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Flashcards in INBR 7 - Multidicipline Self Assesment Examination Deck (300):
1

1.Ciri klinis penyakit BROWN-SEQUARD meliputi hal di bawah ini, KECUALI

A. Hilangnya rasa nyeri kontralateral dan sensasi suhu mulai satu atau dua segmen tulang di bawah lesi

B. Hilangnya propriosepsi secara ipsilateral dan sensasi getar di bawah level benjolan

C. Sindroma HORNER secara ipsilateral jika lesi di servical

D. Hilangnya sensasi peraba kasar secara ipsilateral di bawah level lesi

E. Hilangnya keringat secara ipsilateral di bawah level lesi

D. (DeMyer, p. 137; Greenberg, p. 700; Youmans, pp. 272, 439 7 , 4872) .

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2. Apa yang ditunjukkan pada fotomikrograf di bawah ini ?

A. Sel tegak (palisading) di sekeliling daerah nekrosis pada pasien dengan glioblastoma.

B. Perubahan spongiform pada pasien dengan penyakit prion

C. Homer-Wright Rossete pada laki-laki usia 3 tahun dengan Meduloblastoma

D. Infark akut pada pasien dengan epilepsi mioklonik dengan serat-serat merah yang rusak (MERRF)

E. Nekrosis fibrinoid pada pasien dengan Leukoensepalopati hemoragik akut.

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A.

Note the "picket fence" arrangement (pseudopalisading) of the nuclei surrounding a region of necrosis in this photomicrograph, which depicts a glioblastoma (Ellison, pp. 628-63 1).

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3. Uji laboratorium manakah yang paling peka bagi deteksi neuro-sistiserkosis (NCC)?

A. Hitung eosinopil periferal

B. hitung sel darah putih serum lengkap

C. Stool untuk ova dan parasit

D. Enzyme-linked immunosorbent assay (ELISA)

E. Electroimmunotrasfer blot (EITB)

E.

Complete white blood cell count, peripheral eosinophil level, and serum anticysticercal antibody levels should be obtained in all patients suspected of having NCC. Patients requiring ventriculostomy placement should have cerebrospinal fluid (CSF) analyzed for eosinophil and anticysticercal antibody levels. Stool testing for ova and parasites is helpful in patients with simultaneous intestinal tapeworm infection but is insensitive and nonspecific for T. solium species and is found in less than 33% of cases. Several laboratory methods have been developed to detect host antibodies against circulating cysticercal antigens. From the many tests performed, current data indicate that enzyme-linked immunosorbent assay (ELISA) and electroimmunotransfer blot (EITB) tests are the most effective. Studies comparing these diagnostic modalities have shown that the EITB assay is more sensitive overall than ELISA, especially when serum is being tested. Both techniques are more sensitive in cases with multiple cysts than in cases with solitary or confined lesions. Additionally, no global difference among cases was found with parasites located in different compartments (ventricles, subarachnoid space, parenchyma) of the central nervous system (Greenberg, pp. 236-238; Proano-Narvaez et a l . , p. 2 118).

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4. Degenerasi gabungan subakut dini

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E (DeMyer, p. 135; Brazis, pp. 85-95; Merritt, pp. 136-137 , 186, 7 10- 7 13 , 7 15-717) .

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5. Sringomielia

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F

(DeMyer, p. 135; Brazis, pp. 85-95; Merritt, pp. 136-137 , 186, 7 10- 7 13 , 7 15-717) .

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6

6. Tabes Dorsalis

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D

(DeMyer, p. 135; Brazis, pp. 85-95; Merritt, pp. 136-137 , 186, 7 10- 7 13 , 7 15-717) .

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7. Poliomielitis     

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A (DeMyer, p. 135; Brazis, pp. 85-95; Merritt, pp. 136-137 , 186, 7 10- 7 13 , 7 15-717) .

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8. Amiotropik lateral sklerosis

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C

(DeMyer, p. 135; Brazis, pp. 85-95; Merritt, pp. 136-137 , 186, 7 10- 7 13 , 7 15-717) .

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9. Paraplegia spastis familial

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B

(DeMyer, p. 135; Brazis, pp. 85-95; Merritt, pp. 136-137 , 186, 7 10- 7 13 , 7 15-717) .

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10. Tumor berikut manakah yang memiliki gambaran histopatologi sebagaimana lesi di bawah ini ?

1. Ependimoma sel bening

2. Neurositoma Central

3. Tumor Neuroepitelial disembrioplastis

4. Meningioma fibrous

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A.

The differential diagnosis of oligodendroglia! tumors includes clear cell ependymoma, central neurocytoma, and dysembryoplastic neuroepithelial tumor. All of these entities exhibit the presence of neoplastic cells with a uniform round nucleus and clear cytoplasm. A rare differential diagnosis of oligodendroglioma is clear cell meningioma (not fibrous meningioma), which can be differentiated from oligodendroglioma by abundant diastase-sensitive PAS positivity and immunoreactivity for El\1A. Note the prominent calcification, "chicken wire" capillaries (prominent branching) , "fried egg" cells with round monomorphic nuclei, and perinuclear halos arranged in a back-to-back fashion i n this photomicrograph depicting an oligodendroglioma (Ell ison, pp. 641-644; WHO, p . 59) .

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11. Lapisan dinding abdominal manakah yang paling baik dijahit (daya regang paling kuat) selama penempatan pirau ventrikuloperitoneal?

A. Colles fascia

B. Cruveilhier’s fascia

C. Buck’s fascia

D. Scarpa’s fascia

E. Camper’s fascia

D.

The anterior abdominal wall consists of the epidermis, superficial layer of superficial fascia (of Camper), the deep layer of superficial fascia (of Scarpa) , the deep fascia (investing fascia of musculature ) , the external and internal oblique muscles, the transverse abdominis muscle, transversalis fascia, loose extraperitoneal connective tissue, and peritoneum. Camper's fascia is predominately an adiposelayer that contains most of the fat of the subdermis. It continues over the pubis as the superficial layer (of Cruveilhier) of the superficial perineal fascia, crosses the inguinal ligament to merge with the superficial fascia of the thigh, and continues over the chest as the superficial layer of superficial thoracic fascia. Scarpa's fascia is a fibrous layer that will best hold sutures (highesttensile strength) . It continues over the • pubis as the deep layer of superficial perineal fascia (of Calles) and passes into the upper thigh, where it attaches to - the fascia lata. The deep fascia is the investing fascia of the musculature, aponeuroses, and large neurovascular struc- . tures and is not easily separated from the underlying epimysium of muscle. It extends into the penis as Buck's fascia, continues over the spermatic cord as the external spermatic fascia, and passes over the pubis and perineal musculature as the deep perineal fascia of Gallaudet (April , p. 173).

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12. Simaklah gambar berikut, apa Diagnosisnya

A. Filum lemak dengan tethered cord

B. Ependimoma Miksopapilaris

C. Saluran sinus dermal

D. Hematoma epidural

E. Tumor dermoid

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A.

Note the cord tethering and fatty filum on this sagittal MRI (Ramsey, pp. 104-106) .

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13. Manakah pernyataan yang benar mengenai lesi yang ditunjukkan pada angiogram di bawah ini ?

A. Risiko tahunan pendarahan adalah sekitar 3%

B. Berasosiasi dengan bruit kranial dan gagal jantung kongestif selama periode neonatal

C. Hilangnya gen penekan tumor pada kromosom 22

D. Lesi ini biasanya ditemukan pada parensima otak normal

E. Mencerminkan adanya varian anatomis ekstrim dari pasokan darah arteri kortikal

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D.

This angiogram depicts the classic "caput medusae" pattern of a venous angioma, which is an extreme anatomic variant of medullary (white matter) venous drainage. The precise etiology of this lesion remains unclear, although some authors have proposed that it results from arrested development of parts of the venous vasculature at a time when normal arterial development is nearly complete. This results in the retention of primitive venous channels that typically empty into a single large draining vein (Osborn, pp. 294-295) .

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14. Struktur manakah di bawah ini yang terhubung dengan stria medularis talamus ?

A. Nucleus basal dan nuklei septal

B. Nuklei septal dan nuklei habenular

C. Nuklei habenular dan korteks okipital

D. Nuklei septal dan nuklei talamik depan

E. Kelenjar pineal dan anterior commissure

B.

The stria medullaris thalami contains projections that originate in the septal nuclei, anterior thalamic nuclei, and hypothalamus (preoptic region) and terminate in the habenular nuclei. The habenular nuclei then project to the raphe nuclei of the midbrain via the fasciculus retroflexus. In this manner, the stria medullaris thalami act as a relay point for limbic system information that is transmitted to the midbrain (Carpenter, p. 252; Martin , p. 4 73).

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15. Sel retina manakah yang berperan mekanisme untuk mediator respons berlawanan dalam kelompok selsel fotoreseptor di sekitarnya, yang telah digunakan untuk menguatkan kontras antar obyek?

A. Sel Fleksiform

B. Amakrin

C. Sel-sel horisontal

D. Ganglion

E. Sel-sel bipolar

C.

Visual information flows vertically from photoreceptor cells (outer nuclear layer) to bipolar cells (inner nuclear layer) to ganglion cells (ganglion cell layer) as well as laterally via horizontal cells (outer plexiform layer) and amacrine cells (inner plexiform layer) . Light produces opposite effects on the rate of bipolar cell firing depending on whether it stimulates the center or surrounding part of the cell's receptive field . Additionally, a lateral network of horizontal cells that directly interconnect neighboring groups of photoreceptor cells helps mediate this antagonist property. Hence, horizontal cells pro,•ide a mechanism for mediating opposite responses in adjacent photoreceptor cells, which is used to enhance luminance contrast. The precise role of amacrine cells remains unclear, although some amacrine cells function like horizontal cells. They mediate antagonistic inputs between bipolar cells and ganglion cells in the inner plexiform layer. Other amacrine cells have been implicated in shaping the complex receptive field properties of various types of ganglion cells, such as M-type cells that process orientation information ( Pritchard , pp. 292-302; Kande l , p . 5 15).

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16. Defisit neurologi manakah yang disebabkan oleh rusaknya daerah EXNER?

A. Alexia

B. Aphasia

C. Agraphia

D. Anosmia

E. Apatis

C.

Exner's area lies superior to Broca's area, in Brodmann's area 8, and if damaged may result in pure agraphia without aphasia (Brazis, pp. 515- 516) .

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Jodohkanlah struktur-struktur di bawah ini dengan huruf jawaban yang tepat pada CT scan aksial di bawah ini dari tulang Temporal Petrosus kanan

17. Vestibula

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F

These three axial CT scans (Figures 8 . 1 7-8.24 Q a, b, c) illustrate critical portions of the petrous temporal bone and progress sequentially in a superior-inferior direction. In these figures, A represents the lateral semicircular canal, B the superior semicircular canal, C the internal auditory canal, D the vestibular aqueduct, E the posterior semicircular canal, F the vestibule, G the facial nerve, H the cochlea, and I the endolymphatic sac. Notice the labyrinthine and anterior tympanic portions of the facial nerve, separated by the geniculate ganglion, in figure B . Figure C depicts the horizontal segment of the facial nerve and the vestibular aqueduct joining the endolymphatic sac at the posterior aspect of the petrous temporal bone (Som, pp. 1319 - 1325) .

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Jodohkanlah struktur-struktur di bawah ini dengan huruf jawaban yang tepat pada CT scan aksial di bawah ini dari tulang Temporal Petrosus kanan

18. Koklea

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H

These three axial CT scans (Figures 8 . 1 7-8.24 Q a, b, c) illustrate critical portions of the petrous temporal bone and progress sequentially in a superior-inferior direction. In these figures, A represents the lateral semicircular canal, B the superior semicircular canal, C the internal auditory canal, D the vestibular aqueduct, E the posterior semicircular canal, F the vestibule, G the facial nerve, H the cochlea, and I the endolymphatic sac. Notice the labyrinthine and anterior tympanic portions of the facial nerve, separated by the geniculate ganglion, in figure B . Figure C depicts the horizontal segment of the facial nerve and the vestibular aqueduct joining the endolymphatic sac at the posterior aspect of the petrous temporal bone (Som, pp. 1319 - 1325) .

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Jodohkanlah struktur-struktur di bawah ini dengan huruf jawaban yang tepat pada CT scan aksial di bawah ini dari tulang Temporal Petrosus kanan

19. Kanalis semisirkularis posterior

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E

These three axial CT scans (Figures 8 . 1 7-8.24 Q a, b, c) illustrate critical portions of the petrous temporal bone and progress sequentially in a superior-inferior direction. In these figures, A represents the lateral semicircular canal, B the superior semicircular canal, C the internal auditory canal, D the vestibular aqueduct, E the posterior semicircular canal, F the vestibule, G the facial nerve, H the cochlea, and I the endolymphatic sac. Notice the labyrinthine and anterior tympanic portions of the facial nerve, separated by the geniculate ganglion, in figure B . Figure C depicts the horizontal segment of the facial nerve and the vestibular aqueduct joining the endolymphatic sac at the posterior aspect of the petrous temporal bone (Som, pp. 1319 - 1325) .

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Jodohkanlah struktur-struktur di bawah ini dengan huruf jawaban yang tepat pada CT scan aksial di bawah ini dari tulang Temporal Petrosus kanan

20. Kanalis semisirkularis lateral

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A

These three axial CT scans (Figures 8 . 1 7-8.24 Q a, b, c) illustrate critical portions of the petrous temporal bone and progress sequentially in a superior-inferior direction. In these figures, A represents the lateral semicircular canal, B the superior semicircular canal, C the internal auditory canal, D the vestibular aqueduct, E the posterior semicircular canal, F the vestibule, G the facial nerve, H the cochlea, and I the endolymphatic sac. Notice the labyrinthine and anterior tympanic portions of the facial nerve, separated by the geniculate ganglion, in figure B . Figure C depicts the horizontal segment of the facial nerve and the vestibular aqueduct joining the endolymphatic sac at the posterior aspect of the petrous temporal bone (Som, pp. 1319 - 1325) .

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Jodohkanlah struktur-struktur di bawah ini dengan huruf jawaban yang tepat pada CT scan aksial di bawah ini dari tulang Temporal Petrosus kanan

21. Akuaduk vestibular

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D

hese three axial CT scans (Figures 8 . 1 7-8.24 Q a, b, c) illustrate critical portions of the petrous temporal bone and progress sequentially in a superior-inferior direction. In these figures, A represents the lateral semicircular canal, B the superior semicircular canal, C the internal auditory canal, D the vestibular aqueduct, E the posterior semicircular canal, F the vestibule, G the facial nerve, H the cochlea, and I the endolymphatic sac. Notice the labyrinthine and anterior tympanic portions of the facial nerve, separated by the geniculate ganglion, in figure B . Figure C depicts the horizontal segment of the facial nerve and the vestibular aqueduct joining the endolymphatic sac at the posterior aspect of the petrous temporal bone (Som, pp. 1319 - 1325) .

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Jodohkanlah struktur-struktur di bawah ini dengan huruf jawaban yang tepat pada CT scan aksial di bawah ini dari tulang Temporal Petrosus kanan

22. Saraf Fasial

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G

These three axial CT scans (Figures 8 . 1 7-8.24 Q a, b, c) illustrate critical portions of the petrous temporal bone and progress sequentially in a superior-inferior direction. In these figures, A represents the lateral semicircular canal, B the superior semicircular canal, C the internal auditory canal, D the vestibular aqueduct, E the posterior semicircular canal, F the vestibule, G the facial nerve, H the cochlea, and I the endolymphatic sac. Notice the labyrinthine and anterior tympanic portions of the facial nerve, separated by the geniculate ganglion, in figure B . Figure C depicts the horizontal segment of the facial nerve and the vestibular aqueduct joining the endolymphatic sac at the posterior aspect of the petrous temporal bone (Som, pp. 1319 - 1325) .

23

Jodohkanlah struktur-struktur di bawah ini dengan huruf jawaban yang tepat pada CT scan aksial di bawah ini dari tulang Temporal Petrosus kanan

23. Kanalis semisirkularis superior

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B

These three axial CT scans (Figures 8 . 1 7-8.24 Q a, b, c) illustrate critical portions of the petrous temporal bone and progress sequentially in a superior-inferior direction. In these figures, A represents the lateral semicircular canal, B the superior semicircular canal, C the internal auditory canal, D the vestibular aqueduct, E the posterior semicircular canal, F the vestibule, G the facial nerve, H the cochlea, and I the endolymphatic sac. Notice the labyrinthine and anterior tympanic portions of the facial nerve, separated by the geniculate ganglion, in figure B . Figure C depicts the horizontal segment of the facial nerve and the vestibular aqueduct joining the endolymphatic sac at the posterior aspect of the petrous temporal bone (Som, pp. 1319 - 1325) .

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Jodohkanlah struktur-struktur di bawah ini dengan huruf jawaban yang tepat pada CT scan aksial di bawah ini dari tulang Temporal Petrosus kanan

24. Duktus endolimpatis

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I

These three axial CT scans (Figures 8 . 1 7-8.24 Q a, b, c) illustrate critical portions of the petrous temporal bone and progress sequentially in a superior-inferior direction. In these figures, A represents the lateral semicircular canal, B the superior semicircular canal, C the internal auditory canal, D the vestibular aqueduct, E the posterior semicircular canal, F the vestibule, G the facial nerve, H the cochlea, and I the endolymphatic sac. Notice the labyrinthine and anterior tympanic portions of the facial nerve, separated by the geniculate ganglion, in figure B . Figure C depicts the horizontal segment of the facial nerve and the vestibular aqueduct joining the endolymphatic sac at the posterior aspect of the petrous temporal bone (Som, pp. 1319 - 1325) .

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25. Katup manakah diantara di bawah ini yang merupakan katup pengatur aliran?

A. Katup Orbis-Sigma

B. Katup delta medical PS

C. Katup horisontal-vertikal kordis

D. Katup terprogram Goldman Hakim

E. Katup Holter-Haussner

A.

Some of the valves currently used in clinical practice include the static (Holter-Hausner valve, Denver shunt, Codman Uni-Shunt) and programmable (Codman Medos, Sophy valve) differential pressure valves, flow-regulated valves (Orbis Sigma), and gravity-actuated valves (Cordis horizontal-vertical valve). The PS Medical Delta valve consists of an antisiphoning device just distal to a differential pressure valve. More recently Codman has introduced the Hakim programmable valve with a Siphon-Guard valve, while Medtronic has introduced the Strata valve, a programmable valve with variable pressure settings that can be coupled with their Delta valve antisiphoning device. The valves described above all use different approaches to control flow through the valve system and limit overshunting. Differential pressure valves open when the pressure at the inlet is higher than that the outlet by a preselected amount. Programmable differential pressure valves act in a similar fashion except that the surgeon can change the opening pressure with an external device, which often obviates the need for surgical shunt revision. Flow-regulated valves use a three-stage resistance mechanism to keep the flow rate through the valve constant. Gravity-actuated valves attempt to decrease siphoning by increasing opening pressure with the assistance of gravity when a patient sits or stands. Cordis horizontal-vertical valves are gravity-actuated valves that have traditionally been used with lumboperitoneal shunts (Youmans, pp. 33 76-3379; Albright, pp. 79-80; Wi lkins, pp. 3647-3651; American Society of Pediatric Neu rosurgeons, p p . 506-508; Committee on Education i n Neurological Surgery, pp. 137-138) .

