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Ischemic stroke
Diminished blood flow
Leads to Gliosis
Watershed infarct
Artery
MCA
ACA
Hemorrhagic stroke
Hemorrhage aneurysm
Embolic
Reperfusion
Deficient
-Aphasia (Wernicke or brocas),
-Neglect syndrome (if right parietal, so ignore left side)
-hemiparesis weakness ( arm and face)
-homonymous hemianopsia (temporal more common, so superior
quadrant)
-LEG paresis
-hemiplegia (total paralysis)
PCA
Basilar
Lacunar
stroke
urinary incontinence
-homonymous hemianopsia with macular sparing (since MCA give
blood)
Affect pons ( cranial nerves, coma, apnea, vertigo)
-Pure motor ( internal capsule)
-Pure sensory (thalamus) but the smell intact (since only sensory
that bypass)
-dysarthria
-Ataxic hemiparesis (ipsilateral clumpsy
Imaging:
ACUTE do CT to see if hemorrhagic (dark on CT after 24 hours)
MRI shows up bright in 3-30 min and remain bright 10 days
Histology
12-24 H : RED neurons
24-72: necrosis + PMN
3 -5 day : macrophage
1-2 week : reactive gliosis + vascular proliferation
>2 week: glial scar
Treatment
tPA for occlusive (give within 3 hours)
warfarin/ aspirin for embolic once hemorrhage has been ruled out
Alzheimers
Diseases of myelination
Guillain- Barre Syndrome/ Acute inflammation Demylinating
polyradiculopathy (PNS and motor + autonomic)
Endoneurium and Schwann cells attacked = autoimmune demyliantion
1-3 weeks post GI infection OR RESPIRATORY (campylobacter jejuni) or
herpes
SYMMETRIC Ascending paralysis MOTOR AND AUTONOMIC
Physical exam:
Decrease or absent reflex
Facial paralysis if ascended to face
Autonomic dysfunction : cardiac and blood pressure fluctuation
Need to give respiratory support
Lumbar puncture: high protein, normal cell count (albuminocytologic
dissociation)
-this high protein is also seen in intracranial cancer
Progressive Multifocal Leukoencephalopathy( PML) (CNS )
Demylination by destruction of oligodendrocytes
Associated with JC virus reactivation in AIDS patients (polyomavirus,ds
DNA)
Dementia and neurological deficits with RAPID PROGRESSION
Typically fatal
Histology: widespread demylination, astrogliosis, lymphohistiocytosis
* associated with Natalizumab ( drug against alpha-integrin used in Crohns
and MS) *MS also demylination oligodendrocytes
Usually seen on one side more
Sodium
from low to high, pons will die
from high to low, brain will blow (edema/ herniation)
Multiple sclerosis
destruction of oligodendrocytes by CD8 T cells
anti-myelin Basic protein ( high protein IgG in CSF)
white matter plaque form in brain and spinal cord
in white women 20-40 onset in temperate climates.
HLA-DR2
CN2 is the only cranial nerve that is mylinated by oligodendrocytes therefore
affected in MS
Presentation
Optic neuritis (sudden loss vision)
Marcus Gunn: swinging flashlight test . Affected CN2
-normal eye pupil reflex normal,
-abnormal eye, both eyes dilate.
Intranuclear opthalmoplegia (MLF) : ipsilateral MLF to the CN3 that
cant Adduct . Nystagmus other eye when it Abducts . can be bilateral.
