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Exam Revision


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Premature suture closure:
Coronal/lamboid one side only



basion->bregma nasion->opsthcarnion eurion->eurion small 81 normal
Wormian bones

small thin bones that appear as a result of rapid exapnsion of the neck

Motor Neuron Disease (aetiology and cellular pathology)

Motor neuron disease is loss of muscle mass as a result of degeneration of lateral spinal tracts and scar tissue formation.
Aetiology proposed to be oxidative stress +/- exitotoxicity (SOD1 genes + other genes)
Cellular pathology - neurofilaments (otherwise normal protein) accumulate in spheroids and within cell bodies, and are selective to motor neurons.

Huntington's Disease (aetiology and cellular pathology)
Huntington's disease is an autosomal dominant trinucleotide repeat disorder
Aetiology - repeat expansion of CAG in the Huntingtin gene on Chr 14. Repeats of CAG over 40 times will result in HD developing. There is a high change if between 36-39 repeats.
Cellular pathology: degeneration of neurons in the frontal cortex and caudate nucleus

Huntington's disease clinical features

Chorea (characteristic dancing movement)
Cognitive changes (dementia, abnormal behaviour, personality changes, psychotic features)
Facial expression, standing and sitting, speech, chewing, swallowing.

Clinical Features ALS
Early signs - weakness of arms legs and bulbar muscles
Next combination of UMN and LMN signs
Eventually respiratory decline

Spinocerebellar ataxias (aetiology, cellular pathology and clinical features)

Aetiology - expansion CAG repeats, 30 different genes, mostly autosomal dominant
Pathology - pregressive degeneration cerebellum and spinal cord
Clinical features - decreased co-ordination of gait + others

Friedreich's Ataxia (aetiology, cellular pathology, clinical features)
Most common form of inherited ataxias
Aetiology - autosomal recessive, abnormal increase in GAA repeats (>100) in an intron of the Frataxin gene on Chr 9.
Pathology - degeneration and atrophy of spinal tracts and myelinated peripheral motor nerves
Clinica features - loss co-ordination, speech, vision, impaired senses, scloiosis, foot deformities, cardiac defects.

Main pathological process of dementia
Selective neuronal vulnerability + abnormal filamentous deposits (different names depending on which type)
Common pathological features brain and spinal cord trauma
Contusions, compression (spinal cord, haematoma), frank tissue destruction (lacerations, axonal injury, neuron degeneration)
Causes of degeneration of the retina

Macular degeneration
Hypertensive retinopathy
Diabetic retinopathy f

Define Multiple sclerosis
Inflammatory/degenerative disorder of the CNS - presents a relapsing remitting dysfunction of any part of the CNS (includes spinal cord, optic neuritis)
Hereditary causes of neuropathy
Charcot-Marie Tooth (HMSN)
Herditary sensory and autonomic neuropathy (HSAN)
Motor neuropathies

Diabetic Neuropathies (types)
Symmetrical - polyneuropathy, autonomic neuropathy, painful distal neuropathy and weight loss, insulin/hypoglycaemic/DKA etc.
Asymmetrical - neuropathic pain, mononeuropathies, cranial
role of thyroid hormones in metabolism
o increase metabolism of all cells,enhance action of other hormones
o lead to whole body effects
o essential for cell differentiation,growth and metabolism
o crucial for development and maturation of CNS

What is hypothyroidism
hormone deficiency -> due to iodine deficiency or autoimmune destruction of thyroid gland

What is Hyperthyroidism
hormone excess eg. graves disease is diffuse toxic goitre antibodies mimic TSH to overproduce thyroid hormones
Characteristic symptoms bacterial meningitis

