CNS -1

Question 0

Explain the process following initial injury/stimulus/growth that leads to the clinical manifestations. -sorry didnt know how else to ask this : )

Answer 0

Initial insult –> 1) invasion –> focal deficits & cerebral edema

               - -> 2) compression ---> cerebral edema ---> increase ICP
               - -> 3) Increased ICP --> leads to clinical manifestations

Question 1

What 2 mechanisms can cause brain cell death?

Answer 1

1) Anaerobic metabolism (ATP driven ie NaKpump)

2) Deterioration of ion gradients

Question 2

What are some clinical manifestations of Increase ICP?

Answer 2

Decrease cognitive function --> behavioral changes
HA, vomitting, seizures 
papilledema
unsteady gait 
loss of sphincter control

Question 3

A direct insult of the initial insult is what type of brain injury?

Answer 3

Primary

Question 4

Progressive damage resulting from body’s physio response to initial insult is what type of brain injury?

Answer 4

Secondary

Question 5

What is the critical factor in determining neuronal cell fate after injury?

Answer 5

degree of ATP depletion = decrease cellular function

Question 6

What is a contributing factor to the primary insult or part of the secondary response?

Answer 6

decrease blood flow = decreased 02 at cellular level & cant wash out metabolites

Question 7

Under anaerobic metabolism, what is the importance of mitochondrial dysfunction?

Answer 7

Normally under 02 –> Oxidative phosphorylation occurs in mitochondria highly efficient in forming ATP. w/o 02 –> anaerobic glycolysis

Question 8

Due to mitochondrial dysfunction the anaerobic glycotic pathway is initiated and therefore ____________ is converted to _____________.

Answer 8

pyruvate —> lactate

Question 9

In the anaerobic metabolism pathway what affects neuronal integrity, the cell membrane?

Answer 9

H ions —> acidosis

Question 10

How does inadequate ATP, which maintains ion gradients, lead to cell injury and death?

Answer 10

Anoxic depolarization (K leaves, Na Cl Ca enter) w/o functional ATP pump.. tries to equilibrate …H20 follows solute cell swells = death

Question 11

What excitatory neurotransmitter binds to NMDA receptors?

Answer 11

Glutamate

Question 12

Where does Glutamate act and what ion influx causes depolarization?

Answer 12

Post synaptically. NMDA ligand gated Ca Channel, Ca influx depolarizes

Question 13

Normal glutamate is cleared/reuptake by ATP pump, when ATP is depleted what can occur?

Answer 13

failure to remove excessive glutamate (excitotoxin)

Question 14

Excess glutamate can stimulate nearby neurons to then uptake large amounts of what ions ? and what is the result?

Answer 14

Calcium ions overload injury cytotoxic edema and swelling

Question 15

NMDA receptor activation stimulates production of what? in turn excess of this can increase production of what?

Answer 15

Nitric Oxide–> reactive Nitrogen species, free radicals damage cell components

Question 16

How does reperfusion cause cell death?

Answer 16

02 re-enters = produce reactive products behave as free radicals (hydroxyl radicals, superoxide, peroxide)

Question 17

How does reperfusion (secondary injury) cause injury to the cell membrane therefore not allowing it to act as a barrier?

Answer 17

lipid peroxidation formation of arachidonic acid= more 02 free radicals and mediators of inflammation

Question 18

What contributes to ability to maintain perfusion, supply of 02 and nutrients, to both sides and remove wastes?

Answer 18

Auto regulation (myogenic reflex)

Question 19

Metabolic vasodilation is influenced by what 3 factors?

Answer 19

pH, C02, 02 in arterial blood. stimulus to bring in blood flow and wash out metabolites

Question 20

Interference with vessel dilation leads to ?

Answer 20

ischemia

Question 21

Impaired vasoconstriction causes what 2 things to occur?

Answer 21

hyperperfusion and edema formation as to not deplete the other side

Question 22

As ICP increases volume increases and compliance _________?