CONVERGENCE INTACT
Hemisensory symptoms
Intention tremor
Hemiparesis (weakness)
Bladder/bowl incontinence
SIN : Charcot classic triad of MS
-Scanning speech
-intention tremor, incontinence, intranuclear opthalmoplegia
-nystagmus
Evalutation
MRI gold standard : PERIVENTRICULAR plaques
Two demyelinating lesions separated in time and place
Lumbar puncture: high Leukocytes, oligoclonal banding (high IgG),
high Mylein basic protein, normal glucose
Treatment
IFN-beta : decreases the amount of inflammatory cells crossing BBB
And thought to increase Nerve growth factor
High dose steroids
Natalizumab : humanized monoclonal antibody against Alpha-integrin
a cell adhesion molecule
Neurophysiology
Neuronal cells
Astrocytes: GFAP stain, K+ metabolism, cause REACTIVE GLIOSIS, BBB,
remove excess neurotransmitter
Ependymal cells : line ventricles and maintain flow of CSF With cilia
Microglia : from MESODERM migrate here
-macrophages
-not seen on Nissl stain
-multinucleated with HIV infection
-rods in neurosyphilis
-perivascular in viral encephalitis
Oligodendrocytes : fried egg appearance. CNS myelination
-each mylinated up to 30 axons
-Multiple sclerosis destroys these
Schwann cells : peripheral myelination ( one axon/ Schwann)
-Schwannoma bilateral in NF-2 , at internal acoustic meatus affect CN 7 and 8
-destroyed in Guillian Barre syndrome
Golgi tendon
Ib
Series to intrafusal muscle
Inhibits A alpha motor neurons to relax
muscle
Detect tension
CSF
-Normal
0-4 lymphocytes or macrophage (PMN ALWAYS ABNORMAL)
low protein (high in tumor, Guillain-Barre, and MS = albuminocytologic
dissociation)
equal NA+ to serum
low PH since lower HCO3 higher Cl-, Mg2+ High Mg2+ Cleanse (causes diahrea)
lower K+, Ca2+, Hco3-, glucose
-Made by Choroid plexus in all ventricles (lateral, 3rd , 4th )
-recycled 2-3 times/day
Communicating hydrocephalus Made too much CSF (choroid plexus tumor)
Low absorption (arachnoid granulations scar
following meningitis)
Noncommunication
Blockage
Normal Pressure
Decrease reabsorption with ventricle dilation
therefore no increase in pressure
3W : wet, wacky weird old people
Ex Vacuo
Decreased brain size (stroke, HIV, Alzheimers,,
trauma)
Venticles larger, but CSF pressure normal
Sleep
Stages
BATS Drink Blood
-Awake eyes open : beta ( highest frequency, lowest amplitude)
-Awake eyes closed: alpha
-Stage 1 NON-REM: Theta
-Stage 2: Spindle and K complex
* teeth grinding (Buxism)
-Stage 3: delta (lowest frequency, highest amplitude)
*sleep walking, night terror, bed wetting
-REM: beta
* dreams, and erection
REM sleep
dreaming, penile/clitoris erection
loss motor tone
memory processing function
high O2 use brain, high and variable pulse and BP
extraocular movements due to PPRF
EEG beta (paradoxical sleep)
Every 90 min and increase in duration every cycle
Decrease with age
Ach promote it, NE decrease it
Narcolepsy : start off with REM sleep
-Catplexy: loss all motor tone after strong emotional stimulus
-treat with amphetamines
Sleep Apnea
Types
Obstructive sleep apnea
-Obesity, Craniofacial, nasal congestion, large tonsils
Central sleep apnea : low CNS drive to breath
Symptoms
-excess daytime sleepiness (like narcolepsy) + unrestful sleep(narcolepsy
is restful)
-loud snoring
-small jaw, large neck circumference
-high EPO on labs, because chronic hypoxia
Treatment
-Weight loss
-Continuous positive airway pressure
Complication
-arrhythmia
-pulmonary hypertension
Anatomy
Head and neck
Thoracic Outlet
Subclavian vien and phrenic ON anterior scalene
Btw Anterior and middle scalene above is subclavian artery and below is
trunks brachial plexus
-Thoracic outlet syndrome : compression of brachial plexus and
subcleavian artery btw the anterior and middle scalene
Causes
-due to pancoast tumor
-cervical rib
-hypertophy of scalene muscles : body builders
Symptoms
-numbness and weakness on medial forearm and hand.
-claw hand ( ulnar affected most)
-decreased radial pulse
-Horners syndrome, and recurrent laryngeal n.
Pharyngeal apparatus
Pharyngeal pouch (endoderm) 1,2,3,4,6
Pharyngeal arch (mesoderm and neural crest cells)
Pharyngeal groove/ cleft (ectoderm)
Pharyngeal groove btw 1 and 2 : external ear (only groove)
Pharyngeal pouch 1 : middle ear
2nd pharyngeal arch grows over the other grooves ( if dont fuse properly then
pharyngeal/ lateral cervical/ brachial cyst on lateral part neck)
-Treacher Collins : small jaw, eyes slanted down, malformed ears and
hearing loss, colobomas
-Pierre Robin sequence : very small jaw , cleft palate, posterior displaced
tongue
Pharyngeal fistula : 2nd groove and pouch persist, fistula on anterior border
SCM
Neurons
** same as PICA with the spinothalamic, dissociated pain and temp, and
hypothalamic
CN 7 and 8
Middle peduncle : ipsilateral aaxia
Vestibular nuclei : vertigo, nausea, vomiting, nystagmus
Anterior cerebral
Posterior
communicating
Lenticlostriate
(lentiform and stratum)
Basilar
Anterior communicating
arm
Spinal cord
Basal Ganglia
Cerebellum
-Input
Hypothalamus
1. Hunger
2.
3.
4.
5.
6.
7.
8.
