1
Q
How common are mental health problems?
A
- More than 1 in 3 affected each year
- 1 in 3 GP appointments
2
Q
How many Scots take an antidepressant every day?
A
1 in 8 (12%)
3
Q
What are the “Do’s” of talking about mental health?
A
- Active listening & open questions
- Sensitive & encouraging (trust)
- Non jugmental
- Validate how they are feeling
- Confidentiality, dignity & respect
- Take care of yourself to take care of patient
- Information appropriate to level of understanding
- Avoid clinical language
- Written information where necessary
- Interpreteres where necessary
- Consent
4
Q
What are the “Don’ts” of talking about mental health?
A
- Dismissive comments “snap out of it”, “cheer up”
- Say “you know how they feel” if you don’t
- Point out that others are worse off
- Blame the individual
- Think of mental illness as personal weakness
- Stigmatising words
5
Q
What are the “Red flags” for potential mental health problems?
A
- Unexplained chronic pain/fatigue
- Recurrent presentations
- Eating/sleeping patterns
- Impairment in work, school, home
- Past/present alcohol/drug
- Previous mental health problem
- Chronic physical health problem
6
Q
What are relevant questions for any mental health problem?
A
- Trigger
- Duration
- Own/family history
- Dependents (kids)
- Social support
- Drugs, alcohol, fags
- Employment history
- Forensic history
- Other mental health problems
- Previous treatment
- Neglect
- Psychosis evidence
7
Q
What are 4 services/ideas you could advise & inform a patient with mental health problems?
A
- Self help groups
- Support groups
- Other local & national resources
- Support for family/dependents/carers
8
Q
What are 6 different sign posts for helping those with mental health problems?
A
- Moodcafe
- Samaritans
- Mind Infoline
- Own GP
- Out of hrs (OOH) service (111)
- A&E (999)
9
Q
What are 2 screening questions you could use for depression?
A
- During the last month, have you often been bothered by feeling down, depressed or hopeless?
- During the last month, have you often been bothered by having little interest or pleasure in doing things?
(if yes to either- mental health assessment)
10
Q
What are the key symptoms in assessing depression according to DSM-IV?
A
- Persistent sadness or low mood &/or
- Marked loss of interest or pleasure
- At least 1, most days, most of the time for at least 2 weeks
11
Q
What are associated symptoms for depression?
A
- Disturbed sleep
- Decreased/increased appetite &/or weight
- Fatigue/loss of energy
- Agitation/slowing
- Poor concentration
- Worthlessness/guilt
- Suicidal thoughts/acts
12
Q
What is sub threshold depressive symptoms?
A
Fewer than 5 symptoms
13
Q
What is mild depressive symptoms?
A
Few, if any, symptoms in excess of the 5 required to make the diagnosis, & only minor functional impairment
14
Q
What is moderate depressive symptoms?
A
Symptoms or functional impairment are between “mild” and “severe”
15
Q
What is severe depressive symptoms?
A
Most symptoms & they markedly interfere with functioning
16
Q
What are the different ways you can manage depression?
A
- Lifestyle measures
- Self help/guided self help
- Computerised cognitive behavioural therapy (CCBT)
- Talking therapies
- Drug treatments
- Alternative/complimentary therapies
- Group physical activity
- Referral to specialist
- Combined treatments
- Multi professional & inpatient care
- Crisis service
- Electroconvulsive therapy
17
Q
When would you use electroconvulsive therapy?
A
- Severe depression
- Resistant mania
- Catatonia
18
Q
What are different types of talking therapy for depression?
A
- Cognitive behavioural therapy
- Interpersonal therapy
- Counselling
- Listening services
- Psychodynamic psychotherapy
- Bereavement counselling
- Relationship counselling
- Family therapy
- Mindfulness
19
Q
What are the 4 key symptoms for Generalised anxiety disorder (GAD)?
A
- Excessive anxiety/worry about number of events/activities
- Difficulty controlling worry
- Majority of days for atleast 6 months
- Not keeping with another anxiety disorder
20
Q
What are 6 associated symptoms for generalised anxiety disorder (GAD)?
A
- Restlessness
- Being easily fatigued
- Difficulty concentrating
- Irritability
- Muscle tension
- Disturbed sleep
21
Q
What is the stepping care model for management of GAD?
A
STEP 1: identification & assessment, education & active monitoring
STEP 2: low-intensity psychological interventions (self-help)
STEP 3: choice of high-intensity psychological intervention (CBT) or drug
STEP 4: highly specialised treatment (drug, multiagency, crisis, inpatient etc)
22
Q
What are the 3 different lines of drug treatments for GAD?
A
1st LINE: SSRI ie. sertraline
2nd LINE: SSRI or SNRI
3rd LINE: Pregabalin
23
Q
When would you ONLY offer benzodiazepine (highly addictive) for the treatment of GAD?
A
Short-term measure during crisis
24
Q
Describe what Psychosis is?
A
- Occurs in number of serious mental illnesses
- Interferes with ability to function
- Delusions & hallucinations
25
What is a Delusion?
False, fixed, strange or irrational belief that is firmly held. The belief is not normally accepted by other members of the same culture or group
26
What are 3 examples of delusions?
1. Delusions of grandeur (exaggerated opinion of themselves)
2. Delusions of paranoia (feeling of persecution)
3. Somatic delusions (physically ill)
27
What are Hallucinations?
Sensory perception without an appropriate stimulus (visual, auditory, tactile, olfactory, gustatory, proprioceptive)
28
What questions should you ask yourself when considering assessment of a patients Psychosis?
- Nature of it?
- Timing?
- Recurring theme?
- Insight?
- Recent major life events?
- History of substance abuse?
- Vulnerability?
- Family history of mental illness?
29
What does MSE stand for?
Mental Status Exam
30
What are the different types of treatment for Psychosis?
Combination of anti psychotic drugs, psychological therapies, social support, occupational & educational interventions
31
The cerebellum modulates motor output based on the integration of what 3 things?
1. Activity in pre-motor & motor areas & spinal motor circuits
2. Sensory feedback from vestibular, visual systems & ascending proprioceptive info
3. Effected at the motor cortex & brainstem
32
What does a patient with cerebellar damage do?
Has to think about each movement they make
33
What are the different lobes in the flattened cerebellum?
- Anterior lobe
- Posterior lobe
- Flocculonodular lobe
34
What is the spinocerebellum?
Vermis & intermediate parts of the hemispheres
35
What is the cerebrocerebellum?
Lateral parts of the hemispheres
36
What is the vestibulocerebellum?
Flocculonodular lobe (& immediately adjacent vermis)
37
Where in the cerebellum do the parallel fibres come from?
Granule cell
38
Where in the cerebellum do the inputs of climbing fibres come from?
Inferior olivary nucleus
39
Where in the cerebellum do the inputs of the mossy fibres come from?
Pontine nuclei & other sources
40
How does afferent info from pre & primary motor cortex & somatosensory cortex go to cerebrocerebellum?
Via pontine nucleus & middle peduncle
41
How does afferent dorsal & ventral ascending spinal proprioception go to the vermis?
Dorsal via the inferior peduncle & ventral via the superior peduncle
42
How does afferent information from the reticular nuclei & olives go to the spinocerebellum?
Via inferior peduncle
43
How does afferent information from the vestibular nuclei go to the Vermis & vestibulocerebellum?
