PECHNICK [10 Q]

1. Postganglionic Sympathetic involved in SWEATING use ACEYTLCHOLINE (on Muscarinic Receptor)

2. Sympathetic Aqueous Humor Secretion + Far Vision (B2 receptors); Sympathetics: Mydriasis RADIAL contrct (a1 receptor)
3. TERMINATION OF NE: (1) Diffusion; (2) Re-uptake (NET & VMAT); (3) Metab - CNS via MAO-A, Periph cytosolic COMT
4. EPINEPHRINE: used for SHOCK (a1) or BRONCHODILATOR (B2). CONTRAINDIC in HYPERthyroidism (bc up-reg B1)
5. CLONIDINE: a2 agonist (dec sympathetics); Central-acting for HTN/drug w/d/ADHD. CAUTION: abrpt d/c - HTN crisis, tachy. Also @
parasymp heteroreceptors
6. TYRAMINE: (indirect sympathomimetic in party foods; metab by MAO-A in gut); CONTRAINDICATED in Pts on MAO INHIBITORS
-- explosive NE release -- Fatal HTN Crisis
7. NICOTINIC ACh Receptors found @ ALL GANGLIA, ADRENALS, NMJs. Nicotinics open Na/K channels
8. RATE LIMITING STEP in ACh life = CHOLINE UPTAKE into presynaptic neuron.
9. Methacholine (direct cholinerg agonist) = test for BRONCHIAL HYPERACTIVITY in Asthma
10. Pralidozime or Atropine = Antidotes in AChE poisoning (long acting irreversible AChE inhibitor poisons:
Malathion/Diazinon/Soman/Saran/Echothiophate for glaucoma)
CLARK [14 Q]
1.[Case 2] MG Dx: ACh receptor antibodies, Tensilon Test (Edrophonium: improves w fast AChE inhibitor), Icepack test (eye sx), Repet.
Stim. EMG "DECRIMENTAL" -saturates AChRs & poss THYMOMA chest CT
2.[Case 2] MG Tx: AChE inhibitor PYRIDOSTIGMINE; IVIG & plasmapharese to remove autoantibodies. May need: steroids, steroidsparing agents (Azothioprine/Mycophenylate mofetil), or surgical thymectomy.
3.***[Case 3] ALS assoc. conditions = FRONTOTEMPORAL DEMENTIA (presents as widened lateral ventricles due to cerebral atrophy;
leads to secondary hydrocephalus)
4.[Case 3] ALS tx = RILUZOLE (vs Glutamate transmission) - delays ALS progression ~2 mo; also provide supportive/symptomatic
management (sialorrhea, pseudobulbar affect, fatique, spasticity etc)
5.[Case 4] MS Acute tx: HI DOSE STEROIDS: SOLUMEDROL 1000mg IV for 3 days. MS Long Term tx = DISEASE MODIFYING
THRPY - goal is to reduce # relapses; decr MRI activity; disease prog markers
6. [Case 4] MS features: Prog ATAXIA; INO - Add deficit/Abd Nystagmus; OPTIC NEURITIS-RAPD (Marcus-Gunn)-anterior to Chiasm
bc OPTIC DISK EDEMA. Uhthoff phenom (hot temps=MS sx); Lhermitte's Sign (cervical myelopathy); relatively short transverse myelitis
(as compared to DDx NMO)
7. MS: Epidemiology - Prevalence ~300k in US; 2-3 Females for every Male diagnosed. Age 30 most common; Northern European descent
and in mid/higher latitudes.
8. MS: Types - (1) RELAPSE-REMITTING (most common, high MRI activity); (2) SECONDARY PROG; (3) PRIMARY PROG (~10%,
wont show relapse; continuous); (4) RELAPSNG PROG (worst, lst common)
9. FOCAL SZ: simple/complex/etc. IF @ LEFT FRONTAL SZ = EYES LOOK RIGHT (look away from SZ origin). IF @ MOTOR STRIP =
JACKSONIAN MARCH - Hand to Arm
10. TODD'S PARALYSIS: Post-Ictal Weakness after a FOCAL seizure (weak/numb/aphasic/visual field defects)
11. JUVENILE MYOCLONIC EPILEPSY: GTCS (90%) Myoclonic, in the Morning, onset ~15 yrs, genetic. Don't outgrow this. Note: tx =
clonazepam or levetriacetam monotherapies
12. TERATOGENIC effects of AEDs: MID-LINE DEFORMITIES: Cleft Lip/Palate, Spina Bifida, UG defects, Cardiac Atrial Septal Defects
(ASD); [note: teratogenic AEDs = Val, Pheny, Phenobarb, Carbamaz, Lamo)
13. Causes of BREAKTHROUGH SEIZURES= missed AED doses or low serum levels, EtOH, sleep loss, illness, or these drugs: Tramadol,
Buproprion, Clozapine.
14. WOMEN SZs: Signs of Pre-Eclampsia=HTN & Proteinuria; Treat with MAGNESIUM
AVERSANO [13 Q]
1. [Case 2] MG assoc eye sx: CN IV PALSY (usually first symptom); episodic vertical diplopia; episodic ptosis - (Horner's) loss of
sympathetics to Muller's musc.
2. [Case 3] ALS: UMN (Hyperreflexia/Spasticity/babinki+) & LMN (hyporeflexia/atrophy/FASCICULATIONS)
3. [Case 2] DDx Lambert-Earton Myasthenic Syndrome (LEMS) is autoimmune w antibodies vs PRESYNAPTIC junction, Assoc w nonsmall cell lung CA. Dx of LEMS: EMG shows INCREMENTAL @ prox muscles.
***4. ENTRAPMENT NEUROPATHY - CARPEL TUNNEL syndrome from compressed MEDIAN NERVE. Early signs = wake up with
hands asleep. Dx w EMG or nerve conduction study. Tx: Brace & Vit B6

