NEUROSURGERY SELF-ASSESSMENT
QuestionsandAnswers
RahulS.Shah,BSc(Hons),MBChB(Hons),MRCS(Eng)
SpecialtyRegistrarinNeurosurgeryand WellcomeTrustClinicalResearchFellow UniversityofOxford Oxford,UK
ThomasA.D.Cadoux-Hudson,DPhil,FRCS,MBBS
HonoraryConsultantNeurosurgeon DepartmentofNeurosurgery OxfordUniversityHospitalsNHSTrust Oxford,UK
JamieJ.VanGompel,MD
AssociateProfessorofNeurosurgeryandOtolaryngology MayoClinicCollegeofMedicine Rochester,MN,USA
ErlickA.C.Pereira,MA,BMBCh,DM,FRCS(Neuro.Surg), SFHEA
SeniorLecturerinNeurosurgeryandConsultantNeurosurgeon AtkinsonMorleyNeurosciencesCentre,StGeorge’sHospital StGeorge’s,UniversityofLondon London,UK
Forewordby
EdwardC.Benzel,MD
Chairman,DepartmentofNeurosurgery CenterforSpineHealth,ClevelandClinic Cleveland,OH,USA
Foradditionalonlinecontentvisit ExpertConsult.com
© 2017,ElsevierInc.Allrightsreserved.
TherightofDrs.RahulS.Shah,ThomasA.D.Cadoux-Hudson,JamieJ.VanGompel,ErlickA.C.Pereirato beidentifiedasauthorofthisworkhasbeenassertedbytheminaccordancewiththeCopyright,Designsand PatentsAct1988.
Nopartofthispublicationmaybereproducedortransmittedinanyformorbyanymeans,electronicor mechanical,includingphotocopying,recording,oranyinformationstorageandretrievalsystem,without permissioninwritingfromthepublisher.Detailsonhowtoseekpermission,furtherinformationaboutthe Publisher’spermissionspoliciesandourarrangementswithorganizationssuchastheCopyrightClearance CenterandtheCopyrightLicensingAgency,canbefoundatourwebsite: www.elsevier.com/permissions.
ThisbookandtheindividualcontributionscontainedinitareprotectedundercopyrightbythePublisher (otherthanasmaybenotedherein).
Notices
Knowledgeandbestpracticeinthisfieldareconstantlychanging.Asnewresearchandexperience broadenourunderstanding,changesinresearchmethods,professionalpractices,ormedicaltreatmentmay becomenecessary.
Practitionersandresearchersmustalwaysrelyontheirownexperienceandknowledgeinevaluating andusinganyinformation,methods,compounds,orexperimentsdescribedherein.Inusingsuch informationormethodstheyshouldbemindfuloftheirownsafetyandthesafetyofothers,including partiesforwhomtheyhaveaprofessionalresponsibility.
Withrespecttoanydrugorpharmaceuticalproductsidentified,readersareadvisedtocheckthe mostcurrentinformationprovided(i)onproceduresfeaturedor(ii)bythemanufacturerofeachproductto beadministered,toverifytherecommendeddoseorformula,themethodanddurationofadministration, andcontraindications.Itistheresponsibilityofpractitioners,relyingontheirownexperienceand knowledgeoftheirpatients,tomakediagnoses,todeterminedosagesandthebesttreatmentforeach individualpatient,andtotakeallappropriatesafetyprecautions.
Tothefullestextentofthelaw,neitherthePublishernortheauthors,contributors,oreditors, assumeanyliabilityforanyinjuryand/ordamagetopersonsorpropertyasamatterofproducts liability,negligenceorotherwise,orfromanyuseoroperationofanymethods,products,instructions, orideascontainedinthematerialherein.
ISBN:978-0-323-37480-4
PrintedinChina
Lastdigitistheprintnumber:9 87654321
ContentStrategist: LottaKryhl
ContentDevelopmentSpecialist: HumayraRahmanKhan
ProjectManager: SrividhyaVidhyashankar
Design: MilesHitchen
IllustrationManager: LesleyFrazier
MarketingManager: RachaelPignotti
30 SPINAL INFECTION,418
31 SPINAL ONCOLOGY,424
32 SPINAL VASCULAR NEUROSURGERY,440
PARTV FUNCTIONAL NEUROSURGERY
33 PAIN SURGERY,448
34 ADULTAND PEDIATRIC EPILEPSY SURGERY,459
35 ADULT MOVEMENT DISORDERS,471
36 SURGERYFOR PSYCHIATRIC DISORDERS,485
PARTVI PERIPHERALNERVE SURGERY
37 PERIPHERAL NERVE,489
PARTVII PEDIATRIC NEUROSURGERY
38 PEDIATRIC NEUROSURGERY:GENERAL PRINCIPLESAND NORMAL DEVELOPMENT,513
39 CRANIOSYNOSTOSIS,521
40 CONGENITAL CRANIALAND SPINAL DISORDERS,527
41 PEDIATRIC NEUROSURGERY:GENERALAND HYDROCEPHALUS,546
42 PEDIATRIC NEURO-ONCOLOGY,557
43 PEDIATRIC HEADAND SPINAL TRAUMA,569
44 PEDIATRIC VASCULAR NEUROSURGERY,584
45 PEDIATRIC MOVEMENT DISORDERSAND SPASTICITY,589
46 NEUROSURGERYAND PREGNANCY,593
INDEX,600
NeurosurgerySelf-Assessment:Questionsand AnswersbyShah,Cadoux-Hudson,VanGompel andPereiraisatruemasterpiece.Allneurosurgeonsneed ‘refreshers’;someforcertification, someformaintenanceofcertification,andothers forthemereneedto ‘keepup’.Withover1000 questionsand700imagesavailablebothinprint andinteractivelyonline,thisvolumeprovides anextensivecoverageofneurosurgeryfromtop tobottom,andallpointsinbetween.Multiple choicequestionsareusedtotestfoundationof knowledgeand,mostimportantly,educate.
