neurosurgery self-assessment...neurosurgery self-assessment questions and answers rahul s. shah,...

NEUROSURGERYSELF-ASSESSMENT

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NEUROSURGERYSELF-ASSESSMENTQuestions and Answers

Rahul S. Shah, BSc(Hons), MBChB(Hons), MRCS(Eng)Specialty Registrar in Neurosurgery andWellcome Trust Clinical Research FellowUniversity of OxfordOxford, UK

Thomas A.D. Cadoux-Hudson, DPhil, FRCS, MB BSHonorary Consultant NeurosurgeonDepartment of NeurosurgeryOxford University Hospitals NHS TrustOxford, UK

Jamie J. Van Gompel, MDAssociate Professor of Neurosurgery and OtolaryngologyMayo Clinic College of MedicineRochester, MN, USA

Erlick A.C. Pereira, MA, BM BCh, DM, FRCS(Neuro.Surg),SFHEASenior Lecturer in Neurosurgery and Consultant NeurosurgeonAtkinson Morley Neurosciences Centre, St George’s HospitalSt George’s, University of LondonLondon, UK

Foreword by

Edward C. Benzel, MDChairman, Department of NeurosurgeryCenter for Spine Health, Cleveland ClinicCleveland, 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 tobe identified as author of this work has been asserted by them in accordance with the Copyright, Designs andPatents Act 1988.

No part of this publication may be reproduced or transmitted in any form or by any means, electronic ormechanical, including photocopying, recording, or any information storage and retrieval system, withoutpermission in writing from the publisher. Details on how to seek permission, further information about thePublisher’s permissions policies and our arrangements with organizations such as the Copyright ClearanceCenter and the Copyright Licensing Agency, can be found at our website: www.elsevier.com/permissions.

This book and the individual contributions contained in it are protected under copyright by the Publisher(other than as may be noted herein).

NoticesKnowledge and best practice in this field are constantly changing. As new research and experiencebroaden our understanding, changes in researchmethods, professional practices, ormedical treatmentmaybecome necessary.

Practitioners and researchers must always rely on their own experience and knowledge in evaluatingand using any information, methods, compounds, or experiments described herein. In using suchinformation or methods they should be mindful of their own safety and the safety of others, includingparties for whom they have a professional responsibility.

With respect to any drug or pharmaceutical products identified, readers are advised to check themost current information provided (i) on procedures featured or (ii) by themanufacturer of each product tobe 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 andknowledge of their patients, to make diagnoses, to determine dosages and the best treatment for eachindividual 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 productsliability, negligence or otherwise, or from any use or operation of any methods, products, instructions,or ideas contained in the material herein.

