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330 Cards in this Set
- Front
- Back
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Lecture 131: CV 17
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Myocardial Infarction
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What amino acid is a precursor to each of the following molecules?
• Histamine |
o Histidine
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• Porphyrin, heme
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o Glycine
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• NO
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o Arginine
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• GABA (a neurotransmitter)
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o Glutamate
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• S-adenosyl-methionine (SAM)
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• S-adenosyl-methionine (SAM)
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• Creatine
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o Arginine
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What is the basic equation for cardiac output? What is the Fick principle?
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Cardiac output (CO) = Stroke volume (SV) x Heart rate (HR)
Fick principle: CO = (Rate of O2 consumption )/(Arterial O2 content - Venous O2 content ) |
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What is the mechanism of action of lactulose?
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• Digested by bacteria in the colon
• Creates an acidic environment • NH3 → NH4+ • NH4+ excreted in the stool • Use: lower ammonia level in pts with hepaticencephalopathy |
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Evolution of an MI:
0 – 4 hrs |
Gross features: None
Microscopic features: None Risks and other findings: Arrhythmias |
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Evolution of MI: 4 – 24 hrs
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Gross features: Dark mottling
Microscopic features: Contraction bands, Neutrophil emigration Risks and other findings: Arrhythmias |
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Evolution of MI: 1 – 3 days
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Gross features: Dark mottling
Microscopic features: Coagulative necrosis, Loss of nuclei, Striations, Neutrophils Risks and other findings: Arrhythmias |
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Evolution of MI: 3 – 4 days
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Gross features: Hyperemia
Microscopic features: Neutrophils Risks and other findings: Arrhythmias |
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Evolution of MI: 5 – 10 days
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Gross features: Hyperemic border, Yellow tan softening
Microscopic features: Margin granulation tissue Risks and other findings: Wall rupture, Tamponade |
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Evolution of MI: 10 days – 8 weeks
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Gross features: Gray, white scar
Microscopic features: Increased collagen, Decreased cellularity Risks and other findings: Dressler syndrome |
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Evolution of MI: > 2 months
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Gross features: Complete scar
Microscopic features: Dense collagen scar Risks and other findings: Ventricular aneurysm |
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Lab markers used to Diagnose an MI
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• CK-MB
• Troponin I (most specific) • CPK • Myoglobin |
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Treatment of MI
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“MONA”
o Morphine o Oxygen o Nitrate o Aspirin: Clopidigrel if allergic |
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Treatment of MI
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• “MONA”
• B -Blockers • ACE Inhibitors • Statins • Magnesium (> 2) and Potassium (> 4) |
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Which serum lab markers are commonly used to make the diagnosis of MI?
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• CK-MB
• Troponin I |
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Which coronary artery is most commonly occluded in an MI?
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• Left Anterior Descending (LAD)
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What would cause each of the following findings after an MI?
• Cardiac tamponade |
o Rupture of the ventricular wall
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• Severe mitral regurgitation
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o Rupture of papillary muscle
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• New VSD
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o Rupture of intraventricular septum
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• Stroke
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o Mural thrombus → embolus
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Which ECG leads will show evidence of ischemia in an anterior wall MI?
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• V1-V3
• V4 • V5 |
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What medications would you think to prescribe in an ER patient diagnosed with MI?
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• “MONA”: Morphine, O2, Nitrates, Aspirin
• B -Blockers • ACE or ARB • Statin • Mg+2 and K+ • Enoxaparin • GpIIb/IIIa inhibitor |
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Lecture 132: CV 18
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Cardiomyopathies and Endocarditis
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What does a relative risk less than 1 indicate?
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• Disease is less likely to occur in exposed group
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A screening test under investigation uses a lab marker SCSQ to identify early small cell and squamous cell lung cancer. In a population of 100 smokers over age 60, 20 test positive. Of the 20 that tested positive, 5 actually had either of the two lung cancers. Of those that did not test positive, it was determined that 5 had either of the two cancers. What is the sensitivity, specificity, PPV and NPV of this study?
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• Sensitivity = TP / (TP + FN) = 0.5
• Specificity = TN / (TN + TP) = 0.84 • PPV = TP/ (TP + FP) = 0.25 • NPV = TN/ (FN + TN) = 0.94 |
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What are normal BPs in the right and left ventricles?
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• Right ventricle: < 25/5
• Left ventricle: < 130/10 |
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Hypertrophic Cardiomyopathy (HIGH YIELD) most likely to be tested on
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• Disorganized, tangled myocytes of left ventricle
• Hereditary—50 % AD • Hypertrophy of interventricular septum outflow tract obstruction of mitral valve • On exam—apical impulse is large and diffuse • Possible S4 heart sound • Systolic murmur: o Valsava (decreasing preload) makes murmur louder o Squatting (increase afterload) makes murmur softer |
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What is the most common cause of sudden death in young athletes?
