Neuro4

Question 1

What is the classic triad of symptoms associated with Horner syndrome?

Answer 1

(1) ptosis (drooping of the eyelid; superior tarsal muscle)
(2) miosis (pupil constriction)
(3) anhydrosis (absence of sweating) and flushing of affected side of the face

Question 2

How many neurons are involved in the pathway from the hypothalamus to the eye that is involved in horner syndrom? what is the pathway?

Answer 2

3

1st - hypothalamus to intermediolateral column of spinal cord (lateral horns)
2nd - lateral horns to superior cervical ganglion
3rd - ganglion to :
(a) pupil
(b) smooth muscles of eyelid
(c) sweat glands of forehead and face

**the 2nd neuron is the preganglionic sympathetic neuron; the 3rd neuron is the postganglionic neuron

Question 3

Above what level would we expect a lesion to cause Horner syndrome?

Answer 3

Horner syndrome is associated with a lesion of the spinal cord above T1

Question 4

What information does the ophthalmic division of the trigeminal nerve carry? (V1)

(5 places)

Answer 4

V1 carries sensory information from:

• -the scalp and forehead
• -upper eyelid
• -conjunctiva and cornea (corneal reflex)
• -the nose and nasal mucosa
• -the frontal sinuses

Question 5

What fibers does the oculomotor nerve carry with it?

Answer 5

• -motor efferents that innervate most of the extraocular eye muscles
• -parasympathetic preganglionic fibers that synapse on the postganglionic nerves in the ciliary ganglion. (These will synapse on the pupillary sphincter muscle

Question 6

What is the organization of fibers in the oculomotor nerve?

Answer 6

The motor efferents are located centrally, and the parasympathetic preganglionic fibers are located peripherally

(Motor-Medial, Parasympathetic-Peripheral)

Question 7

How would a lesion of the oculomotor nerve present?

Answer 7

• -mydriasis
• -loss of direct and consensual pupillary light reflex
• -loss of accommodation and convergence
• -loss of extraocular eye movement, adduction in particular –> diplopia on horizantal gaze

Question 8

Hemifacial anesthesia would result from lesion to what?

Answer 8

Trigeminal

Question 9

Hemifacial anhydrosis would result from lesion to what?

Answer 9

• -Descending hypothalamic fibers, above T1

- -The sympathetic chain (e.g., superior cervical ganglion)

Question 10

Hemifacial weakness would result from lesion to what?

Answer 10

Facial nerve

Question 11

Can INO (internuclear opthalmoplegia) be a symptom of an oculomotor nerve palsy?

Answer 11

No. INO is a specific diagnosis; it is caused by lesion of the medial longitudinal fasciculus (MLF), which formed by neuronal axons that extend from the abducens nucleus, decussate, and synapse on the oculomotor nucleus on the opposite side.

INO results in patients who cannot adduct an eye on horizantal gaze –> horizantal diplopia. This is a shared symptom with a CNIII palsy. However, in INO, patients would not have ptosis or pupil abnormalities (mydriasis)

Question 12

Where is the substantia nigra located?

Answer 12

In the midbrain, between the crus cerebri and the red nucleus

Question 13

What are the common symptoms associated with Parkinson disease?

Answer 13

TRAPS

Tremor (e.g., pill-rolling tremor)
Rigidity ("cogwheel" rigidity)
Akinesia (or bradykinesia)
Postural instability
Shuffling gait

**TRA are the “classic” triad

Question 14

What is the histopathologic hallmark of Parkinson disease?

Answer 14

–Lewy bodies: round, eosinophilic, intracytoplasmic inclusions seen in dopaminergic nigrostriatal neurons

–loss of dopaminergic neurons (i.e., depigmentation) of the substantia nigra pars compacta

Question 15

What are Lewy bodies composed of?

Answer 15

alpha-synuclein

Question 16

What two diseases are associated with Lewy bodies?

Answer 16

(1) Parkinson disease

(2) Lewy body dementia

Question 17

How can Lewy body dementia and Parkinson disease be differentiated clinically? (3)

Answer 17

(1) Dementia is a common feature late in the disease in Parkinson’s, whereas early-onset dementia is suggestive of Lewy body disease.
(2) Lewy body disease is also characterized by hallucinations (not present in Parkinsons)
(3) cortical Lewy bodies present in Lewy body disease (only found in substantia nigra in Parkinson’s)

Question 18

What histologic feature is associated with Creutzfeldt-Jakob disease (CJD)?

Answer 18

spongiform changes

Question 19

Adult Polycystic Kidney Disease

Answer 19

Autocomal dominant genetic disorder characterized by bilaterally enlarged kidneys with multiple cyts.