Asadults,welearnmostefficientlyandeffectivelywhenourmindsareexercisedandstressed. Whenmultiplemodalitiesareemployed(suchas questions,answersandexplanations),learning becomesmoreefficient,withagreaterlongterm retentionofthenewlyacquiredinformation. Thisbecomesparticularlyrelevanttothosewho aretosoonbe ‘tested’ intheformofcertification ormaintenanceofcertificationexaminations. Reading,thinking,answering,andthenthecontemplationofanswersandtheirrationalesmakes
themultiplechoicequestionstrategyemployed bytheauthorsparticularlyrelevanttomodern dayfoundationalneurosurgeryinformation acquisitionandretention.
Icommendtheauthorsfortheirtriedandtrue, butuncommonlyused,approachtoeducation.It takestheagonyoutofreadingachapter.Itminimizesthelaboriouseffortsrequiredtogather informationviasearchesandotherstrategies.It bringstheartandcraftofneurosurgerytolife inanenjoyableandrelativelypainlessformat. Finally,itprovidesanearcompletecoverageof thefield – atleastascompleteasishumanlypossibleinthespaceafforded.
So,whetheryouhaveanimpendingexamination,oryousimplydesireto ‘spiffup’ onyour neurosurgicalfoundations,thisbookisforyou. Useitasonemightuseabedsidenovel.Useit toprepare.Useittosimplystayatthetopof yourfield.Thisbookcantrulyfulfillallofthese needs – andmuch,muchmore.
EdBenzel
HOWTO PASS NEUROSURGICAL EXAMINATIONS
LEARNINGBYMULTIPLE CHOICEQUESTIONS
TheWorldFederationofNeurosurgicalSocieties estimatesthatthereare30,000neurosurgeons worldwide.IntheUnitedStates,thereareapproximately3500boardcertifiedneurosurgeonsand 800neurosurgicalresidents.IntheUnited Kingdom,therearecloseto300consultantsand 200trainees,withatotalofapproximately8000 qualifiedneurosurgeonsandtraineesinEurope. Duetointernationalcollaborationthrough researchandeducation,neurosurgicaltraining curriculahavebecomeincreasinglystandardized acrossmostcountries.BothUKandUS-style examinationsarewellestablishedinothercountries(e.g.IndiaandBrazil,respectively),and recentlydevelopedtrainingprogramsinAfrica havebasedtheirexaminationsontheUKformat. Additionally,theneedforalreadyqualifiedneurosurgeonstodemonstratecontinuingprofessional developmentforrevalidationpurposeshasalso increasedthedemandforcoursesandobjective self-assessmenttoolsinneurosurgery.
Althoughthedurationofpostgraduateneurosurgicaltrainingvariesbycountry,completion oftrainingusuallyrequiresthecandidatetopass bothwrittenandoralexaminationssetbythe relevantnationaltrainingboardorcommittee. Forthewrittenexaminations,questionsaregenerallymultiplechoiceandcoverthebasicandclinical sciences;shortanswerandessayquestionsareused insomeregions.Topicsincludeneuroanatomy, neurophysiology,neuropharmacology,critical care,fundamentalclinicalskills,neuroradiology, neuropathology,neurology,neurosurgery,and otherdisciplinesdeemedsuitableandimportant (e.g.statistics,medicallaw,medicalethics).Questionsrelatingtoclinicalneurosurgeryalsocover themainsubspecialties,includingtrauma, neuro-oncology,skullbaseandpituitarysurgery, vascularneurosurgery,spinalsurgery,pediatric neurosurgery,peripheralnervesurgery,and functional/epilepsy/painsurgery.
Forthevastmajorityofmultiplechoicequestions(MCQs)inthisbook,weprovideadetailed explanationofthecorrectanswerwithreferences tocurrentevidence-baseddatawhereappropriate.Liketherealexaminations,questionstest thereader'sknowledgeofbasicandclinicalneurosciencesandneurosurgery,andarearrangedby topictobeusefultodoctorsinneurology,neuroradiology,andneuropathology,andmedicalstudents.Illustrationsincludeanatomicalpictures, graphs,tables,radiologyimages,andhistology slidesinquestionsandanswerswhererequired. Wesuggestthefollowingapproachtousing thisbookandlearningbyMCQs:
• Firstly,startearly!Learningthroughout one'strainingwillleadtoreinforcement andconsolidationofdeepknowledgenot easilyforgotten.Usebookslikethisatthe beginning,middle,andendoftraining, andrelatethemtoyourclinicalpractice.
