Applied Neurosciences

Question 1

What tests may be used to assess the Frontal lobe?

Answer 1

Similarities:
- Assesses correct categorisation not just similarities between parts

Lexical fluency:
- Category fluency i.e. items bought in a store or animals
- Alphabet fluency i.e. starting with certain letter
- Speed and switching between object set

Cognitive estimates test:
- Uses abstract knowledge

Trial making test:
- Simple type A i.e. 1 - 2 - 3 - 4
- Complex type B i.e. 1 - A
- Good frontal lobe test but as executive however not specific also attention, visuospatial

Luria sequence test:
- Fist - edge - palm
- Requires motor planning, execution and error correction

Others include:
- Alternate pyramids, squares drawing and proverb interpretation
- Frontal release sign and digit span affect too

Question 2

What are the tests of parietal function?

Answer 2

Copying shapes
- Ability to draw or copy a shape (esp. non-dominant parietal)

Identifying fingers:
- Dominant parietal function - Gerstmann syndrome
- May identify finger with eyes closed or copy examiners hand shape i.e. interlocking fingers

Calculation ability:
- Dominant parietal lobe dysfunction included in Gerstmann syndrome
- Ability to use numbers or copy is inact however arithmetic ability is only dominant parietal lobe

Graphesia:
- Ability to recognise what number is scratched onto someones skin without seeing
- Bilateral parietal lobe funciton

Right left disorientation:
- Dominant parietal lobe dysfunction

Stereognosis:
- Ability to recognise an object without seeing
- Bilateral function due to somatosensory cortices

Two point discrimination:
- Bilateral parietal lobe function due to somatosensory cortices

Visual inattention:
- Hemineglect - feature of parietal lesions
- Letter or star cancellation task, bisection line task or draw a tree/person

Question 3

How may frontal lobe lesions present?

Answer 3

Unilateral:
- Contralateral spastic hemiplegia
- Slight elevation of mood, increased talkativeness, tendency to joke inappropriately
- Primitive reflexes e.g. suck and grasp
- Anosmia
- Motor speech disorder with agraphia with or without oro-buccal apraxia

Bilateral:
- Bilateral hemiplegia
- Abulia (loss of drive)
- Spastic bulbar palsy
- Decomposition of gait and sphincter incompetence
- Varying combinations of grasping, sucking, utlisation movements

There are specific frontal syndromes too: pseudo depressive illness, dysexecutive and pseudeopsychopathic

Question 4

What is a gelastic seizure?

Answer 4

Epileptic seizure of left prefrontal cortex that results in uncontrollable laughing

Question 5

Describe some presentations linked to unilateral and bilateral parietal lobe lesions?

Answer 5

Unilateral:
- Contralateral mild hemiparesis
- Gerstmann’s syndrome (dominant): finger agnosia, right-left disorientation, dyscalculia, dysgraphia)
- Neglect of other side
- Homonomous hemianopia or inferior quadrantopia
- Corticosensory syndrome or sensory extinction

Bilateral:
- Spatial disorientation
- Ideomotor and ideational apraxia (more common with left)
- Anosognosia, dressing and contructional apraxia (more frequent and severe with non-dominant right)
- Tactile agnosia (more common with left)
- Balint syndrome (optic ataxia, oculomotor apraxia, and simultagnosia)

Question 6

Temporal lobe lesions can present with…

Answer 6

Unilateral:
- Homonymous upper quandrantopia
- Some degree of amusia and/or visual agnosia
- Dysnomia
- Reduced verbal memory
- Wernicke’s aphasia

Bilateral:
- Auditory, visual, olfactory hallucinations
- Disturbances of time perception
- Dreamy states with uncinate seizures
- Korsakoff amesiac defect
- Apathy and
- Hypermetamorphosia (compulsion to attend to all visual stimuli), also hyperorality, hypersexuality and blunted emotional reactivity (Kluver Bucy syndrome)

Question 7

What is Geschwind syndrome?

