#DAVIDSON_REVIEW

#NEUROLOGY_1

(Neurology থেকে প্রায় ১৫ টা প্রশ্ন থাকে।বেশির ভাগ ডেভিডসন থেকে। ইং শা আল্লাহ্ সব টা কভার দেওয়ার
চেষ্টা করব।পোস্ট গুলা ছোট করে সংখ্যা বেশি করা হবে। * indicates importance)

বিসমিল্লাহির রহমানির রহীম

#### Page 1063

*** Examination of gait and posture (Box 1)

Just read,no need to memorise. After completing the chapter,It'll be easier.

** Root values of tendon reflexes (Box 6)

- মুখস্থ

#### Page 1064-65

* Box 25.1 - Just reading

** Cells of nervous system

Astrocytes
• Form the structural framework for neurons & control their biochemical environment
• Forming the blood–brain barrier

Oligodendrocytes
• Formation and maintenance of the myelin sheath
• Maintaining the speed and consistency of action potential propagation along axons
• Peripheral nerves have axons invested in myelin made by oligodendrocytes (Schwann cells)

Microglial cells
• Derive from monocytes/macrophages
• Play a role in fighting infection and removing damaged cells
Ependymal cells
• line the cerebral ventricles

##### Page 1066-67

**************** Box 25.2

(SBA/MCQ - directly/indirectly one or more questions )
+ Box এর কোন কিছু বাদ দেওয়া যাবে না
+++ Functions & feature of lesion relate করে পড়লে সহজ হবে. Dominant & non dominant এর
feature আলাদা করে আসে।

PREVIOUS QUESTION SBA

++++ Verbal memory - Dominant temporal
++++ Versive head movement- Frontal lobe

******* Most important

• Contralateral homonymous lower quadrantanopia - Lesion in parietal lobe

• Contralateral homonymous upper quadrantanopia - Lesion in temporal lobe

(Mnemonic - PITS. Parietal - Inferior, Temporal - Superior)

(In sha ALLAH vision related alada note dibo)

*** Frontal lobe box r next important part

** Reticular formation function

• Control of conjugate eye movements
• Maintenance of balance and arousal,
• Cardiorespiratory control

#### Page 1068-69

* The autonomic system is controlled centrally by diffuse modulatory systems in brainstem,

limbic system, hypothalamus and frontal lobes

* Fibrillations’. Except in the tongue are usually perceptible only on electromyography

* UMN have both inhibitory & excitatory influence on function of LMN in anterior horn

EXTRAPYRAMIDAL SYSTEM

• Circuits between basal ganglia & motor cortex

• controls muscle tone,body posture & initiation of movement

**** Lesions -
• lead pipe rigidity
• Involuntary movements & tremor in combination with rigidity (cogwheel rigidity)
• Bradykinesia
• Postural instability

CEREBELLUM
• Fine-tunes & coordinates movement initiated by motor cortex, including articulation of
speech,planning & learning of skilled movements

**** Lesion in cerebellar hemisphere

• Incoordination
• Nystagmus
• Dysarthria
• Intention tremor,d
• Dysmetria
• Past-pointing
• Dysdiadochokinesis

* Central vermis of cerebellum - coordination of gait and posture. Lesion - ataxic gait

* Control of eye movements begins in cerebral hemispheres, particularly within frontal eye
fields, and the pathway then descends to brainstem with input from visual cortex, superior
colliculus and cerebellum.

** Horizontal and vertical gaze centres - pons & mid-brain respectively

* Ocular motor nerve nuclei (3, 4 and 6) are connected to each other by the medial longitudinal
fasciculus (MLF)

* MLF is particularly important in coordinating HORIZONTAL movements of the eyes

#### Page 1070-71

SPEECH

* Decoding of speech sounds is carried out in upper part of posterior temporal lobe
(WERNICKE’S AREA)

* Attribution of meaning,formulation of language required for expression of ideas and concepts,

occurs predominantly in lower parts of anterior parietal lobe (angular & supramarginal gyri)

* Frontal language area - posterior end of dominant inferior frontal gyrus (BROCA'S AREA) -
receives input from temporal & parietal lobes via arcuate fasciculus.

* Motor commands generated in Broca’s area pass to cranial nerve nuclei in pons,
medulla,anterior horn cells,lips, tongue, palate, pharynx, larynx and respiratory muscles

* Sympathetic supply to bladder arises from roots T11–L2 to synapse in the inferior hypogastric
plexus, while parasympathetic from S2–4. Somatic supply to external (voluntary) sphincter from
S2–4 via pudendal nerves

* REM sleep - most important part of sleep cycle for refreshing cognitive processes, and REM
sleep deprivation causes tiredness, irritability and impaired judgement

+++++ Not in Davidson

AREAS DEVOID OF BLOOD BRAIN BARRIER

• Pineal gland
• Posterior pituitary
• Area postrema
• Optic recess wall
• Organum vasculosum of lamina terminalis (OVLT)
• Supraoptic crest
• Tuber cinereum
• Ventral part of median eminence of hypothalamus

#DAVIDSON_REVIEW
#NEUROLOGY_2

বিসমিল্লাহির রহমানির রাহীম

### Review of page 1072-1082

### Suggestions (You will get a complete one in tazkia nur apu's post)

Box 25.3 **************** (SBA in Jan 20)

Box 25.4 ***** (MCQ in jan 20)
Box 25.6 ********** (Previous question)
Box 25.10 *** (To improve concept)
Box 25.11 *** (Previous SBA)
Box 25.13 ********** (MCQ in Jan 20, Need for concept)
Box 25.14 ** (For concept)
Bell's palsy ***** (Previous question)

BOX 25.3
+ SBA & sometimes MCQ
+ যেকোন পরীক্ষায় প্রশ্ন পাবেন mostly indirectly
+ Box বোঝার জন্য cranial nerve anatomy জানতে হবে
+ প্রশ্নে Nerve lesion এর feature দিবে। Site of lesion or name of syndrome or rarely vessel
involvement জানতে চাওয়া হয়।

********* Wallenberg (SBA Jan 20)

**** Weber
**Millard gublar
* Claude + perinaud

WALLENBERG DETAILS

LATERAL MEDULLARY / POSTERIOR INFERIOR CEREBELLAR ARTERY SYNDROME

/ PICA

Features :
*** Inferior cerebellar peduncle - Ipsilateral cerebellar signs (ataxia,dysmetria/past
pointing,dysdiadochokinesia)

*** Descending sympathetic fibers - Ipsilateral Horner's syndrome (ptosis, miosis & anhidrosis)

*** Lateral spinothalamic tract - Contralateral pain & temperature sensation loss (limbs and
torso)

*** Spinal trigeminal nucleus & tract (CN V) - Ipsilateral pain & temperature loss(face)

** Vestibular nuclei - Vomiting, vertigo, nystagmus

*** Nucleus ambiguus - (CN IX,X,XI) - Ipsilateral dysphagia, hoarseness, absent gag reflex
(localizing lesion - all other deficits are present in lateral pontine syndrome as well)

Cerebellar sign, 5th nerve palsy feature, Contralateral spinothalamic lesion,horner syndrome এই
feature গুলা অবশ্যই মনে রাখতে হবে।আপনাকে direct lesion না দিয়ে এর যেকোনটার feature or
combination দিবে.

Sample question :
A patient came with complain of loss of sensation of one side of face.also loss of pain &
temperature of contralateral body part. On examination ataxic gait + loss of sweating + ptosis.

