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Flashcards in Week 2 Deck (70):
1

CSF is made mostly by the tissue in the chorioid plexus, and some by the tissue lining the ventricles and blood vessels

It is made in a two step process

First, passive filtration of ___ occurs and next ___ modification (HCO3, Cl, K, Mg2+, and aquaporin channels exist)

Serum, ionic

2

Name if the concentrations in the plasma and CSF are greater, lesser, or equal

1) Protein
2) Na
3) ***** Mg2+ ******** and Co2
4)Cl
5) K+
6) HCO3
7) Ca2+
8) Glucose

1) More in plasma than CSF
2) Equal
3) More in CSF than plasma
4) Equal
5) More in plasma than CSF
6) Equal
7) More in plasma than CSF
8) More in plasma than CSF

3

In ___ hydrocephalus, the fluid can't get to the arachnoid villi

In ____ hydrocephalus, the process of absorption is impaired such as the arachnoid villi or pinocytosis has problems

Obstructive

Non-obstructive

4

While production of CSF is ____ of intracranial pressure, absorption of CSF is ____ on intracranial pressure

Independent, Dependent

5

From the arachnoid villi, the CSF enters the ___ by bulk flow

Venous sinus

6

H2O, CO2, O2, and free steroid hormones (not bound to proteins) can passively diffuse across the BBB, however ____ can not so it needs transporters

**** GLUT1 is insulin ____ ****

Glucose

Independent

7

Also on the membranes of the BBB is a ___/___/____ cotransproter, which moves all those ions from the CSF to the blood and expression is tied to ___ 1 and 3 (which is a vasoconstriction)

*** THE MAIN PURPOSE OF THIS TRANSPORTER IS TO CONTROL ___ IN THE CSF

Na/K/2Cl, endothelin

K+

8

Many drugs cross the BBB, however they get moved back into the blood via the ____ aka MDR-1

**So to deliver a drug to the brain, you need to add a port that goes straight into the CSF and by-passes it***

P-glycoprotein

9

The ___ organs are the neural tissue of the brain that are not protected by the BBB as the other neural tissues are

There are 4 regions that fall into this category including

1) Releases hormones into the blood
2) Involved in vomiting in response to blood born substances
3) and 4) Both involved in control of body water/ thirst

Circumventricular

1) Posterior Pituitary
2) Area Postrema
3) and 4) OVLT and Subfornical organ

10

When a sensory or motor pathway conveys their fibers in a highly organized, laminated fashion as they ascend or descend to specific regions of the cortex or body, it is called ____

When certain specific portions of a pathway convey info from specific regions of the body or face, it is called ___ (aka the cartoon exaggerations)

Somatotopic

Homunculus

11

A ___ is a bundle of crossed, secondary nerve fibers in a conscious sensory pathway and a lesion results in a ____ deficit

Lemniscus, contralateral

12

*********************Forvenous drainage of the head, veins on the surface of the cerebral hemisphere drain into the dural venous sinuses (such as the superior sagittal venous sinus) and therefore must pass through the subdural space.

So if a bridging vein were to rupture in that space due to a head trauma, a ____ would occur

^** Also note the onset may be delayed days or weeks and the progression of signs and symptoms are much more insidious than in Epidural Hematomas

***************************

Subdural hematoma

13

********************** For the dural venous sinuses, in 2/3rds of the cases the superior sagittal sinus empties directly into the ____ sinus and the straight sinus drains directly into the ____ sinus

If thrombosis of the posterior portion of the superior or right transverse venous sinus occurs, ____ ischemia and or necrosis results

If thrombosis of the posterior portion of the straight or left transverse venous sinus occurs, ischemia and or necrosis for structures of the ____ occur and this can be fatal

**************************

Right transverse, left transverse

Cortical

Deep cerebrum

14

In a Flax Herniation, a unilateral space-occupying lesion of the cerebrum can cause the cingulate gyrus to herniate across the midline beneath the free edge of the ___

