Blumenfeld

Lab 1: pp 14-17, pp 122-137

Lab 2: 6, 7
Lab 3: 12, 13
Lab 4: 14 pp 626-637
Lab 5: 10, 11, 19
Lab 6: 14
Lab 7: 17, 18
Lab 8: 15, 16
Blumenfeld: 5, 6, 7, 10, 11, 12, 13, 14, 15, 16, 17, 18, 19
No 8, or 9. No 1-4.
Chapter 5: pp 214
Brainstem compression
Symptoms:
Unarousable problem with ascending activating system.
Absent eye movments: problems with CN III, IV, and VI.
Bilateral extensor posture corticospinal tracts involved bilaterally
Diagnosis: hemorrage in the brainstem or something compressing the
brainstem (ie herniation eg transtentorial herniation on CN III
(tonsillar herniation), uncal or subfalcine herniation, PCA hemorrhagic
infarct by compressionof PCA in tentorial notch.
Subdural hemotoma: (with subfalacine and transtentorial herniation)
Symptoms:
Old man found lying on rocks, conscious and then lapses into a coma
with scalp abrasian, non-reactive pupils, no corneal reflexes,
decoritacte posture of upper extremities to pain, upgoing plantar
responses.
Diagnosis: CT crescent shaped hyperdense fluid (cresenct shape
subdural, lense shape epidural, goes into sulci subarachnoid).
Increased ICP/Tumour in posterior third ventricle extending rostrally to
midbrain
Symptoms:
Headaches, nausea and papilledema Increased ICP
Horizontal diplopia and incomplete abduction of the left eye when
looking to left left abducens nerve problem.
T1 weihted images: CSF appears dark, white matter is bright relative to
gray matter,
Mass in the posterior third ventricle between thalami extending into
rostral midbrain. Mass enhances with gadolinium enhancement =
vascular/break down of BBB with inflammation/tissue damage. Mass
blocks the cerebral aqueduct causing increased ICP. Dilated lateral and

third ventricle, non dilated fourth ventricle. Corpus callosum pushed up

by the ventricles. Children may have enlarged head circumference
with increased ICP if before closure of cranial sutures. Need to install a
VP shunt. Shunt one way flow valve. PNET in pineal region =
pineoblastoma uncommon, responds well to treatment, fatal, radiation
and chemotherapy.
Increased ICP Colloid cyst in 3rd ventricle
Symptoms:
Progressive visual loss, mild papilledema, enlarged blind spots,
concentric loss of peripheral visual fields in both eyes could only see
center of the visual field with either eye.
Diagnosis: increased ICP compresses optic nerve causing damage to
superficial fibers = concentric visual loss. Lateral ventricle dilatation
but not third and fourth = obstruction of foramina of monro. = Colloid
cyst in third ventricle. Septum pellucidum midline between two
lateral ventricles.
Brain atrophy normal pressure hydrocephalus
Symptoms:
Old man, progressive gait difficulty, cognitive impairment, incontience
Diagnosis: Brain atrophy enlarged third and fourth ventricle with both
sulci and ventricles proportionately increased in size. If ventricles>
sulci = hydrocephalus. Can be improved via VP shunt improved
urinary incontinence, but memory and attention remain impaired.
Meningeal irritation Bacterial meningitis or viral meningoencephalitis.
Young man, headache, photophobia, fever, confusion, stiff neck (nuchal
rigidity), petechiae scattered on arms, legs, chest. Features of
meningeal irritation: headache, fever, photophobia, nuchal rigidity.
Cerebral dysfunction lethargy + confusion. Purple skin lesions = N.
meningitides or also in Ricketts. Other bacteria = strep pneumonia or
N. meningitids. Viral meningoencephalitis herpes encephalitis.
Patients with acute infectious meningitis can deteriorate within a
matter of hours/minues. Do Ct and lumbar puncture. Dont delay
antimicrobial treatment. Antimicrobial tx: ceftrizaone and ampicillin.
Lumbar puncture CSF removed from subarachnoid space of lumbar
cistern. Lumbar cistern bounded by pia and arachnoid. Iliac crest used
as landmark to enter lumbar cistern at L4-L5, well below conus
medullaris (L1/L2). CSF = high protein, low glucose, very high WBC of
PMN = acute bacterial meningitis. Treat with IV antibiotics = complete
cure with no sequale.
Other notes: caudate nucleus + thalamus bulge inward from lateral
walls of lateral ventricles. Caudate nucleus = c-shaped along the wall