HIGH YIELD |
Hypertrophic Cardiomyopathy
o They need preload to keep the outflow tract less obstructed o Excessive exercise ---> volume depleted ---> decrease in preload |
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Hypertrophic cardiomyopathy treatment
HIGH YIELD |
o B-Blocker
o Non-dihydropyridine CCB o Restrict physical exertion o Avoid dehydration |
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Causes of Restrictive Cardiomyopathy
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o Sarcoidosis
o Granulomas o Amylidosis o Loffler’s syndrome : Eosinophilic infiltrates in the heart o Hemochromatosis -- *Note: more commonly causes dilated cardiomyopathy o Radiation therapy o Endocardial fiberelastosis |
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Myocarditis
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• Generalized inflammation of the myocardium (not resulting from ischemia)
• US: Coxsackie B virus • Histo: diffuse interstitial infiltrate of lymphocytes, with myocyte necrosis |
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Dx of Infective Endocarditis
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o TEE
o Blood cultures (before starting ABX) |
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Bacterial causes of Infective Endocarditis
HIGH YIELD |
Staph aureus
- 30% of cases - Actue endocarditis—large vegetation on previously healthy valves* Viridians strep -Subacute endocarditis—smaller vegetations that were already damaged -Post- dental procedures—give prophylaxis prior to dental procedures for those with abnormal valves Enterococci - 10% of cases - VRE—vancomycin resistant enterococci Staph epidermidis - 5-10% of cases - Is part of normal flora on skin—IV drugs Staph bovius: Associated with colon cancer |
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Infective Endocarditis: Bacteria to think about as possible cause that don’t grow from blood cultures
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“HACEK”
Haemophilus Actinobacillus Cardiobacterium Eikenella Kingella |
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What are the differences between acute and subacute bacterial endocarditis?
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• Acute bacterial endocarditis
o Caused by Staph aureus o Onset is very rapid o Normal valves can be affected • Subacute bacterial endocarditis o Caused by Strep viridians o Preexisting valvular damage o Insidious onset |
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An IV drug user present with chest pain, dyspnea, tachycardia, and tachypnea. What is most likely the cause?
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• Bacterial endocarditis
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A patient in a MVA presents with chest pain, dyspnea, tachycardia, and tachypnea. What is the most likely cause?
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• Tension pneumothorax
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A post-op patient presents with chest pain, dyspnea, tachycardia, and tachypnea. What is the most likely cause?
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• Pulmonary embolism from DVT
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A young girl with congenital valve disease is give penicillin prophylactically. In the ER, bacterial endocarditis is diagnosed. What is the next step in her management?
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• IV vancomycin
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Splinter hemorrhages under the fingernails
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Bacterial endocarditis
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Retinal hemorrhages with pale centers
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Roth spots
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Heart valve most commonly invoved in bacterial endocarditis
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Mitral valve
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Heart valve most commonly involved in an IV drug user with bacterial endocarditis
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Tricuspid valve
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Bacterial Endocarditis
Mnemonic |
“FROM JANE”
o Fever o Roth spots o Osler’s nodes o Murmur o Janeway lesions o Anemia o Nail-bed hemorrhage o Emboli |
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Lecture 133: CV 19
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Other Cardiac Pathology
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While on an ACE inhibitor for hypertension a patient develops a cough. What is a good replacement drug, and why doesn’t it have the same side effects?
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•Replacement drug – ARB
o ARBs don’t inhibit ACE and don’t cause a cough |
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When should a woman begin to receive regular mammograms?
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• At least every other year starting at age 40
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During a high school football game, a young athlete collapses and dies immediately. What type of cardiac disease did he have?
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• Hypertrophic cardiomyopathy
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Cardiac Tamponade
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• Classic EKG findings – Electrical Alternans
o Alternating amplitude QRS segment |
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Complications due to Group A Strep infection
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• Scarlet fever: Type IV hypersensitivity
• Post-streptococcal GN: Type III hypersensitivity • Acute rheumatic fever: Type II hypersensitivity **** KNOW**** • Strep toxic shock syndrome |
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Cardiac Tumors (KNOW)
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• Metastatic
• Myxoma o LEFT ATRIUM o Most common heart tumor of non-metastatic origin •Rhabdomyomas o Most common primary cardiac tumor in children o Associated with: Tuberous sclerosis, Astrocytoma, Angiomyolipomas |
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Under what circumstances might you see pulsus paradoxus?
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• Cardiac tamponade
• Asthma • Croup • Obstructive sleep apnea • COPD |
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What are the Jones criteria for the diagnosis of acute rheumatic fever?
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Rheumatic Fever – Major Criteria
o J – Joints o <3 – Pancarditis (endo/peri/myocarditis) o N – Nodules o E – Erythema marginatum o S – Sydenham chorea / St. Vitus dance |
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What heart pathology fits each of the following statements?
Diffuse myocardial inflammation with necrosis and mononuclear cells |
Myocarditis
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Focal myocardial inflammation with multinucleated giant cells
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Rheumatic heart disease
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Fever + IVDA + new heart murmur
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Bacterial endocarditis
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Chest pain and course rubbing heart sounds in patient with Cr of 5.0
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Uremic pericarditis
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Tree-barking of the aorta
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Syphilis heart disease
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Child with fever, joint pain, cutaneous nodules 4 weeks after a throat infection
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Rheumatic fever
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ST elevation in all EKG leads
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Pericarditis
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Disordered growth of myocytes
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Hypertrophic cardiomyopathy
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EKG shows electrical alternans
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Cardiac tamponade
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Granulomatous nodules in the heart
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Aschoff bodies in rheumatic heart disease
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Most common cardiac tumor in adults
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Metastasis – most common
Left atrial myxoma – most common primary tumor |
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Most common primary cardiac tumor in children
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Rhabdomyoma
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Most common cause of constrictive pericarditis
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U.S. – Lupus
Developing countries – TB |
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Lecture 134: CV 20
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Vascular Diseases
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What are the characteristic features of alkaptonuria?
