MLK USMLE - Step1: Neuro

Created by matthewkraushar 

Upgrade to
remove ads

microglia

mesoderm derived, HIV infected --> multinucleated giant cells

oligodendrocytes

target of MS, fried eggs

schwann cells

neural crest, target of Guillain Barre, acoustic schwannoma tumor
spindle shaped, S100+ (neural crest derived)

free nerve endings

pain + temp; C - slow unmyelinated; Adelta - fast myelinated

meissners corpuscles

fast adaptation and fine touch for hairless skin; Abeta large myelinated fibers

pacinian corpuscles

vibration + pressure; Abeta large myelinated fibers, deep

merkel's disks

slow adapatation and static touch for hair follicles; Abeta large myelinated fibers

endoneurium, perineurium, epineurium

guillame-barre in endoneurium

NTs - location and dz

NE: pons locus ceruleus, high anxiety, low depression
DA: midbrain VTA + SNc, high schizophrenia, low PD
5HT: reticular formation raphae nucleus, low anxiety and depression
AcCh: basal forebrain nucleus of meynert/nucleus basalis, low Alz + Huntingtons, high in REM sleep
GABA: NAcc ventral striatum, low anxiety

BBB

endothelial tight junctions, BM, astrocyte foot processes
size and lipid solubility determine permeability

fenestrated capillaries:
area postrema in medulla - vomiting
aka chemoreceptor trigger zone, dorsal
surface of the medulla
OVLT periventricular - ADH monitor

underdeveloped in infant, susceptible to CNS penetration -
ex: hyperbili in baby causes CNS lethargy, spasms...not in adult
ex: drugs

angiogenesis in brain tumors does not make tight junctions, disordered, therefore disrupts BBB
--> CONTRAST MRI detects
--> also systemic chemo can penetrate these areas for tx

hypothalamus

lateral - hunger, anorexia, failure to thrive
medial - satiety, hyperphagia

anterior - cooling, parasympathetic
posterior - heating, sympathetic

suprachiasmatic - circadian

PP:
supraoptic - ADH
paraventricular - oxytocin

thalamus

relays all sensory except olfaction

VPL - DCMLS
VPM - trigeminal
LGN - vision, superior colliculus
MGN - hearing, inferior collicuolus, superior olive

VA/VL - motor inputs/outputs (BG, SNc, GP, motorCTX)

VPL/VPM/LGN/MGN - sensory inputs/outputs

AN - limbic

MD - PFC/limbic/higher order
lesion = memory loss = wernicke-korsakoff

pulvinar - integrates inputs from all over thalamus and CTX --> lesion = sensory dysphasia

limbic system

cingulate, hippocampus, fornix, mamillary bodies, septal n.,

Papez circuit: amygdala --> mamillary --> ant. thalamus

cerebellum

(all ipsilateral) DCMLS SC, inferior olive --> inferior cerebellar peduncle --> climbing/mossy fibers

(all contralateral) cortical inputs --> middle cerebellar peduncle --> mossy fibers

(all contralateral) cerebellar outputs to CTX, SC = purkinje --> deep nuclei --> superior cerebellar peduncle

lateral ctx - lateral limbs, voluntary movement, to cerebral CTX
medial ctx - coordination/balance, ipsilateral SC inputs

vermis - trunk
lateral ctx - lateral limbs
flocconodular lobe - vestibular nuclei
dentate n. - contralateral CTX
E+G n. = contralateral SC

olivary n

superior = auditory
inferior = movement via inferior cerebellar peduncle

basal ganglia

voluntary movements, posture

striatum = putamen + caudate
lentiform = putamen + globus pallidus
subthalamic n
substantia nigra

direct path: ctx-striatium-GPi-thalamus-ctx
excitatory, SNc-->(+)D1-R striatum-->increase motion

indirect path: ctx-striatum-GP2e-STN-GPi-thalamus
inhibitory, SNc-->(-)D2-R striatum-->increase motion

PD - SNc
Huntingtons - striatum
hemiballismus - STN

PD

Lewy bodies = alpha synuclein
TRAP: tremor, pill roll, akinesia, unstable posture, slooooow
shuffling gait, masked facies, dementia

DA neuron loss in substantia nigra, decr DA to BG

tx: carbidopa + levodopa, pramipexole/bromocriptine
entacopone/tolcapone
selegiline

note: atypical antipsychotics can be anti-DA, schizophrenia pts taking risperidone/clozapine, etc can look like PD. MPTP antiemetic also induces PD sx

s/e of DA tx:
NV - improved with carbidopa, pts can
develop tolerance to this
orthostatic hypotension, hot flashes -
improved by carbidopa
anxiety/agitation - CENTRAL EFFECT OF
DA TX, NO TOLERANCE DEVELOPED TO
THIS

on/off phenomenon with DA tx - DRUG RESPONSE IS UNPREDICTABLE

hemiballismus

contralateral STN, strokes, flailing

huntingtons

ANTICIPATION = CAG repeat in huntingtin, chr4
mutated huntingtin hypermethylates DNA
transcriptional repression
glutamate toxicity/NMDAR, loss of AcCh/GABA in caudate

chorea/agression/depression/dementia/athetosis
(writhing fingers)

atrophy of the striatum (caudate+putamen), loss of GABAergics and cholinergics

...other choreic dz: syndenham's chorea in rheumatic fever, tardive dyskinesia, Wilson's dz

myoclonus

jerks, hiccups

dystonia

sustained cramp

broca vs wernicke

broca - inferior frontal gyrus, motor/expression and agrammatical...associated with arm/face weakness (arm face motor ctx proximity)

wernicke - superior temporal gyrus, receptive, can't name, understanding, anosognosia (unaware of deficit)...associated with contralateral field deficits (optic radiation proximity)

global = broca+wernicke

connected by arcuate fasciculus, lesion = poor repetition

circle of willis

lesions:
generally: anterior circle - sensory/motor/aphasias; posterior circle - CNs/coma/cerebellar ataxia

vertebral a./anterior spinal: medial medullary syndrome, motor paralysis

PICA: lateral medullary syndrome, loss of sensations esp. pain/temp, Horners, loss of gag reflex

AICA: pons, ipsilateral facial paralysis, nystagmus, dystaxia

PCA: occipital, contralateral hemianopia, macular sparing

MCA: contralateral face/arm paralysis, verbal aphasias, left sided neglect

ACA: leg/feet paralysis

anterior communicating: Berry aneurysm, visual field defects

posterior communicating: occulomotor palsy

lateral striae (part of MCA): internal capsule, BG, motor hemiparesis

basilar a - pons/midbrain, locked in syndrome with eyes intact

subclavian steal - thrombosis of left subclavian proximal to vertebral a., retrograde flow down left vertebral to bypass clot --> weak left arm

aneurysms

berry aneurysms in circle of willis bifurcations
high risk: ADPKD, ehlers danlos, marfans, coarctation of the aorta

"worst headache ever", vomiting (sx of high ICP)
if Marfans on board, can hear mitral valve prolapse mid-systolic click
CSF with blood, high bili

charcot-bouchard microaneurysms - htn

intracranial hemorrhages

epidural hematoma - middle meningeal a. (from maxillary a) rupture, temporal bone frac, does not cross suture lines, herniations, will typically see LOC acutely after trauma --> LUCID INTERVAL of normal function recovers...then rapid decline


subdural hematoma - bridging vein rupture, typically from trauma, slow bleed, delayed ssx onset, crosses suture lines...think chronic
can see changes in personality, AMS after a week

subarachnoid hemorrhage - aneurysm rupture, high risk marfans/ehlers danlos/ADPKD/AVM, bloody or yellow spina tap, tx with Ca channel block

parenchymal hematoma - htn, amyloidosis, DM, tumor

ischemia in the brain

high risk in watershed, hippocampus, CTX, cerebellum

irreversible injury in 12-24 hrs
glial scar after 2wks

atherosclerosis - ischemic stroke, necrosis, cyst with gliosis

hemorrage - aneurysm rupture, ischemia/reperfusion

SAH - aneurysms, atherosclerosis, bacterial emboli in vessel wall=mycotic aneurysm
CAN CAUSE SECONDARY ARTERIAL VASOSPASM --> ISCHEMIA
--> days after SAH, will see new FOCAL
NEURO DEFICITS
--> TX: CA CHANNEL BLOCK -
NEMIDIPINE
worst ha ever, NV, photophobia, coma
hyperdense blood all over the place

spontaneous intraparenchymal - HTN typically

Charcot Bouchard aneurysms - chronic HTN, hits along vessel path, ESP BG

ischemic stroke - emboli/Afib/carotid dissection/endocarditis

lacunar stroke - deep penetrating arteries, typically from chronic HTN, MULTIPLE small cavity infarcts

