NEURO-FOR-THE-NOT-SO-NEURO-MINDED

Let’s start from the very beginning…

• How much embryology did you get in nursing school?

• The sperm meets the egg…

1 + 1 = 1

• 1 egg + 1 sperm = 1 zygote• 2 cells, 4 cells, 8 cells, 16, 32, 64, 128 • BLAST-o-cyst • Let the layers begin• Ectoderm (outer), endoderm (inner), mesoderm (filler)• Ectodermal origins—skin and nervous system

Neuroectodermal origins…skin and nervous system

• Von Recklinghausen’s disease

• Café au lait marks• Neurofibromas• Astrocytomas• Acoustic neuromas• Do cell phones cause

brain tumors?

NO, cell phones do NOT cause brain tumors…cell types in CNS

• Neurons• Glial cells—astrocytes, oligodendrocytes,

ependymal cells• Primitive cells--medulloblasts

Brain tumors arise from “glial cells”

• Astrocytomas• Oligodendrogliomas• Ependymomas• medulloblastomas

Neuroectodermal origins—the skin and nervous system

• The neural tube• 1st month• Anterior neuropore (cerebral cortex)• Posterior neuropore (spinal cord)

Anterior neuropore defects…

• Anencephaly• Encephalocele

Posterior neuropore defects…spina bifida syndromes

• Myelomeningocele• Meningocele• Spina bifida occulta• Dermal sinus tract• Rachischisis

Risk factors for neural tube defects…

• Folic acid deficiency• Drugs (anticonvulsants, ETOH, MTX, OCs*)• Obesity• Maternal age• Hyperglycemia• Hyperthermia• Prevention -- *BeYaz (new COC with folic acid)

Dermatomes…sensory input to spinal cord and brainstem segments

• C3,4 (shoulder* and referred pain)

• T4 (nipple)• T10 (umbilicus)• L1 (bikini underwear)• L3,4 (knees)• S1,2 (back of the leg)• S3-5 (perineum)

Herpes viruses and the nervous system…

• The Herpes “Family”—HSV-1, HSV-2, VZV are all neurotrophic viruses

• HSV-1• Prefers to lie dormant in the trigeminal nerve

dorsal root ganglion• V1, V2, V3 (Ophthalmic, maxillary,

mandibular)

The Herpes family…

• HSV-2—the dorsal root ganglion of S3,4,5• VZV—varicella zoster virus• Shingles or “hell’s fire”• V1 of the Trigeminal nerve

The Herpes “family”

• Varicella Zoster Virus (VZV)• Chickenpox is the primary infection• Shingles is the secondary infection• Rx?

The antiherpetics—the “cy{i}clovirs”

• Acyclovir (Zovirax)(4000/d)• Famciclovir (Famvir)(750/d)• Valacyclovir (Valtrex)(3000/d)Tx must be started within 48-72 hours after the first

signs of a rash appear. • +PrednisonePREVENTION• Zostavax (Merck) to reduce the incidence of Herpes

Zoster (shingles/Hell’s fire) in people over 60 (14 x stronger than Varivax)(risk reduction—50%); reduces severity and decreases post-herpetic neuralgia

Chronic neuropathic pain

• Post-herpetic neuralgia follows a dermatome distribution

• Drugs to Tx• Antidepressants that boost norepinephrine and

serotonin in the descending pain pathways of the brainstem--Amitriptyline (Elavil), duloxetine (Cymbalta)

• Anticonvulsants—gabapentin (Neurontin), pregabalin (Lyrica)

THE FRONTAL LOBES…

• Prime real estate of the brain• Comprises one-third of the cerebral cortex• Who’s your Mama? The frontal lobe is your “Mother”• “No, negative, don’t, stop…” She is inhibitory..• Executive functions—socialization, judgment, forward

planning

“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 human frontal lobes

• The TEENAGE brain• “Don’t scratch, don’t pick, don’t dig..”• Judgment• Insight

Abstraction…

• What does “Don’t cry over spilled milk” mean?

• HUH?• How are a car, plane and boat alike?• Cow, horse, and pig?

