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NE NE NE!

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by

heather watson

on 19 June 2016

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Transcript of NE NE NE!

ANATOMY PHYSIOLOGY clinical: CONSCIOUSNESS clinical: DEGENERATIVE clinical: ACUTE clinical: MOVEMENT D/O blood supply upper brain cranial nerves ascending pathways descending pathways anterior posterior venous drainage infarct PCA vertebrals 3D images coronal horizontal sagittal nuclei ANS REFLEXES SOMATOSENSORY MOTOR VESTIBULAR CEREBELLUM spinal supply: coma sleep headache anesthetic pain quick facts demylinating dz dementia neoplasm quick facts cerebrovascular trauma CNS infxn angiography lumbar
puncture quick facts basal ganglia dz epilepsy korsakoffs inf pons lower brain pyramids CN3 CN4 CN5 CN7 optic chiasm hypothalamus mammilaries CN4 CN4 thalamus thalamus CN2 CN2 infundibulum CN3 CN3 crus cerebri crus cerebri motor cortex project to
thalamus CN5 CN5 middle
cerebral
peduncle middle
cerebral
peduncle CN6 CN7 CN8 CN9 CN10 accessory nerve CN11 accessory nerve CN11 CN12 CN12 CN10 CN9 CN8 CN7 CN6 pyramids

pyramids pyramidal
decussaion olive olive superior
colliculus inferior
colliculus superior
cerebellar
peduncle CN4 middle
cerebellar
peduncle inferior
cerebellar
peduncle CN5 CN7 CN8 CN6 CN9 CN10 accessory nerve fasciculus gracilis fasciculus cuneatus olive CN12 optic chiasm hypothalamus mammilaries CN4 CN4 thalamus thalamus CN2 CN2 infundibulum CN3 CN3 crus cerebri crus cerebri motor cortex project to
thalamus CN5 CN5 middle
cerebral
peduncle middle
cerebral
peduncle CN6 CN7 CN8 CN9 CN10 accessory nerve CN11 accessory nerve CN11 CN12 CN12 CN10 CN9 CN8 CN7 CN6 pyramids

