Neuro -Disease Flashcards
Von hippel Lindau presents w/ and increased risk of what
cavernous hemangionomas in the skin, mucosa, and organs;
hemangioblasoma retina, brain stem, cerebellum)
bilateral renal cell carcinoma risk
AD mutation of chromosome 3
Myasthenia gravis associations
Thymoma
Bronchogenic Carcinoma
Parkinsons w/ hallucinations and dementia
Location of lesion(3)
Lewy Body dementia
Lewy body - eosinophilic intracytoplamic inclusions
Located in
the substantial nigra
limbic cortex
subcortical nuclei
Werdnig Hoffman Disease
- presentation
LMN lesions only
due to setruciton of anterior horns ->flaccid paralysis
~polio
Lesions of the caudate nucleus and putamen
Huntingtons
- degeneration of GABAnergic neurons
- trinucleotide expansion of CAG on chromosome 4
Lewy Bodies found in (2)
Parkinsons
Lewy body dementia
Diffuse cortical atrophy sparing primary motor and sensory
Alzheimers
Selective frontal and temporal lobe atrophy
Picks
- silver staining cytoplasmic inclusions (pick bodies)
Pigmentes nodules on iris(Lisch nodules) and cafe au lair spots
-> risk of ?
Defect in ?
AD disease
Neurofibromatosis 1 or von Recklinhausen
optic path gliomas
sub q peripheral nerve nodules (neurofibromas)
Defect in tumor supressor NF1 on Chromosome 17
Low folate levels prior to conception leads to increase risk of what?
What marker may clue in
neural tube defects
elevated alpha fetoprotein in maternal blood and amniotic fluid
Maternal polyhydraminos may be due to this neuro defect
anecephaly(no skull or brain) - lack of cranial end to fuse
lack of swallowing mech
spina bifida occulta
dimple or patch of hair
simple failure of vertebral arch to close
Meningocele
failure of vertebral arch to close w/ protrusion of meninges
meningomyelocele
failure of vertebral arch to close w/ protrusion of meninges and spinal cord
3 congenital conditions that can lead to hydrocephalis
cerebral aqueduct stenosis
Dandy walker malformation
Arnold chiari malformation type II
cerebral aqueduct stenosis prevents what
drainage of CSF from the 3rd to the 4th ventricle -> accumulation in ventricle space
Foramen of monro
Drains lateral ventricles to 3rd ventricle
Foramina of magenie and Luschka
drians 4th ventricle to subarachnoid space
Massively dilated 4th ventricle congenitally called what?
Due to ?
Dandy walker malformation and it is due to failure of cerebellar vermis to form
- no separation of the cerebellum and thus the space is absent on CT
Congenital displacement of cerebellar vermis and tonsils ->
Associated w/ (2)
Arnold chiari malformation type II (type 1 asymptomatic)
- herniation of the cerebellum through the foramen magnum
- > obstruction of CSF flow and hydrocephalus
meningomyolcele (most)
syringomyelia
sensory loss of pain and temp w/ sparing go fine touch and position sense in the upper extremities
What is going on and where?
Causes(2)
syringomyelia -
- Usually C8 -T1, cape like distribution
- > preferential coring out the anterior white commissure where the sensation crosses and then ascends contra laterally in the spinothalamic tract
Caused by trauma or Arnold Chiari malformation
Syrinx expansion of syringtomyelia
2 locations
initally anterior white commissure
Anterior horn -> lower motor neuron defects
Lateral horn and hypothalamospinal tract (sympathetic)-> horner syndrome
ptosis
droopy eyelid
miosis
constricted pupil
anhidrosis
lack of sweating
fecal oral transmission bug leading to anterior horn difficulties
Upper or lower?
poliomyelitis
Lower motor neuron signs - flaccid paralysis fasciulations weakness impaired reflexes neg babinski
Lower motor neuron lesions (6 signs)
flaccid paralysis muscle atrophy fasciulations weakness impaired reflexes neg babinski
things go down
Upper motor neuron lesions(4 signs)
spastic paralysis
hyperreflexia
increased muscle tone
positive babinski
things go up
floppy baby inherited condition affects?
weednig hoffman disease
Auto Recessive disease; death in a few yrs
anterior horn -> LMN symptoms
Sporadic degeneration of the cortical spinal tract
amoyotrophic lateral sclerosis
(AML)
anterior horn degen-> LMN symptoms
Lateral Corticospinal Tract -> UMN symptoms
Atrophy and weakness of the hands w/out loss of sensory?
ALS
Zinc-Coppuer superoxide dismutase often implicated in
familial ALS
Presentation of ataxia and loss of vibratory sensation , proprioception, muscle weakness and loss of deep tendon reflexes
Due to ?
Friedriech ataxia
- degeneration of cerebellum and spinal cord
Autosomal recessive expansion of unstable tinucleotide repeat
Frataxin
Gene implicated in Fredriech ataxia -
- essential for mitochondrial iron regulation -> iron buildup
Friedreich ataxia associated w/ what extra neuro presentation
hypertorphic cardiomyopathy
wheelchair bound w/in few yrs
inflammation of the leptomeninges
meningitis
specifically the pia and the arachnoid
(not dura)
Meningitis in neonate (3)
Group b strep
E Coli
Listeria monocytogenes
Meningitis in childen and teens
Nesseria meningitidis
-nasopharynx -> blood path
Meningitis in adults and elderly
Streptococcus pneumoniae
Nonvaccinated infants and meningitis
H influenza
Most common viral meningitis
Coxsackie
HA, nuchal regidity and fever think
If photophobia?
Meningitis
may be viral
Can also have altered mental status and vomitting
Lumbar puncture done at
L4 and L5 - level of the iliac crest
Spinal cord ends at L2 - just caudal equina
CSF of bacterial meningitis
neutrophils
low CSF glucose (normally 2/3 of serum)
- more complications w/ pus and herniation -> death
CSF of viral meningitis
lymphocytes
normal CSF glucose
CSF of fungal meningitis
lymphocytes
decreased glucose
Sequela of meningitis
W/ healing and fibrosis if not dead
-hydrocephalus(obstruction), seizures(scarring) and hearing loss (nerve damage that exit)
Cerebrovascular disease -
2 causes and sub types w/in
6 total
ischemia (85%) - global -Focal --- >24 hr transient ischemic ---< 24 hr ischemic stroke hemorrhage(15%) - Subarachnoid - Intracerebral
Etiologies of global cerebral ischemia
4
low perfusion - atherosclerosis
acute decreased blood flow - shock
chronic hypoxia - anemia
repeated hypoglycemia
transient confusion and prompt recovery seen in this CVD
mild global ischemia - hypglycemia
Diffuse necrosis and survival -> vegetative state
Severe global ischemia -
laminar necrosis of the cerebral cortex
layer 3,5,6 necrosis w/ moderate global ischemia
-pyramidal neurons of the cerebral cortex
Long term memory affected w/ this CVD
Pyramidal neurons of hippocampus affected w/ moderate global ischemia
sensory perception w/ motor control affected w/ this CVD
moderate global ischemia of purkinje layer of the cerebellum
TIA
Transient ischemic attack 24 hrs
pale infarct seen w/
point often affected?
thrombotic stroke - ischemic
-rupture of atherosclerotic plaque
usually at branch points ( bifurcation of internal carotid or middle cerebral artery of circle of willis)
hemorrhagic infarct seen w/
point often affected
emboli stroke - ischemic
- maybe from the left atrium and atrial fibrillation
- emboli lysed and reprofused area
affects middle cerebral artery often
Hyaline arteriosclerosis secondary to HTN or DM leads to ?
affects?
lacunar strokes - ischemic
lenticulostriate vessels
- internal capsule - pute motor
- thalamus - pure sensory
Ischemic stroke leads to what type of necrosis
Histology?
liquefactive
red nueurons in 12 hrs, necrosis in 24, neutrophils invade followed by microglial cells (macrophages)
Gliosis (2-3 weeks)
Gliosis
healing stage of an ischemic stroke leading to a cystic space surrounded by microglial cells
Charcot bouchard microaneurisms analogous to
similar to lacunar strokes except there is weakening, aneurysm formation and rupture of lenticulostriate vessels
HTN predisposes again
Common site of intracerebral hemorage
basal ganglia fed by lenticulostriate vessels,
HTN risk
Presentation of severe HA, N/V, and eventual coma
Intracerebral hemorrhage -> bleeding into brain parenchyma
Xanthochromia w/ nucal regidity and HA
Subarachnoid Hemorrhage
Xanthochromia - yellow hue of CSF due to bilirubin breakdown on LP
Subarachnoid hemorrhage often occur where?
