NEUROSCIENCE

MAKATI MEDICAL CENTER CN II - Optic

San Beda University- College of Medicine A) Inspect pupil size and alignment
B) Visual acuity - wear glasses 6m- 3m
-3m - counting fingers- move hand- light
MMSE perception; if <6/9 - use pinhole
C) Pupillary reflexes- direct and
Orientation: consensual

(5)Time and Date D) Swinging light - relative afferent

(5) Place
(3) Registration: Give 3 random objects
(5) Attention and Calculation: Subtract 7
from 100, 93, 86, 79, 65 or spell “WORLD”
backwards
(3) Recall: Name 3 object
and pupilary defect
E) Convergence- constriction and
convergence
F) Visual inattention- point at moving
finger with both eyes open
G) Visual field - one eye at a time
H) Fundoscopy - red orange reflex,
Cup disc: 1:3; A:V ratio 2:3

Language CN III- Oculomotor, IV-trochlear, VI-

(2) Name 2 objects: watch and pen Abducens

(1) Repeat “No ifs, and, or buts’” - for extraocular muscle movements

(3) 3 steps commands - SO4; LR6

(1) Written command - note ptosis; restrictions, nystagmus

(1) Write a sentence

CN V- Trigeminal

Copy figure (1) V1- opthalmic

V2-maxillary

>24-30: no cognitive impairment V3-mandibular

18-23: mild cognitive impairment Sensory a) fine touch b) pain and temp

0-17: severe cognitive impairment Motor: a) Lateral pterygoids- opening,

Medial- close; b) temporalis; c) masseter;
d)corneal reflex- cotton in corneal angle
CRANIAL NERVES *Corneal reflex: afferent CN V1(trigeminal),
efferent CN VII (facial)
1) Palpate, 2) Clench jaw, 3) Jaw
CN I - Olfactory
strength 4) Jawjerk reflex

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1- “flicker”, trace of contraction

CN VII- Facial 2- Active movement with gravity
eliminated
Motor
3- Active movement against gravity
a) Raise brows
4- Active movement against gravity
b) Close eyes - tight
with moderate resistance
c) Puff out cheeks
5- Normal power
d) Purse lips
D) Reflexes- deep tendon reflex, babinski
e) Smile
Other reflexes:
Sensory
Chaddock: move an object along
a) taste on anterior 2/3 of the the lateral side of the feet
tongue
Schaeffer: squeeze hard on
b) Stapedius - hearing (impedance Achilles tendon
of sound)
Oppenheim: press your knuckles
on patient’s shin and move them down

CN VIII- Vestibulocochlear Gordon: squeeze the calf muscle

Vestibulo- Truning test; close eyes and
march
Cochlear-
A) Hearing - 15cm, 60cm
B) Rinne’s test - AC> BC
a) AC> BC Sensorineural
hearing loss
b) BC> AC conductive
hearing loss
C) Weber’s test - lateralization
momentarily
Bing: make multiple light
pinpricks on the dorsolateral suface of
the foot
Gonda, Stransky- pull on the 4th
outward an downward for a brief time
and release suddenly
SENSORY

>Dorsal column - fine touch and

MOTOR propioception

A) Inspect- muscle wasting, posture Meissner and Pacinian corpuscles,

movements fasciculations
B) Tone- Spastic; rigidity
C) Power - muscle strength
0- No moevement
muscle spindles and tendon organs > 1st
order neuron: dorsal root ganglia>
Fasciculus gracilis & fasciculus cuneatus>
2nd order N: Nucleus gracilis & Nucleus
cuneatus> Decussate: lower medulla as
internal arcuate fibers> ascend as medial
lemniscus> 3rd order N: Ventral

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posterolateral nucleus of thalamus > Internal 5) Speech - slurred staccato speech

Capsule > Corona radiata > Primary
6) Nystagmus - note direction
Somatosensory Cortex, Postcentral Gyrus
7) Finger to nose test - for coordination (+)
dysmetria
> Anterior Spinothalamic - light touch and
8) Rebound phenomenon
pressure
9) Tone - (+) hypotonia - knee reflex
10) Dysdiadochokinesia
Merkel’s discs, Pacianian corpuscle-
Pressire; Meissner’s corpuscles- Light 11) Heel to shin test (+) incoordination
touch > 1st order neuron: DRG >
posterolateral tract of lissauer >ascend
1-2 spinal segments> enter dorsal gray horn > PRESENTATION OF LESIONS
2nd order neuron: substantia gelatinosa
(rexed lamina I) > decussate: anterior
white commisure> ascend as spinal
Cerebral - aphasia ( seizure, aphasia, right
lemniscus at the ant. Spinothalamic tract>
hemiparesis with Babinski)
medulla, pons, midbrain > 3rd order neuron:
VPL of the thalamus> Internal capsule >
corona radiata> Primary somatosensory
cortex, postcentral gyrus Brainstem - affects cranial nerves (Right
cranial nerve deficits with left motor or
sensory deficits in extremities)
> Lateral Spinothalamic - pain and
temperature
Spinal- quadriplegia, urinary retention
( paraperesis with bilateral babinski,
numbness on both lower extremities with
Free nerve endings; Fast conducting A
sensory level, urinary retention)
delta fibers (thinly myelinated) --> initial
sharp pain, Slow conducting C fibers
(unmyelinated) --> prolonged burning
aching pain >> same as anterior Peripheral nerve- numbness of hands and
spinothalamic except ascend as spinal feet ( weakness, numbness and impaired
lemniscus at the lateral Spinothalamic sensation of both hands and feet;
tract generalized areflexia)

