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Week 5 LOs
Terms in this set (68)
What does it mean if pupils are miototic?
Describe the basic physiologic mechanisms controlling pupillary size.
When shine light into eye the retina and optic nerve will carry the sensory info (afferent) via CN II (optic nerve) to the pretectum-->Edinger Westphal subnucleus-->parasympathetic info via CN III will travel out and-->ciliary ganglion-->pupilo constrictor
What is the normal response to the light reflex?
both pupils should constrict
What is the pathway and response to the accomodation reflex?
place finger like going to make cross-eyed:
-pupils should mitotic (constrict-get small)
-should get convergence of eyes
-should get thickening of lens
What is the pathway and response of the ciliospinal reflex?
pinch the back of neck and should get dilation of pupils (test sympathetics)
hypothalamus-->down and out spinal nerves-->cross up and over lung via subclavian-->in superior cervical ganglion where it will branch and send off info to make face sweat
Another branch with internal carotid-->go up to V1 (long ciliary)-->pupillary dilator and
(pull eyelid) and also to pain and crying (lacrimal gland??)
If someone has one large pupil what could this be? and it doesn't respond to
CN III palsy-->from uncal herniation or aneurysm compressing just the parasympaethics on CN III
What is the presentation of Horner's syndrome?
-ptosis= dropping eyelid (muller's muscles)
-mitosis= pupils are constricted
-anhidrosis= no sweat on one side of face
What is the presentation of Arygll Robertson pupil?
small pupils-->react to respnses that are near but not to light??
What is the presentation of Adie's tonic pupil?
-one large unequal pupil
poor reaction to light but will respond to convergence
What are some of the classic signs of meningitis?
-Brudinski sign (lift head and bring knees to chest)
Learn the common bacterial organisms by age and treatment
infants & older adults= gram - bacilli, E.coli, Klebsiella, Grou B strep. H.influenzae, listeria (when older)
Kids & Adults= Neisseria, S.pneumo
Parasitic= cysticerosis, toxoplasmosis, cerebral malarai
1) what are the treatment options for bacterial meningitis?
2)What are some of the deficits survivors can have or complications?
1)infants & older adults= ampicillin + cefotaxime or aminoglycoside
Kids & adults= vancomycin + 3d gen. cephalosporin
2)encephalisis, hearing loss, cognitive impairments, swelling of brain, hydorocephalus, stroke, herniation, venous sinus thrombosis
What is unique in the treatment of brain abscess?
the fibrous capsule makes it less susceptible to antibiotics so usually have to treat with surgery PLUS antibiotics
What is the treatment for viral meningitis?
What is the one viral cause that you should be wary of?
BUT if HSV-->do acyclivr
if influenza-->give tx
be wary of HSV
What lobe of the brain is common site of infection of viral encephalitis?
If someone comes in with encephalitis (more mental status changes) and it is summer what cause should you think about?
west nile virus caused by mosquito
ZIKa can also cause encephalitis more worldwide
SAMe with COVId can cause encephalitis
If someone comes in with fever, signs of a systemic infection and then become paralyzed what type of infection should you think of?
West nile virus causing myelitis (spinal cord)
If someone presents with a slow developing meningoencephalitis with enlarged ventricles what type of infection should you think about?
What conditions should you be wary of when doing a lumbar puncture?
What does an elevated pressure on lumbar puncture indicate (normal=10-20 cm H2O)?
-coagulopathy (long PT/INR)
-elevated ICP (CT head)
Elevated pressures= bacterial and fungal
What are the CSF findings from lumbar puncture that indicate bacterial infection vs. viral?
Bacterial= increase in PMNs and low glucose
Viral= increase in lymphocytes, normla glucose
Vaccinations in what diseases caused a large decrease in neuroinfectious diseases?
Describe the various structures or condition in the brain that can cause pain.
CN: III, V, VII, IX, X
Venous sinuses and dura (esp. at baes)
Whenever you get distortion or stretching of pain sensitive structures mentioned above-->from ICP (ex)
Inflammation in subarachnoid space can also cause pain (infection, hemorrhage, vasculitis, meds-NSAIDs, HTN)
What is a common site of referred pain in the head?
Trigeminal nerve-->commonly on V1
Review the red flags of headaches as they apply to subarachnoid hemorrhage, tumors, infection.
