsonism
vascular dementia
hypertension
white matter loss in deep white matter
lacunar infarcts and cerebrovascular accidents
stepwise progression
edema
excess fluid
vasogenic, cytotoxic, or interstitial
increased intercranial pressure - flattened gyri, herniation, compressed ventricles
neuro symps - headache, vomit, papilledema
herniation
transtentorial (uncal) - compression CN 3, brain through tentorial notch, duret hemorrhage in midbrain upper pons
subfalcine - lateral cerebral hemisphere forces brain under falx
cerebellar tonsillar - brain forced through foramen magnum, respiratory centers compromised
mechanisms of brain injury
vascular damage - hemorrhage or contusions
direct neuronal damage - gunshot or penetrating wound
shearing injury - axons sheared from acceleration/deceleration
parenchymal injury
concussion - no physical injury, brief loss of consciousness
contusion - bruising (coup or counter coup)
laceration - tearing of vessel
diffuse axonal damage - acceleration deceleration, axonal swelling
vascular damage - hematomas
sequela to head trauma
drowsiness, headache, confusion
transient paraplegia, blindness, migrainous phenomina
delayed hemiplegia
PTSD
reexperiencing, avoidance, negative affect, arousal, exposure
person exposed to death or threatened death, actual or threatened serious injury, actual or threatened sexual violation by experiencing it themselves, witnessing it, or learning it happened to someone close to them
decreased hypocampal volume
tx - exposure therapy, EMDR, cognitive behavioral therapy, group therapy, education and support, SSRIs (paroxetine and sertraline) trazodone for sleep, anti adrenergics - prazosin and propranolol, atypical antipsychotics, anticonvulsants, benzos
acute stress disorder
3 days to 1 mont
9 of 14 in any 5 categories (intursion symptoms, negative mood, dissociative symptoms, avoidance symptoms, arousal symptoms)
adjustment disorders
identifiable stressor
clinically significant emotional or behavioral symptoms
within 3 moths of stressor and resolve within 6 months after removal of stressor
impaired functioning
with depressed mood/anxiety/mixed/conduct disturbance/mixed emotions and conduct disturbance/unspecified
treat with support and antidepressants
short acting benzos
triazolam, midazolam
more useful for insomnia, less hangover
bind GABAa receptor and increase infinity for GABA
hepatic metabolism
medium acting benzos
temazepam, lorazepam, alprazolam, clonazepam, oxazepam
bind GABAa increasing time channel is open
CYP450 inducer interaction
long acting benzos
diazepam, chlordiazepoxide
more useful for anxiety
can be used for physical dependence
benzo antagonist
flumazenil
medium acting barbs
butalbital, pentobarbital
long acting barbs
phenobarbital
can cause respiratory depression
new hypnotics (z drugs)
zolpidem, eszopiclone, zaleplon
used for sleep
bind GABAa alpha 1 subunit
flumazenil is antagonist
5 HT1A agonist
buspirone
can give with past history of addiction
muscle relaxation
benzos - mainly diazepam
alprazolam
DOC for panic disorders and agoraphobia
melatonin agonists
ramelton and tasimelteon
orexin antagonist
suvorexant and almorexant
substance use disorder
problematic pattern of stubstance use leading to clinically significant impairment or distress as manifested by 2 of the following criteria in a 12 month period
mild 2-3 symptoms
moderate 4-5 symptoms
severe 6 symptoms
early remission
no criteria for more than 3 months but less than 1 year
sustained remission
no criteria for over 12 months
alcohol
intoxication - slurred speech, incoordination, unsteady gait, impaired attention or memory
-treatment is supportive
withdrawal - autonomic hyperactivity. hand tremor, insomnia, nausea, vomitting, hallucination, psychomotor agitation, anxiety
-uncomplicated is the shakes
-seizures
-hallucinosis
-delirium with confusion, aggitation, perceptual disturbances
-tx: supportive, chlordiazepoxide, thiamine (to prevent wernicke korsakoff syndrome), rehab (therapy, disulfiram, naltrexone, acamprosate, topiramate, gabapentin)
caffeine
