Neuro Chapter 5

ANATOMY (p.126-139)
- Cranial Vault & Meninges
o All bold terms
 Foramen magnum – largest foramen; at base of skull
 Cervicomedullary junction – occurs at foramen magnum; site of corticospinal
decussation
o Fossa
 Anterior – contains frontal lobe
 Middle – contains the temporal lobe
 Posterior – contains
o Layers of the meninges
 PAD (inside to outside)
 Dura – hard; 2 layers – outer periosteal and inner meningeal; the two layers hug
except where the inner meningeal involutes in the falx cerebri and the tentorium
cerebelli
 Arachnoid – wispy; tightly adherent to dura
 Pia – hugs the brain
o Spaces between meninges
 Epidural – potential space; middle meningeal artery runs here after entering
through the foramen spinosum
 Subdural – potential space; contains bridging veins; can be injured in older people
with less brain matter; drain into dural venous sinuses
 Subarachnoid space – contains the CSF and main arteries of the brain
 Spinal column has PAD with the addition of epidural fat
- Ventricles & Cerebrospinal Fluid (CSF)
o Names & Locations of ventricles (Table 5.1 is helpful)
o CSF
 Made by the choroid plexus
 Normal total volume – 150 cc
 Normal rate of production – 20 cc/hour
 Flow through ventricles/foramina (order) – 2 lateral ventricles  foramen of
Monro  3rd ventricle  aqueduct of Sylvius  laterally into Luschka and
medially into Magendie  subarachnoid space around brain and spinal column 
reabsorbed by arachnoid granulations
o Cisterns – areas of large CSF collection; lumbar cistern at base of spinal column
- Blood-Brain Barrier (BBB)
o Blood-brain – caused by tight junctions in brain capillaries
 Permeable to – gases (O2, CO2); lipid-soluble substances; transport systems exist
o Blood-CSF – caused by choroid epithelial cells separating the CSF and capillaries; the
capillaries in the actual interstitial space are freely permeable
o Substances pass freely between the CSF and brain parenchyma
o CSF is reabsorbed by arachnoid villus cells in the arachnoid granulations
o Circumventricular organs - Location of interruption in BBB
 Area postrema – only paired circumventricular organ; chemotactic trigger zone;
detects toxins that cause vomiting
 Pineal – melatonin-related circadian rhythms
o Types of edema:
 Both types occur together:
 Vasogenic – extra fluids in the interstitial space; caused by tumors,
infections, traumas, anything breaking the blood-brain barrier
  Cytotoxic – cell damage leading to cell swelling
KEY CLINICAL CONCEPTS (p.139-170):
- Headache
o Vascular headache – migraine or cluster headache
o Migraine
 Strong family hx
 Provoked by stress, eye strain, menstrual cycle
 Preceded by an aura, vision blurring, fortification scotoma, etc.
 Photophobia, phonphobia, head movement makes it worse
 Treat by sleeping
o Complicated migraine
 Accompanied by neurologic defects, incl. sensory phenomena, motor deficits
(hemiplegia), visual loss, brainstem findings in basilar migraines, impaired eye
movements in ophthalmologic migraines
 Cluster headache
 Not as common as migraines
 Dull pain behind one eye
 Accompanied by unilateral autonomic symptoms such as tearing, eye
redness, Horner’s syndrome, unilateral flushing, sweating, and nasal
congestion
 Tension headache
 Steady, dull ache; band like
 Similar to migraines
 Low CSF pressure – headache worse when standing
 High CSF pressure – headache worse when lying down
o Broad treatment:
 NSAIDS, anti-emetics (emesis-throwing up), triptans (serotonin agonists)
- Intracranial Mass Lesions
o Intracranial mass lesions causes signs and symptoms by the following:
 Compression and destruction of adjacent regions
 Raise intracranial pressure
 Herniation – displaced nervous system structures
o Potential outcomes of mass effect in different brain regions
 Disruption of BBB – vasogenic edema
 Compression of ventricles – can obstruct CSF flow and lead to hydrocephalus
 Cerebral cortex – seizures are possible
 Brainstem – coma; related to pineal shift
- Elevated Intracranial Pressure
 Cerebral perfusion pressure is the mean arterial pressure minus the intracranial
pressure
 Increasing intracranial pressure leads to a decrease in cerebral perfusion pressure
o Altered mental status is the most important indicator of elevated intracranial pressure
o Treatment measures (Table 5.4)
- Brain Herniation Syndromes – p. 145
o Transtentorial (uncal) herniation
 Location: Herniation of the medial temporal lobe, especially the uncus, through
the tentorial notch (where the midbrain passes through)
 Signs/symptoms – triad of blown pupil, hemiplegia, and coma
 Side of presentation – blown pupil is usually ipsilateral; hemiplegia is usually
contralateral, unless the brain compresses the opposite side of the tentorial notch.
