Neurosurgery Self-Assessment Questions and Answers (2017, Elsevier PDF)

NEUROSURGERY SELF-ASSESSMENT This page intentionally left blank NEUROSURGERY SELF-ASSESSMENT Questions and Answers Rahul S. Shah, BSc(Hons), MBChB(Hons), MRCS(Eng) Specialty Registrar in Neurosurgery and Wellcome Trust Clinical Research Fellow University of Oxford Oxford, UK Thomas A.D. Cadoux-...

NEUROSURGERY SELF-ASSESSMENT This page intentionally left blank NEUROSURGERY SELF-ASSESSMENT Questions and Answers Rahul S. Shah, BSc(Hons), MBChB(Hons), MRCS(Eng) Specialty Registrar in Neurosurgery and Wellcome Trust Clinical Research Fellow University of Oxford Oxford, UK Thomas A.D. Cadoux-Hudson, DPhil, FRCS, MB BS Honorary Consultant Neurosurgeon Department of Neurosurgery Oxford University Hospitals NHS Trust Oxford, UK Jamie J. Van Gompel, MD Associate Professor of Neurosurgery and Otolaryngology Mayo Clinic College of Medicine Rochester, MN, USA Erlick A.C. Pereira, MA, BM BCh, DM, FRCS(Neuro.Surg), SFHEA Senior Lecturer in Neurosurgery and Consultant Neurosurgeon Atkinson Morley Neurosciences Centre, St George’s Hospital St George’s, University of London London, UK Foreword by Edward C. Benzel, MD Chairman, Department of Neurosurgery Center for Spine Health, Cleveland Clinic Cleveland, OH, USA For additional online content visit ExpertConsult.com Edinburgh London New York Oxford Philadelphia St Louis Sydney Toronto 2017 © 2017, Elsevier Inc. All rights reserved. The right of Drs. Rahul S. Shah, Thomas A.D. Cadoux-Hudson, Jamie J. Van Gompel, Erlick A.C. Pereira to be identified as author of this work has been asserted by them in accordance with the Copyright, Designs and Patents Act 1988. No part of this publication may be reproduced or transmitted in any form or by any means, electronic or mechanical, including photocopying, recording, or any information storage and retrieval system, without permission in writing from the publisher. 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With respect to any drug or pharmaceutical products identified, readers are advised to check the most current information provided (i) on procedures featured or (ii) by the manufacturer of each product to be administered, to verify the recommended dose or formula, the method and duration of administration, and contraindications. It is the responsibility of practitioners, relying on their own experience and knowledge of their patients, to make diagnoses, to determine dosages and the best treatment for each individual patient, and to take all appropriate safety precautions. To the fullest extent of the law, neither the Publisher nor the authors, contributors, or editors, assume any liability for any injury and/or damage to persons or property as a matter of products liability, negligence or otherwise, or from any use or operation of any methods, products, instructions, or ideas contained in the material herein. ISBN: 978-0-323-37480-4 Printed in China Last digit is the print number: 9 8 7 6 5 4 3 2 1 Content Strategist: Lotta Kryhl Content Development Specialist: Humayra Rahman Khan Project Manager: Srividhya Vidhyashankar Design: Miles Hitchen Illustration Manager: Lesley Frazier Marketing Manager: Rachael Pignotti  CONTENTS FOREWORD, VII 16 NEUROPSYCHOLOGY AND NEUROLOGICAL REHABILITATION, 236 PREFACE, IX 17 STATISTICS, 241 HOW TO PASS NEUROSURGICAL EXAMINATIONS, XI 18 PROFESSIONALISM AND MEDICAL ETHICS, 242 19 SURGICAL TECHNOLOGY AND PART I PRACTICE, 256 BASIC SCIENCE 1 NEUROANATOMY, 1 PART III 2 EMBRYOLOGY, 22 CRANIAL NEUROSURGERY 3 NEUROPHYSIOLOGY, 34 20 GENERAL NEUROSURGERY AND CSF DISORDERS, 257 4 NEUROPATHOLOGY I: BASICS, 55 21 CRANIAL TRAUMA, 268 5 NEUROPATHOLOGY II: GROSS PATHOLOGY, 66 22A CRANIAL VASCULAR NEUROSURGERY I: ANEURYSMS AND AVMS, 290 6 NEUROPATHOLOGY III: HISTOLOGY, 86 22B CRANIAL VASCULAR NEUROSURGERY II: 7 PHARMACOLOGY, 121 CEREBRAL REVASCULARIZATION AND STROKE, 306 23 CRANIAL ONCOLOGY, 322 PART II 24 SKULL BASE AND PITUITARY CARE OF THE SURGERY, 340 NEUROSURGICAL PATIENT 25 CRANIAL INFECTION, 354 8 NEUROLOGY AND STROKE, 127 9 NEURO-OPHTHALMOLOGY, 161 PART IV 10 NEURO-OTOLOGY, 176 SPINAL NEUROSURGERY 11 NEUROINTENSIVE AND PERIOPERATIVE CARE, 185 26 SPINE: GENERAL PRINCIPLES, 364 12 INFECTION, 201 27 SCOLIOSIS AND SPINAL DEFORMITY, 377 13 SEIZURES, 203 28 SPINAL TRAUMA AND ACUTE 14 NEURORADIOLOGY, 216 PATHOLOGY, 386 15 RADIOTHERAPY AND STEREOTACTIC 29 DEGENERATIVE SPINE, 403 RADIOSURGERY, 226 v vi CONTENTS 30 SPINAL INFECTION, 418 PART VII 31 SPINAL ONCOLOGY, 424 PEDIATRIC 32 SPINAL VASCULAR NEUROSURGERY, 440 NEUROSURGERY 38 PEDIATRIC NEUROSURGERY: GENERAL PRINCIPLES AND NORMAL PART V DEVELOPMENT, 513 FUNCTIONAL 39 CRANIOSYNOSTOSIS, 521 NEUROSURGERY 40 CONGENITAL CRANIAL AND SPINAL 33 PAIN SURGERY, 448 DISORDERS, 527 34 ADULT AND PEDIATRIC EPILEPSY 41 PEDIATRIC NEUROSURGERY: GENERAL AND SURGERY, 459 HYDROCEPHALUS, 546 35 ADULT MOVEMENT DISORDERS, 471 42 PEDIATRIC NEURO-ONCOLOGY, 557 36 SURGERY FOR PSYCHIATRIC 43 PEDIATRIC HEAD AND SPINAL TRAUMA, 569 DISORDERS, 485 44 PEDIATRIC VASCULAR NEUROSURGERY, 584 45 PEDIATRIC MOVEMENT DISORDERS AND PART VI SPASTICITY, 589 PERIPHERAL NERVE 46 NEUROSURGERY AND PREGNANCY, 593 SURGERY INDEX, 600 37 PERIPHERAL NERVE, 489  FOREWORD Neurosurgery Self-Assessment: Questions and the multiple choice question strategy employed Answers by Shah, Cadoux-Hudson, Van Gompel by the authors particularly relevant to modern and Pereira is a true masterpiece. All neurosur- day foundational neurosurgery information geons need ‘refreshers’; some for certification, acquisition and retention. some for maintenance of certification, and others I commend the authors for their tried and true, for the mere need to ‘keep