Week 8 (Test 3) Flashcards
characterized as major depression that recurs at the same time each year usually just before and during winter, with a full spontaneous remission during spring and summer
seasonal affective disorder (SAD)
What’s the treatment for seasonal affective disorder (SAD)?
Bright artificial light phototherapy
When, during the day, do statistically significant more natural deaths occur?
after midnight
Significantly more myocardial infarctions and strokes occur around what time? why?
9 am At this time, blood pressure, heart rate, vascular tone, platelet aggregation and blood coagulability are all increased while coronary flow and fibrinolytic activity are decreased.
The master body clock is anatomically located in the _______.
SUPRACHIASMATIC NUCLEUS OF THE HYPOTHALAMUS
Where does the suprachiasmatic nucleus of the hypothalamus get its info from?
3% of the ganglion cells in the ganglion cell layer have melanopsin and they project to the SCN via the Retino- Hypothalamic Tract (RHT)
Where does the suprachiasmatic nucleus of the hypothalamus send its signals?
SCN output signals are transmitted to the central sympathetic intermediolateral cell column (IML) of the spinal cord and to the central parasympathetic dorsal motor nucleus of the vagus (DMV)
What are the Primary neurons of the olfactory system?
olfactory nerves
Where would you find secondary neurons of the olfactory system?
olfactory bulb (they are called mitral cells)
What’s the Final destinations of olfactory info?
pyriform cortex and amygdala.
The septal area communicates with the amygdala via two fiber tracts:
stria terminalis Diagonal band of Broca
What’s the function of the Papez circuit?
links the limbic system and the cortex
List the important parts of the Papez circuit.
hippocampus–> fornix–> mammillary body–> anterior nucleus of thalamus–> cingulate gyrus–>
amygdala is important for:
Subjective feeling/memory Emotion Like /Dislike
hippocampus is important for:
New memory Short term memory Learning
-bilateral temporal lobe lesion No emotional response Visual agnosia Orally examine subjects Hypersuxuality
Kleuver-Bucy syndrome
Mammillary body degeneration is a common finding. Chronic alcoholism Vit. B. (thiamine) deficiency
Korsakoff syndrome
What is the limbic system responsible for?
5 F’s: Feeding Fleeing Fighting Feeling Sex
Anterior hypothalamus is responsible for:
Parasympathetic Heat loss Thirst/drinking ADH/Oxytocin Circadian Sleep Reproduction, sex
Medial hypothalamus is responsible for:
Satiety Emotion Endocrine
What are the hormones released by the posterior pituitary ?
oxytocin and vasopressin (antidiuretic hormone)
Functions of the hypothalamus:
TAN HATS to bed T: Thirst A: Adenohypophysis (Ant. pituitary) N: Neurohypophysis (post. Pituitary) H: Hunger A: Autonomic T: Temperature S: Sexual urges to bed: Circadian rhythm
Identifies genetic influence even when many genes and much environmental variance is involved. Many genes, each with small effect, combine to produce observable differences among individuals in a population.
Quantitative Genetics
What’s the weakness of using family studies?
This type of study can’t distinguish environmental vs genetic effects
What do you need to make a diagnosis of Schizophrenia?
Two or more of the following, each active for at least ONE month. At least one of these must be 1,2, or 3: 1) Hallucinations 2) Delusions 3) Disorganized speech (Grossly bizarre language) 4) Catatonia or grossly disorganized behavior 5) Negative symptoms; affective flattening, alogia, avolition Continuous signs of disturbance persists for 6 months, with at least 1 month of active symptoms, may include residual symptoms
What are the positive symptoms of schizophrenia?
delusions and hallucinations
What are the negative symptoms of schizophrenia?
blunted affect social withdrawal lack of motivation
For a patient suspected of having schizophrenia, what else should be on your differential diagnosis?