TIA

imaging: BRIGHT on MRI; DARK on CT

tPA for clots, not bleeds

dural veinous sinuses

in dura mater between meningeal/periosteal layers
cerebral veins --> venous sinuses --> INTERNAL JUGLUAR

superior sagittal, inferior sagittal, cavernous, straight sinus, great vein of galen, confluence of sinuses, transverse-->sigmoid sinus --> jugular foramen --> jugular vein

ventricles

CSF from choroid plexus

lateral/ctx --> monro --> third/thalamus --> aqueduct --> fourth/mid-pon-medulla with lateral Luschkas and medial Magendies

hydrocephalus

normal pressure - expansion of ventricles because not absorbing CSF in villi, typically secondary to meningeal hemorrhage
wet, wobbly, wacky

communicating - decr CSF absorption in arachnoid villi typically from adhesions after meningitis, incr ICP, papilledema, herniation

obstructive - blockage/stenosis in ventricles (monroe, aqueduct)

hydrocephalus ex vacuo - incr CSF with normal ICP + with brain atrophy in advanced dz (huntingtons, alz, HIV, picks FTD

benign intracranial htn - incr resistance to CSF outflow at arachnoid villi, obese young women
papilledema without mass, incr CSF pressure, decr vision, slit like ventricles

spinal nerves

cervical nerves above bone, rest below bone

8:12:5:5:1

disk herniations

spinal tap

between L3-L5 cauda equina

SC tracts

lateral corticospinal tract - crosses at pyramidal decussation in caudal medulla

anterior corticospinal tract - crosses at spinal level

spinothalamic - crosses after lissaur two levels up, to VPL thalamus

DCMLS crosses in medulla before ML, to VPL thalamus

spinocerellar stays ipsilateral

note sympathetics only T1-L2

LMN + UMN lesions

UMN - incr gain/reflex/tone, weakness, babinski, spastic paralysis, clasp knife

LMN - decr gain/reflex/tone, with weakness, atrophy, fasciculations

SC lesions

anterior horn - poliomyelitis, Werdnig-Hoffman = flaccid paralysis

DCMLS/spinothalamic - MS = scanning speech/tremor/nystagmus

lateral CS tract + anterior horn - ALS = UMN/LMN ssx, Riluzole tx, SOD1, decr glutamate release

anterior spinal arteries - high risk in thoracic, can include lissaur tract with pernicioius anemia

DRG + DCMLS - tabes dorsalis teritary syphilis = ataxia

spinothalamic - syringomyelia (anterior white commissure)

DCMLS+spinocerebellar - B12 deficiency, Fredreichs ataxia

anterior horn - poliomyelitis, poliovirus, fecal oral, LMN ssx

LMN dz floppy baby - infantile SMA, AR

tabes dorsalis

tertiary syphilis, proprioception/ataxia, Argyll Robertson pupil (accomodates but does not react), loss of DTRs, Romberg

Friedreichs ataxia

AR, trinucleotide repeat, frataxin, gait, nystagmus, hammertoes/high arch, kyphoscoliosis

cause of death: hypertrophic cardiomyopathy

DCMLS, lateral CST, spinocerebellar tract

VITAMIN E DEFICIENCY MIMICS THIS

brown-sequard

SC hemisection
motor ssx: UMN ipsilateral, LMN at level
sensory ssx: ipsilateral DCMLS below + spinothalamic at level, contralateral spinothalamic below

Horners

loss of sympathetics
hypothalamus-intermediolateral SC T1-L2 -sympathetic chain to cervical ganglion on internal carotid/juguluar-third order neuron to end organ

ptosis, anhidrosis, miosis

SC lesion above T1 (superior cervical ganglion), pancoast tumor, brown sequard, brainstem lesions, neck trauma, carotid dissection
note pancoasts tumor can cause ulnar nerve pain

key dermatomes

T4 nipple
T10 umbilicus
L1 inguinal ligament
L4 kneecap
S2/3/4 penis sensation

referred pain from diaphragam + GB to shoulder via phrenic n.

reflex SC segments

S1/2 heel (S1)
L3/4 knee (L3)
C5/6 bicep (C5)
C7/8 tricep (C7)

primitive reflexes

suckle, rooting, palmar/plantar grasp, babinksi

adult - frontal lobe lesions
<1y/o - positive babinski is normal

brainstem

medial CN = motor = 3,6,12
trochlear is only dorsal exiting CN

superior colliculus = vision
inferior colliculus = hearing

parinaud syndrome = superior colliculus lesion, pinealoma --> paralysis of conjugate vertical gaze
also hydrocephalus

brainstem lesions

motor:
pons - locked in
medial medulla - medial medullary syndrome (contralateral UMN paralysis, ipsilateral tongue LMN paralysis)

sensory:
lateral medulla - lateral medullary/Wallenberg
PICA stroke
ipsilateral Horners, nystagmus, on side of the lesion, ipsilateral limb ataxia, vertigo, contralateral loss pain/temp on body, ipsilateral loss pain/temp on face, also LMN paralysis CN 5,9,10,11

CNs

SSMMBMBSBBMM
2:2:4:4
dorsolateral - sensory, alar plate
sulcus limitans
ventromedial - motor, basal plate

1 - olfactory, straight to CTX

2 - optic, sensory arm reflex pupil

3 - oculomotor, everything except SO + LR
motor arm reflex edinger-westphal for pupil constrict, parasymp
paralysis = unilateral ptosis, gaze palsy (down+out)..typically from berry aneurysm or uncal herniation compression, or ischemia (diabetes)

4 - trochlear, SO, down+in, crosses contralateral

5 - trigeminal, sense face, muscles mastication + tensor tympani/palatini
sensory arm reflexes: corneal (V1), lacrimation (V2), jaw jerk (V3)
motor arm reflex: jaw jerk
mesencephalic and principle nucleus. is sensory
motor nucleus. is motor

6 - abducens, LR, think MLF with MR in MS

7 - facial, expression muscles, ant 2/3 taste, stapedius
UMN = upper face gets bilateral, lower face gets contralateral
LMN = Bell's palsy - AIDS, lyme, HSV, Sarcoid, tumors, diabetes
motor arm reflex - corneal (temporal, orbicularis o), lacrimation

8 - vestibulocochlear

9 - glossopharyngeal, post 1/3 taste, swallow, carotid body/sinus baro/chemo-R, stylopharyngeus
sensory/motor arm reflex: gag
external ear sensation
parasymp: parotid gland (otic ganglion)

10 - vagus, epiglotis taste, swallow, midline uvula, talk/cough, aortic bar/chemo-R, thoracoabdominal viscera
motor arm reflex: gag
aneurysms can compress --> cough, hoarseness

11 - spinoaccesory, SCM/trap + larynx

12 - hypoglossal, tongue

vagus n. in medulla

n. Solitarius - all Sensory
n. aMbiguous - all Motor
dorsal motor n. - autonomics

CN pathways in skull

CN1: cribiform plate

CN2-6: middle cranial fossa (sphenoid)
optic canal - CN2
superior orbital fissure - CN3/4/5-1/6
foramen rotundum - CN5-2
foramen ovale - CN5-3

CN7-12: posterior cranial fossa (temporal/occipital)
internal auditory meatus - CN7/8
jugular foramen - CN9/10/11 + jugular v.
hypoglossal canal - CN12
foramen magnum - CN12

cavernous sinus

venous sinus, adjacent to pituitary, sphenoid bone inferior, blood from eye/CTX, drains into internal jugular v.