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o Deficiency in homogentisic acid oxidase
o Dark organs and connective tissue o Dark urine when out for an extended period of time o Benign disease |
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What organisms are known for causing endocarditis?
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• S. aureus (most common)
• Viridians streptococci • Enterococci (VRE) • S. epidermidis • S. bovis • Less common – won’t be able to culture: “HACEK” - Haemophilus - Actinobacillus - Cardiobacterium - Eikenella - Kingella |
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In a study of 100 people, your study results show an average of 500 wth a standard deviation of 50. Calculate the 95% confidence interval.
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• SEM = SD (omega) / sq. root sample size (n)
• SEM = 50/10 • SEM = 5 • CI = mean +/- Z(SEM) • CI = mean +/- (2 x 5) = 500 +/- 10 • 95% CI = 490 to 510 |
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Vasculitis: Small- vessel
HIGH YIELD TOPIC – 5 stars |
o Microscopic polyangitis
o Wegener’s granulomatosis (Granulomatosis with Polyangiitis) o Churg- Strauss syndrome o Henoch- Scholein purpura |
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Vasculitis: Medium- vessel
HIGH YIELD TOPIC – 5 stars |
o Polyarteritis nodosa
o Kawasaki dz -EXCEPTION—give kid’s ASPIRIN o Buerger dz -HY history—SMOKERS |
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Vasculitis: Large- vessel vasculitis
HIGH YIELD TOPIC – 5 stars |
o Temporal arteritis
o Takayasu arteritis |
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Granulomatosis with Polyangiitis (Wegener’s)
HIGH YIELD – 4 star topic (by itself) |
• Classic Triad
o Focal necrotizing vasculitis o Granulomas in the lung and upper airway o Glomerulonephritis • Tx: steroid & cyclophosphomide |
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Polyarteritis Nodosa
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• Spares the lungs
• Associated with Hep B or Hep C • Negative for ANCA |
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Which disorders are commonly discovered in patients with Raynaud phenomenon?
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• Lupus
• CREST scleroderma • Buerger disease • Mixed connective tissue disease |
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What are the characteristic features of Kawaski disease?
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o Vasculitis of the small and medium vessels in children
o Coronary aneurysms o High fever o Conjunctivitis o Bright red inflammation of lips and oral mucosa o Strawberry tongue o Desquamative rash on the palms and soles o Lymphadenopathy |
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Which type of vasculitis fits each of the following high-yield characteristics? (VERRRRY HIGH YIELD)
Weak pulses in upper extremities |
Takayasu arteritis
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Necrotizing granulomas of lung and necrotizing glomerulonephritis
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Granulomatosis with polyangiitis
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Necrotizing immune complex inflammation of visceral/renal vessels
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Polyarteritis nodosa
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Young male smokers
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Buerger disease
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Young Asian women
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Takayasu arteritis
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Young asthmatics
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Churg-Strauss syndrome
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Infants and young children; involved coronary arteries
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Kawasaki disease
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Most common vasculitis
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Temporal arteritis
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Associated with hepatitis B infection
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Polyarteritis nodosa
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Occlusion of ophthalmic artery can lead to blindness
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Temporal arteritis
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Perforation of nasal septum
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Wegener’s granulomatosis
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Unilateral headache, jaw claudication
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Temporal arteritis
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Which vascular tumor fits each of the following descriptions?
Benign, raised, red lesion about the size of a mole in older patients |
Cherry hemangioma
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Raised, red area present at birth, increases in size initially then regresses over months to years
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Strawberry hemangioma
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Lesion caused by lymphoangiogenic growth factors in an infected HIV patient
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Kaposi sarcoma
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Polypoid red lesion found in pregnancy or after trauma
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Pyogenic granuloma
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Benign, painful, red-blue tumor under fingernails
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Glomus tumor
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Cavernous lymphangioma associated with Turner syndrome
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Cystic hygroma
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Skin papule in AIDS patient caused by Bartonella
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Bacillary angiomatosis
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Cold, pale painful digits
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Raynaud phenomenon
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c-ANCA
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Wegener’s granulomatosis
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p-ANCA
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Microscopic polyangiitis
Churg-Strauss syndrome |
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Treatment for Buerger disease
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Smoking cessation
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Treatment for temporal arteritis
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High-dose steroids
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Lecture 135: Neuro 7
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Regions of the Brain
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In a population of 100 workers that worked to clean an oil spill on a beach, 10 develop leukemia. In a population of 1,000 hotel beach umbrella monitors on a clean beach, 50 develop leukemia. What is the attributable risk?
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• A = 10
• B = 100 – 10 = 90 • C = 50 • D = 100 – 50 = 950 • Attributable risk (AR) = A/(A + B) – C / (C + D) • AR = 10 / (90 + 10) – 50 / (50 + 950) • AR = 0.05 |
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Which antihypertensive drug fits each of the following side effects?
• First dose orthostatic hypotension |
o a1 blockers or –zosin
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• Hypertrichosis
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o Minoxidil
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• Cyanide toxicity
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o Nitroprusside
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• Dry mouth, sedation, with severe rebound HTN
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o Clonidine
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• Bradycardia, impotence, asthma exacerbation
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o B-Blockers
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• Reflex tachycardia
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o Nitrates
o Dihydropyridine CCBs o Minoxidil o Hydralazine |
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• Metabolic alkalosis
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o Loop diuretics
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• Elevated anti-histone antibodies
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o Hydralazine
o Drug induced lupus (SHIPP) |
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• Hypercalcemia
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o Hydrochlorothiazide
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An abdominal aortic aneurysm is most likely a consequence of what process?