Answer 22

decreases

Question 23

The cranium is composted of what 3 elements that are effected by ICP? and what is a normal ICP

Answer 23

brain tissue CSF blood

ICP 0-15

Question 24

What are some causes of increase ICP related to increase blood volume?

Answer 24

high C02 & acidosis -vasogenic (vessels) metabolite vasodilation to increase flow increase RAP dural sinus thrombis

Question 25

Causes of increased ICP related to CSF?

Answer 25

obstruction and nonobstructive hydrocephalus | excess CSF production

Question 26

Causes of increased ICP related to brain tissue?

Answer 26

``` tumor masses lesions hemorrhage infection edema ischemia and necrosis ```

Question 27

Clinical manifestation of increased ICP?

Answer 27

HA vomiting altered LOC | blurry vision edema of optic disk (papilledema)

Question 28

Motor clinical manifestations of increase ICP?

Answer 28

as ICP increase LOC decreases... impaired pupil response to light altered resp patterns unresponsive to stimuli unable to move verbalize or open eyes

Question 29

Order of clinical manifestation with increase ICP?

Answer 29

LOC -> sensory -> motor

Question 30

Management for herniation?

Answer 30

``` imagining (CT or MRI) surgical or medical measure ICP and CPP removal lesions or CSF Tx: cerebral oxygentaiton ```

Question 31

What is the minimal CPP needed to ensure adequate blood flow to prevent ischemia?

Answer 31

CPP of at least 60

Question 32

What is the most sensitive indicator of altered brain function?

Answer 32

change in LOC

Question 33

The state of alertness and attentiveness is dependent on what activity what system?

Answer 33

RAS: reticular activating system

Question 34

Changes in pupils size, shape and reactivity is an early indicator of what?

Answer 34

ICP and possible herniation

Question 35

Which maneuver, when assessing oculovestivubular reflex, entails rotating head side to side? what is the normal response?

Answer 35

Doll's eyes normally turn to opposite direction of head rotation

Question 36

Which maneuver to inject cold water into ear? what is normal response?

Answer 36

Cold calorics- tonic deviation of both sides toward side irrigated

Question 37

Absence of blink during assessment of corneal reflex indicates what?

Answer 37

severely impaired brain function

Question 38

How does hypothermia relate to management of increase ICP?

Answer 38

reduces brain's metabolism saving 02 decrease work load

Question 39

What are some factors that can increase brain metabolism thus increasing ICP?