2 conditions the predispose?
Berry aneurism bleeds (lack media layer)
anterior circle of Willis branch points of the anterior communicating artery
Marfan and ADPCK
lens shaped lesion on CT
lesion of what vessels?
epidural hematoma
middle meningeal
Cresecent shaped lesion on CT
lesion of what vessels
subdural hematoma
bridging veins - stretched w/ cortical atrophy in the elderly and prone to tear
Lucid interval preceding neurologic signs
how long and associated w/ what
epidural hematoma
12-24 hrs before collapse
Herniation definition and 3 forms
displacement of brain tissue by mass effect or increased cranial pressure
Tonsillar herniation
Subfalcine herniation
Uncal herniation
tonsillar herniation is?
Compression of what?
cerebellar tonsils into the foramen magnum leading to cardio pulmonary arrest
brain stem
cingutate gyrus under the flax cerebra called?
Compression of what?
subfalcine herniation
compresses tha anterior cerebral artery ->infarction
eye rolling down and out w/ infarction of the occipital lobe (contralateral homonymous hemianopsia) and brain stem hemorrhage
Compression of cranial nerve III, posterior cerebral artery and paramedian artery
All due to Uncal herniation
Oligodendrocytes
Myelinate the CNS
Schwann Cells
myelin ate the PNS
deficiency or aeylsulfatase leads to?
Accumulation of what?
Leukodystrophy (accumulation of myelin)
auto recessive
Sulfatides cannot be degraded and accumulate in oligodendocyte lysosomes
Demylinating disorder
Krabbe disease is a deficiency in ?
Accumulation in?
Glactocerebrocidase
Accumulation of glactocerebrocide in macrophages
demylinating disorder
X linked defect that has impaired addition of coenzyme A to long chain fatty acids
Damage to 2 organs
Adrenoleukidystriophy
Adrenal glands and white matter of brain
Demylinating disorder
HLA DR2
Autoimmune destruction of CNS myeline and oligodendrocytes
MS is more commonly seen in in who where?
young adults , (20-30s), women
colder environements
What is internuclear opthalmoplegia and what is it associated w/
Lesion of the medial longitudinal fascicles leading to impaired coordination of CN3 and CN6 in eye movement (one does not move)
Seen in MS
Scanning speech is characteristic of
what is it?
MS
mimicking alcohol intoxication
Symptoms of MS (8)
Burred vision - one eye
Vertigo
Scanning speech
internuclear opthalmoplegia
Hemiparesis or unilateral loss of sensation
lower extremity weakness or loss of sensation
bowel, bladder, sexual dysfunction - sympathetics
Neurologic symptoms w/ periods of remission - multiple lesions separated by time and space
MS
Oligoclonal IG bands, increased lymphocytes and immunoglobulins on LP
MS
-also see myelin basic protein
Rx for acute and chronic MS
steroids
Chronic - interferon beta
MS MRI results
plaques - white matter demylination
Slowly progressing persistent infection of the brain?
due to
Characterized by
Subacute sclerosing PANencephalitis
Measles
Viral inclusions in the neurons AND oligodendorcytes
JC virus infects what neural structure causing?
Characterized by?
oligodendrocytes infected
causing Progressive multifocal leukoencephalopathy
Progressive multifocal leukoencephalopathy presentation
rapidly progressive nuerologic signs
-visual loss, weakness, dementia-> death
Rapid overcorrection of patient’s electrolytes can lead to ?
Which electrolyte in particular
central pontine myelinolysis
Na
Acute bilateral paralysis sets in a patient being treated for alcoholism or a liver transplant patient think?
central pontine myelinolysis
Rapid Na correction
Degeneration of cortex ->
Dementia
grey matter
Degeneration of the brainstem and basal ganglia
Movement disorders
Grey matter
What is the most common cause of Death in alzheimers
infection
Loss of learned motor skills and language, nut and bed ridden, no focal neuro deficits
What other symptoms
Alzheimers
also have slow onset memory loss short progressing to long term
Progressive disorientation
Increased risk of Alzeimers(2) - sporadic
Old age
Apo E Allele 4; Apo E Allele 2 protective
Early onset Alzheimers seen w/ (2)
Down syndrome (APP on 21) presenilin 1 and 2 mutations
Cerebral atrophy w/ narrowing of the gyri and widening of the sulci, dilated ventricles?
Also see what histological changes
Alzheimers
Abeta amylod
Amyloid precursor protein importance
coded on chromosome 21
- beta claevage vs normal alpha leads to accumulation
May deposit in vessels -> hemorrhage risk
hyperphosphoryated tau protein seen in ?
Make up what ?
Alzheimers
neurofibrillary tangles - tanges due to lack of organization of the microtubules
2nd most common cause of dementia?
Causal agents(3)
Vascular dementia.
HTN, Athersclerosis or vasculitis leading to multifocal infarction or injury
Round aggregates of tau protein
Pick bodies
in the neurons of the cortex of Pick’s Disease
Degenerative disease of the frontal and temporal cortex selectively
Symptoms(3)
Picks disease
Behavioral and language symptoms leading to dementia
Substantia nigra of the basal ganglia implicated in what disease?
what is lost?
Parkinsons
Lose dopaminergic neurons
Clinical features of Parkinsons(4)
TRAP
Tremor - pill rolling tremor at rest
rigidity - cogwheel rigidity
Akinesia/bradykinesia - slowing of voluntary movement- flat affect
Postural instability - shuffeling gate
Loss of pigmented neurons in the substantial nigra seen in what?
What are lewy bodies?
Parkinsons
Lewy bodies are round eosinophilic inclusions of alpha-synuclein - (LATE course vs Lewy body dementia)
Role of dopamine in Movement
D1 has a positive influence on positive movement in the cortex from the striatum of the basal ganglia
D2 inhibits the inhibition of the movement in the cortex
Both boost the signal
Dementia, hallucination ans parkinson like syndromes seen in less than a year is?
See what in histology?
Lewy body dementia
Cortical lewy bodies seen in cortex (Vs just the inner basal ganglia)
Huntington’s is due to loss of what where?
Lose GABAergic neurons in the caudate nucleus of the basal ganglia
The genetic component of Huntington(3)
AD disorder
trinucleotide repeat of CAG
expansion during spermatogenesis -> anticipation
Presentation of Huntingtons(2)
Chorea - loss of inhibition -> random movement
Athetosis - slow involuntary snake like movement of fingers
Dementia
depression
- Age 40
Elderly patient w/ urinary incontenince, gait instability and dementia
caused by?
Normal pressure hydrocephalus
- increase CSF -> dilated ventricles w/ arachnoid granulations not draining as well
- Wakyness due to stretched corona radiate next to the ventricles
What improves normal pressure hydrocephalus?
Presentation?
Lumbar puncture improves symptoms
Ventriculoperitoneal shunting Rx
Wet wobbly and wacky
PrP c
normal prion protein in CNS neuron
alpha helical conformation
PRP sc
beta pleated conformation -> encephalopathy
does not degrade and conerts normal protein to pathologic protein
Spongiform encephalopathy is due to? (3)
sporadic (CJD)
inherited (familial)
transmitted (mad cow)
Damage to neurons and glial cells w/ intracellular vaculoles
Spngiform encephopathy
Rapidly progressive dementia w. ataxia and starle myoclonus
See what on EEG
Creutzfeldt Jakob disease
most common form of spongiform encephalopathy
Periodic sharp waves
Familial encephalopathy characterized by(2)
Severe insomnia
exaggerated startle response
well circumscribed lesion found at the grey white border of the brain
METS
Usually lung breast and kidney
Most common brain tumors of adults (3)
Seen usually
glioblastoma multiforme - astrocyte derived
meningioma
schwannoma
Supratentorium
Most common brain tumors of kids (3)
Seen usually
pilocytic astrocytoma
ependymoma
medulloblastoma - neuroectoderm derived
Seen infratentorium
Cerebral tumor that crosses the corpus collosum - butterfly lesion?
