4Th Year

Front 1

ADC vs DWI

Back 1

Facilitate diffusion:

DWI dark, ADC bright

Restricted diffusion :

DWI bright, ADC dark (if ADC here is also bright than- T2 shine through).

Front 2

Spectroscopy mri

Back 2

Stroke

Lactate ⬆️ (anaerobic metabolism)

NAA⬇️ (N Acetyl Asparate- neuronal density and integrity)

Tumor

Choline ⬆️ (membrane turnover)

NAA⬇️ (N Acetyl Asparate- neuronal density and integrity)

Rest

Front 3

Restricted diffusion

DWI (bright) low ADC (dark)

Back 3

1. Abscess

2. Acute phase stroke (cytotoxic edema)

3. Highly cellular tumor: glioblastome (not necrotic center), lymphoma, medulloblastoma.

4. Epidermmoid cyst (also can have T2 shine through).

Front 4

Anterior fontanelle typically close?

Back 4

Between 12 and 18 months of age.

Closure at 6 months may be normal.

Large fontanelle or persistence beyond 18 months - sign of hypothyroidism

Front 5

The posterior fontanelle typically closes?

Back 5

between 3 and 6 months of age.

Front 6

CN IV

Back 6

Trochlear nerve

Innervate the superior oblique muscle.

Front 7

Most common neurologic examination finding (ophthalmology) in paediatric Pseudotumor cerebri?

Back 7

Aside from papilloedema, sixth nerve (CN VI) palsy is the most common neurologic examination finding in paediatric IIH.

Front 8

CN V (trigeminal nerve)

Motor component:

Back 8

muscles of mastication (temporalis and masseter muscles) and the muscle involved in keeping the jaw open (lateral pterygoid muscle).

Front 9

CN XII

Back 9

Hypoglossal nerve

Paresis of the hypoglossal nerve results in ipsilateral deviation of the protruded tongue to the side of weakness and associated ipsilateral atrophy of the tongue.

Front 10

When tone is increased, it is important to differentiate spasticity from rigidity.

Back 10

When tone is increased, it is important to differentiate spasticity from rigidity. Spasticity results from damage to the descending corticospinal or pyramidal tracts, whereas rigidity results from damage to the basal ganglia. Spasticity is the hallmark of an upper motor neuron lesion (pyramidal tract injury) and results in a characteristic pattern of increased tone in the extremities—flexion of the upper extrem- ities and extension of the lower extremities.

Front 11

Clasp knife phenomenon (spasticity sign)

Back 11

It is velocity dependent!

Initial resistance to passive movement of the joint, followed by sudden reduction in tone allowing the limb to move freely and unrestricted through the rest of the range of movement for that joint).

Front 12

Upper motor neurons lesion

Back 12

1. Hyperreflexia

2. Babinski’s response (extensor toe)

3. +/- clonus

4. spasticity.

Front 13

Spasticity in infants 👶

Back 13

Spasticity typically develops over the course of the first year of life in an infant as myelination of the white matter tracts occurs, and in the first few months of life, upper motor neuron lesion of the infant may result in hypotonia before hypertonia develops. Early hand preference (i.e., a strong hand preference before 12–18 months of age) is abnormal and is generally indicative of weakness or impairment of the opposite arm.

Front 14

Rigidity

Back 14

Rigidity results in increased tone in all directions of movement of the joint that is not velocity- dependent (so-called lead pipe rigidity). Resistance is present in both agonist and antagonist muscles.

Front 15

Cogwheel rigidity

Back 15

Cogwheel rigidity is present when there is a tremor superimposed on the rigidity, giving a “ratchet” feeling to the increased tone.

Front 16

Lower motor neurons lesion

Back 16

1. Hypotonia or flaccidity is decreased or absent resistance of passive movement of a limb ( or cerebellar/cerebellar pathway lesions).

2. Hyporeflexia/areflexia and hyperextensibility of the joint.

3. Muscle wasting

4. fasciculation may also be seen.

Front 17

Disorders or lesions of the cerebellar hemispheres-

Back 17

1. ipsilateral appendicular ataxia

2. dysmetria (impaired judgment of distance with past pointing),

3. dysdiadochokinesia (abnormal or impaired rapid alternating movements).

Front 18

Disorders or lesions of the cerebellar hemispheres-

Back 18

1. ipsilateral appendicular ataxia

2. dysmetria (impaired judgment of distance with past pointing),

3. dysdiadochokinesia (abnormal or impaired rapid alternating movements).

4. Intention or action tremor

Front 19

Midline lesions of cerebellum-

Back 19

produce gait and truncal ataxia.

