Neuro 6.03 - Cerebrovascular Accident

Front 1

Back 1

Pontine tract

Front 2

Back 2

Medial lemniscus

Front 3

Back 3

Cranial nerves

Front 4

Back 4

Reticular formation

Front 5

Back 5

Pontine nuclei

Front 6

Back 6

Reticular formation

Front 7

Back 7

Cranials

Front 8

Back 8

Superior colliculus

Front 9

Back 9

Red nucleus

Front 10

Back 10

Medial lemniscus

Front 11

Back 11

Substantia nigra

Front 12

Back 12

Cerebral peduncle

Front 13

Back 13

Cuneate nucleus

Front 14

Back 14

Gracile nucleus

Front 15

Back 15

Cranials

Front 16

Back 16

Reticular formation

Front 17

Back 17

Medial lemniscus

Front 18

Back 18

Pyramid

Front 19

What are the functions of the brainstem reticular formation?

Back 19

(i) Arousal-Mood Setter
- samples somatic/visceral worlds
- sets forebrain activity (arousal/mood)
(ii) Autonomic Policeman
- monitors somatic/visceral world
- influences crucial reflexes

Front 20

What are the 4 neurotransmitters of the brainstem reticular formation?

Back 20

1. serotonin
2. acetylcholine
3. dopamine
4. noradrenaline

Front 21

Where are the cell bodies of serotinergic neurons of the reticular formation located?

Back 21

The Raphe nuclei

Front 22

What are the functions of the serotinergic neurons of the brainstem formation?

Back 22

- behaviour
- mood (depression)
- aggression (dampens down)
- pain (dampens)
- blood flow control

Front 23

What are the functions of the cholinergic neurons of the brainstem reticular formation?

Back 23

- arousal
- memory (attention)
- ANS control (cardiovascular, baroreceptors)
- pain (dampens)
- dreamer (active when dreaming)

Front 24

What are the functions of the dopaminergic neurons of the brainstem reticular formation?

Back 24

- behaviour regulation
- focus
- pleasure/motivation

Front 25

What are the functions of the noradrenergic neurons of the brainstem reticular formation?

Back 25

- ANS control
- pleasure/motivation
- blood flow control
- neural plasticity
- global attention

Front 26

Where are the cell bodies of the cholinergic neurons in the brainstem reticular formation located?

Back 26

BRF cholinergic groups

Front 27

Where are the cell bodies of the dopaminergic neurons in the brainstem reticular formation located?

Back 27

Substantia nigra, ventral tegmental area

Front 28

Where are the cell bodies of the noradrenergic neurons in the brainstem reticular formation located?

Back 28

Locus coeruleus

Front 29

Which neurons in the brainstem project only to the forebrain?

Back 29

The dopaminergic neurons

Front 30

A lesion to which part of the brainstem would cause coma?

Back 30

Brainstem reticular formation

Front 31

A lesion to which part of the brainstem would cause cerebellar signs?

Back 31

cerebellar peduncles

Front 32

A lesion to which part of the brainstem would cause nystagmus, vertigo, nausea?

Back 32

Vestibular nuclei

Front 33

A lesion to which part of the brainstem would cause speech impairment?

Back 33

Nucleus ambiguus (X)

Front 34

A lesion to which part of the brainstem would cause vomiting?

Back 34

BRF (vomit centre)

Front 35

A lesion to which part of the brainstem would cause motor loss?

Back 35

Corticospinal tract

Front 36

A lesion to which part of the brainstem would cause sensory loss?

Back 36

Trigeminal nuclei/
spinothalamic tract

Front 37

Back 37

Vomit centre on BRF (medulla)

Front 38

Back 38

Vestibular nuclei (medulla)

Front 39

Back 39

Cerebellar peduncle (medulla)

Front 40

Back 40

Nucleus ambiiguus (medulla)

Front 41

Back 41

Corticospinal tract (medulla)

Front 42

Back 42

Spinothalamic tract (medulla)

Front 43

Back 43

Trigeminal nuclei (medulla)

Front 44

Back 44

Edinger-Westphal
- Autonomic parasympathetic nucleus for CN III (ciliaris and sphincter pupillae)

Front 45

Back 45

CN III Somatic motor nucleus (motor eye)

