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NR507 Advanced Pathophysiology
Final Exam Week 8 Exam
Questions and Rationalized Answers Guarantee passing score
This exam features: multiple-choice ques & Ans
- Post-Ictal Phase Post-ictal phase of a seizure is characterized by confusion, unresponsiveness and muscle flaccidity. True False: This statement is true. Post-ictal phase of a seizure is characterized by confusion, unresponsiveness and muscle flaccidity.
- Etiology of Seizures Which of the following is an etiology of a seizure? Meningitis. Psychiatric disorders. Cerebral bleeding. All of the above.: All of the above
- Focal Seizure Which of the following is a characteristic of a focal seizure? Can involve both brain hemispheres. Usually involves one brain hemisphere. The symptoms are generalized. Patient will have both motor and sensory symptoms at the same time.: A focal seizure only involves on brain hemisphere.
- Seizure Development Which of the following electrolyte abnormality is involved in the initiation and propagation phase of seizure development? Hyponatremia. Hypokalemia. Hypercalcemia. Hypernatremia.: The initiation and propagation phase of seizure development is impacted by hyponatremia.
- Epilepsy vs Seizure: Convulsions Epilepsy is a disorder that is due to one or more chronic conditions in the body. It is characterized by disturbed nerve cell activity in the brain. This leads to recurrent seizures. Seizures may occur due to brain trauma that leads to disturbed and uncontrolled nerve activity in the brain. It is important to differentiate between epilepsy and seizure. Seizure is a condition that occurs due to excessive and uncontrolled neuronal activity in
the brain. The uncontrolled neuron activity can be generalized or localized to one area of the brain. For example, it can be localized just to the area that perceives the touch sensation. Whether it is generalized or localized, the excessive neuronal activity lead to the seizure. The type of seizure will depend on the area of the brain affected.
- Mechanisms of Seizure Development: Normally there exists a balance be- tween the excitation and inhibition of neurons in the CNS. Neuronal activity is regulated by acetylcholine (ACH) and gamma-Aminobutyric acid (GABA). Neurons are synchronously active at the same time when they are not supposed to be. The term active denotes neuron firing where they are sending electrical signals from neuron to neuron. A microscope view of a neuron will demonstrate that each electrical signal that passes through it are just ions floating in and out through protein channels (see diagram below). The ion flow is controlled through neurotransmitters. Neurotransmitters bind to the receptors to tell the cell to either open the ion chan- nels to relay the chemical message (excitatory neurotransmitters) or close the ion channels to inhibit the electrical message (inhibitory neurotransmitters).
- Phases of seizures: Phases of Seizures During a seizure, clusters of neurons in the brain become temporarily impaired. Seizures develop in a group of neurons when there is hyperexcitability and usually happens in two phases: Initiation phase: Some neurons become hyperexcited and start to have excess neuron discharges. One of the most important reasons relates to the body's sodium level as in
the case of hyponatremia. Propagation phase: Normally the neurons that have neuronal discharges are sur- round by a zone of inhibitory neurons called the zone of hyperpolarization. This zone prevents the spread of excessive neuron discharges to other parts of the brain. But due to some abnormality in the brain, as in the case of decreased sodium levels, the zone of hyperpolarization gets depolarized that allows the spread of neurons to other parts of the brain. In the diagram below, the electrical activity in the normal brain is displayed. Seizures can be partial or generalized in terms of the extent of the neuronal discharges. In a partial seizure, a portion of the brain is involved. During a generalized seizure, the neuronal discharge encompasses the entire cerebral cortex.
- This seizure is most common in children. It is caused by a genetic ab- normality. They are characterized by sudden and brief loss of consciousness without muscle tone and last for only a few seconds. There is no associated post-ictal confusion.: Absent Seizures
- This seizure is characterized by unconsciousness and muscle rigidity.: - Tonic Seizures
- There is wide-spread and uncontrolled neuron activity in the entire cere- bral cortex. These occur in 10% of patients who have epilepsy. There is exces-
sive neuronal discharge in the motor nerves through the brain.: Generalized tonic-clonic seizures:
- This seizure is characterized by muscle spasms.: Clonic Seizures
- Post-Ictal Phase The post-ictal phase of a seizure can last up to two hours. True False: True
- Focal Seizure An individual having a focal seizure without dyscognitive features will: Not be able to interact with the environment Have gradual loss of consciousness Have no impairment of consciousness. Lose cognitive ability momentarily: A lack of dyscognitive features will have no impairment of consciousness.