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26. Simaklah di bawah ini. Apa Diagnosisnya?

A. Porensepali

B. Displasia kortikal

C. Skizensepali bibir terbuka (open lip)

D. Kiste araknoid

E. Skizensepali bibir terbuka

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C

The process of celltilar migration typically occurs between the second and fifth gestational months . Faulty cellular migration can result in heterotopias, callosal agenesis, lissencephaly, pachygyria/polymicrog\Tia, and openor closed-lip schizencephaly. Note the prominent cleft (open-lip) that is lined entirely by gray matter on this sagittal MRI. Porencephalic clefts are predominately lined by gliotic white matter (Osborne DN, pp. 5 2 - 55 ) .

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27. Kelainan ini diyakini disebabkan oleh gangguan tahap embriologis yang mana?

A. Neurulasi primer

B. Neurulasi sekunder

C. Disjungsi

D. Migrasi sel

E. Mielinasi

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D

The process of celltilar migration typically occurs between the second and fifth gestational months . Faulty cellular migration can result in heterotopias, callosal agenesis, lissencephaly, pachygyria/polymicrog\Tia, and openor closed-lip schizencephaly. Note the prominent cleft (open-lip) that is lined entirely by gray matter on this sagittal MRI. Porencephalic clefts are predominately lined by gliotic white matter (Osborne DN, pp. 5 2 - 55 ) .

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28. Semua hal di bawah ini berasal dari sebuah prekursor yang sama, KECUALI

A. ACTH

B. Hormon perangsang melanosit

C. Lipotropin Beta

D. Endorpin Beta

E. Leusin-enkepalin

E.

Proopiomelanocortin (PO.MC) gives rise to betalipotropin and ACTH. The sequences of beta-endorphin and melanocyte-stimulating hormone are contained in beta-lipotropin ( Kandel, p. 487).

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29. Ny. X, 62 tahun menjalani reseksi transpenoidal tanpa komplikasi atas makroadronema pituitaris dan sedang mengalami pemulihan di UPI. Pasca-bedah, dia merasa semakin merasa haus, mual, output urine naik (>300 ml/3 jam), hipernatremia (149 mEq/L) dan osmolaritas serum sebesar 323 mEq/L. Pada titik ini, perawatan optimal untuk pasien ini seharusnya mencakup…

A. Fludrokortison asetat

B. Urea

C. Desmopressin astetat (DDAVP) oral

D. Vasopresin arginin (aqueous Pitressin) secara intravena

E. Pitressin pada minyak tonik dari suspensi secara intramuscular

D.

This patient has developed diabetes insipidus (DI). Criteria frequently used to make the diagnosis include: urine osmolarity 50 to 150 mOsm/L, specific gravity 1.001 to 1 .005, urine output :2 250 to 300 cc/hr for 3 consecutive hours, and progressively increasing Na• levels on serial lab draws. This patient should receive aqueous vasopressin (Pitressin) (IVP/IM/SQ), as the lipid-soluble form is poorly absorbed compared to the aqueous form. This patient would likely not tolerate oral DDA VP due to her nausea, and a n asogastric tube is generally contraindicated after a transsphenoidal operation. Fludrocortisone acetate acts directly on the renal tubules to increase sodium absorption. This medication, along with urea, would be more applicable for patients with cerebral salt wasting or SIADH. Complications with fludrocortisone acetate include pulmonary edema, hypokalemia, and hypertension (Greenberg, p p . 20-23; Committee on Education i n Neurological Surgery, p . 99) .

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30. Apa yang ditunjukan pada EEG di bawah ini

A. Kejang-kejang absen

B. Left temporal lobe spike-and-wave discharge

C. Irama alpha

D. Irama tetap

E. K kompleks

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C.

This EEG depicts normal posterior dominant rhythm ("alpha rhythm") in a healthy adult man, maximal in the posterior head regions when the eyes are closed ( Rowa n , pp. 2 5 - 26).

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31. Ny. X, 54 tahun siuman setelah pembedahan kliping aneurisma arteri optalamik kanan elektif dengan mata kanan mengalami kebutaan total dan tanpa defisit neurologis lainnya. Angiogram serebral mengungkapkan menyatunya origin arteri optalamik ke dalam konstruksi klip. Temuan-temuan apa lagi yang kemungkinan ada pada angiogram tersebut?

A. Oklusi arteri karotid dalam kanan dengan menyamping ke belakang atau ke depan kolateral-kolateral komunikasi depan.

B. Vasospasma materi karotid dalam

C. Pengisian kolateral yang buruk pada globe kanan dari arteri maksilaris dan arteri fasial

D. Aliran kolateral arteri paringeal yang tidak cukup naik ke sebelah globe kanan

E. Jawaban A, B, C dan D semuanya benar

C.

A number of extracranial-to-intracranial anastomoses exist that may potentially provide collateral blood flow to the orbit and preserve vision after occlusion of the internal carotid or ophthalmic arteries. This collateral flow is mainly supplied by branches of the external carotid artery, including the internal maxillary (most important) and facial arteries, via their extensive ethmoid, ophthalmic, and cavernous carotid collaterals. Although this collateral filling is not always evident on angiography, this patient's angiogram is more likely to show poor collateral flow to the globe from the ma.'Cillary or facial arteries, considering her symptomatology. The ascending pharyngeal artery does not usually provide collateral blood supply to the globe, while vasospasm would be highly unlikely in this setting. There should be other accompanying neurologic deficits if there 1vas complete occlusion of the right internal carotid artery with inadequate collateral feeding of that hemisphere (Osborn D N , p. 397 ) .

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32. Tn. X, gemuk, 28 tahun dibawa dengan riwayat sakit kepala dan diplopia selama dua bulan terakhir. Ternyata pasien mengalami lesi sebagaimana yang ditunjukkan pada fotomikrograf di bawah ini. Langkah perawatan apakah yang selanjutnya perlu dilakukan setelah reseksi bedah atas benjolan ini?

A. Terapi radiasi seluruh kepala

B. Radiosurgeri

C. Kemoterapi

D. Observasi dan MRI serial

E. Radioterapi sinar proton

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D

One of the hallmarks of pilocytic astrocytomas is their relatively indolent growth rate with low mitotic acti\•ity . .Management typically includes gross total resection, if possible, followed by radiation therapy for recurrence. In some cases, invasion of the brainstem and/or cranial nervesprecludes gross total resection. Macroscopic features common to these tumors include the formation of a cyst with a solid mural nodule. Tumors without cyst wall enhancement are typically adequately treated with mural nodule excision alone, while tumors with a thickened, enhancing cyst wall are best managed with gross total excision. Microscopically, these tumors show a biphasic pattern consisting of bipolar, highly fibrillated (or piloid) cells with Rosenthal fibers and a loose-knit cystic component associated with granular bodies or protein droplets. The arrow depicts Rosenthal fibers, which are ubiquitin a

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Tn. X, gemuk, 28 tahun dibawa dengan riwayat sakit kepala dan diplopia selama dua bulan terakhir. Ternyata pasien mengalami lesi sebagaimana yang ditunjukkan pada fotomikrograf di bawah ini. Langkah perawatan apakah yang selanjutnya perlu dilakukan setelah reseksi bedah atas benjolan ini?

33. Apakah yang dijelaskan oleh tanda panah pada fotomikrograf tersebut?

A. Telangiestasia kapilaris

B. Gemitosit

C. Serat Rosenthal

D. Pembuluh darah normal

E. Granula melanin

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C

One of the hallmarks of pilocytic astrocytomas is their relatively indolent growth rate with low mitotic acti\•ity . .Management typically includes gross total resection, if possible, followed by radiation therapy for recurrence. In some cases, invasion of the brainstem and/or cranial nervesprecludes gross total resection. Macroscopic features common to these tumors include the formation of a cyst with a solid mural nodule. Tumors without cyst wall enhancement are typically adequately treated with mural nodule excision alone, while tumors with a thickened, enhancing cyst wall are best managed with gross total excision. Microscopically, these tumors show a biphasic pattern consisting of bipolar, highly fibrillated (or piloid) cells with Rosenthal fibers and a loose-knit cystic component associated with granular bodies or protein droplets. The arrow depicts Rosenthal fibers, which are ubiquitin a

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34. Seorang bayi mampu memindahkan benda dari tangan ke tangan, menopang berat badannya, mengangkat kepalanya dari meja sebelum ditarik, dan menolehkan kepalanya ke arah sumber suara. Berapa taksiran umur bayi ini?

A. 2 bulan

B. 4 bulan

C. 6 bulan

D. 8 bulan

E. 10 bulan

C.

A 6-month-old infant is able to transfer objects from hand to hand, support most of his weight, lift his head off the table prior to being pulled up, turn his head to voice, and reach for objects ( Rudolph, p. 15).

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35. Semua refleks di bawah ini pada umumnya akan menghilang pada umur 4 sampai dengan 6 bulan, KECUALI

A. Menghisap

B. Mengepalkan tangan

C. Leher menegak

D. Suspensi ventral (Landau)

E. Duduk/merayap

D.

The suck reflex can be elicited in infants below 4 months of age and consists of bursts of upward tongue pressure and buccinator contraction when the examiner places a clean finger or pacifier into the infants mouth. The tonic neck reflex (typically disappears by 6 months) involves turning the head of a supine infant to one side. The opposite arm should extend 90 degrees from the trunk and the opposite leg should extend downward ("fencing position"). Placing a finger in an infant's hand or under the toes can elicit the palmar grasp or plantar reflex, respectively. The palmar grasp reflex usually disappears by 6 months, while the plantar reflex is often present until 10 months of age . The stepping/ placing reflex is produced when the baby is held upright and the dorsal edge of the foot is allowed to brush against an object such as a bed or table. Infants less than 6 weeks of age should flex the knee and lift the foot. The ventral suspension (Landau) reflex results in extension of the head, trunk, and hips and knee flexion when an infant is supported on the examiner's hand in a prone position. This reflex does not usually disappear until the age of 2 years. The Moro reflex occurs when the baby is placed in the supine position and the examiner lifts the baby's head by placing his or her hand under it. Sudden release of the head a few centimeters toward the bed should elicit a complete Moro response in infants less than 3 to 4 months of age . It consists of abduction of the arms at the shoulder, extension of the forearms at the elbow, and extension of the fingers, followed by arm adduction at the shoulders. Additional reflexes include the crossed adductor (disappears by 7 months), parachute, and neck righting (disappears by 2 years) reflexes (Rudolph, p . 15).

36

36. Pemutusan bidang pandangan paling awal manakah yang dialami pasien dengan aneurisma arteri optalamik?

A. Kuadrantanopsia temporal bawah monokular

B. Kuadrantanopsia temporal atas monokular

C. Nasal kuadran anopsia superior monokular

D. Kuadrantanopsia nasal bawah binokular

E. Hemianopsia temporal binokular.

C

Extensive removal of the anterior clinoid process and optic strut (roof of the optic canal), as well as sectioning of the falciform ligament and distal dural ring is often required for successful clipping of large ophthalmic segment CHAPTER 8 Multidisciplinary Self-Assessment Answers 26.7 aneurysms. Attempts to clip large and giant paraclinoid/ ophthalmic artery aneurysms with broad necks without this degree of exposure may place the ophthalmic and internal carotid arteries in jeopardy of clip-induced stenosis/ocqh.Ision. Ophthalmic segment aneurysms typically arise beneath the lateral aspect of the optic nerve, which initially results in compression of temporal fibers and an ipsilateral monocular superior nasal quadrantanopsia. With aneurysmal enlargement, the optic nerve is deflected further medially and superiorly against the rigid falciform ligament, which causes superior fiber compression and a monocular inferior nasal field cut (Greenberg, p. 783; Wilkins, pp. 2291-2299; Samson, pp. 41- 53) .

37

37. Struktur manakah diantara struktur-struktur di bawah ini yang biasanya dilubangi atau disayat selama paparan bedah aneurisma arteri optalamik?

1. Ligamen falsiform

2. Cincin dural jauh

3. Prosesus klinoid anterior

4. Strut optik

E

Extensive removal of the anterior clinoid process and optic strut (roof of the optic canal), as well as sectioning of the falciform ligament and distal dural ring is often required for successful clipping of large ophthalmic segment CHAPTER 8 Multidisciplinary Self-Assessment Answers 26.7 aneurysms. Attempts to clip large and giant paraclinoid/ ophthalmic artery aneurysms with broad necks without this degree of exposure may place the ophthalmic and internal carotid arteries in jeopardy of clip-induced stenosis/ocqh.Ision. Ophthalmic segment aneurysms typically arise beneath the lateral aspect of the optic nerve, which initially results in compression of temporal fibers and an ipsilateral monocular superior nasal quadrantanopsia. With aneurysmal enlargement, the optic nerve is deflected further medially and superiorly against the rigid falciform ligament, which causes superior fiber compression and a monocular inferior nasal field cut (Greenberg, p. 783; Wilkins, pp. 2291-2299; Samson, pp. 41- 53) .

38

38. Tn X, tidak kidal, 42 tahun dibawa ke UGD dalam keadaan kejang. Hasil pemeriksaan CT dan MRI-nya menunjukkan adanya lesi frontal kanan batas tegas tapi dengan penyengatan yang heterogen dengan pengapuran pada beberapa bagian dan edema di sekelilingnya yang mengisyaratkan adanya Oligodendroglioma. Semua pernyataan mengenai tumor di bawah ini adalah benar, KECUALI

A. Protein asam fibrilaris glial polipeptida (GFAP) tidak diekspresikan oleh oligodendrosit.

B. Merupakan sekitar 5% dari semua neoplasma intra-kranial

C. Memastikan unsur oligodendrogial pada Potong Beku biasanya oleh penampilan “telur goreng” dari halo perinuklir-nya.

D. Semakin tinggi kadar anaplasia-nya,, maka akan semakin pendek umur ketahanan hidupnya

E. Ada suatu asosiasi kuat antara respons kepada kemoterapi PCV (prokarbazin, CCNU dan Vinkristin) dan hilangnya alelik pada 1p/19q dalam Oligodendroglioma anaplastik

C.

Identification of the oligodendroglia! component on permanent section is usually aided by the classic "fried egg" appearance of the perinuclear halo. This develops as a consequence of the fixation process; it is not evident on smear or frozen examination and may be absent in rapidly fixed tissue and in paraffin sections made from frozen material (Ellison , pp. 641-645; WHO, pp. 56-6 1) .

39

39. Diantara struktur-struktur di bawah ini, struktur manakah yang mengandung neuron ordo kedua dari saluran spinoserebelar?

A. Nukleus Clarke

B. Grasilis/kutanus nukleus

C. Nukleus kuneatus aksesoris

D. Olive bawah

E. Baik A dan C

E.

The spinocerebellar tracts convey unconscious proprioception from Golgi tendon organs, muscle spindles, and joint receptors in the periphery to the CNS. Dorsal spinocerebellar fibers (C8-L2) enter the medial aspect of the dorsal roots and synapse in the dorsal nucleus of Clarke. Second-order neurons in Clarke's nucleus then project to the vermis and paramedian lobule of the cerebellum via the inferior cerebellar peduncle, where they terminate as mossy fibers. Above the level of C8, Ia and lb afferents enter the fasciculus cuneatus and synapse in the accessory cuneate nucleus of the medulla (the equivalent of Clarke's nucleus of the spinal cord). Second-order neurons then enter the cerebellum (cuneocerebellar fibers) via the inferior cerebellar peduncle before synapsing in the cerebellum. The ventral spinocerebellar tract is a crossed tract that originates in Rexed laminae V to VII in the lower lumbar and coccygeal levels. This tract then decussates a second time in the pons before entering the cerebellum as mossy fibers via the superior cerebellar peduncle (Carpenter, pp. 90-94).

40

40. Di manakah representasi kortikal dari visi macular?

A. Kutub (poles) okcipital

B. Lemniskus Lateral

C. Jungsi temporoperieto-okipital

D. Prekuneus

E. Tepi atas dari calcarine salcus

A.

The cortical representation for macular retinal vision is located in the occipital poles. The primary visual cortex (area 1 7 ) is located along the upper and lower banks of the calcarine sulcus. Layer IV of the primary visual cortex is particularly prominent and is known as the "band of Gennari. " The occipital poles often receive collateral blood flow from the middle cerebral arteries, which is thought to account for macular sparing with field cuts that originate from cortical infarctions secondary to posterior cereb

41

42. Yn. X, 42 tahun menjalani prosedur neuroradiologis intervensional terapeutik. Apa yang ditunjukan oleh angiogram di bawah ini

A. Pecahnya aneurismal intra-prosedural

B. Perfusi arteri serebral tengah yang buruk

C. Arteri tentorial yang membesar dan memasok Malformasi arterial-Venus pontin lateral

D. Fistula arteri-vena dural

E. Fistula karotid-kavernus Tipe II

Q image thumb

C.

The superior olivary nuclei receive the ventral acoustic striae and contain third-order auditory neurons that subsequently project to the contralateral lateral lemniscus. The superior olives are the initial sites of binaural convergence within the auditory pathway ( Kandel, pp. 606-608) .

42

43. Apa yang ditunjukkan oleh EKG di bawah ini

A. Infarksi miokardial

B. Hiperkalemia

C. Torsades des pointes

D. Toksisitas digoksin

E. Atrial flutter

Q image thumb

A.

The angiogram depicts a right posterior carotid wall aneurysm as well as extravasation of contrast dye from the aneurysm in a patient about to be treated with GDC embolization (mi

43

Seorang laki-laki usia 16 tahun dengan hasil MRI sebagaimana ditunjukkan di bawah ini, dirujuk ke kantor anda. Hasil pemeriksaan laboratorium pasien mengungkapkan bahwa dia menderita hipotirodisme, kekurangan kortisol dan kadar prolaktin sebesar 69. Keluarganya mengatakan bahwa mereka mencatat adanya berbagai perubahan perilaku dan baru-baru ini mengalami kenaikan berat badan. Mata kirinya tidak bisa melihat dan lapang pandangan temporal mata kanannya terputus.

44. Diagnosis manakah yang paling mungkin?

A. Makroadenoma pituitaris

B. Tumor metastatis yang menyerang kelenjar pituitaris belakang

C. Kraniofaringioma

D. Sinusitis sphenoid

E. Mukosel invasif dari sinus sphenoid

Q image thumb

A .

Note the prominent ST-segment elevation i n leads V1 through V6 on this EGG, depicting an anterior wall myocardial infarction. In general, ST-segment and T-wave changes appear over the first minutes to hours of an infarction, and Q waves appear over hours to days. An evolving myocardial infarction may first manifest with peaked T waves followed by ST segment elevation and T-wave inversion. Eventually Q waves may appear. In a large anterior wall infarction, these changes are most apparent in leads V1 through V6, while in an inferior infarction, these changes often occur in leads II, III, and aVF. Of note, if a patient's T waves are chronically inverted, the peaking may make them appear normal-a process referred to as pseudonormalization. T waves are the least reliable of ST- and T-\\'ave segment abnormalities because many• noncardiac events may influence them (i.e., elevated W). Dying myocardial cells release their enzymes into the bloodstream, and the increased concentration should be confirmed in the peripheral _ blood ( Fishman, pp. 9 - 24; Marino, pp. 301-313 ) .

