Brain & Behaviour #4

Front 1

List the five types of intracerebral hemorrhage

Back 1

1. Epidural (Btw skull & dura)
2. Subdural (Btw dura & arachnoid)
3. Subarachnoid (Btw arachnoid & pia)
4. Intraparenchymal (within the parenchyma of brain)
5. Intraventricular

Front 2

What are the differences between the cerebral arteries and others in the body?

Back 2

1. Thinner intima
2. Lack external elastica
3. Medial defects

Front 3

What are the sites of aneurysms?

Back 3

1. Anterior communicating artery = 30%
2. Posterior communicating artery = 25%
3. Middle cerebral artery = 20%
4. Carotid bifurcation = 8%
5. Basilar bifurcation = 7%

Front 4

What are the causes of sub-arachnoid hemorrhages?

Back 4

1. Cerebral aneurysms (most common)
2. Other vascular malformations
3. Vasculitis
4. Bleeding disorders
5. Hemorrhagic infarction
6. Trauma

Front 5

What is the clinical presentation for someone with a SAH?

Back 5

1. Sudden, severe headache
2. Nausea
3. Photophobia
4. Loss or alteration of consciousness
5. Focal neurological deficits
6. Sudden death

Front 6

What are the pathological features of SAH?

Back 6

1. Raised ICP
2. Cerebral edema
3. Crainal nerve injury
4. Intracerebral hemorrhage
5. Intraventricular hemorrhage
6. Hydrocephalus

Front 7

What is the epidemiology of SAH?

Back 7

Incidence is ~2%
Most commonly occur in 40 to 60 y.o.
More common in females than males

Front 8

What are the initial management steps for SAH?

Back 8

1. Stabilization - ABCs
2. Imaging - CT, Cerebral angiography
3. Dx - Lumbar puncture

Front 9

How is SAH managed (post-initial presentation)?

Back 9

1. Neurosurgical ICU
2. Airway, ventilation
3. BP control
4. ICP Control
5. Fluid and electrolyte monitoring
6. Early aneurysm repair

Front 10

What is the yearly risk of an aneurysm bleeding out?

Back 10

Risk of bleeding out is ~ 1 to 3% ANNUALLY

Increases with previous SAH, larger size, HTN, smoking, posterior fossa location

Front 11

When is a repair of an aneurysm indicated?

Back 11

When the aneurysm reaches a size of 5 mm or greater

Front 12

What are the three components of an AVM?

Back 12

1. Feeding arteries
2. Nidus
3. Draining arteries

Front 13

What are the clinical features of AVMs?

Back 13

1. Hemorrhage
2. Seizures
3. Headaches
4. Focal neurology

Front 14

On what basis are AVMs graded?

Back 14

size, location (eloquence), deep venous drainage

Front 15

How are AVMs treated?

Back 15

1. None
2. Microsurgical removal
3. Stereotatic radiosurgery
4. Embolization
5. Combination / multidisciplinary

Front 16

Name two cerebro-vascular ischemic syndromes

Back 16

1. TIA - transient ischemic attack
2. infarction

Front 17

What are the treatment goals for cerebro-vascular ischemic syndromes

Back 17

Prevent or reverse brain injury
by;
1. Medical support
2. Anti-platelet agents
3. Thromolysis
4. Anticoagulation
4. Neuroprotection

Front 18

When and how should px be treated with IV tPA

Back 18

Patients treated within 3 hours of onset of symptoms were at least 30% more likely to have minimal or no disability at 3 months

Front 19

Describe Intra-arterial thrombolysis

Back 19

- Direct local delivery of thrombolytic
- This allows for a lower dose to be administered with fewer systemic effects
- There is an increased rate of clot lysis which allows for an expanded time window of treatment to 6 hours for MCA

Front 20

How do carotid ischemic syndromes present?

Back 20

1. Unilateral weakness / numbness
2. Dysphasia
3. Amaurosis fugax (fleeting blindness)

Front 21

How do you evaluate carotid ischemic syndromes?

Back 21

1. PE - Neurological / ocular, vascular, arterial bruit
2. Imaging - Brain (CT, MRI), Vascular (U/S, CTA, MRA, DSA)

Front 22

what are the major causes of intracranial hemorrhage?