SBA 1 - Dx - PICA/ WALLENBERG / LMS

SBA 2 - Site of lesion - Lateral medulla
SBA 3 - Which artery responsible - Posterior inferior cerebellar artery

(Other medullary & pontine syndrome r feature আমার Neuroanatomy & physiology post e পাবেন।
যদিও খুব বেশি লাগেনা. পারলে Medial medullary syndrome টা পড়ে নিবেন।সহজ আছে)

Box 25.4
+ Advantage & disadvantage

********* CT & MRI

Others:

*** PET - display GLUCOSE metabolism in dementia and epilepsy

*** SPECT - lipid-soluble properties of radioactive tracers to mark cerebral blood flow in
seizures

***** CT: FIRST LINE FOR STROKE. Intra-arterial angiography: gold standard for vascular
lesions

******* MRI resolution is unaffected by bone - useful for posterior fossa and temporal lobe
disease,Differentiation of white & grey matter - modality of choice in MS,epilepsy.
** MRA images blood flow, not vessel anatomy

** EEG -
• Alpha rhythm - most prominent occipitally and suppressed on eye opening. Other frequency
bands beta (fastest), theta and delta
• Beta seen with sedating drugs such as benzodiazepines & marked focal slowing noted over a
structural lesion such as a tumour or an infarct
• 50% of patients with epilepsy have a normal ‘routine’ EEG
• Up to 5% of some normal populations may demonstrate epileptiform discharges on EEG

** Nerve condution study - Reading (Important for disease. Will be discussed individually)

** Lumber puncture - Indication,Contraindication,Adverse effect (Reading from any book or

guide)
+ Done in Between L3/4
+ Most common A/E - Postural headache

***** In idiopathic intracranial HTN - LP is both diagnostic & therapeutic

Box 25.6 **********

+ MCQ বেশি আসে
+ Scenario দিয়ে findings দিতে পারে

***** Normal findings (must)

***** Cell count & type (Must)
***** Glucose must

• RBC increased only in SAH

• Glucose decreased in bacterial & TB meningitis (N.B: In viral normal except in mumps where
it may be decreased )
• Oligoclonal band - mainly important for MS

Biopsy
* Muscle biopsy
• Quadriceps
• To differentiate myositis & myopathy
* Nerve biopsy - Sural or radial nerve

Box 25.11 ***

+ Previously SBA আসছে
+ Evolution এর সাথে possible cause কি হতে পারে মিলিয়ে পড়তে হবে

Facial pain:

** Most common neurological causes of facial pain - trigeminal neuralgia,herpes zoster

(shingles) and post-herpetic neuralgia
** Trigeminal neuralgia - 2nd & 3rd divisions of the nerve

** Facial shingles - first (ophthalmic) division of trigeminal nerve & pain usually precedes the
rash

** Destructive lesions of trigeminal nerve usually cause numbness rather than pain

Box 25.11 Drug এর নাম + reading দিয়েন।

TRANSIENT GLOBAL AMNESIA (TGA)

(Just reading)
• An abrupt discrete loss of anterograde memory function lasting up to a few hours
• During episode patients are unable to record new memories
• REPETITIVE QUESTIONING - THE HALLMARK Of THIS CONDITION
• Consciousness is preserved & patients may perform even complex motor acts normally
• After 4–6 hours memory function & behaviour return to normal but patient has persistent
complete amnesia for the duration of attack itself
• There are no seizure markers
• No investigation is necessary & patients may be reassured

Box 25.13 *****

+ MCQ আসে
+ পরবর্তীতে UMN & LMN lesion বুঝতে লাগবে
+ LMN এ অল্প জায়গায় ( focal) সব কমে ( Mass,power,tone,reflex, plantar ও নিচে যায় - flexor)
+ UMN এ সব বেশি বেশি হয়।(Tone,power,Reflex এমনকি plantar ও উপরে উঠে - Extensor,সাথে
clonus থাকে). কিন্তু অনেকদিন পরে (Muscle mass) কমতে পারে ( Cause - disuse atrophy ****)

BELL’S PALSY ***** (Both SBA & MCQ)

• Affecting all ages & both sexes

• More common following upper RTI,during pregnancy & DM, immunosuppression & HTN
• Lesion is within facial canal
• C/F : Pain around ear preceding unilateral facial weakness. Others - Hyperacusis,diminished
salivation & tear secretion
• No objective sensory loss (except to taste, if chorda tympani is involved)
• Vesicles in ear / on palate may indicate primary herpes zoster infection
• Rx - GLUCOCORTICOIDS . ANTIVIRAL DRUGS ARE NOT EFFECTIVE
• Patients unable to close eye should be referred urgently to an ophthalmologist
• 80% of patients recover spontaneously within 12 weeks
• Recurrence is unusual & should prompt further investigation
• Complication - eye closure when mouth is moved (synkinesis) or ‘crocodile tears’ (tearing
during salivation)

* Bilateral facial palsy

• Sarcoidosis
• Lyme disease
• GBS
• Poliomyelitis

* Neuropathic Pain
• Causes:-: Diabetic neuropathies, trigeminal & post-herpetic neuralgias & trauma to a peripheral
nerve
• Rx - Amitriptyline,Gabapentin,Duloxetine
• Localised Rx (topical or nerve blocks) sometimes succeeds but may increase sensory deficit &
worsen situation

#DAVIDSON_REVIEW_23rd
#NEUROLOGY_3

বিসমিল্লাহির রহমানির রহীম

### page 1083 -1092

Brown sequared syndrome ***** (Previous question)
Fig 25.18 ***** (H no SBA in Jan 20,also for concept)
Box 25.15 ***** (MCQ in Jan 20)
Box 25.16 **
Box 25.17 *****
Box 25.18 *
Fig 25.19 ***
Box 25.19 *****
Box 25.20 **********
Box 25.21 *****
Box 25.22 *****
Box 25.23 *****
Box 25.24 ***
Box 25.26***

***** Brown sequard syndrome (Will explain later in sha ALLAH )

FEATURES
Below the level of lesion
• Ipsilateral UMN lesion sign
• Ipsilateral dorsal column lesion sign
• Contralateral spinothalamic tract lesion sign

Box 25.15
+ এইবার mcq আসছিল
+ Hyper & hypokinetic এর নাম পড়তে হবে

Box 25.16
+ Mainly character পড়তে হবে
+ Body parts - Head never involved in parkinson
Box 25.17
+ Drugs ****
+ Metabolic **
+ Autoimmune **
+ Hereditary *
+ Site of lesion - Caudate *****
+ Wilson's disease - Chorea হয় (But not in hemochromatosis) ***

*** Rhythmical - Tremor

*** Non rhythmical - Athetosis,Balismus,Chorea,Dystonia, Myoclonus,Tic

*** Chorea - jerky, brief, purposeless involuntary movements, appearing fidgety and affecting
different areas

**** Balism - Lesion in contralateral SUBTHALAMIC NUCLEI. Most common cause - stroke

* Myoclonus - Physiological at onset of slip

* Tic - Suppressible, associated with psychiatric disease,also occur in Huntington, wilson disease
& Post streptococcal infection

** Labyrinthine vertigo usually lasts days at a time

* Vertigo arising from central (brainstem) disorders is often persistent and accompanied by other
brainstem signs

*** Benign paroxysmal positional vertigo lasts a few seconds on head movement

**** Apraxic gait - Feet stuck to floor & patient can't walk.

Causes
• Diffuse bilateral hemisphere disease (Normal pressure hydrocephalus)
• Diffuse frontal lobe disease

** Marche a petit pas - Like parkinson but lack increasing pace & freezing
Cause -
• Small vessel cerebrovascular disease

*** Fluent aphasia

• Wernicke’s aphasia (which localises to the superior posterior temporal lobe),
• Transcortical sensory aphasia
• Conduction aphasia
• Anomic aphasia

*** Non-fluent aphasias, also called expressive aphasia

• Broca’s aphasia (associated with pathologies in the inferior frontal region)
• Transcortical motor aphasia
• Global aphasia

* Pure’ aphasias are selective impairments in reading, writing or the recognition of words

Box 25.19 (Will discuss later)

+ Scenario দিয়ে SBA আসে
+ Site of lesion, Complaint & Visual field loss relate করে পড়তে হবে
+ Optic chiasm lesion এর cause *****

Some important points *********

• Retina / Optic disc - Arcuate scotoma
• Optic nerve - Central vision particularly affected, Central or paracentral scotoma
• Optic chiasm - Bitemporal hemianopia
• Optic tract ( Remember incongruous ******) ,temporal,parietal,occipital - Visual field loss
• Bumping into things - Parietal & occipital
• Difficulty reading, Macula sparing - occipital *****

Box 25.20 ***********

+ SBA mainly
+ CN 6 - ponto - medullary Junction ***
+ Raised ICP - Mainly 6 ****
+ Post. communicating artery aneurysm - CN 3 **********
+ Basilar artery aneurysm - CN 6 **********
+ Cavernous sinus - 3,4,6 +- 5 **********

Question pattern:
No.1- Brainstem sign + on investigation brainstem tumor. Which nerve will most commonly
involved? Ans - CN 6

No. 2 - Headache of sudden onset + 3 rd or 6th nerve palsy feature. Investigation? Or finding?
Ans. Aneurysm (See above)

