Test Flashcards
81 yr old woman with a 3 yr history of atrial fibrillation is brought to ER because suddenly unable to speak normally and is paralyzed on the right side. She had no complaints of headache or pain. A day later she remains paralyzed on the right side and can only say single words. Physicians suspect what
An embolic stroke
Afib is a major risk factor.
Patient suffer lesion in ventro medial midbrain, what structures are affected
CN 3 and corticospinal tract
Most medial dorsal part of rostral medulla is lesioned on left side. What clinical symptom would you see
Left deviation of protruded tongue (lesion of hypoglossal nucleus)
What artery supplies ventromedial rostral medulla
Paramedian branch of anterior artery - ventral and medial structures
Paramedian branch of basilar is for pons
46 yr old male realizes changes in speech and vocalization and difficulty swallowing completely. Neurological exam revealed on the right side decreased palatal elevation, paresis of the vocal cord and weakness in both the trapezius and strenoclediomastoid muscles. The gag reflex was absent on the right and the patient has moderate difficulty swallowing, what 3 CNs are affected
CN 9.10.11
All of these nerves can be affected together within the jugular foramen
Your patient has trouble using right ear on the phone. After an auditory exam it was determined that he was unable to hear frequencies above 2000 hz. Testing his left ear revealed normal hearing range. What could have happened
INner hair cell death at base of cochlea
Inner hair cells are responsible for pitch discrimination.
a child possibly has a right sided conduction loss. What sign would you see on Weber
Hearing in right ear is greater than left ear.
a 53 yr old fisherman is affected by intermittent bouts of vertigo. Upon testing, it appears that the vertigo only occurs in certain head positions. For example when lying in bed with his head at about 45 degrees. Which of the following mechanisms most likely is causing the vertigo
Calcium carbonate crystals moving in the semicircular canal. What appears to be described is Benign positional vertigo caused by dislodging of calcium carbonate crystals where they activate 9th nerve when the head is in different positions
Man is in coma. Cold water is placed in left ear to test integrity of brainstem. What would indicate its intact
Both eyes move slowly to the left.
*if person was awake they would have a fast beat to the right side after the slow movement.
What nerve things are being activated when looking to the right
Left MLF, left FEF, right abducens, right PPRF
Patient has complaints of clumsiness in left hand and arm. When examined by a neurologist for finger to nose the patient shows past pointing. He also has difficulty in making rapid alternating rotational movements of the left hand. The right hand has normal strength and coordination. The neurologist expects that this lesion might be in which of the following structures
Left cerebellar hemisphere lesion
sudden stroke affects the ventral medulla in the region of the inferior olivary nucleus. As a result which neurons in cerebellum are affected
the climbing fibers from the contralateral inferior olivary nucleus are excitatory to the deep cerebellar nuclei and to the purkinje cell neurons
Right eye has esotropia. During right gaze neither the right nor left move past the midline. Leftward gaze also shows abnormalities in that the left eye abducts and demonstrate nystagmus. The right eye does not move to the left. What do you expect
This suggest a 1 & 1/2 syndrome caused by a tumor.
Right nucleus of CN6 and right MLF
visual loss and muscle weakness. Subsequent examination revealed tingling and burning sensations and weakness of the lower limbs. There was hyperreflexia in the legs and bladder disturbances. Six months ago she reported not being able to move her arm but this was resolved. No signs of infection were detected as measured by blood analysis. What is expected to be visible on patients MRI?
White matter perventrical lesions
MS
40 yr old man presents with progressive difficulty in controlling movements of the face, head and limbs. This even happens when he is just sitting there. his movements look as if he is fidgeting or restless. Until now he also reports that he has been very healthy and rarely needed to go to a doctor. He reports that his older brother has had similar symptoms over the last several years
This patient has huntington’s disease. In which the primary lesion is usually the caudate nucleus.
