Blumenfeld H. Neuroanatomy through clinical cases. 1st ed. Sunderland: Sinauer Associates, 2002.

Transcription

1 Anatomy Question 1: Anatomy - Cortex and Connections The arcuate fasciculus is a connection between Wernicke's area in the superior temporal gyrus and Broca's area in the inferior frontal gyrus. The inferior frontal gyrus can be subdivided into three parts: pars opercularis, pars triangularis, and pars orbitalis with the first two being the anatomical substrate for Broca's area. Carpenter MB. Core text of neuroanatomy. Baltimore: William & Wilkins, Blumenfeld H. Neuroanatomy through clinical cases. 1st ed. Sunderland: Sinauer Associates, Kandel ER, Schwartz JH, Jessel TM. Principles of neural science. 4th ed. New York: McGraw-Hill, Question 28: Anatomy - Peripheral Nervous System The tibialis anterior, which dorsiflexes and inverts the foot, is innervated by the deep peroneal nerve. The gastrocnemius plantar flexes the foot and is innervated by the tibial nerve (a branch of the sciatic nerve). The semitendinosus, one of the hamstring muscles, is innervated by the sciatic nerve. The tensor fasciae latae, innervated by the superior gluteal nerve, abducts and medially rotates the thigh. The sartorius muscle inwardly rotates the hip, and flexes the hip and knee and is innervated by the femoral nerve. Blumenfeld H. Neuroanatomy through clinical cases. 1st ed. Sunderland: Sinauer Associates, No author. Aids to the examination of the peripheral nervous system. 2nd ed. London: Bailliere Tindall, Question 45: Anatomy - Peripheral Nervous System The tibial nerve innervates the tibialis posterior muscle, which inverts the foot. It also innervates the gastrocnemius, soleus, flexor digitorum longus, and flexor hallucis longus. The deep peroneal nerve controls the tibialis anterior, extensor digitorum longus, extensor hallucis longus, and extensor digitorum brevis. The femoral nerve innervates the iliopsoas and quadriceps femoris. The medial plantar nerves innervate the small muscles of the foot, tested by observing the patient cupping the sole of the foot. The obturator nerve innervates hip adductors. Brain. Aids to the Examination of the Peripheral Nervous System. 4th ed. Edinburgh: WB Saunders, Question 56: Anatomy - Spinal Cord

2 On the side of a spinal cord hemisection there would be an upper motor neuron syndrome, greatly impaired discriminatory tactile sense, loss of kinesthetic sense, and reduced muscle tone below the level of the lesion. Contralateral to the lesion there would be loss of pain and temperature due to interruption of the ascending spinothalamic tracts (which cross soon after entry) Haines DE. Fundamental neuroscience. 2nd ed. New York: WB Saunders, Question 67: Anatomy - Blood Supply of Brain/Spinal Cord To reach its area of distribution, the posterior cerebral artery crosses the border of the tentorium cerebelli from the infratentorial compartment into the supratentorial compartment. Increased intracranial pressure in the supratentorial compartment may compress the posterior cerebral artery against the tentorium cerebelli leading to compromised blood flow to the visual cortex. Haines DE. Fundamental neuroscience. 2nd ed. New York: WB Saunders, Question 68: Anatomy - Brainstem/Cerebellum The internal arcuate fibers from the dorsal column nuclei (cuneate and gracile nuclei) decussate completely to form the medial lemniscus which then travels upward to the thalamus. Campbell WW. DeJong's the neurologic examination. Philadelphia: Lippincott, Williams & Wilkins, Question 82: Anatomy - Spinal Cord The anterior spinal artery supplies the descending corticospinal tracts and ascending spinothalamic tracts. The dorsal columns are spared with preservation of fine touch and joint position sense. Spinal cord ischemia is a recognized complication of aortic aneurysm repair. Haines DE. Fundamental neuroscience. 2nd ed. New York: WB Saunders, Question 83: Anatomy - Basal Ganglia and Thalamus Ballism is associated with discrete lesions in the subthalamic nucleus. The dyskinesia occurs contralateral to the lesion and is associated with hypotonia. As the hemiballismus improves, the movements are more like chorea. The subthalamic nucleus modulates (suppresses) ispilateral basal ganglionic activity, which in turn modulates cortical motor outflow to the contralateral effector muscles.

3 Blumenfeld H. Neuroanatomy through clinical cases. 1st ed. Sunderland: Sinauer Associates, Question 93: Anatomy - Peripheral Nervous System The synapse of the afferent axons for the muscle stretch reflex is located in the anterior (ventral) horn. The muscle stretch reflex is monosynaptic directly from sensory neuron to an alpha motor neuron. The dorsal root ganglion contains cell bodies of the pseudo-unipolar sensory neurons. The intermediate column contains synapses related to sympathetic function while the substantia gelatinosa is the site of synapse for afferent fibers which will form the spinothalamic tract. The substantia gelatinosa sits within the zone of Lissauer. Campbell WW. DeJong's the neurologic examination. Philadelphia: Lippincott, Williams & Wilkins, Question 100: Anatomy - Peripheral Nervous System The supraspinatus helps abduct the shoulder through the first 15 degrees. With deltoid contraction, the arm is abducted (raised laterally) to the horizontal plane. Elevation above the horizontal plane is assisted by contraction of trapezius and serratus anterior. Campbell WW. DeJong's the neurologic examination. Philadelphia: Lippincott, Williams & Wilkins, Question 102: Anatomy - Peripheral Nervous System Although they are part of the sympathetic nervous system, the postganglionic fibers to the sweat glands (sudomotor fibers) are cholinergic. Glutamine is not a traditional transmitter but is, instead, the form in which glutamate (and therefore GABA) are shuttled between neurons. Norepinephrine is the neurotransmitter at all other post-ganglionic sympathetic synapses. Serotonin is a traditional central transmitter while substance P is a neuromodulatory peptide found in the periphery and important in nocioception. Haines DE. Fundamental neuroscience. 2nd ed. New York: WB Saunders, Question 108: Anatomy - Cranial Nerves Light first enters the innermost layer of the retina, the ganglion cell layer. Light will also pass through the inner plexiform layer, the bipolar nuclear layer, and the outer plexiform layer prior to reaching the rods and cones. Campbell WW. DeJong's the neurologic examination. Philadelphia: Lippincott, Williams & Wilkins, Question 115: Anatomy - Blood Supply of Brain/Spinal Cord