Histology you see
Glioblastoma multiforme
See necrosis w/ pseudopalisading and endothelial proliferation
MOST COMMON in ADULTS - Malignent
GFAP positive tumor cells(2)
Glioblastoma multiforme - adults
Pilocytic astrocytoma - kids
positive due to presence of intermediate filament in glial cells
Cerebral lesion presenting w/ seizures and a round mass attached to the dura
Preferentially seen in?
Meningioma
Seen in women
Histology shows whorled appearance in this benign tumor of arachnid cells
also see what on histo
Meningioma
psammoma bodies
Presentation of hearing loss and tints w/ a S100 marker
Schwannoma - benign
Frequently affects CN8 at the cerebrellopontine angle
Schawnnomas are seen bilateral in
Neurofibromatosis type 2
Calcified white matter in the front lobe presenting w/ siezures
Oligodendroglioma
Malignant tumor
Fried egg appearance on biopsy -
Oligodendroglioma
cystic lesion w/ mural nodule seen in a kid
pilocytic astrocytoma
Benign tumor of cerebellum
Rsenthal fibers are what?
thick eosinophilic processes of astrocytes
also are GFAP positive
small round blue cells -> hormer wright rosette
original cell type?
Medulloblastoma - malignant tumor seen in kids
Neuroectoderm derived
Drop METS refers to
medullablastoma which spreads to CSF and cauda equine due to rapid growth
poor prognosis
tumor along the 4th ventricle leading to hydrocephalus
Histology see?
ependymoma - malignant tumor in kids
perivascular psudorosettes
Cariopharyngiomas come from
May present w/
epithelial remnants of Rathke’s pouch
Supratentoral mass in a child or adult
Bitemporal hemianopsia due to (2)
pituitary adenoma
craniopharyngioms - especially if a kid
Calcifcation on imaging of this benign but highly recurring tumor
craniopharyngioma
unilateral facial drooping involving the forehead
bells palsy
Weber syndrome which nerve?
contrallateral hemiparesis and eye motor nerve palsy w/ CN3
Medial pontine syndrome which nerve?
Contralateral hemiparesis and sensation and abducens
Posterior infereior cerebellar arter infarct affects which nerves
glossopharyngeal, vagus and spinal accessory
Symptoms of Central Pontine myelinilysis(6)
acute paralysis dysarthias dysphagias diplopia LOC locked in syndrome
- overly rapid correction of Na
- also see increased signal density in the pons
Corticospinal tract desiccates
above the medullary pyramids in the caudal medulla before descending
Spinothalmic tract desiccates
early and crosses in anterior white cosmissure before ascending
Dorsal thalamic pathway desiccates?
later in the caudal medulla
after becoming the medial lemniscal
Lesion of the R vagus nerve or nuclei -> uvula deviates?
deviates to the left. (pulled to the right)
Right side is not working
- could have issues w/ the left corticobulbar tract or
soft palate portion of the left motor cortex
Lesion of the L hypoglosseal nuclei or nerve the young deviates
Pushed to the right side
-Licking your wound
-Could also have issues with the Right corticobulbar tract and higher up the tounge portion of the right motor cortex
Artery that supplies the medial lemniscus and medullary pyramids
Anterior spinal artery
Stroke differs from Bells palsy how
Stroke you have eyebrow function
- contralateral paralysis of the lower face - UMN lesion
- the ipsilateral side of the lesion compensates for the upper portion of the face
bells palsy is lower in the tract and thus you have ipsilateral loss of upper and lower face
6 diseases you see bells palsy
AIDS
Lymes
Herpes simplex/zoster
less common-
Sarcoidosis,
tumors
Diabetes
midline CN nuclei in the brainstem
12 divides equally
- 3 - mid brain
- 4 - mid brain
- 6 - pons
- 12 - medulla
lateral CN nuclei in the brainstem
5 - pons 7 - pons 9 - medulla 10? 11 - spinal cord/medulla
berry aneurysms in the circle of will associated w/ (3)
ADPCKD
Ehlers Danlos
Weber Syndrome is due to a lesion in
Level of lesion
See(2):
CN (1)
Paramedian branches of posterior cerebral artery
Middle lesion (12/3) at the midbrain level
CN 3 involvement - ophtalmoplegia, ptosis, dilation and down and out
Cerebral peduncle lesion -> contralateral spastic paralysis(lesion occurs before motor cortex info coming down hits the cerebral peduncles)
Causes of locked in syndrome (2)
pontine lesions
hyponatremia rapid correction
basalir artery rupture
Medial inferior pontine syndrome lesion in
Symptoms?(4)
CN (1)
Basilar artery - paramedial branches
contralateral spastic hemiparesis -corticospinal
contralateral loss of light/touch and kinesthetic - ML
Paralysis of gaze to side of lesion (CN6 and PPRF)
Ipsilateral paralysis of Lateral rectus (CN6)
lateral inferior pontine syndrome lesion in
Symptoms(7)
CN (3)
Anterior inferior cerebellar Artery (AICA)
- Lateral lesion and a lower pontine, rule of 4
ipsilateral facial nerve palsy - CN 7
ipsilateral loss of taste anterior 2/3 - CN7
ipsilateral deafness, Nystagmus, N/V - CN8
Ipsilateral limb and gait ataxia - middle and inferior cerebral peduncles
ipsilateral loss of pain and temp from face - spinal trigeminal (CN5) tract
Contralateral loss of pain/temp body - spinothalmic
Ipsilateral horner
Lateral Superior pontine syndrome lesion
Symptoms(7)
CN - 2
Anterior inferior cerebellar artery (AICA)
lateral and upper pontine level
Ipsilateral loss of taste - anterior 2/3 -CN 7
ipsilateral limb and gait ataxia damage to middle and inferior cerebella peduncle
ipsilateral loss of pain/temp to face - spinal trigeminal nucleus (5) and nerve fiber
ipsilateral loss of light touch and vibration from face - Main sensory trigeminal nucleus
ipsilateral jaw weakness and deviation of jaw towards lesion - trigeminal motor nut
contralateral loss of pain/temp from body - spinothalamic
ipsilateral horner - descending symp
medial medullary syndrome lesion
Symptoms(3)
CN - 1
anterior spinal artery (ASA)
-medial lesion of medulla
Contralateral spastic hemiparesis - corticopinal
contralateral tactile and kinesthetic defects
-ML
Tounge deviates towards the lesion (CN12) - middle divisible by 12
Wallenberg syndrome lesion
Symptoms(6)
CN - 3
AKA Lateral medullary syndrome
Posterior inferior cerebellar artery (PICA)
Loss of pain/temp contralateral body - spinothalmic
loss of pain/temp ipsilateral face - trigeminal thalamic
hoarsness/swallowing. loss of gag - CN 9 and 10
Ipsilateral horners
Vertigo, nystagmus, N/V (Some CN 8 nuc in medulla)
ipsilateral cerebellar deficits - inferior cerebellar peduncle
Presentation of internuclear opthalmoplegia (2)
Lesion is where?
Nystagmus of affected eye lesion and pact of adduction in lateral gaze movement
Convergence is normal
Lesion is in the medial longitudinal fasiculus
Causes of MLF syndrome (2)
Stroke >50 years old
MS < 50 years old - HIGHLY myelinated
lack of communication w/ CN6 and CN III* so they do not work together
most common site of berry aneurisms
anterior communicating artery
Assiated risk factors in berry aneurisms in addition to congenital defects (4)
Race - blacks
HTN
Smoking
Advanced age
Complications of a epidural hematoma (2)
Presentation on CT
transtentorial herniation w/ CNIII palsy
lucid period -> coma
CT shows biconvex (lens hyper dense blood collection
CT bone looks ?
Blood?
Order what when ruling out ischemic vs hemorragic stroke?