Front 46

Back 46

CN IV Somatic motor nucleus (motor eye)

Front 47

Back 47

Vm - CN V Pharangeal (branchial) motor nucleus (motor to muscles of mastication)

Front 48

Back 48

CN VII Pharyngeal (branchial) motor nucleus (motor to face)

Front 49

Back 49

Vp - Principal nucleus of CN V (somatic sensory head)

Front 50

Back 50

CN VI Somatic motor nucleus (abducens - motor eye)

Front 51

Back 51

Superior salivary (CN VII) and inferior salivary (CN IX) autonomic nuclei

VII - sublingual and submandibular glands
IX - parotid gland

Front 52

Back 52

Vestibular/ cochlear (CN VII) nucleus (special sensory - hearing, equilibrium)

Front 53

Back 53

Cochlear (CN VII) nucleus (special sensory - hearing, equilibrium)

Front 54

Back 54

Vsp - Spinal tract of CN V (somatic sensory head)

Front 55

Back 55

NAm - Nucleus ambiguus (pharyngeal motor CN IX & X)

Front 56

Back 56

SoIT - Nucleus of the Solitary Tract (visceral sensory)
Rostral part - CN VII, IX, X (Taste)
Caudal part - CN IX, X (sensory pharynx, larynx)

Front 57

Back 57

DMX - Dorsal motor X (parasymp to thorax and gut)

Front 58

Back 58

Somatic motor nucleus for XII (motor to tongue)

Front 59

What is the key clinical difference between Bells Palsy and a stroke affecting the facial muscles?

Back 59

Forehead spring occurs with stroke, as the forehead receives bilateral innervation

- Stroke will result in loss of lower facial muscles on contralateral side
- Bells palsy will result in loss of upper and lower facial muscles on the ipsilateral side

Front 60

Back 60

1. Anterior communicating artery

Front 61

Back 61

2. Anterior cerebral artery

Front 62

Back 62

3. Internal carotid artery

Front 63

Back 63

4. Middle cerebral artery

Front 64

Back 64

5. Posterior communicating artery

Front 65

Back 65

6. Posterior cerebral artery

Front 66

Back 66

7. Superior cerebellar artery

Front 67

Back 67

8. Basilar artery

Front 68

Back 68

9. Anterior inferior cerebellar artery

Front 69

Back 69

10. Vertebral artery (cut)

Front 70

Back 70

11. Posterior inferior cerebellar artery

Front 71

Back 71

1. Middle meningeal artery
2. Buccal artery
3. External carotid artery
4. Superior thyroid artery
5. Common carotid artery
6. Internal carotid artery
7. Facial artery
8. Maxillary artery
9. Superficial temporal artery

Front 72

Back 72

1. Middle cerebral artery
2. Posterior communicating artery
3. Pontine arteries
4. Anterior spinal artery
5. Vertebral artery
6. Posterior inferior cerebellar artery
7. Anterior inferior cerebellar artery
8. Basilar artery
9. Superior cerebellar artery
10. Posterior cerebral artery
11. Anterior choroidal artery
12. Opthalmic artery
13. and 14. Anterior cerebral artery
15. Anterior communicating artery

Front 73

Which is the more common form of stroke: infarction or haemorrhage?

Back 73

Infarction (80%) vs Haemorrhage (20%)

Front 74

What are the most common extracranial and intracranial sites for atherosclerosis?

Back 74

Extracranial (most common) ICA near common carotid bifurcation
Intracranial at origin of MCA and at ends of basilar artery

Front 75

What are the 4 acute pathologic features of brain infarct?

Back 75

• Softening
• Swelling (raised intracranial pressure can cause brain stem compression and death)
• Neutrophils (as part of acute inflammation)
• Ischemic (“red cell”) neuronal change

Front 76

What are the 3 post-acute pathologic features of brain infarct?

Back 76

• Foamy macrophages (start at about 3 days) - remove debris
• Reactive astrocytes (start at about 10 days) - form glial scar
• Cavitation

Front 77

What is the difference between the ischaemic core and the ischaemic penumbra?

