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91

Duret Hemorrhage MOD (2)

A: Herniated [TUMTL-Transtentorial Uncal Medial Temporal lobe] from various mass lesions (hemorrhage/neoplasm) --> 

1. Pons Compression

2. Perforating Arteriole stretching --> ischemia

 

92

A: What type of Cerebral Pathology is depicted in image?

B: MOD

C: Prognosis

Epidural Hematoma

B: [Temporal Bone Fracture] --> [Middle Meningeal Artery rupture]--> [Football/Lens shaped lesion from blood between dura & skull]

C: Pt may be lucid b4 any neuo signs manifest but Herniation is lethal complication

93

A: What type of Cerebral Pathology is depicted in image?

B: MOD

C: Prognosis

D: Demographic and Why them? 

Subdural Hematoma

B: [Truama vs. Age]  -> [Tearing of bridge veins between Dura & Arachnoid] --> [Crescent shaped lesion]

C: Progressive neuro signs but Herniation is lethal complication

D: Elderly (Age-related cerebral atrophy stretches bridging veins)

94

Describe: 

A: Tonsillar Herniation

B: Subfalcine Herniation

A: [Cerebellar tonsils] --herniates into--> [Foramen magnum]--> Brainstem compression --> Cardiopulm arrest! 

B: [Cingulate Gyrus] --herniates into--> [Falx Cerebri]--> [ACA compression] --> infarct

95

Describe: 

A: Uncal Herniation (including which 3 vessels it affects)

B: What are the manifestation of each vessel affected

C: Which Letter in image below is associated with Uncal Herniation

[TUMTL-Transtentorial Uncal Medial Temporal lobe] --herniates under--> [Tentorium Cerebelli]--> Compression of [POP- PCA / Oculomotor CN3 / Paramedian Pontine vessels] -->

1. [Occipital lobe infarct from PCA compression] ( --->CTL homonymous hemianopsia w/Macular/fovea sparing)

2. ["Down and Out" Eye + Dilated Pupil]

3. Duret Hemorrhage (with Pons compression)

C: {letter C} = Duret Hemorrhage

96

Identify

A- [Middle Cerebral Artery Infarct]

B1 - Subfalcine Herniation

B2 - [TUMTL-Transtentorial Uncal Medial Temporal Lobe] Herniation

C - Duret Hemorrhage (comes from TUMTL Herniation)

97

A: [Snellen Wall Chart] is used for Visual Acuity. What does 20/100 vision actually mean for a pt?

B: What does a Negative Pinhole Result (pt vision does not improve when looking through pinhole) possibly indicate?

C: Is the Optic Nerve lateral or medial? Identify the structures in the image

A: [Pt reads at 20 feet] what a [normal person would read at 100 feet] in that eye

B: Visual problem may be neurological

C: Optic Nerve is Medial.

So [R = [Optic Disc w/ Optic N.]] vs. [L = Macula]

98

Describe:

A: Physiological Blindspot

A2: What happens to this Blindspot during Papilledema

B: Pathological Blindspot (AKA ____ )

C: How do you differentiate [Glaucoma/Retinal Degeneration] from [Psychogenic Tunnel Vision] in pts with Constricted Visual Fields

A: Normal Blind spot that occurs due to Optic disc having no rods/cones (center of vision). This ENLARGES with papilledema from INC ICP

B: Pathological Blindspot (AKA SCOTOMA) occurs from [Ocular/Retinal/Optic N.] Disorder. Usually in 1 eye.

C: 

-If Pt Visual Field enlarges once you move target away from them = [Glaucoma/Retinal Degeneration]

-If Pt Visual Field continues to be Constricted even as you move target away from them = [Psychogenic Tunnel Vision]

99

A: What type of Visual Defect would result from a Bilateral Outer Chiasm lesion?

B: What type of Visual Defect would result from [PCA-Post Cerebral Artery] dz (2)

B2: This defect would still have what things intact (2)

A: Heteronymous (BilateralNasal Hemianopsia

B: 

1. Cortical Blindness from Bilateral Occipital lobe infarct

vs.