Via inferior peduncle
44
What is the flocculonodular lobe involved in?
Maintaining balance & posture
45
What does the spinocerebellum modulate?
Axial or antigravity muscles & eye movement
46
What does the spinocerebellum contain?
Somatotopical map of the body
47
What is the cerebrocerebellum involved in?
Motor planning & feeds information back towards the cerebra
48
What is the function of the cerebrocerebellum
Sequence & coordinate distal muscles esp. during locomotion or juggling (complex movements)
49
What do cerebellar outputs go through?
Deep nuclei
50
What are the deep nuclei for cerebellar outputs from lateral to medial?
"Don't Eat Greasy Food"
1. Dentate nucleus
2. Emboliform nucleus
3. Globose nucleus
4. Fastigial nucleus
51
What is Interposed nucleus made up of?
1. Emboliform nucleus
| 2. Globose nucleus
52
What does the Dentate nucleus (in cerebrocerebellum) project to?
Motor & premotor cortices --> Motor planning
53
What does the Fastigial nucleus (in vestibulocerebellum) project to?
Vestibular nuclei, tectum & cranial nerve nuclei --> Head & eye movements
54
What does the Interposed nucleus (paravermal area of spinocerebellum) project to?
Lateral descending systems (distal & extremities via spindles) --> Motor execution
55
What does the Fastigial nucleus (in vermis) project to?
Medial descending systems (trunk & proximal via reticular formation) --> Motor execution
56
Where does information from the vestibular nucleus go?
Flocculonodular lobe & vermal/paravermal areas & processed (feed forward from cortex) & feedback from vestibular & olivary
57
What does Olivary information enable?
Calculation of predicted posture in advance of it happening, so feed forwar posture adjustment allows fast postural changes
58
What are motor instructions/corrections sent to?
Fastigial nucleus & then bilaterally to vestibular nuclei & medullary reticulum (inhibitory)
59
What do medullary reticular output & medial & lateral vestibulospinal output do?
Stabilise balance by acting on axial & proximal muscles
60
What is Flocculonodular lobe syndrome?
- Seen in children with medulloblastoma
| - Characterised by truncal ataxia, wide based stance & swaying
61
What is the result of vermal lesions?
Cerebellar hypoplasia
62
How does proprioceptive information arrive at the spinocerebellum?
Via spinocerebellar & cuneocerebellar tracts
63
Describe how motor output information is sent/processed from the spinocerebellum, cerebra & interposed nucleus?
- Relayed to cerebellum with ascending sensory info
- Planned & actual motor output compared & corrective signals sent via thalamus to cerebra, red nucleus & vestibular nuclei
64
Whats it called when there are errors in the corrections of motor output in spinocerebellum?
Anterior lobe syndrome
65
Describe the characteristics of Anterior lobe syndrome?
- Overshoot (dysmetria)
- Intention tremor
- Lack of movement damping
66
Does the cerebellum directly synapse with lower motor neurons?
NO
67
Describe how complex movements are produced and processed in the cerebrocerebellum?
- Pre-motor & sensory areas in cortex start to plan
- Plan is transferred to cerebrocerebellum via pontine nuclei
- Output concerning order & timing of movements is routed through dentate nucleus & back via thalamus to cortex
68
What is the timing skills of the cerebrocerebellum also used by?
Other senses (visual) to predict movement of objects / movement of oneself in relation to object
69
What should you remember about complex movement abilities in the cerebellum?
Improve with practice (plasticity & learning)
70
Describe the result of medial cerebellar lesions affecting medial descending pathways?
- Unsteady gate (truncal ataxia)
- Balance problems
- Posture problems
- Eye movement abnormalities (nystagmus)
71
Why do most unilateral cerebellar lesions give ipsilateral effects?
Output from cerebellum is contralateral to motor centres, which then crosses back to pyramids (double cross)
72
How do medial lesions to the vermis have bilateral effects for trunk & proximal?
Medial motor system innervation is bilateral
73
What do lateral cerebellar lesions affect?
Control of distal muscles & motor planning = limb ataxia
74
What do lesions of the cerebrocerebellum mainly cause?
1. Delay in initiation of movement
| 2. Decomposition of multi-joint movements (loss of complex motor skills)
75
What do lesions of the vermis (spinocerebellum) or fastigial nucleus affect?
- Axial & trunk muscles, making balance unsteady so you have a wide stance
- Some facial muscles feed-forward to vermis so you get slowed & slurred speech
76
What do lesions of the intermediate (paravermis/spinocerebellum) lobe cause?
Affect distal muscles & cause limb ataxia & action tremor
77
Cranial nerves arise mainly from the ____, & exit via ______ or ______?
- Brainstem
- Skull fissures
- Foramina
78
What is the purpose of the sulcus limitans?
Separates efferent & afferent
79
Where do the 12 cranial nerves (I to XII) arise from?
Clusters of cell bodies (nuclei)
80
Why do "special" nuclei/modalities exist in the brainstem?
Additional structures/muscles are derived from pharyngeal arches
81
What are the 7 brainstem modalities from medial to lateral?
1. General somatic efferent to striated voluntary muscle
2. Special visceral efferent to muscles from pharyngeal arches
3. General visceral efferent (parasympathetic)
4. General visceral afferent
5. Special visceral afferent for olfaction & gustation
6. General somatic afferent for perception of pain, touch & temp
7. Special somatic afferent for vision, hearing & balance
82
List the names of the 12 cranial nerves?
```
I- olfactory
II- optic
III- oculomotor
IV- trochlear
V- trigeminal
VI- abducens
VII- facial
VIII- vestibuloconchlear
IX- glossopharyngeal
X- vagus
XI- spinal accessory
XII- hypoglossal
```
83
What is the main primary function of I olfactory cranial nerve?
Sense of smell/olfaction (special visceral afferent)
84
What is the main primary function of II optic cranial nerve?
Sense of sight/vision (special somatic afferent)
85
What is the main & additional function of III oculomotor cranial nerve?
- MAIN: eye movements (general somatic efferent)
| - ADDITION: parasympathetic (general visceral efferent)
86
What is the main function of IV trochlear cranial nerve?
Eye movement (general somatic efferent)
87
What is the main & additional function of V trigeminal cranial nerve?
- MAIN: sensation of head & cavities (general somatic afferent) & motor to muscles of mastication (special visceral efferent)
- ADDITION: carrier of autonomic parasympathetic fibres
88
What is the main function of the VI Abducens cranial nerve?
Eye movemnents (general somatic efferent)
89
What is the main & additional function of VII facial cranial nerve?
- MAIN: muscles of facial expression (special visceral efferent)
- ADDITION: parasympathetic (general visceral efferent) & anterior 2/3 taste (special visceral afferent)
90
What is the main function of VIII vestibulocochlear cranial nerve?
Hearing & Balance (special somatic afferent)
91
What is the main & additional function of IX glossopharyngeal cranial nerve?
- MAIN: sensation of posterior 1/3 of tongue & oropharynx (general somatic afferent)
- ADDITION: parasympathetic (general visceral efferent), posterior 1/3 taste (special visceral afferent)
92
What is the main & additional function of X vagus cranial nerve?
- MAIN: sensation of Pharynx & Larynx (general somatic afferent), parasympathetic heart, lungs, GI Tract (general visceral efferent)
- ADDITION: motor to pharynx & larynx (special visceral efferent)
93
What is the main function of XI spinal accessory cranial nerve?