• Secondly,letthisbookbeaguidetoconsolidatetheinformationlearnt.Annotate materialfromotherresourceslikecomprehensivetextbooks.Usethe “red,”“amber,” and “green” gradingstodistinguishbetweenlower-yieldandmoredifficultquestionsandhigh-yieldeasyquestions.Make connectionsbetweendifferentsubspecialtiesandgeneralprinciples,andfocus onmaterialmostlikelytobetested. Rememberthatthisisneitheracomprehensivereviewbooknorapanaceaforinadequatepreparationinthelastfewmonths beforetheexam.
• Thirdly,primeyourmemorybyreturning tochallengingandannotatedquestionsin thefinaldaysbeforetheexam.Thisbook canserveasausefulwayofretainingkey associationsandrefreshingimportantfacts freshinyourmemoryfortheexam.Finally, contributetothebooktoenableactive learning.Emailusifyoufinderrorsorsee waysinwhichthebookcanbeupdated.
HOWTOTACKLESINGLEBEST ANSWER(SBA)ANDEXTENDED MATCHINGITEM(EMI)QUESTIONS
Testperformanceisinfluencednotjustbyyour knowledgebutalsobyyourtest-takingskills. Youcanimproveyourperformancebyhoning yourtest-takingskillsandstrategieswellin advanceoftheexamsothatyoucanconcentrate ontheinformationandyourknowledgeduring thetestitself.Thefollowingstrategiesmaybe useful.
Trytodealwitheachquestioninturn,identifyingitaseasy,workableorimpossiblefromyour ownperspective;ourgreen,amber,andredclassificationprovidesanapproximateexaminer's guidetodifficultyforsomeonehavingcompleted theirneurosurgicaltraining.Aimtoanswerallthe easyquestions,resolvetheworkableonesinreasonabletime,andmakequickeducatedguessesat anyapparentlyimpossibleones.Therearedifferenttechniquesforquestionreadingthatinclude readingthestem,thinkingoftheanswer,and turningtothechoicesorskimmingtheanswer choicesandthelastpartofthequestionbefore returningtothestem.Trydifferenttechniques toseewhatworkbestforyouandyieldsthehighestmarks.Ouronlinetestingareashouldhelp withthat.
Setagoodpaceforansweringthequestions. Dividethetotaltimefortheexambythenumber ofquestionsandbestrictwithyourself.Ifyouare takingtoolongthenmarkthequestion,pickyour bestanswer,andcomebacktoitlaterifyouhave timeattheend.Avoidburnoutbypracticing timedteststodevelopendurance.Useextratime tocheckmarkedquestions.Nevergiveup takea shortone-minutebreakandcomebacktothetest iftoodisheartened.
Answeralltestquestions evenifitmeans guessing!Whereasinthepastmanyneurosurgicalexaminationswerenegativelymarked,that processhaslargelybeensupersededbyonlypositivelymarkedexams,sothereisnoharminan educatedorinstinctiveguess,orevenjustablind punt.Ifyouhavetoguess,goonahunchandpick anansweryouarevaguelyfamiliarwithrather thansomethingyouhaveneverheardof.
COMPUTER-BASEDTESTING
TheUKFRCS(NeurologicalSurgery)examinationhasbeenusingcomputer-basedtestingfor severalyears,theAmericanBoardofNeurologicalSurgerymovedtoaweb-basedformatforthe PrimaryExaminationin2015,andtheEANS Part1remainsapencil-and-papertest.TheUK examtakesplaceindedicatedtestcentersfound
inmostcitiesinfrontofdesktopcomputerswith headphones,pencil,andpaperavailable,andthe softwareiscontrolledbyamouse.Residents takingtheUSexaminationusecertifiedlaptops providedbytheresidencyprogram.Bothhave high-quality,distinctimages,andsometimes includeaudioandvideomaterial.
Giventheartificialenvironmentofcomputerbasedtesting,itisimportanttobecomefamiliar withitbeforetheactualexam.Mostexamination boardsofferadownloadableorinteractivemock examinationwithafewsamplequestionstofamiliarizeyourselfwiththeenvironment.Skipping thetutorialontheexamdaysometimesaddsextra timetoanswertheactualquestionsinthetest itself.Learnhowtomarkquestions,gobackto themandifthereareanyrulespreventinggoing backtopreviousblocks.Becomefamiliarwith howtoviewimagesandspottheiconsforplaying audioandvideoclips.Bevigilantthatsomemultipartquestionspreventchangingtheanswertothe firstpartofthequestiononcethesecondparthas beenrevealed.
US,UK,ANDEUROPEAN NEUROSURGICALEXAMINATION STRUCTURE
MCQtestsgenerallyformthefirstpartofmost neurosurgicalexaminations,withthesubsequent partsbeingacombinationoforalandclinical examinations.The2015ABNSPrimaryExaminationconsistedof350questions(in6h45min), whiletheUKFRCSWrittenExaminationisin twoparts,thefirstconsistingof135SBAquestions (in2h)andthesecondpartof110EMIquestions (in2.5h).TheEuropeanAssociationofNeurosurgicalSocietiesPart1examinationconsistsof approximately200MCQstobeansweredin3h. Questionsinallthreeexaminationscoverneuroanatomy,neurobiology,neuropathology,neurology,neuroradiology,clinicalneurosurgery (includingsubspecialties),fundamentalclinical skills,andotherdisciplinesdeemedsuitableand important.