CEREBELLAR VITAMIN D

1) Gait- stance and stability Vascular Diseases

2) Tandem gait Idiopathic

3) Romberg’s test - for propioception rather Trauma

than cerebellar Autoimmune
4) Posture - note truncal ataxia Metabolic diseases

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Infection Babinski + -
sign
Neoplasm
Demyelinating diseases
LEVEL OF CONSCIOUSNESS

Awake > Patient aroused without stimulus

Mass lesions ( Tumor. Abscess)
- insidious onset and slowly
progressive focal neurologic deficits
Lethargy > easily arousable by vocal
stimulus and able to sustain consciousness
for a long period
Obtundation > marked decreased arousal
with some response to touch or voice

Cerebrovascular disease ) Cerebral Stupor> Severely decreased arousal with

infarct/ hemorrage)
- sudden onset and rapid course of
meningeal irritation, inc ICP and focal
neurologic deficits referable to brain
some response to vigourous or painful
stimuli
Coma > Total unresponsiveness

HEADACHE
Infection, Trauma, Metabolic, Toxic
-commonly presents with diffuse
Primary Headache
neurologic dysfunction
- Migraine (recurrent; mod-severe
intensity; aggravated by activity, w/ or
LESIONS without photophobia, N/V; W>M)
Cataminial Migraine- migraine
during before after menstruation in
UMN LMN woman
Function Inhibitory on Motor - Tension (occurs mostly in the
muscle component afternoon; band-lke headache)
stretch reflex of muscle
reflex - Cluster (happens at night before
sleeping)
Type of spastic flaccid
paralysis - Sinus

DTR hyperreflexia hyporeflexia -Cervicogenic (HA radiating to the

nape)
Muscle tone hypertonic hypotonic
-Mixed type
Muscle mass Disuse Wasting
atrophy atrophy
Red flags for Headache(SSNOOP4)
Fasciculation - +

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Systemic symptoms (Fever, weight loss)

Secondary risk factors (HIV, Cancer)
Neurologival sign and symptoms
( confusion, impaired alertness)
Onset: sudden. Abrupt
TYPES OF DIZZINESS
Older: new onset or progressive pain
Previous headache history; first time or
1) Vertigenous- “umiikot”
change in pattern
Papilledema Peripheral vs Central Vertigo

Precipitated by Valsalva maneuver Peripheral Central

Postural Aggravation Onset Sudden Slow,

Gradual

Positional Yes No
SEIZURE
Intensity Severe Ill defined
- generalized stiffening and jerking of
extremities Nausea Frequent Infrequent

- upward rolling, tongue biting, duration, Nystagmus Horizontal Vertical

generalized/focal, aware/not aware, with
Hearing loss Yes No
urinary/fecal incontinence
Duration Paroxysmal Constant
CNS No Yes
Ddx: Syncope - no urinary/fecal
incontinence

2) Cerebellar- imbalance
Psychogenic Seizure a) Flocculonodular
- lack of an aura such as inititating cry, - vestibular system
hurtful fall. Incontinence
- posture, balance, eye movements
- presence of peculiar movements such
as grimacing, squirming, thrashing and b) Anterior ( Palleocerebellum)
flaking of limbs side to side motions of head - spinocerebellar (trunks and
resisting assistance extremities)
- retention of consciousness during - regulation of movement
motor seizure involving bot sides of the
body c) Posterior (Neocerebellum)

- long duration of seixure its abrupt

termination by strong sensory stimulation,
3) Lightheaded
lack of post ictal confusion, failure to
produce rise in CK - mcc: cardiac and/or vertebrobasillar

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4) Anxiety- “inuuga” Sympathetic Parasympath

etic

Nature of Dominates Dominates

CELLS OF THE NERVOUS SYSTEM
activity in in quiet,
emergency relaxed
situations situations
Glial cells : neurons --- 10:1 “fight or
Neurons -process information flight”

Glia - mechanical and metabolic Energy Catabolic Anabolic

support utilization

Response Response Response

appropriate favors
PNS to digestion
Satellite cells - support cell bodies emergency and
situations; absorption of
Schwann cells- neurotropic factor synchronize food
secretion; myelin sheath d and
coordinated
Range of Widespread Discrete,
CNS
effect regions of selective and
Oligodendrocytes -myelin sheath the body limited

