Step 1 First Aid – Neurology – Flashcards

CNS neurons Ependymal cells (inner lining of ventricles, make CSF) Oligodendrocytes Astrocytes

Schwann cells PNS neurons

M icroglia, like M acrophages, originate from M esoderm

Comprise nervous system. Permanent cells -- do not divide in adulthood. Large cells w/ prominent nucleoli.

RER found in cell body and dendrites, but not axon of neurons.

Physical support, repair, K+ metabolism, removal of excess NT. Maintenance of BBB. Reactive gliosis in response to injury.

GFAP

CNS phagocytes. Mesodermal origin. Not readily discernible in Nissle stains. Have small, irregular nuclei and relatively little cytoplasm.

Microglia --(tissue damage)--< large ameboid phagocytic cells

HIV-infected microglia fuse to form multinucleated giant cells in the CNS

Each oligodendrocyte myelinates multiple CNS axons (up to 30 each). In Nissle stains, they appear as small nuclei with dark chromatin and little cytoplasm.

Oligodendrocytes.

Oligodendrocytes.

"Fried Eggs"

Each Schwann cell myelinates only 1 PNS axon. Also promote axonal regeneration. Derived from neural crest.

Schwann cells.

Acoustic neuroma is a type of Schwannoma. It is typically located in internal acoustic meatus (CN VIII)

In all skin, epidermis, some viscera. Senses pain and temperature.

Free nerve endings (C, A-delta fibers)

In glabrous (hairless) skin. Senses dynamic fine touch (e.g., manipulation), adapt quickly.

Meissner's corpuscles

In deep skin layers, ligaments, and joints. Sense vibration, pressure.

Pacinian corpuscles

(cup-shaped, unencapsulated) In hair follicles. Sense static touch (e.g., shapes, edges, textures), adapt slowly.

Merkel's disks

Invests a single nerve fiber (Endo = inner)

(P erineurium is the P ermeability barrier) Surrounds a fascicle of nerve fibers. (Peri = around) Must be rejoined in microsurgery for limb reattachment.

Dense connective tissue that surrounds entire nerve (fasicles and blood vessels) (Epi = outer)

Increased in anxiety, decreased in depression. Made in the locus ceruleus.

NE

Increased in schizophrenia, decreased in Parkinson's. Made in the ventral tegmentum and SNc

Dopamine

Decreased in anxiety, depression. Made in the raphe nucleus

5-HT

Decreased in Alzheimer's, Huntington's. Made in the basal nucleus of Meynert.

ACh

1.) Tight junctions btw nonfenestrated capillary endothelial cells 2.) Basement membrane 3.) Astrocyte processes

1.) Blood-testis barrier 2.) Maternal-fetal blood barrier of placenta

Infarction destroys endothelial cell tight junctions, leading to vasogenic edema

Cross slowly by carrier-mediated transport mechanism.

Cross rapidly via diffusion.

Allow molecules in the blood to affect brain function (e.g., area postrema - vomiting center after chemo, OVLT - osmotic sensing) or neurosecretory products to enter circulation (e.g., neurohypophysis - ADH release)

The hypothalamus wears TAN HATS : T hirst and water balance A denohypophysis control N eurohypophysis releases hormones from hypothalamus H unger A utonomic regulation T emperature regulation S exual urges

OVLT (senses change in osmolarity) Area postrema (responds to emetics)

Area that makes ADH.

Supraoptic nucleus of the hypothalamus

Area that makes oxytocin.

Paraventricular nucleus of the hypothalamus

Controls hunger: destruction leads to anorexia. ("If you zap the lateral nucleus, you shrink laterally ") Inhibited by leptin.

Controls satiety: destruction leads to hyperphagia. ("If you zap your ventromedial nucleus, you grow ventrally and medially .") Stimulated by leptin.

Cooling (Anterior = cooling, or A/C). A nterior is pA rasympathetic.

Heating (posterior = get fired up / heating). Sympathetic. If you zap your P osterior hypothalamus, you become a P oikilotherm (cold-blooded, like a snake)

area responsible for sexual urges

Septal nucleus of the hypothalamus

Circadian rhythm. ("You need to sleep to be charismatic [chiasmatic]").

Receives hypothalamic axonal projections from supraoptic (ADH) and paraventricular (oxytocin) nuclei. Oxytocin: oxys = quick; tocos = birth.

A nterior pituitary = A denohypophysis

Major relay for ascending sensory information that ultimately reaches the cortex.

posterior communicating, posterior cerebral, and anterior choroidal arteries.

(hint: "L ateral for L ight") area of thalamus for visual information.

Lateral geniculate nucleus (LGN) of thalamus  (hint: "L ateral for L ight")

(hint: M edial for M usic) Area of the thalamus responsible for auditory information

Medial geniculate nucleus (MGN) of the thalamus  (hint: M edial for M usic)

part of the thalamus responsible for body sensation (proprioception, pressure, pain, touch, vibration via dorsal columns, spinothalamic tract).

Ventral posterior nucleus, lateral part (VPL) -- of thalamus

(hint: you put M akeup on your face, and sensory info is relayed through the VPM ) Area of thalamus responsible for facial sensation (via CN V)

Ventral posterior nucleus, medial part (VPM) -- of the thalamus  (hint: you put M akeup on your face, and sensory info is relayed through the VPM )

Motor is anterior to sensation in the thalamus, just like the cortex.

Includes cingulate gyrus, hippocampus, fornix, and mammillary bodies. Responsible for F eeding, F leeing, F ighting, F eeling, and sex (....) (The famous 5 F's )

Receives contralateral cortical input via middle cerebellar peduncle and ipsilateral proprioceptive information via inferior cerebellar peduncle. Input nerves = climbing and mossy fibers.

Provides stimulatory feedback to contralateral cortex to modulate movement. Output nerves = Purkinje fibers output deep to nuclei of cerebellum, which in turn output to cortex via superior cerebellar peduncle.

Lateral to medial: D entate, E mboliform, G lobose, F astigial ("D on't E at G reasy F oods")

area of the cerebellum responsible for voluntary movement of extremities

Lateral cerebellum

Area of cerebellum responsible for balance, truncal coordination.

Medial cerebellum

Important in voluntary movements and making postural adjustments. Receives cortical input, provides negative feedback to cortex to modulate movement.

Basal ganglia (overall function)

Substantia Nigra pars compacta's (SNc's) dopamine binds to D1 receptros in the excitatory pathway, stimulating the excitatory pathway (incr motion). Therefore, loss of dopamine in Parkinson's inhibits the excitatory pathway (decr motion).  Key: Grey = stimulatory || Black = inhibitory SNc = Substantia nigra pars compacta GPe = Globus pallidus externus GPi = Globus pallidus internus STN = Subthalamaic nucleus D1 = Dopamine D1 receptor (excitatory) D2 = Dopamine D2 receptor (inhibitory)

SNc's dopamine binds to D2 receptros in the inhibitory pathway, inhibiting the inhibitory pathway (incr motion). Therefore, loss of dopamine in Parkinson's dz excites (i.e., disinhibits) the inhibitory pathway (decr motion).  Key: Grey = stimulatory || Black = inhibitory SNc = Substantia nigra pars compacta GPe = Globus pallidus externus GPi = Globus pallidus internus STN = Subthalamaic nucleus D1 = Dopamine D1 receptor (excitatory) D2 = Dopamine D2 receptor (inhibitory)

Degenerative disorder of CNS associated w/ Lewy bodies (composed of alpha-synuclein) and depigmentation of the substantia nigra pars compacta (loss of dopaminergic neurons). Rare cases have been linked to exposure to MPTP, a contaminant in illicit street drugs. ("TRaP = T remor (at rest), cogwheel R igidity, a nd P ostural instability. You are TRaP ped inside your body.")