17 yr old girl has experiences a variety of movements of the face and upper body since age 6. Her movements initially consisted of facial grimacing, frequent blinking, and puckering of the lips At age 8 she started producing various sounds, including hissing, clucking and grunting. These symptoms are characteristic of tourettes syndrome
Began before age 18
Both motor and sensory tics
>1 yr
Tourettes
What is sufficient to increase excitability of hippocampal neurons
high frequency tetanic stimulation of pre-synpatic neurons. (pyramidal in hippocampus)
Activation of NMDA receptors is needed for long term potentiation and postsynaptic changes to occur. NMDA activation requires both glutamate and depolarization of the post synaptic membrane.
Man has blood in the rostral frontal and temporal lobes bilaterally. After several weeks of recovery, man exhibits putting objects in mouth, overeating, frequent touching of genitalia. he man likely has a lesion of what
Amygdala - Kluver-Bucy syndrome which is cause by BILATERAL damage of amygdala
*Baby smiles because of parents behavior, what is responsible for the smile.
Hypothalamus. Emotional expression pathways originate in the limbic portions of the medial forebrain and temporal lobe and project through the hypothalamus. These are distinct pathways from those originating in the motor cortex (corticobulbar). The nuclei within the brainstem that are involved are the facial nuclei.
What is a good test to assess attention deficit.
Repeat 3 objects.
Occlusion of what leads to medial medullary syndrome
Paramedian branches of the anterior spinal artery
Man has medial medullary syndrome, in addition to right sided hemiparesis, what else would you expect sensation wise.
Usually this syndrome affects medial lemniscus and CST, loss of touch and vibration on the right body
79 yr old hits head. Neuroradiologist described are with an older subdural hematoma. Looking at CT, you notice same region is what relative to brain tissue
Hypodense, CT scans, densities are compared and a chronic hematoma would be hypodense.
For sugar, what kind of receptor is activated
G-protein coupled receptor
MVA, no damage to CNS and makes a full recovery. Later she realizes her sense of smell is severely dinminshed. WHat was lesioned?
Olfactory nerves
Patient has
severe left retro-orbital pain for 6 weeks, two days prior to admission left eye has ptosis and mydriasis, and tendency to drift to the left.
Deduced left third nerve palsy. What would MRA reveal?
aneurysm of left posterior communicating artery
Right hemianopsia with macular sparing
Posterior cerebral artery occlusion.
He keeps bumping into stuff on his right side, acute onset, does not have vertigo or dizziness, pupils are equally round and reactive to light, extraocular movements are intact, visual acuityis 20/20 but right VF is missing. What is the lesion?
PCA
Damage to the left AICA would cause what motor deficit?
Supplies the left lateral caudal pons and anterior inferior cerebellum. Would most likley produce cerebellar symptoms on the limbs on the same side of lesion. This artery would most likely spare the CN VI so horizontal eye movements to the left would be unaffected. The CST would also be spared.
A 75-year old man is brought to the emergency department after he was found unresponsive at home. The patient has a history of poorly controlled hypertension. Blood pressure is 240/120 mm Hg and puklse is 104/min. He has extensor posturing and pinpoint pupils. CT scan of the head without contrast reveals an acute pontine hemorrhage with associated mass effect. The patient dies several hours later. Autopsy reveals disruption of all pigmented neurons in the posterior rostral pons at the lateral floor of the fourth ventricle. These neurons normaly produce which of the following?
Norepinephrine
The patient had a hypertensive hemorrhage in the pons at the level of the locus ceruleus, a paired pigmented brainstem nucleus located in the posterior rostral pons near the lateral floor of the 4th ventricle. The locus ceruleus functions as the principal site for norepinephrine synthesis in the brain and projects virtually to all parts of the central nervous system. It is involved in the control of mood, arousal (reticular activating system), sleep-wake states, cognition, and autonomic functions (eg blood pressure control). Abnormal activation of the locus ceruleus has been implicated in the pathogenesis of anxiety disorders (eg panick attacks).
What is metabolic syndrome?