** There may not be any clinical deficits associated with this herniation

falx

15

**************************In an Epidural hematoma, the ____ artery can rupture and cause blood to pool in the epidural space, which is between the endocranium and dura mater and this causes the dura to peel off********************

The increased volume and pressure from the hematoma can result in either a ___ herniation where the cerebrum can be pressed under the falx ____ or a ____ herniation where the midbrain can slide down into the _____ created by the tentorium cerebelli

*************************

Know the location in the brain layers this occurs

Middle meningeal artery

Falx, Falx cerebri, Cerebri Uncal, tentorial notch.

16

If red blood cells (erythrocytes) are present in the CSF, then a ____ hemorrhage has most likely occured

Subarachnoid

17

CSF starts being made in the lateral ventricles, passes through the interventricular foramen of ___ to the 3rd ventricle and then CSF can move to the 4th ventricle via the cerebral ___ and then the CSF can finally get out of the 4th ventricle into circulation (aka into the subarachnoid space) via the 2 lateral apertures called ___ or the median aperture called ___, or the central canal which goes into the spinal cord

Finally it can be reabsorbed back into the blood stream via the subarachnoid villi

Monroe, aqueduct, Luschka (Lateral=L), Madendie (Median=M)

18

***************************An excessive amount of CSF in the ventricular system is called ___

If you see a child with a huge head, this is hydrocephalus because the intracranial pressure caused by the extra CSF is compensated by enlargement of the head at the cranial sutures

If CSF is accumulated in the subarachnoid space, it's an ___ hydrocephalus

More importantly, ____ hydrocephalus is where there is excess CSF but not in the location of the subarachnoid space (so fore example, some type of ventricular obstruction)
^** It is important to note that an internal hydrocephalus results in dilation of the ventricles ___ to the obstruction

^** So for example, if the cerebral aqueduct is obstructed, what will be enlarged?

***************************

Hydrocephalus

External

Internal (non-communicating)
Proximal

3rd and lateral ventricles (since it is everything proximal)

19

****************A communicating hydrocephalus is a combination of ___ and ___ hydrocephalus so in other words, CSF can move through ventricles into infratentorial subarachnoid space, but can't circulate over the cerebrum to be reabsorbed at the arachnoid vili, which results in the internal hydrocephalus and external hydrocephalus

This can occur at the level of the ___

******************

Infratentorial external and internal

Tentorial notch

20

**************If the regional cerebral blood flow is getting only 10-20ml of blood (53 is normal), then ___ occurs***********

The body has an autoregulation mechanism called ____ that sends blood to adjacent normal tissue to reach those ischemic areas and this can cause cerebral edema

***************** A ___can occur in with ischemia pneumbra and it is localized to the border zones between the territories of two major arteries in the brain***********

Ischemia pneumbra (a stroke)

Luxury Perfusion

Watershed infract

21

Cortical branches of the ___ artery supply the anterior 2/3 of the medial side and supero-lateral potion of the hemisphere aka **********the ACA supplies the ____ region************

************Occlusions may result in ____ paresis (muscle weakness) and/or paraesthesia (pin and needle feeling) of the ___ and ___************

There are also important penetrating branches of the ACA and ones just proximal to the ACoA is called the ___ artery, which supplies the brain's core

ACA, paracentral lobule

Contralateral, leg and foot

Recurrent artery of Heubner

22

The ___ artery has a strong correlation with Parkinson's disease

^** Block it can treat Parkinson

Anterior choroidal artery

23

The MCA also has penetrating and cortical branches that come off it

The penetrating branches are called the medial and lateral ___ arteries and also supply the core of the brain

The cortical branches have extensive distribution coming from 5 main different branches. Name them based off of their description for location or when thrombosis of the artery branch occurs

