Part 36 Flashcards
The cranial nerves with exception to CN__ are part of the ____, not the ___
CN II, PNS, CNS
Neuron definition
Non-reproducing unit of nervous system composed of a body, dendrites (receivers), and axon (conductor) surrounded by a myelin sheath, has greatest sensitivity of any cells to oxygen and glucose deprivation and thus shows first signs of hypoxia or hypoglycemia
Grey matter vs white matter
Grey matter is neural cell bodies located on the inner part of the spinal cord and outer part of the brain vs white matter is axons (myelin sheaths) located at the outer spinal cord or inner portion of the brain
Sensory/afferent neurons
Communicate stimuli toward the CNS such as light, heat, or pressure
Motor/efferent neurons
Conduct signals way from CNS mostly leading to muscle cells and other target organs
Interneurons
Lie entirely within the CNS and have an integrative function to associate, process, store, and retrieve information and interconnect incoming sensory to outgoing motor pathways
3 reasons bony anatomy is important to cranium
- Injury to bony anatomy can affect deeper underlying structures
- CT scans, need to be able to identify suture lines vs fractures
- Skull is a “closed box” particularly susceptible to any swelling
List the suture lines of the skull (5)
Corneal - formed between parietal and frontal bone
Sagittal - Formed between the two parietal bones at the dome of the skull moving anterior to posterior
Lambdoid - formed between occipital and parietal bones
Bregma - point of intersection between corneal and sagittal sutures
Lambda - Point of intersection between sagittal suture and lambdoid sutures
Meninges (definition and the 3 of them)
3 layers of tissue covering the CNS including…
The dura mater (thick outer layer of vascular connective tissue that forms dural sinuses between 2 layers periosteal and meningeal, also forming falx cerebri and tentorium cerebelli)
The arachnoid mater (nonvascular thin filamentous connective tissue that adjoins but does NOT adhere to dura allowing for subdural potential space, meanwhile subarachnoid space beneath it is where CSF and veins/arteries flow)
The pia mater (thinnest delicate layer that adheres directly to surface of brain and spinal cord invaginating along the surface)
Epidural hematoma definition and appearance on CT
Arterial bleed between skull and osteum dura often in skull fractures appearing as “football shaped” bright lesion on side of head on CT scan
Subdural hematoma definition and appearance on CT
Tearing of the bridging veins between the meningeal dura and arachnoid mater appearing as a crescent shaped lesion on CT scan of head
Subarachnoid bleed definition and appearnce on CT
Bleed in the subarachnoid space above the pia mater that tends to layer within sulci and gyri of brain due to tearing of subarachnoid vessels that appears as layering around the invaginations of the brain on a CT scan
Rostral vs caudal and dorsal/ventral
Rostral is towards the front/anterior of the brain that then shifts superiorally moving down the brain to the spinal cord, vs caudal is toward the back/posterior of the brain that then shifts inferiorally moving down the brain to the spinal cord, with dorsal and ventral being perpendicular to these points
3 main parts of the brain
1) forebrain (composed of telencephalon and diencephalon)
2) midbrain (mesencephalon)
3) hindbrain (metencephlaon and myelencephaon)
Mid brain and hind brain combine to form the….