Motor of sternocleidomastoid & trapezius (special visceral efferent/general somatic efferent)
94
What is the main function of XII hypoglossal cranial nerve?
Motor of tongue (general somatic efferent)
95
Where is the location of the I olfactory cranial nerve on the base of the skull?
Cribriform plate foramina
96
Where is the location of the II optic cranial nerve on the base of the skull?
Optic canal
97
Where is the location of the III oculomotor, IV trochlear & VI abducens cranial nerves on the base of the skull?
Superior orbital fissure
98
Where is the location of the V trigeminal cranial nerve?
- V1: Superior orbital fissure
- V2: Foramen rotundum
- V3: Foramen ovale
99
Where is the location of the VII facial & VIII vestibulocochlear cranial nerves?
Internal acoustic meatus
100
Where is the location of the IX glossopharyngeal, X vagus & XI spinal accessory cranial nerves on the base of the skull?
Jugular foramen
101
Where is the location of XII hypoglossal cranial nerve on the base of the skull?
Hypoglossal canal
102
How many cranial nerves are there?
12 pairs (24 total)
103
Where do the nuclei of the cranial nerves lie?
Sequentially & longitudinally in midbrain, pons & medulla oblongata of brainstem
104
What is the only cranial nerve which emerges posteriorly in brainstem?
IV trochlear cranial nerve
105
What sweeps around VI abducens nucleus?
VII facial nerve nerve
106
What lies immediately posterior to III oculomotor nucleus in midbrain?
Edinger-Westphal nucleus (parasympathetic)
107
How does the sympathetic supply get to the eye muscles?
From cavernous sinus
108
What is the clinical significance of the location of VI abducens cranial nerve?
Passes upwards on the clivus & may be stretched in raised intracranial pressure
109
What is the clinical significance of the location of III oculomotor cranial nerve?
Immediately adjacent to the tentorium cerebello & hence will be compressed in raised intracranial pressure
110
What is the clinical significance of the location of IV trochlear cranial nerve?
Enters at the edge of tentorium cerebelli & may be vulnerable in raised intracranial pressure
111
What arteries does the III oculomotor cranial nerve pass between?
Posterior cerebral & superior cerebellar arteries before lying close to posterior communicating artery- ANEURYSMS OF VESSELS MAY COMPRESS CN III
112
What are the cranial nerves III, IV & VI passing close to?
Sympathetic fibres forming the plexus on the internal carotid artery & may pick up sympathetic fibres
113
Where is the superior orbital fissure located on the skull?
Between the lesser & greater wings of the sphenoid bone
114
What does III oculomotor cranial nerve innervate?
- Extraocular muscles (superior rectus, medial rectus, inferior oblique, inferior rectus)
- Levator palpebrae superioris
115
Describe the Levator palpebrae superioris muscle?
- Striated & smooth muscle
| - Elevates superior eyelids
116
What supplies the smooth muscle component of Levator palpebrae superioris muscle?
Sympathetics from carotid plexus
117
What happens in III oculomotor cranial nerve palsy?
Leaves superior oblique & lateral rectus unopposed to turn the eye downwards & outwards along with ptosis (drooping)
118
What does the IV trochlear cranial nerve innervate?
Superior oblique to turn the eye downwards & laterally
119
What does the VI abducens cranial nerve innervate?
Lateral rectus to abduct the eye
120
What does sympathetic innervate do to the eye?
- Smooth muscle component of levator palpebrae superioris
| - Pupil dilatation (nasociliary & long ciliary nerve)
121
What is another name of the levator palpebrae superioris muscle?
Superior tarsal muscle
122
What does parasympathetic innverate in the eye?
- Pupil constriction (short ciliary nerve)
| - Lens accommodation (short ciliary nerve)
123
Where does the parasympathetic in ciliary ganglion come from?
Edinger-Westphal nucleus via CN III
124
Where does the sympathetic in ciliary ganglion come from?
Carotid plexus
125
Parasympathetic _____ & sympathetics only _________?
- Synapse
| - Pass through
126
What is the pathway of the sympathetics to lead to the eye?
Superior cervical ganglion --> Carotid plexus --> Nasociliary nerve, oculomotor nerve & ciliary ganglion
127
What syndrome is due to injury of the sympathetic trunk?
HORNERS SYNDROME (miosis, ptosis, anhydrous, flushed face)
128
What is the pathway of parasympathetics to lead to the eye?
Oculomotor nerve (CN III) --> Synapse in ciliary ganglion --> Short ciliary nerve --> Pupil constrictor & ciliary muscle for lens accommodation
129
What controls the lacrimal gland in the orbit?
Parasympathetic system but derived from facial nerve (VII)
130
Describe the Epidemiology of head & neck cancer?
- Males aged 60-70 the average no. of cases per year is highest
- Upward trends in male/female as age increases
- Increased alcohol consumption, smoking, more sexual partners causes an upwards trend
- Age-standardised incidence rates highest in Scotland
131
What are 3 psychological factors associated with head & neck cancer?
1. Quality of life
2. Psychological distress (anxiety/depression)
3. Fears of recurrence
132
What are the 3 ways you can assess quality of life?
1. EORTC H&N
2. FACT H&N
3. UoW QoL H&N
133
Describe the average Anxiety HAD subscale for head & neck cancer patient?
- At diagnosis are in an anxiety state at diagnosis (33%)
| - Months after their anxiety decreases to around 20% as cancer patients are usually good at adapting
134
Describe the average depression HAD subscale for head & neck cancer patient?
- At diagnosis have a depressive/low mood state (17%)
- During 2-6 months as chemotherapy/radiotherapy begins, increased rate of depression (30%) as they are suffering with pain, fatigue, hard to swallow, talk, held in isolation etc.
- After 12 months they are almost back to baseline of depression (17%)
135
Why are people concerned about facial appearance?
- Facial info is 1st to be available
- Continuously available
- Info does not require complex processing
- Increased incidence of meeting new people
136
What are the 3 psychological problems associated with requests for plastic surgery?
1. Eating disorders (anorexia, bulemia, compulsive eating)
2. Sexual abuse
3. Familial/social estrangement
137
How can people usually cope better with a physical facial problem?
- Reduced sense of personal vulnerability
- High level of intelligence
- Sense of humour
- Stable childhood
- Strong self-esteem
138
What is major versus minor psychological consequences of disfigurement?
- MINOR: unpredictable response from others, increase in anxiety & helplessness, increased scanning of face
- MAJOR: anticipate response of others
139
Describe Monosymptomatic hypochondriacal psychosis (MHP)?
- Delusions of ugliness
- Obsessional to obtain a "cure"
- Anxious & vigilant
- Rational about other things
140
Describe Body dysmorphic disorder (BDD)?
- Nondelusional
- Preoccupation with imagined defect
- Overvalued idea that can be discussed rationally
- Coexists with depression, OCD, social phobia
141
What is an Anomaly according to expert Committee on Dental Health (1962) WHO, Geneva?
Requiring treatment if the disfigurement/functional defect is an obstacle to the patients physical or emotional well-being
142
What are 2 alternative hypotheses for link between illness concerns & psychological distress?
1. Specific illness fears effect general distress
| 2. General distress effects illness fears & other beliefs
143
What is the common sense model of illness?