Answer 7

Personality change sometimes observed in TLE - may arise from altered white matter tracts

Signs include hypergraphia, hyperreligosity, hyposexuality, circumstantiality and interpersonal viscosity

Question 8

Name some auras associated with TLE:

Answer 8

Autonomic sensations
- Hypersalivation, gustaroy sensations

Evocation of thought:
- Intrusion of stereotypes words or thoughts

Forced thinking:
- Individual thinking to a certain topic

Psychic seizures

Disturbed perception of time:
- Deja Vu

Panoramic memory:
- Recall of expansive memories in detail +++

Uncinate crisis:
- Taste and smell hallucinations with a lot of detail and reminiscent of the past with altered consciousness

Transient dysphasia:
- L hemisphere in origin

Strong affective experiences:
- Fear or anxiety

Dostoveksys epilepsy:
- Ecastatic sensations in epilepsy

Question 9

What may unilateral occipital lesions present with?

Answer 9

Contralateral homonomyous hemianopia (central or peripheral)

Homonomymous hemiachromatopsia

Elementary hallucinations (lights colours and indiscrete objects)

Visual object agnosia

Visual hallucinations

If corpus callosum or splenum affected - alexia and a colour naming defect

Question 10

How may bilateral occipital lobe lesions present?

Answer 10

Cortical blindness (reactive pupil)

Anton syndrome (visual anosognosia and denial of cortical blindness)

Loss of colour perception achromatopsia

Prosopagnosia

Simultanagnosia

Balint syndrome

Question 11

In Vascular dementia if there is loss of cognitive functioning does a patient retain insight?

Answer 11

Usually

Question 12

Which orientation is first to go in Delirium?

Answer 12

Time

Question 13

Poor performance in the Hayling tests indicates?

Answer 13

Inhibition defects

The hayling test an examiner reads out a sentance leaving the last word blank:
- In part 1 subjects finish the sentance
- In part 2 subjects have to say a word unrelated to the sentance

Question 14

What is alexia without agrahpia?

Answer 14

Impaired ability to read however can still write their own thoughts, understand other speech and speak clearly

Normally affects dominant occipital lobe (left) and posterior corpus callousum (splenium) - subjects may also have right homonymous hemianopia

Question 15

Name some findings associated with lesions in the following areas:

a) Medial frontal circuit and ACC

b) Dorsolateral prefrontal circuit

c) Orbitofrontal and ventromedial circuit

Answer 15

a) Disruptions in motivation and willful behaviour
Apathy
Abulia
Akinetic mutism

b) Disturbed executive planning (planning, goal directed behaviour and attention)
Perseverative behaviour
Deficits in academic and general intellectual functioning

c) Acquired psychopathy and deficits in social intelligence
Frustration and anger
Disturbances in social functioning, behavioural regulation

Question 16

What visual symptom is seen in conversion disorder?

Answer 16

Tunnel vision

Question 17

What is a semantic paraphrasia?

Answer 17

A paraphasia is a substitution

• Semantic means category/meaning therefore may use a different type of fruit
• Phonetic will be the sound “fort” rather than “fork”

Question 18

What is Ribots law?

Answer 18

That in retrograde amnesia newest memories are first to go, remote memories are the most resistant

Question 19

What test may be used to differentiate organic coma from a psychogenic one?

Answer 19

Caloric testing - injection of cold water into the external auditory canal

Here normal response is for quick phase nystagmus away from injected site - present in psychogenic coma

In organic coma may get tonic deviation of eyes towards the site injected OR no movement at al

Question 20

What is a vegetative state?

Answer 20

Unconscious dissociative state of wakefulness without awareness

Eyes open spontaneously
EEG shows sleep-wake cycles
May have stereotyped gestures independent of normal context (yawn, smiling etc.)
If wakefulness this indicates brainstem is working
If lack of awareness indicates cortical dysfunction

Question 21

What is Broca’s aphasia?

Answer 21

Non-fluent speech and poor repetition but good comprehension (damage to frontal area BA 44 - left inferior frontal convolution)

Question 22

Where in the brain does the defect for Gerstmann’s syndrome arise from?

Answer 22

Dominant (left) angular gyrus

Question 23

What is an Argyll-Robertson pupil?

Answer 23

Defect of pupil such that it does not react to light but constricts when looking at closely held objects (accomodation)

Irregular, small and asymmetric in size

Historically from syphillis but also diabetic neuropathy and cataracts surgery

Question 24

What are neglect syndromes?

Answer 24

Failure to detect visual or tactile stimuli or move limb in contralateral side of body:
- most commonly result from right sided parietal lesions

Question 25

What is Wallenberg syndrome and its underlying pathology?

