Updated Mini Exam 6 Review

7/21/2019 Updated Mini Exam 6 Review

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MINI-EXAM

#6 REVIEW


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The cingulate, septal,orbitofrontal, sensory andmedial prefrontal corticalregions have major inputsto the hypothalamus.

The insula connects withthe hypothalamus andbrainstem ANS centers.

You have no consciouscontrol over ANS responseto emotions.

Review

orte! via "imbicSystem to

#ypothalamus

to ANS

ANS $ %motions

enters in thebrainstem reticularformation and theNTShelp coordinatethe activities of theANS. These brainstem

areas receive a&erentsfrom the h othalamus

NT

S!


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The 'orsal "ongitudinal (asciculus )'"(* is the major pathwayconnecting the hypothalamus with the ANS. The hypothalamuscontrols the ANS+ it is the "head anlion$.

rainstem lesions can disrupt spinal ANS.


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-T#% A'R%NA"NR/S#.0

The adrenal medulla,acting via the releaseof adrenaline into theblood stream, spreadthe e&ects of

generali1edsympathetic activity toall cells of the body.lood shunted from 2

system and s3in to NSand s3eletal mm.

Release of glucose+increased heart rate $

contractility+ increased


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R%2/"AT4N 4("44' 5R%SS/R%

lood pressure isconstantly monitoredthrough input from thebaroreceptors in the

carotid sinus and aorticarch

Orthostatic hypotension,

an acute decrease inblood pressure whensuddenly assuming anupright positionindicates an interruptionof the baroreceptor


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SNS %ia &el%ic &le'us()res*n( neurons in +,.!

)SNS

SNS is tonicallyinhibiting the5SNSfrominitiatingdetrusor

contraction $tonicallyconstricts theinternalurethral

sphincter.

S789

MI/T0RITI1N/ENTERS/orte': Sup. frontalgyrus

2rainstem: 5ons)arrington;s nucl.*

'escending control


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The level of NS injurydetermines bladder function.

Note: an uninhibitedbladderis a result of injuryto the NS above the ponsthat disrupts higher NSpathways to the pons. -An

infantile bladder.0

5athway from pontinestorage area disrupted.ladder walls contract

upon minimal stretch.No control over e!ternal.urethral sphincter.

No a&erent or e&erentinformation to or frombladder.

2+A77ER 0N/TI1N8 +ESI1NS


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'amage to the 5SNS will result in problems with voiding the bladder. fthe damage is abo%e s&inal sements S.-9a RE+EX)old term >spastic* neurogenic bladder will result. There are two types of re6e!ive

bladder: uninhibited and automatic.

?ith the uninhibited re:e' bladder, the lesion lies above thelevel of the pons. Since the pontine storage and micturition centers areintact )but voluntary control over these centers are lost* the bladder

completely empties whenever it gets full 8 just li3e in an infant. ?ith an automatic re:e'i%e bladder, the damage is below thepontine storage and micturition centers, but above S789. n thiscondition, the bladder wall contracts with just minor pressure)generated by the presence of urine* within the bladder. Since thevoluntary control over the e!ternal urethral sphincter is lost, the

bladder has fre@uent involuntary voiding which never completelyempties the bladder.

f the spinal cord is damaed at S.-9, or if the cauda e@uina islesioned, a N1N-RE+EX)old term > 6accid* neurogenic bladder will

result. n this case, there are no visceral sensory


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'isruption of SNS to thehead can occur in spinalcord lesions above TB,

ventral root lesions ofspinal nn. TB8C, traumaanywhere along cervical $upper thoracicsympathetic chain, traumato internal carotid n. or the

internal carotid a. )afterthe n. joins it*, as well asdisruption of descendinginputs from thehypothalamus to thebrainstem or cervical

spinal cord.

HORNER SYNDROME


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Hirschprungs disease

Also called congenital aganglionic megacolon %!treme dilation and hypertrophy of the colon,

with fecal retention Absence of anlion cells in the m*enteric

&le'us )neural crest cells fail to migrate into thecolon*


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Familial dysautonomia (Riley-Day syndrome)

Autosomal recessive disorder characteri1ed byabnormal sweating, unstable blood pressure,

diDculty in feeding )inade@uate muscle tone inthe 2T*, and progressive sensory loss

+oss of neurons in autonomic and sensor*anlia

5redominantly a&ects Eewish childrenTo determine whether or not a patient has an

intact sympathetic innervation, a small s3insample is surgically removed and prepared for

immunostaining with antibodies againstNE0R1)E)TI7E ; released by manysympathetic postganglionic fbers, includingthose that innervate blood vessels of the s3in

2enerally, sympathetic ganglion cells usenore ine hrine rather than e ine hrine as a


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Raynaud syndrome

Painul disorder of the terminal arteries of thee!tremities

haracteri1ed by idiopathic bilateral cyanosis ofthe digits, due to arterial and arteriolarconstriction caused by emotion or cold

Treatment8 )reanlionic s*m&athectom*


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Shy-Drager syndrome nvolves preganglionic sympathetic neuron Now considered as an entity of M0+TI)+E S;STEM

ATR1)


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5rimary brain tumors.

Feninges: meningioma 2lia 8

Astrocytes 8 astrocytoma 4ligodendrocytes 8 oligodendroglioma

%pendyma G ependymoma, choroid ple!uspapilloma, colloid cyst )Hentricles*.