up’. With over 1000 but uncommonly used, approach to education. It questions and 700 images available both in print takes the agony out of reading a chapter. It min- and interactively online, this volume provides imizes the laborious efforts required to gather an extensive coverage of neurosurgery from top information via searches and other strategies. It to bottom, and all points in between. Multiple brings the art and craft of neurosurgery to life choice questions are used to test foundation of in an enjoyable and relatively painless format. knowledge and, most importantly, educate. Finally, it provides a near complete coverage of As adults, we learn most efficiently and effec- the field – at least as complete as is humanly pos- tively when our minds are exercised and stressed. sible in the space afforded. When multiple modalities are employed (such as So, whether you have an impending examina- questions, answers and explanations), learning tion, or you simply desire to ‘spiff up’ on your becomes more efficient, with a greater long term neurosurgical foundations, this book is for you. retention of the newly acquired information. Use it as one might use a bedside novel. Use it This becomes particularly relevant to those who to prepare. Use it to simply stay at the top of are to soon be ‘tested’ in the form of certification your field. This book can truly fulfill all of these or maintenance of certification examinations. needs – and much, much more. Reading, thinking, answering, and then the con- templation of answers and their rationales makes Ed Benzel vii This page intentionally left blank  PREFACE Neurosurgical training is delivered worldwide those about sit their examinations who require a with the goal of producing a surgeon who is safe mix of questions (in terms of both topic and diffi- for independent practice. Today, neurosurgical culty), this is provided by the interactive question residents and their trainers are trying to achieve bank accessed via the online Inkling platform and this goal in the face of reduced working hours, smartphone app. This book consists of single best increasing demand on services, individual sur- answer (SBA) and extended matching item (EMI) geon outcome publication, and increasing litiga- questions constructed according to the guidelines tion, to name but a few challenges. In this from the US National Medicine Licensing Board environment, the value of targeted learning mate- and the UK Joint Committee on Intercollegiate rials and advanced surgical simulation is clear. Examinations, to enable the user to become The content of this question book aims to reflect familiar with the respective formats before the the evolving expectations placed on residents in exam. While SBA- and EMI-style questions are an age of evidence-based practice, subspecializa- not yet universal in postgraduate neurosurgical tion, and multidisciplinary teams: one must also examinations across the world, we hope all trainees be familiar with allied specialties advancing just find them valuable and cost-effective for self- as fast as our own. study. As a counterpoint to currently available self- Finally, I would like to thank Elsevier—their assessment books, we have organized questions support has ensured that this book could also by the highly specific topic areas outlined in most serve as a comprehensive and representative cat- modern neurosurgical textbooks and training cur- alogue of commonly examined clinical images ricula. Furthermore, most questions are accompa- and investigation results in a single resource for nied by in-depth answers and, where appropriate, neurosurgical residents. I hope you enjoy using it! suggestions for further reading. We hope this will enable junior trainees to use it as a learning aid and Rahul S. Shah for focused revision prior to rotating onto partic- Oxford ular neurosurgical firms. For senior trainees or July 2016 ix This page intentionally left blank  HOW TO PASS NEUROSURGICAL EXAMINATIONS LEARNING BY MULTIPLE For the vast majority of multiple choice ques- tions (MCQs) in this book, we provide a detailed CHOICE QUESTIONS explanation of the correct answer with references to current evidence-based data where appropri- The World Federation of Neurosurgical Societies ate. Like the real examinations, questions test estimates that there are 30,000 neurosurgeons the reader's knowledge of basic and clinical neu- worldwide. In the United States, there are approx- rosciences and neurosurgery, and are arranged by imately 3500 board certified neurosurgeons and topic to be useful to doctors in neurology, neuro- 800 neurosurgical residents. In the United radiology, and neuropathology, and medical stu- Kingdom, there are close to 300 consultants and dents. Illustrations include anatomical pictures, 200 trainees, with a total of approximately 8000 graphs, tables, radiology images, and histology qualified neurosurgeons and trainees in Europe. slides in questions and answers where required. Due to international collaboration through We suggest the following approach to using research and education, neurosurgical training this book and learning by MCQs: curricula have become increasingly standardized Firstly, start early! Learning throughout across most countries. Both UK and US-style one's training will lead to reinforcement examinations are well established in other coun- and consolidation of deep knowledge not tries (e.g. India and Brazil, respectively), and easily forgotten. Use books like this at the recently developed training programs in Africa beginning, middle, and end of training, have based their examinations on the UK format. and relate them to your clinical practice. Additionally, the