Stimuli --> Illness representation OR emotional response --> Coping --> Appraisal
144
According to Easterling & Leventhal 1989 how can you check a patients fears of recurrence?
"Over the past month, how often have you worried about the possibility that cancer might come back?”
145
What is a "carer"?
Person who has supported you through your illness & encourages emotional expression
146
What is the 5 important things that the carer provides to promote recovery?
1. Retain structure to daily life
2. Assist with medication, treatments & adherence to medical recommendations
3. Practical support
4. Maintain emotional life (possible act as a safety valve)
5. Family interactions are complex and not always supportive (‘toxic’ environment)
147
What is the definition of a stroke?
Interruption of the blood supply to a focal part of the brain causing loss of neurological function
148
Whats the difference between a stroke & a transient ischaemic attack?
STROKE: symptoms last >24hrs
| TRANSIENT ISCHAEMIC ATTACK: same cause but symptoms last <24hrs
149
What are the 3 different types of strokes & how common are they?
1. Ischaemic (80-85%)
2. Haemorrhagic (15%)
3. Subarachnoid haemorrhage (5%)
150
What are the 4 possible causes of haemorrhagic stroke?
1. Hypertension
2. Tumour bleeding disorder
3. Vascular malformation
4. Amyloid angiopathy
151
What does cerebral venous sinus thrombosis commonly present with?
Cerebral haemorrhage
152
What 2 secondary brain damage can a haemorrhage cause?
1. Surrounding oedema
| 2. Vascular disease
153
What are the 4 possible causes of ischaemic stroke?
1. Cardioembolism
2. Large vessel artherothrombosis
3. Small vessel disease
4. Hypoperfusion
154
What is the definition of "Ischaemic Penumbra"?
Term generally used to define ischemic but still viable cerebral tissue
155
How many neurons are lost per year in normal aging?
~30 million
156
What are embolisms in ischaemic strokes usually from?
- Small vessel disease
- Carotid/vertebral dissection
- Watershed areas
157
What are "Watershed" areas in the brain?
- Vulnerable border zones between tissues supplied by the Anterior, Posterior and Middle Cerebral arteries
- The blood supply here is decreased
158
What are the 3 "Watershed" areas in the brain called?
1. Cortical border zone (between ACA & MCA)
2. Internal border zone (between LCA & MCA)
3. Cortical border zone (between MCA & PCA)
159
What is cerebral autoregulation?
Physiological mechanism that maintains blood flow to cerebrum at an appropriate level during changes in blood pressure
160
What does the internal carotids supply in the brain?
- Anterior 3/5 of cerebrum
| - Diencephalon
161
What are the 3 main branches of the internal carotid arteries?
1. Middle cerebral artery (MCA)
2. Anterior cerebral artery (ACA)
3. Striate arteries
162
What does the vertebrobasilar arteries supply in the brain?
- Posterior 2/5 of cerebrum
- Diencephalon
- Cerebellum
- Brainstem
163
What are the 4 main branches of the vertebrobasilar artery?
1. Posterior cerebral arteries
2. Striate & thalamus
3. Pontine
4. Cerebellar
164
What are the presenting symptoms & signs of a Stroke & TIA (Transient ischemic attack)?
- Diplopia (double vision)
- Ataxia (loss of full body movements)
- Hemianopia (blindness over half field of vision)
- Speech
- Sensory
- Motor
165
What is the emergency room assessment for stroke patient (A+E, MAU, Hospital at night)?
- Airway
- Breathing
- Circulation
- History!
- Medical background
- Signs
- Stroke mimics excluded
- Level 1 investigations
166
What are the different steps in examination of vascular neurology?
- BP and pulse measurement in 2 arms
- Conscious level (GCS)
- Cardiac & carotid bruits
- BM/blood glucose value
- Neck stiffness/meningism (Kernig’s/Brudzinski signs)
- Abnormal/involuntary movements
- Seizure-like activity
- Skin rash/infarcts (vasculitic, papular rash)
- Specific neurological (eye movements, speech, visual fields, inattention, motor & sensory, gait)
167
What are the 2 types of stroke classification?
1. Oxford community stroke project (OCSP)- clinical
| 2. TOAST classification- mechanism
168
What is the OCSP definition of Lacunar Syndrome (LACS)?
Pure motor, pure sensory, sensorimotor, ataxic hemiparesis
169
What is the OCSP definition of Posterior Circulation Syndrome (POCS)?
Brainstem, cerebellar &/or isolated homonymous hemianopia
170
What is the OCSP definition of Total anterior circulation syndrome (TACS)?
Triad of hemiparesis (or hemisensory loss), dysphagia (or other higher cortical function) & homonymous hemianopia
171
What is the OCSP definition of Partial anterior circulation syndrome (PACS)?
2 of the features of TACS or isolated dysphasia or parietal lobe signs (i.e.. inattention, agnosia, apraxia, alexia)
172
What is the ABCD2 assessment in TIA (transient ischemic attack) & risk of stroke?
1. Age (>60) = 1
2. Blood pressure (systolic > 140 &/or diastolic =/>90) =1
3. Clinical features (unilateral weakness = 2, speech disturbance / weakness = 1)
4. Duration in mins (=/>60 = 2, 10-59 = 1, <10 = 0)
5. Diabetes = 1
6. 2day strokes scores/risk: 0-3 (1%), 4-5 (4%), 6-7 (8%)
173
What are the 5 "S's" in Stroke Mimics?
1. Seizures
2. Sepsis
3. Syncope
4. SOL (tumour, subdural)
5. Somatisation
174
What are the 4 risk factors of recurrent stroke in mild stroke/TIA?
1. Recurrent events of likely vascular aetiology
2. Long duration of TIA (>10mins)
3. Concomitant vascular risk factors
4. High risk of cardioembolism ie. AF
175
What investigations would you do for assessing stroke?
- Good history & exam
- ECG/Holter, ECHO
- Cholesterol/autoimmune & thrombophilia screen
- Carotid doppler
- CT brain/MRI brain
- Cerebral angiography
176
What are 7 indications for urgent head imaging?
1. Depressed level of consciousness
2. Unexplained progressive/fluctuating symptoms
3. Papilloedema, neck stiffness/fever
4. Severe headache at onset
5. History of trauma
6. Indication for thrombolysis/anticoagulation
7. History of anticoagulant treatment/known bleeding tendency
177
What can CT brain scan show?
- Cerebellar haemorrhage
- Another cause (tumour, subdural haemorrhage)
- Early ischemia
- Loss of normal grey white differentiation
178
What do DWI & ADC stand for in MRI?
DWI- Diffusion Weighted Image (T2 & diffusion weighting)
| ADC- Apparent Diffusion Coefficient (pure water diffusion)
179
What are the changes in DWI & ADC after stroke?
- INITIALLY: high signal DWI, low signal ADC
- 1-2 WEEKS: DWI high, ADC increases to norm
- 2 WEEKS+: DWI lower, ADC stays high
180
What are the advantages & disadvantages of CT brain?
- ADVANTAGES: detect bleed, available 24/7, quick
| - DISADVANTAGES: lacks sensitivity
181
What are the advantages & disadvantages of MRI brain?
- ADVANTAGES: sensitive, diagnostic, management, prognostic
| - DISADVANTAGES: limited availability, precautions, slow
182
What is the different types of management for Acute Stroke?