Back 22

1. htn
2. amyloid angiopathy
3. aneurysms
4. vascular malformations

Front 23

What are the most common locations for hemorrhages

Back 23

1. Basal ganglia (most common)
2. Thalamus
3. pons
4. Cerebellum
5. Cerebral white matter
6. Brainstem

Front 24

What are the common sites of aneurysm rupture

Back 24

1. Anterior communicating artery (ACommA)
2. Posterior communicating artery (PCommA)
3. Middle cerebral artery (MCA)
4. Basilar artery
5. Vertebral artery

Front 25

What is the primary risk if AVMs?

Back 25

1. rupture at ~4% / year
2. seizures

Front 26

When is treatment suggested for AVMs?

Back 26

When the risk of subsequent hemorhage is greater than the risk of treatment

Front 27

What is the primary risk of unruptured aneurysms?

Back 27

Primary risk is rupture = 1 to 3% / year

Large aneurysms, especially those greater than 10mm have a higher risk of rupture.

Front 28

what is "amaurosis fugax"?

Back 28

A transient loss of vision involving one eye and is the second most common presenting symptom in patients with atherosclerotic carotid artery disease

Front 29

What are the symptoms of a TIA?

Back 29

Vague sx including;
1. unilateral weakness
2. clumsiness
3. numbness
(also dysphasia and dysarthria)

Front 30

Define TIA

Back 30

Transient ischemic attack is a transient neurological deficit secondary to dysfunction of a part of the cerebral hemisphere because of lack of blood flow
- this is the MOST common symptom in patients with atherosclerotic carotid disease.

Front 31

What are the indications of Intra-arterial rTPA for acute stroke?

Back 31

1. Clinical dx of ischemic stroke
2. Onset of symptoms to time of drug administration less than 3 hours
3. CT scan shows no hemorrhage and no infarct or edema of 1/3 MCA territory
4. Patient age is greater than 18 years

Front 32

What are the contra-indications of Intra-arterial rTPA for acute stroke?

Back 32

1. Sustained BP of 185 / 110 despite treatment
2. Plt <100,000
3. Use of heparin within previous 48 hours; prolonged PTT or INR
4. Rapidly improving symptoms
5. Major surgery within preceeding 14 days
6. GI Bleeding within 21 days
7. Recent myocardial infarction
8. Coma or stupor

Front 33

Define and list state aspects of cognition

Back 33

- These are functions that modulate information processing diffusely in multiple sensory and cognitive systems.
- Include:
1. Arousal
2. Attention
3. Motivation
4. Mood

Front 34

Define and list Channel aspects of cognition

Back 34

- These mediate specific cognitive and sensorimotor operations
- include:
1. Language
2. Memory
3. Visuospatial function
4. Somatomotor function

Front 35

Define: Consciousness

Back 35

- Awareness of self and environment
- Reticular activating system in brainstem
- Cortical projections

Front 36

Define: Sensorium

Back 36

- Refers to level of alertness
- Basic arousal process
- normal; sleeping; stuporous; comatose
- note - specific stimuli needed to alert patient

Front 37

Define: Alertness

Back 37

- Brainstem RAS
- Diffuse thalamic projection system
- Cortex

Front 38

Define: Attention

Back 38

- Ability to attend to a specific stimulus without being distracted
- Attention presupposes alertness
- Vigilance: ability to sustain attention fo >30sec
- Results from an interplay between brain stem and cortex

Front 39

Name 2 bedside tests for attention

Back 39

1. Simple attention: Digit span
2. Vigilance: Letter "A" cancellation

Front 40

What is the neuroanatomic basis for attention?

Back 40

Cortical
- Reticular modulation of ascending reticulocortical stimulation
- Focusing attention requires conscious voluntary effort (frontal) i.e. studying
- Limbic input adds emotional importance to attention i.e. fear of failure
- Limbic influences may be critical to screening out extraneous stimuli

Front 41

What is the neuroanatomic basis for episodic memory?

Back 41

Key structures;
- Medial temporal lobes
- Hippocampus
- Parahippocampus
- Anterior thalamic nucleus
- Mamillary body
- Fornix
- Prefrontal cortex

Front 42

What is episodic memory?

Back 42

Memory system for;
- temporally specific events
- episodes which are personally experienced
- Autobiographical form of memory for contextually specific events

Front 43

What are the bedside tests for episodic memory?

