Neurology Flashcards by Kevin G

Define “Stroke”

Sudden onset of a neurological deficit from the death of brain tissue

How well did you know this?

Not at all

Perfectly

Stroke is the _____ leading cause of death in the US

3rd

How well did you know this?

Not at all

Perfectly

Risk factors for stroke?

HTN, Diabetes, Hyperlipidemia, Tobacco smoking

same as for MI

How well did you know this?

Not at all

Perfectly

Possible origins of emboli?

Heart: A. fib, valvular heart disease, paradoxical DVT passing through PFO

Carotid Stenosis

How well did you know this?

Not at all

Perfectly

Stroke: most common artery affected?

MCA (>90% of cases)

How well did you know this?

Not at all

Perfectly

MCA stroke presentation?

Contralateral hemiparesis (weakness/sensory loss)
Contralateral Homonymous hemianopsia (so eyes “look toward side of lesion”)
Aphasia if on same side as speech center (left in 90% of patients)
Hemineglect if on non-dominant hemisphere

How well did you know this?

Not at all

Perfectly

Brain region involved in pure motor lacunar stroke?

Contralateral Internal Capsule

Lateral Striate Artery

How well did you know this?

Not at all

Perfectly

Brain region involved in pure sensory lacunar stroke?

Contralateral Thalamus

Lateral Striate Artery

How well did you know this?

Not at all

Perfectly

Where is the stroke?

Contralateral paralysis & loss of sensation, both in the lower limb

Anterior Cerebral Artery

motor & sensory cortex of lower limbs

How well did you know this?

Not at all

Perfectly

Where is the stroke?

Contralateral hemiparesis/hemiplegia

Lateral Striate Arteries

Striatum, Internal Capsule
– common location of lacunar infarcts 2/2 unmanaged HTN

How well did you know this?

Not at all

Perfectly

Locate Stroke:
Contralateral: hemiparesis of lower limbs & dec’d proprioception
Ipsilateral: hypoglossal dysfunction (tongue deviates ipsalaterally)

Anterior Spinal Artery (commonly bilateral)

Medial Medullary Syndrome
- infarct of Paramedian branches of the AS & vertebral arteries

How well did you know this?

Not at all

Perfectly

When do you use Diffusion-weighted imaging?

When you want to highlight “extravasation” or inflammatory processes i.e. tumor, infection, breakdown of BBB, etc.

How well did you know this?

Not at all

Perfectly

Stroke:
Contralateral: homonymous hemianopia

Post. Cerebral Artery
(Occipital Lobe)
- macular sparing also

How well did you know this?

Not at all

Perfectly

If PCA stroke involves thalamus, what other Sx would you expect?

Thalamic involvement: Sensory loss to all modalities or pain

How well did you know this?

Not at all

Perfectly

Sx of Lateral Pontine Syndrome? Artery involved?

•Contralateral:
- Loss of P & T from trunk & limbs (Lat SpThlmic)

•Ipsilateral:

Loss of P & T from face (Spinal CN5 Nuc)
Facial hemiparalysis, loss of lacrimation/salivation, taste from ant. ⅔ tongue, corneal reflex efferent (CN7)
Hearing Loss (CN8)
Limb & Gait ataxia (Mid & Inf Cer Peduncles)
Horner’s syndrome (ptosis, miosis, & anhydrosis) (Symp Tract)
Nystagmus, nausea, vomiting, & vertigo (Vestibular Nuclei)

Anterior Inferior Cerebellar Artery

How well did you know this?

Not at all

Perfectly

Stroke Localization:
• Contralateral: hemibody pain & temperature loss
• Ipsilateral: facial pain, hemifacial pain & temperature loss, ataxia, nystagmus, nausea/vomiting, vertigo, Horner’s syndrome, dysphagia
• Hiccups

Posterior Inferior Cerebellar Artery (PICA)

– Lateral Medulla (Wallenburg Sydrome)

How well did you know this?

Not at all

Perfectly

Artery involved in Wallenburg Syndrome? Sx?

PICA (lateral medulla)
– or can also be Vertebral Artery (less common)

Contralateral: hemibody pain and temperature loss
Ipsilateral: facial pain, hemifacial pain and temperature loss, ataxia, nystagmus, nausea/vomiting, vertigo, Horner’s syndrome, dysphagia
Hiccups

How well did you know this?