No. 3 - feature of all 3,4&6 nerve lesion + loss of facial sensation (CN 5).Site?
Ans - Cavernous sinus

Box 25.21
+ Cause / Mechanism - name + associated feature ( Complete /partial/bilateral)
+ Horner syndrome cause

**** The earliest sign of papilloedema is the cessation of venous pulsation seen at the disc

**** Lack of papilloedema never excludes raised intracranial pressure

Box 25.22 *****

+ Dilated pupil in 3rd nerve palsy when there is external compression
+ Horner - Iris heterochromia if congenital
+ Tonic pupil - cause & feature. Generalised areflexia ***
+ Argyll Robertson pupil *******
(Mnemonic - ARP - Accommodation reflex present. Pupillary reflex absent)

Box 25.23 *****

+ All are causes of optic disc swelling but papilloedema r cause 1 st para te daoa (When there is
raised ICP)
+ Systemic disorder **
+ Only toxin in box - Methanol
+ Hypocalcemia - Papilloedema করে।Not given here but written in endocrine

*******
Ptosis + dilated pupil - 3rd nerve lesion
Ptosis + constricted pupil - Horner syndrome

###DAVIDSON_REVIEW_23rd
###NEUROLOGY_4
(sorry for late post😑😑)

বিসমিল্লাহির রহমানির রহীম

### Page 1093-1011

Box 25.24 *****

Box 25.25 ***
Migraine *****
Cluster headache *****
Trigeminal neuralgia *****
Box 25.29 ***
Box 25.31 ***
Box 25.35 *****
Box 25 40 **********
Box 25.41 *****
Benign paroxysmal positional vertigo ***
Box 25.44 *** (SBA IN Jan 2020)
Box 25.45 *
Box 25.46 / Restless leg syndrome ***
Box 25.48 *****
Box 25.49 *

Box 25.24
+ Mainly MCQ
+ Pseudo bulbar r cause ta porben..onno kisu hole seita bulbar
+ MND - Both bulbar & pseudobulbar
*** Features of pseudobulbar palsy
• Small & contracted tongue & moves slowly
• Brisk jaw jerk
• Emotional variability ***

Box 25.25

+ For SBA & MCQ

+ Type,Site,Result & anticholinergic drug 3 tar name porte hbe
+ Atonic - overflow incontinence
+ Hypertonic - Urge incontinence

MIGRAINE

+ For SBA Mainly

+ Scenario দেওয়া থাকে
+ প্রশ্ন হবে dx?Acute e Rx? Severe e Rx?Prevention e drug? Patient r asthma thakle drug?

Important for exam :

• Language function can be affected, leading to similarities with TIA/stroke

• The 80% of patients with characteristic headache but no ‘aura’ are said to have migraine
without aura (previously called ‘common’ migraine)
• Migraine headache is usually severe and throbbing, with photophobia, phonophobia and
vomiting lasting from 4 to 72 hours
• Movement makes the pain worse and patients prefer to lie in a quiet, dark room

Mx
• Acute attack - simple analgesia with aspirin, paracetamol or non-steroidal anti-inflammatory
agents
• Severe attacks - ‘triptans’ (e.g. sumatriptan), which are potent 5-hydroxytryptamine (5-HT,
serotonin) agonists
• If attacks are frequent (more than two per month), prophylaxis should be considered
• 1st line prevention (β-blockers)
• If patient has h/0 asthma - antidepressants (amitriptyline, dosulepin) and antiepileptic drugs
(valproate, topiramate)

(N.B. Migraine is usually unilateral but bilateral history my be given in scenario.but then look
for photophobia, phonophobia, preference for quiet,dark room to dx migraine)

MEDICATION OVERUSE HEADACHE

• Common with migraine and chronic tension-type headache

• Most frequent culprits are compound analgesics (particularly codeine and other opiate-
containing preparations) and triptans
• MOH is usually associated with use on more than 10–15 days per month
CLUSTER HEADACHE

+ Mainly for SBA

+ Question will be Dx/ Rx of acute attack

Important:

• Risk factors - Male, alcohol, smoking

• Also known as migrainous neuralgia
• Most common of the trigeminal autonomic cephalalgia syndromes
• Awoken from sleep by symptoms (‘alarm clock headache’)
• Severe, unilateral periorbital pain with autonomic features, such as ipsilateral tearing, nasal
congestion and conjunctival injection (occasionally with the other features of a Horner’s
syndrome)
• The pain, though severe, is characteristically brief (30–90 minutes)
• *** In contrast to the behaviour of those with migraine, patients are highly agitated during the
headache phase
• ***** Acute attacks - subcutaneous injections of sumatriptan or inhalation of 100% oxygen

TRIGEMINAL NEURALGIA

+ SBA (Dx / Rx)

Important

• Unilateral LANCINATING facial pain, most commonly involving the second and/or third
divisions of the trigeminal nerve territory,over the age of 50 years
• Repetitive, severe and very brief (seconds or less)
• It may be triggered by touch, a cold wind or eating

***** Rx - carbamazepine

• Decompression of the vascular loop encroaching on the trigeminal root is said to have a 90%
success rate
• Other option - localised injection of alcohol or phenol

Box 35.31

+ Mainly MCQ
+ Drugs ***, Toxins ***, Metabolic ***

Box 25.40

+ SBA VVI
+ Only First line drug *********
+ All are important but absence is the most important
Box 25.41

+ MCQ mainly

Important:

• start folic acid (5 mg daily for 2 months) before conception to reduce the risk of fetal
malformations

*** Carbamazepine and lamotrigine have the lowest incidence of major fetal malformations

*** The risk with sodium valproate is higher but should be carefully balanced against its benefits

** Levetiracetam may be safe but avoid other newer drugs if possible

• Carbamazepine levels may fall in the third trimester
• Lamotrigine and levetiracetam levels may fall early in pregnancy

BPPV

• The history is diagnostic, with transient (seconds) vertigo precipitated by movement (typically,
rolling over in bed or getting into or out of bed)
• Dx - Hallpike maneuver
• Rx - Epley maneuver

Box 25.44
+ Both SBA & MCQ

RESTLESS LEG SYNDROME

+ For SBA (Dx & Rx ) & MCQ

Important:

• Usually idiopathic but may be associated with iron deficiency, pregnancy, peripheral
neuropathy, Parkinson’s disease or uraemia
• Treatment - dopaminergic drugs (dopamine agonists or levodopa) or benzodiazepines
• Most common secondary cause - Iton deficiency
• Investigation - Serim ferritin

Box 25.48
+ For both SBA & MCQ
+ Common presentation ****

Box 25.49
+ Only drug name
+ Interferon beta *****
MULTIPLE SCLEROSIS

+ VVI For SBA

+ MS IS UMN Lesion******. So if you won't find any LMN feature. Remember to dx a case

Important:

Scenario pattern:
(A Middle age patient with Relapsing/remitting sensory symptom or Painful visual loss or
Trigeminal neuralgia <50 yr or Lhermitte’s symptom (tingling in spine or limbs on neck flexion)
+ Internuclear ophthalmoplegia with ataxia )

A coomon scenario
পেশেন্ট এর আগে একটা sensory or motor symptom ছিল। যেটা treatment or without treatment ভাল
হয়ে গেছে। এখন একই feture or a new motor or sensory feature নিয়ে আসছে। MS এর feature এর site
usually anatomically expkain করা যায় না। অনেক গুলা site এর feature এক সাথে থাকে।

*** Most commonly in periventricular regions of brain,optic nerves & subpial regions of spinal
cord

• Much of the initial acute clinical deficit is caused by effect of inflammatory cytokines on
transmission of the nervous impulse rather than structural disruption of myelin

• Peak age of onset fourth decade,onset before puberty or after age of 60 years is rare

****** About 85–90% of patients have an initial relapsing & remitting clinical course

• Frequent relapses with incomplete recovery - poor prognosis.