…brainstem
Parts of telencephalon (4)
- Cerebrum and all of its cortexes
- Basal ganglia
- Amygdala
- Hippocampus (all part of limbic system)
Cerebrum
Largest portion of brain divided into 2 halves called hemispheres, communicating with each other thru corpus callosum, functions for thought, voluntary movement, language, reasoning, and perception, cerebrum is a gross division of brain that has many subdivisions and sub regions
Cerebral cortex definition and the lobes of the cerebral cortex (4)
Outer layer of grey matter in the cerebrum that is highly convoluted into ridges (gyri) and grooves (sulci/fissures)
The lobes of the cerebral cortex include
Frontal - goal oriented, motor, cognitive functions
Occipital - visual perception
Parietal - touch, pain, limb position, size/shape perception
Temporal - perceive, localize sound, visual form/color, emotions
Fissure vs sulci
Fissures are deep groves consistently present from one brain to next vs sulci are not as deep and can vary in location
Longitudinal and transverse cerebral fissure
Separate left and right hemisphere and cerebrum from cerebellum, invaginated by the falx cerebri and tentorium cerebelli overlying
Central sulcus and lateral sulcus
- Divides frontal from parietal lobe creating a precentral gyri and post central gyri on each side
- Divides parietal lobe from temporal lobe
Pre-central gyrus
Located directly anterior to the central sulcus containing the motor cortex
Post-central gyrus
Located directly posterior to the central sulcus containing the somatosensory cortex
Frontal lobe
Largest lobe responsible for planning, complex movements, organizing, problem solving, and higher cognitive function, has a prefrontal cortex for higher cognitive functions and premotor and primary motor cortex (premotor modifies movement and stores muscle memory from primary motor), as well as olfactory bulb is on inferior aspect
Frontal lobe injury can cause… (4)
- Lack of focus/organization
- Difficulty learning new info
- Loss of inhibition
- Inability to retrieve recent memories
Broca’s aphasia
Injury to frontal lobe at the broca area (most commonly found in left hemisphere at posterior portion of inferior frontal gyrus) causes partial loss in ability to produce language (spoken, manual, or written), patients are aware that they cannot speak properly but can comprehend perfectly well (often known as motor or expressive aphasia)
Parietal lobe
Integrates sensory information from perceptions of touch, pain, limb position (includes postcentral gyrus/somatosensory cortex), controls how we receive info about the environment around us such as distance and position of object
Parietal lobe injury can cause… (4)
- Inability to discriminate between stimuli
- Locate and recognize parts of body
- Process/integrate diverse sensory info for speech and perception
- Write accurately
Temporal lobe
Controls audiory processing/ability to recognize words, auditory cortex allows for perception and localization of sound (receives sounds from ears and areas process info into meaningful speech or words) also perception of visual form and color, participates in processing of new memory also plays a role in mediating emotions
Temporal lobe injury causes… (4)
- Left side difficulty remembering what people said
- Right side may impair recalling music or pictures
- Difficulty perceiving or localizing sound
- Difficulty perceiving visual form and color
Wernicke’s aphasia
Injury to area located on the temporal lobe near the caudal end of the lateral sulcus that causes fluent but meaningless speech with comprehension generally being impaired, speech may sound fluent but pattern is disordered and illogical (global aphasia)
Occipital lobe
Visual center, area allows to interpret what looking at including visual perception, differentiating form and color, and facial recognition
Occipital lobe injury causes… (4)
- Visual impairment
- Visual hallucinations
- Impaired color perception
- Inability to recognize faces
Parts of limbic system and their function, what portion of the forebrain are they part of?
- Amygdala (emotional responses, hormonal secretion, emotional memory)
- Hippocampus (learning and memory)
- Cingulate gyrus (emotion, pain, memory)
Not absolutely part of telencephalon or diencephalon
Parts of diencephalon (3)
- Limbic system (sorta this sorta telencephalon)
- Thalamus (relays info between cortex and brain stem, role in alert/awakeness
- hypothalamus (body temp, emotion, hunger, thirst, circadian rhythm, pituitary gland control)
Parts of mesencephalon/midbrain (2)
1) Tectum - more posterior component considered roof of midbrain, has the superior colliculus involved in visual reflexes and inferior colliculus involved in auditory reflexes, the 4 colliculi form the corpora quadrigema)
2) Tegmentum - floor of midbrain, network of neurons involved in many reflexive pathways, has motor centor that sends inhibitory signals to the hypothalamus
Cerebellum
Part of metencephalon located on posterior-inferior portion of brain that functions in coordination of voluntary movement, balance, posture, motor learning and reflex memory
Pons
Part of metencephalon that relays sensory info between forebrain and hindbrain, houses cranial nerve nuclei V-VIII, contains pneumotaxic centers that help regulate respiration
Medulla oblongata
Part of the myelencephalon, most inferior portion of brainstem that gradually transitions into spinal cord, relays nerve signals between the two, helps regulate several autonomic functions of the body including respiration, blood pressure, heart rate, digesjtion, and voluntary functions such as vomiting, sneezing, coughing, and gagging
