MMD exam II part II
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. What would you like to do?
Trouble finding the right words is called
Word soup is also known as..
CSF if produced in the ___ and reabsorbed in the ____
chroroid plexus, arachnoid granulations
The left common carotid comes off the __ while the right common carotid comes off the ___
aortic arch, right subclavian
the vertebral arteries come off the right and left __ arteries
One of the most common symptoms of uncal herniation is compression of CN3 which causes what PE finding
ipsilateral dialation of the pupil
Monroe kellie doctrine
total volume of the cranium must remain constant and is balenced betwene venous blood, arterial blood, brain and CSF
pyramidal compression due to uncal herniation causes
Lateral displacement of the brain stem causes what symptom
Bleeding in the potential space betwen the dura and the skull is called a
Epidural hematoma is most often associated with what type of fracture?
What is the most common location of fracture causing an epidural hematoma and why?
temporal skull fracture, middle meningeal artery gets severed
What are some nontraumatic causes of an epidural hematoma?
- congenital anomalies
- complications of neurosurgery
- epidural abcess
- sickle cell
23 y.o. M presents after motor vehicle crash. He seems fine and is A&O x3, 15 mins after being admitted he reports HA, N,V, and drowsyness and one of his pupils dialates. What are you concerned he might have? and what is your next step?
Head CT for epidural bleed
What is the cushing reflex?
HTN, Bradycardia, decreased RR
32 y.o. M presents after a motor cross accident w/ lumbar spine trauma. He has local back pain around L2, with sensory loss below the waist and bladder and bowel incontinence. He has already had an X-ray which showed no broken bones. What imaging study will you order and what do you suspect he has?
- URGENT MRI
- rule out spinal epidural hematoma
CT of a pt who was hit in the head with a baseball bat shows a lens shaped pattern with clear boarders at the convexity what do they have?
What is a "swirl sign" and what type of bleed is it found in?
when the hematoma is hypodense with a central area that is hyperdense it is a swirl sign and indicates active bleeding of an epidural hematoma
What is the treatment for and epidural hematoma?
- craniotomy and hematoma evacuation
- or watch and wait
What are the criteria for sending an epidural hematoma pt for a craniotomy?
- volume >30ml
- GCS < 9 with anisocoria
When can you watch and wait for a pt with an epidural hematoma?
- when they have a volume of <30
- no coma
- no focal deficits
Which is more common epidural hematoma or subdural hematoma?
Is a subdural hematoma typically a vein problem or an artery?
Is an epidural hematoma typically caused by artery or vein disruption?
you have a 90 y.o. F on coumadin who has HA, nausea, anisocoria, dysphagia, bells palsey and nuchal ridgidity. You note that the nursing home put her in a wheel chair 2 days ago because they notices she was having gait difficulties. What type of bleed would you expect this is? and Where is the bleed?
- Subdural hematoma
- Posterior fossa
a 87 y.o. M presents with HA, and light headedness X2 wks. He states that he has not been able to focus long enough to do his crosswords or read, he feels he has lost intrest in most things and has been drowsing off which he never used to do. He is worried that he may have alzheimers but you think it might be a....
Chronic subdural hematoma!
What are the indications to operate on a subdural hematoma?
- clot thickness >10cm
- midline shift > 5mm
- or elevated ICP
- any herniation
What do you do for a subdural hematoma that does not meet surgical criteria?
close f/u or observation and monitoring with serial CTs
A focal ishcemic cerebral neurological deficit that lasts for less than 24 hours and often preceeds a stroke is a ___
TIA transient ischemic attack
The greatest risk of stroke after TIA is ___
in the first month after
If the TIA lasts longer than ____, or is associated with weakness, ___ impairment or gait changes then there is a higher risk of subsequent stroke
Which is more likely to lead to stroke a carotid TIA or a verterbrobasilar TIA?
if a pt has a carotid TIA what should you listen for?
What motor changes are common with a carotid TIA?
- heaviness of the contralateral arm or leg
- slow movements
- monocular vision loss in the eye on the same side as the lesion
What sensory changes are common with carotid TIA?
numbness, paresthesias, hyperreflexia
What are some Sx of a Vertebrobasilar TIA?
- slurred speach
- blurry vision
- peiroral numbness or tingling
What diagnostic tests should you perform on a pt who has a TIA?
- CT/MRI to rule otu hemorrhage or tumor
- Carotid duplex ultrasound
- Echo with bubble study for patent foramen ovale
- Holter monitor for arrhythmias causing wall thrombus
When should you hospitalize a pt with a TIA?
- if they present within 4-9 hours of the first attck
- crescendo attacks
- sx lasting more than 1 hour
- sx of carotid stenosis(blurred vision, weakness, numbness of the arm leg or face, slurring speech, difficulty understanding, loss of coordination, dizziness, trouble swallowing)
- pt has known cardiac source of emboli
What is the treatment for a pt who has a carotid TIA and a carotid buit on auscultation?
How do you treat a pt with a vertebrobasilar TIA?