Back 77

Core - necrotic cell death
Penumbra - some tissue survival, retains viability if blood flow restored

Front 78

What type of infarct:
• Causes small (up to 20 mm) infarct in deep structures of brain (basal ganglia, thalamus, internal capsule) and in the brain stem
• Is associated with arterial hypertension
• Is often clinically silent

Back 78

Lacunar infarct (small penetrating artery)

Front 79

What is CADASIL?

Back 79

• Cerebral autosomal dominant arteriopathy with subcortical infarcts and leukoencephalopathy
• Presents with TIAs or migraine, can progress to subcortical dementia
• Notch 3 receptor gene mutations

Front 80

When are boundary zone infarcts most often seen?

Back 80

When abrupt hypotension is followed by rapid recovery

Front 81

Where are boundary zone infarcts more often seen?

Back 81

Between
– Middle and anterior cerebral arteries
– Middle and posterior cerebral arteries

Front 82

Which groups of people are more likely to get venous infarcts?

Back 82

Babies (dehydrated) and pregnant women (hypercoagulable)

Front 83

Where are the most common locations of berry aneurysms?

Back 83

Front 84

What is the most common cause of subarachnoid haemorrhage?

Back 84

Ruptured berry aneurysm

Front 85

What are the 5 key symptoms of stroke?

Back 85

1. Amaurosis fugax (transient monocular visual loss)
2. (hemi-)paresis/weakness
3. Sudden speaking probem
4. Hemianopia
5. Double vision

Front 86

How do you predict the risk of stroke in patients with atrial fibrillation?

Back 86

CHADS1:
C - Congestive Heart failure (1)
H - Hypertension (1)
A - Age >75y (1)
D - Diabetes (1)
S - Prior TIA or Stroke (2)

Front 87

Back 87

Cerebral aquaduct

(caudal midbrain)

Front 88

Back 88

Inferior colliculus

(caudal midbrain)

Front 89

Back 89

Midbrain periaqueductal gray

(caudal midbrain)

Front 90

Back 90

Trochlear (IV) nucleus

(caudal midbrain)

Front 91

Back 91

Spinothalamic tract

(caudal midbrain)

Front 92

Back 92

Medial lemniscus

(caudal midbrain)

Front 93

Back 93

Substantia nigra

(caudal midbrain)

Front 94

Back 94

Cerebral peduncle - CsT/RubroST

(caudal midbrain)

Front 95

Back 95

Closed medulla (motor decussation)
1. Central canal
2. Gracile tract
3. Cuneate tract
4. V spinal
5. Autonomic nuclei
6. Spinothalamic tract
7. Spinocerebellar tract
8. Pyramids (CsT decussating)

Front 96

Back 96

Midbrain

1. Posterior cerebral (long circumferential branches)
2. Posterior cerebral (short circumferential branches)
3. Posterior cerebral (paramedian branches)

Front 97

Back 97

Pons

1. AICA (anterior inferior cerebellar artery)
2. Basilar artery (short circumferential branches_
3. Basilar artery (paramedial branches)

Front 98

Back 98

Open Medulla

1. PICA )posterior inferior cerebellar artery)
2. Vertebral artery
3. Anterior spinal artery

Front 99

Back 99

Closed medulla

1. Posterior spinal artery
2. vertebral artery
3. Anterior spinal artery

Front 100

Occlusion of WHAT arteries results in damage to the midline corticospinal and corticobulbar tracts, damage to the reticular formation and loss of the oculomotor nuclei. This can result in locked in with ocular palsy syndrome. The patients typically have sudden onset of vomiting and may have transient loss of consciousness. There is acute onset quadriplegia (corticospinal tracts), bilateral facial paralysis (corticobulbar tracts), loss of speech (corticobulbar tracts for cranial nerve nuclei controlling larynx, pharynx, tongue and lips) and loss of voluntary eye movements (loss of oculomotor nuclei).

Back 100

Midbrain paramedian/basal arteries

Front 101

Occlusion of WHAT arteries results in damage to the midline corticospinal and corticobulbar tracts and damage to the reticular formation. The oculomotor nuclei are spared. This can result in "locked in syndrome without ocular palsy" so the patient still has voluntary eye movements. Facial muscles are paralysed due to damage to corticobulbar fibres.

