Test

Question 1

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

Answer 1

An embolic stroke

Afib is a major risk factor.

Question 2

Patient suffer lesion in ventro medial midbrain, what structures are affected

Answer 2

CN 3 and corticospinal tract

Question 3

Most medial dorsal part of rostral medulla is lesioned on left side. What clinical symptom would you see

Answer 3

Left deviation of protruded tongue (lesion of hypoglossal nucleus)

Question 4

What artery supplies ventromedial rostral medulla

Answer 4

Paramedian branch of anterior artery - ventral and medial structures

Paramedian branch of basilar is for pons

Question 5

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

Answer 5

CN 9.10.11

All of these nerves can be affected together within the jugular foramen

Question 6

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

Answer 6

INner hair cell death at base of cochlea

Inner hair cells are responsible for pitch discrimination.

Question 7

a child possibly has a right sided conduction loss. What sign would you see on Weber

Answer 7

Hearing in right ear is greater than left ear.

Question 8

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

Answer 8

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

Question 9

Man is in coma. Cold water is placed in left ear to test integrity of brainstem. What would indicate its intact

Answer 9

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.

Question 10

What nerve things are being activated when looking to the right

Answer 10

Left MLF, left FEF, right abducens, right PPRF

Question 11

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

Answer 11

Left cerebellar hemisphere lesion

Question 12

sudden stroke affects the ventral medulla in the region of the inferior olivary nucleus. As a result which neurons in cerebellum are affected

Answer 12

the climbing fibers from the contralateral inferior olivary nucleus are excitatory to the deep cerebellar nuclei and to the purkinje cell neurons

Question 13

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

Answer 13

This suggest a 1 & 1/2 syndrome caused by a tumor.

Right nucleus of CN6 and right MLF

Question 14

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?

Answer 14

White matter perventrical lesions

MS

Question 15

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

Answer 15

This patient has huntington’s disease. In which the primary lesion is usually the caudate nucleus.

Question 16

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

Answer 16

Began before age 18
Both motor and sensory tics
>1 yr

Tourettes

Question 17

What is sufficient to increase excitability of hippocampal neurons

Answer 17

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.

Question 18

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

Answer 18

Amygdala - Kluver-Bucy syndrome which is cause by BILATERAL damage of amygdala

Question 19

*Baby smiles because of parents behavior, what is responsible for the smile.

Answer 19

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.

Question 20

What is a good test to assess attention deficit.

Answer 20

Repeat 3 objects.

Question 21

Occlusion of what leads to medial medullary syndrome

Answer 21

Paramedian branches of the anterior spinal artery

Question 22

Man has medial medullary syndrome, in addition to right sided hemiparesis, what else would you expect sensation wise.

Answer 22

Usually this syndrome affects medial lemniscus and CST, loss of touch and vibration on the right body

Question 23

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

Answer 23

Hypodense, CT scans, densities are compared and a chronic hematoma would be hypodense.

Question 24

For sugar, what kind of receptor is activated

Answer 24

G-protein coupled receptor

Question 25

MVA, no damage to CNS and makes a full recovery. Later she realizes her sense of smell is severely dinminshed. WHat was lesioned?

Answer 25

Olfactory nerves

Question 26

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?

Answer 26

aneurysm of left posterior communicating artery

Question 27

Right hemianopsia with macular sparing

Answer 27

Posterior cerebral artery occlusion.

Question 28

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?

Answer 28

PCA

Question 29

Damage to the left AICA would cause what motor deficit?

Answer 29

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.

Question 30

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?

Answer 30

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).

Question 31

What is metabolic syndrome?

Answer 31

It is caused by drugs overdose (barbituates, benzodiazepines)

but not opiods

Lesions the prectectal nucleus, causing fixed, large bilateral pupils

Question 32

Galactorrhea, what leads to it?

Answer 32

dopamine projection to the hypothalamus inhibits prolactin

blockage of this pathway leads to galactorrhea

Question 33

Role of serotonin in:

forebrain (cortex, thalamus, BG)

Cerebellum, medulla, spinal cord

SIDS

Answer 33

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

Question 34

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.

Answer 34

Subarachnoid hemmorhage

On a noncontrast brain CT the subarachnoid space would show up as hyperdense

Nuchal ridgidity is from meningeal irritation

Question 35

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.

Answer 35

Parkinsons

Question 36

How is parkinsons diagnosed?

Answer 36

Clinically - history and physical examination. Response to dopaminergic agents is another diagnostic. If patient does not react consider something else.

Question 37

What type of medication frequently causes Parkinson like symptoms

Answer 37

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

Question 38

What are side effects of Sinemet (levodopa, carbidopa)

Answer 38

Early and frequent dyskinesias are common.

Others: psychiatric problems, depression, hallucinations, psychosis, nausea, vomiting and postural hypotension.

Question 39

Patient has

Difficulty swallowing and vocalizing
Loss of pain and temp from right side of face

Answer 39

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.

Question 40

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?)

Answer 40

Stem ischemic infarction of middle cerebral artery on the left

• global aphasia
• no acute blood on CT
• lesion of temporal lobe

Question 41

Man has a growing schwannoma, in addtion to hearign loss tinnitus, vertigo and unsteady gait what else will he develop

Answer 41

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.

Question 42

What are players in non-volitional (not voluntary) emotional expressions

Answer 42

1. limbic system
2. Reticular activation formation
3. LMN of CN7
4. hypothalamus

Question 43

IN addition to motor program selection and implementation, what else is the basal ganglia involved with?

Answer 43

• drug seeking behaviors
• mood changes
• initiation and termination of thought patterns related to planning and attention
• disorders such as Tourettes and schizophrenia.

Question 44

Why is nitrous oxide useful besides pharmacokinetics

Answer 44

useful component of anesthesia protocols because it lacks cardiovascular depression

Question 45

Which inhalational general anesthetic has the lowest MAC

Answer 45

Methoxyflurane - really potent

Question 46

what are the actions of ketamine as a monotherapy>

Answer 46

• analgesia
• cardiovascular stimulant
• minimal respiratory depression

Question 47

Postoperative vomiting is uncommon with this intravenous agent and patients are often able to ambulate faster than those who receive other anesthetics.

Answer 47

Propofol

favorable because of

• antiemetic effect
• fast recovery
• does not cause cumulative effects
• good for maintanence.