This ipsilateral hemiplegia is called Kernohan’s phenomenon
 o Central herniation
 Location – central downward displacement of the brainstem
 Signs/symptoms – causes traction on CN VI
o Tonsillar herniation
 Location: herniation of the tonsils through the foramen magnum
 Signs/symptoms – compresses medulla and leads to respiratory arrest, blood
pressure instability, death
o Subfalcine herniation
 Location: cingulate gyrus herniates under the falx cerebri (horizontal structure)
 Signs/symptoms: none usually; can lead to infarcts in the ant. cerebral artery
territory
- Head Trauma
o Concussion
 Definition – reversible impairment of neurologic function for a period of min. to
hours following a head injury
 CT/MRI findings - normal
 Clinical features – LOC, seeing stars, headache, dizziness, nausea, possible
amnesia
 Post-concussive syndrome – headaches, lethargy, mental dullness, etc. that lasts
up to several months after the accident
o Mechanisms of more severe head trauma:
 Diffuse axonal shear injury
 Petechial hemorrhages
 Intracranial hemorrhages
 Cerebral contusion
 Penetrating trauma
 Cerebral edema
- Intracranial Hemorrhage
o Traumatic or atraumatic
o Epidural hematoma
 Location - between dura and skull
 Usual cause – rupture of middle meningeal artery due to temporal bone fracture
by head trauma
 Clinical features/radiologic appearance – rapidly expanding hemorrhage peels
away the dura forming a lens-shaped biconvex hematoma; the cranial sutures stop
it from expanding; possible lucid interval before death
o Subdural hematoma
 Location – potential space between dura and arachnoid
 Clinical features – venous blood dissects easily and spreads out, forming a
crescent-shaped hematoma
 Chronic subdural hematoma
o Seen in elderly patients where a smaller brain allows more
movement
o Collects over a period of weeks to months
o Results in headache, cognitive impairment, unsteady gait
o Hypodense
 Acute subdural hematoma
 Subarachnoid hemorrhage
 Location – CSF-filled subarachnoid space
 Radiological appearance – follows the contours of the pia
  Cause – nontraumatic and traumatic
o Nontraumatic
 “Worst headache of my life”
 Cause – rupture of an arterial aneurysm or AV malf
 Saccular aneurysms – out pouching of a vessel wall
near the circle of Willis; in dec. order: AComm,
PComm, MCA
 Vertebobasilar aneurysm
 Signs/symptoms – Pcomm aneurysm can lead to painful
third-nerve palsy; headache, meningeal irritation, coma,
death
o Do CT scan without contrast
o Delayed cerebral vasospasm can occur in half of patients; use
Triple H therapy – hypertension, hypovolemia, hemodilution
 Traumatic subarachnoid hemorrhage
o Intracerebral or intraparenchymal hemorrhage
 Location – within the brain parenchyma
 Causes – nontraumatic or traumatic
 Traumatic intracerebral or intraparenchymal hemorrhage
o Contusions are more common at the temporal and frontal poles;
least common in the occipital poles
o Coup or countercoup injuries can occur
 Nontraumatic intracerebral or intraparenchymal hemorrhage
o Most commonly due to hypertensive hemorrhage
o Extracranial hemorrhage
 Results in Battle’s sign raccoon eyes
o Appropriate/Inappropriate use of Lumbar puncture – use only in negative CT
o Classifications of vascular malformations
 AV malf
 Cavernomas
 Capillary telangiectasias
 Developmental venous anomalies
- Hydrocephalus
o Signs/Symptoms – headache, nausea, vomiting, cognitive impairment, decreases level of
consciousness, papilledema, decreased vision, and sixth-nerve palsies
o Can lead to a magnetic gait
o Communicating – impaired reabsorption
o Noncommunicating – obstruction of flow within the ventricular system
o Treatment options
 External ventricular drain – drains from lateral ventricles to outside of head
 Ventriculoperitoneal shunt – lateral ventricle to peritoneal cavity
 Endoscopic neurosurgery
 Third ventriculostomy – the floor of the third ventricle is perforated
o Normal pressure = chronically dilated ventricles; results in the triad of gait difficulties,
urinary incontinence, and mental decline
o Ex vacuo – excess CSF where tissue was lost
- Brain Tumors
o Two primary categories
 Primary CNS and metastatic
 Metastases are more common
  Most common types of tumors in adults: gliomas and meningiomas
 Most common types of tumors in children: astrocytomas and medulloblastomas
 Pediatric tumors usually cause hydrocephalus by blocking the fourth ventricle or
aqueduct of Sylvius
 Tumors with explicitly mentioned symptoms:
o Pituitary adenoma – cause endocrine problems and bitemporal
visual field defects
o Pineal region tumors – obstruct the cerebral aqueduct of Sylvius,
causing hydrocephalus, or compress the dorsal midbrain, causing
Parinaud’s syndrome
o Subcategories of Gliomas
 Astrocytomas are rated from I to IV
 IV is glioblastoma mulitforme – most malignant
- Infectious Disorders of the Nervous System
- This would have taken me 2+ hours. Just read it. Sorry.
o For each infection know the following (if provided):
 Name
 Infective agent
 Signs/Symptoms
 Radiologic findings
 Presentation in CSF
 Start becoming familiar with basic CSF presentation for each infection
(what levels would be increased/decreased) but you can save the specific
levels/units (as presented in Table 5.7) for year 2
- Lumbar Puncture
o Uses – samples CSF, measure CSF pressure, remove CSF in normal pressure
hydrocephalus, and introduce drugs
o Level of insertion – L4 – L5
o Normal vs traumatic tap findings – finding RBCs in the CSF
 Traumatic tap is due to the spinal needle causing bleeding
 Normally no blood should be found
o Distinguish traumatic tap from pathological subarachnoid blood
 Traumatic tap will show a decrease in RBCs from the first to last tubes when
collecting CSF. A traumatic tap will also not have a yellow, or xanthochromic,
appearance if centrifuged right away. If WBCs are present the ratio of RBC to
WBC will be similar in both the traumatic tap CSF sample and blood from the
patient’s periphery.
- Craniotomy
 Pterional craniotomy
 Region accessed – inferior frontotemporal lobes
 Temporal craniotomy
 Region accessed – temporal lobe
 Frontal craniotomy
 Region accessed – frontal lobe
 Transphenoidal approach
 Region accessed – pituitary via the nasal passages; sellar and suprasellar
regions