FRCS

Question 1

Foster Kennedy Syndrome?

Answer 1

Ipsilateral optic atrophy and contralateral pappilloedema.
Secondary to tumour compression and raised ICP.

Question 2

Gerstmann Syndrome?

Answer 2

Dominant parietal lobe dysfunction, involving the angular gyrus.
Agraphia without alexia
Finger agnosia
Right to left disorientation
Acalcula

Question 3

Radiological indication for decompressive hemicraniectomy in MCA stroke?

Answer 3

CT Head infarct involving >50% of MCA territory
+/- PCA or ACA infarct
+/- MRI restricted diffusion > 145cm3

Question 4

ATRT?

Answer 4

Atypical Teratoid Rhaboid tumours.
WHO grade IV.
10-20% of paediatric CNS tumours under 3 years old.
Poor prognosis with CNS metastasis.
Associated with mutated INI1 tumour suppressor gene on chromosome 22.

Question 5

Grading of atlantoaxial rotatory subluxation?

Answer 5

Fielding and Hawkins:
I: rotation without anterior displacement of C1
- transverse ligament intact
II: rotation with 3-5mm of C1 anterior displacement
- transverse ligament damaged
III: rotation with >5mm of C1 anterior displacement
IV: posterior displacement of C2
- rare, in rheumatoid

Question 6

NF1

Answer 6

Incidence 1/3,000 births.
Chromosome 17.
Gene product = neurofibromin.
Occasional pheochromocytoma and common scoliosis.
Malignant peripheral nerve sheath tumour = 2%
Intra medullary cord tumour = astrocytoma

Question 7

NF2

Answer 7

Incidence 1/40,000
Autosomal dominant.
Chromosome 22.
Gene product Schwannomin/ Merlin.
Cutaneous schwannomas
Cataracts common.
Most common spinal cord tumour = ependymoma

Question 8

Most common extradural tumour of clivus?

Answer 8

Chordoma

Question 9

Two most common sites of origin for chordoma?

Answer 9

1) sacrum
2) clivus

Question 10

CSF tumour marker positive in Germinomas?

Answer 10

Placental alkaline phosphotase

Question 11

What tumours are associated with raised alpha fetal protein?

Answer 11

Embryonal carcinoma and yolk sac tumours.

Question 12

Test to distinguish Primary CNS Lymphoma from other HIV mass lesions?

Answer 12

Fluorine-18 flurodeoxyglucose PET. Higher uptake in Primary CNS lymphoma.

Question 13

Most common posterior fossa primary brain tumour in adults and children?

Answer 13

Adults: haemangioblastoma
Children: polycytic astrocytoma

Question 14

What is the test dose for intrathecal baclofen?

Answer 14

50micrograms

Question 15

How is spasticity graded?

Answer 15

Modified Ashworth scale:
0 = normal tone
1 = ‘catch and release’
1+ = catch followed by slight increase in tone
2 = increased tone throughout range of movement but passive movement easy
3 = difficulty with passive movement
4 = Rigid limb fixed in flexion or extension

Question 16

Mechanism of Baclofen?

Answer 16

GABA-B agonist

Question 17

Dermatomes of the trigeminal nerve?

Answer 17

Opthalmic V1: Anterior scalp, forehead, upper eyelid, cornea, nose, frontal sinus.
Maxillary V2: Lower eye lid, cheek, upper lip and gums, maxillary and ethmoid sinus
Mandibular V3: Jaw, chin, lower lip, gums and teeth

Question 18

What are Hartel’s landmarks?

Answer 18

Percutaneous trigeminal rhizotomy.
2.5cm lateral to the mouth
Coronal plane aiming 3cm anterior to the external auditory meatus
Sagittal plane towards the ipsilateral pupil

Question 19

Anatomical relations of the subthalamic nucleus

Answer 19

STN:
lateral to the red nucleus
medial to the internal capsule
ventral to the thalamus
dorsal to the substantia nigra
The STN is caudal in the diencephalon, close to the junction with the midbrain

Question 20

What cognard grade has the highest risk of haemorrhage?

Answer 20

Type 2a + b

Question 21

Describe the cognard grading for dural AV fistulas

Answer 21

Type 1: Antegrade flow in the venous sinus
Type 2a: retrograde flow in the venous sinus
Type 2b: retrograde flow with reflux into cortical vein
Type 3: Direct cortical drainage without venous ectasia
Type 4: Direct cortical drainage with venous ectasia
Type 5: Spinal venous drainage

Question 22

Medial cranial nerve within the cavernous sinus

Answer 22

Abducens nerve VI

Question 23

Serviceable hearing in acoustic neuroma

Answer 23

Less than 50dB in pure tone audiogram and greater than 50% in speech discrimination test

Question 24

Circumventricular organs

Answer 24

Midline areas of increased permeability without the blood brain barrier.
7 in total

Sensory
Area postrema
Lamina terminalis
Subforniceal organ

Secretory:
Posterior pituitary
pineal gland
Subcommissural gland
Median eminence

Question 25

Diastematomyelia

Answer 25

Disorder of gastrulation Type 1: Hemicords in 2 separate dural scas separated by rigid osseous spur. Likely symptomatic with tethered cord, syrinx or scoliosis. Can require surgery Type 2: Hemicords in a single dural sac. Likely asymptomatic. Associated with spina bifida

Question 26

Parsonage-Turner syndrome

Answer 26

Brachial plexus neuritis Causes shoulder and upper arm pain, and weakness

Question 27

Spinal level targeted during spinal cord stimulation for failed back surgery syndrome

Answer 27

T8-T9

Question 28

ASIA scale

Answer 28

A: Complete spinal cord injury B: Incomplete spinal cord injury. No motor power below level but sacral sensation spared C: Power less than 3/5 in more than 50% myotomes below level D: Power 3/5 or better in more than 50% myotomes below level E: Neurologically intact

Question 29

Recurrent artery of Heubner

Answer 29

Arises from the proximal A2 Supplies the head of the caudate nucleus and anterior limb of internal capsule, anterior putamen and globus pallidus Infarction causes contralateral hemiparesis, gaze neglect and dysarthria

Question 30

Normal atlanto-dental interval

Answer 30

Adults < 3mm Children < 5mm

Question 31

Powers ratio

Answer 31

(Basion to posterior arch of C1)/ (Opisthion to anterior arch of C1) Normal < 1 Atlanto-occipito dissociation > 1

Question 32

McRae's line

Answer 32

Basion to opisthion If Odontoid peg crosses this line = basilar invagination

Question 33

Chamberlain's line

Answer 33

Hard palate to opisthion Odontoid peg >3mm above the line = basilar invagination

Question 34

McGregor's line

Answer 34

Hard palate to caudal occipital bone Odontoid peg >5mm above the line = basilar invagination

Question 35

Klippel-Feil syndrome

Answer 35

Congenital fusion of 2 or more cervical vertebrae

Question 36

Lesser petrosal nerve

Answer 36

Branch of Glossopharyngeal nerve IX Arises from tympanic plexus in petrous bone Passes through foramen ovale and synapses in the otic ganglion Parasympathetic supply to the parotid gland

Question 37

Fisher and modified fisher risks of vasospasm

Answer 37

Fisher 1: No blood visible on CT = 20% risk 2: SAH < 1mm thick = 25% 3: SAH > 1mm thick = 37% 4: IVH or ICH = 30% Modified fisher 0: No blood visible on CT = 0% 1: Thin SAH and no IVH = 25% 2: Thin SAH and IVH = 33% 3: Thick SAH and no IVH = 33% 4: Thick SAH and IVH = 40%

Question 38

Berger-Sanai classification

Answer 38

Insular gliomas Separates the insula into 4 zones Vertical is foramen of munro Horizontal is sylvian fissure

Question 39

Meyerding clasffification

Answer 39

Spondylolisthesis grade I: 0-25% grade II: 26-50% grade III: 51-75% grade IV: 76-100% grade V (spondyloptosis): >100%

Question 40

Name, location and function of dorsal columns

Answer 40

Fasciculus cuneatus is the lateral dorsal column which is for upper limb, above T6. For proprioception and fine touch sensation Fasiculus gracilus is the medial dorsal column for lower limb, below T6. For proprioception and fine touch sensation

Question 41

Is methylated or unmethylated MGMT better for prognosis in Glioblastoma?

Answer 41

Methylation of the promotor region will silence the MGMT gene. Therefore, the cancer cells will not be able to repair the DNA alkylation and will be sensitive to Temozolomide. Methylated MGMT carries a better prognosis

Question 42

Hypothalamic hamartomas cause

Answer 42

Gelastic seizures Episodes of unprovoked laughter Precocious puberty

Question 43

Wallenberg syndrome pathophysiology

Answer 43

PICA infarct Ipsilateral ataxia - inferior cerebellar peduncle Ipsilateral facial sensory loss - trigeminal nucleus Ipsilateral horners syndrome - descending sympathetic fibres Contralateral loss of pain and temperature - spinothalamic tract Vomiting and vertigo - vestibular nucleus VIII Swallowing difficulties and hoarse voice - nucleus ambiguus/ glossopharyngeal nucleus IX and vagus X

Question 44

Sensory nerve fibres

Answer 44

A-alpha: myelinated Conduction speed 120m/s Diameter 20micrometers Proprioception A-beta: myelinated Conduction speed 75m/s Diameter 12micrometers Tactile sensation A-delta: myelinated Conduction speed 30m/s Diameter 5micrometers Pain C: Unmyelinated Conduction speed of 2m/s Diameter 1micrometer Pain

Question 45

Genetic mutation in pilocytic astrocytoma

Answer 45

BRAF mutation Chromosome 7 Oncogene which promotes cell proliferation

Question 46

Trigeminal nucleus

Answer 46

Mesencephalic nucleus in midbrain - proprioception for jaw movements Principle nucleus in pons - tactile sensation of the face Spinal nucleus in upper cervical cord - pain and temperature (Also afferents from IX and X) Motor nucleus in pons - mastication

Question 47

Most common dermatome involved in trigeminal neuralgia

Answer 47

Right V2

Question 48

Bill's bar separates which 2 nerves

Answer 48

Facial VII anterior Superior vestibular VIII posterior

Question 49

Schwannomatosis

Answer 49

SMARCB1 tumour suppressor gene mutation on chromosone 22, normally regulates chromatin Unilateral acoustic neuroma Meningiomas Do not get cataracts or spinal ependymomas

Question 50

Brown-Sequard syndrome

Answer 50

Ipsilateral loss of motor power and proprioception Contralateral loss of pain and temperature

Question 51

Cavernous sinus inflow and outflow

Answer 51

Drain into the cavernous sinus: Superior and inferior opthalmic veins Superficial middle cerebral vein Sphenoparietal sinus Drain out of the cavernous sinus: Inferior petrosal sinus to jugular bulb Sperior petrosal sinus to the transverse sinus

Question 52

Branches of external carotid

Answer 52

SALFOPSI Superior thyroid Ascending pharyngeal Lingual Facial Occipital Posterior auricular Superficial temporal Maxillary

Question 53

Red nucleus

Answer 53

Ventral midbrain III nerve fibres pass through it Inhibits extensor tone Projections to the rubrospinal tract which stimulates flexor muscles in the upper limbs

Question 54

Persistent trigeminal artery

Answer 54

Cavernous ICA proximal to the menigohypophyseal trunk Basilar artery between AICA and SCA 0.1-0.6% of cerebral angiograms Usually unilateral

Question 55

Persistent hypoglossal artery

Answer 55

Cervical segment of internal carotid artery Basilar artery via the hypoglossal canal 0.02% of cerebral angiograms