- Aspirin in ischaemic
- Thrombolytic treatment & IV recombinant tissue plasminogen activator if onset <4.5hrs
- Endovascular treatment/mechanical thrombectomy
- Aggressive early BP correction in intracerebral hemorrhage
- Neurosurgical for secondary hydrocephalus
- Anticoagulation in AF
183
How do you manage ischaemic stroke?
Only use Antihypertensive drugs if MAP >130mmHg
184
What systolic blood pressure should you aim for in haemorrhagic stroke management?
<140 mmHg esp in first 6hrs
185
What should you do if BP is persistently elevated whilst trying to manage acute stroke?
IV Labetolol but avoid abrupt falls in BP
186
What can you do if you have raised intracranial pressure during management of acute stroke?
- Hyperventilate mechanically
- Mannitol
- Decompressive hemicraniectomy
187
What 3 investigations can you do for subarachnoid haemorrhage?
1. CT brain
2. Lumbar puncture if CT norm looking for bilirubin & xanthochromia
3. Cerebral angiogram
188
How can you manage subarachnoid haemorrhage?
- Itubate if severe hypoxaemia
- 3L of 0.9% NaCl per 24hr
- Keep MAP <130mmHg, if higher give IV labetolol/esmolol/enalapril
- Nimodipine 60mg
- Codeine/tramadol for pain (avoid NSAIDS)
- Phenytoin if seizures occurred
189
What are the 3 different secondary precaution drug treatments for stroke?
1. Anti-thombotics: clopidogrel/aspirin + Dipyridamole. In AF give warfarin/NOAC
2. Blood pressure: calcium channel blocker, thiazide diuretic, ACE inhibitor
3. Anti-lipids: if cholesterol >4 mol/l give statin ie. Simvastatin
190
When should you be cautious in giving a statin for secondary prevention of stroke?
- Intracerebral hemorrhage
| - Cerebral haemorrhage
191
When should Carotid endarterectomy (CEA) be considered for secondary stroke prevention?
- Symptomatic stroke/TIA patients
- Patients with 50-99% stenosis or 70-99%
- Asymptomatic >60% stenosis with >5yr life-expectancy & peri-operative stroke/death rate <3%
192
What is the longer term management associated with stroke patients?
- Psychosocial & support reviewed on regular basis
- Issues with communication, mobility, depression, pressure sores, sepsis, nutrition, post-stroke seizure, shoulder pain, cognitive impairment, behavioural problem
193
What is the outcome for stroke patients?
- 2nd commonest cause of death
- Disability in survivors
- High risk developing stroke after TIA (highest within first 72hrs)
194
What travels with/close to the 7th cranial nerve (facial)?
Nervus intermedius
195
Describe the nuclei of the special visceral efferent of the trigeminal cranial nerve (V) ?
From motor nucleus in pons to muscles of mastication (derived from 1st pharyngeal arch)
196
Describe the nuclei of the general somatic afferent of the trigeminal cranial nerve (V)?
To mesencephalic, chief sensory & spinal nuclei in midbrain, pons & medulla oblongata
197
What is the cranial nerve V mesencephalic nucleus for?
Proprioception
198
What is the cranial nerve V chief sensory nucleus for?
Discriminative touch
199
What is the cranial nerve V spinal nucleus for?
Pain & temperature & general conscious sensation for viscera supplied by CN IX & X
200
What are the 3 division of the trigeminal cranial nerve (V) & where do they exit?
1. CN V1 ophthalmic (supraorbital notch/foramen)
2. CN V2 maxillary (infraorbital foramen)
3. CN V3 mandibular (mental foramen)
201
What is the clinical significance of the mandibular division (V3) of trigeminal nerve?
Has motor root for muscles of mastication and so if injured there is DEVIATION TO AFFECTED SIDE
202
Where does the trigeminal ganglion lie?
Meckel's cave (made of dura mater) on apex of petrous temporal bone
203
Where do the nerve roots of cranial nerve V emerge from?
Mid-pons & pass forwards onto apex of petrous temporal bone
204
What is the trigeminal ganglion equivalent to?
Dorsal root ganglion
205
Describe the course of cranial nerve V1 & V2 trigeminal divisions?
Pass anteriorly in lateral wall of cavernous sinus to reach the superior orbital fissure (V1) & foramen rotundum (V2)
206
Describe the course of cranial nerve V3 trigeminal division?
Passes through foramen ovale
207
Where is the lesion if all 3 divisions of the trigeminal cranial nerve are affected?
Pons (ie. stroke) or at the cranial base (ie. trauma or tumour)
208
In the cavernous sinus what 2 structures lie in close proximity?
Internal carotid artery & its sympathetic plexus
209
What does the Frontal nerve (branch from CN V1) divide into to supply?
Supraorbital & Supratrochlear to supply skin of vertex & upper eyelid/forehead
210
What does the Lacrimal nerve (branch from CN V1) supply?
- Lacrimal gland
| - Skin of lateral upper eyelid & forehead
211
What fibres does the Lacrimal nerve (branch of CN V1) carry to send to lacrimal gland?
Parasympathetic secretomotor fibres from pterygopalatine ganglion
212
What does the Nasociliary nerve (branch of CN V1) divide into to supply?
- Long ciliary nerve
- Anterior & posterior ethmoidal nerve
- Continuing as Infratrochlear nerve to skin of medial upper eyelid & root of nose
213
What does the anterior ethmoidal nerve continue as?
External nasal nerve to skin at the tip of the nose
214
What does the Nasociliary nerve also supply?
Sensation to the cornea of the eye
215
What can Shingles (herpes zoster) at the tip of the nose by a warning sign of?
Disease will also develop on the cornea
216
What 3 things do the ethmoidal nerves supply?
1. Ethmoidal sinuses
2. Lateral wall of nasal cavity
3. Nasal septum
217
What dilates the pupils?
Sympathetics in nasociliary branch of CN V1 (as V1 passes carotidd artery in cavernous sinus) & then long ciliary nerve
218
What does the trigeminal cranial nerve V2 divide into?
Zygomatic & Infraorbital branches into the orbit via inferior orbital fissure
219
Where does the Infraorbital (V2 branch) emerge from & what does it supply?
Infraorbital foramen to supply lower eyelid, cheek, nose & upper lip
220
What is the skin over the angle of the mandible supplied by?
Cervical plexus with the great auricular nerve (C2,3)
221
What areas does the trigeminal cranial nerve V3 supply general sensation to?
- Floor of the mouth
- Lower teeth & gums
- Anterior 2/3 of tongue via lingual nerve
222
What nerve does the lingual nerve carry?
Chorda tympani nerve (branch of CN VII)
223
What is Trigeminal neuralgia?
Terrible pain usually in CN V3 & occasionally in CN V2 distribution
224
What other muscles (apart from mastication) does trigeminal cranial nerve V3 supply?
- Tensor tympani in middle ear
- Tensor palati
- Mylohyoid
- Anterior belly of digastric (via inferior alveolar branch)
225
Describe the nerves involved in Jaw Jerk reflex?
- Afferent signal to mesencephalic nucleus of trigeminal nerve (proprioception)
- Efferent signal via trigeminal motor nucleus
226
Describe the CN VII with nervus intermedius general visceral efferent nuclei & what it supplies?
(Parasympathetic) from superior salivatory nucleus in pons to lacrimal gland, nasal & oral cavities, sinuses, submandibular & sublingual salivary glands
227
Describe the CN VII with nervus intermedius special visceral afferent nuclei & what it supplies?