need for already qualified neuro- Secondly, let this book be a guide to con- surgeons to demonstrate continuing professional solidate the information learnt. Annotate development for revalidation purposes has also material from other resources like compre- increased the demand for courses and objective hensive textbooks. Use the “red,” “amber,” self-assessment tools in neurosurgery. and “green” gradings to distinguish bet- Although the duration of postgraduate neuro- ween lower-yield and more difficult ques- surgical training varies by country, completion tions and high-yield easy questions. Make of training usually requires the candidate to pass connections between different subspe- both written and oral examinations set by the cialties and general principles, and focus relevant national training board or committee. on material most likely to be tested. For the written examinations, questions are gener- Remember that this is neither a compre- ally multiple choice and cover the basic and clinical hensive review book nor a panacea for inad- sciences; short answer and essay questions are used equate preparation in the last few months in some regions. Topics include neuroanatomy, before the exam. neurophysiology, neuropharmacology, critical Thirdly, prime your memory by returning care, fundamental clinical skills, neuroradiology, to challenging and annotated questions in neuropathology, neurology, neurosurgery, and the final days before the exam. This book other disciplines deemed suitable and important can serve as a useful way of retaining key (e.g. statistics, medical law, medical ethics). Ques- associations and refreshing important facts tions relating to clinical neurosurgery also cover fresh in your memory for the exam. Finally, the main subspecialties, including trauma, contribute to the book to enable active neuro-oncology, skull base and pituitary surgery, learning. Email us if you find errors or see vascular neurosurgery, spinal surgery, pediatric ways in which the book can be updated. neurosurgery, peripheral nerve surgery, and functional/epilepsy/pain surgery. xi xii HOW TO PASS NEUROSURGICAL EXAMINATIONS HOW TO TACKLE SINGLE BEST in most cities in front of desktop computers with headphones, pencil, and paper available, and the ANSWER (SBA) AND EXTENDED software is controlled by a mouse. Residents MATCHING ITEM (EMI) QUESTIONS taking the US examination use certified laptops provided by the residency program. Both have Test performance is influenced not just by your high-quality, distinct images, and sometimes knowledge but also by your test-taking skills. include audio and video material. You can improve your performance by honing Given the artificial environment of computer- your test-taking skills and strategies well in based testing, it is important to become familiar advance of the exam so that you can concentrate with it before the actual exam. Most examination on the information and your knowledge during boards offer a downloadable or interactive mock the test itself. The following strategies may be examination with a few sample questions to famil- useful. iarize yourself with the environment. Skipping Try to deal with each question in turn, identi- the tutorial on the exam day sometimes adds extra fying it as easy, workable or impossible from your time to answer the actual questions in the test own perspective; our green, amber, and red clas- itself. Learn how to mark questions, go back to sification provides an approximate examiner's them and if there are any rules preventing going guide to difficulty for someone having completed back to previous blocks. Become familiar with their neurosurgical training. Aim to answer all the how to view images and spot the icons for playing easy questions, resolve the workable ones in rea- audio and video clips. Be vigilant that some multi- sonable time, and make quick educated guesses at part questions prevent changing the answer to the any apparently impossible ones. There are differ- first part of the question once the second part has ent techniques for question reading that include been revealed. reading the stem, thinking of the answer, and turning to the choices or skimming the answer choices and the last part of the question before US, UK, AND EUROPEAN returning to the stem. Try different techniques to see what work best for you and yields the high- NEUROSURGICAL EXAMINATION est marks. Our online testing area should help STRUCTURE with that. Set a good pace for answering the questions. MCQ tests generally form the first part of most Divide the total time for the exam by the number neurosurgical examinations, with the subsequent of questions and be strict with yourself. If you are parts being a combination of oral and clinical taking too long then mark the question, pick your examinations. The 2015 ABNS Primary Exami- best answer, and come back to it later if you have nation consisted of 350 questions (in 6 h 45 min), time at the end. Avoid burnout by practicing while the UK FRCS Written Examination is in timed tests to develop endurance. Use extra time two parts, the first consisting of 135 SBA questions to check marked questions. Never give up—take a (in 2 h) and the second part of 110 EMI questions short one-minute break and come back to the test (in 2.5 h). The European Association of Neuro- if too disheartened. surgical Societies Part 1 examination consists of Answer all test questions—even if it means approximately 200 MCQs to be answered in 3 h. guessing! Whereas in the past many neurosurgi- Questions in all three examinations cover neuro- cal examinations were negatively marked, that anatomy, neurobiology, neuropathology, neuro- process has