Parkinson's disease

Sudden, wild flailing of 1 arm. Characteristic of contralateral subthalamic nucleus lesion. Loss of inhibition of thalamus through globus pallidus. ("Hemiballismus = Half ballistic -- like throwing a baseball")

Autosomal-dominant trinucleotide repeat d/o. Chromosome 4. Atrophy of caudate nucleus (loss of GABAergic neurons) leads to enlarged lateral ventricles on CT.  Chorea, depression, progressive dementia. Sx manifest in affeccted indvls btw ages 20-50. (Expansion of CAG repeats: "C audate loses A Ch and G ABA")

Huntington's dz

Sudden, jerky, purposeless movements. Characteristic of basal ganglia lesion (e.g., Huntington's disease) (Chorea = dancing (Greek). Think choral dancing or choreography)

Slow, writhing movements, especially if fiingers. Characteristic of basal ganglia lesion (e.g., Huntington's dz) (Athetos = not fixed (Greek). Think snakelike.)

Action tremor, autosomal dominant. Essential tremor pts often self-medicate w/ alcohol, which decreases the tremor. Tx: beta-blockers.

Not noticeable distally. Seen in Parkinson's ("pill-rolling" tremor)

Slow, zigzag motion when pointing twd a target; associated w/ cerebellar dysfunction.

A: Sylvian fissure is above temporal lobe; central sulcus divides frontal and parietal lobes.

Connection between Associative auditory cortex (Wernicke's area; dominant hemisphere) and Motor speech area (Broca's area; dominant hemisphere)

"Executive functions" Planning, inhibition, concentration, orientation, language, abstraction, judgment, motor regulation, mood. Lack of social judgment is most notable in frontal lobe lesion. ("D amage = D isinhibition" - e.g., Phineas Gage)

Topographical representation of sensory and motor areas in the cerebral cortex. Used to localize lesion (e.g., in blood supply) leading to specific defects. For example, lower extremity deficit in sensation or movement indicates involvement of anterior cerebral artery.

(hint: BRO ca's is BRO ken speech.) Consequence: Motor (nonfluent/expressive) aphasia w/ good comprehension.

Broca's area (hint: BRO ca's is BRO ken speech.)

(hint: W ernicke's is W ordy but makes no sense.) Consequence: Sensory (fluent/receptive) aphasia w/ poor comprehension, neologisms.

Wernicke's area (hint: W ernicke's is W ordy but makes no sense.)

Consequence: Conduction aphasia; good comprehension, fluent speech, but poor repitition.

Arcuate fasciculus (connects Wernicke's to Broca's area)

Consequence: Kluver-Bucy syndrome (hyperorality, hypersexuality, disinhibited behavior)

Amygdala (bilateral)

Consequence: Personality changes and deficits in concentration, orientation, and judgment; may havve reemergence of primitive reflexes.

Frontal lobe

Consequence: Spatial neglect syndrome (agnosia of the contralateral side of the world)

Right parietal lobe

Consequence: Reduced levels of arousal and wakefulness (e.g., coma)

Reticular activating system (midbrain)

Consequence: Wernicke-Korsakoff syndrome (confusion, confabulation, ophthalmoplegia, ataxia)

Mammillary bodies (bilateral)

Consequence: May result in tremor at rest, chorea, or athetosis

Basal ganglia

(hint: cerebellar hemispheres are laterally located, so they affect the lateral limbs) Consequence: Intention tremor, limb ataxia; Damage to the cerebellum results in ipsilateral deficits; Fall toward side of lesion

Cerebellar hemisphere (hint: cerebellar hemispheres are laterally located, so they affect the lateral limbs)

(hint: vermis is centrally located, so it affects the central body) Consequence: Truncal ataxia, dysarthria.

Cerebellar vermis (hint: vermis is centrally located, so it affects the central body)

Consequence: Contralateral hemiballismus

Subthalamic nucleus

Consequence: Anterograde amnesia -- inability to make new memories

Hippocampus

Consequence: Eyes look away from side of lesion

Paramedian pontine reticular formation (PPRF)

Consequence: Eyes look toward lesion.

Frontal eye fields

Aphasia is a higher-order inability to speak. vs. Dysarthria is a motor inability to speak.

Nonfluent aphasia w/ intact comprehension. Broca's area -- inferior frontal gyrus. ("Bro ca's Bro ken Boca " [boca = mouth in Spanish])

Fluent aphasia with impaired comprehension. Wernicke's area -- superior temporal gyrus. ("W ernicke's is W ordy but makes no sense." or "W ernicke's = W hat?")

Nonfluent aphasia w/ impaired comprehension. Both Broca's and Wernicke's areas affected.

Poor repitition but fluent speech, intact comprehension. Arcuate fasciculus -- connects Broca's and Wernicke's areas.

Supplies anteromedial surface of brain [darkest grey]

Supplies lateral surface of brain [White areas below]

Supplies posterior and inferior surfaces [medium grey areas below]

[Right anterior cerebral artery is labeled below -- top/left]  Supplies medial surface of the brain, leg-foot area of motor and sensory cortices.

[Labeled below at top/left, just beneath right anterior cerebral art.]  Supplies lateral aspect of brain, trunk-arm-face area of motor and sensory cortices, Broca's and Wernicke's speech areas (on dominant hemisphere), optic radiations.

Contralateral face and arm paralysis and sensory loss, aphasia (dominant sphere), left-sided neglect.

[labeled below along middle/right]  Supplies the visual cortex.

Contralateral homonymous hemianopia with macular sparing.

[labeled below along top/right]  Most common site of circle of Willis aneurysm; lesions may cause visual field defects.

[labeled below along middle/left]  Common area of aneurysm; Causes CN III palsy.

[labeled below along middle/right]  Divisions of the middle cerebral artery that supply the internal capsule, caudate, putamen, and globus pallidus.

"Arteries of stroke"; infarct of internal capsule causes pure motor hemiparesis.

Between anterior cerebral/middle cerebral, posterior cerebral/middle cerebral arteries. Damaged in severe hypotension --< upper leg/upper arm weakness, defects in higher-order visual processing.

[labled below at bottom/right]  Infarcts cause Wallenberg's syndrome (aka lateral medullary syndrome) (nystagmus, ipsilateral ataxia, nausea, vomiting, Horner's syndrome)

[labeled below along middle/left] Infarct causes locked-in syndrome.

stroke of the anterior circle : General sensory and motor dysfunction, aphasia. stroke of the posterior circle : Cranial nerve deficits (vertigo, visual deficits), coma, cerebellar deficits (ataxia)

[at bottom of picture, below] Medial medullary syndrome: contralateral hemiparesis (lower extremities), medial lemniscus (decr proprioception), ipsilateral paralysis of hypoglossal nerve

[labeled below in lower right] Lateral inferior pontine syndrome: ipsilateral facial paralysis, ipsilateral cochlear nucleus, vestibular (nystagmus), ipsilateral facial pain and temperature, ipsilateral dystaxia (MCP, ICP)

Occur at the bifurcations in the circle of Willis. Most common site is bifurcation of the anterior communicating artery. Rupture (most common complication) leads to hemorrhagic stroke/subarachnoid hemorrhage.

Associated with: Adult polycystic kidney dz Ehlers-Danlos syndrome Marfan's syndome Risk factors: Advanced age HTN Smoking Race (higher risk in blacks)

Associated with chronic HTN Affects small vessels (e.g., in basal ganglia, thalamus)

Rupture of middle meningeal artery (branch of maxillary artery), often secondary to fracture of temporal bone. Lucid interval. CT shows "biconvex disk" not crossing suture lines. Can cross falx, tentorium.

Rupture of bridging veins. Venous bleeding (less pressure) with delayed onset of Sx's. Seen in elderly individuals, alcoholics, blunt trauma, shaken baby. Crescent-shaped hemorrhage that crosses suture lines. Cannot cross falx, tentorium.

