A health condition that involves the Nervous System

 “disease of the brain” generally in its entirety (both cerebral hemispheres). i.e., metabolic encephalopathy

“disease of the spinal cord” i.e, compressive myelopathy (tumor, disc, etc causing weakness, sensory loss, spasticity below the level of compression)

: “disease of the nerve root(s)” i.e., any process affecting a single or multiple nerve roots at cervical, thoracic or lumbar or sacral level

“disease of a nerve” (one is mononeuropathy or neuropathy, several individual is mononeuropathy multiplex, and many/diffuse is polyneuropathy peripheral nerves. Dysfunction of a single cranial nerve = cranial mononeuropathy)

“primary disease of muscle”

________: Implies a group of mental processes that includes attention, memory, learning, reasoning, problem solving,, decision making (processing, applying knowledge and adjusting).

Is generally bi-hemispheric in nature

Critical task it to separate

reversible from irreversible

causes

Plexopathy/plexitis:

CHARACTERIZED BY DIFFICULY WITH INITIATION OF GAIT  (FEET “GLUED TO THE FLOOR”)

BASAL GANGLION DYSFUNCTION (PARKINSON DISEASE); GAIT IS  CHARACTERISTICALLY SLOW, SHUFFLING, FLEXED POSTURE, BRADYKINETIC… TURNING 180 DEGREES TAKES EXTRA STEPS.

FESTINATION (CAN’T STOP FORWARD PROGRESS ONCE ENGAGED

WIDE-BASED UNSTEADY GAIT (LOOKS LIKE A PERSON ENEBRIATED) 

HEMIPARETIC GAIT (STIFF, CIRCUMDUCTION, OVEREXTENDED LEG)

(Ex:MYELOPATHY); both legs stiff, spastic gait, sometimes with scissoring motion of each leg around the other 

A 50 year  old man presents to your emergency room with a  6 day history  of numbness and tingling from his mid chest area  down both legs. When he flexes his  neck forward he  perceives an electrical shock like sensation down his  back and into his arms.

Exam shows mild weakness in both legs generally  (4.5/5) and decreased sensation to pinprick below his  nipples, and  in his  lower chest, abdomen and legs. Reflexes  are  brisk in his legs , and planter responses are extencasorbilaterally.

Which of the following best describes his  clinical syndrome?

A 76 year old woman, with 6 year history of diabetes mellitus comes to your clinic because of severe pain.

The pain is sharp and burning, begins in her medial scapular region, radiates around her trunk to beneath  her right breast.

The pain is not exacerbated with breathing, but is uncomfortable, in this area, to touch

She takes oral  hypoglycemic medication. She has seen several specialists, including a cardiologist and  gastroenterologist, but no  diagnosis was forthcoming.

On your examination, her general  examination is unremarkable, and there is no skin rash.

Neurologic exam is normal except for severe discomfort to touch under her right breast and below her  right scapula (about 2-3 cm. in height from mid thoracic spine posteriorly  to the lower sternum anteriorly.

What best describes the  localization of her pain syndrome?

Left posterior hemispheric lesion

R-L confusion

Inability to recognize fingers

Agraphia (inability to write)

Acalculia (Inability to write)

Olfaction

test each nostril for smell fragrance

Optic nerve

Check visual fields and acuity. fundoscopic exam

Asymmetric pupils

 Anisocoriaindicates a lesion in the efferent fibers (away from the brain)  supplying the pupillary sphincter muscles.

can indicate problem with CN III

The smaller pupil is abnormal when the degree of anisocoria is greatest in darkened settings, while the larger pupil is abnormal when the degree of anisocoria is greatest in bright light.

droopy eyelid (ptosis) plus constriction of pupil of eye; SMALL pupil is the abnormal one and due to lesion of Sympathetic tract

_______ lesion is manifest by impaired adduction on affected side, accompanied by nystagmus in the other, abducting eye. one eye cant look one way.  

test facial sensation by touching with cotton.  3 branches, ophthalmic, maxillary, and mandibular

also involved in the muscles of mastication

________: a peripheral weakness or paralysis of one side of the face causing a facial droop; drooling, eye issues with tearing (excessive, dry eye); loss of taste, pain behind ear, increase sensitivity to sound

A facial nerve (Cr N VII) lesion

Vestibular nerve

hearing, balance

______ can result from any condition that damages motor control of the structures necessary for speech production, including cerebellar or basal ganglia disorders, and the specific characteristics of the ______ may be useful in localization and differential diagnosis. 