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CONTENTS

FOREWORD, VII

PREFACE, IX

HOW TO PASS NEUROSURGICAL

EXAMINATIONS, XI

PART IBASIC SCIENCE

1 NEUROANATOMY, 1

2 EMBRYOLOGY, 22

3 NEUROPHYSIOLOGY, 34

4 NEUROPATHOLOGY I: BASICS, 55

5 NEUROPATHOLOGY II: GROSS

PATHOLOGY, 66

6 NEUROPATHOLOGY III: HISTOLOGY, 86

7 PHARMACOLOGY, 121

PART IICARE OF THENEUROSURGICAL PATIENT

8 NEUROLOGY AND STROKE, 127

9 NEURO-OPHTHALMOLOGY, 161

10 NEURO-OTOLOGY, 176

11 NEUROINTENSIVE AND PERIOPERATIVE

CARE, 185

12 INFECTION, 201

13 SEIZURES, 203

14 NEURORADIOLOGY, 216

15 RADIOTHERAPY AND STEREOTACTIC

RADIOSURGERY, 226

16 NEUROPSYCHOLOGY AND NEUROLOGICAL

REHABILITATION, 236

17 STATISTICS, 241

18 PROFESSIONALISM AND MEDICAL

ETHICS, 242

19 SURGICAL TECHNOLOGY AND

PRACTICE, 256

PART IIICRANIAL NEUROSURGERY

20 GENERAL NEUROSURGERY AND CSFDISORDERS, 257

21 CRANIAL TRAUMA, 268

22A CRANIAL VASCULAR NEUROSURGERY I:ANEURYSMS AND AVMS, 290

22B CRANIAL VASCULAR NEUROSURGERY II:CEREBRAL REVASCULARIZATION

AND STROKE, 306

23 CRANIAL ONCOLOGY, 322

24 SKULL BASE AND PITUITARY

SURGERY, 340

25 CRANIAL INFECTION, 354

PART IVSPINAL NEUROSURGERY

26 SPINE: GENERAL PRINCIPLES, 364

27 SCOLIOSIS AND SPINAL

DEFORMITY, 377

28 SPINAL TRAUMA AND ACUTE

PATHOLOGY, 386

29 DEGENERATIVE SPINE, 403

v

30 SPINAL INFECTION, 418

31 SPINAL ONCOLOGY, 424

32 SPINAL VASCULAR NEUROSURGERY, 440

PART VFUNCTIONALNEUROSURGERY

33 PAIN SURGERY, 448

34 ADULT AND PEDIATRIC EPILEPSY

SURGERY, 459

35 ADULT MOVEMENT DISORDERS, 471

36 SURGERY FOR PSYCHIATRIC

DISORDERS, 485

PART VIPERIPHERAL NERVESURGERY

37 PERIPHERAL NERVE, 489

PART VIIPEDIATRICNEUROSURGERY

38 PEDIATRIC NEUROSURGERY: GENERAL

PRINCIPLES AND NORMAL

DEVELOPMENT, 513

39 CRANIOSYNOSTOSIS, 521

40 CONGENITAL CRANIAL AND SPINAL

DISORDERS, 527

41 PEDIATRIC NEUROSURGERY: GENERAL AND

HYDROCEPHALUS, 546

42 PEDIATRIC NEURO-ONCOLOGY, 557

43 PEDIATRICHEAD AND SPINALTRAUMA, 569

44 PEDIATRIC VASCULAR NEUROSURGERY, 584

45 PEDIATRIC MOVEMENT DISORDERS AND

SPASTICITY, 589

46 NEUROSURGERY AND PREGNANCY, 593

INDEX, 600

vi CONTENTS

FOREWORD

Neurosurgery Self-Assessment: Questions andAnswers by Shah, Cadoux-Hudson, Van Gompeland Pereira is a true masterpiece. All neurosur-geons need ‘refreshers’; some for certification,some for maintenance of certification, and othersfor the mere need to ‘keep up’. With over 1000questions and 700 images available both in printand interactively online, this volume providesan extensive coverage of neurosurgery from topto bottom, and all points in between. Multiplechoice questions are used to test foundation ofknowledge and, most importantly, educate.

As adults, we learn most efficiently and effec-tively when our minds are exercised and stressed.When multiple modalities are employed (such asquestions, answers and explanations), learningbecomes more efficient, with a greater long termretention of the newly acquired information.This becomes particularly relevant to those whoare to soon be ‘tested’ in the form of certificationor maintenance of certification examinations.Reading, thinking, answering, and then the con-templation of answers and their rationales makes

the multiple choice question strategy employedby the authors particularly relevant to modernday foundational neurosurgery informationacquisition and retention.

I commend the authors for their tried and true,but uncommonly used, approach to education. Ittakes the agony out of reading a chapter. It min-imizes the laborious efforts required to gatherinformation via searches and other strategies. Itbrings the art and craft of neurosurgery to lifein an enjoyable and relatively painless format.Finally, it provides a near complete coverage ofthe field – at least as complete as is humanly pos-sible in the space afforded.

So, whether you have an impending examina-tion, or you simply desire to ‘spiff up’ on yourneurosurgical foundations, this book is for you.Use it as one might use a bedside novel. Use itto prepare. Use it to simply stay at the top ofyour field. This book can truly fulfill all of theseneeds – and much, much more.

Ed Benzel

vii

PREFACE

Neurosurgical training is delivered worldwidewith the goal of producing a surgeon who is safefor independent practice. Today, neurosurgicalresidents and their trainers are trying to achievethis goal in the face of reduced working hours,increasing demand on services, individual sur-geon outcome publication, and increasing litiga-tion, to name but a few challenges. In thisenvironment, the value of targeted learningmate-rials and advanced surgical simulation is clear.The content of this question book aims to reflectthe evolving expectations placed on residents inan age of evidence-based practice, subspecializa-tion, and multidisciplinary teams: one must alsobe familiar with allied specialties advancing justas fast as our own.

As a counterpoint to currently available self-assessment books, we have organized questionsby the highly specific topic areas outlined in mostmodern neurosurgical textbooks and training cur-ricula. Furthermore, most questions are accompa-nied by in-depth answers and, where appropriate,suggestions for further reading. We hope this willenable junior trainees to use it as a learning aid andfor focused revision prior to rotating onto partic-ular neurosurgical firms. For senior trainees or

those about sit their examinations who require amix of questions (in terms of both topic and diffi-culty), this is provided by the interactive questionbank accessed via the online Inkling platform andsmartphone app. This book consists of single bestanswer (SBA) and extended matching item (EMI)questions constructed according to the guidelinesfrom the US National Medicine Licensing Boardand the UK Joint Committee on IntercollegiateExaminations, to enable the user to becomefamiliar with the respective formats before theexam. While SBA- and EMI-style questions arenot yet universal in postgraduate neurosurgicalexaminations across the world, we hope all traineesfind them valuable and cost-effective for self-study.