Cerebrospinal fluid (CSF)
Formed by choroid plexus in the 4 ventricles, 2 lateral ones and a 3rd and 4th that then empty into the subarachnoid space creating a protective fluid filled chamber against concussive trauma that also bathes and removes waste products
CSF pathway
- Lateral ventricles
- interventricular foramina
- 3rd ventricle
- cerebral aquaduct
- 4th ventricle
- 2 lateral and one median aperture
- subarachnoid space
- circulation
- reabsorption via arachnoid villi
- superior sagittal sinus
Circle of Willis Components
- 2 vertebral arteries combining to form the basilar artery
- Off the basilar artery see anterior inferior cerebellar artery, pontine arteries, and superior cerebellar arteries
- Basilar terminates into 2 posterior cerebral arteries
- branching off each posterior cerebral artery is a posterior communicating artery
- Internal carotids ascending meet with this, sending off middle cerebral artery branches as well as anterior cerebral artery branches
- Anterior communicating artery is a small link between the anterior cerebral arteries
Anterior cerebral artery
Derived from the internal carotids, supplies very deep portions of the anterior cerebrum including midline structures reaching all the way back posteriorally to midline of parietal lobe as well, has collateral supply due to anterior communicating artery and is thus rare to have ACA infarct
2 divisons of middle cerebral artery
- MCA superior and inferior division (superficial division) supplies outer cortex portion of cerebrum
- Lenticulostriate arteries supply the inner portion of brain,
What artery is most common site of stroke?
Middle Cerebral artery and its branches lenticulostriate and superficial divisions
Venous drainage system of the brain
No arterial/venous counterpart, cerebrum, midbrain, pons, cerebellum, and rostral medulla drain via the dural sinuses while spinal cord and caudal medulla drain directly into systemic circulation
Arachnoid granulations
Small projections that extend into the dural sinus to allow csf to remove waste products
Venous drainage of the brain components (9)
Superior sagittal - runs along the ceiling of the skull anterior to posterior eventually draining into the confluens of sinuses
Inferior sagittal sinus - runs along the same path as superior but is located deep in the cerebrum, empties into the straight sinus upon merging with the great cerebral vein of galen
Great cerebral vein of galen - Large midline vessel inferior to inferior sagittal sinus that forms the straight sinus upon merging with the inferior sagittal sinus
Straight sinus - posterior continuation from the inferior sagittal sinus, combines with superior sagittal sinus to form the confluens of sinuses
Transverse sinuses - derived from the confluens of sinuses and travel bilaterally along the posterior wall of the skull before entering into the sigmoid sinus
Sigmoid sinuses - 2 s shaped sinuses that receive blood from the transverse sinuses and superior petrosal sinuses and drain into the internal jugular vein
Cavernous sinuses - drain the eye area and empty into inferior and superior petrosal sinuses
Inferior petrosal sinuses - derived from cavernous sinuses and drains directly to internal jugular
Superior petrossal sinuses - derived from canvernous sinuses and drains to sigmoid sinus upon meeting with the transverse sinuses
___ total vertebrae, how many of each?
-33 7 cervical 12 thoracic 5 lumbar 5 fused sacral 4 fused cocyx
Spinal column functions (6)
Protection, attachment, structural support, flexibility/mobility, extension, production and storage of RBC and minerals
C1
Also known as the atlas, this is the 1st cerivcal vertebra that functions to support the skull, ring of bone that has no vertebral body associated but does have superior articular facets to articulate with the occipital condyles of the skull
C2
Also known as the axis, features a dens or odontoid process allows head to pivot and rotate around, has the first semblance of a vertebral body
Thoracic vertebrae
Increased sized of body vertebrae compared to cervical spine, these also serve as the articulation points of the ribs (2 ribs coming off each of the 12), has thick spinous process sticking directly dorsally and thick transverse processes for the site of ligament and muscle attachment
Lumbar vertebrae
Increased vertebral body size to bear majority of weight, often see nerve root compression in this area
sacrum and coccyx
Groups of 5 and 4 fused bones, respectively, forming an articulation of the pelvic girdle and tail bone, respectively
Intervertebral disks
Function to help disperse the weight of the spinal column, composed of jelly like interior known as nucleus pulposus and cartilagenous exterior the annulus fibrosis (herniation occurs when the nucleus pulposus protrudes out of the intervertebral disk)
anterior longitudinal ligament
Most anterior ligament of the spinal column, located in front of the vertebral bodies running superiorally along each body of the spine
Posterior longitudinal ligament
Anterior to spinal cord travelling in canal but right up against posterior of vertebral bodies running superiorally along each body of the spine
Ligamentum flavum
yellow ligament, located beneath the lamina of the spinal column, first defining structure right before the dura that runs superiorally along the entire length of the spinal column
vertebral column stability determination and how do they heal?