- lifestyle modifications (stop smoking, loose wt, regular exercise)
- Anticoagulate if an embolic source: Heparin bridge to coumadin or if it is an elderly person at high risk of falls then use ASA or clopidogrel
Location of stroke that causes unilateral blindness, severe contralateral hemiplegia, and hemianesthesia and profound aphasia
Internal carotid artery
Location of stroke that causes: emotial liability, confusion, amnesia, personality changes, urinary incontinence impaired mobility with more sensation in the lower extremity than the upper extremity, contralateral hemiplegia or hemiparesis
Middle cerebral artery
Location of stroke that causes: hemianesthesia, contralateral hemiplegia in teh face UE>LE, homonymous hemianopia, receptive aphasia (aphasia fluent but meaningless speech and severe impariment of understood/spoken or written words)
cortical blindness (total or partial loss of vision in a normal appearing eye caused by damage to the visual area in the brain's occipital cortex
Posterior cerebral artery
Location of stroke that causes: unilateral or bilateral weakness of extremities, diplopia, homonymous heminaopsia, nausea, vertigo, tinnitus, syncope, dysphagia, dysarthria, locked in syndrome (anterior portion of the pons no movement except eyelids, sensation and conciousness preserved)
respiratory and circulatory abnormalities
Location of stroke that causes: vertigo, nausea, vomiting, nystagmus, ipsilateral limb ataxia, contralateral spinothalamic loss
(note: spinothalamic loss= pain and temperature sensation and tactile sensation)
a 56 y.o. male presents with loss of lateral conjugate gaze and AMS following a weight lifting competition he was having with his friends at the gym. He has a Hx of poorly controlled HTN and chronic ITP. What is the most likely dx?
Hemorrhagic stroke putaminal hemorrhage
What are the major risk factors for hemorrhagic stroke?
- Advanced age
- liver disesae
- excessive alcohol consumption
- primary or secondary brain tumors
- hematologic disorders
- anticoagulatn therapy
Should you do an LP on someone with Sx of hemorrhagic stroke?
NO WAY HOSE! LP is contraindicated!
What imaging study should be done on a pt with possible hemorrhagic stroke?
CT without contrast
How do you treat a hemorrhagic stroke?
- Ventilation support
- Fever control
- Seizure prophylaxis
- surgical evacuation
In which hemmorrhagic stroke location is surgical evacuation of the hematoma especially important?
In a ___ brain hemorrhage, conciousness is initially lost or impaired in half of all pts. NV HA and focal deficits may be seen depending, disequilibrium and LOC
a ___ hemorrhage is characterized by loss of conjugate lateral gaze
A ___ hemorrhagic stroke is characterized by loss of upward gaze and downward or skew deviation of the eyes lateral gaze palsies and pupillary inequality
Location of stroke that causes: vertigo, nausea, vomiting, nystagmus, ipsilateral limb ataxia, contralateral spinothalamic loss
Pt presents with "worst HA of my life". pt also reports NV, and pts friend reports temporary LOC. pt now also complains of nuchal ridgidity too. DDX?
What causes an intracranial aneurysm?
weakness in the wall of an artery or vein that causes a localized dilation or balloing of the blood vessel in the brain.
3 risk factors for intracranial anerysm
- HTN, smoking, hypercholesterolemia
- (also polycystic kidney disease and coarctation of the aorta)
a burst anerysm causes what type of intracranial bleed?
What is the Tx for a intracranial anerysm?
- surgical clipping of anerysm base
- endovascular coiling
- stent assisted coiling
in a stroke an infarct that is less than 5 mm in diameter is called a
Lacunar infarcts are associated with what two comorbid conditions
Lacunar infarcts are associated with (contra or ipsi-) -lateral pure motor or pure sensory deficits or (contra- or ipsi-) lateral ataxia with muscle weakness and clumsiness of the hand and dysarthria
What is the prognosis for lacunar infarction?
good usually resolution in 4-6 wks
Explain the pathophysiology of a cerebral infarct
cerebral ischemia lieads to a release of excitatory and other neuropeptides that leads to a increase in calcium influx into the neuron which causes cell death and increased neurological deficit
if the internal carotid artery is occluded what other two arteries are affected
middle cerebral artery and the anterior cerebral artery
if the vertebrobasilar arter is occluded what other 2 arteries are also affected
posterior cerebral artery and cerebellar artery
What is the Tx for ischemic stroke?
- TPA if within 3 hours
- prednisone if there is cerebral edema
What are the contraindications for using TPA in the setting of an ischemic stroke?
- recent hemorrhage
- arterial puncture at a noncompressible site
- systolic BP of >185 or DBP of >110
A GCS score of less than ___ is a coma
a mild traumatic brain injury is considered a GCS of __ to __
a moderate traumatic brain injury is considered a GCS of __ to __
GCS should be measured ___ mins post injury
A milder form of traumatic brain injury is also known as a __
what is the pathophysiology of a concussion?
disruption of axonal neurofilament organization leading to axonal swelling and wallerian degen and transection
While you are at a lacrosse game one of the players is "knocked silly" he has a vacant stare, delayed and slurred speech and disorientation, but he did not pass out. He most likely has a ___
s the standardized assessment of concussion score used inside or outside of the hospital?
outside typically coaches are trained to recognize it
What is the imaging study of choice for a traumatic brain injury
What concussion criteria is used by health care professionals?