Brain atrophy Shaking Whiplash

Rupture of aneurysm (usually berry aneurysm) or an AVM. Pts complain of "worst headache of my life." Bloody or yellow (xanthochromic) spinal tap. 2-3 days afterward, there is a risk of vasospasm (Tx w/ Ca2+ channel blockers).

Caused by HTN, amyloid angiopathy [see below], DM, and tumor. Typically occurs in basal ganglia and internal capsule.

Intracerebral bleeding, often due to aneurysm rupture. May be secondary to ischemic stroke following reperfusion (incr vessel fragility)

Emboli block large vessels; etiologies include: atrial fibrillation, carotid dissection, patent foramen ovale, endocarditis. Lacunar strokes block small vessels, are secondary to HTN. Tx: tPA w/in 3 hours.

Brief, reversible episode of neurologic dysfunction due to focal ischemia. Typically, Sx's last >24 hours.

Bright on diffusion-weighted MRI in 3-30 minutes [below/left], dark on CT in ~24 hours [below/right] [Images are of a right MCA stroke; diffusion MRI and CT]

Venous sinuses run in the dura mater where its meningeal and periosteal layers separate. Cerebral veins --< venous sinuses --< internal jugular vein

The superior sagittal sinus (main location of CSF return via arachnoid granulations) is along the superior/median border of the brain. The confluence of the sinuses is posterior, bringing together the occipital sinus (inferiorly), sagittal sinus (superiorly), transverse sinuses (laterally), and straight sinus (ventrally)

The inferior sagittal sinus runs deep to the superior sagittal sinus in the median line. The great cerebral vein runs inferior to that, and the two sinuses meet at the straight sinus, which feeds into the confluence of the sinuses posteriorly.

The Superior ophthalmic vein feeds into the cavernous sinus, which reaches the sup. sagittal sinus and the transverse sinus by way of the Sphenoparietal sinus.

CSF is made by ependymal cells lining the ventricles; it is reabsorbed by venous sinus arachnoid granulations.

The foramen of Munro.

The cerebral aqueduct

Foramina of L ushka = L ateral Foramen of M agendie = M edial

Accumulation of excess CSF in ventricular system --< increased intracranial pressure; ventricular dilation --< clinical triad of dementia, gait problems, urinary incontenincence. ("Wet, wobbly, and wacky")

Caused by impaired absorption of CSF by arachnoid granulations (e.g., arachnoid adhesions post-meningitis)

Caused by structual blockage of CSF circulation w/in the ventricular system (e.g., stenosis of the aqueduct of Sylvius)

Appearance of increased CSF in atrophy. Intracranial pressure normal, triad not seen.

There are 31 spinal nerves. ("31 like the 31 flavors at Baskin-Robbins") 8 Cervical 12 Thoracic 5 Lumbar 5 Sacral 1 Coccygeal

Nerves C1-C7 exit via intervertebral foramina above the corresponding vertebra. All other nerves exit below .

Vertebral disk herniation (nucleus pulposus hernaites through annulus fibrosus) usually occurs btw L5 and S1.

In adults, the spinal cord extends to the loweer border of L1-L2; subarachnoid space extends to lower border of S2. Lumbar puncture is usually performed in L3-L4 or L4-L5 interspaces, at the level of the cauda equina. ("To keep the cord alive , keep the spinal needle btw L3 and L5 ")

CSF is obtained from lumbar subarachnoid space btw L4 and L5 (at the level of iliac crests)

1.) Skin/superficial fascia 2.) Ligaments (supraspinous, interspinous, ligamentum flavum) 3.) Epidural space 4.) Dura mater 5.) Subdural space 6.) Arachnoid 7.) Subarachnoid space - CSF (Pia is not pie rced)

Pressure, vibration, touch, proprioception.

Medially: fasciculus gracilis (lower body, extremities) Laterally: fasciculus cuneatus (upper body, extremities) ("Dorsal column is organized as you are, with hands at sides. Arms outside, legs inside.")

Lateral corticospinal tract relays voluntary motor information, is located in the lateral spinal cord. Spinothalamic tract relays pain and temperature, is located antero-laterally. ("L egs are L ateral in L ateral corticospinal, spinothalamic tracts")

2 Posterior spinal arteries, 1 anterior spinal artery

The lateral gray matter of the thoracic [only] spinal cord

They synapse then cross.

function? Ascending pressure, vibration, touch, and proprioceptive sensation

Dorsal column -- medial lemniscal pathway

function? Ascending pain and temperature sensation

Spinothalamic tract

function? Descending vvoluntary movement of contralateral limbs

Lateral corticospinal tract

What is the 1st order neuron? Sensory nerve ending --< cell body in dorsal root ganglion --< enters spinal cord, ascends ipsilaterally in dorsal column

Dorsal column -- medial lemniscal pathway

What is the 1st order neuron? Sensory nerve ending (A-delta and C fibers) (cell body in dorsal root ganglion) --< enters spinal cord

Spinothalamic tract

What is the 1st order neuron? Upper motor neuron: cell body in primary motor cortex | Descends ipsilaterally (thru internal capsule) until decussating at caudal medulla (pyramidal decussation) | Descends contralaterally

Lateral corticospinal tract

What is the 1st synapse? Ipsilateral nucleus cuneatus or gracilis (medulla)

Dorsal column -- medial lemniscal pathway

What is the 1st synapse? Ipsilateral gray matter (spinal cord)

Spinothalamic tract

What is the 1st synapse? Cell body of anterior horn (spinal cord)

Lateral corticospinal tract

What is the 2nd order neuron? Decussates in medulla --< ascends contralaterally in medial lemniscus

Dorsal column -- medial lemniscal pathway

What is the 2nd order neuron? Decussates at anterior white commissure --< ascends contralaterally

Spinothalamic tract

What is the 2nd order neuron? Lower motor neuron : leaves spinal cord

Lateral corticospinal tract

What is the 2nd synapse? VPL of thalamus

Dorsal column -- medial lemniscal pathway OR Spinothalamic tract

What is the 2nd synapse? Neuromuscular junction

Lateral corticospinal tract

What is the 3rd order neuron? Sensory cortex

Dorsal colum -- medial lemniscal pathway OR Spinothalamic tract

What is the 3rd order neuron? N/A (no 3rd-order neuron)

Lateral corticospinal tract

Lower MN lesion = everything lowered (less muscle mass, decr muscle tone, decr reflexes, downgoing toes) Upper MN = everythinig up (tone, DTRs, toes)

What is the 3rd order neuron? Both

This is the 3rd order neuron in which spinal tract? UMN vs. LMN lesion: Weakness

What is the 3rd order neuron? (-) UMN (+) LMN

UMN vs. LMN lesion: Atrophy

What is the 3rd order neuron? (-) UMN (+) LMN

UMN vs. LMN lesion: Fasciculations (muscle twitching)

What is the 3rd order neuron? Increased in UMN Decreaseed in LMN

UMN vs. LMN lesion: Reflexes

What is the 3rd order neuron? Increased in UMN, decreased in LMN

UMN vs. LMN lesion: Tone

What is the 3rd order neuron? (+) in UMN, (-) in LMN

UMN vs. LMN lesion: Babinski sign (upgoing toes -- normal in infants)

What is the 3rd order neuron? (+) in UMN (-) in LMN

UMN vs. LMN lesion: Spastic paralysis

Lower motor neuron lesion only, due to destruction of anterior horns; flaccid paralysis

Poliomyelitis and Werdnig-Hoffmann disease

Mostly white matter of cervical region; random and asymmetric lesions, due to demyelination; scanning speech, intention tremor, nystagmus

Multiple sclerosis

Combined upper and lower motor neuron deficits with no sensory deficit; both upper and lower motor neuron signs.