4 The primary input to the cerebellum is via the middle cerebellar peduncle which, along with the flocculonodular lobe, is supplied by the anterior inferior cerebellar artery. The vertebral arteries and the posterior inferior cerebellar arteries supply the lateral medulla. The posterior cerebral artery supplies the parieto-occipital region. Blumenfeld H. Neuroanatomy through clinical cases. 1st ed. Sunderland: Sinauer Associates, Question 118: Anatomy - Spinal Cord Anesthesia over the perineal area ("saddle anesthesia") in conjuction with loss of sphincter tone and erectile dysfunction can be caused by a lesion of the lower cauda equina or the conus medularis. The region of sensory abnormality is in the S2 to S5 dermatomes. There is no weakness noted indicating that the lumbar and lumbosacral plexi are likely spared. Since this happend 3 weeks ago and his sphincter function remains flacid, this is most likely to be a peripheral (lower motor neuron) problem. These factors implicate the bilateral S2-S5 roots as the most likely culprit. An intramedullary lesion occuring 3 weeks ago would be expected to have some component of spasticity at this point. A medial frontal lesion would explain the bladder incontinence but would not explain the sensory findings and there is no lower extremity weakness. Onuf's nucleus is a sphincteromotor nucleus located at S2 and S4 and would only explain part the patient's urinary symptoms. Given the sesory and bowel and bladder symptoms, this process is involving the distal rather than the proximal cauda equina. Since the more distal roots of the cauda equina are located more medially, a central disc herniation would be entirely consistent with this clinical vignette. Blumenfeld H. Neuroanatomy through clinical cases. 1st ed. Sunderland: Sinauer Associates, Question 121: Anatomy - Cortex and Connections Bilateral lesions of the fusiform (occipitotemporal) gyri produce prosopagnosia, the inability to recognize people by looking at their face. Blumenfeld H. Neuroanatomy through clinical cases. 1st ed. Sunderland: Sinauer Associates, Question 123: Anatomy - Cortex and Connections Seizures arising from the supplementary sensorimotor area (SSMA) are of brief duration, usually lasting 10 to 40 seconds. Rapid onset of asymmetric tonic posturing involving one or more extremities is characteristically observed. SSMA seizures may be frequent and can occur in clusters. They tend to occur primarily in sleep. The clinical picture with involvement of all four extremities and simultaneous preservation of awareness can inadvertently lead to the misdiagnosis of psychogenic seizures. Wyllie E. The treatment of epilepsy: principles and practices. 4th ed. Philadelphia: Lippincott, Williams & Wilkins, Question 125: Anatomy - Basal Ganglia and Thalamus

5 The anterior nucleus of the thalamus receives information from the mammilothalamic tract and hippocampus and sends its outputs to the cingulate gyrus. The dorsomedial (or mediodorsal) nucleus connects prefrontal, olfactory, and limbic cortex with prefrontal cortical regions. These last two nuclei are the only two of those listed that would be reasonably expected to affect multimodal attention and motivational drive. These two nuclei are preferentially affected by fatal familial insomnia. The ventral anterior and ventral lateral nuclei receive input from the basal ganglia and cerebellum, respectively, and send their outputs to the motor cortex. The ventral posterior medial and lateral nuclei receive primary somatosensory information from the face and body on its way to primary sensory cortex. The pulvinar and lateral posterior nuclei are both involved in visual processing and subcortical modulation of visual attention. The medial and lateral geniculate receive primary auditory and visual information, respectively. Murray S, Guillery R. Exploring the thalamus. San Diego: Academic Press, Question 139: Anatomy - Basal Ganglia and Thalamus Axonal fibers arising from the subthalamic nucleus terminate on the globus pallidum, internal segment and the substantia nigra, pars reticulata. Neurons of the subthalamus contain glutamate and exert excitatory input into the globus pallidum, pars internal. This connection is one component of the indirect loop that decreases thalamocortical excitation. Carpenter MB. Core text of neuroanatomy. Baltimore: William & Wilkins, Campbell WW. DeJong's the neurologic examination. Philadelphia: Lippincott, Williams & Wilkins, Gilman S, Newman SW. Essentials of clinical neuroanatomy and neurophysiology. 10th ed. Philadelphia: FA Davis, Question 140: Anatomy - Brainstem/Cerebellum Irregularly irregular breaths alternating with periods of apnea, known as ataxic breathing, localize to the bilateral dorsomedial medulla and may signify impending respiratory failure. Bilateral involvement of the hemispheres, midbrain or thalami may result in Cheyne-Stokes respiration, hyperpnea alternating with shorter periods of apnea. Lesions of the lower half of pons cause apneustic breathing, characterized by a long inspiratory pause, brief air retention, then release. High cervical cord and caudal medullary tegmental lesions may result in the loss of automatic breathing during sleep. Brazis PW, Masdeu JC, Biller J. Localization in clinical neurology. 5th ed. Philadelphia: Lippincott, Williams & Wilkins, Question 146: Anatomy - Brainstem/Cerebellum The patient has components of Parinaud syndrome (conjugate upgaze paresis, nystagmus retractorius, and unreactive pupils). A lesion producing these findings occurs in the midbrain tectal region. It often occurs by extraaxial compression on the quadrigeminal plate (particularly the superior colliculi). Pineal region masses as well as obstructive hydrocephalus may also cause the syndrome.