Answer 39

``` fever seizures agitation pain all should be avoided ```

Question 40

What are the three types of primary TBI?

Answer 40

focal- primary polar- opposite (acceleration and deceleration) diffuse- global injury

Question 41

What are the three intracranial hematomas (secondary TBI)?

Answer 41

epidural subdural subarachnoid

Question 42

Which type of primary TBI is localized to site of impact?

Answer 42

focal (coup)

Question 43

Which type of primary TBI is d/t acceleration and deceleration movement of the brain within the skull?

Answer 43

Polar injury (coup contracoup) resulting in usually double injury (usually opposite focal injury)

Question 44

Which type of primary TBI is caused by movement of the brain within the skull resulting in widespread axonal injury?

Answer 44

diffuse injury

Question 45

What is the criteria for a concussion?

Answer 45

mild TBI alteration in LOC <30min but NO evidence of damage on CT HA N&V dizziness fatigue blurred vision etc

Question 46

Which will show injury on CT or MRI... concussion or contusion?

Answer 46

Contusion reveals damage necrosis laceration bruising

Question 47

What is a localized collection of blood in the cranium called?

Answer 47

intracranial hematoma--> disruption of vasculature can lead to hemorrhage

Question 48

Which type of hematoma generally involves arterial injury?

Answer 48

Epidural hematoma

Question 49

Epidural hematoma has a rapid onset, why is that?

Answer 49

arterial injury high pressure

Question 50

Which type of hematoma has a minor primary injury characterized with lucid intervals of disturbed then normal levels of cognition with a final rapid deterioration?

Answer 50

epidural

Question 51

Which 2 hematomas generally involve rupture of bridging veins?

Answer 51

subdural and subarachnoid

Question 52

A chronic subdural hematoma is prone to what?

Answer 52

re-bleeding

Question 53

Subdural hematoma has a slower onset d/t involvement with veins when might you see symptoms in an acute situation?

Answer 53

within 24 hours

Question 54

Which hemorrhage is commonly associated with rupture of cerebral aneurysms or AVM (arterial in origin)?

Answer 54

Subarachnoid

Question 55

What are important treatments in patients with TBI to reduce brain swelling and decrease ICP?

Answer 55

maintain normal body temp or mild hypotherm normal PaC02 normal glucose and intravascular volume

Question 56

What is a sudden onset of neurologic dysfunction d/t vascular disease resulting in an area of brain infarction? which is the most common?

Answer 56

Stroke- ischemic

Question 57

Ischemic strokes result from sudden occlusion of cerebral artery secondary to thrombus or emboli. Which of the two are associated with atherosclerosis and coaguloaphies?

Answer 57

Thrombotic

Question 58

Which type of ischemic stroke is associated with cardiac dysfunction or dysrhythmias (afib)

Answer 58

Embolic strokes

Question 59

What are some clinical manifestations of ischemic strokes?

Answer 59

contralateral hemiplegia hemisensory loss contralateral visual field blindness

Question 60

What is the penumbra?

Answer 60

peripheral to the insult, it's reversible ischemia | salvaging penumbra is aim of early thrombotic therapy

Question 61

What type of ischemic stroke has completely resolved neurologic deficits?

Answer 61

TIA symptoms last minutes as long as 24 hours

Question 62

What is an important warning sign of thrombotic disease and carries a significant risk for subsequent stroke?

Answer 62

TIA

Question 63

What is the treatment for a TIA?

Answer 63

ASA, CEA, or angioplasty if 70% occluded

Question 64

What type of stroke usually occurs secondary to severe, chronic hypertension?

Answer 64

Hemorrhagic

Question 65

Where does a hemorrhagic stroke occure?

Answer 65

in the midbrain (basal ganglia or thalamus)

Question 66

Which type of stroke has a higher degree of secondary injury and associated morbidity and mortality ?

Answer 66

hemorrhagic

Question 67

The treatment for hemorrhagic stroke is aimed at minimizing infarct size and preserving neurologic function, what are some of these treatments?

Answer 67

thrombolytics, anticoagulant, antiplatelet, endarterectomy, angioplasty, stents, BP managment (keep mildly HTN at first)

Question 68

Initial motor deficits occurs as ________ or _________; recovery of motor function occurs with onset of ____________. Does this occur ipsilateral or contralateral on side brain stroke occurred

Answer 68

flaccidity paralysis spasticity -contralateral

Question 69

Loss of visual field on the paralyzed side also contributes to?

Answer 69

neglect of movement

Question 70

what is it called when the same side of the retina in each is is blinded?

Answer 70

homonyzmous hemianopsia | contralateral field blindness

Question 71

Aphasia occurs with brain damage to which cerebral hemiphere?

