1. Block 3 review
Karina and Andrew

2. What we picked out to cover…
Stroke
Epilepsy BG
Depression and pharm mental health
Pain pharm
Anatomy
Some MCQs at the end if we have time

3. Stroke Give 4 risk factors for a stroke…
Hypertension, obesity, AF and hypercholesteraemia
How do you calculate someone's risk of a stroke after a TIA?
ABCD2
A age >60 years (1 point); B blood pressure >140/90 (1 point); C clinical features: unilateral weakness (2 points); speech problems (1 point); D duration of symptoms >60 minutes (2 points); 10-1 hour (1 point); D diabetes (1 point)
What is the scoring system used to predict someones risk of a stroke if they have atrial fibrillation?
CHADSVASC
Congestive heart failure; Hypertension; Age >75years; Diabetes; Stroke; Vascular disease; Age 65-74years; Sex Category
What are the 4 main types of stroke as outlined by the Oxford Stroke Classification system?
What artery has caused this infarct?
Left PCA
What are watershed infarcts?
Infarcts were territories overlap. These areas are very susceptible to ischaemia.
The watershed infarct ACA-MCA causes what symptoms?
Man in the barrel syndrome: bilateral arm weakness, intact CN & leg function.

4. Epilepsy
Sally day dreams a lot in class. The doctor suggests that she has what form of epilepsy?
Absent seizures
What medication is best given for this type of seizure?
Ethosuximide
Sodium valporate
Bob is out walking his dog and has a seizure. What are the symptoms of a generalised seizure?
The whole brain is involved. Symptoms: tonic (whole body stiffness)  clonic (muscle jerks)  unconsciousness (may stop breathing)  slow regain of consciousness no recall of episode.
Importantly NO aura or hallucinations with this type.

5. BG and cerebellum Label these parts of the BG…
Name a condition which causes hypokinesia
Parkinsons
What are the cardinal features of parkinsons
TRAP: tremor, ridgity, akinesia (bradykinesia) and postural instabilty.
Which area is affected in parkinsons?
Substantia nigra
Which area is affecting in someone with hemiballismus?
Subthalamic nuclei
Damage occurring within the subthalamic nuclei is associated with Hemiballismus.
Damage occurring within the caudate nucleus (striatum) is associated with Huntington’s, choreas and athetosis.
Damage occurring within the globus pallidus is associated with generation of tremors.
Damage occurring within the putamen (striatum) is associated with choreas and athetosis.
Damage occurring within the substantia nigra is associated with Parkinson’s disease and parkinsonism. 11

6. Depression Rob is a 55 year old accountant suffering with depression.
Give 5 symptoms/signs of depression
Low mood, anhedonia, fatigue, weight change, sleep change, suicidal thoughts, poor concentration, feelings of worthlessness/ guilt.
Where is serotonin normally produced?
Raphe nuclei
Rob wants to swap to MAOIs, what is the MoA?
MAOI stop the action of monoamine oxidase enzyme which means that the monoamines (dopamine, 5HT and  NA) cannot be broken down.
Give an example of an MAOI?
Phenelzine, isocarboxazide, moclobemide (RIMA – therefore the best)
But Rob loves his cheese why is this a potential problem?
MAOI must not be taken with yeast, cheese or red wine, This is because they are all tyramines (dietary amines). Because of the affect of MAOI they cannot be broken down and instead act to increase NA (which also cannot be broken down due to the action of MAOI). Therefore, augumenting the adrenergic response - the so called cheese reaction.
Cheese reaction: hypertension, tachycardia, cardiac arrhythmias, headache, nausea.
Rob decides that giving up cheese just isnt an option and so instead opts for mirtazepine. What is the MoA of this drug?
Alpha 2 adrenoreceptor antagonist

7. Head trauma What is the Glasgow Coma Scale?
Tool used to assess level of consciousness
What are the elements of the GCS?
Types of brain bleeds
What is a contrecoup injury?
A recoil injury to the opposite side of the brain after the initial impact
What is a diffuse axonal injury?
When force is applied to the brain with rotation or deceleration causing a sheering of nerve axons 3 6 4 2 1 5