Drug intoxication -Cocaine -Amphetamine -PCP -“Bath Salts” Medical Conditions Other psychiatric disorders
Patient has schizophrenia and also has prominent mood (manic or depressive syndrome) at times
Schizoaffective disorder
Huntington’s is an autosomal dominant disease effecting which chromosome? It’s a triplet repeat disease. What is the sequence of the triplet repeat?
chromosome 4 CAG
Prominent delusions without hallucinations or language disturbance Usually starts later in life (40s or 50s) Uncommon Often paranoid, may have medical fixation (delusions of parasites or worms)
Delusional Disorder
If a patient has had psychosis that meets schizophrenia criteria for more than six months, What’s the diagnosis?
Schizophrenia
If a patient has had psychosis that meets schizophrenia criteria for less than six months, What’s the diagnosis ?
Schizophreniform disorder
The ______ of schizophrenia have been associated with a reduction of dopamine activity in the mesocortical pathways.
negative symptoms
Overactivity of the mesolimbic pathway has been implicated in development of _________ of schizophrenia
positive symptoms
All antipsychotics block ____.
D2 receptors
What is the most effective drug for schizophrenia ?
Clozapine
What is the only antipsychotic that increases nausea ?
Aripiprazole
What are the severe side effects of Clozapine?
it can cause agranulocytosis (loss of neutrophils) and seizures
Metabolic risk much worse with ______ antipsychotic drugs.
Metabolic risk much worse with “-pine” drugs Clozapine Olanzapine Quetiapine
EPS [Extrapyramidal symptoms (EPS: Parkinsonism, dystonia, akathisia)] risk much worse with _____ antipsychotic drugs.
EPS risk worse with “-done/ole’s”
Which antipsychotics have the worst weight gain side effects?
Olanzapine and clozapine
Which antipsychotics put patients at the least risk for diabetes, weight gain, and hyperlipidemia?
Aripiprazole and ziprasidone
Which antipsychotics put patients at greatest risk for diabetes, weight gain and hyperlipidemia?
Clozapine and olanzapine
If antipsychotics caused extrapyramidal parkinson like symptoms, how would you treat?
Lower the dose, switch drug, or use anticholinergics (benztropine), or amantadine (a dopamine agonist)
If antipsychotics caused extrapyramidal Tardive dyskinesia (TD; involuntary movements) like symptoms, how would you treat?
Not much helps so prevention best; clozapine may help
If antipsychotics caused extrapyramidal Akathisia (uncomfortable restlessness) like symptoms, how would you treat?
Propanolol, lorazepam for short term symptomatic relief
Describe how antipsychotics effect prolactin.
They can increase it and cause gynecomastia (breast swelling) and galactorrhea (milky discharge) via blockade of tuberoinfundibular dopamine receptors
How would you treat a patient with Neuroleptic Malignant Syndrome (NMS)?
stop the drugs causing it and then the patient needs ICU management
-Discrete episodes of losing control of aggressive impulses -Acute onset, remit spontaneously -Individual describes as spell or attack -Genuine regret or remorse; no impulsiveness between attacks
Intermittent explosive disorder
Intermittent Explosive Disorder cannot be diagnosed before the age of ___.
6
Chronic, psychiatric condition characterized by uncontrollable, self-inflicted, hair pulling, resulting in noticeable hair loss
Trichotillomania
Fascination with, interest in, curiosity about or attraction to fire and its situational contexts; Deliberate and purposeful fire setting on more than one occasion
pyromania
Recurrent skin picking resulting in skin lesions.