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• Smoking
• Atherosclerosis |
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Cerebral Artery Distribution
HIGH YIELD TOPIC – 4 stars |
***Know what infarcts to the ACA, MCA, and PCA would affect/cause and clinical presentation***
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• Anterior medial artery --> anteromedial surface
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o Legs, feet
o Lesion—decreased sensation and motor of legs and feet o Branch of anterior medial artery—sensory OR motor loss |
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• Middle cerebral artery--->supplies lateral surface
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o Face, Broca’s area, hands
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• Posterior cerebral artery ---> supplies posterior and inferior surfaces
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o Occipital lobe
o Lesion ---> visional defects |
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Gerstmann syndrome
HY – 3 star/ 4 star topic |
• Parietal lobe (dominant) Lesion
• Agraphia – inability to write • Acalculia – inability to calculate • Finger agnosia – inability to distinguish fingers • Right to left disorientation • Lesion at angular graphia |
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Wernicke-Korsakoff syndrome (HIGH YIELD)
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• Mamillary body Lesion
• Confusion • Ophthalmoplegia • Ataxia • Memory loss • Confabulation • Associated with thiamine deficiency |
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Carotid Arteries
HIGH YIELD |
•2 internal carotid
•2 vertebral arteries |
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Internal carotids
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o From 3rd aortic arch (C is the 3rd letter of Alphabet)
o Carotid sheath—internal jugular vein, internal carotids, vagus n. |
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Vertebral arteries
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o Branch off the subclavian artery
o Provide blood flow to anterior spinal artery & PICA (posterior inferior cerebellar artery) o Then form the basal artery o Supplies hypoglossal nucleus o Vertebrals & basal artery= major blood supply for cerebellum & brain stem (know), Some blood to cerebrum |
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A lesion to which area of the brain is responsible for each of the following clinical scenarios?
• Hemispatial neglect syndrome |
o Non-dominant parietal lobe
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• Poor repetition
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o Arcuate fasciculus
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• Poor comprehension
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o Wernicke’s area
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• Poor vocal expression
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o Broca’s area
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• Personality changes
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o Frontal lobe
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• Dysarthria
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o Cerebellar vermis
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• Agraphia and acalculia
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o Dominant parietal lobe
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• Hyperorality, hypersexuality, disinhibited behavior
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o Bilateral amygdala lesion
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What typically is the case of a lesion to the mamillary bodies?
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• Thiamine deficiency
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What is the most feared consequence of carotid artery stenosis?
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• Rupture atherosclerotic carotid plaque
• Plaque embolus to the brain • Ischemic, embolic stroke |
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What artery is damaged with each of the following presentations?
• Broca or Wernicke aphasia |
o MCA
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• Unilateral lower extremity sensory and/or motor loss
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o ACA
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• Unilateral facial and arm sensory and/or motor loss
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o MCA
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Lecture 136: Neuro 8
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Brainstem in Cross Section
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What heart defect is associated with each of the following disorders?
• Chromosome 22q11 deletions |
o Truncus arteriosus
o Tetralogy of Fallot |
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• Down syndrome
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o Endocardial cushion defect
o ASD o VSD o AV septal defect |
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• Congenital rubella
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o PDA
o Pulmonary artery stenosis o Septal defect |
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• Turner syndrome
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o Coarctation
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• Marfan syndrome
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o Aortic insufficiency
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In which section of the brainstem is each of the cranial nerve nuclei located?
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• CN III, IV – Midbrain
• CN V, VI, VII, VIII – Pons • CN IX, X, XI, XII – Medulla |
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What information is communicated at the nucleus solitaries?
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o Sensory
-Taste - Baroreceptors - Gut distention |
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What information is communicated at the Dorsal motor nucleus?
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o Autonomic
- Heart - Lungs - Upper GI tract |
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What information is communicated at the Nucleus ambiguus?
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o Motor
- Pharynx - Larynx - Upper esophagus |
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What name is given to a collection of symptoms indicative of a lesion of the facial nerve or nucleus?
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• Bell’s palsy
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What artery supplies the medial Lemniscus and medullary pyramid of the medulla?
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• Anterior spinal artery
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Where does the corticospinal tract decussate in the brainstem? Where does the dorsal column-medial Lemniscal pathway decussate?
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• Corticospinal tract: Caudal medulla prior to medullary pyramids
• Dorsal column-medial Lemniscal: Medulla then ascends as Medial Lemniscus |
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What artery supplies the following medullary structures: spinal thalamic track, inferior cerebellar peduncle, nucleus ambiguus, and lateral Spinothalamic tract?
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• Posterior inferior cerebellar artery (PICA)
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How can a stroke of the facial motor cortex be distinguished from Bell palsy?
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• Stroke to the facial motor cortex: Spare the upper face
• Bell’s palsy: Unable to wrinkle the forehead on affected side |
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How do the symptoms of a lesion to the cortical motor region of the face differ from a lesion of the facial nerve or nucleus?
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• Lesion in cortical motor face region: Paralysis of contralateral side of lower face
• Lesion of facial nerve or nucleus: Paralysis of ipsilateral side of entire face |
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A patient has leftward deviation of the tongue on protrusion, and has a right-sided spastic paralysis. Where is the lesion?