Fever, headache, meningismus, altered mental status +/- neck stiffness, Kernigs/Brudzinski's sign
Symptoms viral meningitis
non-specific constitutional symptoms (diarrhoea, fever, vomiting, anorexia, rash, myalgia - severe in meningococcal)
Sequelae meningitis
Cranial nerve palsies
Cerebral infarction (inflammatory occlusion basal arteries)
Cerebral Abscess
Obstructive hydrocephalus: either blocking drainage (external) or problem with ventricles (internal)
Subdural effusion of sterile or infected fluid
Seizures (cortical inflammation)

What differentiates viral from bacterial meningitis in CSF?
Viral less white blood cells, mononuclear cell type, normal glucose
Bacterial more white blood cells, neutrophil cell type, very high protein, low glucose
Pathogenesis bacterial meningitis
colonisation of mucosal surfaces (nasopharynx) -> haematogenous/contagious spread -> bacterial invasion of meninges -> replication within subarachnoid space -> inflammatory response
Features of meningococcal disease (Neisseria meningitidis)
Short incubation, spread via respiratory secretions.
Ix - gram stain from pustule, PCR
Treatment penicillin + dexamethasone (+ceftriaxone, vancomycin)
Notifiable, prophylaxis to contacts
Vaccine - C conjugate (long term protection), polysaccharide (more strains, shorter term protection i.e. travel, endemic)

Features Haemophilus Influenzae Meningitis
Young children
nasopharynx -> haemotogenous -> meninges

Strep pneumoniae meningitis features
sequelae pneumococcal infection
long term neurologic sequelae
penicillin/ceftriaxone 21 days
pneumococcal vaccination (polysaccharide adults, conjugate children)

Listeria meningitis features

food -> intestinal epithelium -> macrophages -> disseminates -> meninges, septicaemia, placenta
leads to PROM, or meningitis etc. after birth
usually mild in non-pregnant healthy people

Cryptococcal meningitis features
fungal infection
poor prognosis (esp. if raised ICP)
Antigen titre monitors response
Tx - IV amphotericin, flucytosine then 8 weeks fluconazole, then maintenance therapy

Eosinophilic meningitis features
Angiostrogylus, Gnathostoma
Worms migrate to brian/sometimes lungs and die there

Cerebral abscess clinical features and diagnosis
clinical - head, fever, focal neurological signs
diagnosis - MRI/CT (LP may be dangerous due to increased ICP); aspiration culture necessary for antibiotic therapy
Pathological process of clinical abscess (days)
Day 1-3: focal area inflammation and oedema
Day 4-9: expansion of cerebritis and development of necrotic central focus
Day 10-14: establishment of ring enhancing capsule of well vascularised tissue, early appearance of peripheral gliosis/fibrosis
Day 14+: well formed capsule develops

Cerebral abscess - risk factors for unfavourable diagnosis
Delayed Dx
Posterior fossa location
Multiple, deep, multiloculated lesions
Rupture into ventricles
Fungal aetiology

Cerebral Abcess treatment
Prolonged IV treatment 2-6 weeks and maybe also oral Ab 2-3 months
Consult ID physician
Depends on surgical outcomes and evidence of resolution

Toxoplasma gondii features
protozoan parasite
always suspect HIV
self limited in immunocompetent persons
diagnosis - parsites in specimens, PCR, serology

Nocardia features (cerebral abscess)
opportunistic infection, found in soil
Tx - trimethoprim + sulpamethoazole, imipenem
Mycobacteria Cerebral Abscess
epitheloid granuloma with caseous necrosis
Neurocyticercosis Cerebral Abscess Features
Caused by larvae stage of Taenia solium
One/many cerebral lesions
Associated with seizures

Epidural Abscess (spinal cord) clinical features, pathology, Dx, Tx
Clinical features: fever and severe local vertebral pain and tenderness -> distal paralysis
Pathology: osteomyelitis, disc infection (staph)
Dx - MRI
Tx - urgent surgery + antibiotics