Answer 25

Occlusion of posterior inferior cerebellar artery (a branch of the vertebral artery) - causes infarction in the lateral portion of the medulla: - Dysarthria - damage of ipsilateral palate (CN nerve IX to XI damage) - Contralateral anaesthesia of body from ascending spinothalamic tract - Ipsilateral facial numbness (damage of CN V nucleus) - Horners syndrome (ptosis, meiosis, anhidrosis) - Ataxia (inferior cerebellar peduncle damage) - Vestibulocochlear nerve damage - ipsilateral ataxia and nystagmus

Question 26

Poor score in the seashore musical test could indicate damage to which area of the brain?

Answer 26

Right temporal lobe Seashore musical test is where individuals have to say if non-verbal sounds are the same (S) or different (D)

Question 27

Which domain of the WAIS test is used to cognitive design with aging?

Answer 27

Block design

Question 28

The most common IQ test used in clinical practice is the Wechsler Adult Intelligence scale - what two categories of tests exist and given examples of each?

Answer 28

Verbal: - Similarities NH - Arithmetic - Digit span NH - Vocabulary H - Information H - Comprehension Performance: - Picture arrangement - Block design NH - Picture completion H - Digit symbol NH - Matric reasoning H - held i.e. should not decline with age - these tests may detect organic illness i.e. dementia NH - non-held tests i.e these tests decline with age

Question 29

Outline some tests of set-shifting ability (part of executive functioning)?

Answer 29

Trail making test B Wisconsin Card Sorting Test Hayling test - sentence completion Brixton Task

Question 30

What does the stroop test assess and which part of the brain is associated with this neuropsychological function?

Answer 30

Response inhibition - frontal lobe

Question 31

What is the Raven's progressive matrix?

Answer 31

Test if IQ independent of education and cultural influences - uses visuospatial problem-solving tasks to assess performance IQ

Question 32

What is the national adult reading test?

Answer 32

Tests previous word knowledge before becoming ill (reading ability seems to be resistant to brain damage) therefore NART may be a good measure for premorbid IQ

Question 33

What is the Weschler Memory Scale-Revised?

Answer 33

A memory test battery for adults that produces a memory quotient - this is corrected for age and approximates the WAIS IQ. For memory decline there may be a low MQ but preserved IQ WMS-R consists of: - Verbal paired associated - Paragraph retention - Visual memory for designs - Orientation - Digit span - Rote recall of alphabet - Counting backwards

Question 34

Name a short term visual memory test?

Answer 34

The benton visual retention test: - A geometric figure is presented for 10 seconds after which the patient attempts to draw the figure from memory

Question 35

What is the bender visual motor gestalt test?

Answer 35

A test of visuomotor coordination useful for children and adults

Question 36

What two domains make up consciousness and describe the brain regions responsible for each?

Answer 36

Wakefulness (arousal) - achieved via Ascending Reticular Activating System (network that connects brainstem, thalamic nuclei, basal forebrain, hypothalamus and areas of the cortex). Here thalamocortical connections produce rhythmical neuronal activity. ARAS via thalami nuclei synchronises the oscillation. How in synch they are correlates to degree of wakefulness Attention - maintenance of which is achieved by right frontal love

Question 37

What is stupor?

Answer 37

State of decreased consciousness - appears asleep but when vigorously stimulated may become alert with eye opening and ocular movement Caloric testing is used to distinguish between coma stupor and psychiatric. In psychiatric horizontal nystagmus but tonic deviation/no eye movement in true coma

Question 38

What condition may present with akinetic mutism pre death?

Answer 38

CJD Akinetic mutism - sleep/wake cycle with eye opening but patient immobile, reduced vocalisation and generally eye closure. No spasticity or rigidity.

Question 39

How does akinetic mutism differ from vegetative state?

Answer 39

Akinetic mutism: - No spasticity or rigidity - Damage to anterior cingulate Vegetative state: - Spasticity or rigidity - Occurs from only ARAS and thalamus acting without higher cortex due to severe damage At the start the two are in distinguishable

Question 40

What is locked in syndrome?