Question 56

Persistent otic artery

Answer 56

Petrous segment of internal carotid artery Basilar artery via the internal acoustic meatus

Question 57

Nerves within the annulus of zinn

Answer 57

Optic nerve II Superior and inferior division of occulomotor nerve III Nasociliary nerve of Opthalmic V1 Abducens VI

Question 58

Nerves in the superior orbital fissure outside the annulus of zinn

Answer 58

Trochlear nerve IV Frontal nerve of Opthalmic V1 Lacrimal nerve of Opthalmic V1

Question 59

Solitary nucleus

Answer 59

Dorsomedial medulla Receives afferents from VII, IX, X Regulates autonomic nervous system Mediates cough and gag reflex

Question 60

Nucleus ambiguous

Answer 60

Ventrolateral medulla Sends motor efferent fibres via the IX and X for swallowing and voice

Question 61

Segments of the internal carotid artery

Answer 61

C1 Cervical C2 Petrous C3 Lacerum C4 Cavernous C5 Clinoidal C6 Supraclinoid C7 Communicating

Question 62

Artery arising from the Cavernous segment C5, of internal carotid artery

Answer 62

Meningohypophyseal artery Gives rise to 3 branches: inferior hypophyseal artery Tentorial artery of Bernasconi and Cassirini Dorsal clival artery

Question 63

Arteries arising from the Supraclinoid segment C6, of internal carotid artery

Answer 63

Superior hypophyseal artery Opthalmic artery

Question 64

Arteries arising from the Communicating segment C7, of the internal carotid artery

Answer 64

Posterior communicating artery Anterior choroidal artery

Question 65

Anterior cerebral artery

Answer 65

A1 = proximal to ACom Medial lenticulostriate A2 = Distal to ACom Recurrent artery of huebner Orbitofrontal Frontopolar A3 = Once A2 divides into the callosal marginal and pericallosal

Question 66

Middle cerebral artery

Answer 66

M1 = Sphenoidal Anterior temporal artery Lateral lenticulostriate M2 = Insular M3 = Opercular M4 = cortical

Question 67

Vertebral artery

Answer 67

V1 = Pre foraminol Subclavian to C6 V2 = Foraminol C6 to C2 V3 = Extradural C2 to C1 and into dura Posterior meningeal artery V4 = Intracranial PICA Anterior and Posterior spinal arteries

Question 68

PICA Segments

Answer 68

Origin to medullary olive = Anterior-medullary Curves laterally around medulla supplying IX, X, XI = Lateral-medullary Caudal loop, down to foramen magnum = Tonsillomedullary Cranial loop/ choroid point, correlates with 4th ventricle = Telovelartonsillar Hemispheric

Question 69

Striae medullaris in rhomboid fossa

Answer 69

Part of auditory system Separates the pons from the medulla

Question 70

Evidence for treatment of ruptured aneurysms

Answer 70

Molyneux lancet 2002 n = 2,143 Primary end point: death or dependency/ mRS 3-6 Coiling 23% Clipping 30%

Question 71

Spinal arteries

Answer 71

2 paired posterior spinal arteries 1 single anterior spinal artery Posterior supplied by multiple radicular arteries Anterior supplied by segmental arterial supply Watershed area is mid thoracic

Question 72

Risk factors bleeding from a cerebral AVM

Answer 72

Previous haemorrhage Flow aneurysm Deep location Deep venous drainage Single draining vein Diffuse morphology Small nidus

Question 73

Risk of intracranial haemmorhage for cerebral AVM

Answer 73

Annual risk 2-4% After haemorrhage increases to 7-17% for 1 year

Question 74

Grade of AVM size 4cm, located in the motor strip and drains into the straight sinus

Answer 74

Spetzler Martin: <3cm = 1 3-6cm = 2 >6cm = 3 Non eloquent = 0 Eloquent = 1 Superficial venous drainage = 0 Deep venous drainage = 1

Question 75

Galassi classification

Answer 75

1 limited to anterior part of middle fossa. No mass effect 2 extends into sylvian fissure and displaces the temporal lobe 3 occupies entire middle fossa, displaces parietal and frontal lobes, midline shift

Question 76

Sensitivity

Answer 76

Odds a patient with the disease will test positive = true positives/ (true positives+false negatives)

Question 77

Specificity

Answer 77

Odds a patient without the disease will test negative = true negatives/ (true negative+false positives)

Question 78

Type 1 error

Answer 78

Rejecting the null hypothesis when it is in fact true. p value is the probability of a type 1 error. Type 1 error is reduced by lowering the significance level from 0.05 to 0.01

Question 79

Type 2 error

Answer 79

Accept the null hypothesis that is in actual fact false. Reducing the significance level from 0.05 to 0.01 increases the risk of a type 2 error. Risk of type 2 error is minimised by increasing the sample size

Question 80

Answer 80

Question 81

Locus Coeruleus

Answer 81

Blue spot Superior-lateral aspect of the rhomboid fossa Produces noradrenaline

Question 82

Answer 82

Question 83

Musculocutaneous nerve

Answer 83

C5-C7 Lateral cord of brachial plexus Motor: Biceps, Coracobrachalis, Brachalis Sensory: lateral forearm

Question 84

Axillary nerve

Answer 84

C5-C6 Posterior cord of brachial plexus Motor: Teres minor, Deltoid Sensory: Regimental badge area of arm

Question 85

Radial nerve

Answer 85

C5-T1 Posterior cord of brachial plexus Sensory: Posterior aspect of forearm, lateral aspect of dorsum of hand, dorsal surface of lateral 3.5 digits Motor: Triceps and extensors in forearm

Question 86

Median nerve

Answer 86

C6-T1 Medial and lateral cords of brachial plexus Sensory: Palmar cutaneous nerve - lateral palm (does not pass through the carpal tunnel) Digital cutaneous branch - lateral 3.5 digits palmar surface Motor: Flexors of the forearm except flexor carpi ulnaris and medial aspect of flexor digitorum profundus. Thenar muscles; opponens pollicis, flexor pollicis brevis, abductor pollicis brevis and lateral 2 lumbricals.

Question 87

Ulnar nerve

Answer 87

C8-T1 Medial cord of brachial plexus Sensory: Medial 1.5 fingers and medial palm Motor: 2 flexors in forearm - Flexor carpi ulnaris and medial aspect flexor digitorum profundus In hand - hypothenar, dorsal and palmar interossei, medial 2 lumbricals, adductor pollicus

Question 88

Answer 88

Wartenberg's sign Ulnar nerve palsy Involuntary abduction of 5th digit Weakness of palmar interosseous muscles Radial innervation of extensor digiti minimi is unnaposed

Question 89

Pain terminology: Dysethesia Hyperpathia Causalgia Anaesthesia Dolorosa Allodynia Nociceptive pain

Answer 89

Dysethesia = unpleasant abnormal sensation, can be spontaneous or provoked Hyperpathia = Exaggerated response to a painful stimulus, especially a repetitive painful stimulus Causalgia = Complex regional pain syndrome type 2, results from nerve damage Anaesthesia dolorosa = painful numbness Allodynia = Non painful stimulus evokes pain Nociceptive pain = damage to non neural tissue stimulates nociceptors

Question 90

Osborne's ligament

Answer 90

Fibrous band between the olecranon and medial epicondyle Responsible for cubital tunnel syndrome

Question 91

Answer 91

Meningioma Whorling of cells Whorling around an imaginary stem

Question 92

Answer 92

Meningioma Whorling of cells Whorling around an imaginary stem

Question 93

Answer 93

Acoustic neuroma Antoni A = densely packed schwann cell area Antoni B = Loosely packed schwann cell area with foamy macrophages

Question 94

Answer 94

Acoustic neuroma Antoni A = densely packed schwann cell area Antoni B = Loosely packed schwann cell area with foamy macrophages

Question 95

Answer 95

True ependymal rosettes surround an empty lumen Perivascular rosettes surround a vessel Both seen in Ependymoma

Question 96

Answer 96

Hypercellular, angiogenesis, necrosis. Glioblastoma

Question 97

Answer 97

Microvascular proliferation is noticeable in this GBM

Question 98

Answer 98

Microvascular proliferation is noticeable in this GBM

Question 99

Answer 99

GBM with pseudopallisading necrosis

Question 100

Answer 100

Verocay body pathognomonic of acoustic neuroma Parallel rows of nuclear bodies

Question 101

Answer 101

Verocay body pathognomonic of acoustic neuroma Parallel rows of nuclear bodies

Question 102

Answer 102

Array of nuclei surrounding necrosis GBM

Question 103

Answer 103

Question 104

Incidence of craniosynostosis and proportion of different suture involvement

Answer 104

1 in 2,000 live births Sagittal > Metopic > Unicoronal Sagittal = 45-70% of cases Metopic = 20-25% Unicoronal = 15-20% Lmabdoid = 1%

Question 105

Answer 105

Question 106

Most common gene mutation in craniosynostosis

Answer 106

FGFR Fibroblast growth fractur receptors 1, 2, 3 Regulates osteoblast differentiation and function

Question 107

Age that cranial sutures close

Answer 107

Metopic = 3 to 9 months Others = adulthood

Question 108

Clinical presentation in sagittal synostosis

Answer 108

Cranial index <75 Elongated head Occipital bullet Reversal of bregma/vertex ratio Developmental delay, particularly speech and language Raised intracranial pressure

Question 109

Clinical presentation of unicoronal synostosis

Answer 109

Harlequin sign Elevation of ipsilateral orbit due to superior displacement of greater wing of sphenoid Strabismus Forehead flattening with compensatory contralateral frontal bossing Nasal displacement towards ipsilateral side Ipsilateral ear displaced anteriorly

Question 110

Answer 110

Harlequin sign Unicoronal synostosis Elevation of ipsilateral orbit

Question 111

Answer 111

Question 112

Gorlin syndrome

Answer 112

90% develops basal cell carcinoma of skin 5% develop Medulloblastoma Tumour suppressor gene for Patched on Chromosome 9, regulates cell proliferation

Question 113

Turcot syndrome

Answer 113

DNA mismatch repair cancer syndrome Autosomal recessive Familial polyposis of the colon associated with increased risk of colorectal cancer, Glioblastoma and Medulloblastoma

Question 114

Answer 114

Question 115

Evidence for Dexamethasone

Answer 115

Vecht Neurology 1994 RCT in 100 patients with brain metastases and oedema No significant difference in KPS 4mg vs 16mg Significantly more adverse effects with higher Dexamethasone dose

Question 116

Mechanism of Dexamethasone

Answer 116

Binds to Glucocorticoid receptors which reduces inflammation Decreases the permeability of the blood brain barrier

Question 117

Half life of Dexamethasone

Answer 117

48 hours

Question 118

Dose equivalents for Hydrocortisone, Prednisolone, Dexamethasone

Answer 118

Hydrocortisone 20mg = Prednisolone 5mg = Dexamethasone 0.75mg

Question 119

Evidence for Nimodipine

Answer 119

Pickard 1989 BMJ n = 550 Placebo versus Nimodipine within 96 hours of subarachnoid haemorrhage Cerebral infarction 33% versus 22% Poor outcome (GOS 1-3) at 3 months 33% versus 20% No difference in re-bleeding

Question 120

Mechanism of Nimodipine

Answer 120

Calcium channel blocker, acting on smooth muscle to cause vasodilation

Question 121

Artery of Adamkiewicz

Answer 121

Largest radiculomedullary artery in the thoracolumbar region anastamozes with the anterior spinal artery Variable location Most commonly left sided and anastamoses between T9-T12

Question 122

Foix-Alajouanine syndrome

Answer 122

Neurological deterioration due to a spinal dural AV fistula causing venous hypertension and congestive myelopathy

