Questions
QUESTIONS
TUMOR
  • Tumor w/ MRI + T1 low, T2 high, restricted diffusion
  • Most common intracranial tumor a/w NF1

GBM
  • Temporal cyst, displaces arteries & nerves, near basal cisterns
  • Seizures, cystic mesial temporal lobe T1 dark, T2 bright, mild enhancement
  • Most common mets to brain
  • Multiple meningiomas a/w
  • CPA - rad tumor differential






  • Ependymal enhancement, nodular, irregular
  • MENS



  • BCNU / carmustine - unique SE
  • Meningioma - common chromosomal abnormality
    Most aggressive types
    Immunochemistry
  • Calcification, hemorrhage, cystic, T1 heterogeneous, mild enhancement
  • FDG PET (+ in GBM, recurrent tumor). Hypometabolism in radiation necrosis.
  • Glomeruloid vascular proliferation, pseudopalisading cells
  • GOF: 7, 20
  • Loss of allele: 10p, 10q, 9p, 19q

  • Br > Lu > Kd > Melanoma
  • Fourth ventricle
  • Sclerosis, T1/T2 dark, variable enhancement, +/- cystic
  • I: pancreas, pituitary, PTH
    II: PTH, pheochrom, medullary thyroid
  • III: pheochrom, medullary thyroid, mucosa neuromas
  • Stalk effect: compression on stalk --> decreased dopamine --> no inhibition on prolactin --> mild elevation (25-150)
  • Hook effect: so much prolactin that Ab/prolactin completely bound. Need to dilute 1: 100. 
  • Pulmonary fibrosis / interstitial fibrosis
  • Monosomy 22
  • RAP: rhabdoid, anaplastic, papillary
  • Vimentin, desmosome
  • Cushing's disease: responds to HIGH dexamethasone test, metapyrone
  • schwannoma, meningioma, ependymoma, astrocytoma - NOT neurofibromas
  • Germinoma: PTAH (clear cells, granulomatous inflam, lymphocytes)
  • Teratoma: AFP, CEA
    Yolk sac: AFP (Schilar Duval)
    Chorio: HCG (syncytiotrophoblasts)
    Embryonal: all
  • VHL: tumors a/w
  • Hemangioblastoma w/ abnormal CBC



  • Staghorn vasculature - tumor
  • Cerebellar hemangioblastoma, retinal hemangioma, paraganglioma, pheochromocytoma, RCC, cysts, endolymphatic sac tumors
  • Polycythemia vera
  • Susentacular cells: S100+
  • Chief cells: synaptophysin, chromagranin A, neurofilament
  • TN, peripheral neuropathy, hypopit, osteogenic sarcoma
  • CN V
  • Pituitary hyperplasia + reticulin
  • Wave I, 2, 3 (AC SLIM)
VASCULAR
  • Dural AVF - 
    Spinal Type 1: tx
  • SAH - perimesencephalic management
  • Lindegaard ratios account for
  • Vitrous hemorrhage a/w SAH


  • ICA artery a/w tentorial meningiomas & AVMs
  • Amaurosis fugax, polymyalgia rheumatica, HA, 60s - dx
  • How to prevent optic nerve damage when opening for ophthalmic artery aneurysm clipping
  • GRE, Angio neg +/- vascular blush, AD
  • Cav mal - NO intervening brain vs. AVM - intervening brain
  • Embolization
  • Retrograde cortical venous drainage
  • Angio, cardiac/electrolyte, HCP monitoring. No need for vasospasm watch
  • LR: hyperremia vs. vasospasm
  • Terson's syndrom

  • Anticoagulation
  • Fetal PCA: Pcomm -> PCA
    PTA: Cavernous ICA
    Otic: Petrous ICA
    Hypoglossal: Cervical ICA
    Proatlantal: ICA/ECA
  • Early release of falciform ligament
SPINE
  • Vertebral body collapse, lytic with no sclerosis
  • Asthma pt on chronic steroids or obese pt w/ lumbar stenosis, T2 bright dorsal lesions
  • Polka dot sunburst vertebral body
  • Discs - types of collagen

  • Lumbar spine w/ pain @ night, alleviated by ASA
  • Cervical spine
    NF-2
  • Indicates granulation
    • If rim enhanced --> reherniated disc
    • If grossly enhanced --> scar or chronic reherniated disc with capillary ingrowth
  • Odontoid tip > McRae or Wackenheim. >4.5 mm McGregor, >6 mm Chamberlain
  • Type 1: anterior
    Type II: vertical >2mm
    Type IIb: + C1-2 laxity
    Type III: posterior
  • Hyperflexion
  • Nucleus propulsus - Type II
  • Annulus fibrosis - Type I
  • Thoracic spine
  • Hyperextension
  • Sprengel's deformity, Chiari I, basilar impression, GU abnormalities
  • 30 mg/kg x 15 min, then 5.4 mg/kg/hr x 23 hrs
FUNCTIONAL
  • VPL / ViM (medial lemniscus/STT)
  • Periaqueductal gray
  • CL GPi or VL thalamus
VENTRICLES
  • Low pressure HA after LP. MRI + leptomeningeal enhancement & thickening
  • Septum pellucidum, T1 Isointense, mild enhancement
  • Only non-enhancing ventricular tumor
  • Islands of blue in sea of pink
  • Vulnerable areas of hemorrhage in premies vs. full term

