Pretest Flashcards
+ romberg means problems in …
cerebellar, vestibulopathy, and posterior column
resting tremor in parkinsons is
asymetric
resting tremor vs intentional tremor anatomy
Resting: substaintia nigra
Intentional: cerebellum
sensory disturbances is likely due to
thalamus
what happens to pill rolling tremor during sleep
disappears
phenytoin can cause what side effect
gaze evoked nystagmus
problem w convergence is due to
midbrain
what is the weber test and what does it inidcate
Vibration in the middle:
louder in the affected side: conductive hearing loss as outside voice is blocked and you hear lower on affected side
louder in unaffected side: sensisinoral hearing loss due to loss of cochlear nerve
ocular bobbing
up and down of eyes even in sleep or open eyes; pons
triad of parkinsonism
is asymmetric resting
tremor, rigidity, and bradykinesia.
post viral cases are
ADEM or demylenating in nature
Hyperacusis is an indication that
the
damage to the facial nerve is close to its origin from the brainstem, because
the nerve to the stapedius muscle is one of the first branches of the facial
nerve. Non functional stapedius muscle means undampened transmission of acustic sound
Inappropriate slack to tympanic membrane means
damage to tensor tympani controlled by motor nerve of CN5
atrophy and fasciculation of tongue means
denervation of 12th hypoglossal never which provides motor to tongue;
hypersensitivity to acetylcholine acting at the dener-
vated neuromuscular junction;
—brainstem disease, such as stroke or bulbar
amyotrophic lateral sclerosis (ALS), or with transection of the hypoglossal nerve.
caloric testing tests which organ
medulla
how does caloric testing normally work
Cold: turns off singnal in that ear, acts as if head turns in the opposite direction=> eyes towards stimulated ear but nystagmus away
warm: turns on signal in that ear, acts as if head turns in the stimulated direction=> eyes away from stimulation but nystagmus towards stimulated
Nystagmus: COWS
how does caloric testing normally work
Cold: turns off singnal in that ear, acts as if head turns in the opposite direction=> eyes towards stimulated ear but nystagmus away
warm: turns on signal in that ear, acts as if head turns in the stimulated direction=> eyes away from stimulation but nystagmus towards stimulated
Nystagmus: COWS
horner syndrome has
ptosis and myosis
horner syndrome, the problem is in..
superior cervical ganglion
sympathetic pathway
begins in the hypothala-
mus, travels down through the lateral aspect of the brainstem, synapses in the intermediolateral cell column of the spinal cord, exits the spinal cord at
the level of T1, and synapses again in the superior cervical ganglion.
painful horner without anhidrosis after vigorous activity is a sign of what? and why
– Aortic dissection
- postganglionic fibers travel along the surface of the common carotid
and internal carotid arteries until branches leave along the ophthalmic artery
to the eye. Fibers of the sympathetic nervous system, which are destined
to serve the sudomotor function of the forehead, travel with the external carotid artery. Thus diseases affecting the internal carotid artery and the overlying sympathetic plexus do not produce anhidrosis, the third ele-
ment of Horner syndrome.
how to distinguish CNS3 pstosis w horner syndrome.
How to distinguish superior cervical ganglion from T1 nerve root lesion
Lesions of cranial nerve (CN) III do cause ptosis, but they would also be expected to cause ipsilateral mydriasis, or pupillary enlargement, not miosis. The degree of ptosis is usually much more severe in third nerve palsy than in Horner syndrome; this is because CN III supplies the levator palpebrae, the primary levator of the lid, whereas the sympathetics supply Müller muscle, which plays an accessory role.
The sympathetic pathway does exit the spinal cord at T1, but injury at this location would not cause orbital pain, which is typical of carotid arterial dissection.
most dense on CT
bone>blood
hx of bells palsy now treated, pt he has noticed invol-
untary twitching at the left corner of the mouth each time he tries to blink the left eye. why
Aberrant regeneration is possible only if the nerve cell bodies survive the injury and produce axons
that find their way to neuromuscular junctions. Fibers intended for the periorbital muscles end up at the perioral muscles, and signals for eye closure induce mouth retraction.
hx of bells palsy now treated, pt he has noticed invol-
untary twitching at the left corner of the mouth each time he tries to blink the left eye. why
Aberrant regeneration is possible only if the nerve cell bodies survive the injury and produce axons
that find their way to neuromuscular junctions. Fibers intended for the periorbital muscles end up at the perioral muscles, and signals for eye closure induce mouth retraction.
subarchnoid hemorrage can present w headache and
neck stiffness
suspect subarachnoid hemorrage but ct non con is neg. what next
LP to rule out SAH
Which of the follow-
ing is the most definitive test for identifying intracranial aneurysms?
cerebral angiography
what happens to RBC in traumatic LP
RBC numbers decrease from tube 1 to 4. If not, then increased RBC
how to know if wbc is elevated in CSF
1 wbc: 500 RBC is appropirate. Any more WBC means infection
site most likely to produce non communicating hydrocephalus is…
aqueduct
of Sylvius, which connects the third ventricle with the fourth ventricle.
communicating hydrocephalus vs non comm
com: problem is production vs absorption of csf
non com: obstrcution of ventricle
Chiari MF 1 vs 2 vs dandywalker
1: tonsilar herniation
2: tonsilar + vermis herniation
dandywalker: enlargement of 4th ventricle w mega cisterna magna
Tumors common in posterior fossa
a) Meningiomas
b. Ependymomas
c. Hemangioblastomas
d. Medulloblastomas
tentorium cerebelli is
part of the meninges that separates the superior cerebellum from the cerebrum
tentorium cerebelli is the common site for
meningiomas
enpendymomas orgin is
choroid plexus
astrocytoma orignate in
glial cells + healthy brain tissues
distinguish vascular vs calcemic mass on CT
Calcemic: hyperdense wo contrast
vascular: hyperdense after contrast
posterior fossa mass without involvement of the eighth CN, seems to arise from bone, the most
probable neoplasm is
meningioma
tx for calcified mass in right frontal
meningioma=> resection
NF1 vs NF2
1) chromosomal involvement
2) chracteristics
1) NF1: deletion of chrm 17
NF2: deletion of long arm of chr 22
2) NF1: cutaneous manifestations
NF2: Meningiomas and bilateral acoustic neuromas occur
eeg in normal relaxed person
8-13 hertz aka alpha wave => becomes less obvious w drowsy or when eye opening and concentration on math
how to test wernicke aphasia
(impaired naming, com-
prehension, and repetition with fluent speech).