1) Supplies the primary motor and somesthetic cortices so when thrombosis occurs, contralateral spastic paralysis and or/paraesthesia of the face and upper 1/2 of the body occurs
**********2) Supply Premotor and prefrontal cortices and Broca's speech area in dominant hemisphere *********
3) Primary auditory cortex and a lesion in this area can result in difficulty localizing sound
4) Supply association cortex
********5) Main artery that that when obstructed in the dominant hemisphere, Wernicke's aphasia can result. It supplies the supra marginal and angular regions********

___ aphasia is when the patient has problems initiating speech motor patters (automatic, profane speech) aka they know what your are talking about but they cant say it

___ aphasia is when patients have fluent speech but they lack content or meaning in their spoken and written comprehension of language

Striate (aka thalamostriate)

1) Central artery
2) Frontal branches
3) Temporal branches
4) Parietal branches
5) Angular artery

Brocas

Wernickes

24

KNOW ANGIOGRAM STUFF

NOW IT, ITLL BE ON A TEST

25

**************The ____ artery, which comes off of the ___ artery, supplies blood to the central core of the spinal cord so if you have disruption of blood flow to this artery, you get ___ syndrome*************

^*The ____ contributes to the ASA and is the major supply to the inferior 2/3rds of the spinal cord

The posterior spinal artery (PspA) comes off either the vertebral or posterior inferior cerebellar arteries and supplies ___ roots and 75% of posterior ____ aka posterior 1/3 of cord

Anterior spinal artery, vertebral, central cord syndrome

Greater anterior artery of Adamkiewicz

Dorsal, columns

26

The ____ artery supplies the posterior and inferior portion of the cerebellum, the posterolateral aspect of the medulla, and the choroid plexus of the 4th ventricle

**************If the PICA is displaced on an angiogram in the posterior cranial fossa, it can be indicative of a ____ aka a space occupying mass*****************

^** If there is thrombosis of the PICA, it can result in ___ syndrome

Posterior inferior cerebellar artery (PICA)

Tumor

Lateral medullary (wallenberg)

27

The primary visual cortex might be ischemic and necros if the ___ artery undergoes thrombosis or compressed by a ___ herniation

Posterior cerebral artery (PCA), uncal

28

*****************The Great vein of Galen receives the ___ and ___ veins and drains into the ___ and then into left transverse venous sinus, therefore drains most of the deep cerebrum

^** So ___ transverse venous sinus drains the core of the hemispheres and the ___ transverse venous sinus drains the cortical aspects of the hemispheres ***************

YOU DO NOT want the left vein occluded since you would prevent blood from the core being drained

Internal cerebral and basal vein of Rosenthal, Straight sinus

Left, Right

29

Sympathetic innervation of the cerebral vasculature releases the NTs ___ and ____ and leads to ____ when activated

Parasympathetic innervation goes to large blood vessels and release of ___, ___, and ____ to cause vasodilation

There is also ___ inervation of the distal/smaller blood vessels and the NTs are substance P, Neurokinin A and CGRP and are very sensitive to torsion/manipulation that can lead to pain

^**In a lumbar puncture, CSF is removed from the system and this small reduction causes the brain to feel heavier and this causes more torsion on the blood vessels and even this simple motion can cause pain

NE and NPY

Constriction

Ach, VIP, PHM-27

Sensory

30

There are two parts to being conscious which include ___ and ____

*^People in comas are neither awake or aware

Sleep/wake cycles can appear in _____ states, but not evidence of awareness

Sleep wake cycles, along with some awareness aka the ability to respond to simple commands appears in ___ states

Arousal (being awake) and Awareness

Persistent vegetative

Minimally conscious

31

While the cortex activates both arousal and awareness, it is the ___ regions that allow excitation because the cortex has no intrinsic mechanisms for activation

Brainstem

32

Name where the NTs are coming from in the brain in order to activate the arousal systems

1) EAA (name both)
2) Cholinergic
3) Noradrenergic
4) Serotonergic
5) Dopaminergic

