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2 causes of subarachnoid hemorrhage:

1. rupture of an aneurism (eg. Berry)
2. rupture of an AVM


3 diseases and 4 risk factors associated with berry aneurisms:

2. Ehlers-Danlos
3. Marfan's
1. advanced age
2. hypertension
3. smoking
4. African Am.


A child presents with kyphoscoliosis, muscle weakness, loss of DTRs, and decreased proprioception. What disease are you suspecting? What is the cause? What is the major cause of death in these patients?

Friedrich ataxia.
Autosomal recessive trinuc. repeat of GAA on chromosome 9 in gene that encodes frataxin (iron binding protein) --> impaired mitochondrial function --> degeneration of multiple sipinal chord tracts and hypertrophic cardiomyopathy (cause of death)


A patient has a stroke with eyes looking contralateral to the lesioned side. What area is affected?

Paramedian pontine reticular formation


A patient tells you he/she has the worst headache of thier life? What are you concerned about? What additional findings would you suspect? What complications might ensue?

Subarachnoid hemorrhage
- Spinal tap: xanthochromic or bloody

- blood breakdown --> vasospasm 2-3 days later; treat with nimodipine
- rebleed


A stroke patient presents with a tongue deviating to the right, proprioceptive loss on the left, and left hemiparesis. What is this syndrome and artery responsible?

Medial medullary syndrome. ASA paramedian branches/ vertebral a. occlusion


Blood supply to both Wernicke's and Broca's area? What sensory/motor deficits would accompany an obstruction here?

- contralateral paralysis of upper limb and face
- contralateral sensory loss to upper and lower limbs and face


Brain atrophy, shaking, and whiplash increase the risk for what kind of hematoma?



Cerebral perfusion pressure is proportional to PCO2 until PCO2 is > ___ mmHg. Above this level, PCO2 increases while cerebral blood flow ___.

90; remains maxed out


Damage to what areas can cause conduction aphasia?

Left superior temporal lobe and/or
left supramarginal gyrus


During what time period is tPA administered after an ischemic stroke? What risk factors must be excluded?

3-4.5 hours; exclude current hemorrhage or risk of hemorrhage (BP > 185S/110D; platelets >100,000, PTT > 40 after heparin use, PT > 15 or INR > 1.7; be cautious if: MI in last 3 mo., recent surgery/trauma, pregnancy)


Dysphagia + ipsilateral Horner's syndrome make you think of what stroke syndrome? Vascular supply?

Lateral medullary (Wallenberg) PICA


Eyes look toward the side of this lesion

Frontal eye fields


Facial paralysis + ipsilateral Horner syndrome make you think of what syndrome? Vascular supply?

lateral pontine syndrome; AICA


Hypoxemia increases cerebral perfusion pressure only when PO2 < ___ mmHg? (normal PO2 = ____)

50; 100


Severe hypotension affecting watershed zones will lead to what deficits?

upper leg/ upper arm weakness
higher-order visual processing deficit


The anterior spinal artery supplies what 3 areas + 1 imporant nucleus? Syndrome name when stroke? Symptoms?

Medial medullary syndrome (ASA paramedian branches/ vertebral a. occlusion):
1. lateral corticospinal tract --> contralateral hemiparesis of arms and legs
2. medial lemniscus --> contralateral proprioception
3. Caudal medulla - hypoglossal nerve --> tongue deviates ipsilaterally
*NOTE: stroke is often bilateral


What are 4 causes of intraparenchymal hemorrhages? Where is the most common location?

1. Hypertension (most common)
2. Amyloid angiopathy
3. Vasculitis
4. Neoplasm

Usually occurs in basal ganglia and internal capsul (Charcot-Bouchard aneurism ruptures), but can be lobar.


What are the most vulnerable areas of damage in brain ischemia?

pyramidal neurons of hippocampus, neocortex, and cerebellum, as well as watershed areas.


What are the symptoms of central pontine myelinolysis?