FRONTAL LOBES…

• Alcohol and socialization• Loss of inhibitions with .05 blood alcohol

levels• You lose your “FILTER”…MOM• Baso-orbital region and the loss of inhibitions

in patients with dementia/Traumatic Brain Injury

Acetylcholine…cognitive function

• Alzheimer’s disease—90% of acetylcholine is lost with destruction of brain tissue

• 1st described 1906• Amyloid plaques and neurofibrillary tangles• BAP v\s. TAU• Acetylcholinesterase inhibitors such as donepezil (Aricept)• Drugs that block NMDA receptors (memantine/Namenda)

CT scan of the demented brain

• Cortical atrophy; Sulcal widening• Atrophy of gyri• Brain weight• Alzheimer’s dementia, HIV dementia,

dementia pugilistica, nutritional dementia,Traumatic Brain Encephalopathy

Brain food? How about the incredible, edible egg? Berries? Marine Omega 3 fatty acids? Olive oil? B12

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

Clock drawing…global function

Frontal lobes…

• Voluntary speech center—left inferior frontal gyrus

• Kids• Dr. Pierre Paul Broca• Broca’s aphasia• Non-fluent aphasia—telegraphic, staccato

speech

The homunculus (“little man”)…

• Areas of greatest representation are the areas used the most

Frontal lobes…• Pre-central gyrus (motor cortex—upper motor neurons)—

contralateral control• Right pre-central gyrus controls left side• Left pre-central gyrus controls right side• Voluntary movement centers bilaterally• The neurons located in the pre-central gyrus are known as

“Upper Motor Neurons” or UMNs• The UMNs send their message through the Corticospinal tract

down through the white matter, into the brainstem where the pathway decussates or crosses to the other side in the medulla

UMN and CS tract synapse with LMN in the brainstem and spinal cord

The reflex arc…

• Sensory information into the spinal cord• Synapses in same spinal cord segment• Sent right back out via lower motor neuron to

the…• Peripheral motor nerve• S1,2 (Achilles); L3,4 (Patellar); C5,6 (Biceps);

C7,8 (Triceps)• 50% of the elderly (over 75) do NOT have an

Achilles reflex

Dermatomes…sensory input to spinal cord and brainstem segments

• C3,4 (shoulder* and referred pain)• T4 (nipple)• T10 (umbilicus)• L1 (bikini underwear)• L3,4 (knees)• S1,2 (back of the leg)• S3-5 (perineum)

Damage to the upper motor neurons/CS tract

Signs and symptoms of UMN disease include: • Contralateral hemiparesis• Pronator drift (weakness)• Hemiparalysis (spastic paralysis)• + Babinski (extensor plantar reflex)—is it

present or absent? (not positive or negative)

Josef Francois Felix Babinski• The Babinski reflex• Babinski, Josef Francois Felix,

(1857-1932), a Parisian of Polish origin, described the famous abnormality of the extensor plantar response seen in disorders involving the corticospinal tracts in a series of short articles beginning in 1896.

• English physicians used their “Rolls Royce” key

• “And that’s why we always stand to the side when we check reflexes…”

• Hyperreflexia

Causes of UMN signs and symptoms?

• Head injury• Spinal cord injury below the level of the lesion• Stroke• Tumor• Epidural• Subdural

Damage to the Lower Motor Neurons and the peripheral nerve to muscle

• NO INPUT• Loss of reflexes (areflexia)• Atonia/hypotonia• Flaccidity/muscle atrophy

UMN vs. LMN

Reflex Chart—normal vs. stroke

• Achilles, patellar, biceps, triceps (S1,2; L3,4; C5,6; C7,8)

• Normal--2+ to 3+

Reflex Chart—post-stroke

• Contralateral to stroke• Areflexia (shock after a

stroke)—0• As the brain recovers, and

there’s no “mother” (inhibition), the reflexes are uncontrolled

• Hyperreflexia 4+• TOES up

Reflex Chart—slipped disc at L5 compresses S1, S2

• Areflexia on the same side as the slipped disc

TEMPORAL LOBES…

• Superior temporal gyrus• Wernicke’s area—reception of speech• Do you understand what I am telling you?• Interpretation of speech and sounds• Wernicke’s aphasa– “I’m going to the

kredistan to get a preeble…want one?”• Jargon aphasia— “Ca, ca, ca, ca CAH!”