Neglect and left hemiparesis
would be more likely with
right brain lesion
Alexia without agraphia is a disconnection syndrome associated with lesions involving
left occipital lobe or splenium of corpus colosum
window for tpa
3 hours
absence seizure on eeg
3-Hz spike-
and-wave pattern
elevated ESR and periungual telangiectasias in pt w proximal weakness probably has …
dermatomyositis
muscle biopsies of myopahties
polymyositis: extensive necrosis of mus-
cle fiber segments is seen with macrophage and lymphocyte infiltration.
dermatomyositis: perifascicular muscle fiber atrophy, and the inflammatory infiltrate occurs in the perimy-
sial connective tissue rather than throughout the muscle fibers themselves.
Inclusion body myositis: same as polymyositis except that rimmed vacuoles are also seen.
muscle biopsies of myopahties
polymyositis: extensive necrosis of mus-
cle fiber segments is seen with macrophage and lymphocyte infiltration.
dermatomyositis: perifascicular muscle fiber atrophy, and the inflammatory infiltrate occurs in the perimy-
sial connective tissue rather than throughout the muscle fibers themselves.
Inclusion body myositis: same as polymyositis except that rimmed vacuoles are also seen.
CSF in seizure is..
normal
classic guimbre csf
high protein due to albumin with normal everything else
what is elevated in LP of SAH
RBC, WBC, opening pressure, xanthocromia (aka yellow)
signs of spinal cord involvment, ataxia, incontience, transient impotence CSF is
likely MS showing elevated IgG and oligoclonal bands
obese woman w headache csf
elevated opening pressure => pseudotumor cerebri
pure motor function deficit without any sensory involvement is
lacunar infarct with involvement of posterior limb of internal capsule being the site of injury
loss of ONLY sensation involving the entire left side of his
body (face, arm, and leg).
right posteroventral nucleus of the lateral thalamus
Thalamic pain syndrome
During recovery from this thalamic stroke, paradoxical
pain may develop in the area of sensory impairment. This paradoxical pain associated with decreased pain sensitivity is referred to as the thalamic pain
syndrome.
Wallenberg syndrome has
ipsilateral ataxia and ipsilateral Horner syndrome. The trigeminal tract damage may produce ipsilateral loss of facial pain and temperature perception and ipsilateral impairment of the corneal reflex.
The lateral spinothalamic damage produces pain and temperature disturbances contralateral to the
injury in the limbs and trunk.
Wallenberg syndrome is due to interurption of which vessel
vertebral artery
most common cause of hemosideran deposit
in elderly patients without hypertension.
hemosiderin deposit = sign of lobar hemorrage => most common sign is
cerebral B amyloid angiopathy
hoarseness and dysphagia in an pt w vertebral artery dissection is due to…
The nucleus ambiguus, located in the ventrolateral medulla, contains the motor neurons that contrib-
ute to the ninth (glossopharyngeal) and tenth (vagus) cranial nerves.
motor neurons of the nucleus ambiguus innervate the striated muscles of the larynx and pharynx + preganglionic parasympa-
thetic supply to thoracic organs, including the esophagus, heart, and lungs.
nucleus solitarius
combines afferents from CNs VII, IX, and X responsible for visceral sensation.
Its projections are primarily to parasym-
pathetic and sympathetic preganglionic neurons in the medulla and spinal cord.
headache during sex or defaction
aneurysm rupture
lesion not enchanced by contrast on ct
bleeding
IV drugs + aortic valve lesion + several hemoragic lesion in the brain
endocarditis => septic emboli or mycotic aneurysm (shape) => bleeds a lot so xanthochromic
mycotic aneurysm
- bleeds a lot but not easily detected on imaging
- present in gram pos or neg infection of the brain ie endocarditic septic embolism
todd’s paralysis may last
many hours, or even days.
encephalofacial angiomatosis (Sturge-Weber syndrome),is associated w
leptomeningeal angiomas and seizures
PICA stroke produces what…
a variety
of brainstem and cerebellar signs,
Anterior cerebral artery
stroke would be expected to cause
lower extremity weakness and would
not affect vision, although it could result in decreased speech production.
mca stroke
contralateral motor weakness, speech, vision (optic radiata loops arounds temporal lobe)
Vertebral or basilar artery occlusion would primarily affect
brainstem or cerbellar structure
If either posterior cerebral artery had its blood supply
compromised, there could be
visual loss or posterior (fluent) aphasia
Choroidal artery occlusions might produce
focal weakness wo speech problems
problems w pupil dilation + oculomotor muscles dysfunction is most likely due to
compression by saccualar aneurysm; transfemoral angiogram is diagnositic
Hippel Lindau
Hemangioblastomas are vascular tumors seen in association with polycystic disease of the kidney
and telangiectasias of the retina
Charcot Buchard aneurysm ASSOCIATED W
chronic hypertension and most commonly appear in perforating
arteries of the brain like lenticulostrial arteries
is especially susceptible to the formation of Charcot-
Bouchard aneurysms.
dentate nucleus of cerebellus
61
k
TIA or amourosis fugax is due to
carotid artery disease occluding central retinal artery
symptomatic carotid stenois by 70%. tx is
carotid endarterectomy
Patients with the rare syndrome of
conduction aphasia have problems with repetition that are more obvious
than their problems with comprehension. Their speech usually does not
sound very fluent.
conduction aphasia
type of speech loss in brocas aphasia
Speech becomes telegraphic (ie, consisting of short phrases
with omission of small connecting words such as articles and conjunctions)
permanent loss of all ability to produce meaning-
ful language is unlikely if the area of infarction is less than a few centimeters across.
The most persistent difficulty usually exhibited by patients with this type of stroke is a permanent loss of syntax.
Mixed transcortical aphasia
can repeat but cannot spontaneously speak or comprehension aka broca and wernicke but can repeat
hypotension => watershed areas => affects brocas and wernecke
Anomic aphasia
Naming is impaired. Comprehension, repetition, and
fluency are relatively maintained.