White
Hyperdense whitish
CT w/out contrast
CT presentation of subdural hematoma and timeline
crescent shape that crosses suture lines and midline shift potentially
rupture of bridging veins leads to longer time to develop hematoma
common in alcoholics, neonates and ELDERLY post fall
Presentation of Subdrual hematoma
HA
Dorwainess
focal neuro defects and dementia sometimes
Causes of subdural hematoma
Give what to help w/ morbidity
Most common overall is trauma
Most common non trauma is rupture of aneurism
2nd most common is rupture of arterial venous malformation
nimodipine - Ca channel blocker - and vessel spasm
Xanthocromic is?
yellow CSF seen on a spinal tap a few days after subarachnoid rupture due billirubin
Intraparanchymal hemorrhage most often due to
Worry about damage where
Systemic HTN, cocaine use?
- basal ganglia and internal capsule
- -> lenticulostriate vessel rupture (Charcot Bouchard )
Timeline to give a thrombolytic in a stroke
4.5-3 hrs
if asleep assume too long
Most common area of damage in an ischemic stroke(4)
5 minutes hippocampus neocortex cerebellum watershed areas
Causes of ischemic stroke (2)
atrial fib (L side) _. emboli Athersclerotic emboli block or rupture (carotid)
Also
septic emboli
DVT w/ Patent foramen ovale
fat emboli
transient ischemic attack?
brief reversible episode of focal neruo deficits lasting < 24 hrs
> 24 is stroke
Treat the same b/c you don’t know which is which
Foramen of Monroe located where?
Foramen of Luschka located where?
Foramen Mefenid located where?
between Lateral and 3rd ventricle
(cerebral aqueduct between 3rd and 4th ventricle)
Between 4th ventricle and subarachnoid - laterally
Between 4th ventricle and subarachnoid 0 medially
Communicating hydrocephalous due to
Symptoms
low CSF absorption by arachnoid granulations
Communicating:
-HA, papilledema, uncal herniation (CN3), death
Normal pressure: wet, wobbly and wacky
Hydocephales ex vacule - increase CSF in atrophy
Noncommunicating hydrocephalis
Symptoms
physical blockage or stenosis - compression
HA, papilledema, uncal herniation (CN3), death
arachnoid granulations located in
superior sagital sinus
Drains through sigmoid sinus -> jugular foramen -> internal jugular
Hydrocephalous ex vacuo
Increase Csf in atrophy due to Alzheimers
inctracranial pressure is normal, no triad of Wet, Wobbly and wacky
Normal pressure hydrocephalous symptoms(3)
Wet Wobbly and wacky
Urinary incontinence
ataxia
reversible dementia
increase in subrachnoid volume seen (meningitis or trauma maybe) but no increased pressure of CSF
Pseudotumor Cerebri presentation
Rx
increased intracranial pressure w/ NO hydrocephalous
See daily HA w, papilldema and N/V, worry of vision loss
Nothing on CT(tumor or dilation) in overweight women
Rx: stop Vit A, tetracycline, corticosteriod withdrawal,
- Weight loss and acetazolmide
- Some invasive options as well
Tension HA location and timing?
Associated feature -
Rx
Bilateral - band like HA -> frontal and occipital lobe
lasting 4-6 hrs
NO associated features
Rx - Tylenol/NSAIDS
Cluster HA location and timing?
Associated features
Rx
Unilateral -retrorbital pain, piercing/nonthrobing
lasting 15 min -3 hrs; daily timing w/ month clusters
Partial horners - Myosis and ptosis, tearing, rhinnorrhea, nasal congestion
Rx: 100% O2
-Also nasal sumatripatn
Migraine HA location and timing?
Associated Features
Rx
Unilateral pulsitile HA w or w/o aura (scintillating scotomat - light, smell)
lasting 4-72 hrs
Has moderate intensity prohibiting work, made worse w/ tyrosine and activity
N/V
Photo/phonophobia
Rx: Sumatriptan - > vasoconstriction by 5HT 1b and 1d agonist; take as SOON as possible
HA seen in male smokers
Cluster
the rat more likely women especially migranes
Sumatriptian contraindicated in migraine management for (3)
CAD
Prinzmetal angina
Pregnancy
Vasoconstriction and vasospasm worries
obese female w/ papilledema and HA
pesudotumor cerebelli or hydrocephalis
HA w/ elevated ESR and jaw muscle pain when chewing
Temporal arteritis
HA w/ extraoccular muscle palsies
cavernous sinus thrombosis
Sever HA w/ fever and neck stiffness
meningitis
Severe HA- > constant, no wax or waining
-> develops over time
brain tumor
-May have seizures and focal defects
If Hx of trauma and lasts over a week could be Subdural hematoma as well
CN nucleus responsible for?
Carotid blood pressure
Aortic blood pressure
hypoxemia aorta
muscle info for swallowing
10
9
9
10 and 9
Common brain tumors in adults in order
top 4
Usually supratentorial
MGM Studios
METS
glioblastoma
meningioma
Schwanoma
Also oligodendroplioma, pituitary adenoma
Common brain tumor in Kids top 3
Usually infratentorial
Pilocytic astrocytoma
medulloblastoma
ependymoma
also- hemangioblastoma, craniopharyngioma
Pseudopalisading pleomophic tumor w/in the cerebral hemispheres
Stains what?
glioblastoma - adult
Stains astrocytes for GFAP
cells in whirls of fascicles that grow slowly arising from the arachnoid cells
Also see what inclusions
meningioma - adult
psammoma bodies
S 100 tumor that is associated w/ neruofibromatosis type 2
schwanoma - adult
most common CN 8 -> acoustic schanoma
frontal lobe tumor that has fried egg appearance, chicken wire capillary pattern
oligodendroglioma - adults
Fried egg also: koiliocyte and seminomas
bitemporal hemanopia w/ ammenorrhea
prolactinemia
posterior fossa of the cerebella affected that is benign and has rosenthal fibers
cell affected?
pilocytic astrocytoma- kids
-benign
astrocytoma (remember #1 primary tumor of adults and kids involve astrocytes)
rosenthal fibers - eiosinophilic corkscrews
Hydrocephalis seen in a kid with a brain tumor think
medulloblastoma - cerebellar
ependymoma - ependymal
both compress the 4th ventricle
homer Wright rosettes are
circumfrential pattern surrounding fibers seen in medulloblastoma - kids brain tumor - cerebellar
- worry about drop METS
differs from perivascular psuedorosettes in ependymoma
perivascular pseudorosettes are
circumferential pattern surrounding a vessel seen in ependymoma - kids brain tumor -ependymal cells
differs from hormer Wright rosettes in medulloblastoma
Tumor derived from rathkes pouch seen in kids
cranipharyngioma
pituitary adenoma-
Note:supratentoral
Hemangioblastoma think 2 things
hippel lIndeau syndrome (w/ retinal angiomas)
see -> renal cell carcinoma
foamy cells w/ high vascularity and polycythemia
hemagioblastoma
EPO producing tumor
Part of hippel-lindau syndrome leading to renal cell carcinoma
cingulate subfalcine herniation under falx cerebra can compress?
anterior cerebral artery
Ia afferent differs from Ib how in the muscle spindle
Ia delivers signal from the muscle spindle to the dorsal horn in response to stretch/∆length of the intrafuscial muscle
-> alpha motor neuron reflex leads to tightening of the extrafusal muscle fibers
Ib delivers signal from golgi tendon organ in the tendons in response to tension and inhibits alpha motor fiber contraction of extrfusial muscles if too high
Gamma loop in the muscle spindle
regulates the sensitivity of the reflex arc from the CNS through a gamma motor neuron which contracts the intrafusal fiber increasing sensitivity
Clinical reflexes tested with a hammer
Achilles
Patellar
Bicepts
Tricepts
S1, S2
L3, L4
C5, C6
C7 and C8
a positive babinksi in an adult may indicate what and looks like?