ALS

Spares dorsal columns and tract of Lissauer; upper throacicc ASA territory is a watershed area, as artery of Adamkiewicz supplies ASA below ~T8

Complete occlusion of the anterior spinal artery

Degeneration of dorsal roots and dorsal columns; impaired proprioception, locomotor ataxia

Tabes dorsalis (tertiary syphilis)

Crossing fibers of spinothalamic tract damaged; bilateral loss of pain and temperature sensation.

Syringomyelia

Demyelination of dorsal columns, lateral corticospinal tracts, and spinocerebellar tracts; ataxic gait, hyperreflexia, impaired position and vibration sense.

Vitamin B12 neuropathy and Friedrich's ataxia

Caused by poliovirus, which is transmitted by fecal/oral route. Replciates in the oropharynx and small intestine before spreading through the bloodstream to the CNS, where it leads to destruction of cells in the anterior horn of the spinal cord, leading in turn to LMN destruction.

Malaise, hedache, fever, nausea, abdominal pain, sore throat. Signs of LMN lesions -- muscle weakness and atrohphy, fasciculations, fibrillation, and hyporeflexia.

CSF w/ lymphocytic pleocytosis w/ slight elevation of protein (w/ no change in CSF glucose). Virus recovered from stool or throat.

Autosomal-recessive inheritance; presents at birth as a "floppy baby," tongue fasciculations; median age of death 7 months. Associated w/ degenration of anterior horns. LMN involvement only.

Associated w/ both LMN and UMN signs; no sensory, cognitive, or oculomotor deficits. Can be caused by defect in superoxide dismutase 1 (SOD1), betel nut ingestion.

Degeneration of dorsal columns and dorsal roots due to tertiary syphilis, resulting in impaired proprioception and locomotor ataxia.

Charcot's joints Shooting (lightning) pain Argyll Robertson pupils (aka "prostitute's pupils" - accomodate, but do not react) Absence of DTRs

Autosomal-recessive trinucleotide repeat disorder (GAA; frataxin gene). Leads to impairment in mitochondrial functioning. Staggering gait, frequent falling, nystagmus, dysarthria, hypertrophic cardiomyopathy. Presents in childhood w/ kyphoscoliosis.

Heisection of the spinal cord

1.) Ipsilateral UMN signs (corticospinal tract) below lesion 2.) Ipsilateral loss of tactile, vibration, proprioception sense (dorsal column) below lesion 3.) Contralateral pain and temperature loss (spinothalamic tract) below lesion 4.) Ipsilateral loss of all sensation at level of lesion 5.) LMN signs (e.g., flaccid paralysis) at level of lesion If lesion occurs above T1, presents w/ Horner's syndrome

Sympathectomy of face: 1.) P tosis (slight drooping of eyelid) 2.) A nhidrosis (absence of sweating) and flushing (rubor) of affected side of face 3.) M iosis (pupil constriction) ("PAM is horny [Horner's]) Associated w/ lesion of spinal cord above T1 (e.g., Pancoast's tumor, Brown-Séquard syndrome [cord hemisection], late-stage syringomyelia)

The 3-neuron oculosympathetic pathway projects from the hypothalamus to the intermediolateral column of the spinal cord, then to the superior cervical (sympathetic) ganglion, and finally to the pupil, the smooth muscle of the eyelids, and the sweat glands of the forehead and face. Interruption of any of these pathways results in Horner's syndrome.

Ischial spine

2/3 of the way from the umbilicus to the anterior superior iliac spine (McBurney's point)

Iliac crest.

Posterior half of a skull "cap"

High turtleneck shirt

Low-collar shirt

At the nipple. (T4 at the teat pore )

Xiphoid process

At the umbilicus (important for early appendicitis pain referral) (T10 at the belly butTEN )

At the inguinal ligament ("L1 is IL [I nguinal L igament])

Includes kneecaps

Erection and sensation of penile and anal zones ("S2, 3, 4, keep the penis off the floor")

Muscle spindles monitor muscle length (help you pick up a heavy suitcase when you didnt know how heavy it was). Golgi T endon organs monitor muscle T ension (make you drop a heavy suitcase you've been holding too long).

In parallel with muscle fibers. Muscle stretch --< intrafusal stretch --< stimulates Ia afferent --< stimulate alpha motor neuron --< reflex muscle (extrafusal) contraction

CNS stimulates gamma motor neuron --< contracts intrafusal fiber --< increased sensitivity of reflex arc

Achilles = S1 nerve root Patella = L4 nerve root Biceps = C5 nerve root Triceps = C7 nerve root * Note that they count up in order: S1,2 L3,4 C5,6 C7,8

Dorsiflexion of the big toe and fanning of other toes; sign of UMN lesion, but normal reflex in 1st year of life.

Normally disappear within 1st year of life. May reemerge following frontal lobe lesion. Include: Moro reflex, rooting reflex, suckling reflex, Palmar and plantar reflexes, Babinski reflex

Extension of limbs when started

Movement of head toward one side if cheek or mouth is stroked (nipple seeking)

Sucking response when roof of mouth is touched

Curling of fingers/toes if palms of hands/feet are stroked

III, VI, XII Remember: 3 (x2) = 6 (x2) = 12

CN IV [see below, CN IV is along left in the middle]

Melatonin secretion, circadian rhythms.

Conjugate vertical gaze center. ("you have your eyes above your ears, and the superior colliculus (visual) is above the inferior colliculus (auditory).")

Auditory ("you have your eyes above your ears, and the superior colliculus (visual) is above the inferior colliculus (auditory).")

Paralysis of conjugate verticle gaze due to lesion in superior colliculi (e.g., pinealoma)

Smell (only CN w/o thalamic relay to cortex) S ensory; "S ome" [Mnemonic for type of information carried by CN's: "Some Say Marry Money, But My Brother Says Big Brains Matter Most."]

Olfactory (CN I)

Sight. S ensory; "S ay" [Mnemonic for type of information carried by CN's: "Some Say Marry Money, But My Brother Says Big Brains Matter Most."]

Optic (CN II)

Eye movement (SR, IR, MR, IO), pupillary constriction, accommodation, eyelid opening (levator palpebrae) M otor; "M oney" [Mnemonic for type of information carried by CN's: "Some Say Marry Money, But My Brother Says Big Brains Matter Most."]

Oculomotor (CN III)

Eye movement (SO) M otor; "M oney" [Mnemonic for type of information carried by CN's: "Some Say Marry Money, But My Brother Says Big Brains Matter Most."]

Trochlear (CN IV)

Mastication, facial sensation. B oth, "B ut" [Mnemonic for type of information carried by CN's: "Some Say Marry Money, But My Brother Says Big Brains Matter Most."]

B oth, "B ut" [Mnemonic for type of information carried by CN's: "Some Say Marry Money, But My Brother Says Big Brains Matter Most."] Trigeminal (CN V)

Eye movement (LR) M otor; "M y" [Mnemonic for type of information carried by CN's: "Some Say Marry Money, But My Brother Says Big Brains Matter Most."]

Abducens (CN VI)

Facial movement, taste from anterior 2/3rds of tongue, lacrimation, salivation (submandibular and sublingual glands), eyelid closing (orbicularis oculi), stapedius muscle in ear B oth; "B rother" [Mnemonic for type of information carried by CN's: "Some Say Marry Money, But My Brother Says Big Brains Matter Most."]

Facial (CN VII)

Hearing, balance. S ensory; "S ays" [Mnemonic for type of information carried by CN's: "Some Say Marry Money, But My Brother Says Big Brains Matter Most."]

Vestibulocochlear (CN VIII)

Taste from posterior 1/3rd of tongue, swallowing, salivation (parotid gland), monitoring carotid body and sinus chemo- and baroreceptors, and stylopharyngeus (elevates pharynx, larynx) B oth; "B ig" [Mnemonic for type of information carried by CN's: "Some Say Marry Money, But My Brother Says Big Brains Matter Most."]

