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58 Cards in this Set

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  • Back
List the five types of intracerebral hemorrhage
1. Epidural (Btw skull & dura)
2. Subdural (Btw dura & arachnoid)
3. Subarachnoid (Btw arachnoid & pia)
4. Intraparenchymal (within the parenchyma of brain)
5. Intraventricular
What are the differences between the cerebral arteries and others in the body?
1. Thinner intima
2. Lack external elastica
3. Medial defects
What are the sites of aneurysms?
1. Anterior communicating artery = 30%
2. Posterior communicating artery = 25%
3. Middle cerebral artery = 20%
4. Carotid bifurcation = 8%
5. Basilar bifurcation = 7%
What are the causes of sub-arachnoid hemorrhages?
1. Cerebral aneurysms (most common)
2. Other vascular malformations
3. Vasculitis
4. Bleeding disorders
5. Hemorrhagic infarction
6. Trauma
What is the clinical presentation for someone with a SAH?
1. Sudden, severe headache
2. Nausea
3. Photophobia
4. Loss or alteration of consciousness
5. Focal neurological deficits
6. Sudden death
What are the pathological features of SAH?
1. Raised ICP
2. Cerebral edema
3. Crainal nerve injury
4. Intracerebral hemorrhage
5. Intraventricular hemorrhage
6. Hydrocephalus
What is the epidemiology of SAH?
Incidence is ~2%
Most commonly occur in 40 to 60 y.o.
More common in females than males
What are the initial management steps for SAH?
1. Stabilization - ABCs
2. Imaging - CT, Cerebral angiography
3. Dx - Lumbar puncture
How is SAH managed (post-initial presentation)?
1. Neurosurgical ICU
2. Airway, ventilation
3. BP control
4. ICP Control
5. Fluid and electrolyte monitoring
6. Early aneurysm repair
What is the yearly risk of an aneurysm bleeding out?
Risk of bleeding out is ~ 1 to 3% ANNUALLY

Increases with previous SAH, larger size, HTN, smoking, posterior fossa location
When is a repair of an aneurysm indicated?
When the aneurysm reaches a size of 5 mm or greater
What are the three components of an AVM?
1. Feeding arteries
2. Nidus
3. Draining arteries
What are the clinical features of AVMs?
1. Hemorrhage
2. Seizures
3. Headaches
4. Focal neurology
On what basis are AVMs graded?
size, location (eloquence), deep venous drainage
How are AVMs treated?
1. None
2. Microsurgical removal
3. Stereotatic radiosurgery
4. Embolization
5. Combination / multidisciplinary
Name two cerebro-vascular ischemic syndromes
1. TIA - transient ischemic attack
2. infarction
What are the treatment goals for cerebro-vascular ischemic syndromes
Prevent or reverse brain injury
by;
1. Medical support
2. Anti-platelet agents
3. Thromolysis
4. Anticoagulation
4. Neuroprotection
When and how should px be treated with IV tPA
Patients treated within 3 hours of onset of symptoms were at least 30% more likely to have minimal or no disability at 3 months
Describe Intra-arterial thrombolysis
- 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
How do carotid ischemic syndromes present?
1. Unilateral weakness / numbness
2. Dysphasia
3. Amaurosis fugax (fleeting blindness)
How do you evaluate carotid ischemic syndromes?
1. PE - Neurological / ocular, vascular, arterial bruit
2. Imaging - Brain (CT, MRI), Vascular (U/S, CTA, MRA, DSA)
what are the major causes of intracranial hemorrhage?
1. htn
2. amyloid angiopathy
3. aneurysms
4. vascular malformations
What are the most common locations for hemorrhages
1. Basal ganglia (most common)
2. Thalamus
3. pons
4. Cerebellum
5. Cerebral white matter
6. Brainstem
What are the common sites of aneurysm rupture
1. Anterior communicating artery (ACommA)
2. Posterior communicating artery (PCommA)
3. Middle cerebral artery (MCA)
4. Basilar artery
5. Vertebral artery
What is the primary risk if AVMs?
1. rupture at ~4% / year
2. seizures
When is treatment suggested for AVMs?
When the risk of subsequent hemorhage is greater than the risk of treatment
What is the primary risk of unruptured aneurysms?
Primary risk is rupture = 1 to 3% / year