–common in patients with diffuse brain dysfunction.
Transcortical motor aphasia
similar to Broca aphasia with the exception of preserved repetition.
-poor naming ability and is nonfluent.
Comprehension and repetition are relatively preserved.
Transcortical sensory aphasia
similar to Wernicke aphasia with the exception of preserved repetition.
lesion generally occupies the white matter underlying the
cortex of Wernicke area. In most cases, the prognosis for improvement is
better than that for Wernicke aphasia.
1-2 vs 2-3 hertz spike on EEG
3 Hz spike-and-wave pattern would confirm absence.
1-2 Hz would be consistent with severe neurological dysfunction and symptomatic generalized epilepsy.
preferred benzo for status
1) lorazepam: fast acting and remains in brain for long time
Past: diazapam- fast acting to reach brain, but cleared from brain in 20 min thus would need another medicine after 20 mninutes
side effects of
b. Diazepam
c. Phenobarbital
d. Clonazepam
e. Phenytoin
Phenytoin: if infused at greater than 50mg/min, then cardioarrythmia
Fospheytoid: if infused at greater than 150 mg/min then cardioarrythmia; IM possible
phenobarbital: hypotension and resp distress
pam: hypotension and autonomic dysfunction
pt comes to hospital after simple compelx seizure. now normal. What next
MRI to figure the cause of seizure.
EEg is useless as already know its seizure and it adds nothing new to information
timeline for alcoholic withdrawl
seizures: 1-2 days
delirious tremens: 2-4 days
symtoms resolve within 7-14 days
Landau-Kleffner syndrome
associated with loss of
language function and an abnormal EEG during sleep.
Juvenile myoclonic epilepsy
benign epilepsy syndrome with onset in late ado-
lescence or early adulthood.
LGS eeg
by mental dysfunction, multiple seizure types, and 1-to 2-Hz generalized spike-wave discharges on EEG.
oldfactory aura in seizure - lesion?
the mesial temporal lobe, particularly the hippocam-
pus or parahippocampal gyrus.
what is given for seizure prophalaxis in traumatic head? Why?
Phenytoin - to prevent post traumatic EARLY seizure. they are not been shown to be helpful against longterm or late seizures. Preventing early seizure decreases mortality. so phenytoin given for short amount of time.
most common complication of temporal lobectomy
visual field defect caused by interruption of
fibers from the optic tracts passing over the temporal horn of the lateral
ventricles. Superior quadrantanopsia
history of febrile seizure => now intractable seizure in the last year. MRI shows
sclerotic hippocampus aka mesial temporal sclerosis
the most common cause of intractable complex
partial seizures in adults.
mesial temporal sclerosis
tx of mesial temporal sclerosis
anterior temporal lobe may produce seizure freedom in up to 80% of cases.
jacksonian march
1) sequential seizure, the patient develops focal seizure activity that is primarily motor and spreads.
2) starts w hand and then generalizes w loss of consciousness
3) The face may be involved early because the thumb and the mouth are situated near each other on the motor strip of the cerebral cortex.
myoclonic jerks is …
associated w….
invountary muscle jerking, no loss of consciousness
benign juvenile myoclonic epilepsy (BJME) when mycolonic jerks occur after waking up
general clonic tonic seizures
high risk for a variety of injuries, such as dislocated shoulders, broken bones, and head trauma.
Patients with this type of seizure always lose consciousness during the attack.
—- may
be mistaken for a psychiatric problem,
complex partial seizure– esp if uncinate (from temporal lobes uncus) features like unpleasant smell or taste
complications of status
include respiratory failure,
aspiration, acidosis, hypotension, rhabdomyolysis, renal failure, and cogni-
tive impairment.
def of status
generalized clonic tonic seizure that lasts continuously for 30 minutes or a series of
seizures over a 30-minute period without the patient regaining full con-
sciousness between them.
Epilepsia partialis continua
aka focal motor status elipticus
- persistent focal seizures for hours or for months. The
response to therapy is often poor.
- alert, able to follow commands, and has no gaze deviation.
tx for having complex
partial seizures without secondary generalization.
levicitaram
tx for seizure localized to temporal lobe
levicitaram
west syndrome characterisitics
generalized seizure disorder of infants characterized by recurrent spasms,
the EEG pattern of hypsarrhythmia (diffuse, high-voltage, polyspike-
and-slow-wave discharges between spasms and suppression of these bursts
during the spasms.) and retardation.
tx of seizures in someone whose sibling died with a brainstem glioma, and the father
has several large areas of hypopigmented skin in the shape of ash leaves.
The infant had obvious psychomotor retardation even before the appear-
ance of the spasms.
its tuberous sclerosis thus ACTH
seizures due to west sydnrome
ACTH
tx for absence seizure
1) Ethusuximide is first choice
2) If side effect of GI probs in children, seizures not under control on ethusximide, then Divalproex sodium
3) If the absence seizures
are associated with generalized tonic-clonic seizure ====> divalproex sodium
eclampsia seizure
that magnesium sulfate (MgSO4)
what is unique about classic migraine
visual aura
classic migraine vs bibasilar migrane
Similarity: women > men, vision changes, the aura usually resolves within 10-to-30 minutes,
and the headache invariably follows, rather than precedes, the neurological deficits;
DIfference: the character and severity of neurological deficits associated with basilar migraine are distinct. The visual change may evolve to complete blindness. Irritability may develop into psychosis. Rather than
a mild hemiparesis, the patient may have a transient quadriplegia. Stupor, syncope, and even coma may appear and persist for hours.
trigenmnal neuralgia vs atypical facial pain
Trigeminal: praoxysmal, lancinating pains
atypical facial pain: constant, deep pain, uni or bilateral,
- – responds to SSRI indicating may be related to depression
- –Progressive loss of sensation in the distribution of the fifth cranial nerve (CN) should prompt search for malignancy
BOTH: can be unilateral
trigeminal neuralgia is assocaited w
- multiple sclerosis
- basilar artery aneurysms, acoustic schwanno-
mas, and posterior fossa meningiomas => all of which cause injury to 5th nerve compression
Tolosa-Hunt syndrome
inflammatory disorder that produces ophthalmoplegia associated with headache and loss of sensation over the forehead.