44

Seorang laki-laki usia 16 tahun dengan hasil MRI sebagaimana ditunjukkan di bawah ini, dirujuk ke kantor anda. Hasil pemeriksaan laboratorium pasien mengungkapkan bahwa dia menderita hipotirodisme, kekurangan kortisol dan kadar prolaktin sebesar 69. Keluarganya mengatakan bahwa mereka mencatat adanya berbagai perubahan perilaku dan baru-baru ini mengalami kenaikan berat badan. Mata kirinya tidak bisa melihat dan lapang pandangan temporal mata kanannya terputus.

45. Kadar prolaktinnya yang meningkat paling mungkin disebabkan oleh?

A. Efek Hook

B. Efek Stalk

C. Efek Avengaard

D. Sekresi tumor

E. Nodula paru-paru yang mengeluarkan prolaktin

Q image thumb

C

The clinical history and 1UU are most consistent with a cystic craniopharyngioma. The modestly elevated prolactin level is likely the result of the "stalk effect," whereby injury of the hypothalamus or pituitary stalk (i.e., from large tumors) results in modest ele,•ations of prolactin from reduced prolactin inhibitory factor levels (dopamine) . As a general rule, prolactin levels > 150 ng/mL are rarely secondary to a stalk effect, whereas le,•els

45

Seorang laki-laki usia 16 tahun dengan hasil MRI sebagaimana ditunjukkan di bawah ini, dirujuk ke kantor anda. Hasil pemeriksaan laboratorium pasien mengungkapkan bahwa dia menderita hipotirodisme, kekurangan kortisol dan kadar prolaktin sebesar 69. Keluarganya mengatakan bahwa mereka mencatat adanya berbagai perubahan perilaku dan baru-baru ini mengalami kenaikan berat badan. Mata kirinya tidak bisa melihat dan lapang pandangan temporal mata kanannya terputus. 46. Semua hal di bawah ini biasanya berasosiasi dengan sindroma BEHCET’S, KECUALI

A. Uveitis

B. Borok pada alat kelamin

C. Stomatis aptus

D. Artritis

E. Naiknya enzim pengubah angiotensin serum

B

The clinical history and 1UU are most consistent with a cystic craniopharyngioma. The modestly elevated prolactin level is likely the result of the "stalk effect," whereby injury of the hypothalamus or pituitary stalk (i.e., from large tumors) results in modest ele,•ations of prolactin from reduced prolactin inhibitory factor levels (dopamine) . As a general rule, prolactin levels > 150 ng/mL are rarely secondary to a stalk effect, whereas le,•els

46

46. Semua hal di bawah ini biasanya berasosiasi dengan sindroma BEHCET’S, KECUALI

A. Uveitis

B. Borok pada alat kelamin

C. Stomatis aptus

D. Artritis

E. Naiknya enzim pengubah angiotensin serum

E. Sarcoidosis, not Beh9et's syndrome, is associated with elevated levels of angiotensin-converting enzyme ( Merritt, pp. 12 1 - 122).

47

47. Fasilitasi pasca olah raga

A. Miastenia Gravis

B. Sindroma LAMBERT-EATON

C. Polimiositis

D. Sindroma saluran Carpal

E. miotonia

F. Bukan salah satu antara A s/d E

B ( Merritt, pp. 613, 7 1 1 , 723-724, 7 2 7-728, 766; Greenberg, pp. 72-75, 78-79) .

A image thumb
48

48. Respons motorik menurun 


A. Miastenia Gravis

B. Sindroma LAMBERT-EATON

C. Polimiositis

D. Sindroma saluran Carpal

E. miotonia

F. Bukan salah satu antara A s/d E

A

( Merritt, pp. 613, 7 1 1 , 723-724, 7 2 7-728, 766; Greenberg, pp. 72-75, 78-79) .

A image thumb
49

48. Respons motorik menurun 


A. Miastenia Gravis

B. Sindroma LAMBERT-EATON

C. Polimiositis

D. Sindroma saluran Carpal

E. miotonia

F. Bukan salah satu antara A s/d E

E

( Merritt, pp. 613, 7 1 1 , 723-724, 7 2 7-728, 766; Greenberg, pp. 72-75, 78-79) .

A image thumb
50

50. Unit motorik miopatis, fibrilasi, pseudomiotnis 


A. Miastenia Gravis

B. Sindroma LAMBERT-EATON

C. Polimiositis

D. Sindroma saluran Carpal

E. miotonia

F. Bukan salah satu antara A s/d E

C

( Merritt, pp. 613, 7 1 1 , 723-724, 7 2 7-728, 766; Greenberg, pp. 72-75, 78-79) .

A image thumb
51

51. Latensi sensori > motorik 


A. Miastenia Gravis

B. Sindroma LAMBERT-EATON

C. Polimiositis

D. Sindroma saluran Carpal

E. miotonia

F. Bukan salah satu antara A s/d E

D

( Merritt, pp. 613, 7 1 1 , 723-724, 7 2 7-728, 766; Greenberg, pp. 72-75, 78-79) .

A image thumb
52

52. Anak laki-laki berumur 13 tahun dengan lesi litik tengkorak dibawa dengan diabetes insipidus dan MRI koronal sebagaimana yang dijelaskan pada Diagnosis manakah yang paling memungkinkan?

A. Tumor sel granular

D. Histiositosis sel Langerhan’s

B. Sarkoidosis

E. Germinoma

C. Adenoma Hipofise

D.

Note the abnormally thickened stalk with high signal intensity on this coronal MRl depicting Langerhans' cell histiocytosis. The etiology of this condition is unknown, but it is believed to result from overproliferation of an antigen-presenting dendritic cell of bone marrow origin. Although it is usually treated as a neoplastic process, some speculate that it is due to malfunction of the immune system. Other manifestations of this disease may include lytic skull lesions (approximately 80% of cases) as well as hematopoietic, hepatic, and pulmonary abnormalities. A pathognomic finding of this condition on electron microscopy is the presence of Birbeck granules, a unique organelle of the Langerhans' cell ( Ramsey, pp. 381-385; Merritt, p. 872) .

53

53. Gangguan ini ditandai oleh berlipat gandanya sel yang mana? A. Fibroblast B. Limposit sel-T C. Antigen yang menampilkan Sel dendrit D. Eosinopil E. Sel yang berasal dari kantung Rathke

C. Note the abnormally thickened stalk with high signal intensity on this coronal MRl depicting Langerhans' cell histiocytosis. The etiology of this condition is unknown, but it is believed to result from overproliferation of an antigen-presenting dendritic cell of bone marrow origin. Although it is usually treated as a neoplastic process, some speculate that it is due to malfunction of the immune system. Other manifestations of this disease may include lytic skull lesions (approximately 80% of cases) as well as hematopoietic, hepatic, and pulmonary abnormalities. A pathognomic finding of this condition on electron microscopy is the presence of Birbeck granules, a unique organelle of the Langerhans' cell ( Ramsey, pp. 381-385; Merritt, p. 872) .

54

54. Temuan patognomoik dari kondisi ini pada mikroskop meliputi adanya A. Granula Birbeck D. Granula keratohialin B. Kompleks jungsional E. Kromatin stippled C. Kristal kolesterol

A. Note the abnormally thickened stalk with high signal intensity on this coronal MRl depicting Langerhans' cell histiocytosis. The etiology of this condition is unknown, but it is believed to result from overproliferation of an antigen-presenting dendritic cell of bone marrow origin. Although it is usually treated as a neoplastic process, some speculate that it is due to malfunction of the immune system. Other manifestations of this disease may include lytic skull lesions (approximately 80% of cases) as well as hematopoietic, hepatic, and pulmonary abnormalities. A pathognomic finding of this condition on electron microscopy is the presence of Birbeck granules, a unique organelle of the Langerhans' cell ( Ramsey, pp. 381-385; Merritt, p. 872) .

55

55. Apa yang dijelaskan pada fotomikrograf A. Neurofibroma B. Meningioma transisional C. Neuroma akustik D. Astrositoma pilositik E. Ksantoastrositoma pleomorfik

C Acoustic neuroma. Note the palisading of nuclei (picket fence-like arrangement) separated by an anuclear area (arrow) on this photomicrograph, which depicts a Verocay body ( El lison, pp. 695- 699) .

56

56. Apa yang ditunjukkan oleh tanda panah? A. Badan verocay B. Whorls C. Batang psammoma D. Pseudopalisasing E. Daerah Antoni B

A Acoustic neuroma. Note the palisading of nuclei (picket fence-like arrangement) separated by an anuclear area (arrow) on this photomicrograph, which depicts a Verocay body ( El lison, pp. 695- 699) .

57

57. Ketika seorang pasien tidak bisa aduksi mata kanannya pada saat memandang ke arah kiri tetapi mata tersebut bisa aduksi bila melihat konvergens, maka benjolan yang terjadi kemungkinan terdapat di lokasi mana? A. Faskikulus longitudinal medial kanan B. Faskikulus melintang tengah kiri C. Nukleus adusen kiri D. Nukleus adusen kanan E. Nukleus saraf kranial III

A. A lesion of the MLF does not allow for transfer of information from the abducens nucleus (CN VI) to the oppositeoculomotor nucleus (CN III) and results in internuclear ophthalmoplegia (INO). It is characterized by deficient adduction during attempted conjugate gaze away from the side of the MLF lesion and monocular nystagmus of the abducting eye. An MLF lesion is on the same side as the eye with the adduction wealmess, and I TO is named for the side of the MLF lesion . A lesion in the nucleus of CN I I I would paralyze volitional movements and convergence (Kline, pp. 63-64).

58

58. Cedera saraf Medianus pada ketinggian siku

B Compressive lesions of the ulnar nerve at the level of the elbow, forearm, or wrist can produce a "claw hand" (A) in severe cases. The ulnar half of the flexor digitorum profundus, lumbricals 3 and 4, the dorsal and palmar interossei, and the hypothenar muscles are typically paralyzed. When the metacarpophalangeal joints are extended, the distal and proximal interphalangeal joints cannot be extended because the interossei and half the lumbricals are not functional, which results in a "claw-like" posture. Laceration of the ulnar nerve in the wrist leaves the innervation of the ulnar side of the flexor digitorum profundus intact but can•also result in a claw hand. There is also loss of abduction of the thumb, so that a piece of paper cannot be held between the side of the thumb and the index finger. Lesions of the median nerve near the elbow can produce paralysis of the flexor digitorum superficialis, the flexor digitorum profundus I and II, the flexor pollicis longus, as well as the thenar muscles and lumbricals 1 and 2. This produces the "sign of benediction, " in which the index and middle fingers cannot flex and the thumb cannot be opposed. In addition, there may be numbness over the radial side of the palm and of the digits lateral to the center of the ring finger. C8 nerve root or anterior interosseous nerve injury causes weakness of the long flexors of the thumb (flexor pollicis longus), index and middle fingers (weak flexor digitorum profundus I and II), and the pronator quadratus. In trying to pinch the index finger and thumb, the terminal phalanges extend and instead of the tips, the pulps touch ("pinch sign," C) (April , pp. 98-100; Patten, pp. 285-296; Greenberg, p. 540) .

59

59. Cedera saraf ulnar pada ketinggian siku

A Compressive lesions of the ulnar nerve at the level of the elbow, forearm, or wrist can produce a "claw hand" (A) in severe cases. The ulnar half of the flexor digitorum profundus, lumbricals 3 and 4, the dorsal and palmar interossei, and the hypothenar muscles are typically paralyzed. When the metacarpophalangeal joints are extended, the distal and proximal interphalangeal joints cannot be extended because the interossei and half the lumbricals are not functional, which results in a "claw-like" posture. Laceration of the ulnar nerve in the wrist leaves the innervation of the ulnar side of the flexor digitorum profundus intact but can•also result in a claw hand. There is also loss of abduction of the thumb, so that a piece of paper cannot be held between the side of the thumb and the index finger. Lesions of the median nerve near the elbow can produce paralysis of the flexor digitorum superficialis, the flexor digitorum profundus I and II, the flexor pollicis longus, as well as the thenar muscles and lumbricals 1 and 2. This produces the "sign of benediction, " in which the index and middle fingers cannot flex and the thumb cannot be opposed. In addition, there may be numbness over the radial side of the palm and of the digits lateral to the center of the ring finger. C8 nerve root or anterior interosseous nerve injury causes weakness of the long flexors of the thumb (flexor pollicis longus), index and middle fingers (weak flexor digitorum profundus I and II), and the pronator quadratus. In trying to pinch the index finger and thumb, the terminal phalanges extend and instead of the tips, the pulps touch ("pinch sign," C) (April , pp. 98-100; Patten, pp. 285-296; Greenberg, p. 540) .

60

60. Cedera saraf ulnar pada pergelangan tangan

A Compressive lesions of the ulnar nerve at the level of the elbow, forearm, or wrist can produce a "claw hand" (A) in severe cases. The ulnar half of the flexor digitorum profundus, lumbricals 3 and 4, the dorsal and palmar interossei, and the hypothenar muscles are typically paralyzed. When the metacarpophalangeal joints are extended, the distal and proximal interphalangeal joints cannot be extended because the interossei and half the lumbricals are not functional, which results in a "claw-like" posture. Laceration of the ulnar nerve in the wrist leaves the innervation of the ulnar side of the flexor digitorum profundus intact but can•also result in a claw hand. There is also loss of abduction of the thumb, so that a piece of paper cannot be held between the side of the thumb and the index finger. Lesions of the median nerve near the elbow can produce paralysis of the flexor digitorum superficialis, the flexor digitorum profundus I and II, the flexor pollicis longus, as well as the thenar muscles and lumbricals 1 and 2. This produces the "sign of benediction, " in which the index and middle fingers cannot flex and the thumb cannot be opposed. In addition, there may be numbness over the radial side of the palm and of the digits lateral to the center of the ring finger. C8 nerve root or anterior interosseous nerve injury causes weakness of the long flexors of the thumb (flexor pollicis longus), index and middle fingers (weak flexor digitorum profundus I and II), and the pronator quadratus. In trying to pinch the index finger and thumb, the terminal phalanges extend and instead of the tips, the pulps touch ("pinch sign," C) (April , pp. 98-100; Patten, pp. 285-296; Greenberg, p. 540) .

61

61. Cedera saraf interoseus anterior

C Compressive lesions of the ulnar nerve at the level of the elbow, forearm, or wrist can produce a "claw hand" (A) in severe cases. The ulnar half of the flexor digitorum profundus, lumbricals 3 and 4, the dorsal and palmar interossei, and the hypothenar muscles are typically paralyzed. When the metacarpophalangeal joints are extended, the distal and proximal interphalangeal joints cannot be extended because the interossei and half the lumbricals are not functional, which results in a "claw-like" posture. Laceration of the ulnar nerve in the wrist leaves the innervation of the ulnar side of the flexor digitorum profundus intact but can•also result in a claw hand. There is also loss of abduction of the thumb, so that a piece of paper cannot be held between the side of the thumb and the index finger. Lesions of the median nerve near the elbow can produce paralysis of the flexor digitorum superficialis, the flexor digitorum profundus I and II, the flexor pollicis longus, as well as the thenar muscles and lumbricals 1 and 2. This produces the "sign of benediction, " in which the index and middle fingers cannot flex and the thumb cannot be opposed. In addition, there may be numbness over the radial side of the palm and of the digits lateral to the center of the ring finger. C8 nerve root or anterior interosseous nerve injury causes weakness of the long flexors of the thumb (flexor pollicis longus), index and middle fingers (weak flexor digitorum profundus I and II), and the pronator quadratus. In trying to pinch the index finger and thumb, the terminal phalanges extend and instead of the tips, the pulps touch ("pinch sign," C) (April , pp. 98-100; Patten, pp. 285-296; Greenberg, p. 540) .

62

62. Kelumpuhan Klumpke

D Compressive lesions of the ulnar nerve at the level of the elbow, forearm, or wrist can produce a "claw hand" (A) in severe cases. The ulnar half of the flexor digitorum profundus, lumbricals 3 and 4, the dorsal and palmar interossei, and the hypothenar muscles are typically paralyzed. When the metacarpophalangeal joints are extended, the distal and proximal interphalangeal joints cannot be extended because the interossei and half the lumbricals are not functional, which results in a "claw-like" posture. Laceration of the ulnar nerve in the wrist leaves the innervation of the ulnar side of the flexor digitorum profundus intact but can•also result in a claw hand. There is also loss of abduction of the thumb, so that a piece of paper cannot be held between the side of the thumb and the index finger. Lesions of the median nerve near the elbow can produce paralysis of the flexor digitorum superficialis, the flexor digitorum profundus I and II, the flexor pollicis longus, as well as the thenar muscles and lumbricals 1 and 2. This produces the "sign of benediction, " in which the index and middle fingers cannot flex and the thumb cannot be opposed. In addition, there may be numbness over the radial side of the palm and of the digits lateral to the center of the ring finger. C8 nerve root or anterior interosseous nerve injury causes weakness of the long flexors of the thumb (flexor pollicis longus), index and middle fingers (weak flexor digitorum profundus I and II), and the pronator quadratus. In trying to pinch the index finger and thumb, the terminal phalanges extend and instead of the tips, the pulps touch ("pinch sign," C) (April , pp. 98-100; Patten, pp. 285-296; Greenberg, p. 540) .

63

63. Lesi akar saraf C8

C Compressive lesions of the ulnar nerve at the level of the elbow, forearm, or wrist can produce a "claw hand" (A) in severe cases. The ulnar half of the flexor digitorum profundus, lumbricals 3 and 4, the dorsal and palmar interossei, and the hypothenar muscles are typically paralyzed. When the metacarpophalangeal joints are extended, the distal and proximal interphalangeal joints cannot be extended because the interossei and half the lumbricals are not functional, which results in a "claw-like" posture. Laceration of the ulnar nerve in the wrist leaves the innervation of the ulnar side of the flexor digitorum profundus intact but can•also result in a claw hand. There is also loss of abduction of the thumb, so that a piece of paper cannot be held between the side of the thumb and the index finger. Lesions of the median nerve near the elbow can produce paralysis of the flexor digitorum superficialis, the flexor digitorum profundus I and II, the flexor pollicis longus, as well as the thenar muscles and lumbricals 1 and 2. This produces the "sign of benediction, " in which the index and middle fingers cannot flex and the thumb cannot be opposed. In addition, there may be numbness over the radial side of the palm and of the digits lateral to the center of the ring finger. C8 nerve root or anterior interosseous nerve injury causes weakness of the long flexors of the thumb (flexor pollicis longus), index and middle fingers (weak flexor digitorum profundus I and II), and the pronator quadratus. In trying to pinch the index finger and thumb, the terminal phalanges extend and instead of the tips, the pulps touch ("pinch sign," C) (April , pp. 98-100; Patten, pp. 285-296; Greenberg, p. 540) .