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?• Coins jingling in your pocket• Auditory agnosia

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)• Cranial Nerve 0 (Nervus Terminalis)—runs in tandem with

CN1; connects to the hypothalamic area of sexual function--pheromones

Clonal selectivity

• They stick their nose where the “sun don’t shine” and say… “You’re the one for me…”

Oops.

• Why don’t humans do that? Well we kind of do…

Because we have a “mother”—the frontal lobe…

• “Don’t even think about it…”

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)

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)

• **auras are also associated with migraine headaches…migraine with aura is a major risk factor for strokes

TEMPORAL LOBES…

• Déjà vu—feeling like you’re been there before• Jamais vu—familiar place becomes totally

unfamiliar• Illusions—distortion of an ongoing stimuli

(marijuana)• Hallucinations—seeing or hearing something

that is not there

Hallucinations

• Drugs and hallucinations—boosting dopamine triggers hallucinations—drugs for Parkinson’s disease, hallucinogenic drugs (LSD, peyote) and mushrooms, ETOH withdrawal, Herpes encephalitis

• Schizophrenia—dopamine and serotonin excess; Drugs used to treat schizophrenia block dopamine and serotonin; glutamate may play a role as well

• Causes of schizophrenia? Genetic? Maternal infection during a critical period of fetal brain development?

TEMPORAL LOBES…

• Self-preservation and preservation of the species—the autonomic nervous system

• The 4 F’s…fight, flight

• Feeding activities • And….

And…

• Sexual Function

Sexual function in the brain and dopamine…

• Dopamine plays a major role in the pleasure centers of the brain, including sexual pleasure

• SSRIs (prescribed for depression) increase serotonin and you’re happy, but…

• When serotonin goes up, dopamine goes down (in as many as 40-60% of patients on the SSRIs)

TEMPORAL LOBES…

• Self-preservation and preservation of the species—The other 2 F’s

• Fight—Flight (epi, NE)• Episodic dyscontrol syndrome—TBI patients

Dopamine and the nucleus accumbens

• Addiction and dopamine• Nicotine• Alcohol• Methamphetamine• French fries• The earlier you start, the greater the addiction

potential

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

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?

Loss of neurons and the hippocampus

• cortisol receptors and the hippocampus

• Chronic stress and depression

• Post-traumatic stress disorder

NEUROGENESIS

• November 1, 1998• Dr. Fred Gage and a colleague at the

Karolinska Institute in Sweden discovered that neurons CAN and DO regenerate

• Specifically in the hippocampus of the brain• How can neurogenesis be stimulated?

Neurogenesis

• SAY YES TO DRUGS!• (antidepressants and statins)• Exercise• Meditation

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• Treatment of partial complex seizures

PARIETAL LOBES…

• Integration of tactile sensations—touch, pressure, vibration, and proprioception (do you know where your body parts are right now?)

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

PARIETAL LOBES..testing• Ability to localize stimuli• Sharp vs. dull• Tests for proprioception• Graphesthesia• Tattoos may give a false negative

• Apraxia—example: a dressing apraxia, ideomotor apraxia,

constructional apraxia

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

QUIZ…

• What were those 3 items I asked you to remember?

The BASAL GANGLIA…

• The 2nd area of the motor “triad”

The basal ganglia…

• 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

Substantia nigra

Subthalamic nucleus

Globus pallidus

Caudate nucleus

The BASAL GANGLIA

The functions of the basal ganglia depend on a balance between various neurotransmitters

GABA-- ↓ dopamine:acetylcholine 50:50When this balance is disturbed, movement

disorders occur

The BASAL GANGLIA…

• Control of movement, initiation and cessation of movement

• Postural reflexes—the righting reflex

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

Clinical symptoms• Resting tremor (70%)—unilateral or bilateral

(unopposed acetylcholine in Parkinson’s patients)• Unilateral presentation with Parkinson’s; bilateral

presentation with Parkinsonism from drugs• 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