To solitary nucleus in medulla oblongata receiving taste from ant 2/3 of tongue (via chord tympani nerve)
228
Describe the CN VII special visceral efferent nuclei & what it supplies?
From motor nucleus in pons to facial expression muscles & few additional muscles ie. stapedius, stylohyoid & posterior belly of digastric (all derived from 2nd pharyngeal arch)
229
Where does the motor root of CN VII (with nervus intermedius) emerge from?
Angle between lower pons & cerebellum (cerebellopontine angle)
230
What is the course of the CN VII & nervus intermedius?
- Enter petrous temporal bone at internal acoustic meatus with CN VIII & labyrinthine artery.
- Takes tortuous course through middle ear, giving off taste & parasympathetic branches
231
What can proximal compression of CN VII cause?
Affect muscles of facial expression & stapedius causing hyperacusis (loud noises are painful)
232
What special thing does the CN VII also contain?
Tiny sensory component to parts of external acoustic meatus & deep auricle
233
Where are the CN VII cell bodies for taste fibres located?
Geniculate ganglion
234
Where does the CN VII emerge from at the end of its course & what does it supply?
- From stylomastoid foramen
- Supplies occipitalis & auricular muscles before dividing to form plexus within parotid gland that sends branches to facial expression muscles
235
What is the clinical consequence of the mastoid process being missing at birth?
CN VII is at risk of compression/injury during forceps delivery leading to paralysis of facial muscles
236
What does "Two Zebras Befriended My Cat" stand for?
BRANCHING OF FACIAL NERVE IN PAROTID GLAND:
- Temporal
- Zygomatic
- Buccal
- Marginal mandibular
- Cervical
237
What muscles does the temporal branch of the facial nerve VII supply?
Frontalis & orbicularis orbis
238
What muscles does the zygomatic branch of the facial nerve VII supply?
Orbicularis oculi & upper lip muscles
239
What muscles does the buccal branch of the facial nerve VII supply?
Buccinator (cheek) & lip muscles
240
What muscles does the marginal mandibular branch of the facial nerve VII supply?
Lower lip muscles
241
What muscles does the cervical branch of the facial nerve VII supply?
Platysma
242
What happens to the face in upper motor neuron lesions (due to cortical control of facial nerve nuclei)?
- Bilateral for upper half of face with upper facial sparing in UMN lesions (e.g. stroke)
- Contralateral for lower half with contralateral weakness/paralysis of lower face in UMN lesions (e.g. stroke)
243
What happens to the face in lower motor neuron lesions (due to cortical control of facial nerve nuclei)?
Weakness/paralysis of whole ipsilateral half in LMN lesions (e.g. Bell’s palsy)
244
What does facial nerve injury distal to stylomastoid foramen cause?
Ipsilateral facial muscle paralysis
245
What happens if injury is within the petrous temporal bone or proximal to it?
- Ipsilateral facial muscle paralysis
- Hyperacusis
- Taste disturbances
246
What is at risk during surgery on parotid gland & duct or following facial lacerations?
CN VII & its branches
247
What is the clinical significance of the location of the marginal mandibular branch of CN VII?
- Inferior to mandible overlying the submandibular gland & at risk during surgery on this gland.
- Lower lip muscles paralysed causing saliva to dribble
248
Describe the nerves involved in Corneal reflex?
- Touch detected by nasociliary nerve (ophthalmic division of V)
- Synapse on chief sensory nucleus for discriminative touch
- Facial motor nucleus sends efferent info to orbicularis oculi for direct & consensual responses = bilateral blink response
249
What are the 3 modalities of the trigeminal (V) & Facial (VII) cranial nerves?
1. General visceral efferent
2. Special visceral afferent (taste/gustation)
3. General somatic afferent (conscious pain, touch, temp from nasal & oral cavities)
250
What is the trigeminal cranial nerve (V) a carrier of?
Parasympathetic & taste fibres originating in nervus intermedius component of CN VII
251
What are the 3 nuclei for facial cranial nerve (VII) & nervus intermedius?
1. Motor nucleus (facial expression)
2. Solitary nucleus (taste from ant 2/3 tongue)
3. Superior salivary nucleus (parasympathetic secretomotor)
252
Where does the Chorda tympani nerve arise?
From facial cranial nerve (VII) & nervus intermedius just before the stylomastoid foramen
253
Describe the location & route of the Greater Petrosal nerve?
- Escapes from middle ear & lies on surface of petrous temporal bone in middle cranial fossa
- Through foramen lacer & towards pterygoid canal
254
Where does the greater petrosal nerve come from?
Nervus intermedius of facial cranial nerve (VII)
255
What modality does the greater petrosal nerve carry & innervate?
General visceral efferent (parasympathetic secretomotor) fibres that contribute to innervation of lacrimal gland & special visceral afferent (taste) fibres from palate
256
What does the greater & deep petrosal nerves combine as?
Nerve of the pterygoid canal
257
What 2 nerves are both in the pterygopalatine fossa?
1. Pterygoid canal nerve
| 2. Trigeminal cranial nerve V2
258
Describe the location of the pterygopalatine fossa?
Lateral to the upper aspect of the nasal cavity & nasopharynx behind the orbit & above the hard/soft palate
259
What synapses at the pterygopalatine ganglion within the pterygopalatine fossa?
Preganglionic parasympathetic fibres from nerves intermedius of CN VII via greater petrosal & nerve of pterygoid canal
260
What are all branches of CN V2 accompanied by?
Branches of maxillary artery branch of external carotid artery
261
What are the 4 general distributions of CN V2 & pterygopalatine ganglion?
1. Orbit (lacrimal gland)
2. Maxilla (sinus, palate, upper teeth & gums)
3. Nasal cavity
4. Nasopharynx
262
What innervates the lacrimal gland?
1. CN V2 (postganglionic parasympathetic fibres)
| 2. Zygomatic --> Zygomaticotemporal --> Lacrimal branch of CN V1 (parasympathetic secretomotor)
263
What is the frontal sinus innervated by?
Supraorbital nerve
264
What does the anterior & posterior ethmoidal nerves innervate?
- Ethmoidal sinuses
- Lateral wall of nasal cavity
- Nasal septum
265
What 2 nerves pass through the cribriform plate?
1. Olfactory nerves
| 2. Anterior ethmoidal nerves
266
What nerve & vessel passes through the nares?
1. Branches of facial artery
| 2. Infraorbital nerve
267
What nerve & vessel passes through the incisive canal?
1. Nasopalatine nerve
| 2. Greater palatine artery
268
What nerve & vessel passes through the sphenopalatine foramen?
1. Sphenopalatine artery
| 2. Nasopalatine branch of CN V2
269
What is the nerve supply of the lateral wall of the nasal cavity?
CN V1 & V2 with parasympathetic from nerves intermedius of CN VII
270
What nerves are capable of regeneration?
Olfactory nerves
271
What are all nerves innervating the nasal cavity (lateral wall) accompanied by?
Arteries & parasympathetics from pterygopalatine "hay fever" ganglion
272
What is the innervation of the nasal cavity medial wall & septum?
CN V1 & V2
273
What are CN V1 branches in the medial wall & septum of the nasal cavity accompanied by?
Branches of the ophthalmic branch of internal carotid artery
274
What innervates the palate?
