neuro for the not so neuro minded l.
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  1. NEURO-FOR-THE-NOT-SO-NEURO-MINDED Barb Bancroft, RN, MSN, PNP CPP Associates, Chicago, IL

  2. Prime real estate of the brain Comprises one-third of the cerebral cortex This is your “Mother” “No, negative, don’t, stop…” She is inhibitory.. Socialization THE FRONTAL LOBES…

  3. “Mom” and socialization • Frontal lobes are not mature in babies and young children…it actually takes about 17-22 years for full maturity of the frontal lobes • “Don’t scratch, don’t pick, don’t dig..” • Judgment • Insight

  4. FRONTAL LOBES… • Alcohol and socialization • Loss of inhibitions with .05 blood alcohol levels • Baso-orbital region and the loss of inhibitions in patients with dementia

  5. Acetylcholine…cognitive function • Alzheimer’s disease—90% of acetylcholine is lost with destruction of brain tissue • Amyloid plaques and neurofibrillary tangles • BAP v.s. TAU • Tumeric (cucurmin) and beta amyloid • Acetylcholinesterase inhibitors

  6. Alzheimer’s… • The Alzheimer’s brain • Cortical atrophy • Sulcal widening • Atrophy of gyri • Brain weight

  7. Quick mental status check… • Time and Change Test Clock with hands—What time is it? 3 quarters, 7 dimes, 7 nickels—Can you give me change in the amount of $1.00? 97% negative predictive value if correct on both parts of the test

  8. Clock drawing…global function

  9. Frontal lobes… • Voluntary speech center • Dr. Pierre Paul Broca • Broca’s aphasia • Non-fluent aphasia—telegraphic, staccato speech

  10. Frontal lobes… • Pre-central gyrus (motor cortex—upper motor neurons) • Voluntary movement center

  11. Upper Motor Neurons/CS tract • Contralateral hemiparesis • Pronator drift • Hemiparalysis (spastic paralysis) • Head injury, stroke,tumors

  12. “And that’s why we always stand to the side when we check reflexes…” • Hyperreflexia • Babinski—extensor plantar reflex

  13. TEMPORAL LOBES… • Wernicke’s area—reception of speech • Do you understand what I am telling you? • Interpretation of speech and sounds • Coins jingling in pocket • Auditory agnosia

  14. TEMPORAL LOBES… • Cranial Nerve VIII (Acoustic Nerve) “hears” for you…(primary sensory modality) • The Superior Temporal Gyrus (STG) interprets what you are hearing (higher cortical function) • What am I hearing?

  15. TEMPORAL LOBES… • Cranial Nerve I “smells” for you (primary sensory modality) • The uncus interprets what you are smelling (higher cortical function) • The uncus is connected to the hippocampus (memory)

  16. TEMPORAL LOBES… • Inferior surface of frontal and temporal lobes--a meningioma displacing the olfactory nerve (cranial nerve 1) • Loss of smell • Loss of inhibitions (baso-orbital frontal lobe)

  17. TEMPORAL LOBES… • An “aura”—the beginning of a temporal lobe seizure with a funny taste or smell (rotten eggs) • Anosmia—loss of smell or the loss of the ability to interpret smell may be the first sign of a neurodegenerative disease (PD, DAT)

  18. TEMPORAL LOBES… • Déjà vu—feeling like you’re been there before • Jamais vu—familiar place becomes totally unfamiliar • Hallucinations—seeing or hearing something that is not there • Illusions—distortion of an ongoing stimuli • Drugs and hallucinations—boosting dopamine triggers hallucinations—drugs for Parkinson’s disease, hallucinogenic drugs and mushrooms, ETOH withdrawal, Herpes encephalitis • Marijuana and illusions

  19. TEMPORAL LOBES… • Self-preservation and preservation of the species—the autonomic nervous system • The 4 F’s…fight, flight • Feeding activities • And….

  20. Sexual Function And…

  21. Sexual function in the brain and dopamine… • SSRIs increase serotonin and you’re happy, but… • When serotonin goes up, dopamine goes down

  22. TEMPORAL LOBES… • Self-preservation and preservation of the species—The other 2 F’s • Flight—Fright (epi, NE) • Episodic dyscontrol syndrome—TBI patients

  23. TEMPORAL LOBES… • Recent memory (hippocampus) • Remember 3 items… • Red ball, clock, tennis shoe • Repeat them after me… • Red ball, clock, tennis shoe • Continue with exam for 10 minutes and ask them to repeat those 3 items • Post-traumatic stress disorder (cortisol receptors) • Depression and neurogenesis

  24. Loss of hippocampal cell function • Loss of recent memory • This is the first neurologic function to go with the aging process • When does this process begin? • When do you reach your peak mental capacity?