CN2-6 (incl V1/V2) pass through - if engorged = opthalmoplegia, opthalmic/maxilla sensory loss

CN 12, 5, 10, 11 lesions

CN12 - tongue pushes
CN5 - jaw pushes
CN10 - uvula pulls
CN11 - SCM pulls, trap droops

note all corticobulbar are UMN bilaterally innervated except lower face/CN7 = contralateral

CN5 muscles of mastication

close =
Masseter, teMporalis, Medial pterygoid

open =
Lateral pterygoid

eye and glaucoma

aqueous humor from ciliar body EPITHELIUM -->anterior chamber --> drains via canal of schlemm

glaucoma: incr IOP from aqueous humor, optic disk atrophy, CUPPING

typically affects PERIPHERAL vision, spares central
(unlike macular degeneration which hits central)

- angle = cornea/iris

- open/wide angle: canal of schlemm doesnt drain,
anterior chamber incr IOP, silent/painless
tx: pilocarpine/carbachol - cholinergic agonits,
contracts ciliary m, slack suspensory ligaments,
widen canal of Schlemm, incr drainage
pilocarpine - M3/M2 agonist

can also use Epi, non selective beta block (timolol) + acetazolamide (CA
inhib) to decr secretion from ciliary epithelium, and PG (incr outflow)

- closed/narrow angle: space between iris and cornea doesnt fill anterior chamber --> incr posterior chamber IOP, painful, blindness, rock hard eye, ha, EMERGENCY

can be precipitated by ATROPINE, this is sometimes given for brady/hypotensive MI

cataracts

painless, bilateral opacification of lens, decr vision
think: sorbitol/DM

papilledema

(normal eye image)

incr ICP, elevated optic disk w/ blurred margins

think hydrocephalus, cavernous sinus

EOMs

trochlear/SO - down and in
abducens/LR - laterally

pupil control

constriction/miosis:
pupillary sphincter, parasymp, CN3 edinger-westphal --> ciliary ganglion

dilation/mydriasis:
pupillary dilator, symp, T1-->superior cervical ganglion -->long ciliary nerve

pupil reflex

CN2 --> pretectal nuclei midbrain --> EW n. --> bilateral parasymp vai CN3 --> ciliary ganglion

oculomotor nerve outside is parasympathetic fibers - affected by compression (berry aneurysm, blown pupil)

oculomotor nerve inside is CN to EOM - affected by vascular dz (diabetes/glucose --> sorbitol)

retinal detachment

trauma, diabetes

macular degeneration (age related)

hits fovea/macula - loss of CENTRAL vision
(unlike glaucoma which hits peripheral)
macula - temporal to optic disk, fine detail vision
fovea - center of macula, highest density of cones
and least convergent inputs to bipolar cells

dry/slow = fat deposition (Drusen)
wet/rapid = neovascularization (metamorphosia)

assess with Amsler grid, will see grid distortion in the center

visual field defects

internuclear opthalmoplegia

MLF syndrome in MS
DENUDATION/demyelination OF AXONS in MLF
ipsilateral MR palsy, contralateral LR nystagmus

Alzheimer's dz

decr AcCh hippocampus + n. basalis
beta-amyloid plaques extracellular
tau tangles intracellular

early onset: APP, presnilin1/2
late onset: ApoE4

Picks FTD

dementia, aphasia, personality change
parietal lobe, superior temporal gyrus
tau tangles

Lewy body dementia

PD + dementia + hallucinations
alpha-synulein defect

creutzfeldt-jakob dz

prions, spongiform ctx w/ vaculoes, beta-sheets resistant to proteases

NO inflammation

MS

AI demyelination
scanning speech, intention tremor, nystagmus
initially ASYMMETRIC, disseminated:
optic neuritis (PAIN WITH EYE MOVEMENTS), MLF syndrome, hemiparesis, hemisensory sx, incontinence

IgG in CSF, oligoclonal, suggests Bcell**
(typically normal WBC, but can be elevated, nonspecific)

periventricular demyelinating plaques on MRI
oligodendrocyte apoptosis

tx: beta-IFN, immunosuppress

relapsing remitting, secondary progressive

guillain-barre

inflammatory demyelinating polyradiculopathy, symmetric ascending paralysis, autonomic dysfunction

associated with infections: campylobacter, HSV, CMV, EBV, mycoplasma pneumo

albumin-cytologic dissociation: high protein, without elevated cells

plasmapheresis, IV Ig, resp support

progressive multifocal leukoencephalopathy

demyelinating CNS, oligodendrocyte destruction

JC virus = papova family, latent in immunocompetent hosts, flares up with immunocompromised (HIV, lymphoma/leukemia), SLOW viral infection, progressive demyelination

progressive decline in mental function

acute disseminated post-infectious encephalomyelitis

multifocal perivenular inflammation/demyelination

Zoster, measles

metachomatic leukodystrophy

AR lysosomal storage dz, demyelinating

charcot-marie-tooth dz

hereditary motor/sensory neuropathy, myelin mutation

feet/ankles, high arch, claw toes

subacute combined degeneration of the cord

B12 deficiency, DCMLS + CST demyelination, axon degeneration

SYMMETRIC myelin layer vacuolization and axon degeneration

eg: CANT WALK (BILATERAL)

seizures

parital: 1 brain area (medial temporal), often aura
will get sx restricted to one area, not whole body

simple partial: consciousness intact with motor/sensory change

complex partial: impaired consciousness/aura/post ictal with motor/sensory change

generalized: multiple brain regions

absence (generalized): 3hz, no post-ictal sx

myoclonic (generalized): jerks

tonic (generalized): stiffening on/off

tonic/clonic (generalized)

atonic (generalized): drop seizures

epilepsy: recurrent

febrile seizure: NOT epilepsy

can be breathing deeply after seizure from uncoupling of breathing rhythm --> met acidosis

tx: incr GABA, open Cl channels, hyperpol
barbituates - incr duration of Cl channel opening
benzos - incr frequency of Cl channel opening
valproate: hepatotoxic, neutropenia,
thrombocyotpenia, teratogen
carbamazepine
hepatotoxic, aplastic anemia, agranulocytosis
phenytoin - gingival hypertrophy, teratogen
ethosuximide/lamotrigine - SJ syndrome (bullous erythema multiforme)
phenobarbital+carbamazipine - CYP450 inducer, drug interactions
primidone

headaches

migraine - unilateral, nausea, photophobia, phonophobia...irritation CN5, substanceP
can be associated with menstruation, higher in women, gradual onset with crescendo, pulsatile,
+/- aura
tx: betablock, NSAID, sumatriptan (5HT agonist) for acute, for chronic beta-blocker/verapamil, aceta/indomethacin

tension - bilateral >30mins, NO photphobia or aura, band-like tightness/pressure

cluster - ALWAYS unilateral, periorbital/temporal, lacrimation, runny nose, sweating, more in men, maybe Horners
tx: sumatriptan

SAH - worst headache ever

vertigo

peripheral - inner ear: menieres, semicircular canal, vestibular nerve infection

central - brain stem/cerebellum: tumor

sturge-weber syndrome

aka encephalotrigeminal angiomatosis

neurocutaneous, congenital, port-wine stain (typically in distribution of CNV branch), leptomeningeal angiomas, pheo's, glaucoma, heterochromia of the iris, visual field changes, seizures, hemiparesis

tuberous sclerosis

neurocutaneous, AD TSC1/2 tumor suppressor gene, typically location of denovo two hit determines distribution of ssx
CNS:
hamartomas, subependymal nodules, astrocytomas
cause seizures, MENTAL RETARDATION
retinal hamartoma
skin:
ash-leaf spots: elliptical HYPOpigmented macules
adenoma sebaceum: small angiofibromas typically
malar on face
shagreen patches: firm red raised leathery on back
heart:
cardiac rhabdomyosarcoma
renal:
angiomyolipomas, cysts

neurofibromatosis type 1

aka Von Recklinghausens

inherited PERIPHERAL nervous sx tumors
neural crest derived
neurocutaneous, neurofibromas, cafe au lait spots, Lisch nodules in iris, optic gliomas, pheo's