Answer 40

There is total paralysis below CN III but intact consciouness, Patients can only open eyes, elevate and depress. Caused by : - Vental pons - Pontine tumour - Pontine haemorrhage - Central pontine myelinolysis - Head injury - Brain stem encephalitis

Question 41

Outline some tests of attention

Answer 41

Serial 7s - often incorrectly performed. by elderly Reverse-order month of the year - good measure of sustained attention Spell WORLD backwards Digit span - generally 7 (+/- 2 with age or intellectual ability), 5 may be normal for old people. Reverse digit span generally 1 less than forward.

Question 42

What tests may there be reduced digit span?

Answer 42

Delirium, focal left frontal damage, aphasia, moderate-severe dementia Preseved in MTL damage or amnesiac syndromes e.g. Korsakoff's syndrome

Question 43

What would disorientation to one's own name indicate?

Answer 43

Psychogenic amnesia

Question 44

What is reduplicative paramnesia?

Answer 44

Belief that ones surroundings have been duplicated - they have been moved Commonly seen in delirium

Question 45

What brain region is responsible for executive control?

Answer 45

DLPFC using frontal-subcortical connections

Question 46

How does impulsivity arise

Answer 46

Impulsivity is a failure of response inhibition - often associated with inferior frontal lobe pathology

Question 47

What is executive functioning and name some associated cognitive tasks?

Answer 47

Initiation, sequencing, coordination, error detection error correction, set shifting and termination Associated with other frontal lobe functions e.g. abstract reasoning, problem solving, impulse control and judgement

Question 48

What are the "where" and "what" streams of visual information?

Answer 48

"where" stream - dorsal - links visual information with spatial info and orientation through the parietal lobe "what" stream - ventral - links visual information with semantic information through the temporal lobe

Question 49

Where in the brain does a lesion affect to cause neglect of left side personal or extrapersonal space?

Answer 49

Right parietal or prefrontal areas - Left sided visuospatial function comes from right hemiphere - Right sided visuospatial function has bilateral neural correlates

Question 50

Name some tests of dressing apraxia or constructional ataxias?

Answer 50

Dressing - put on a piece of clothing that is turned inside out Constructional - copy a wire cube, interlocking pentagon or clock fae

Question 51

Classify different types of memory:

Answer 51

Explicit (declarative): - Episodic - time-locked personal (hippocampus-diencephalic) memory loss can be anterograde or retrograde - Semantic - general knowledge of words Implicit: - Procedural skills Working memory - function of few seconds of memory depends upon andexecutive system (attention, DLPFC), visuospatial sketchpad (R hemisphere) and phonological loop (L hemisphere) Memory can be immediate (seconds), recent (minutes - days), remote (months years)

Question 52

What parts of the brain are associated with the following memory functions a) Verbal declarative (episodic memory) b) Non-verbal declarative memory c) Navigational memory d) Semantic memory e) Procedural memory f) New learning generally g) Emotional aspects to memory

Answer 52

a) Left hippocampus - verbal episodic b) Right hippocampus - non-verbal episodic c) Navigational - orientation and animal place code maps are both hippocampus d) Semantic memory - anterior temporal lobe e) Procedural memory - striatum, cerebellum, amygdala and neocortex (motor cortex) associated with procedural memory. In Parkinson's there may in tact declarative but poor procedural due to nigrostrial degeneration f) Diencephalic structures - dorsal medial nucleus of thalamus and mamillary bodies g) Amygdala

Question 53

In transient global amnesia how do patients present?

Answer 53

Pronounced anterograde amnesia Variable retrograde amnesia

Question 54

How does semantic dementia present?

Answer 54

Loss of vocabulary - use of "thing" etc when speaking Loss of comprehension - The anomia in semantic dementia is progressive - Associated with atrophy of the left temporal lobe

Question 55

Dissociative amnesia presents as?

Answer 55

Retrograde episodic amnesia of minutes to years that presents from minutes to years Memories were fully formed but now unavailable Memories are usually stressful or traumatic

Question 56

What is the function of Broca's and Wernicke's area

Answer 56

Wernicke's area (temporal lobe) is responsible for comprehension (together with higher association cortices) - sound is transmitted from the ears Broca's area is the higher motor area of language production (signals are transmitted from here to the lips and teeth) Arcuate fasciculus connects both

Question 57

What areas of the brain are responsible for fluency?

