Neuro 2

Question 1

What are the adult brain tumors

Answer 1

Glioblastoma multiforme (astrocytes)
Meningioma (arachnoid cells)
Schwannoma (Schwann cells)
Oligodendroglioma (oligodendrocytes)
Hemangioblastoma
Pituitary adenoma

Question 2

What are the child brain tumors

Answer 2

Pilocytic astrocytoma (astrocytes)
Medulloblastoma (cerebellum)
Ependymoma (surrounding ventricles)
Craniopharyngioma (Rathke’s pouch)

Question 3

Location of Broca’s area

Answer 3

Inferior frontal gyrus

Question 4

Location of Wernicke’s area

Answer 4

Posterior section of superior temporal gyrus

Question 5

What is Gerstmann syndrome

Answer 5

Lesion of dominant parietal cotex

Causes: agraphia (inability to write), acalculia (inability to calculate), finger agnosia (inability to distinguish fingers), left-right disorientation

Question 6

Anatomy that may cause weakness

Answer 6

o	Motor cortex
o	Pyramidal tract (e.g. corticospinal tract)
o	Extrapyramidal tract (e.g. basal ganglia)
o	Cerebellum 
o	Spinal cord
o	Lower motor neurons
o	Neuromuscular junction disease 
o	Muscular weakness

Question 7

In which aphasia is repetition affected?

Answer 7

Broca’s, Wernicke’s, and conduction

So it is affected in the cortical aphasias, but not in the precortical aphasias

Question 8

Describe path of dorsal column/medial lemniscus

Answer 8

♣ Processes fine touch, pressure, vibration, and proprioception
♣ First order neurons (dorsal column) have cell bodies in dorsal root ganglion or cranial nerve ganglion and ascend ipsilaterally to the nucleus gracilis (lower body) or nucleus cuneatus (upper body) in the medulla
♣ In the medulla they synapse on second order neurons which then cross the midline
♣ Second order neurons (now called the medial lemniscus) ascend to the contralateral thalamus (VPL) where they synapse on 3rd order which ascend to the somatosensory cortex and synapse on 4th order

Question 9

Describe path of spinothalamic tract

Answer 9

♣ Processes pain, temperature, and light touch (crude touch?)
♣ First order neurons have cell bodies in dorsal horn (of gray matter) and synapse on thermoreceptors and nociceptors in the skin
♣ First order nerves synapse on second order in the dorsal horn of the spinal cord, where the second order cross the midline at the anterior white commissure and ascend to the contralateral thalamus (VPL) when second order synapse on third order which ascend to somatosensory cortex and synapse on fourth order

Question 10

Describe path of corticospinal tract

Answer 10

♣ UMN from motor cortex descend to pyramid in the medulla
♣ Axons cross to contralateral side in the caudal medulla and descend via lateral cortico-spinal tract
♣ Enter the spinal cord at lateral white column and travel to the anterior grey horn
♣ Synapse to LMN (alpha motor neuron) which then exits via ventral spinal root to innervate muscle

Question 11

Where is lesion in conductive aphasia

Answer 11

Arcuate fasciculus

Question 12

Describe glioblastoma multiforme

Answer 12

• Malignant tumor of astrocytes GFAP (+)
• Found in cerebral hemispheres and may cross corpus callosum – “butterfly lesion”
• Pseudopalisading – tumor surrounding central necrosis
o THINK:
♣ Pseudopallisading looks like a star = astrocyte
♣ Central area is necrotic/dead so this must be an old people tumor – astocyte tumor of adults = glioblastoma multiforme

Question 13

Describe meningioma

Answer 13

• Benign tumor of arachnoid cells
• Most often occurs near surfaces of brain
• Extra-axial (external to brain parenchyma) and may have a dural attachment (“tail”)
• May present with seizures
• Histology shows whorled pattern and Psammoma bodies

Question 14

Describe hemangioblastoma

Answer 14

• Tumor of the CNS that originates from vascular origin
• Associated with Von-Hippel Lindau syndrome (increased risk of bilateral renal cell carcinoma)
• Can produce erythropoietin secondary polycythemia

Question 15

Describe Schwannoma

Answer 15

• Benign tumor of Schwann cells S-100 (+)
• Most frequently involved CN VIII (loss of hearing and tinnitus)
• Bilateral vestibular schwannomas seen in neurofibromatosis-2

Question 16

Describe Oligodendroglioma

Answer 16

• Most often in frontal love

* “Fried egg” appearance (round nuclei with clear cytoplasm)

Question 17

Describe pituitary adenoma

Answer 17

• Most often a prolactinoma (hypogonadism)

* Bitemporal hemianopia (due to compression of optic chiasm)

Question 18

Describe pilocytic astrocytoma

Answer 18

• Benign tumor of astrocytes GFAP (+)
• Usually arises in posterior fossa
• Cystic lesion with mural nodule
• Rosenthal fibers – eosinophilic corkscrew fibers

♣ THINK: Chris Rossman (Rosenthal) putting the star (astrocytes) on the top of a child’s (tumor of children) christmas tree, so it has a swirly base (corkscrew fibers)