6 Gilman S, Newman S. Manter & Gatz's essentials of clinical neuroanatomy and neurophysiology. 7th ed. Philadelphia: FA Davis, Blumenfeld H. Neuroanatomy through clinical cases. 1st ed. Sunderland: Sinauer Associates, Question 147: Anatomy - Brainstem/Cerebellum The largest cerebellar efferent bundle, the superior cerebellar peduncle, is formed by fibers from the dentate, emboliform, and globose nuclei. Most fibers enter and surround the contralateral red nucleus. Carpenter MB. Core text of neuroanatomy. Baltimore: William & Wilkins, Question 158: Anatomy - Basal Ganglia and Thalamus The suprachiasmatic nucleus receives direct inputs from the retina (retinohypothalamic tract). These inputs, from specialized ganglion cells, are involved in entrainment of circadian rhythms on the basis of the light/dark cycle and, via a somewhat indirect route, control melatonin secretion. Brazis PW, Masdeu JC, Biller J. Localization in clinical neurology. 5th ed. Philadelphia: Lippincott, Williams & Wilkins, Question 169: Anatomy - Cortex and Connections Fifty patients with elevations of serum cardiac troponin levels had strokes involving the right posterior, superior medial insula, and the right inferior parietal lobule. Among patients with right middle cerebral artery strokes, the insular cortex was involved in 88% of patients with elevated serum cardiac troponin but in only 33% of patients without the elevation. Ay H, Koroshetz WJ, Benner T, et al. Neuroanatomic correlates of stroke-related myocardial injury. Neurology 2006; 66: Question 188: Anatomy - Blood Supply of Brain/Spinal Cord The internal carotid artery (ICA) can be divided into four segments: cervical, intrapetrosal, intracavernous, and supraclinoid. The ophthalmic artery arises from the ICA just as it emerges from the cavernous sinus, in the supraclinoid segment. Campbell WW. DeJong's the neurologic examination. Philadelphia: Lippincott, Williams & Wilkins, 2005.

7 Carpenter MB. Core text of neuroanatomy. Baltimore: William & Wilkins, Question 228: Anatomy - Spinal Cord The arrow is pointing to the anterior commisure of the spinal cord which is where the fibers of the anterolateral system, carrying pain and temperature, decussate. Nolte J. The human brain. 4th ed. St Louis: Mosby, Haines DE. Neuroanatomy: an atlas of structures, sections and systems. 2nd ed. Baltimore: Urban & Schwarzenberg, Question 229: Anatomy - Spinal Cord The tract indicated by the arrow is the anterior corticospinal tract which carries fibers arising from the ipsilateral precentral gyrus. It is the uncrossed component of the pyramidal tract. Haines DE. Neuroanatomy: an atlas of structures, sections and systems. 2nd ed. Baltimore: Urban & Schwarzenberg, Blumenfeld H. Neuroanatomy through clinical cases. 1st ed. Sunderland: Sinauer Associates, Question 247: Anatomy - Cortex and Connections The arrow indicates the anterior commisure which connects the temporal lobes - particularly inferior and middle gyri and also carries some olfactory tract fibers. The superior colliculi and pre-tectal nuclei are connected via the posterior commisure. The hippocampi are connected via the hippocampal commisure while the frontal lobes are connected via the corpus callosum. Nolte J. The human brain. 4th ed. St Louis: Mosby, Blumenfeld H. Neuroanatomy through clinical cases. 1st ed. Sunderland: Sinauer Associates, Carpenter M, Sutin J. Human neuroanatomy. 8th ed. Baltimore: Williams and Wilkins, Question 266: Anatomy - Cranial Nerves The structure indicated by the arrow is the trochlear (fourth) nerve which completely decussates before it exits from the dorsal aspect of the brainstem. After it exists the brainstem, the trochlear nerve innervates the superior oblique muscle and results in depression and intorsion of the ipsilateral eye.

8 Blumenfeld H. Neuroanatomy through clinical cases. 1st ed. Sunderland: Sinauer Associates, Wilson-Pauwels L, Akesson E, Stewart P. Cranial nerves: anatomy and clinical components. Toronto: BC Decker Inc, Haines DE. Neuroanatomy: an atlas of structures, sections and systems. 2nd ed. Baltimore: Urban & Schwarzenberg, Question 293: Anatomy - Basal Ganglia and Thalamus The structure indicated by the arrow is the lateral geniculate body which may be recognized by its convex shape (some say it looks like Napoleon's hat) and proximity to the thalamus. The tail of the caudate is lateral to the LGB. The amygdala and hippocampus would be in the mesial temporal lobe. The juxtarestiform body lies next to the inferior cerebellar peduncle in the medulla. Haines DE. Fundamental neuroscience. 2nd ed. New York: WB Saunders, Question 305: Anatomy - Cortex and Connections The photomicrograph shows a coronal section of the corpus callosum and cingulate gyri. The arrows identify the indusium griseum. The indusium (also called the supracallosal gyrus) is a direct continuation of the hippocampal formation located dorsal to the corpus callosum. Parent A. Carpenter's human neuroanatomy. 9th ed. Baltimore: Williams & Wilkins, Question 306: Anatomy - Cortex and Connections The coronal image shows a large area of increased T2-intensity signal on the right hemisphere. It's homogeneity and high signal intensity are incompatible with an acute infarction but typical of a chronic infarction. They do not suggest multiple sclerosis or postradiation changes. The large chronic right middle cerebral artery infarction has caused Wallerian degeneration of the corticospinal tract, outlined by a hyperintense track along the right side of the brainstem. Bakshi R, Ketonen L. Brain MRI in clinical neurology. In: Joynt RJ, Griggs RC, editors. Baker's clinical neurology. Philadelphia: Lippincott, Williams & Wilkins, Question 317: Anatomy - Peripheral Nervous System The terminal branches of the posterior cord of the brachial plexus are the radial and axillary nerves. The long thoracic nerve arises from C5-7, the median nerve is formed from the lateral and medial cord, the musculocutaneous nerve is a terminal branch of the lateral cord, and the ulnar nerve is a terminal branch of the medial cord.