What is the pneumonic?
-fever, weight loss
-onset: thunderclap headaches
-headache that lasts more than 72hrs or progresses
S=systemic: wt loss, fever, jaw claudication
N=neurologic sx (ataxia, diplopia, tinnitis)
O=onset age (>65)
P=phenotype (trigeminal autonomic, sex-induced)
If a 55 year old women comes in with temporal headache, fever, jaw claudication, and vision loss what should you think of?
Giant cell arthritis:
Treat with prednisone (to prevent blindness) and need to get a biopsy
May also see: anemia, may have shoulder/arm pain, elevated ESR
1)What is the most common demigraphic to see idiopathic intracranial HTN headaches in?
1)women in child-bearing age who are overweight
If someone has pretty constant headaches who has normal neurologic exam and imaging but you do a lumbar puncture and they have high ICP (>28 mmHg) what type of headache is this?
Idiopathic intracranial HTN-->most common in women who are child-bearing age
May also see obscurations-blindness/blurry when standing, double vision, visual field loss, pulsatile tinnitus
Papilledeam-->increase in blind spot
If somone's headache is better when they are laying down but worse when they stand, what type of headache?
Intracanial hypotension (aka CSF leak)
When sleep-->hypoventilate-->increase CO2-->blood vessels in brain dilate-->increase ICP-->strech brain structures-->headache
If someone has episodic headaches that are unilateral and tend to be severe and throbbing and don't like light or sound what type might this be?
Family hx, childhood of motion sickness
Describe what a migraine aura is.
Waves of deep depolarization (3mm/min) that cause the neruons to not work properly
Can cause activation of trigeminal fibers or cause visual or somatosensory dysfunctions
What are some treatment options for acute management of migraines?
Can also do prophlyactic meds: if have more than 8 headaches days/month (BB, amitriptyline)
Ibuprohen (start early), ASA, Naproxen
Triptans-->selective steratonin receptor agonist
Calcitonin gene related protein monoclonal antibodes
What constitutes as a medication overuse/rebound headaches?
when you have chronic headaches and end up taking medication for it more than 3x/week over many weeks
Describe what trigeminal neuralgia is and some treatment and what can be triggers?
Paraxoysmal (seconds) of
facial pain and distruption of trigmeinal nerve
Can activate or tigger by chewing, talking, brushing teeth
Etiology: idiopathic, compression, demylination (MS)
Tx: carbamazepine, TCAs, Gabapentin, surgical decompression
Actions of superior oblique
Actions of superior rectus
Actions of inferior rectus
Actions of inferior oblique
Superior rectus= elevate, adduction, intorsion
Inferior rectus= depression, extorsion, abduction
Inferior oblique= elevation, adduction, extorsion
What muscles cause extorsion?
inferior recuts and oblique
What is the classic presentation of CN III palsy?
-can't elevate, depression, or look in (medially)
-can't elevate eyelid
-can't constrict pupils
-convergence affected (worse with near gaze)
People looking down and out
What are some causes of isolated CN III palsy?
-Microvascular: DM, HTN, tobacco use
-Aneurysm: compression by posterior communicating artery-->esp. think about if older and if have huge pupils
-brain herniation from elevated ICP
Classic presentation of trochlear nerve (IV) palsy?
What is the most common cause of it?
this nerve decussates
* so identify the eye and then whatever eye it is-->it is the opposite side
-eye affecetd is deviated upward (hypertrophic)
-trouble seeing down so walking down the stairs
-if do chin tuck, the person will tilt their head away from the affected eye (will elevate and extorted) becuase will try to correct
What is the presentation of abducens nerve palsy?
What are common causes of this?
can't abduct the affected eye
common causes: small vessel disease, increase ICP, trauma
**can be first affected CN with damage or infecrtion to canvernous sinus-->esp. ICA
If someone has an enlargement of ICA at the cavernous sinus what CN is most likely gonna be affected first?
Abducens (lateral rectus)
vs. posterior communicating artery aneruysm is CN III (esp. parasympathetics)
If you take out the abducens nucleus it also has other elements (so what might you see on exam)?
affect conjugate horizontal gaze on that side
If someone has one eye that is deviating to the lateral side, what might be the lesion?