intoxication - restless, nervous, excitement, insomnia, flushed face, GI disturbances, twitching, rambling, tachycardia
withdrawal - headache, fatigue, dysphoric mood, difficulty concentrating, flu like symptoms
-tx: benzos or NSAIDs, taper usage
cannabis
intoxication - conjunctival injection, increased appetite, dry mouth, tachycardia (some with perceptual disturbances)
withdrawal - irritable, nervous or anxious, decreased appetite, restless, depressed mood, discomfort
tx - antianxiety meds, abstinence, support, education
hallucinogen (LSD 5HT agonism, DMT, MDMA)
intoxication - pupil dilation, tachycardia, sweating, palpations, blurring vision, tremors
persisting perception disorder - geometric hallucinations, false perceptions of movement, intensified colors, trails of images, positive afterimages, macropsia/micropsia
tx - supportive, benzos, antipsychotics
no withdrawal symptoms
PCP
intoxication - vertical or horizontal nystagmus, HTN/tachycardia, numbness, ataxia, dysarthria, muscle rigidity
tx: supportive, caution aggression
no withdrawal
NMDA antagonist
opioid
intoxication - constricted pupil, drowsiness, slurred speech, impared attention or memory (naloxone is antidote for overdose)
withdrawal - dysphoric, nausea, muscle aches, diarrhea, fever, insomnia
-tx: clonidine to withdraw (or methadone or buprenorphine), NSAIDS, dicyclomine
sedatives
intoxication - slurred speech, incoordination, unsteady gait, impaired cognition
-tx: flumazenil
withdrawal - autonomic hyperactivity, tremor, insomnia, nausea, hallucinations, psychomotor agitation, seizures
-tx: CIWA-B, taper
stimulants (amphetamines, cocaine)
intoxication - pupil dilation, change in HR and BP, sweating or chills, weight loss, nausea, agitation
withdrawal - fatigue, unpleasant vivid dreams, insomnia, increased appetite, psychomotor retardation or agitation
tx: no FDA approved pharm, support, abstinence
tobacco
withdrawal - irritbale, anxiety, difficult concentrating, increased appetite, restlessness, depressed mood, insomnia
anorexia
loss of body weight and refusal to eat
appetite usually intact
for 3 months either purging or restrictive type
bulimia nervosa
recurrent and frequent binge eating with and without vomitting
symptoms at least once a week for 3 months
binge eating disorder
occasional binge eating, once a week
lasts for 3 months
PICA
eating of nonnutritional substances
over at least 1 month
rumination disorder
repeated regurgitation of food
for at least 1 month
avoidant restrictive food intake disorder
lack of interest in food or eating leading to failure to thrive
rewards circuit
ventral tegmental area increases or decreases release of dopamine on nucleus accumbens (ventral striatum) which sends signals to the prefrontal cortex/amygdala/hippocampus
phasic increase in firing rate shifts to the conditional stimulus
overstimulation of dopamine
leads to risky behavior
drugs lead to increase in dopamine with or without VTA firins, so subsequent actions are not viewed as bad as they are
you remember long term associative memories of good feelings while on the drug
somatic symptom disorder
general and nondelusional preoccupation with fears of having a serious disease that is not yet detected
symptom is truly present
tx - therapy and pharmacotherapy for depression/anxiety
illness anxiety disorder
preoccupation with being sick, few or no symptoms present, if they do have illness anxiety is out of proportion to diagnosis and assume worst possible outcome
treatment - therapy and anxiety meds
functional neurologic disorder
conversion disorder
affects voluntary motor or sensory functions, caused by psychological factors, stressors occuring prior to illness
not intentionally produced
commonly paralysis, blindness, mutism
pseudo seizures
tongue biting/incontinence/injuries typically absent
pupillary and gag reflex retained
no postseizure increase in prolactin secretion
tx - therapy, anxiolytics
factitious disorder
patient stimulate, induce, aggravate illness to receive medical attention
often had child abuse or deprevation