If 2 or more columns are injured (fracture or ligament tear, etc.), considered unstable, if one then considered stable
-all take a long time to heal due to low blood supply
3 columns of the spine and their components
Posterior column composed of spinous processes, transverse processes, lamina, facet joints, pedicles, and posterior ligaments of the spine
Middle column composed of posterior longitudinal lig, posterior annulus fibrosis, and posterior vertebral body
Anterior column ant longitudinal lig. anterior annulus fibrosis, anterior vertebral body
Each pair of spinal nerves exit between adjacent vertebrae except for this one
C1
C7 and above exits ___ corresponding vertebral body, C8 exits below ___, T1 downward exits ____ corresponding vertebral body
above, C7, below
Spinal cord commencement level and termination level in the spinal column, what is it called where it terminates?
What are the fibers after that? What is the filum terminale?
- At foramen magnum, L1 or L2
- Conus medullaris
- Cauda equina
- An extension of pia matter past the conus medullaris within the cauda equina down to the coccyx that functions to anchor the spinal cord floating in CSF
Arterial supply to the spinal cord (3)
Anterior spinal artery - single artery derived from branches of the vertebral arteries, moves downward along the anterior surface of the spinal cord and supplies the grey matter and majority of the spinal cord as well despite only being one
Posterior spinal arteries - Paired arteries derived from branches of the vertebral arteries, move downward along the posterior surface of the spinal cord
Anterior and posterior radicular arteries - travel out laterally to the nerve root from the segmental arteries within the spinal cord
CNS contains ___ neurons (what type?) while PNS contains ___ and ___ neurons
Relay or interneurons, sensory, motor
Motor end plate
site of contact between an axon and a muscle fiber where neuromuscular junction is, Ach is transmitted across here to stimulate muscle cells
Schwann cells
Cells of the PNS that produce myelin around an axon
Oligodendrocytes
Cells of the CNS that produce myelin around an axon
Parts of the metencephalon (2)
- Pons
- Cerebellum
Parts of myelencephalon (1)
Medulla oblongata
Small vertebral bodies in the cervical spine lack ___ but make up for it with ____. They have ___ processes but lack ____ processes
strength to bear weight, great mobility, spinous, transverse
Pedicle
Stub of bone that connects the vertebral body to the lamina forming a vertebral arch to house the spinal cord
Lamina
Part of vertebra that is located directly on either side of the spinous process
An injury to which column of the vertebrae is most likely to result in unstable classification and why?
Middle column - it is connected to the anterior and posterior columns and is thus a lot more vulnerable!
Healthy curvature of the spine
Cervical should be lordotic, thoracic should be kyphotic, and lumbar should be lordotic
Venous supply to the spinal cord (4)
Posterior spinal vein - single traveling vein located between the posterior spinal arteries
Anterior spinal vein - single traveling vein located alongside the anterior spinal artery
Posteriorlateral veins - 2 traveling veins located lateral to each of the posterior spinal arteries
Radicular veins - travel with the radicular arteries
Spinal columns
The dorsal, 2 lateral, and anterior areas of white matter within the cross section of the spinal cord
Spinal tracts
Ascending or descending pathways for sensory or motor signaling located within the different spinal columns (anterior, 2 lateral, or dorsal)
Spinal horns
The dorsal, ventral, and lateral projections of grey matter within the spinal cord composed of cell bodies and interneurons on a bisection
Spinal roots
Either dorsal and ventral, bundles of neurons that enter or exit the spinal cord laterally at a certain nerve root level
Spinal cord dorsal root
Afferent sensory root that carries sensory information to the spinal cord from the spinal nerve somewhere in the periphery
Spinal cord ventral root
Efferent motor root that carries motor information from the spinal cord to an effector site in the periphery
Lateral horn function
Houses cell bodies of preganglionic sympathetic neuron fibers
Corticospinal tract cross over at the level of ___
the medulla
Corticospinal vs corticobulbar tracts
Corticospinal is motor efferent nerves associated with spinal nerves from the cerebral cortex vs corticobulbar is similar but composed of non oculomotor cranial nerve motor functions from where the cranial nerves originate on the brain surface slightly lower down in the medulla itself, only about 50% of them deccusate compared to the 90% of the corticospinal but for the sake of this class just say they both cross over at medulla
Upper vs lower motor neuron