Large aneurysms, especially those greater than 10mm have a higher risk of rupture.
what is "amaurosis fugax"?
A transient loss of vision involving one eye and is the second most common presenting symptom in patients with atherosclerotic carotid artery disease
What are the symptoms of a TIA?
Vague sx including;
1. unilateral weakness
2. clumsiness
3. numbness
(also dysphasia and dysarthria)
Define TIA
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.
What are the indications of Intra-arterial rTPA for acute stroke?
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
What are the contra-indications of Intra-arterial rTPA for acute stroke?
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
Define and list state aspects of cognition
- These are functions that modulate information processing diffusely in multiple sensory and cognitive systems.
- Include:
1. Arousal
2. Attention
3. Motivation
4. Mood
Define and list Channel aspects of cognition
- These mediate specific cognitive and sensorimotor operations
- include:
1. Language
2. Memory
3. Visuospatial function
4. Somatomotor function
Define: Consciousness
- Awareness of self and environment
- Reticular activating system in brainstem
- Cortical projections
Define: Sensorium
- Refers to level of alertness
- Basic arousal process
- normal; sleeping; stuporous; comatose
- note - specific stimuli needed to alert patient
Define: Alertness
- Brainstem RAS
- Diffuse thalamic projection system
- Cortex
Define: Attention
- 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
Name 2 bedside tests for attention
1. Simple attention: Digit span
2. Vigilance: Letter "A" cancellation
What is the neuroanatomic basis for attention?
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
What is the neuroanatomic basis for episodic memory?
Key structures;
- Medial temporal lobes
- Hippocampus
- Parahippocampus
- Anterior thalamic nucleus
- Mamillary body
- Fornix
- Prefrontal cortex
What is episodic memory?
Memory system for;
- temporally specific events
- episodes which are personally experienced
- Autobiographical form of memory for contextually specific events
What are the bedside tests for episodic memory?
Bedside tests
- Recent event recall
- Word lists Paragraph recall
- Object location
What are the key structures of semantic, Procedural and working memory
- semantic
o inferolateral temporal lobes
- Procedural
o Basal ganglia
o Cerebellum
o Supplementary motor area
- Working
o Words: prefrontal
o Cortex: language
Define: Aphasia
Definition
- Acquired loss of language skills
- Errors in word choice and grammar
- Affects both oral and written communication
What are some causes of aphasia?
Causes
- Stroke
- Degenerative dementias
o Ex. Alzheimer disease (transcortical sensory), Fronto-temporal degeneration
- Neoplasm of dominant hemisphere
What are paraphasic errors?
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
What are the features of Wernicke's aphasia?
Spontaneous speech: Fluent
Repetition: Abnormal
Auditory comprehension: Abnormal
Reading: Abnormal
Writing: ??
What are the features of Broca's aphasia?
Spontaneous speech: non-Fluent
Repetition: Abnormal
Auditory comprehension: Good
Reading: ??
Writing: Abnormal
What are the features of Orbitofrontal Syndrome?
Dis-inhibition
Impulsive behavior
Distractible
Emotional liability, Irritable
Inane euphoria
Jocularity
Poor judgment and insight
Hyperactive / manic
Sexual pre-occupation
What are the features of Dorsolateral Frontal Syndrome?
Verbal fluency
Non-verbal fluency
Perseveration
Abstraction
Retrieval deficits
Poor set shifting
Poor strategies for copying tasks
Impaired attention Depressed mood
What are the features of Medial Frontal Syndrome?
Apathy (primary feature)
Unmotivated
Emotional emptiness
Failure to implement new plans
Loss of generative thought / slowed
Decreased motor activity
In extreme akinetic mutism
Define: Ideomotor Apraxia
- 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
Define: Ideational Apraxia
- Conceptual deficit
- Difficulty in performing a sequence of steps to complete a task
- Loss of knowledge to select tools / objects
- Localization: bilateral parietal
Define: Visual Agnosia
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
Define: Prosopagnosia
- 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
What are the left hemisphere specializations?
- 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
What are the right hemisphere specializations?
- 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