Back 43

Bedside tests
- Recent event recall
- Word lists Paragraph recall
- Object location

Front 44

What are the key structures of semantic, Procedural and working memory

Back 44

- semantic
o inferolateral temporal lobes
- Procedural
o Basal ganglia
o Cerebellum
o Supplementary motor area
- Working
o Words: prefrontal
o Cortex: language

Front 45

Define: Aphasia

Back 45

Definition
- Acquired loss of language skills
- Errors in word choice and grammar
- Affects both oral and written communication

Front 46

What are some causes of aphasia?

Back 46

Causes
- Stroke
- Degenerative dementias
o Ex. Alzheimer disease (transcortical sensory), Fronto-temporal degeneration
- Neoplasm of dominant hemisphere

Front 47

What are paraphasic errors?

Back 47

Errors in word form or meaning
Semantic (verbal)
- word substitution of similar category
- e.g. horse for pig; bus for taxi
Literal (phonemic)
- Substitution of incorrect “syllable” (phoneme)
- E.g. Blish for Fish
Neologism
- Unrecognizabel assemblage of phenomes
- E.g. snopel

Front 48

What are the features of Wernicke's aphasia?

Back 48

Spontaneous speech: Fluent
Repetition: Abnormal
Auditory comprehension: Abnormal
Reading: Abnormal
Writing: ??

Front 49

What are the features of Broca's aphasia?

Back 49

Spontaneous speech: non-Fluent
Repetition: Abnormal
Auditory comprehension: Good
Reading: ??
Writing: Abnormal

Front 50

What are the features of Orbitofrontal Syndrome?

Back 50

Dis-inhibition
Impulsive behavior
Distractible
Emotional liability, Irritable
Inane euphoria
Jocularity
Poor judgment and insight
Hyperactive / manic
Sexual pre-occupation

Front 51

What are the features of Dorsolateral Frontal Syndrome?

Back 51

Verbal fluency
Non-verbal fluency
Perseveration
Abstraction
Retrieval deficits
Poor set shifting
Poor strategies for copying tasks
Impaired attention Depressed mood

Front 52

What are the features of Medial Frontal Syndrome?

Back 52

Apathy (primary feature)
Unmotivated
Emotional emptiness
Failure to implement new plans
Loss of generative thought / slowed
Decreased motor activity
In extreme akinetic mutism

Front 53

Define: Ideomotor Apraxia

Back 53

- Most common form of apraxia
- Failure to perform a skill / learned motor sequence on command or to imitation
- Types of error include “body part as object”, extensional and rotational
- Screening for apraxia (“show me how you would…”)
o Brush teeth, comb hair
o Whistle, blow
o Bow, box

Front 54

Define: Ideational Apraxia

Back 54

- Conceptual deficit
- Difficulty in performing a sequence of steps to complete a task
- Loss of knowledge to select tools / objects
- Localization: bilateral parietal

Front 55

Define: Visual Agnosia

Back 55

Apperceptive
- Shape perception abnormal
- Worse for geometric figures, pictures
- Seen most often after anoxic damage;
- Occipitotemporal>inferior parietal lesions / degen
Associative
- Relatively intact perception, but poor recognition
- Unable to match or describe use by sight
- Typically seen with bilateral occipito-temporal damage/disease: L peri-striate involvement common

Front 56

Define: Prosopagnosia

Back 56

- Loss of face recognition
- Usually associated with left hemifeld defect
- Localization:
o Medial occipitotemporal cortex (lingual, fusiform and parahippocampal gyri)
o Right or bilateral lesions
- Right PCA territory infarct

Front 57

What are the left hemisphere specializations?

Back 57

- Syntactic and most semantic aspects of language and linguistic aspects of prosody
- Memory for verbal material, internal detail
- Manipulation of symbols, formal operations
- Temporal ordering / sequence
- Fine motor control

Front 58

What are the right hemisphere specializations?

Back 58

- Attention (especially to left hemispace)
- Emotional prosody / gesture
- Social skills
- Rhythm generation: pitch melody recognition
- Visospatial analysis / orientation
- Comprehension of form or “gestalt”
- Visual memory (external configuration / arrangement of elements)
- Relative superiority for face recognition