May be a UMN lesion where the feet fan out and up while the big toe dorsalflexes
Moro reflex
startle reflex -arms extend then abduct
Rooting reflex
head turns to side of cheek
sucking reflex
sucks when roof of mouth touched
plantar reflex
normal in babies where toes fan out when bottom of heel stroked
Galant reflext
on stomach baby laterally flexes towards side their spine is stroked
UMN Lesion presents w?(3)
spastic paralysis
hyperreflexia - lost inhibiton
positive babinski
LMN lesion presents w?(4)
Flaccid paralysis
hyporeflexia - lost arc
fasiculations - muscle quivers
Atrophy
Somatosensory from the body (Medial lamiscus and spinothalamic tract) goes through what part of the thalamus
VPL- very painful legs
Cerebellum (dentate nucleus) and basal ganglia goes through what part of the thalamus enrout tot the motor cortex and supplementary motor cortex
VL
Trigeminalthalamic tract and taste pathway goes through what part of the thalamus enroute
VPM - very painful mouth
Retina stimulation going to the occipital lobe passes through what part of the thalamus
Lateral geniculate nucleus
Brachium of inferior colliculus (auditory info) enroute to the primary auditory cortex goes through what portion of the thalamus
medial geniculate nucleus
What are the longitudinal zones of the cerebellum starting medial (4)
Vermis - central
Intermediate (paravemal zones) -arms/legs
lateral hemispheres- arms/legs
folliculonodular lobe w/in
What are the inputs to the cerebellum and the corresponding out put fibers?
Whats in-between?
Mossy/climbing fibers go in
Purkinje fibers come out
the cerebellar cortex is in-between
- deep nuclei of the cerebellum come after -> output targets
Major output pathway of the cerebellum?
brachium conjunctivum (superior cerebellar peduncle) -> contralateral vental lateral nucleus of the thalamus -> motor/supplementary cortex
3 functional regions of the cerebellar cortex that ingrates information
Vestibulocerebellum (flocculonodular lobe and vermis)
-balance and eye movement
Spinocerebellum ( vermis and paravermal regions)
-motor execution (medial and latera descending systems depending on nuclei)
Cerebrocerebellum (lateral hemispheres)
-motor planning to premotor and premotor cortices
Deep nuclei of the cerebellum media to lateral (4)
Fastigial
Globes
Epoliform
Dentate
Motor control on the would be effected on what side of a cerebellelar lesion?
Ipsilateral to the lesion
There is 2 crossings
-> movent contemplates in the contralateral motor cortex but there again is a desiccation in the cortical spinal tract on descent
What neuro abnormalities can be attributed to damage of the spinocerebellum (vermis and paravermis)(4)
Postural instability
Slurred/slowed speech
Hypotonia
pendular knee jerk reflexes
Symptoms seen in anterior lobe (Anterior vermis syndrome)?
Most common cause?
Ataxia/dystaxia w/ broad based staggering gait
due to chronic alcohol use -> thiamine deficiency -> cerebellar cortex degeneration
What neuro defects can be seen in cerebrocerebellum damage (4)
Lack of control of voluntary movements -timing and rate(fail rapid hand movement)
delay in initiating/stopping movement
Dysmetria (impaired control of speed/distance/power)
Intention tremor
What are the 3 types of tenors seen and how are they different?
Essential tremor - familial and seen in both rest and movement
Intention tremor - Seen w/ initiation of movement and sound in cerebellar defects
Resting tremor- seen at rest and disappear w/ movement (Parkinsons)
what are the features of essential (Familal) tremor?(3)
Rx?
fine tremors of head/hands/arms/voice
50% familial
occurs at rest and movement
Rx w/ beta blockers or primidone (anticonvulsent)
What neuro defects are seen in vestibulocerebellum(vermis and floculonodular) damage?(2)
Disequilibrium- can’t maintain balance
Abnormal eye movements (cerebellar nystagmus that are more pronounced when looking at the lesion)
Positive rhomberg indicates what type of pathology
3 parts in balance tested
Problem w/ dorsal column giving proprioception from the legs
take away vision and have faulty proprioception, the vestibular apparatus has nothing to gauge against
the basal ganglia to the prefrontal, premotor and orbital cortices traces through what part of the thalamus
VA
Globus pallidus internal segment generally has what impact at on movement
It decreases movement through inhibiting the thalamus before signal goes to cerebral cortex
Subthalamic nucleus generally has what impact on movement
it decreases movement by increasing the negative signal by the globus pallidus internus
Substantia nigra pars compacta normally has what impact on movement
Generally increases movement 2 ways
- Direct pathway of the neostriatum w/ D1 agonist activity blocking globes pallidus negative effect
- Inhibits the indirect pathway w/ D2 agonist (inhibits). It inhibits the indirect pathway which normally has neg effect on globus pallidus external which has a negative effect on the sub thalamic nuclei (remember it is generally neg)
Neurotransmitters implicated in Huntingtons(3)
Decreased ACh and Gaba
Increased Dopamine
Eosinophilic inclusions in the cytoplasm of neurons
Lewy bodies
-parkinsons and lewy body dementia
basil ganglias role in the brain?
regulates the amount of movement. Cortex controls how much
Neostriatum made of?
Cuadate nucleus and putamen
Lentiform is made of?
putamen and globus pallidus
Lesions of substantial nigra pars compact leads to?
As seen in?
Lack of D
parkinsons- not enough movement
Lesions of sub thalamic nucleus leads to?
As seen in?
hemiballismus - unilateral flailing of a limb
Lacunar stroke (contralateral to flail)
D1 vs D2 in the basil ganglia
Both lead to movement
D2 agonist leads to inhibition of the indirect pathway which normally inhibits movement
D1 agonist leads to agonist of the direct pathway
5 symptoms of parkinsons
Resting tremor (disappears w/ movement)- pill rolling
Cogwheel rigidity
Mask like facies
Fenestrating Gait/postural instability
akinesia
MPTP exposure leads to?
Parkinson like symptoms due to chemical degradation of the substantial niga
MPTP -> MPP by MAOI which leads to lesion
Athetosis
slow writhing movements especially fingers
Seen in huntingtons
Myoclonus
sudden brief uncontrolled muscle contraction
-can be repetitive vs hemiballismus or chorea
Hemiballismus
sudden wild flailing go 1 arm +/- the leg due to contralateral sub thalamic nuclear stroke
Chorea
suddern jerky purposeles movements NON- repetative
Seen in huntingtons
Akathisia
Feeling the NEED to constantly move , dance in plase
symptom of some neuroleptics
Lesion in huntingtons?
caudate nucleus loses ACh and GABA lose of inhibition of movement -> chorea
Rx for Huntingtons(3)
Block Dopamine receptors
- Haloperidol
- Olanzapin
Inhibit Dopaine release
-Tetrabenazine
1st line in Parkinsons Rx
Levodopa w/ Carbidopa
crosses the BBB barrier while Carbidopa blocks peripheral decarboxylation
Carries voluntary motor commands from the motor cortex to the head and face
Corticobulbar tract
Mixed upper and lower motor neuron disease
ALS
Lissauers tract
receives pain and temp info and ascends 2-3 segments before crossing in anterior white commissure -> spinothalamic tract
Fasiculus cuneatus
Touch/Pressure/Vibration in the arms -> dorsal columns
Lateral to fasiculus gracilis
Fasiculus gracilis
Touch/Pressure/Vibration in the legs -> dorsal columns
medial to the fascicles cuneatus
Lateral corticospinal tract
Carries UMN signal w/ volantary muscle control.
Seen in the laterally in the grove of the Anterior and Posterior horn
Accessory voluntary movement tracts(2)
Reticulospinal tract
anterior cotical spinal tract
Vestibulospinal tract
reflexive bundle from vestibular apparatus responsible for making fine postural movements
Located most anterir/ventral portion of the spinal tract
- ventral spinothalamic tract found just posterior
Ventral spinothalamic tract
Crossed signal of pain and temp from the lissauers tract
Just posterior to the vestibulospinal tract in the ventral portion of the spinal cord- continuous with the lateral spinal tract
ventral spinocerebellar tract/dorsal spinocerebellar tract
Carries proprioception information to the the cerebellum for fine adjustments in movement correction
- located in the lateral spinal tract adjacent to the edge
Poliomyeolitis is spread?