AD, NF-1, chr17

von hippel-lindau dz

neurocutaneous, AD, VHL tumor suppressor gene, chr 3

diffuse hemangiomas, cavernous hemangiomas in cerebellum/medulla/SC
bilateral retinal hemangioma
cysts and/or neoplasm anywhere - liver, epididymis, pancreas, renal
high risk renal clear cell/retinal carcinoma, pheo's

death by renal cell carcinoma in 40s - watch kidneys

adult brain tumors

typically primary
think progressive HA, weakness, chronic and non-palliating
typically supra tentorial


most common = glioblastoma multiforme
typically in subcortical white matter
astrocyte derived
bad prognosis, GFAP+ astrocytes, can cross corpus callosum, pseudopalisading - crosses corpus collosum, butterfly glioma along vetricles supra tentorial, GFAP positive
NECROSIS essential feature, microvascular proliferation comomon


next = meningioma
in hemispheres, parasagittal typically (leg weakness/spasticity), arachnoid cell orgin penetrating dura, psommoma bodies, spindle cells, benign, slow growing, can present asymptomatic, or hydrocephalus, seizures, etc


next = acoustic schwannoma
local to CN8, cerebellopontine angle, NF-2 associated
tinnitus and unilateral hearing loss
S100+ (neural crest derived)

pituitary adenoma: typically prolactinoma, bitemporal hemianopsia, Rathke's pouch

CNS lymphoma = typically Bcell derived, think AIDS

mets (MORE COMMON than primary CNS tumors):
Lots of Bad Stuff Kills Glia =
lung, breast, skin (melanoma), kidney (renal cell), GI
hematogenous spread - gray/white junctions and watershed areas
ha, siezures, stroke, NV, AMS, personality change,
aphasia, weakness, etc

child brain tumors

kids get tumors typically infra-tentorial

most common = pilocytic astrocytoma
cerebellum/brainstem/hypothalamus/ optic pathways, GFAP+, benign, Rosenthal fingers, spindle cells with hair-like glial processes associated with microcysts, granular eosinophilic bodies

medulloblastoma = malignant cerebellar tumor, hydrocephalus causing, +Rosettes
headaches, vomiting, fatigue, ataxia
primitive neuroectoderm tumor
small, poorly differentiated

ependymoma - hydrocephalus, typically 4th ventricle in kids, spinal in adults
process tapering toward blood vessels

hemangioblastoma - VHL sydrome associated, cerebellum, EPO producing --> polycythemia

craniopharyngioma - benign, supratentorial, Rathke's pouch ectoderm, CALCIFIC, cystic with solid areas, filled with yellow viscous fluid rich in CHOLESTEROL
ssx: ha, growth failure, bitemporal hemianopia

neuroblastomas - most common extracranial solid tumor in kids
undifferentiated, small, round, blue cells
neuropil is pathognomonic, neuron marker stain +
elevated homovanillic acid (HVA) or vanillylmandelic acid (VMA) in UA
N-MYC* chr2

Turcot's syndrome - association between colonic and brain tumors
AD familial adenomatous polyposis - high risk for
medulloblastoma and glioma
hereditary nonpolyposis colorectal carcinoma -
high risk for gliomas

brain germinoma

pineal gland tumor, precocious puberty, obstructive hydrocephalus, Parinaud syndrome (upward gaze paralysis + convergence)

brain herniations with supratentorial mass

- cingulate herniation under falx cerebri, ACA compression

- downward transtentorial herniation

- uncal herniation if in medial temporal lobe
mydriasis, ptosis: CN3 --> levator palpebrae
contralateral hemianopa: PCA compression
ipsilateral paresis: crus cerebri compression
duret hemorrhages: caudal displacement

- cerebellar tonsillar herniation into foramen magnum

if brain stem compressed - coma/death

lesion imaging characteristics

ring enhancing - metastases, abscess/infection, AIDS lymphoma

uniformly enhancing - lymphoma, meningioma

heterogeneously enhancing - glioblastoma

glaucoma drugs

alpha agonists: Epi, brimonidine
decr aqueous humor synthesis from vasoconstriction
mydriasis
NOT for closed angle glaucoma

beta blocker: lol's
decr aqueous humor secretion
no s/e

diuretics: acetazolamide - HCO3 excretion

cholinomimetics: pilocarpine, charbachol, physostigmine
incr outflow of aqueous humor
miosis, spasm
PILOCARPINE in EMERGENCIES

PG: latanoprost
incr outflow of aqueous humor
darkens iris

opiate analgesics

decr synaptic transmission - open K, close Ca
decr AcCh, NE, 5HT, glut, subP

resp depression, miosis, constipation, CNS depression

morphine (mu), enkephalins (delta), dynorphin (kappa)
fentanyl, codeine, heroin, methadone (taper), meperidine (no miosis, Demerol), dextromethorphan (cough), loperamide (diarrhea)

butorphanol

partial opioid agonist, mu-R, for pain without withdrawl

tramadol

weak opioid agonist, works on all NTs, for chronic pain

phenytoin

first line for generalized seizures, also simple + complex partial

first line prophylaxis for status epilepticus

use-dependent Na channel inactivation, decr glut release

do NOT give in pregnancy - teratogen
gingival hyperplasia, SLE syndrome

carbamazepine

first line for generalized seizures, also simple + complex partial

first line for trigeminal neuralgia

Na channel inactivation

s/e: blood dyscrasias/aplastic anemia, SIADH, Steven-Johnson

gabapentin

for simple and complex partial seizures
GABA analog
also peripheral neuropathy, bipolar disorder

phenobarbital barbituate

-arbitals

simple and complex partial, tonic-clonic seizures
incr GABA action, incr Cl conductance DURATION

first line in pregnancy

sedative, anesthesia,

valproate

first line for generalized seizures, also simple and complex partial, myoclonic seizures

incr Na channel inactivation
NMDAR, GABA, K channels too

do NOT give in pregnancy, spina bifida
s/e: hepatotoxicity, neural tube

ethosuximide

first line for absence seizures
T-type Ca channel block

s/e: GI, ha, urticaria, Stevens-Johnson

benzodiazepines (diazepam/lorazepam)

-azepams

first line for acute status epilepticus
also for eclampsia after MgSO4

incr gaba action, incr Cl channel OPENING FREQ

short acting: alpra, TRIAZOLAM, oxa
medium: esta, LORAZEPAM, tema
long (days): chlordiazepoxide, clorazepate, diazepam, flurazepam

THE LONGER ACTING HAVE HIGHER RISKS FOR FALLS IN THE ELDERLY

overdose tx: flumazenil competative antagonist

Steven-Johnson sydrome

malaise, fever, erythema, purpura macules (oral, ocular, genital), epidermal necrosis, sloughing

inhaled anesthesia

lipid soluble to cross BBB or active transport, ideally low solubility in blood

Halothane, NO
cardio suppression, resp depression

mech unknown

s/e: nausea, hepatotoxicity, malignant hyperthermia

IV anesthesia

propofol
rapid induction for short procedures
potentiates GABA

barbituates - thiopental
induction of anesthesia

benzo's - midazolam
adjuct
OD tx: flumazenil

ketamine
PCP analog, blocks NMDARs therefore
glutamate transmission
cardio stimulant, incr cerebral blood flow

opiates
morphine during general anesthesia
OD tx: naloxone

local anesthetics

esters - procaine, cocaine, tetracaine
amides - lidocaine

block activated Na channels

order of block: pain > temp > touch > pressure

NMJ blockers

paralysis in surgery, mechanical ventilation

succinylcholine - depolarizing
antidote: cholinesterase inhibitors

tubocurarine, -urium's - nondepolarizing
competitive AcChR antagonist
antidote: neostigmine

PD drugs

PD has decr Da + incr AcCh

BALSA:

DA agonists:
bromocriptine, L-DOPA/levodopa/carbidopa, amantidine
ergot - bromocriptine, pergolide
non ergot - pramipexole, ropinerole

prevent DA breakdown:
selegiline (MAOB inhibitor, central)
entacapone (COMT inhibitor, peripheral)

anticholinergic:
benzotropine - decr tremor/rigidity

Alzheimers drugs

memantine: NMDAR antagonist
donepezil: AcChE inhibitor

Huntington's drugs

HD has incr DA, decr GABA and AcCh

reserpine + tetrabenaine - decr DA
haloperidol - DA-R antagonist

adrenergic and cholinergic receptor types

alpha1 (NE) - vascular SM, Gq, incr IP3/Ca,
CONTRACTION
agonist - NE, phenylephrine
antagonist - phenoxybenamine, phentolamine,
prazosin
alpha2 (NE) - sympathetic R/GI, Gi, decr AC/cAMP,
RELAX
agonist - clonidine
beta1 (E/NE) - heart, Gs, incr AC/cAMP, incr
CONTRACTION/CO....SA, AV, ventricular m.
agonist - NE, dobutamine
antagonist - propranolol, metoprolol

beta2 (E) - SM/lung, Gx, incr AC/cAMP, RELAX
agonist - albuterol
antagonist - butoxamine, propranolol

nAcChR - preganglionics, adrenal medulla to release E/NE
agonist - carbachol
antagonist - curare, hexamethonium
hexamethonium - ganglion nAcChR blocker, not
NMJ

M1 - CNS
M2 - heart
M3 - glands, SM
antagonist - atropine, mAcChR blocker

key autonomic CNS centers

medulla - vasomotor, resp, swallow, cough, vomit
pons - pneumotaxic
midbrain - micturition
hypothalamus - temp, thirst, food intake

neuron fiber types in PNS

Aalpha
alpha MNs
Ia - spindle afferents
Ib - GTO
Abeta
II - touch/pressure
Agamma
gamma MNs to intrafusal m. fibers
Adelta
III - fast touch, pressure, pain, temp
B
preganglionics
C
postganglionics
IV - slow pain temp

DCMLS

fine touch, pressure, two point, vibration, proprioception
gracilis, cuneatus
second order CROSSES to contralateral thalamus
VPL thalamus - lower body
VPM thalamus - face

pain pathway

nociceptors on free nerve endings, subP NT
inhibited by opioids

referred pain from visceral regions track with overlying somatic nerve segment dermatomes

vision

rhodopsin = opsin protein + retinal molecule (vitA)
vitA deficiency - night blindness
cis-retinal + photon = trans retinal -->
PDE* --> decr cGMP --> close CNG Na channel -->
hyperpolarize --> decr NT release -->
ON center, OFF surround
OFF center, ON surround
depending if glut or GABA

rod/cone - bipolar + horizontal/amacrine - ganglion
optic nerve - LGN thalamus/superior colliculus
occipital lobe
simple cells - bar position/orientation
complex cells - movement/edges

few cones converge on one bipolar for acuity
many rods converge on one bipolar for sensitivity

refractive lens power = diopters, 1/focal distance
emmetropia - normal
hypertropia - farsighted, light focuses behind retina
fix with convex lens
myopia - nearsighted, light focuses in front of retina
fix with concave lens
astigmatism - nonuniform lens curve
fix with cylindric lens
presbyopic - can't accomodate, nearpoint farther away
fix with convex lens

audition

freq - Hz; intensity - dB (log)
middle ear = TM, ossicles MIS, oval window
inner ear = semicircular canal, cochlea, vestibule
perilymph (scala vestibuli) - high Na
endolymph (scala media) - high K

organ of corti sits on basilar membrane
tectorial and basilar membranes --> spiral ganglia --> auditory nerve
inner hair cells - single row, few
out hair cells - parallel rows, many

base of basilar membrane - high f
apex - low f

auditory nerve - lateral lemniscus - inferior colliculus - MGN - ctx
fibers are both crossed and uncross, redundant
contralaterally

vestibular system

semicircular = angular/rotation acceleration
unit is crista ampullaris with cupula filled w fluid
utricle/saccule = linear acceleration + static position
unit is macula with otolithic membrane filled fluid

3 perpendicular semicircular canals + utricle + saccule
filled with endolymph, surrounded by perilymp
hair cells embedded in cupula
kinocilium - single big hair
stereocilia - many small hairs
stereocilia toward kinocilia - excitation
stereocilia away from kinocilia - hyperpolarization

turn head - eyes slowly move in opposite direction, snap back same direction = nystagmus
nystagmus = same direction of rotation
excitation on side toward rotation
inhibition on side opposite rotation

vestibular sx projects to:
4 vestibular nuclei in brainstem
FLOCCONODULAR cerebellum
MLF for eye movements/nystagmus
ctx

test in comatose pt by turning head, if eyes stay fixed with head movement - no vestibular

olfaction

olfactory epithelium receptor cells are TRUE NEURONS
Golf, active - incr cAMP, Na
basal support cells turn over
C fibers - olfactory nerve
trigeminal afferents for painful stim - ammonia
intact with cribiform plate frac because different path

mitral cells in olfactory bulb --> olfactory tract -->
prepiriform cortex

taste

taste buds with microvilli on papillae - NOT NEURONS
ant 2/3 - fungiform papillae, salt/sweet/umami,
facial n. CHORDA TYMPANI branch)
post 1/3 - circumvallate/foliate papillae, sour/bitter
glossopharyngeal n.
post-pharynx/epiglottis - vagus n.

afferents via SOLITARY TRACT to SOLITARY nucleus - VPM thalamus

motor control

MN - fine control, few muscle fibers; large movement, many muscle fibers
small MN - few m. fibers, fire first
large MN - many m. fibers, fire last

force/tension - extrafusal m., recruitment of additional alpha MN MOTOR UNITS

fine adjustments - intrafusal m, gamma MN innervated,+ afferents:
spindles (Ia, II) - intrafusal, detect changes in length
parallel to extrafusal
Ia - velociy change
II - static change

GTO (Ib) - detect changes in tension
series with extrafusal

reflexes

knee - monosynaptic, responds to stretch, Ia, contract
same muscle that was stretched
GTO clasp knife - disynaptic, responds to contraction,
Ib, relaxes agonist muscle (opposite of knee jerk),
contracts antagonist muscle
pain withdraw - polysynaptic, responds to pain,
II/III/IV, ipsilateral flex, contralateral extend

note Renshaw cells in ventral SC - recurrent inhibition, prevent refiring same MN

UMN tracts in SC

pyramidal tracts - coticospinal/corticobulbar

extrapyramidal tracts -
rubrospinal - red n, lateral SC stim flex, inhibit
extensor
lesion above - tonic posturing of neck
pons reticulospinal - ventromedial SC, stim flex and
extensors
lesion - tonic rigidity
medulla reticulospinal - intermediate gray SC,
inhibits flex and extend
vestibulospinal - stim extend, inhibit flex
lesion - tonic rigidity, ataxia
tectospinal - superior colliculus, to cervical SC,
controls neck

key SC lesions

C7 - loss of symp tone to heart
C3 - breathing stops, loss of phrenic control
C1 - death

cerebellum

layers:
inner: granular, filters mossy fiber afferents
middle: Purkinje, inhibitory output
outer: molecular, stellate/basket cells, parallel fibers

inputs:
inf. olive --> climbing fibers --> synapse on Purkinje
complex burst spiking, condition Purkinje
all brainstem/SC --> mossy fibers --> synapse on
Purkinje
simple spikes

outputs: PURKINJE ONLY, INHIBITORY GABA to deep
nuclei and vestibular nuclei
vestibular - balance, eye movement
pons - planning/initiation of movement
SC - rate/force/direction of movement

cerebellum disorder = ataxia, can't rapid alternate movements (dysdiadochokinesia), intention tremor

motor ctx

premotor/supplementary - generate plan for movement, supplementary programs complex sequences

primary motor - execution of movement, motor homunculus, epilepsy

EEG

beta waves = awake, eyes open
alpha waves = awake, eyes closed
slow waves = sleep

sleep

circadian rhythm driven by suprachiasmatic n. hypothalamus, receives input from retina