Associated with Berry aneurysms in the circle of Willis, which can bleed and produce a subarachnoid hemorrhage

Question 20

Location of lesion in Wernicke aphasia

Answer 20

superior temporal gyrus

Question 21

Location of lesion in Broca aphasia

Answer 21

Inferior frontal gyrus

Question 22

Location of lesion in Conduction aphasia

Answer 22

Arcuate fasciculus

Question 23

Type of aphasia?

Fluent: Yes
Comprehends: No
Repeats: No

Answer 23

Wernicke

Question 24

Type of aphasia?

Fluent: NO
Comprehends: Yes
Repeats: No

Answer 24

Broca

Question 25

Type of aphasia?

Fluent: Yes
Comprehends: Yes
Repeats: No

Answer 25

Conduction

Question 26

Why can symptoms in a patient with a subdural hematoma present later (even several days to weeks) than a person with an epidural hematoma?

Answer 26

The bleeding in a subdural hematoma originates from bridging veins, which are under venous pressure, giving more time for blood to accumulate before symptoms arise.

Unlike the subdural hematoma, the epidural hematoma is under high arterial pressure (middle meningeal artery), and has limited outflow space (confined to area within suture lines). This results in rapid compression of the brain and production of symptoms.

Question 27

Classic presentation of an epidural hematoma? (5 steps)

Answer 27

(1) trauma
(2) immediate loss of consciousness (from initial impact)
(3) recovery/transient lucid period
(4) declining consciousness
(5) even coma from brain stem compression (if untreated)

Question 28

Diffuse (cortical) atrophy with prominent sulci might be indicative of?

Answer 28

Alzheimer Disease

Other anatomical findings in this disease include prominent atrophy in the hippocampal region

Question 29

Evidence of intraventricular blood might be indicative of?

Answer 29

Subarachnoid hemorrhage

Question 30

What is the classic presentation/patient hx of a subdural hemorrhage?

Answer 30

(1) trauma
(2) clinical presentation days later (late onsent)
(3) older patient
(4) obtunded patient (diminished consciousness)

Question 31

72 year old patient found lying in her bed unresponsive. She was in good condition 2 hours prior. She has a history of Alzheimer disease, no evidence of fall or trauma. CT shows a large intraparenchymal hemorrahge centered in the left parietal lobe. What might we suspect?

Answer 31

Amyloid angiopathy

Question 32

What is amyloid angiopathy?

Answer 32

Amyloid deposition in the walls of cerebral blood vessels in Alzheimers patients. Amyloid makes the vessels weak and prone to rupture; can make Alzheimers patients prone large lobar hemorrhages usually centered in the parietal lobe

Question 33

72 year old patient found lying in her bed unresponsive. She was in good condition 2 hours prior. She has a history of Alzheimer disease, no evidence of fall or trauma. CT shows a large intraparenchymal hemorrahge centered in the left parietal lobe.

Why wouldn’t this be due to a subdural hematoma (and what about the case would put subdural hematoma on the differential)?

Answer 33

Alzheimers patients are more susceptible to subdural hematomas due to brain atrophy, which stretches the bridging veins, making them more prone to rupture.

However, subdural hematomas are typically associated with trauma, and do not cause intraparenchymal hemorrhage. Subdural hematomas also have symptoms that are slow-onset. In this case, her symptoms developed rapidly.

Question 34

72 year old patient found lying in her bed unresponsive. She was in good condition 2 hours prior. She has a history of Alzheimer disease, no evidence of fall or trauma. CT shows a large intraparenchymal hemorrahge centered in the left parietal lobe.

What would put Charcot-Bouchard aneurysm on the list, and why would it not be suspected in this case?

Answer 34

Charcot-Bouchard aneurysms can lead to sudden onset intraparenchymal hemorrhage.

However, Charcot-Bouchard aneurysms are not associated with lobar hemorrhages, and are typically seen in patients with severe hypertension.

Question 35

What is the most common cause of intraparenchymal hemorrhage?

Answer 35

(systemic) Hypertension

Question 36

What three conditions besides hypertension may be associated with intraparenchymal hemorrhage?

Answer 36

(1) amyloid angiopathy
(2) vasculitis
(3) neoplasm

Question 37

45 yo man with a hx of uncontrolled hypercholesterolemai and hypertension presents to the ED after collapsing at home, and passes. Autopsy reveals massive intracerebral hemorrage filling the ventricles. What the most likely location of the hemorrhage?

Answer 37

Basal ganglia and internal capsule

Question 38

What is the most common site of (massive) intraparenchymal bleed (due to hypertenstion)?

Answer 38

The basal ganglia and internal capsule

Question 39

What would be the classic basic pathology of intraparenchymal hemorrhage in the basal ganglia and internal capsule due to hypertension?

Answer 39

Rupture of Charcot-Bouchard aneurysm of lenticulostriate vessels.

–> lenticulostriate vessels are branches of the middle meningeal artery