INO: lesion to medial longitudinal fasciculus (MLF) that has fibers for abducens-->lesion of an MLF will generate an ipsilateral internuclear ophthalmoplegia (INO)-->ipsilateral eye adduction is weak/absent
also may see contralateral nystagmus with abduction
Some diseases that affect vertical gaze:
-progressive supranuclear palsy (PSP), midbrain atrophy
-locked-in syndrome, large pontine infact
-dorsal midbrain syndrome (Parinaud's) due to pineal tumor, hydrocephalus
If someone has upgaze impairment, large pupils (can converge but won't respond to light), bilateral lid retraction or ptosis, impaired convergence-->indicate dorsal midbrain syndrome probs pineal tumor
How do you tell the difference between a lesion in the abducens nucleus vs. paramedian pontine reticular formation (PPRF)
Ex: if have lesion on R side
both will have right lateral gaze palsy (eye deviate medially??) but PPPRF will have VOR reflex affected
Can still or not do VOR when in coma?
Can still do VOR if in coma but if brain dead then not able to
Doll's eye relfex: in coma patient move head to one side and eyes should correct in opposite direcrtion but if something wrong and move head and eyes won't correct or move
What is a clinical finding consistent with a central etilology?
Ex of central causes of vertigo: MS, tumor, Chiari malformation (downbeat nystagmus &
nystagmus in all directions
How do you diagnose BPPV and treat ?
Dix-Hallpike maneuver: layback with head tiled and if have then will see upbeat torsional nystagmus
Treat with Epley maneuver
If someone has a rapid onset of vertigo, nausea, balance problems and no ataxia in appendes
They also have horizontal nystagmus that beats toward side that is
What side (affected or unaffected) does the nystagmus for vestibular neruitis?
beat toward unaffected side
What is the head impulse test used for?
looks for a peripheral vestibular nerve lesion-->tests vestiublar ocular response
A positive test is abnormal= when see corrective saccade
What is a good way to distinguish between central and peripheral lesions for vertigo?
head impulse test
What disease can cause someone to randomly drop down to the ground?
Also can see vertigo, hearing loss, tinnitius and aural fullness?
What is the pathophys.??
Excess endolymph (high K+)
think of Meniere dieases-->drop down unconscious
What type of hearing is associated with Meniere disease?
What testing do you need?
sensorineural hearing loss
Need MRI to rule out vestiublar schwannoma
Betahistine (analogue of histamine)
Hearing + tinnitus= what type (central vs. peripheral vertico causes?)
direction changing nystagmus= what type (central vs. peripheral vertico causes?)
Dysarthria, dysphagia, diplopia, numbness or weakness= what type (central vs. peripheral vertico causes?)
hearing + tinnitus= peripheral
directional changing nystagmus= central
dysarthria, etc= central
What imaging do you do for stroke management?
Note when giving alteplase only useful when can see have some tissue that is still alive or salvageable
ALso need to make sure not on Warfarin (blood thinner?) and that the blood pressure is not too low
What is the treatment for intracranial hemorrhage?
but need to watch if have chronic HTN becuase might have shifted the auto-regulation curve to the right and 120/80 might be too low for then
What is the most common causes of embolic strokes?
atril fibrilation-->most common
carotid stenosis (also very common)
arterial disections in the young
What is Bell's Palsy?
viral infection of the facial nerve?? that results in facial droopiness AND taste invovlemnet??
Which tracts run in the ventralmedial side of the brianstem?
Which tracts run in the dorsolateral side of the brainstem?
Ventromedial= dorsal columns/medial lemniscus (vibrations, conscious proprioception)
Dorsolateral= spinocelebellar (unconscious proprioception) & spinothalamic (pain, touch, temp)
Where is the medial leminscus as it travels through the midbrain?
What about in the pons and medulla?
in the pons and medulla the medial leminsucs will switch and run more ventromedially
1)What symptoms will someone have if they have a lesion at the arcuate fasciculus?
2)What about if it between primary auditory cortex and wernickes?
3)What about if it between brocas and prefrontal cortex?
1)Conduction aphasia= just not able to repeat things
2)able to repeat, but can't comprehend and name but fluency okay-->
transcortical sensor aphasia
2)able to repeat, but
and can't name, but comprehension okay-->
transcortical motor aphais
What is alexia?
What is word deafness?
Alexia= but can understnad lanague but can't write
Word deafness= can't understand when spoken to but can write normally
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