2.  [CTL homonymous hemianopsia w/Macular/fovea sparing] from Unilateral Occipital lobe infarct

B2: Normal [Pupillary light reflex] & [No Optic Atrophy]

100

A: Nystagmus are __ ___ ___ that have both _ and __ components (but during test refers to ___ component only) *There are 3 types*

B1: Describe the [IPNB- Induced Postrotatory Nystagmus of Barany]

B2: What does this test ultimately indicate

Nystagmus are OSCILLATING EYE MOVEMENTS that have both slow and Fast components (but test refers to Fast component only) 

B1.[IPNB- Induced Postrotatory Nystagmus of Barany] = Rotation of Head by 45º (Dix-Hallpike maneuver) sets endolymph of [Post semicircular canal] in motion--->causes deflection of stereocilia hair cells.

B2: If Nystagmus occurs after this = overly sensitive [Post semicircular canal] on the side being lowered. = Positional Vertigo

 

101

Nystagmus are __ ___ ___ that have both _ and __ components (but during test refers to ___ component only) *There are 3 types*

B1. [Induced CALORIC Nystagmus] is when irrigation of the ____ ___ ____with warm/Cold water creates___ _____ in the ____ _____. This as a result stimulates ______ by ______ 

B2: What does [Cold water vs. Warm water] do during Nystagmus testing? What test is used for this?

C: What does the [Induced CALORIC Nystagmus] test for? (2)

Nystagmus are OSCILLATING EYE MOVEMENTS that have both slow and Fast components (but test refers to Fast component only) .

B1. [Induced CALORIC Nystagmus] is when irrigation of [External Auditory Canal] with Cold/Warm water creates convection currents in Vestibular labyrinths--->stimulates [crista ampullaris] by deflecting stereocilia

B2: COWS (ENG-Electronystagmogram)= 
Cold Water--->Eyes move Opposite direction of irrigation
Warm water -->eyes move in Same direction of irrigation 

C: test function of individual semicircular canals (ESPECIALLY LATERAL CANAL) & [Brainstem normality]

102

A: Why is having a Complete Circle of Willis so important 

B: Name 3 important Circle Of Willis collaterals

A:[Ischemic infarct] 2º to [Cerebral a. occlusion] can be circumvented if competent [Circle of Willis] collateral circulation detours inadequate blood flow. 

B: Example: If Internal Carotid becomes occluded....Collaterals = 

1) Basilar a. (via PCA and PICA)

2) [Ipsilateral External Carotid a.] (retrogradely from ophthalmic a.) perfusing [Intracranial Internal Carotid A.]

3) [CTL Internal Carotid a.] (via ACA and AICA)

103

A: Define [TIA-Transient Ischemic Attack]

B: What usually causes it? 

C: [Carotid-area TIA] manifestation (2)

D: [Vertebrobasilar-area TIA] manifestation (2)

A: Reversible Stroke with sx that resolve in a [less than 24 hour period (usually 10-20 min.)] = 3rd leading Cause of Death in Developed countries!

B: Embolus (fibrin vs. platelets vs. cholesterol)

C: 

-[Amaurosis Fugax monocular blindness] (lowered dark shade)

-Hemispheric syndromes (aphasia & hemiparesis)

 

D: 

-[Brainstem vs. Cerebellar] ataxia & diplopia

-Homonymous Hemianopsia

104

Name the most common Cardiac sources of Emboli to Large Arteries (5)

105

A1: Radiographic evaluation of any Cerebral Ischemic Infarct (2). Why?

A2:  Vascular evaluation of any Cerebral Ischemic Infarct (2)

A3: Cardiac evaluation of any Cerebral Ischemic Infarct

B: What else should be done to work this up (2)

C: List Other DDx with similar presentation (4)

(TIA vs. [Cortical Large Artery Ischemic Infarction])

A1: 

1st Choice: [Brain MRI] = confirms suspected vascular territory involved if infarct occurred

2nd Choice: CT

A2: [Carotid US vs. MR/CT/Catheter Angiogram]

A3: Echocardiograph

B: Also Determine sources of emboli and other infarct causes

C:[Atypical tumor] vs. Hemorrhage vs. Abscess vs. Encephalitis 

 

106

A: What pathology is depicted in image?

