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Flashcards in Neuro Deck (109):
1

What is the difference between arousal and awareness?  In what parts of the brain do they arise?

  • Arousal
    • vegetative function
    • brainstem and RAS (diencephalon)
  • Awareness
    • cognitive and affective function
    • cortex

2

What is included in a neuro exam for a possible coma patient?

  • C = level of consciousness
  • O = Ocular motility and pupils
  • M = Motor response
  • A = Airway and breathing

3

What does fruity breath signify in a possible coma patient?

Diabetic ketoacidosis

4

What does fishy breath signify in a possible coma patient?

Hepatic failure

5

What does musty breath signify in a possible coma patient?

Renal failure

6

If the patient has a hemispheric lesion, where will the eyes and head deviate?

Toward lesion

7

If the patient has a brainstem lesion, where will the eyes and head deviate?

Away from the lesion

8

If the patient's pupils are in a mid-position and non-reactive, where is the lesion?

Midbrain

9

If the patient's pupils are dilated on one side and non-reactive, where is the lesion?

CN III paralysis

10

If the patient's pupils are small but reactive, where is the lesion?

Pontine

11

If the patient's pupils are pinpoint but reactive, what is the cause?

Opiate intoxication

12

In the oculocephalic reflex, if the patients head is moved to one side, where should the eyes move?

To the opposite side (to stay focused on the same thing)

13

In the oculovestibular reflex, cold water in the ear should cause the eyes to move where?  Warm water?

COWS: Cold water = Opposite; Warm water = Same

Cold water = nystagmus to opposite side

Warm water = nystagmus to same side

14

What part of the brain is responsible for inducible reflex lateral eye movements?

Pons and midbrain

15

If a patient lacks inducible reflex eye movements with the doll's eye maneuver but has preserved pupillary reactivity, what is the likely diagnosis?

Drug intoxication

16

If patient presents with decerebrate rigidity (extended arms and legs), where is the lesion located?

upper brainstem (between red nucleus and vestibular nucleus)

Midbrain or pontine level

17

If the patient presents with decorticate rigidity (extended legs and flexed arms), where is the lesion located?

  • level of diencephalon or above
    • hemispheres
    • internal capsule
    • thalamus

18

Where is the lesion if an unconscious patient presents with small reactive pupills, full conjugate lateral eye movements, and an appropriate motor response?

Early diencephalic

19

Where is the lesion if an unconscious patient presents with small reactive pupills, full conjugate lateral eye movements, and decorticate rigidity?

Late diencephalic

20

Where is the lesion if an unconscious patient presents with midposition, fixed pupills, dysconjugate lateral eye movements, and decerebrate rigidity?

Midbrain

21

Where is the lesion if an unconscious patient presents with midposition, fixed pupills, absent lateral eye movements, and lack of a motor response?

Pons or Medulla

22

What are the possible causes of Cheyne-Stokes respiration?

  • Definition
    • Hyperpnea alternating with apnea
  • Causes:
    • Diffuse bilateral cerebral hemispheric dysfunction
    • Diencephalic dysfunction
    • CHF

23

What are the possible causes of central neurogenic hyperventilation?

  • Definition
    • sustained rapid and deep hyperpnea
  • Cause:
    • Lower midbrain or pons lesion

24

What is the cause of Apneustic breathing?

  • Definition:
    • end inspiratory pause alternating with end expiratory pause
  • Cause
    • Lwr pontine lesion

25

What is the cause of Ataxic breathing?

  • Definition
    • irregular breathing pattern
  • Cause:
    • Medullary lesion

26

What is invaded/ destroyed in a supratentorial lesion?  What are some causes?

  • Damage to diencephalon
  • Causes:
    • cerebral hemorrhage
    • tumor
    • Encephalitis

27

What is compressed in a subtentorial lesion?  What are some causes?

  • Compresses
    • midbrain-pontine reticular formation
  • Causes
    • Pontine or cerebellar hemorrhage
    • Infarction
    • Tumor

28

What size lesion does a CT detect?  What type of lesion is best visualized?  What is the advantage over an MRI?

  • Size
    • >5mm
  • Type of lesion
    • best for acute hemorrhage
  • Advantage
    • faster than MRI

29

What size lesion does an MRI detect?  What can prevent a patient from being able to get an MRI?