  • Endoderm
PEDIATRICS
  • 12M, CN deficits, T2 diffuse pontine lesions
  • HCP, cerebellar sx w/ midline enhancing posterior fossa lesion
  • Infant w/ seizures & bilateral basal ganglia calcifications
  • Fused thalami, monoventricle, peripheral rim of undifferentiated cerebral tissue, craniofacial abnormalities, polydactyly, trisomy 13
  • Small, agyric brain, thin cortical mantle, BL calcification, atrophy, HCP in infant

  • Choroid plexus papilloma - most common location in kids
  • Chiari II malformation a/w which bone abnormalities: 
  • Opsoclonus, myoclonus, encephalopathy
  • Tumor origin
  • Amplified gene
  • Precocious puberty, gelastic seizures - dx
  • None. If risk for mechanical injury or >4 yo for cosmesis, cranioplasty
  • Gestational DM
  • Secondary neurulation
  • Cardiac

  • Lateral ventricle (left)
  • GP, thalamus, subthalamus, dentate nucleus
  • Both: AD, frontoethmoid synostosis, FGF-R mutation
  • Aperts: MR. Crouzon's: more common
  • Tower skull = Oxycephaly
    Clover shaped = Kleeblattschadel

    Metopic = Trigonocephaly
    BL lamboid or coronal = Brachiocephaly
    UL lamboid or coronal = Plagiocephaly
    *Sagittal = Dolichocephaly / Scaphocephaly
TRAUMA
  • DAI - areas involved



  • Square ACA sign 
  • GI bleeds a/w closed head injuries
  • Petechiae chest/shoulders, SOB/tachy, stroke, after fracture
  • SDH - predictor of expansion
  • brainstem, deep white matter, corpus callosum, thalamus
  • IB, ID, BD, BB, DD.
  • Extracellular x 3, Intracellular.
  • Ox, Deoxy, Meth x2, Hemosiderin
  • Pseudomembrane hemorrhage
  • High ICPs / herniation --> pontine perforator stroke / hemorrhagic conversion
  • Cheyne Stokes - BL cerebral
    Central neurogenic: midbrain
    Apneustic: pons
    Cluster: pontomedullary
    Ataxic / biot: medulla
    Odine's curse: cervicomedullary
CRITICAL CARE
  • high K: tx w/ symptomatic EKG changes
  • U waves, muscle weakness, AMS
  • Peak T, prolonged PR interval, QTC
  • Torsades de pointes, a/w other electrolyte abn
  • Hemolytic anemia, decreased CO, decreased tissue O2 availability
  • Hyperreflexia, tetany
  • Cerebral edema, seizures, encephalopathy
  • SIMV - settings and variability

  • 2 arrhythmias tx'd with IV Mg
  • VWF - lab abnormalities, Tx


  • CSW vs. SIADH
  • Dx
  • Correction rate
  • Complication if too quick
  • Free Na deficit
  • Tx