Glossopharyngeal (CN IX)

Taste from epiglottic region, swallowing, palate elevation, talking, coughing, thoracoabdominal viscera, monitoring aortic arch chemo- and baroreceptors. B oth; "B rains" [Mnemonic for type of information carried by CN's: "Some Say Marry Money, But My Brother Says Big Brains Matter Most."]

Vagus (CN X)

Head turning, shoulder shrugging M otor; "M atter" [Mnemonic for type of information carried by CN's: "Some Say Marry Money, But My Brother Says Big Brains Matter Most."]

Accessory (CN XI)

Tongue movement M otor; "M ore" [Mnemonic for type of information carried by CN's: "Some Say Marry Money, But My Brother Says Big Brains Matter Most."]

Hypoglossal (CN XII)

Located in tegmentum portion of brainstem (btw dorsal and ventral portions). Lateral nuclei = sensory M edial nuclei = M otor

Nuclei of CN III and IV

Nuclei of CN V, VI, VII, and VIII

Nuclei of CN IX, X, XI, and XII

Afferent = V-1 Efferent = VII

Corneal OR Lacrimation (use the same nerves)

Afferent = V-3 (sensory) Efferent = V-3 (motor)

Jaw jerk

Afferent = II Efferent = III

Pupillary

Afferent = IX Efferent = IX and X

Gag

Visceral S ensory information (e.g., taste, baroreceptors, gut distension) CN VII, IX, X ("S olitarius = viS ceral S ensory")

M otor innervation of pharynx, larynx, and upper esophagus (e.g., swallowing, palate elevation) CN's IX, X, XI ("aM biguous = M otor")

Sends autonomic (parasympathetic) fibers to heart, lungs, and upper GI.

CN I

CN II-VI, thru the sphenoid bone: 1.) Optic canal : CN II, ophthalmic artery, central retinal vein 2.) S uperior orbital fissure : CN III, IV, V-1, VI, ophthalmic vein 3.) Foramen R otundum : CN V-2 4.) Foramen O vale : CN V-3 5.) Foramen spinosum : middle meningeal artery ("Divisions of CN-V exit owing to S tanding R oom O nly")

CN VII-XII, thru the temporal and occipital bone: 1.) Internal auditory meatus : CN VII, VIII 2.) Jugular foramen : CN IX, X, XI, jugular vein 3.) Hypoglossal canal : CN XII 4.) Foramen magnum : Spinal roots of CN XI, brain stem, vertebral arteries

A collection of venous sinuses on either side of the pituitary. Blood from eye and superficial cortex | Cavernous sinus | Internal jugular vein

CN II, IV, V-1, V-2, VI, and postganglionic sympathetic fibers en route to the orbit all pass thru the cavernous sinus. Only CN VI is "free-floating". Cavernous portion of internal carotid artery is also here.

Nerves that control extraocular muscles (plus V-1 and V-2) pass thru the cavernous sinus. Therefore, cavernous sinus syndrome (e.g., due to mass effect): ophthalmoplegia, ophthalmic and maxillary sensory loss.

Tongue deviates toward the side of the lesion ("lick your wounds")

Jaw deviates toward the side of lesion

Uvula deviates away from side of lesion

Weakness turning head to contralateral side of lesion. Shoulder droop on side of lesion.

Lesion of motor cortex or connection btw cortex and facial nucleus. Contralateral paralysis of lower face only, since upper face recives bilateral UMN innervation.

Ipsilateral paralysis of upper and lower face.

Complete destruction of the facial nucleus itself or its branchial efferent fibers (facial nerve proper) Peripheral ipsilateral facial paralysis w/ inability to close eye on involved side. Can occur idiopathically; gradual recovery in most cases.

A IDS L yme dz H erpes zoster S arcoidosis T umors D iabetes ("AL exander graH am Bell with STD ")

Say it aloud. "Kuh-kuh-kuh" tests palate elevation (CN X - vagus) "La-la-la" tests tongue (CN XII - hypoglossal) "Mi-mi-mi" tests lips (CN VII - facial) ("It would be a K aL aM ity to lose CN X, XII, and VII")

3 Muscles close jaw: M asseter, teM poralis, and M edial pterygoid ("M 's M unch") 1 Muscle opens jaw: Lateral pterygoid ("Lateral Lowers" -- [lateral pterygoid]) All above are innervated by the trigeminal nerve (V-3)

All muscles with the root glossus in their names (except palatoglossus, innervated by vagus nerve) are innervated by the hypoglossal nerve. Palat : vagus nerve Glossus : hypoglossal nerve

All muscles with the root palat in their names (except tensor veli palatini , innervated by mandibular branch of CN V) are innervated by vagus nerve. Palat : vagus nerve (except TENS or, who was too TENSE )

A series of tubes in the temporal bone (bony labrynth) filled with perilymph (Na+ rich, similar to ECF) that includes cochlea, vestibule, and semicircular canals. W/in the bony labyrinth is a 2nd series of tubes (membranous labyrinth) filled w/ endolymph (K+ risch, similar to ICF) that includes cochlear duct (w/in the cochlea), utricle and saccule (w/in the vestibule), and semicircular canals. *peri = think outside of the cell (Na+), vs. Endo = think inside the cell (K+)

Made by the stria vascularis.

Contain maculae - detect linear acceleration.

Contain A mpullae, detect A ngular acceleration.

Located w/in the organ of Corti. Are the sensory elements in both vestibular apparatus (spatial orientation) and cochlea (hearing).

The cochlear membrane = scuba flipper: narrow/stiff at the base (high frequency), and wide/flexible at the apex (low frequency).

Bone conduction < air conduction on Rinne; Weber localizes to the affected ear.

Air conduction < Bone conduction on Rinne; Weber localizes to normal ear.

High frequency --< low frequency

Answers

Dilator/radial muscle (alpha1 --< myd riasis [pupillary d ilation]) Sphincter/circular/constrictor muscle (M3 --< miosis [pupillary constriction])

Shown below/right. M3 --< accomodation

Aqueous humor is made by ciliary process | Travels past lens to posterior Chamber | Anterior chamber | Trabecular meshwork (absorbs aqueous humor | Canal of Schlemm (collects aqueous humor from trabecular meshwork)

Impaired flow of aqueous humor | Increased intraocular pressure | Optic disk atrophy w/ cupping

Obstructed outflow (e.g., canal of Schlemm); associated w/ myopia, advanced age, African-American race. More common, "silent," painless.

Obstruction of flow btw iris, lens --< pressure builds up behind iris. Painful, impaired vision. Do NOT give epinephrine.

Painless, bilateral opacification of lens, leading to decrease in vision. Risk factors: age, smoking, EtOH, sunlight, DM, trauma, infxn.

Increased intracranial pressure --< elevated optic disk with blurred margins, bigger blind spot.

CN VI innervates the L ateral R ectus CN IV innervates the S uperior O blique CN III innervates the R est Thus, the "chemical formula": LR6 SO4 R3

It abducts, intorts, and depresses.

Eye looks down and out; ptosis, pupillary dilation, loss of accomodation.

Diplopia w/ defective downward gaze

Medially directed eye.

To test fxn of each muscle, have te pt look in the following directions: [*note that the oblique muscles are tested by looking medially and opposite to what you would expect from "superior" and "inferior"] "IOU : to test I nferior O blique, have pt look U p."

Strabismus is misalignment of eyes. Multiple etiologies. Amblyopia is a reduction of vision from disuse in critical period. May be secondary to strabismus, deprivation, unequal refractive errors.

P upillary sphincter muscle, P arasympathetic innervation. Innervation -- CN III from Edinger-Westphal nucleus --< ciliary ganglion.