–pathologic site: superior orbital fissure or the cavernous sinus
prophalactic meds for migraine
amitriptyline hydrochloride, propranolol, verapamil, and valproate.
acute tx for migraine
Metoclopramide hydrochloride,
sumatriptan, and ergotamine tartrate
presentation of giant cell arteritis aka temporal arteritis
persistent fevers and progres-
sive weight loss.
tx for postherpetic neuralgia
imipramine hydrochloride,
sudden headache that prompts CT non con and LP is..
thunderclap headache
- —even if ct and LP negative, consider angiogram as changes in aneurysm can cause that type of headache
- ——classic occurs during sex
MRI and LP in pseudotumor cerebri
normal MRI w increased LP opening pressure + papiledema; presents w morning headaches w vision changes and tinnitus
tx for pseudo tumor cerebri
include lumbar
puncture, diuretics, ventriculoperitoneal shunting, and optic nerve sheath
fenestration.
causes of headache worsened by standing but relieved w laying down
Intracranial hypotension due to following causes:
1) LP
2) continued leak of cerebrospinal fluid (CSF) from the subarachnoid space after head trauma, neurosurgery, or even pneumonectomy (thoracoarachnoid fistula)
3) occult pituitary tumor
4)a leak from a dural tear in the spinal root sleeves; traumatic nerve root avulsion
5) systemic illness
such as dehydration, diabetic coma, uremia, or meningoencephalitis.
what happens when elbow is injured
ulnar nerve runs superficially and is at high risk of damage:
- –claw hand w failure of last two fingers to extend
- –lumbricals weakness
gunshot wound to upper arm causing partial damage to median nerve may result in what?
Even though median nerve ws not directly hit, it can be affected through passing of energy or force
Trauma to nerves in the extremities may give rise to causalgia, a disturbance in sensory perception
characterized by hypesthesia, dysesthesia, and allodynia.
Hypesthesia: decrease in the accurate perception of stimuli.
dysesthesia: persistent discomfort, which in the situation described is likely to be an unremitting burning pain.
Allodynia: perception of pain with the application of
nonpainful stimuli.
Acoustic trauma may produce
severe— in persons who have relatively little hearing loss.
tinnitus
nerve damage in humerus fracture
- musculocutenaous nerve injury
——–supplies the
biceps brachii, brachialis, and coracobrachialis muscles
——–Flexion at the elbow with damage to this nerve is most impaired with the forearm supinated.
saturday nigth palsy is related to
radial injury: at radial groove, wrist drop and impaired extension
why is ct bad at dectecting bleeding several days old
because within few days, the blood will be broken down into less dense material equal in density as brain so difficult to assess at that point
what to do w respiratory setting in ICP
hypervenlation
head trauma => consciousness in and out => then coma
epidural hematoma: middle meningeal artery
Although subdural hemato-
mas are often bilateral, epidural hematomas are invariably unilateral.
j
Chronic subdural hematoma is rel-
atively common in
elderly and renal dialysis patients
- –often times not picked on CT as blood turns isodense after several days but MRI should pick up
- —should not cause a shift as this is a chronic process and brain has a chance to adjust
most commonly involved part of brain in trauma such as car accident
temporal lobes and infe-
rior frontal lobes
more common effects of TBI occurs due to..
1)anosmia –occurs due to Avulsion of olfactory rootlets. Taste sense also affected simultaneously
He is awake and alert, has intact cranial nerves (CNs),
and is able to move his shoulders, but he cannot move his arms or legs. He
is flaccid and has a sensory level at C5. Management?
spinal cord injury is initially flaccid then takes some time for spasticity to develop
High-dose intravenous
methylprednisolone improves outcomes in SCI
On examina-
tion the abductor pollicus brevis is weak bilaterally,. think..
carpal tunnel
(encephalitis lethargica) aka post viral encephalitis presents w features of
features of parknsonism
sarcoidosis affects which cranial nerve
facial weakness aka facial paresis from CN 7 injury
Polio vs guimbre
Both: ascending paralysis
Polio: preceded by fever + affects anterior horn of motor neuron + elevated protein and white count on LP
Guimbre: preceded by diarrhea
most common causes of fungal meningitis in immunocompromised
cryptococcos and india stain
subacutely evolving paraparesis due to parasite
Schistosoma mansoni: The fluke deposits eggs in the valveless veins of Batson, which drain the intestines and communicate with the drainage from the lumbosacral spinal cord. The patient develops granulomas around the ova that lodge in the spinal cord, and these granulomatous lesions crush the cord.
The parasitic brain
lesion most likely to have a large cyst containing numerous daughter cysts
is that associated with
Echinococcus granulosa: acquired
by ingesting material contaminated with fecal matter from sheep or dogs.
children more likely than adults to have these hydatic cyts
82 yo w bacterial meningitis. what first
intravenous ceftriaxone plus ampicillin=> then LP
LP of prions disease
normal typically: if (14-3-3 proteinase
inhibitor) it is specific to prion but not common
recurrent meningitis often occurs in person w
csf leak — can have rhinohrea secondary to trauma
tb in brain has
caseating granuloma that makes them act like mass
in HIV pt w potential of bleed, abscess or mass, what is the best first test when someone presents w hemiparesis
keep it broad so ct w contrast
diagnosis of most common etiologies
of rim-enhancing brain lesions in AIDS patients are
Primary CNS lymphoma: PCR EBV of CSF
Toxo: CSF
thus..LP
tx of toxoplasmosis
combination of sulfadiaz-
ine and pyrimethamine
tx for pml
HAART is effective against JC virus
most common form of acute encephalitis
herpes: high lymphocytes w elveated opening pressure
Lyme disease affects which neurological problems?
facial weakness aka CNS 7
why does the mass in cerebellum not cause seziure
because you need cerebrocortical (or at least
cerebral) lesion.
herpes encephalitis shows what in eeg
Bilateral, periodic epileptiform discharges
HIV and cyto-
megalovirus infections in the brain characteristically produce what
microglial nodules
HIV: the microglial nodules are distributed around blood vessels throughout the brain; microglial nodules associated with syncytial cells in the brain and spinal cord,
CMV: nodules are more char-
acteristically subpial and subependymal.
primary amebic meningoencephalitis.