1) RAS (Retricular activating system) and Parabrachial nuclei
2) PPT (Pedunculopontine tegmental) and LDT (Laterodorsal nuclei)
3) Locus Ceruleus
4) Raphe Nuclei
5) Ventral tegmental area

33

All the ascending ___ tracts send their information to the RAS where they converge on the post-synaptic cells of RAS and the consequence is that ____ is lost (aka it just knows something happened, but not what event it actually detected)

Sensory

Modal specificity

34

Once RAS receives a signal, it has two output ways including the ___ pathway and the ___ pathway

The dorsal pathway has the RAS send a signal to the ____ nucleus of the ___ and then from there, the signal is sent to higher levels of the cortex

The ventral pathway has the RAS system bypass the ___ and instead send a signal to the __ and ___ (so it goes all the way up to the cortex before being released) and then diffuse to higher levels of the cortex

** Note that RAS neurons are EAA/glutamate, and there are also interneurons that release GABA and some that release Ach

**Also note the Thalamic Arousal System is via the ___ pathway

Dorsal and ventral

Intralaminar nucleus (non specific), thalamus

Thalamus, basal forebrain and hypothalamus

Dorsal

35

The parabrachial nuclei are located in the ___ and are a second source of EAAs and these axons reinforce the RAS system and the axons travel via the ___ pathway

Pons, Ventral

36

If the EAA system is functional, then sleep/wake cycles are possible aka arousal is possible, but no ____ since only the baseline excitation is being provided

awareness

37

The Cholinergic arousal system has PPT and LDT nuclei and these receive so much sensory input just like the RAS and also outputs are like RAS (ventral and dorsal), however the major NT is ___ and this also provide a baseline excitation

ACh

38

So going from a Coma to Arousal/wakefulness, you need ___ and ___

Then to get to awareness you need ___

Finally, to get to alertness, you need ___

EAA/Ach

NE/5HT

39

In order to gain awareness, the locus Ceruleus releasing ___ is important

The inputs are not well understood, but the outputs include the ___ and ____ pathways and the ___ pathway uses both dorsal and ventral pathway with the RAS

The ascending fibers from this group of cells become the ____

NE

Ascending and descending, ascending

Dorsal noradrenergic bundle

40

These noradrenergic functions include startle and alerting responses on an ___, sleep-wake, and behavioral ___

(So NE gave us true awareness)

EEG, vigilance

41

Serotonin from the Raphe nuclei has various inputs, and their outputs uses the ___ and ___ pathways and is important in quiet ____, mood and affect, and modulation of pain

Dorsal and ventral

Awareness

42

The VTA provides a ___ input that is important to provide alertness

Dopaminergic

43

Like we said before, the dorsal pathway synapses in non-specific nuclei of the thalamus, then the tholamocortical neurons release EAAs that go to the cortex and interact with a series of intracortical neurons that release ___, (this produces _____ seen on the EEG)

GABA, oscillations

43

Cerebral blood flow is under ___ control and is strongly influenced by intracranial pressure and as pressure ___, venous outflow becomes obstructed (sinuses become compressed) and this can lead to a ___ in arterial flow and this is why the blood flow must be autoregulated

If the mean arterial blood pressure gets to high, the BBB can be damaged so the ____ system is activated in order to cause vaso___ of the brain's vasculature and this protects the capillaries in the brain from damage

Local

Increases, decrease

Sympathetic, vasoconstriction

44

If the brain's blood perfusion decreases, the vasomotor centers become activated and an ___ in systemic BP occurs to drive blood to the brain

^** This can occur with hydrocephalus, edema, or bleeding within the skull

Increase

45

If a patient comes in with ptosis (droopy eyelid), mydriasis (pupil dilation), and eyes turned down and out it is a problem with the ___ nerve

Occumlomotor (III)

46

___ hematomas do not cross suture lines, whereas ____ hematomas can

Epidural, Subdural

47

Know the neurological testing stuff

***

48

For the different layers of the scalp, you have the SCALP (skin, close-subcutaneous tissue, aponeurotic, loose-subaponeurotic layer, and periosteum of the cranium)