  25. TEMPORAL LOBES… • Partial complex seizures—altered state of consciousness; most common cause is a closed head injury; also consider a history of shaken baby syndrome; mid-forceps delivery • Automatisms • Semi-purposeful behavior

  26. PARIETAL LOBES… • Integration of tactile sensations—touch, pressure, vibration, and proprioception (do you know where your left buttocks is, right now?)

  27. PARIETAL LOBES..testing • Double simultaneous stimuli—kids vs. adults • Touch two areas at the same time.. • Kids will always neglect their body and will recognize touch on the face • The neglect syndrome in adults

  28. PARIETAL LOBES..testing • Ability to localize stimuli • Sharp vs. dull • Tests for proprioception • Graphesthesia • Apraxia—example: a dressing apraxia ideomotor apraxia constructional apraxia

  29. Abstraction… • What does “Don’t cry over spilled milk” mean? • HUH? • How are a car, plane and boat alike? • Cow, horse, and pig?

  30. OCCIPITAL LOBES… • Visual integration—problems manifest as cortical blindness (visual agnosia) • Do you see this object? • If they can see it, CN2 (the optic nerve) • What is it? The occipital cortex

  31. QUIZ… • What were those 3 items I asked you to remember?

  32. The 2nd area of the motor “triad” The BASAL GANGLIA…

  33. Paired nuclei at the base of the brain 50:50 balance between acetylcholine and dopamine All dopamine is made in the substantia nigra from melanin Gamma-amino butyric acid (GABA) keeps dopamine in check The basal ganglia… Caudate nucleus Globus pallidus Substantia nigra Subthalamic nucleus

  34. Dopamine • Dopamine levels decrease with aging gradually—we all slow down (loss of 45%) • Dopamine loss of greater than 80% results in signs and symptoms of Parkinson’s disease

  35. The BASAL GANGLIA The functions of the basal ganglia depend on a balance between various neurotransmitters GABA-- ↓ dopamine:acetylcholine 50:50 When this balance is disturbed, movement disorders occur

  36. The BASAL GANGLIA… • Control of movement, initiation and cessation of movement • Postural reflexes—the righting reflex

  37. Clinical symptoms • Resting tremor (70%)—unilateral or bilateral (unopposed acetylcholine in Parkinson’s patients) • Rigidity (decreased dopamine) (vs. spasticity of stroke patients) • Loss of voluntary movements (spontaneous) • Bradykinesia (decreased dopamine) (check gait) • Postural instability (sternal push) • Presence of severe seborrheic dermatitis suggests PD (unopposed acetylcholine) • Anosmia

  38. Huntington’s chorea…chromosome #4 • Excess dopamine due to the loss of GABA-minergic input from the degeneration of the caudate nucleus • Chorea—rapid, jerky movements of muscle groups • Dementia • Neuroleptic drugs to block dopamine

  39. Other movement disorders • Tourette’s syndrome • Athetoid Cerebral Palsy • Tardive dyskinesia

  40. The cerebellum—the 3rd area of the motor “triad”

  41. Coordination Synergy Balance Equilibrium The cerebellum…

  42. The cerebellum… • Romberg test—stand up with your feet together and close your eyes • Tandem walk • Close your eyes and touch your finger to your nose • Rapid alternating movements

  43. The cerebellum… • Truncal ataxia—wide, staggering gait • Dysdiadochokinesia—inability to make rapid alternating movements • Dysmetria—inability to light on an object (touching nose with finger, for example) • Dysarthria • Puppet-like movements

  44. THINK BOOZE and the CEREBELLUM The cerebellum…

  45. The CEREBELLUM… • Multiple sclerosis • Down syndrome • Spinocerebellar ataxia • (The cerebellum is not “strictly” motor—it also monitors sensory input from “the outside”—may play a role in autism and schizophrenia)

  46. Small cell carcinoma of the lung with mets to the cerebellum

  47. The BRAINSTEM…(the “bulb”) • Cardiorespiratory center—C2, C3 “Hangman’s fracture) • ARAS (Ascending reticular activating system) • Cranial Nerves III – XII (I and II are not located in the brainstem)

  48. The BRAINSTEM…(the “bulb”) • II (Optic) and III (Oculomotor)—light reflex, accommodation, and the optic disk (papilla)

  49. The BRAINSTEM…(the “bulb”) • II (Optic) and III (Oculomotor)—light reflex, accommodation, and the optic disk (papilla) • The Argyll Robertson pupil—it will accommodate but not react (to light)

  50. CN III, IV, VI—follow my finger (extraocular movements) The BRAINSTEM…