Finally, I would like to thank Elsevier—theirsupport has ensured that this book could alsoserve as a comprehensive and representative cat-alogue of commonly examined clinical imagesand investigation results in a single resource forneurosurgical residents. I hope you enjoy using it!

Rahul S. ShahOxford

July 2016

ix

HOW TO PASS NEUROSURGICAL

EXAMINATIONS

LEARNING BY MULTIPLECHOICE QUESTIONS

TheWorldFederation ofNeurosurgical Societiesestimates that there are 30,000 neurosurgeonsworldwide. In theUnited States, there are approx-imately 3500 board certified neurosurgeons and800 neurosurgical residents. In the UnitedKingdom, there are close to 300 consultants and200 trainees, with a total of approximately 8000qualified neurosurgeons and trainees in Europe.Due to international collaboration throughresearch and education, neurosurgical trainingcurricula have become increasingly standardizedacross most countries. Both UK and US-styleexaminations are well established in other coun-tries (e.g. India and Brazil, respectively), andrecently developed training programs in Africahave based their examinations on the UK format.Additionally, the need for already qualified neuro-surgeons to demonstrate continuing professionaldevelopment for revalidation purposes has alsoincreased the demand for courses and objectiveself-assessment tools in neurosurgery.

Although the duration of postgraduate neuro-surgical training varies by country, completionof training usually requires the candidate to passboth written and oral examinations set by therelevant national training board or committee.For thewritten examinations, questions are gener-allymultiple choice andcover thebasic and clinicalsciences; short answer andessay questions are usedin some regions. Topics include neuroanatomy,neurophysiology, neuropharmacology, criticalcare, fundamental clinical skills, neuroradiology,neuropathology, neurology, neurosurgery, andother disciplines deemed suitable and important(e.g. statistics, medical law, medical ethics). Ques-tions relating to clinical neurosurgery also coverthe main subspecialties, including trauma,neuro-oncology, skull base and pituitary surgery,vascular neurosurgery, spinal surgery, pediatricneurosurgery, peripheral nerve surgery, andfunctional/epilepsy/pain surgery.

For the vast majority of multiple choice ques-tions (MCQs) in this book, we provide a detailedexplanation of the correct answer with referencesto current evidence-based data where appropri-ate. Like the real examinations, questions testthe reader's knowledge of basic and clinical neu-rosciences and neurosurgery, and are arranged bytopic to be useful to doctors in neurology, neuro-radiology, and neuropathology, and medical stu-dents. Illustrations include anatomical pictures,graphs, tables, radiology images, and histologyslides in questions and answers where required.

We suggest the following approach to usingthis book and learning by MCQs:

• Firstly, start early! Learning throughoutone's training will lead to reinforcementand consolidation of deep knowledge noteasily forgotten. Use books like this at thebeginning, middle, and end of training,and relate them to your clinical practice.

• Secondly, let this book be a guide to con-solidate the information learnt. Annotatematerial from other resources like compre-hensive textbooks. Use the “red,” “amber,”and “green” gradings to distinguish bet-ween lower-yield and more difficult ques-tions and high-yield easy questions. Makeconnections between different subspe-cialties and general principles, and focuson material most likely to be tested.Remember that this is neither a compre-hensive review book nor a panacea for inad-equate preparation in the last few monthsbefore the exam.

• Thirdly, prime your memory by returningto challenging and annotated questions inthe final days before the exam. This bookcan serve as a useful way of retaining keyassociations and refreshing important factsfresh in your memory for the exam. Finally,contribute to the book to enable activelearning. Email us if you find errors or seeways in which the book can be updated.

xi

HOW TO TACKLE SINGLE BESTANSWER (SBA) AND EXTENDEDMATCHING ITEM (EMI) QUESTIONS

Test performance is influenced not just by yourknowledge but also by your test-taking skills.You can improve your performance by honingyour test-taking skills and strategies well inadvance of the exam so that you can concentrateon the information and your knowledge duringthe test itself. The following strategies may beuseful.

Try to deal with each question in turn, identi-fying it as easy, workable or impossible from yourown perspective; our green, amber, and red clas-sification provides an approximate examiner'sguide to difficulty for someone having completedtheir neurosurgical training. Aim to answer all theeasy questions, resolve the workable ones in rea-sonable time, and make quick educated guesses atany apparently impossible ones. There are differ-ent techniques for question reading that includereading the stem, thinking of the answer, andturning to the choices or skimming the answerchoices and the last part of the question beforereturning to the stem. Try different techniquesto see what work best for you and yields the high-est marks. Our online testing area should helpwith that.

Set a good pace for answering the questions.Divide the total time for the exam by the numberof questions and be strict with yourself. If you aretaking too long then mark the question, pick yourbest answer, and come back to it later if you havetime at the end. Avoid burnout by practicingtimed tests to develop endurance. Use extra timeto checkmarked questions. Never give up—take ashort one-minute break and come back to the testif too disheartened.