Answer 71

dominant

Question 72

Which aphasia is associated with motor/expressive and consists of poor articulation and sparse vocabulary?

Answer 72

Broca

Question 73

Which aphasia is associated with sensory, acoustic, receptive, and characterized by impaired auditory comprehension and speech that is fluent but doesn't make sense ?

Answer 73

Wernicke

Question 74

What are the most common causes of Subarachnoid hemorrhage?

Answer 74

AVM and cerebral aneurysms

Question 75

What is characterized as ballooning and dilation of a segment of the vessel?

Answer 75

Cerebral aneurysm

Question 76

In Marfans an congenital defect in which layer of the artery becomes weakened causing an eventual burst= hemorrhage?

Answer 76

Medial layer (normally has autoregulation to dilate or constrict with changes in pressure) but defected

Question 77

Where are most cerebral aneurysms found?

Answer 77

Circle of Willis- saccular/berry aneurysms | areas of bifurcation

Question 78

What are the 3 components of meningismus?

Answer 78

1) photophobia 2) N&V 3) stiff neck

Question 79

What does a sudden severe HA with meningismus indicate?

Answer 79

cerebral aneurysm rupture

Question 80

what is the treatment for cerebral aneursym?

Answer 80

arterial clipping embo manage vasospasm by keeping blood volume and blood pressure normal to high and Ca Channel blockers

Question 81

What is the failure of capillary system to develop called?

Answer 81

AVM

Question 82

Arterial blood shunted to venous system in the case of AVM, how does this result in rupture and hemorrhage?

Answer 82

Vessels englarge=high vasc pressure

Question 83

How might AVM clinically manifest? treatment?

Answer 83

seizure and neuro dysfunct. surgical removal, gamma knife/sterotactic radio surgery irradiation or glue embo

Question 84

What might dilated vessels on imagining reveal?

Answer 84

AVM

Question 85

Which two of the three CNS infections we discussed in class are bacterial infections and which is viral?

Answer 85

Bacterial- meningitis and cerebral abscess | encephalitis viral

Question 86

Risk factors for CNS infections?

Answer 86

immunocompromised debilitation poor nutrition (AA needed for immunoglobulins) radiation, steroid therapy, contact with vectors

Question 87

Meningitis is most commonly associated with what bacteria?

Answer 87

streptococcus pneumoniae

Question 88

Which CNS infection is described as hematogenous dissemination of bacteria ?

Answer 88

Meningitis

Question 89

Where does the bacteria colonize in meningitis?

Answer 89

nasopharynx, enter blood stream, and enter subarch space and CSF

Question 90

The pathogenesis of meningitis starts with bacterial toxins how does this lead to neuronal necrosis?

Answer 90

Bacterial toxins-> neuronal apoptosis-> BBB damange-> vasc permeability-> edema = increase ICP=decrease CPP--> hypoxia-> neuronal necrosis

Question 91

In meningitis there is an accumulation of neutrophils which release their contents to destroy bacteria, what is this called?

Answer 91

degranulation- destroys bacteria but also damages normal tissue (brain nerves blood vessels)

Question 92

The degranulation of neutrophils leads to vasculitis and clotting causing cerebral infarcts, accumulation of inflammatory exudate care result in what?

Answer 92

obstructive hydrocephalus

Question 93

Diagnose meningitis by lumbar puncture which will show what?

Answer 93

bacterial and increase neutrophils in CSF. Protein elevated glucose low d/t high cellular use/function

Question 94

Meningitis is treated with IV antibiotics and prevention includes vaccinations for what?

Answer 94

Hib and N.meningitis

Question 95

What CNS infection is characterized by inflammation of brain cause by a virus?

Answer 95

Encephalitis

Question 96

In encephalitis the virus attacks what membrane ?

Answer 96

arachnoid membrane and CSF

Question 97

A patient is bitten by an insect, he is likely to have what CNS infection?

Answer 97

Encephalitis

Question 98

Treatment for encephalitis is supportive with control of symptoms, this includes?

Answer 98

antripyretics, antivirals, steroids, antiseizure, fluid resuscitation

Question 99

Which CNS infection is characterized by a newly formed cavity filled with pus (pyogenic) ?

Answer 99

Brain Abscess

Question 100

Treatment for brain abscess includes?

Answer 100

drainage or excision of abscess and IV antibiotics

Question 101

What makes up the infected core in a brain abscess ?

Answer 101

neutrophils and tissue debris

Question 102

What surrounds the granulation tissue in a brain abscess? and what occurs there?

Answer 102

perifocal edema- proliferation of astrocytes

Question 103

Long term chronic phase of a brain abscess would have what two characeristics?

Answer 103

liquefied core and fibrous fliosis- inflamm response - scar tissue