9 Brazis PW, Masdeu JC, Biller J. Localization in clinical neurology. 5th ed. Philadelphia: Lippincott, Williams & Wilkins, Campbell WW. DeJong's the neurologic examination. Philadelphia: Lippincott, Williams & Wilkins, Question 324: Anatomy - Peripheral Nervous System The Martin-Gruber anastomosis occurs in 15% to 30% of the population. It consists of a communicating branch from the median nerve, usually from the anterior interosseous nerve, to the ulnar nerve in the forearm. It consists of nerve fibers destined for the first dorsal interosseous, most commonly, followed by the adductor pollicis and abductor digiti minimi. Dumitru D, Amato A, Zwarts M. Electrodiagnostic medicine. 2nd ed. Philadelphia: Hanley and Belfus, Question 334: Anatomy - Peripheral Nervous System The tibial nerve enters the tarsal tunnel behind or inferior to the medial malleolus. It will divide into the medial and lateral plantar branches and the calcaneal branch. Campbell WW. DeJong's the neurologic examination. Philadelphia: Lippincott, Williams & Wilkins, Question 357: Anatomy - Cranial Nerves The masseter, temporalis, medial and lateral pterygoids, tensor veli palati, tensor tympani, anterior belly of the digastric, and mylohyoid are innervated by the trigeminal nerve. The stapedius, buccinator, posterior belly of the digastric, frontalis, as well as other muscles of facial expression are all innervated by the facial nerve. The stylopharyngeus is innervated by the glossopharyngeal nerve. Brazis PW, Masdeu JC, Biller J. Localization in clinical neurology. 5th ed. Philadelphia: Lippincott, Williams & Wilkins, Question 363: Anatomy - Brainstem/Cerebellum A lesion at the base of the midbrain (cerebral peduncle) will produce an ipsilateral third nerve palsy and contralateral hemiparesis (Weber's syndrome) as it involves both the descending corticospinal tract (which later mostly crosses to run in the contralateral cord) and the exiting ipsilateral third nerve fibers into the interpeduncular space. Brazis PW, Masdeu JC, Biller J. Localization in clinical neurology. 5th ed. Philadelphia: Lippincott, Williams & Wilkins, Blumenfeld H. Neuroanatomy through clinical cases. 1st ed. Sunderland: Sinauer Associates, 2002.

10 Question 366: Anatomy - Basal Ganglia and Thalamus The mammillothalamic tract ends in the anterior nuclear group of the thalamus. The dorsomedial nucleus receives input from prefrontal cortex and limbic structures and then projects back to the prefrontal cortex. The pulvinar is an association nucleus involved in visual processing. The ventral anterior nucleus receives input from the globus pallidus while the ventral lateral nucleus receives input from the deep cerebellar nuclei. Campbell WW. DeJong's the neurologic examination. Philadelphia: Lippincott, Williams & Wilkins, Question 368: Anatomy - Cranial Nerves Weakness of the stapedius muscle, innervated by cranial nerve VII and controlling the stapes bone, causes hyperacusis because the bone is unable to cover the oval window to protect it from low vibratory tones. The incus and malleus are other bones in the ossicular chain without motor control from the cranial nerve VII. The utricle and saccule are part of the labyrinth. Brazis PW, Masdeu JC, Biller J. Localization in clinical neurology. 5th ed. Philadelphia: Lippincott, Williams & Wilkins, Ropper AH, Samuels M. Adams and Victor's principles of neurology. 9th ed. New York: McGraw-Hill, Question 374: Anatomy - Embryology The prosencephalon divides into the diencephalon and the telencephalon. The diencephalon gives rise to, among other structures, the thalamus, globus pallidus, and hypothalamus. The telencephalon gives rise to the striatum and cerebral cortex. Parent A. Carpenter's human neuroanatomy. 9th ed. Baltimore: Williams & Wilkins, Question 376: Anatomy - Cortex and Connections Functional neuroimaging shows thermal pain is associated with activation of the anterior cingulate gyrus. Kandel ER, Schwartz JH, Jessel TM. Principles of neural science. 4th ed. New York: McGraw-Hill, Question 387: Anatomy - Cranial Nerves The ciliary ganglion gives rise to the postganglionic parasympathetic fibers of the short ciliary nerve which innervates the sphincter muscle of the iris and the ciliary muscle. Loss of this ganglion will produce loss of the direct pupillary reflex and

11 pupillary dilation. An afferent pupillary defect would result from a lesion of the optic nerve. The lacrimal glands are innervated by the greater petrosal branch of the 7th cranial nerve. Wilson-Pauwels L, Akesson E, Stewart P. Cranial nerves: anatomy and clinical components. Toronto: BC Decker Inc, Blumenfeld H. Neuroanatomy through clinical cases. 1st ed. Sunderland: Sinauer Associates, Carpenter M, Sutin J. Human neuroanatomy. 8th ed. Baltimore: Williams and Wilkins, Question 398: Anatomy - Basal Ganglia and Thalamus The pulvinar receives fibers from the superior colliculus and projects to areas 17, 18 and 19. Both the inferior and lateral pulvinar have reciprocal connections with the occipital cortex. The medial geniculate receives input from the inferior colliculus while the ventral anterior nucleus receives input from the globus pallidus pars interna - particularly the non-motor information stream. The ventral posteromedial and posterolateral nuclei receive somatosensory input. The lateral dorsal nucleus has connections similar to those of the anterior nucleus to which it is adjacent though it may also have posterior parietal connections as well. Blumenfeld H. Neuroanatomy through clinical cases. 1st ed. Sunderland: Sinauer Associates, Parent A. Carpenter's human neuroanatomy. 9th ed. Baltimore: Williams & Wilkins, Question 413: Anatomy - Blood Supply of Brain/Spinal Cord Contralateral hemianesthesia and hemiparesis followed by spontaneous pain in the affected limbs is due to involvement of the thalamoperforate branches of the posterior cerebral artery. Some of these branches supply portions of the posterior limb of the internal capsule and may produce contralateral hemiparesis in addition to the sensory changes and a central (thalamic) pain syndrome. Blumenfeld H. Neuroanatomy through clinical cases. 1st ed. Sunderland: Sinauer Associates, Question 414: Anatomy - Cortex and Connections The orbitofrontal syndrome consists of socially inappropriate behaviors as well as poor impulse control with disinhibition. The lateral convexity syndrome is associated with dysexecutive symptoms. The mesial frontal syndrome is associated with amotivation. Cummings JL, Mega MS. Neuropsychiatry and behavioral neuroscience. New York: Oxford University Press, Campbell WW. DeJong's the neurologic examination. Philadelphia: Lippincott, Williams & Wilkins, 2005.