^** Note the subcutaneous and subaponeurotic layers are connective tissue

************Scalp lacerations involve the deep portion of the ___ layer and this is one of the most vascular layers*********

*******The spread of infections, and more importantly, avulsion injuries of the scalp tend to separate the ___ layer, which is right below the aponeurotic layer**********

*********The inner most layer of the skull. The ___, has very poor osteogenic properties so when surgeons drill through it, no new bone will form and instead scar tissue will form********

Deep close-subcutaneous tissue (note that the close-subcutaneous tissue layer has a fatty, avascular, superficial, and deep portion)

Loose subaponeurotic layer

Periosteum

49

***********A depressed skull fracture can tear some of the venous sinuses and a scalp hematoma would form in the ___ layer (might be some CSF in the blood as well)***********

Loose subaponeurotic layer

50

Name the branch of the Trigeminal nerve that supplies the scalp

1) Skin on the lateral aspect of the forehead and scalp
2) Skin on the medial aspect of the forehead and scalp
3) Skin of the temporal region

4) Skin on the posterior and lateral regions of the occiput
5) Skin in the parietal region behind the ear
^** 4 and 5 are not trigeminal branches

Also what are the companinon arteries for these nerves?

1) Supraorbital n.
2) Supratrochlear n.
3) Auriculotemporal n.
4) Greater occipital N.
5) Lesser occupital n.

1) Supraorbital a.
2) Supratrochlear a.
^ off internal carotid

3) Superficial temporal a.
4) Occipital a.
5) Posterior auricular a.
^off external carotid

51

The scalp drains indirectly into the dural venous sinuses via ___ veins and this can be an important route for the spread of superficial scalp infections to the brain

Emissary

52

The ___ nerve is embedded in the parenchyma of the parotid gland, so if surgeons are doing a facelift and working in the superficial musculoaponeurotic system (SMAS), then all is well because the SMAS is above the parotid gland.

However if they go to deep, you can cut the facial nerve

***********Also note that the facial nerve has a close relationship with, and crosses, the ___ vein (which drains into the external jugular vein) and the ___ artery ***********

Facial nerve

Retromandibular vein and external carotid artery

53

**********Name the exact pathway of the parotid gland and also make sure you know the innervation of sublingual and submandibular***********

^ WILL BE ON TEST

Sympathetic: Preganglionic fibers to superior cervical ganglion -> Postganglionic fibers from Internal carotid nerve and plexus -> Carotico-tympanic nerve -> tympanic plexus -> lesser petrosal nerve -> otic ganglion -> Auriculotemporal nerve -> Parotid gland

Parasympathetic: Preganglionic fibers from Inferior salivatory nucleus -> Glossopharyngeal nerve -> tympanic nerve -> tympanic plexus -> Lesser petrosal nerve -> otic ganglion synapse -> Postgnaglionic fibers from otic ganglion -> auriculotemporal nerve -> Parotid gland

54

******************The ___ nerve is the sensory nerve for the skin of the face and muscles of mastication

The ___ nerve is the motor to the muscles of facial expression and taste to the anterior 2/3rds of the tongue****************

Trigeminal

Facial

55

***************************The muscles of facial expression (called Mimetic) are listed below and ALL are innervated by the ___ nerve... For each muscle, name what part of the facial nerve innervates it and also know what test to perform to check that muscle and its nerve supply are intact

1) Frontalis
2) Orbicularis Oculi
3) Zygomatic Major
4) Oribuclaris Oris
5) Platysma
6) Buccinator
^ Buccinator is not innervated by the Trigeminal (instead it is innervated by VII), but it is an accessory muscle of mastication
******************