8. Pain pharm What are the steps on the WHO pain ladder?
What are the 2 types of pain?
Nociceptive and neuropathic
What is nociceptive pain?
Pain that arises from stimulation of pain receptors and can be somatic or visceral
Which medication groups are used for nociceptive pain?
NSAIDs and Opioids
What is neuropathic pain?
Pain that arises from nerve cell injury and can be:
local e.g. post-herpetic neuralgia or neuroma
radicular e.g. post amputation phantom limb pain, trigeminal neuralgia, post-stroke pain
Which medication groups are used for neuropathic pain?
TCAs and AEDs
A patient ‘accidently’ takes too much of their morphine medication, silly them, what should we give them?
Naloxone

9. Anatomy 1 Can you name the following?
What are the two sensory neve fibres that supply the dura?
CN5 and cervical spinal nerve
Can you name the following? 5 6 4 7 3 2 8 1
What would happen if the subarachnoid granulations were blocked? What could cause this?
Raised ICP. Meningitis 9

10. Anatomy 2 Can you name the following? 4 5 3 2 6 7 1 8
SOF
Rotundum
IAM 7 1
Name the hole that these CN come out of:
CN4: SOF
CN5b: Rotundum
CN8: IAM 8 9 10

11. Anatomy 3 Can you name the following? 3
What pattern of tissue injury would follow an infarct?
Liquefactive necrosis – the CNS is special in that you see liquefactive and NOT coagulative 4 5 6 2 7 1 8 9 10 11 12

12. Anatomy 4
Can you name the following? 1 2 3 4 5

13. Brainstem
Stan an 86 year old man has suffered a brain stem stroke. Examination revealed an infarction in the region shown here….
What CN are likely to be affected
CNVII, VIII and IX
Explain what nuclei are potentially at risk
Vestibular, cochlea, spinal part of trigeminal. Superior parts of nucleus ambiguus, solitaris and facial nucleus
Which artery is most likely blocked to cause the lesion shown in the image?
Anterior inferior cerebellar artery is the most likely one blocked.

14. Brainstem Rule of 4
What type of signs and symptoms are you likely to experience with the different types of brainstem infarcts?! THIS IS HARD
The 4 rules of 4
There are 4 cranial nerves above the pons (CN III and IV and 2 in the midbrain – CN I and CN II), 4 in the pons (CN V, VI, VII, VIII) and 4 in the medulla (CN IX, X, XI, XII)

15. Brainstem Rule of 4 The 4 rules of 4
2. The 4 motor nuclei that are in the midline are those that divide equally into 12 except for 1 and 2, that is 3, 4, 6 and 12 (5, 7, 9 and 11 are in the lateral brainstem)

16. Brainstem Rule of 4 The 4 rules of 4
3. There are 4 structures in the ‘midline‘ (medial) beginning with M
Motor pathway (or corticospinal tract): contralateral weakness of the arm and leg
Medial Lemniscus: contralateral loss of vibration and proprioception in the arm and leg
Medial longitudinal fasciculus: ipsilateral inter-nuclear ophthalmoplegia (failure of adduction of the ipsilateral eye towards the nose and nystagmus in the opposite eye as it looks laterally)
Motor nucleus and nerve: ipsilateral loss of the cranial nerve that is affected (3, 4, 6 or 12)
4. There are 4 structures to the ‘side‘ (lateral) beginning with S
Spinocerebellar pathway: ipsilateral ataxia of the arm and leg
Spinothalamic pathway: contralateral alteration of pain and temperature affecting the arm, leg and rarely the trunk
Sensory nucleus of the 5th cranial nerve: ipsilateral alteration of pain and temperature on the face in the distribution of the 5th cranial nerve (this nucleus is a long vertical structure that extends in the lateral aspect of the pons down into the medulla)
Sympathetic pathway: ipsilateral Horner’s syndrome, that is partial ptosis and a small pupil (miosis)

17. Brainstem Rule of 4
So don’t panic!! Think…which cranial nerves are affected? Then what else is affected – is it a midline or ‘side’ (lateral) effect?
A ‘medial brainstem syndrome (infarct)’ will damage the 4 M’s and the 4 motor nuclei of CN III, IV, VI and XII
A ‘lateral brainstem syndrome (infarct)’ will damage the 4 S’s and depending on if in pons (CN V-VIII) and medulla (CN IX – XII)
Also arterial supply helps:
The Medial (‘midline’) aspect of the brainstem is supplied by the penetrating ‘paramedian branches’ of the basilar and vertebral arteries.
The lateral aspect of the brainstem is supplied by the long outside arteries SCA, AICA and PICA.
So if the question is ‘a man has PICA syndrome, what are his signs and symptoms’ you can work it out!