  • DI - free H20 deficit
  • Anesthetics
    -tension pneumocephalus, increase CBF, CMRO2
    -increase CBF, disrupt autoregulation
    -Increases seizure threshold
    -reduces CMRO2, increases CSF absorption
    -Reduces CBF, ICP, cortisol production
    -Uncouples CBF, CMRO2
    -Most reduction in CMRO2
  • Best indicator of adequate tissue perfusion
  • MI: tx, Indications for IV TPA
  • Ca gluconate
  • Vagal maneuver, adenosine
  • set volume & rate, synchronized to pt's breath with ability to breath over vent
  • Sinus tachy, T wave changes > S1 wide, Q3 long, T3 inverted
  • Hypotension, JV distension, muffled heart sounds
  • Abs vs ABO vs. leukocytes
  • Graft vs. host disease
  • Long PTT, BT
  • Cryoprecipitate (Factor VIII, VWF), desmopressin (increases release of VWF)
  • CVP 3-8
    CI 2.5-4
    PCWP 6-12
    SVR 900-1200
  • All low: neurogenic
  • All low, except high SVR: hypovolemic, anaphylactic, late sepsis
  • High CVP, PCWP, SVR, low CI: cardiogenic
  • Low SVR, high CI: sepsis
  • Normal: pH 7.4, pCO2 40, HCO3 24
  • Resp alkalosis/acidosis: 0.008(PCO2+/-40)
  • Met alkalosis: 0.7(HCO3) +20 +/-2
  • Met acidosis: 1.5(HCO3) +8 +/-2
  • Early sepsis: respiratory alkalosis
  • Late sepsis: metabolic acidosis
  • Trauma: resp/metabolic alkalosis
  • Both: Na <135, sOsm <280 (low)
    CSW: hypovolemic, UNa >20
    SIADH: eu/hypervolemia, uOsm>sOsm
  • <12 mEq/L / day
  • CPM
  • TBW (125-Na)
  • Tx: SIADH - fluid restriction, 3%, demeclocycline, hemodialysis
  • TBW (Na -140) / 140
  • Beta 1: dopamine low
    Beta 1 = Beta 2: epinephrine low, dobutamine, isoproterenol
    Beta 1 = Alpha 1: dopamine mod, NE
    Alpha 1: phenylephrine, dopamine high
    All: epinephrine high
  • BL pulmonary infiltrates
  • PaO2/FiO2 <200
  • PCWP <18
  • CRP, fibrinogen, haptoglobin
  • MONAB, TPA if CP >30 min <12h, no CHF or hypotension
  • Toxicity: delirium, abd pain, SOB, n/v
  • Tx: methylene blue
  • Thyrotoxicosis after iodine contrast in pt w/ toxic nodular goiter
  • TPN -  acid-base disorder, other SE


  • Coumadin - factors inhibited, reversal tx
  • Tension PTX - tracheal deviation, tx

  • After induction, acute onset increase end tidal CO2, skeletal muscle rigidity, fever - dx & tx
  • ARF: 
    Leukocyte casts
    Epithelial casts
  • High: PT, PTT, D-dimer
    Low: fibrinogen, platelets
  • Pontine micturation center, Detruser atonic, Bethanecol
  • NS, lasix, calcitonin, bisphosphonate, dialysis
  • Hyperchloremic metabolic acidosis, hepatic cholestasis, low vitamins/minerals/fatty acids, high volume/glucose
  • Factors II, VII, IX, X, proteins C, S
  • HTN, hypernatremia, metabolic alkalosis, hypokalemic, hypoMg
  • Away from PTX, emergent needle thoracocentesis --> thoracostomy
  • Distal convoluted tubule. Rids Na, K. Resorbs Ca, uric acid, lipids.
NEUROLOGY
  • HSV appearance on MRI

  • GPi hypodensity on CT
  • NF1 dx, genetics



  • Best AEDs and seizure types





  • Poisons - name disease & tx: 
    Sx: Hypochromic anemia. Gingivostomatitis/psych. Cardiomyopthy/pancytopenia/hypotensive shock. 
    Txs: Fe, Lead in children, Wilson's, Manganese, Arsenic
  • Vitamin to prevent peripheral neuropathy in isoniazid pts
  • Lowers seizure thresold - antiemetic
Histology bodies 
  • Ubiquitin
  • P-Tau
  • Lewy body components
  • Opalsky, Alzheimer's II
  • Bunina bodies
  • Polyglucosans
  • Hirano bodies: diseases

  • ALS - AD gene
  • sx
  • pr
  • a/w
  • Fe in GP, Snr, MRI eye of the tiger: dx, gen
  • AD, 80% penetrance, SEGA, subependymal nodules, cortical tubers
  • Temporal lobe - T2 bright, contrast enhancing
  • High during seizures, low interictal
  • 6 cafe au lait, axillary freckling, 2 neurofibroma (or 1 plexiform), optic glioma, 2 lisch nodules, sphenoid dysplasia, relative w NF1. AD, 100% penetrance
  • GTC: pheytoin
    CPS: carbamezepime 
    Lennox-Gaustault: valproic acid
    West: ACTH
    Absence: ethosuccimide (valproic if GTC)
    Neonatal: phenobarbital 
  • Increase CBF, cerebral perfusion. Uncouples flow w/ metabolism --> decrease CMRO2. Shunts blood from normal to ischemic brain. T1/2 100 hrs
  • Sx: Lead, Mercury, Arsenic
  • Tx: Deferoxamine, succimer, pennicillamine, L-Dopa, BAL