5rimitive cells: -blastoma0 e.g.neuroblastoma.

Neuronal I: ganglioglioma, gangliocytoma Nerve sheath: schwannoma, neuro


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linical features:

Raised ntracranial 5ressure.#eadache, vomiting, slow pulse,

papilledema. "ocaldamage:Nerve $ tract de


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Feningiomas

5redominantly benign tumors ofadults, usually attached to the dura

Arise from the meningothelial cell of

the arachnoid


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Feningioma:

ommon sites: parasagittal )fal!*, sphenoidridge, olfactory groove (emales common )7:B*

?ell demarcatedG ompression 8 Nonvasion

Ficroscopic: whorls and psammoma bodies #yperostosis over the tumor.

Slow growth, well di&erentiated, no spread)enign*.


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#istologic patterns

Syncytial8 whorled clusters of cellsthat sit in tight groups without visiblecell membranes+


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At medium power, this meningioma is composed ofwhorled nests of cells. A variety of patterns are

possible.


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5sammoma bodies


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Astrocytoma

AstrocytomaG ommonest tumorsof adults. )JKL*

?ell di&erentiated, slow growing. enign 8 but malignant behavior.

n


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Astrocytomas

Adults: Supratentorial )erebrum*,

Solid, Falignant, (ibrillary

hildren: nfratentorial )erebellum*,

ystic, enign, 5ilocytic


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(ibrillary astrocytomas

2rossly solid ommon in cerebral hemispheres

"ow grade in young, higher grade

in older 2rading

'i&use astrocytoma )low grade*

Anaplastic astocytoma2lioblastoma multiforme )high

grade*


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2lioma:


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2lioblastoma Fultiforme G foci of necrosis withpseudopalisading of malignant nuclei


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(ibrillary astrocytoma: microscopic

"ow grade8 hypercellularity,pleomorphism

Anaplastic8 as above plus mitosis,vascular endothelial proliferation

2lioblastoma multiforme8as aboveplus necrosis and pseudopalisades.2rossly variegated appearance)multiforme*


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2lioblastoma

Necrosis in serpentine pattern8occurs in areas of hypercellularity with

highly malignant tumor cells crowdedalong the edges of the necroticregions,

5roducing a histologic pattern Gpseudopalisading


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2lioblastoma

Hascular cell proliferationis characteri1edby tufts of piled8up vascular cells thatbulge into the vascular lumen+

The minimal criterion is a double layer ofendothelial cells.

?hen vascular cell proliferation ise!treme, the tuft forms a ball8li3estructure, the glomeruloid body


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5ilocytic astrocytoma

ommon in childhood Fost slow growing of the gliomas

Fost childhood brain tumors arise below

the tentorium, which is the reverse of theadult.

Sites: cerebellum, around H., optic nerve

2rossly cystic with mural nodule Ficroscopic elongated hair8li3e )pilo* elongated cells Rosenthal


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5ilocytic astrocytoma8 bipolar cells with long, thinMhairli3eM processes that are 2(A58positive+ Rosenthal


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4ligodendroglioma

The lesions are found mostly in the cerebralhemispheres, with a predilection for white matter.

(rontal lobe mass with areas of calci


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Tumors are composed of sheets of regular cells with sphericalnuclei containing


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%pendymoma

Arise ne!t to the ependyma8lined ventricularsystem

occur near the fourth ventricle

%nlargement of the lateral ventricles with ahomogenous, well8circumscribed mass within thefourth ventricle.

The mass e&ect can produce an obstructivehydrocephalus.

The headaches are associated with dull pain andseem di&use, in time will become more fre@uent

and prolonged.


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The microscopic appearance of an ependymoma reveals a rosettepattern with the cells arranged about a central vascular space. t is

histologically benign. )5erivascular pseudorosettes*


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Fedulloblastoma #ighly malignant cerebellar tumor.

)primitive neuroectodermal tumor*

an compress 9th ventricle, causinghydrocephalus

'issemination through the S( is acommon complication,

5resenting as nodular masses elsewhere inthe NS,

metastases to the cauda e@uina that aresometimes termed MdropM metastasesbecause of their direct route ofdissemination through the S(.


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Neuro


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Fultiple neuro


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Schwannoma

?ell8circumscribed

%ncapsulated massesthat are attached to the

nerve but can beseparated from it

(irm, gray masses

'iscrete


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The mass lesion here is arising in the acoustic)eighth cranial* nerve at the cerebellopontine angle.

This is a schwannoma. 5atients may present with

hearing loss.


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5eripheral nerve tumors

Schwannoma Schwann cells

Compress the nerve trunk

Encapsulated

Easily resectable without nerve

damage Microscopic:

Antony A and B fibers

Verocay bodies

eurofibroma Schwann cells! neurites!

fibroblasts

"usiform and involves nerve trunk

ot encapsulated

ot resectable without sacrificingnerve

Micro# $ntermingled cells withwavy nuclei


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Neuro


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Neuro


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N(

The NF1gene, located at [email protected],has been identi


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Tuberous Sclerosis

1. Dominant inheritance

2. Clinical triad:seizuresmental retardation

adenoma sebaceum

3. Retinal hamartoma (phakoma)

. !ubers (hamartomas) in cerebral corte"

#. $ubepend%mal &iant cell astroc%toma

'. amartomas in other or&ans: heart kidne%


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S3in lesions are common in tuberous sclerosis

MAsh leavesM8 white lesions lac3ing normal s3incolor that have the shape or appearance of an ashleaf and may appear anywhere on the body.