Question 123

Spetzler spinal vascular malformation

Answer 123

1 = Dural AV fistula 2 = AVM 3 = Neoplastic vascular lesion (Haemoangioblastoma or cavernoma)

Question 124

Answer 124

Hypertensities within the anterior horn cells cord ischaemia secondary to anterior spinal artery infarct

Question 125

Answer 125

Question 126

Obersteiner-Redlich zone

Answer 126

Myelin sheeth changes from glial in the central to schwann cell in the peripheral nervous system The site of origin for acoustic neuroma

Question 127

Acoustic neuroma

Answer 127

Rinnes positive Air > bone conduction Weber localises to the contralateral side

Question 128

Unilateral facial weakness Forehead movement = reduced Asymmetry at rest = no Eye closure = complete

Answer 128

House Brackman Grade II

Question 129

Unilateral facial weakness Forehead movement = minimal Asymmetry at rest = no Eye closure = complete

Answer 129

House Brackman III

Question 130

Unilateral facial weakness Forehead movement = None Asymmetry at rest = no Eye closure = incomplete

Answer 130

House Brackman IV

Question 131

Unilateral facial weakness Forehead movement = None Asymmetry at rest = yes Eye closure = incomplete

Answer 131

House Brackman V

Question 132

Unilateral facial weakness Total paralysis

Answer 132

House Brackman VI

Question 133

Central neurocytoma

Answer 133

0.1% of primary brain tumours Intraventricular, arising from the septum pellucidum WHO grade II Heterogenously enhancing Synaptophysin, diagnostic in immunohistochemistry

Question 134

Synaptophysin

Answer 134

Central neurocytoma

Question 135

Answer 135

Colloid cyst risk score High risk zone = 1 Age < 65 = 1 Headaches = 1 Hyperintense on FLAIR = 1 Axial diameter > 7mm = 1 Total 4+ indicates high risk of hydrocephalus and neurological deterioration

Question 136

PHASES score

Answer 136

Population (Finish, Japanese or European/ American) Hypertension Age > or < 70 years Aneurysm size <7mm, 7-9mm, 10-19mm, >20mm Previous aneurysmal subarachnoid haemorrhage Location of aneurysm ICA MCA ACA, PCOM, Posterior circulation Calculates a 5 year risk of rupture. Based on data from over 8,000 patients

Question 137

Functional MRI

Answer 137

Cortical activity increases the oxygen demand Leading to increases cerebral blood flow and an increased ratio of oxyhaemaglobin to deoxyhaemaglobin

Question 138

5 year recurrence rate for meningioma as per Simpson grading

Answer 138

Question 139

Meningioma grade subtypes

Answer 139

Grade 1: Angiomatous, fibrous, Lymphoplasmacyte, secretory, metaplastic, Psammomatous, microcystic, meningothelial Grade 2: Atypical, Choroid, Clear cell Grade 3: Anaplastic, Rhabdoid, Papillary

Question 140

Entry point for lumbar pedicle screws

Answer 140

Question 141

Tokuhashi score

Answer 141

For metastatic spinal disease: Performance status/ KPS Number of extraspinal metastases Number of vertebral metastases Primary origin of cancer Systemic metastases resectable Neurological deficit/ Frankel Score 0-8: Survival < 6 months Score 9-11: Survival 6-12 months Score 12-15: Survival >12 months

Question 142

Intracranial branches of the facial nerve

Answer 142

Distal to the Geniculate ganglion Greater Petrosal nerve = Lacrimal gland Nerve to stapedius = Protected the inner ear from loud noise Chorda Tympani = Anterior 2/3 tongue taste + parasympathetic supply to submandibular gland

Question 143

Extracranial branches of the facial nerve

Answer 143

Question 144

Answer 144

Stupp NEJM 2005 18-70 with histologically confirmed GBM, WHO performance 0-2 Radiotherapy alone versus Temozolomide + Radiotherapy n = 570 Median survival 12.1 vs 14.6 months Hazard ratio 0.63 (p<0.001) 2 years survival 10 vs 25% 7% had grade 3 or 4 haematological toxicity = Platelets < 50 or neutrophils < 1

Question 145

Answer 145

Dome: neck 2+ favours coiling Aspect ratio > 1.5 favours coiling Neck width < 5mm favours coiling

Question 146

Autoregulation in traumatic brain injury

Answer 146

Question 147

Answer 147

Question 148

Cerebral blood flow as per O2 and CO2

Answer 148

Question 149

Define Cerebral blood flow, Cerebral perfusion pressure and Mean arterial pressure

Answer 149

CBF = CPP/CVR CPP = MAP-ICP MAP = DP + 1/3PP

Question 150

Answer 150

Question 151

Answer 151

Question 152

Answer 152

Wilby Lancet 2021 Lumbar discectomy versus transforaminal epidural steroid injection Adults with 6 weeks to 12 months of unilateral sciatica Primary outcome was Oswestry Disability Questionnaire at 18 weeks n = 163 No significant difference in ODQ scores

Question 153

Answer 153

Mallucci Lancet 2019 Antibiotic vs Silver vs Silicone VP shunt n = 1,605 Primary outcome VP shunt infection 2% vs 6% vs 6% Shunt revised for other reason 22% vs 20 vs 18 Reduced gram positive but not gram negative infection Save £13,500 per shunt infection avoided

Question 154

Hazard ratio versus Odds ratio versus Risk ratio

Answer 154

Hazard ratio = Risk of an event in group 1 divided by risk of event in group 2 over a period of time Used in clinical trials eg Survival analysis Odds ratio = odds of event in group 1 divided by the odds of event in group 2 Used in retrospective case control studies Risk ratio = risk of an event in group 1 divided by risk of event in group 2 Used in prospective cohort studies

Question 155

Confidence interval

Answer 155

The outcome eg HR, RR, OR, or mean will be within this range 95 times if the study is repeated 100. If the confidence interval cross 1 in OR or HR then the result is not statistically significant. CI becomes more narrow with increasing sample size

Question 156

Answer 156

Question 157

Knosp classication

Answer 157

Question 158

Answer 158

Knosp grade 2

Question 159

Answer 159

Knosp grade 3

Question 160

Answer 160

Hook affect in Prolactinoma If high number of prolactin, then the antibiodies become saturated, and therefore the antibody sandwich complex cannot be formed required in the immunoassay. False negative. Serial dilutions required to acquire a reliable result

Question 161

Cabergoline

Answer 161

Dopamine agonist Used for medical management of Prolactinoma Normalises Prolactin levels and reduces tumour volume in 80-90% of patients Bromocriptine not tolerated due to gastroentestinal side effects

Question 162

Answer 162

Question 163

Answer 163

Growth hormone increases with sleep, stress, exercise Growth hormone decreases with hyperglycaemia

Question 164

Excess growth hormone causes

Answer 164

Prior to closure of epiphyseal plates -> Gigantism After closure of the epiphyseal plates -> Acromegaly

Question 165

Biochemical diagnosis of Acromegaly

Answer 165

Oral glucose tolerance test Performed in the morning, as exercise and stress increase growth hormone Drink to cause hyperglycaemia which decreases growth hormone release Measure serial growth hormone over 2 hours Normal = Decreasing GH levels Acromegaly + GH remains high IGF-1 is more reliable for diagnosis acromegaly and assessing response to treatment. IGF-1 does not change with stress or exercise.

Question 166

Medical treatment for Acromegaly

Answer 166

Somatostatin analogs Octreotide, Lanreotide Reduce GH and IGF-1 in 50-70% Reduce tumour volume in 40-50%

Question 167

Pterion formed by: bones sutures

Answer 167

Bones: Greater wing of sphenoid, frontal, parietal, squamous part of temporal bone Coronal, Squamous, sphenofrontal, sphenosquamous, sphenoparietal

Question 168

Acetazolomide on ABG

Answer 168

Metabolic acidosis with respiratory compensation Carbonic anhydrase inhibitor

Question 169

Differentiate L5 motor deficit from a common peroneal nerve palsy

Answer 169

In common peroneal nerve palsy the patient can invert their foot whereas this is weak in L5 radiculopathy Ankle dorsiflexion = Deep peroneal nerve Foot eversion = Superficial peroneal nerve Foot inversion = Tibial nerve

Question 170

Answer 170

Question 171

Answer 171

Crash 3 Lancet 2019 n = 12,737 Tranexamic acid versus placebo within 3 hours of head injury Tranexamic acid improved survival in mild-moderate head injury but not severe. The benefit was time related Head injury related death: mild to moderate = 5-8%, severe = 39-41% No difference in adverse events/ stroke

Question 172

Meralgia Parasthetica

Answer 172

Lateral cutaneous nerve of the thigh L2-L3 Sensory nerve, no motor innervation Passes under the inguinal ligament, 2cm medial to the anterior superior iliac spine More common in obesity

Question 173

Ulnar paradox

Answer 173

Proximal ulnar nerve damage causes weakness of the medial half of flexor digitorum profundus Distal ulnar nerve damage, at guyans canal, spares flexor digitorum profundus

Question 174

Signs of Cushings Syndrome

Answer 174

Question 175

Nelson Syndrome

Answer 175

A complication of bilateral adrenalectomy which was indicated to treat Cushings Disease After adrenalectomy, the negative feedback on the pituitary is lost. Serum ACTH levels increase. This causes skin pigmentation and tumour progression/ increased invasiveness

Question 176

Rare forms of trigeminal neuralgia

Answer 176

Exclusively V1 = 2% Bilateral = 1%

Question 177

Answer 177

C shape halo with temporal disc margin sparing No elevation No vessel obscuration = Grade 1

Question 178

Answer 178

Circumferential halo Elevation of nasal border No vessel obscuration = Grade 2

Question 179

Answer 179

Circumferential halo Elevation of all borders Obscuration of one vessel leaving the disc = Grade 3

Question 180

Answer 180

Circumferential halo Complete elevation including the cup Obscuration of a major vessel on the disc = Grade 4

Question 181

Answer 181

Circumferential halo Complete elevation including the cup Obscuration of all vessel on the disc and leaving the disc = Grade 5

Question 182

Answer 182

Papilloedema Optic nerve sheath diameter less than 5mm is normal in adults Occular Point of care ultrasound

Question 183

Pupillary response, damage in mid brain versus pons

Answer 183

Question 184

Types of aphasia

Answer 184

1) Expressive aphasia. Brocca's area. Non-fluent. Comprehension intact. 2) Receptive aphasia. Wernicke's area. Fluent. Comprehension impaired. 3) Conductive aphasia. Arcuate fasciculus. Fluent. Comprehension intact. Paraphasic speech and poor speech repetition. 4) Transcortical aphasia. Can be motor or sensory. Fluency and awareness of errors depends on type. Differentiated from Wernicke's and Brocca's aphasia as patient can repeat words.