*** If optic neuritis is the initial manifestation - there is no recurrence of disease

*** Prognosis is good for patients with optic neuritis & only sensory relapses

** OIligoclonal bands of IgG in 70–90% of patients between attacks but not specific for MS

• Prolonged administration of glucocorticoids does not alter long-term outcome & is associated
with severe adverse effects

***** Investigation - MRI

• Rx : Mild case - Interferonbeta, Glatiramer acetate,Teriflunomide, Dimethyl fumarate

Fingolimod. Severe case - Alemtuzumab Natalizumab

TRANSVERSE MYELITIS
• Acute, usually monophasic, demyelinating disorder affecting spinal cord,usually post-
infectious in origin. It occurs at any age

***** Presents with a subacute paraparesis with a sensory level, accompanied by severe pain in
the neck or back at the onset

• Oligoclonal bands are usually absent

• Treatment - high-dose intravenous methylprednisolone

NEUROMYELITIS OPTICA / previously Devic’s disease)

• Occurrence of transverse myelitis and bilateral optic neuritis

• Antibody to a neuronal membrane channel, aquaporin 4
• Typically high-signal lesions restricted to periventricular regions

*** Spinal MRI scans show lesions that are typically longer than three spinal segments (unlike
the shorter lesions of MS)

Box 25.53
+ Associated tumor & Antibody পড়তে হবে
+ Myasthenia & Lambert eaton *****
+ Polymyositis ***

Some other important information:

NARCOLEPSY

• Key symptom is sudden, irresistible ‘sleep attacks’, often in inappropriate circumstances such
as while eating or talking.

***Narcolepsy may be due to loss of hypocretin-secreting hypothalamic neurons

• Diagnosis requires sleep study with sleep latency testing (demonstrating rapid onset of REM
sleep).
• Cataplexy is characteristic/pathognomonic of narcolepsy

EPILEPSY :

• Withdrawal of medication may be considered after a patient has been seizure-free for more than
2 years.
• Childhood-onset epilepsy, particularly classical absence seizures, carries the best prognosis for
successful drug withdrawal

***** Sodium valproate and levetiracetam have no interaction with hormonal contraception
• Most associated with teratogenesis is sodium valproate
• Menstrual irregularities and reduced fertility are more common in women with epilepsy, and
are also increased by sodium valproate.
• Patients with epilepsy are at greater risk of osteoporosis

#DAVIDSON_REVIEW
#NEUROLOGY_5

বিসমিল্লাহির রহমানির রহীম

# Page 1112 - 1126

Box 25.54 ***

Parkinson's disease *****
Box 25.55 ***
Box 25.56 *****
MSA ***
PSP ***
Box 25.59 ***
Box 25.60 **********
Fig 25.33 ***
Meningitis *****
Box 25 62 *****
Box 25.63 **********
Box 25.64 ***
Box 25.72 **

Box 25.54
+ For MCQ
+ Drugs & Toxin ***

Box 25.55
+ Both SBA & MCQ
+ Normal findings *****

Important :

***** Clinical features

• Average age - 60 years,progressive & incurable with a variable prognosis

• Pathological hallmarks - depletion of pigmented dopaminergic neurons in substantia nigra &

presence of α-synuclein and other protein inclusions in nigral cells

• Lewy bodies are also found in basal ganglia,brainstem and cortex & increase with disease
progression
***** Motor symptoms - most common & ASYMMETRICAL. HALLMARK IS
BRADYKINESIA

*** Cognition is spared in early disease; if impaired, it should trigger consideration of alternative
diagnoses, such as dementia with Lewy bodies

*** Functional dopaminergic imaging (SPECT or PET) is abnormal in early stage but not
specific for PD

***Levodopa (LD) - most effective treatment available

• LD is most effective for relieving akinesia and rigidity but has no effect on posture, freezing

*** A/E:- postural hypotension,nausea & vomiting, hallucinations & abnormal LD-seeking
behaviour (dopamine dysregulation syndrome)

***** Ergot-derived dopamine agonists are no longer recommended because of rare but serious
fibrotic effects. Other - nausea, vomiting,disorientation and hallucinations, impulse control
disorders

** MAOI-B inhibitors - selegiline and rasagiline

** COMT inhibitors - entacapone and tolcapone

*** Amantadine - LD-induced dyskinesias *** Anticholinergic drugs - for Tremor

( trihexyphenidyl (benzhexol) and orphenadrine)

** DBS site - thalamus (only effective for tremor),globus pallidus & subthalamic nucleus

MULTIPLE SYSTEM ATROPHY (MSA)

• Characterised by parkinsonism, autonomic failure (Postural hypotension,Atonic

bladder,Erectile dysfunction) & cerebellar symptoms
• Early falls,postural instability & lack of response to LD are clues. Cognition is usually
unaffected
• Pathological hallmark is α-synuclein-containing glial cytoplasmic inclusions found in the basal
ganglia,cerebellum & motor cortex

PROGRESSIVE SUPRANUCLEAR PALSY (PSP)

• Presents with symmetrical parkinsonism, cognitive impairment, early falls & bulbar symptoms

*** CHARACTERISTIC EYE MOVEMENT DISORDER - SLOWED VERTICAL

SACCADES LEADING TO IMPAIRMENT OF UP- AND DOWNGAZE may take years to
emerge - worse in down gaze - difficulty in reading & descending stair
* Abnormal accumulation of TAU (Τ) PROTEINS & degeneration of substantia
nigra,subthalamic nucleus & mid-brain

ESSENTIAL TREMOR
• Autosomal dominant pattern
• Improves in about 50% of patients with small amounts of alcohol
• Rx - Beta-blockers (1st line) & primidone DBS of thalamus - in severe cases

MND

+ VVI for SBA

Some clue to dx

+ If you find fibrillation in scenario first think about MND

+ Both UMN + LMN features in same patient
+ Exxagerated reflex in wasting limb

Important :

• Neurodegenerative condition.
• Chromosome 9 is associated with MND and frontotemporal dementia.
• Usually after the age of 50 years,very uncommon before the age of 30 years.

*** Abnormalities in the superoxide dismutase (SOD1) gene account for about 20%.

• *** Most common form of MND is amyotrophic lateral sclerosis (ALS).

*** MND typically presents focally, either with limb onset (e.g. foot drop or loss of manual
dexterity) or with bulbar symptoms (dysarthria, swallowing difficulty).
• Respiratory onset is rare but type II respiratory failure is a common terminal event.

***** Sensory, autonomic and visual symptoms do not occur, although cramp is common.

• *** External ocular muscles and sphincters usually remain intact.

• *** No objective sensory deficit.
• Evidence of cognitive impairment with frontotemporal dominance.
• Even with treatment, MND is relentlessly progressive.
• EMG will usually confirm the typical features of widespread denervation and re-innervation.
• Spinal fluid analysis is not usually necessary.

***** Riluzole, a glutamate release antagonist, is licensed for ALS - 3 month

MENINGITIS

• *** Viruses are the most common cause of meningitis, the most common being enteroviruses
*** Where specific immunisation is not employed, the mumps virus is a common cause

** Listeria monocytogenes is an increasing cause of meningitis and rhombencephalitis

(brainstem encephalitis) in the immunosuppressed, people with diabetes, alcoholics and pregnant
women (p. 259). It can also cause meningitis in neonates

** Prevention - Rifampicin. Alternative - Ciprofloxacin

Box 25.62
+ For MCQ
+ Non infective / Sterile ***
+ Inflammatory cause - Recurrent

Box 25.63
+ According to Age porate hobe

VIRAL ENCEPHALITIS

*** Most serious cause - herpes simplex (reaches the brain via olfactory nerves)

• HIV may cause encephalitis with a subacute or chronic presentation but occasionally has an
acute presentation with seroconversion

*** HERPES SIMPLEX ENCEPHALITIS - TEMPORAL LOBES, CYTOMEGALOVIRUS -

AREAS ADJACENT TO VENTRICLES (VENTRICULITIS)

*** CT - low-density lesions in temporal lobes (Petechial haemorrhage in medial temporal &
inferior frontal lobe) but MRI is more sensitive in detecting early abnormalities

• EEG in herpes simplex encephalitis - characteristic periodic slow wave activity in temporal
lobes
• Rx - aciclovir in all patients, raised intracranial pressure - dexamethasone

BOTULINUM

*** Its classical form is an acute onset of bilateral cranial neuropathies associated with
symmetric descending weakness

** Toxin causes predominantly bulbar and ocular palsies (difficulty in swallowing, blurred or
double vision, ptosis), progressing to limb weakness and respiratory paralysis.