Shagreen patches: These appear on the lower bac3as raised patches of s3in with an orange8peelte!ture.

Adenoma sebaceum )angio


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Tuberous Sclerosis

The more commonly mutatedtuberous sclerosis locus )TSC2* is

found on chromosome BQpBC.Candencodes a protein )tuberin*

Hon #ippel "indau


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Hon #ippel8"indau'isease

An autosomal8dominant disease inwhich a&ected individuals developtumors )capillary hemangioblastomas*

within the cerebellar hemispheres, theretina, and, less commonly, thebrainstem and spinal cord.

ysts involving the pancreas, liver, and3idneys and have a propensity to

develop renal cell carcinomaof the

2 f #i l "i d


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2ene for von #ippel8"indaudisease

A tumor8suppressor gene, is locatedon chromosome Cp787Q and

encodes a protein )pH#"*4ne of the targets of the comple!containing pH#" is hypo!ia8induced

factor B )#(8B*,a transcription factorinvolved in regulation of e!pressionof H%2(


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Sturge!eber syndrome)also called encephalotrigeminal angiomatosis*

A rare congenital disorder associated with venousangiomatous masses in the cortical leptomeninges andipsilateral facial port wine nevi+

Fental retardation, sei1ures, hemiplegia, and s3ull radioopacities also occur.

Thus, a large acial "ascular malormation in a child withmental defciency may indicate the presence o moree#tensi"e "ascular malormations

2laucoma: sites of action


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2laucoma: sites of action

Site of action of miotics in anleclosure glaucoma: contraction of

sphincter pupillae removes pupillarybloc3 and removes the obliteration ofiridocorneal angleSite of action of miotics in o&en anleglaucoma: contraction of ciliary musclepulls on scleral spur and improves

trabecular patencySite of action of )a* bloc3ers )b* Bagonists )c* 7 agonists )d* carbonicanhydrase inhibitors: all reduce a@ueoussecretion by acting on ciliary bodySite of action of prostaglandins and

possibly adrenaline: increaseuveoscleral out6ow by alteringpermeability andor pressure gradientsSite of action of adrenaline: possiblyincreases a@ueous conductivity oftrabecular filtering cells )7 action*

B

B

7

C

9

0%eoscleral out:o=

Trabecularout:o=

S&hincter&u&illae

2laucoma


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>+A0/1MA8f the normal a@ueous humor 6ow

through the scleral venous sinuses isbloc3ed, pressure builds up in theanterior and posterior chambers of theeye compressing the retina and theretinal arteries resulting in blindness, acondition called GLAUCOMA

1&en?=ide anle laucoma: 5rimarycause is un3nown. Seen in elderly.Secondary causes include uveitis, trauma,corticosteroids and vasoproliferativeretinopathly that can obstruct or decrease

the 6ow of a@ueous humor. 5eripheralvision lost


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7rus for o&en?=ide anle laucoma:5rostaglandin analogues:

'rugs: "atanoprost, bimatoprost, travoprost Fost fre@uently used antiglaucoma medicines ncreasing uveoscleral out6ow, possibly by

increasing permeability of tissues in ciliary muscle or

by an action on episcleral vessels lurring of vision, increased iris pigmentation)browning*, thic3ening and dar3ening of eyelashes

arbonic anydrase inhibitors:

'rugs: aceta1olamide "imits generation of bicarbonate ion in the ciliary

epithelium No pupillary or vision changes

2laucoma drugs

2laucoma drugs


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7rus for o&en?=ide anle laucoma:holinomimietics:

'rugs: 'irect )5ilocarpine, carbachol*+ ndirect)5hysostigmine, echothiphate*

ncreased out6ow of a@ueous humor via contractionof ciliary muscle and opening of trabecular

meshwor3 Fiosis )contraction of sphincter pupillae* andcyclospasm )contraction of ciliary muscle*

5ilocarpine in emergencies is very e&ective inopening the meshwor3 into the canal of Sclemm

7rus for closed?narro= anle laucoma8 'rugs: aceta1olamide, miotics, topical bloc3er and

aproclonidine 'rugs are used only to terminate the attac3. ut

surgical or laser iridotomy is the de


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Antipar3insonian dugs

ANTI)AR@IN1SNIAN 7R0>S /+ASSII/ATI1N8

. 'rugs a&ecting brain do&amineric s*stem)a* 'opamine precursor: "evodopa )B8dopa*)b* 5eripheral decarbo!ylase inhibitors: arbidopa,ensera1ide.)c* 'opaminergic agonists: romocriptine,

Ropinirole, 5ramipe!ole)d* FA48 inhibitor: Selegiline)e* 4FT inhibitors: %ntacapone, Tolcapone)f* 'opamine facilitator: Amantadine.

. 'rugs a&ecting brain cholineric s*stem)a* entral anticholinergics: Trihe!yphenidyl)en1he!ol*, 5rocyclidine, iperiden.)b* Antihistaminics:4rphenadrine, 5rometha1ine.