1) caused by
2) introduced to body through
1) caused by organisms from the genera Hartmanella or
Acanthamoeba.
2) fresh water swimming: parasites enter the nervous system through: the cribriform plate at the perforations for the olfactory nerves.
tx of meningieal involvement of lyme disease
high-dose penicillin or ceftriaxone must be given intravenously for 10-to-14 days. Tetracycline qid for 30 days should be used for patients who are
allergic to the intravenous treatments.
Abscesses in the brain most often develop from
Hematogenous spread of infection
known infection + a rim-enhancing lesion in the left
frontal lobe. Which of the following is the most common site for formation
of this type of lesion?
Abscess; starts at grey white junction
symphylis affects brain in creating
A gumma is a largely or entirely
avascular granuloma that grows and masks picture as brain tumor
rabies goes and resides in
animal saliva
cause of malignant external otitis and osteomyelitis of the
base of the skull in HIV pt
aspergillus
the most common symptom in patients with
brain abscess?
headache
Which of the following is the most common cause of brain abscess
in patients with AIDS?
toxo»_space;> fungal (crypto, aspergillus, etc)
General paresis eg due to symphilis
tx
early symptoms are a subtle dementia, characterized by memory loss
and impaired reasoning, with later development of dysarthria, myoclonus,
tremor, seizures, and upper motor neuron signs, leading to a bedridden
state. CHRONIC process
penecillin
—- of the brain are involved
in general paresis infection.
Both the meninges and the parenchyma
bacterial cause of absess
1 cause is strep; if stab wound or surgery causing abscess then staph most common
spongiform disease is transmitted through..
infected nervous system tissue, including dura mater grafts, and occasionally via growth hormone preparations acquired from cadaver
pituitary glands.
listerial meningtis tx
ampicillin and gentamicin are recommended therapy.
cause of meningtis in 90 yo w pleacytosis, no organism,
listeria
162,
x
Biopsy of this lesion reveals oli-
godendrocytes with abnormally large nuclei that contain darkly staining
inclusions. There is extensive demyelination, and there are giant astrocytes
in the lesion.
PML w JC virus in the large nuclei
tabes dorsalis is associated with
neurosyphyllis; exhibit
abnormal (Argyll Robertson) pupils and optic atrophy.
SSPE produces a CSF pattern
similar to that seen with multiple sclerosis, whose features include an increase in the γ-globulin fraction and the presence of oligoclonal bands.
seizure. A neurologist exam-
ining the child discovers chorioretinitis, ataxia, hyperactive reflexes, and
bilateral Babinski signs. With
EEG exhibits periodic bursts of high-voltage
slow waves followed by recurrent low-voltage stretches (burst suppression
pattern).
SSPE
bartonella in HIV pt causes … MRI shows
more virulent encephalitis associated with status epilepticus.
—(bacillary angiomato-
sis).
—-MRI may show a characteristic increased signal intensity in the
pulvinar, suggesting a tropism of the organism or immune response to this
particular structure in the posterior thalamus.
Cysticercosis causes…
Brain lesion looks like…
Cysticercal infection of
muscles produces a nonspecific myositis. Brain involvement may lead to
seizures. The lesions in the brain may calcify and often appear as multiple small cysts spread throughout the cerebrum.
Cysticercosis is produced by
the larval form (cysticercus) of the pork tapeworm, Taenia solium=> invades gut
In adults, the most common primary brain tumor is the
gial cell tumor called astrocytoma
is the usual
location for brain tumors in children.
posterior fossa aka infratentorial : Medulloblastoma, ependymomas, and cerebellar (or brainstem) gliomas
left hemisphere mass with an overlying hyperostosis of the skull.
meningioma
Several different types of germ cell tumors arise from the
tissues in this region,
this region is called pineal gland
the most common source of meta-
static tumors to the brain in patients without a known primary tumor?
lung tumor
brain mets usually lie in
gray-white matter junction
The shortest life expectancy with metastatic disease to the brain will
be found in the patient with which of the following metastatic cancers?
Malignant melanoma
compliation of colloid cyst
hydrocephalus: Colloid cysts may produce
transient or persistent obstruction of the flow of cerebrospinal fluid
bitemporal hemianopsia. Which of the following tumors is most
likely responsible for this finding?
1) only the temporal quadrants of the field in each eye are affected.
2) Pituitary adenoma => sella turcia presses on optic chaiasm causing the #1 visual defect
Which of the following tumor types is common in the brain of
patients with acquired immune deficiency syndrome (AIDS), but otherwise
extremely rare?
primary CNS lymphoma
delayed girl has precocious puberty or excess growth harmone
and poorly controlled seizures. Her seizures are typically preceded by
episodes of uncontrollable laughter. Which of the following mass lesions
might explain her symptoms?
hypothalamic hamartomas => non malignant => surgical resection successful
an ependymoma. This patient is potentially at risk of dying because of
transforminal herniation. Ependymoma is in posterior fossa.
A 4-year-old boy presents with ataxia, lethargy, and obstructive
hydrocephalus.
Medulloblastomas (lies in posterior fossa) and are one
of the most common CNS tumors of childhood.
A 16-year-old boy with café au lait spots and cutaneous nodules has
a gradual decrease of vision in his left eye.
optic glioma -NF1
A 55-year-old woman presents with mild unsteadiness, tinnitus, and
hearing loss.
Schwannomas usually develop
on the vestibular division of CN VIII and are pathologically derived from Schwann cells rather than nerve tissue. Although this is not the division of the nerve that carries information from the cochlea, the cochlear division is crushed as the tumor expands.
NF2
Pineocytomas
This patient’s symptoms and signs
constitute Parinaud syndrome, which may include loss of vertical gaze, loss of pupillary light reflex, lid retraction, and convergence–retraction nystag-
mus, in which the eyes appear to jerk back into the orbit on attempted upgaze.
lesion for pineocytomas
dorsal midbrain in the region of the superior colliculus.
paraneoplastic cerebellar dysfunction
harbor anti-Purkinje cell antibodies (called anti-Yo antibod-
ies), and these are especially commonly found in women with breast cancer
or gynecologic malignancies.