64

64. Girus angular kiri A. Apraksia berpakaian B. Apraksia menulis C. Apraksia berbicara D. Apraksia gait E. Prosopagnosia F. Astereognosis G. Bukan salah satu dari A /d D

C Apraxia is defined as the inability to execute a normal volitional act despite the fact that the motor systems and mental status are relatively intact. Speech apraxia often results from a lesion near the posterior part of the inferior frontal gyrus (approximately area 44) , while writing apraxia or dysgraphia results from damage in the left angular gyrus. Dressing apraxia results from damage in the posterior right parietal lobe, while gait apraxia is usually associated with diffuse cerebral disease such as Alzheimer's disease. Lesions that affect the inferomedial part of the temporo-occipital region tend to cause an inability to recognize facial features (prosopagnosia) , while lesions of either parietal lobe may produce astereognosis, in which patients fail to recognize the forms of objects when felt but not when viewed (Brazis, pp. 481-508) .

65

65. Lobus parietal kanan bagian posterior A. Apraksia berpakaian B. Apraksia menulis C. Apraksia berbicara D. Apraksia gait E. Prosopagnosia F. Astereognosis G. Bukan salah satu dari A /d D

B Apraxia is defined as the inability to execute a normal volitional act despite the fact that the motor systems and mental status are relatively intact. Speech apraxia often results from a lesion near the posterior part of the inferior frontal gyrus (approximately area 44) , while writing apraxia or dysgraphia results from damage in the left angular gyrus. Dressing apraxia results from damage in the posterior right parietal lobe, while gait apraxia is usually associated with diffuse cerebral disease such as Alzheimer's disease. Lesions that affect the inferomedial part of the temporo-occipital region tend to cause an inability to recognize facial features (prosopagnosia) , while lesions of either parietal lobe may produce astereognosis, in which patients fail to recognize the forms of objects when felt but not when viewed (Brazis, pp. 481-508) .

66

66. Penyakit serebral menyeluruh A. Apraksia berpakaian B. Apraksia menulis C. Apraksia berbicara D. Apraksia gait E. Prosopagnosia F. Astereognosis G. Bukan salah satu dari A /d D

A Apraxia is defined as the inability to execute a normal volitional act despite the fact that the motor systems and mental status are relatively intact. Speech apraxia often results from a lesion near the posterior part of the inferior frontal gyrus (approximately area 44) , while writing apraxia or dysgraphia results from damage in the left angular gyrus. Dressing apraxia results from damage in the posterior right parietal lobe, while gait apraxia is usually associated with diffuse cerebral disease such as Alzheimer's disease. Lesions that affect the inferomedial part of the temporo-occipital region tend to cause an inability to recognize facial features (prosopagnosia) , while lesions of either parietal lobe may produce astereognosis, in which patients fail to recognize the forms of objects when felt but not when viewed (Brazis, pp. 481-508) .

67

67. Regio temporo-okcipital medial inferior A. Apraksia berpakaian B. Apraksia menulis C. Apraksia berbicara D. Apraksia gait E. Prosopagnosia F. Astereognosis G. Bukan salah satu dari A /d D

D Apraxia is defined as the inability to execute a normal volitional act despite the fact that the motor systems and mental status are relatively intact. Speech apraxia often results from a lesion near the posterior part of the inferior frontal gyrus (approximately area 44) , while writing apraxia or dysgraphia results from damage in the left angular gyrus. Dressing apraxia results from damage in the posterior right parietal lobe, while gait apraxia is usually associated with diffuse cerebral disease such as Alzheimer's disease. Lesions that affect the inferomedial part of the temporo-occipital region tend to cause an inability to recognize facial features (prosopagnosia) , while lesions of either parietal lobe may produce astereognosis, in which patients fail to recognize the forms of objects when felt but not when viewed (Brazis, pp. 481-508) .

68

68. Regio temporo-okcipital medial inferio A. Apraksia berpakaian B. Apraksia menulis C. Apraksia berbicara D. Apraksia gait E. Prosopagnosia F. Astereognosis G. Bukan salah satu dari A /d D

E Apraxia is defined as the inability to execute a normal volitional act despite the fact that the motor systems and mental status are relatively intact. Speech apraxia often results from a lesion near the posterior part of the inferior frontal gyrus (approximately area 44) , while writing apraxia or dysgraphia results from damage in the left angular gyrus. Dressing apraxia results from damage in the posterior right parietal lobe, while gait apraxia is usually associated with diffuse cerebral disease such as Alzheimer's disease. Lesions that affect the inferomedial part of the temporo-occipital region tend to cause an inability to recognize facial features (prosopagnosia) , while lesions of either parietal lobe may produce astereognosis, in which patients fail to recognize the forms of objects when felt but not when viewed (Brazis, pp. 481-508) .

69

69. Kedua lobus parietal A. Apraksia berpakaian B. Apraksia menulis C. Apraksia berbicara D. Apraksia gait E. Prosopagnosia F. Astereognosis G. Bukan salah satu dari A /d D

F Apraxia is defined as the inability to execute a normal volitional act despite the fact that the motor systems and mental status are relatively intact. Speech apraxia often results from a lesion near the posterior part of the inferior frontal gyrus (approximately area 44) , while writing apraxia or dysgraphia results from damage in the left angular gyrus. Dressing apraxia results from damage in the posterior right parietal lobe, while gait apraxia is usually associated with diffuse cerebral disease such as Alzheimer's disease. Lesions that affect the inferomedial part of the temporo-occipital region tend to cause an inability to recognize facial features (prosopagnosia) , while lesions of either parietal lobe may produce astereognosis, in which patients fail to recognize the forms of objects when felt but not when viewed (Brazis, pp. 481-508) .

70

70. Di manakah akson yang berbeda melayani sinaps refleks peregangan otot? A. Ganglia akar dorsal D. Nukleus Clark B. Neuron tanduk dorsal E. Rexed Lamina III C. Motoneuron ventral

C. The muscle stretch reflex is a monosynaptic circuit that is dependent on two neurons. Afferent axons serving the muscle stretch reflex synapse directly with ventral motaneurons (Carpenter, p. 79).

71

71. Seorang buruh bangunan berusia 35 tahun terjatuh dari bangunan tiga lantai pada saat bekerja dan menderita cedera “complete spinal cord” pada level C2. Di antara fungsi-fungsi di bawah ini, fungsi-fungsi mana saja yang kemungkinan masih selamat setelah terjadinya cedera “complete spinal cord “semacam ini? 1. Mikturisi 2. Ejakulasi 3. Peristalsis 4. Bernafas

A. After a complete spinal cord i njury, all voluntary movements and sensation below the level of the lesion are lost, but a number of visceral reflexes may be preserved in some cases. A patient with a complete C2 spinal cord injury is unlikely to be able to breathe, since the spinal cord does not contain intrinsic circuitry for breathing. Retained reflexes may include micturition, defecation, peristalsis, and possibly even ejaculation, although there may be no sensation of the sexual act (Brazis, pp. 85-88; DeMyer, pp. 142 - 143 ) .

72

72. Nn. X, 15 tahun mengunjungi dokternya serebelum dimulainya musim pertandingan sepak bola. Dokternya melihat bahwa ketika pasien mengatakan “Aah” sisi kiri lidahnya tidak terangkat. Cacad apa lagi yang mungkin dapat ditemukan pada pasien semacam ini? 1. Mengunyah 2. Mengucapkan bunyi 3. Mengecap 4. Mengeluarkan air liur

. A . The most important cranial nerve for palatal elevation is generally CN X. Interruption of the left CN X can causeparalysis of palatal elevation on the left side. Taste, swallowing, and phonation are also partially subserved by CN X; therefore an insult to this cranial nerve may result in problems with speech, swallowing, and taste. Salivation problems may be evident with deficits in CN VII and IX (Carpenter, pp. 137 - 144, 172 - 173)

73

73. Serat-serat perifer kecil termielinasi dari jalur ini bersinapse di substantia gelatinosa dari dorsal horn

I The major ascending tracts of the spinal cord (left) are the dorsal columns, spinothalamic tract, dorsal spinocerebellar tract, and ventral spinocerebellar tract. The dorsal columns convey tactile discrimination (Meissner corpuscles), vibration (pacinian corpuscle) , joint position sense (muscle spindles and Golgi tendon organs), and conscious proprioception . First-order neurons give rise to axons that ascend in the fasciculus cuneatus (A, upper extremity fibers) and gracilis (B, lower extremity), which terminate in the gracile and cuneate nuclei of the medulla. Second-order neurons, known as arcuate fibers, cross to the contralateral side as the medial lemniscus and ascend to the ventral posterolateral (VPL) nucleus of the thalamus. Synaptic connections are then made in the thalamus with third-order neurons, which travel through the posterior limb of the internal capsule to reach the postcentral gyrus of the cerebral cortex. Four groups of fibers have been distinguished in the anterolateral system (I) on the basis of their anatomic projections: spinothalamic, spinoreticular, spinomesencephalic, and spinotectal. First-order neurons of the lateral spinothalamic tract (pain and temperature sensation) project axons via the dorsolateral tract of Lissauer to secondorder neurons in the substantia gelatinosa of the dorsal horn . Second-order neurons then decussate in the ventral white commissure, ascend in the ventral half of the lateral funiculus, and synapse in the VPL nucleus of the thalamus. Third-order neurons from the thalamus are then relayed to the somatosensory cortex of the postcentral gyrus (areas 3, 1 , and 2) through the posterior limb of the internal capsule. A number of collateral fibers from the spinothalamic tract are relayed to the reticular formation (spinoreticulothalamic tract), which transmits nociceptive fibers to the intralaminar nuclei of the thalamus. Additional fibers of the anterolateral system terminate in either the periaqueductal gray (spinamesencephalic) or the deep layers of the superior colliculus (spinotectal). The periaqueductal gray sends descending projections to serotonergic neurons of the raphe nucleus of the pons and nucleus gigantocellularis (noradrenergic neurons) of the medulla. Both of these areas, in turn , send projections to the dorsal horn and inhibit postsynaptic responses to nociceptive input. The spinotectal pathway directs visual attention to areas of the body that experience intense somatosensory input. Other pathways, such as the dorsal spinocerebellar (K) and ventral spinocerebellar tracts (J), transmit unconscious proprioception from the lower limbs and inferior half of the body to the cerebellum, while the cuneocerebellar and rostrocerebellar tracts com•ey similar information from the upper body and limbs (not shown ) . The corticospinal tract arises predominately from three cortical areas (approximately 30% each): the premotor cortex (area 6), the precentral motor cortex (area 4), and the postcentral sensory cortex (areas 3, 1, and 2). It undergoes a 90% decussation in the caudal medulla and travels in the dorsal quadrant of the lateral funiculus of the spinal cord. The ventral corticospinal tract (H) is a small, uncrossed tract that decussates in the ventral white commissure and is mainly concerned with control of axial musculature. The vestibulospinal tract (F) arises from the lateral vestibular nucleus (Dieter's) and influences extensor tone. The medial longitudinal fasciculus (G) carries fibers from medial and inferior vestibular nuclei, tectospinal tract, and interstitial nucleus of Cajal and coordinates eye movements, mediates nystagmus, and helps control conjugate gaze (Carpenter, pp. 83-106; Pritchard , pp. 114-125; Brazis, pp. 80-85; DeMyer, pp. 120- 132 ) .

74

74. Serat-serat ini melewati pedunkulus serebelar superior

J The major ascending tracts of the spinal cord (left) are the dorsal columns, spinothalamic tract, dorsal spinocerebellar tract, and ventral spinocerebellar tract. The dorsal columns convey tactile discrimination (Meissner corpuscles), vibration (pacinian corpuscle) , joint position sense (muscle spindles and Golgi tendon organs), and conscious proprioception . First-order neurons give rise to axons that ascend in the fasciculus cuneatus (A, upper extremity fibers) and gracilis (B, lower extremity), which terminate in the gracile and cuneate nuclei of the medulla. Second-order neurons, known as arcuate fibers, cross to the contralateral side as the medial lemniscus and ascend to the ventral posterolateral (VPL) nucleus of the thalamus. Synaptic connections are then made in the thalamus with third-order neurons, which travel through the posterior limb of the internal capsule to reach the postcentral gyrus of the cerebral cortex. Four groups of fibers have been distinguished in the anterolateral system (I) on the basis of their anatomic projections: spinothalamic, spinoreticular, spinomesencephalic, and spinotectal. First-order neurons of the lateral spinothalamic tract (pain and temperature sensation) project axons via the dorsolateral tract of Lissauer to secondorder neurons in the substantia gelatinosa of the dorsal horn . Second-order neurons then decussate in the ventral white commissure, ascend in the ventral half of the lateral funiculus, and synapse in the VPL nucleus of the thalamus. Third-order neurons from the thalamus are then relayed to the somatosensory cortex of the postcentral gyrus (areas 3, 1 , and 2) through the posterior limb of the internal capsule. A number of collateral fibers from the spinothalamic tract are relayed to the reticular formation (spinoreticulothalamic tract), which transmits nociceptive fibers to the intralaminar nuclei of the thalamus. Additional fibers of the anterolateral system terminate in either the periaqueductal gray (spinamesencephalic) or the deep layers of the superior colliculus (spinotectal). The periaqueductal gray sends descending projections to serotonergic neurons of the raphe nucleus of the pons and nucleus gigantocellularis (noradrenergic neurons) of the medulla. Both of these areas, in turn , send projections to the dorsal horn and inhibit postsynaptic responses to nociceptive input. The spinotectal pathway directs visual attention to areas of the body that experience intense somatosensory input. Other pathways, such as the dorsal spinocerebellar (K) and ventral spinocerebellar tracts (J), transmit unconscious proprioception from the lower limbs and inferior half of the body to the cerebellum, while the cuneocerebellar and rostrocerebellar tracts com•ey similar information from the upper body and limbs (not shown ) . The corticospinal tract arises predominately from three cortical areas (approximately 30% each): the premotor cortex (area 6), the precentral motor cortex (area 4), and the postcentral sensory cortex (areas 3, 1, and 2). It undergoes a 90% decussation in the caudal medulla and travels in the dorsal quadrant of the lateral funiculus of the spinal cord. The ventral corticospinal tract (H) is a small, uncrossed tract that decussates in the ventral white commissure and is mainly concerned with control of axial musculature. The vestibulospinal tract (F) arises from the lateral vestibular nucleus (Dieter's) and influences extensor tone. The medial longitudinal fasciculus (G) carries fibers from medial and inferior vestibular nuclei, tectospinal tract, and interstitial nucleus of Cajal and coordinates eye movements, mediates nystagmus, and helps control conjugate gaze (Carpenter, pp. 83-106; Pritchard , pp. 114-125; Brazis, pp. 80-85; DeMyer, pp. 120- 132 ) .

75

75. Traktus ini tumbuh dari nukleus Dieter’s

F The major ascending tracts of the spinal cord (left) are the dorsal columns, spinothalamic tract, dorsal spinocerebellar tract, and ventral spinocerebellar tract. The dorsal columns convey tactile discrimination (Meissner corpuscles), vibration (pacinian corpuscle) , joint position sense (muscle spindles and Golgi tendon organs), and conscious proprioception . First-order neurons give rise to axons that ascend in the fasciculus cuneatus (A, upper extremity fibers) and gracilis (B, lower extremity), which terminate in the gracile and cuneate nuclei of the medulla. Second-order neurons, known as arcuate fibers, cross to the contralateral side as the medial lemniscus and ascend to the ventral posterolateral (VPL) nucleus of the thalamus. Synaptic connections are then made in the thalamus with third-order neurons, which travel through the posterior limb of the internal capsule to reach the postcentral gyrus of the cerebral cortex. Four groups of fibers have been distinguished in the anterolateral system (I) on the basis of their anatomic projections: spinothalamic, spinoreticular, spinomesencephalic, and spinotectal. First-order neurons of the lateral spinothalamic tract (pain and temperature sensation) project axons via the dorsolateral tract of Lissauer to secondorder neurons in the substantia gelatinosa of the dorsal horn . Second-order neurons then decussate in the ventral white commissure, ascend in the ventral half of the lateral funiculus, and synapse in the VPL nucleus of the thalamus. Third-order neurons from the thalamus are then relayed to the somatosensory cortex of the postcentral gyrus (areas 3, 1 , and 2) through the posterior limb of the internal capsule. A number of collateral fibers from the spinothalamic tract are relayed to the reticular formation (spinoreticulothalamic tract), which transmits nociceptive fibers to the intralaminar nuclei of the thalamus. Additional fibers of the anterolateral system terminate in either the periaqueductal gray (spinamesencephalic) or the deep layers of the superior colliculus (spinotectal). The periaqueductal gray sends descending projections to serotonergic neurons of the raphe nucleus of the pons and nucleus gigantocellularis (noradrenergic neurons) of the medulla. Both of these areas, in turn , send projections to the dorsal horn and inhibit postsynaptic responses to nociceptive input. The spinotectal pathway directs visual attention to areas of the body that experience intense somatosensory input. Other pathways, such as the dorsal spinocerebellar (K) and ventral spinocerebellar tracts (J), transmit unconscious proprioception from the lower limbs and inferior half of the body to the cerebellum, while the cuneocerebellar and rostrocerebellar tracts com•ey similar information from the upper body and limbs (not shown ) . The corticospinal tract arises predominately from three cortical areas (approximately 30% each): the premotor cortex (area 6), the precentral motor cortex (area 4), and the postcentral sensory cortex (areas 3, 1, and 2). It undergoes a 90% decussation in the caudal medulla and travels in the dorsal quadrant of the lateral funiculus of the spinal cord. The ventral corticospinal tract (H) is a small, uncrossed tract that decussates in the ventral white commissure and is mainly concerned with control of axial musculature. The vestibulospinal tract (F) arises from the lateral vestibular nucleus (Dieter's) and influences extensor tone. The medial longitudinal fasciculus (G) carries fibers from medial and inferior vestibular nuclei, tectospinal tract, and interstitial nucleus of Cajal and coordinates eye movements, mediates nystagmus, and helps control conjugate gaze (Carpenter, pp. 83-106; Pritchard , pp. 114-125; Brazis, pp. 80-85; DeMyer, pp. 120- 132 ) .