Answer 57

Fluency - Broca's area Comprehension - Wernicke's Repetition - Broca's, Wernicke's and Arcuate Fasciculus but not higher association areas

Question 58

How does fluency, repetition, comprehension and naming alter with a) Broca's motor aphasia b) Wernicke's aphasia (also termed Jargon Aphasia) c) Conduction aphasia d) Transcortical sensory aphasia e) Transcortical motor aphasia

Answer 58

a) Broca's - not fluent, can't repeat, can comprehend, can't name. Speech is telegraphic and agrammatical function words (conjunctions, propositions are lost) b) Wernicke's - fluent, can't repeat, cannot comprehend, can't name. Speech is fluent but highly paraphasia, circumlocutions and neologisms. c) Transcortical sensory aphasia - fluency and repetition intact, but comprehension and naming lost d) Transcortical motor aphasia - fluency lost, repetition and comprehension intact, naming lost

Question 59

What is pure word deafness?

Answer 59

Can speak, write and read fluently but comprehension is impaired for spoken language only - bilateral damage to superior temporal pole (or left sided with damage to non-dominant circuit impaired)

Question 60

What is pure word blindness?

Answer 60

Alexia with no agraphia: - Speak normally and write on own or to dictation but unable to read (can't comprehend when reading) - Damage to Left Posterior Cerebral Artery with damage to poster corpus callosum (splenium) and left visual cortex

Question 61

What is pure word dumbness?

Answer 61

Can't speak but can understand language, read & write

Question 62

What is isolated limb apraxia indicative of?

Answer 62

Corticobasal degeneration

Question 63

Outline the brain regions affected in the following different types of apraxia's a) Constructional b) Ideational c) Ideomotor d) Limb kinetic e) Buccofacial

Answer 63

a) Constructional - R cerebral hemisphere often parietal lobe (non-dominant) b) Ideational (unable to follow a correct sequence of actions) - L parietoccipital or L parietotemporal regions c) Ideomotor - inability to do goal-directed behaviour that have previously been learned e.g. using a hairbrush - they don't know what to do with it - usually L hemisphere (frontal/parietal and association areas). Unilateral lesions in R handed patients produce bilateral deficits R>L d) Limb kinetic - dominant frontoparietal or primary motor cortex. Inability to make fine motor actions e) Buccofacial - inability to carry out mouth or lip movements normally accompanies broca's aphasia. Lesions of left inferior frontal lobe and the insula.

Question 64

Where is the fusiform gyrus located?

Answer 64

Bilateral or right sided lesions of the occipital-temporal junction Occassionally can happen in L sided lesions in L handed subjects

Question 65

What is a) Visual object agnosia b) Apperceptive visual agnosia c) Associative visual agnosia

Answer 65

a) Unable to identify the object despite in tact perception b) Unable to identify the object by looking but can do if description read aloud or by touch (in tact semantic knowledge) - bilateral occipoto-temporal lesions c) The semantic knowledge of the lesion is affected due to anterior temporal lobe lesions

Question 66

What is... a) Achromatopsia b) Colour agnosia c) Colour anomia

Answer 66

a) Inability to discriminate between colours and is commonly associated with pure alexia - medial occipotemporal dysfunction (left PCA lesion) b) Inability to retrieve colour information from semantic memory --> left occipito-temporal damage c) Can't name a colour --> disconnection between language structures of temporal lobe and visual cortex

Question 67

What is acalculia?

Answer 67

Inability to read, write and comprehend numbers. Acalculia differs from anarithmetrica which is the inability to perform simple equations. Can test acalculia but given numbers via dictation to be copy, read aloud do calculation and explain answer

Question 68

If I say to you Simultagnosia Optic ataxia Oculumotor apraxia What is the disease and where in the brain is it affected?

Answer 68

Balint syndrome Bilateral pariteooccipital dysfunction - damage to "where" stream linking spacial and visual cortices Caused by infarction, carbon monoxide poisoning or dementia

Question 69

Cortically blind but deny a problem (anosognosia) what is the disease?

Answer 69

Anton's syndrome - bilateral occipital damage

Question 70

Name some causes of impaired sense of smell?