largely been superseded by only pos- logy, neuroradiology, clinical neurosurgery itively marked exams, so there is no harm in an (including subspecialties), fundamental clinical educated or instinctive guess, or even just a blind skills, and other disciplines deemed suitable and punt. If you have to guess, go on a hunch and pick important. an answer you are vaguely familiar with rather The marking of such MCQ examinations is than something you have never heard of. now quite standardized and relies upon principles of statistics and psychology. Many examination boards use the modified Angoff method, whereby COMPUTER-BASED TESTING experts are briefed then allowed to take part or all of the test with the performance levels in mind. The UK FRCS (Neurological Surgery) examina- They are then asked to provide estimates for each tion has been using computer-based testing for question of the proportion of minimally accept- several years, the American Board of Neurologi- able candidates that they would expect to get cal Surgery moved to a web-based format for the the question correct. The final determination of Primary Examination in 2015, and the EANS the cut score is then made by averaging the esti- Part 1 remains a pencil-and-paper test. The UK mates. Controversial questions—those that exam takes place in dedicated test centers found polarized the candidates' answers between two  HOW TO PASS NEUROSURGICAL EXAMINATIONS xiii answers or those that candidates scoring highly ability to satisfy patients and colleagues that those overall got wrong whereas those scoring poorly passing have attained a minimum standard overall got right—are scrutinized and potentially of basic and applied science knowledge and clin- removed from the overall scoring at examiners' ical decision-making to practice independently. standard setting meetings. It is good practice Oral examinations are crucial in this process as for a trainee representative who has sat the exam- they assess communication skills, clinical skills, ination to participate in the whole process. and decision-making and professionalism in a Whereas the written examination explores an high-pressure environment. In contrast, MCQs applicant's knowledge in various relevant disci- focus on assessing knowledge and analytical and plines, the oral examination explores knowledge decision-making skills. More clinically integra- and judgment in clinical neurosurgical practice tive questions test higher orders of Bloom's tax- after an applicant has been an independent prac- onomy and are more effective than simple titioner. The oral examination is accomplished factual questions in assessing and developing in a series of face-to-face examinations. The the clinical problem-solving skills of trainee applicant is presented with a series of clinical surgeons. vignettes using real patients, clinical descriptions, Patients fundamentally wish for their treating radiographs, computerized images, anatomical surgeon to be as independent as possible in order models, and/or diagrams. The examiners grade to maximize their chances for an excellent the applicant on specific tasks including diagnos- outcome. Therefore, when setting minimum tic skills, surgical decision-making, and manage- standards for independent practice, an expert ment of complications. peer group of examiners is accountable to patients, other neurosurgeons and healthcare professionals, and the general public. Postgrad- STANDARDS FOR INDEPENDENT uate medical examinations have therefore gen- NEUROSURGICAL PRACTICE erally evolved to become as standardized and fair as possible, while maintaining rigor, expand- The credibility of professional examinations ing, and adapting as trends change in clinical taken at the end of surgical training rests on their practice. This page intentionally left blank  PART I BASIC SCIENCE CHAPTER 1 NEUROANATOMY SINGLE BEST ANSWER (SBA) QUESTIONS 1. From inferior to superior (i.e. ascending), 5. Lesion of which structure increases extensor what is the 4th branch of the external carotid tone? artery in the neck? a. Dentate nucleus a. Maxillary artery b. Pedunculopontine nucleus b. Occipital artery c. Red nucleus c. Facial artery d. Ventral tegmentum d. Lingual artery e. Superior olive e. Posterior auricular artery 6. Which one of the following drain into the 2. The pathway best describing how sympa- cavernous sinus? thetic fibers of the autonomic nervous system a. Superior ophthalmic vein exit the spinal cord is: b. Superior petrosal sinus a. Via the dorsal roots and white rami c. Inferior petrosal sinus communicans d. Basal vein of Rosenthal b. Via the ventral roots and white rami e. Vein of Labbe communicans c. Via the dorsal roots and gray rami 7. Persistent trigeminal artery is commonly: communicans a. Found in 3-5% of people d. Via the ventral roots and gray rami b. Found to connect to the proximal basilar communicans artery e. Via the ventral roots and spinal nerves c. Found to branch off from the ICA just proximal to the meningohypophyseal 3. The left vertebral artery usually arises from trunk the: d. Found to have a vascular abnormality in a. Arch of the aorta approximately 50% of cases b. Brachiocephalic trunk e. Found in conjunction with internal c. Left common carotid carotid artery aplasia d. Left subclavian artery e. Costocervical trunk 8. The afferent loop of the Hering-Breuer inflation and deflation reflexes is mediated 4. Hemiballismus results from lesioning which by: basal ganglia target? a. CN XIII a. Globus pallidus interna b. CN IX b. Subthalamic nucleus c. CN X c. Substantia nigra pars reticularis d. CN XI d. Striatum e. C2 e. Pedunculopontine nucleus 1 2 PART I BASIC SCIENCE 9. Which one