Question 185

Answer 185

Question 186

Explain macular sparing

Answer 186

The occipital lobe has dual blood supply from the PCA and MCA

Question 187

Parinaud's syndrome

Answer 187

1) Impairment of upgaze 2) Light near dissociation. Dilated pupils that do not react to light but constrict on convergence 3) Convergence retraction nystagmus

Question 188

Describe the light reflex

Answer 188

Question 189

Answer 189

Inter nuclear ophthalmoplegia Lesion within the medial longitudinal fasciculus Unable to adduct the contralateral eye. Signal from VI nucleus to III nucleus impaired. Associated with nystagmus

Question 190

Describe the course of the facial nerve

Answer 190

Question 191

Motor examination of VII

Answer 191

Raise forehead - Temporal branch - Frontalis Close eyes - Zygomatic branch - Obicularis occuli Puff out cheeks - Buccal branch - Buccinator Whistle - Buccal branch - Orbicularis oris Show teeth - Buccal and Zygomatic branches - Zygomaticus major Wrinkle chin - Marginal mandibular branch - Mentalis Wrinkle neck - Cervical branch - Platysma

Question 192

Pathophysiological mechanism for horners syndrome

Answer 192

Question 193

Describe the different abnormalities of gait

Answer 193

1) Hemiplegic— spastic leg traces a semicircle due to fixed plantarflexion and extension at the knee 2) Diplegic— narrow-based, scissoring gait often due to cerebral palsy 3) Myelopathic— broad-based clumsy gait 4) Equine— high stepping gait seen in patients with foot drop due to L5 radiculopathy or common peroneal palsy 5) Myopathic— waddling gait with pelvis dropping on alternating sides 6) Parkinsonian— slow little steps marche à petits pas 7) Cerebellar— veering uncontrolled gait 8) Magnetic— feet seem to be stuck to the floor, seen in normal pressure hydrocephalus

Question 194

Housefield units of different tissues

Answer 194

Acute blood 56 to 76 Air − 1000 Bone 1000 to 3000 Calcification 140 to 200 Cerebrospinal fluid 0 Fat − 30 to − 100 Grey matter 32 to 41 White matter (centrum semiovale) 23 to 34

Question 195

Signal intensity of blood as per age, and name the products

Answer 195

Question 196

Mechanism of floseal

Answer 196

Contains gelatin, calcium chloride and Thrombin Gelatin swells and tamponades Thrombin converts Fibrinogen into a fibrin clot

Question 197

Mechanism of surgicel

Answer 197

Oxidised regenerated cellulose Swells causing tamponade Acts as a surface for platelet aggregation and fibrin deposition

Question 198

Mechanism of anticoagulants

Answer 198

Question 199

Epidemiology of diffuse low grade gliomas

Answer 199

DLGG are WHO grade 2 tumours including astrocytoma and oligodendroglioma Incidence 1 in 100,000 per year 10% of all adult primary brain tumours Median age at diagnosis is 35 years old

Question 200

Clinical presentation of low grade glioma

Answer 200

Most commonly seizures. Oligodendrogliomas are more likely to present with seizures Focal deficits are rare Absence of seizures is associated with worse prognosis

Question 201

Answer 201

WHO grade 2: Astrocytoma Hypercellular compared to white matter Cellular pleomorphism No necrosis or vascular proliferation

Question 202

Answer 202

Monomorphic cells with uniform round nuclei surrounded by halos Fried egg appearance Histological artefact from formalin

Question 203

How to classify low grade gliomas

Answer 203

Histology followed by IDH-1 and 1p19q status

Question 204

Answer 204

Jakola Annals of Oncology 2017 Norway, 2 different regions n = 153 Overall survival 5.8 versus 14.4 years

Question 205

Classification of peripheral nerve injury

Answer 205

Class 1: Neuropraxia - Interruption of conduction without loss of axon continuity. Function recovers rapidly and returns to normal Class 2: Axonotmesis - Loss of axon and myelin continuity but intact endoneurium. Variable prognosis Class 3: Neurotmesis - Loss of all layers of nerve, severed. Prognosis poor and function unlikely to return to normal.

Question 206

Gross motor function classification System GMFCS

Answer 206

Question 207

Answer 207

McRae’s line runs across the foramen magnum from the basion to the opisthion, Chamberlain’s line runs from the back of the hard palate to the posterior margin of the foramen magnum (opisthion). McGregor’s line is similar running from the palate to the lowest visible part of the occiput. The tip of the dens should be = < 3 mm above Chamberlain’s line, less than 4.5 mm above McGregor’s line and usually 5 mm below but not above McRae’s line.

Question 208

Answer 208

Skull base angle of Boogard Line from nasion to centre of sella joined by line from basion Normal 125-143 Platybasia >143 Basilar kyphosis <125

Question 209

Transthoracic approach for discectomy: Left or right?

Answer 209

High thoracic - right side approach avoids the aortic arch T8 and below - a left sided approach avoids the liver and thoracic duct

Question 210

Modic changes on MRI

Answer 210

Question 211

MRI signal intensities for intradural extramedullary tumours

Answer 211

Nerve sheath tumour T1 hyper T2 hyper Meningioma T1 iso T2 iso Epemdymoma T1hypo T2 hyper

Question 212

Myxopapillary edenymoma

Answer 212

Median age 35 90% of tumours arising at the conus medullaris Upgraded in 2016 from WHO grade 1 to 2, due to high recurrence rate Arises from filum terminale

Question 213

Types of spinal lipomas

Answer 213

Dorsal - does not involve conus Transitional - dorsal and involves the conus Terminal - base of conus only, does not involve cord or nerve roots Chaotic - ventral and dorsal with Involvement of nerve roots

Question 214

Answer 214

Fibromuscular dysplasia Affects the cervical carotid in 75% and vertebrals in 15%. Disease is bilateral in 60%. Angiography: "String of beads" Risk of dissection = 15%

Question 215

Perimesencephalic haemorrhage risk of aneurysm

Answer 215

5%

Question 216

Haemangioblastoma blood results

Answer 216

Polycythaemia Tumour secretes erythropoietin

Question 217

Problem with paediatric radiotherapy in medulloblastoma

Answer 217

Can occur in patients younger than 3, where radiotherapy is innapropriate

Question 218

Brainstem auditory evoked potential in acoustic neuroma

Answer 218

Delayed V wave latency on ipsilateral side

Question 219

Ankylosing spondylitis

Answer 219

Incidence 1 in 20,000 Male: Female 3:1 90% are HLA-B27 +ve Negative rheumatoid factor Sacroiliitis on the X ray Enthesopathy - inflammation of bone at the sites of ligament/ tendons/ capsule on bone. Leads to bamboo spine = bridging syndesmophyte Schober test

Question 220

Schober test

Answer 220

While patient standing mark a point at L5 Draw a line 10cm above and 5cm below Patient then flexes there back to touch their toes Normal = distance between two lines increases by 5cm+

Question 221

Paget's disease

Answer 221

Disorder of osteoclasts Only 30% of Paget's disease sites are symptomatic. Can cause bone pain or fracture Pelvis > thoracic and lumbar spine > skull > femur

Question 222

Ossification of posterior longitudinal ligament

Answer 222

More prevalent in Japanese (2-3%) Hypervascular fibrosis and calcification extends into the dura Annual growth rate of 0.6ml in AP and 4mm longitudinally Cervical 70% Thoracic 20% lumbar 10%

Question 223

Diffuse Idiopathic Skeletal Hyperostosis DISH

Answer 223

Usually idiopathic but can present with globus and dysphagia Flowing osteophytic formation without degenerative changes Sacroiliac joints are spared

Question 224

Scheuermann's kyphosis

Answer 224

Prevalence 1-8%. Diagnosed in ages 11-17 Anterior wedging 5+ degrees of 3+ adjacent thoracic vertebrae Pain when thoracic kyphosis >50 degrees Type 1: Thoracic spine only. Apex T7/T8 Type 2: Adult variation. Involves thoracolumbar spine. Scoliosis in 90%

Question 225

Answer 225

Bertolotti’s syndrome Hypertrophied L5 transverse process is fused with the sacrum Prevalence 5%

Question 226

Mechanism of Gamma Knife

Answer 226

201 Cobalt-60 sources of radiation

Question 227

Principles of fractionated radiotherapy

Answer 227

Redistribution: Cells are most radiosensitive during M phase and are radioresistant during S phase. Re-oxygenation: Cancer cells close to the oxygen source are killed first. Then cancer cells move from the hypoxic core towards the oxygen source, thereby increasing radiosensitivity. Indirect cytotoxic effects of ionizing radiation involves creation of reactive oxygen species. Repair: Healthy cells repair DNA damage and therefore less likely to apoptosis. Cancer cells are less able to repair their DNA. Direct cytotoxic effect of ionizing radiation

Question 228

Scalp block anatomical landmarks

Answer 228

Question 229

Neuro toxoplasmosis

Answer 229

Protozoan parasite. Definitive host are cats. Radiologically seen in basal ganglia and grey-white matter junction, often multifocal. Diagnosis with serum IgG. Treated medically with Sulfadiazine and Pyrimethamine.

Question 230

Answer 230

Question 231

Gradenigo's syndrome

Answer 231

Otitis media, trigeminal neuralgia and VI nerve palsy

Question 232

Answer 232

ATRT Rhabdoid cells: Eosinophilic granular cytoplasm with eccentric nuclei

Question 233

Development of rathke's cleft cyst

Answer 233

Posterior pituitary forms from the neural ectoderm originating at the diencephalon. Anterior pituitary forms from the oral ectodermal tissue called stomadeum, rathke's pouch which migrates away from the oral cavity and then separates

Question 234

Difference between pineoblastoma and pineocytoma

Answer 234

Pineoblastoma arise from primitive neuroectoderm, necrotic, CSF drop metastases, occur in young children, poor prognosis, hypercellular +/- rosettes, WHO grade IV Pineocytoma arise from pineal parenchyma, don't metastasis, solid core, occur in young adults, good prognosis, well differentiated pineocytes, WHO grade I

Question 235

Anatomical risk factors for cervical cord injury in paediatrics

Answer 235

1 Absent uncinate processes 2 Higher water content of intervertebral discs 3 Increases stretch of ligaments 4 Proportionally larger head therefore higher fulcrum of movement 5 Odontoid is not ossified 6 Vertebral bodies are wedged 7 More horizontal orientated facets, less resistant to forward movements. In adults, facets are more oblique 8 Less muscle mass

Question 236

Evidence for folic acid supplementation to prevent spina bifida

Answer 236

MRC study Lancet 1991 Multi national RCT n 1,817 Women who had previously had a pregnancy with spina bifida Folic acid = 6 cases Placebo = 27 cases 72% relative risk reduction in mothers with previous Spina bifida pregnancy 41% relative risk reduction in first pregnancy spina bifida

Question 237

Spina bifida prevention medical regime

Answer 237

400 micrograms of Folic Acid once daily. Start 1 month prior to conception and continue through the 1st trimester

Question 238

Trautmann triangle

Answer 238

Superior border = superior petrosal sinus Posterior = sigmoid sinus Anterior = semicircular canal

Question 239

Dolenc triangle

Answer 239

Lateral = Occulomotor nerve Medial = Optic nerve Posterior = tentorial edge

Question 240

Kawase triangle

Answer 240

Arcuate eminence (bony ridge on temporal bone which marks the superior semicircular canal) Greater Superficial Petrosal nerve Petrous ridge

Question 241

Tolosa Hunt syndrome

Answer 241

Idiopathic inflammation of cavernous sinus Painful ophthalmoplegia Orbital pain with III, IV or VI palsy

Question 242

Where does the gate control theory of pain occur

Answer 242

Substantia gelatinosa

Question 243

The most epileptogenic primary brain tumour

Answer 243

DNET

Question 244

DNET

Answer 244

Dysembryoplastic neuroepithelial tumour WHO Grade 1 1% of primary brain tumours Associated with cortical dysplasia Median age 8 years old 90% present with seizures Most commonly found in temporal lobe

Question 245

Rolandic epilepsy

Answer 245

Consider benign. Not associated with learning difficulties Familial Occurs in childhood 8 years old, often resolves by adulthood Focal seizures involving face, tongue, drooling or speech Do not require surgery

Question 246

Pathophysiology of Huntington's disease

Answer 246

Huntington gene on chromosome 4 Inheritance is autosomal dominant CAG repeats Loss of neurons in the striatum Reduced GABA Excess of Dopamine

Question 247

Substantia nigra

Answer 247

Pars reticula = GABAergic neurons = ventral Pars compacta = Dopaminergic neurons = dorsal

Question 248

STN versus GPi stimulation for Parkinson's Disease

Answer 248

STN superior for rigidity, bradykinesia, tremor, off symptoms and medication reduction. GPi superior for dyskinesia, dystonia, postural stability and mood.