RaD ial muscle (aka pupillary D ilator muscle), sympathetic. Innervation -- T1 preganglionic sympathetic --< superior cervical ganglion --< postganglionic sympathetic --< long ciliary nerve.

Light in either retina sends a signal via CN II to pretectal nuclei (dashed lines, below) in midbrain that activate bilateral Edinger-Westphal nuclei; pupils constrict bilaterally (consensual reflex). Result: illumination of 1 eye results in bilateral pupillary constriction.

Afferent pupillary defect (e.g., due to optic nerve damage or retinal detachment). Decreased bilateral pupillary constriction when light is shone in affected eye.

Center carries output to ocular muscles, affected primarily by vascular disease (e.g., DM) Outside carries parasympathetic output, affected 1st by compression (e.g., PCA berry aneurysm, uncal herniation); use pupillary light reflex in assessment, "blown pupil"

Separation of neurosensory layer of retina from pigment epithelium | Degeneration of photoreceptors | Vision loss May be secondary to trauma, diabetes.

Degeneration of macula (central area of retina). Causes loss of central vision (scotomas). "Dry"/atrophic ARMD is slow, causes gradual decrease in vision "Wet" ARMD is rapid, due to neovascularization.

#1, below

Right anopia

#2, below

Bitemporal hemianopia

#3, below

Left homonymous hemianopia

#4, below

Left upper quadrantic anopia (right temporal lesion)

#5, below

Left lower quadrantic anopia (right parietal lesion)

#6, below

Left hemianopia w/ macular sparing

#7, below

Central scotoma (macular degeneration)

Lesion in the medial longitudinal fasciculus (MLF) --< medial rectus palsy on attempted lateral gaze. Nystagmus in abducting eye. Convergence normal. Syndrome is seen in many pts w/ multiple sclerosis ("M LF = M S") When looking left, the left nucleus of CN VI fires, which contracts the lateral rectus and stimulates the contralateral (right) nucleus of CN III via the right MLF to contract the right medial rectus.

Decreased cognitive ability, memory, fxn, with intact consciousness.

Most common cause of dementia in the elderly. Down syndrome pts are at increased risk of developing AD.

Familial form (10%) assocaited w/ genes on chromosomes 1, 14, 19 (APOE4 allele; autosomal dominant), and 21 (p-App ) gene.

Widespread, accelerated cortical atrophy with decreased ACh. Associated w/ senile plaques (extracellular, beta-amyloid core) and neurofibrillary tangles (intracellular, abnormally phosphorylated tau protein; tangles correlate w/ degree of dementia). May cause amyloid angiopathy --< intracranial hemorrhage.

Dementia, aphasia, parkinsonian aspects; Associated w/ Pick bodies (intracellular, aggregated tau protein), frontotemporal lobe atrophy. Spares parietal lobe and posterior 2/3rds of superior temporal gyrus.

Parkinsonism with dementia and hallucinations. Caused by alpha-synuclein defect.

Rapidly progressive (wks-mos) dementia w/ myoclonus, spongiform cortex; associated w/ prions.

Multi-infarct (2nd most common cause of dementia in the elderly) Syphilis HIV Vitamin B12 deficiency Wilson's dz

Autoimmune inflammation and demyelination of CNS (brain and spinal cord).

Pts can present with: optic neuritis (sudden loss of vision) MLF syndrome (internuclear ophthalmoplegia) Hemiparesis Hemisensory Sx's Bowel/bladder incontinence. Relapsing and remitting course.

Most often affects women in their 20s and 30s; more common in whites.

Elevated protein (IgG) in CSF. Periventricular plaques (areas of oligodendrocyte loss and reactive gliosis) w/ preservation of axons.

Charcot's traid of MS is a SIN : S canning speech I ntention tremor (+I ncontinence, I nternuclear ophthalmoplegia) N ystagmus

Beta-interferon or immunosuppressant therapy. Symptomatic Tx for neurogenic bladder, spasticity, and pain.

Inflammation and demyelination of peripheral nerves and motor fibers of ventral roots (sensory effect less severe than motor), causing symmetric ascending muscle weakness beginning in distal lower extremities. Facial paralysis in 50% of cases. Autonomic fxn may be severely affected (e.g., cardiac irregularities, HTN, or hypotension).

Almost all pts survive; the majority recover completely after wks to months.

Elevated CSF protein w/ normal cell count (albuminocytologic dissociation). Elevated protein --< papilledema.

Associated with infxns --< autoimmune attack of peripheral myelin due to molecular mimicry (e.g., Campylobacter jejuni or herpesvirus infxn), inoculations, and stress, but no definitive link to pathogens.

Respiratory support is critical until recovery. Additional Tx: plasmapheresis, IV immune globulins.

Demyelination of CNS due to destruction of oligodendrocytes. Associated w/ JC virus and seen in 2-4% of AIDS pts (reactivation of latent viral infxn). Rapidly progressive, usually fatal.

Multifocal perivenular inflammation and demyelination after infxn (e.g., chickenpox, measles) or certain vaccinations (e.g., rabies, smallpox)

Autosomal-recessive lysosomal storage dz, most commonly due to arylsulfatase A deficiency. Builup of sulfatides leads to impaired production of myelin sheath.

Group of progressive hereditary nerve d/o's related to defective production of proteins involved in the structure and fxn onf peripheral nerves or the myelin sheath.

Characterized by synchronized, high-frequency neuronal firing. Variety of forms.

1 area of brain. Most commonly originates in the mesial temporal lobe. Often preceded by seizure aura; can secondarily generalize.

1.) Simple partial (consciousness intact): motor, sensory, autonomic, psychic 2.) Complex partial (impaired consciousness)

Diffuse.

1.) Absence (petit mal) - blank stare 2.) Myoclonic - quick, repetitive jerks 3.) Tonic-clonic (grand mal) - alternating stiffening and movement 4.) Tonic - stiffening 5.) Atonic - "drop" seizures (falls to floor); commonly mistaken for fainting

A d/o of recurrent seizures (febrile seizures are not epilsepsy)

Genetic Infxn (febrile) Trauma Congenital Metabolic

Tumors Trauma Stroke Infxn

Stroke Tumor Trauma Metabolic Infxn

Pain due to irritation of structures such as dura, cranial nerves, or extracranial structures, not brain parenchyma itself.

4-72 hours of unilateral pulsating pain w/ nausea, photophobia, or phonophobia. +/- "aura" of neurologic Sx before HA, including visual dsensory, speech disturbances. Due to irritation of CN V and release of substance P, CGRP, vasoactive peptides.

< 30 minutes of bilateral steady pain. Not aggravated by light or noise; no aura.

Repetitive brief headaches characterized by unilateral periorbital pain associated w/ ipsilateral lacrimation, rhinorrhea, Horner's syndrome. Much more common in males.

Subarachnoid hemorrhage ("worst headache of my life") Meningitis Hydrocephalus Neoplasia Arteritis

Illusion of movement, not to be confused w/ dizziness or lightheadedness.

More common type. Inner ear etiology (e.g., semicircular canal debris, vestibular nerve infxn, Meniere's dz). Positional testing --< delayed horizontal nystagmus.

Brain stem or cerebellar lesion (e.g., vestibular nuclei, posterior fossa tumor). Positional testing --< immediate nystagmus in any direction; may change directions.

Congenital d/o w/ port-wine stains and ipsilateral leptomeningeal angioma. Can cause glaucoma, seizures, hemiparesis, and mental retardation. Occurs sporadically.

Hamartomas in CNS, skin, organs; cardiac rhabdomyoma, renal agiomyolipoma, subependymal giant cell astrocytoma, MR, seizures, hypopigmented "ash leaf spots," sebaceous adenoma, shagreen patch. Autosomal dominant.