of the following nerves is outside e. Preganglionic fibers synapse in either the the annulus of Zinn? sympathetic chain or prevertebral ganglia a. Abducens b. Nasociliary 14. Nervi erigentes are responsible for: c. Trochlear a. Inhibition of the external anal sphincter d. Oculomotor (superior division) b. Inhibition of the internal vesicle sphincter e. Oculomotor (inferior division) c. Inhibition of the internal anal sphincter d. Inhibition of the external vesicle sphincter 10. The C2 vertebra has how many secondary e. Inhibition of the rectal muscles ossification centers? a. 2 15. Parasympathetic sensory afferents terminate b. 3 in which one of the following? c. 4 a. Nucleus ambiguus d. 5 b. Solitary nucleus e. 6 c. Edinger-Westphal nucleus d. Red nucleus 11. A line drawn between the highest point of the e. Superior colliculus iliac crests across the back usually denotes: a. L1/2 interspace 16. Which one of the labels in the diagram below b. L2/3 interspace of the internal auditory canal identifies the c. L3/4 interspace facial nerve? d. L4/5 interspace e. L5/S1 interspace 12. Which one of the following is labeled X in the image below? A C B D E F X 17. Blood supply to the posterior pituitary gland arises from branches of which internal carotid artery segment? a. Ophthalmic division of the trigeminal nerve b. Meckel’s cave c. Oculomotor nerve d. Maxillary division of trigeminal nerve e. Abducens nerve 13. Which one of the following statements about C7 C6 the sympathetic nervous system is FALSE? C4 C5 a. Innervation of thoracic viscera arises from T1-T4 spinal segments C2 b. Splanchnic nerves are unmyelinated C3 c. Preganglionic fibers enter the sympa- thetic chain via white rami communicans C1 d. Sensory afferent fibers are important for visceral pain sensation  1 NEUROANATOMY 3 a. C1 (Cervical) 27. Internal auditory canal: b. C2 (Petrous) c. C3 (Lacerum) d. C4 (Cavernous) e. C5 (Clinoid) f. C6 (ophthalmic/supraclinoid) g. C7 (communicating) C D E F G QUESTIONS 18–25 H Additional questions 18–25 available on ExpertConsult.com I B A J EXTENDED MATCHING ITEM (EMI) QUESTIONS 26. Cavernous sinus imaging: For each of the following descriptions, select the most appropriate answers from the image above. Each answer may be used once, more than once or not at all. 1. AICA 2. Basal turn of cochlea 3. Cochlear nerve 28. Cavernous sinus anatomy: G B A A F B H C F C G D D H E I E J K F L M For each of the following descriptions, select the most appropriate answers from the image above. Each answer may be used once, more than once For each of the following descriptions, select the or not at all. most appropriate answers from the diagram 1. Right optic nerve above. Each answer may be used once, more than 2. Oculomotor nerve once or not at all. 3. Abducens nerve 1. ACA 2. Maxillary division of CN V (V2) 3. Oculomotor nerve (III) 4 PART I BASIC SCIENCE 29. Internal auditory canal: 31. Basal Ganglia: A B C R D F E F VI A Pons G G Q AICA B 1 2 H C I VIII D H P IX E J K X I O 1 Lateral medullary lamina XI L 2 Medial medullary lamina J N For each of the following descriptions, select the K most appropriate answers from the image above. Each answer may be used once, more than once L or not at all. M 1. Caudate nucleus For each of the following descriptions, select the 2. Claustrum most appropriate answers from the image above. 3. Globus pallidus interna Each answer may be used once, more than once 4. Internal capsule or not at all. 5. Putamen 1. Facial nerve 2. Superior vestibular nerve 32. Projection and association tracts: 3. Greater superficial petrosal nerve a. Central tegmental tract 4. Posterior semicircular canal b. Lamina terminalis c. Median forebrain bundle 30. Internal auditory canal: d. Stria medullaris e. Stria terminalis f. Postcommissural Fornix g. Nucleus of the diagonal band of Broca (vertical limb) h. Retinohypothalamic tract i. Supraopticohypophyseal tract C j. Tuberoinfundibular D A (tuberohypophyseal) tract k. Trapezoid body B l. Thalamic fasciculus (Forel’s field H1) m. Nucleus of the Diagonal band of Broca (horizontal limb) A n. Mammillothalamic tract o. Tapetum A E For each of the following descriptions, select the B G H most appropriate tracts from the list above. Each F answer may be used once, more than once or not at all. For each of the following descriptions, select the 1. Conducts fibers to the posterior pituitary most appropriate answers from the images above. gland Each answer may be used once, more than once 2. Arcuate nucleus to hypophyseal portal sys- or not at all. tem of infundibulum 1. Anterior inferior cerebellar artery 3. Septal nuclei to hippocampus 2. Vestibulocochlear nerve 4. Connects sepal area, hypothalamus, basal 3. Facial nerve olfactory areas, hippocampus/subiculum to midbrain, pons and medulla 5. Hippocampus to cingulate gyrus  1 NEUROANATOMY 5 33. Vascular territories: 35. Offending Artery: a. Middle cerebral artery a. A1 portion of anterior cerebral artery b. Basilar artery b. Anterior choroid artery c. Perforators from internal carotid artery c. Anterior communicating artery d. Ophthalmic artery d. Anterior inferior cerebellar artery e. P2 portion of posterior cerebral artery e. Basilar arteries f. Vertebral artery f. Facial artery g. Superior cerebellar artery g. Internal carotid artery h. Posterior inferior cerebellar artery h. M3 portion of middle cerebral artery i. Anterior inferior cerebellar artery i. Ophthalmic artery j. Posterior communicating artery j. Posterior cerebral artery k. A2 portion of anterior cerebral artery k. Posterior communicating artery l. P3 portion of posterior cerebral artery l. Posterior inferior cerebellar artery m. Recurrent artery of Heubner