Question 249

Pedunculopontine nucleus DBS

Answer 249

Axial symptoms of Parkinson's; gait freezing, postural instability

Question 250

Lateral Gaze palsies

Answer 250

Lesion in the paramedian pontine reticular formation causes ipsilateral loss of eye abduction and contralateral eye adduction. Lesion in the medial longitudinal fasciculus causes loss of ipsilateral lateral eye adduction and the contralateral eye abducts with nystagmus. Lesion in both PPRF and MLF causes one and a half syndrome, loss of all lateral gaze movements except contralateral abduction.

Question 251

How to diagnose Horner's syndrome

Answer 251

Unilateral miosis, anhydrosis, ptosis. Topical Cocaine eye drops. Cocaine blocks reuptake or noradrenaline in the synapse, causing pupil mydriasis. In Horner's syndrome, there is loss of noradrenaline neruones. Therefore, the pupil does not dilate.

Question 252

Adie's syndrome

Answer 252

Tonic dilation of a pupil which does not react to like. Associated with loss of tendon reflexes. Viral infection causes damage to ciliary ganglion impairing parasympathetic supply to the eye, and also dorsal root ganglion.

Question 253

Argyl Robertson syndrome

Answer 253

Bilaterally small pupils which do not react to like but constrict on accommodation. Sign of neuro syphilis.

Question 254

Answer 254

Noise induced hearing loss

Question 255

Answer 255

Low frequency sensorineural loss - Menieres disease

Question 256

Answer 256

High frequency sensorineural loss - presbyacusis

Question 257

Superior and inferior vestibular nerve supplies

Answer 257

Question 258

Brainstem auditory evoked potentials in acoustic neuroma

Answer 258

Delayed latencies, in wave V

Question 259

Hitzelberger’s sign

Answer 259

Reduced sensation of posterior wall in external ear canal Due to compression of the nervus intermedius of VII in acoustic neuroma

Question 260

Grading haemorrhagic shock

Answer 260

Question 261

Define ARDS

Answer 261

Pa02:FiO2 < 200mmHg Ration of arterial oxygen to inspired oxygen is reduced.

Question 262

Annual incidence of sudden unexpected death in epilepsy

Answer 262

Overall: 1 in 1,000 Medically refractory epilepsy: 1 in 200

Question 263

Answer 263

Question 264

Stereotactic radiosurgery dose for trigeminal neuralgia

Answer 264

90Gy to the dorsal root entry zone, near the pons

Question 265

Maximum STRS dose when near the optic apparatus

Answer 265

Contraindicated when <3mm adjacent to optic nerve Maximum marginal dose of 10Gy to the optic nerve

Question 266

PCV chemotherapy

Answer 266

Procarbazine, Lomustine, Vincristine Higher haematological toxicity than Temozolomide Procarbazine = alkylating agent/ methylates guanine similar to Temozolamide Lomustine = alkylating agent, causing DNA crosslinking Vincristine is a Vinca Alkaloid, binds to tubulin. Therefore, chromosomes cannot be separated during metaphase

Question 267

Identify central sulcus on sagittal MRI

Answer 267

cingulate sulcus joins with marginal sulcus Marginal sulcus separates precuneus and paracentral lobule Central sulcus is the next sulcus anterior to the marginal sulcus

Question 268

Why do cerebellar lesions cause ipsilateral symptoms?

Answer 268

Dento-rubro-thalamic tract. Dentate nucleus within the cerebellum sends afferent neurons via the superior cerebellar peduncle and decussate at the red nucleus and terminate in the contralateral ventral lateral nucleus of the thalamus to synapse with the corticospinal tract Therefore, there is a double decussation

Question 269

Identify the central sulcus on axial MRI brain

Answer 269

Superior frontal sulcus joins the precentral sulcus The next sulcus posterior is the central sulcus

Question 270

Describe the pineal tumour markers

Answer 270

Question 271

Diagnostic criteria for brainstem death testing

Answer 271

Question 272

Cerebellar nuclei

Answer 272

Lateral to medial Dentate nucleus: Afferents to the Red nucleus and thalamus for motor function Globose and Embiloform nuclei: coordinates agaonist/ anatagonist muscle pairs Fastigial nucleus: Afferents to vestibular system

Question 273

Answer 273

Gamma waves: Problem solving, higher level thinking Beta waves: Alert, busy Alpha waves: Calm and restful awakeness Delta waves: REM sleep Theta waves: Non-REM sleep, seen in infants and adults with severe brain dysfunction

Question 274

Why would thoracic extrinsic cord compression cause ascending sensory loss starting at the toes?

Answer 274

The motor and sensory tracts are arranged somatotopically, with the sacral nerves more lateral to the thoracic nerves medially.

Question 275

Clinical spinal level is T10 Radiological spinal level is T7 Explain

Answer 275

The spinal cord is 3 segments shorter than the spinal canal

Question 276

Kernohan's phenomenen

Answer 276

False lateralising sign. Midline shift causes the contralateral cerebral peduncle to compress against the contralateral tentorium, producing a motor deficit ipsilateral to the lesion.

Question 277

Nerve root compressed in paracentral versus far lateral lumbar disc herniation

Answer 277

Paracentral disc herniation compresses the traversing nerve root whereas the far lateral compresses the exiting nerve root

Question 278

Spurling's test

Answer 278

Lateral flexion, slight extension and axial load the neck to the ipsilateral side of the pain, will reproduce the radicular pain, by compressing the exiting foramen

Question 279

Micturition reflexes damaged in cauda equina syndrome

Answer 279

Somatic control is lost: Pudendal nerve S2-S4, for voluntary control of the external urethral sphincter. Parasympathetic control is lost: S2-S4, for parasympathetic control which contracts the detrusor and relaxes the internal urethral sphincter for bladder emptying.

Question 280

Define ischaemic penumbra on CT perfusion

Answer 280

Parenchyma with mean transit time > 6 seconds but normal cerebral blood volume 2.2-4.2ml/100g. Cerebral blood flow <10ml/100g/minute causes irreversible infarction

Question 281

Difference between vasogenic and cytotoxic oedema on CT

Answer 281

Both = gyral enlargement Vasogenic = hypoattenuation in white matter only Cytotoxic = hypoattenuation involving white and grey matter/ loss of differentiation

Question 282

Stroke causing hemiballismus

Answer 282

PCA territory infarct damaging the contralateral subthalamic nucleus

Question 283

VIM DBS inserted for Parkinson’s complicated by paraesthesia

Answer 283

Electrode is in ventral posterior lateral nucleus which involves spinothalamic tract. Reposition the lead anteriorly

Question 284

Hering-Breuer reflex

Answer 284

Inflation and deflation reflexes mediated by vagus nerve X in the medulla

Question 285

Contents of the inferior orbital fissure outside the annulus of Zinn

Answer 285

Inferior ophthalmic vein Infraorbital nerve Zygomatic nerve

Question 286

Splanchnic nerves

Answer 286

Paired myelinated nerves that pass through the sympathetic chain. Supply sympathetic innervation via the greater and lesser splanchnic nerves, to the coeliac and mesenteric ganglions

Question 287

Autonomic ganglions receiving parasympathetic efferent input from cranial nerves

Answer 287

Cilliary ganglion: Receives efferent from III and stimulates pupillary constriction. From midbrain, Edinger Westphalt nucleus. Sphenopalatine ganglion: Receives efferent from VII as greater superficial petrosal nerve, stimulates lacrimation Submandibular ganglion: Receives efferent from VII as chorda tympani, stimulates salivation in submandibular gland Otic ganglion: Receives efferent from IX as lesser petrosal nerve, stimulates parotid gland salivation

Question 288

Nervi erigentes versus pudendal nerve

Answer 288

Nervi erigentes are pelvic splanchnic nerves providing parasympathetic innervation to the bladder, stimulating urination by contraction of detrusor muscle and inhibition of internal vesicular sphincter. S2-S4 Pudendal nerve are somatic nerves which provide voluntary control of urinary continence by stimulating the external vesicular sphincter. S2-S4

Question 289

Branches of the basilar artery

Answer 289

1) Pontine perforators 2) AICA 3) SCA 4) Labarynthine artery

Question 290

Segments of PCA

Answer 290

P1) Pre communicating - Posterior thalamoperforators - If present, artery of percheron P2) Ambient - Medial posterior choroidal - Thalamogeniculate P3) Quadrigeminal - Lateral posterior choroidal P4) Calcarine - Parieto occipital artery which anastomoses with pericallosal

Question 291

Blood supply to the basal ganglia

Answer 291

A) Medial striate artery - ACA/ A1 B) Lenticulostriate artery - MCA/ M1 C) Thalamoperforating artery - PCA/ P1 D) Medial posterior choroid artery - PCA/ P2 E) Thalamogeniculate artery - PCA/ P2 F) Anterior choroid artery - ICA/ C7

Question 292

Cerebal fasciculi

Answer 292

A) Superior longitudinal fasciculus. Connects frontal lobe to parietal and temporal lobes via operculum, for motor, visuospatial and memory processing D) - Arcuate fasciculus. Connects Brocca's and Wernicke's area for speech and language function E) - Inferior fronto occipital fasciculus. Connects frontal to temporal and occipital lobes for somatic language control and executive function G) Uncinate fasciulus. Connects frontal and temporal lobe for memory and social-emotional function

Question 293

Answer 293

a, Labyrinthine segment; b, Greater superficial petrosal nerve; c, Cochlea; d, Geniculate ganglion; e, Stapes; f, Malleus; g, Incus; h, Tympanic segment of facial nerve; i, Vertical (mastoid) segment of facial nerve; j, Stylomastoid foramen; k, Horizontal (lateral) semicircular canal; l, Posterior semicircular canal; m, Superior semicircular canal; n, Inferior vestibular nerve; o, Superior vestibular nerve; p, Internal auditory canal; q, Facial nerve; r, Meatal foramen.

Question 294

Answer 294

a, Caudate nucleus; b, Putamen; c, Globus pallidus (External segment); d, Globus pallidus (Internal segment); e, Substantia innominate; - nucleus of meynert. Produces acetylcholine f, Internal capsule; g, External capsule; h, Extreme capsule; i, Claustrum; - involved in behaviour j, Amygdala; k, Hippocampus; l, Thalamus.

Question 295

Answer 295

a, Anterior nucleus; b, Ventral anterior nucleus; c, Lateral dorsal nucleus; d, Ventral lateral nucleus (oral part); e, Ventral lateral nucleus (caudal part); f, Lateral posterior nucleus; g, Ventral posterolateral and ventral posteromedial nuclei; h, Dorsomedial nucleus (Magnocellular); i, Dorsomedial nucleus (Parvicellular); j, Pulvinar; k, Medial geniculate nucleus; l, Lateral geniculate nucleus.

Question 296

Answer 296

a, Edinger-Westphal nucleus; b, Oculomotor nucleus; c, Trochlear nucleus; d, Trigeminal motor nucleus; e, Abducens nucleus; f, Facial motor nucleus; g, Salivatory nuclei (superior); h, Salivatory nuclei (inferior); i, Dorsal vagal motor nucleus; j, Nucleus ambiguous; k, Hypoglossal nucleus; l, Trigeminal mesencephalic nucleus; m, Trigeminal main sensory nucleus; n, Trigeminal spinal nucleus; o, Dorsal cochlear nucleus; p, Nucleus of tractus solitaries.

