Session 4 Flashcards
James, a 40 year old man, sustains a head injury after falling from his motorcycle driving at 15 mph. He was not wearing a helmet. He hit his head on the pavement and was knocked unconscious for up to a minute.
On regaining consciousness he was alert and orientated and was able to stand up. He had a few minor grazes on his elbow. He declined the option of going to hospital and instead returned home.
Several hours later, his partner finds him on the chair, confused and drowsy.
An intracranial haemorrhage is suspected. What type of intracranial haemorrhage is most likely?
What vessel is the most likely source of the bleeding?
pan
Rose, a 85 year old woman, is found wandering the streets disorientated and confused. A concerned shop keeper rings for an ambulance, which takes her to hospital.
On arrival, her vital signs are BP 140/90, PR 72, RR 16, temperature 36.8°C, oxygen saturations on air 98%. There are no other signs on physical examination and she appears comfortable though a little agitated. History is difficult due to the patient’s confusion.
CXR, blood tests and urinalysis are all normal
What would be your differential diagnosis in a patient presenting with confusion?
What is the significance of the other physical examination and investigation findings in helping to determine a differential?
An intracranial haemorrhage is one differential.
What type of intracranial haemorrhage, if the cause, would be most likely?
What vessel is the most likely source of the bleeding?
a pan
Luther, a 50 year old, presents with a headache. He complains of the light hurting his eyes, and finds it painful when the doctor tries to flex his neck. He feels nauseous and has vomited several times. He has felt generally unwell the last 3 days, with a sore throat and a fever.
Vital signs show: temperature 38.0°C, PR 100, BP 125/60, RR 18 and oxygen saturations 100% on air
What is the most likely cause for the patient’s clinical signs and symptoms
po
Luther, a 50 year old, presents with a severe, sudden onset headache. He complains of the light hurting his eyes, and finds it painful when the doctor tries to flex his neck. He feels nauseous and has vomited several times.
Vital signs show: temperature 36.5°C , PR 75, BP 165/97, RR 18 and oxygen saturations 100% on air
What is the most likely cause for the patient’s clinical signs and symptoms
panop
Arnold, a 65 year old man, presents to his GP following an episode of sudden monocular blindness affecting the right eye. He described the visual loss like a black curtain falling over the eye, lasting 10 minutes before he regained normal vision. He reported no other signs at the time or since.
The GP suspects amaurosis fugax, a type of transient ischaemic attack and arranges for some initial investigations, including an ECG
What does the ECG show?
include image from slide 22 lec 1
review
Arnold, a 65 year old man, presents to his GP following an episode of sudden monocular blindness affecting the right eye. He described the visual loss like a black curtain falling over the eye, lasting 10 minutes before he regained normal vision. He reported no other signs at the time or since.
The GP suspects amaurosis fugax, a type of transient ischaemic attack and arranges for some initial investigations, including an ECG
The patient is referred to secondary care for further investigations, including an ultrasound. This indicates stenosis of an artery in the neck, secondary to atherosclerosis.
He subsequently undergoes an arteriogram of the blood vessels (shown opposite).
(i) In which vessel is the stenosis?
Explain, with reference to your understanding of head and neck anatomy, how atherosclerotic disease within this artery could have caused this man’s transient loss of vision.
Use a schematic (draw) to support your explanation using the next slide.
use slide 23 and 25 lec 1
rev
Arnold, a 65 year old man, presents to his GP following an episode of sudden monocular blindness affecting the right eye. He described the visual loss like a black curtain falling over the eye, lasting 10 minutes before he regained normal vision. He reported no other signs at the time or since.
The GP suspects amaurosis fugax, a type of transient ischaemic attack and arranges for some initial investigations, including an ECG
What does the ECG show?
The patient is referred to secondary care for further investigations, including an ultrasound. This indicates stenosis of an artery in the neck, secondary to atherosclerosis.
He subsequently undergoes an arteriogram of the blood vessels
some months later:
Arnold is rushed to the Emergency Department with a sudden onset of weakness and numbness affecting the left side of his face and left upper limb
Other than motor weakness and paraesthesia involving the left half of Arnold’s face and left arm there are no other neurological signs found. The doctor suspects a stroke.
Indicate (by shading) on the correct image the specific area of the brain affected the stroke
insert slide 28
use panopto
Cortical Homunculus
Topographical representation of one half of body in primary motor cortex and primary somatosensory cortex
inser slide 29 lec 1
Indicate and name the area where the motor fibres (tracts) descending from the primary motor cortex will cross (decussate) to the opposite side?
slide 30
slide 30 but with paopto
Is there contralateral cortical control of the cranial nerves?
panoptooo
Cranial Nerves
Part of the peripheral nervous system
12pairs
Relate to brainstem (except two which arise from [fore]brain)
Arise at irregular intervals from CNS (rather than segments as seen in spinal nerves)
Supply structures of the head and neck*
Individual names + Roman Numeral (which relates to order that they arise rostral to caudal)
ranial nerves carry 1000s of axons which may be • General sensory • Special sensory • Motor • Autonomic
What is the brainstem?
Adjoins the brain to the spinal cord
Continuous with spinal cord caudally
Vital role in regulation of cardio-respiratory functions and maintaining consciousness
Ascending sensory and descending motor fibres between brain and rest of body run through the brainstem
Location of majority of cranial nerve nuclei
*Nuclei = collections of the cell bodies of nerve fibres (nerve fibres that will then make up the whole cranial nerve)
Brainstem and craial nerve
slide lec 2
CN I Olfactory Nerve
Paired anterior extensions of forebrain rather than a ‘true’ cranial nerve
olfactory bulb -> olfactory tract -> Temporal lobe
panopto
special senory
function - olfaction sense of smell
• Not often tested: may just ask about difficulties/ changes in sense of smell • If do test formally, test one nostril at a time
• Loss of sense of smell = anosmia • Commonest cause of anosmia? .
• Head injury can also cause anosmia (secondary to shearing forces and/or basilar skull fracture)
• Tumours at base of frontal lobes (within anterior cranial fossa) may involve CN I
CN II Optic Nerve
Paired anterior extensions of forebrain rather than a ‘true’ cranial nerve Part of the visual pathway
Impulses generated by cells within retina in response to light: generates action potentials which propagate along optic nerve
Via other components of the visual pathway they reach primary visual cortex where the are perceived as vision
Retinal ganglion cells -> Axons form optic nerve
-> Exits back of orbit via x -> fibres cross and merge at the optic chiasm
Optic nerve - Carries sensory fibres from the one eye (retina)
Optic chiasm - Mixing of sensory fibres from right and left optic nerves
Optic tract - Contain sensory information from part of the right eye and part of the left eye
Different lesions within the visual pathway give very different patterns of visual loss e.g. retinal detachment, optic neuritis, pituitary tumour, stroke
Pituitary tumours compress optic chiasm, causing bilateral visual symptoms (“bitemporal hemianopia”)
- Visual acuity tests e.g. Snellen Chart, • Visual fields • Pupillary light responses
- Seen directly with ophthalmoscope (i.e. optic disc= point at which nerve enters the retina)
- Carry extension of meninges: nerve affected when raised ICP: • Swollen optic disc (papillodema)
Visual pathway extends back from the retina towards the primary visual cortex found within the occipital lobe
There is communication from the optic tracts with brainstem (midbrain) to allow for certain visual reflexes e.g. pupillary reflexes to light