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• Left medulla: Lesion of corticospinal tract
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Lecture 137: Neuro 9
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Occlusion syndromes
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Which type of vasculitis fits each of the following descriptions?
• Necrotizing granulomas of lung and necrotizing glomerulonephritis |
o Wegener’s granulomatosis
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• Necrotizing immune complex inflammation of visceral/renal vessels
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o Polyarteritis nodosa
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• Young Asian women
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o Takayasu’s
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• Young asthmatics
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o Churg-Strauss syndrome
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• Infants and young children; involved coronary arteries
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o Kawasaki’s disease
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• Most common vasculitis
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o Temporal arteritis
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• Associated with hepatitis B infection
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o Polyarteritis nodosa
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What portion of the brain is supplied by the anterior cerebral artery? Middle cerebral artery?
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• ACA – Medial surface
• MCA – Lateral surface |
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How does the presentation of a dominant parietal lobe lesion differ from the presentation of a non-dominant parietal lob lesion?
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• Nondominant Parietal Lobe Lesion
o Right parietal lobe o Hemispatial neglect |
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What are the signs of Weber syndrome?
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o Contralateral spastic paralysis or hemiparesis
o CN III palsy (eye looks down and out) o Ptosis |
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What are the signs of Wallenberg syndrome?
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o Contralateral loss of pain and temperature sensation
o Ipsilateral loss of pain and temperature on the face o Hoarse voic, difficulty swallowing, loss of gag reflex o Ipsilateral Horner syndrome o Vertigo, nystagmus, nausea/vomiting o Ipsilateral cerebellar deficits |
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A patient cannot abduct her left eye on lateral gaze and convergence is normal. She is also having difficulty smiling. In what part of the CNS is there a lesion?
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• Pontine lesion
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A lesion of what artery can cause a locked-in syndrome?
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• Basilar artery
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What are the causes and symptoms of Weber syndrome?
HY 4 Stars **** |
Midbrain infarction resulting from occlusion of the paramedian branches of the posterior cerebral artery
- Cerebral peduncle lesion ---> contralateral spastic paralysis (AKA contralateral hemiparesis) - Oculomotor nerve (CN III) palsy ----> ipsilateral ptosis, pupillary dilation, and lateral strabismus (eye looks down and out) |
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What are the causes and symptoms of lateral medullary syndrome (AKA Wallenberg syndrome)? Damage to which areas cause these symptoms?
HY 4 Stars **** |
Caused by occlusion of one of the posterior inferior cerebellar arteries (PICA) ---> unilateral infarct of lateral portion of rostral medulla (AKA posterior inferior cerebellar artery syndrome)
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What are the causes and symptoms of lateral medullary syndrome (AKA Wallenberg syndrome)? Damage to which areas cause these symptoms?
HY 4 Stars **** |
- Loss of pain and temp, over contralateral body (spinothalamic tract damage)
- Loss of pain and temp, over ipsilateral face (trigeminothalamic tract damage) - Hoarseness difficulty swallowing, loss of gag reflex (nucleus ambiguous: glossopharyngeal and vagus damage) - Ipsilateral Horner syndrome (descending sympathetic tract) - Vertigo, nystagmus, nausea/ vomiting, (vestibular nuclei damge) - Ipsilateral cerebellar deficits (i.e., ataxia, past pointing) (inferior cerebellar peduncle damage) |
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Lecture 138: Neuro 10
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Vascular Events
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On auscultation of a patient, you hear a pansystolic murmur at the apex with radiation to the axilla. What is the most likely cause of this murmur?
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• Mitral regurgitation
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Your study shows that high LDL does not increase one’s risk of CAD. What type of error is this?
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• Type II error
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What medication inhibits alcohol dehydrogenase? Which medications inhibit acetaldehyde dehydrogenase?
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• Fomepizole-- Inhibits alcohol dehydrogenase
• Disulfiram-- Inhibits acetaldehyde dehydrogenase |
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Structures in the Carotid Sheath
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• Carotid artery
• Internal jugular vein • Vagus nerve |
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Normal Pressure Hydrocephalus Triad (KNOW)
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o Wet – urinary incontinence
o Wobbly – ataxia o Wacky – dementia |
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What is the most common site of berry aneurysm? What diseases are often associated with berry aneurysms?
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• Most common location
o Anterior communicating artery • Associated diseases o Autosomal dominant polycystic kidney disease o Ehlers-Danlos syndrome |
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An 85 year old man with Alzheimer disease falls at home and presents 3 days later with severe headache and vomiting. What is the most likely diagnosis and structures were damaged?
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• Diagnosis: Subdural hematoma
• Structures damaged: Bridging veins |
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Where is CSF generated? Where is CSF reabsorbed?
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• Generated: Via Choroid plexus
• Reabsorbed: via Arachnoid granulations |
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What is the difference between communicating and noncommunciating hydrocephalus?
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• Communicating hydrocephalus: Decreased absorption of CSF at the archnoid villi
• Noncommunicating hydrocephalus: Physical, mechanical obstruction of the ventricles |
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What clinical features characterize normal pressure hydrocephalus?
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•Triad
o Wet – urinary incontinence o Wobbly – ataxia o Wacky – dementia |
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“worst headache of my life"
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Subarachnoid hemorrhage
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Lucid interval following head trauma
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Epidural hematoma
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Bloody CSF on LP
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Subarachnoid hemorrhage
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Most common cause of subdural hematoma
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Rupture of the bridging veins
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Most common cause of epidural hematoma
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Rupture of the middle meningeal artery
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Lecture 139: Neuro 11
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Movement
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What are the treatments for overdose of heparin and warfarin?