76

76. Propriosepsi secara sadar dari kaki terutama ditransmisikan di dalam traktus ini ini

B The major ascending tracts of the spinal cord (left) are the dorsal columns, spinothalamic tract, dorsal spinocerebellar tract, and ventral spinocerebellar tract. The dorsal columns convey tactile discrimination (Meissner corpuscles), vibration (pacinian corpuscle) , joint position sense (muscle spindles and Golgi tendon organs), and conscious proprioception . First-order neurons give rise to axons that ascend in the fasciculus cuneatus (A, upper extremity fibers) and gracilis (B, lower extremity), which terminate in the gracile and cuneate nuclei of the medulla. Second-order neurons, known as arcuate fibers, cross to the contralateral side as the medial lemniscus and ascend to the ventral posterolateral (VPL) nucleus of the thalamus. Synaptic connections are then made in the thalamus with third-order neurons, which travel through the posterior limb of the internal capsule to reach the postcentral gyrus of the cerebral cortex. Four groups of fibers have been distinguished in the anterolateral system (I) on the basis of their anatomic projections: spinothalamic, spinoreticular, spinomesencephalic, and spinotectal. First-order neurons of the lateral spinothalamic tract (pain and temperature sensation) project axons via the dorsolateral tract of Lissauer to secondorder neurons in the substantia gelatinosa of the dorsal horn . Second-order neurons then decussate in the ventral white commissure, ascend in the ventral half of the lateral funiculus, and synapse in the VPL nucleus of the thalamus. Third-order neurons from the thalamus are then relayed to the somatosensory cortex of the postcentral gyrus (areas 3, 1 , and 2) through the posterior limb of the internal capsule. A number of collateral fibers from the spinothalamic tract are relayed to the reticular formation (spinoreticulothalamic tract), which transmits nociceptive fibers to the intralaminar nuclei of the thalamus. Additional fibers of the anterolateral system terminate in either the periaqueductal gray (spinamesencephalic) or the deep layers of the superior colliculus (spinotectal). The periaqueductal gray sends descending projections to serotonergic neurons of the raphe nucleus of the pons and nucleus gigantocellularis (noradrenergic neurons) of the medulla. Both of these areas, in turn , send projections to the dorsal horn and inhibit postsynaptic responses to nociceptive input. The spinotectal pathway directs visual attention to areas of the body that experience intense somatosensory input. Other pathways, such as the dorsal spinocerebellar (K) and ventral spinocerebellar tracts (J), transmit unconscious proprioception from the lower limbs and inferior half of the body to the cerebellum, while the cuneocerebellar and rostrocerebellar tracts com•ey similar information from the upper body and limbs (not shown ) . The corticospinal tract arises predominately from three cortical areas (approximately 30% each): the premotor cortex (area 6), the precentral motor cortex (area 4), and the postcentral sensory cortex (areas 3, 1, and 2). It undergoes a 90% decussation in the caudal medulla and travels in the dorsal quadrant of the lateral funiculus of the spinal cord. The ventral corticospinal tract (H) is a small, uncrossed tract that decussates in the ventral white commissure and is mainly concerned with control of axial musculature. The vestibulospinal tract (F) arises from the lateral vestibular nucleus (Dieter's) and influences extensor tone. The medial longitudinal fasciculus (G) carries fibers from medial and inferior vestibular nuclei, tectospinal tract, and interstitial nucleus of Cajal and coordinates eye movements, mediates nystagmus, and helps control conjugate gaze (Carpenter, pp. 83-106; Pritchard , pp. 114-125; Brazis, pp. 80-85; DeMyer, pp. 120- 132 ) .

77

77. Membawa serat dari nuklei vestibular medial dan inferior, traktus tektospinal, dan nukleus interstitial dari Cajal.

G The major ascending tracts of the spinal cord (left) are the dorsal columns, spinothalamic tract, dorsal spinocerebellar tract, and ventral spinocerebellar tract. The dorsal columns convey tactile discrimination (Meissner corpuscles), vibration (pacinian corpuscle) , joint position sense (muscle spindles and Golgi tendon organs), and conscious proprioception . First-order neurons give rise to axons that ascend in the fasciculus cuneatus (A, upper extremity fibers) and gracilis (B, lower extremity), which terminate in the gracile and cuneate nuclei of the medulla. Second-order neurons, known as arcuate fibers, cross to the contralateral side as the medial lemniscus and ascend to the ventral posterolateral (VPL) nucleus of the thalamus. Synaptic connections are then made in the thalamus with third-order neurons, which travel through the posterior limb of the internal capsule to reach the postcentral gyrus of the cerebral cortex. Four groups of fibers have been distinguished in the anterolateral system (I) on the basis of their anatomic projections: spinothalamic, spinoreticular, spinomesencephalic, and spinotectal. First-order neurons of the lateral spinothalamic tract (pain and temperature sensation) project axons via the dorsolateral tract of Lissauer to secondorder neurons in the substantia gelatinosa of the dorsal horn . Second-order neurons then decussate in the ventral white commissure, ascend in the ventral half of the lateral funiculus, and synapse in the VPL nucleus of the thalamus. Third-order neurons from the thalamus are then relayed to the somatosensory cortex of the postcentral gyrus (areas 3, 1 , and 2) through the posterior limb of the internal capsule. A number of collateral fibers from the spinothalamic tract are relayed to the reticular formation (spinoreticulothalamic tract), which transmits nociceptive fibers to the intralaminar nuclei of the thalamus. Additional fibers of the anterolateral system terminate in either the periaqueductal gray (spinamesencephalic) or the deep layers of the superior colliculus (spinotectal). The periaqueductal gray sends descending projections to serotonergic neurons of the raphe nucleus of the pons and nucleus gigantocellularis (noradrenergic neurons) of the medulla. Both of these areas, in turn , send projections to the dorsal horn and inhibit postsynaptic responses to nociceptive input. The spinotectal pathway directs visual attention to areas of the body that experience intense somatosensory input. Other pathways, such as the dorsal spinocerebellar (K) and ventral spinocerebellar tracts (J), transmit unconscious proprioception from the lower limbs and inferior half of the body to the cerebellum, while the cuneocerebellar and rostrocerebellar tracts com•ey similar information from the upper body and limbs (not shown ) . The corticospinal tract arises predominately from three cortical areas (approximately 30% each): the premotor cortex (area 6), the precentral motor cortex (area 4), and the postcentral sensory cortex (areas 3, 1, and 2). It undergoes a 90% decussation in the caudal medulla and travels in the dorsal quadrant of the lateral funiculus of the spinal cord. The ventral corticospinal tract (H) is a small, uncrossed tract that decussates in the ventral white commissure and is mainly concerned with control of axial musculature. The vestibulospinal tract (F) arises from the lateral vestibular nucleus (Dieter's) and influences extensor tone. The medial longitudinal fasciculus (G) carries fibers from medial and inferior vestibular nuclei, tectospinal tract, and interstitial nucleus of Cajal and coordinates eye movements, mediates nystagmus, and helps control conjugate gaze (Carpenter, pp. 83-106; Pritchard , pp. 114-125; Brazis, pp. 80-85; DeMyer, pp. 120- 132 ) .

78

78. Serat-serat dari traktus ini berasal dari lapisan V korteks serebral

C The major ascending tracts of the spinal cord (left) are the dorsal columns, spinothalamic tract, dorsal spinocerebellar tract, and ventral spinocerebellar tract. The dorsal columns convey tactile discrimination (Meissner corpuscles), vibration (pacinian corpuscle) , joint position sense (muscle spindles and Golgi tendon organs), and conscious proprioception . First-order neurons give rise to axons that ascend in the fasciculus cuneatus (A, upper extremity fibers) and gracilis (B, lower extremity), which terminate in the gracile and cuneate nuclei of the medulla. Second-order neurons, known as arcuate fibers, cross to the contralateral side as the medial lemniscus and ascend to the ventral posterolateral (VPL) nucleus of the thalamus. Synaptic connections are then made in the thalamus with third-order neurons, which travel through the posterior limb of the internal capsule to reach the postcentral gyrus of the cerebral cortex. Four groups of fibers have been distinguished in the anterolateral system (I) on the basis of their anatomic projections: spinothalamic, spinoreticular, spinomesencephalic, and spinotectal. First-order neurons of the lateral spinothalamic tract (pain and temperature sensation) project axons via the dorsolateral tract of Lissauer to secondorder neurons in the substantia gelatinosa of the dorsal horn . Second-order neurons then decussate in the ventral white commissure, ascend in the ventral half of the lateral funiculus, and synapse in the VPL nucleus of the thalamus. Third-order neurons from the thalamus are then relayed to the somatosensory cortex of the postcentral gyrus (areas 3, 1 , and 2) through the posterior limb of the internal capsule. A number of collateral fibers from the spinothalamic tract are relayed to the reticular formation (spinoreticulothalamic tract), which transmits nociceptive fibers to the intralaminar nuclei of the thalamus. Additional fibers of the anterolateral system terminate in either the periaqueductal gray (spinamesencephalic) or the deep layers of the superior colliculus (spinotectal). The periaqueductal gray sends descending projections to serotonergic neurons of the raphe nucleus of the pons and nucleus gigantocellularis (noradrenergic neurons) of the medulla. Both of these areas, in turn , send projections to the dorsal horn and inhibit postsynaptic responses to nociceptive input. The spinotectal pathway directs visual attention to areas of the body that experience intense somatosensory input. Other pathways, such as the dorsal spinocerebellar (K) and ventral spinocerebellar tracts (J), transmit unconscious proprioception from the lower limbs and inferior half of the body to the cerebellum, while the cuneocerebellar and rostrocerebellar tracts com•ey similar information from the upper body and limbs (not shown ) . The corticospinal tract arises predominately from three cortical areas (approximately 30% each): the premotor cortex (area 6), the precentral motor cortex (area 4), and the postcentral sensory cortex (areas 3, 1, and 2). It undergoes a 90% decussation in the caudal medulla and travels in the dorsal quadrant of the lateral funiculus of the spinal cord. The ventral corticospinal tract (H) is a small, uncrossed tract that decussates in the ventral white commissure and is mainly concerned with control of axial musculature. The vestibulospinal tract (F) arises from the lateral vestibular nucleus (Dieter's) and influences extensor tone. The medial longitudinal fasciculus (G) carries fibers from medial and inferior vestibular nuclei, tectospinal tract, and interstitial nucleus of Cajal and coordinates eye movements, mediates nystagmus, and helps control conjugate gaze (Carpenter, pp. 83-106; Pritchard , pp. 114-125; Brazis, pp. 80-85; DeMyer, pp. 120- 132 ) .

79

79. Membawa serat yang naik ke arah thalamus, periaqueduktal gray, formasio retikular, atau kolikulus superior

I The major ascending tracts of the spinal cord (left) are the dorsal columns, spinothalamic tract, dorsal spinocerebellar tract, and ventral spinocerebellar tract. The dorsal columns convey tactile discrimination (Meissner corpuscles), vibration (pacinian corpuscle) , joint position sense (muscle spindles and Golgi tendon organs), and conscious proprioception . First-order neurons give rise to axons that ascend in the fasciculus cuneatus (A, upper extremity fibers) and gracilis (B, lower extremity), which terminate in the gracile and cuneate nuclei of the medulla. Second-order neurons, known as arcuate fibers, cross to the contralateral side as the medial lemniscus and ascend to the ventral posterolateral (VPL) nucleus of the thalamus. Synaptic connections are then made in the thalamus with third-order neurons, which travel through the posterior limb of the internal capsule to reach the postcentral gyrus of the cerebral cortex. Four groups of fibers have been distinguished in the anterolateral system (I) on the basis of their anatomic projections: spinothalamic, spinoreticular, spinomesencephalic, and spinotectal. First-order neurons of the lateral spinothalamic tract (pain and temperature sensation) project axons via the dorsolateral tract of Lissauer to secondorder neurons in the substantia gelatinosa of the dorsal horn . Second-order neurons then decussate in the ventral white commissure, ascend in the ventral half of the lateral funiculus, and synapse in the VPL nucleus of the thalamus. Third-order neurons from the thalamus are then relayed to the somatosensory cortex of the postcentral gyrus (areas 3, 1 , and 2) through the posterior limb of the internal capsule. A number of collateral fibers from the spinothalamic tract are relayed to the reticular formation (spinoreticulothalamic tract), which transmits nociceptive fibers to the intralaminar nuclei of the thalamus. Additional fibers of the anterolateral system terminate in either the periaqueductal gray (spinamesencephalic) or the deep layers of the superior colliculus (spinotectal). The periaqueductal gray sends descending projections to serotonergic neurons of the raphe nucleus of the pons and nucleus gigantocellularis (noradrenergic neurons) of the medulla. Both of these areas, in turn , send projections to the dorsal horn and inhibit postsynaptic responses to nociceptive input. The spinotectal pathway directs visual attention to areas of the body that experience intense somatosensory input. Other pathways, such as the dorsal spinocerebellar (K) and ventral spinocerebellar tracts (J), transmit unconscious proprioception from the lower limbs and inferior half of the body to the cerebellum, while the cuneocerebellar and rostrocerebellar tracts com•ey similar information from the upper body and limbs (not shown ) . The corticospinal tract arises predominately from three cortical areas (approximately 30% each): the premotor cortex (area 6), the precentral motor cortex (area 4), and the postcentral sensory cortex (areas 3, 1, and 2). It undergoes a 90% decussation in the caudal medulla and travels in the dorsal quadrant of the lateral funiculus of the spinal cord. The ventral corticospinal tract (H) is a small, uncrossed tract that decussates in the ventral white commissure and is mainly concerned with control of axial musculature. The vestibulospinal tract (F) arises from the lateral vestibular nucleus (Dieter's) and influences extensor tone. The medial longitudinal fasciculus (G) carries fibers from medial and inferior vestibular nuclei, tectospinal tract, and interstitial nucleus of Cajal and coordinates eye movements, mediates nystagmus, and helps control conjugate gaze (Carpenter, pp. 83-106; Pritchard , pp. 114-125; Brazis, pp. 80-85; DeMyer, pp. 120- 132 ) .

80

80. Serat-serat piramidal yang tidak menyilang dan terutama memasok muskulatur aksial

H The major ascending tracts of the spinal cord (left) are the dorsal columns, spinothalamic tract, dorsal spinocerebellar tract, and ventral spinocerebellar tract. The dorsal columns convey tactile discrimination (Meissner corpuscles), vibration (pacinian corpuscle) , joint position sense (muscle spindles and Golgi tendon organs), and conscious proprioception . First-order neurons give rise to axons that ascend in the fasciculus cuneatus (A, upper extremity fibers) and gracilis (B, lower extremity), which terminate in the gracile and cuneate nuclei of the medulla. Second-order neurons, known as arcuate fibers, cross to the contralateral side as the medial lemniscus and ascend to the ventral posterolateral (VPL) nucleus of the thalamus. Synaptic connections are then made in the thalamus with third-order neurons, which travel through the posterior limb of the internal capsule to reach the postcentral gyrus of the cerebral cortex. Four groups of fibers have been distinguished in the anterolateral system (I) on the basis of their anatomic projections: spinothalamic, spinoreticular, spinomesencephalic, and spinotectal. First-order neurons of the lateral spinothalamic tract (pain and temperature sensation) project axons via the dorsolateral tract of Lissauer to secondorder neurons in the substantia gelatinosa of the dorsal horn . Second-order neurons then decussate in the ventral white commissure, ascend in the ventral half of the lateral funiculus, and synapse in the VPL nucleus of the thalamus. Third-order neurons from the thalamus are then relayed to the somatosensory cortex of the postcentral gyrus (areas 3, 1 , and 2) through the posterior limb of the internal capsule. A number of collateral fibers from the spinothalamic tract are relayed to the reticular formation (spinoreticulothalamic tract), which transmits nociceptive fibers to the intralaminar nuclei of the thalamus. Additional fibers of the anterolateral system terminate in either the periaqueductal gray (spinamesencephalic) or the deep layers of the superior colliculus (spinotectal). The periaqueductal gray sends descending projections to serotonergic neurons of the raphe nucleus of the pons and nucleus gigantocellularis (noradrenergic neurons) of the medulla. Both of these areas, in turn , send projections to the dorsal horn and inhibit postsynaptic responses to nociceptive input. The spinotectal pathway directs visual attention to areas of the body that experience intense somatosensory input. Other pathways, such as the dorsal spinocerebellar (K) and ventral spinocerebellar tracts (J), transmit unconscious proprioception from the lower limbs and inferior half of the body to the cerebellum, while the cuneocerebellar and rostrocerebellar tracts com•ey similar information from the upper body and limbs (not shown ) . The corticospinal tract arises predominately from three cortical areas (approximately 30% each): the premotor cortex (area 6), the precentral motor cortex (area 4), and the postcentral sensory cortex (areas 3, 1, and 2). It undergoes a 90% decussation in the caudal medulla and travels in the dorsal quadrant of the lateral funiculus of the spinal cord. The ventral corticospinal tract (H) is a small, uncrossed tract that decussates in the ventral white commissure and is mainly concerned with control of axial musculature. The vestibulospinal tract (F) arises from the lateral vestibular nucleus (Dieter's) and influences extensor tone. The medial longitudinal fasciculus (G) carries fibers from medial and inferior vestibular nuclei, tectospinal tract, and interstitial nucleus of Cajal and coordinates eye movements, mediates nystagmus, and helps control conjugate gaze (Carpenter, pp. 83-106; Pritchard , pp. 114-125; Brazis, pp. 80-85; DeMyer, pp. 120- 132 ) .

81

81. Tergesernya saraf Fasialis oleh neuroma akustik paling lazim (dengan frekuensi yang menurun) menuju ke arah mana? A. Bawah, kemudian depan, atas, belakang B. Anterior, diikuti superior, inferior dan posterior C. Depan, kemudian bawah, atas, dan belakang D. Belakang, kemudian depan, bawah dan jarang ke atas E. Atas, kemudian bawah, depan belakang.

B. Facial nerve displacement by an acoustic neuroma is most commonly (in decreasing order of frequency) anterior, followed by superior, inferior, and posterior. The facial nerve is often stretched during microdissection and is most susceptible to injury at the proximal rim of the porus acusticus (Connolly, p. 475).

82

82. Kelumpuhan lantai pelvis, anestesia sadel simetris, gangguan ereksi dan ejakulasi, konstipati dan “autonom neurogenic bladder” paling menjelaskan lesi spinal cord yang mana? A. Benjolan pada segmen sakral pertama dan kedua B. Sindroma Cauda equine C. Sindroma conus medularis D. Sindroma tethered cord E. Siringomielia

C. Paralysis of pelvic floor muscles, early sphincter and bladder dysfunction, symmetric saddle anesthesia, impaired erection and ejaculation , constipation, and minimal pain best characterize the conus medullaris syndrome. A tethered cord may present with a combination of neurologic, urologic, orthopedic, and dermatologic manifestations. Commonly patients present with numb feet, muscle atrophy, upper motor neuron signs, bowel and bladder dysfunction, foot deformities, scoliosis, and cutaneous stigmata of spinal dysraphism. Compression of the lumbar and sacral roots below L3 often results in cauda equina syndrome, which is characterized by early pain, asymmetric saddle anesthesia, and a variable patellar reflex response. Sphincter changes are often similar to those of the conus medullaris syndrome but tend to occur late in the clinical course. With S 1 lesions, there is weakness of the triceps surae, flexor digitorum longus (FDL), flexor hallucis longus (FI-lL) , and small foot muscles. The Achilles reflexes are absent, whereas the patellar reflexes are preserved. There is complete sensory loss over the sole, heel, and outer part of the foot and ankle . The gastrocnemius and soleus muscles are stronger with S2 segmental lesions, however, the FDL, FI-lL, and foot muscles remain weak. The sensory loss tends to involve the upper part of the dorsal calf, dorsolateral thigh, and the saddle area (Brazis, pp. 99- 100) .

83

83. Temuan yang ditunjukkan pada CT scan di bawah ini paling mungkin terjadi setelah A. Pecahnya aneurisma Berry B. Infeksi C. Diseksi arteri karotid ekstradural D. Trauma E. Pemberian kontras

D. This CT demonstrates a subarachnoid hemorrhage (SAI-l), which is most commonly seen after trauma. Althoughthe blood pattern may vary, traumatic SAH often involves the convexities of the cerebral hemispheres, while aneurysmal subarachnoid hemorrhages generally have a preponderance of blood in the basal cisterns (Greenberg, p. 754).