- Febrile Seizures Antiseizure medication is the first line treatment for a febrile seizure. True False: false
- what are the phases of tonic-clonic seizure: Tonic-clonic phase (lasts 10- seconds): Due to the excessive discharge of neurons in the motor nerves that results in: The muscles of the body become contracted. without any relaxation.
Loss of consciousness. Ictal cry. This is a typical sound produced by the tonic contractions of the laryngeal muscles and muscles of expiration. Respiratory impairment that results in cyanosis. Tonic contraction of the jaw muscles that can cause tongue biting. Increased sympathetic activity. This will cause increased heart rate and blood pressure
- Tension Headache Which of the following is characteristic of a tension headache? Is the most common type of headache Is limited to one side of the face Can be the worst headache experienced Has associated symptoms: Tension headache is the most common type of headache.
- The symptoms of the aural phase of a migraine headache correspond directly to the movement of the cortico-spreading depression across the cerebral cortex.
True False: This statement is true. The symptoms of the aural phase of a migraine headache correspond directly to the movement of the cortico-spreading depression across the cerebral cortex.
- Pharmacological management of a tension headache involves the use of opioids during acute headache True False: Simple analgesics and Non-steroidal anti-inflammatory drugs (NSAIDS) are commonly used for a tension headache.
- Types of primary headaches: migraine, tension type, cluster, sinus
- Secondary Headaches: Secondary headaches are a result of serious underly- ing diseases. Secondary headaches will consist of warning signs and symptoms. These most often occur in individuals >50 years of age. It is often described as being "the worst headache of my life". It also has the maximum intensity at onset (thunderclap headache). It may also be triggered or worsened by exertion (subarachnoid hemorrhage). Other concerns include decreased level of conscious- ness, fever, seizure, present concurrently with infection, malignancy, pregnancy, thrombotic therapy or ophthalmological findings (papilledema). You can remember these by the acronym SNOOP:
- Primary vs secondary headaches:
- Cluster headaches are a group of idiopathic headaches that are associated with trigeminal neuralgia True False: true
- Associated symptoms of a cluster headache include: Nausea and vomiting Lateral neck pain Runny nose, eye redness and tearing Sensitivity to noise: Runny nose, eye redness and tearing are associated with cluster headaches.
- Which of the following interventions are used in the treatment of a migraine headache? Non-steroidal anti-inflammatory drugs (NSAIDS) or Aspirin Antiemetic medication Hydration All of the above: all
- The facial nerve plays a role in taste sensation in the anterior two-thirds of the tongue. True
False: This statement is true. The facial nerve plays a role in taste sensation in the anterior two-thirds of the tongue.
- Which of the following are signs and symptoms of Bell's Palsy? Prominent nasolabial fold Increased taste sensation on the anterior two-thirds of the tongue Drooping mouth and eyelid All of the above: Drooping mouth and eyelid are characteristics signs and symp- toms of Bell's Palsy.
- Bell's Palsy is caused by damage to the trigeminal nerve True False: It is caused by damage to the 7th cranial nerve (facial nerve).
- The trigeminal nerve (5th cranial nerve) has a motor component and lacks a sensory component True False: The trigeminal nerve has both a motor and sensory component.
- Bell Palsy: Bell's palsy involves weakness or paralysis of the muscles on one side of the face that is caused by damage to the 7th cranial nerve (facial nerve). The underlying cause of cranial nerve damage is idiopathic. When there is facial nerve paralysis from a known cause (stroke, tumor, trauma), it is not considered a Bell's palsy. Peripheral nerves that emerge from the brain and brain stem are called cranial nerves. Their anatomical location is shown in the diagram below:
- Symptoms of bell palsy: Absence of a nasolabial fold (runs from the side of the nose to the corner of the mouth) Drooping eyelid Drooping mouth
Dryness of the affected eye or mouth Hypersensitivity to loud noises Loss of taste sensation on anterior two-thirds of the tongue.
- trigeminal neuralgia: inflammation of the fifth cranial nerve characterized by sudden, intense, brief attacks of sharp pain on one side of the face. The trigeminal nerve is the fifth cranial nerve. It originates from the brain and branches into the ophthalmic branch,maxillary branch, and mandibular branch
- Treatment of trigeminal neuralgia involves the use of anticonvulsant med- ication. True False: True
- Bell's palsy involves an upper motor neuron lesion (False)- True False: Bell's palsy involves a lower motor neuron lesion.
- Which of the following are characteristic of trigeminal nerve pain? Often attacks suddenly and is intermittent Pain can be incapacitating Pain is described as sharp and stabbing All of the above: all
- Which of the following organisms are the most common causes of bacte- rial meningitis in newborns? Streptococci pneumoniae Group B streptococci Cryptococcus Varicella zoster: Group B streptococci are the most common bacteria causing bacterial meningitis in newborn.