m. Superior cerebellar artery n. Vertebral artery For each of the following descriptions, select the most appropriate answers from the list above. For each of the following descriptions, select the Each answer may be used once, more than once most appropriate answers from the list above. or not at all. Each answer may be used once, more than once 1. Posterior limb of the internal capsule or not at all. 2. Medial and lateral geniculate nuclei 1. Glossopharyngeal neuralgia 3. Anterior limb of internal capsule and head 2. Trigeminal neuralgia of caudate 3. Hemifacial spasm 4. Posterior pituitary gland 4. Horner’s syndrome 5. Splenium of corpus callosum 5. CN III palsy 34. Cerebral veins: 36. Autonomic nervous system: a. Erdinger-Westphal nucleus B C b. Superior salivatory nucleus A c. Inferior salivatory nucleus d. Dorsal nucleus D e. Ciliary ganglion f. Pterygopalatine ganglion E g. Otic ganglion h. Submandibular ganglion F i. CNII j. CNV R G k. Chorda tympani H l. Vidian nerve Q m. Superior cervical ganglion I n. Greater petrosal nerve P o. Lesser superficial petrosal nerve J O p. Auriculotemporal nerve N L K M For each of the following descriptions, select the most appropriate answers from the list above. For each of the following descriptions, select the Each answer may be used once, more than once most appropriate answers from the image above. or not at all. Each answer may be used once, more than once 1. Mediates bronchoconstriction or not at all. 2. Receives preganglionic parasympathetic 1. Inferior anastamotic vein of Labbe fibers via CNIII 2. Superficial middle cerebral vein of Silvius 3. Postganglionic parasympathetic fibers to 3. Superior anastamotic vein of Trolard parotid gland 4. Basal vein of Rosenthal 4. Preganglionic parasympathetic fibers to the 5. Vein of Galen submandibular ganglion 5. Origin of preganglionic parasympathetic fibers transmitted in GSPN IX 6 PART I BASIC SCIENCE 37. Projection and association tracts: 39. Thalamus: a. Ansa lenticularis b. Fasciculus retroflexus C A c. Lenticular fasciculus (Forel’s field H2) D C d. Postcommissural fornix C e. Precommissural fornix B F J f. Thalamic fasciculus (Forel’s field H1) E M g. Nucleus of the diagonal band of Broca H G h. Mammillothalamic tract I i. Tapetum j. Uncinate fasciculus K L k. Commissure of Probst l. Central tegmental tract m. Lamina terminalis For each of the following descriptions, select the n. Median forebrain bundle most appropriate part of the thalamus from the o. Stria medullaris image above. Each answer may be used once, more than once or not at all. For each of the following descriptions, select the 1. Receives major input from inferior colliculi most appropriate option from the list above. Each 2. Major projection to the primary visual cortex answer may be used once, more than once or not 3. Receives major projections from mammillary at all. body 1. Globus pallidus interna to thalamus 4. Auditory relay nucleus through internal capsule 5. Contains the area of face representation 2. Globus pallidus interna to thalamus around internal capsule 40. Projection and association tracts: 3. Septal nuclei to amygdala a. Inferior collicular commissure 4. Temporal lobe to occipital lobe b. Cingulate fasciculus 5. Connection between nuclei of lateral c. Arcuate fasciculus lemniscus d. Corpus callosum e. Posterior commissure 38. Thalamus: f. Hypothalamospinal tract g. Brachium conjunctivum A H h. Brachium pontis I i. Restiform and juxtarestiform bodies B j. Dorsal longitudinal fasciculus C k. Medial longitudinal fasciculus J l. Uncinate fasciculus D m. Lamina terminalis E n. Commissure of Probst o. Stria medullaris F K For each of the following descriptions, select the G L most appropriate X from the list above. Each answer may be used once, more than once or not at all. For each of the following descriptions, select the 1. Periventricular hypothalamus and mam- most appropriate part of the thalamus from the millary bodies to midbrain central gray image above. Each answer may be used once, matter more than once or not at all. 2. Covered with indusium griseum 1. Pulvinar 3. Contains crossing fibers of pretectal 2. Ventral anterior nucleus nucleus for light reflex 3. Ventral posterolateral nucleus 4. Connects Wernicke and Broca’s areas 4. Lateral geniculate nucleus 5. Interruption can result in Horner’s 5. Medial geniculate nucleus syndrome  1 NEUROANATOMY 7 41. For each of the following descriptions, select 43. Sulci and gyri: the most appropriate answers from the image A B below. Each answer may be used once, more C1 C than once or not at all. D E B1 F A1 G Z G Y H I X H W J A V U B I T K S L R C J Q P M D O N K Frontal lobe Parietal lobe Temporal lobe Occipital lobe E L F For each of the following descriptions, select the most appropriate answers from the image above. Each answer may be used once, more than once 1. Cisterna magna or not at all. 2. Interpeduncular cistern 1. Angular gyrus 3. Chiasmatic cistern 2. Supramarginal gyrus 3. Pars opercularis of inferior frontal grus 42. Cranial Nerve Nuclei: 4. Middle frontal gyrus 5. Parieto-occipital sulcus 44. Sulci and gyri: A D1 A B C1 B C L B1 C A1 D D M Z E E N F F Y B G G X G Septum H O H Superior W R S I V Thalamus I J P Lateral U K T J Dorsal cochlear S K R L Efferent cranial Inferior Q M nerve nuclei Medial P N O Vestibular nuclei Frontal lobe Limbic lobe Temporal lobe Parietal lobe Occipital lobe Afferent cranial nerve nuclei For each of the following descriptions, select the For each of the following descriptions, select the most appropriate answers from the image above. most appropriate answers from the image above. Each answer may be used once, more than once Each answer may be used