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• Heparin: Protamine sulfate
• Warfarin: Fresh frozen plasma and vitamin K |
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What are five hereditary thrombosis syndromes?
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o Protein C deficiency
o Protein S deficiency o Factor V Leiden o Prothrombin 20210A mutation o Antithrombin deficiency |
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Which cancer drugs are known for being cardiotoxic?
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• Doxorubicin
• Daunorubicin |
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What portion of the thalamus relays the following information? (LESS THAN 3 stars)
• Somatosensory form body (via medial Lemniscus and Spinothalamic) |
o Ventral posterolateral nucleus (VPL)
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• Communications with prefrontal cortex; memory loss results if destroyed
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o Medial dorsal nucleus (MD)
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•Cerebellum (dentate nucleus) and basal ganglia ---> motor cortex
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o Ventrolateral nucleus (VL)
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• Trigeminothalamic and taste pathways to somatosensory cortex
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o Ventroposteromedial nucleus (VPM)
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• Retina ---> occipital lobe
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o Lateral geniculate body
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• Basal ganglia ---> prefrontal, Premotor, and orbital cortices
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o Ventral anterior nucleus (VA)
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• Mamillothalamic tract ---> cingulate gyrus (part of Papez circuit)
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o Limbic system
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• Integration of visual, auditory, and somesthetic input
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o Pulvinar nucleus
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• Dentate nucleus an basal ganglia ---> supplementary motor cortex
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o Ventrolateral nucleus (VL)
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• (Auditory info) brachium of inferior colliculus ---> primary auditory cortex
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o Medial geniculate body
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What are the differences between the 1a afferent motor pathway and the 1b afferent motor pathway?
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• 1a – comes from the muscle spindle and stimulates the alpha-motor neurons
• 1b – comes from the golgi tendon organ, and will inhibit muscle contraction |
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What portion of the thalamus relays the following types of information?
• Somatosensory from body (via medial Lemniscus and Spinothalamic) |
o Ventral posterolateral nucleus (VPL)
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• Cerebellum (dentate nucleus) and basal ganglia ---> motor cortex
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o Ventrolateral nucleus (VL)
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• Trigeminothalamic and taste pathways to somatosensory cortex
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o Ventroposteromedial nucleus (VPM)
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• Retina ---> occipital lobe
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o Lateral geniculate body
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•Basal ganglia ---> prefrontal, Premotor, and orbital cortices
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o Ventral anterior nucleus (VA)
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• (Auditory info) brachium of inferior colliculus ---> primary auditory cortex
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o Medial geniculate body
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What are classic signs of an upper motor neuron lesion? Of a lower motor neuron lesion?
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• Upper motor neuron lesion (UMN)
o Spastic paralysis o Hyperreflexia • Lower motor neuron lesion (LMN) o Flaccid paralysis o Atrophy o Fasciculations |
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What is the difference between essential tremor, resting tremor, and intention tremor?
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• Essential Tremor
o Family history of tremor o Occurs with movement and at rest • Resting tremor o Disappears with voluntary movement o Associated with Parkinson disease • Intention tremor o Associated with cerebellar damage o Appears only with voluntary movements |
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Toe extension upon stimulating the sole of the foot with a blunt instrument
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Positive Babinski reflex
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Hyperreflexia, increased muscle tone, and positive Babinski sign
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Upper motor neuron lesion
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Hyporeflexia, decreased muscle tone, and muscle atrophy
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Lower motor neuron lesion
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Lecture 140: Neuro 12
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Basal Ganglia
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What is the rate-limiting step in heme synthesis?
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• Aminolevulinic synthase
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What is the structure of HbH? What disease results in HbH production? What si the structure of Hb Bart’s? What disease results in Hb Bart’s production?
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• HbH
o Structure – 4 beta globin o Alpha thalassemia or HbH disease • Hb Bart’s o Structure – 4 gamma globins o Hydrops fetalis |
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What excitatory neurotransmitter is involved in pain?
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• Substance P
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Basal Ganglia (HIGH YIELD POINTS)
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1. Lesions of the substantia nigra pars compacta cause hypokinesia
2. Lesions of the subthalamic nucleus cause hemiballismus |
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Parkinson Disease Drugs
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“BALSA”
o Bromocriptine o Amantadine o Levodopa (Given with Carbidopa—inhibits dopamine dehydrogenase in periphery, 1st choice) o Selegiline: MOA type B inhibitor, Blocks conversion of MPTP to MPP o Antimuscarinic • Lesion subthalamic nucleus o Deep brain stimulation |
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Huntington Disease
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• CAG repeat disorder
• Chromosome 4 • Cuarenta (40yo) • Chorea • Cognitive decline (dementia) • Caudate atrophy |
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What are the cardinal features of Parkinson disease?
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o Tremor
o Rigidity o Akinesia or hypokinesia o Postural instability o Mask-like facies o Festinating gait |
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A 28-year-old chemist presents with MPTP exposure. What neurotransmitter is depleted?
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• Dopamine
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How do each of the following structures normally impact movement?
• Globus pallidus internal segment |
o Inhibitor of movement
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• Subthalamic nucleus
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o Inhibitor of movement
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• Substantia nigra pars compacta
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o Facilitation of movement
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A male patient presents with involuntary flailing of one arm. Where is the lesion?