Upper body originates in the brain at the motor cortex, crosses over midline at the medulla, and then goes down in the white matter of spinal cord before synapsing into the gray matter lower motor neuron body in the lateral horn, and then leaves via the anterior horn to the target muscle
Signs of upper motor neuron lesion on motor exam (6)
- spasticity
- increased tone
- positive babinski sign
- clonus
- hemiparesis/weakness
- increased tone and reflexes
Signs of lower motor neuron lesion on motor exam
- Flaccid muscles with atrophy
- fasciculations
- paralysis
- decreased tone and reflexes
Spinothalamic tract (what 3 things is it responsible for and where does it cross)
- Responsible for pain, temp, and crude touch
- Crosses over at the level of the spinal cord and then travels up the contralateral side to the thalamus and cerebral cortex
Posterior/dorsal column tract (what 3 things is it responsible for and where does it cross)
- Responsible for position, vibration, and fine touch
- Travels up ipsalateral side of spine where signal entered and crosses over at medulla then to thalamus and cerebrum
Components of reflex arc
- Receptor
- sensory neuron
- CNS interneuron that immediately responds faster than message to brain
- motor neuron
- effector muscle or gland
2 divisions of PNS
Sensory and motor
2 divisions of sensory PNS
Somatic sensory (skin limb and body wall) and visceral sensory (internal organ sensations)
2 divisions of motor PNS
Somatic motor (voluntary) and visceral motor (autonomic)
2 divisions of ANS
Parasympathetic (bladder contraction) and sympathetic (bladder relaxation)
Headache epidemiology
90-95% will experience in lifetime, 90% of headaches fall into either tension, migraine, or cluster type with tension being most prevalent in population
Pain sensitive structures of head (7)
- Arteries (circle of willis, cerebral arteries, meningial arteries, veins/dural sinuses)
- Scalp
- neck muscles
- cranial nerves V, VII, IX, X
- sinus mucosa
- teeth
- skin
Primary vs secondary headaches
Primary include migraine, tension type, and cluster as well as other categories vs secondary which are caused by potentially serious underlying disease such as a space occupying mass, vascular lesion, infection, etc.
Red flags that point toward a worrisome secondary headache (6)
- Fixed neurological deficits
- extremely abrupt onset
- papilledema (increased intracranial pressure)
- New onset of headache in patients <5 or >50 years old
- signs of infection (nuchal rigidity for example)
- altered state of consciousness
Aneurysms presentation and treatment
- A secondary cause of headache that is often asymptomatic until rupture occurs, sees the ballooning out of a blood vessel with a berry appearance, if rupture sudden onset headache with severe “worst headache of life” resulting in stiff neck, fever, nausea, vomiting, with several neurological signs dependent on location of aneurysm
- need immediate treatment such as surgical clipping
Meningitis definition, presentation, and diagnosis
- Inflammation of the meninges that is a 2ndary cause of headache
- Usually presents with stiff neck, early prodromoal illness fever may be present and later focal neurological signs develop
- need CT to rule out mass then immediate lumbar puncture
Cervicogenic headache definition, diagnosis, and treatment
- 2ndary cause of headache that is from referred pain from cervical spine or neck soft tissue pathology
- best diagnosed by resolution of headache following diagnostic blockade of a cervical structure or its nerve supply
- pain resolves within 3 months after treatment of causative lesion
Idiopathic intracranial hypertension/pseudomotor cerebri presentation, diagnosis, and treatment
- Characterized by transient headache with visual loss or decrease for no apparent reason usually affecting young obese women of childbearing years, increased risk with use of estrogen and vit A
- Diagnosis made by obtaining lumbar puncture with opening pressure
- Weight loss is curative in many cases, acetazolamide (diamox) is used often alongside optic nerve sheath decompression to treat
Low pressure headache definition, presentation, and treatment
- Headache that resolves or greatly decreases in supine and returns when upright position is maintained
- very intense pain with vomiting that can be spontaneous (sometimes rarely brought on by sneeze or cough) or related to a spinal procedure such as lumbar puncture (slow leakage causing decreased pressure)
- can be treated by placing blood patch at the site of the leak to cure it completely
Temporal arteritis/giant cell arteritis definition, presentation, diagnosis, treatment, comorbidity
- Inflammation of temporal artery causing head pain close to temporal region
- associated with jaw claudication almost exclusively in patients over 60
- typically ESR is elevated, temporal artery biopsy is gold standard for diagnosis
- treat with steroids to prevent vision loss
- 50% also develop polymyalgia rheumatica
Temporal arteritis is often the first presenting condition in a patient that will develop….