= weakness of BOTH LOWER extremities

DTR’s _______ in Central nervous system (CNS) lesions

  DTR’s _______ or absent in Peripheral Nervous System 

Options: increase or decrease

DTR= deep tendon reflex

_______ maneuver is distracting patient in order to achieve relaxation and better facilitate the reaction

PATIENT WITH HEAD TRAUMA  PLUS HEADACHE OR ALTERED MENTAL STATUS OR FOCAL FINDING ON EXAM

what do u do?

Chronic Alcohol Abuse Patients with Poor Nutritional Intake; need to give __1___.  They will present with :

1.  Apathetic – confused state

2.  Ophthalmoplegia (eye paralysis); or Nystagmus

3.  Gait ataxia

This triad of symptoms is known as ___2____

Thiamine

Wernicke's encephalopathy

Acute inflammatory demyelinating polyneuropathy

Rapidly progressive demyelinating polyneuropathy

Image of the ventricular system within the brain by draining the cerebrospinal fluid (CSF) out of the subarachnoid space by Lumbar Puncture, and replacing it with air

MYELOGRAPHY

 CONTRAST MATERIAL INJECTED INTO THE SPINAL SUBARACHNOID CANAL

Angiography

direct injection of contrast

material into the carotid artery

Liver

300

brain, also has GLUT3

20

muscle and adipose

90

Brain

20

The parasympathetic NS has a ____ preganglionic and a ____ postganlionic neuron

choices :Long or short

The parasympathetic NS has a long preganglionic and a short postganlionic neuron

The sympathetic NS has a ____ preganglionic and a ____ postganlionic neuron

choices :Long or short

The parasympathetic NS has a short preganglionic and a long postganlionic neuron

Acetylcholine neurotransmiFer at preganglionic synapse, norepinephrine at postganglionic synapse because its faster

Lower motor cellbodies for the head and neck are located in the ______

Lower motor cellbodies for the body are located within the ______

How is the formation of acetylcholine powered?

Deficiency of choline interferes with lipid processing and leads to _______

Tryptophan hydroxylase (Adds OH) and 5-hydroxytryptophan decarboxylase (Removes CO2)

Tryptophan

What type of synapse is this?

Gap junctions

Fast bidirectional

group control

Channels are large and unselective

What is α-Latrotoxin?

A spider toxin that generates massive vesicle depletion and transmitter release by binding to neurexin, which is a similar to syntaxin.  vessicles get stuck and it depletes the terminal.

The binding of Ca2+ and ______ triggers the fusion with the terminal membrane and release of the neurotransmitter for fast synaptic transmission.

Ionotropic Receptors

•  Ligand-gated: a molecule binds to the receptor and opens the channel that is part of the receptor.

•  The neuromuscular junction is the classic example.

Metabotropic Receptors

•  The receptor is a separate protein from the ion channel.

•  The receptor activates a G-protein that will work directly or through an intermediate effector to change the ion channel.

G-αs (Gs )

G-αi (Gi )

G-αq (Gq )

Is this Ionotropic or Metabotropic?

–  Much slower

–  Activate diffusable second messengers

–  More widespread action

–  Can open or close channels.

–  Usually does not lead directly to action potentials

–  Modulatory effect on synaptic action

Ionotropic or metabotropic?

–  Simpleon/offs witch for opening channels

–  Excite or inhibit neuronal firing

–  Local action

ACh activates muscarinic receptors to stimulate a G- protein that activates the ____ channel.

GIRK (G-protein inward rectifier K channel)

Opening this allows K to leave the cell and it hyperpolarizes. Used to slow the heart.

For the best nerve condution you want a __1__length constant and a __2___ time consant.

Choices: big, small

1. big

2. small

How does myelination affect neurons in terms of :

Rm, Ri, Cm

How does thick axons affect neurons in terms of :

Rm, Ri, Cm

What are the gaps between the myelin called?

These are used in saltatory conduction

__ system amino acid transporter moves large neutral AA with branced or ringed side chains through the BBB.

Choices: ASC, A, L

___ system moves glycine and other neutral amino acids with short linear or polar side chains through the BBB. Energy dependent, Na+ dependent. Limits glycine within spinal cord and glutamate within brain. Powered by Na+/K+ -ATPase

Choices: ASC, A, L

ASC system is also energy dependent and moves alanine, serine, and cysteine.

Choices: ASC, A, L

Monro-Kellie doctrine

an increase in volume of brain Issue, blood, CSF or other brain fluids will produce an increase in intracranial pressure because the bony calvarium fixes the total cranial volume.

•  This is caused by increased permeability of brain capillary endothelial cells which leads to increased volume of extracellular fluid.