once, more than once or not at all. or not at all. 1. Marginal sulcus 1. Abducens nerve nucleus 2. Calcarine sulcus 2. Principal sensory nucleus of trigeminal nerve 3. Cuneus 3. Solitary tract nucleus 4. Collateral sulcus 4. Facial nerve motor nucleus 5. Lamina terminalis 5. Nucleus ambiguus 8 PART I BASIC SCIENCE 45. Sulci and gyri: 47. Cranial Nerve Nuclei: C H A D A I E B J SC F C IC K G D G S L H I E M J K F N L O M G N O IO P Q For each of the following descriptions, select the R most appropriate answers from the image above. S Each answer may be used once, more than once T or not at all. 1. Central sulcus B U 2. Paracentral sulcus 3. Calcarine sulcus 4. Marginal sulcus 5. Precuneus 46. Fourth ventricular floor: For each of the following descriptions, select the most appropriate answers from the image above. A Each answer may be used once, more than once J or not at all. K 1. Red nucleus B 2. Erdinger-Westphal nucleus L 3. Oculomotor nucleus C 4. Trochlear nucleus D M 5. Abducens nucleus N 6. Facial nucleus O 7. Nucleus ambiguus of vagus nerve E F 48. Medulla at sensory decussation: P G Q A H R L B I S M C N D O For each of the following descriptions, select the P most appropriate answers from the image above. E Q Each answer may be used once, more than once F R or not at all. G S 1. Facial colliculus H T 2. Striae medullaris I U 3. Sulcus limitans V 4. Median sulcus J W 5. Vagal trigone X K Y  1 NEUROANATOMY 9 For each of the following descriptions, select the 1. Posterior cochlear nucleus most appropriate answers from the image above. 2. Vestibulocochlear nerve Each answer may be used once, more than once 3. Spinal trigeminal nucleus or not at all. 4. Medial longitudinal fasciculus 1. Nucleus gracilis 5. Nucleus ambiguus 2. Nucleus cuneatus 3. Spinothalamic tract 51. Caudal pons: 4. Posterior spinocerebellar fibers A B P 49. Medulla and vagal nuclei: C Q R K A O L S B M D T U C N E V O F D P G W Q H E R I F S J X K T Y U G L Z V A1 M W N B1 H X I For each of the following descriptions, select the Y J most appropriate answers from the image above. Z Each answer may be used once, more than once or not at all. For each of the following descriptions, select the 1. Facial nucleus most appropriate answers from the image above. 2. Facial nerve Each answer may be used once, more than once 3. Superior olivary nucleus or not at all. 4. Abducens nucleus 1. Solitary nucleus and tract 5. Abducens nerve 2. Dorsal motor vagal nucleus 3. Reticular formation 52. Mid-pons: 4. Principal olivary nucleus (inferior olivary A N nucleus) B O M 5. Medial lemniscus C P D 50. Rostral medulla: Q E F A N R B O G C P S Q H R T E S I D J U F G K V T W L H U I V W J For each of the following descriptions, select the X K most appropriate answers from the image above. Y Each answer may be used once, more than once L Z or not at all. M 1. Locus ceruleus 2. Corticospinal fibers For each of the following descriptions, select the 3. Principal trigeminal sensory nucleus most appropriate answers from the image above. 4. Fourth ventricle Each answer may be used once, more than once 5. Brachium pontis or not at all. 10 PART I BASIC SCIENCE 53. Rostral pons: For each of the following descriptions, select the I most appropriate answers from the image above. J Each answer may be used once, more than once A or not at all. K B L 1. Medial lemniscus M 2. Medial longitudinal fasciculus C N D 3. Trochlear nerve O P 4. Central tegmental tract E 5. Tectobulbospinal tract Q F QUESTIONS 54–58 G R Additional questions 54–58 available on S ExpertConsult.com H SBA ANSWERS 1. c—Facial artery 2. b—Via the ventral roots and white rami communicans The external carotid artery has several branches in the neck (SALFOPSI in ascending order): superior 3. d—Left subclavian artery thyroid, ascending pharyngeal, lingual, facial (aka external maxillary), occipital, posterior auricular, Each vertebral artery arises from its ipsilateral superficial temporal, maxillary (aka internal maxil- subclavian artery. The aortic arch gives off three lary). It can be distinguished on angiogram (figure) branches in order: brachiocephalic trunk (or from the ICA, which has no branches in the neck. innominate artery), left common carotid and left During EC/IC bypass procedures for Moya Moya subclavian arteries (A). The second commonest disease, anastomosis of the superficial temporal branching pattern (termed a “bovine arch”) is artery to the middle cerebral artery (or less com- where the left common carotid arises from the monly occipital artery to the posterior cerebral brachiocephalic trunk (B). artery/posterior inferior cerebellar artery) may be performed. Right carotid Right carotid artery Left carotid Right artery Left carotid Right artery artery vertebral vertebral Left artery Left artery vertebral vertebral artery artery Right Right subclavian Left Left subclavian artery subclavian subclavian artery artery artery Innominate Innominate artery artery A B Image redrawn from Layton KF, Kallmes DF, Cloft HJ, Lindell EP, Cox VS. Bovine aortic arch variant in humans: Clarification of a common misnomer. AJNR Am J Neuroradiol 2006;27:1541-1542. In: Low M, Som PM, Naidich TP. Problem solving in neuroradiology. Elsevier.  