Back 101

Pontine paramedian/ basal arteries

Front 102

Occlusion of WHAT artery causes: ipsilateral cerebellar ataxias (loss of middle and/or superior cerebellar peduncles), nausea and vomiting, slurred speech, loss of pain and temperature over the opposite side of the body.

Back 102

Superior cerebellar artery

Front 103

The second most common brainstem stroke involves WHAT artery. These patients present with sudden onset vertigo, vomiting and falling to one side. They have usually marked horizontal nystagmus but the characteristic features are absent sensation on one side of the face, ipsilateral facial paralysis and ipsilateral hearing loss. They also lean to the affected side when you make them sit.

Back 103

Anterior inferior cerebellar artery

Front 104

The most common brainstem stroke involves WHAT artery. They often present with:
(a) loss of pain and temp on the ipsilateral side of the face
(b) loss of pain and temp on the contralateral body. This odd combination of loss of pain and temperature sensation on the ipsilateral side of the head and contralateral side of the body is unique to this brainstem stroke.
(c) ipsilateral paralysis of soft palate, pharynx and larynx leading to dysphagia and dysarthria
(c) vertigo and nystagmus - saccadic dysmetria (overshoot) or saccadic pulsion
(d) ipsilateral ataxia
(vi) ipsilateral Horner’s syndrome characterised by ptosis, miosis and facial anhidrosis

Back 104

Posterior inferior cerebellar artery - causes lateral medullary syndrome or Wallenberg's syndrome

Front 105

A blockage of this artery would result in loss of pain and temperature sensation in the ipsilateral face, ipsilateral facial pain (SpV), contralateral pain and temperature loss of the body (spinathalamic tract), ipsilateral ataxia and gait ataxia (IO), hoarseness and dysphagia (NA) and Horner's syndrome.

Back 105

Vertebral artery

Front 106

An occlusion of this artery would result in contralateral weakness of both the upper and lower extremities (pyramidal tract before it crosses), contralateral sensory loss, e.g. vibration, propriception (not pain and temperature), and ipsilateral tongue weakness (hypoglossal nucleus).

Back 106

Anterior spinal artery

Front 107

The following are indicative of which condition in a patient with longstanding diabetes?

• Postural lightheadedness
• Heat intolerance
• Erectile dysfunction
• GI dysmotility- bloating, constipation, diarrhoea
• Bladder dysfunction - retention, incontinence
• Glare sensitivity

Back 107

Autonomic neuropathy

Front 108

What syndrome is described?
• Any primary autonomic failure without central nervous system findings
• Postural lightheadedness, dizziness worse in the morning, worse after meals or exercise, in hot weather
• May have bladder symptoms, erectile dysfunction, constipation
• May report reduced sweating

Back 108

Pure autonomic failure
Idiopathic orthostatic hypotension
Bradbury-Eggleston syndrome

Front 109

Patient presents with:
- Orthostatic hypotension
- Features of parkinsonism
- Rigidity and bradykinesia > tremor
- No, poor or poorly sustained response to l-dopa
- Mild cerebellar or pyramidal signs

Back 109

MSA - multiple system atrophy

Front 110

Midodrine

Back 110

Selective alpha agonist (sympathomimetic) used to treat orthostatic hypotension

Front 111

What are the 4 P's - goals of stroke imaging?

Back 111

• Evaluation of Parenchyma – Non contrast CT or MR
• Evaluation of Pipes – CT or MR angiography
• Evaluation of Perfusion – CT perfusion or MR perfusion
• Evaluation of Penumbra – CT perfusion

Front 112

Back 112

ACA infarction

Front 113

Back 113

PCA infarction

Front 114

Back 114

Watershed infarction

Front 115

Back 115

Lacunar infarcts (in thalamus, putamen, globus pallidus, caudate nucleus, and internal capsule)

Front 116

Back 116

Hypertensive intracerebral haemorrhage

Front 117

Back 117

1. Tentorium cerebelli
2. Herniation of temporal lobe
3. Skull fracture affecting middle meningeal artery
4. Midline shift of falx cerebri and third ventricle
5. Compression of cerebral peduncle
6. Herniation of cerebellar tonsil in foramen magnum
7. Compression of CN III