…..polymyalgia rheumatica
Polymyalgia rheumatica
Inflammatory disease in patients older than 65 characterized by muscle pain and stiffness, particularly in the shoulders
Medication overuse headache definition, prevalence among men vs women, treatment (what should be delayed in using)
- Headache from frequent and regular use of any analgesic (opiod, acetaminophen, etc), a consequence of regular overuse for more than 3 months
- more common in women than men
- withdrawal of overused medication is treatment of choice while bridge therapy used during withdrawal to provide symptomatic relief, prophylactic medication used to treat suspected primary headache disorder should only be initiated after withdrawal
Sinus headache misdiagnosis, presentation
- Although commonly diagnosed by physicians and patients, acute and chronic sinusitis is an uncommon cause for recurrent headaches, many times these patients are actually having migraine headaches
- usually bilaterally pressure like or dull sensation, not usually associated with nausea vomiting or photophobia unlike migraines
Migraine epidemiology
Affects 12% of population with women>men, most common in 30-39 year old range, tends to run in families
Migraine mech of action
(proposed)
- Cortical spreading depression (self propagating wave of neuronal and glial cell depolarization across cerebral cortex)
- aura caused by this
- activation of the afferent components of trigem nerve that triggers the release of inflammatory and pain producing substances that can be significantly disabling
Migraine
Episodic disorder characterized by recurrent attacks that occur over the course of several hours or days resulting in severe headache, nausea, photophobia, phonophobia that progresses thru 4 phases typically (prodrome, aura, headache, postdrome)
Prodrome phase of migraine
Occurs in 60% of people about 24-48 hrs prior to the headache, symptoms can include euphoria, depression, irritability, food cravings, constipation, neck stiffness, and increased yawning
Aura phase of migraine
25% of patients experience gradual development of symptoms, seeing visual changes (most common) - shapes, bright lines, etc. Auditory changes such as tinnitus, hearing noises, somatosensory changes such as burning, pain, parasthesia, or motor symptoms such as jerking or repetitive movements, as well as loss of vision, hearing, feeling, or ability to move part of body often mischaracterized as stroke
Migraine aura without headache
Variant of migraine headache where the patient, often occurring later in life with history of migraines, get stereotyped spells of aura only, important to exlude TIA or seizure
Headache phase of migraine
Usually unilateral, throbbing or pulsatile quality, nausea and sometimes vomiting, photophobia or phonophobia, usually seek relief by lying down in dark quiet room, 4 hours to several days in length if untreated
Postdrome phase of migraine
Once the headache throbbing resolves, sometimes sudden head movmeent transiently causes pain, feels drained or exhausted, feel mild elation or euphoria, depression, irritability, food cravings, etc
Common precipitating factors of migraines (6)
- emotional stress
- dehydration or alcohol
- weather
- odors
- lights
- food
Migraine diagnosis
Clinical, meeting diagnostic criteria, neuroimaging is NOT necessary in most patients
Treatment principle for migraine
Acute and preventative therapies are available, not everyone needs preventative but everyone needs acute treatment
Acute treatment of migraine medications (3)
- Simple analgesics such as tylenol, motrin, or otc meds such as excedrine migraine
- Triptans (sumatriptan (imitrex), rizatriptan (maxalt), eletriptan (relpax))
- ergot derivatives
Triptans are contraindicated in patients that have these conditions (3)
- uncontrolled hypertension
- history of stroke
- heart attack history
Migraine headache cocktail and its 4-5 components
Emergency department medication for abortive treatment of a migraine composed of a triptan, fluids, and antiemetic med (dopamine receptor antagonist) alongside diphenhydramine (benadryl) to prevent dystonic reaction and sometimes dexamethasone to reduce risk of early headache recurrance