  • Vitamin B6 / pyridoxine
  • Ubiquitin: bunina, marinesco, Lewy body, Pick
  • P-Tau: Pick, neurofibrillary tangles, plaque
  • Lewy body: ubiquitin, a-synuclein, aB crystallin, neurofilaments
  • Wilson's disease
  • ALS
  • Lafora bodies
  • Alzheimer's Pick
  • Hippocampus, frontal (spares occipital and motor cortex)
  • Forgetfulness / auditory hallucinations (in elderly)
  • SOD
  • UMN, LMN in UE, speech, swallow
  • Fatal in 3-5 yrs
  • parkinson's
  • HLA A3, B7, DR 2, 3, 15
  • Sporadic
  • Hunters: X linked, less MR
  • Hurler's: Ar, corneal clouding
  • Hippocampus (CA1>CA3), cortex 3, 5, 6, watershed, basal ganglia, cerebellum Purkinje cells 
  • Subthalamic nucleus infarct, no glutamate (from STN to GPi/SNr), dopamine.
  • ACh Ab, MUSK, weak w/ stimulation, Tensilon +
  • EOMI, but no accomodation, facial weakness, ascending paralysis - dx
  • Leukodystrophy
  • aspartocytase deficiency + subcortical U fiber involvement
  • HMSN: Refsum's deficiency
  • Abdominal pain/diarrhea, fever/tachy/HTN, acute paranoia - Dx, Tx


  • Painful ophthalmoplegia, CN palsies - dx, loc, MoA



  • Can't write, count, tell fingers or R/L apart
  • Infant w/ extensor spasms: EEG, Dx
  • X linked
  • Polymyositis: T cells, within muscles, EMG fibrillations
  • Dermatomyositis: B cells @, a/w cancer
  • High: homocystine, methionine
    Low: cystathione B-synthase
    Tx: low proteins, B12, B6, cysteine
  • Ch 4, AD, CAG w/ anticipation, caudate nucleus, indirect pathway
  • Glucocerebrosidase


  • Canavan's

  • Phytanonoyl-CoA hydroxylase
  • Tolosa-Hunt, lateral wall cavernous sinus, granulomatous inflammation
  • Vernet: 9, 10, 11, IC
  • Collett-Siquard: 9, 10, 11, 12, EC
  • Villarett: 9, 10, 11, 12, SNS, RP
  • Leigh's (from nuclear DNA)
  • I: Von Gierke's --| glucose 6 phosphatase
    II: Pompe --| lysosomal lactate maltase
    III: Cori's --| debranching enzyme
    V: McArdle's --| myophophorylase
    VII: Tauri's --| phosphofructokinase
  • frataxin gene, GAA repeats, 10-15 yo M, DCML, CST, spinocerebellar. Cardiac.
  • Stage 1: alpha -> slow voltage
    Stage 2: sleep spindles, K
    Stage 3: sleep spindles, K, <50% delta (somnoambulism, night terrors, enuresis)
    Stage 4: >50% delta
    (somnoambulism, night terrors, enuresis, deep sleep)
    REM: diverse, EtOH withdrawal, sleep deprivation, OSA.
  • Starts w/ REM, = total sleep/24h, hypagnogic hallucinations (beginning), cataplexy, paralysis of voluntary muscles except EOMs, low orexin from hypothalamus.
INFECTIOUS
  • Lacunar infarcts --> gelatinous pseudocyts
  • Asymmetric, periventriclar, white matter w/ subcortical U fiber, parietal-occipital (+/- BG, brainstem, cerebellum), T1/T2 hyperintensities
  • Symmetric, frontal (centrum semiovale) T2 hyperintesity
  • Eccentric target sign
  • Periventricular hyperintensity, FLAIR +
  • Cerebral abscess: Stages of formation
    Most common organism



  • Meningitis: most common organisms
  • Skull fx
  • Shunt
  • Neonates
  • Infants
  • Adults
  • Elderly
  • Fungus: southwest dust, endospores inside bigger spore
  • TB: intracranial location
  • Retro-orbital pain, CN VI palsy, draining ear - dx
  • Akinetic mutism - structures involved


  • EBV: Epstein-Barr virus 
  • <1 wk: Early cerebritis: inflammation
    1-2 wk: Late cerebritis: ring enhancement
    2-3 wk: Early capsule: necrotic center
    >3 wk: Late capsule: gliotic capsule
  • Strep milleri
  • Vitamin B6
  • S. pneumoniae 
  • S. epidermidis
  • GBS, Ecoli, Listeria
  • S. pneumo, N. meningitis, H. influenzae
  • S. pneumo, N. meningitis
  • S. pneumo, Listeria, GNR

  • Direct cytotoxic assay
  • Hyphae non-septated vs. septated
  • Basal
  • RAS, thalamus, hypothalamus, cingulate gyrus
ANATOMY
  • Midline sulci immediately posterior to central sulcus
  • Pars marginalis
  • Hippocampus dentate nucleus, subependymal zone, olfactory lobe
  • Parkinson's/infratrochlear
  • Glascock/posterolateral
  • Kawase's/posteromedial
SURGERY
  • CPA approach for intracananilicular lesion w/ preserved hearing
  • Sitting position, low end tital CO2 (cough, hypotension, hypoxia) - dx, tx, a/w
  • Venous air embolism
  • Tx: Hemostasis, irrigate surgical field, lower head, left lateral decubitus, TEE
  • A/w: upright position, open sinus, DBS
  • 2 months