of lateral ventricle. Septum pellucidum hangs from corpus callosum at

the roof of lateral ventricles. Fornix is at the bottom of septum
pellucidum paralleling the curve of lateral ventricles. Fornix =
mylinated axons conneting temporal lobes to hypothalamus and basal
forebrain.
Hippocampus memory/limbic functions floor + medial wall of
temporal horn of lateral ventricles.
Foramina of monro bounded medially and superiorly by fornix,
laterally by thalamus, inferiorly by anterior commisure.
Thir ventricle bounded laterally by thalami and hypothalamus,
superiorly by fornix, inferiorly by hypothalamus, anteriorly by anterior
commisure, fornix and hypothalamus, posteriorly by posterior
commisure and hypothalamus.
Cerebral aqueduct of sylvius CSF located within midbrain.
Fourth ventricle on dorsal pons and medulla, apex covered by
cerebellum.
Chapter 6: pp. 269
Isolated right hand weakness with no sensory deficits = precentral
gyrus primary motor cortex, hand area infarct of left MCA
Symptoms:
Isolated right sided weakness of wrist fleion and extension, finger
flexion, extension, abduction and addution and thumb opposition.
Diagnosis: Isolated hand weakness = primary motor cortex or
peripheral nerve. Peripheral nerve would present with sensory deficit
as well. Infarct to left MCA supplying outer aspect of the cortex
precentral motor cortex (especially with history of a fib, emboli or
hypertension/atherosclerosis). Treat with anticoags if due to embolism
to MCA.
Isolated left foot weakness with no sensory deficit = precentral gyrus
primary motor cortex, leg area infarct of right ACA.
Symtpoms:
Isolated left sided weakness, slowness of iliopsoas, hamstrings, ankle,
dorsiflexors and extensor halllucis longs, right frontal headache =
weakness over sciatic and femoral nerve distribution. No sensory loss
= cortical not peripheral. Headache = cranial location, not spinal cord.
Right Face Weakness, Slurred Speech, Curling right fingertips = Left
motor cortex lesion impinging on left internal capsule of genu
(corticobulbar and corticospinal tracts) infarct of left MCA
Symptoms: right lower face showed delay of movements with smile,
speech mildly slurred, trace curling of right fingertips.
Diagnosis: Isolated Unilateral facial weakness (ie. No dysrthria or finger
curling/other neurologic deficits)= peripheral lesion of facial nerve. Can

also be a lesion to internal capsule of genu. Dysarthria corticobulbar

tract deficiency. Finger curling corticospinal trat. Eyebrows/upper face
is spared in UMN lesion due to bilateral innervation. MRI Omega in
central sulcus = hand area. Infarction lateral to this = face area.
Pure Left Motor Hemiparesis - Left face, arm and leg weakness with
dysarthria and unsteady gait right corticobulbar and corticospinal
tracts in posterior limb of internal capsule or pons lacunar infarct of
contralteral internal capsule/pons, or multiple sclerosis if no CV history.
In MS - symptoms worsen with temperature.
Symptoms: left face, arm and leg weakness, clumsiness, slowness,
increased tone, hyperreflexia, equivocal Babinskis sign, dysarthria,
unsteady gait, falling to the left, decreased left arm swing. Pure motor
hemiparesis lesion of contralteral corticobulbar and corticospinal
tracts in internal capsule or pons. Gandolinium enhancement on MRI
BBB breakdown/demylinating plaques, or seen a few days after an
infarct. MS oligoclonal bands in CSF.
Pure Right Motor Hemiparesis right face, arm, leg, dysarthria, right
tongue deviation, decreased right palate movement, hyperreflexia and
Babinskis sign increased right reflexes confirms UMN lesion. No other
deficits like neglect, aphasia or cog/visual disorders = pure motor
hemiparesis = lesion to ontralateral corticobulbar and corticospinal
tracts in the posterior limb of internal capuse or pons. CN IX and X
(right palate movement), CN XII (rightward tongue deviation) due to
contralateral corticobulbar tract lesion. CV history = lacunar infarct of
contralteral internal capsule/pons.
ALS - Progressive gait difficulty (off balance) difficulty raising feet while
seated, bilateral progressive leg weakness, arms and hands became
weak, Muscle Twitching of arms and legs, Cramps in legs. Increased
tone in bilateral lower extremities, continuous fasiculations, atrophy in
left hand interosseous muscles, bilateral foot intrinsic muscles,
weakness present bilaterally affecting legs more than arms on right
side, required assitance to walk, paraparetic and spastic gait.
Weakness = UMN and LMN sign. Fasiculations + atrophy LMN sign.
Increased tone, spastic gait, hyperreflexia + Babinkis Hoffmans and
Jaw jerk reflexes = UMN sign.
D/Diagnosis: Cervical cord compression = UMN findings in arms and
legs, LMN in arms due to local nerve root compression. Fasciculations
in lower extremities suggests this isnt the case, so its diffuse upper
and lower motor neuron dysfunction extending from brain to
lumbosacral spinal cord. No sensory deficits with progressive weakness
with UMN and LMN signs = ALS. Could also be lead toxicity. Treatment
= riluzole with rehabilitation. EMG shows denervation and