70-year-old man with a history of lung cancer develops nausea
and vomiting and then becomes lethargic. On examination, he is lethargic
but arousable, disoriented, and inattentive. He is weak proximally and has
diminished reflexes.
hypercalcemia
Tay-Sachs disease,- deficiency in ..
Hexosaminidase A
An 8-month-old boy develops spasticity, head retraction, and diffi-
culty swallowing.
His physician discovers an abnormal accumulation of
glucosylceramide and tells the parents their child will continue to deteriorate and likely die within 3 years. This child has which of the following?
β-glucosidase deficiency
The cerebrospinal fluid (CSF) protein content of pt w hypertensive stroke is likely to be which of the following?
elevatedelevated but less than 100
A 42-year-old man presents to the emergency room with seizures,
mental status change, and vision difficulties. A magnetic resonance imag-
ing (MRI) reveals an abnormally high T2 signal in the posterior cerebral
white matter. There is proteinuria, and blood pressure is 210/120 mm Hg.
The cerebrospinal fluid (CSF) protein content of this patient is likely to be
which of the following?
elevated but less than 100
A patient has had progressive, chronic liver failure for the past 5 years.
At the time of death, he would be expected to exhibit changes in which
type of brain cells?
increase in Alzheimer type II astrocytes. These astrocytes are
relatively large cells.
An 8-month-old boy develops spasticity, head retraction, and diffi-
culty swallowing. His physician discovers an abnormal accumulation of
glucosylceramide and tells the parents their child will continue to deterio-
rate and likely die within 3 years. This child has which of the following?
1) The disease responsible for
the accumulation of glucosylceramide is Gaucher disease.
2) deficient glucocerebrosidase in fibroblasts or leukocytes.
the most common neurological
complication of chronic renal failure?
Peripheral neuropathy
what helps restless leg syndrome
clonazepam, gabapentin, L-dopa,
dopamine agonists (eg, pramipexole or ropinirole), and opiates.
visual manifestation of B12 def, alcoholism -thimine def, tobacco
Centrocecal scotoma: blind spot enlarges
hx of alcoholism and benzodiazepine use, including diazepam, loraze-
pam, and clonazepam. Before long surgery, what should have bene given
thaimine
tx of alcohol and benzo withdrawl with
benxo like chlordiazepoxide
Her diet is strictly
vegetarian and limited almost entirely to grains, such as corn. what deficiency
niacin or tryptophan def => causes pallegra
vitamin D def causes what
- rare but usually during early childhood.
- spinocerebellar degeneration (ATAXIA), polyneuropathy, and pigmentary retinopathy.
korsikoff can also cause neurolgoic problems like slow mentation
k
hx of blood transfusions, don’t forget
AIDS
pickwickian syndrome
obesity associated with hypersomnelence in someone with OSA.
trauma to brain => pt disoriented after 4 days
post ictal —significant trauma can cause seizures esp during sleep
Carbon tetrachloride can cause
hepatic encephalopathy as it is a hepatic toxin=> high NH3
triphasic waves
hepatic encepathopathy
path of alzhiemers
neuronal loss, fibrillary tangles, loss of
synapses, and amyloid (or neuritic) plaque formation in hipocampus
eeg on alzhiemers
Generalized background slowing
disturbance, dementia, and incontinence.
normal pressure hydrocephalus
complication of VP shunts for NPH
Subdural hema-
toma occurs because the reduction in intracranial pressure brought on
by the reduction in CSF volume may cause the brain to pull away from
the covering meninges, stretching and potentially rupturing the bridging
veins.
Language testing is most likely to uncover which of the following
deficits in a patient with Alzheimer disease?
Transcortical sensory aphasia:which refers to a reduction in the ability to understand complex linguistic structures. Repetition of verbal material is intact.
transient global amnesia
TGA refers to an episode of
complete and reversible anterograde and retrograde memory loss lasting
up to 24 hours.
A 50-year-old woman began having double vision and blurry vision
3 months ago and has since had diminishing interaction with her family,
a paucity of thought and expression, and unsteadiness of gait. Her whole
body appears to jump in the presence of a loud noise. A magnetic reso-
nance imaging (MRI) scan and routine cerebrospinal fluid (CSF) examina-
tion are unremarkable.
CJD
normal development untile 2 but LOSS OF language and stereotyped movement
rhett sydnrome
—- is one of the manifestations of neurosyphilis. It is a chronic, often insidious meningoencephalitis that may be delayed up to 20 years after the original spirochetal infection.
General paresis
t whippei on neurology
seizures, myoclonus, ataxia, supra-
nuclear gaze disturbances, hypothalamic dysfunction, and dementia.
Oculomasticatory myorhythmia (pendular convergence movements of the eyes in association with contractions of the masticatory muscles) may occur
and is considered pathognomonic.
one hand buttons shirt while other unbuttons is called….
occurs due to lesion in…
this is seen in…
alien hand syndrome
parietal lobe
subcortical white matter, particularly in the occipital or parietal regions= > JC virus causing PML
dementia, delusions, dysar-
thria, tremor, myoclonus, seizures, spasticity, and Argyll Robertson pupils.
general paresis assocaited with neurosyphillis
– designates an
involuntary movement disorder that occurs during pregnancy and involves
relatively rapid and fluid, but not rhythmic, limb and trunk movements.
chorea gravidarus or estrogen use in non prego
A mag-
netic resonance imaging (MRI) indicates atrophy in the head of the caudate
nucleus. This MRI finding would be expected to affect the shape of which
of the following?
lateral ventricle rhomboid in shape
dopaminergic drugs in huntington causes
unmasking of chorea
1-methyl-4-phenyl-1,2,3,
6-tetrahydropyridine (MPTP). The neurological syndrome for which he is
at risk is clinically indistinguishable from which of the following?
MTP caues degenration of substantia nigra => parkinsonism symptoms
what is dysfunctional in parkinson?
Brainstem nuclei
252
ü
Postmortem
study of the substantia nigra of a patient with Parkinson disease is likely to
exhibit which of the following?