Excoriation (Skin-Picking) Disorder
One or more episodes of inability to recall important personal information, usually of a traumatic or stressful nature, that is too extensive to be explained by ordinary forgetfulness
dissociative amnesia
Apparently purposeful travel or bewildered wandering that is associated with amnesia for identity or for other important autobiographical information
fugue
•Experiences of unreality, detachment, or being an outside observer with respect to one’s thoughts, feelings, sensations, body, or actions
–(e.g., perceptual alterations, distorted sense of time, unreal or absent self, emotional and/or physical numbing).
depersonalization
•Experiences of unreality or detachment with respect to surroundings
–(e.g., individuals or objects are experienced as unreal, dreamlike, foggy, lifeless, or visually distorted).
derealization
•Disruption of identity characterized by two or more distinct personality states, which may be described in some cultures as an experience of possession. The disruption in identity involves marked discontinuity in sense of self and sense of agency, accompanied by related alterations in affect, behavior, consciousness, memory, perception, cognition, and/or sensory-motor functioning. These signs and symptoms may be observed by others or reported by the individual.
Dissociative Identity Disorder
What is the preferred medication for patients with parkinson’s disease who develop psychotic symptoms from their dopaminergic treatments (such as L-Dopa or dopamine agonists)?
quetiapine b/c it is a ‘fast off’ antipsychotic with little risk for EPS symptoms or elevated prolactin
what’s the treatment for an acute dystonic reaction?
intramuscular (IM) benztropine (Cogentin™) 2mg or diphenhydramine (Benadryl™) 50 mg.
What’s the treatment for a patient with Akathisia?``
propranolol
What’s the best option when a patient has Tardive Dyskinesia?
switch to clozapine, as it doesn’t cause TD and often improves the movements
Deep sleep occurs in which part of the night?
non-REM
first third of the night
When does REM sleep occur?
latter half of the night
What would you see on a Polysomnogram if the patient was awake but had their eyes closed?
alpha waves
Describe stage 1 non REM sleep
slow eye movements
Myoclonic (aka Hypnic) Jerks
Many deny sleeping, easy arousal
What woud you see on a polysomnogram of a patient in stage 1 of non-REM sleep?
theta waves
What woud you see on a polysomnogram of a patient in stage 2 of non-REM sleep?
Sleep Spindles and K Complexes
What woud you see on a polysomnogram of a patient in stage 3 of non-REM sleep?
delta waves
Describe stage 2 of non-REM sleep
No eye movements
Breathing, HR Regular
Body Temp Decreases
More difficult to arouse
Describe stage 3 of non-REM sleep
Decrease in Blood Pressure, RR
Growth Hormone Released
Most difficult to arouse, the “deepest” stage of sleep
Confusion upon waking, little to no recall of dreaming
In which sleep stage do most Parasomnias (like sleepwalking/night terrors) occur?
stage 3 of non-REM sleep
Describe REM sleep
Dream Sleep (Ability to Remember Dreams) “processing information”
Purposeful Atonia (muscles actively suppressed)
Cortical is Active
Autonomic Instability
Arousable without confusion
Dominates the second half of the night
Nocturnal Penile/Clitoral Tumescence
Describe Circadian Phase Advancement .
going to bed earlier and waking up earlier
Describe Circadian Phase Delay.
going to bed later and waking up later
neurotransmitter that promotes sleep
melatonin
Bright Light ______ Melatonin Release by Pineal Gland
prevents
REM sleep is influenced by what system?
The Circadian System
Slow wave sleep is influenced by which system?
The Homeostatic System
What is the main mechanism by which the homeostatic system makes us feel sleepy?
accumulation of Adenosine from use of ATP in the brain
By what mechanism does caffeine keep us awake?
caffeine works as an Adenosine Receptor Antagonist
Chronic insomnia, characterized by Difficulty initiating or maintaining sleep (Occurring despite adequate opportunity) and Causing significant distress or impairment in functioning must occur in what timeframe to be considered the correct diagnosis?
At least 3 nights/wk for 3 months
What is the Most Common Cause of Hypersomnia?
Obstructive Sleep Apnea (OSA)
What’s the best treatment for Obstructive Sleep Apnea ?
Positive Airway Pressure (PAP)
How does a Mean Sleep Latency Test (MSLT) differ from a Polysomnogram (PSG)?
PSG’s collect data from longer periods of sleep (like overnight) while MSLT’s collect data during four to five 20 minute nap trials
They are Always done after an overnight PSG!!