B:  MOD

C: Describe the associated syndrome with this pathology (2)

A: Multiple Lacunar Infarcts

B: Lacunar Stroke= ischemia of lenticulostriate vessels -->  [cystic infarcts < 1.5 cm (mostly seen with MRI)] --> Lacunar Syndrome

C: Lacunar Syndrome: 

lenticulostriate vessels perfuse [BTIPC]

1) Lacunar Stroke= ischemia of lenticulostriate vessels -->  [cystic infarcts < 1.5 cm (mostly seen with MRI)] --> Lacunar Syndrome (listed below)

1A: [Internal Capsule/Pons/Corona Radiata] Stroke--> pure Motor stroke (ataxia vs. hemiplegia vs. clumsy hand)

1B: ThalamuS Stroke --> pure Sensory stroke

1C: Basal Ganglia - not included in Syndrome

Note: Lacunar lesions may be WITHOUT sx

107

A: [Acute Cerebral Infarction] 1st line tx (2)

B: What tx is used if 1st line tx is not available? (2)

C: What other management should be done (3)

A: Thrombolytic Drugs (tPA)

1. [IV tPA within 3 hours of stroke onset]

2. [intraArterial tPA] to break up clot in stroke center

B: Antiplatelet drugs (or anticoagulant drugs in RARE situations)

C: 

-Control BP!!

-Control Hyperglycemia

-Control other complication (edema / sepsis)

108

A: Which Rx is given to prevent Cardiac Emboli (especially from aFib) (2)

B: Rx given to prevent [TIA/Small vs. Large cerebral ischemic infarct] (3)

C: What are 2 other good preventative Rx for Cerebral Ischemia. Which has caveots? Describe the caveot.

A: Heparin vs. Warfarin = AntiCoagulants

B: [ASA vs. Clopidogrel vs. Dipyridamole] = AntiPlatelets

C: 

-Control Atherosclerosis

-Carotid Endarterectomy (only for symptomatic-flow limiting [NON-Cranial Internal Carotid A.] with 70-99% Stenosis)

109

Cerebral Hemorrhage

A: List Causes (6) 

A2: Which is MOST COMMON and where does it affect (2)

B: Sx (3). Which Sx helps to differentiate Cerebral Hemorrhage from Infarct

C: Radiographic scan used to diagnose

High arterial pressure -->blood rupture into brain

A: "Can't hear yo CHATTA, if I'm Bleeding in Ma Brain!"

1) [HTN-Uncontrolled] = MOST COMMON (can also be from illicit drugs). Affects basal ganglia & thalamus most commonly

2)Trauma

3) [Coagulopathy DEC] (usually accompanied with systemic bleeding)

4) [AVM rupture]-Use angiography to visualize

5) [Tumor vs. Ischemic Infarct]

6) [Amyloid Angiopathy in Elderly]

 

B: [Early impairment of consciousness] is not usually associated with infarct. + HA + [INC ICP/edema --> potential local ischemia]

C: CT Scan (since it'll show location & severity)

110

A: What Afferents travel TO the Thalamic [Lateral Geniculate] nc. (2) 

B: Where does the Efferent fibers of the Thalamic [Lateral Geniculate] nc.  project to? 

C: What type of Thalamic nucleus is the [Lateral Geniculate]

[Lateral Geniculate nc.] "L for Light! " 

A: Aff= Optic Tract & [SUP colliculus] --> nc

B: Eff= nc---> [Area 17 CPVC]  

C: [Specific Relay nuclei] 

111

A: What Afferents travel TO the Thalamic [medial Geniculate] nc.  

B: Where does the Efferent fibers of the Thalamic [medial Geniculate] nc.  project to? 