Affects what portion of the spinal tract leading to symptoms(4)
Spread fecal oral-pharnyx before CNS
Affects the LMN neurons of the anterior horn
flaccid paralysis, fasiculations, hyporeflexia,
w/ fever, HA, ab pain, sore throat
CSF of polio has:(3)
lymphocytic pleotosis
slight protein elevation
No change in glucose
Floppy baby at birth due to LMN lesion that is auto recessive
Werdnig Hoffman disease
Death by 7 months
Charcots triad in MS(3)
Other symptoms?(3)
Damage to highly myelinated cells
Scanning speech
nystagmus
intention tremmor
intranucleat opthammoplegia
Bowel and bladder issues,
optic neuritis
Lumbar puncture of MS -?(2)
Increased protein levels
- Ig Light chains
- Oligoclonal clonal bands on electrophoresis
Patient w/ both upper and lower motor neuron lesions, sensory is intact
suspect a defect in what enzyme?
Amyolotrophic lateral sclerosis (ALS)
Defect in superoxide dismutase 1
ALS affects what 2 spinal tracts?
Rx:
Lateral corticospinal tract
anterior motor horn
Riluzole - decreases presynaptic glutamate release
Symptoms in ALS
Both upper and motor neuron lesions ->
Fasciulations progressive weakness dysarthia - speech dysphagia - swallowing dypsnea -> death w/ diaphragm muscle atrophy
Tabels dorsales is a defect in ?
Symptoms?(3)
Doral columns and roots
impaired sensation and proprioceptioin -> progressive sensory ataxia
Charcots joints (banging them around) argyll robbertson w/ terry syphilis
Absent DTRs and positive rhomberg
Lesion where the dorsal column is spared but have bilateral loss of pain and temp as well as motor command
due to occlusion of what vessel
Presents as?
Anterior spinal artery occulusion
Presents w/ intact sensation but loss of spinothalamic and lateral corticospinal tract and anterior motor horns leads to
complete motor paralysis, loss of pain and temp, areflexia
2 congenital ataxia lesions?
Freideichs ataxia
- staggering gait
- trinucleutid repeat - GAA in the gee frataxin
Ataxia telengiectasia
- lowered immune
- lymphoma risk
- telengiectasi presenting in the sclera 1st
Frataxin is the gene implicated in what disease?
Pathogeneisis
trinucleutide repeat of GAA in Friederichs ataxia
leads to mitochondrial functioning impairment
Friedrichs ataxia presents w?(6)
Degeneration of sensory neurons
Staggering gait* nystagmus* dysarthya pes cavus hammer toes hypertophic cardio myopathy*
Brown Sequard tract defects- 5
Ipsilatateral loss of UMN signal w/ lateral corticospinal tract
Ipsilateral loss of LMN -> flaccid paralysis
Ipsilateral loss of tactile/pressure/vibration in w/ dorsal column
Contralateral loss of pain/temp w/ spinothalamic tract 2-3 segments below lesion (Lissaure tract ascends)
Loss of all sensation at the lesion - loss of lessor and dorsal columns
Hemisection of the spinal cord is called?
Brown sequard syndrome
5 major parts of the brachial plexus
Real Texans Drink Cold Beer
5 Roots 3 Trunks 2 Divisions 3 Cords 5 branches
Brachial plexus is made from roots off of?
C5-T1
Nerves off the the Upper trunk/lateral cord of significance (2)
Muscles?
Suprascapular nerve - infraspinatus and supraspinatus
Lateral pectoral nerve - pectoralis major
Long thoracic nerve enervates what?
Made of
Serratus anterior
SALT
Made off roots of C5-C7
extra nerves off the Medial cord(3) and muscles innervates
Lower subscapularis - subscapularis
Thoracodorsal nerve - latismus dorsi
Upper subscapularis - teres major
Terminal branches of the brachial plexus and major muscle innervations (5)
Muscularcutaneous - bicep, coricobrachialis, brachialis, flexors of forearm
Axillary - deltoid and teres minor
Radial - extensors of the forearm and triceps
Median- thenar muslce and protinators
Ulnar - interosseous and hypothenar
Erb duchenne palsy damages what nerve
Common presentation?(3)
Common cause?(2)
C5-C6
Waiters tip w/ loss of suprascapular, muscularcutaneous and axillary nerve most common -> medial rotation, pronation and limp arm
Difficult birth/landing on shoulder
Waiters tip w/ loss of suprascapular, muscularcutaneous and axillary nerve most common -> medial rotation, pronation and limp arm
Erb Duchenne palsy w/ C5-C6 Damage
Thoracic outlet syndrome is due to?
Presentation?(3)
Compression of the subcalvian artery and inferior brachial plexus (C8-T1) by a cervical rib
atrophy of thenar and hypothenar, interossous muscles
Loss of sensation on medial forearm and hand
Disappearance of radial pulse
Klumpke palsy due to ?
Symptoms?(2)
Characterized by damage to lower brachial plexus w/ C8 and T1
Falling out of a tree and yank arm up
atrophy of thenar and hypothenar, interossous muscles
Loss of sensation on medial forearm and hand
Radial nerve sensation(3)
skin of posterior arm
Superfical - lateral and posterior hand
Deep - posterior forearm
Deep branch of the radial nerve innervates (4)
Supinator
brachioradialis
Extensors of the forearm
adductor pollicus longus (not main one)
Radial nerve inervates?(4)
BEST
Brachioradialis
Extensores of wrist and hand
Supinator
Tricepts
Saturday night palsy?
radial nerve compression against spiral groove
- triceps ok but weak wrist and finger extension
cannot flex the 4th and 5th DIP and unable to extend the interphalangeal joints of the 4th and 5th joint
Ulnar claw
loss of lateral 2 lumbricals which flex the MCP and extend the DIP and PIP
always is abnormal
Ulnar skin sensation
Skin over the medial hand
Muscles of the ulnar nerve (5)
Flexor carpi ulnaris
medial 1/2 of flexor digitorium profundis
Deep
- hypothenar muscles
- Adductor pollicis
- Ulnar 2 lumbricles
Median nerve skin sensation(2)
Lateral palm
distal 1st 3 and a half digits
Median nerve muscles (10)
Pronators
- Pronator teres
- pronator quadratis
Wrist flexors
- flexor carpi radialis
- plamaris longus
- flexor digitorium superficialis
Thumb - thenar muscles
- Oppenens pollicis - ape hand
- Abducto pollicis brevis
- flexor pollicus brevis
Lateral 1/2 flexor digitoriom perfundis - benedicitine
radial 2 lumbricals
Ape Hand
Loss of the recurrent branch of the median nerve -> innervates the thenar muscles
- Oppenens pollicis - ape hand
- Abducto pollicis brevis
- flexor pollicus brevis
Hand of benedictine
median nerve
Loss of PIP flexion in digits 1-3 and loss of DIP in digits 2-3 when making a fist
digits 2 and 3 remain extended
Lateral 1/2 flexor digitoriom perfundis - benedicitine
radial 2 lumbricles
Carpal tunnel syndrome is trapping ow what nerve between what 2 structures
median nerve between
carpel bones and flexor retinaculum
Musculocutaneous nerve sensation
Lateral forearm
Musculocutaneous muscle innervation (3)
biceps
croacobrachialis
brachialis
Axillary nerve muscle innervation (3)
teres minor and deltoid and long head of triceps brachia
Axillary sensation
skin of lateral shoulder
Fracture of surgical neck at risk of damaging what artery and nerve?
axillary nerve
posterior circumflex
Femoral nerve innervates what muscles?(2 groups - 7 muslces
commonly damaged in?
Flexors
- illopsoas
- Pectineus
- sartorius
Knee extensors (quads)
- Vastus lateralis
- Vastus medialis
- Vastus intermedias
- Rectus femoris
Damaged in pelvic fractures
loss of sensation in anterior thigh
- nerve damaged?
Femoral
Obturator nerve innervates what muscles and
Commonly damaged in?
Thigh Adductors **
- adductor magnus
- adductor longus
- adductor brevis
Gracilus (knee flexion)
Commonly damaged in anterior hip dislocation
Lower leg muscle innervated by both the obturator and the sciatic nerve
Adductor magnus
Loss of sensation to the medial thigh thigh - nerve damage?