12 Question 422: Anatomy - Blood Supply of Brain/Spinal Cord Venous blood from the superior sagittal sinus travels to the confluence (torcula). Venous blood from the inferior sagittal sinus is joined by the great cerebral vein, forms the straight sinus, and empties into the torcula. From the torcula, venous blood flows to the transverse sinus, the sigmoid sinus and then the inferior jugular vein. Blumenfeld H. Neuroanatomy through clinical cases. 1st ed. Sunderland: Sinauer Associates, Carpenter MB. Core text of neuroanatomy. Baltimore: William & Wilkins, Behavioral/Psychiatry Questions : Behavioral/Psychiatry - General Psychiatry Alcohol intoxication is associated with slurred speech, Incoordination, unsteady gait, and nystagmus. Caffeine intoxication is associated with restlessness, nervousness, diuresis, GI disturbance, and muscle twitching. PCP intoxication is associated with nystagmus, hypertension, tachycardia, muscle rigidity, dysarthria, decreased responsiveness to pain, seizures. Bath salts or methylenedioxypyrovalerone (MDPV) intoxication is associated with hypertension, tachycardia, delusions, hallucinations, and violent behavior. American Psychiatric Association. Diagnostic and statistical manual of mental disorders (DSM-5). 5th ed. Washington DC: American Psychiatric Publishing, Question 2: Behavioral/Psychiatry - Neurobehavioral/Neuropsychological Exam Digit span, which involves attentional processes, immediate recall (active working memory) and ability to sequence bits of information, may be reduced following lesions of dorsolateral frontal cortex. Lesions of the fornix, hippocampus, mammillary bodies and medial dorsal nucleus of the thalamus, on the other hand, cause memory impairment of various types without directly affecting active working memory. Cummings JL, Mega MS. Neuropsychiatry and behavioral neuroscience. New York: Oxford University Press, Question 3: Behavioral/Psychiatry - Anatomic syndromes Although bilateral occipitotemporal lesions can cause associative visual agnosia, the syndrome is also frequently seen in left occipitotemporal junction lesions. The majority of patients will also have a dense right homonymous hemianopia. Cummings JL, Mega MS. Neuropsychiatry and behavioral neuroscience. New York: Oxford University Press, 2003.

13 Heilman KM, Valenstein E. Clinical neuropsychology. New York: Oxford University Press, Question 4: Behavioral/Psychiatry - Psychopharmacology Citalopram is the most pure selective serotonin reuptake inhibitor (SSRI). Mirtazapine has a tetracyclic chemical structure and is classified as a noradrenergic and specific serotonergic antidepressant (NaSSA). Bupropion acts as a norepinephrine reuptake inhibitor and dopamine reuptake inhibitor. Venlafaxine is an antidepressant of the serotonin-norepinephrine reuptake inhibitor (SNRI) class. Venlafaxine is classified as a noradrenergic and serotonergic antidepressant (NaSSA). Arana GW, Rosenbaum JF. Handbook of psychiatric drug therapy. 5th ed. Philadelphia: Lippincott, Williams & Wilkins, Question 7: Behavioral/Psychiatry - Genes, Biomarkers, & Networks This patient has a clinical history suggestive of dementia with Lewy bodies (prominent visuospatial deficits, early hallucinations, and extrapyramidal symptoms with even small doses of antipsychotics). The most common protein abnormality in this condition is alpha-synuclein. TDP-43, tau, and progranulin are more commonly found in the frontotemporal spectrum, whereas PrPc is the protein linked to some forms of Creutzfeldt-Jakob disease. Possin KL, Kaufer DI. Parkinsonian dementias. Continuum Lifelong Learning Neurol, 2010;16:65. Question 14: Behavioral/Psychiatry - Psychopharmacology Although much emphasis is placed on its causing agranulocytosis, seizures occur more frequently with the use of clozapine than with other atypical antipsychotics. Sadock BJ, Sadock VA. Kaplan & Sadock's Pocket handbook of clinical psychiatry. 5th ed. Philadelphia: Lippincott, Williams & Wilkins, Sadock BJ, Sadock VA. Kaplan and Sadock's Synopsis of psychiatry: behavioral sciences/clinical psychiatry. 10th ed. Philadelphia: Lippincott, Williams & Wilkins, Question 23: Behavioral/Psychiatry - Anatomic syndromes Capgras delusions and psychosis in general are typically thought to originate in the temporal lobe. Lesions in the occipitalparietal, posterior cingulate, and the superior parietal lobule are all unlikely to cause Capgras delusions. Occasionally frontal pathology makes it difficult to resolve conflicting information which may result in delusional ideas. However, a tumor in the left dorsolateral frontal lobe causing a seizure would typically cause speech arrest due to involvement of the Broca area.

14 Fried I. Auras and experiential responses arising in the temporal lobe. J Neuropsychiatry Clin Neurosci 1997;9: Question 25: Behavioral/Psychiatry - Psychopharmacology Bupropion has had a low incidence of erectile dysfunction associated with its use. All of the selective serotonin reuptake inhibitors (SSRIs) have been reported to have erectile dysfunction as a side effect. Amitriptyline and venlafaxine also cause erectile dysfunction. Arana GW, Rosenbaum JF. Handbook of psychiatric drug therapy. 5th ed. Philadelphia: Lippincott, Williams & Wilkins, Question 26: Behavioral/Psychiatry - Behavioral Complications of Systemic Disease Niacin deficiency, commonly found in malnourished individuals and in those taking isoniazid, classically presents with the 3 D's: dementia, dermatitis, and diarrhea. Other neurologic manifestations include peripheral neuropathy and myelopathy. Vitamin E deficiency typically presents with cognitive dysfunction, ataxia, and neuropathy. Mendez MF, Cummings JL. Dementia: a clinical approach. 3rd ed. Philadelphia: Butterworth-Heinemann, Geschwind MD. Rapidly progressive dementia: prion disease and other rapid dementias. Continuum Lifelong Learning Neurol 2010;16: Question 33: Behavioral/Psychiatry - Behavioral Complications of Systemic Disease Wernicke-Korsakoff syndrome, related to thiamine deficiency, produces an amnestic disorder with abnormalities limited to memory and learning rather than a dementia syndrome. The syndrome occurs most commonly among alcoholics with thiaminedeficient diets, but it may be seen in other patients who have malnutrition or gastrointestinal absorption disorders. Alcoholic dementia and Wernicke-Korsakoff syndrome commonly coexist. Paraneoplastic syndromes include limbic encephalitis where individuals can develop prominent memory, behavioral, and mood disturbances. However, ophthalmoplegia and gait ataxia are not typically present. The classic symptoms of botulism include double vision, blurred vision, drooping eyelids, slurred speech, difficulty swallowing, dry mouth, and muscle weakness. Symptoms generally begin 18 to 36 hours after eating a contaminated food and mental status is usually normal. Marchiafava-Bignami disease is seen most often in alcoholics and results in corpus callosum damage. It may present with sudden onset of stupor or coma and seizures. Other patients have acute, subacute, or chronic onset of dementia, gait problems, psychiatric disturbances, incontinence, hemiparesis, aphasia, and apraxia of the left hand (due to callosal disconnection). Ophthalmoplegia is not common and there is no specific treatment which provides partial recovery. Myasthenia gravis may cause ophthalmoplegia or even ataxia but it does not result in delirium. Scharre DW. Metabolic, infectious and other dementia conditions. American Academy of Neurology Annual Meeting: non- Alzheimer dementia course. Seattle, Washington; May 1, Kopelman MD. The Korsakoff syndrome. Br J Psychiatry 1995;166: Question 34: Behavioral/Psychiatry - Behavioral Complications of Systemic Disease