Unwanted/Irresistible periods of sleep in non-permissive (while eating, talking, driving or during sex) and permissive environments (BHS lecture)
narcolepsy
A hallmark of narcolepsy is a mean sleep latency of ____.
< 8 minutes
What is the most specific symptom of narcolepsy (although rarely seen)?
Cataplexy (Bilateral loss of muscle tone with intense emotion)
Narcolepsy is linked to a Deficiency of what Hypothalamic Peptide?
Hypocretin-1 aka Orexin-A (Narcolepsy Type 1)
Narcolepsy has been linked to what specific HLA linkage (suggesting a possible autoimmune basis)?
HLA DQB1*0602
Nightmare disorder occurs in which stage of sleep?
REM sleep
Recurrent episodes of outward appearance of intense fear and signs of autonomic arousal, such as tachycardia, rapid breathing, dilated pupils, and sweating
sleep terror disorder
Sleep terror disorder occurs in which stage of sleep?
slow wave sleep (stage 3 non REM)
Somnambulism aka Sleepwalking occurs in which stage of sleep?
slow wave sleep (stage 3 non REM)
Loss of Atonia during REM Sleep
–Resulting in motor activity usually of a violent nature
REM Behavior Disorder
What are the classic sleep findings in depression?
Difficulty maintaining sleep
EARLY MORNING WAKENINGS
Decreased REM Latency
Increased REM Density
Decreased SWS
Decreased Sleep Efficiency
What are the Most common adult CNS neoplasms?
ASTROCYTIC NEOPLASMS
OLIGODENDROGLIOMAs are usually found where?
cerebral white matter (where all of the oligodendrocytes are)
What molecular pathology finding indicates better prognosis and better response to chemotherapy in oligodendrogliomas?
Codeletions of chromosomal arms 1p and 19q
What molecular pathology finding indicates better prognosis and better response to chemotherapy in glioblastomas? Why?
Identification of MGMT promoter methylation. This indicates better response to TMZ (chemotherapy drug) because if the MGMT promoter is methylated, the gene is silenced and isn’t able to perform its function of DNA repair (obviously in cancer cells in this case)
With metastatic neoplasms, there are usually multiple lesions at the grey-white matter junctions. Why?
The reason grey-white junction is preferred is because the capillary circulation slows down in this area, allowing the neoplastic cells or micro-organisms to set up shop easier in this area.
presents as a sausage-like swelling of the entire peripheral nerve because it includes all the components of the nerve, including Schwann cells, fibroblasts and perineurial cells.
neurofibroma
arises from the Schwann cells and has a biphasic appearance
schwannoma
each and every nerve fascicle is an individual neurofibroma, creating a “bag of worms” appearance
plexiform neurofibroma
localized abnormal dilatation of a blood vessel
Aneurysm
What do you see in Cobalamin (Vit B12) Deficiency?
- Megaloblastic anemia
- Subacute combined degeneration of the
spinal cord: myelin loss in dorsal and lateral columns
•Another common problem is memory problems mimicking
dementia
decreased oxygen to the brain
hypoxia
lack of perfusion
ischemia
Ischemia leads to what in the neurons?
Leads to eosinophilic change in neurons–>RED NEURONS
What is this a picture of?
atherosclerosis
What often causes subdural hemotomas?
damage to Bridging veins: so think elderly, baby, alcoholic
What often causes epidural hematomas?
damage to the middle meningeal artery
What is this an image of?
subdural hematoma;
CT scan shows a crescent shaped (concave) hematoma which is less dense than an epidural hematoma due to dilution of the blood by CSF. Subdural hematomas are also more likely to cross suture lines than epidural hematomas.
Treatment for a subdural hematoma is emergency surgical decompression.
What is this an image of?
epidural hematoma;
In epidural hematomas, CT scan shows a highly attenuating convex (“lenticular”) shaped mass overlying the brain. Epidural hematomas are also less likely to cross suture lines than subdural hematomas.