-with psychological signs and symptoms - often have depression, hallucinations, dissociative and conversion symptoms, bizarre behavior as feigned symptoms
-with physical signs and symptoms - present physical symptoms so can stay in hospital, may feign multiple system symptoms
-by proxy - producing physical signs and symptoms in another person who is under your care
Ganser syndrome
use of incorrect answers to simple questions
typical in prison inmates
pain disorder
presence of pain, not imaginary or made up
tx - therapy, TCAS, SSRIs
cluster a personality disorders
suspicious, odd
paranoid, schizoid, schizotypal
cluster b personality disorders
dramatic
antisocial, borderline, histrionic, narcissistic
cluster c personality disorders
anxious
avoidant, dependent, obsessive compulsive
paranoid personality disorder
pervasive distrust and suspiciousness of others
schizoid personality disorder
pervasive pattern of detachment from social relationships
restricted expression of emotion
schizotypal personality disorder
pervasive pattern of social and interpersonal deficits with reduced capacity for close relationship
cognitive or perceptual distortions and eccentricities of behavior
antisocial personality disorder
pervasive pattern of disregard for and violation of the rights of others
borderline personality disorder
pervasive pattern of instability of interpersonal relationships, self image, and marked impulsivity
histrionic personality disorder
pervasive pattern of excessive emotionality and attention seeking
narcissistic personality disorder
pervasive pattern of grandiosity
need for admiration
lack of empathy
avoidant personality disorder
pervasive pattern of social inhibition
feelings of inadequacy and hypersensitivity to negative evaluation
dependent personality disorder
pervasive and excessive need to be cared for
leads to submissive and clinging behaviors
fears of seperation
obsessive compulsive personality disorder
pervasive pattern of preoccupation with orderliness, perfectionism
mental and imterpersonal control at the expense of flexibility, openness
treatment for personality disorders
increase serotonin levels
low dose neuroleptics and mood stabilizers
attention deficit hyperactivity disorder
persistent pattern of inattention and or hyperactivity impulsivity that interferes with functioning or development
6 or more aspects of inattention and or 6 or more aspects of hyperactivity
must be present prior to 12
must be present in 2 or more environments
must impair academic or occupational functioning
autism spectrum disorder
persistent imparment in reciprocal social communication and social interaction AND restricted, repetitive patterns of behavior, interests, or activities
present from early childhood and limit or impair daily function
general present in second year of life
retts disorder
progressive condition mainly in females
head circumference normal at birth, between 5 and 48 months head growth decelerates and developmental regression occurs
MECP2 gene on X chromosome
loss of purposeful hand movements and midline movements occur
tourettes
multiple motor tics and one or more vocal tics for at least 1 year
specific learning disorder
difficulty in learning or using academic skills, persist for longer than 6 months, despite interventions to target these difficulties
impairment with reading - accuracy, rate/fluency, comprehension
impairment with written expression - spelling accuracy, grammar/punctuation accuracy, clarity/organization
impairment wiht mathematics - number sense, memorization.arithmetic facts, accurate/fluent calculations, accurate math reasoning
oppositional defiant disorder
frequent and persistent pattern of angry irritable mood
for at least 6 months towards 1 individual that is not a sibling
can be confined to only 1 setting
conduct disorder
repetitive and persistent pattern of behavior in which basic rights of others or major age appropriate social norms are violated
3 of criteria occur over 12 months
aggression, property destruction, theft, violation of rules
develop before 13 years
-childhood onset, adolescent onset, unspecified, with limited prosocial emotion