Answer 70

Early stage Parkinson's or Alzheimer's If unilateral suspect meningioma Head injury Olfactory fibres are the only not to have thalamic relay

Question 71

Where in the optic pathway is the defect causing: a) Unilateral one eye blindness b) Bitemporal hemianopia c) Homonomous hemianopia d) Superior quadrantopia e) Inferior quadrantopia f) Cortical blindness

Answer 71

a) Eye itself - retina or macula b) Optic chiasma c) Any retrochiasmatic structure (optic tract, lateral geniculate body or optic radiation) d) Temporal lobe - Meyer's loop e) Parietal lobe f) Occipital lobe

Question 72

Which nerve is responsible for the pupillary light reflex?

Answer 72

CN III Afferent fibres from optic nerve to Edinger Westphal nuclei (via pretectal nuclei) then efferent fibres to ciliary muscles

Question 73

Name two important pupils that show near-light dissociation (i.e. the converge but pupil does not constrict)

Answer 73

Argyll robertson pupil Holmes Adie pupil (peripheral pupillary defect producing a tonic pupil)

Question 74

How do the cranial nerves exit the skull?

Answer 74

I - Cribiform plate II - Orbital Canal III - Superior Orbital Fissure IV - Superior Orbital Fissure V - V1 SOF V - V2 Foramen Rotundum V - V3 - Foramen Ovale VI - SOF VII - Internal auditory meatus VIII - Internal auditory meatus IX - Jugular foramen X - Jugular foramen XI - Jugular foramen XII - Hypoglossal canal

Question 75

Outline the function of the cranial nerves

Answer 75

I - smell II - sight III - innervation to medial recti, inferior recti and inferior oblique - pupil constriction - eye lid opening - accommodation IV - innervation to superior oblique V - sensation to face - mastication - corneal reflex (afferent) - jaw jerk (afferent and efferent) VI - innervation of lateral rectus VII - taste to anterior 2/3 tongue - muscles of facial expression - lacrimation - salivation - corneal reflex (efferent) VIII - balance hearing IX - salivation - swallowing (pharyngeal musculture) - mediates input to carotid and sinus - passes through CN IX to nucleus solitarus an area important for neural control of BP - gag reflex (afferent) - taste to posterior 1/3 tongue X - phonation - innervation to viscera (smooth muscles of GI tract (upper and tracheobronchal tree) - gag reflex (efferent) - swallowing XI - innervation to accessory muscles XII - tongue movements

Question 76

What does a lesion of each cranial nerve result in?

Answer 76

III - ptosis, down and out pupil, fixed and dilated IV - vertical diplopia - due to defective downward gaze V - trigeminal neuralgia, paralysis of muscles of mastication, loss of sensation to face (ipsilateral), deviation of jaw to weak side VI - horizontal diplopia VII - loss taste, flaccid paralysis of muscle of face, hyperacusis, loss of corneal reflex VIII - Hearing loss, nystagmus, vertigo IX - hypersensitive carotid sinus or loss of gag reflex X - loss of gag reflex, deviation of uvula away from affected side XI - weakness of shoulders and neck XII - tongue deviates towards side of lesion

Question 77

Where do the cranial nerves originate from?

Answer 77

CN I Telencephalon CN II - Diencephalon CN III - IV: Midbrain CN V - VIII: Pons CN IX - XII: Medulla

Question 78

What are some other causes of horizontal homonymous diplopia other than CN VI lesion?

Answer 78

Raised ICP

Question 79

What does bell's palsy result from?

Answer 79

A lower motor neurone lesion to CN VII (ipsilateral facial paralysis and inability to close eye) A UMN lesion to CN VII only sensation to the bottom half of the face is lost and patient can close eye

Question 80

What is the nucleus ambiguous?

Answer 80

The cranial nerve nucleus of CN IX and X often indistinguishable in anatomical position

Question 81

What pathophysiological action leads to coma?

Answer 81

Brain contusion Can occur beneath injury (coup) or contralateral (contrecoup) Contrecoup is most common in orbitofrontal and temporal regions - bilateral temporal injury may cause behaviour dyscontrol syndrome from contrecoup

Question 82

What is DAI

Answer 82

Diffuse axonal injury - can happen to neurons after trauma

Question 83

Where may a head injury occur to cause personality changes?

Answer 83

Orbitofrontal cortex or temporal lobes

Question 84

What is post concussion syndrome?

Answer 84

headache; dizziness; insomnia; irritability; emotional lability; increased sensitivity to noise, light, etc.; fatigue; poor concentration; anxiety; and depression.