ThemarkingofsuchMCQexaminationsis nowquitestandardizedandreliesuponprinciples ofstatisticsandpsychology.Manyexamination boardsusethemodifiedAngoffmethod,whereby expertsarebriefedthenallowedtotakepartorall ofthetestwiththeperformancelevelsinmind. Theyarethenaskedtoprovideestimatesforeach questionoftheproportionofminimallyacceptablecandidatesthattheywouldexpecttoget thequestioncorrect.Thefinaldeterminationof thecutscoreisthenmadebyaveragingtheestimates.Controversialquestions thosethat polarizedthecandidates'answersbetweentwo
answersorthosethatcandidatesscoringhighly overallgotwrongwhereasthosescoringpoorly overallgotright arescrutinizedandpotentially removedfromtheoverallscoringatexaminers' standardsettingmeetings.Itisgoodpractice foratraineerepresentativewhohassattheexaminationtoparticipateinthewholeprocess.
Whereasthewrittenexaminationexploresan applicant'sknowledgeinvariousrelevantdisciplines,theoralexaminationexploresknowledge andjudgmentinclinicalneurosurgicalpractice afteranapplicanthasbeenanindependentpractitioner.Theoralexaminationisaccomplished inaseriesofface-to-faceexaminations.The applicantispresentedwithaseriesofclinical vignettesusingrealpatients,clinicaldescriptions, radiographs,computerizedimages,anatomical models,and/ordiagrams.Theexaminersgrade theapplicantonspecifictasksincludingdiagnosticskills,surgicaldecision-making,andmanagementofcomplications.
STANDARDSFORINDEPENDENT NEUROSURGICALPRACTICE
Thecredibilityofprofessionalexaminations takenattheendofsurgicaltrainingrestsontheir
abilitytosatisfypatientsandcolleaguesthatthose passinghaveattainedaminimumstandard ofbasicandappliedscienceknowledgeandclinicaldecision-makingtopracticeindependently. Oralexaminationsarecrucialinthisprocessas theyassesscommunicationskills,clinicalskills, anddecision-makingandprofessionalismina high-pressureenvironment.Incontrast,MCQs focusonassessingknowledgeandanalyticaland decision-makingskills.MoreclinicallyintegrativequestionstesthigherordersofBloom'staxonomyandaremoreeffectivethansimple factualquestionsinassessinganddeveloping theclinicalproblem-solvingskillsoftrainee surgeons.
Patientsfundamentallywishfortheirtreating surgeontobeasindependentaspossibleinorder tomaximizetheirchancesforanexcellent outcome.Therefore,whensettingminimum standardsforindependentpractice,anexpert peergroupofexaminersisaccountableto patients,otherneurosurgeonsandhealthcare professionals,andthegeneralpublic.Postgraduatemedicalexaminationshavethereforegenerallyevolvedtobecomeasstandardizedand fairaspossible,whilemaintainingrigor,expanding,andadaptingastrendschangeinclinical practice.
BASICSCIENCE CHAPTER 1
NEUROANATOMY
SINGLEBESTANSWER(SBA)QUESTIONS
1.Frominferiortosuperior(i.e.ascending), whatisthe4thbranchoftheexternalcarotid arteryintheneck?
a.Maxillaryartery
b.Occipitalartery
c.Facialartery
d.Lingualartery
e.Posteriorauricularartery
2.Thepathwaybestdescribinghowsympatheticfibersoftheautonomicnervoussystem exitthespinalcordis:
a.Viathedorsalrootsandwhiterami communicans
b.Viatheventralrootsandwhiterami communicans
c.Viathedorsalrootsandgrayrami communicans
d.Viatheventralrootsandgrayrami communicans
e.Viatheventralrootsandspinalnerves
3.Theleftvertebralarteryusuallyarisesfrom the:
a.Archoftheaorta
b.Brachiocephalictrunk
c.Leftcommoncarotid
d.Leftsubclavianartery
e.Costocervicaltrunk
4.Hemiballismusresultsfromlesioningwhich basalgangliatarget?
a.Globuspallidusinterna
b.Subthalamicnucleus
c.Substantianigraparsreticularis
d.Striatum
e.Pedunculopontinenucleus
5.Lesionofwhichstructureincreasesextensor tone?
a.Dentatenucleus
b.Pedunculopontinenucleus
c.Rednucleus
d.Ventraltegmentum
e.Superiorolive
6.Whichoneofthefollowingdrainintothe cavernoussinus?
a.Superiorophthalmicvein
b.Superiorpetrosalsinus
c.Inferiorpetrosalsinus
d.BasalveinofRosenthal
e.VeinofLabbe
7.Persistenttrigeminalarteryiscommonly:
a.Foundin3-5%ofpeople
b.Foundtoconnecttotheproximalbasilar artery
c.FoundtobranchofffromtheICAjust proximaltothemeningohypophyseal trunk
d.Foundtohaveavascularabnormalityin approximately50%ofcases
e.Foundinconjunctionwithinternal carotidarteryaplasia
8.TheafferentloopoftheHering-Breuer inflationanddeflationreflexesismediated by:
a.CNXIII
b.CNIX
c.CNX
d.CNXI
e.C2
9.Whichoneofthefollowingnervesisoutside theannulusofZinn?
a.Abducens
b.Nasociliary
c.Trochlear
d.Oculomotor(superiordivision)
e.Oculomotor(inferiordivision)
10.TheC2vertebrahashowmanysecondary ossificationcenters?
