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What is the earliest change in ischemic stroke? How long after infarction does this develop? What type of necrosis?

Red neurons
develops 12 hours after infarction
(shrinkage of cell body, eosinophilia of cytoplasm, pyknosis/shrinking of nuclei, loss of Nissl substance/RER)

liquefactive necrosis


Bleed on the bottom of the brain? What is the presentation?

Subarachnoid hemorrhage! (only thing that does this)

Presentation: "worst headache of my life", nuchal rigidity, xanthochromia (yellow hue due to bilirubin breakdown) on LP


What lesions causes hemiballismus? Due to what? Ipsilateral or contralateral?

lesion to the subthalamic nucleus
most commonly due to a lacunar stroke



What vitamin deficiencies result in posterior column degeneration?

Vitamin B12 and Vitamin E deficiencies


Lesions or atrophy of the mammillary bodies? What can trigger this? What is the triad?

Wernicke encephalopathy
associated with thiamine/B1 deficiency and excessive alcohol use
can be triggered by glucose infusion to a B1-deficient pt

Triad (CAN of beer):


Most common presentation of cerebral amyloid angiopathy?

recurrent hemorrhagic stroke
multiple, small lobar hemorrhages with history
due to deposition of beta-amyloid into arterial wall, resulting in weakening

lower mortality rate and more benign course than hemorrhagic storkes associated with HTN
usually in cerebral hemispheres (lobar strokes) and involve smaller areas, where HTN strokes are larger and tend to involve deep structures like the basal ganglia


Where is the pineal gland? What is its function?

dorsal midbrain, between midbrain and cerebellum

melatonin secretion, circadian rhythms


45yo with bouts of nausea and ringing in left ear, feels fine between episodes?

Ménière's disease - increased volume of endolymph in vestibular apparatus
- tinnitus
- vertigo
- sensorineural hearing loss


Lake-like cavitary lesions in the internal capsule -- due to? Pathogenesis?

Lacunar infarcts
occur secondary to hyaline arteriolosclerosis (complication of HTN)

leads to small, cystic areas/spaces areas of infarction weeks later due to necrotic liquefactive tissue lined by astrocytes/gliosis


Lacunar infarct vs. Charcot-bouchard?

lacunar infarct -- OBSTRUCTION of lacunar vessels, resulting in lacunae on healing

Charcot-Bouchard -- HEMORRHAGE


Brain tumor positive for synaptophysin?

indicates neuronal origin (NOT glial origin)
synaptophysin -- protein found in presynaptic vesicles of neurons, neuroendocrine, and neuroectodermal cells


Small bilateral pupils that constrict to accommodation but not to light?

Argyll Robertson pupils
associated with tabes dorsalis (tertiary syphilis)


What are the features of tabes dorsalis? due to?

degeneration of dorsal columns and roots
- impaired sensation and porprioseption
- progressive sensory ataxia

also associated with
- Argyll Robertson pupils
- absence of deep tendon reflexs
- positive Romberg


5yo with midline posterior fossa mass -- sheets of primitive cells and many mitotic figures?


sheets of small cells with deeply basophilic nuclei and scant cytoplasm (small, round, blue cells)
abundant mitoses -- undifferentiated and aggressive (bad prognosis)


Thunderclap headache / worst headache of my life?

Subarachnoid hemorrhage
usually due to berry aneurysm rupture


Potential complications 2-3 days after subarachnoid hemorrhage? Symptoms? Findings on CT

1. secondary arterial vasospasm in the vessels surrounding the ruptured aneurysm
- causes cerebral ischemia
- new onset confusion and/or focal neurological deficit
- NOT visible on CT, treat with nimodipine (selective Ca channel blocker)

2. rebleeding
- sudden development of a severe headache, severe nausea/vomiting, change in consciousness, new neurological deficits
- seen on CT


Headache that is recurrent, on the right side, starts with pain around eye for about 30minutes, and associated with tearing and nasal congestion?

Cluster headache

most common in males (only one)
lasts >15 minutes (vs. trigeminal neuralgia which lasts <1 minute)


What tracts do vitamin B12 and E deficiencies result in?

- dorsal columns
- lateral corticospinal (descending)
- spinocerebellar (part of ALS)


Sporadic encephalitis that targets the temporal lobes? Findings?

HSV-1 sporadic encephalitis
reactivation of latent virus in trigeminal ganglion and spread to the cerebral vault


Bilateral paresthesias of the thumb, index, and middle finger?

Carpal tunnel syndrome
compression of median nerve in carpal tunnel
(can also see weakness of thumb adduction and thenar atrophy in advanced cases)

Common causes:
- chronic repetitive stress (typing, knitting)
- conditions with fluid retention (renal failure, pregnancy, hypothyroidism)
- DM, RA, and acromegaly
- dialysis-associated amyloidosis


Worsening weakness/tingling of feet ascending to knees with absent DTRs in legs and history of mild respiratory infection?

Guillain-Barré syndrome
autoimmune destruction of peripheral myelin and Schwann cells
leads to symmetric ascending muscle weakness/paralysis beginning in lower extremities


What fibers are at the interior of CN III? What fibers are at the periphery of the nerve? What damages each and what are the results?

Interior/central part of CN III:
- motor fibers (controls levator palpebrae and extraoculars)
- primarily affected by vascular disease (DM2)
- ptosis, "down and out" gaze

Periphery of CN III:
- parasympathetic fibers (sphincter of the iris, ciliary muscle)
- primarily affected by compression
- diminished/absent pupillary light reflex, blown pupil


Angiomatous lesions of the cerebellum and cystic mass in kidney? Inheritance and other features?

Von Hippel-Lindau disease
autosomal dominant
mutated VHL tumor suppressor on chromosome 3

- cavernous hemangiomas in skin, mucosa, organs
- bilateral renal cell carcinomas
- hemangioblastoma (retina, brain stem, cerebellum)
- pheochromocytoma


Findings in Von Recklinghausen's disease?

Neurofibromatosis type 1

- cafe-au-lait spots
- Lisch nodules (pigmented iris hamartomas)
- neurofibromas in skin (derived from neural crest)
- optic gliomas
- pheochromocytomas

mutated NF1 tumor suppressor gene (chromosome 17)


Sturge-Weber syndrome?

congenital non-inherited/somatic neurocutaneous disorder

- cutaneous facial angiomas (port-wine stain of the face, a non-neoplastic "birthmark" in CN V1/V2 distribution)
- leptomeningeal angioma (ipsilateral)

- seizures/epilepsy
- intellectual disability
- episcleral hemangioma

port-wine Stain
Tram track calcifications
Glaucoma (increased intraocular pressure)
GNAQ gene


Tuberous sclerosis?


Hamartomas in CNS and skin
Mitral regurgitation
Ash-leaf spots
Rhabdomyomas (cardiac)
(Tuberous sclerosis)
dOminant, autosomal
Mental retardation
Angiomyolipoma, renal
Shagreen patches

increased incidence of subependymal astrocytomas and ungual fibromas


What is the most important neurotransmitter abnormality in Alzheimer's disease? Where is this most notable?

decrease in ACh level
due to deficiency of choline acetyltransferase

most notable in the basal nucleus of Meynert (participates in memory and cognition) at the base of the forebrain, projecting widely to the neocortex


What NT is synthesized in the locus ceruleus? Location?

caudal pontine gray matter (pons)

plays a role in pathogenesis of panic attacks and panic disorder
- increased in anxiety
- decreased in depression


Where is serotonin made?

Raphe nucleus (pons, medulla, midbrain)


Where is GABA made? Levels are decreased in which disorders?

Nucleus accumbens

decreased in anxiety and in Huntington's