Question 297

Answer 297

a, Anterior medullary velum; b, Middle cerebellar peduncle; c, Median sulcus of rhomboid fossa; d, Striae medullares; e, Foramen of Luschka; f, Hypoglossal trigone; g, Vagal trigone; h, Tela choroidea (cut edge); i, Gracile tubercle; j, Superior cerebellar peduncle; k, Medial eminence of fourth ventricle; l, Facial colliculus; m, Superior fovea; n, Vestibular area; o, Lateral recess; p, Sulcus limitans; q, Restiform body; r, Inferior fovea; s, Cuneate tubercle.

Question 298

Evan's index Callosal angle Lundberg wave All in Normal Pressure Hydrocephalus

Answer 298

Maximum frontal horn diameter/ maximum internal skull diameter Ventriculomegally = Evan's index>0.3 Callosal angle< 90 degrees B waves on ICP monitoring during sleep

Question 299

CSF outflow resistance indicative of normal pressure hydrocephalus

Answer 299

> 18mmHg/ml/min

Question 300

Incidence of idiopathic intracranial hypertension

Answer 300

general public = 0.9 in 100,000 Obese women aged 20-44 = 19 in 100,000

Question 301

Radiological signs of IIH

Answer 301

1) Empty sella 2) Enlarged peri optic subarachnoid space 3) Flattened posterior globe 4) Tortuous optic nerve 5) transverse sinus stenosis

Question 302

Answer 302

Differential pressure versus flow regulated valves. Orbis sigma valve exerts a variable resistance between 5-25mmHg enabling stabilisation of flow

Question 303

Difference between syringomyelia and hydromyelia

Answer 303

Syrinx = cavitation within the spinal cord not lined by ependymal Hydromyelia = dilation of the central canal, lined by ependymal

Question 304

The 4 theories for syrinx formation

Answer 304

1) Gardner's hydrodynamic water hammer theory - hindbrain malformation obstructs foramen of magendie causes pulsatile CSF flow through the obex 2) William's craniospinal dissociation theory causes suck and slosh - hindbrain malformation causes ball and valve mechanism. High intracranial pressure and low pressure within the central canal causes suction of CSF down the pressure gradient. During valsalva. The CSF then rebounds off the caudal cord causing a slosh effect 3) Ball and Dayan - raised CSF pressure in the spinal canal during coughing causes CSF to move through virchow robin spaces into the spinal cord to form a cyst 4) Oldfield's piston theory - During systole the cerebellar tonsils create a downward pulsation of CSF

Question 305

Chiari 1.5

Answer 305

Chiari 1 plus descent of the medulla Obex lies below the foramen magnum No spina bifida

Question 306

Epidemiology of head injury

Answer 306

Ratio of mild: moderate: severe TBI 22: 1.5: 1 UK annual incidence of head injury attendances at emergency department = 1,500 in 100,000 per year UK annual death due to TBI = 1 in 10,000

Question 307

Complications of concussion/ mild traumatic brain injury

Answer 307

Mild TBI GCS 13-15 has a mortality rate <1% Post concussion syndrome: Headache, vertigo, neuropsychiatric disorder, BPPV. Lasts up to weeks to months Second impact syndrome: Further head injury while still symptomatic from first head injury. Loss of cerebral autoregulation leads to cerebral oedema and raised intracranial pressure. Chronic traumatic encephalopathy: Slowly progressive cognitive decline, impulsivity, depression. Years or decades after the head injury Seizures: Risk after concussion is low.

Question 308

Guideline on evacuating an extradural haematoma

Answer 308

Haematoma volume > 30cm3 to be removed regardless of GCS

Question 309

Evidence for drains in CSDH

Answer 309

Santarius. Lancet. 2009 UK RCT comparing drain versus no drain n = 215 Recurrence rate = 9% versus 24% 6 month mortality = 8.6% versus 18.1%

Question 310

Transalar herniation

Answer 310

Brain tissue across the greater wing of sphenoid

Question 311

Steroids in traumatic brain injury evidence

Answer 311

CRASH study Lancet 2004 International RCT n=10,000 Age > 16 and GCS 14 or less 48 hours methylprednisolone versus placebo 2 week mortality 21% versus 18%

Question 312

Facial nerve injury higher in transverse or longitudinal mastoid fractures

Answer 312

transverse mastoid fractures are more likely to cause facial nerve damage

Question 313

Pressure reactivity index

Answer 313

Intact autoregulation: Increase in blood pressure causes cerebral vasoconstriction, and fall in ICP. Disturbed autoregulation: Changes in blood pressure lead to passive changes to ICP. Correlation coefficient between ABP and ICP is negative when autoregulation is intact and positive when autoregulation is disturbed.

Question 314

Genetic disorders associated with cerebral aneurysms

Answer 314

Loeys-Dietz Adult polycystic kidney disease Marfans syndrome Type IV Ehlers-Danlos Neurofibromatosis type 1

Question 315

number needed to treat to create 1 patient with mRS 3 or less in craniectomy for stroke

Answer 315

4

Question 316

Molecular difference between primary and secondary glioblastoma

Answer 316

Primary GBM: EGFR overexpression Secondary GMB: IDH1 mutation

Question 317

DBS inserted into Globus Pallidus interna for dystonia, complicated by visual distrubance

Answer 317

Withdraw the electrode as the optic radiation is caudal to the GPi

Question 318

DBS inserted into VIM for tremor complicated by dysarthria and ataxia

Answer 318

Withdraw the electrode as the dento-rubro-thalamic tract is caudal to the VIM

Question 319

Differentiating glioblastoma pseudoprogression for disease progression

Answer 319

Pseudoprogression: Increased ADC values due to cell death. Reduced cerebral blood flow. Low FDG uptake due to lower glucose metabolism. More common in patients receiving Temozolomide, with methylated MGMT. Pseudoprogression is associated with a better prognosis.

Question 320

Advanced radiological characteristics of GBM

Answer 320

Elevated regional Cerebral blood volume on perfusion MRI Decreased NAA and increased choline/ lipid/ lactate on MR spectroscopy Increased 18F-fluorodeoxyglucose compared to normal grey matter on PET

Question 321

18F-Fluorodeoxyglucose update on PET for gliomas

Answer 321

WHO Grade 2 = similar to white matter, less than grey matter WHO grade 3 = greater than white matter, similar to grey matter WHO grade 4 = greater than white and grey matter

Question 322

Role of 18F-Fluorodeoxyglucose PET in gliomas

Answer 322

(1) Grading tumours and estimating prognosis; (2) Localizing the optimum biopsy site, (3) Defining target volumes for radiotherapy (RT), (4) Assessing response to therapy, and (5) Detecting tumour recurrence and distinguishing it from radionecrosis.

Question 323

Difference between CRW and Leksel frame

Answer 323

Cosman-Roberts-Wells have 0 in the middle whereas Leksell has 0 in the upper, posterior, right corner and the middle is 1000m in the x, y and z axis

Question 324

DBS inhibition and stimulation of neural tissue

Answer 324

High frequency inhibits Low frequency stimulates

Question 325

DBS stimulation of neuronal parts at low frequency

Answer 325

Activated at high frequency = cell body Activated at lower frequency = axon Larger axons are more easily activated than smaller axons Axons with multiple branches are activated at lower stimulus

Question 326

Answer 326

Conventional electrodes stimulate circumferentially around however directional electrodes can be configured to spare specific tissue adjacent to the target, such as the internal capsule which is lateral to the red nucleus

Question 327

Summarise the Parkinson's Disease pathophysiology

Answer 327

Loss of dopaminergic neurons in the substantia nigra pars compacta Normally dopamine from SNpc stimulates D1 receptors in the direct pathway and inhibits D2 receptors in the indirect pathway In Parkinson's disease there is a net over inhibition of the thalamus and projecting cortical neurons

Question 328

Diagnostic imaging in Parkinson's Disease

Answer 328

DAT-SPECT Dopamine transporter Single Photon emission CT Reveals reduced uptake in the Putamen In Essential tremor and drug induced Parkinsonism this would be normal

Question 329

Radionucleotide used in DAT SPECT

Answer 329

I-123 Ioflupane

Question 330

Head impulse test suggestive of vestibulo-occular reflex dysfunction - peripheral vestibular dysfunction

Answer 330

Corrective saccades

Question 331

IDH in glioma

Answer 331

Isocitrate dehydrogenase IDH 1 gene is on chromosome 2 IDH 2 gene is on chromosome 15 IDH mutation carries a favourable prognosis Mutations occur early in oligodendroglioma and astrocytoma, seen in secondary glioblastoma

Question 332

1p19q

Answer 332

Longer progression free survival and improved chemotherapy responsiveness in oligodendroglioma

Question 333

How many dentate ligaments are there?

Answer 333

21 pairs Lateral projections of cord pia that anchors to the dura

Question 334

Recovery rates by 12 months after traumatic spinal cord injury as per initial ASIA scale

Answer 334

ASIA A = 10% will improve to an incomplete spinal cord injury B+ and 2% will improve to D ASIA C = 70% will improve to D or E

Question 335

Probability of walking 1 year after complete spinal cord injury

Answer 335

Complete paraplegia = 5% Complete quadriplegia = 0%

Question 336

Cervical spine fractures

Answer 336

1 in 10,000 per year 10% associated with a neurological injury

Question 337

Clinically clearing a patient of neck trauma

Answer 337

Question 338

Jefferson's fracture

Answer 338

C1 burst fracture Mechanism is axial loading Atlantodental distance predicts integrity of transverse ligament ADI <3mm in adults and <5mm in children If transverse ligament intact then hard collar If transverse ligament torn then halo

Question 339

Hangman fractures

Answer 339

Levine and Edwards

Question 340

Odontoid peg fractures with highest rate of non-union

Answer 340

Anderson and D'Lonzo type 2 fractures 25% of non-union Treat with anterior odontoid peg screws

Question 341

Unilateral versus bilateral cervical facet joint dislocation

Answer 341

Flexion with distraction in road traffic accidents Unilateral jumped facet is a rotational injury Intact cord function but nerve root compression Manage via closed reduction with cervical traction followed by halo X ray shows 25% anterior subluxation Bilateral jumped facet is not rotational. High energy trauma Spinal cord is injured X ray shows 50+% anterior subluxation Manage via 360 fusion

Question 342

Clay shoveler fracture

Answer 342

Avulsion fracture of the spinous process of C spine Most commonly C7

Question 343

Tear drop fracture

Answer 343

Fracture of anterior inferior vertebral body Can miss an unstable injury MRI may show ligamentous disruption

Question 344

Lateral mass screw insertion

Answer 344

Aiming laterally avoids the vertebral artery Aiming cranially avoids the nerve root Magerl's technique 20 degrees laterally and 25 degrees cranially

Question 345

Thoracolumbar fractures

Answer 345

AO classification B1 = chance fracture B3 = common in ankylosing spondylitis A1 = osteoporotic fracture

Question 346

Define the spinal level in trauma

Answer 346

Sensory: Lowest level with intact tactile sensation to pin prick Motor: Lowest level with power at least 3/5 Neurological: Most cephald of the motor and sensory levels

Question 347

Acute systemic complications of traumatic spinal cord injury

Answer 347

Neurogenic shock: Peripheral vasodilation and bradycardia due to loss of sympathetic tone. Hypotension worsens cord perfusion and ischemia - Arterial line and inotropes Respiratory dysfunction and hospital acquired pneumonia: Aim MAP > 90mmHg Ileus causes abdominal distension which can splint the diaphragm - NG tube and IV fluids. Neurogenic bowl - Bowel regime to empty contents In spinal shock the bladder becomes atonic there can overfly leading to vesiculoureteric reflux and infection - insert a urethral catheter Pressure sores can be life threatening. Muscle catabolism, muscle atrophy and loss of nitrogen - nutritional management