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• Subthalamic nucleus on the contralateral side
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What neurotransmitters are altered in Huntington disease?
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• Decreased acetylcholine and GABA
• Increased dopamine |
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Depigmentation of the substantia nigra
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Parkinson disease
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Chorea, dementia, and atrophy of the caudate and putamen
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Huntington disease
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Eosinophilic inclusions in the cytoplasm of neurons
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Lewy bodies
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Lecture 141: Neuro 13
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Spinal Cord and Lesions
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What defect is associated with the following type of murmur?
• Crescendo-decrescendo systolic murmur best heard in the 2nd-3rd right interspace close to the sternum |
o Aortic stenosis
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• Rumbling late diastolic murmur with an opening snap
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o Mitral stenosis
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• Pansystolic (aka holosystolic or uniform) murmur best heard at the 4th-6th left intercostals spaces, adjacent to the sternum
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o Tricuspid regurg or VSD
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• Continuous machine-like murmur (in systole and diastole)
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o Patent ductus arteriosus (PDA)
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What organisms are known for causing endocarditis?
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• Staph aureus
• Viridians Streptococci • Enterococci (VRE) • Staph. Epidermidis • Strep bovis |
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What is the four drug regimen is used to treat TB?
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“RIPE”
o Rifampin o Isoniazid o Pyrazinamide o Ethambutol |
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Spinal Cord Lesions: Polio, Werdnig- Hoffman, and West Nile Virus
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o Anterior horn lesions
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Spinal Cord Lesions: Werdinig- Hoffman
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o Infantile spinal muscular atrophy
o AD o Floppy baby syndrome o Death at 7 mos o Degeneration at Anterior Horn |
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Spinal Cord Lesions: Multiple sclerosis
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o Random and asymmetric lesions in white matter
o Lesions present in random locations along spinal cord o Autoimmune disease—inflammation & demyelination |
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Spinal Cord Lesions: ALS
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o Damage to anterior horn and lateral corticospinal tract
o Defect in superoxide dismutase 1 |
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Spinal Cord Lesions: Tabes Dorsalis
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o Dorsal columns
o Positive Romberg Test |
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Spinal Cord Lesions: ASA Occlusion
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o Lesion everywhere BUT the dorsal column
o Loss of pain & temperature, motor neuron of anterior horn o Think of it as the opposite of Tabes Dorsalis |
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Spinal Cord Lesions: Brown-Sequard Syndrome
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o Hemisection of spinal cord
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Which spinal tract conveys the following types of information?
• Touch, vibration, and pressure sensation |
o Dorsal columns
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• Voluntary motor command from motor cortex to body
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o Lateral and ventral corticospinal tracts
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• Voluntary motor command from motor cortex to head/neck
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o Corticobulbar tract
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• Alternate routes for the mediation of voluntary movement
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o Reticulospinal and rubrospinal tracts
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• Pain and temperature sensation
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o Lateral Spinothalamic tract
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• Important for postural adjustments and head movements
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o Vestibulospinal tract
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• Proprioceptive information for the cerebellum
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o Dorsal and ventral Spinocerebellar tracts
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What are the findings of Brown-Sequard syndrome?
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• Ipsilateral UMN signs below the lesion
• Ipsilateral dorsal column loss of information below the lesion • Contralateral pain and temperature loss at 2-3 segments below the lesion • Ipsilateral pain and temperature loss at the level of the lesion • LMN signs at level of lesion |
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What clinical presentation would lead you to suspect amyotrophic lateral sclerosis as a diagnosis?
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o Combined UMN and LMN defects
o No sensory deficit |
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What are some of the more classic presenting scenarios for multiple sclerosis?
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o Charcot’s triad: Scanning speech, Intention tremor, Nystagmus
o Bowel or bladder incontinence o Internuclear ophthalmoplegia o Optic neuritis |
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Conjugate lateral gaze palsy, with nystagmus and diplopia during lateral gaze
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Internuclear ophthalmoplegia
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Degeneration of the dorsal columns
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Tabes dorsalis
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Demyelinating disease in a young woman
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Multiple sclerosis
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Mixed upper and lower motor neuron disease
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ALS
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Lecture 142: Neuro 14
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Brachial plexus and upper extremity nerves
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What is pulsus paradoxus, and what are the causes?
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• Systolic blood pressure drops > 10 mmHg with inspiration
• Causes (KNOW) o Asthma o COPD o Croup o Cardiac tamponade |
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With what hematologic disease would you expect to see each of the following?
• (+) Ham’s test |
o Paroxysmal nocturnal hemoglobinuria
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• Heinz bodies
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o G6PD deficiency
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• Basophilic stippling
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o Lead poisoning
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• (+) Osmotic fragility test
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o Hereditary spherocytosis
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• (+) DEB test
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o Fanconi anemia
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• D-dimer
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o DIC
o DVT/PE |
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• Comb (+)
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o Autoimmune hemolytic anemia
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• Comb (-)
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o Non-autoimmune hemolytic anemia
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• (+) Ristocetin test
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o Von Willebrand disease
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Neck Anatomy (IMPORTANT TO KNOW)
• Posterior triangle |
o Borders: Sternocleidomastoid, Trapezius, Clavicle
o Contains: - Subclavian v. - Brachioplexus - External jugular v. - Inferior omohyoid m. |
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Neck Anatomy (IMPORTANT TO KNOW)
• Anterior triangle |
o Borders: Midline border of neck, Mandible, Sternocleidomastoid
o Contains: - Anterior digastric m. - Posterior digastrics m. - Sternothyroid m. - Superior omohyoid m. - Sternohyoid m. |
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An elderly woman with chronic osteoarthritis and diffuse pain now presents with numbness and tingling over the lateral digits of her right hand that sometimes radiates up to the elbow. Exam reveals wasting of the thenar eminence. What is the diagnosis?