- The ability for the bacteria that causes meningitis to exit the primary infection site to enter the meninges is based on the organism's virulent factors which include: Colonization Immune Evasion Meningeal invasion All of the above: All affect the virulence of the bacteria.
- The cells responsible for producing cerebrospinal fluid (CSF) in the ven- tricle cavity are: Ependymal cells Synaptic cells Glial cells Nerve cells: The epidymal cells are responsible for producing CSF.
- The basement membrane of the blood-brain barrier is surrounded by
astrocytes (glial cells). True False: This statement is true. The basement membrane of the blood-brain barrier is surrounded by astrocytes (glial cells).
- Meningitis: Meningitis is inflammation of the meninges. The meninges are the layers that surround and protect the brain. It can be caused by either a bacteria, virus or fungus
- Bacterial Meningitis: Newborns: Group B streptococci; E. Coli; Listeria Mono- cytogenes Children and Teens: Neisseria Meningitidis; Streptococcus Pneumoniae Streptococcus Pneumoniae; Listeria Monocytogenes
- viral meningitis: More common:Enteroviruses, Herpes simplex, HIV Less common: Mumps, varicella zoster, lymphocytic choriomeningitis
- Fungal meningitis: Affects immunocompromised: Cryptococcus Coccidioides genuses Tubercular Meningitis: Mycobacterium tuberculosis Parasitic Meningitis:P. Falciparum
- Pathophysiology of Meningitis: In bacterial meningitis, the bacteria from the primary source allow it to enter the meninges based on the its virulent factors.: Colonization: the bacteria's ability to colonize the area. For example, the bacteria streptococcus pneumoniae can break down the hosts' antibodies using IgA proteins which breaks down the mucosal antibody IgA. This allows bacteria to colonize the area. Some bacteria also have pili or fimbriae that allows them to attach to the host's epithelium and invade the area. At this point, the bacteria cause the infection. We can say that this is the primary infection, whether it is pneumonia or sinusitis. Some bacteria have virulent factors or mechanisms that allow them to invade. Immune evasion: some bacteria have virulent factors or mechanisms that allow them to evade the immune system. For example, the bacteria group B streptococcus and streptococcus pneumoniae have a capsule that allow it to evade macrophages as well as complement factors. The bacteria can enter the blood stream that causes bacteremia allowing it to travel towards the brain. This is known as hematogenous spread. It is important to know that the bacteria can invade the meninges directly from sinusitis, pneumonia or it can go through the cerebrospinal fluid. Meningeal invasion: Let's focus on the cerebral spinal fluid (CSF). The CSF is produced in the brain by the lateral ventricle and provides nourishment for the brain tissues. After production, it flows to the third ventricles then to the fourth ventricle. From the
fourth ventricle it enters the subarachnoid space. From the subarachnoid space, it will go through arachnoid granulation and enter the venous sinus. The venous sinus are the big veins that transport the blood back to the heart. The brain is protected by the blood-brain barrier which is a semi-permeable mem- brane barrier that separates circulation from the brain and prevents substances from getting inside the brain. Blood vessels are composed of endothelial cells. The endothelial cells are surrounded by the basement membrane. The basement membrane is surrounded by astrocytes (glial cells). These are the brain's supporting cells. This formation only allows certain things to pass through to the brain. The blood brain barrier allows glucose and oxygen to get inside the brain.
- Arachnoid Space Let's focus even further into the arachnoid space. The dura mater is located below the skull. The arachnoid membrane is located below the dura mater followed by the arachnoid space.:
- Clinical Manifestations of Meningitis: Clinical Manifestations of Meningitis There is a triad of classic meningitis symptoms: Headache Fever Nuchal rigidity (neck stiffness) Other symptoms: Photophobia Phonophobia Meningoencephalitis: Altered mental state Seizures
- Meningitis Diagnosis: Physical exam: Kernig's sign Brudzinski's sign Lumbar puncture: if meningitis is suspected: Measures pressure Analyze CSF: WBCs, protein, and glucose Polymerase Chain Reaction (PCR): can be used to identify specific causes of the meningitis (HIV, enteroviruses, HSV, or tuberculosis). If the specific cause is identified, a test for it may be used. For example: The Western Blot for Borrelia Burgdorferi Thin blood smear for malaria
- meninigis treatment: Treatment The treatment of meningitis depends on the underlying cause. Bacterial: Steroids followed by antibiotics to prevent massive injury the lep- tomeninges from the inflammation that can be caused as the antibiotics destroy the bacteria. In general, drug treatments using antivirals, antibiotics, antifungals and antiparasitic drugs are aimed at a specific cause of meningitis Prevention: a vaccine can be given for some causes such as Neisseria meningitis,
mumps and disseminated tuberculosis. Prophylactic antibiotics: to avoid outbreaks of bacterial meningitis
- Kernig's sign: Kernig's is performed by having the supine patient, with hips and knees flexed, extend the leg passively. pain upon extension is a positive sign
- The Brudzinski's sign: The Brudzinski's sign is positive when passive forward flexion of the neck causes the patient to involuntarily raise his knees or hips in flexion.