VP Shunt Infection bacteria
staph -> gram negative -> strep -> diptherioids -> anaerobes
Encephalitis definition and causes
inflammation of parenchyma +/- meninges and spinal cord
Enterovirus most common (seasonal), HSV, adenovirus, measles, VZV, rubella, influenza
Encephalitis diagnosis
progressive headache, fever, alterations in cognitive state
Ix - MRI, lumbar puncture (rule out meningitis, HSV PCR), EEG, serology
HSV Encephalitis Pathogenesis
Children - exogenous acquired, enters CNS through olfactory bulb
Adults - reinfection with another strain or reactivation of latent HSV-1 in trigeminal/autonomic nerve roots (in CNS via nerves innervating middle cranial fossa)
Other CNS infections (not meningitis, abscess, VP shunt, encephalitis)
Crueutzfeldt-Jakob Disease - transmissible neurodegenerative disease
Trypanosoma cruzi (Chagas disease)
Cerebral malaria

Glia of central nervous system (cell and function)
Oligodendrocyte - produces myelin
Astrocyte - support, transports, recycling neurotransmitters, structural component BBB, injury (glial scar)
Microglia - phagocytosis
Ependymal cells - produce CSF

Glia of peripheral nervous system (cell and function)
Schwann cells - produce myelin, phagocytosis
Satellite cells - similar to astrocytes, regulate external chemical environment
Arteries of the thyroid gland (and origin)

Inferior thyroid artery - thyrocervical trunk (subclavian artery)
Superior thyroid artery - external carotid artery
Veins thyroid gland (and drain point)
Inferior thyroid vein - left subclavian, right brachiocephalic
middle and superior thyroid vein IJV
PSNS parotid salivary gland
inferior salivatory nucleus -> glossopharyngeal n -> otic ganglion -> auriculotemporal n
PSNS submandibular/sublingual salivary gland
superior salivatory nucleus -> facial n -> submandibular ganglion -> lingual n
Branches external carotid (from bottom to top)
Superior thyroid
Ascending pharyngeal
Posterior auricular
Superficial temporal

Subclavian artery branches
vertebral artery
internal thoracic
thyrocervcial trunk
costocervical trunk
dorsal scapular

arteries that supply the scalp
superficial temporal
posterior auricular
occipital artery

Cutanous nerves of anterolateral neck (branches cervical plexus)
Lesser auricular
greater auricular
transverse cervical nerve
supraclavicular nerve

Muscles of the floor of the posterior triangle (superior to inferior)
Splenius capitus, levator scapulae, posterior scalene, middle scalene, anterior scalene

inferior belly omohyoid crosses superficial to some of these

Anatomical relationships of phrenic nerve, cervical plexus, and proximal brachial plexus to the scalene muscles
Phrenic nerve - anterior to anterior scalene
Proximal brachial plexus is between anterior and middle scalenes
Which parts of the brachial plexus are located in the neck and axilla?
Neck - roots and trunks
Junction - divisions
Axilla - cords and branches

What does the anterior choroidal artery supply and what is it's origin?
Internal carotid/middle cerebral artery
Supplies choroid plexus, hippocampus, globus pallidus, internal capsule (susceptible to stroke)
Areas supplied by PCA (from basilar a)
occipital lobe (visual cortex, optic radiation)
inferior part of temporal lobe
parts of midbrain, thalamus
splenium of corpus callosum

Areas supplied by Middle cerebral artery
Broca's and Wernicke's areas left hemisphere
Auditory cortex
Motor and sensory face, trunk, upper limbs
Contributes to optic radiation

Areas supplied by anterior cerebral artery
olfactory bulb and tract
medial aspect of frontal and parietal lobes up to parietoccipital sulcus (motor and sensory for lower limbs)
small branches dorsal surface
all of corpus callosum (except splenium)

Where does CNV3 enter the infratemporal fossa (which foramen in the skull)
Foramen ovale
Which muscles do CNV3 supply?
muscles of mastication
anterior belly digastric
tensor tympani
tensor veli palatini

What are the cutaneous branches of CNV3?
Buccal (cheek)
Auriculotemporal (temple)
Lingual (tongue)
Inferior alveolar to teeth and chin

How does CNV2 enter cranial cavity?
Foramen rotunda
What are the suprahyoid muscles and what is their innervation?
Anterior belly digastric, mylohyoid - CNV3
Stylohyoid, posterior belly digastric - CNVII
Geniohyoid - C1 ventral ramus

What are the muscles that arise from the styloid process and what is their innervation?