REM - EEG has awake patterns, loss of muscle tone, pupillary constrict, penile erection

benzodiazepines and incr age - decr REM sleep

hemisphere functions

right - facial expression, spatial tasks

left - language
Wernicke = sensory/understanding aphasia
Broca = motor/speaking aphasia

BBB and CSF

barrier between cerebral capillary blood and CSF
capillary endothelium + choroid plexus epithelium
lipids, gases, and water diffuse unimpeded

CSF ~ blood except
low in K, Ca, glucose, C, protein
high in Mg, creatinine

normal CSF: clear, colorless, low WBC, low protein, low glocose

bac meningitis CSF: cloudy, PMNs, high protein, low glucose

viral meningitis: clear/cloudy, elevated WBC with lymphocyte predominance, mildly elevated protein, normal glucose

SAH CSF: frank blood, xanthochromic, RBC, slightly elevated protein, normal glucose

space occupying lesions can incr CSF opening pressure

temperature regulation

anterior hypothalamus:
integrates core temp inputs and compares this to
set-point
pyogens incr set-point: high IL1 --> incr PG
ASA --> block COX/decr PG --> decr set
point/fever
steroid --> block AA from PL --> decr PG --> decr
set point/fever

heat generators:
TH --> incr BMR
sympathetic --> brown fat*
posterior hypothalamus --> MN --> shivering

heat shunters:
anterior hypothalamus --> decr symp tone -->
dilates vessels, AV shunting
symp mAcChR in sweat glands

heat exhaustion - excessive sweating with volume loss
heat stroke - temp reaches point of tissue damage,
impaired heat control mechanisms

malignant hyperthermia - rxn to anesthetics, heat production by skel muscle, incr O2 intake

spinal shock

SC transection --> temporary loss of all local reflexes below the lesion

anesthesia stages

stage 1 = analgesia, conscious

stage 2 = excitement, delirium, violent behavior, incr BP/resp/HR, retching, vomiting, etc

stage3 = no eye movement, fixed pupils, regular resps, relax skel muscle

stage 4 = resp depression, decr vasomotor

inhaled anesthetics

MAC = minimum alveolar concentration, required to stop movement in 50% of pts = potency
small MAC = more potent
MAC values are additive, use lower dose if combo
MAC is lower in elderly, use lower dose
blood/gas partition coefficient = solubility in blood
high coefficient incr time to induction/recovery bc
blood holds onto anesthetic instead of dumping it
into the brain
lipid soluble = more bioavailable

inhaled anesthetics decr response to PCO2, incr ICP, relax SM

many are halogenated hydrocarbons, except NO

- halothane - smallest MAC, high blood/gas partition
decr HR, decr renal/hepatic perfusion
risk of MALIGNANT HYPERTHERMIA, can be familial
antidote = DANTROLENE
risk of hepatitis, but not in kids
risk of arrhythmias
- NO - largest MAC, low blood/gas partition
coefficient, expands trapped gas
- isoflurane (-fluranes) - incr bronchiolar secretions,
bronchiolar spasms, incr HR

IV anesthetics

propofol - rapid induction and recovery, only short
procedures, antiemetic
fentanyl - opiod
risk of chest wall rigidity
ketamine - blocks NMDARs
causes dissociative amnesia (unconcious, but looks
awake)...delirium, hallucinations, incr cerebral BF
heart stimulant, vivud dreams, hallucinations
midazolam - benzodiazepine
anterograde amnesia
Flumazenil - antidote for resp depression
thiopental - barbituate, for induction
(decr cerebral blood flow, resps, and BP)
risk of laryngospasm - watch in asthmatics
etomidate - very CARDIAC STABLE

local anesthetics

locals are weak bases - inhibit Na channels
active in ionized form to bind Na channels
all vasodilate except cocaine
most sensitive: small, myelinated fibers, w/ high
firing rate (types B/C)
s/e (more common in esters): hypotension (not
cocaine), nystagmus, seizures, dizzy, atopy
amide: lidocaine/prilocaine
>1 "i" in name
metabolized by amidases in liver
esters: cocaine/benzocaine/procaine
1 "i" in name
metabolized by esterases in tissues/blood
note cocaine is the only drug that vasoconstricts

can use with epinephrine in combo to locally vasoconstrict and limit systemic effects
BUT do not use in digits, nose, ears, penis..end
arteries

opioids

works best for persistent pain
POMC derived - POMC enzymatic cleavage
(ACTH, MSH are also from POMC)

endogenous:
enkephalin - binds delta-R
dynorphin - binds kappa-R
betaendorphin - binds mu-R
opioid-Rs in:
midbrain - periaqueductal gray, activates raphae n.,
descending inhibition
dorsal SC: primary afferents, inhibits subP

opioid-R's: GPCRs
presynaptic opioid-R's: inhibit Ca flux, decr NT release
postsynaptic opioid-R's: incr K efflux, hyperpolarize

prototype: morphine
incr histamine degranulation from mast cells -->
hypotension, pruritis
incr ICP, head trauma contraindicates
decr peristalsis --> constipation
use loperamide, diphenoxylate for diarrhea
incr tone biliary, bladder, ureter
except meperidine
incr urinary retention - incr ADH
decr uterine contractions
miosis - seen in OD, incr parasymp pupil constrictor*
except meperidine
incr emesis - chemoR trigger zone* in area postrema
resp depression - decr sensitivity of CO2 sensors
common cause of death
antidote = naloxone, mu-R antagonist

dextromethorphan - for cough, a synthetic
heroin and fantanyl - highly lipid, cross BBB fast
morphine is least lipo
clonidine for heroin withdrawl - alpha2 agonist
naltrexone - for alcoholics, decr cravings
methadone - synthetic, for withdrawl and rehab
meperidine - synthetic

weak opiates: codeine, tramadol
partial agonists: buprenorphine, butorphanol

morphine metabolized by phase II
tolerance not developed for: constipation, miosis

withdrawl ssx: tears, runny nose, diaphoretic, anxiety, pain, diarrhea

do not give meperidine or dextromethorphan with MAOIs --> seratonin syndrome

opioids

works best for persistent pain

endogenous:
enkephalin - binds delta-R
dynorphin - binds kappa-R
betaendorphin - binds mu-R
opioid-Rs in:
midbrain - periaqueductal gray, activates raphae n.,
descending inhibition
dorsal SC: primary afferents, inhibits subP

opioid-R's: GPCRs
presynaptic opioid-R's: inhibit Ca flux, decr NT release
postsynaptic opioid-R's: incr K efflux, hyperpolarize

prototype: morphine
incr histamine degranulation from mast cells -->
hypotension, pruritis
incr ICP, head trauma contraindicates
decr peristalsis --> constipation
use loperamide, diphenoxylate for diarrhea
incr tone biliary, bladder, ureter
except meperidine
incr urinary retention - incr ADH
decr uterine contractions
miosis - seen in OD, incr parasymp pupil constrictor*
except meperidine
incr emesis - chemoR trigger zone* in area postrema
resp depression - decr sensitivity of CO2 sensors
common cause of death
antidote = naloxone, mu-R antagonist

dextromethorphan - for cough, a synthetic
heroin and fantanyl - highly lipid, cross BBB fast
morphine is least lipo
clonidine for heroin withdrawl - alpha2 agonist
naltrexone - for alcoholics, decr cravings
methadone - synthetic, for withdrawl and rehab
meperidine - synthetic

weak opiates: codeine, tramadol
partial agonists: buprenorphine, butorphanol

morphine metabolized by phase II
tolerance not developed for: constipation, miosis

withdrawl ssx: tears, runny nose, diaphoretic, anxiety, pain, diarrhea

do not give meperidine or dextromethorphan with MAOIs --> seratonin syndrome

anxiolytics and sedatives

action sequence: sedation-anxiolysis-hypnosis-
anesthesia-medullary depression-coma

ethanol - metabolized by alcohol dehydrog to
acetaldehyde, then acetaldehyde dehydrog to acetate
ha/hypotension/NV hangover - from acetaldehyde
disulfiram - inhibits acetaldehyde dehydrog, incr
acetaldehyde, for neg conditioning