84

84. Daerah korteks serebral manakah yang asosiasinya paling kuat dengan indera penciuman secara sadar? A. Korteks asosiasi temporal B. Girus singulate C. Sistem limbik D. Korteks orbitofrontal E. Amigdala

D. Experimental studies indicate the orbitofrontal cortex is a key region involved with the conscious perception of smell, as lesions in this region have been shown to result in failure to discriminate between various odorants ( Kandel, p. 633) .

85

85. Diagnosis apakah yg paling memungkinkan? A. Astrositoma pilositik B. Meduloblastoma C. Infark Subakut D. Penyakit LHERMITTE-DUCLOS E. Ependimoma

D This T2-weighted image shows the hyperintense and thickened folia in a characteristic laminated pattern that is most consistent with Lhermitte-Duclos disease. It is associated with hypertrophy of granular cell neurons and axonal hypermyelination in the molecular layer (Osborn DN, pp. 69-70) .

86

86. Di antara ciri-ciri di bawah ini, ciri-ciri manakah yang paling menjelaskan kelainan ini? A. Benjolan ini biasanya cukup banyak memiliki serat Rosenthal. B. Paling sering merupakan benjolan sekunder dari oklusi arteri vertebral. C. Hipertropi sel neuron-granular dan hipermielinisasi aksonal pada lapisan molekular D. Bukti rosette Homer-Wright pada sectioning histopatologis E. Pseudoroset pada sectioning histopatologis

C This T2-weighted image shows the hyperintense and thickened folia in a characteristic laminated pattern that is most consistent with Lhermitte-Duclos disease. It is associated with hypertrophy of granular cell neurons and axonal hypermyelination in the molecular layer (Osborn DN, pp. 69-70) .

87

87. Ny. X, 42 tahun dibawa ke UGD dalam keadaan berkunang-kunang dan citra MR T2-weighted sebagaimana yang ditunjukkan di bawah ini. Diagnosis manakah yang paling mungkin? A. Ganglioglioma lobe temporal B. Tumor neuroepitelial disembrioplastis C. Kiste epidermoid D. Aneurisma E. Neurokistiserkosis

D . This T2-weighted MRI shows a right temporal lobe mass with signal loss (flow void), which is most consistent with a large middle cerebral artery aneurysm (Osborn DN, pp. 266-268).

88

88. Diensepalon posterior/pretektum (nukleus interstitial dari Cajal); regio suprasellar M A. Nistagmus downbeat B. Nistagmus upbeat C. Nistagmus seesaw D. Nutan spasmus E. Bobbing ocular F. Flutter ocular G. Nistagmus Konvergens-retraksi H. Mioklonus Okular I. Nistagmus Abducting J. Nistagmus Bruns

C (Brazis, pp. 221- 232; Wi lkins, pp. 118-125).

89

89. Midbrain dorsal A. Nistagmus downbeat B. Nistagmus upbeat C. Nistagmus seesaw D. Nutan spasmus E. Bobbing ocular F. Flutter ocular G. Nistagmus Konvergens-retraksi H. Mioklonus Okular I. Nistagmus Abducting J. Nistagmus Bruns

G (Brazis, pp. 221- 232; Wi lkins, pp. 118-125).

90

90. Pons (fasikulus longitudinal medial) A. Nistagmus downbeat B. Nistagmus upbeat C. Nistagmus seesaw D. Nutan spasmus E. Bobbing ocular F. Flutter ocular G. Nistagmus Konvergens-retraksi H. Mioklonus Okular I. Nistagmus Abducting J. Nistagmus Bruns

I (Brazis, pp. 221- 232; Wi lkins, pp. 118-125).

91

91. Pons sentral A. Nistagmus downbeat B. Nistagmus upbeat C. Nistagmus seesaw D. Nutan spasmus E. Bobbing ocular F. Flutter ocular G. Nistagmus Konvergens-retraksi H. Mioklonus Okular I. Nistagmus Abducting J. Nistagmus Bruns

E (Brazis, pp. 221- 232; Wi lkins, pp. 118-125).

92

92. Olive inferior ipsilateral, nukleus Red, nukleus dentate kontralateral (Segitiga Mollaret). A. Nistagmus downbeat B. Nistagmus upbeat C. Nistagmus seesaw D. Nutan spasmus E. Bobbing ocular F. Flutter ocular G. Nistagmus Konvergens-retraksi H. Mioklonus Okular I. Nistagmus Abducting J. Nistagmus Bruns

H (Brazis, pp. 221- 232; Wi lkins, pp. 118-125).

93

93. Medulla, tegmentum ventral dari pons, jalur serebellar A. Nistagmus downbeat B. Nistagmus upbeat C. Nistagmus seesaw D. Nutan spasmus E. Bobbing ocular F. Flutter ocular G. Nistagmus Konvergens-retraksi H. Mioklonus Okular I. Nistagmus Abducting J. Nistagmus Bruns

B (Brazis, pp. 221- 232; Wi lkins, pp. 118-125).

94

94. Cervicomedullary junction A. Nistagmus downbeat B. Nistagmus upbeat C. Nistagmus seesaw D. Nutan spasmus E. Bobbing ocular F. Flutter ocular G. Nistagmus Konvergens-retraksi H. Mioklonus Okular I. Nistagmus Abducting J. Nistagmus Bruns

A (Brazis, pp. 221- 232; Wi lkins, pp. 118-125).

95

95. Pontomedullary juction, jalur vestibular A. Nistagmus downbeat B. Nistagmus upbeat C. Nistagmus seesaw D. Nutan spasmus E. Bobbing ocular F. Flutter ocular G. Nistagmus Konvergens-retraksi H. Mioklonus Okular I. Nistagmus Abducting J. Nistagmus Bruns

J (Brazis, pp. 221- 232; Wi lkins, pp. 118-125).

96

96. Seorang pasien menderita memar kepala setelah tabrakan kendaraan bermotor dan tercatat menderita ecimosis pada mata kanan, dengan diplopia pada saat melihat ke bawah dan ke kiri. Diplopia ini paling mungkin mencerminkan kelemahan otot yang mana? A. Oblik Superior kanan B. Rektus atas kiri C. Rektus bawah kanan D. Oblik bawah kiri E. Oblik bawah kanan

A. Orbital injuries often impair the action of the superior oblique muscle because of displacement of the trochlea, which attaches to the anterior rim of the orbit and acts as a sling for the recurrent course of the trochlear tendon. Looking down and to the left typically involves the right superior oblique (trochlear nerve, IV) and left inferior rectus (oculomotor nerve, III) muscles. •when the eyes look conjugately toward any object, the muscle that is the prime moverworks in unison with the muscle of the opposite eye (Kline, pp. 105-114) .

97

97. Lesi yang ditunjukkan pada fotomikrograf di bawah ini mungkin berasosiasi dengan hal-hal di bawah ini, KECUALI A. Faktor keturunan dominan autosaomal B. Karsinoma sel ginjal C. Kiste Pankreatis D. Terlalu banyak produksi eritropoietin E. Gen penekan tumor yang memetakan kromosom 9p25

E. Note the numerous capillaries and cells with a vacuolated appearance in this. photomicrograph depicting a hemangioblastoma. This tumor is associated with VHL in about 25% of cases, is carried in an autosomal dominant fashion (chromosome 3p25), and is associated with retinal angioma, renal cell carcinoma, renal and pancreatic cysts, pheochromocytoma, or epididymal papillary cystadenoma. This tumor may cause polycythemia in about 1 0% of cases due to inappropriate production of erythropoietin (Ellison , pp. 736- 738) .

98

Ny. X, 47 tahun menjalani kliping aneurisma bifurkasi arteri serebral tengah yang pecah dan memerlukan transfusi darah selama menjalani perawatan pemulihan di UPI. Pasien mengalami hipotensi, demam. pusing, dan sakit punggung begitu menerima unit pertama sel darah merah paket (PRBC). 98. Etiologi manakah yang paling mungkin berdasarkan temuan ini? A. Sensititasi sebelumnya atas pasien yang tingkat antibodi-nya tidak terdeteksi pada saat pemeriksaan golongan darah. B. ABO tidak cocok C. Adanya berbagai antibodi antileukosit pada pasien yang terjadi pada transfusi darah sebelumnya. D. PRBC telah tercemar virus E. Jawaban A, B, C, dan D semuanya salah

B Acute hemolytic transfusion reactions are uncommon and are rarely life-threatening. They are produced by antibodies in the recipient that bind to ABO surface antigens or erythrocytes of mismatched do

99

Ny. X, 47 tahun menjalani kliping aneurisma bifurkasi arteri serebral tengah yang pecah dan memerlukan transfusi darah selama menjalani perawatan pemulihan di UPI. Pasien mengalami hipotensi, demam. pusing, dan sakit punggung begitu menerima unit pertama sel darah merah paket (PRBC). 99. Langkah pengelolaan berikutnya yang manakah yang paling perlu ditempuh? A. Transfusi harus diteruskan, tetapi harus diperiksa kadar haemoglobin dan bilirubin-nya B. Berikan dipendidramin (25 mg) IV segera dan lanjutkan transfusi C. Berikan Epineprin (1:1000) dengan dosis 0,5 mg setiap 10 sampai dengan 15 menit sampai reaksi perlawanan mereda. D. Transfusi harus segera dihentikan dan darah pasien harus dikirim untuk ditest kadar hemoglobin, Haptoglobin dan test Coombs. E. Hentikan transfusi, berikan asetaminopen dan dipenhidramin 30 menit sebelum melakukan transfusi darah berikutnya.

D Acute hemolytic transfusion reactions are uncommon and are rarely life-threatening. They are produced by antibodies in the recipient that bind to ABO surface antigens or erythrocytes of mismatched do

100

100. Tumor manakah yang merupakan tumor spinal cord intradural yang paling lazim pada pasien neurofibromastosis tipe II (NF-2)? A. Schwannoma B. Meningioma C. Paraganglioma D. Astrositoma E. Ependimoma

E. The presence of multiple intradural spinal cord tumors is relatively common with NF-2 and may include ependymomas (most common), schwannomas, and meningiomas (Greenberg, p . 478).

101

101. Rusaknya sel-sel piramidal dari “Ammon’s Horn” paling mungkin menyebabkan hilangnya proyeksi aksonal berat kepada struktur mana? A. Korteks subikulum dan entorhinal. B. Korteks pramotorik C. Amigdala D. Talamus Ventrilateral E. Kolikulus atas

A. The pyramidal neurons of the hippocampus (Ammon's horn) send numerous fiber projections to the subiculum and entorhinal cortex (area 28), which form the anterior part of the parahippocampal gyrus (Carpenter, pp. 369-382)

102

102. Apa yang ditunjukan pada fotomikrograf di bawah ini A. Hemangioperisitoma B. Medulloblastoma C. Melanoma D. Tumor rabdoid E. Germinoma

A. Note the "staghorn" vascular channel in this grade II hemangiopericytoma. These tumors are vimentin-positive, EMA-negative, have a dense arrangement of sheet-like cells, and have a high nuclear-cytoplasmic ratio. Other characteristics include focal lobularity, paucicellular areas, and dense pericellular reticulin (Ell ison, pp. 736-738).

103

103. Seorang pasien dibawa kepada seorang neurolog dengan riw 2 minggu lemah otot wajah kanan bawah. Jika pasien ini menderita apasia, jenis apasia manakah yang paling mungkin menyertai lemah pada wajah? A. Agrapia B. Alexia tanpa agraphia C. Apasia ekspresif D. Apasia fluent E. Agnosia kata auditoris

C. Lesions that occupy the anterior part of the left parasylvian fissure may cause a nonfluent type of aphasia (Broca's). This region may abut the parts of the motor cortex that supply • the upper motor neuron fibers for the contralateral facial nucleus. Therefore a patient with right-sided upper motor neuron facial deficit may also have an expressive-type of aphasia originating from Broca's area (Brazis, pp. 511-5 16)

104

104. Potongan koronal melalui bidang genu kapsula interna akan membelah struktur yang mana? A. Putamen B. Globus Pallidus C. Nukleus kaudate D. Hipotalamus E. Talamus

B. A coronal section through the genu of the internal capsule would almost exclusively bisect the globus pallidus, which is triangle-shaped, with its apex fitting into the genu of the internal capsule (Carpenter, pp. 33 7-344 ) .

105

105. Lesi yang dijelaskan di bawah ini paling mungkin berasal dari pembuluh darah yang mana? A. Arteri serebral tengah aksesoris B. Arteri frontopolar C. Arteri temporal anterior D. Arteri temporal belakang E. Lentikulostriata

C. The middle cerebral artery (l'dCA) is divided anatomically into four major segments:

106

106. Berapa persen pasien dengan perdarahan subaraknoid yang sekunder dari pecahnya aneurisma kemudian berkembang menjadi vasospasma angiografis ada suatu saat tertentu selama perawatan rawat inap mereka? A. 20% B. 30% C. 70% D. 80% E. 90%

C. Most patients develop some degree of vessel narrowing after aneurysmal subarachnoid hemorrhage. About 70% will develop angiographic vasospasm, and approximately 30% will go on to develop symptomatic vasospasm (Youmans, p. 1545).

107

107. Ny. X, 43 tahun dengan akromegali dan hasil MRI pasien menunjukkan adanya makroadenoma pituitaris 3 cm yang memanjang ke dalam sinus kavernosus kanan. Pandangan pasien normal dan kadar hormon pertumbuhan serum setelah pemicuan hiperglikemia adalah 220 mg/dl. Langkah berikutnya yang paling tepat dalam mengelola pasien ini bisa meliputi: A. Bedah trans-spenoidal B. Radiosurgeri C. Oktreotida D. Terapi radiasi konvensional E. A dan C.

E. Over the past few decades a variety of medical, surgical, and radiation interventions have evolved that have proven effective in reducing GH levels. No one treatment is uniformly effective, and often a combination of interventions is required. When a macroadenoma is surgically resected transsphenoidally, endocrine remission rates vary between 65 and 90%. When a macroadenoma is resected, immediate postoperative remission is reported to be even lower (30 and 79%) . The rate of remission is adversely affected by a higher preoperative GH level and larger invasive tumors. Therefore biochemical cure with surgery for large GH-secreting macroadenomas is typically not expected. Conventional radiation therapy can usually shrink pituitary tumors when up to 50 Gy is delivered in 1 . 8-Gy fractions over 6 weeks, but a decrease or normalization of GH levels usually takes many years. 'When initial GH levels are > 100 f!g/mL, only 60% of patients will attain GH levels

108

108. Vena talamostriata

A Figure 8. 108-8 . 1 16Q demonstrates the surgical anatomy of the right lateral and anterior third ventricle during endoscopic third ventriculostomy for aqueductal stenosis. The ventriculostomy site is depicted in the floor of the third ventricle in this figure. The veins of the third ventricular system collect into deeper veins that course in a subependymal location as they travel through the margins of the choroidal fissure to empty into the internal cerebral, basal, and great veins. In general, the veins draining the frontal horn and body of the third ventricle drain into the internal cerebral vein (not depicted here) as it courses through the velum interpositum; those draining the temporal horn drain into a segment of the basal vein of Rosenthal coursing through the ambient cistern; and the veins from the atrium drain into segments of the basal, internal cerebral, and great veins coursing through the quadrigeminal cistern. Of note, the thalamostriate vein passes forward in the sulcus between the caudate nucleus and thalamus toward the foramen of Monro (FOM), where it turns sharply posterior to enter the velum interpositum to join the internal cerebral vein. The angle formed by the junction of the internal cerebral vein and thalamostriate vein, referred to as the venous angle, approximates the level of the FOM on the lateral view of a cerebral angiogram (Wil ki ns, pp. 1427-1429; Youmans, pp. 1237 - 1240 ) .

109

109. Vena septal

D Figure 8. 108-8 . 1 16Q demonstrates the surgical anatomy of the right lateral and anterior third ventricle during endoscopic third ventriculostomy for aqueductal stenosis. The ventriculostomy site is depicted in the floor of the third ventricle in this figure. The veins of the third ventricular system collect into deeper veins that course in a subependymal location as they travel through the margins of the choroidal fissure to empty into the internal cerebral, basal, and great veins. In general, the veins draining the frontal horn and body of the third ventricle drain into the internal cerebral vein (not depicted here) as it courses through the velum interpositum; those draining the temporal horn drain into a segment of the basal vein of Rosenthal coursing through the ambient cistern; and the veins from the atrium drain into segments of the basal, internal cerebral, and great veins coursing through the quadrigeminal cistern. Of note, the thalamostriate vein passes forward in the sulcus between the caudate nucleus and thalamus toward the foramen of Monro (FOM), where it turns sharply posterior to enter the velum interpositum to join the internal cerebral vein. The angle formed by the junction of the internal cerebral vein and thalamostriate vein, referred to as the venous angle, approximates the level of the FOM on the lateral view of a cerebral angiogram (Wil ki ns, pp. 1427-1429; Youmans, pp. 1237 - 1240 ) .

110

110. Talamus

G Figure 8. 108-8 . 1 16Q demonstrates the surgical anatomy of the right lateral and anterior third ventricle during endoscopic third ventriculostomy for aqueductal stenosis. The ventriculostomy site is depicted in the floor of the third ventricle in this figure. The veins of the third ventricular system collect into deeper veins that course in a subependymal location as they travel through the margins of the choroidal fissure to empty into the internal cerebral, basal, and great veins. In general, the veins draining the frontal horn and body of the third ventricle drain into the internal cerebral vein (not depicted here) as it courses through the velum interpositum; those draining the temporal horn drain into a segment of the basal vein of Rosenthal coursing through the ambient cistern; and the veins from the atrium drain into segments of the basal, internal cerebral, and great veins coursing through the quadrigeminal cistern. Of note, the thalamostriate vein passes forward in the sulcus between the caudate nucleus and thalamus toward the foramen of Monro (FOM), where it turns sharply posterior to enter the velum interpositum to join the internal cerebral vein. The angle formed by the junction of the internal cerebral vein and thalamostriate vein, referred to as the venous angle, approximates the level of the FOM on the lateral view of a cerebral angiogram (Wil ki ns, pp. 1427-1429; Youmans, pp. 1237 - 1240 ) .

111

111. Pleksus koroid

B Figure 8. 108-8 . 1 16Q demonstrates the surgical anatomy of the right lateral and anterior third ventricle during endoscopic third ventriculostomy for aqueductal stenosis. The ventriculostomy site is depicted in the floor of the third ventricle in this figure. The veins of the third ventricular system collect into deeper veins that course in a subependymal location as they travel through the margins of the choroidal fissure to empty into the internal cerebral, basal, and great veins. In general, the veins draining the frontal horn and body of the third ventricle drain into the internal cerebral vein (not depicted here) as it courses through the velum interpositum; those draining the temporal horn drain into a segment of the basal vein of Rosenthal coursing through the ambient cistern; and the veins from the atrium drain into segments of the basal, internal cerebral, and great veins coursing through the quadrigeminal cistern. Of note, the thalamostriate vein passes forward in the sulcus between the caudate nucleus and thalamus toward the foramen of Monro (FOM), where it turns sharply posterior to enter the velum interpositum to join the internal cerebral vein. The angle formed by the junction of the internal cerebral vein and thalamostriate vein, referred to as the venous angle, approximates the level of the FOM on the lateral view of a cerebral angiogram (Wil ki ns, pp. 1427-1429; Youmans, pp. 1237 - 1240 ) .