#DAVIDSON_REVIEW
#NEUROLOGY_6

N.B. লেখার মাঝে মাঝে Capital letter e কিছু word লেখা আছে।এইগুলা বেশি impotant বোঝানোর জন্য।
## Page 1127 - END

Box 25.74 **
Box 25.75 ***
Box 25.76 ***
Acoustic neuroma *****
Neurofibromatosis ***
Box 25.77 ***
Normal pressure hydrocephalus *****
Idiopathic intracranial hypertension ********
Fig 25.47 ***
Fig 25.48 ***
Box 25.79 ***
Box 25.81 ***
Box 25.84 **********
Box 25.85 ***
Box 25.87 ***
Box 25.88 *
GBS **********
Box 25.89 **
Myasthenia gravis **********
Lambert eaton *********
Box 25.94 **
Fig 25.53 *****

Box 25.74
+ For MCQ
+ Reading dilei para jabe
+ Infective cause ***

Box 25.75
+ Focal symptoms **
+ Raised ICP ***

Box 25.76
+ Only name of benign & malignant

Important:

• In developing countries tuberculoma and other infections are frequent causes, but in the West
intracranial haemorrhage and brain tumours are more common

*** In adults, intracranial pressure is less than 10–15 mmHg

• Papilloedema is not always present, either because the pressure rise has been too rapid or
because of anatomical anomalies of the meningeal sheath of the optic nerve
** In RICP, the 6th cranial nerve (unilateral or bilateral) is most commonly affected but the 3rd,
5th and 7th nerves may also be involved

* Vomiting, coma, bradycardia and arterial hypertension are later features of RICP

• Primary malignant brain tumours are rare, accounting for 1% of all adult tumours

*** The most common benign brain tumour is a meningioma

**Primary brain tumours do not metastasise due to the absence of lymphatic drainage in the
brain

• However medulloblastoma, which do have a propensity to metastasise;

• Gliomas account for 60% of brain tumours, with the aggressive glioblastoma multiforme
(WHO grade IV) the most common glioma, followed by meningiomas (20%) and pituitary
tumours (10%)

• Isolated stable headache is almost never due to intracranial tumour

• The more malignant tumours are more likely to demonstrate contrast enhancement on imaging

ACOUSTIC NEUROMA
+ SBA (Scenario based) & MCQ

Important

*** This is a BENIGN tumour of SCHWANN CELLS of the 8TH CRANIAL NERVE (SBA),
which may arise in isolation or as part of NEUROFIBROMATOSIS TYPE 2.

• More frequent in females

• The tumour commonly arises NEAR THE NERVE’S ENTRY POINT into the medulla or in
the internal auditory meatus, usually on the VESTIBULAR DIVISION

• Acoustic neuromas account for 80–90% of tumours at the cerebellopontine angle

• Acoustic neuroma typically presents with unilateral progressive hearing loss, sometimes with
tinnitus. Corneal reflex - lost

• Facial weakness is unusual at presentation but facial palsy may follow surgical removal of the
tumour

*** MRI is the investigation of choice (SBA)

• Surgery is the treatment of choice

Clue -
• Progressive sensory hearing loss
• Cerebellopontine angle tumor

Box 25.77
+ Neurofibroma ছাড়া সব oma type 2 তে হবে
+ Bone,GIT,cardiorespiratory - type 1

NEUROFIBROMATOSIS

(নিচের কোন লাইন বাদ দেখে যাবে না)

• Autosomal dominant

Type 1 (All 1)
• More common
• NF1 gene
• Chromosome 17
• Characterized by neurofibroma (benign peripheral nerve sheath tumours
• Affect many systems
• Malignant change may occur

Type 2 (All 2)
• NF2 gene
• Chromosome 22
• Characterised by schwannomas (benign peripheral nerve sheath tumours comprising Schwann
cells only) with little skin involvement
• Clinical manifestations are more restricted to the eye and nervous system

NORMAL PRESSURE HYDROCEPHALUS

+ SBA mainly & MCQ

• Intermittent rises in CSF pressure, particularly at night

***** It is described OLD AGE as being associated with a TRIAD OF GAIT APRAXIA,
DEMENTIA AND URINARY INCONTINENCE.

• DILATED VENTRICLES AND NARROWED AQUEDUCT

• Diversion of the CSF by means of a shunt placed between the ventricular system and the
peritoneal cavity or right atrium may result in rapid relief of symptoms in obstructive
hydrocephalus

***** Scenario:

Old age + Gait abnormality + loss of memory + urinary incontinence

IDIOPATHIC INTRACRANIAL HYPERTENSION
+ SBA

Clue
++++++++ Obese young female with headache

Important

• This usually occurs in obese young women

• RICP occurs in the absence of a structural lesion, hydrocephalus or other identifiable cause

• Defect of CSF reabsorption by the arachnoid villi.

• ***** A number of drugs may be associated, including tetracycline, vitamin A and retinoid
derivatives (+steroid)

• *** C/F: HEADACHE, DIPLOPIA and visual disturbance (most commonly, transient
obscurations of vision associated with changes in posture),PAPILLOEDEMA.

• False localising cranial nerve palsies (usually of the 6th nerve) may be present

• Brain imaging is required to exclude a structural or other cause

• *** The ventricles are typically normal in size or small (‘slit’ ventricles)

• ***** The diagnosis may be confirmed by lumbar puncture, which shows raised normal CSF
constituents at increased pressure (USUALLY> 30 CM H20 CSH).

• Rx - Wt. Loss *** , Acetazolamide or topiramate, repeated lumber puncture ***

Fig 25.47 & 25.48

+ SBA
+ কোন root এ lesion হলে কোন reflex lost & muscle weakness হবে মিলিয়ে পড়তে হবে
+ প্রশ্নে কোন muscle weakness & reflex lost দেওয়া থাকবে। Question will be what is the site of
lesion)/ which nerve root involved ?

Froin’s syndrome *** ( 1137 p )

If myelography is performed, CSF should be taken for analysis; in cases of COMPLETE

SPINAL BLOCK, this shows a NORMAL CELL COUNT with a VERY ELEVATED
PROTEIN causing YELLOW DISCOLORATION OF THE FLUID

Box 25.84
+ Drugs & toxin ***
+ Vitamins *****
+ Infection & systemic disease **

*****
B1 / Thiamin, B6 / Pyridoxine, B12 / Cobalamin, E / Tocopherol

Box 25.85
+ only Demyelinating porben .others are axonal
+ Amiodarone + GBS -> Demyelinating

Box 25.87

+ Scenario তে muscle weakness, sensory loss & symptoms দেওয়া হবে। Nerve involvement জানতে
চাওয়া হবে।

*****
Median / Carpal tunnel - Waking patient from sleep
Common peroneal - Foot drop
*** Lateral cutaneous - meralgia paraesthetica - lateral border of thigh

GBS

+ SBA

***** CLUE
H/0 diarrhoea + All reflex loss + Distal paraesthesia + Muscle weakness

Areflexia + Ataxia + Ophthalmoplegia - Miller fisher syndrome / anti-GQ1b antibodies. *****

(SBA)

Important :

• Immune-mediated conditions

• The most common variant is an acute inflammatory demyelinating polyneuropathy (AIDP)

• Often associated with Campylobacter jejuni

• The hallmark is an acute paralysis evolving over days or weeks with loss of tendon reflexes
(SBA)

• Distal paraesthesia and pain precede muscle weakness that ascends rapidly from lower to upper
limbs and is MORE MARKED PROXIMALLY THAN DISTALLY.

*** Investigation : CSF study (SBA)

***** The CSF protein is raised, but may be normal in the first 10 days. There is usually no
increase in CSF white cell count (> 10 × 106 cells/L suggests an alternative diagnosis).

• Antibodies to the ganglioside GM1 are found in about 25%,

***• Rx - IV Ig (SBA)

***• Monitoring - Vital capacity (SBA)

MYASTHENIA GRAVIS

+ For SBA

Clue *****

Old age + Female + FATIGUABLE WEAKNESS/WEAKNESS AT END OF DAY+ NO

SENSORY LOSS

• Preferentially affects ocular, facial and bulbar muscles.

• 80% caused by antibodies to acetylcholine receptors (SBA)

In others muscle-specific kinase (MuSK).(Type 2 hypersensitivity)

• About 15% of patients (mainly those with late onset) have a thymoma, most of the remainder
displaying thymic follicular hyperplasia.