reinnervation in all four extremities ALS hallmark. Serum protein and

B1`2, folate, CBC were normal. These patients progressively get worse
dysarthria, dysphagia, complete loss of strength, then death from
respiratory failure.
Chapter 7:
right somatosensory loss + fluent aphasia. - Left MCA infarction to
post-central left somatosensory cortex including Wernickies area.
Right arm numbness, extinction, astereognosis (cant identify object by
touch without seeing it associated with parietal lobe or dorsal column),
agraphesthesia (cant recognize writing in skin tests parietal lobe
function or problems with the dorsal columns on the way to the
parietal lobe, contralateral side) with preserved primary sensory
modalities, mild fluent aphasia (Wernickies aphasia), difficulty at times
seeing fingers on right side, right pronator drift. lesion in left
postcentral gyrus in primary somatosensory cortex arm area. Fluent
aphasia lesion in dominant (left) parietal lobe + right sided visual
difficulties. R. pronator drift corticospinal fibers involved arising from
adjacent motor cortex. Diagnosis: Occlusion of left MCA causes infarct
to left postcentral gyrus arm area + adjacent parietal cortex.
Decreased pinprick, temperature, vibration and light touch sensation in
right face and body, decreased two-point discrimination in right hand
left VPL/VPM thalamus lesion from lacunar infarct. Thalamus receives
input from dorsal columns and spinothalamic tract, so loss of thalamus
causes contralteral spinothalamic and dorsal column loss.
Lesion to VPM/VPL of thalamus = lacunar infarct of lenticulostriate
arteries (middle cerebral), anterior choroidal (internal carotid), or
thalamoperforator (posterior cerebral).
Cauda equina syndrome - Bilateral leg flaccid paralysis, decreased
rectal tone, absent bulbocavernosus reflex, T10 sensory loss at all
levels after fall from a 2 story balcony. Lesion: complete transection of
the spinal cord causing cauda equina syndrome at the T10 level. Cauda
equina = contains all the nerve roots from L1 to S5 (including those to
maintain rectal tone; lesion = detrusor weakness, urinary retention,
post-void residual incontinence, sexual dysfunction, saddle
anesthesia). No bulbocavernosus reflex = spinal shock. Remember T10
spinal cord = T9 vertebral level. (spinal nerves run under vertebrae).
Treatment for acute spinal cord injuries methylprednisolone (a
steroid). Burst fractures are seen of T9 and T10 vertebral bones
leading to complete obliteration of spinal cord = complete transection
of the spinal cord. No hope for receovery. Causes permanent
paraplegia.

Left leg weakness, increased tone, hyperreflexia, Babinskis sign,

decreased vibration and joint position sense in left foot and leg,
decreased pinprick sensation on right side below the umbilicus with
right leg numb, tingling paresthesia, left sided thoracic back pain, stiff
legged unsteady gait, impaired bowel and bladder function. Diagnosis:
Left hemicord lesion at approximately T9/T10 = Brown-Sequard
syndrome. Bowel and bladder dysfunction = bilateral involvement with
spastic ggait. Most likely a tumor compressing thoracic spinal cord, or
could be arthritc bony changes or MS.