pyramids pyramidal
decussaion olive olive superior
colliculus inferior
colliculus superior
cerebellar
peduncle CN4 middle
cerebellar
peduncle inferior
cerebellar
peduncle CN5 CN7 CN8 CN6 CN9 CN10 accessory nerve fasciculus gracilis fasciculus cuneatus olive CN12 superior cerebellar peduncle medial
lemniscus Medial
Longitudinal
Fasiculus Antero
Lateral
System cortico
spinal
fibers pontine
nuclei origin: motor cortex
via: internal capsule
decuss: pyramids
synapse: ventral horn synapse: gracilis, cuneate
nuclei @ medulla
decuss: olive
via: internal arcurate fibers
destin: PVL thalamus proprioception spinothalamic - pain info
spinoreticular - alert to pain
spinotectal - orient to pain dorsal column medial lemniscus anterolateral
spino-thalamic, -reticular, -mesencephalic) special perception Origin: peripheral proprioception
vibration, fine touch
Path: dorsal column
fascilicus gracilis, cuneatus
Decuss: pyramids - "arcurate fibers"
Path: pons - medial, close prox
to spinothalamic
Synap: VPL thalamus -> cortex via
posterior limb Int. Caps. Origin: peripheral pain & temp
Decuss: level of entry, 10% one
level superior
Path: spinal cord - lateral
medulla, far prox to DCML
Synap: VPL thalamus -> cortex via
posterior limb Int. Caps. trigeminal pain & temp joins spinothalamic
tract as decusses at CAUDAL MEDULLA
touch & prop joins DCML tract as it
decusses at MID-MEDULLA TRACT ORIGIN DECUSS SYNAPSE FXN corticospinal primary motor
cortex, parietal pyramids lateral cst largest part of the corticospinal tract. Run the entire length of the medulla spinalis,
on x-section = oval area ventral to dorsal colum, medial to the posterior spinocerebellar tract. 85% ventral horns
entire spine mvt c-lateral
limbs lateral corticospinal anterior primary motor
cortex, suppl.
motor area cervical spine bilateral axial
& girdle muscles rubrospinal red nucleus midbrain dorsal lateral
funiculus near cst some duplic of CST
flexion of U.E. cervical spine plus T1-5 corticobulbar cortex medulla does not
stop in pons innervates nuclei:
CN11 & CN12
gracile & cuneate CN5 & CN7
innervated
BILATERALLY RECALL: VST anterior medial & lateral
vestibular nuclei dorsal pons cervical spine plus T1-5 positions
head & neck ispilateral int. carotid MCA ACA ant. communicating most common site
for berry aneurysm opthalmic a. ant. choroid a. ACA medial frontal & parietal lobes corpus colosum basal ganglia internal capsule olfactory bulb genu
corpus
collosum trunk of corpus collosum amygdala rostrum of corpus collosum fornyx: body fornyx: crus fornyx:
commisure septum pellucidum mamillary bodies hippocampal fimbrea fornyx: column CONTRALATERAL LEG & FOOT Weakness
Paralysis
Sensory loss GAIT APRAXIA GU INCONTINENCE
if damage bilateral GRASP, SUCKING REFLEX GegenHalten MCA ACA MCA lateral hemispheres Broca's & Wernicke's deep basal ganglia deep internal capsule posterior communicating vertebral a. PCA post. comm. sup. cerebellar a. BASILAR A. pontine a's AICA PICA PCA posterior choroid temporal lobe occipital lobe uncus
fusiform
inferior temp. cuneus
calcarine
post. occip. thalami 3rd ventricle primary
visual
cortex primary
visual
cortex calcarine
sulcis thalamus thalamus splenium corpus collosum choroid plexus UNCUS Seizures preceded by olfactory aura Herniation leading to:
insertion between tentorium & brainstem
compression of CN3 (ipsi dilated, down & out)
compression of RAS (lethargy, coma, death)
Contralateral loss of pain and temperature sensations.
Visual field defects (contralateral hemianopia with macular sparing).
Prosopagnosia with bilateral obstruction of the lingual and fusiform gyri.
Superior Alternating Syndrome (Weber's syndrome)
Contralateral deficits of facial nerve (only lower face, upper face receives bilateral input), vagus nerve and hypoglossal nerve
Ipsilateral deficit of oculomotor nerve
Horner's Syndrome superior
cerebellar a. sup. cerebellum pineal body 3rd vent anterior inferior
cerebellar a. lateral pontine syndrome vestibular nuceli sens. trigeminal nucleus facial nucleus cochlear nuclei 1. VERTIGO, nystagmus, vomiting
2. FACIAL ANESTHESIA - ipsilateral
3. FACIAL PARALYSIS - ipsilateral
4. HEARING LOSS, tinnitus INFARCT posterior inferior
cerebellar a. nucleus ambiguus lat. spinothalamic t. desc. SNS fibers lateral medullary syndrome 1. VERTIGO, nystagmus, vomiting
2. FACIAL ANESTHESIA - ipsilateral
3. FACIAL PARALYSIS - ipsilateral
4. HEARING LOSS, tinnitis
5. DYSPHAGIA, hoarsenss, decr gag
6. HORNER's - ipsilateral infarct CN10 CN11 efferent efferent pharyngeal
laryngeal
uvula stylopharyngeus sup. sagittal sinus inf. sagittal sinus int. cerebral vein L int. cerebral vein R basal vein of Rosenthal GREAT
vein of
GALEN straight sinus transverse sinus L transverse sinus R confluence
of sinuses emissary veins igmoid sinus R igmoid sinus L epidural plexus spinal venous drainage Only anatomic location where an artery travels completely through a venous structure. If the internal carotid artery ruptures within the cavernous sinus, an arteriovenous fistula is created Pituitary gland lies between the two paired cavernous sinuses. Mass effect of tumour:
disrupts CN III, IV, and VI, causing total
ophthalmoplegia,
fixed, dilated pupil.
Involvement of CN V (V1 and variable involvement of V2) causes sensory loss in these divisions of the trigeminal nerve. CN3 CN4 CN6 CN5 v1 attached to diencephalon
at ant. margin of tentorium eye mvt sensory face
chewing taste
pharynx tectum above aqueduct midbrain =
tectum +
c. peduncle PCA supplies SCA supplies PARINAUD SYNDROME
Paralysis of conjugate upgaze PONS:
spinothalamic tract
and medial lemniscus
in CLOSE proximity Red
nucleus MEDIAL LONGITUDINAL FASICULUS allows communication between CN6 & CN3
for conjugate eye movement PATHWAY LESION CATEGORIES TRIGEMINAL SYSTEM recieve signal peripheral nerve spinal cord thalamus cerebrum 1st order n. 2nd order n. 3rd order n. stereognosis graphesthesia TOUCH
PROPRIOCEPTION
PAIN
THERMOS PROPRIOCEPTION: muscle I-III
TOUCH: cutaneous A