Question 348

Chronic systemic complications of spinal cord injury

Answer 348

Autonomic dysreflexia: Headaches, blurry vision, skin flushing about spinal level. Hypertension and bradycardia after stimulus such as bladder being full. If untreated can cause myocardial infarction, brain haemorrhage and death Venous thromboembolism Heterotopic ossification: Bone forms in soft tissues, adjacent to joints. Limits range of movement and rehabilitation. NSAIDs. Can be resected. Neurogenic bladder - small volume with high tone. Suprapubic catheter with urine bypassing. Detrusor external sphincter dyssynergy. Intravesicular botulin injection. Supra pubic catheter avoids genital ulceration and infection Spasticity. Baclofen. Contracture release surgery

Question 349

Pelvic incidence

Answer 349

PI = Pelvic tilt + sacral slope Used to estimate sagittal balance Sagittal imbalance predicts poor outcome after spinal fusion

Question 350

Assessing sagittal balance

Answer 350

Sagittal vertical axis: Draw a plumb line from the middle of C7 to S1 This should line up with the posteriosuperior edge of the sacrum

Question 351

Aberrant internal carotid artery

Answer 351

Congenital agenesis of the cervical segment of ICA Inferior tympanic artery from ascending pharyngeal artery to the middle ear then to the petrous ICA via carototympanic artery Associated with a persistent stapedial artery Presented with tinnitus

Question 352

5-ala mechanism in glioblastoma

Answer 352

Selectively fluoresces cancer cells as their mitochondria convert 5-ALA into protoporphyrin IX

Question 353

Evidence for prenatal closure of myelomeningocele

Answer 353

MOMS trial Adzick. NEJM. 2011 n = 158 VP shunt in prenatal repair group = 40% versus 82% in postnatal repair Preterm group associated with higher prematurity and wound dehiscence at delivery

Question 354

Pressure volume index

Answer 354

Change in volume required to cause a 10x increase in ICP PVI = 25ml in teenagers but on 8ml in infants

Question 355

Grading of IVH in prematurity

Answer 355

Question 356

ETV success score

Answer 356

Kulkarni JNS 2009 n = 618 overall success rate 64% ETV failure = death related to hydrocephalus or subsequent definitive CSF diversion within 6 months.

Question 357

Chater’s point

Answer 357

6cm above external auditory meatus = posterior limit of sylvian fissur

Question 358

Batson's plexus

Answer 358

valveless veins from intra abdominal compartment to the spine

Question 359

Anton Babinski syndrome

Answer 359

Blind Lack insight - anosognisia Confabulation Bilateral occipital lobe infarction

Question 360

Collier’s sign

Answer 360

Upper eye lid retraction

Question 361

Parkinson triangle

Answer 361

Between trochlear and opthalmic nerve - entry into cavernous sinus

Question 362

Jugular foramen syndromes

Answer 362

Question 363

American society of anaesthesiologists grading

Answer 363

Question 364

Explain the triphasic response following pituitary surgery

Answer 364

1) Diabetes indipidous due to posterior pituitary or infundibulum damage leading to reduced ADH secretion 2) hyponatraemia due to release of ADH from dead cells 3) diabetes insipidous due to depletion of stored ADH

Question 365

Circulating blood volume by age

Answer 365

Premature infant 90-100ml/kg Full term neonate 80-90ml/kg Infant > 1 month 70-80ml/kg Child 70ml/kg

Question 366

Number of ossification centres for cervical vertebrae

Answer 366

c1 and C3-C7 = 3 C2 = 5

Question 367

Hyperintense on T1

Answer 367

Fat Melanin Intracellular methamglobin - subacute blood

Question 368

Resonances for different MR spectroscopy peaks

Answer 368

Lipid = 1 Lactate = 1.3 N-acetylaspartate = 2 Creatinine = 3 Choline = 3.2

Question 369

Imaging for bone metastases

Answer 369

Technetium-99 radioisotope scan Accumulates in areas of osteoblast activity

Question 370

Arachnoid cysts

Answer 370

Incidence 5 in 1,000 Male: female 4:1 50% involve sylvian fissure Usually asymptomatic but can cause seizures or headaches, suprasellar cysts can cause hypopituitarism

Question 371

Answer 371

Broad big toe seen in Pfeffer syndrome

Question 372

Answer 372

Syndatyly Seen in aperts syndrome

Question 373

Dandy walker malformation

Answer 373

Cerebellar vermis agenesis Cystic dilation of 4th ventricular Inversion of the torcular-lambdoid

Question 374

Congenital hydrocephalus

Answer 374

70% aqueductal stenosis X linked recessive gene

Question 375

Answer 375

Holoprosencephaly Congenital defect Lack of separation of 2 hemispheres Normally occurs at 5th week gestation Lobar Semilobar Alobar

Question 376

Difference between schizenceohaly and porencephalic cyst

Answer 376

Schizencephaly is a congenital defect, cyst lined with grey matter Porencephalic cyst is acquired brain injury during neonatal period, cyst lined with white matter

Question 377

Spina Bifida with meningocele or myelomeningocele incidence

Answer 377

1 in 1,000 births Hydrocephalus up to 80% of cases Latex allergy in up to 75% Low lying conus up to 70%, most not symptomatic of tethered cord syndrome Post op dermoid up to 15% Ambulatory 50% Urinary incontinence 10% most patients remain dry with CIC Club foot 50%, more frequent with higher level Spina Bifida

Question 378

Tethered cord and scoliosis

Answer 378

If scoliosis mild < 10 degrees then 70% improved neurological and remainder stabilize following untethering If scoliosis severe > 50 degrees then patients risk neurological deterioration, 15%

Question 379

Hemivertebrae

Answer 379

Question 380

Differentiate severe hydrocephalus from hydranencephaly

Answer 380

EEG: hydranencephaly shows no cortical abnormality whereas severe hydrocephalus has abnormal EEG Imaging: severe hydrocephalus has thin layer of brain. In hydranencephaly there may be normal posterior fossa Angiography: hydranencephaly has no flow through carotids with normal posterior circulation.

Question 381

Holoprosencephaly associated with chromosomal abnormalities

Answer 381

Trisomy 13

Question 382

Ponticulus posticus

Answer 382

Calcification of atlantoccipital ligaments forms a boney ridge overlying the vertebral artery

Question 383

Difference between thoracic vertebrae

Answer 383

T1 resembles a cervical vertebrae and 1st rib articulates with single articular facet T2-T9 heart shaped and have superior, inferior articular processes for the ribs and transverse process has an articular process for rib T11 and T12 do not have costrotransverse articulations

Question 384

Answer 384

physaliphorous cells - bubbly cytoplasm Seen in chordoma Malignant

Question 385

Osteoid osteoma versus osteosarcoma

Answer 385

Osteoma is benign whereas osteosarcoma is malignant Osteoma located in lumbar posterior elements whereas osteosarcoma in the sacrum Osteoma is well circumscribed hypodense with sclerotic border whereas osteosarcoma is lytic

Question 386

Surgery in metastatic spinal disease evidence

Answer 386

Patchell. Lancet. 2005 Randomised to radiotherapy alone versus radiotherapy and early surgery n = 101 Trial stopped early More patients in surgical group were ambulatory 84% versus 57% and were ambulatory for longer 122 versus 13 days Steroid and opioid requirements also less in surgery group

Question 387

Answer 387

Scheuermann’s kyphosis is a kyphotic deformity of > 45° in the thoracic spine with > 5° of anterior wedging across three consecutive vertebrae, and is the commonest cause of thoracic back pain in children and adolescents.

Question 388

Answer 388

Ulegyria Prenatal hypoxia Vulnerable area between MCA and PCA territory parasagittal

Question 389

Answer 389

Ash leaf patch seen in Tuberous Sclerosis

Question 390

Answer 390

Facial Angiofibromas seen in Tuberous Sclerosis

Question 391

Mutations in Tuberous Sclerosis

Answer 391

Tuberous Sclerosis Complex 1 on Chromosome 9 and TCS 2 on Chromosome 16

Question 392

Answer 392

Shagreen patch seen in Tuberous Sclerosis

Question 393

Answer 393

Collagenomas Multiple endocrine neoplasia 1 Pituitary adenoma - Prolactinoma Hyperparathyroidism Pancreatic carcinoma

Question 394

Medulloblastoma 4 subtypes

Answer 394

Wingless 10% - Very good prognosis, rarely metastasises Sonic Hedgehog 30% - infants good prognosis Group 3 25% - Poor prognosis, frequently metastasises Group 4 35% - intermediate prognosis

Question 395

Chromosomes for Gorlin, Turcot, Cowden, MEN-1

Answer 395

Gorlin syndrome (Multiple BCCs) Chromosome 9 - Medulloblastoma Turcot syndrome (colorectal polyposis) Chromosome 5 - Medulloblastoma and Glioblastoma Cowden (Multiple hamartomas) Chromosome 10 - Lhermitte Duclos MEN 1 (Prolactinoma, hyperparathyroidism, pancreatic cancer) Chromosome 11

Question 396

Answer 396

Flexner-Wintersteiner rosettes seen in retinoblastoma True rosettes - columnar cells surrounding an empty lumen with cytoplasmic projections within

Question 397

Answer 397

Homer- Wright pseudorosettes Cells surrounding neuropil Seen in olfactory neuroblastoma and medulloblastoma

Question 398

4 types of rosettes in histology

Answer 398

Homer-Wright pseudorosettes: Cells surrounding neuropil - olfactory neuroblastoma and medulloblastoma Flexner-Wintersteiner rossettes: Cells surrounding empty lumen with cytoplasmic projections - Seen in Retinoblastoma and olfactory neuroblastoma True rosettes: cells surrounding empty lumen - Seen in ependymoma Perivascular pseudorosettes: cells surrounding blood vessel - seen in ependymoma and medulloblastoma

Question 399

Koos grading

Answer 399

1 Intracanalicular acoustic 2 Extends out of internal acoustic meatus but does not contact the brainstem 3 Fills cerebellarpontine angle but no mass effect on brainstem 4 Mass effect on the brainstem and cranial nerves

Question 400

Answer 400

Pars venosa - sigmoid sinus, X, XI Pars nervosa- IX

Question 401

Bones of orbit

Answer 401

Question 402

Calcar Avis

Answer 402

Prominence seen intraventricularly - landmark for calcarine sulcus

Question 403

Lesion in middle frontal gyrus causes

Answer 403

Conjugate eye deviation towards ipsilateral side

Question 404

Internal capsule neurons

Answer 404

Corticobulbar tract in genu Corticospinal tract in posterior limb

Question 405

How many cortical layers in cerebrum versus cerebellum

Answer 405

6 versus 3

Question 406

Weber syndrome

Answer 406

3rd nerve palsy and contralateral hemiparesis secondary to medial midbrain infarct

Question 407

Millard-Gubler syndrome

Answer 407

Ipsilateral VI and VII palsy with contralateral hemiparesis due to infarct in ventrocaudal pons

Question 408

Mechanism of Botox

Answer 408

Inhibits release of acetylcholine from synapses

Question 409

Duret haemorrhage versus DAI

Answer 409

Duret - paramedian DAI - dorsolateral

Question 410

Primary and secondary brain vesicles

Answer 410

Question 411

Rosenthal fibres

Answer 411

Pilocytic astrocytoma

Question 412

Which movement is unaffected in one and a half syndrome

Answer 412

Contralateral abduction

Question 413

Diabetic versus aneurysmal 3rd nerve palsy

Answer 413

Parasympathetic fibres in the periphery of 3rd nerve, therefore an aneurysm will dilate the pupil. In diabetes the pupil will be normal