Prophylaxis treatment against migraines (9)
- lifestyle modifications
- Physical therapy
- Nutritional supplements
- TCA’s
- B blockers
- antiepileptics
- C-GRP antagonist such as erenumab (aimovig) antibody injection given once a month
- Butterbur
- Magnesium and riboflavin
Botox relation to migraines
Approved for treatment of chronic migraine
Tension type headache epidemiology, characteristics, and pathophysiology
- Most common type of primary headache in general population that usually affects women more than men,
- is bilateral and characterized by pressing/tightening pain not as severe or pounding or with nausea
- unknown pathophysiology but theorized to be multifactorial
Tension type headache classification (3)
- Episodic: 1 day a month
- Frequent: 1-14 days a month
- Chronic: 15 or more days per month
Guideline to avoid medication overuse in treating tension type headaches
Combine with caffeine for simple analgesics and limit treatment 9 days per month and a max of 2 doses per treatment day
Tension type headache treatment (1) and which 2 are not recommended
- Most common reason OTC analgesics purchased
- Triptans and muscle relaxants are not recommended
Cluster headaches epidemiology
100/100,000 people, more males than females, called suicide headache
Cluster headaches are part of a group of headache entities called….
…Trigeminal autonomic cephalgias
Cluster headaches pathophysiology
-not understood, increasing evidence of familial risk
Cluster headaches clinical presentation (4)
- Severe orbital, supraorbital, or temporal pain
- restless and agitation
- unilateral with associated unilateral autonomic symptoms (ptosis, lacrimation, rhinorrhea)
- circadian periodicity 15-180 min in length up to 8 attacks per day
Cluster headaches diagnostic studies (2)
- IS advised to do neuroimaging:
- MRI with or without contrast
- CT
Cluster headaches acute treatment options (2)
- O2 therapy via nonrebreather is mainstay***
- subQ sumatriptan
Treatment of choice for preventative treatment of cluster headaches (1)
-Verapamil (ca2+ channel blocker)
Important history questions when inquiring about primary cause of headache (5)
- visual changes
- menstrual related
- trauma history
- history of high blood pressure
- headache diary?
Every patient presenting with headache requires a….
….fundoscopic exam
When is neuroimaging necessary for headache? (5)
- abnormal neurological exam
- recent significant change in pattern, frequency, or severity of headaches
- progressive worsening of headaches
- onset after 40
- history of seizures
When is lumbar puncture necessary for headache? (2)
- First unusually severe headache
- co-occurrence with fever, confusion, or seizures
Headache diagnostic studies (4)
- Brain MRI
- CT of head
- ESR (for temporal arteritis)
- Lumbar puncture
Acetazolamide (diamox) drug class
Carbonic anhydrase inhibitor
Triptan mech of action (2)
- Activates vascular serotonin 5HT1 receptors producing vasoconstriction
- inhibit release of vasoactive peptides, promote vasoconstriction, and block pain pathways in brainstem
Ergot derivatives mech of action
-constrict cranial and peripheral blood vessels
Neurosurgery definition
To provide care for patients in treatment of pain or pathological processes that may modify the function or activity of the CNS or PNS or ANS, supporting structures, or vascular supply
Purposes for neurosurgery (4)
- Diagnosis via biopsy or puncture
- Evacuation of fluid or abscess
- Excision/decompression
- Repair of damaged structures
Burr hole
Drilling of 2 holes to the level of depth needed to reach a lesion/clot/etc. and then one is used to irrigate with fluid and the other evacuates with a suction
Craniotomy
Opening into skull via hole or flap that is retractable
Craniectomy
Excision of part of skull
Cranioplasty
Plastic surgery of skull, bone or plate replacement
ICP monitoring
Measuring of intracranial pressure of the patient thru a small incision and placement of monitor thru the skull into the tissue of the cerebrum out into the ventricles (but measuring cerebral pressure not ventricular pressure, but this will allow for drainage of CSF in patients with swelling due to lesions, hydrocephalus, etc.)