  • Lesion
    • 1-2 mm
  • Exclusion
    • people with metallic objects like pacemakers, aneurysm clip

30

What is the treatment for raised intracranial pressure from a brain tumor?

IV steroids

31

What is the treatment for diabetic ketoacidosis?

Insulin

32

What is the treatment for opiate overdose?

Naloxone

33

What is the treatment for benzodiazepine overdose?

Flumazenil

34

What is the treatment for ETOH abuse?

Thiamine

35

What is the treatment for hepatic encephalopathy?

Lactulose

36

What is a vegetative state?

  • Arousal without awareness
  • Termed persistant after 4 weeks
  • Vegetative after:
    • 3 months (non-traumatic)
    • 12 months (traumatic)

37

What is a locked-in state?

  • Patient is awake and aware
  • Reactive pupils
  • Preserved voluntary vertical eye movements and blinking only
  • Otherwise paralyzed

38

What is Brain Death?

  • Irreversible damage that leaves the brain incapable of maintaining homeostasis of body

 

  • Unperceptie/Unresponsive to pain (Cortex)
  • Unreactive pupils (Midbrain)
  • Absent reflex eye movements (Pons)
  • Apnea (Medulla)

39

Patient reports severe headache with maximal intensity at onset ("thunderclap headache") and neck stiffness.  What is the diagnosis?  What is the cause?

  • Diagnosis
    • Subarachnoid hemorrhage
  • Cause
    • Ruptured aneurysm (most common)
    • Ruptured AVM

40

What is the cause of subdural hematomas?

Tearing of bridging veins from trauma

41

Patient describes a headache following head trauma.  They had a period of lucidity then deteriorating mental status.  What is the diagnosis?  What is the likely cause?

  • Diagnosis:
    • Epideral Hematoma
  • Cause:
    • Damage to middle meningeal artery
  • Imaging
    • Convex (like a lens)
      • b/c expansion stops at skull sutures

42

What is shown?

Q image thumb

Epidural Hematoma

  • Convex shape (like a lens)
    • b/c expansion stops at skull sutures

43

How can you tell the difference between an epidural hematoma and a subdural hematoma via imaging?  Why does this occur?

  • Epidural
    • Convex in shape (like a lens)
      • b/c expansion stops at skull sutures
  • Subdural
    • Concave in shape
      • expansion not limited by sutures

44

Patient describes a headache that is increasing in severity.  What is the diagnosis?  What are some possible causes?

  • Diagnosis:
    • Intracerebral Hemorrhage
  • Causes:
    • HTN
    • anticoagulation

45

What is shown?

Q image thumb

Acute Subdural hematoma

  • Hyperdense
  • Concave toward brain
  • Not limited by suture lines

46

What is shown?

Q image thumb

Subarrachnoid hemorrhage

Can see temporal horns from increased ICP

47

What is shown?

Q image thumb

Chronic Subdural Hematoma

  • Dark color from CSF
  • Concave

48

What is shown?

Q image thumb

Subarachnoid hemorrhage

White fluffy stuff in sulci

49

What is shown?

Q image thumb

Intracerebral Hemorrhage

50

Patient describes unilateral head pain preceded by bright zigzag lines.  What is the diagnosis?  How is it treated?

  • Diagnosis
    • Classic migraine
  • Treatment
    • Triptans (only with acute!)

51

Patient describes unilateral headpain with hemiparesis and paresthesia.  What is the diagnosis?

Complex migraine

(includes other neuro symptoms)

52

Why can triptans not be used with complex migraine?

It can cause a stroke

53

Patient describes headpain located more occipitally and neck pain.  What is the diagnosis?

Tension headache

54

Patient describes a "pressure" in the head located more frontally.  What is the diagnosis?

Sinus headache

55

Patient describes unilateral, sharp head pain that occurs multiple times a day.  Other symptoms include ipsilateral corneal injection, tearing, and rhinorrhea.  Symptoms normally last a few weeks and then disappear for a few months.  What is the diagnosis?

Cluster headache

56

What medications can cause headache if used in excess?

  • Triptans
  • NSAIDS
  • Tylenol

57

The vertebral a is a branch of which artery?

1st branch of the subclavian

58

The ophthalmic a is a branch of which artery?