Greater (hard) & lesser (soft) palatine branches of CN V2 (& secretomotor from pterygopalatine ganglion) with addition of nasopalatine nerve anteriorly
275
What is the clinical significance of the innervation of glossopharyngeal nerve (CN IX)?
Supplies tonsils & may encroach onto the soft palate (referred pain to middle ear)
276
What are the sphenoidal sinuses innervated by?
CN V1 & V2
277
What are the maxillary sinuses innervated by?
- Infraorbital nerve
| - Superior alveolar nerves (ant, middle, post) on their way to teeth & gums
278
Describe the location of the Chorda tympani nerve?
Passes anteriorly through middle ear between incus & malleus just medial to tympanic membrane
279
Where does the Chorda tympani nerve emerge?
Through petrotympanic fissure to join lingual nerve in infratemporal fossa
280
What are the 3 modalities of the lingual nerve (CN V3)?
1. General somatic sensation from ant 2/3 tongue, floor of mouth & mandibular lingual gum
2. General visceral efferent to sublingual & submandibular glands
3. Special visceral afferent for taste of ant 2/3 tongue via chord tympani
281
What does the chorda tympani nerve carry?
Parasympathetic & taste fibres
282
Describe the location of the lingual nerve in the oral cavity?
- Between mylohyoid & hyoglossus
| - Lateral to submandibular duct then passes inferior to duct to ascend into medial side of tongue
283
Describe the pre- and postganglionic branches of the lingual nerve supplying the salivary glands?
1. PREGANGLIONIC parasympathetic leave lingual nerve & synapse in submandibular ganglion
2. POSTGANGLIONIC pass to submandibular & sublingual salivary glands
284
What nerve innervates the cheek & lateral gum?
Buccal nerve
285
What nerve innervates the lower teeth, skin of chin & lower lip?
Inferior alveolar (dental) nerve which then emerges as Mental nerve
286
Where does CN V3 divide?
Below foramen oval into lingual & inferior alveolar (dental) nerve
287
What is the epidemiology of head injury?
- 1.4million/year in UK
- Male:Female 2:1
- 2 peaks: early 20s & 80s
- 65% adult head injuries involve alcohol
- Falls, assaults, RTA
288
Describe primary brain injuries?
- Occurs at moment of impact
- Pattern & extent of damage depends in nature
- Not treatable
- Target prevention
289
How can medical intervention minimise secondary brain injury?
- Optimise O2
- Optimise cerebral perfusion
- Blood glucose
- Hypo/hypercapnia
- Body temp?
290
Describe the different secondary processes which occur at the cell & molecular level to exacerbate neurological damage (secondary brain injury)?
- Neurotransmitter release (glutamate)
- Free radical generation
- Calcium mediated damage
- Inflammatory response
- Mitochondrial dysfunction
- Early gene activation
291
Describe the intracranial compensation for an expanding mass (Monro-Kellie doctrine)?
- Venous volume decreases
- CSF volume decreases
Max combined compensation of ~150ml
292
What chain reaction does Increased cerebral blood volume (CBV) lead to?
Increased CBV --> Increased intracranial pressure --> Decreased cerebral perfusion pressure --> Vasodilation
293
What are the 2 things to do in early management of head injury?
1. Assessment & identification of patient at risk of secondary brain injury
2. Pre-emptive investigation (CT scan)
294
What patients with head injuries are we going to send to hospital?
- Extremes of age (<5yr, >65yr)
- Amnesia for events before/after injury
- Any loss of consciousness
- High energy injury
- Vomiting
- Seizure
- Bleeding/clotting disorder
295
Describe the 3 parts of the glasgow coma scale (GCS)?
1. Eye opening (score 1-4)
2. Verbal response (score 1-5)
3. Motor response (score 1-6)
TOTAL OUT OF 15!
296
Describe the degree's of head injury with different ranges of Glasgow coma scores?
- Minimal: 15
- Mild: 13-15
- Moderate: 9-12
- Severe: 8 or less
297
When should you immediately request a CT scan in adult patients?
- GCS <13 on initial assessment
- GCS <15 2hrs after
- Suspected open/depressed skull fracture
- Any sign of basal skull fracture
- Post traumatic seizure
- 1 or more episode of vomiting (3 in kids)
- Amnesia for events more than 30mins before
298
What are the 4 red flags for NOT discharging a head injury patient?
1. Loss of onsciousness, drowsiness, confusion, fits
2. Painful headache which doesn’t settle, vomiting or visual disturbance
3. Clear fluid from ear or nose, bleeding from ears, new deafness
4. Problems understanding/speaking, loss of balance, difficulty walking/weakness in arms/legs
299
What should you always remember when opening the airway?
Remember the cervical spine! (immobilisation, plain X-ray)
300
What should you do to assess/help breathing of head injury patient?
- Administer O2
- Monitor SpO2
- Monitor ABGs
- GCS < 8 intubate!
301
How can you minimise the damage of low PaO2 in head injuries?
- Convulsions occur 15% of severe head injuries: treat with phenytoin
- Brain metabolic rate increases 6-9% every degree rise in temp: treat pyrexia
- Think about sedation (propofol/midazolam)
302
What happens over a wide range of PaCO2?
Cerebral vessel diameter (& CBF) changes
303
What equation allows you to assess circulation?
Cerebral perfusion pressure (CPP) = Mean arterial pressure (MAP) - Intracranial pressure (ICP)
304
How common is hypotension in pre admission cases of head injuries?
25% of cases
305
How common is SpO2 < 90% in pre admission cases of head injuries?
50% of cases
306
What does normal cerebral auto regulation maintain constant blood flow at?
Between MAP 50mmHg & 150mmHg
307
What happens to cerebral blood flow in a traumatised or ischaemic brain?
May become blood pressure dependent
308
What cerebral perfusion pressure should you maintain after severe head injury?
Above 60-70mmHg
309
What systolic blood pressure should you maintain after severe head injury?
Higher than 90mmHg (preferably >120mmHg)
310
What intracranial pressure should you maintain after severe head injury?
Less than 20mmHg (invasive pressure monitor)
311
What could hypotension not due to head injury be cause by?
- Chest trauma
- Pelvic fracture
(stop bleeding & give IV fluids of saline)
312
What 2 things can you do to encourage venous drainage?
1. Nurse head up tilt (15o - 30o)
| 2. Check straps & ties are not obstructing venous flow
313
What history would suggest risk of intracranial mass?
- High impact injury
- Significant retrograded amnesia
- Coagulopathy
- Post traumatic seizures
314
What features of examination would suggest risk of intracranial mass?
- GCS 12/15 or less
- GCS 13/15 or 14/15 & failing to improve within 2hrs
- Clinical signs of skull fracture
315
What can peri-orbital bruising suggest?
Anterior cranial fossa fracture
316
What can Battle's sign suggest (over mastoid process)?
Petrous temporal bone fracture
317
Describe an extradural haematoma?
- Associated with fracture
- Middle meningeal artery
- 1/3 due to venous bleeding
- Classically a lucid interval
318
Describe a subdural haematoma?
- Complicates 20-30% of head injuries
- Rupture of veins from brain surface to sagittal sinus
- Worse prognosis
319
Describe a subarachnoid haemorrhage?
- Associated with ruptured aneurysm
| - More commonly caused by head injury
320
Describe an intracerebral haemorrhage?