15 Wernicke-Korsakoff syndrome, related to thiamine deficiency, produces an amnestic disorder with abnormalities limited to memory and learning rather than a dementia syndrome. Language, calculation, and visuospatial abnormalities are often spared. The syndrome occurs most commonly among alcoholics with thiamine-deficient diets, but it may be seen in other patients who have malnutrition or gastrointestinal absorption disorders. Alcoholic dementia and Wernicke-Korsakoff syndrome commonly coexist. Kopelman MD. The Korsakoff syndrome. Br J Psychiatry 1995;166: Scharre DW. Metabolic, infectious and other dementia conditions. American Academy of Neurology Annual Meeting: non- Alzheimer dementia course. Seattle, Washington; May 1, Question 36: Behavioral/Psychiatry - Dementia The NINCDS-ADRDA criteria is still used as one of the main criteria for the clinical diagnosis of Alzheimer disease. The criteria states that an individual with probable Alzheimer disease must have an onset between ages 40 and 90 and have progressive cognitive loss with deficits in two or more areas of cognition. Dementia is established by clinical examination and confirmed by neuropsychological tests. The diagnosis of possible Alzheimer disease includes having a dementia syndrome in the absence of other psychiatric or systemic disorders but in the presence of a second systemic or brain disorder sufficient to produce a dementia but is not considered to be the cause of the dementia syndrome after a careful clinical evaluation. Definite Alzheimer disease occurs only when the clinical criteria for probable Alzheimer disease is met and histopathologic evidence of Alzheimer disease is available from an autopsy or biopsy. A non-alzheimer disease dementia is not correct since there were no psychiatric or systemic disorder found to cause the dementia and the vascular disease was not thought to be the cause of ther dementia. McKhann G, Drachman D, Folstein M, et al. Clinical diagnosis of Alzheimer's disease: report of the NINCDS-ADRDA work group under the auspices of Department of Health and Human Services task force on Alzheimer disease. Neurology 1984;34: Question 41: Behavioral/Psychiatry - Developmental Disorders Patients with parital urea cycle enzyme deficiencies can present with adolescent or early adult onset neuropsychiatric symptoms including episodic psychosis, depression, and bipolar disorder. These attacks frequently accompanied by gastrointestinal symptoms can be precipitated by high protein ingestion, periods of fever, and can be triggered by valproate. Additionally, x- linked urea cycle enzyme deficiencies can present with strokes. Sedel F, Baumann N, Turpin JC, et al.. Psychiatric manifestations revealing inborn errors of metabolism in adolescents and adults.. J Inherit Metab Dis 2007;30: Gropman AL, Summar M, Leonard JV. Neurological implications of urea cycle disorders. J Inherit Metab Dis 2007;30: Question 55: Behavioral/Psychiatry - Anatomic syndromes

16 The man has a slow growing tumor in the right cortical parietal region with some surrounding edema. Examination reveals agraphesthesia typical for right cortical parietal lesions. Other cortical-mediated sensory modalities that are likely to also be affected in this case include astereognosis and decreased 2-point discrimination both on the left hand. An expressive aposodia is not likely as it is due to right frontal lobe pathology. Visual object agnosia, transcortical sensory aphasia, and right/left confusion are all feature of dominant parietal cortical lesions. Sturb RL, Black FW. The mental status examination in neurology. Philadelphia: FA Davis, Question 63: Behavioral/Psychiatry - Neurobehavioral/Neuropsychological Exam This clinical condition is prosopagnosia, or failure visually to identify familiar faces (or classes of objects such as cars) despite good visual acuity. Auditory recognition remains intact. The fusiform gyrus located in the occipitotemporal cortex is usually impaired. Cummings JL, Mega MS. Neuropsychiatry and behavioral neuroscience. New York: Oxford University Press, Question 72: Behavioral/Psychiatry - Genes, Biomarkers, & Networks In patients with Creutzfeldt-Jakob disease, the MRI has been shown to have higher specificity and sensitivity than EEG and CSF testing for protein. Of the sequences available, the DWI/ADC is likely to show all of the abnormalities. These changes include hyperintensity in the cortical gyri, caudate, and thalamus. Geschwind MD. Rapidly progressive dementia: prion disease and other rapid dementias. Continuum Lifelong Learning Neurol 2010;16: Question 88: Behavioral/Psychiatry - Language Disorders This type of stroke more than likely effects Broca's area since most individuals are left brain dominated for language. Agrammatism is classically seen with Broca's aphasia. Agrammatism refers to the inability to speak in a grammatically correct fashion with simplified formation of sentences (in which many or all function words are omitted) sometimes referred to as telegraphic speech. Dysarthria is an articulatory condition not related to damage in Broca's region. Broca's aphasia produces shortened phrase lengths. Neologisms are made up words seen often in Wernicke's aphasia. Expressive aprosodia is an inability to generate the emotion conveyed in spoken language and it is seen with damage on the right frontal area of the brain. Goodglass H. Agrammatism in aphasiology. Clin Neurosci 1997;4(2):51-6 Question 90: Behavioral/Psychiatry - Language Disorders