Internal carotid

(clot here can cause vision problems)

59

Patient experiences episodes of focal neurological dysfunction.  There is no brain tissue infarct.  What is the diagnosis?

TIA

60

A patient experiences transient loss of vision in one eye.  What is the disease? What is the cause?

  • Disease
    • Amaurosis Fugax
  • Cause
    • extracranial carotid artery disease (internal CA) with retinal emboli

61

Patient presents with left-sided hemiparesis and sensory impairment that is more pronounced in the arms in addition to homonymous hemianopsia of the left fields.  Eyes are deviated to the right.  What is the diagnosis?

MCA Stroke on right side

  • Contralateral hemiparesis and sensory impairment
    • arms > legs
  • Contralateral homonymous hemianopsia
  • Look toward the lesion (cortical)

62

What is the gaze preference in a cortical lesion?  In a brainstem lesion?

  • Cortical
    • eyes look toward lesion
  • Brainstem
    • eyes look away from lesion

63

Patient presents with left-right confusion, finger agnosia, acalculia and agraphia.  What is the diagnosis?

Gerstmann's syndrome

64

Lesions in what area of the brain cause agraphia?

Angular and supramarginal gyri

65

Anosognosia (neglect) occurs in which hemisphere?

Non-Dominant

66

Patient presents with left-sided hemiparesis and sensory impairment that is more pronounced in the legs, abulia, personality change, and release signs.  What is the diagnosis?

ACA stroke on right

  • Contralateral hemiparesis and sensory impairment
    • legs > arms
  • Cognitive and personality effects
  • Frontal lobe release signs

67

Patient presents with left-sided arm and leg weakness and decreased proprioception and vibration sense.  The tongue is deviated to the right.  What is the diagnosis?

Medial Medullary Syndrome on Right

*Occlusion of Anterior Spinal artery*

  • Contralateral weakness
    • CST and pyramids
  • Contralateral loss of proprioception and vibration
    • Medial lemniscus
  • Tongue deviation toward side of lesion
    • Hypoglossal nucleus

68

Patient presents with left-sided arm and leg numbness, right-sided facial numbness and ataxia, dysphagia, Horner's syndrome, and vertigo.  What is the disease?

Lateral Medullary Syndrome on Right

*caused by occlusion of PICA (or VA)*

  • Contralateral arm and leg numbness
    • STT
  • Ipsilateral facial numbness
    • Spinal trigeminal tract
  • Ipsilateral ataxia
    • ICP
  • Dysphagia
    • nu ambiguus
  • Horner's
    • descending sympathetics
  • Vertigo
    • Vestibular nuclei

69

Patient presents with hearing loss and facial weakness.  What is the diagnosis?

AICA stroke

70

Patient presents with Diplopia, dysconjugate eye movements, gaze palsy with eyes looking to side of hemiplegia, and limb ataxia.  What is the diagnosis?

Basilar artery stroke

"Crossed findings are the hallmark of brain stem stroke"

(does not elaborate)

71

Patient presents with homonymous hemianopsia with macular sparing and memory difficulties.  No other focal symptoms are found.  What is the diagnosis?

Posterior cerebral artery

(occipital and temporal lobes supplied)

72

What causes alexia without agraphia?

Lesion involving left occipital lobe and splenium of corpus callosum

Disconnection syndrome

 (fyi: supplied by PCA) 

73

What is the cause of Cortical blindness (aka Anton syndrome)?

Bilateral PCA stroke

74

What is lacunar syndrome?

Small, focused stroke located anywhere

(absence of large vessel symptoms)

75

What causes hemiballismus?

infarction of the subthalamic nucleus

76

What treatment is used for cardioembolic stroke?

Anticoagulants

77

What treatment is used for non-cardioembolic ischemic stroke prevention?

Antiplatelets (Aspirin)

78

When can tPA be used?

w/i 3 hours of stroke if caused by clot

79

Where is the most likely site of a bleed from HTN injury?

Putamen

80

What symptoms are associated with intracerebral hemorrhage?

Symptoms of increased ICP

  • Headache
  • vomiting
  • lethargy

81

Patient presents with headache, nausea, hemiplegia and homonymous hemianopsia.  What is the diagnosis?