Acute paralysis
Loss of consciousness
Can cause "locked-in syndrome"


What area does AICA supply? Which nuclei? Which tracts

Lateral pons
Cranial nerve nuclei:
1. spinal trigeminal nucleus (CN 5)
2. facial nucleus (CN 7)
3. vestibular nuclei (CN 8)
4. cochlear nuclei (CN 8)

1. sympathetic nerve fibers
2. middle and inferior cerebellar peduncles


What brain lesion can present with reemergence of primitive reflexes? What other deficits may co-present?

Frontal lobe
+ deficits in concentration, orientation, and judgement


What drug would you use to treat a patient with vasospasm subsequent to a subarachnoid hemorrhage?

nimodipine (the vasospasm is caused by blood breakdown)


What is central post-stroke pain syndrome? How common is it?

Neuorpathic pain due to thalamic lesions.
Initially: numbness & tingling
Weeks - months later: allodynia (normally painless stimuli cause pain) and dysaesthesia (abnormal sensation)

10% of stroke patients


What is dysarthria? One lesion that might produce it?

Difficulty speaking, cerebellar vermis


What is the cause of lacunar infarcts? Where are they usually found?

unmanaged hypertension; striatum and internal capsule (lenticulostriate a. distribution)


What is the consequence of a lesion of the left parietal-temporal cortex?

Gerstmann syndrome:
- Agraphia
- Acalculia
- Finger agnosia
- L/R disorientation


What is the key difference between symptoms of AICA and PICA strokes?

PICA - nucleus ambiguus (motor root of CN 9 & 10) effects: "Don't pick a (PICA) horse (hoarsenses) that can't eat (dysphagia).
AICA - facial nucleus: "facial droop means AICA's pooped"


What is the medial medullary syndrome? What vessels are involved? Symptoms?

Medial medullary syndrome (ASA paramedian branch/ vertebral a. occlusion):
1. lateral corticospinal tract --> contralateral hemiparesis of arms and legs
2. medial lemniscus --> contralateral proprioception
3. Caudal medulla - hypoglossal nerve --> tongue deviates ipsilaterally
*NOTE: stroke is often bilateral


What is the nucleus ambiguus? Where is it located? Arterial supply?

It is a structure in the lateral medulla that contains the motor roots of CN 9 & CN 10. PICA


What is the triad of Kluver-Bucy syndrome? What lesion? Infection?

- hyperorality
- hypersexuality
- disinhibited behavior
--> bilateral amygdala lesion
--> HSV-1 infection


What is the triad of Wernicke-Korsakoff syndrome? What causes this syndrome? What organ is affected?

Wernicke problems come in a CAN of beer:
- caused by thiamine (B1) deficiency and EtOH
- C: confusion
- A: ataxia
- N: nystagmus
- Mammilary bodies affected bilaterally


What lesion leads to hemiballismus? Ipsi- or contra- laterally?

Hemiballismus: STN, contralateral


What structures does PICA supply?

Lateral medulla:
1. vestibular nuclei
2. lateral spinothalamic tract
3. spinal trigeminal nucleus
4. nuclus ambiguus
5. sympathetic fibers
6. inferior cerebellar peduncle


When the partial pressure of oxygen falls below ___, cerebral perfusion pressure increases. (normal PO2 = ___).

When the partial pressure of oxygen falls below 50 mmHg, cerebral perfusion pressure increases. (normal PO2 = 100 mm Hg).


Where is Broca's area?

Intferior frontal gyrus of frontal lobe


Where is Wernicke's area?

superior temporal gyrus of temporal lobe


Which hematoma cannot cross the falx or tentorium?



Which structures does the lenticulostriate artery supply? Symptoms of stroke here?

striatum, internal capsule; contralateral hemiparesis/hemiplegia


Why might you hyperventilate a patient with acute cerebral edema?

decrease PCO2 --> vasoconstriction --> decreased cerebral perfusion --> decreased intracranial pressure


What are they symptoms of EtOH withdrawal?

6-12 h: ↑ autonomic activity, tremor, headache, N/V, anxiety

12-24 h: Alcoholic hallucinations

24-48 h: seizures

3-5 d: Delirium tremens