PAIN: muscle IV, cutaneous C and A-delta
TEMP: muscle IV, cutaneous C large, myelinated
high velocity medial lemniscus DISCRIMINATORY TOUCH VIBRATION PRESSURE PROPRIOCEPTION back = 70mm 2PD
tongue = 1mm 2PD 2PD ~ cortical surface dedicated to given structure Meissner = 50Hz oscillation
"flutter"
Pacinian = 300Hz oscillation
"humming" - deep stabilize proximal joint - move distal
can patient perceive & ID mvt? spinothalamic tract PAIN
temp
crude touch
tickle
itch pinprick
temp sense mechanoreceptors
chemoreceptors
nociceptors & photoreceptors
thermoreceptors Fast pain travels via type A-delta fibers Slow pain is transmitted via slower type C fibers to laminae II and III of the dorsal horns, together known as the substantia gelatinosa sharp, easily
localized achy, poorly
localized
Autoimmune

Diabetes

End Organ Fail

Infection

Toxin

Trauma

Tumour

Vit. Defish (EtOH) PERIPHERAL NERVE LESION DDx Guillian-Barre: 2-4wks post GI/UR infxn
acute inflammatory polyradiculoneuropathy with resultant weakness and diminished reflexes 50% neuropathy rate Lyme, Shingles, HIV, EBV, HepC heavy metals, chemo sever, compress, ischemia thiamine B-vits
niacin
VitE SPINAL CORD LESION - HEMISECTION BROWN-SEQUARD SYNDROME CONTRALATERAL
loss of fine touch
pain and temp IPSILATERAL