18. MCQ
A 73 year old male is reviewed following recovery from a recent stroke. He states that he has not noticed any major problems in his activities of daily living. You notice, however, that he seems oblivious to the fact that his left arm is moving erratically. You ask him to raise both arms and he raises only the right arm and as you move around him to stand on his left side he seems unaware of your presence there. Which lobe is most likely to have been affected by the stroke in this patient?
Frontal
Limbic
Parietal 
Temporal
Occipital
Parietal
Hemispatial neglect is common in lesions of the parietal lobe

19. MCQ
A 34 year old man is brought into the Emergency Department after being found unconscious in his flat following an overdose of diamorphine. On making your initial examination you notice his pupils are fixed and pinpoint. To manage the coma you administer a combination of thiamine, dextrose, naloxone, flumazenil and oxygen. Which component of this combination will reverse the miosis?
Dextrose
Flumazenil
Naloxone 
Oxygen
Thiamine
Naloxone is an opioid antagonist and will reduce opioid-­induced miosis. Diamorphine is an opioid drug, more commonly known as
heroin.
Dextrose is used to redress sugar balance as hypoglycemia is one of the commonest causes of coma.
Flumazenil is an antagonist for the benzodiazepine site on the GABA receptor and will reverse symptoms of benzodiazepine
drugs, e.g. diazepam.
Oxygen is used to restore saturation levels to maximal oxygenation.
Thiamine (vitamin B1) can help in alcohol-­dependent or nutritionally starved patients.

20. MCQ
A 14 year old girl is brought into the Emergency Department with photophobia, neck stiffness and a non-blanching rash. Which cell type would be predominant in a cerebrospinal fluid sample taken from the girl?
Basophils
Eosinophils
Lymphocytes
Macrophages
Neutrophils 
Neutrophils!
The key feature in the stem is the presence of a non-­blanching rash, this should point you to a meningococcal cause for the
meningitis, which would elicit and acute inflammatory response and hence neutrophils would predominate.
Lymphocytes are more likely to be seen in viral meningitis or in TB. Eosinophils would be present if this was a parasitic infection.
Basophils in the CSF are very rare, their presence is most likely to indicate a severe allergic processes. Macrophages could be
seen in a variety of conditions, notably chronic inflammation, post-­operatively and in the presence of neoplastic disease.

21. MCQ
A 64 year old man suffered an infarction of his cerebral cortex in the region marked X in the diagram that resulted in a specific functional deficit.
Expressive dysphasia 
Receptive dysphaia
Right apraxia
Right facial anaesthesia
Right facial palsy with forehead sparing
What is this area called?
Expressive dysphasia
The damaged region corresponds to Broca’s motor speech area. Damage to this region results in expressive dysphasia/aphasia
(depending upon the extent of damage). The patient can understand written and spoken language and knows what they want to
say but is unable to express it due to issues with the motor-­articulation of speech.

22. Spinal Tracts First 7 – Ascending Second 5 – Descending
Spinothalamic – decussates a few levels above spinal cord level
Dorsal Spinocerebellar (lower limb) – does not decussate
Dorsal Spinocerebellar (upper limb) – does not decussate
Ventral Spinocerebellar (lower limb) - decussates at level and again in pons
Ventral Spinocerebellar (upper limb) does not decussate
Fasciculus Gracilis – decussates in medulla
Fasciculus Cuneatus – decussates in medulla
Corticospinal – lateral in medulla; ventral at spinal cord level
Tectospinal – decussates in midbrain
Rubrospinal – decussate in midbrain
Reticulospinal – does not decussate but 2 strands join in Renshaw cells
Vestibulospinal – does not decussate

23. Spinal Tracts First 7 – Ascending Second 5 – Descending
Spinothalamic – decussates a few levels above spinal cord level
Dorsal Spinocerebellar (lower limb) – does not decussate
Dorsal Spinocerebellar (upper limb) – does not decussate
Ventral Spinocerebellar (lower limb) - decussates at level and again in pons
Ventral Spinocerebellar (upper limb) does not decussate
Fasciculus Gracilis – decussates in medulla
Fasciculus Cuneatus – decussates in medulla
Corticospinal – lateral in medulla; ventral at spinal cord level
Tectospinal – decussates in midbrain
Rubrospinal – decussate in midbrain
Reticulospinal – does not decussate but 2 strands join in Renshaw cells
Vestibulospinal – does not decussate