1 NEUROANATOMY 11 4. b—Subthalamic nucleus After the Pcomm, persistent primitive trigeminal artery is the next commonest remnant of the fetal circulation. It is seen in 0.1-0.6% of cerebral angio- Hemiballismus is a condition characterized by grams. It connects the cavernous ICA (just proxi- unilateral, involuntary, violent flinging of the mal to meningohypophyseal trunk) to the basilar limbs. Lesion is based in the contralateral subtha- artery between superior cerebellar and anterior lamic nucleus or its connections and due to vascu- inferior cerebellar arteries. Its persistence is usually lar cause (PCA territory) but can occur in MS. associated with a hypoplastic basilar and vertebral Often settles spontaneously and drug treatment arteries proximal to the anastomosis, as well as a is ineffective. hypoplastic PcommA. Its frequency is explained 5. c—Red nucleus as the order of regression during embryogenesis is otic/acoustic artery first, then hypoglossal fol- Factors normally inhibiting extensor action in the lowed by trigeminal. Vascular abnormalities arms and legs are: (AVM, aneurysm) is seen in 25%. Characterized (A) Cortical inhibition of lateral vestibular by the tau sign (flow void) on sagittal MRI. nucleus (vestibulospinal tract) and pontine reticular formation PCOMM (B) Red nucleus projections to spinal cord (rubrospinal tract; possibly arms only) (C) Medullary reticular formation Disconnection lesion involving red nucleus Trigeminal Otic results in loss of normal inhibition of extension (rubrospinal and medullary reticular formation) and loss of cortical inhibition of extensor action Proatlantal Hypoglossal of LVN and pontine RF, producing hyperreflexia and increased extensor tone (decerebrate rigid- ity). Disconnection lesions above the red nucleus result in extension in legs, but flexion in arms (decorticate rigidity). This is explained as in humans the rubrospinal tract terminates in the ICA cervical spine, meaning intact rubrospinal input could counteract vestibulospinal (extensor) input in the arms but it remains unopposed in Vertebral artery the legs. 6. a—Superior ophthalmic vein Image from Law M, Som P, Naidich T. Problem Solving in Neuroradiology, Elsevier, Saunders, 2011. The cavernous sinus receives the superior and inferior ophthalmic veins, sphenoparietal sinus and the superficial middle cerebral vein (coursing 8. c—CN X from superiorly to inferiorly in the Sylvian fis- sure). It drains via superior petrosal sinus (to The Hering-Breuer inflation and deflation reflexes the junction of the transverse and sigmoid are thought to play a role in controlling the depth sinuses), inferior petrosal sinus (to the internal of breathing, although may be less important in jugular vein). Right and left cavernous sinuses humans at rest. Their overall effect is to prevent are also connected across the midline anterior overinflation and extreme deflation of the lungs. and posteriorly to the pituitary gland via the ante- The inflation reflex is mediated by pulmonary rior and posterior intercavernous sinuses, result- stretch receptor afferents signaling via CNX dur- ing in the circular sinus. Each cavernous sinus is ing lung inflation to inhibit medullary inspiratory also connected to the pterygoid venous plexus center and the pontine apneustic center, as well via small branches in the foramen Vesalii, fora- as inhibiting cardiac vagal motor neurons resulting men ovale and foramen lacerum. in sinus tachycardia. The deflation reflex also acts via CNX and directly activates medullary inspira- 7. c—Found to branch off from the ICA just tory centers, stopping expiration and initiating proximal to the meningohypophyseal trunk inspiration. 12 PART I BASIC SCIENCE 9. c—Trochlear nerve Cartilaginous stage—chondrification centers appear in the centrum and vertebral arches, The Annulus of Zinn (or annular tendon) is a causing cartilaginous fusion, and spinous fibrous ring which surrounds the optic nerve, and transverse processes develop from and which is continuous with the dura of the mid- extensions of the chondrification centers in dle cranial fossa. It is divided into upper (superior the vertebral arches. Chondrification tendon of Lockwood) and lower (inferior tendon spreads until a cartilaginous vertebral col- of Zinn) parts which together give rise to the umn is formed. four recti muscles (superior, inferior, medial, Bony stage—By the end of the embryonic period lateral) and superior oblique. The remaining two each vertebrae usually has three primary ossi- extraocular muscles, inferior oblique and levator fication centers (centrum and each half verte- palpabrae superioris arise from the maxillary and bral arch), and the cartilaginous connection sphenoid bones respectively. The Annulus of between the arch and centrum allows growth Zinn contains the optic nerve, ophthalmic artery, as the spinal cord enlarges after birth. After superior division of CNIII, nasociliary division puberty, five secondary ossification centers of CNV1, CNVI, and the inferior division of appear—tip of spinous process, tip of both CNIII. transverse processes and annular epiphyses of the vertebral body. Recurrent Superior Superior rectus Levator palpebrae meningeal orbital fissure superioris artery Primary Common Ossification Secondary tendinous ring Vertebra Centers Ossification Centers IV Superior C1 2 posterior 1 anterior Lacrimal nerve oblique (atlas) Rim of C2 (axis) 1 centrum 1 tip of dens Frontal nerve optic canal and 2 1 ring apophysis Superior Dural vertebral arch 1 spinous process ophthalmic vein III sheath 2 base of and 2 transverse Nasociliary nerve VI Optic dens (odontoid process nerve III peg) Lateral rectus Medial rectus Inferior orbital fissure Ophthalmic 11. d—L4/5 Interspace artery Zygomatic nerve Inferior Intercristal line (Tuffier’s line)—space between rectus L4 and L5 spinous process, or through L4 spi- Infraorbital nerve Inferior ophthalmic nous process. In infants this is at the L5/S1 level. and artery vein Image from Mancall EL. Gray's Clinical Neuroanatomy: 12. b—Meckel’s cave (containing Gasserian The Anatomic Basis for Clinical Neuroscience, Elsevier, ganglion). Axial view in T2 MRI is