GABA
GABA-R has 5 subunits, GABA binds alpha
incr Cl influx, K efflux --> hyperpol
benzodiazepines bind gamma, need GABA to activate
incr FREQ of Cl channel opening
barbituates bind beta, need GABA to activate
incr DURATION of Cl channel opening
baclofen - binds GABA-B, muscle relaxant

benzo's:
prototype - chlordiazepoxide
diazepam, lorazepam - long acting
midazolam, triazolam, oxazepam - short acting
roofie = flunitrazepam
anticonvulsants = diazepam, clonazepam
alcohol withdrawl tx: long acting benzo's
sleep aids: temaepam, triazolam
anxiolytics: diazepam, lorazepam...long acting

benzo s/e: obtunded, ataxia, amnesia, decr resp
benzo withdrawl: insomnia, anxiety, agitation, seizure
benzo antidote: flumazenil - benzo-R antagonist
benzo OD: add barbituates and alcohol

non-benzo sleep aids (made for this action only):
eszopiclone, zolpidem (ambien), zaleplon
antidote = flumazenil

barbituates
phenobarbital, pentobarbital - long acting
ambobarbital, secobarbital - short acting
for sedation, hypnosis
thiopental - ultrashort acting, induce anesthesia

barbituates for seizures - partial, generalized,
tonic/conic
CYP450 inducing
barbituate s/e: obtunded, resp/cardio depression,
addiction
barbituate withdrawl: insomnia, tremor, anxiety, NV, seizures
prevent with long acting benzos

anxiolytics and sedatives

action sequence: sedation-anxiolysis-hypnosis-
anesthesia-medullary depression-coma

ethanol - metabolized by alcohol dehydrog to
acetaldehyde, then acetaldehyde dehydrog to acetate
ha/hypotension/NV hangover - from acetaldehyde
disulfiram - inhibits acetaldehyde dehydrog, incr
acetaldehyde, for neg conditioning

GABA
GABA-R has 5 subunits, GABA binds alpha
incr Cl influx, K efflux --> hyperpol
benzodiazepines bind gamma, need GABA to activate
incr FREQ of Cl channel opening
barbituates bind beta, need GABA to activate
incr DURATION of Cl channel opening
baclofen - binds GABA-B, muscle relaxant

benzo's:
prototype - chlordiazepoxide
diazepam, lorazepam - long acting
midazolam, triazolam, oxazepam - short acting
roofie = flunitrazepam
anticonvulsants = diazepam, clonazepam
alcohol withdrawl tx: long acting benzo's
sleep aids: temaepam, triazolam
anxiolytics: diazepam, lorazepam...long acting

benzo s/e: obtunded, ataxia, amnesia, decr resp
benzo withdrawl: insomnia, anxiety, agitation, seizure
benzo antidote: flumazenil - benzo-R antagonist
benzo OD: add barbituates and alcohol

non-benzo sleep aids (made for this action only):
eszopiclone, zolpidem (ambien), zaleplon
antidote = flumazenil

barbituates
phenobarbital, pentobarbital - long acting
ambobarbital, secobarbital - short acting
for sedation, hypnosis
thiopental - ultrashort acting, induce anesthesia

barbituates for seizures - partial, generalized,
tonic/conic
CYP450 inducing
barbituate s/e: obtunded, resp/cardio depression,
addiction
barbituate withdrawl: insomnia, tremor, anxiety, NV, seizures
prevent with long acting benzos

sleep aids OTC

sedating antihistamines

diphenhydramine, doxylmine, hyrdroxyzine

sleep aids OTC

sedating antihistamines

diphenhydramine, doxylmine, hyrdroxyzine

antidepressants used for sedation and hypnosis

trazodone, amitriptyline = TC antidepressants, incr 5HT

partial agonist of 5HT1A-R, for generalized anxiety disorders

buspirone
NO SEDATION, no addiction, no tolerance, no withdrawl
not anticonvulsant, not muscle relaxant

takes 1-2 weeks

partial agonist of 5HT1A-R, for generalized anxiety disorders

buspirone
no sedation, no addiction, no tolerance, no withdrawl
not anticonvulsant, not muscle relaxant

takes 1-2 weeks

MAOI antidepressants

depression - biogenic amine theory = low 5HT, NE
MAO-A = inactivates 5HT, NE
MAO-B = inactivates NA
nonselective MAOIs --> incr 5HT, NE, DA
tranylcypromine, phenelzine, isocarboxazid
for atypical depression, takes weeks to work, wait
weeks before switching
s/e: orthostatic hypotension, blurry vision,
constipation, urinary retention, drowsy

selective MAO-B inhibitor - Selegiline, for PD

serotonin syndrome - opiate + MAOI
rigidity, diaphoresis, hyperthermia, seizure
+dextromethorphan - cough
+meperidine - analgesic

hypertensive crisis - MAOI + tyramine (ingested)
htn, ha, tachy, NV, stroke, arrhythmia

MAOI antidepressants

depression - biogenic amine theory = low 5HT, NE
MAO-A = inactivates 5HT, NE
MAO-B = inactivates NA
nonselective MAOIs --> incr 5HT, NE, DA
tranylcypromine, phenelzine, isocarboxazid
for atypical depression, takes weeks to work, wait
weeks before switching
s/e: orthostatic hypotension, blurry vision,
constipation, urinary retention, drowsy

selective MAO-B inhibitor - Selegiline, for PD

serotonin syndrome - opiate + MAOI
rigidity, diaphoresis, hyperthermia, seizure
+dextromethorphan - cough
+meperidine - analgesic

hypertensive crisis - MAOI + tyramine (ingested)
htn, ha, tachy, NV, stroke, arrhythmia

TCA antidepressants

inhibits 5HT + NE reuptake
amitryptiline, imipramine, clomipramine
metabolites specifically inhibit NE reuptake:
amitryptiline-->nortriptyline
imipramine-->desipramine
for migraines and neuropathic pain - amitriptiline
for OCD - clomipramine
for pediatric nocturnal enuresis - imipramine
incr bladder spincter contraction
takes weeks

more s/e with TCA than SSRI
s/e:
central/peripheral mAcChR block - tachy,
delirium, dilated, flushing, hyperthermia
ileus, urinary retention
alpha1R inhibition - peripheral vasodilate,
orthostatic
cardiac fast Na channel inhibition -
conduction defects, arrhythmias,
hypotension
NE/5HT reuptake inhibition - seizure,
tremor
histamine R inhibition - sedation

TCA antidepressants

inhibits 5HT + NE reuptake
amitryptiline, imipramine, clomipramine
metabolites specifically inhibit NE reuptake:
amitryptiline-->nortriptyline
imipramine-->desipramine
for migraines and neuropathic pain - amitriptiline
for OCD - clomipramine
for pediatric nocturnal enuresis - imipramine
incr bladder spincter contraction
takes weeks

more s/e with TCA than SSRI
s/e:
dry mouth, blurry vision, urinary retention,
constipation, glaucoma, arrhythmia, seizure, tachy,
sedation
toxicity: coma, convulsions, cardiotoxicity
antidote - activated charcoal, Nabicarb
also inhibit other receptors:
anticholinergic - inhibits mAcChR
blocks adrenergicR
blocks histamineR

atypical antidepressants

trazodone/nefazodone - 5HT reuptake inhib
s/e: priapism

bupropion - incr DA, 5HT, NE by unknown
also for smoking cessation, OCD
does not affect sexual function like SSRI
contraindicated in epilepsy - decr seizure threshold

mirtazapine - s/e is weight gain

yohimbine - also for erectile dysfunction, alpha2 antagonist

atypical antidepressants

trazodone/nefazodone - 5HT reuptake inhib
s/e: priapism

bupropion - incr DA, 5HT, NE by unknown
also for smoking cessation, OCD
does not affect sexual function like SSRI
contraindicated in epilepsy - decr seizure threshold

mirtazapine - s/e is weight gain

yohimbine - also for erectile dysfunction, alpha2 antagonist

SSRI/SNRI antidepressants

SSRIs: fluoxetine, paroxetine, sertraline, citalopram
floxetine - longest acting, also for premenstrual
dysphoric disorder, bulimia, OCD, panic, mutilism
citalopram, sertraline - fewest drug interactions

big s/e: sexual dysfunction
also, agitation, anxiety, seizures, NVD, sedation,
serotonin syndrome
CYP450 inhibitor
DO NOT cause arrhythmias like TCA

paroxetine - also for social/generalized anxiety, PTSD
venlafaxine - s/e is htn
duloxetine - SSNRI (5HT and NE)