17 Semantic dementia is a subtype of frontotemporal lobar degeneration. Patients early on have fluent spontaneous speech but have increasing difficulty understanding nouns and recognizing objects. Some patients will also develop visual agnosia as well as prosopagnosia. With time, patients usually demonstrate symptoms typical of frontotemporal dementia. van der Zee J, Sleegers K, Van Brockhoven C. Invited article: the Alzheimer disease-frontotemporal lobar degeneration spectrum. Neurology 2008;71: Kertesz A. Frontotemporal dementia: a topical review. Cogn Behav Neurol 2008;21: Question 101: Behavioral/Psychiatry - Dementia One of the earliest findings on PET scanning in Alzheimer disease is hypometabolism in bilateral parietal and precuneus. Bilateral parietal-occipital hypometabolism is classic for dementia with Lewy bodies, bilateral frontotemporal is more commonly seen in frontotemporal dementia. Cummings JL, Mega MS. Neuropsychiatry and behavioral neuroscience. New York: Oxford University Press, Question 105: Behavioral/Psychiatry - Dementia REM Sleep Behavior Disorder often manifests as violent behavior that emerges out of REM sleep and is associated with increase motor activity during REM sleep on PSG. There is an association between synucleinopathies adn REM Sleep Behavior Disorder. Kryger MH, Roth T, Dement WC. Principles and practice of sleep medicine. 5th ed. Philadelphia: Saunders, Question 106: Behavioral/Psychiatry - Language Disorders Broca aphasia leads to expressive impairments but also to deficits in comprehension of short connector words and passive speech (eg, if a lion was killed by a tiger, which animal would be dead?). Wernicke aphasia would impair comprehension for a 4-step pointing command. Repetition would be intact with transcortical aphasias. Conduction aphasia will have intact comprehension skills. Alexander MP, Benson DF, Stuss DT. Frontal lobes and language. Brain Lang 1989;37(4): Question 114: Behavioral/Psychiatry - Language Disorders In clinical practice disorders of language and articulation must be differentiated. Patients with aphasia have variable degrees of awareness of their deficit and have impairment in other general language functions to include comprehension, naming, reading, etc). Disorders of articulation can be further broken down into dysarthrias and apraxia of speech. Patients with dysarthria

18 typically have impairment in resonance and errors are generally consistent and predictable. In apraxia of speech, the articulatory errors are variable and repeated attempts to correctly pronounce words impair the normal flow and prosody of speech. Ogar J, Willock S, Baldo J, et al. Clinical and anatomical correlates of apraxia of speech. Brain Lang 2006;97: Question 124: Behavioral/Psychiatry - Genes, Biomarkers, & Networks Of the autosomal dominant mutations causing early-onset, familial Alzheimer disease, the most common (up to 70%) involves the presenilin 1 gene on chromosome 14. Bird TD. Genetic aspects of Alzheimer disease. Genetic Med 2008;10(4): Question 127: Behavioral/Psychiatry - Dementia The angular gyrus syndrome results from an infarct or mass lesion affecting the angular gyrus on the dominant side. The syndrome consists of difficulty with naming, reading, writing, memory and contains the elements of a Gerstmann syndrome. Patients with semantic dementia lose conceptual knowledge of memories and words. They tend to have frequent pauses in their speech and can present with prosopagnosia. Patients with posterior cortical atrophy present with progressive deficits that affect the dorsal and ventral streams of vision. They tend to have preserved insight and lack the characteristic memory deficits which are pathognomonic for Alzheimer disease. McMonagle P, Deering F, Berliner Y, Kertesz A. The cognitive profile of posterior cortical atrophy. Neurology 2006;66: Question 128: Behavioral/Psychiatry - Psychopharmacology Choice of an antidepressant for an individual is based on the side effect profile of the medication and how it fits with the patients needs. Mirtazapine is an antidepressant that promotes weight gain and helps with sleep. Both are important for this individual. Paroxetine often results in weight gain but it can also cause insomnia. The most commonly observed adverse events consistently associated with the use of Bupropion are dry mouth and insomnia while weight is usualy not effected. Sertraline does not typically cause weight gain and insomnia occurs with about the same frequency as somnolence. Insomnia and anorexia are more typical adverse events with imipramine than weight gain or sleepiness. Question 142: Behavioral/Psychiatry - Language Disorders Several disorders of language can result following damage to the dominant hemisphere. Detailed examination of the six components of the language examination (fluency, comprehension, repetition, reading, writing, and naming) is essential to help

19 distinguish them. Wernicke's aphasia is characterized by fluent speech with impaired comprehension of written and spoken words. Patient's with aphemia are relatively nonfluent in spoken language; however, comprehension and written communication are much better preserved. The hallmark of conduction aphasia is impaired repetition with relative sparing of other components of language. Patients who suffer from pure word deafness are unable to repeat or comprehend spoken language; however, they can still communicate effectively via writing. Benson DF, Ardila A. Aphasia: a clinical perspective. New York: Oxford University Press, Question 157: Behavioral/Psychiatry - Genes, Biomarkers, & Networks TAR DNA-binding protein 43 (TDP-43) is a major protein component of the ubiquitin-immunoreactive inclusions characteristic of sporadic and familial frontotemporal lobar degeneration with ubiquitin-positive, tau-negative inclusions (FTLD-U), with and without motor neuron disease, as well as in sporadic amyotrophic lateral sclerosis (ALS). These conditions with TDP-43 do not have tau, beta-amyloid, or alpha-synuclein inclusions. Tau inclusions are seen in some other types of frontotemporal dementias and Alzheimer disease. Beta-amyloid inclusions are classically seen in Alzheimer disease. Alpha-synuclein inclusions are seen in dementia with Lewy bodies and Parkinson disease. Pick bodies are aggregations of tau protein in neurons associated with Pick disease, a subtype of frontotemporal lobar degeneration. Neumann M, Sampathu DM, Kwong LK, et al. Ubiquitinated TDP-43 in frontotemporal lobar degeneration and amyotrophic lateral sclerosis. Science 2006;314(5796): Cairns NJ, Neumann M, Bigio EH, et al. TDP-43 in familial and sporadic frontotemporal lobar degeneration with ubiquitin inclusions. Am J Pathol 2007;171(1): Question 167: Behavioral/Psychiatry - Dementia Tetrabenazine is a reversible depletor of monoamines (dopamine, norepinephrine, epinephrine, serotonin, others). It reduces the uptake of dopamine and other monamines into synaptic vesicles and blocks their transport. Since it provides greater selectivity for dopamine than the other monoamines, it particularly reduces dopaminergic activity in the brain. <br> Haloperidol, perphenazine, and trifluoperazine are antipsychotics with a mechanism of action of antagonism of dopamine receptors in the mesolimbic and mesofrontal systems. They block postsynaptic mesolimbic dopaminergic D1 and D2 receptors in the brain. Lorazepam and other benzodiazepines may act by enhancing the effects of GABA in the brain. Huntington Study Group. Tetrabenazine as antichorea therapy in Huntington disease: A randomized controlled trial. Neurology 2006;66: Question 180: Behavioral/Psychiatry - Dementia Dementia with Lewy bodies responds very positively to cholinesterase inhibitors. Rivastigmine has the most positive data, but all cholinesterase inhibitors may improve the symptoms of dementia with Lewy bodies. Corticobasal degeneration does not have the cholinergic loss seen with dementia with Lewy bodies. Frontotemporal dementias have a very poor record of response to cholinesterase inhibitors. Catatonia seems to have a more positive response to benzodiazepines. Tourette syndrome is associated with dopamine excess.