Intracranial hemorrhage in Putamen

  • Hemiplegia
    • from pressure on internal capsule
  • Hemianopsia
    • from pressure on optic radiations

82

Patient presents with headache, nausea, sensory and motor deficit, and limited eye movements.  What is the diagnosis?

Intracranial hemorrhage in Thalamus

83

Patient had an acute headache, nausea and vomiting before losing consciousness.  Patient currently has pinpoint pupils.  What is the diagnosis?

Pontine hemorrhage

84

Patient presents with occipital headache, nausea, vertigo, and ataxia.  What is the diagnosis?

Cerebellar hemorrhage

***needs rapid surgical treatment***

85

What is commonly associated with subarachnoid hemorrhage?

  1. Polycystic kidney disease (most important)
    • History of renal failure
    • Find cyst on scan
  2. HTN
  3. Smoking

86

What layer of tissue is missing in aneurysms?

Internal elastic lamina

87

Where are aneurysms most likely to rupture?

Posterior circulation

88

Patient presents with acute onset of the worst headache ever experienced then lost consciousness.  What is the likely diagnosis?

Aneurysm rupture

(subarachnoid hemorrhage)

"thunderclap headache"

89

What is the definition of epilepsy?

2 or more unprovoked seizures

90

Which type of seizure is preceded by an aura?  What are common auras?

  • Seizure type:
    • Simple partial
  • Auras
    • Sense of fear
    • Rising sensation
    • Unusual odor

91

What is the typical EEG pattern of absence seizures?

3 Hz Spike and wave discharges

92

What are the risk factors for seizure?

  • Family history
  • Febrile seizures
  • Head injury with significant loss of consciousness
  • Meningitis/Encephalitis

93

Patient presents with gait disturbance, bradykinesia, and progressive loss of eye movements with preservation of oculocephalic reflexes.  No tremor is present, and symptomatic response to dopamine is poor.  What is the diagnosis?

Supranuclear Palsy

  • Differences from Parkinson's
    • No tremor
    • loss of eye movements with preservation of oculocephalic reflexes
    • Symptomatic response to DA is poor
    • Neurofibrillary tangles form

94

Patient presents with ataxia, cerebellar dysmetria, and abnormal limb coordination and smooth pursuit eye movements.  What is the disease?  What cytoplasmic inclusions are found in brainstem nuclei?

  • Disease
    • Olivopontocerebellar atrophy
  • Inclusions:
    • alpha-synuclein

95

Patient presents with bradykinesia, symmetric rigidity, and postural instability.  There is no tremor and the patient is refractory to levadopa.  What is the diagnosis?

Striatonigral degeneration

96

Patient presents with early autonomic dysfunction, bradykinesia, rigidity and postural instability.  What is the diagnosis?

Shy-Drager syndrome

97

What does the suprachiasmatic nucleus control?  How is it regulated?

  • Controls sleep/wake cycle
  • Regulated by light

98

What stage of sleep is characterized by K complexes and sleep spindles on EEG?

Stage 2

99

Delta waves are present in the EEG of what sleep stages?

Stages 3 & 4

100

What is the sleep phase of a "night owl"?

Delayed Sleep phase

  • Tired all day except evening

101

What is the sleep phase of an "early bird"?

Advanced Sleep Phase 

  • Wake early
  • Fatigue in late afternoon/ evening

102

What is the duration and number of respiratory cycles affected in sleep apnea?

  • Duration: 10 seconds
  • Cycles: 2

103

What is the effect of the Chiari Malformation on sleep?

Central obstructive sleep apnea

(brain doesn't tell you to breathe)

104

What are the health effects of obstructive sleep apnea?

  • Pulmonary HTN
  • CHF

105

What is the primary treatment of obstructive sleep apnea?

Continuous Positive Airway Pressure (CPAP)

106

What is REM Behavior Disorder?

Disappearance of muscle atonia in REM sleep causes people to act out their dream

107

What is the only required symptom to diagnose narcolepsy?  What other symptoms are often present?

  • Required:
    • excessive daytime sleepiness
  • Others:
    • Cataplexy (weak / paralyzed with emotion)
    • Hallucinations
    • Sleep paralysis
    • REM shows up very early in sleep

Think of it as "bits of REM showing up in wakefulness"

108

What is the primary test used to diagnose sleep disorders?

Polysomnogram

109