SSRI/SNRI antidepressants

SSRIs: fluoxetine, paroxetine, sertraline, citalopram
floxetine - longest acting, also for premenstrual
dysphoric disorder, bulimia, OCD, panic, mutilism
citalopram, sertraline - fewest drug interactions

big s/e: sexual dysfunction
also, agitation, anxiety, seizures, NVD, sedation,
serotonin syndrome
CYP450 inhibitor
DO NOT cause arrhythmias like TCA

paroxetine - also for social/generalized anxiety, PTSD
venlafaxine - s/e is htn
duloxetine - SSNRI (5HT and NE)

bipolar aka manic depression drugs

Li - unknown MoA, narrow therapeutic window
eliminated by KINDEY, like Na, follows Na
in kidney
toxicity exacerbated by low Na, thiazides,
ACE-I, NSAIDs (NOT loop diuretics)

s/e:
nephrogenic diabetes insipidus (ADH antagonist)
baby of mom using Li - Ebstein anomaly, tricuspid
valve malformation
hypothyroid (inhibs 5-deiodinase), tremor,
acne, seizures, ataxia
coadmin with amiloride for d. insipidus

carbamazepine, valproic acid, benzos, gabapentin, topiramate

bipolar aka manic depression drugs

Li - unknown MoA, narrow therapeutic window
eliminated like Na, follows Na in kidney
toxicity exacerbated by low Na
s/e:
nephrogenic diabetes insipidus (ADH antagonist)
baby of mom using Li - Ebstein anomaly, tricuspid
valve malformation
hypothyroid (inhibs 5-deiodinase), tremor,
acne, seizures, ataxia
coadmin with amiloride for d. insipidus

carbamazepine, valproic acid, benzos, gabapentin, topiramate

antipsychotics

block central D2Rs

schizophrenia psychosis - excess DA
positive sx: hallucinations, delusion
negative sx: flat affect, social withdrawl, speech prob

typical antipsychotics - inhibit DA-R in mesolimbic sx
haloperidol, chlorpromazine, thioridazine
also for Tourettes - haloperidol
extrapyramidal sx: PD like - dystonia, akinesia
(motor restlessness), rigid, tremor, bradykinesia,
tardive dyskinesia (from DA-R hypersensitivity)
prolactinemia (inhib DA-R in ant. pituitary)
s/e mostly haloperidol b/c strongest
thioridazine + chlorpromazine - less extrapyramidal
sx because also anticholinergic (mAcChR)...but
other sx --> dry mouth, blurry vision, constipated
tx extrapyramidal sx with benzotropine, amantidine,
diphenydramine (anticholinergics)
chlorpromazine - for intractable hiccups
thioridazine s/e: priapism, agranulocytosis, blue-
gray skin, seizures
chlorpromazine - low potency, NON neuro s/e
haloperidol - high potency, NEURO s/e

atypical antipsychotics - inhibit 5HT-Rs
first line bc less s/e
risperidone, clozapine, aripiprazole, olanzapine
mostly for neg sx
clozapine - third line, for intractable shizophrenia
s/e: agranulocytosis (low WBC), seizure, sialorrhea
risperidone s/e: gynecomastia,
PROLACTINEMIA --> AMENORRHEA,
weight gain
clozapine + olazapine - cause weight gain

life threatening s/e: neuroleptic malignant syndrome
ssx: fever, rigid, AMS, cardio instability
tx: dantrolene + bromocriptine (DA agonsits)

antipsychotics

schizophrenia psychosis - excess DA
positive sx: hallucinations, delusion
negative sx: flat affect, social withdrawl, speech prob

typical antipsychotics - inhibit DA-R in mesolimbic sx
haloperidol, chlorpromazine, thioridazine
also for Tourettes - haloperidol
extrapyramidal sx: PD like - dystonia, akinesia
(motor restlessness), rigid, tremor, bradykinesia,
tardive dyskinesia (from DA-R hypersensitivity)
prolactinemia (inhib DA-R in ant. pituitary)
s/e mostly haloperidol b/c strongest
thioridazine + chlorpromazine - less extrapyramidal
sx because also anticholinergic (mAcChR)...but
other sx --> dry mouth, blurry vision, constipated
tx extrapyramidal sx with benzotropine, amantidine,
diphenydramine (anticholinergics)
chlorpromazine - for intractable hiccups
thioridazine s/e: priapism, agranulocytosis, blue-
gray skin, seizures

atypical antipsychotics - inhibit 5HT-Rs
risperidone, clozapine, aripiprazole, olanzapine
mostly for neg sx
clozapine - third line, for intractable shizophrenia
s/e: agranulocytosis (low WBC), seizure, sialorrhea
risperidone s/e: gynecomastia,
PROLACTINEMIA --> AMENORRHEA
clozapine + olazapine - cause weight gain

life threatening s/e: neuroleptic malignant syndrome
ssx: fever, rigid, AMS, cardio instability
tx: dantrolene + bromocriptine (DA agonsits)

PD drugs

PD = low DA, high AcCh in sub. nigra and striatum
bradykinesia, rigidity, tremor, gait, posture

anti muscarinics (mAcChR)
for tremor + rigidity, not bradykinesia
benztropine, tirhexyphenidyl
s/e: dry mouth, blurry vision, constipation, mydriasis

incr DA
amantidine - DA reuptake inhib, incr DA release
also for influenza A
helps with bradykinesia, not tremors
s/e: livedo reticularis - patchy red macules
selegiline - MAO-B inhibitor
selegiline metabolized to amphetamines
s/e: stim heart
ergots
bromocriptine, pergolide
bromocriptine also for prolactinoma
s/e: ha, dizzy, N, orthostatic, dyskinesia,
hallucinations, pschosis
non-ergots - preferred over ergots
pramipexole, ropinirole
s/e: sedation, syncope, NV, hallucinations,
dyskinesia
levodopa - precursor to DA that crosses BBB (unlike
DA)
not useful in very advanced dz bc need DA neuron
to convert to DA
on/off effect - move, then frozen
apomorphine is antidote - fast acting DA agonist
s/e: anorexia, NV, tachy, discolored urine/saliva,
hallucination, mydriasis, dyskinesia, incr IOP
dont coadmin with vitB6 - incr levodopa metabo

anti-metabolics
DDC inhibitor - inhibs levodopa to DA metabolism
carbidopa, first line, acts PERIPHERALLY
COMT inhibitor - inhibs L-dopa metabolism
tolcapone, entacapone
s/e: brown-orange urine, hallucinations, ND,
cramps
tolcapone - hepatotoxic

See More

Flickr Creative Commons Images

Some images used in this set are licensed under the Creative Commons through Flickr.com. Click to see the original works with their full license.

Please allow access to your computer’s microphone to use Voice Recording.

Having trouble? Click here for help.

We can’t access your microphone!

Click the icon above to update your browser permissions above and try again

Example:

Reload the page to try again!

Reload

Press Cmd-0 to reset your zoom

Press Ctrl-0 to reset your zoom

It looks like your browser might be zoomed in or out. Your browser needs to be zoomed to a normal size to record audio.

Please upgrade Flash or install Chrome
to use Voice Recording.

For more help, see our troubleshooting page.

Your microphone is muted

For help fixing this issue, see this FAQ.

Star this term

You can study starred terms together

NEW! Voice Recording

Create Set