Front 20

To be certain that the ataxia is of cerebellar origin,

Back 20

proprioceptive loss has to be excluded;

*** The Romberg sign (positive test) removes the visual and vestibular components that contribute to maintaining balance and can thus identify a proprioception-related neurologic disease.

Front 21

Cerebellar lesions

Back 21

1.Gait ataxia- stand with the feet wide apart for stability and sways side to side with walking, often falling to the side of the lesion (if unilateral).

2.Impairment of the visual pathways with resultant nystagmus (maximal toward side of lesion)

3. impairment of speech (scanning dysarthria and staccato speech) are often accompaniments to cerebellar lesions.

Front 22

Walking in children timing

Back 22

Walking is typically achieved by 12 to 18 months of age with fast walking and running by 18 to 24 months of age.

Front 23

Involuntary movements

Back 23

Damage or dysfunction of the basal ganglia results in involuntary movements (dyskinesias) that may be broadly classified into either an excess of move- ments (hyperkinesia) or a paucity of voluntary movements (hypokinesia) unrelated to weakness or spasticity. Collectively, these movements are known as extrapyramidal symptoms.

Front 24

Hyperkinetic movements include:

Back 24

Extra pyramidal symptoms (basal ganglia damage)

1. Chorea

2. Athetosis

3. Tremors

4. Ballismus

5. Dystonia (sustained or intermittent muscle contractions causing abnormal movements and posture of the limbs, trunk, or neck).

6. Tics

7.Myoclonus-sudden, brief,rapid involuntary jerking of a muscle or group of muscles; may be focal, multifocal, or generalized.

Front 25

Hypokinetic movements include:

Back 25

Extra pyramidal symptoms (basal ganglia damage)

1. Bradykinesia (slowness of movement).

2. Akinesia (difficulty initiating and terminating movement).

3. Rigidity (stiffness and/or inflexibility of a limb or trunk).

Front 26

Sensory systems

Back 26

— Primary sensory testing includes assessment of

1. pain, temperature and crude touch (spinothalamic tracts)

2. proprioception and vibration (dorsal columns).

Cortical sensory modalities include graphesthesia, two-point discrimination, and stereognosis, tactile localization (extinction), and point localization—- Parietal lobe

Front 27

Gerstmanm syndrome

Back 27

Gerstmann’s syndrome is caused by specific brain lesions which affect the posterior lobule of the parietal lobe in the dominant hemisphere resulting in tetrad of symptoms which include

1. acalculia

2. finger agnosia

3. agraphia

4. left-right disorientation

Front 28

Atlas ? Axis ?

Back 28

Atlas -C1

Axis- C2

Front 29

Fasciculus gracilis ? cuneatus?

Back 29

Gracilis - below T6

Cueatus- above T6

Front 30

Anterior and lateral spinothalamic tracts??

Back 30

Pain and temperature fibers enter the lateral spinothalamic tract. Light touch and pressure fibers enter the anterior spinothalamic tract

Front 31

Hypercapnia

CO2 rentation

Back 31

Due to hypoventilation.

Result in cerebral vasodilation which lead increase CBF and ICP

Front 32

Hypercapnia

CO2 rentation

Back 32

Due to hypoventilation.

Result in cerebral vasodilation which lead increase CBF and ICP

Front 33

Hypocapnia

Back 33

Due to hyperventilation.

Result in cerebral vasoconstriction which decreases CBF and thus ICP

Front 34

Pleomorphic Xanthoastrocytomas

Back 34

-WHO II (worst outcome than LGG).

-PXAs with anaplastic features have been described and tend to have worse outcome.

-very rare. ~1% of all pedis brain tumors.

-peripheral or cortical mass com- posed of cystic and solid components and hetero- geneous enhancement.

- must have staging with neuroaxis.

-have the highest frequency of BRAF V600E mutations out of all CNS neoplasms.

-GTR is the primary goal as it is a strong predictor of PFS.

-PXAs have very variable outcome. Five-year PFS is reported to be 40 to 68% and 5-year OS rate is 76 to 87%.

-There has been no difference in pediatric PXA with and without anaplastic features regarding outcome. Prognosis is overall worse in children than in adults

Front 35

Atypical Teratoid Rhabdoid Tumors

Back 35

-Part of group of embryonal tumors.

-Highly malignant.

-Mostly in infants. Around 80% of the patients diagnosed with ATRT are children younger than 3 years.

- 50% infra, 50% supratentorial.

-A supratentorial tumor with a thick, wavy (irregular) heterogeneously enhancing wall sur- rounding a central cystic region is suggestive of ATRT,as it is a distinctive and unusual pattern.

-Neuroaxis MRI mandatory.