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Dru& !herap%

Dopamine and !%rosine are not used +or ,D therap%

Dopamine doesn-t cross the blood brain barrier.

u&e amount o+ t%rosine shuts o++ rate limitin&

enz%me t%rosine h%dro"%lase that normall% conerts

t%rosine to dopamine


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/0dopa therap% +or ,D

,harmacokinetics

/eodopa is absorbed +rom the duodenum b% the

same process that absorbs neutral amino acids.

Dietar% amino acids compete ith leodopa and can

reduce the dru&-s absorption and transport into thebrain.

/eodopa is metabolized b% to patha%s. t is

conerted to dopamine b% /0aromatic amino acid

decarbo"%lase (/D)and it is metabolized to 3040meth%ldopa (345D) b% catechol40meth%ltrans+erase

(C45!).


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6++ects o+ / Dopa on Cardioascular $%stem

!he cardioascular e++ects are cardiac stimulation due to

beta adrener&ic e++ect on heart

tolerance to this e++ect in seeral eeks

treat ith propranolol to block cardiac stimulation

e++ects

5ust be care+ul in treatment o+ elderl% as most ill hae

underl%in& cardioascular problems can cause transient

tach%cardia cardiac arrh%thmias and h%pertension

n some indiiduals l dopa produces orthostatich%potension

tolerance ill deelop ithin +e eeks

$id 6++ t + / D


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$ide 6++ects o+ / Dopa

$ome are irreersible and dose dependent

6arl% in therap% 789 o+ patients hae nausea and omitin&due to chemoreceptor tri&&er zone stimulation

389 o+ patients hae orthostatic h%potension so care+ull%re&ulate dose

Cardiac arrh%thmia +rom stimulation o+ adrener&ic receptors in

heart ad;ust dose +or people ith cardiac problems #89 o+ patients hae abnormal inoluntar% moements ie.

&rimacin& o+ +ace and ton&ue moements slo rithin& t%peo+ moements (not ;erk% moements) in arm and +ace this is due to hi&h dose o+ dopa (peak dose d%skinesias)

and occurs earl% in therap% at 2 to eeks best a% to handle is b% reducin& dose


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Dru& nteractions ith / Dopa

ntips%chotic dru&s0 antips%chotic dru&s blockdopamine receptor

Reserpine0reserpine depletes dopamine stora&e


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5onoamine o"idase inhibitors

$ele&iline+or !reatin& ,arkinson Disease $electiel% nhibits 5onoamine 4"idase = >hich 5etabolizes

Dopamine but Does hich 5etabolizes


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Catechol040meth%ltrans+erase (C45!)

inhibitors

!olcaponeand 6ntacaponeare to ell0studied C45!inhibitors.

ncreases the duration o+ e++ect o+ leodopa dose

Can increase peak leels o+ leodopa

$hould be taken ith carbidopa?leodopa (not e++ectieused alone)

Can be most bene+icial in treatin& @earin& o++@responses

Can reduce carbidopa?leodopa dose b% 280389 ssociated ith seere hepatoto"icit% so hepaticenz%me estimation has to be per+ormed durin& therap%.


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!reatments o+ ,D

!he belladonna alkaloids hae been replaced b%

anticholiner&ic a&ents ith more selectie central

nerous s%stem e++ect.

!hese include trihe"%phenid%l benztropine mes%late

biperiden A proc%clidine Bsed in earl% sta&es o+ the disease as an ad;uant to /0

dopa

!he% are the onl% dru&s that can proide bene+it in the

treatment o+ the dru& induced parkinsonism seen ithantips%chotic dru&s.

t di


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n antiiral dru& moderatel% e++ectie in treatin&s%mptoms o+ parkinsonism.

5echanism unclear but mi&ht be a++ectin& dopaminerelease and uptake.nta&onism at


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lzheimers disease: 5emantine

5emantine:the ne


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FS: !reatment

nter+eron beta01bis the +irst dru& to demonstrate an

abilit% to halt and een reerse the pro&ression o+

multiple sclerosis.

ts use has been shon to reduce the +reFuenc% o+

relapses and the number o+ ne lesions. ts e++ects in patients ith multiple sclerosis ma% be due

to its immunomodulatin& properties.

nter+eron beta01b increases the c%toto"icit% o+ natural

killer cells and increases the pha&oc%tic actiit% o+macropha&es.


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!reatment

!he treatment +or /$ is lar&el% s%mptomatic. $pasticit%ma% be partl% controlled ith baclo+en a G==a&onist.!he decline in muscle stren&th ma% be sloed b%&abapentin.

!he +irst dru& that has been speci+icall% approed +or usein the treatment o+ /$ is riluzole. t prolon&s the timebe+ore patients reFuire a tracheostom% and prolon&s li+eb% about 3 months. Riluzole is belieed to protect motor

neurons +rom the neuroto"ic e++ects o+ e"citator% aminoacids such as &lutamate and to preent the ano"ia0related death o+ cortical neurons.