112

112. Vena kaudate anterior

F Figure 8. 108-8 . 1 16Q demonstrates the surgical anatomy of the right lateral and anterior third ventricle during endoscopic third ventriculostomy for aqueductal stenosis. The ventriculostomy site is depicted in the floor of the third ventricle in this figure. The veins of the third ventricular system collect into deeper veins that course in a subependymal location as they travel through the margins of the choroidal fissure to empty into the internal cerebral, basal, and great veins. In general, the veins draining the frontal horn and body of the third ventricle drain into the internal cerebral vein (not depicted here) as it courses through the velum interpositum; those draining the temporal horn drain into a segment of the basal vein of Rosenthal coursing through the ambient cistern; and the veins from the atrium drain into segments of the basal, internal cerebral, and great veins coursing through the quadrigeminal cistern. Of note, the thalamostriate vein passes forward in the sulcus between the caudate nucleus and thalamus toward the foramen of Monro (FOM), where it turns sharply posterior to enter the velum interpositum to join the internal cerebral vein. The angle formed by the junction of the internal cerebral vein and thalamostriate vein, referred to as the venous angle, approximates the level of the FOM on the lateral view of a cerebral angiogram (Wil ki ns, pp. 1427-1429; Youmans, pp. 1237 - 1240 ) .

113

113. Vena koroidal superior

C Figure 8. 108-8 . 1 16Q demonstrates the surgical anatomy of the right lateral and anterior third ventricle during endoscopic third ventriculostomy for aqueductal stenosis. The ventriculostomy site is depicted in the floor of the third ventricle in this figure. The veins of the third ventricular system collect into deeper veins that course in a subependymal location as they travel through the margins of the choroidal fissure to empty into the internal cerebral, basal, and great veins. In general, the veins draining the frontal horn and body of the third ventricle drain into the internal cerebral vein (not depicted here) as it courses through the velum interpositum; those draining the temporal horn drain into a segment of the basal vein of Rosenthal coursing through the ambient cistern; and the veins from the atrium drain into segments of the basal, internal cerebral, and great veins coursing through the quadrigeminal cistern. Of note, the thalamostriate vein passes forward in the sulcus between the caudate nucleus and thalamus toward the foramen of Monro (FOM), where it turns sharply posterior to enter the velum interpositum to join the internal cerebral vein. The angle formed by the junction of the internal cerebral vein and thalamostriate vein, referred to as the venous angle, approximates the level of the FOM on the lateral view of a cerebral angiogram (Wil ki ns, pp. 1427-1429; Youmans, pp. 1237 - 1240 ) .

114

114. Forniks

E Figure 8. 108-8 . 1 16Q demonstrates the surgical anatomy of the right lateral and anterior third ventricle during endoscopic third ventriculostomy for aqueductal stenosis. The ventriculostomy site is depicted in the floor of the third ventricle in this figure. The veins of the third ventricular system collect into deeper veins that course in a subependymal location as they travel through the margins of the choroidal fissure to empty into the internal cerebral, basal, and great veins. In general, the veins draining the frontal horn and body of the third ventricle drain into the internal cerebral vein (not depicted here) as it courses through the velum interpositum; those draining the temporal horn drain into a segment of the basal vein of Rosenthal coursing through the ambient cistern; and the veins from the atrium drain into segments of the basal, internal cerebral, and great veins coursing through the quadrigeminal cistern. Of note, the thalamostriate vein passes forward in the sulcus between the caudate nucleus and thalamus toward the foramen of Monro (FOM), where it turns sharply posterior to enter the velum interpositum to join the internal cerebral vein. The angle formed by the junction of the internal cerebral vein and thalamostriate vein, referred to as the venous angle, approximates the level of the FOM on the lateral view of a cerebral angiogram (Wil ki ns, pp. 1427-1429; Youmans, pp. 1237 - 1240 ) .

115

115. Vena talamik superficial Superior

H Figure 8. 108-8 . 1 16Q demonstrates the surgical anatomy of the right lateral and anterior third ventricle during endoscopic third ventriculostomy for aqueductal stenosis. The ventriculostomy site is depicted in the floor of the third ventricle in this figure. The veins of the third ventricular system collect into deeper veins that course in a subependymal location as they travel through the margins of the choroidal fissure to empty into the internal cerebral, basal, and great veins. In general, the veins draining the frontal horn and body of the third ventricle drain into the internal cerebral vein (not depicted here) as it courses through the velum interpositum; those draining the temporal horn drain into a segment of the basal vein of Rosenthal coursing through the ambient cistern; and the veins from the atrium drain into segments of the basal, internal cerebral, and great veins coursing through the quadrigeminal cistern. Of note, the thalamostriate vein passes forward in the sulcus between the caudate nucleus and thalamus toward the foramen of Monro (FOM), where it turns sharply posterior to enter the velum interpositum to join the internal cerebral vein. The angle formed by the junction of the internal cerebral vein and thalamostriate vein, referred to as the venous angle, approximates the level of the FOM on the lateral view of a cerebral angiogram (Wil ki ns, pp. 1427-1429; Youmans, pp. 1237 - 1240 ) .

116

116. Nukleus kaudate

I Figure 8. 108-8 . 1 16Q demonstrates the surgical anatomy of the right lateral and anterior third ventricle during endoscopic third ventriculostomy for aqueductal stenosis. The ventriculostomy site is depicted in the floor of the third ventricle in this figure. The veins of the third ventricular system collect into deeper veins that course in a subependymal location as they travel through the margins of the choroidal fissure to empty into the internal cerebral, basal, and great veins. In general, the veins draining the frontal horn and body of the third ventricle drain into the internal cerebral vein (not depicted here) as it courses through the velum interpositum; those draining the temporal horn drain into a segment of the basal vein of Rosenthal coursing through the ambient cistern; and the veins from the atrium drain into segments of the basal, internal cerebral, and great veins coursing through the quadrigeminal cistern. Of note, the thalamostriate vein passes forward in the sulcus between the caudate nucleus and thalamus toward the foramen of Monro (FOM), where it turns sharply posterior to enter the velum interpositum to join the internal cerebral vein. The angle formed by the junction of the internal cerebral vein and thalamostriate vein, referred to as the venous angle, approximates the level of the FOM on the lateral view of a cerebral angiogram (Wil ki ns, pp. 1427-1429; Youmans, pp. 1237 - 1240 ) .

117

117. Cedera pembuluh vena talamostriate selama operasi 1. Cepat mengantuk 2. Infark hemorargis pada ganglia basal 3. Hemiparesis 4. Mutisme

E . Occlusion or injury of the thalamostriate vein may cause drowsiness, hemiplegia, mutism, and hemorrhagic infarction of the basal ganglia (Wilkins, pp. 1427-1429) .

118

118. Ciri-ciri mikroskopis khas dari cedera aksonal menyebar (DAI) 12 sampai 24 jam setelah terjadinya bisa mencakup 1. Astrogliosis 2. Bola retraksi aksonal 3. Makropagus Hemosiderin-laden 4. Perdarahan perivaskular

C. Acute microscopic changes after DAI typically include axonal retraction balls and perivascular hemorrhages, while in later stages there can be astrogliosis, endothelial proliferation, and accumulation of hemosiderin-laden macrophages (Marion, pp. 40-45; Ellison, pp. 249 - 2 5 7 ; Ramsey, pp. 431- 434)

119

119. Sampai seberapa jauhkah jarak iliac crest di bawah skiatic notch? A. 3 sampai dengan 4 cm B. 4 sampai dengan 5 cm C. 7 sampai dengan 8 cm D. 10 sampai dengan 12 cm E. 14 cm

C. In approaching the posterior ilium during autogenous iliac bone graft harvesting, a limited incision that stays within 8 em of the posterior superior iliac spine typically avoids the superior cluneal nerves. Dissection is then carried down to the gluteal fascia, which should be opened directly above the iliac crest to facilitate fascial closure. During subcrestal exposure, the lateral subperiosteal dissection should be carried to the gluteus medius and tensor fascia lata muscles. Subperiosteal dissection usually avoids damage to the superior gluteal artery, which courses through the musculature. The sciatic notch usually lies approximately 7 to 8 em below the iliac crest and must not be violated, as it harbors the main trunk of the sciatic artery, the sciatic nerve, and the CHAPTER 8 Multidisciplinary Self-Assessment Answers 273 ureter, which runs ventral to the superior gluteal artery. Medially, the dissection should extend to the iliacus muscle, which prevents injury to the iliohypogastric and ilioinguinal nerves (Connolly, pp. 819-820).

120

120. Etiologi kelainan pada scan MRI A. Iatrogenik C. Traumatis E. Neoplastis B. Infeksi D. Pertumbuhan

D Not the absence of the corpus callosum and the high-riding third ventricle on this sagittal MRI depicting agenesis of the corpus callosum. This condition is usually not associated with Chiari I malformation but rather with the Chiari II malformation (Osborn DN, pp. 29-33) .

121

121. Apa Diagnosisnya? A. Cedera aksonal menyebar B. Rusaknya saluran air Sylvius C. Meningitis D. Agenesis corpus callosum E. Obstruksi foramen Monro

D Not the absence of the corpus callosum and the high-riding third ventricle on this sagittal MRI depicting agenesis of the corpus callosum. This condition is usually not associated with Chiari I malformation but rather with the Chiari II malformation (Osborn DN, pp. 29-33) .

122

122. Berbagai kondisi terkaitnya mungkin mencakup hal-hal di bawah ini, KECUALI A. Skizensepali B. Malformasi Chiari I C. Malformasi Dandy-Walker D. Sepalokel E. Arteri serebral anterior azigos

B Not the absence of the corpus callosum and the high-riding third ventricle on this sagittal MRI depicting agenesis of the corpus callosum. This condition is usually not associated with Chiari I malformation but rather with the Chiari II malformation (Osborn DN, pp. 29-33) .

123

123. Otot-otot tendon manakah yang paling penting untuk mempertahankan stabilitas atlantoaksial? 1. Muskulus atlantal transverse (Porsi horisontal dari ligamentum kruciate) 2. Ligament apical 3. Ligamentum alar 4. Ikatan inferior ligamentum kruciate

B. Stability at the atlantoaxial unit is mainly provided by the horizontal portion of the cruciate ligament (transverse atlanta! ligament), and the paired alar lig

124

Seorang agen telemarketing usia 45 tahun telah mera-sakan bahwa pendengarannya terus menerus menurun selama beberapa bulan ini, dan baru-baru ini ditambah dengan melemahnya lengan kanannya. Hasil pemeriksaan fisik menunjukkan hasil gerak ekstraokular penuh, pergerakan wajah simetris, test Weber lateralisasi ke arah kanan, test Rinne menunjukkan konduksi tulang yang lebih baik dari konduksi udara pada sisi kiri, penyimpangan uvula sedikit ke arah kanan, dan lidah menyimpang ke arah kiri. Hasil MRI pasien ditunjukkan di bawah ini 124. Diagnosis manakah yang paling mungkin? A. Meningioma magnum foramen B. Neuroma akustik C. Tumor jugularis glomus D. Hemangioperisitoma E. Kordoma

C This patient harbors a glomus jugulare tumor, which often presents with unilateral hearing loss or pulsatile tinnitus. I ntracranial extension usually affects multiple cranial nerves, which may result in a number of clinical problems including dysphagia. Angiography is essential because it helps with surgical planning. It helps delineate the blood supply to the tumor as well as collateral blood flow to the brain. Often preoperative embolization is a useful adjunct for these highly vascular and locally invasive tumors. Although observation with serial imaging studies to determine tumor progression may be an appropriate option for medically frail patients, gross total resection is considered the treatment of choice for symptomatic lesions (Youmans, pp. 1295-1308)

125

Seorang agen telemarketing usia 45 tahun telah mera-sakan bahwa pendengarannya terus menerus menurun selama beberapa bulan ini, dan baru-baru ini ditambah dengan melemahnya lengan kanannya. Hasil pemeriksaan fisik menunjukkan hasil gerak ekstraokular penuh, pergerakan wajah simetris, test Weber lateralisasi ke arah kanan, test Rinne menunjukkan konduksi tulang yang lebih baik dari konduksi udara pada sisi kiri, penyimpangan uvula sedikit ke arah kanan, dan lidah menyimpang ke arah kiri. Hasil MRI pasien ditunjukkan di bawah ini 125. Strategi perawatan terbaik untuk pasien ini adalah A. Radiosurgeri B. Radiasi sinar-proton C. Observasi dengan MRI scans serial D. Percobaan reseksi gross total E. Radiasi sinar-ekstern konvensional

D This patient harbors a glomus jugulare tumor, which often presents with unilateral hearing loss or pulsatile tinnitus. I ntracranial extension usually affects multiple cranial nerves, which may result in a number of clinical problems including dysphagia. Angiography is essential because it helps with surgical planning. It helps delineate the blood supply to the tumor as well as collateral blood flow to the brain. Often preoperative embolization is a useful adjunct for these highly vascular and locally invasive tumors. Although observation with serial imaging studies to determine tumor progression may be an appropriate option for medically frail patients, gross total resection is considered the treatment of choice for symptomatic lesions (Youmans, pp. 1295-1308)

126

126. Mekanisme manakah yang paling memungkinkan untuk menjelaskan pola retakan yang ditunjukkan pada Gambar : A. Beban aksial langsung pd leher netral B. Beban aksial langsung pd leher fleksi C. Distraksi D. Beban aksial langsung pd leher miring lateral E. Hiperekstensi

A The fracture-pattern (Jefferson fracture) depicted on this axial CT scan most often results from an axial load on a neutral neck. These patients are usually neurologically intact due to the large diameter of the spinal canal at this level. If the sum of. overhang of both lateral masses on C2 is 7 mm, the transYerse ligament js probably disrupted, which requires rigid immobilization (usually with a halo vest) or surgical fi..xation if additional fractures are present (Greenberg, pp. 702-703 )

127

127. Berapa jumlah ekskursi dari massa lateral CI diluar sumbu yang menunjukkan rusaknya otot transverse…mm A. 4 B. 5 C. 6 D. 7 E. 9

D The fracture-pattern (Jefferson fracture) depicted on this axial CT scan most often results from an axial load on a neutral neck. These patients are usually neurologically intact due to the large diameter of the spinal canal at this level. If the sum of. overhang of both lateral masses on C2 is 7 mm, the transYerse ligament js probably disrupted, which requires rigid immobilization (usually with a halo vest) or surgical fi..xation if additional fractures are present (Greenberg, pp. 702-703 )

128

128. Sebuah lesi pada saraf fasial distal dari ganglion genikulate tetapi proksimal dengan foramen stilomastoid akan menyebabkan semua defisit di bawah ini, KECUALI A. Dahi tidak bisa mengernyit B. Refleks kornea melemah C. Gangguan sekresi kelenjar sublingual dan submandibular D. Hiperakusis E. Gangguan lakrimasi

E A lesion o f the facial nerve distal t o the geniculate ganglion but proximal to the stylomastoid foramen typically results in complete paralysis of all ipsilateral facialmuscles, a diminished corneal reflex (with preserved corneal sensation, CN V), impaired sublingual and submandibular salivary gland secretions, hyperacusis, and frequently loss of taste in the anterior two-thirds of the tongue ipsilaterally. Hyperacusis results from paralysis of the stapedius muscle, while salivary secretions are impaired due to the interruption of preganglionic parasympathetic fibers. Lesions proximal to the geniculate ganglion produce all of the disturbances described above and invariably loss of taste in the anterior two-thirds of the tongue and decreased lacrimation. This lesion interrupts all SVA fibers that course centrally and all preganglionic (GVE) fibers as they pass to the pterygopalatine and submandibular ganglia. Taste is permanently lost and no regeneration of sensory fibers takes place. Preganglionic parasympathetic fibers may regenerate, but this may occur in an aberrant fashion. Fibers that previously projected to the submandibular ganglion may regrow and enter the greater petrosal nerve, which may result in lacrimation after a salivary stimulus ("crocodile tears") (Carpenter, pp. 1 72-173)

129

129. “Air mata buaya” disebabkan regenerasi menyimpang dari serat mana? A. Serat parasimpatetis yang sebelumnya terproyeksi kepada ganglion submandibular dan kemungkinan tumbuh kembali dan memasuki saraf petrosal besar B. Serat-serat parasimpatetis yang sebelumnya terproyeksi kepada ganglion submandibular yang kemungkinan tumbuh kembali dan memasuki saraf petrosal kecil. C. Serat-serat parasimpatetis dari nukleus Adinger-Westphal yang secara menyimpang terproyeksi kepada saraf petrosal besar D. Serat-serat saraf trigeminal yang secara menyimpang terproyeksi kepada nukleus salivatoris atas. E. Serat-serat parasimpatetis yang sebelumnya terproyeksi kepada kelenjar lakrimal dan kemungkinan tumbuh kembali dan memasuki saraf petrosal kecil

A A lesion o f the facial nerve distal t o the geniculate ganglion but proximal to the stylomastoid foramen typically results in complete paralysis of all ipsilateral facialmuscles, a diminished corneal reflex (with preserved corneal sensation, CN V), impaired sublingual and submandibular salivary gland secretions, hyperacusis, and frequently loss of taste in the anterior two-thirds of the tongue ipsilaterally. Hyperacusis results from paralysis of the stapedius muscle, while salivary secretions are impaired due to the interruption of preganglionic parasympathetic fibers. Lesions proximal to the geniculate ganglion produce all of the disturbances described above and invariably loss of taste in the anterior two-thirds of the tongue and decreased lacrimation. This lesion interrupts all SVA fibers that course centrally and all preganglionic (GVE) fibers as they pass to the pterygopalatine and submandibular ganglia. Taste is permanently lost and no regeneration of sensory fibers takes place. Preganglionic parasympathetic fibers may regenerate, but this may occur in an aberrant fashion. Fibers that previously projected to the submandibular ganglion may regrow and enter the greater petrosal nerve, which may result in lacrimation after a salivary stimulus ("crocodile tears") (Carpenter, pp. 1 72-173)

130

130. Traktus mammilotalamik mengandung serat-serat yang terproyeksi dari nukleus mamilaris medial kepada struktur yang mana? A. Pulvinar B. Nukleus talamik anterior C. Nuklei tegmental dorsal dan ventral D. Nukleus sentromedian (CM) dari thalamus E. Nukleus talamik belakang ventral

B. Mammillary fibers projecting from the medial mammillary nucleus and, to a lesser extent, intermediate and lateral mammillary nuclei form a fiber bundle called the fasciculus mammillaris princes, which divides into two components: the mammillothalamic tract and mammillotegmental tract. The mammillothalamic tract contains fibers that originate from the .medial mammillary nucleus and project to the anterior thalamic nucleus. Fibers from the hippocampus are also superimposed on this fiber bundle as they travel to the anterior thalamic nucleus through the fornix. The mammillotegmental tract terminates in the dorsal and ventral tegmental nuclei (Carpenter, p. 309)

131

131. Serat-serat silang dari nukleus fastigial muncul dari serebelum melalui struktur yang mana? A. Saluran fastigial-tektak B. Ulcinate Fasciculus (dari Russell) C. Batang jukstarestiform D. Pedunkel serebellar tengah E. Saluran fastigial-rubral

B. Crossed fibers from the fastigial nucleus emerge from the cerebellum through the uncinate fasciculus of Russell, which arches . around the superior cerebellar peduncle. Uncrossed fastigial efferents project to the brainstem in the juxtarestiform body. The largest number of fastigial efferents project to structures in the lower brainstem (nucleus reticularis gigantocellularis, central pontine reticular formation, dorsal paramedian reticular nucleus). A small number of fibers ascend in the dorsolateral brainstem and send collaterals to the superior colliculus and nuclei of the posterior commissure prior to terminating in various thalamic regions (VLc and VPLo) (Carpenter, pp. 241-243 )

132

132. Beberapa dampak ekscitatoris sistem saraf simpatetis yang kekurangan oposisi parasimpatetik meliputi 1. Kontraksi kapsul splenik 2. Berkeringat dan piloereksi 3. Naiknya alis bagian atas 4. Mengerutnya dinding bladder

A . Some excitatory effects o f the sympathetic nervous system that lack parasympathetic opposition include

133

133. Mekanisme benjolan cedera manakah yang paling mungkin menjelaskan cedera kelainan yang ditunjukkan pada Gambar di bawah ini A. Hiperekstesi dan pembebanan aksial B. Beban aksial pada leher netral C. Beban aksial pada leher miring lateral D. Hiperfleksi parah dan beban aksial E. Hipertensi dan distraksi

A The mechanism of most modern hangman's fractures results from hyperextension and axial loading (diving and motor vehicle accidents), while judicial hangings often resulted in hyperextension and distractive forces from submeatal knot placement. Patients rarely require surgical intervention for this type of fracture, which is typically reserved for irreducible fractures, failure of external immobilization, traumatic C2-3 elise herniation (with canal compromise and progressive neurologic deficit), and established nonunion. All fusion techniques typically involve fusing C2 to C3, although the majority of patients can be successfully treated with a cervical collar, SOMI brace, or halo vest (most common) (Greenberg, pp. 704-706) .

