Since this was a pediatric neurology conference, the treatment course was discussed in the context of the brain. Impaired vasodilation in intracerebral vessels has been linked to brain damage. How do we increase blood flow to prevent said damage? With the potent vasodilator, nitric oxide (NO), of course. As a biochemistry major in undergrad, metabolic pathways always appealed to me. “Oh, ‘X’ becomes ‘Y’ which becomes ‘Z’ which is shuttled inside the organelle and phosphorylated to ‘Z-P’ and…” blah blah blah. A nightmare, right?

The figure above illustrates how our body normally synthesizes nitric oxide. Of interest, according to the speaker, L-citrulline is more efficacious than L-arginine in producing a vasodilatory effect – both substrates are included in the pathway above. Patients are currently started on regimens of L-arginine, but perhaps in the future, L-citrulline will become the mainstay as more evidence emerges.

Here are some other images:

Sagittal view

Coronal view

In spite of having looked at countless brain MRIs, looking at my own is totally different. I’m just glad it didn’t show… well… hollow space.

Certain populations are more susceptible to delirium, namely the elderly and those with existing mental conditions like dementia. It can be brought on by a tremendous variety of infectious, metabolic, and neuro processes making treatment difficult in many cases.

So how does this relate to our patients?

Let’s consider a simple scenario: John Doe notices his dad has been coughing a lot over the last two days, and started producing blood-tinged sputum this morning. He rushes his family member to the hospital and leaves to pick his sister up from the airport, so they can both come back and stay with their dad overnight. Upon returning, the patient seems lethargic and isn’t oriented to person, place, or time. He doesn’t pay attention to his kids whatsoever and requires forceful stimulation (firmly tapping his chest) to elicit a brief moment of eye contact.

Mental status is the link between a patient and his or her loved ones.

While at the bedside, John Doe and his sister could care less what their dad’s electrolytes are. Or what the chest X-ray could possibly show. Or how much of the hospital costs their insurance provider is going to cover. Loved ones care if the patient can appreciate an inside joke they share, what’s going on at school, what their plans are next week, etc. Imagine dropping off your parent in a stable mental condition only to be unacknowledged by them 12 hours later. If John Doe’s dad had pneumonia, congestive heart failure, or even terminal cancer, at least the “link” they share would still be preserved. They could share stories over laughter and be optimistic about the treatment course. But seeing a loved one fall into delirium… wow.

Delirium is indeed a medical emergency putting patients at an increased risk for morbidity and mortality; however, it seems that the impact it can have on the loved ones of a patient can be even more detrimental.

As with most neurological topics, the answer is “we don’t know for sure, but here’s our latest understanding.” When we make an observation, study, or just experience life in general, information bounces around in a “working memory” heavily regulated by the hippocampus for roughly fifteen minutes, and is then shipped off diffusely into the cortex. Long term memory is actually long term because the memory has structurally modified a neural network. The more we exercise said network, the more ingrained the memory becomes. What’s incredibly fascinating is that when we recall from our long term bank, the thought is placed back into working memory and risks being “knocked out” (theoretically) in the event of trauma.

Memory is a global process – there’s no single spot on the brain dedicated for remembering things, although they tend to be stored near their respective sensory origins. For example, things you’ve seen are stored more posteriorly towards the occipital lobe (primary visual cortex). Yet due to the brain’s amazing plasticity (especially early during infancy), in the event of a structural malformation or parenchymal damage, the already blurry distinction between structure and function is made even more obscure as neurons find a way to compensate for the defect.

So what modulates all of this activity? How do some people remember facts better than others? How do I find it easier to remember the lyrics to music from ten years ago but not the behavioral science lectures I covered yesterday evening? Well the real answer is no one really knows.

It’s just a testament to the tremendous complexity yet elegance of neuroscience.

Finally, I’ll get to peer inside this incredibly elegant organ outside of the operating room to see what it’s like in a normal (albeit preserved) state. No more pulsations with every heart beat. No more looking through a surgical microscope. This time, it’s just me and brain (perhaps with a scalpel and/or forceps too).

It’ll be a grueling eight weeks of trying to balance immunology (in which I’ve had no prior exposure) with pharmacology. Throw in some First Aid review of the first semester, a lot of head and neck anatomy, the beginning of a hate-hate relationship with pathology, and I’ve got one heck of a block ahead of me.

I do, however, see myself having fun. After all, enjoying something doesn’t imply that it’s easy.

With all due respect to his family, I wonder if/how Kim’s brain will be studied post-mortem. It would be an incredible contribution to science indeed.

First of all, let’s define “death.” It varies from state to state, but in most cases, it’s defined in terms of the heart and/or brain no longer being functional without assistance. What about the liver? And pancreas? Or your big toe? Apparently, legislation has already placed the heart and brain above all others.

So why is the brain more important than the heart? Heh, that’s an easy one – the heart is just a boring ‘ol muscle and the brain is three pounds of inconceivable perfection. But honestly, who’s heard of a brain transplant? Thanks to pioneers like the late Dr. DeBakey, cardiologists/cardiothoracic surgeons have countless techniques to alleviate (and cure) heart problems. Blocked coronary artery… oh, just get a bypass surgery (or two, or three, or four). Your heart doesn’t work?! Fear not, you’re on a transplant list and we’ll be able to keep you alive on a bypass machine. Abnormal rhythm? Psh, take this handy-dandy pacemaker! Now don’t get me wrong. With the high prevalence of heart disease, it’s a blessing that we have so many ways to combat such a terrible foe.

Note: There is a poll embedded within this post, please visit the site to participate in this post's poll.But how many times have you heard of a brain transplant or brain bypass? There are plenty of heart medications which people use for years without any noticeable side effects (essentially a “cure”). How many curative agents are there for Alzheimer’s or Parkinson’s? It’s such a mysterious organ which a tremendous amount of variability. It holds our cognitive skills, our memory, and our consciousness. Without it, you wouldn’t be able to read this.

If you’re a specialist in any of the not-so-neuro-related-fields, and I’ve offended you in any way, I do apologize and wish to remind you that the above is simply a testament to my 5 month old medical school mentality.