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S2Secrets Case13 ChristopherWatanabe Objective So what does the Case 13 book say about LOs? H1.Compareand contrast consciousand unconsciousstates H2.Identify the mechanismsof nerve cell damage and the responseto injury H3.Relate the changesin intracranial pressure to brain function H4.Describethe mechanisms of neck injury and the role of stabilisation H5.Describethe anatomical pathwaysof the cranial nerves and their function H6.Describethe structure and function of the meninges H7.Outline the microbiology of central nervous systeminfections H8.Describethe pharmacologyof drugs used to minimise intracranialswelling H9.Relate the underlyingpathological changes to the clinical presentation of different neurological conditions H10.Outline the different neuro-radiological investigations available for diagnosisof neurological conditions H11.Assessthe social impact of stigma caused by illness or injury on patient experience and relate this to clinical practice H12. Identify and describethe component parts of the airway,including adjacent structures and explain their importance with regardsto maintaining the airway in a clinical setting.Y1RevisionContents Anatomy & Function of Cranial Nerves Anatomy & Function of Skull & Meninges Anatomy & Radiology of BrainY2SpecificContents Assessment of Consciousness Change & Control of ICP Haemorrhage & Ischaemia & Infection Brain Herniation FunctionofCranialNervesPart1 CN I: Olfactory Nerve Function: Provides sense of smell CN II: Optic Nerve Function: Provides sense of vision CN III: Occulomotor Nerve Function: Controls superior, inferior, medial rectus and inferior oblique muscle and Raises the upper eyelid & Elevates, depresses, adducts, laterally rotates the eyeball CN IV: Trochlear Nerve Function: Depresses, abducts, internally rotates the eyeball CN VI: Abducens Nerve Function: Abducts the eyeball FunctionofCranialNervesPart2 CN V: Trigeminal Nerve Function: Provides sensations to the face, and innervates the muscle of mastication CN VII: Facial Nerve Function: Provides sense of taste to anterior 2/3 of tongue, innervates the glands & muscle of facial expression, prevents hyperacusis CN VIII: Vestibulocochlear Nerve Function: Provides sense of hearing & balance CN IX: Glossopharyngeal Nerve Function: Provides sense of taste to posterior 1/3 of tongue and sensations to oropharynx, carotid body & sinus, middle ear cavity, Eustachian tube FunctionofCranialNervesPart3 CN X: Vagus Nerve Function: Provides visceral sensation of the heart & abdominal viscera, Provides sense of taste to epiglottis & roof of tongue, Provides sensation to laryngolarynx & larynx CN XI: Accessory Nerve Function: Innervating the sternocleidomastoid & trapezius muscle CN XII: Hypoglossal Nerve Function: Innervates the extrinsic & intrinsic muscle of tongue CourseofCranialNerves Where does it come from? - CN I & II comes from cerebrum - CN IV comes from midbrain - CN IIIcomes from midbrain-pontine junction - CN V comes from pons - CN VI,VII, VIIIcomes pontine-medulla junction - CN IX– XIIcomes from medulla oblongata Where does it pass through? - CN I passesthrough cribriform plate - CN II passesthroughoptic canal - CN III,CN IV,CN V1, CNVI passesthrough superior orbital fissure - CN V2 passesthroughforamen rotundum - CN V3 passesthroughforamen ovale - CN VII& VIIIpasses throughinternal acoustic meatus - CN IX,X, XI passesthrough jugular foramen - CN XIIpassesthrough hypoglossalcanal Anatomy&FunctionofSkull&Meninges S kin And then below scalp is Skull or Cranium C onnective tissue (dense) And the main function is … A poneurosis L oose connective tissue P eriosteum And then below skull is Meninges And they are three layers, does anyone And the main function is … AnatomyofBrain1(Vasculature) A is the anterior cerebral artery I is the internal carotid artery B is the middle cerebral artery C is the posterior cerebral artery K is the anterior choroidal artery D is the superior cerebellar artery E i tthe anterior inf rior M is the basila artery N i tthe vertebral arteryr P is the anterior spinal artery G is the anterior Common Carotid → Internal Carotid communicating artery H is the posterior Subclavian → Vertebral communicating artery AnatomyofBrain2(CerebralCortex) Frontal lobe – personality, behaviour, problem solving, executive function, motor (primary motor cortex), creating speech (Broca’s area) Parietal lobe – sensation pain, touch, temperature, proprioception (primary somatosensory cortex) Temporal lobe – hearing (primary auditory cortex), understanding speech (Wernicke’s area), memory (Hippocampus) Red is longitudinal fissure Occipital lobe – vision (primary visual cortex) Orange is central sulcus (fissure of Rolando) Purple is lateral cerebral fissure (fissure of Sylvius) Blue is parieto-occipital sulcus RadiologyofBrain1 White bit is… Red is midbrain Lateral ventricle Blue is pons 3rd ventricle4th ventricle Yellow is medulla RadiologyofBrain2 Corpus callosum Thalamus Insular cortex Lentiform nucleus RadiologyofBrain3 Caudate Cingulategyrus Cingulategyrus nucleus AssessmentofConsciousness Glasgow Coma Scale 6 points for obeying commands 5 points for movements localising pain 4 points for withdrawing pain 1. Motor response 3 points for abnormal flexion (decorticate) 2 points for ab ormal extension (decerebrate) 2. Verbal response 1 point for no motor responserds 4 points forspontaneous eye openings 3 points for eye ope ing in response to speech 3. Eye response 2 points for eye opening in response to pain 1 point for no eye opening What is the lowest possible GCS? Answer is 3 and not 0 RaisedICP What is ICP? Force exerted by contents within the skull Normal ICP ranges between 7-15mmHg So what is the content within the skull? - Brain Parenchyma (80%) - Venous & Arterial Blood (10%) - Cerebral Spinal Fluid (10%) What is Monro Kellie Doctrine? States that sum of brain + blood + CSF is constant It is also good to remember this that: CPP = MAP - ICP RaisedICP But if patient develops tumour What is signs of raised ICP? Skull initially accommodates via - Widening pulse pressure compensatory mechanism (e.g: increased - Bradycardia drainage of blood or CSF) which allows for - Irregular Breathing space to be created for new lesion This is referred to as But if tumour continue to grow, Cushing’s reflex compensatory mechanism become exhausted and cause ICP to rise What are other signs of raised ICP? - Headache - Nausea & Vomiting - Reduced GCS - Papilloedema ManagementofRaisedICP CONSERVATIVE MEDICAL SURGICAL Neuroimaging IV Mannitol Lumber Puncture Head elevation to 3° IV Dexamethasone EVD Drain Insertion Controlled Hyperventilation VP Shunt Definitive is Craniectomy HaemorrhagicStroke What is the 5 types of haemorrhagic stroke? 1. Extradural / Epidural 2. Subdural 3. Subarachnoid 4. Intracerebral 5. Intraventricular ExtraDural Location: between skull & periosteal layer of dura Cause: low impact head trauma Demographics: Seen in younger patients Underlying Pathology: rupture of middle meningeal artery due to trauma to pterion Presentation: LOC → Lucid Interval (regains consciousness) → LOC CT Image: Biconvex/Lentiform/Lens shaped pool of Blood (Blood typically appears white – hyperdense) SUBDURAl Location: between meningeal layer of dura & subarachnoid Cause: high impact head trauma, deceleration injury Demographics: Seen in older patients, alcoholics Underlying Pathology: tearing of bridging veins Presentation: worsening headache, n&v, coma CT Image: Crescent/Moon shaped pool of Blood which crosses over suture line due to mass effect & midline shift (Blood is white/hyperdense - acute & darker/hypodense - chronic) SUBArachnoid Location: between arachnoid & pia Cause: 80% of patient has no trauma i.e spontaenous Demographics: Seen in hypertension & ADPKD patient Underlying Pathology: rupture of berry aneurysm Presentation: thunder-clap headache, “worst headache of their life” CT Image: Spider shaped Blood (But if no visible Blood is seen on CT, LP should be requested) ManagementofSUBArachnoid MEDICAL: Nimodipine (Ca2+ channel blocker) → Prevents Vasospasm SURGICAL: Endovascular Coiling or ClippingQuickQuestion IschaemicStroke What is the cause? What is the management? Caused by reduction in blood supply to Acute management: brain due to obstruction. CONSERVATIVE - CT Head MEDICAL - Alteplase within 4.5 hours of Stroke can be categorised by the nature presenting of obstruction in the vessel: SURGICAL - Mechanical Thrombectomy 1. Thrombotic 2. Embolic Post Acute management: What is the risk factor? Investigation with CT/MR angiography Chronic management: Male Sex, Family History, Hypertension, Manage hypertension, hyperlipidemia, DM, AF, Smoking give antiplatelets (e.g clopidogrel) Rehabilitation MAINTYPESofISCHAEMICSTROKE Presentation depends on the location of thrombus or embolus ACA: prefrontal cortex, motor & sensory cortex of lower limb MCA: Broca’s area + Wernicke’s area, motor & sensory cortex of upper limb & lower face PCA: occipital lobe OTHERTYPESOFISCHAEMICSTROKE Lenticulostriate Artery: supplies striatum & internal capsule and stroke can lead to contralateral paralysis with no cortical signs Basilar Artery: supplies pons, medulla, midbrain and stroke can lead to Locked in Syndrome (quadriplegia with only vertical eye movement) Anterior Inferior Cerebellar Artery (AICA): supplies CN VII & VIII nuclei, spinothalamic tract & spinotrigeminal nucleus (and many more) Posterior Inferior Cerebellar Artery (PICA): supplies CN IX, X, XI nuclei, spinothalamic tract & spinotrigeminal nucleus (and many more) and leads to lateral medullary (Wallenburg) syndrome Anterior Spinal Artery: supplies corticospinal tract (and many more) and lead to medial medullary syndrome which causes contralateral paralysis MENINGITIS1 What is meningitis? What is the symptoms of meningitis? Meningitis is inflammation of meninges - Neck stiffness (Nuchal rigidity) - Photophobia What causes meningitis? - Headache Age Causative Bacteria - Fever Newborn Group B Strep, Strep pneumoniae, E Coli, Listeria Other symptoms include: N&V, Drowsiness, Babies/Children Strep pneumoniae, Neisseria Confusion, Seizures, Purpuric Rash meningitidis, Hib Teen & Young Adults Neisseria meningitidis What is the investigation for meningitis? Strep pneumoniae Older Adults Strep pneumoniae, Neisseria Blood Test, Blood Cultures, CT Head, LP meningitidis, Hib,, Listeraai MENINGITIS2 Appearance Polymorphs Lymphocytes Protein Glucose Normal Clear Bacterial Yellow ↑ - ↑↑ ↓ Viral Clear - ↑↑ - - Fungi Fibrin Web - ↑↑ ↑ ↓ TB Cloudy - ↑↑ - - /↓ What is the treatment for meningitis? - 2g of IV Ceftriaxone BD (To cover for listeria in younger & older patient, IV amoxicillin is added) OTHERINFECTION Encephalitis Abscess / Empyema Inflammation of brain parenchyma Pus-filled pocket of infection: - Found between skull & dura for Caused by HSV-1 infection epidural abscess Treated with 10mg/kg of IV Acyclovir - Found between dura & arachnoid for subdural empyema Treated with surgical debridement of abscess or empyema and give IV Cephalosporin & Metronidazole UnderstandingDuralReflections The dura mater folds inward and form 4 dural reflections Falx cerebri – separates the right & left cerebral hemisphere Tentorium cerebelli – separates the occipital lobes from the cerebellum Falx cerebelli – separates the right & left cerebellar hemisphere Diaphragm sellae – covers the hypophyseal fossa of sphenoid boneBrainHerniation Cingulate – cingulate gyrus is pushed down and under the free edge of falx cerebri Central – midbrain is pushed down and displace brainstem Uncal – part of temporal lobe (uncus) is pushed down and displace brainstem Tonsillar – cerebellar tonsils is pushed down through foramen magnum SBA SBAquestion: You find 32-year-old male patient is in Neuro-Intensive Care Unit. Consultant asks you to crotated. The patient occasionally makes mumbling and does not open eye even whenernally pinched on his shoulder. Given the information above, what is his GCS score? A Five B Six C Seven D Eight SBA SBAquestion: You find 32-year-old male patient is in Neuro-Intensive Care Unit. Consultant asks you to rotated. The patient occasionally makes mumbling and does not open eye even whenternally pinched on his shoulder. Given the information above, what is his GCS score? A B Six C Motor – decorticate posture scoring 3 Verbal – mumbling sound scoring 2 Eye – no eye opening scoring 1 D So total GCS is 6 SBA SBAquestion: There is 72-year-old female patient in neurosurgery ward. She withdraws away from pain. She is currently iShe opens eyes in response to voice.erly aside from making groaning noise. How would you write this in ward round note? A M5 V2 E3 B M4 VT E3 C M4 VT E2 D M4 V2 E4 SBA SBAquestion: There is 72-year-old female patient in neurosurgery ward. She withdraws away from pain. She is currently intuShe opens eyes in response to voice.y aside from making groaning noise. How would you write this in ward round note? A B M4 VT E3 C Motor – withdrawing form pain scoring 4 Verbal – intubated so cannot be scored Eye –eye opening in response to voice scoring 3 D So can be written as M4 VT E3 SBA SBAquestion: 32-year-old female patient presents to the ED after TBI. You find out that her blood pressure What is the ICP which can be estimated from the measurement provided in the description (rounding up to whole numbers)? A 30mmHg Little Bit