Microglia - immune cells Fiber due to 1:1 or 1:2

connections divergent
Astrocyte- substarate for ATP connections
production; forms BBB; secrete neurotropic (1:20)
factors, takes up K+, H2O, N+, source of
neural stem cells Branching or extensive limited
preganglioni
Ependydymal cells- creates barriers c fiibers
between compartments
Neurotransm Cathecolami No Ach in
itters nes secreted circulation
Acetylcholine - found in basal nuclei by adrenal
medulla are
Dopamine- substantia nigra distributed to
Norepinephrine- Locus coereleus all regions of
the body
Epinephrine - median raphe through
circulation
Histamine - tuberomamillary nuclei
Duration of Sustained Short
response duration due duration due
PARASYMPATHETIC VS to slow to fast
SYMPATHETIC NERVOUS SYSTEM deactivation deactivation
of of
Norepinephr acetylcholin

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ine e D) Sudden trouble walking, dizziness,
HEMATOMA
Epidural
- between skull and dura
- blunt trauma (mc: temporal)
- Laceration of arterial vessels (mc:
middle meningeal artery)
-CT: convex, lens shaped hyperdensity,
can cross midline
Subdural
-between dura and arachnoid
-requires tremendous force
-rupture of bridging veins
CT: crescent, concave hyperdensity,
does not cross the midline
STROKE
- a sudden onset of focal (or global)
neurologic deficit due to an underlying
cause
Common sign and symptoms of stroke:
A) Sudden numbness or weakness of
the face, arm or leg, especially on one side
of the body
B) Sudden confusion, trouble of
speaking or understanding
C) Sudden trouble of seeing in one or
both eyes
NEUROSCIENCE
loss of balance and coordination
E) Sudden, severe headache with no
known cause.
Onset of 41/2 post ictus- indication to
give rTPA
Relative contraindications: Abrasion,
aneurysm, cavernoma
Absolute contraindications:
Hemorrhage, severe head trauma,
hypertensive
Risk Factors for stroke: SMoking,
Hypertension, Hypercholesterolemia, DM
( may increase risk of 20-25 %
STROKE: Infarct vc SAH vs ICH
Infarct: BP of 180-200 mmHg
Thrombotic - progressive onset
Embolic - sudden onset
SAH - mc cause: trauma
- mc non traumatic cause- ruptured
aneurysm
ICH- headache, N/V, dec sensorium,
with papilledema and inc BP 200-220
mmHg
Transiet Ischemic Attack
-a transient episode of neurologic
dysfunction caused by focal brain, spinal
cord or retinal ischemia without evidence of
acute infarction in which clinical symptoms
typically lasts less than an hour
DEMENTIA
- memory loss
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-may be vascular. Azheimer, or Artificial tears for corneal abrasions

disease-associated
Therapy
- always do MMSE and MOCA-p to
assess
- rule out first other modifiable risk
factor such as hypothyroidism, Vit B12 def,
other metabolic disease before diagnosing
dementia
HYPERTENSIVE EMERGENCY vs
HYPERTENSIVE URGENCY
Treatment
Cholinesterase inhibitors-
HTN urgency - diastolic BP of 110 mmHg
Donepezil - reversibly and or greater without the acute signs of end
non-competitively inhibits Ach ; a/e: GI organ damage.
disturbances, H1/2: 70 hours
HTN emergency- presence of acute and
Rivastigmine-fewer a/e; oral and rapidly evolving end-organ damage with an
transdermal elevated diastolic blood pressure, usually
greater than 120mmHg
Memantine- NMDA receptor antagonist

DRUGS AND MEDICATIONS

PARKINSONS
- tremors, cog-wheel rigidity, stoop
posture Used to decrease, increase intracranial
- Treatment: Levodopa, Carbidopa pressure
- Shunt: hole in skull or SC
- Mannitol and hyperttonic saline - dec
BELL’S PALSY
fluids
- 90% idiopathic
- Hyperventilation- dec paCO2>
- Affects dorsal root ganglia vasoconstriction > dec cerebral blood flow >
dec cerebral blood volume > dec ICP
- red flags: age, sensory deficits
- also check patient for hyperacusis

Tissue plasminogen activator (t-PA)

Treatment
- dosage for ischemic stroke
Prednisone- treatment for Bell’s palsy
- 0.9 mg/kg (90 mg) infused ovr 60
- anti-inflammatory
minutes with 10 % of the total dose infused
-dosage: 1mg/kg for 1 week fast drip in 1 minute and the rest for 60 mins

- fast tapering; if not tapered may cause

adrenal insufficiency

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Aspirin
-irreversible activation of COX
(cyclooxygenase) enzyme->inhibits
prostaglandin

Clopidogrel
-selectively inhibits binding of ADP to
PZY12 ->GPIIb/IIIa ->platelet aggregation

Enoxaparin
- activates antithrombin III -> inhibits
factor Xa & IIa, anticoagulant

Phenobarbital
-increases chloride influx to GABA
receptors which decreases excitability

Citicholine
-increases synthesis of
phosphatidylcholine -> neuroprotective

CIRCLE OF WILLIS

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