Question 414

A horizontal object appears slanted. Patient sat with head tilted

Answer 414

4th nerve palsy

Question 415

Area damaged in NPH causing urinary incontinence

Answer 415

Paracentral lobule

Question 416

Ptosis in Horners syndrome versus 3rd palsy

Answer 416

In horners syndrome the ptosis is partial and disappears on looking up

Question 417

Bell’s phenomenon

Answer 417

Eyeball rotates up and out on attempting to close the eye lid

Question 418

Keyhole

Answer 418

Above frontozygomatic suture

Question 419

Damage to which thalamic nuclei when opening the choroidal fissure

Answer 419

Dorsal medial nuclei

Question 420

What tumour arises from neuroectodermal remnant of rathkes pouch

Answer 420

craniopharyngioma

Question 421

Histological difference between chordoma and chondrosarcoma

Answer 421

Chordoma - keratin Chondrosarcoma - S100

Question 422

Which pineal tumour is most radiosensitive

Answer 422

Germinoma

Question 423

Collin's law

Answer 423

Tumour considered cured if it has not recurred in the duration equal to the patient's age + 9 months

Question 424

Receptor often expressed in meningiomas

Answer 424

Progesterone

Question 425

Most common primary skull lesion

Answer 425

Osteoma

Question 426

Difference between osteoid osteoma and osteoblastoma

Answer 426

Both benign, same thing Former <2cm Latter >2cm

Question 427

Dysplastic gangliocytoma of cerebellum

Answer 427

Lhermitte-Duclos Seen in cowden syndrome

Question 428

Chiasm location relative to pituitary infundibulum

Answer 428

Post fixed 10% Pre fixed 10% Immediately above 80%

Question 429

Answer 429

Subependymal grey matter heterotropia = more common than subcortical grey matter heterotropia Abnormal migration of neurons during development X linked recessive Causes epilepsy

Question 430

Answer 430

Subcortical grey matter heterotropia Abnormal migration of neurons during development Causes epilepsy

Question 431

Answer 431

Lissencephaly Smooth brain with absent sulci Incidence 1 in 11 million Abnormal neuronal migration Causes epilepsy and developmental delay

Question 432

18F Fluorodeoxyglucose PET in epilepsy

Answer 432

Can show an area of hypometabolism correlating to the epileptogenic focus

Question 433

Dorsal anterior cingulate cortex important for what aspect of pain

Answer 433

affective Attachment of the emotional association to pain

Question 434

Cumulative risk of re bleeding if an aneurysm left unsecured

Answer 434

20% at 2 weeks 30% at 4 weeks

Question 435

Toxoplasmosis medications

Answer 435

Pyrimethamine and sulfadiazine

Question 436

HouseBrackman Forehead movement

Answer 436

1 = normal 2 = reduced 3 = minimal 4-6 = none

Question 437

House Brackman Appearances at rest

Answer 437

1-4 = normal 5 = asymmetry at rest 6 = Complete loss of tone

Question 438

House Brackman Eye lid closure

Answer 438

1-3 = complete 4-5 = incomplete 6 = none

Question 439

MCA velocity in vasospasm

Answer 439

120-200cm/s = mild vasospasm >200cm/s = severe vasospasm

Question 440

Lindegard ratio

Answer 440

Ratio of velocity of MCA to ICA flow. >6 indicates severe vasospasm <3 is normal

Question 441

Horners syndrome with retro orbital pain

Answer 441

Carotid dissection

Question 442

Rendu-Osler-Weber syndrome

Answer 442

Hereditary telangelectasia Higher prevalence of AVM in brain and lung Recurrent epistaxis Telangectasia on lips, tongue, conjunctiva

Question 443

Answer 443

Sturge-Weber syndrome Subcortical calcification Tram-track sign calvarial thickening

Question 444

Sturge Weber syndrome

Answer 444

Congenital Port wine stain in V1 Epilepsy refractory to medical management Associated with glaucoma Is not inherited, it's due to a developmental mutation during pregnancy on GNAQ -Chromosome 9

Question 445

Most common cutaneous lesion in Tuberous Sclerosis

Answer 445

Ash leaf macule

Question 446

4 normal embryological arteries

Answer 446

Trigeminal Otic Hypoglossal Proatlantic

Question 447

Hunt and Hess grade 3

Answer 447

Question 448

Hunt and Hess grade 2

Answer 448

Question 449

Proportion Engel Class 1, 5 years after temporal lobectomy

Answer 449

70% 1 = Seizure free 2 = Disabling seizures rare 3 = some improvement 4 = no improvement

Question 450

Answer 450

C1C2 transarticular screw facet of C2 -> Pars of C2 -> lateral mass of C1 Contraindicated in 30% due to position of vertebral artery

Question 451

SSEP TC MEP Pedicle stimulation

Answer 451

Somatosensory evoked potential: Stimulate tibial nerve, assess dorsal column function Transcranial motor evoked potential: Stimulate scalp over motor cortex, assess corticospinal tract Pedicle stimulation: If nerve stimulated at less than 8mA then pedicle breeched

Question 452

Answer 452

Anterior longitudinal ligament Anterior atlanto-occipital and anterior atlanto-axial membranes Apical ligament = tip of dens to foramen magnum Transverse ligament = dens to foramen magnum and lateral mass of C1 Tectorial membrane = continuation of posterior longitudinal ligament to clivus Alar ligaments = Dens to occipital condyles

Question 453

Odontoid peg fracture classification

Answer 453

Anderson and D'Lonzo

Question 454

Occipital condyle fracture causing a syndrome involving cranial nerves

Answer 454

Collet-Sicard Hypoglossal and jugular foramen nerves IX, X, XI, XII

Question 455

Symptom triad in autonomic dysreflexia

Answer 455

Hyperhydrosis Cutaneous vasodilation Headache

Question 456

Fortin’s sign

Answer 456

Tenderness of sacroiliac joint

Question 457

Answer 457

Copper beating Chronic hydrocephalus

Question 458

Answer 458

Blake’s pouch cyst Non perforation of foramen magendie 4th ventricular choroid plexus seen in the cyst

Question 459

Answer 459

Cobblestone cortex in lissencephaly type 2

Question 460

Type 1 versus type 2 lysencephaly

Answer 460

Type 1 = undermigration Type 2 = over migration

Question 461

Grisel’s syndrome

Answer 461

Spontaneous Atlantlo axial subluxation secondary to pharyngeal infection

Question 462

Chordoma is a remnant of what?

Answer 462

Notocord

Question 463

Spinal level of typical osteochondroma

Answer 463

C2

Question 464

Gestational age the anterior and posterior neuropores close

Answer 464

24 and 26

Question 465

Cervical spine abnormalities in Down's Syndrome

Answer 465

25% Atlanto-axial instability ADI > 5mm Only 1% symptomatic Also, Os Odontoideum

Question 466

Garnder's theory William's Oldfield's

Answer 466

Garnder's Hydronamic theory - pulsations created by systole force water down the obex William's theory - valsalva/ cough causes hydrodissection through spinal cord tissue. With a pressure gradient between intracranial and intraspinal Oldfield's cerebellar tonsils act as pistons, leading to high spinal subarachnoid space pressure, and CSF transmitting through virchow robins spaces

Question 467

Tinea Solium

Answer 467

Neurocysticerosis Eating undercooked infested pork Most common cause of paediatric epilepsy in endemic countries

Question 468

How many paediatric CT heads to cause 1 extra case of cancer

Answer 468

10,000

Question 469

Answer 469

Rotatory atlanto-axial subluxation Fielding and Hawkins

Question 470

Neonate versus adult CSF production

Answer 470

Neonate Total CSF volume 5ml Production 25ml/ day Adult Total CSF volume 150ml Production 450ml/ day

Question 471

Frontal horn/ internal diameter of skull

Answer 471

Evans ratio > 0.3 hydrocephalus

Question 472

Answer 472

Enlarged sylvian fissure with narrow convexity sulci

Question 473

Miller Fisher test

Answer 473

40ml CSF from lumbar puncture High positive predictive value Low sensitivity

Question 474

Answer 474

Knee of willebran - nasal fibres enter contralateral optic nerve before tract Lesion at the optic nerve adjacent to the chiasm

Question 475

Which structure gives rise to wave 5 in brainstem auditory evoked potentials

Answer 475

Inferior colliculus

Question 476

Calculate cerebral compliance

Answer 476

Change in volume/ change in pressure

Question 477

Febrile seizures

Answer 477

Prevalence 2-3% Age 6 months to 5 years old 1% risk of developing epilepsy

Question 478

Motor innervation of posterior cord (axillary and radial)

Answer 478

Question 479

Motor innervation of ulnar and median nerves

Answer 479

Question 480

Martin Gruber anastamosis

Answer 480

Connection between median and ulnar nerves in the forearm

Question 481

Nerve conduction finding in carpal tunnel syndrome

Answer 481

Sensory latency > 3.7 milliseconds

Question 482

Answer 482

Wallerian degeneration Antegrade degeneration of axons and myelin sheath following proximal axon or cell body damage

Question 483

Answer 483

Lesion in the medial longitudinal fasciculus

Question 484

Gene mutations in Tuberous Sclerosis

Answer 484

Tumour suppressor genes TSC1 on chromosome 9 TCS2 on chromosome 16

Question 485

Incidence of tuberous sclerosis and Von Hippel Lindau syndrome

Answer 485

1 in 6,000 births 1 in 35,000 births

Question 486

Difference between essential criteria for oligodendroglioma and astrocytoma

Answer 486

Both: diffusely infiltrating tumour Both: IDH mutation Astrocytoma: ATRX mutation Oligodendroglioma: whole arm deletions of 1p and 19q

Question 487

Essential diagnostic criteria for glioblastoma

Answer 487

Difusely infiltrating astrocytoma glioma IDH wild type Microvascular proliferation or necrosis or TERT mutation or EGFR amplification

Question 488

Most common lobe location for glioblastoma

Answer 488

Temporal (31%) Parietal (24%) Frontal (23%) Occipital (16%)

Question 489

Answer 489

Diffuse midline glioma H3 K27M-altered

Question 490

Answer 490

Rosenthal fibres seen in Pilocytic astrocytoma

Question 491

SPORT Trial

Answer 491

Weinstein JAMA 2006 n = 501 Lumbar radicular pain > 6 weeks Oswestry Disability index similar between non-operative and surgical groups at 2 years follow up However, at 2 years 60% of operative group and 45% had undergone surgery

Question 492

Maternal diabetes is a risk factor for which congenital spinal abnormality

Answer 492

Sacral agenesis

Question 493

Answer 493

Lundberg A waves seen in raised ICP

Question 494

4 molecular and 4 histological subtypes of medulloblastoma

Answer 494

Wingless activated Sonic Hedhehog activated Group 3 Group 4 Classic Nodular/ desmoplastic Extensive nodularity Large cell/ anaplastic

Question 495

4 molecular and 4 histological subtypes of medulloblastoma

Answer 495

Question 496

Post operative staging for medulloblastoma

Answer 496

Question 497

Most common pineal tumour

Answer 497

Germinoma

Question 498

Types of craniopharyngioma

Answer 498

Adamantinomatous versus pappillary Addemantinomatous is more common and occurs in children Papillary occurs in adults 40-60 Adamantinomatous forms cysts whereas papillary is solid Adamantinomatous has keratin and calcifications whereas papillary does not

Question 499

Clinical outcomes for AVM treatment as per grade

Answer 499