a.2
b.3
c.4
d.5
e.6
11.Alinedrawnbetweenthehighestpointofthe iliaccrestsacrossthebackusuallydenotes:
a.L1/2interspace
b.L2/3interspace
c.L3/4interspace
d.L4/5interspace
e.L5/S1interspace
12.WhichoneofthefollowingislabeledXin theimagebelow?
a.Ophthalmicdivisionofthetrigeminalnerve
b.Meckel’ scave
c.Oculomotornerve
d.Maxillarydivisionoftrigeminalnerve
e.Abducensnerve
13.Whichoneofthefollowingstatementsabout thesympatheticnervoussystemisFALSE?
a.Innervationofthoracicvisceraarisesfrom T1-T4spinalsegments
b.Splanchnicnervesareunmyelinated
c.Preganglionicfibersenterthesympatheticchainviawhiteramicommunicans
d.Sensoryafferentfibersareimportantfor visceralpainsensation
e.Preganglionicfiberssynapseineitherthe sympatheticchainorprevertebralganglia
14.Nervierigentesareresponsiblefor:
a.Inhibitionoftheexternalanalsphincter
b.Inhibitionoftheinternalvesiclesphincter
c.Inhibitionoftheinternalanalsphincter
d.Inhibitionoftheexternalvesiclesphincter
e.Inhibitionoftherectalmuscles
15.Parasympatheticsensoryafferentsterminate inwhichoneofthefollowing?
a.Nucleusambiguus
b.Solitarynucleus
c.Edinger-Westphalnucleus
d.Rednucleus
e.Superiorcolliculus
16.Whichoneofthelabelsinthediagrambelow oftheinternalauditorycanalidentifiesthe facialnerve?
17.Bloodsupplytotheposteriorpituitarygland arisesfrombranchesofwhichinternal carotidarterysegment?
a.C1(Cervical)
b.C2(Petrous)
c.C3(Lacerum)
d.C4(Cavernous)
e.C5(Clinoid)
f.C6(ophthalmic/supraclinoid)
g.C7(communicating)
QUESTIONS18–25
Additionalquestions18–25availableon ExpertConsult.com
EXTENDEDMATCHINGITEM(EMI) QUESTIONS
26. Cavernoussinusimaging:
Foreachofthefollowingdescriptions,selectthe mostappropriateanswersfromtheimageabove. Eachanswermaybeusedonce,morethanonce ornotatall.
1.Rightopticnerve
2.Oculomotornerve
3.Abducensnerve
27. Internalauditorycanal:
Foreachofthefollowingdescriptions,selectthe mostappropriateanswersfromtheimageabove. Eachanswermaybeusedonce,morethanonce ornotatall.
1. AICA
2. Basalturnofcochlea
3. Cochlearnerve
28. Cavernoussinusanatomy:
Foreachofthefollowingdescriptions,selectthe mostappropriateanswersfromthediagram above.Eachanswermaybeusedonce,morethan onceornotatall.
1.ACA
2.MaxillarydivisionofCNV(V2)
3.Oculomotornerve(III)
29. Internalauditorycanal:
Foreachofthefollowingdescriptions,selectthe mostappropriateanswersfromtheimageabove. Eachanswermaybeusedonce,morethanonce ornotatall.
1.Facialnerve
2.Superiorvestibularnerve
3.Greatersuperficialpetrosalnerve
4.Posteriorsemicircularcanal
30. Internalauditorycanal:
Foreachofthefollowingdescriptions,selectthe mostappropriateanswersfromtheimagesabove. Eachanswermaybeusedonce,morethanonce ornotatall.
1.Anteriorinferiorcerebellarartery
2.Vestibulocochlearnerve
3.Facialnerve
31. BasalGanglia:
Foreachofthefollowingdescriptions,selectthe mostappropriateanswersfromtheimageabove. Eachanswermaybeusedonce,morethanonce ornotatall.
1.Caudatenucleus
2.Claustrum
3.Globuspallidusinterna
4.Internalcapsule
5.Putamen
32. Projectionandassociationtracts:
a.Centraltegmentaltract
b.Laminaterminalis
c.Medianforebrainbundle
d.Striamedullaris
e.Striaterminalis
f.PostcommissuralFornix
g.NucleusofthediagonalbandofBroca (verticallimb)
h.Retinohypothalamictract
i.Supraopticohypophysealtract
j.Tuberoinfundibular (tuberohypophyseal)tract
k.Trapezoidbody
l.Thalamicfasciculus(Forel’sfieldH1)
m.NucleusoftheDiagonalbandofBroca (horizontallimb)
n.Mammillothalamictract
o.Tapetum
Foreachofthefollowingdescriptions,selectthe mostappropriatetractsfromthelistabove.Each answermaybeusedonce,morethanonceornot atall.