Intracytoplasmic inclusion bodies- w eosinophils
Trihexyphenidyl
aniticholinergic: it reduces parkinsonism when given antidopa meds like haloperidol
L dopa ___ haloperidol induced parkinsonism
worsens
in parkinsons’s the decrement in
speech that would be expected would result in
Progressively inaudible speech: low volume and speed
why L dopa but not dopamine as a tx for parkinson
Dopamine cannot cross the blood–brain barrier and therefore has no therapeu-
tic effect in the central nervous system (CNS).
why add carbidopa to l-dopa
L-dopa can be converted to dopamine in variety of tissues peripherally. Dopamine cna’ tcross to brain. Carbidopa inhbits the conversion of L dopa into dopa peripherally.
Once in brain, L dopa converts to dopa.
tx for tourette
haloperidol
After several years of successful antiparkinsonian treatment, a patient
abruptly develops acute episodes of profound bradykinesia and rigidity.
Remission of these signs occurs as abruptly as the onset. Which of the fol-
lowing is the most likely etiology?
on-off phenomenon
Meige sydnrome
tx
blepharospasm, forceful jaw opening,
lip retraction, neck contractions, and tongue thrusting.
—also elicited by phenothiazine or butyrophenone use,
tx: botulinum injectiion
He breathes independently and even
swallows food when it is placed in his mouth, but he remains mute. With
painful stimuli, he exhibits semipurposeful withdrawal of his limbs. His
clinical status remains unchanged for several more months.
The vegetative state is a clini-
cal condition in which autonomic activity is sustained with little evidence of cognitive function.
cause of : Consciousness is preserved in the
locked-in syndrome, but the patient is paralyzed from the eyes down.
ischemic or hemorrhagic damage to the pons, such as that occurring with
basilar artery occlusion.
Hepatolenticular degeneration
Wilson disease
- Renal tubular acidosis develops along with hepatic fibrosis=> brain and liver disease w progressive dimentia
- atrophy of putamen and globus pallidus
oligoclonal bands are
- limited number of bands of excess immunoglobulin indicates that the
species of IgG produced by the disease - syphilis, Lyme, and sub-
acute sclerosis panencephalitis may also produce oligoclonal bands.
MS neck exam
peculiar sensory phenomenon
in which the patient feels an electrical sensation radiating down the spine
when the neck is passively flexed is called Lhermitte sign and is believed to
signify spinal cord disease.
Which of the following evoked response
patterns is most often abnormal in patients with early MS?
Optic neuritis occurs early
and often in many patients with MS. This involves inflammation and
demyelination of the optic nerve and slows conduction along the optic
nerve.====> slow Visual evoked response (VER)
pt on corticosteriod should be given what
Ranitidine: Gastric disturbances are a
possible side effect of corticosteroid use.
A papovavirus infection of the central ner- vous system (CNS) in this person would be most likely to produce which
of the following?
also known as jC virus => PML
Canavan disease
-produce
developmental regression at about 6 months age
- extensor posturing and rigidity.
- Myoclonic seizures may develop.
- Underlying the disease is a defect in N-acetylaspartic acid metabolism.
-Elevated levels of this material can be detected in the blood and urine, but elevated
levels in the brain establish the diagnosis. Changes in brain white matter
are widespread and may result in a spongiform appearance. There is an
increase in brain volume and weight. =>MACROENCEPHALY
how does ms affect bladder
more spasticity => thus urinary incontinence aka inappropirate emptying of bladder
tx of leg spasm in ms
Baclofen is an antispasmodic
agent that may be used in MS.
what worsens ms symtpoms
hot weather
young woman with bilateral leg weakness and
numbness, urinary retention, and impaired bowel control.
transverse myelitis due to nmo
Two weeks after recovering from a febrile illness associated with a
productive cough, a 19-year-old man complains of headache and neck
stiffness. These complaints are associated with fever and are soon followed
by deteriorating cognitive function. He becomes disoriented, lethargic, and
increasingly unresponsive. MRI reveals widespread damage to the white
matter of the cerebral hemispheres.
Acute disseminated encephalomyelitis aka post viral autoimmune encephalitis affecting white matter
a mutation of mito-
chondrial DNA.
A young man presenting
with centrocecal scotoma pattern of visual loss is much more likely to have Leber optic
atrophy or another cause of optic atrophy (eg, tobacco-alcohol amblyopia,
tertiary syphilis, or vitamin deficiencies)
ATP-binding transporter in the peroxisomal system
responsible for long-chain fatty acid metabolism.
X lined adrenal leukodystrophy
exhibit limb ataxia, nystagmus,
and mental retardation. MRI of their brains reveals areas of abnormal signal
in the white matter. Cerebellar involvement is substantial.
A 3-month-old boy exhibits nystagmus and limb tremors unassoci-
ated with seizures. Over the next few years, he develops optic atrophy, choreoathetotic limb movements, seizures, and gait ataxia. He dies dur-
ing status epilepticus and at autopsy is found to have widespread myelin breakdown with myelin preservation in islands about the blood vessels.
The pathologist diagnoses a sudanophilic leukodystrophy to describe
the pattern of staining observed on slides prepared to look for myelin
breakdown products.
Pelizaeus-Merzbacher
demyelinating disorder that belongs to a group of degenerative diseases known as sudanophilic leukodystrophies.
rapid increase of sodium causes
Central pontine myelinolysis. quadriplegic and unre-
sponsive
a mutation in the gene that encodes a subunit of the
——, which results in impaired VLDL
formation and consequent decreased vitamin E delivery to the peripheral
and central nervous system.
microsomal triglyceride transfer protein => causes ataxia
spinal bifida oculta
meningocele
meningomyelocele
1) spine protuding out
2) dura protuding out
3) dura+spinal cord protuding out
best menagement for hemangioblastoma found in von Hippel-Lindau syndrome
surgical resection
c1 fused to skull increases risk of
chiari malformation
second cervical vertebra extends above the
level of the foramen magnum and places the patient at high risk of having
brainstem compression
agenesis of the corpus callosum causes what on MRI
1) Abnormally shaped lateral and third ventricles
agenesis of the corpus callosum,
divalproex sodium dur-
ing the first trimester of pregnancy.
ntd
A 17-month-old boy had developed normally until approximately 13
months of age, when he began having progressive gait problems. On exam-
ination, the patient is spastic, yet nerve conduction studies (NCS) reveal
slowed motor and sensory conduction velocities. Cerebrospinal fluid (CSF)
protein is elevated. MRI reveals white matter abnormalities. Leukocyte test-
ing reveals deficient arylsulfatase A activity. Which of the following tests
may also provide useful diagnostic information in this condition?
this is
metach-
romatic leukodystrophy.