Obterator
Superior gluteal nerve innervates? (3 muscles)
Commonly damaged in?
Thigh Abductors
- Gluteal medius
- Gluteal minimus
- tensor fascia late
Damaged in posterior hip dislocation
also polio
Inferior gluteal nerve innervates?(1 muscle)
Commonly damaged in?
Thigh extensors and lateral rotation
-Gluteus maximus
Posterior hip dislocation
Trendelenberg gait is described as what if the lesion was on the R for example
What muscles implicated
The L hip would drop due to failure of the hub abductors contrallaterally to flex and old the hip up when staring on the affected leg
- inferior gluteal nerve w/ gluteus minimus and gluteus medius
Sciatic nerve innervates what muscles (4)
Lesion may be due to?
Breaks into tibial and perineal nerve later on
knee flexors and hip extendors
- biceps femoralis - latera
- semiteninosus
- semimembrnous
- adductor magnus
Lesion w/ intervertebral disk herniation, spinal stenosis , spndodylolisthesis
Tibial nerve innervates what 7 muscles
lesion may be due to ?
Plantarflexors
- gastrocnemius
- Soleus
- plantaris
Popliteus - unlocks knee
Toe flexion
- Flexor hallucis longus
- flexor digitorium longus
Tibialis posterior - inversion
Knee injury -> TIP issues
Loss of sensation on the sole of the foot nerve injury?
Tibial nerve
Common perineal nerve innervates which muscles (6)
Commonly injured w?
Deep Peroneal Dorsiflexion - Tibialis anterior -extensor hallicus longus -extensor digitorium longus
-peroneus tertius - eversion
Superfical peroneal - Eversion
- peroneous longus
- peroneus brevis
Lateral knee injury, fibula neck fracture -> PED
“foot drop”
Loss sensation to the lateral foot and dorsal foot. Nerve injury?
May see what associated feature?
Common perineal nerve
“foot drop”
Vasculature off the aorta leading to the foot?
Common iliac
- > internal iliac
- > external iliac
External
- > deep femoral
- > femoral
Femoral -> popliteal(behind the knee)
Popliteal -> tibial
Tibial
- > posterior tibial -> fibular
- > anterior tibial -> dorsalis pedis
Anterior dermatome ditribution?
T10 L1 L5 S1 S2-3
Umbilical groin L2-L3 (stripes down) top of foot lateral foot genitalia
Posterior dermatome distribution?
S5
S2
S1
S5 - recum
S3-4 radiates out
S2- Medial leg
S1 lateral leg
2 muscle receptors responsible for opening the sarcoplasmic reticulum
dihydropiridine - volage sensitive
Ryanodine
- mechanically coupled
- (blocked by dantrolene)
Sarcomere labels
A band
I band
H band
M line
Z line
A band is total myosin
I band - is just actin off the Z line
H band - just myosin of the M line
M line - middle of sarcomere, myosin radiates off
Z line - holds actin radiating off w/ titin filaments connection to the myosin
Which bands change w/ sarcomere contraction
I band - just actin
H band - just myosin/out actin
A band- constant myosin w and w/out actin
Binding of Ca to what causes a conformational change allowing contraction?
What moves out of the way?
Troponin C binds to Ca
Tropomyosins wove out of my son binding groove on actin filaments
Type 1 muscles are found where?
in long acting muscles (slow twitch) like calves
High in myoglobin -> oxidative phosphorylation in mitochondria (deep red)
Type 2 are found where?
in fast twitch muscles (like the pects) which contract anaerobially w/ low mitochondria and myoglobin
Body building muscles
Rapidly adapting sensory receptors(2)
Messieners (superficial) Pacinian corpuscle (deep)
Slowly adapting sensory receptors (2)
Merkels (superficial)
Ruffini (deep)
Prickling pain is carried by?
A delta fibers (fast and mylinated)
Burning or dull pain - itch is carried by?
C polymodal fibers (slow unmylinated)
Vibration and pressure
Characteristic look?
pacinian receptor
onion in cross section
Dynamic/changing light and discriminatory touch
Where are they found the most?
Messieners capsule
found in areas of skin w/out hair - fingertips, lips, eyelids
Static unchanging light touch
On histology hard to distinguish from what cell?
Merkel - think of erkel awkwardly touching too long
Confused w/ melanocytes
Propioception regarding the muscle length sensed by
muscle spindels
Proprioception regarding muscle tension sensed by?
Golgi tendon aparatus
Ropust spindle shape structures found on soles of feet?
raffinii
Layers of peripheral nerve (3)
Epineurium - vessels
Perineurium - fascicle
Endoneurium - individual nerve
Gulliane barre damages these nerves?
Schwann Cells
Cells that promote axonal regeneration
Schwann cells
Classic presentation of Guilliane Barre
Causal agent?
Ascending symetrical paralysis w/out loss of sensory
May include the face (50%)
Causal agent: Unknown - associated w/ camplobacter or CMV or herpes - post respiratory , maybe stress
Increased CSF protein w/ NO change in the cell count?
Guilliane Barre
Rx for guillaine BArre
Supportive
- respiratory especially, the autoimmune attack of the schann cells eventually subsides and most recover completely
Demylination of the CNS due to destruction of the oligodendrocytes?
Associated w/ what cause?
Progressive multifocal leukoencephalopathy (PML)
Reactivation of JC virus in AIDS patients -> fatal
JC virus in AIDS patients be concerned w/ what path?
Destroys what cells?
progressive multifocal leukoencephalopathy
Attacks oligodendrocytes
progressive multifocal leukoencephalopathy
Reactivation of JC virus in AIDS patients -> fatal
Demylination of the CNS due to destruction of the oligodendrocytes
Acute disseminated encephalomyelitis
multifocal perivenular inflammation and demylination after infection (viral - measles or VSV), or vaccination
Pathology seen after receiving a vaccine leading to symptoms of encephalitis
Pathology?
Acute disseminated encephalomyelitis
multifocal perivenular inflammation and demylination after infection (viral - measles or VSV), or vaccination
Autosomal recessive lysosomal storage disease leading to demylination?
deficient in what?
Metachromatic leukodystophy
Arylsulfatase A
-> sulfa tide build up and impaired myelin production
Arylsulfatase A deficiency leads to?
Metachromatic leukodystophy
-> sulfa tide build up and impaired myelin production
Metachromatic leukodystophy
Autsomal recessive lysosomal storage disease leading to demylination
Arylsulfatase A deficiency
-> sulfa tide build up and impaired myelin production
Charcot Marie tooth syndrome presentation
Affects (2)
hereditary motor AND sensory neuropathy
due to defect in production of proteins involved in the
1. function of peripheral nerves 2. myelin sheath
hereditary motor AND sensory neuropathy
Charcot Marie tooth
due to defectim production of proteins involved in the function of peripheral nerves or myelin sheath
Mcburneys point
Appendix
2/3 of the way from umbilicus to ASIS
cotton wool spots seen in (3)
seen on the retina in
DM
HTN
AIDS
White reflex on an infant most likely indicates
retinoblastoma
Uveitis is?
Associated w?(2)
inflammation of the uveal coat(iris, ciliary body(anterior) and choroid (posterior)
systemic inflammatory disorders - sarcoidosis, RA
HLA b27 - PAIR associated conditions
Flow of aqueous humor
Made by ciliary epithelium (B2)
- > posterior chamber
- > around the lens -> anterior chamber; between angle formed by lens and iris diaphragm
- > Drains into the trabecular meshwork
- > Drains the trabecular meshwork
Open angle glacoma presentation(4)
Bilateral
insidious onset in an older patient due to either an overproduction or lack of drainage issue
loss of peripheral vision first then central
painless
Presentation of closed narrow angle - acutely(6)
Emergency. Increased IOP pushes iris fotfard and angle closes abruptly
PAIN -unilateral sudden vision loss halos around eyes rock hard eye frontal HA
Gaucoma medication 2 groups 6 drugs
Increase outflow
- prostglandins
- alpha agonists
- cholinergic agonists
Decreas aqueous production
- beta blockers
- acetazolamide
- alpha agonists
Mannitol in acute angle
Catarct is?