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'epression: TypesMild Se%ere

Stable 'ysthymia /nipolar)majordepression*

Alternating yclothymia ipolar

)manic8depression*

7*sthmiais chronic depression for at least 7 years but notsevere enough for hospitali1ation+ patient is functional at

suboptimal level/*cloth*miais alternate episodes of mania and depression ofchronic duration0ni&olar disorder maor de&ression! is severe form ofdepression with impaired functioning of the individual+ suicidaltendencies+ symptoms should present at least for 7 wee3s


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SYF5T4FS

persistently sad, an!ious, or empty moods loss of pleasure in usual activities )anhedonia* feelings of helplessness, guilt, or worthlessness crying, hopelessness, or persistent pessimism fatigue or decreased energy

loss of memory, concentration, or decision8ma3ingcapability restlessness, irritability sleep disturbances change in appetite or weight physical symptoms that defy diagnosis and do not

respond to treatment )especially pain andgastrointestinal complaints*

thoughts of suicide or death, or suicide attempts poor self8image or self8esteem )as illustrated, for

e!ample, by verbal self8reproach*

% of &

'(

SI>E M /A)S> Sleep disturbance+ loss of Interest+ >uilt+loss of Energy+ depressed Mood+ loss of /oncentration+

Appetiteweight changes+ )sychomotor


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FA4S 4N T#% FARU%T

FA4 nhibitors )nonselective* 5henel1ine

Tranylcypromine

socarbo!a1idFA48 nhibitors )selective for

FA48*

Selegiline


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FA4S S'% %((%TS

Side e&ects have put FA4s in thesecond or third line of defense despitesuperior eDcacy

FA48A inhibitors interfere with

brea3down of tyramine #igh tyramine levels cause hypertensive

crisis )the -cheese e&ect0*

an be controlled with restricted dietFA4s interact with certain drugs

Serotonin syndrome )muscle rigidity, fever,sei1ures*

5ain medications and SSRs must be avoided


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TAS 4N T#% FARU%T

Amitriptyline'esipramine'o!epin

mipramineNortriptyline

5rotriptyline

Trimipramine


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TAS F%#ANSF 4( AT4N

TAs inhibitserotonin,norepinephrine, and

dopaminetransporters,slowing reupta3e

TAs also allow for

the downregulationof post8synapticreceptors


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TAS S'% %((%TS

Fuscarinic FB receptor antagonism 8anticholinergic e&ects including dry mouth,blurred vision, constipation, urinary retention andimpotence

#istamine #B receptor antagonism8 sedation

and weight gain Adrenergic receptor antagonism G tachycardia,

postural hypotension, Arrhythmigenic at to!icdoses

'irect membrane e&ects 8 reduced sei1urethreshold, arrhythmia

Serotonin 8#T7 receptor antagonism 8 weightgain )and reduced an!iety*


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Fost important SSR

luo'etine

lu%o'amine

)aro'etine

Sertraline/italo&ram

Escitalo&ram

Selective Serotonin Re upta3e


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Selective Serotonin Re8upta3enhibitors )SSR*

Fore modern )Bstdrug 6uo!etineavailable in BVJJ* and safeantidepressants

)rinci&al mechanism of action8 selecti%e inhibition of B-


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Ad%erse eDects

Relative improvement to other antidepressants )mostlymild*

>IT

nausea, vomiting, abdominal cramps,

diarrhea relatively fre@uent, higher doses=


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N4R%5N%5#RN%8'45AFN%R%/5TAU% N#T4RS )N'RS*

urrent drugs 2u&ro&ion

Fechanims of Action

Similar to SSRs and SNRs Fore potent in inhibiting dopamine Also anC89 nicotinic antagonist

Adverse e&ects "owers sei1ure threshold Suicide 'oes not cause weight gain or se!ual dysfunction

)even used to treat the two*

use: severe depression X SM1@IN>/ESSATI1N TREATMENT

=upropion 1:1

); 1


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); 1ANTI7E)RESSANTS

A"" tricyclics bloc3 the reupta3e of both N% and8#T.

SSR;s bloc3 8#T reupta3e.

SNR;s bloc3 N% reupta3e.

other cyclics have mi!ed e&ects on N% and 8#T reupta3e.

FA4;s prevent metabolism of theneurotransmitters )elevation of synaptic levels*.


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S;M)T1MS 1 MANIA

increased energy)buying, phoning, se!*

increasedgregariousness

pressured speech,tal3ativenessdecreased sleepdrun3enness

combative, dangerousbehavior

distractibilityracing thoughts

impulsive actions anddecisions

elevated mood

euphoria

grandiosity

irritabilityhostility)easily angered*AT+EAST of the follo=in and should last at least , =eeC7I>AST> 7istractibility+ Irresponsible behavior )see3s pleasurewithout regard to conse@uences+ >randiosity)increased self8esteem*+ light of ideas+ Agitation )psychomotor* and increasedgoal8directed activity+ Sleep )decreased*+ Tal3ativeness or


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/+INI/A+ );

primary therapy for mania

a narrow therapeutic window )K.J8B.7me@"+ some guides say K.Q8B.9

me@"*

absolutely necessary to monitorserum level )trough level appro!. days after initial dose*

solely eliminated by 3idney, thereforeassess patient;s 3idney function

"ithium to!icity and adverse


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"ithium G to!icity and adversereactions

Acute into'ications*m&toms8

2T: vomiting, profuse diarrhea NS: confusion, tremorata!ia,

convulsions, coma. #eart:arrhythmias, hypotension

To'icit* of lon-term thera&* Renal to!icity G the 3idneys ability to

concentrate theurine is decreasedAd%erse reactions: polyuria and polydipsia, weight

gain, 2T disturbances )vomiting, nausea, dyspepsia*,alopecia

7ru interactions: thia1ides G increased "ireabsorption into!ication

+ithium side eDects8MN1)> Movement )tremor*+ Nephrogenic diabetes insipidus+ 1#yp1thyroidism+ )regnancy problems

oronal sections


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The rostral surface of asection of brainthrough the anteriornucleus o thethalamus$mammillothalamictract$ and mammillarybodies