*** Triggers : penicillamine (may persist after drug withdrawal).aminoglycosides and

quinolones (should be avoided) (Others - B blocker, Lithium, Phenytoin)

• Between 15 and 50 years & relapsing and remitting course.

*** Worsening of symptoms towards the end of the day or following exercise is characteristic.

*** No sensory signs or signs of involvement of the CNS

• The first symptoms are usually intermittent ptosis or diplopia.

• Resting of the eyelids (looking downwards) may be followed by increased reflex elevation with
up-gaze (so-called Cogan’s lid twitch sign).

• Any limb muscle may be affected, most commonly those of the shoulder girdle

*** Repetitive stimulation during NCS may show a characteristic decremental response .

• All patients should have a thoracic CT to exclude thymoma, especially those without anti-
acetylcholine receptor antibodies.
*** Mostly used anticholinesterase drug is pyridostigmine

***** Acute condition - IV Ig (SBA)

Box 25.90
+ Only name
+ Glucocorticoid Rx - Exacerbation may occur

LAMBERT–EATON MYASTHENIC SYNDROME

+ For SBA

Clue *****
H/O malignancy/Lung Ca + MG like feature

***** Cardinal clinical sign is absence of tendon reflexes, which return after sustained
contraction of the relevant muscle

*** Ab against pre synaptic Ca ion channel (SBA)

* In contrast to MG,less bulbar or ocular muscle involvement,weakness more in legs but

*** ANS features present (Dry mouth, impotence, difficult micturition)

*** Association with SCLC (50%),in lesser extent breast & ovarian cancer.

• Diagnosis is made electrophysiologically on the presence of post-tetanic potentiation of motor

response to nerve stimulation at a frequency of 20–50/sec.

N.B:
Features of MG + Malignancy -> LE syndrome
Reflex / weakness improvement after exercise -> LE syndrome

Box 25.94
+ Channel & associated disease specially hperkalemic & hypokalemic periodic paralysis

Fig 25.53
+ MCQ
+ METABOLIC *****
+ DRUGS ***
+ TOXIC **

#NEUROLOGY
(N.B. Neuro anatomy & physiology theke direct question khb besi thake na. Ja thake Davidson
theke cover hoie jai. Bt disease or lesion bujhar jnno anatomy jana thakle sohoj hoi)
(In sha ALLAH this note will almost cover genesis sheet of neuroanatomy & physiology. Some
information are from anatomy book & Wikimedia)
(Please mention if you have any correction or suggestions)

Pdf :
https://drive.google.com/…/1AKny9FjUuUjkWGO0mdctnyQ7Z…/view…

[ ] CLASSIFICATION OF NEURON

UNIPOLAR
• Mesencephalic nucleus of trigeminal
• Dorsal root ganglion
• Cranial root ganglion

BIPOLAR
• Olfactory cells
• Bipolar cells of retina
• Vestibular ganglia
• Hair cells of Cochlea

MULTIPOLAR
• Spinal cord - Dorsal & Ventral column
• Mitor cortex of cerebrum
• Autonomic ganglia

GOLGI TYPE I
• Pyramidal cells
• Purkinjee cells
• Anterior horn cells of spinal cord

GOLGI TYPE II
• Cerbral & Cerebellar cortex
• Retina

CELLS OF CEREBRAL CORTEX

• Pyramidal cells
• Fusiform cells
• Stellate cells
• Horizontal cells of Cajal
• Cells of Martinotti

PYRAMIDAL CELLS FOUND IN

• Cerebral cortex
• Hippocampus
• Amygdala
LAYERS OF CEREBRAL CORTEX
• Molecular layer (plexiform layer)
• External granular layer
• External pyramidal layer
• Internal granular layer
• Ganglionic layer (internal pyramidal layer) - In motor cortex of precentral gyrus , pyramidal
cells of this layer are very large (Betz cells - account for 3% of projection fibers of corticospinal
or pyramidal tract)
• Multiform layer (layer of polymorphic cells)

• Granular type - layers 2 & 4 are well developed & layers 3 & 5 are poorly developed -
predominantly granular cells that receive thalamocortical fibers. Granular type of cortex is found
in postcentral gyrus,superior temporal gyrus & parts of hippocampal gyrus.

• Agranular type of cortex - 2 & 4 are practically absent. Pyramidal cells in layers 3 & 5 are
densely packed & are very large. Agranular type of cortex is found in precentral gyrus & other
areas in frontal lobe. These areas are associated with motor function

MOTOR AREA
• Primary motor area - carry out individual movements of different parts of body,final station for
conversion of design into execution of movement
• Premotor area - no giant pyramidal cells of Betz. Store programs of motor activity assembled as
result of past experience. It is particularly involved in controlling coarse postural movements
through its connections with basal ganglia
• Supplementary motor area is - Removal of produces no permanent loss of movement
• Frontal eye field - Electrical stimulation causes conjugate movements of eyes, especially
toward the opposite side, control voluntary scanning movements of eye & is independent of
visual stimuli
• Prefrontal cortex (Brodmann 9, 10, 11, and 12) - makeup of individual’s personality,depth of
feeling,initiative & judgment of an individual
• Motor speech area of Broca - inferior frontal gyrus (Brodmann 44 & 45)

• Handedness,perception of language & speech are controlled by the dominant hemisphere.

Spatial perception, recognition of faces & music are interpreted by nondominant hemisphere

LESION

• Muscle Spasticity - Primary motor cortex gives origin to corticospinal & corticonuclear tracts -
tend to increase muscle tone & secondary motor cortex gives origin to extrapyramidal tracts that
pass to basal ganglia & reticular formation - inhibitory impulses that lower muscle tone. A
discrete lesion of PMC (area 4) results in little change in muscle tone but larger lesions involving
SMC (area 6),which are most common,result in muscle spasm
• Destructive lesions of frontal eye field of one hemisphere - cause two eyes to deviate to side of
the lesion & inability to turn to opposite side. Irritative lesions of frontal eye field of one
hemisphere cause two eyes to periodically deviate to opposite side of lesion. Involuntary tracking
movement of eyes following moving objects is unaffected because lesion does not involve visual
cortex in occipital lobe
• Persistent Vegetative State : intact reticular formation but a nonfunctioning cerebral cortex -
person is awake (eyes are open & move around & has sleep–awake cycles) but has no awareness
(cannot respond tostimuli such as a verbal command or pain). It is possible to have wakefulness
without awareness but not possible to have awareness without wakefulness. Cerebral cortex
requires input from reticular forma-tion in order to function

[ ] WHITE MATTER OF CEREBRUM

COMMISSURAL FIBERS (Connection between two cerebral hemisphere)

• Corpus callosum (all parts except olfactory & hippocampus)

• Fornix
• Anterior commissure (between olfactory areas)
• Posterior commissure (between pretectal nucleus)
• Habenular commissure

ASSOCIATION FIBERS (Within same hemisphere)

• Short association fibers

• Long association fibers
• Superior longitudinal fasciculus
• Inferior longitudinal fasciculus
• Fronto-occipital fasciculus
• Uncinate fasciculus
• Cingulum

PROJECTION FIBERS (With hemisphere to other area)

• Internal capsule
• Corona radiata
• Optic radiation

INTERNAL CAPSULE

ANTERIOR LIMB (by anterior cerebral artery )

• Frontopontine fibers
• Anterior thalamic radiation

GENU (by internal carotid artery )

• Corticonuclear fibers - CN 3,4,5,6,7,12
• Ant. part of superior thalamic radiation

POSTERIOR LIMB (by middle cerebral artery )

• Corticospinal fibers
• Corticorubral fibers
• Corticopontine fibers
• Superior thalamic radiation
• Fibers from globus pallidus to subthalamic nucleus

RETROLENTICULAR PART (by posterior cerebral artery )

• Occipitopontine fibers
• Parietopontine fibers
• Posterior thalamic radiation
• Optic radiation

SUBLENTICULAR PART (by posterior cerebral artery )

• Temporopontine fibers
• Parietopontine fibers
• Auditory radiation

[ ] BASAL NUCLEUS

STRUCTURE
• Caudate nucleus
• Lentiform nucleus - Globus pallidus plus putamen
• Claustrum
• Amygdaloid nucleus

• Corpus striatum/Neostriatum (striatum) - Caudate nucleus plus putamen

• Amygdaloid nucleus - Influence body’s response to environmental changes (in sense of fear for
example it can change heart rate, BP,skin color & rate of respiration
• Basal nuclei control movements by influencing cerebral cortex & have no direct control
through descending pathways to brainstem & spinal cord