- Stretching & shearing injury
- Impact on inside of skull
- Often contre coup injury (damage on opposite side of injury)
321
What are 3 clinical signs of herniation?
1. Dilated or unreactive pupil(s)
2. Extensor posturing
3. Decrease in GCS of 2 or more
322
What can decrease intracranial pressure & help to "buy time" in head injuries?
Temporary hyperventilation
323
If your patient is ventilated, how would you decrease the patient's arterial pCO2?
- 20% Mannitold (decreases blood viscosity, osmotic diuretic)
- Hypertonic saline
324
Describe the role of Glucose monitoring in head injuries?
Tight control been shown to improve outcome BUT dangers of unrecognised hypoglycaemia
325
What does the cranial root of CN XI (cranial accessory) join the CN X (vagus) to become?
Its special visceral efferent component from nucleus ambiguus
326
Where do cranial nerve IX, X & cranial root of XI emerge from?
Medulla oblongata & pass through jugular foramen
327
Where does the spinal root of CN XI (cranial accessory) emerge from?
Superior spinal cord, ascends to skill via foramen magnum before passing through jugular foramen
328
Where does cranial nerve XII (hypoglossal) emerge from?
Medulla oblongata & passes through hypoglossal canal
329
What nuclei does the cranial nerve IX (glossopharyngeal) components arise from?
Inferior salivatory nucleus in pons & all others arising from nuclei in medulla oblongata (ambiguus)
330
From what 2 cranial nerves does the spinal tract & nucleus of CN V receive general somatic afferent?
CN IX & X (pharynx & larynx)
331
What does the nucleus solitarius receive?
Special (taste) & general visceral afferent from CN IX & X
332
What does the inferior salivary nucleus on pons send to parotid gland?
General visceral efferent (parasympathetic) secretomotor via CN IX
333
What does the nucleus ambiguus send to pharyngeal & laryngeal muscles?
Special visceral efferent that are derived from pharyngeal arches (4&6) via CN IX, X & cranial XI
334
What does the hypoglossal nucleus send to the tongue muscles?
General somatic efferent (derived from occipital somites) via CN XII
335
What does the CN X dorsal nucleus send?
Parasympathetic to heart, lungs & GI tract
336
What does the spinal root of XI (spinal accessory) supply?
Arises from C1 to C5 & supplies sternocleidomastoid & trapezius muscles
337
What cranial nerve does contribution to the Auriculotemporal nerve come from?
CN IX (glossopharyngeal)
338
Where does the CN IX (glossopharyngeal) get its general visceral afferent (sensory) supply?
From carotid body (chemoreceptors) & carotid sinus (baroreceptors) for reflex cardiovascular control
339
What does the tympanic branch of CN IX to middle ear contain?
- Preganglionic parasympathetic neurons for parotid gland that leave plexus in lesser petrosal nerve
- Referred pain from tonsils & oropharynx to middle ear!
340
Describe the location of the lesser petrosal nerve?
Lies on surface of petrous temporal bone in middle cranial fossa before emerging through foramen oval
341
What reflex does the cranial nerve IX provide?
Gag reflex: by supplying sensation deep to hyoglossus to reach posterior 1/3 tongue & oropharynx
342
What do the ganglionic swellings on CN IX & X house?
Cell bodies of primary sensory neurons like trigeminal ganglion / dorsal root ganglion
343
What is the innervating distribution of CN X (vagus) "wanderer nerve"?
- Taste from vallecula & epiglottis
- General sensation from deep auricle & parts of external acoustic meatus
- General sensation from larygopharynx & larynx
- General visceral sensory afferents from blood vessels for CVS control & afferents from heart, lungs, GI
344
Describe the CN X (vagus) with cranial XI (spinal accessory) distribution?
- Motor supply to striated muscles of pharynx & larynx (from 4-6th arches via cranial root of XI)
- Parasympathetic supply to heart, lands & GI as far as 2/3 transverse colon
345
What do defects in CN IX (glossopharyngeal) & X (vagus) affect?
Swallowing & the gag reflex
346
What is the soft palate innervation a combination of?
CN V2 & CN IX
347
What is the pharyngeal parasympathetic secretomotor innervation from?
CN X directly & pterygopalatine ganglion (CN VII) via CN V2
348
What is the gag reflex afferent & efferent nerves?
- AFFERENT: CN IX
- Nucleus ambiguus
- EFFERENT: CN X
349
What are the sneezing & coughing reflexes afferent & efferent nerves?
- AFFERENT: CN V2
- Nucleus ambiguus
- EFFERENT: CN IX, X
350
Describe the course & distribution of cranial nerve XII (hypoglossal)?
1. Pass through hypoglossal canal & descend to neck passing lateral to internal & external carotid arteries
2. Enters oral cavity under tongue between mylohyoid & hyoglossus to supply all tongue muscles except palatoglossus (CN X)
351
What is the clinical sign of an injured CN XII?
Ipsilateral tongue weakness with deviation to the side of lesion
352
What is the 3 different innervations of the tongue?
1. Anterior 2/3 lingual nerve (CN V3) for general sensation with taste from nervus intermedius of CN VIII
2. Posterior 1/3 CN IX for general sensation & taste
3. Motor supply CN XII, except palatoglossus by CN X via pharyngeal plexus
353
What is the 2 different innervations of the larynx?
1. Superior laryngeal nerve (CN X)
| 2. Sensation of larynx above vocal folds by internal laryngeal branch
354
What is the innervation of cricothyroid?
External branch & is only intrinsic muscle of larynx not supplied by recurrent laryngeal nerve
355
Describe the course & distribution of the recurrent laryngeal branch of CN X?
Left is Inferior to the aortic arch (close to the lung hilum) / Right the subclavian artery & ascends between trachea & oesophagus to intermingle with branches of inferior thyroid artery close to the thyroid gland before entering the larynx
356
What happens when there is complete paralysis of the recurrent laryngeal nerve?
- Vocal fold lying in semi-abducted position
- Vocal fold vibrates & respiration noisy
- Hoarse voice & compensation by extra movement of opposite fold
357
What happens when there is partial paralysis of the recurrent laryngeal nerve?
- Vocal fold moves into midline & even crosses it
| - Bilateral partial paralysis is life threatening
358
What happens when there is paralysis of the external laryngeal nerve?
- May not be noticed/some hoarseness of voice
| - Recovery is good due to hypertrophy of opposite cricothyroid
359
What is known as the "hay-fever" ganglion?
Pterygopalatine ganglion
360
Where does the deep petrosal nerve come from?
Sympathetic plexus on the internal carotid artery in carotid canal
361
Where is the location of parasympathetic submandibular ganglion?
Hangs from the lingual V3 nerve
362
What information does the neurosurgeons want to know before making a decision about operating on a head injury patient?
- Mechanism of injury
- Age of patient
- Respiratory & cardiovascular status
- GCS score & pupil response
- Alcohol/drugs
- Associated injuries
- Results of CT scan
363
What is the route of parotid innervation?
Tympanic branch on CN IX --> Tympanic plexus --> Lesser petrosal --> Synapsing in otic ganglion suspended from CN V3 --> Auriculotemporal nerve --> Branches to Parotid
364
What is the musculature of pharynx motor innervation?
CN X (vagus) except stylopharyngess that is by CN IX (glossopharyngeal)
MD4001
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