Answer all test questions—even if it meansguessing! Whereas in the past many neurosurgi-cal examinations were negatively marked, thatprocess has largely been superseded by only pos-itively marked exams, so there is no harm in aneducated or instinctive guess, or even just a blindpunt. If you have to guess, go on a hunch and pickan answer you are vaguely familiar with ratherthan something you have never heard of.

COMPUTER-BASED TESTING

The UK FRCS (Neurological Surgery) examina-tion has been using computer-based testing forseveral years, the American Board of Neurologi-cal Surgery moved to a web-based format for thePrimary Examination in 2015, and the EANSPart 1 remains a pencil-and-paper test. The UKexam takes place in dedicated test centers found

in most cities in front of desktop computers withheadphones, pencil, and paper available, and thesoftware is controlled by a mouse. Residentstaking the US examination use certified laptopsprovided by the residency program. Both havehigh-quality, distinct images, and sometimesinclude audio and video material.

Given the artificial environment of computer-based testing, it is important to become familiarwith it before the actual exam. Most examinationboards offer a downloadable or interactive mockexamination with a few sample questions to famil-iarize yourself with the environment. Skippingthe tutorial on the exam day sometimes adds extratime to answer the actual questions in the testitself. Learn how to mark questions, go back tothem and if there are any rules preventing goingback to previous blocks. Become familiar withhow to view images and spot the icons for playingaudio and video clips. Be vigilant that somemulti-part questions prevent changing the answer to thefirst part of the question once the second part hasbeen revealed.

US, UK, AND EUROPEANNEUROSURGICAL EXAMINATIONSTRUCTURE

MCQ tests generally form the first part of mostneurosurgical examinations, with the subsequentparts being a combination of oral and clinicalexaminations. The 2015 ABNS Primary Exami-nation consisted of 350 questions (in 6 h 45 min),while the UK FRCS Written Examination is intwo parts, the first consisting of 135 SBA questions(in 2 h) and the second part of 110 EMI questions(in 2.5 h). The European Association of Neuro-surgical Societies Part 1 examination consists ofapproximately 200 MCQs to be answered in 3 h.Questions in all three examinations cover neuro-anatomy, neurobiology, neuropathology, neuro-logy, neuroradiology, clinical neurosurgery(including subspecialties), fundamental clinicalskills, and other disciplines deemed suitable andimportant.

The marking of such MCQ examinations isnow quite standardized and relies upon principlesof statistics and psychology. Many examinationboards use the modified Angoff method, wherebyexperts are briefed then allowed to take part or allof the test with the performance levels in mind.They are then asked to provide estimates for eachquestion of the proportion of minimally accept-able candidates that they would expect to getthe question correct. The final determination ofthe cut score is then made by averaging the esti-mates. Controversial questions—those thatpolarized the candidates' answers between two

xii HOW TO PASS NEUROSURGICAL EXAMINATIONS

answers or those that candidates scoring highlyoverall got wrong whereas those scoring poorlyoverall got right—are scrutinized and potentiallyremoved from the overall scoring at examiners'standard setting meetings. It is good practicefor a trainee representative who has sat the exam-ination to participate in the whole process.

Whereas the written examination explores anapplicant's knowledge in various relevant disci-plines, the oral examination explores knowledgeand judgment in clinical neurosurgical practiceafter an applicant has been an independent prac-titioner. The oral examination is accomplishedin a series of face-to-face examinations. Theapplicant is presented with a series of clinicalvignettes using real patients, clinical descriptions,radiographs, computerized images, anatomicalmodels, and/or diagrams. The examiners gradethe applicant on specific tasks including diagnos-tic skills, surgical decision-making, and manage-ment of complications.

STANDARDS FOR INDEPENDENTNEUROSURGICAL PRACTICE

The credibility of professional examinationstaken at the end of surgical training rests on their

ability to satisfy patients and colleagues that thosepassing have attained a minimum standardof basic and applied science knowledge and clin-ical decision-making to practice independently.Oral examinations are crucial in this process asthey assess communication skills, clinical skills,and decision-making and professionalism in ahigh-pressure environment. In contrast, MCQsfocus on assessing knowledge and analytical anddecision-making skills. More clinically integra-tive questions test higher orders of Bloom's tax-onomy and are more effective than simplefactual questions in assessing and developingthe clinical problem-solving skills of traineesurgeons.