•  More swelling occurs around white maZer than gray maZer because fluid tends to accumulate along fiber tracts which are hydrophobic.

increase in volume of thecerebral ventricles.

Oversecretion of CSF

impaired absorption of CSF

obstruction of CSF pathways

failure to develop brain

Results from failure to close anterior neuropore

Hirschsprung’s disease

results from a failure of neural crest migration

newborn has constipation without physical

obstruction

latex cryptococcal agglutination test

encapsulated spheres with a gelatinous capsule that shows a clear halo with

India Ink stain

The classic hallmark of viral infections of the CNS is the presence of ______ involving small arteries and arterioles.

1.Stimulate 5-HT1B receptors causing vasoconstriction

2.Reduce excitability of trigeminal nuclei in the brainstem by stimulating 5-HT1B/1D

3. inhibit inflamation by targeting pre-synaptic 5-HT1D receptors.

AKA:

1. vasoconstriction

2. trigeminal inhibition

3. decreased pain transmission.

vasoconstriction

Targets 5-HT alpha-1-adrenergic receptor.

5-HTR gets stimulated which blocks the release of the neurotransmitter 5-HT

rizatriptan (oral 1 hr)

sumatriptan (subcutaneous 15 mins)

including paresthesias, flushing, and mild, transient neck tightness or chest pressure 

vascular condition like arterial vasospasm

HTN

hemiplegic or basilar migraine

SSRIs, SNRIs

Dont give if they are on a MAO-A inhibitor

nausea vomiting, 

MAJOR: arterial vasoconstriction

CYP 3A4 inibitors

anything ending in: -vir, -conazole, -romycin

Need 2 of these 3:

Limiting activity, causea, photophobia

Which of these is an alpha adrenergic receptor agonist?

Truptans or Ergots

Inhibition of neurons causes ______.

Choices: depolarization or hyperpolarization

The driving force across the brain capillaries.

CPP=MAP-ICP

MAP=mean arterial pressure

ICP= intracranial pressure

Brain arterioles ___1___ with increased blood pressure and ___2____ with lowered blood pressure.

Choices: dilate and constrict

1. Constrict

2. Dilate

Raised arterial CO2 causes brain arterioles to ___1___ and cerebral blood flow will ___2____.

1 choices: dilate or constrict

2 choices: Increase or decrease

1. Dilate

2. Increase

Low arterial CO2 causes brain arterioles to ___1___ and cerebral blood flow will ___2____.

1 choices: dilate or constrict

2 choices: Increase or decrease

1. Constrict

2. Decrease

Which affects blood flow to the brain more?

O2 or CO2 concentration

Wall tension

Tension=(pressure)*(radius)

Increase in metabolites leads to ______.

Choices dilation or contraction

mostly the basal ganglia thalmus

also pons and cerebellum.

Cerebral infarcts caused by embolization are ____

Choices: bland or hemorrhagic

cerebral infarcts caused by thrombic occlusions are chronic, largely ischemic and ____

Choices: bland or hemorrhagic

What are parenchymal cells more predisosed to having damage them?

choices: atherosclerosis or HTN?

1. Vasoconstriction

2. Platelet actions

3. coagulation (clot formation)

4.Fibrinolysis

Vascular endothelium

platelets

coagulation system

fibrinolytic system

primary is dealing with platelets

vWF causes platelets to adhere to the vessel wall.

platelets release ADP and TXA2 granules that recruit more platelets.

Secondary deals with fibrin.

Tissue factor is released that causes phospholipic complex expression.  Then there is thrombin generation which causes fibrin polymerization.

Plasminogen activator inhibitors (PAI)= inactivates tPA.

α2-antiplasmin= binds free plasmin.

breaking a clot/

t-PA turns plasminogen into plasmin that breaks the clot by splitting the fibrins.

if there is an increased chance of bleeding.

hemmorhage, anticoagulate or antiplatelets in last 24 hrs, seizure during stroke. different stroke in the last 3 months, head injury.

Block COX-1 with asprin

Block ADP receptor with clopidogrel

makes glucose that makes ATP that is used for:

glutamate -> glutamine so that the high energy glutamine can travel to the presynaptic neuron to be converted to glutamate without needing energy.

long term lack of O2-> no oxidative phosphorylation -> depleted ATP -> shutting down of active transports -> Ca2+ entering cells -> cells swell and lyse

->phospholipases and proteases digesting the cell.

no, Individual cells delete themselves by an intrinsic mechanism - there is no rupture of the cell membrane and thus no inflammation

1. β-amyloid

2. hyperphosphorylated tau protein