disruptive mood dysregulation
chronic, severe persistent irritability (frequent temper tantrums, persistant irritability between outbursts)
3 or more a week
must occur before age 10
astrocytoma
GFAP positive
poorly defined borders, often surround neurons
astrocytoma - grade 2
anaplastic astrocytoma - grade 3, increased cellularity and pleomorphisms
glioblastoma (wild type) - necrosis, vascular proliferation
-primary: older, amplification EGFR gene, MDM2 overexpression, p16 deletion, PTEN mutation
-secondary: children, p53 inactivation and PDGF-A amplification
-chemo not effective
tx - surgery, radiation, immunotherapy
pilocytic astrocytoma
grade 1
young children and adults
long hair like pilocytic cells
longer survival than grade 2
oligodendroglioma
occurs mostly in white matter
fried eggs
calcifications
GFAP positive
deletion of 1p/19q
tx - surgery, chemo
ependymoma
choroid plexus papilloma
s100, cytokeratin, transthyretin positive
central around ventricles
perivascular pseudorosettes (clear around vessels)
ependymal rosettes
common in NF2
neuronal tumors
seizures often
cerebral neuroblastoma - small blue cell, hemispheres, aggressive
cerebral neurocytoma - neuronal markers positive, within and adjacent lateral or 3rd ventricles
medulloblastoma
poorly differentiated
arises in cerebellum
small blue cells, homer wright rosettes
positive synaptophysin
loss of 17q
tx - radiation and chemotherapy
CNS lymphoma
B cell
immunocompromised
perivascular orientation, infiltration of blood vessel walls
CD 20 positive
poor response to chemo
meningioma
dural based, slow growing, arise from meningothelial cells
whorls of meningothelial cells, calcifications, stains positive for EMA
progesterone and estrogen receptors
lose chromosome 22
occur in NF2
schwannoma
attached to peripheral nerve, can be seperated
antoni a dense areas
antoni b loose areas
varacay bodies around white antoni area
mutations of NF gene
S100 positive
neurofibroma
cannot be seperated from nerve
s100 and cd34 positive
strong association with NF1
NF1 - neurofibromas, gliomas of optic nerve, cafe au lait, chromosome 17
NF2 - bilat schwannomas, gliomas, chromosome 22
von hippel lindau
hemangioblastoma - cerebellum, retina, brain, spinal cord
renal cell carcinoma
pancreas, liver, kidney cysts
gene on chromosome 3
sturge weber
angioma of face and underlying leptomeninges
tuberous sclerosis
hamartomas of brain, retina, viscera
subependymal giant cell astrocytoma
most have seizures
TSC1 and 2 genes
shaken baby syndrome
subdural hemorrhages, retinal hemorrhages, damage to spinal cord and neck, fracture of ribs and bones
can be up to 5 yrs but most under 2
-skull fractures common but can also be caused by osteogenesis imperfecta or vitamin D deficiency
acute cerebellar ataxia
after infection usually
rapid onset
gait ataxia, speech, eye movement, coordination or voluntary movement
supportive care
neonatal brachial plexus injury
erbs palsy - C5/6, waiters tip, cant abduct shoulder or supinate arm
erbs palsy plus - C5/6/7
tx - physical therapu, muscle group transplants, nerve grafts
avulsion nerve injury
nerve torn out of spinal cord
neurotmesis
axonal rupture with disruption of nerve sheath
axonotmesis
axonal rupture but sheath intact
neuropraxia
damage to sheath alone
tethered cord syndrome
mow lying conus medullaris with short thickened filum terminale rendering spinal cord immobile
neurocutaneous stigmata, bladder/bowel dysfunction, lower limb deficits, spinal deformity
MRI for imaging
sx to fix
febrile seizures
between 6 months and 5 years
usually roseola or influenza
simple - less than 15 minutes, nonfocal, 1 per 24 hours, no past history, temp over 100.4
complex - focal onset, over 15 min, more than 1 in 24 hours
LP IF - meningeal signs, less than 12 mo, not vaccinated, on antibiotics
infantile spasms
most less than 1 year
clusters of 2-125 up to 13/min
most havev neurodevelopmental delay and or regression of motor and cognitive munction
treat with adrenocorticotropic hormone, often combine with antiseizure therapy