#ori1ontal section


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Hentral surface of ana!ial section of brainthrough the genu othe corpus callosum$head o caudatenucleus$ centromediannucleus$ and dorsalportions o the pul"inar

Normal T


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Normal T

A. Anterior #orn of the "ateralHentricle. audate Nucleus. Anterior "imb of the nternalapsule'. 5utamen and 2lobus 5allidus%. 5osterior "imb of the nternalapsule(. Third Hentricle

N l T


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Normal T

angiogram


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angiogram

Schi1ophrenia


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p Subtypes

)aranoid8 'elusions of persecution or grandeur+4ften auditory hallucinations+ 'isorgani1ed speechand behavior

/atatonic8Fotor immobility as evidenced bycatalepsy or complete stupor+ rigidity of posture+

%!treme negativism+ %cholalia or echopra!ia+alternatively can be e!cited and show e!cessive motoractivity

7isoraniFed8'isorgani1ed speech and behavior+6at a&ect+ e!plosive laughter+ poor personal

appearance 0ndiDerentiated85sychotic symptoms that doesn;t

meet criteria for paranoid, catatonic or disorgani1ed

Residual8 5revious episode, but no psychoticsymptoms+ but negative symptoms are present

Schi1ophrenia


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5ossible mechanisms 7o&amine8

'rugs that increase dopamine will enhance or producepositive psychotic symptoms

All 3nown antipsychotics drugs capable of treating positivepsychotic symptoms bloc3 the dopamine receptors

(indings of increased dopamine receptor sensitivity in

postmortem studies Serotonin8

2enes involved in serotonergic neurotransmission areimplicated in the pathogenesis of schi1ophrenia

>lutamate8

Fajor neurotransmitter in pathways 3ey to schi1ophrenicsymptoms

loc3ing the NF'A channel may produce positive andnegative psychotic symptoms identical to schi1ophrenia

Typical antipsychotics


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To!icity: %!trapyramidalsymptoms

?ithin B w3 dystonia )muscle spasm, sti&ness, oculogyric crisis* ?ithin 7 w3 a3inesia )inability to initiate movement*

?ithin C8Q w3 rigidity, tremor and brady3inesia )par3insonism*

?ithin BK w3 a3athisia )restlessness*

9 months tardive dys3inesia )long term use: tremors and spasm

of nec3, body and limbs* %ndocrineside e&ects: dopamine receptor antagonism

leading to hyperprolactinemia

Fuscarinic bloc3ing may cause dry mouth, constipation+histamine bloc3ing may cause sedation+ B8bloc3ade may

result in hypotension ?eight gain and sedation common due to #B receptor

bloc3ade

Adverse e&ects of thiorida1ine include cardioto!icity)torsades de pointes8@uinidine li3e* and retinal deposits

syndrome


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syndrome To!ic e&ect of typical antipsychotics )#aloperidol, Tri6uopera1ine,

(luphena1ine*

A rare but life8threatening reaction to a neuroleptic medication

characteri1ed by: Fental status changes

Severe muscle rigidity )board8li3e rigidity*

(ever

Autonomic instability

linical features

Treatment:

'antrolene

'opamine '7 agonists

Mental status chanes nitial symptom Agitated delirium

with confusion atatonic signs Futism )inability to

spea3* %volution to profound

encephalopathy andcoma is typical

Muscular riidit* -"ead pipe rigidity0throughout range ofmotion

Superimposed tremor 'ysarthria,

dysphagia

Autonomic instabilit* Tachycardia mostcommon

"abile blood pressure Tachypnea 'iaphoresis


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Fechanism of action: A&ect both positive and negative symptoms

8#T7A antagnoists lo1apine has very high aDnity for 8#T7A receptors+ but lowaDnity to '7 receptors and thus dissociate rapidly. So lesse!trapyramidal symptoms

Also 8#TBA agonists )1iprasidone, @uetiapine, clo1paine* thatwould increase dopamine release )prefrontal corte!* and reduce

glutamate release linical uses

Schi1ophrenia

ipolar disorder

An!iety disorder

'epression and mania Adverse e&ects

lo1apineolan1apine has high aDnity for serotonin receptors+ maycause weight gain

lo1apine causes life8threatening agranulocytosis and sei1ure+patients on olan1apine may develop diabetes

Neurotransmitter changes


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7IS1R7ER NE0R1TRANSMITTER

/ES

5ar3insons disease 'ecreased dopamine,ncreased Ach andSerotonin

#untington;s disease 'ecreased Ach and

2AA, ncreaseddopamine

Schi1ophrenia ncreased dopamine

Al1heimer;s 'ecreased Ach

'epression 'ecreased serotonin,

norepinephrine anddopamine

An!iety ncreasednorepinephrine,'ecreased 2AA andserotonin

Neuromuscular8bloc3ingd


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drugs /sed for muscle paralysis in surgery or mechanical ventilation.