FUNCTION

• Regulation of voluntary movement & learning of motor skills

• Influence execution of a particular movement
• Help prepare for movements by controlling axial and girdle movements of body & positioning
of proximal parts of limbs
• Destruction of the primary motor cerebral cortex prevents individual from performing fine
discrete movements of hands & feet on opposite side of body. However individual is still capable
of performing gross crude movements of opposite limbs. If destruction of corpus striatum then
takes place,paralysis of remaining movements occurs

DIENCEPHALON
• Thalamus
• Hypothalamus including the Posterior pituitary
• Epithalamus which consists of Habenular nuclei,Posterior commissure,Pineal body
• Subthalamus
[ ] LIMBIC SYSTEM

STRUCTURES
• Subcallosal
• Cingulate
• Parahippocampal gyri
• Hippocampal formation
• Amygdaloid nucleus
• Mammillary bodies
• Anterior thalamic nucleus

FUNCTION (Mnemonic FEARS)

• Control of the ENDOCRINE system

• Influence EMOTIONAL behavior (reactions of FEAR & ANGER & emotions associated with
SEXUAL behavior)
• Converting RECENT MEMORY to long-term memory

• A lesion of hippocampus results in the individual being unable to store long-term memory.
Memory of remote past events before the lesion developed is unaffected - anterograde amnesia.
• Injury to the amygdaloid nucleus and the hippocampus produces a greater memory loss than
injury to either one of these structures alone
• There is no evidence that the limbic system has an olfactory function

THALAMUS

• Sensory information of all types (except smell) converges on thalamus.

• Olfactory information is first integrated at a lower level with taste and other sensations &
relayed to thalamus from amygdaloid complex & hippocampus through mammillothalamic tract

NUCLEUS

• Anterior - Emotional tone,mechanisms of recent memory

• Dorsomedial - Integration of somatic, visceral & olfactory information & relation to emotional
feelings & subjective states
• Ventral anterior - motor
• Ventral lateral - motor
• VPM - Sensation from face,head & taste (trigeminal & solitariothalamic tract)
• VPL - Sensory (medial & spinal lemnisci)
• Medial geniculate - Auditory
• Lateral geniculate - Vision
• Intralaminar - level of consciousness
• Lateral dorsal, Lateral posterior, pulvinar
• Midline
• Reticular
HYPOTHALAMUS

• Supraoptic nucleus - Synthesizes vasopressin (antidiuretic hormone)

• Paraventricular nucleus - Synthesizes oxytocin
• Preoptic and anterior nuclei - Control parasympatheticsystem
• Posterior and lateral nuclei - Control sympathetic system
• Anterior hypothalamic nuclei - Regulate temperature (response to heat)
• Posterior hypothalamic nuclei - Regulate temperature (response to cold)
• Lateral hypothalamic nuclei - Initiate eating & increase food intake (hunger center) & water
intake (thirst center)
• Medial hypothalamic nuclei - Inhibit eating & reduce food intake (satiety center)
• Suprachiasmatic nucleus - Controls circadian rhythms

[ ] CEREBELLUM

FUNCTIONAL CLASSIFICATION

• Cerebrocerebellum / Neocerebellum - largest part - Middle lobe except uvula & pyramid -
planning movement that is about to occur
• Spinocerebellum / paleocerebellum - Anterior lobe,Uvula & Pyramid - fine-tune body and limb
movements
• Vestibulocerebellum / Archicerebellum - Flocculonodular lobe, smallest, oldest part -
participates mainly in balance & spatial orientation - vestibular nuclei. Damage to this region
causes disturbances of balance and gait

THREE MAIN LOBES:

• Anterior lobe
• Middle lobe
• Flocculonodular lobe

THREE LAYERS:
• External / molecular layer - Stellate cell, Basket cell
• Middle / Purkinje cell layer - purkinjee cell, Golgi cell
• Internal / granular layer

NUCLEI (From lateral to medial)

• Dentate - largest
• Emboliform
• Globose
• Fastigial

• Dentate + Emboliform - Nucleus interpositus

SIGNS AND SYMPTOMS OF CEREBELLAR DISEASE

• Hypotonia
• Postural Changes and Alteration of Gait
• Disturbances of Voluntary Movement (Ataxia)
• Dysdiadochokinesia
• Disturbances of Reflexes - Pendular knee jerk
• Disturbances of Ocular Movement
• Disorders of Speech

BRAINSTEM

From medial to lateral :

• Medial lemniscus
• Trigeminal lemniscus
• Lateral lemniscus
• Spinal lemniscus

MEDIAL MEDULLARY SYNDROME

(paramedian branches of anterior spinal artery and/or vertebral arteries)

• Corticospinal tract - Contralateral spastic hemiparesis
• Medial leminiscus - Contralateral loss of dorsal column sensation
• CN XII - Deviation of tongue to side of the lesion

MEDIAL PONTINE SYNDROME

(paramedian branches of basilar artery)

• Corticospinal tract - Contralateral spastic hemiparesis
• Medial leminiscus - Contralateral loss of dorsal column sensation
• CN VI - Strabismus (ipsilateral lateral rectus muscle paralysis)
• Depending upon the size of the infarct, it can also involve the facial nerve.

LATERAL MEDULLARY / WALLENBERG / POSTERIOR INFERIOR CEREBELLAR

ARTERY SYNDROME / PICA

• Inferior cerebellar peduncle - Ipsilateral cerebellar signs (ataxia,dysmetria/past

pointing,dysdiadochokinesia)
• Descending sympathetic fibers - Ipsilateral Horner's syndrome (ptosis, miosis & anhidrosis)
• Central tegmental tract - Palatal myoclonus
• Lateral spinothalamic tract - Contralateral pain & temperature sensation loss (limbs and torso)
• Spinal trigeminal nucleus & tract - Ipsilateral pain & temperature loss(face)
• Vestibular nuclei - Vomiting, vertigo, nystagmus
• Nucleus ambiguus - (CN IX,X,XI) - Ipsilateral dysphagia, hoarseness, absent gag reflex
(localizing lesion - all other deficits are present in lateral pontine syndrome as well)

LATERAL PONTINE SYNDROME /ANTERIOR INFERIOR CEREBELLAR OR

CIRCUMFERENTIAL ARTERIES / AICA
• Middle & inferior cerebellar peduncle - Ipsilateral limb & gait ataxia
• Descending sympathetic tract - Ipsilateral Horner's syndrome
• Lateral spinothalamic tract - Contralateral loss of pain & temperature from trunk & extremities
• Spinal trigeminal nucleus and tract - Ipsilateral loss of pain & temperature sensation from face
• Vestibular Nuclei - Nystagmus, nausea, vomiting & vertigo
• CN VII - Ipsilateral paralysis of face (LMN),Ipsilateral loss of lacrimation & reduced
salivation. Ipsilateral loss of taste from anterior 2/3 of tongue,Loss of corneal reflex (efferent
limb)
• CN VIII(Cochlear nuclei) - Hearing loss - ipsilateral central deafness

******BRAINSTEM DEATH

• Fixed pupils which do not respond to sharp changes in the intensity of incident light.
• No corneal reflex.
• Absent oculovestibular reflexes – no eye movements following slow injection of at least 50ml
of ice-cold water into each ear in turn (the caloric reflex test).
• No response to supraorbital pressure.
• No cough reflex to bronchial stimulation or gagging response to pharyngeal stimulation.
• Confirmation - apnoea test - No observed respiratory effort in response to disconnection of
ventilator for long enough (5 min) to ensure elevation of arterial Pco2 to at least 6.0 kPa (6.5 kPa
in patients with chronic carbon dioxide retention)

FUNCTIONS OF RETICULAR FORMATION

• Control of skeletal muscle
• Control of somatic and visceral sensations
• Control of the autonomic nervous system
• Control of the endocrine nervous system
• Influence on the biologic clocks
• Arousal & level of consciousness

[ ] CAVERNOUS SINUS

STRUCTURES PASS THROUGH

• Internal carotid artery
• CN VI
• Sympathetic nerve plexus

IN THE WALL
• CN III,IV,Va,Vb (Oculomotor,Trochlear, Ophthalmic,Maxillary)