Thalamus
* SENSORY RELAY ( except olfactory bypass it )
1. Lateral geniculate : visual ( Lateral= light)
2. Medial geniculate : auditory (medial= music)
3. VPL ( ventral posterior lateral) : all sensory body
4. VPM ( ventral posterior medial) : all sensory face
5. Ventral anterior/ lateral (VL and VL): MOTOR inform from basal ganglia and
cerebellum
Epithalamus: pineal gland
Subthalamus lesion; hemiballismus
Limbic System
5 Fs : feeding, fight or flight, feelings, fuking,
Hunger
Fight or flight
Emotion
Sex
MEMORY
-bilateral destroy Hippocampus : anterograde memory
-bilateral destroy mammilary bodies: anterograde and
retrograde
Limbic contains : cingulate gyrus, fornix, mammillary, amygdala, hippocampus
Kluver- Bucy Syndrome: bilateral lesion amygdala and hippocampus
Anterograde amnesia, hypersexuality, oral behavior
Decreased aggressiveness (they are passive)
Objects in visual field treat inappropriate, human approach lion without fear
Cortex
Prefrontal: organize and planning intellectual and emotional
-cant concentrate, easily distracted, apathy, emergence infantile suckling
and grasp reflex
Premotor: planning motor activities
-Lesion: APRAXIA cant do purposeful movements (even tho motor and
desire there). Cant perform things in correct sequence
Frontal eye field : cant move both eyes to contralateral side (deviate to side of
lesion)
Posterior parietal associated areas(left side): also APRAXIA , cant draw a circle.
(bilateral)
-Astereognosia : cant recognize objects in hand (contralateral)
Internal capsule:
Eye
-Lower retinal field lateral geniculate Dorsal optic radiation/
calicarine/parietal lobe SUPRA-calcarine (cuneus)
-upper retinal fieldLG Meyers loop/ Temporal lobe INFRA-calcarine
(lingual)
Additional pathways
Optic tract pretectal area ( light reflex)
superior colliculus ( vertical conjugate gaze)
suprachiasmatic nuclei ( circadian rhythm)
Pupil
Present in cortically blind and unconscious
Constriction : CN2 pretectal bilateral Edinger westphal ciliary
ganglion SHORT CILIARY nerves pupillary sphincter
Dilation: T1 superior cervical ganglion LONG CILIARY
* Adies: dilated pupil slow react light, lack knee jerk reflex (normal accom)
Clinical
1. Otosclerosis: conductive hearing loss bc the ossicles dont amplify
sound
2. Hyperacusis: CN7 damage.
3. Presbycusis: loss of hair cell in the base of cochlea (therefore high
frequency sound loss) OLD PEOPLE
4. Lesion at cochlear nucleus or pontomedullary junction= unilateral
sensory hearing loss
5. Lesion anything higher up causes BILATERAL hearing DECREASED
(not lost)
MEDBULLETS
KLM SOUNDS
KUH: CN 10
LA-LA-LA : CN 12
MI-MI-MI : CN 7
Lumbar Puncture:
Ends L2 adults, L3 neonates. Do puncture L4-L5 using iliac crest
Aneurysm
RBC in lumbar is acute, with turn yellow (xanthochromia)
Give calcium channel blocker (nimodipine) to prevent secondary vasospasm
which occurs 2-3 days post SUBARACHNOID hemorrhage
Berry aneurysm at anterior communication ( ADPCK, marfan, Ehler danlos,
artery vien malformation)
o Subarachnoid (headache)
Charcot Bouchard aneurysm is lenticostriate vessel at basal ganglia ( HTN
chronic and diabetes)
o Intraparenchimal (usually motor or sensory loss)
Internal carotid
In cavernous sinus
In the foramen lacerum
Parkinsons
Huntington
high Dopamine, low ACH and GABA
high Dopamine in nigro-striatal = direct pathway activated so hyperkinesis
high dopamine in meso-limbic = psychotic symptoms
Alzheimers vs Picks Disease
both have Tau protein aggregates intacellularly
-Alzheimers is TANGLES
-Picks disease is ROUND
Poliomyelitis
Fecal- oral infection: replicates in oropharynx and small intestine blood
CNS
Sore throat LMN symptoms
WERDNIG-HOFFMAN DISEASE : autorecessive, destroy anterior horns like
polio. FLOPPY BABY
Friedreich Ataxia
MITOCHONDRIAL FUNCTION INPAIRED
GAA
Macular degeneration
Dry: fat deposits in macula, slow disease course
Wet: neovascularization of the macula, fast disease course
RANDOM
Alpha- feto Protein
U WORLD
Guillian Barre : segmental demylination , ENDONEURAL inflammation
Werdnig- Hoffman syndrome: anterior horne degeneration in neonates
inherited. FLOPPY BABY
Craniopharyngioma is calcified cystic tumor
ATM : Ataxia Telangiectasis Mutated
-DNA breaks