Characterized by lucid interval (brief period of improvement) followed by rapid signs of cerebral compression.
epidural hematomas
Characterized by gradual signs of cerebral compression that may manifest in hours to days. In this scenario, an elderly person can have progressive confusion which goes unnoticed until a coma occurs.
subdural hematoma
Subarachnoid hemorrhage is often caused by:
Trauma
Rupture of a berry (saccular) aneurysm
Rupture of an arteriovenous malformation
The classic presentation is the patient complaining of sudden onset of the “worst headache of my life” that may be accompanied by nausea and vomiting secondary to increased intracranial pressure.
subarachnoid hemorrhage
What is this an image of?
Subarachnoid hemorrhage
note the blood in the sulci
What is this an image of?
Intraparenchymal hemorrhage
Intraparenchymal hemorrhage is most often secondary to _____.
hypertension
Rupture of a berry aneurysm will cause a ______.
subarachnoid hemorrhage. The patient will present with the “worst headache of my life” or hemorrhagic stroke symptoms.
A growing berry aneurysm can compress the optic chiasm causing a ____.
bitemporal hemianopia
Where are Berry aneurysms most commonly found?
Berry aneurysms are most commonly found in the Circle of Willis, specifically at the bifurcation of the anterior communicating artery and anterior cerebral artery.
◦What disease has absent cerebellum vermis?
Dandy Walker malformation
◦What disease has herniated cerebellar tonsil?
arnold chiari
occurs when the cerebellar tonsils are displaced through the foramen magnum.
Cerebellar tonsillar herniation
occurs when a cerebral hemisphere displaces the cingulate gyrus under the falx cerebri.
Cingulate (subfalcine) herniation
Cingulate (subfalcine) herniation can lead to compression of which artery?
anterior cerebral artery resulting in paralysis, weakness, and sensory loss in the contralateral foot and leg.
occurs when the uncus, the most medial aspect of the temporal lobe, puts pressure on the brainstem (particularly the midbrain).
Uncal (uncinate, transtentorial) herniation
Uncal herniation has a common triad of symptoms. What are they?
- Ipsilateral fixed-dilated pupil with an eye that is “down and out” from compression of the ipsilateral CN III
- Contralateral homonymous hemianopsia from compression of the ipsilateral posterior cerebral artery
- Ipsilateral hemiparesis (false-localizing sign) from compression of the contralateral crus cerebri
Grade IV astrocytoma=
Glioblastoma
Amplification and overexpression of what gene is a striking feature of glioblastomas?
Epidermal Growth factor receptors (EGFR’s)
What is this a histological image of?
◦glioblastoma
pseudopalisading around necrosis
What is this a histological image of?
Oligodendroglioma
Histopathologically, oligodendrogliomas show closely packed cells with large nuclei surrounded by clear halo of cytoplasm (fried egg appearance) along with a chicken-wire capillary pattern.
a rare, slow-growing tumor that often presents in the frontal lobes of the cerebrum in middle-aged patients.
Oligodendroglioma
What is this a histological image of?
meningioma
Histologically, meningioma shows whorled pattern of spindle cells with psammoma bodies (laminated calcifications)
benign slow-growing tumors that arise from meningothelial cells (most commonly the arachnoid mater).
meningioma
benign encapsulated tumors of Schwann cells that occur on the vestibular division of CN VIII at the cerebellopontine angle
schwannoma
What is this a histological image of?
Ependymomas
◦Histology-True and Pseudo rosettes
True rossettes-actually surround a space creating their own ventricle
Pseudo rosettes get confused and surround space already there such as blood vessel
What is this a histological image of ?
Pilocytic astrocytomas
Histopathologically, pilocytic astrocytomas show Rosenthal fibers (eosinophilic corkscrew fibers)
What is this a histological image of?
medulloblastoma
◦Histology-solid,small blue cells
a type of primitive neuroectodermal tumor (PNET) making them highly malignant, but they are also radiosensitive.
medulloblastomas
(a grade I astrocytoma) is a low grade, slow-growing, benignneoplasm with a good prognosis that often affects young children.