- The meninges are pain sensitive. True False: This statement is true. The meninges are pain sensitive.
- Polymerase Chain Reaction Polymerase Chain Reaction (PCR) test is used to differentiate between bacte- rial and viral meningitis
True False: It is used to establish the cause of the meningitis.
- Which of the following is one of the layers of the meninges? Dura mater Pia Arachnoid membrane All of the above: all
- Which of the following are part of the triad of classic symptoms of menin- gitis? Hypothermia Ptosis Neck flaccidity Nuchal rigidity: Nuchal rigidity is the only symptom listed that is part of the triad of classic symptoms of meningitis.
- Subclavian Steal Syndrome Subclavian steal syndrome is characterized by: Hemianopia. Symptomatic at rest and with activity at the onset of subclavian artery block- age. Pain in the occipital area. Asymptomatic until the patient engages in arm movement.: Individuals with subclavian steal syndrome will be asymptomatic until they engage in arm movement.
- In atherosclerosis of the vertebral arteries, that patient will report pain in neck or occipital area True False: This statement is true. In atherosclerosis of the vertebral arteries, that patient will report pain in neck or occipital area.
- Choose the following that are part of the posterior cerebral circulation:
Posterior Inferior cerebellar artery (PICA) Vertebral arteries Middle cerebral artery Posterior cerebral artery Anterior cerebral artery Superior cerebellar artery Basilar artery: Parts of the posterior cerebral circulation include: Vertebral arteries Posterior Inferior cerebellar artery (PICA) Basilar artery
Superior cerebellar artery Posterior cerebral artery
- vessel involvement: Anterior Cerebral Artery
Motor and sensory deficit: Lower extremities: (leg and foot) Slight upper extremity involvement Contralateral Middle Cerebral Artery Motor and sensory deficit: Upper extremities and face Contralateral Decrease in conjugate gaze Homonymous hemianopia (decreased vision on one half of both sides) Speech (motor): aphasia
- Transient Ischemic Attack (TIA): A transient ischemic attack (TIA) is an episode of neurological dysfunction. If an infarction does not occur, it is a TIA (reversible ischemia). If an infarction does occur, then it is a stroke (irreversible infarct). A TIA increases the risk for a future stroke. It can be associated with sudden onsets of syncope, amnesia or seizures. Risk factors for a TIA include: Hypertension Atherosclerosis Diabetes mellitus Obesity Hypercoagulable states Amyloid angiopathy Atrial fibrillation
Myocardial infarction Previous TIA Valvular disease
- TIA pathophysiology: Anterior Circulation: the first artery encountered in the anterior circulation is the internal carotid artery. There is a branch from the internal carotid artery to the ophthalmic artery that innervates the eyeball. Sometimes when there is a TIA involving the ophthalmic artery, the patient may present with ocular blindness. The internal carotid artery continues to the Circle of Willis and branches into the anterior towards the brain between the two hemispheres. It also splits into the middle cerebral artery on the side of the brain Posterior Circulation: The posterior circulation: starts at the vertebral arteries and continues into the back of the brain.
Vertebral arteries (two): posterior circulation starts here and continues to the back of the brain Posterior Inferior cerebellar artery (PICA): it supplies the posterior brain and inferior cerebellum. Blood then circulates to the dura mater and eventually becomes: Basilar artery: the two vertebral arteries converge to form one basilar artery. Superior cerebellar artery Posterior cerebral artery
- CVA: Cerebrovascular Accident (CVA) Ischemic stroke: is due to decreased blood flow to the brain due to an embolus that may originate from: Cardiogenic: it begins in the heart. The embolus can break and travel into the aorta to the carotid artery and continue moving on into either the anterior cerebral artery or the middle cerebral artery.