Not at all

Perfectly

Stroke Localization:
•Bilateral: progressive quadriplegia, facial weakness
•Lateral gaze weakness with sparing of vertical gaze

Basilar Artery

– Pons (Locked-in syndrome)

How well did you know this?

Not at all

Perfectly

Dx?

Acute quadriparesis, loss of consciousness, & respiratory failure

Basilar Artery Thrombosis – urgent & potentially devastating

How well did you know this?

Not at all

Perfectly

The anterior limb of the internal capsule separates what 2 subcortical structures?

Caudate nucleus & Lenticular nucleus

Lenticular nucleus = Putamen + Globus Pallidus

How well did you know this?

Not at all

Perfectly

The posterior limb of the internal capsule separates what 2 subcortical structures?

Thalamus & Lenticular nucleus

Lenticular nucleus = Putamen + Globus Pallidus

How well did you know this?

Not at all

Perfectly

The ________ arteries are small penetrating blood vessels that supply blood flow to most of the subcortical structures.

Lenticulostriate

How well did you know this?

Not at all

Perfectly

What is meant by Lenticular or Lentiform nucleus?

Globus Pallidus + Putamen

How well did you know this?

Not at all

Perfectly

What are the calcified structures seen in the lateral ventricles on CT?

Choroid Plexus

How well did you know this?

Not at all

Perfectly

Most, but not all, of the Thalamus is supplied by Thalamoperforating branches of the ______.

PCA

Is the Internal Capsule lateral or medial to the Lentiform nucleus?

Medial to it

What structures are included in the Basal Ganglia?

Caudate, Putamen, & Globus Pallidus | Caudate + Lenticular nucleus

What nerve & artery travel through the optic canal?

Optic nerve & Ophthalmic artery

Suture that separates Occipital from Temporal bone?

Lambdoid suture

What type of imaging is FLAIR Imaging?

T2 MRI w/ the CSF removed | so CSF looks black, but the tissue is stained T2, i.e. white matter is dark

What type of imaging is most sensitive to measure acute changes in ischemic stroke?

DWI MRI

How do you confirm that a bright spot on DWI is indeed an ischemic lesion?

ADC image -- the same area should appear dark

What type of imaging is good for looking at deposition of minerals in the brain (i.e. iron, Ca)

Gradient ECHO MRI sequence

How are shades of black/gray/white described on MRI vs. CT?

CT: Hyper or Hypo - Dense MRI: High or Low - intensity signal

What does it mean if a lesion is "contrast enhancing" on MRI?

That it has a dark signal on T1 and bright signal with gadolinium (can be homogeneously- or ring- enhancing)

Which is better to view brain parenchyma - T1 or T2?

Which is better to view CSF - T1 or T2?

What is the 1 purpose of DWIs?

To visualize an area of acute ischemia

In what type of lesion is brain CT the go-to study?

Brain Hemorrhage | can also see calcifications

If the lateral & 3rd ventricles appear large on CT, consider what pathology?

Normal-pressure hydrocephalus

If the temporal horns of the lateral ventricles are enlarged, consider what pathology?

Acute obstructive hydrocephalus

When does an ischemic stroke appear on CT?

Not until 24-48 hrs after the stroke

Approach to reading a CT scan?

Bone - Air - Water - Brain

Loss of pain & temp sensation in the LEFT half of face & RIGHT half of body suggests lesion where?

Left lateral medulla or caudal pons Face & body would be on same side (contralateral) if lesion were in midbrain

Where is CN 3 nucleus?

Medial midbrain

Where is CN 4 nucleus?

Medial midbrain

Which CNs are found in the Pons?

Pons = 5 Pontomedullary junction = 6, 7, 8 - 6 is medial, 5 & 7 are lateral, w/ 5 superior to 7. 8 is lateral to 7. (5 spinal nucleus partly in both Pons & Medulla)

Stroke: What structure is injured? Artery? | Contralateral hemiparesis of lower limbs

Lateral corticospinal tract (in brain) | - ASA

Stroke: What structure is injured? Artery? | Dec'd contralateral proprioception

Medial Lemniscus | - ASA

Stroke: What structure is injured? Artery? | Ipsilateral tongue dysfunction

Caudal medulla -- CN 12 | - ASA

Stroke: What structure is injured? Artery? | Vomiting, Vertigo, Nystagmus

Vestibular nucleui | - PICA or AICA

Stroke: What structure is injured? Artery? | Ipsilateral Ataxia, Dysmetria, Dysdiadochokinesia