It is caused by drugs overdose (barbituates, benzodiazepines)
but not opiods
Lesions the prectectal nucleus, causing fixed, large bilateral pupils
Galactorrhea, what leads to it?
dopamine projection to the hypothalamus inhibits prolactin
blockage of this pathway leads to galactorrhea
Role of serotonin in:
forebrain (cortex, thalamus, BG)
Cerebellum, medulla, spinal cord
SIDS
Forebrain: psychiatric disorders (depression, anxiety, OCD, aggressive behavior
Cerebellum, medulla, spinal cord (caudal): pain, modulation, breathing, temperature, motor control.
The brains of infants who die of sudden infant death syndrome (SIDS) produce low levels of serotonin, a brain chemical that conveys messages between cells and plays a vital role in regulating breathing, heart rate, and sleep
Alexa is a 39 yr old woman. She suddenly had severe occipital headache and began vomiting. She denies a history of headache other than a similar one a couple days ago which was much less severe and only lasted coupe of seconds. She denies hitting her head or having a fever. She had severe nuchal rigidity and her language motor and sensory exams were normal.
Subarachnoid hemmorhage
On a noncontrast brain CT the subarachnoid space would show up as hyperdense
Nuchal ridgidity is from meningeal irritation
70 yr old has reduced appetite, difficulty getting out of chair. His wife reports that his voice has become softer. Vital signs are normal and he is no acute distress. He has no abnormalities in short or long term memory or language. His gait is slow and he takes 8 steps to turn. He has retropulsion (two steps back) and resting tremor in both hands but more prominently in the right. You find cogwheel rigidity in both arms but again more prominently displayed on the right.
Parkinsons
How is parkinsons diagnosed?
Clinically - history and physical examination. Response to dopaminergic agents is another diagnostic. If patient does not react consider something else.
What type of medication frequently causes Parkinson like symptoms
Antipsychotics
- first and second gen antipsychotics are antagonists of D2 receptors which can cause PD like symptoms. Other medications include SSRIs, valproate and lithium. This can last up to 6 months after discontinuation
What are side effects of Sinemet (levodopa, carbidopa)
Early and frequent dyskinesias are common.
Others: psychiatric problems, depression, hallucinations, psychosis, nausea, vomiting and postural hypotension.
Patient has
Difficulty swallowing and vocalizing
Loss of pain and temp from right side of face
Lateral medullary lesion (PICA)
Significance is that there is ONLY loss of pain and temp from the face because after CN5, it dips down to join in spinal V and then it travels up and joins the contralateral trigeminolemniscus pathway and carries proprioception and vibration too.
Obese woman has
- globally aphasic
- eye deviation to the left
- right sided facial droop
- decreased muscle tone on the right in upper and lower extremities
- positive babinski on the right
- agitation (why?)
Stem ischemic infarction of middle cerebral artery on the left
- global aphasia
- no acute blood on CT
- lesion of temporal lobe
Man has a growing schwannoma, in addtion to hearign loss tinnitus, vertigo and unsteady gait what else will he develop
Ipsilateral numbness of the face.
Schwannomas may enlarge rostrally and impinge the sensory root of the trigeminal nerve and case loss sensation on the same side of the face.
What are players in non-volitional (not voluntary) emotional expressions
- limbic system
- Reticular activation formation
- LMN of CN7
- hypothalamus
IN addition to motor program selection and implementation, what else is the basal ganglia involved with?
- drug seeking behaviors
- mood changes
- initiation and termination of thought patterns related to planning and attention
- disorders such as Tourettes and schizophrenia.
Why is nitrous oxide useful besides pharmacokinetics
useful component of anesthesia protocols because it lacks cardiovascular depression
Which inhalational general anesthetic has the lowest MAC
Methoxyflurane - really potent
what are the actions of ketamine as a monotherapy>
- analgesia
- cardiovascular stimulant
- minimal respiratory depression
Postoperative vomiting is uncommon with this intravenous agent and patients are often able to ambulate faster than those who receive other anesthetics.
Propofol
favorable because of
- antiemetic effect
- fast recovery
- does not cause cumulative effects
- good for maintanence.