1.Conductsfiberstotheposteriorpituitary gland
2.Arcuatenucleustohypophysealportalsystemofinfundibulum
3.Septalnucleitohippocampus
4.Connectssepalarea,hypothalamus,basal olfactoryareas,hippocampus/subiculum tomidbrain,ponsandmedulla
5.Hippocampustocingulategyrus
33. Vascularterritories:
a.Middlecerebralartery
b.Basilarartery
c.Perforatorsfrominternalcarotidartery
d.Ophthalmicartery
e.P2portionofposteriorcerebralartery
f.Vertebralartery
g.Superiorcerebellarartery
h.Posteriorinferiorcerebellarartery
i.Anteriorinferiorcerebellarartery
j.Posteriorcommunicatingartery
k.A2portionofanteriorcerebralartery
l.P3portionofposteriorcerebralartery
m.RecurrentarteryofHeubner
Foreachofthefollowingdescriptions,selectthe mostappropriateanswersfromthelistabove. Eachanswermaybeusedonce,morethanonce ornotatall.
1.Posteriorlimboftheinternalcapsule
2.Medialandlateralgeniculatenuclei
3.Anteriorlimbofinternalcapsuleandhead ofcaudate
4.Posteriorpituitarygland
5.Spleniumofcorpuscallosum
34. Cerebralveins:
Foreachofthefollowingdescriptions,selectthe mostappropriateanswersfromtheimageabove. Eachanswermaybeusedonce,morethanonce ornotatall.
1.InferioranastamoticveinofLabbe
2.SuperficialmiddlecerebralveinofSilvius
3.SuperioranastamoticveinofTrolard
4.BasalveinofRosenthal
5.VeinofGalen
35. OffendingArtery:
a.A1portionofanteriorcerebralartery
b.Anteriorchoroidartery
c.Anteriorcommunicatingartery
d.Anteriorinferiorcerebellarartery
e.Basilararteries
f.Facialartery
g.Internalcarotidartery
h.M3portionofmiddlecerebralartery
i.Ophthalmicartery
j.Posteriorcerebralartery
k.Posteriorcommunicatingartery
l.Posteriorinferiorcerebellarartery
m.Superiorcerebellarartery
n.Vertebralartery
Foreachofthefollowingdescriptions,selectthe mostappropriateanswersfromthelistabove. Eachanswermaybeusedonce,morethanonce ornotatall.
1.Glossopharyngealneuralgia
2.Trigeminalneuralgia
3.Hemifacialspasm
4.Horner’ssyndrome
5.CNIIIpalsy
36. Autonomicnervoussystem:
a.Erdinger-Westphalnucleus
b.Superiorsalivatorynucleus
c.Inferiorsalivatorynucleus
d.Dorsalnucleus
e.Ciliaryganglion
f.Pterygopalatineganglion
g.Oticganglion
h.Submandibularganglion
i.CNII
j.CNV
k.Chordatympani
l.Vidiannerve
m.Superiorcervicalganglion
n.Greaterpetrosalnerve
o.Lessersuperficialpetrosalnerve
p.Auriculotemporalnerve
Foreachofthefollowingdescriptions,selectthe mostappropriateanswersfromthelistabove. Eachanswermaybeusedonce,morethanonce ornotatall.
1.Mediatesbronchoconstriction
2.Receivespreganglionicparasympathetic fibersviaCNIII
3.Postganglionicparasympatheticfibersto parotidgland
4.Preganglionicparasympatheticfiberstothe submandibularganglion
5.Originofpreganglionicparasympathetic fiberstransmittedinGSPNIX
37. Projectionandassociationtracts:
a.Ansalenticularis
b.Fasciculusretroflexus
c.Lenticularfasciculus(Forel’sfieldH2)
d.Postcommissuralfornix
e.Precommissuralfornix
f.Thalamicfasciculus(Forel’sfieldH1)
g.NucleusofthediagonalbandofBroca
h.Mammillothalamictract
i.Tapetum
j.Uncinatefasciculus
k.CommissureofProbst
l.Centraltegmentaltract
m.Laminaterminalis
n.Medianforebrainbundle
o.Striamedullaris
Foreachofthefollowingdescriptions,selectthe mostappropriateoptionfromthelistabove.Each answermaybeusedonce,morethanonceornot atall.
1.Globuspallidusinternatothalamus throughinternalcapsule
2.Globuspallidusinternatothalamusaround internalcapsule
3.Septalnucleitoamygdala
4.Temporallobetooccipitallobe
5.Connectionbetweennucleioflateral lemniscus
Foreachofthefollowingdescriptions,selectthe mostappropriatepartofthethalamusfromthe imageabove.Eachanswermaybeusedonce, morethanonceornotatall.
1.Pulvinar
2.Ventralanteriornucleus
3.Ventralposterolateralnucleus
4.Lateralgeniculatenucleus
5.Medialgeniculatenucleus
39. Thalamus:
Foreachofthefollowingdescriptions,selectthe mostappropriatepartofthethalamusfromthe imageabove.Eachanswermaybeusedonce, morethanonceornotatall.
1.Receivesmajorinputfrominferiorcolliculi
2.Majorprojectiontotheprimaryvisualcortex
3.Receivesmajorprojectionsfrommammillary body
4.Auditoryrelaynucleus
5.Containstheareaoffacerepresentation
40. Projectionandassociationtracts:
a.Inferiorcollicularcommissure
b.Cingulatefasciculus
c.Arcuatefasciculus
d.Corpuscallosum
e.Posteriorcommissure
f.Hypothalamospinaltract
g.Brachiumconjunctivum
h.Brachiumpontis
i.Restiformandjuxtarestiformbodies
j.Dorsallongitudinalfasciculus
k.Mediallongitudinalfasciculus
l.Uncinatefasciculus
m.Laminaterminalis
n.CommissureofProbst
o.Striamedullaris
Foreachofthefollowingdescriptions,selectthe mostappropriateXfromthelistabove.Each answermaybeusedonce,morethanonceor notatall.