Patients fundamentally wish for their treatingsurgeon to be as independent as possible in orderto maximize their chances for an excellentoutcome. Therefore, when setting minimumstandards for independent practice, an expertpeer group of examiners is accountable topatients, other neurosurgeons and healthcareprofessionals, and the general public. Postgrad-uate medical examinations have therefore gen-erally evolved to become as standardized andfair as possible, while maintaining rigor, expand-ing, and adapting as trends change in clinicalpractice.

xiiiHOW TO PASS NEUROSURGICAL EXAMINATIONS

PART IBASIC SCIENCE

CHAPTER 1

NEUROANATOMY

SINGLE BEST ANSWER (SBA) QUESTIONS

1. From inferior to superior (i.e. ascending),what is the 4th branch of the external carotidartery in the neck?a. Maxillary arteryb. Occipital arteryc. Facial arteryd. Lingual arterye. Posterior auricular artery

2. The pathway best describing how sympa-thetic fibers of the autonomic nervous systemexit the spinal cord is:a. Via the dorsal roots and white rami

communicansb. Via the ventral roots and white rami

communicansc. Via the dorsal roots and gray rami

communicansd. Via the ventral roots and gray rami

communicanse. Via the ventral roots and spinal nerves

3. The left vertebral artery usually arises fromthe:a. Arch of the aortab. Brachiocephalic trunkc. Left common carotidd. Left subclavian arterye. Costocervical trunk

4. Hemiballismus results from lesioning whichbasal ganglia target?a. Globus pallidus internab. Subthalamic nucleusc. Substantia nigra pars reticularisd. Striatume. Pedunculopontine nucleus

5. Lesion of which structure increases extensortone?a. Dentate nucleusb. Pedunculopontine nucleusc. Red nucleusd. Ventral tegmentume. Superior olive

6. Which one of the following drain into thecavernous sinus?a. Superior ophthalmic veinb. Superior petrosal sinusc. Inferior petrosal sinusd. Basal vein of Rosenthale. Vein of Labb�e

7. Persistent trigeminal artery is commonly:a. Found in 3-5% of peopleb. Found to connect to the proximal basilar

arteryc. Found to branch off from the ICA just

proximal to the meningohypophysealtrunk

d. Found to have a vascular abnormality inapproximately 50% of cases

e. Found in conjunction with internalcarotid artery aplasia

8. The afferent loop of the Hering-Breuerinflation and deflation reflexes is mediatedby:a. CN XIIIb. CN IXc. CN Xd. CN XIe. C2

1

9. Which one of the following nerves is outsidethe annulus of Zinn?a. Abducensb. Nasociliaryc. Trochleard. Oculomotor (superior division)e. Oculomotor (inferior division)

10. The C2 vertebra has how many secondaryossification centers?a. 2b. 3c. 4d. 5e. 6

11. A line drawn between the highest point of theiliac crests across the back usually denotes:a. L1/2 interspaceb. L2/3 interspacec. L3/4 interspaced. L4/5 interspacee. L5/S1 interspace

12. Which one of the following is labeled X inthe image below?

X

a. Ophthalmicdivisionof the trigeminal nerveb. Meckel’s cavec. Oculomotor nerved. Maxillary division of trigeminal nervee. Abducens nerve

13. Which one of the following statements aboutthe sympathetic nervous system is FALSE?a. Innervation of thoracic viscera arises from

T1-T4 spinal segmentsb. Splanchnic nerves are unmyelinatedc. Preganglionic fibers enter the sympa-

thetic chain via white rami communicansd. Sensory afferent fibers are important for

visceral pain sensation

e. Preganglionic fibers synapse in either thesympathetic chain or prevertebral ganglia

14. Nervi erigentes are responsible for:a. Inhibition of the external anal sphincterb. Inhibition of the internal vesicle sphincterc. Inhibition of the internal anal sphincterd. Inhibition of the external vesicle sphinctere. Inhibition of the rectal muscles

15. Parasympathetic sensory afferents terminatein which one of the following?a. Nucleus ambiguusb. Solitary nucleusc. Edinger-Westphal nucleusd. Red nucleuse. Superior colliculus

16. Which one of the labels in the diagram belowof the internal auditory canal identifies thefacial nerve?

A

B C

D

E

F

17. Blood supply to the posterior pituitary glandarises from branches of which internalcarotid artery segment?

C1

C2C3

C4C5

C6C7

2 PART I BASIC SCIENCE

a. C1 (Cervical)b. C2 (Petrous)c. C3 (Lacerum)d. C4 (Cavernous)e. C5 (Clinoid)f. C6 (ophthalmic/supraclinoid)g. C7 (communicating)

QUESTIONS 18–25

Additional questions 18–25 available onExpertConsult.com

EXTENDED MATCHING ITEM (EMI)QUESTIONS

26. Cavernous sinus imaging:

GFA

HF

BC

DE

For each of the following descriptions, select themost appropriate answers from the image above.Each answer may be used once, more than onceor not at all.1. Right optic nerve2. Oculomotor nerve3. Abducens nerve

27. Internal auditory canal:

B A J

H

GFEC D

I

For each of the following descriptions, select themost appropriate answers from the image above.Each answer may be used once, more than onceor not at all.1. AICA2. Basal turn of cochlea3. Cochlear nerve