Stylohyoid - CNVII
Stylopharyngeus - CNXII
Styloglossus - CNIX

Extrinsic muscles of the tongue and innervation
Genioglossus - CNXII
Hyoglossus- CNXII
Styloglossus - CNXII
Palatoglossus - pharyngeal branch CNX

How does glossopharyngeal nerve exit the skull and describe anatomical relationships
Via jugular foramen, lies across stylopharyngeus (between styloglossus and stylohyoid)
How does hypoglossal n exit the skull and describe anatomical relationships
via hypoglossal canal
passes deep to the posterior belly of digastric muscle
Cavernous sinus nerves, superior to inferior

Function of the aqueous humour
Nutrients to cornea and lens (avascular)
Describe sound transduction (through the cochlea)
sound impinges on typmanic membrane -> vibrates ossicles (malleus, incus and stapes) -> oval window which sets up fluid pressure waves in the perilymph -> distends oval window -> displaces vestibular, basilar membranes and displacing sterocilia in tectorial membrane
What is the spiral ganglion?
Contains primary sensory neurons that give rise to the cochlear nerve
What is - scala vestibuli and scala tympani?
Perilymph filled cochlear
Symptoms of primary hyperparathyroidism (parathyroid hyperplasia)
Stones - renal calculi, nephrocalcinosis
Bones - bone pain, fracture
Abdominal groans - ileus, pancreatitis, peptic ulcers
Psychic moans - fatigue, poor concentration, depression

Primary hyperparathyroidism cause
80-85% pituitary adenoma
Secretions of functional pituitary adenoma
GH, TSH, prolactin, FSH/LH, ACTH
Secreting functioning adrenal adenoma
glucocorticoids, oestrogen, testosterone, aldosterone
Types of neuroblastic tumours
Undifferentiated (no differentiation, haemorrhage and necrosis)
Differentiating (some differentiation eg. neuropil, calcification, haemorrhage and necrosis)
Ganglioneuroblastoma (immature ganglion cells, calcification, no haemorrhage or necrosis)
Ganglioneuroma (mature, no haemorrhage and necrosis)

Causes of cerebral infarct
Thrombosis - changes in blood composition, atheroma, vasculitis, arterial dissection, arterial vasospasm, external compression (causes proximal vessel to thrombosis)
Embolism - pulmonary vein, atrial, paradoxial, valvular disease, ventricular, carotid/aorta
Causes of cerebral haemorrhage
Coagulation disorders
Increased luminal pressure and vessel wall damage (hypertension, amyloidosis)
Mural weakening - vascular malformation etc.

What is a seizure?
What is epilepsy?
Abnormal and synchronised excess activity of a group of brain cells (positive phenonemon)
Epilepsy is a group of conditions defined by repeat seizures (similar characteristics)
Complex vs simple seizures
consciousness altered vs consciousness maintained
Epilepsy - clinical syndromes
Idiopathic generalised epilepsies (no structural abnormalities or other neurological signs)
symptomatic generalised epilepsies (structural abnormalities, developmental delays)
Focal epilepsies - look for focal brain abnormalities
Status epilepticus - over 5min no medical recovery

Management of seizures
Status epilepticus

Sodium valproate first line, don't use carbamazepine; phenytoin IV in emergencies
carbamazepine, surgical resection region
midazolam IV, phenytoin IV next, treat precipitant, establish cause

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