- Horner's

FACIAL:
- pain, temp
- fine touch PONS: CN 5, 7 & 8
involvement

MEDULLA:
CN 9, 10, 11 involve BRAINSTEM LESION SYRINGOMYELA MOUTH-EAR CN5 NEURALGIA NOSE-ORBIT CN5 NEURALGIA PATHOPHYSIOLOGY CARDINAL SIGNS & Sx Dx Tx syrinx = fluid filled cavity (cyst) in cord Hydromyelia
dilatation of
central canal
by CSF 50% blockage of CFS
10% spinal cord injury
<10% intramedullary tumour
25% idiopathic most common Arnold-Chiari
Masses
Infxn brainstem malformation trauma
radiation
infxn
hemorrhage
cavitation only 2-4% of all tumors of CNS INTRAMEDULLARY TUMOURS Generalized back pain > 2 years
Night & supine >> pain
Combo UMn signs and LMn signs Tx = surgery Fluid results from
hemorrhage or
neoplastic edema Blockage of Foramen Magendie
creates "water-hammer" fx on
pulsatile CFS pressures, generating
cavity/cyst. MULTIPLE SCLEROSIS PATHOPHYSIOLOGY CARDINAL SIGNS & Symps Dx Tx BBB lymphos
macros enhanced adhesion Y Y Y Y Y Y Y Y Y Y Y Y & free radicals
proteases
complement
chemotaxis HLA
+
Enviro demyelination remyelination axonal loss insufficient remyelination failed remyelination faulty conduction dentrites oligodendrocyte
destruction terminal bud 2+ deficits @ diff loci & diff times LP: oligoclonal
bands
+CF
-Serum MR: plaques (T1 loci, Galadium times) slow
dispersed
blocked conduction 0.1% prevelance
2:1 female:male
20-40 yoa onset Sensory Motor Autonomic Cognitive parasthesias
viz. disturb 33%
optic neuritis weakness >70%
spasticity >70%
hyperreflex > 60% dropsies diplopia bladder >50%
bowel >40%
e.d. 33% FATIGUE >>70%
depression
personality change 85% 1. +RR 0 atrophy
2. SP + atrophy
3. -RR ++ decline Natural Hx 2yrs
5-10
10-20 Prevent exaccerbations
& delay progression Tx breakthru relapse Neuroprotection
& regeneration beta-interferon monoclonal Ab's 0 / upper Mn dz lower Mn dz pyramidal cells in layer V of the cerebral cortex. 80% decuss @ pyramid 10% decuss @ level of exit 10% ipsilateral Slow-twitch:
only 100 fibres per unit Fast-twitch:
aprox 10,000 fibres all or none: every fiber in a unit contracts
simultaneously or none of them will nerves which contrib to corticospinal tract nerves which directly stimulate muscle impaired control impaired execution EMG Distinguish b/t neural & muscular dz myopathy TONE

REFLEXES

BABINSKI TONE

REFLEXES

BABINSKI N weakness = dermatomal spasticity, rigidity tremor, seizure, dyskinesias incr. tone weakness muscle-specific fasciculations, fibrillation, cramps DDx for Reflexes peripheral nerve dz

synapse dysfxn

muscle dz neuron loss
demylenation ALS, polio Guillan-Barre Ca2+ channel loss
receptor loss
poison Lambert-Eaton Myasthenia Gravis botulism Channel defect
Myopathies
Dystrophies hyper/hypokalemic P.Ps toxic/metabolic/congenital duchene's red nuclei vestibular
nuclei pontine
nuclei parkinsons huntingtons parkinsonsim neuropathy PATHOPHYSIOLOGY CARDINAL SIGNS & Sx Dx Widespread pain and tenderness
• No other explanation
• Poor sleep (unrefreshed)
• Cognitive issues
• Interferes with life
• Muscles aren’t the problem Fam Hx =
50% risk + TRIGGER • Peripheral pain
• Epstein-­Barr, Lyme
• Physical trauma
• Psychological trauma
Peripheral Nerves
Sensitized Spinal
Interneurons
Sensitized nociceptors non-nociceptors Diffuse
Noxious
Inhibitory
Controls serotonin
norepi Substance P
Glutamate stim NMDA receps + nerve growth + Gray matter loss
on imaging PHARMA NON-PHARM aerobic exercise
CBT
education TCAs
Gabapeninnoids
SNRIs CBC + diff

LFTs, RFTs

Glucose ESR, CRP, CK

TSH

Urinalysis Ca2+, Mg2+, PO4, VitD

albumin

Lipid panel r/o Viral, spirochetal, bacterial RA, PMR/GCA
spondy's
vasculi1s r/o Osteomalacia,
metabolic myopathies,
scurvy, HyperCa++ r/o EtOH/narc w/d r/o Hypothyroidism,
adrenal insufficiency r/o Statins, fibrates r/o diabetic neuropathy r/o referred pain from abdom organs some lipids enhance pain
signal transduction IMAGING
- r/o stress #
- bony mets

EMG
- r/o myopathy

PSYCH
- r/o depression
psychosis
FIBROMYALGIA
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