28. Cavernous sinus anatomy:

B A

GHI

C

D

E

M

LK

J

F

For each of the following descriptions, select themost appropriate answers from the diagramabove. Each answer may be used once, more thanonce or not at all.1. ACA2. Maxillary division of CN V (V2)3. Oculomotor nerve (III)

31 NEUROANATOMY


A

R

AICA

VIII

IX

X

XI

P

O

ML

N

PonsVI

Q

B

CD

EFG

H

I

J

K

For each of the following descriptions, select themost appropriate answers from the image above.Each answer may be used once, more than onceor not at all.1. Facial nerve2. Superior vestibular nerve3. Greater superficial petrosal nerve4. Posterior semicircular canal


A

F

EG H

CD A

B

A

B

For each of the following descriptions, select themost appropriate answers from the images above.Each answer may be used once, more than onceor not at all.1. Anterior inferior cerebellar artery2. Vestibulocochlear nerve3. Facial nerve

31. Basal Ganglia:

A

B

G

I

H

E J

K

F

C

D

L

1 Lateral medullary lamina2 Medial medullary lamina

12

For each of the following descriptions, select themost appropriate answers from the image above.Each answer may be used once, more than onceor not at all.

1. Caudate nucleus2. Claustrum3. Globus pallidus interna4. Internal capsule5. Putamen

32. Projection and association tracts:a. Central tegmental tractb. Lamina terminalisc. Median forebrain bundled. Stria medullarise. Stria terminalisf. Postcommissural Fornixg. Nucleus of the diagonal band of Broca

(vertical limb)h. Retinohypothalamic tracti. Supraopticohypophyseal tractj. Tuberoinfundibular

(tuberohypophyseal) tractk. Trapezoid bodyl. Thalamic fasciculus (Forel’s field H1)

m. Nucleus of the Diagonal band of Broca(horizontal limb)

n. Mammillothalamic tracto. Tapetum

For each of the following descriptions, select themost appropriate tracts from the list above. Eachanswer may be used once, more than once or notat all.

1. Conducts fibers to the posterior pituitarygland

2. Arcuate nucleus to hypophyseal portal sys-tem of infundibulum

3. Septal nuclei to hippocampus4. Connects sepal area, hypothalamus, basal

olfactory areas, hippocampus/subiculumto midbrain, pons and medulla

5. Hippocampus to cingulate gyrus


33. Vascular territories:a. Middle cerebral arteryb. Basilar arteryc. Perforators from internal carotid arteryd. Ophthalmic arterye. P2 portion of posterior cerebral arteryf. Vertebral arteryg. Superior cerebellar arteryh. Posterior inferior cerebellar arteryi. Anterior inferior cerebellar arteryj. Posterior communicating arteryk. A2 portion of anterior cerebral arteryl. P3 portion of posterior cerebral artery

m. Recurrent artery of Heubner

For each of the following descriptions, select themost appropriate answers from the list above.Each answer may be used once, more than onceor not at all.

1. Posterior limb of the internal capsule2. Medial and lateral geniculate nuclei3. Anterior limb of internal capsule and head

of caudate4. Posterior pituitary gland5. Splenium of corpus callosum

34. Cerebral veins:

AB C

D

E

F

G

H

I

J

KLM

NO

P

Q

R


1. Inferior anastamotic vein of Labb�e2. Superficial middle cerebral vein of Silvius3. Superior anastamotic vein of Trolard4. Basal vein of Rosenthal5. Vein of Galen

35. Offending Artery:a. A1 portion of anterior cerebral arteryb. Anterior choroid arteryc. Anterior communicating arteryd. Anterior inferior cerebellar arterye. Basilar arteriesf. Facial arteryg. Internal carotid arteryh. M3 portion of middle cerebral arteryi. Ophthalmic arteryj. Posterior cerebral arteryk. Posterior communicating arteryl. Posterior inferior cerebellar artery

m. Superior cerebellar arteryn. Vertebral artery


1. Glossopharyngeal neuralgia2. Trigeminal neuralgia3. Hemifacial spasm4. Horner’s syndrome5. CN III palsy

36. Autonomic nervous system:a. Erdinger-Westphal nucleusb. Superior salivatory nucleusc. Inferior salivatory nucleusd. Dorsal nucleuse. Ciliary ganglionf. Pterygopalatine gangliong. Otic ganglionh. Submandibular ganglioni. CNIIj. CNVk. Chorda tympanil. Vidian nerve

m. Superior cervical ganglionn. Greater petrosal nerveo. Lesser superficial petrosal nervep. Auriculotemporal nerve