New Orleans criteria
What are the components of the new orleans criteria and what does it tell you?
- the NOC tells you when to image a pt with a concussion
- GCS of 15
- drug or ETOH intox
- persistant anterograde ampnesia
- visible trauma above the clavical
When should you admit a pt with a concussion?
if they have a GCS of less than 15 abnormal CT, seizures, past medical history of bleeds/ bleeding disorders
how should you educate a pt who is going home after a concussion that was not complicated?
- - have someone awaken the pt every 2 hours for the first night
- - no strenuous activity for 24 hours
- - seek medical attention if intracranial bleeding, cerebral edema, inability to waken from sleep, severe heacache, somnolence, restlnessness, changes in vision, voming, fever, stiff neck, urinary incontinence
You should councel a pt who has had a concussion against....
- getting another concussion before the first heals
- alcohol consuption
- drug use
- caffiene use
- OTC meds
If a pt got a concussion in a sports game and had a LOC how long should they sit out from play?
1 wk or until asymptomatic
When the brain swells quickly and seriously from a suffereing another concussion before the first concussion truely heals
Second impact syndrome
___ is a set of symptoms a person can experience for weeks to months after a concussion
post concussion syndrome
Some symptoms of post concussion syndrome include:
- neuropsych sx
- cognitive impairment
- behavior personality changes
- speech and gait abnormalities
a type of neurodegenerative disease that is caused by repetative minor brain trauma
A state of deep unconciousness that lasts for a prolonged or indefinite period of time caused by an expecially severe brain injury or illness with a GCS of 8 or less is called a ___
What are some toxic/metabolic causes of coma
- electrolyte imbalence
- endocrine disorders
- alcohol overdose
- drug overdose
- carbon monoxide poisoning
- infectious/inflammatory meningitis/encephalitis
- organ failure
What are some structural causes of coma
- herniation by mass effect
A seizure that has diffuse invovlement of the brain and loss of conciousness from the onset
A seizure that begins locally and represents a structural lesion until proven otherwise, may become secondarily generalized and is more common in children
Describe a simple partial seizure
- motor jerking
- conciousness preserved
- somatosensory (paraesthesias or tingling)
- sensory (flashing or lights or buzzing)
- autonomic (epigastric sensation, sweating flushing and pupillary dilitation)
- dysmnesic symptoms (deja vu or jamais vu)
Describe a complex partial seizure
- transient impariment of conciousness may be preceeded by or come with, or be followed by the same sx experienced with simple seizures
- often begin with an aura and accompanied by automatisms such as lip smacking
Describe a Generalized Absense seizure
- sudden impairment of consiousness
- onset and termination abrupt
- bilateral signs such as blinking, chewing or small amplitude hand movements
- may miss a few words or break off mid sentence
- begin in childhood and usually cease by age 20
Describe a generalized atypical absense seizure
- more gradual onset and termination
- more obvious motor signs that include focal and lateralizing features
- associated with multifocal structural abnormalities of the brain
- more commonly ddxed in children with developmental delay or mental retardation
Describe a myoclonic seizure
sudden breif muscle contraction that invovles one part of teh body or the entire body often occurs shortly after waking up begins between puberty and early adulthood
Describe a Tonic clonic seizure
- a tonic phase where all muscles in the body tense followed by a clonic phase with uncontrolled jerking and relaxing of teh muscles.
- main seizure type associated with epilepsy
- tounge and lips are often bitten
- urinary or fecal incontinence occurs
- may begin abruptly without warning and sometimes with an aura
- typically has a post ictal period
A continuous seizure activity or multiple successive seizures that last more than 30 minutes withotu intervals of conciousness is called
What drugs should be avoided in a pt with status epilepticus
narcotics, phenothiazines, neuromuscular blocking agents,
a disorder characterized by recurrent seizures due to a chronic underlying process is called
A progressive disease that causes damage to the myelin sheaths of the brain and spinal cord
MS typically affects women who are of what age
child bearing age
What are the two type of MS
- relapsing remitting
A 34 y.o. F presents with weakness and urinary frequency. On exam you note that she has nystagmus and some peripheral numbness what neurological disorder are you worried she may have?
What will the CSF analysis of an MS pt show?
Oligoclonal IgG bands
what will be seen on the CT/MRI of a pt with MS?
plaques/neural lesions in the brain and spinal cord
Is fat or water brighter in a T2 weighted image on MRI?
water (H2o is brighter in T2)
What is the Tx for an acute MS exacerbation?
What is the Tx for progressive MS long term?
- tx with beta-interferon or glatiramer acetate
- natalizumab can be used to reduce frequency of exacerbations but srisk of multifocal encephalopathy is not good
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