Selective for motor )vs . autonomic* nicotinic receptor

Types of neuromuscular8bloc3ing drugs 'epolari1ing: 'epolari1es the motor8end plate. %.g., succinyl choline

Non8depolari1ing: competitive antagonists at the Ah receptor. %.g.,Tubocurarine, atracurium, mivacurium, pancuronium, vecuronium ,rocuronium

Re%ersal of blocCade 7e&olariFin8

'uring phase )depolari1ing phase*, they cause muscular fasciculations )muscletwitches* while they are depolari1ing the muscle


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Addiction pathway

The basic addiction pathway in the brain is adopamine pathway

Food8altering drugs share a remar3able ability toelevate brain dopamine levels

t is synthesi1ed by neurons in the ventraltegmental area, and released onto neurons in thenucleus accumbens and prefrontal corte!

The series of projections from: B* prefrontalcorte! to 7* nucleus accumbens to C* ventral

pallidum is a


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WernicCeGs ence&halo&ath*

G 'egenerative brain disease

G Fental confusionG 'ue to thiamine de


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%&ects on fetal e!posure in utero )(etal alcoholsyndrome*

Small stature, underweight for length Small brain, facial dysmorphia, small mid8face, smooth

philtrum )vertical groove in median part of upper lip*,thin vermilion, small palpebral


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p 5sychostimulants

Fechanism: releases hih le%els of

do&amine binding to the pre8synaptic membrane

of dopaminergic neurones andinducing the 'A release

interacting with dopamine containingsynaptic vesicles

binding to monoamine o!idase indopaminergic neurones and preventingthe degradation of dopamine, leavingfree dopamine in the nerve terminal

hronic abuse may causee!tensive tooth decay )called

meth8mouth* and a 5ar3inson8li3e movement disorder

ndications A'#'

Narcolepsy

Short term weight loss

%cstacy


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'erivative of amphetamine

chemical name is C,98

methylenedio!ymethamphetamine )F'FA* Fechanism: serotonin pathways are thevulnerable pathways+ bloc3s serotonintransporters+ After long8term or repeateduse, %cstasy causes degeneration ofserotonin nerve terminals

Acute e&ects of ecstacy #eightened perceptions )neocorte!*

Reduced appetite )hypothalamus*

Stimulation )asal ganglia*

%levated mood )Amygdala*

louded thin3ing )short8term e&ect+ neocorte!

and hippocampus* Femory impairment )long8term+ neocorte! and

hippocampus*

Sometimes, muscle spasms and jaw8clenchingare due to ecstasys action at the motor neuronsin the spinal cord

Serotoninneuron

Serotonin

#eadache MI>RAINE8


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MI>RAINE8

enign and recurrent syndrome of headache,nausea and vomiting and varying neurologicalde


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/+0STER


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TENSI1N


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Be able to draw this pattern. -RandyTravis 'rin3s old eer0

The origin of the brachialple!us is from ventral rami./nfortunately, the term-roots0 has been used. Thebrachial ple!us does N4Tarisefrom dorsal or ventral roots,nor from the dorsal rami.

2ranches of the cords

Lateral cord branches:" t l t f di


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"ateral root of medianN),Q,O*"ateral pectoral N

),Q,O*Fusculocutaneous N),Q,O*

Medial cord branches: All Ms!Fedial root of median N)J,TB*Fedial pectoral N )J,TB*Fedial cutaneous N of arm )TB* and

forearm )J,TB*

"osterior cordbranches:0+TRA08/pper subscapularnr),Q*+8"ower subscapularnr),Q*T8Thoracodorsalnr)Q,O,J*R8Radial nr),Q,O,J,TB*A8A!illary nr),Q*

"ong thoracic nerve


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Subclavian v., a.

at. thoracic a.

rratus ant. m.s B8J

tracts, secures and rotates scapula

Subscapularismuscle

"ong thoracic n. ),Q,O*7escends behind the roots

Runs alon the Serratus anteriorsu&erKciall*7urin a mastectom*-it could becut accidentall* res#lting in$inged scap#la or Angel scap#laSerratus anterior =ill no loner

hold the sca&ula in &lace

WINGING OF SCAPULAScalenus ant.

calenus med.

0&&er TrunC +esion of the 2rachial )le'usSite of +esion:


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Site of +esion:Tearing of upper trun3 orits roots.

/sually occurs pro!imal tothe branch point of thesuprascapular n. but distalto the branch point of thelong thoracic n. and dorsalscapular n

/ause of +esion:Trauma incurred in

infants durincom&licated deli%er*+

n adults, by %iolent fallson side of head and

shoulder(

ErbLs )als*H Erb-7uchenne )aral*si

0&&er TrunC +esion of the 2rachial )le'usN I l d


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Ner%es In%ol%ed:

A!illary n.Suprascapular n.Fusculocutaneous n."ateral cutaneous n.of forearm

+oss of motorfunction:

Fuscles of the &ro'imal

u&&er limb innervated bythe nerves listed above)deltoid, teres minor,supraspinatus,infraspinatus, biceps

brachii, coracobrachialis,

+oss of Sensation:0&&er TrunC +esion of the 2rachial )le'us


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+oss of Sensation:5osterolateral aspect ofthe superior part of the

arm, lateral aspect ofthe forearm

)osition of the +imb8

Arm: %!tended,adducted and rotatedmedially.(orearm: %!tendedand pronated.IThis position of thelimb is often describedas Mhead =aiterLs ti&Mposition.