1. Mediates bronchoconstriction2. Receives preganglionic parasympathetic

fibers via CNIII3. Postganglionic parasympathetic fibers to

parotid gland4. Preganglionic parasympathetic fibers to the

submandibular ganglion5. Origin of preganglionic parasympathetic

fibers transmitted in GSPN IX

51 NEUROANATOMY

37. Projection and association tracts:a. Ansa lenticularisb. Fasciculus retroflexusc. Lenticular fasciculus (Forel’s field H2)d. Postcommissural fornixe. Precommissural fornixf. Thalamic fasciculus (Forel’s field H1)g. Nucleus of the diagonal band of Brocah. Mammillothalamic tracti. Tapetumj. Uncinate fasciculusk. Commissure of Probstl. Central tegmental tract

m. Lamina terminalisn. Median forebrain bundleo. Stria medullaris

For each of the following descriptions, select themost appropriate option from the list above. Eachanswer may be used once, more than once or notat all.

1. Globus pallidus interna to thalamusthrough internal capsule

2. Globus pallidus interna to thalamus aroundinternal capsule

3. Septal nuclei to amygdala4. Temporal lobe to occipital lobe5. Connection between nuclei of lateral

lemniscus

38. Thalamus:

H

I

J

K

L

B

C

D

E

F

G

A

For each of the following descriptions, select themost appropriate part of the thalamus from theimage above. Each answer may be used once,more than once or not at all.1. Pulvinar2. Ventral anterior nucleus3. Ventral posterolateral nucleus4. Lateral geniculate nucleus5. Medial geniculate nucleus

39. Thalamus:

A C

B

E

CD

FC

J

HG

I

M

K L

For each of the following descriptions, select themost appropriate part of the thalamus from theimage above. Each answer may be used once,more than once or not at all.1. Receives major input from inferior colliculi2. Major projection to the primary visual cortex3. Receives major projections frommammillary

body4. Auditory relay nucleus5. Contains the area of face representation

40. Projection and association tracts:a. Inferior collicular commissureb. Cingulate fasciculusc. Arcuate fasciculusd. Corpus callosume. Posterior commissuref. Hypothalamospinal tractg. Brachium conjunctivumh. Brachium pontisi. Restiform and juxtarestiform bodiesj. Dorsal longitudinal fasciculusk. Medial longitudinal fasciculusl. Uncinate fasciculus

m. Lamina terminalisn. Commissure of Probsto. Stria medullaris

For each of the following descriptions, select themost appropriate X from the list above. Eachanswer may be used once, more than once ornot at all.

1. Periventricular hypothalamus and mam-millary bodies to midbrain central graymatter

2. Covered with indusium griseum3. Contains crossing fibers of pretectal

nucleus for light reflex4. Connects Wernicke and Broca’s areas5. Interruption can result in Horner’s

syndrome


41. For each of the following descriptions, selectthe most appropriate answers from the imagebelow. Each answer may be used once, morethan once or not at all.

A

B

C

D

E

F

G

H

I

J

K

L

1. Cisterna magna2. Interpeduncular cistern3. Chiasmatic cistern

42. Cranial Nerve Nuclei:

A

L

M

N

O

P

Efferent cranialnerve nuclei

Afferent cranialnerve nuclei

B

C

DE

F

GH

I

JK

Superior

Lateral

Dorsalcochlear

InferiorMedial

Vestibular nuclei

For each of the following descriptions, select themost appropriate answers from the image above.Each answer may be used once, more than onceor not at all.1. Abducens nerve nucleus2. Principal sensory nucleus of trigeminal nerve3. Solitary tract nucleus4. Facial nerve motor nucleus5. Nucleus ambiguus

43. Sulci and gyri:

Frontal lobe

A BC

DE

FG

H

I

J

K

L

MNO

PQ

RS

TUV

W

X

YZ

A1B1

C1

Parietal lobe Temporal lobe Occipital lobe

For each of the following descriptions, select themost appropriate answers from the image above.Each answer may be used once, more than onceor not at all.1. Angular gyrus2. Supramarginal gyrus3. Pars opercularis of inferior frontal grus4. Middle frontal gyrus5. Parieto-occipital sulcus

44. Sulci and gyri:

AB

C

D

EF

G

H

I

JK

LM

NO

PQ

RS

T

U

V

WX

Y

Z

GB

S

Septum

Thalamus

Frontal lobe Limbic lobe Temporal lobe Parietal lobe Occipital lobe

R

A1

B1

C1D1

For each of the following descriptions, select themost appropriate answers from the image above.Each answer may be used once, more than onceor not at all.1. Marginal sulcus2. Calcarine sulcus3. Cuneus4. Collateral sulcus5. Lamina terminalis

71 NEUROANATOMY

45. Sulci and gyri:

O

H

I

J

K

L

M

N

G

F

E

D

C

B

A

GGGSS

For each of the following descriptions, select themost appropriate answers from the image above.Each answer may be used once, more than onceor not at all.1. Central sulcus2. Paracentral sulcus3. Calcarine sulcus4. Marginal sulcus5. Precuneus