Facial

1) Temporal facial nerve, raise the eyebrows
2) Temporal and Zygomatic facial nerve, Close eyelids very tightly
3) Zygomatic facial nerve, smile
4) Buccal facial nerve, Pucker lips
5) Cervical facial nerve, flair neck
6) Buccal facial nerve, sucking or blowing actions

56

Name which muscle is paralyzed based on the symptoms

1) Drooping of lower lid, spilling of tears, and corneal dying
2) Drooling of saliva from the corner of the mouth
3) Inability to elevate and retract the angle of the mouth
4) Inability to elevate eyebrows
5) Food accumulates in the vestibule of the oral cavity

1) Oricularis Oculi
2) Oribularis Oris
3) Zygomatic Major
4) Frontalis
5) Buccinator

57

*************** If a patient comes in with ectropion (eyelid drooping), Piphora (spilling of eyelid tears), dying cornea, inability to wink, unequal smile, drooling from corner of the mouth, and hyperacusis then it is almost certainly ____, from enlargement or a mass in the ___ gland, surgery, or really anything that destroys the facial nerve

Bell's palsy, Parotid

58

What are the three branches of the Trigeminal nerve?

** This is important for the Neuro exam because it is based on the three points you touch starting from the top of the head, check, and then mandible region

Opthalamic, Maxillary, and Mandibular

59

The muscles of mastication are all supplied by the ___ artery and innervated by branches of the ____ division of V off the trigeminal nerve

Maxillary, mandibular

60

The ___ artery and ___ nerve pass between the two heads of the lateral pterygoid muscle

Maxillary artery, buccal nerve

61

********** For the Jaw-Jerk reflex (aka masseteric reflex) the rapid depression of the chin results in a reflex closing of the mouth

It occurs via the pathway:

Stimulus: rapid depression of chin -> Receptor: stretching of neruomuscular spindles in ___ muscle -> Afferent fibers: Course in the ___ nerve -> ____ nucleus receives the sensory information -> This sends the signal the the ___ nucleus -> Efferent fibers: course back through the masseteric nerve -> Effector: Neuromuscular endplates in the Masseter muscle -> Response: Contraction of masseter muscle

****************

Masseter, masseteric, Mesencephalic nucleus of V (sensory nucleus), Motor nucleus of V

62

Normal opening of the mouth and wide opening is done mainly via the ___ muscle, and closing of the mouth is done via the ___, ___, and ___ muscles

Lateral pterygoid

Temporalis, Masseter, Medial Pterygoid

63

The TMJ is subdivided by an ____ into two separate and functionally different synovial joint cavities

The superior joint is a ___ joint and the inferior joint is a ___ joint

Articular disk

Gliding, hinge

64

For fractures of the mandible, if you fracture the neck you can injure the ____ nerve or ____ vessels

If you fracture the ramus you can disrupt the ___ nerve or ___ nerve

If you fracture the body you can disrupt the ___ nerve and vessels

Auriculotemporal nerve, maxillary vessels

Lingual nerve, Inferior Alveolar nerve

Inferior alveolar nerve and vessels

65

In order to find the long buccal nerve, you need to identify the ___ band (aka a portion of the temporails tendon that is attached to the buccinator muscle, so when you bite down the band pulls the buccinator muscle out from where you are going to bite down)

The nerve supplies ___ fibers to the epithelia of the inner and outer ___

Temporo-buccinator

GSA, cheek

66

The ___ nerve comes off of the inferior alveolar nerve and innervates the ___ and ___ muscles

Mylohyoid, mylohyoid and anterior digastric muscles

67

The ___ artery is between the two roots of the auriculotemporal nerve

Middle meningeal artery

68

Terminal branches of the maxillary artery supply the ___ 2/3 of the ___ cavity

So if you have a nose bleed in that part of the nasal cavity, that is NOT good

Posterior, nasal

69

In a newborn, the mental angle is about ___, a 4 year old has one around ___ and an adult has one around ___. Finally, a senior patient has a regression in their mental angle to around ____

175, 140, 114, 140