***5. DIABETIC NEUROPATHY commonly causes 3rd Nerve Palsy: innermost fibers of nerve (oculomotor functions) are MOST
SUSCEPTIBLE to compromised blood flow. (Spares outer autonomics from E-W)
6. GUILLAIN BARRE-demyelination. ASCENDING progressive weakness, areflexia. LABS: Antiganglioside Ab, HIGH CSF protein. Tx:
plasmaphoresis, stabilize, monitor, give IVIG.
7. KAYSER-FLEISCHER ring CORNEA (Cu2+): WILSON'S DISEASE (definitively). Most important DDx to r/o in new-onset young
dystonia pts (via brain imaging). Auto Rec. Tremor/dysarthria/sardonic smile
8. ESSENTIAL TREMOR: Auto Dom. Adult-Onset ; postural/kinetic tremor. Tandem Gait. Improves w EtOH (ddx vs PD); also must r/o
hyperthyroidism. Tx: propanolol (beta antagonist) or botox
***9. DUCHENNE MUSC DYSTROPHY (DMD): Gower's Sign/Pseudohypertrophy of calves. Proximal weakness initially, lumbar
lordosis, NO DYSTROPHIN (ABSENT) in DMD Pts.
***10. MYOTONIC DYSTROPHY TYPE ONE (DM1): Pts have more DISTAL muscle weakness (an exception among the myopathies!).
Also see: Hatchet Face, Swan Neck & Myotonia (delayed musc relaxation)
***11. RHABDOMYOLYSIS: ACUTE Musc destructn (overexertion/trauma/toxins) -Myoglobin released into blood --> ARF-renal tubule
necrosis. MONITOR urinary output -if diminished, consider DIALYSIS.
12. WERNICKE'S ENCEPHALOPATHY: Thiamine deficiency. Symptom Triad (1) Ataxia (2) Dementia (3) Ophthalmoplegia. Note:
metabolic disorders cause Decreased LOC WITHOUT focal findings.
13. B/L PONTINE INFARCT (eg Basilar A. Thromb): LOCKED-IN SYNDROME . Pinpoint react pupils/decorticate posture. Eyes deviate
OPPOSITE. Damaged corticospinal (QUADRIPLEGIA); except eyes blink ok.
BERTETTA [4 Q]
1. LEGAL death defn = IRREVERSIBLE + brainstem; CLINICAL death defn = REVERSIBLE circ/resp cessation
2. Herniations: CINGULATE, BRAINSTEM, UNCAL, TONSILAR (worst, compress medulla & cease breathing)
3. Ex-vacuo hydrocephalus: Ventricular dilation due to brain tissue loss inside & outside
4. Persistent Vegetative State: Brainstem is functioning, but the cerebral hemispheres are NON-FUNCTIONAL
PARSA [6 Q]
1. [GLIOBLASTOMA] (grade IV. MOST COMMON adult astrocytoma) - worst progn. p53 mutation, NECROSIS w PALISADING
neoplastic cells. +EGFR PROLIFERATION of Blood Vessels, pleomorphism.
2. [MENINGIOMA]: benign tumor w PSAMMOMA BODIES & spindle cell WHORLS
3. RED INFARCT/neurons -venous EMBOLISM infarct <12 hrs; vs PALE infarct = arterial thrombosis>48hrs -- Both CVAs due to
atherosclerosis -esp @ bifurcation of Carotids/origin of MCA
4. [COLLOID CYST] - blocks 3rd ventricle. Non-Communicating Hydrocephalus, HA, personality changes, etc
5. [PICK BODIES] FRONTOTEMPORAL DEMENTIA - Lobar Atrophy. (TAU proteins, neurofilaments, vesiculated ER & paired helical
filaments)
6. MS - progressive demyelination. Patchy PLAQUES in the white matter.
BALES RF & LIMBIC:
4. [POSTERIOR PITUITARY]: Inferior Hypophyseal A. Oxytocin & ADH from supraoptic & paraventricular nuclei
5. [VENTROMEDIAL HYPOTHALAMIC NUC] LESION = OVEReating; [LATERAL HYPOTHALAMIC NUC] STIMULATION =
OVEReating
6. [MAMMILLARY NUC]: input from hippo via fornix); outputs to thalamus via Mammillothalamic tract (for MEMORY & LIMBIC
functions) *Wernicke-Korsakoff
10. [HIPPOCAMPUS PATHWAY] (input frm cingulum) -->ENTORHINAL pyramidal neurons thru subiculum-->DENTATE granule cells->HIPPOCAMPUS CA3 --> Schaffer Collaterals CA1 --> thru subiculum again back to entorhinal (closed-loop!) Except some collaterals of
CA3 form alveus-fimbria then CRUS of Fornix (unidirectional output of HF--projecting to hypothalamic mammillary& septal nuclei); Blood
supply from PCA br.
11. [AMYGDALA] - recieves AFFERENTS: (1) olfactory (2) sensory & assoc cortices (3) Hippocampus; OUTPUTS to: (1)
THALAMUS/Hypothalamus (via VENTRAL AMYGDALOFUGAL PATH under lenticular nuc) (2) Hypothalamus/SEPTAL nuc (via
STRIA TERMINALIS); blood supply from Anterior Choroidal A of ICA.
12.[CINGULUM] White Matter bundle 2-way. INPUT from motor/premotor anteriorly, somatosensory input posteriorly. OUTPUTS limbic
fibers to ENTORHINAL CORTEX.