Difficult B 32mmHg C 34 mmHg D 36mmHg SBAquestion: SBA 32-year-old female patient presents to the ED after TBI. You find out that her blood pressure is 129/80 mmHg and that her cerebral perfusion pressure is 60mmHg. What is the ICP which(rounding up to whole numbers)?urement provided in the description A Explanation: B Mean Arterial Pressure = Diastolic Pressure + 1/3 (Systolic Pressure-Diastolic Pressure) Mean Arterial Pressure = 80 + 1/3 (129-80) = 96.3mmHg C Cerebral Perfusion Pressuren Arterial Pressure - Intracranial Pressure = 96.3 - 60 = 36.3 mmHg D 36mmHg SBA SBAquestion: A 62-year-old female patient is found to have subdural haematoma after she smashed her car into a wall of concrete. She has rhaematoma. of 13/15. She is found to have ICP of 30mmHg due to What is the three signs & symptoms you would expect to see in this patient? A Muffled Heart Sound, Raised JVP, Systolic Hypotension B Jaundice, Fever, RUQ Pain C Bradycardia, Irregular Breathing, Systolic Hypertension D Tachycardia, Reduced GCS, Systolic Hypotension SBA SBAquestion: A 62-year-old female patient is found to have subdural haematoma after she smashed her car into a wall of concrete. She has redhaematoma.f 13/15. She is found to have ICP of 30mmHg due to What is the three signs & symptoms you would expect to see in this patient? A Explanation: B This is the correct answer. As raised ICP causes Cushing’s reflex which is a triad of Bradycardia, Irregular Breathing, Systolic Hypertension. C Bradycardia, Irregular Breathing, Systolic Hypertension D SBA SBAquestion: A 25-year-old male comes to ED after being struck with a bat. He is bleeding profusely from the woconsciousness and he feels relatively fine right now aside from the pain from the wound.egain Which description of CT image fits the presentation of this patient? A Dilation of Ventricle B Crescent Shaped Hypodense Region C Petechial Haemorrhages D Lens Shaped Hyperdense Region SBAquestion: SBA A 25-year-old male comes to ED after being struck with a bat. He is bleeding profusely from the wound. He states that he lost consciousness for brief period of time, but he was able to regain consciouWhich description of CT image fits the presentation of this patient?m the wound. A Explanation: This is correct, because the patient is most likely presenting with extradural haemorrhages. As this patient experienced B LOC followed by lucid interval which is unique to extradural haemorrhages. For these patient you would expect to see biconvex shaped pool of hyperdense region representing blood between skull C & dura mater. To explain the other options, A is hydrocephalus, B is subdural haemorrhages, C is diffuse axonal injury. D Lens Shaped Hyperdense Region SBA SBAquestion: A 56-year-old female presents to ED after nausea and vomiting and experiencing “worst headache of thconsulting with the neurosurgical registrar, she is said to need surgical management.elow. After What would be a good medication to give before admitting the patient? A Amlodipine B Bisoprolol C Nimodipine D Mannitol SBA SBAquestion: A 56-year-old female presents to ED after nausea and vomiting and experiencing “worst headache of thconsulting with the neurosurgical registrar, she is said to need surgical management.elow. After What would be a good medication to give before admitting the patient? A Explanation: B This is the correct answer. Because Nimodipine is the gold standard treatment for patient with SAH. And it can prevent vasospasm and prevents further bleeding. C Nimodipine D SBAquestion: SBA A 55-year-old male had ischaemic stroke 5 days ago and is recovering in the neurology ward. On examination, he has anywhere. You review his CT Angiogram. he needs a walking aid to walk Which artery would you expect to see a thrombus or embolus? A ACA of right side Difficultt B MCA of left side C PCA of right side D Lenticulostriate Artery of left side SBAquestion: SBA A 55-year-old male had ischaemic stroke 5 days ago and is recovering in the neurology ward. On examination, he haanywhere. You review his CT Angiogram.so he needs a walking aid to walk Which artery would you expect to see a thrombus or embolus? A B Explanation: This is correct, blockage in lenticulostriate artery can produce a contralateral paralysis with no cortical signs. C He has no sensory loss which excludes all the options. And he also has no signs of Broca’s or Wernicke’s aphasia. And he also has no signs of homonymous hemianopia with macular sparing. D