- Clinical Manifestations of Ischemic Stroke: Anterior circulation: Internal carotid artery: an atherosclerotic plaque is commonly involved that leads to a decreased blood flow to the area. The patient is typically asymptomatic because the Circle of Willis can compensate for diminished blood flow for the lack of blood flow on one side. To exhibit symptoms, both the carotid arteries would have to exhibit diminished blood flow. However, the patient may present with ocular blindness because of the disruption of blood flow to the ophthalmic artery. Clinically, there will be a high- pitched carotid bruit identified on exam.
- anterior cerebral artery: Anterior Cerebral Artery
Motor and sensory deficit: Lower
extremities: (leg and foot) Slight upper extremity involvement Contralateral Urinary incontinence Abulia: lack of will: due to some frontal lobe involvement
- Middle cerebral artery: Motor and sensory deficit: Upper extremities and face Contralateral Decrease in conjugate gaze Homonymous hemianopia (decreased vision on one half of both sides) Dominant side symptoms Speech (motor): aphasia Non-dominant side symptoms: Neglect Anosognosia
- Posterior Circulation: The posterior circulation supplies the entire brainstem, cerebellum and spine. There are two vertebral arteries that eventually form the single basilar artery. Before branching out to form the basilar artery it gives branch to the posterior cerebral artery shown in the diagram below. The area of the brain supplied by the posterior cerebral artery is shaded in blue in the second diagram. The anterior inferior cerebellar artery and then splits into the superior cerebellar arteries. This comprises the entire brainstem and is controlled by the posterior circulation.
- Vertebral Arteries: Extracranial: Subclavian steal syndrome: as you locate the subclavian artery below note that with this syndrome, there will be a blockage in the subclavian artery. Also note that one of the first branches of the subclavian artery is the vertebral artery that eventually come together to form the basilar artery. When there is a subclavian artery blockage, the patient will be asymptomatic. But when the individual begins to use their arms (e.g. during exercise), there is more blood flow required and instead of traveling up, travels down. The patient will experience dizziness, diplopia due to decreased circulation to the posterior cerebral artery. They may have staggering due to lack of blood flow to the cerebellum. Atherosclerosis of the vertebral arteries: the patient will report pain in the neck or in the occipital area. There may also be some minor complaints of dizziness and hemianopia as the severity increases. A bruit may be heard in the supraclavicular region or the posterior cervical muscles since the vertebral artery goes through the vertebrae.
- Lateral Medullary Syndrome (Sensory Symptoms): Wallenberg syndrome: involves the posterior-inferior cerebellar artery e.g. if lesion is on the left brain Symptoms: face symptoms will be ipsilateral to the lesion. In the rest of the body,
symptoms will be on the right side (contralateral): Face symptoms: pain and numbness related to the trigeminal nerve (5th cranial nerve); nystagmus; diplopia; vertigo; nausea and vomiting Body symptoms: Decreased pain and temperature sensation in the lower extremities due to major effect on spinothalamic area. Dysphagia* Hoarseness* Decreased gag reflex* *9th and 10th cranial nerves
- Medial Medullary Syndrome (Motor Symptoms): Involves the anterior spinal artery e.g. If lesion is on the left brain Symptoms: face symptoms will be ipsilateral to lesion. In the rest of the body, symptoms will be on the right side (contralateral) Face symptoms: tongue paralysis (12th cranial nerve)
Body symptoms: paralysis of the entire body on affected side and decreased proprioception
- Basilar Artery and Midbrain Syndrome: Basilar Artery Syndrome Affects the pons area of the brain. Locked in syndrome indicates that the patient cannot move or talk, but their sensory functions are intact. The only intact motor movement is eye movement.
- Midbrain syndrome (Weber's syndrome): Affects 3rd cranial nerve, the ocular motor nerve (ptosis); eye is also down and out as shown in the individual's right eye below:
- Treatment of TIA and Ischemic Stroke: Management of the patient will occur in the acute care setting. Perform stabilizing measures if necessary: Check airway, breathing and circulation Check vital signs Obtain blood glucose level Arterial blood gas Obtain CT scan without contrast to rule out hemorrhagic stroke If hemorrhagic stroke is ruled out, the individual would receive thrombolytic therapy or thrombectomy To identify the cause of the stroke: Duplex ultrasound and doppler of cerebral arteries MRI-to visual smaller cerebral arteries Cardiac evaluation to identify valve disorders, thrombus ECG and holter monitor (to identify A-fib) Our next focus is on the hemorrhagic stroke which requires a different type of management from that of the ischemic stroke.
- Hemorrhagic Stroke: Hemorrhagic Stroke Hemorrhagic stroke is caused by a rupture of a blood vessel that leads to a hemor- rhage. It accounts for approximately 10-15% of all strokes. Cause can be related to long- standing hypertension or venous malformation. The location of the hemorrhage may be