46. Fourth ventricular floor:

J

K

L

M

N

O

P

Q

R

SI

H

G

F

E

D

C

B

A

For each of the following descriptions, select themost appropriate answers from the image above.Each answer may be used once, more than onceor not at all.1. Facial colliculus2. Striae medullaris3. Sulcus limitans4. Median sulcus5. Vagal trigone

47. Cranial Nerve Nuclei:

O

C

D

E

F

IC

SC

G

H

I

JK

L

M

N

P

Q

R

S

T

UB

A

IO

For each of the following descriptions, select themost appropriate answers from the image above.Each answer may be used once, more than onceor not at all.1. Red nucleus2. Erdinger-Westphal nucleus3. Oculomotor nucleus4. Trochlear nucleus5. Abducens nucleus6. Facial nucleus7. Nucleus ambiguus of vagus nerve

48. Medulla at sensory decussation:

A

B

C

D

J

I

HG

K

L

M

N

O

QP

RS

TU

VW

X

Y

EF


For each of the following descriptions, select themost appropriate answers from the image above.Each answer may be used once, more than onceor not at all.1. Nucleus gracilis2. Nucleus cuneatus3. Spinothalamic tract4. Posterior spinocerebellar fibers

49. Medulla and vagal nuclei:

EF

YZ

J

I

H

G

A

B

C

D

KL

MN

OP

QRST

UV

X

W

For each of the following descriptions, select themost appropriate answers from the image above.Each answer may be used once, more than onceor not at all.1. Solitary nucleus and tract2. Dorsal motor vagal nucleus3. Reticular formation4. Principal olivary nucleus (inferior olivary

nucleus)5. Medial lemniscus

50. Rostral medulla:

AB

C

DE

H

I

K

J

LM

N OPQ

RS

T

UVW

X

Y

Z

FG


1. Posterior cochlear nucleus2. Vestibulocochlear nerve3. Spinal trigeminal nucleus4. Medial longitudinal fasciculus5. Nucleus ambiguus

51. Caudal pons:

O

PQ

R

UTS

V

W

X

YZ

A1B1N

M

L

KJ

I

H

G

FE

D

C

B

A

For each of the following descriptions, select themost appropriate answers from the image above.Each answer may be used once, more than onceor not at all.1. Facial nucleus2. Facial nerve3. Superior olivary nucleus4. Abducens nucleus5. Abducens nerve

52. Mid-pons:

W

V

U

T

S

R

Q

PO

N

M

L

K

J

I

H

G

FE

CD

BA

For each of the following descriptions, select themost appropriate answers from the image above.Each answer may be used once, more than onceor not at all.1. Locus ceruleus2. Corticospinal fibers3. Principal trigeminal sensory nucleus4. Fourth ventricle5. Brachium pontis

91 NEUROANATOMY

53. Rostral pons:

IJ

KL

MN

OP

Q

R

S

H

G

F

E

DC

B

A

For each of the following descriptions, select themost appropriate answers from the image above.Each answer may be used once, more than onceor not at all.1. Medial lemniscus2. Medial longitudinal fasciculus3. Trochlear nerve4. Central tegmental tract5. Tectobulbospinal tract

QUESTIONS 54–58

Additional questions 54–58 available onExpertConsult.com

SBA ANSWERS

1. c—Facial artery

The external carotid artery has several branches inthe neck (SALFOPSI in ascending order): superiorthyroid, ascending pharyngeal, lingual, facial (akaexternal maxillary), occipital, posterior auricular,superficial temporal, maxillary (aka internal maxil-lary). It can be distinguished on angiogram (figure)from the ICA, which has no branches in the neck.During EC/IC bypass procedures for Moya Moyadisease, anastomosis of the superficial temporalartery to the middle cerebral artery (or less com-monly occipital artery to the posterior cerebralartery/posterior inferior cerebellar artery) may beperformed.

2. b—Via the ventral roots and white ramicommunicans

3. d—Left subclavian artery

Each vertebral artery arises from its ipsilateralsubclavian artery. The aortic arch gives off threebranches in order: brachiocephalic trunk (orinnominate artery), left common carotid and leftsubclavian arteries (A). The second commonestbranching pattern (termed a “bovine arch”) iswhere the left common carotid arises from thebrachiocephalic trunk (B).

Innominateartery

Rightsubclavian

artery

Leftsubclavianartery

Rightvertebral

artery Leftvertebralartery

Right carotidartery Left carotid

artery

Innominateartery

Rightsubclavian

artery

Leftsubclavianartery

Rightvertebral

artery Leftvertebralartery

Right carotidartery Left carotid

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, NaidichTP. Problem solving in neuroradiology. Elsevier.


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