1.Periventricularhypothalamusandmammillarybodiestomidbraincentralgray matter
2.Coveredwithindusiumgriseum
3.Containscrossingfibersofpretectal nucleusforlightreflex
4.ConnectsWernickeandBroca’sareas
5.InterruptioncanresultinHorner’ s syndrome
38. Thalamus:
41.Foreachofthefollowingdescriptions,select themostappropriateanswersfromtheimage below.Eachanswermaybeusedonce,more thanonceornotatall.
1.Cisternamagna
2.Interpeduncularcistern
3.Chiasmaticcistern
42. CranialNerveNuclei:
Foreachofthefollowingdescriptions,selectthe mostappropriateanswersfromtheimageabove. Eachanswermaybeusedonce,morethanonce ornotatall.
1.Abducensnervenucleus
2.Principalsensorynucleusoftrigeminalnerve
3.Solitarytractnucleus
4.Facialnervemotornucleus
5.Nucleusambiguus
43. Sulciandgyri:
Foreachofthefollowingdescriptions,selectthe mostappropriateanswersfromtheimageabove. Eachanswermaybeusedonce,morethanonce ornotatall.
1.Angulargyrus
2.Supramarginalgyrus
3.Parsopercularisofinferiorfrontalgrus
4.Middlefrontalgyrus
5.Parieto-occipitalsulcus
44. Sulciandgyri:
Foreachofthefollowingdescriptions,selectthe mostappropriateanswersfromtheimageabove. Eachanswermaybeusedonce,morethanonce ornotatall.
1.Marginalsulcus
2.Calcarinesulcus
3.Cuneus
4.Collateralsulcus
5.Laminaterminalis
45. Sulciandgyri:
Foreachofthefollowingdescriptions,selectthe mostappropriateanswersfromtheimageabove. Eachanswermaybeusedonce,morethanonce ornotatall.
1.Centralsulcus
2.Paracentralsulcus
3.Calcarinesulcus
4.Marginalsulcus
5.Precuneus
46. Fourthventricularfloor:
Foreachofthefollowingdescriptions,selectthe mostappropriateanswersfromtheimageabove. Eachanswermaybeusedonce,morethanonce ornotatall.
1.Facialcolliculus
2.Striaemedullaris
3.Sulcuslimitans
4.Mediansulcus
5.Vagaltrigone
47. CranialNerveNuclei:
Foreachofthefollowingdescriptions,selectthe mostappropriateanswersfromtheimageabove. Eachanswermaybeusedonce,morethanonce ornotatall.
1.Rednucleus
2.Erdinger-Westphalnucleus
3.Oculomotornucleus
4.Trochlearnucleus
5.Abducensnucleus
6.Facialnucleus
7.Nucleusambiguusofvagusnerve
48. Medullaatsensorydecussation:
Foreachofthefollowingdescriptions,selectthe mostappropriateanswersfromtheimageabove. Eachanswermaybeusedonce,morethanonce ornotatall.
1.Nucleusgracilis
2.Nucleuscuneatus
3.Spinothalamictract
4.Posteriorspinocerebellarfibers
49. Medullaandvagalnuclei:
Foreachofthefollowingdescriptions,selectthe mostappropriateanswersfromtheimageabove. Eachanswermaybeusedonce,morethanonce ornotatall.
1.Solitarynucleusandtract
2.Dorsalmotorvagalnucleus
3.Reticularformation
4.Principalolivarynucleus(inferiorolivary nucleus)
5.Mediallemniscus
50. Rostralmedulla:
1.Posteriorcochlearnucleus
2.Vestibulocochlearnerve
3.Spinaltrigeminalnucleus
4.Mediallongitudinalfasciculus
5.Nucleusambiguus
51. Caudalpons:
Foreachofthefollowingdescriptions,selectthe mostappropriateanswersfromtheimageabove. Eachanswermaybeusedonce,morethanonce ornotatall.
1.Facialnucleus
2.Facialnerve
3.Superiorolivarynucleus
4.Abducensnucleus
5.Abducensnerve
52. Mid-pons:
Foreachofthefollowingdescriptions,selectthe mostappropriateanswersfromtheimageabove. Eachanswermaybeusedonce,morethanonce ornotatall.
1.Locusceruleus
2.Corticospinalfibers
Foreachofthefollowingdescriptions,selectthe mostappropriateanswersfromtheimageabove. Eachanswermaybeusedonce,morethanonce ornotatall.
3.Principaltrigeminalsensorynucleus
4.Fourthventricle
5.Brachiumpontis
SBAANSWERS
1. c Facialartery
Theexternalcarotidarteryhasseveralbranchesin theneck(SALFOPSIinascendingorder):superior thyroid,ascendingpharyngeal,lingual,facial(aka externalmaxillary),occipital,posteriorauricular, superficialtemporal,maxillary(akainternalmaxillary).Itcanbedistinguishedonangiogram(figure) fromtheICA,whichhasnobranchesintheneck. DuringEC/ICbypassproceduresforMoyaMoya disease,anastomosisofthesuperficialtemporal arterytothemiddlecerebralartery(orlesscommonlyoccipitalarterytotheposteriorcerebral artery/posteriorinferiorcerebellarartery)maybe performed.