"ateralcutaneous n ofarm )froma!illary*

"ateralcutaneous n offorearm )frommusculocutaneous*

Anterior%ie=

A'illar* ner%e inur*Site of +esion:


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Site of +esion:/sually in the portion of nervewhich is adjacent to the surgicalnec% o the humerus./ause of +esion:(racture at surgical nec3 ofhumerus. 5osterior dislocation of

the head of the humerus+oss of Muscle unction:'eltoid and teres minor mm.+oss of Sensation:

S3in on the posterolateral aspect ofthe superior portion of the arm.)osition of the +imb:

Arm: Adducted )loss ofabduction at shoulder joint*

(orearm, ?rist, #and: No e&ect

"ateralcutaneous n ofarm )froma!illary*

)osterior%ie=

+o=er TrunC +esion of the 2rachial )le'us

Also called @lum&Ce


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so ca ed u & e)aral*sis

Site of +esion:Tearing of lower trun3 or itsroots.

/ause of +esion:Trauma incurred in infantdurin com&licateddeli%er* often in breech&resentationswhere arm iscarried over the head.

n adults, fallin =ith thearm outstretched o%erthe head )as in falling froma ladder and attempting tocatch oneself by one hand*

from a tumor at the ape!

+o=er TrunC +esion of the 2rachial )le'us


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Ner%es in%ol%ed:/lnar,

medial cutaneous n of arm,medial cutaneous n offorearm.

+oss of motor

function:Fuscles of the distal u&&erlimbthat are innervated byulnar nerve, i.e., 6e!or carpiulnaris, medial B7 of 6e!or

digitorum profundus m.,medial two lumbrical mm.,all interosseous mm.,adductor pollicis m.

Also called @lum&Ce)aral*sis+o=er TrunC +esion of the 2rachial )le'us


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+oss of sensation:?idespread loss of sensation on

the medial aspect of the arm)medial cutaneous nerve ofarm*,The medial aspect of forearm)medial cutaneous nerve of

forearm*,wrist and hand )cutaneousdistribution of the ulnar nerve*.

)osition of the +imb8

Arm8 No changeorearm8 No change


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Site of +esion8/sually at the wrist

where the median nervepasses through the carpaltunnel )carpal tunnelsyndrome*.

/ause of +esion85ressure on the nerve inthe carpal tunnel, most

often related to nonspeci


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Ape hand

Fedian n

unction8"ateral two lumbrical

mm.+ All thenarmuscles: 6e!or pollicisbrevis m., abductorpollicis brevis m.,opponens pollicis m.

+oss of Sensation8"ateral aspect of thepalm and lateral C B7

digits )loss of sensationin thumb and inde!


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Site of +esion8B* most commonly at the

level of the elbow due tocompression of the nervein the roo%e for theulnar ner%e, or afracture of the mediale&icond*le of thehumerus or a lacerationat this location+

7* occasionally the ulnarnerve is lesioned at the=rist due to alaceration.

0lnar ner%e inur*+oss of muscle function8

i di l i d l i


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)B*Lesion at medial epicondyle )7*Lesion at%rist

Fedial two heads of 6e!or Fedial two lumbricals,digitorum profundus, 6e!or all interossei,

adductorcarpi ulnaris, medial two pollicis and mm. of

lumbricals, all interossei hypothenar eminence.adductor pollicis, mm ofhypothenar eminence.

0lnar ner%e inur*+oss of sensor* function8&1'Lesion at medial epicondyle )7*Lesion at%rist


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/lnar n

"oss of sensation for medial "oss of sensation overthe

aspect of hand including the hypothenar eminenceand

hypothenar eminence and palmar surface of themedial B B7 digits 8 both medial B B7 digits

)dorsaldorsally and ventrally surfaces of these digits

are una&ected because thedorsal branch of the ulnar

nerve is spared*

0lnar ner%e inur*


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)osition of the +imb8)B*Lesion at medial epicondyle )7*Lesion at

%rist#and slightly abducted. nability to abduct

and adductnability to abduct and adduct digits 7 8 ,

digits 7 8 , inability to adduct inability toadduct the thumb the thumb

Radial ner%e inur*Site of +esion8


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/sually at the mid8shaft of the

humerus. hronic pressure in thea!illa e.g. rutch use

/ause of lesion8

(racture of mid8shaft of thehumerus+ pressure on the nervecaused by crutches.

+oss of muscle function8

%!tensors of the wrist and


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5osterior forearm+ dorsum of the hand on the radialside, including the dorsum of the lateral C B7 digits

)e!cept over the distal phalan!*. The s3in on thedorsum of the hand, overlying the interval between theBst and 7nd metacarpals, can be tested in evaluatingthe function of the radial nerve.

5osteriorcutaneous

n offorearm)fromradialnerve*Superi


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cannot be e!tended. #owever, this doesnot mean that an object can be gripped


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/ommon ibular )eroneal!Ner%e Inur* 8

njury generally occurs as thenerve wraps around the lateralaspect of the


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Su&erior >luteal

Ner%e Inur* 8njury to this nerveleads to a -gluteusmedius limp0 due to thegluteus minimus and

medius beingdenervated.

The person leans away

from the unsupportedside )i.e., leans towardthe side of the injury*when wal3ing+ this is a-5ositive Trendelenberg0


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Updated Mini Exam 6 Review