Question 19

Describe medulloblastoma

Answer 19

• Malignant tumor derived from neuroectodem
• Cerebellar tumor
• Can compress 4th ventricle leading to hydrocephalus
• Homer Wright rosettes (small blue cells wrap around pink areas of neuritic processes)

o THINK: Homer Simpson is dumb like a kid (tumor of children); it seems like he lost actual brain cell, neurons (tumor of neurons)

Question 20

Describe ependymoma

Answer 20

• Malignant tumor of ependymal cells (most often in 4th ventricle)
• Can compress 4th ventricle leading to hydrocephalus
• Perivascular pseudorosettes (tumor cells surrounding vessel)

o THINK: Ependymoma = tumor surrounding ventricles; ventricles are open spaces containing body fluids; pseudorosettes is surrounding a vessel which contains body fluids

Question 21

Describe craniopharyngioma

Answer 21

• Derived from remnant of Rathke’s pouch (where anterior pituitary sprouted from mouth)
• Supretentorial mass that may lead to bitemporal hemianopia
• Often see calcifications (derived from “tooth-like” structures)

Question 22

Describe Tuberous sclerosis presentation

Answer 22

♣ Triad = Angiofibromas, mental retardation, seizures

♣ Other symptoms: Ash-leaf spots, hamartomas of CNS and skin, angiomyolipoma

Question 23

What is the difference between partial and generalized seizures

Answer 23

Partial = involves single part of brain at onset

Generalized = starts as partial and spreads to rest of brain

Question 24

Difference between simple and complex partial seizures

Answer 24

Simple = no LOC or postictal state

Complex = LOC and postictal state

Question 25

Describe Sturge Weber syndrome

Answer 25

♣ Port-wine stain of the face in CN V1/V2 distribution ♣ Seizures/epilepsy ♣ Intellectual disability ♣ Glaucoma

Question 26

Tx of absence seizures

Answer 26

Ethosuximide

Question 27

Tx of status epilepticus

Answer 27

Benzos, Phenytoin, Phenobarbital

Question 28

Triad of Wernicke Korsakoff

Answer 28

Vitamin B1 (Thiamine) deficiency o Triad: confusion, ophthalmoplegia, ataxia o Confabulation, personality change, memory loss (permanent)

Question 29

Work-up for dementia

Answer 29

``` ♣ Mini mental status exam ♣ RPR syphilis screen ♣ HIV test ♣ TSH ♣ Vitamin B12 ♣ MRI of brain ```

Question 30

Presentation of CJD

Answer 30

♣ Rapidly progressive dementia + ataxia + startle myoclonus

Question 31

Presentation of Lewy Body dementia

Answer 31

Characterized by dementia and visual hallucinations, followed by Parkinsonian - Early onset dementia (vs. Parkinsons late onset)

Question 32

Presentation of Frontotemporal dementia

Answer 32

♣ Degenerative disease of frontal and temporal cortex (vs. Alzheimer’s which is diffuse) ♣ Presentation: • Early Behavior/personality changes (frontal lobe) and/or aphasia (temporal lobe) • Late Dementia

Question 33

What is the most sensitive imaging to demonstrate early cerebral ischemia or infarction

Answer 33

DWI - may be positive within 30 min of sx onset

Question 34

When should you restart anticoagulation after an acute stroke

Answer 34

Remember: 1, 3, 6, 12 Tiny stroke = 1 day Small = 3 days Medium = 6 days Large = 12 days

Question 35

Normal LP opening pressure

Answer 35

6-20

Question 36

What will you see on EMG for neuropathy vs. myopathy

Answer 36

Neuropathy = rapid firing and decreased recruitment (there are less muscle fibers so there is no reserve to call in, so instead the existing fibers must fire more rapidly) Myopathy = early recruitment (muscle fibers are weaker so they have to call in reserve earlier)

Question 37

What is a natural age to lose ankle jerk reflex

Answer 37

Age 60

Question 38

How can you determine brain death

Answer 38

CT arteriogram (ICP > arterial BP so dye will not reach head) Nuclear medicine studies (add tagged RBCs which will not reach head because ICP > BP)

Question 39

What are the components of Glasgow coma scale

Answer 39

o Eye opening ♣ Spontaneous, to verbal command, to pain, none o Verbal response ♣ Oriented, disoriented/confused, inappropriate words, incomprehensible sounds, none o Motor response ♣ Obeys, localizes, withdraws, flexion posturing (decorticate), extension posturing (decerebrate), none

Question 40

Describe administration of glucose/thiamine in Wernicke-Korsakoff

Answer 40

Give thiamine before glucose - glucose can worsen WK

Question 41

Describe difference in management of a comatose patient with present vs. absent focal signs

Answer 41

Focal signs present = suspect structural cause (urgent neuroimaging) Focal signs absent = suspect metabolic/toxic/infectious cause

Question 42

Clinical approach to patient with AMS

Answer 42

1. ABCs 2. Look for obvious clues to etiology 3. Try reversing common causes (Naloxone, Thiamine, Glucose) 4. Use neuro exam to check brainstem reflexes and look for focal signs