ICP and normal value
Intracranial pressure, normal levels of 7-15 mmHg supine
CPP and normal value
Cerebral perfusion pressure, ability to perfuse brain dependent on mean arterial pressure minus intracranial pressure, should be 50-150 mmHg
Ventricular peritoneal shunt (VP shunt)
Functions to divert CSF from the ventricles into the peritoneal space thru subcutaneous tube attachment that is indicated for treatment of hydrocephalus
Lumbar peritoneal shunt (LP shunt)
Less common used way to divert CSF from the lumber region to the peritoneal space thru tube placement often for treatment of hydrocephalus
Craniotomy/craniectomy indications (5)
- open cerebral aneurysm repair
- massive hemorrhage repair
- resection of brain tumor
- removal of brain abscess
- biopsy of abnormal brain tissue
Sterotaxy
Usage of 3d reconstruction and MRI guidance to target lesions such as brain metastases, pituitary adenoma, etc.
Neuroendovascular surgery
Less invasive operative treatment of vascular diseases affecting the brain’s blood flow
Neuroednovsacular indications (3)
- Acute ischemic stroke
- intracranial atherosclerosis
- cerebral aneurysm repair
Vagal nerve stimulator
Device implanted in chest wall programmed to stimulate vagus nerve which may help treat seizure activity
Deep brain stimulation
Implantation of electrodes within certain areas that regulate abnormal impulses useful in treatment of many diseases
Kyphoplasty
Minimally invasive surgical filling of an injured or collapsed vertebral body to treat compression fractures due to osteoperosis, myeloma, metastasis, and vertebral angioma but have to have NO neurological symptoms
Laminectomy
More invasive spine process involving removal of the lamina of the spine
Laminectomy indications (5), discectomy indications
- spinal stenosis
- sciatica
- herniated disk
- osteoarthritis
- posterior column tumors
-same as laminectomy but all with radiculopathy (pinched nerve)
Discectomy
Removal of part of the disk to prevent compression of a spinal nerve
Laminectomy, discectomy, and posterior fusion are often all done….
….at the same time
Posterior spinal fusion
Involves mechanical screwing using pedicle screws after removing lamina connected by slabs that prevent the movement and any further pain in that joint
Posterior spinal fusion indications (3)
- severe degenerative disc dz
- trauma
- iatrogenic destabilization of joint due to multiple disc or laminectomies
Anterior cervical discectomy and fusion
Common procedure performed similar to lumbar fusion done easily thru retraction of trachea and esophagus to side
Lumbar puncture indications (6)
- Suspected CNS infection
- Idiopathic intracranial hypertension (pseudomotor cerebri)
- normal pressure hydrocephalus
- MS
- Guillan Barre syndrome
Lumbar puncture general steps (12)
1) verify no contraindications exist by getting good history or physical (high intracranial pressure is NOT a contraindication as long as know what it is caused by)
2) use anticoagulants to prevent increased risk of developing epidural hematoma
3) evidence of cellulitis or abscess (don’t want to introduce into subarachnoid space)
4) drape and prep patient
5) position patient in lateral decubitus/fetal position or sitting upright and leaning over small table
6) locate L3/L4 space by locating superior iliac crests and placing thumbs midline to spine
7) mark location, inject local anasthetic
8) insert spinal needle cephalad angle with bevel oriented to longitudinal fibers to separate instead of cutting them
9) entry into subarachnoid space is a pop, CSF from obturator will drip out
10) check laying down CSF pressure with sterile manometer
11) reinsert obturator and withdraw needle to ensure no other tissue is removed
12) bandage up and apply pressure
Lumbar puncture complications (6)
- herniation of brainstem
- accidental puncture of retroperitoneal vessels, aorta, or vena cava
- accidental puncture of spinal cord
- introduce infection
- pain over LP site
- headache from CSF leak after*** most common complication
Most common complication from lumbar puncture
Headache from CSF leak
Carpal tunnel and ulnar nerve decompression
- Cutting of the transverse carpal ligament to release pressure on median nerve
- Roof of cubital tunnel and sometimes transposition of nerve to relieve pressure on the ulnar nerve