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

Other movement disorders

• Tourette’s syndrome (Giles de Tourette)• Athetoid (slow, writhing movements) cerebral

palsy—kernicterus (elevated bilirubin levels in newborns)

• Tardive dyskinesia

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

The cerebellum…

• Coordination• Synergy• Balance• Equilibrium• Muscle tone

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 (lighting on an object)• Rapid alternating movements

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—”scanning speech”• Puppet-like movements

The cerebellum…

• THINK BOOZE and the CEREBELLUM

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)

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 and have only a “central component”)• III – XII have their nuclei in the brainstem but send their

information via the peripheral nerves• Hence, III – XII have the capacity to “regenerate” their

peripheral components

Example of peripheral vs. central

• Amyotrophic Lateral Sclerosis—Lou Gehrig’s disease—central nervous system involvement of central brainstem nuclei (IX and X)—swallowing, speech

• Guillain-Barré syndrome (GBS)—peripheral demyelination of XI and X (the bulbar presentation)—difficulty swallowing, but patients have the capacity to recover

• Multiple Sclerosis—central demyelination• GBS—peripheral demyelination (undercooked

chicken)

The BRAINSTEM…(the “bulb”)

• II (Optic) and III (Oculomotor)—light reflex, accommodation, and the optic disk (papilla)

• Papilledema—swelling of the optic disk• Usually, but not always, indicates cerebral

edema• What are the circumstances?

The BRAINSTEM…(the “bulb”)

• II (Optic) and III (Oculomotor)—light reflex, accommodation, and the optic disc (papilla)

• The Argyll Robertson pupil—a pupil that will accomodate accommodate but not react to light—aka as “the prostitute’s pupil)

The BRAINSTEM…

• CN III, IV, VI—follow my finger (extraocular movements)

• End-positional nystagmus• Ptosis

The BRAINSTEM…

• V (Trigeminal) and VII (Facial)• Corneal reflex—touch cornea with a cotton

wisp and the patient blinks; if the patient is in a coma, use a syringe with saline drops

• VII (Bell’s palsy)—paralysis of facial muscles – smile, puff cheeks, frown

• Cause of Bell’s Palsy? Virus usually, also consider Borrelia burgdorferi if in an endemic area for deer ticks

The BRAINSTEM…

• IX (Glossopharyngeal) and X (Vagus)• The gag reflex• The uvula• Closing off nasopharynx—say “K, K, K”• Cleft palate

The BRAINSTEM…

• CN XII (Hypoglossal)—tongue movement and strength

• Left, right, midline

The PERIPHERAL NERVOUS SYSTEM

• Dermatome chart• Stocking-glove distribution with peripheral

neuropathy• The reflex arc—S1,2 (Achilles), L3,4(Patellar),

C5,6 (Biceps),• C7,8 (Triceps)

Peripheral neuropathy“Where in the H#!l did I put that sewing needle?”

Disease of the lower motor neuron or it’s pathway to the peripheral nervous system

• Peripheral neuropathy• Diabetes, alcoholism (thiamine deficiency—

B1), B12 deficiency• Heavy metals• Chemotherapy• others

Neuromuscular junction

• Disease of the neuromuscular junction—myasthenia gravis

• Muscle weakness—consider thyroid disease, drug-induced myopathy, polymyositis, inherited muscular dystrophies

• "No study has shown that a drug can do what we showed is possible with exercise", said study leader, J. Carson Smith. "People with MCI are on a very sharp decline in their memory function, so being able to improve their recall is a very big step in the right direction.“

• Journal of Alzheimer’s Disease, July 2013

• Not only did the cardiovascular fitness improve by ten percent in both groups during this time, but their cognitive abilities also improved. The memory recall function was enhanced and the brain worked more efficiently. At the end of the study, the subjects needed fewer neural resources to master the same memory tasks.

Thanks.

• Barb Bancroft, RN, MSN, PNP• CPP Associates, Inc.• Chicago, IL.• BBancr9271@aol.com• www.barbbancroft.com