-The main histologic characteristics of rhabdoid tumor cells are abundant cytoplasm with juxtanuclear eosi- nophilic inclusions and nuclei that display a sin- gle, prominent nucleolus in clear, uncondensed chromatin.

● SMARCB1. A defect in the INI 1 gene (SMARCB1) leading to loss of expression is associated with rhabdoid tumors and is used for diagnosis.

*** Those tumors that do not have alterations of either INI1 or BRG1 are classified as embryonal tumors with rhabdoid features.

-5-year survival is 28%.

-The median OS is about 10 months and metastatic disease correlates with a worse prognosis.

Front 36

Desmoplastic Neuroepithelial Tumors

Back 36

-The presenting symptom is often seizures. characteristically, it causes intractable partial seizures.

-DNET is a grade I glioneuronal tumor

-DNETs are characterized as hav- ing a “bubbly” appearance, are multilobulated, are hypointense on T1 in a wedge-shaped configura- tion, and hyperintense on T2-weighted images. FLAIR imaging shows a characteristic bright rim.

-DNETs have one of the highest ADC values among benign tumors. (Meaning they facilitate diffusion = bright).

-surgery is curative if can be completely resected.

Front 37

Gangliogliomas

Back 37

- Seizures are the most common presentation.

-Two different cell types (combination of neuronal and glial cell).

- mostly Who I. Rarely can be anaplastic WHo III

- very good prognosis with GTR.

-The majority of gangliogliomas are localized in the temporal lobe, but can occur throughout the CNS.

-Well-differentiated, slow-growing neuroepithelial tumor composed of neoplastic, mature ganglion cells alone (gangliocytoma) or in combination with neoplastic glial cells (ganglioglioma).

-Five-year PFS rate is 81.2% and the OS rate is 97.4%.

Front 38

Interesting about NF2

Back 38

After vestibular schwannoma, the next most common tumor type in NF2 is meningioma, which is encountered in roughly half of the cases.

Front 39

BRAF mutation

Back 39

Pleomorphic xan- thoastrocytoma (PXA), ganglioglioma, and a small subset of extracerebellar PA have BRAF V600E mutations.

Front 40

Supratentorial LGG

Back 40

The aim of surgery in supratentorial hemispheric LGGs is GTR.

If GTR cannot be achieved, further surveillance is indicated, as residual disease can be stable (progression-free disease) in up to 55%.

Front 41

Most common type of craniopharyngiomas in Pedis

Back 41

Adamantinomatous tumors are the most common subtype, particularly in the pediatric population.

These tumors are characterized by keratinized cells that face a cyst lumen, and “wet” keratin nodules consisting of desquamated epithelial cells. The nodules may become calcified over time.

The cystic regions of adamantinomatous craniopharyngiomas contain fluid with a “motor oil” consistency, rich in cholesterol.

Front 42

Above the red nucleus

Back 42

Lesions above the red nucleus produce decorticate posturing: flexion of upper limbs and extension of lower, rubrospinal tract function.

M3

Front 43

Decorticate posturing

Back 43

Lesions above the red nucleus produce decorticate posturing: flexion of upper limbs and extension of lower, rubrospinal tract function.

Front 44

Decorticate posturing

Back 44

Lesions above the red nucleus produce decorticate posturing: flexion of upper limbs and extension of lower, rubrospinal tract function.

Front 45

Lesions Below red nucleus

Back 45

Those below the red nucleus produce decerebrate posturing: extension in upper and lower limbs, vestibulospinal tract function.

Normal flexion (M4) constitutes flexion with supinatio

Front 46

Decorticate posturing

Back 46

Lesions above the red nucleus produce decorticate posturing: flexion of upper limbs and extension of lower, rubrospinal tract function.

M3

Front 47

Lesions Below red nucleus

Back 47

Those below the red nucleus produce decerebrate posturing: extension in upper and lower limbs, vestibulospinal tract function.

M2

Front 48

Decerebrate posturing

Back 48

Those below the red nucleus produce decerebrate posturing: extension in upper and lower limbs, vestibulospinal tract function.

M2

Front 49

Which one of the GCS components differentiate the severity of the injury?

Back 49

Of the three divisions (eye opening, verbal response, and motor response) the motor response is most likely to differentiate the severity of injury.

Front 50

Gerstmann’s syndrome

Back 50

Lesions of the dominant parietal lobe . It includes tetrad of symptoms :

1. impairment in performing calculations (acalculia).

2. discriminating their own fingers (finger agnosia).

3. writing by hands (agraphia).

4. impairment of distinguishing left from right (left-right disorientation).

Front 51

Contralateral neglect

Back 51

Non dominant parietal lobe lesion.

Usually left side neglect due to right side lesion.