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• Carpal Tunnel Syndrome
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What nerves run with each of the following arteries?
• Dorsal scapular artery |
o Dorsal scapular nerve
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• Lateral thoracic artery
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o Long thoracic nerve
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• Posterior circumflex artery
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o Axillary nerve
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• Suprascapular artery
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o Suprascapular nerve
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• Thoracodorsal artery
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o Thoracodorsal nerve
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• Deep brachial artery
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o Radial nerve
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• Ulnar artery
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o Ulnar nerve
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• Brachial artery
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o Median nerve
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• Anterior interosseous artery
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o Anterior interosseous nerve
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• Posterior interosseous artery
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o Deep branch of the radial nerve
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What are the symptoms of a lesion to the C5 and C6 nerve roots?
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• Erb-Duchenne Palsy
o Paralysis of upper extremity o Medial rotation o Forearm pronation o Arm hangs at side |
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What are the symptoms of a lesion to the inferior trunk of the brachial plexus?
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• Klumpke’s Palsy
o Sensory deficits of the forearm and hand on the medial side o Atrophy of the thenar, hypothenar, and interosseous muscles |
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What nerve is damaged when a patient presents with the following symptom (upper extremity)?
• Claw hand |
o Ulnar nerve or median nerve
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• Ape hand
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o Median nerve
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• Wrist drop
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o Radial nerve
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• Scapular winging
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o Long thoracic nerve
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• Unable to wipe bottom
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o Thoracodorsal nerve
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• Loss of forearm pronation
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o Median nerve
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• Cannot abduct or adduct fingers
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o Ulnar nerve
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• Loss of shoulder abduction
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o Axillary nerve
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• Weak external rotation of arm
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o Suprascapular nerve
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• Loss of elbow flexion and forearm supinaton
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o Musculocutaneous nerve
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• Loss of wrist extension
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o Radial nerve
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• Trouble initiating should abduction
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o Suprascapular nerve
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• Unable to abduct arm beyond 10 degrees
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o Axillary nerve
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• Unable to raise arm above horizontal
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o Long thoracic nerve and spinal accessory nerve
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What nerve is most at risk of injury with the following types of fractures/injury?
• Fracture of the shaft of the humerus |
o Radial nerve
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• Fracture of the surgical neck of the humerus
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o Axillary nerve
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• Supracondylar humerus fracture
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o Median nerve
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• Fracture of the medial epicondyle
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o Ulnar nerve
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• Anterior shoulder dislocation
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o Axillary nerve
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• Injury to the carpal tunnel
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o Median nerve
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A patient falls off a motorcycle and lands on his right shoulder. On physical exam you notice his shoulder has an abnormal configuration. X-rays indicate an anterior dislocation of his shoulder. What artery and nerve are at risk of being damaged?
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• Axillary nerve
• Posterior circumflex artery |
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A high-school athlete falls on his arm during practice. In the ER, a radiograph shows a midshaft break of the humerus. Which nerve and which artery have the highest risk of being damaged? What muscular actions are affected?
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• Radial nerve
• Deep brachial artery • Muscular actions affected o Wrist drop o Loss of brachioradialis reflex |
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A patient with decreased pain and temperature sensation over the lateral aspects of both arms. Where I the lesion?
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• Central canal of the cervical spinal cord
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Newborn with arm paralysis following a difficult labor
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Erb-Duchenne Palsy
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Lecture 143: Neuro 15
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Lower Extremity & Skeletal Muscle
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What drug categories do the following medications fall under?
• Losartan |
o ARB
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• Vecuronium
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o Neuromuscular blocker
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• Ticarcillin
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o Penicillin antibiotic
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• Desipramine
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o TCA
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• Enalapril
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o ACE inhibitor
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• Lorazepam
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o Benzodiazepine
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• Rosiglitazone
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o TZD
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Which brachial arches develop into the following structures?
• Common carotid artery |
o 3rd arch
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• Aortic arch
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o 4th arch (left)
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• Right subclavian
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o 4th arch (right)
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• Pulmonary arteries
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o 6th arch
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What is the classic clinical presentation of a thyroglossal duct cyst?
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• Midline neck mass that moves with swallowing
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Exam of a patient reveals decreased rick sensation on the lateral aspect of her foot and leg. What muscular defect would you also expect to be present?
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• Dorsiflexion and eversion
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A patient fractures her fibular neck. What nerve is most at risk of being damaged?
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• Deep peroneal nerve
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Which two muscle receptors are responsible for opening the sarcoplasmic reticulum in response to depolarization?
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• Dihydropyridine receptor
• Ryanodine receptor |
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What drug prevents the release of calcium from the sarcoplasmic reticulum of skeletal muscle?
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• Dantrolene
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For what conditions is this drug useful?
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• Malignant hyperthermia
• Neuroleptic malignant syndrome |
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Which type of muscle fiber would you usually be dominant in the gastrocnemius muscle?
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• Type 2 muscle fiber
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