C: What type of Thalamic nucleus is the [medial Geniculate]

[medial Geniculate nc.] "M for Music"

A: Aff= [inf colliculus] --> nc

B: Eff= nc---> Primary Auditory Cortex 

C: [Specific Relay nuclei] 

112

A: [Lower Motor Neurons] are Motor neurons of the ___ &  _____ They are arranged into 4 columns and release ____ onto _____ receptors of ____ _____ Lower Motor Neurons are recruited based on __ &amp; ____

B: What are the 4 Column Arrangements and which muscles do they innervate?

A: Lower Motor Neurons are Motor neurons of the Brainstem & Spinal Cord.

They are arranged into 4 columns and release ACETYLCHOLINE onto nicotinic receptors of target m.

Lower Motor Neurons are recruited based on size & Force

B: 4 Column Arrangement:

1. medial LMN-->axial trunk m.

2. Lateral LMN--->Distal Limb m. (extremities)

3. Dorsal LMN--->FLEXORS

4. venTral LMN------->exTensors

113

A: Cells of Origin for [Area 4 precentral gyrus] are called the ____ ____ ____. So...Corticospinal Tract is AKA ____ Tract

B: CST starts in _______--->forms ___ ____--->which travels in _____ Capsule----> _________ --->________ inside Pons -----> decusates in ___ _____---(travels in) -->____ ______ as the ________---> synapse on [ANT horn cells]

C1: 10% of CST fibers DON'T CROSS AT [___ ____] These are called the ____

C2: These ______ cross over at diff levels of the __ _____to still synapse on contralateral [ANT horn cells] like the _________

D: CST Fibers are ____[Upper/lower] Motor Neurons and is the ___[smallest/Largest] Descending Tract

E: CST is used for what type of movements?

A: Cells of Origin for [Area 4 precentral gyrus] = [Pyramidal Betz Cells]

So...Corticospinal Tract is AKA Pyramidal Tract

B: CST starts in [Area 4 precentral gyrus]--->forms [CORONA RADIATA]--->travels in [Posterior limb: Internal Capsule]----> [Crus Cerebri Cerebral Peduncle] --->[Base of the Pontine Gray] -----> decusates in medullary pyramid---(travels in)-->[Lateral funiculus] as the [Lateral CST]---> synapse on [ANT horn cells]

C1: 10% of CST fibers DON'T CROSS AT [medullary pyramids= [ANT CST] .

C2:[ANT CST] crosses over at diff levels of [Ventral Funiculus] to still synapse on contralateral [ANT horn cells] like the [Lateral CST]

D: CST Fibers are Upper Motor Neurons and is the LARGEST Descending Tract

E: CST is used for [Fine motor movements] like piano playing/picking up pennies

114

A: Corticospinal Tract originates and terminates from ___origins and consist of __[#] fibers. 50% of it comes from ______ while other 50% comes from _______

B: CST projects to the __ ___&; _____. Its collaterals (both direct & indirect) travel to_____, ____, ______ and _____

C: CST Passes through the ____ limb of ____ _____

A: Corticospinal Tract has MULTIPLE origins and terminations and consist of ~1 million fibers.

50% of it comes from Primary motor cortex while other 50% comes from areas [Adjacent Frontal motor and Parietal areas]

B: The CST projects to [Brainstem & Spinal Cord]. Its collaterals (both direct & indirect) travel to basal ganglia, thalamus, [reticular formation of midbrain] and sensory nuclei

C: CST Passes through POSTERIOR limb of Internal Capsule

115

A: Define Coma

B: Coma prognosis (3)

C: [Irreversible Brain Death]

-cause (2)

-Dx

-caveot  

A: Sleep like [unarousable (not alert/awake even after pain) vs. unresponsive] state where cortex is not functioning

B: 

1. Reversible (only if treated in time and after a reversible cause)

2. Minimal Return = [Days-weeks post cerebral anoxia] pt may appear awake + [roving eyes] + [pain response] but still no real interaction = Persistent Vegetative State

3. [Irreversible Brain Death]:

-mostly from progressive edema & neuron death and can be declared even with heart beat 

-Dx at least 6 hour observation of no imprvmnt + Absent Cerebral blood flow over 10 min on brain scan)

-(Caveot: Muscle reflexes & Babinski can be present in Coma Dx) 

116

A: [Ascending Reticular Activating System] or ARAS plays a role in _______, _______& _______. It helps to _______ the Cerebral Cortex. 