Café-au-lait spots Lisch nodules (pigmented iris hamartomas) Neurofibromas in skin. Autosomal dominant

Cavernous hemangiomas in skin, mucosa, organs; renal cell carcinoma hemangioblastoa in retina, brain stem, cerebellum. Autosomal dominant.

Clinical presentation due to mass effects (e.g., seizures, demential, focal lesions); Primary tumors rarely undergo metastasis. The majority of adult primary tumors are supratentorial, while the majority of childhood primary tumors are infratentorial. Note: half of adult brain tumors are metastases (well circumscribed; usually present at the gray-white junction).

Most common primary brain tumor. Prognosis grave; > 1yr life expectancy. Found in cerebral hemispheres. Can cross corpus callosum ("butterfly glioma" [below]) Stain astrocytes for GFAP. "Pseudopalisading" pleomorphic tumor cells -- border central areas of necrosis and hemorrhage [above/right]

Glioblastoma multiforme (grade IV astrocytoma)

2nd most common primary brain tumor. Most often occurs in convexities of hemispheres and parasagittal region. Arises from arachnoid cells external to brain. Resectable. Spindle cells concentrically arranged in a whorled pattern; psammoma bodies (laminated calcifications).

Meningioma

3rd most common primary brain tumor. Schwann cell origin; often localized to CN VIII --< acoustic schwannoma. Resectable. Bilateral schwannoma found in neurofibromatosis type II.

Relatively rare, slow groing. Most often in frontal lobes. Chicken-wire capillary pattern.  Oligodendrocytes = "fried egg" cells -- round nuclei w/ clear cytoplasm. Often calcified in oligodendroglioma.

Most commonly prolactinoma. Bitemporal hemianopia (due to pressure on optic chiasm) and hyper- or hypopituitarism are sequelae. Rathke's pouch.

Usually well circumscribed. In children, most often found in posterior fossa. May be supratentorial. GFAP positive. Benign; good prognosis. Rosenthal fibers -- eosinophilic, corkscrew fibers.

Pilocytic (low-grade) astocytoma

Highly malignant cerebellar tumor. A form of primitive neuroectodermal tumor (PNET). Can compress 4th ventricle, causing hydrocephalus. Rosettes or perivascular pseudorosette pattern cells. Radiosensitive.

Medullo-blastoma

Ependymal cell tumors most commonly found in 4th ventricle. Can cause hydrocephalus. Poor prognosis. Characteristic perivascular pseudorosettes. Rod-shaped blepharoplasts (basal ciliary bodies) found near nucleus.

Ependymoma

Most often cerebellar; associated w/ von Hippel-Lindau syndrome when found w/ retinal angiomas. Can produce EPO --< secondary polycythemia. Foamy cells and high vascularity are characteristic.

Hemangioblastoma

Benign childood tumor, confused w/ pituitary adenoma (can also cause bitemporal hemianopia). Most common childhood supratentorial tumor. Derived from remnants of Rathke's pouch. Calcification is common (tooth enamel-like).

Craniopharyngioma

Can compress anterior cerebral artery. #1 below:

Cingulate (subfalcine) herniation under falx cerebri

#2 below

Downward transtentorial (central) herniation

(hint: Uncus = medial temporal lobe) #3 below:

Uncal herniation (hint: Uncus = medial temporal lobe)

#4 below:

Cerebellar tonsillar herniation into the foramen magnum

Coma and death result when these hernations compress the brain stem.

Stretching of CN III (innervates levator palpebrae)

Compression of ipsilateral posterior cerebral artery

Compression of contralateral crus cerebri (Kernohan's notch)

Caudal displacement of brain stem.

alpha-agonist. Decreases aqueous humor synthesis due to vasoconstriction. SE: mydriasis, stinging; do not use in closed-angle glaucoma.

alpha-agonist. Decreased aqueous humor synthesis. SE: no pupillary or vision changes.

beta-blockers. Decrease aqueous humor secretion SE: no pupillary or vision changes.

Diuretic. Decrease aqueous humor secretion due to decreased HCO3- (via inhibition of carbonic anhydrase) SE: no pupillary or vision changes.

Cholinomimetics Increase outflow of aqueous humor; contract ciliary muscle and open trabecular meshwork; use pilocarpine in emergencies; very effective at opening canal of Schlemm. SE: Miosis, cyclospasm.

Prostaglandin. Increases outflow of aqueous humor. SE: darkens color of iris (browning).

Morphine Fentanyl Codeine Heroin Methadone Meperidine Dextromethorphan

Act as agonists at opioid receptors (mu = morphine, delta = enkephalin, kappa = dynorphin) to modulate synaptic transmission -- open K+ channels, close Ca2+ channels, leading to decrease in synaptic transmission.

Pain cough suppression (dextromethorphan) diarrhea (loperamide and diphenoxylate) acute pulmonary edema maintenance programs for addicts (methadone)

Addiction Respiratory depression Constipation Miosis (pinpoint pupils ) Additive CNS depression with other drugs. Tolerance does not develop to miosis and constipation. Toxicity treated w/ naloxone or naltrexone (opioid receptor antagonist).

Partial agonist at opioid mu receptors, agonst at kappa receptors.

Pain; causes less respiratory depression than full agonists.

Causes withdrawal if on full agonist.

Very weak opioid agonist; also inhibits serotonin and NE reuptake (works on multiple neurotransmitters -- "tram it all " in).

Chronic pain.

Similar to opioids. Decreases seizure threshold.

Used in partial seizures (simple and complex). 1st line drug for Tonic-clonic seizures. 1st line drug for prophylaxis of status seizures. Mechanism: increased Na+ channel inactivation.

Phenytoin

Used for partial seizures (simple and complex). 1st line drug for tonic-clonic seizures. Mechanism: increases Na+ channel inactivation. *Also 1st line drug for trigemnial neuralgia.

Carbamezepine

Used for partial seizures (simple and complex). May be used for tonic-clonic seizures. Mechanism: blocks VG-Na+ channels.

Lamotrigine

Used for partial seizures (simple and complex). May be used for tonic-clonic seizures. Mechanism: increases GABA release. *Also used for peripheral neuropathy.

Gabapentin

Used for partial seizures (simple and complex). May be used for tonic-clonic seizures. Mechanism: blocks Na+ channels, increases GABA action

Topiramate

Used for partial seizures (simple and complex). May be used for tonic-clonic seizures. Mechanism: increases GABA-A action. *1st line in pregnant women, children.

Phenobarbital

Used for partial seizures (simple and complex). 1st line drug for tonic-clonic seizures. May also be used in absence seizures. Mechanism: increases Na+ channel inactivation, increases GABA concentration. *Also used for myoclonic seizures.

Valproic acid

1st line drug for absence seizures. Mechanism: blocks thalamic T-type Ca2+ channels.

Ethosuximide

1st line for acute status seizures. Mechanism: increase GABA-A action. *Also used for seizures of eclampsia (1st line to prevent seizures of eclampsi is MgSO4)

Benzodiazepines (diazepam or lorazepam)

Sedation Tolerance Dependence

Diplopia Ataxia Blood dyscrasias (agranulocytosis, aplastic anemia) Liver toxicity Teratogenesis Induction of cytochrome P-450

GI distress Fatigue Headache Urticaria Stevens-Johnson syndrome ("EFGH = E thosuximide, F atigue, G I, H eadache")

prodrome of malaise and fever followed by rapid onset of erythematous/purpuric macules (oral, ocular, genital). Skin lesions progress to epidermal necrosis and sloughing.

Sedation Tolerance Dependence Induction of cytochrome P-450

Nystagmus Diplopia Ataxia Sedation Gingival hypreplasia Hirsutism Megaloblastic anemia Teratogenesis SLE-like syndrome Induction of cytochrome P-450

GI distress rare but fatal hepatotoxicity (measure LFTs) Neural tube defects in fetus (spina bifida) Tremor Weight gain. Contraindicated in pregnancy.