Foreachofthefollowingdescriptions,selectthe mostappropriateanswersfromtheimageabove. Eachanswermaybeusedonce,morethanonce ornotatall.
1.Mediallemniscus
2.Mediallongitudinalfasciculus
3.Trochlearnerve
4.Centraltegmentaltract
5.Tectobulbospinaltract
QUESTIONS54–58
Additionalquestions54–58availableon ExpertConsult.com
2. b Viatheventralrootsandwhiterami communicans
3. d Leftsubclavianartery
Eachvertebralarteryarisesfromitsipsilateral subclavianartery.Theaorticarchgivesoffthree branchesinorder:brachiocephalictrunk(or innominateartery),leftcommoncarotidandleft subclavianarteries(A).Thesecondcommonest branchingpattern(termeda “bovinearch”)is wheretheleftcommoncarotidarisesfromthe brachiocephalictrunk(B).
ImageredrawnfromLaytonKF,KallmesDF,CloftHJ,LindellEP,CoxVS.Bovineaorticarchvariantinhumans: Clarificationofacommonmisnomer.AJNRAmJNeuroradiol2006;27:1541-1542.In:LowM,SomPM,Naidich TP.Problemsolvinginneuroradiology.Elsevier.
4. b Subthalamicnucleus
Hemiballismusisaconditioncharacterizedby unilateral,involuntary,violentflingingofthe limbs.Lesionisbasedinthecontralateralsubthalamicnucleusoritsconnectionsandduetovascularcause(PCAterritory)butcanoccurinMS. Oftensettlesspontaneouslyanddrugtreatment isineffective.
5. c Rednucleus
Factorsnormallyinhibitingextensoractioninthe armsandlegsare:
(A)Corticalinhibitionoflateralvestibular nucleus(vestibulospinaltract)andpontine reticularformation
(B)Rednucleusprojectionstospinalcord (rubrospinaltract;possiblyarmsonly)
(C)Medullaryreticularformation
Disconnectionlesioninvolvingrednucleus resultsinlossofnormalinhibitionofextension (rubrospinalandmedullaryreticularformation) andlossofcorticalinhibitionofextensoraction ofLVNandpontineRF,producinghyperreflexia andincreasedextensortone(decerebraterigidity).Disconnectionlesionsabovetherednucleus resultinextensioninlegs,butflexioninarms (decorticaterigidity).Thisisexplainedasin humanstherubrospinaltractterminatesinthe cervicalspine,meaningintactrubrospinal inputcouldcounteractvestibulospinal(extensor) inputinthearmsbutitremainsunopposedin thelegs.
6. a Superiorophthalmicvein
Thecavernoussinusreceivesthesuperiorand inferiorophthalmicveins,sphenoparietalsinus andthesuperficialmiddlecerebralvein(coursing fromsuperiorlytoinferiorlyintheSylvianfissure).Itdrainsviasuperiorpetrosalsinus(to thejunctionofthetransverseandsigmoid sinuses),inferiorpetrosalsinus(totheinternal jugularvein).Rightandleftcavernoussinuses arealsoconnectedacrossthemidlineanterior andposteriorlytothepituitaryglandviatheanteriorandposteriorintercavernoussinuses,resultinginthecircularsinus.Eachcavernoussinusis alsoconnectedtothepterygoidvenousplexus viasmallbranchesintheforamenVesalii,foramenovaleandforamenlacerum.
7. c FoundtobranchofffromtheICAjust proximaltothemeningohypophysealtrunk
AfterthePcomm,persistentprimitivetrigeminal arteryisthenextcommonestremnantofthefetal circulation.Itisseenin0.1-0.6%ofcerebralangiograms.ItconnectsthecavernousICA(justproximaltomeningohypophysealtrunk)tothebasilar arterybetweensuperiorcerebellarandanterior inferiorcerebellararteries.Itspersistenceisusually associatedwithahypoplasticbasilarandvertebral arteriesproximaltotheanastomosis,aswellasa hypoplasticPcommA.Itsfrequencyisexplained astheorderofregressionduringembryogenesis isotic/acousticarteryfirst,thenhypoglossalfollowedbytrigeminal.Vascularabnormalities (AVM,aneurysm)isseenin25%.Characterized bythetausign(flowvoid)onsagittalMRI.
ImagefromLawM,SomP,NaidichT.ProblemSolving inNeuroradiology,Elsevier,Saunders,2011.
8. c CNX
TheHering-Breuerinflationanddeflationreflexes arethoughttoplayaroleincontrollingthedepth ofbreathing,althoughmaybelessimportantin humansatrest.Theiroveralleffectistoprevent overinflationandextremedeflationofthelungs. Theinflationreflexismediatedbypulmonary stretchreceptorafferentssignalingviaCNXduringlunginflationtoinhibitmedullaryinspiratory centerandthepontineapneusticcenter,aswell asinhibitingcardiacvagalmotorneuronsresulting insinustachycardia.Thedeflationreflexalsoacts viaCNXanddirectlyactivatesmedullaryinspiratorycenters,stoppingexpirationandinitiating inspiration.
PCOMM
Trigeminal
Proatlantal
Vertebral artery
ICA
Hypoglossal
Otic