Front 118

Back 118

1. Lateral (Sylvian) fissure
2. Inferior frontal gyrus
3. Middle frontal gyrus
4. Superior frontal gyrus
5. Precentral gyrus
6. Central sulcus
7. Postcentral gyrus
8. Supramarginal gyrus
9. Angular gyrus
10. Parietooccipital sulcus
11. Calcarine fissure

Front 119

Back 119

1. Superior parietal lobule
2. Visual association cortex
3. Primary visual cortex
4. Multisensory association areas of cortex
5. Primary auditory cortex
6. Wernicke’s area
7. Secondary somatosensory cortex
8. Broca’s area
9. Primary somatosensory cortex
10. Premotor cortex
11. Frontal eye fields
12. Primary motor cortex
13. Supplemental motor cortex

Front 120

Back 120

1. Optic chiasm
2. Lamina terminalis
3. Anterior commissure
4. Thalamus
5. Fornix
6. Cingulate gyrus
7. Paracentral lobule
8. Corpus callosum
9. Cuneus
10. Calcarine cortex, upper bank
11. Calcarine sulcus (fissure)
12. Calcarine cortex, lower bank
13. Pineal gland

Front 121

Back 121

1. Superior sagittal sinus
2. Cortical gyrus
3. Lateral ventricle
4. Thalamus
5. Third ventricle
6. Corpus callosum
7. Lateral ventricle
8. Thalamus
9. Occipital lobe
10. Midbrain
11. Pons
12. Cerebellum
13. Medulla

Front 122

Back 122

1. Genu, corpus callosum
2. Head of caudate nucleus
3. Putamen
4. Columns of the fornix
5. Internal capsule
6. Thalamus
7. Hippocampal formation
8. Cingulate cortex
9. Lateral ventricle
10. Fornix
11. Colliculi
12. Hypothalamus
13. Cisterna magna

Front 123

Back 123

1. Subarachnoid space
2. Frontal pole, lateral ventricles
3. Hippocampal formation
4. Temporal pole, lateral ventricle
5. Optic radiations
6. Site of lateral ventricle
7. Subarachnoid space
8. Cerebellum
9. Medulla
10. Cisterna magna
11. Subarachnoid space

Front 124

Back 124

1. Genu of corpus callosum
2. Head of caudate nucleus
3. Columns of the fornix
4. Internal capsule (anterior limb, genu, posterior limb)
5. Insular cortex
6. Putamen
7. Globus pallidus
8. Claustrum
9. Tail of caudate nucleus
10. Choroid plexus of lateral ventricle
11. Occipital (posterior) horn of lateral ventricle

Front 125

Back 125

1. Trochlear nerve (CN IV)
2. Facial nerve (CN VII)
3. Inferior cerebellar peduncle
4. Vestibular area
5. Olive
6. Hypoglossal trigone
7. Vagal trigone
8. Gracile tubercle
9. Cuneate tubercle
10. Facial colliculus
11. Medial eminence
12. Superior medullary velum
13. Inferior colliculus
14. Superior colliculus

Front 126

Back 126

1. C5 cross section
2. T8 cross section
3. L3 cross section
4. Spinothalamic/spinoreticular tracts
5. Dorsolateral fasciculus (of Lissauer)
6. Fasciculus cuneatus
7. Fasciculus gracilis
8. Anterior white commissure
9. Lateral corticospinal tract
10. Vestibulospinal tract
11. Anterior corticospinal tract

Front 127

Back 127

1. Anterior horn of left lateral ventricle
2. Body of left lateral ventricle
3. Inferior (temporal) horn of left lateral ventricle
4. Posterior (occipital) horn of left lateral ventricle
5. Cerebral aqueduct
6. Fourth ventricle
7. Left lateral foramen of Luschka
8. Median foramen of Magendie
9. Third ventricle
10. Left interventricular foramen of Monro
11. Right lateral ventricle

Front 128

Back 128

1. Middle cerebral artery
2. Anterior cerebral artery
3. Internal carotid artery
4. Basilar artery
5. Vertebral artery
6. Common carotid artery
7. Subclavian artery
8. Brachiocephalic trunk
9. Aortic arch

Front 129

Back 129

1. Neural plate of forebrain
2. Neural groove
3. Neural folds
4. Future neural crest
5. Neural plate
6. Fused neural folds
7. Caudal neuropore
8. Neural crest