Pilocytic Astrocytoma
frequently cerebellar, where they may compress the 4th ventricle and impede CSF outflow causing a non-communicating hydrocephalus.
medulloblastoma
Huntington disease has a visible affect on what part of the brain?
caudate nucleus
In what common disease do you see cerebral atrophy?
Alzheimers
rare tumors of the ependymal cells, which line the ventricular system of the brain and the central canal of the spinal cord.
Ependymomas
Which artery supplies blood to the hippocampus?
posterior cerebral artery
Why is the hippocampus more vulnerable to long-term stress than most other brain areas?
hippocampus contains high levels of glucocorticoid receptors
the blood brain barrier breaks down and fluid travels mainly in the white matter along axons
vasogenic edema
the BBB remains intact and is seen in stroke or hypoxia and equally involves both gray and the white matter.
cytoxic edema
Instead of going to the spinal cord, corticobulbar tracts go to _____.
cranial nerve nuclei
What structures compose the striatum?
caudate and putamen
List the 4 inputs to the striatum.
- cortex
- substantia nigra
- centromedial nucleus
- raphe nucleus
List the 3 outputs of the striatum (where does it project to).
- external segment of the globus pallidus
- internal segment of the globus pallidus
- substantia nigra
In Huntington’s chorea, neurons in which structure in the basal ganglia loop initially die?
striatum
The ansa lenticularis is a bundle of fibers originating in the ____
globus pallidus interna
Which cerebellar peduncle contains mostly cerebellar efferents?
superior cerebellar peduncle
Which cerebellar peduncle contains mossy fibers that originate in pontine nuclei and travel up to the cerebellum?
middle cerebellar peduncle
What is the cause of most ischemic strokes?
Thromboembolism - Diminished blood supply to focal area caused by a clot
t-PA must be given within ______ hours of iscehmic stroke.
the first three (3)
A stroke that results from the occlusion of a single penetrating artery or arteriole;
Typically in deeper brain structures:
Basal ganglia, Internal/external capsule, Brainstem
lacunar stroke
What signs would you see for a patient with a stroke in the left hemisphere?
Typical Signs –Right Side
- Right visual Field deficit
- Aphasia
- Left gaze preference
- Right Hemiparesis
- Right Hemisensory loss
What signs would you see in a patient with a stroke in the right hemisphere?
Typical Signs - Left Side
- Left Hemi-inattention
- Left Visual Field Deficit
- Right Gaze Preference
- Left Hemiparesis
- Left hemisensory Loss
What signs would you see in a patient with a stroke in the brainstem?
Typical Signs – Both Sides
- Quadriparesis or Hemiparesis/ Hemisensory Loss)
- Sensory Loss in all 4 Limbs or Crossed Signs (1 side of face and opposite side of body)
What signs would you see in a patient with a stroke in the cerebellum?
Ipsilateral Limb Ataxia (dyscoordination)
Truncal or Gait Ataxia (Imbalance)
how do you rule out hemorrhagic stroke?
Non-Contrast CT scan is essential to rule out hemorrhagic stroke
A stroke in the anterior cerebral artery would lead to:
sensorimotor defects
A stroke in the middle cerebral artery would lead to:
language defects
A stroke in the posterior cerebral artery would lead to:
visual defects
What’s the function of the lateral nuclei of the hypothalmus?
mediates hunger; destruction leads to anorexia
What’s the function of the anterior nucleus of the hypothalamus?
mediates heat dissipation via parasympathetics; destruction leads to hyperthermia
What’s the function of the posterior nucleus of the hypothalamus?
mediates heat conservation via sympathetics; destruction leads to hypothermia
What two medical conditions should be on your differential diagnsosis of shizophrenia?
Huntington’s and Lupus