Lenticulostriate Artery of left side SBA SBAquestion: A 72-year-old male patient comes to ED after slurring of speech and paralysis of face. He has PMH of hypertension and funderlying cause. The image is shown below.ely give CT angiogram to find the Looking at the image what vessel is involved in his condition? A PCA of left side B MCA of left side C Ophthalmic Artery of left side R D Lenticulostriate Artery of left side SBA SBAquestion: A 72-year-old male patient comes to ED after slurring of speech and paralysis of face. He has PMH ofangiogram to find the underlying cause. The image is shown below. give CT Looking at the image what vessel is involved in his condition? A B MCA of left side C Explanation: This is the correct answer as the CT Angiogram shows blockage on the MCA of the left side. D SBA SBAquestion: A 6-year-old male presents with fever and rashes going across his back. He is complaining of right or left. You immediately worry about meningitis and perform LP and collect yellow CSF. You find that there is increased levels of neutrophils. What is the most likely diagnosis? A Bacterial Meningitis B Viral Meningitis C Fungal Meningitis D Cryptococcal Meningitis SBAquestion: SBA A 6-year-old male presents with fever and rashes going across his back. He is complaining of headache. On examination, he screams in pain when you ask the boy to tilt his head towards the rightfind that there is increased levels of neutrophils. What is the most likely diagnosis?. You A Bacterial Meningitis B Explanation: This is correct because yellow colour of CSF and increased meningitis. In both viral & fungal meningitis, you would C expect to find significantly increased levels of lymphocytes which is not found in this patient’s CSF. Don’t be alarmed by Cryptococcal Meningitis, it only occurs D in HIV or Immunocompromised patients. SBA SBAquestion: A 6-year-old male who presented with meningitis recovers after being given IV Ceftriaxone and sensory loss of right side of his face and upper limb. On CT head with contrast, you find a suspicious mass near lateral cerebral fissure. What is the most definitive management for this patient? A IV Acyclovir B Surgical Debridement C IV Dexamethasone D IV Ceftriaxone SBAquestion: SBA A 6-year-old male who presented with meningitis recovers after being given IV Ceftriaxone and sensory loss of right side of his face and upper limb. On CT head with contrast, you find a suspicious mass near lateral cerebral fissure. What is the most definitive management for this patient? A B Surgical Debridement C Explanation: This is correct because surgical debridement is the most abscess. But patient do receive IV Ceftriaxone &intracerebral Metronidazole as part of treatment. D SBA SBAquestion: A 63-year-old male has a subdural haematoma and results in compression of the brain parenchyma. The patiendragging his own feet as he moves.d is dilated. The patient seems to be What is the most likely type of herniation given the patient’s signs & symptoms? A Uncal Herniation B Central Herniation C Tonsillar Herniation D Cingulate Herniation SBAquestion: SBA A 63-year-old male has a subdural haematoma and results in compression of the brain parenchyma. The patient’s eye is looking “down & out” and is dilated. The patient seems to be What is the most likely type of herniation given the patient’s signs & symptoms? A Uncal Herniation B Explanation: This is correct because uncal herniation results in: - compression of CN III which results in oculomotor nerve dilatedhich result in eye looking down & out and is C - compression of cerebral peduncle which is involved in motor control which results in hemiparesis The eye looking “down & out” and hemiparesis is present in the 63 yo patient. D Uncal herniation also lead to coma/death SBA SBAquestion: A 1-year-old mexamination, you find a characteristic ‘sunset eyes’.ing raised ICP. On What type of herniation might you observe in this baby? A Uncal Herniation B Central Herniation C Tonsillar Herniation D Cingulate Herniation SBA SBAquestion: A 1-year-old examination, you find a characteristic ‘sunset eyes’.sing raised ICP. On What type of herniation might you observe in this baby? A B Central Herniation C Explanation: characteristic ‘sunset eyes’. And central herniation ishe associated with obstructive hydrocephalus. D Thank You!/Break/ Questions? Follow our Socials: Instagram: @cu_cardiosoc Facebook: Cardiff University Cardiovascular Society Cardiovascularsociety@outlook.com