Inferior Cerebellar Peduncle (Lat Med synd) - PICA or Middle & Inferior Cerebellar Peduncle (Lat Pon synd) - AICA (dysdiadochokinesia = problems doing rapid alternating movement)

Stroke: What structure is injured? Artery? | Dysphagia, Hoarseness, diminished Gag Reflex

Nucleus Ambiguus - PICA (distinguishes this from AICA in Lat Pon Synd)

Stroke: What structure is injured? Artery? | Paralysis of face, dec'd lacrimation & salivation, loss of taste from ant 2/3 tongue, dec'd corneal reflex (efferent)

Facial nucleus - AICA (distinguishes this from PICA in Lat Med Synd)

Hemiballismus

Contralateral Subthalamic nucleus

Eyes look away from side of lesion

Paramedian pontine reticular formation

Reduced levels of arousal & wakefulness (e.g. coma)

Reticular activating system (midbrain)

Spacial neglect (agnosia of 1 side of the world)

Contralateral Right Parietal Lobe

Acute paralysis, dysarthria, dysphagia, diplopia, & LOC

Central Pontine Myelinolysis (can cause "locked in syndrome) | - Massive axonal demyelination in pontine white matter tracts

Common cause of Central Pontine Myelinolysis?

Iatrogenic -- overly rapid correction of Na+ levels (hyponatremia)

What is the goal BP when using tPA?

< 185/100

Platelets < ______ = c/i of using tPA

Platelets < 50,000

Seizure descriptive word that refers to loss of consciousness?

Complex | "Simple" = no loss of consciousness

What is Amaurosis Fugax?

A sudden, temporary, partial or complete loss of vision lasting a few seconds to several minutes before returning to normal. It is usually of vascular etiology.

What are Hollenhorst plaques?

Cholesterol emboli lodged in the retinal vessels that can be seen on dilated fundoscopic exam (such as those following TIA w/ ocular symptoms)

Where do nerves from the Posterior Column cross to the other side?

Caudal Medulla (they cross & become the Medial Lemniscus on their way to the Thalamus. The ML is located medially @ first & moves somewhat lateral as it heads rostrally)

What CN nucleus received input from afferent jaw jerk reflex? Where is this nucleus located?

Mesencephalic Nucleus of CN 5 | - location = superior to Main Sensory N. of CN 5

Discriminative touch of the face goes to which CN nucleus? Where is this nucleus located?

Main Sensory Nucleus of CN 5 | - location = mid-Pons

Proprioception of the jaw goes to which CN nucleus? Where is this nucleus located?

Main Sensory Nucleus of CN 5 | - location = mid-Pons

Pain & Temp sensation of the face afferents go to which CN nucleus? Where is this nucleus located?

Spinal Nucleus of CN 5 (caudal) | mid-Pons & goes inferior, sometimes until C2

Which is the only CN whose motor output from the brainstem goes to contralateral skeletal muscle?

Trochlear Nerve

Brainstem nuclei general arrangement of motor nuclei vs. sensory nuclei

Motor Nuclei tend to be located medial & anterior to Sensory Nuclei

Which CN nuclei are located in the medulla?

9, 10, 12

Which branch of CN 5 receives input from the nose?

V1 - Ophthalmic

Where are the vestibular & cochlear CN nuclei located?

Lateral Ponto-Medullary junction - Vestibular stretches & spans both - Cochlear sits more lateral & just in caudal Pons

Afferent of Corneal Reflex inputs to what CN nuclei?

Spinal Nuclei of CN 5

Reduced pain and temperature sensation on one side of the face but the opposite side of the body implies a lesion where?

Lateral brainstem between the mid-pons & the cervical spinal cord

Reduced pain and temperature sensation on one side of the face and on the same side of the body implies a lesion where?

Midbrain or above (for instance, in the cerebral cortex)

Stroke Localization? | Nonfluent (Broca's) Aphasia + R UMN face/arm

Superior branch of MCA

Stroke Localization? | Fluent (Wernicke’s) aphasia + R visual field deficit

Inferior branch of MCA

Incontinence: a) usually a spastic, hyperreflexic bladder w/ longstanding bilateral lesions where? b) Usually a flaccid, areflexic or acontractile bladder with lesions where?

a) Above S2-4 (UMN) | b) At S2-4 (LMN)

@ what spinal level would complete transection = quadriplegia?

C4-5

Lesions at what locations can produce the same cerebellar Sx as if the lesions were in the cerebellum itself?

Any of the Cerebellar peduncles or the Pontine nuclei