BALES LESIONS [6 Qs]

MCA:
ORIGIN - contralateral hemiplegia of lower face/UE/LE; contralateral hemianesthesia of face/UE/LE
INFERIOR DIV - Wernicke Aphasia, Upper Quadrantinopia +/- macular sparing
SUPERIOR DIV - Broca's Aphasia; agraphia, alexia (angular gyrus). contralateral anesthesia & paralysis Face/UE. Ipsilateral taste loss
PCA:

ACA:

UNCAL HERNIATION:
ROSTRAL MIDBRAIN!!!:
DORSAL (PARINAUD'S Pineal Tumor)
TEGMENTUM (NOTHNAGEL's) Ipsilateral CN III
MEDIAL (BENEDIKT's) - superior alternating hemiplegia
CEREBRAL PEDUNCLE (WEBER's, PCA) Superior alt hemipleg, ipsi eye down & out, parkinsonism
ROSTRAL PARAMEDIAN (CLAUDE's, paramedian br) - III, MLF, E-W, Red Nuc, ataxias
CAUDAL MIDBRAIN:
CAUDAL PARAMEDIAN (paramedian br off basilar A) - IV contralateral SO, INO, Ataxia
CEREBELLUM:
DISTAL PICA - ipsilateral spino/vestibulo-cerebellum (vestibular/fall ipsi/spinning/nystagmus/truncal ataxia)
PONS:
LOCKED-IN (basilar A paramedian/short circumf) diving bell & but
LATERAL PONTINE (MARIE-FOIX) - (AICA & Long circumf br) --> Horner's! Analgesia, anesthesia, ipsi masticatory mm, MORE
CAUD BASOLATERAL PONS (MLLRD-GUBLR is all motor!) - VI eye LOOKS AWAY from lesion, Ipsi Facial Paralysis. Contra
hemiplegia (CST)
CAUDAL PARAMEDIAN PONTINE (FOVILLE's)- Conj gaze paralysis TOWARD lesion (PPRF), lesion side of face paralyzed (VII
fibers). Eye looks AWAY from lesion (VI). Contra touch/prop (ML), "Middle alternating hemiplegia"
MEDULLA:
TONSILLAR HERNIATION - Resp & Cardiac dysreg; Fatal
LATERAL MEDULLA (PICA INFARCT) - Ipsi Horner's, no Gag, no Taste (solitary nuc), vertigo, fall ipsi, ataxia (ICP), alternating
hemianalgesia (ipsi face STT & contra body ALS). hearing remains in tact!
MEDIAL MEDULLA (ANT SPINAL infarct) - Inferior Alternating Hemiplegia. Tonge deviates TOWARD lesion (XII). contralat spastic
limbs (CST)
SPINAL CORD:
BROWN-SEQUARD (C4): ISPI LOSSES - touch/conc+unconc proprioception, spastic UE/LE BELOW, Flaccid UE/LE AT level.
CONTRALAT LOSS of Pain/Temp BELOW lesion (ALS).
ANTERIOR SPINAL A SYNDROME (T9): ALL BILATERAL!

POSTERIOR SPINAL A SYNDROME (cervical) - ALL IPSILATERAL!

CERVICAL SYRINGOMYELIA (C5-C8) CAPE-LIKE pain/temp