DO: nerve biopsy
phenylketonuria (PKU) have high levels of
phenelalanine
fragile x in men vs women
Men with the fragile X syn-
drome have hyperextensible joints and prominent thumbs, seizure but carrier women may appear quite normal.
women mostly normal but may have retardation in half of case
16 month old; dysarthric and mental functioning decreases, low reflexes, deficiency of arylsulfatase
metrachormatic leukodystrophy
Hexosaminidase deficiencies
produce
Sandhoff and Tay-Sachs diseases.
Glucocerebrosidase is deficient in
gaucher
4-year-old previously healthy girl develops an intermittent red, scaly rash over her face, neck, hands, and legs.
+
devleopmental delay + emotional lability + episodic cerebellar ataxia.
Hartnup disease
tx of hartnup disease
its is inability to absorb tryptophan and other neutral aa so giving the prodruct of trpytophan aka nicotinamide provides relief
CT reveals calcifications in the cerebral cortex in a railroad track pattern.
Sturge-Weber syndrome
association of erythrocytosis with cerebellar signs, microscopic hematuria, and hepatospleno-
megaly suggests
von Hippel-Lindau syndrome.
- polycystic liver disease, polycystic kidney disease, reti-
nal angiomas (telangiectasia), and cerebellar tumors.
causes of retinitis pigmentosa
abetalipoproteinemai, mitochondrial diseases, Bardet-Biedl syndrome, Laurence-
Moon syndrome, Friedreich ataxia, and Refsum disease.
features of Abetalipoproteinemia
what helps
abnormally shaped
erythrocytes (acanthocytes), low/absent cholesterol and triglyceride, ataxia, reveals posterior column
and spinocerebellar tract degeneration, retinits pigmentosa
—–vitamin E
inheritance pattern of tuberous scleorsis
autosomal dominant but variable penetrance
Congenital hydrocepha-
lus may develop as a consequence of which of the following first-trimester
maternal disorders?
A maternal infection with
mumps or rubella virus may produce aqueductal stenosis and, as a con-
sequence, hydrocephalus.
uncorrected hydroencephalus leads to
macroencephaly
type 2 Chiari malformation. Which of
the following defects would this child be likely to have?
spina bifida
Adenoma sebaceum occurs
in about 90% of patients with
tuberous sclerosis.
metastatic cncer in von hippau is likely from what organ
VHL has high rate of renal cell carcinoma=> causing mets
—the cerebellar hemangioblastomas can bleed but does not have mets
eye finding in tuberous sclerosis
Retinal phakomas are gliomatous
tumors that require no treatment and are a principal criterion for making the
diagnosis of tuberous sclerosis.
Calcifications evident on the skull x-ray or CT scan of a patient with
tuberous sclerosis usually represent
subependymal glial nod-
ules that have calcified.
—–not malignant but can obstruct
Tay-Sachs disease develop blindness before they
die, with retinal accumulation of gangliosides that produces which of the
following?
cherry red spots
sign of upper motor neuron disease in child
congeni-
tal weakness, hypotonia, and muscle atrophy
hyperpigmentation in 9 yo boy could be
cafe aulit sign present in NF1>2
a cyst occupying 50% of his posterior fossa and incomplete fusion of the cerebel-
lar elements inferiorly. Lifespan?
This is Dandy walker malformation => if obstructive hydrocephalus, death soon after birth
If no obstructive hydrocephalus, then pt will be asymtpomatic
having hundreds of seizures per day. The clini-
cal manifestations are somewhat subtle and consist of sit-up like movements. Interictal EEG shows multifocal, high-amplitude spikes (hypsarrhythmia) and slowing.
Adrenocorticotropic hor-
mone is usually given as a gel intramuscularly to control infantile spasms in children with tuberous sclerosis;
Cerebral palsy is a static encephalopathy because
the injury to the brain does
not progress.
DS brain
Smaller than normal for age and body size
right parietal parenchymal defect that
is continuous with the ventricle and does not appear to be lined with gray
matter. This type of lesion usually develops as a consequence
Vascular or other destructive injuries to the fetal brain
fetal alcohol on brain
Impaired neuronal migration causing heterotopias (collections of cortical neurons in abnormal locations),
type 1 and 2 Chiari malformation usually becomes symptomatic as which of the following in adults?
ataxia
proximal weakess in cancer pt
lung:Les=repetition helps
thymus: mg= weak w repetition
all= dermatomyositis
ALS: cough becomes totally ineffective for clearing his
airway- tx?
Chest physical therapy
A high — in a woman
with male relatives affected by Duchenne dystrophy indicates a high prob-
ability that she is a carrier of the abnormal dystrophin gene.
cpk
The spontaneous mutation rate for the dystrophin gene is presumed
to be high for which of the following reasons?
Men with Duchenne dystrophy do not reproduce.
intellectual in dystrophy
Slightly impaired. Beckers better intelllectual than duchenne
pseudohypertorphy in dystrophy occurs in
limited to calves
exhibit problems with relaxing their grip, hypersom-
nolence, premature baldness, testicular atrophy, and cataracts.
myotonic dystrophy
myotonic dystrophy eeg
Repetitive discharges with minor stimulation
EMG of anterior horn damage
abnormal fibrillation: conduction time normal even with extensive motor neuron disease, but the pattern of spon-
taneous and evoked muscle potentials would be abnormal.
The pathologist reports that there
are numerous abnormally small muscle fibers intermingled with hypertro-
phied muscle fibers. THis is due to
denervation atrophy: some groups supplied by certain nerves atropy due to denervation while other still innervated muscles do not atrophy
Which of the following is the
most common manifestation of muscle weakness with myasthenia gravis?
ocular weakness
shortest life expectancy is associated with which clinical sign in
amyotrophic lateral sclerosis?
Fasciculations in the tongue—bulbar involvement is poor prognosis
alcohol affects what of cerebellum
superior vermis
Triorthocresyl phos-
phate is an organophosphate that may cause lethal neurological complica-
tions by which of the following means?
Causing a severe motor polyneuropathy
lead effect in brain
small: ataxia and tremor
large: edema=>herniation and encephalopahty