TRIBUTARIES

FROM EYE
• Superior ophthalmic vein
• Inferior ophthalmic vein
FROM BRAIN
• Superficial middle cerebral vein
• Inferior cerebral vein
FROM MENINGES
• Sphenoparietal sinus

BRANCHES OF INTERNAL CAROTID

• Ophthalmic artery
• Anterior cerebral artery
• Middle cerebral artery
• Posterior communicating artery
• Choroidal artery

ENDING
• At L1 - Spinal cord
• At S2 - Dura & Arachnoid matter, Epidural,Subdural & Subarachnoid space

LIGHT REFLEX PATHWAY

Optic nerve - Chiasma - Tract - pretectal nucleus - EW nucleus - Ciliary ganglion - Short Ciliary
nerve - Constrictor pupillae

CORNEAL REFLEX PATHWAY

Touch of cornea - Nasociliary branch of V1 - Central nucleus of pons - Temporal & zygomatic
branch of facial nerve - Orbicularis oculi - Blinking

ACCOMODATION REFLEX

Optic nerve - Chiasma - Tract - LGB - Primary & Secondary visual area - (Frontal eye field -
Somatic CN III - Medial recti - Convergence) + ( Pretectal nucleus of midbrain - EW nucleus -
Ciliary ganglion - Short ciliary nerve )

CRANIAL NERVES
SSA - 2,8
SVA - 1,7,9,10
SVE - 5,7,9,10,11 (Muscles of brachial arch)
GSA - 5,7,9,10
GVA - 7,9,10
GSE - 3,4,6,12 (Pure motor)
GVE - 3,7,9,10 (Parasympathetic)

OCULOMOTOR NERVE
• GSE - levator palpebrae superioris, superior rectus,medial rectus,inferior rectus & inferior
oblique muscles
• GVE - preganglionic parasympathetic to the ciliary ganglion

TRIGEMINAL NERVE

• GSA - skin of face

• SVE - innervate muscles of mastication via mandibular division.

FACIAL NERVE

• GVE (Parasympathetic - Superior salivatory nuclei) - lacrimal, sublingual,

submandibular,mucosa of nasal cavity.
• SVE - muscles of facial expression, stapedius,posterior belly of digastric & stylohyoid
• GSA skin of the posterior ear
• GVA soft palate & parts of the nasal cavity
• SVA taste to anterior two-thirds of tongue via chorda tympani

GLOSSOPHARYNGEAL NERVE

• GVE - parasympathetic fibers to parotid gland via otic ganglion

• SVE - stylopharyngeus muscle, the only motor component of this cranial nerve.
• GSA - from tonsils,pharynx,middle ear & posterior 1/3 of tongue
• GVA - from the carotid bodies, carotid sinus
• SVA - from posterior 1/3 of tongue

PHYSIOLOGY

[ ] PRINCIPAL NEUROTRANSMITTERS
• Acetylcholine (nicotinic),
• L-glutamate
• GABA

[ ] NEUROMODULATORS
• Acetylcholine (muscarinic)
• Serotonin
• Histamine

[ ] FUNCTION OF NEUROGLIA

FIBROUS
• Provide supporting framework
• Electrical insulators
• Limit spread of feetneurotransmitters
• Take up K ions
PROTOPLASMIC
• Store glycogen
• Have a phagocytic
• Take place of dead neuron
• Conduit for metabolites or raw perivascular feetmaterials
• Produce trophic substances

MICROGLIA
• Proliferate in disease and phagocytosis

OLIGODENDROCYTES
• Form myelin in CNS
• Influence biochemistry of neurons

EPENDYMOCYTES
• Circulate CSF,absorb CSF

TANYCYTES
• Transport substances from CSF to hypophyseal-portal system

CHOROIDAL EPITHELIAL
• Produce and secrete CSF

[ ] CLASSIFICATION OF NERVE FIBER

A (MYELINATED)
Alpha
• Proprioception
• Somatic motor
Beta
• Fine touch
• Vibration
• Pressure
Gama
• Motor to muscle spindle
Delta
• Crude touch
• Fast pain
• Temperature

B (MYELINATED)
• Preganglionic autonomic

C(UNMYELINATED)
Dorsal root
• Slow pain
• Temperature
Sympathetic
• Postganglionic sympathetic

SUSCEPTIBILITY

• Pressure : A>B>C
• Local anaesthetic : C>B>A
• Hypoxia : B>A>C

[ ] NEUROTRANSMITTER (FAST ACTING)

EXCITATORY
• Glutamate
• Epinephrine
• Acetylcholine
• Substance P

INHIBITORY
• GABA
• Dopamine
• Serotonin
• Glycine
• Alanine
• Taurine

BOTH
• Acetylcholine
• Nor epinephrine
• Histamine
• Prostaglandin5 - HT

# Neurotransmitter + Aspartate + NO - Rapidly acting transmitter

#Neuropeptide - Mostly hormone - Slowly acting

CHOLINERGIC NEURON

• All preganglionic
• All postganglionic parasympathetic
• Sympathetic postganglionic that innervates sweat gland,blood vessels on skeletal muscle
# Sympathetic postganglionic - Secrete norepinephrine,not epinephrine

FACTORS AFFECTING SYNAPTIC TRANSMISSION

• pH - Alkalosis increases activity
• O2 - Hypoxia decreases activity
• Ca - Hypocalcemia increases activity
• Anaesthetic drug + Botulinum - Decrease
• Tetanus - Increase

FACTORS OF CBF

• Arterial pressure - Proportional

• Venous pressure - Inversely proportional
• ICP - Inversely proportional
• Viscosity - Inversely proportional
• pH - Inversely proportional
• Po2 - Inversely proportional
• Pco2 - proportional

[ ] BLOOD BRAIN BARRIER

STRUCTURE

• Endothelial cells of capillary wall

• Endothel basement membrane
• Foot process of astrocytes

PERMEABLE SUBSTANCE

• O2, CO2, H20

• Na, K, Cl, Glucose
• NH3, Urea
• L-dopa, Chloramphenicol, Sulfonamide, Tetracycline,Cefuroxime,3rd & 4th generation
Cephalosporin
• Anxiolytic, Anaesthetic, Atropine, Alcohol,Morphine, Phenytoin, Heparin, Penicillin
(inflammed meninges), Beta blocker

RESTRICTED SUBSTANCES

• Bile pigment, Bile salt

• Catecholamine
• Dopamine, Carbidopa
• Penicillin, Phenylbutazone,1st & 2nd generation Cephalosporin except Cefuroxime

AREAS DEVOID OF BARRIER

• Pineal gland
• Posterior pituitary
• Area postrema
• Optic recess wall
• Organum vasculosum of lamina terminalis (OVLT)
• Supraoptic crest
• Tuber cinereum
• Ventral part of median eminence of hypothalamus

ENCAPSULATED RECEPTOR

• Meissner's corpuscles
• Pacinian corpuscles
• Ruffini's corpuscles
• Neuromuscular spindle

NON ENCAPSULATED RECEPTOR

• Free nerve endings

• Hair follicle receptor
• Merkel's disc

EXTRAPYRAMIDAL SYSTEM

• Basal ganglia
• Reticular formation
• Red nucleus
• Subthalamic nucleus
• Vestibular nucleus

DESCENDING TRACTS

1. Pyramidal
• Corticospinal
• Corticonuclear
2. Extrapyramidal
• Reticulospinal
• Rubrospinal
• Vestibulospinal
• Olivospinal
• Tectospinal
• Descending autonomic fibers

DORSAL COLUMN
• Fine touch
• Vibration
• Two point/Tactile discrimination
• Tactile localisation
• Kinesthetic sensation
• Sesory pathway for superficial reflex
ANTERIOR SPINOTHALAMIC
• Crude touch
• Pressure

LATERAL SPINOTHALAMIC
• Pain
• Temperature
• Tickling & itching
• Sexual sensation

# Conscious proprioception - Dorsal column - Cerebrum

# Unconscious proprioception - Dorsal & vetral spinocerebellar pathway (Mainly lower limb) -
Cerebellum
# Upper limb - Cuneo cerebellar & Rostral spinocerebellar pathway
# Chemical stimuli for pain - Histamine, Serotonin,Bradykinin,K+, Acetylcholine,Acid
Proteolytic enzyme
# Increase sensitivity of pain endings - Prostaglandin & Substance P
Endogenous opioid peptides - Enkephalin, Endorphin, Dynorphin