20 McKeith IG, Del Ser T, Spano PF, et al. Efficacy of rivastigmine in dementia with Lewy bodies: a randomized, double-blind, placebo-controlled international study. Lancet 2000;356(9247): Question 182: Behavioral/Psychiatry - Psychopharmacology Excessive weight gain and sedation from amitriptyline is caused by strong blockade of the histamine H1 receptor. Doxepin and mirtazapine convey strong blockade of this receptor as well while imipramine and amoxapine convey moderate blockade of the H1 receptor. Nortriptyline has the weakest blockage of the H1 receptor and is least likely to cause weight gain and sedation. Stahl SM. Stahl's essential psychopharmacology. 3rd ed. New York: Cambridge University Press, Questions : Behavioral/Psychiatry - General Psychiatry Alcohol intoxication is associated with slurred speech, Incoordination, unsteady gait, and nystagmus. Caffeine intoxication is associated with restlessness, nervousness, diuresis, GI disturbance, and muscle twitching. PCP intoxication is associated with nystagmus, hypertension, tachycardia, muscle rigidity, dysarthria, decreased responsiveness to pain, seizures. Bath salts or methylenedioxypyrovalerone (MDPV) intoxication is associated with hypertension, tachycardia, delusions, hallucinations, and violent behavior. American Psychiatric Association. Diagnostic and statistical manual of mental disorders (DSM-5). 5th ed. Washington DC: American Psychiatric Publishing, Question 316: Behavioral/Psychiatry - Behavioral Complications of Systemic Disease This individual most likely has Herpes Simplex encephalitis. Temporal and frontal lobes are often affected with this acute infection. Initial clinical features include headache, fever, stiff neck, and photophobia. This progresses over a few days to produce lethargy, mental status changes, personality changes, memory impairment, aphasia, focal neurologic deficits, seizures, dementia, and eventually coma. Frontal lobe injury may cause grasp reflexes, frontal release signs, motor impersistence, disinhibition, impulsivity, confabulation, psychomotor hyperactivity, hyperoral behavior, apathy, echolalia, mutism, anomia, inattention, and utilization behaviors. Temporal lobe damage often results in amnesia and if bilateral, the Kluver-Bucy syndrome. Schmutzhard E.. Viral infections of the CNS with special emphasis on herpes simplex infections. J Neurol 2001;248: Scharre DW. Metabolic, infectious and other dementia conditions. American Academy of Neurology Annual Meeting: non- Alzheimer dementia course. Seattle, Washington; May 1, Question 319: Behavioral/Psychiatry - Anatomic syndromes

21 Anosognosia (unawareness of deficit or illness) is usually seen associated with nondominant parietal lobe lesions. Achromatopsia is found after lesions of the inferior lip of the occipital lobe. Limb kinetic apraxia is seen after lesions of the anterior corpus callosum. Expressive aprosodia is seen after right frontal lesions. Semantic aphasia is seen after dominant hemisphere lesions. Feinberg TE, Farah MJ. Behavioral neurology and neuropsychology. 2nd ed. New York: McGraw-Hill, Question 330: Behavioral/Psychiatry - Behavioral Complications of Systemic Disease Compulsive behavior has been associated with the use of dopamine agonists to treat Parkinson's disease. Early descriptions were of pathological gambling but other compulsive behaviors have been described. M. Leann Dodd, MD; Kevin J. Klos, MD; James H. Bower, MD; Yonas E. Geda, MD; Keith A. Josephs, MST, MD; J. Eric Ahlskog, PhD, MD. Pathological Gambling Caused by Drugs Used to Treat Parkinson Disease. Arch Neurology 2005;62 Question 344: Behavioral/Psychiatry - Anatomic syndromes Patients who have pure alexia generally have a lesion in the dominant occipital lobe with involvement of the splenium of the corpus callosum. They may have the complete inability to read, however more commonly they read by sounding out individual letters to make a word. Because of this, patients with pure alexia read better if the word is shorter in length. Most retain the ability to implicitly identify the word and comprehend, despite the inability to read it out loud. Coslett H. Acquired dyslexia. Semin Neurol 2000;20: Question 349: Behavioral/Psychiatry - Neurobehavioral/Neuropsychological Exam The Wisconsin Card Sort Test (WCST), which challenges a patient to change cognitive sets without warning, is particularly sensitive to frontal damage. Language skills may be unaffected, and vocabulary is often spared. Face recognition and visual perception abnormalities such as hemi-inattention syndromes are most often associated with damage to the parietal, temporal, or occipital lobes, rather than the frontal lobes. Therefore, the best answer is the WCST. Kimberg DY, D'Esposito M, Farah MJ. Frontal lobes: cognitive neuropsychological aspects. In: Feinberg TE, Farah MJ, editors. Behavioral neurology and neuropsychology. New York: McGraw-Hill, Question 358: Behavioral/Psychiatry - Behavioral Complications of Systemic Disease Numerous neurological symptoms can be seen associated with systemic lupus erythematosis (SLE). These manifestations include peripheral neuropathy and cerebritis as well as neuropsychiatric symptoms such as depression, mania, and psychosis. SLE is more frequently associated with psychosis than are Bechet's syndrome, sarcoidosis, rheumatoid arthritis, or Sjogren's syndrome.