Stevens-Johnson syndrome

Sedation Ataxia

Sedation Mental dulling Kidney stones Weight loss

Use-dependent blockade of Na+ channels; inhibition of glutamate release from excitatory presynaptic neuron.

Tonic-clonic seizures. Also a class IB antiarrhythmic.

Nystagmus, ataxia, diplopia, sedation, SLE-like syndrome, induction of cytochrome P-450. Chronic use produces gingival hyperplasia in children, peripheral neuropathy, hirsutism, megaloblastic anemia (decreased folate absorption). Teratogenic (fetal hydantoin syndrome).

Facilitate GABA-A action by increasing duration of Cl- channel opening, thus decreasing neuron firing. ("BarbiDURAT e [increased DURAT ion]")

Sedative for anxiety, seizures, insomnia, induction of anestheisa (thiopental)

Dependence, additive CNS depression effects w/ EtOH, respiratory or CV depression (can lead to death), drug interactions owing to induction of liver microsomal enzymes (cytochrome P-450). Tx overdose w/ Sx managment (assist respiration, increase BP) Contraindicated in pregnancy.

Facilitate GABA-A action by increasing frequency of Cl- channel opening. Decreases REM sleep. Most have long half-lives and active metabolites. ("FRE enzodiazepines [increased FRE quency]")

TOM thumb T riazolam O xazepam M idazolam. Highest addictive potential.

Anxiety, spasticity, status epilepticus (lorazepam and diazepam), detoxification (especially EtOH withdrawal - DTs), night terrors, sleep walking.

Dependence, additive CNS depression effects w/ EtOH. Less risk of respiratory depression and coma than w/ barbiturates. Tx overdose w/ flumazenil (competitive antagonist at GABA receptor)

CNS drugs must be lipid soluble (cross the BBB) or be actively transported.

Drugs with low solubility in blood = rapid induction and recovery times. Drugs with high solubility in lipids = high potency = 1 / MAC (where MAC = Minimum Alveolar Concentration at which 50% of the population is anesthetized. Decreases w/ age). e.g., N2O has low blood and lipid solubility, and thus fast induction and low potency. Halothane, in contrast, has high lipid and blood solubility, and thus high potency and slow induction.

Halothane Enflurane Isoflurane Sevoflurane Methoxyflurane Nitrous oxide

Unknown!

Myocardial depression Respiratory depression Nausea/emesis Increased cerebral blood flow (decreased cerebral metabolic demand)

Hepatoxicity (halothane) Nephrotoxicity (methoxyflurane) Proconvulsant (enflurane) Malignant hyperthermia (rare) Expansion of trapped gas (nitrous oxide)

B arbiturates B enzodiazepines Arylcyclohexylamins (K etamine) Opiates Propofol ("BB K ing on OPIATES POPO ses FOOL ishly")

Thiopental -- high potency, high lipid solubility, rapid entry into brain. Used for induction of anesthesia and short surgical procedures. Effect terminated by redistribution from brain. Decreased cerebral blood flow.

Midazolam most common drug used for endoscopy; used adjuctively w/ gaseous anesthetics and narcotics. May cause severe postoperative respiratory depression, decr BP (Tx overdose w/ flumazenil), and amnesia.

PCP analogs that act as dissociative anesthetics. Block NMDA receptors. Cardiovascular stimulants. Cause disorientation, hallucination, and bad dreams. Increase cerebral blood flow.

Morphine, fentanyl used w/ other CNS depressants during general anesthesia.

Used for rapid anesthesia induction and short procedures. Less postoperative nausea than thiopental. Potentiates GABA-A.

Esters Procaine, cocaine, tetracain Amides lI docaI ne, mepI vacaI ne, bupI vacaI ne ("amI des have 2 I 's in their names)

Block Na+ channels by binding to specific receptors on inner portion of channel. Preferentially bind to activated Na+ channels, so most effecctive in rapidly firing neurons. Tertiary amine local anesthetics penetrate membrane in uncharged form, then bind to ion channels in charged form.

1.) In infected (acidic) tissue, alkaline anesthetics are charged and cannot penetrate membrane effectively. More anesthetic is needed in these cases. 2.) Order of nerve blockade: Small-diameter fibers < large diameter. Myelinated fibers < unmyelinated fibers. Overall, size factor predominates over myelination such that: small myelinated fibers < small unmyelinated fibers < large myelinated fibers < large unmyelinated fibers. Order of loss: pain (lose first) < temperature < touch < pressure (lost last). 3.) Except for cocain, given w/ vasoconstrictors (usually epinephrine) to enhance local action: decreased bleeding, increased anesthesia by decreasing systemic concentration.

Minor surgical procedures, spinal anesthesia. If allergic to esters, give amides.

CNS excitation, severe cardiovascular toxicity (bupivacaine), HTN, hypotension, and arrhytmias (cocaine)

Used for muscle paralysis in surgery or mechanical ventilation. Selective for motor (vs. autonomic) nicotinic receptor.

Succinylcholine (complications include hypercalcemia and hyperkalemia) Reversal of blockade: Phase I (prolonged depolarization) -- no antidote. Block potentiated by cholinesterase inhibitors. Phase II (repolarized but blocked) -- antidote consists of cholinesterase inhibitors (e.g., neostigmine)

Tubocurarine, atracurium, mivacurium, pancuronium, vecuronium, rocuronium. Competitive: compete w/ ACh for receptors. Reversal of blockade: neostigmine, edrophonium, and other cholinesterase inhibitors.

Used in Tx of malignant hyperthermia, which is caused by the concomitant use of inhalation anesthetics (except N2O) and succinylcholine. Also used to Tx neuroleptic malignant syndrome (a toxicity of antipsychotic drugs)

Prevents the release of Ca2+ from the sarcoplasmic reticulum of skeletal muscle.

Parkinsonism is due to loss of dopaminergic neurons and excess cholinergic activity. "BALSA" B romocriptine A mantadine L evodopa (with carbidopa) S elegiline (and COMT inhibitors) A ntimuscarinics

Bromocriptine (ergot alkaloid and partial dopamine agonist) Pramipexole Ropinirole

Amantadine (may increase dopamine release); also used as an antiviral against influenza A and rubella; toxicity = ataxia. L-dopa/carbidopa (converted to dopamine in the CNS)

Selegiline (selective MAO type B inhibitor); Entacapone, Tolcapone (COMT inhibitors)

Benz tropine (A ntimuscarinic; improves tremor and rigidity but has little effect on bradykinesia). ("Tx your tremor before you drive your Mercedes-BENZ ")

Use beta-blocker.

Increase level of dopamine in brain. Unlinke dopamine, L-dopa can cross BBB and is converted by dop decarboxylase in the CNS to dopamine.

Parkinsonism

Arrhythmias from peripheral conversion to dopamine. Long-term use can --< dyskinesia following administration, akinesia btw doses. Carbidopa, a peripheral decarboxylase inhibitor, is given w/ L-dopa in order to increase the bioavailability of L-dopa in the brain and to limit peripheral SE's.

Selectively inhibits MAO-B, thereby increasing the availability of dopamine.

Adjunctive agent to L-dopa in Tx of Parkinson's dz.

May enhance adverse effects of L-dopa.

5-HT[1B/1D]* agonist. Causes vasoconstriction, inhibition of trigeminal activation and vasoactive peptide release. Half-life is > 2 hours. [*the "1B/1D" in brackets is subscript]

Acute migraine, cluster HA attacks.

Coronary vasospasm (contraindicated in pts w/ CAD or Prinzmetal's angina) Mild tingling.

NMDA receptor antagonist; helps prevent excitotoxicity (mediated by Ca2+)

Dizziness, confusion, hallucinations.

Acetylcholinesterrase inhibitor

Nausea, dizziness, insomnia.