B: Other "candidates" that Activate Cerebral Cortex are the...[3]


C: Why does the Cerebral Cortex project TO the [Reticular Formation]? 

A: [Ascending Reticular Activating System] or ARAS plays a role in level of alertness, [sleep-wake] rhythms & "Startle" rxns. It helps to Activate the Cerebral Cortex. 

B: Other "candidates" for activating Cerebral Cortex...
1. Basal forebrain--->[Basal nucleus of Meynert]---->ACH

2. [Orexin of LAT Hypothalamus]---->tuberomammillary body and STABILIZES WAKE STATE

3. Cholinergic neurons near [locus ceruleus]  

C: Motor Cortex, influences alertness and allows focusing of attention

117

A: Orexin comes from the [_______ Hypothalamus] and is responsible for _______. It makes sure _______ states are TURNED OFF! 

B: Narcolepsy occurs when _______

B2: What is Cataplexy? 

C: What are these caused by? 

D: The part of the Hypothalamus Orexin is synthesized in was previously considered the ____or ____ center

A: Orexin comes from the [Lateral Hypothalamus] and is responsible for STABILIZING WAKE STATE. It makes sure REM/Non-REM states are TURNED OFF! 

B: Narcolepsy occurs when pt randomly falls asleep and IMMEDIATELY enters REM Sleep. 

B2: w/ Cataplexy:  sudden episode of REM-like muscle Weakness but during FULL CONSCIOUS AWAKEFULLNESS

C: Cataplexy is caused by Autoimmune dz: Body destroying Orexin Neurons  

D: LATERAL Hypothalamus was previously considered the FEEDING or PLEASURE center

118

Name the common causes of Coma (2)

 

1. [Upper Brain Stem lesions that interupt (ARAS-Ascending Reticular Activating System]

2. [Bilateral Extensive Cerebral Cortex Damage]

a: Unilateral Cerebral lesion --> Edema which affects CTL hemisphere vs. herniation compresses ARAS

b: Toxic changes (Drugs vs. anoxia) --> DIFFUSE DAMAGE

 

119

A: How should you initially examine an Unresponsive pt (4)

B: Describe the MOTOR testing (5)

A: Examine [Brain Stem Reflexes] (ME then PB Motor vs. Breathing vs. Pupils vs. Eye mvmnt)

Motor testing

1. Withdrawal to pain = some cortical function

2. [DecorTicate posturing (UE Flexion & LE Extension)] = Cerebral Hemisphere damage

3. [Decerebrate posture (ALL EXTREMITIY EXTENSION)] = [Midbrain Red Nucleus lesion]

4. [Myoclonic jerks & Asterixis] = [Toxic metabolic coma]

5. [Spontaneous Nystagmus & Twitching] = [Coma 2° to electrical status epilepticus]

120

A: How should you initially examine an Unresponsive pt (4)

B: Describe the Eye Movement testing (2)

A: Examine [Brain Stem Reflexes] (ME then PB Motor vs. Breathing vs. Pupils vs. Eye mvmnt)

Eye Movement testing = Both Test indicate Normal Brain Stem

1. [Oculocephalic Doll's Eyes Reflex] = eyes conjugately move in direction opposite from head rotation (normal brain stem response) - RULE OUT CERVICAL SPINE FRACTURE BEFORE DOING THIS

2. [Induced CALORIC Nystagmus] is when irrigation of [External Auditory Canal] with Cold/Warm water creates convection currents in Vestibular labyrinths--->stimulates [crista ampullaris] by deflecting stereocilia

COWS (ENG-Electronystagmogram)= 
Cold Water--->Eyes move Opposite direction of irrigation
Warm water -->eyes move in Same direction of irrigation