Risk factors?(9)
painless opacification of the lens leading to decreased vision (lock of night vision, can’t read fine print)
Risks
- Smoking
- age
- sunlight
- corticosteroid use
- galacosemia
- galatokinase deficieny
- diabetes - sorbitol
- trauma
- infection - rubella in utero
Diagnose glaucoma (2 ways)
tonometry test -pressure
optic cup to disc ratio greater than 50% the cup is bulging out in comparison to the disc (ganglion exit point)
Sudden onset of plashing light followed by poor vision think of?
Retinal seperation
Seperation of the neurosensory layer of the retina from outermost pigmented epithelium. -> degeneration of photoreceptors
Retinal detachment risks?(3)
retinal breaks - trauma
diabetic traction
inflammatory effusions
Diabetic eye problems(4)
retinal detachment
neurovascularization/proliferation retinopathy
Glaucoma
cataracts
2 types of macular degeneration and associated Rx
Dry - nonexudative (>80%) - deposition of “drusen” yellowish extracellular pigment
-Rx stop smoking and antioxidant vitamins
Wet- exudative - rapid loss of vision w/ bleeding secondary to choroidal neovascularization
-Rx antivascular endothelial growth factor injections (Anti VEGF)
Outer hair cells vs Inner hair cells
Damaging Abx?
Outer hair cells receive signal from the olevochochlear tract causing the the outer hair cells to contract -> stiffening of the basalir membrane -> sensitization of the inner hair cells to frequencies
Aminoglycosides damage the Outer hair cells
Pathway of hearing - 10
Tympanic membrane-> middle ear ossicles (malleus, incus, stapes)-> auditory hair cells on the cochlea-> Spiral (cochlear ganglion)-> Chochlear nuclei-> lateral lemniscus-> inferior colliculus-> medial geniculate body -> primary auditory cortex (temporal lobe)
Weber and Rinne Tes
*Weber
Normal is midline
Conductive hearing loss -> lateralizes to affected ear
Sensorineural hearing loss lateralizes to the opposite ear
- Rhinne
Normal - Air conduction > bone
Conductive hearing loss BC>AC
Most common organisms implicated in Acute otitis external(2)
Rx?
Pseudomonas
S aureus
Irrigation and topical Abx
Kid comes in that jumps off the table when you put in your otoscope, also does not like his pinna pulled on diagnosis
Acute otitis externa - pseudomonas most likely
Diagnosis of Acute Otitis Media (4)
Rx?
Bulging TM
Middle ear effusion
Erythema
TM immobility under positive pressure
Amoxicillin w or W/o clauvinate
Most common causes of otitis media (3)
Strep pneumonia
Hamophelis influenza - nontypable
Morexella Catarrhalis
Patient complains post auricular swelling redness and mastoid tenderness =?
What did they have before?
Acute mastoiditis
Complication of Otitis media
Difficulty maintaining inner ear pressure and due to allergic rhinitis?
Rx?
Eustachian tube dysfunction
Intranasal steriods Rx
Overgrowth of desquamated keratin debris w/in the middle ear space?
Complication
Cholesteatoma
eventually may erode the ossicular chain and math mastoid air cells
Causes predesposing chosteastoma (2)
Symptoms (3)
negative middle ear pressure - estachian tube dysfunction
direct grown of epithelium through TM perforation
Conductve hearing loss
vertigo
pearly white lesion behind the TM
Feeling like the room is spinning is most likely due to ?
caused by(2)
Benigne paroxysmal positional vertigo
Cellular debris or displaced otoliths in the vestibular apparatus -> illusion of spinning
Dx and Rx for BPPV?(2)
Dix hallpike procedure
Epley maneuver
Causes of vertigo(4)
BPPV
Vestibular neuritis
Meniere disease - tinnitus, vertigo and hearing loss
Central vertigo - branstem/cerebellar lesion -> damaged vetibular nuclei
Patient presents w/ tinnitus, vertigo and hearing loss Dx?
due to
Meniere disease
Due to imbalance in the composition of electrolytes and fluid in the endolymph
Intranuclear inclusions seen in herpes simplex encephalitis?
Cowdry Type A
Cytoplasmic inclusions pathognomonic of rabies?
Negri Bodies
Neuronal inclusions characteristic of parkinsons
lewy bodies
Cytoplasmic inclusions associated w/ aging
Lipofuscian
Dark cytoplasmic pigment in neurons of the substantial nigra and locus coeruleus, not seen W/ Parkinsons
melanin
Eosinophilic, rod like inclusions in the hippocampus of alzheimer pateints
Hirano bodies
Diagnostic of alzheimers disease
neurofibrillary plaques or tangles (intracellular)
Filamentous inclusions (tau proteins) that stain slier and do not survive neuronal death - spherical
Picks Bodies
Filamentous inclusions that stain w/ PAS and ubiquitian
Lewy Bodies
What 3 diseases have lewy bodies?
Parkinsons
Lewy body dementia
Rare type of alzheimers
The difference in daily course and level of consciousness in dementia and delerium
Dementia is consistent w/ normal levels of consciousness
Delerium has waxing and waning levels throughout the day maybe and the has a decreased level of consciousness (taking more naps)
intracellular deposits of hyperphosphorylated tau proteins
Neurofibratory tangles seen in Alzheimers
Extracellular amyloid deposits in the grey matter?
Beta amyoild - senile plaques in alzheimers
1st and 2nd most common cause of dementia
- alzheimers
2. multi infarct dementia (vascular dementia)
Usual workup of dementia -
6 tests
mini mental HIV - encephalopathy RPR - teriary syphilis B12- megaloblastic anemia MRI - vascular or hydrocephalis (NPH) TSH - hypothyroidism
neurotransmitter change in alzheimers and drug Rx
(2 classes)
decreased ACh
cholinesterase inhibitors
- domeprizol, reostigmine, galantamine
Memantine - NMDA antagonist, decreasing gluamte excitability in the brain which is toxic
2 pathologies found in the brain w/ alzheimers and makeup and location
Senile plaques
- extracellular
- Abeta amyloid
- from APP (amyloid precursor Protien)
Neurofibrillary tangles
- intracellular
- tau proteins
- insoluble cytoskeleton elements(hyperphos)
Dementia seen with aphasia
underlying path?
Pick’s Disease
- spherical tau protein that build up in the frontal and temporal regions of the brain
- spares the parietal and posterior superior temporal gyrus
Dementia seen w. change in personality
underlying path?
Picks disease
- spherical tau protein that build up in the frontal and temporal regions of the brain
- spares the parietal and posterior superior temporal gyrus
Dementia seen w/ parkinsonian like symptoms and visual hallucinations
Underlying path?
Lewy body dementia
alpha synuclein defect -> lewy bodies in the cortex instead of substantial nigra
Dementia w/ syncope episodes
Lewy body dementia
alpha synuclein defect -> lewy bodies in the cortex instead of substantial nigra
Lewy body dementia characterized by 3 things
Parkinsonain like symptoms
Syncope episodes
visual hallucinations
alpha synuclein defect -> lewy bodies in the cortex instead of substantial nigra
alpha synuclein defect
-> lewy bodies in the cortex instead of substantial nigra
Lewy body dementia
Rapidly progressive dementia w/in weeks to months
Associated finding?
Prion disease Creutzfield- Jacob
-> Beta pleated sheet
myoclonus (startle)
Beta pleeted sheet buldup and myoclonus noted be worried about
Prion disease CJD
rapidly progressive dementia
Other causes of dementia
Multi infarct syphilis HIV B12 deficiency Wilsons Normal press hydrocephalus hypothyroidism
dementia w/ urinary incontinence and magnetic gait?
Normal pressure hydrocephalus
-reversible
Most common causes of delirium(2)
Drugs
- Benzodiazapines
- Anticholinergics
Infection - UTI
Delerium characterized by(6)
What may be abnormal?
acute onset disorganized thinking disturbance in sleep patterns waxing and waning levels of consciousness hallucinations
EEG abnormal
Dementia characterized by?(7)
progessive/persisitent decline of intellectual ability or cognition w/out affecting consciousness (prefrontal/temporal lobe neuronal death)
memory aphasia apraxia loss of abstract though behavioral/personality changes impaired judgement