134

134. Opsi terapeutiknya bisa mencakup hal-hal di bawah ini, KECUALI A. Servikal collar B. Immobilisasi vest Halo C. Reduksi terbuka dengan fiksasi interna (C2 ke C3) D. Skrup odontoid E. Brace SOMI

D The mechanism of most modern hangman's fractures results from hyperextension and axial loading (diving and motor vehicle accidents), while judicial hangings often resulted in hyperextension and distractive forces from submeatal knot placement. Patients rarely require surgical intervention for this type of fracture, which is typically reserved for irreducible fractures, failure of external immobilization, traumatic C2-3 elise herniation (with canal compromise and progressive neurologic deficit), and established nonunion. All fusion techniques typically involve fusing C2 to C3, although the majority of patients can be successfully treated with a cervical collar, SOMI brace, or halo vest (most common) (Greenberg, pp. 704-706) .

135

135. Semua hal di bawah ini berasosiasi dengan sindroma Klippel-Feil, KECUALI A. Deformitas Sprengel B. Tidak adanya sebelah ginjal C. Tuli D. Skoliosis E. Naevus flammeus

E. Klippel-Feil syndrome ranges from fusion of only a few vertebral bodies to fusion of the entire spine. It results from failure of somite segregation between 3 and 8 weeks' gestation. The classic triad (usually present in

136

136. Fontanelle anterior A. 2 sampai dengan 3 bulan B. 1 tahun C. 2,5 tahun D. Jawaban A, B dan salah semua

C The anterior fontanelle, the largest fontanelle, is diamond-shaped and normally closes by 2 . 5 years of age. The posterior fontanelle is triangle-shaped and closes by 2 to 3 months. The sphenoid and mastoid fontanelles are smaller, more irregular, and usually close by 2 to 3 months and 1 year, respectively (Greenberg, p. 138).

137

137. Fontanelle posterior A. 2 sampai dengan 3 bulan B. 1 tahun C. 2,5 tahun D. Jawaban A, B dan salah semua

A The anterior fontanelle, the largest fontanelle, is diamond-shaped and normally closes by 2 . 5 years of age. The posterior fontanelle is triangle-shaped and closes by 2 to 3 months. The sphenoid and mastoid fontanelles are smaller, more irregular, and usually close by 2 to 3 months and 1 year, respectively (Greenberg, p. 138).

138

138. Fontanelle spenoid A. 2 sampai dengan 3 bulan B. 1 tahun C. 2,5 tahun D. Jawaban A, B dan salah semua

A The anterior fontanelle, the largest fontanelle, is diamond-shaped and normally closes by 2 . 5 years of age. The posterior fontanelle is triangle-shaped and closes by 2 to 3 months. The sphenoid and mastoid fontanelles are smaller, more irregular, and usually close by 2 to 3 months and 1 year, respectively (Greenberg, p. 138).

139

139. Fontanelle mastoid A. 2 sampai dengan 3 bulan B. 1 tahun C. 2,5 tahun D. Jawaban A, B dan salah semua

B The anterior fontanelle, the largest fontanelle, is diamond-shaped and normally closes by 2 . 5 years of age. The posterior fontanelle is triangle-shaped and closes by 2 to 3 months. The sphenoid and mastoid fontanelles are smaller, more irregular, and usually close by 2 to 3 months and 1 year, respectively (Greenberg, p. 138).

140

140. Pasokan darah kepada dura berasal dari arteri yang mana? 1. Arteri optalamik 2. Arteri oksipital 3. Arteri vertebral 4. Arteri maksilaris

E. Blood supply to the dura originates from the middle meningeal artery, which is a branch of the maxillary artery. It enters the skull through the foramen spinosum. The ophthalmic artery (anterior meningeal branches) and occipital and vertebral arteries (posterior meningeal arteries) also provide meningeal branches to the dura (Carpenter, pp. 1-2 )

141

141. Berapa pembuluh besar yang berasal dari busur aorta? A. 2 B. 3 C. 4 D. 5 E. 6

B. The typical order o f the three great vessels that originate from the aortic arch is the brachiocephalic trunk (innominate artery) followed by the left common carotid artery (LCCA) and then left subclavian artery (LSCA). This configuration is fatind in approximately two-thirds of all cases. A shared origin of the brachiocephalic trunk and left common carotid artery is seen in 27% (most frequentvariant) of cases, while in 7% of cases the left common carotid artery arises from the proximal brachiocephalic artery instead of the aortic arch. In 1 to 2% of cases, the LCCA and LSCA share a common origin and form a left-sided brachiocephalic trunk (Osborn DCA, p. 16).

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142. Ny. X, 38 tahun mengeluh ptosis dan diplopia yang hilang timbul selama sekitar 4 bulan. Dia tidak mengalami gangguan kelemahan otot pernafasan atau ujung-ujung anggota badan, tapi ditemukan adanya antibodi-antibodi untuk myofibrilar protein selama pemeriksaannya. Semua pernyataan di bawah ini mengenai kondisi tersebut adalah benar, KECUALI A. Diagnosis dapat diperkuat dengan pemberian endroponium klorida, yang memulihkan kelemahan ototnya B. Elektromiografi (EMG) serat-tunggal mungkin akan menunjukkan “jitter” dan “blocking” C. Tanda denervasi seringkali tampak dari hasil EMG selama tahap-tahap terakhir penyakit ini. D. Antibodi melawan protein non-serat ini mungkin menjadi gejala awal simptomatologi klinis E. Terapi prednisone, plasmaferesis dan/atau IVIG dapat digunakan untuk pasien denganpenyakit yang sifatnya umum atau krisis pernafasan

C. Formal diagnosis of myasthenia gravis depends on demonstration of response to cholinergic medications, EMG evidence of abnormal neuromuscular transmission ("jitter," "blocking"), and identification of circulating antibodies to Ach receptors or myofibrillar proteins such as actin, titin, myosin, and actinomycin (in approximately 85 to 90% of cases). In single-muscle-fiber EMG studies, an electrode measures the interval between evoked potentials of muscle fibers in the same unit. This interval normally varies by "jitter", for which the temporal limits have been defined. In myasthenia gravis, "jitter" is increased. If muscle fibers are not activated due to abnormal neuromuscular transmission, it is called "blocking. " Myasthenia gravis is characterized by both "blocking" and increased "jitter," although these findings are not specific for myasthenia gravis, as other disorders may show a similar response on EMG studies. Signs of denervation are almost never seen in disorders of ACh release unless other conditions supervene. Cholinergic medications should be stopped once an endotracheal tube has been placed to reduce the amount of pulmonary secretions. Prednisone, plasmapheresis, and IVIG therapy have all been used in patients with generalized disease and/or respiratorycrisis. Thymectomy is generally recommended for patients with generalized myasthenia gravis, not ocular myasthenia (Merritt, pp. 723 - 726)

143

143. Sulfatase β Jodohkanlah gangguan (mukopolisakaridosis) dengan kelainan enzimnya, A. Hurler B. Hunter C. Sanfilippo A D. Sanfilippo B E. Morquio A F. Morkuio B G. Maroteaux-Lanny H. Sly I. Jawaban A sampai dG H semuanya salah.

G Refer to Table 8. 143- 8. 148A (Merritt, p. 525) .

144

144. Galaktosidase-β Jodohkanlah gangguan (mukopolisakaridosis) dengan kelainan enzimnya, A. Hurler B. Hunter C. Sanfilippo A D. Sanfilippo B E. Morquio A F. Morkuio B G. Maroteaux-Lanny H. Sly I. Jawaban A sampai dG H semuanya salah.

F Refer to Table 8. 143- 8. 148A (Merritt, p. 525) .

145

145. Sulfamidase Jodohkanlah gangguan (mukopolisakaridosis) dengan kelainan enzimnya, A. Hurler B. Hunter C. Sanfilippo A D. Sanfilippo B E. Morquio A F. Morkuio B G. Maroteaux-Lanny H. Sly I. Jawaban A sampai dG H semuanya salah.

C Refer to Table 8. 143- 8. 148A (Merritt, p. 525) .

146

146. Sulfatase Galakose-6-sulfat Jodohkanlah gangguan (mukopolisakaridosis) dengan kelainan enzimnya, A. Hurler B. Hunter C. Sanfilippo A D. Sanfilippo B E. Morquio A F. Morkuio B G. Maroteaux-Lanny H. Sly I. Jawaban A sampai dG H semuanya salah.

E Refer to Table 8. 143- 8. 148A (Merritt, p. 525) .

147

147. Sulfatase idurnat-2-sulfat Jodohkanlah gangguan (mukopolisakaridosis) dengan kelainan enzimnya, A. Hurler B. Hunter C. Sanfilippo A D. Sanfilippo B E. Morquio A F. Morkuio B G. Maroteaux-Lanny H. Sly I. Jawaban A sampai dG H semuanya salah.

B Refer to Table 8. 143- 8. 148A (Merritt, p. 525) .

148

148. α-L-Iduronidase Jodohkanlah gangguan (mukopolisakaridosis) dengan kelainan enzimnya, A. Hurler B. Hunter C. Sanfilippo A D. Sanfilippo B E. Morquio A F. Morkuio B G. Maroteaux-Lanny H. Sly I. Jawaban A sampai dG H semuanya salah.

A Refer to Table 8. 143- 8. 148A (Merritt, p. 525) . 149.

149

149. Diantara struktur-struktur di bawah ini, struktur manakah yang mengirimkan jumlah proyeksi paling banyak kepada striatum? A. Nukleus subtalamik B. Korteks serebral C. Substantia nigra D. Serebelum E. Urat tulang

B. The largest quantity of afferents projecting to the striatum originate in the cerebral cortex, although the amygdala, intralaminar nuclei of the thalamus, the substantia nigra, and dorsal raphe nucleus send fibers to various parts of the striatum as well (Carpenter, pp. 332 -336).

150

150. Atetosis Jodohkanlah letak lesi di bawah ini dengan gambaran klinisnya A. Amigdala B. Substantia nigra C. Di sekitar nukleus red D. Status marmoratus dari corpus striatum dan thalamus E. Nukleus subtalamus

D Athetoid movements are slow, writhing movements predominately of the hand and wrist, while dystonia characteristically affects the axial muscles. The lesion "status marmoratus" characterizes one form of cerebral palsy, which consists of a "marbled appearance of the corpus striatum and thalamus secondary to perinatal hypoxia. Hypoxic damage i n. these areas results i n overgrowth o f astrocytes a s part o f the healing process. Oligodendrocytes then mistakenly myelinate astrocytic processes, which causes white patches to appear in the nuclei, giving them a marbled appearance. Damage to the striatum and thalamus from other causes such as infarcts may also result in athetosis. Lesions of the substantia nigra can result in rigidity -and resting tremor, which are some of the hallmarks of Parkinson's disease. Lesions of the subthalamicnucleus can produce hemiballism, while terminal tremor, ataxia, and CN III palsy usually result from injury in the vicinity of the red nucleus. Bilateral lesions of the amygdala can produce the Kliiver-Bucy syndrome, which is characterized by visual agnosia, oral-exploratory behavior, hypersexuality, hypomotility, and hypem1etamorphosis (tendency to take notice and attend to every visual stimulus) (Brazis, pp. 433-436, 439-442, 552; Merritt, pp. 681-682)

151

151. Kaku dan tremor saat istirahat Jodohkanlah letak lesi di bawah ini dengan gambaran klinisnya A. Amigdala B. Substantia nigra C. Di sekitar nukleus red D. Status marmoratus dari corpus striatum dan thalamus E. Nukleus subtalamus

B Athetoid movements are slow, writhing movements predominately of the hand and wrist, while dystonia characteristically affects the axial muscles. The lesion "status marmoratus" characterizes one form of cerebral palsy, which consists of a "marbled appearance of the corpus striatum and thalamus secondary to perinatal hypoxia. Hypoxic damage i n. these areas results i n overgrowth o f astrocytes a s part o f the healing process. Oligodendrocytes then mistakenly myelinate astrocytic processes, which causes white patches to appear in the nuclei, giving them a marbled appearance. Damage to the striatum and thalamus from other causes such as infarcts may also result in athetosis. Lesions of the substantia nigra can result in rigidity -and resting tremor, which are some of the hallmarks of Parkinson's disease. Lesions of the subthalamicnucleus can produce hemiballism, while terminal tremor, ataxia, and CN III palsy usually result from injury in the vicinity of the red nucleus. Bilateral lesions of the amygdala can produce the Kliiver-Bucy syndrome, which is characterized by visual agnosia, oral-exploratory behavior, hypersexuality, hypomotility, and hypem1etamorphosis (tendency to take notice and attend to every visual stimulus) (Brazis, pp. 433-436, 439-442, 552; Merritt, pp. 681-682)

152

152. Palsy CN III dan tremor terminal Jodohkanlah letak lesi di bawah ini dengan gambaran klinisnya A. Amigdala B. Substantia nigra C. Di sekitar nukleus red D. Status marmoratus dari corpus striatum dan thalamus E. Nukleus subtalamus

C Athetoid movements are slow, writhing movements predominately of the hand and wrist, while dystonia characteristically affects the axial muscles. The lesion "status marmoratus" characterizes one form of cerebral palsy, which consists of a "marbled appearance of the corpus striatum and thalamus secondary to perinatal hypoxia. Hypoxic damage i n. these areas results i n overgrowth o f astrocytes a s part o f the healing process. Oligodendrocytes then mistakenly myelinate astrocytic processes, which causes white patches to appear in the nuclei, giving them a marbled appearance. Damage to the striatum and thalamus from other causes such as infarcts may also result in athetosis. Lesions of the substantia nigra can result in rigidity -and resting tremor, which are some of the hallmarks of Parkinson's disease. Lesions of the subthalamicnucleus can produce hemiballism, while terminal tremor, ataxia, and CN III palsy usually result from injury in the vicinity of the red nucleus. Bilateral lesions of the amygdala can produce the Kliiver-Bucy syndrome, which is characterized by visual agnosia, oral-exploratory behavior, hypersexuality, hypomotility, and hypem1etamorphosis (tendency to take notice and attend to every visual stimulus) (Brazis, pp. 433-436, 439-442, 552; Merritt, pp. 681-682)

153

153. Sindroma KLUVER-BUCY Jodohkanlah letak lesi di bawah ini dengan gambaran klinisnya A. Amigdala B. Substantia nigra C. Di sekitar nukleus red D. Status marmoratus dari corpus striatum dan thalamus E. Nukleus subtalamus

A Athetoid movements are slow, writhing movements predominately of the hand and wrist, while dystonia characteristically affects the axial muscles. The lesion "status marmoratus" characterizes one form of cerebral palsy, which consists of a "marbled appearance of the corpus striatum and thalamus secondary to perinatal hypoxia. Hypoxic damage i n. these areas results i n overgrowth o f astrocytes a s part o f the healing process. Oligodendrocytes then mistakenly myelinate astrocytic processes, which causes white patches to appear in the nuclei, giving them a marbled appearance. Damage to the striatum and thalamus from other causes such as infarcts may also result in athetosis. Lesions of the substantia nigra can result in rigidity -and resting tremor, which are some of the hallmarks of Parkinson's disease. Lesions of the subthalamicnucleus can produce hemiballism, while terminal tremor, ataxia, and CN III palsy usually result from injury in the vicinity of the red nucleus. Bilateral lesions of the amygdala can produce the Kliiver-Bucy syndrome, which is characterized by visual agnosia, oral-exploratory behavior, hypersexuality, hypomotility, and hypem1etamorphosis (tendency to take notice and attend to every visual stimulus) (Brazis, pp. 433-436, 439-442, 552; Merritt, pp. 681-682)

154

154. Hemibalisme Jodohkanlah letak lesi di bawah ini dengan gambaran klinisnya A. Amigdala B. Substantia nigra C. Di sekitar nukleus red D. Status marmoratus dari corpus striatum dan thalamus E. Nukleus subtalamus

E Athetoid movements are slow, writhing movements predominately of the hand and wrist, while dystonia characteristically affects the axial muscles. The lesion "status marmoratus" characterizes one form of cerebral palsy, which consists of a "marbled appearance of the corpus striatum and thalamus secondary to perinatal hypoxia. Hypoxic damage i n. these areas results i n overgrowth o f astrocytes a s part o f the healing process. Oligodendrocytes then mistakenly myelinate astrocytic processes, which causes white patches to appear in the nuclei, giving them a marbled appearance. Damage to the striatum and thalamus from other causes such as infarcts may also result in athetosis. Lesions of the substantia nigra can result in rigidity -and resting tremor, which are some of the hallmarks of Parkinson's disease. Lesions of the subthalamicnucleus can produce hemiballism, while terminal tremor, ataxia, and CN III palsy usually result from injury in the vicinity of the red nucleus. Bilateral lesions of the amygdala can produce the Kliiver-Bucy syndrome, which is characterized by visual agnosia, oral-exploratory behavior, hypersexuality, hypomotility, and hypem1etamorphosis (tendency to take notice and attend to every visual stimulus) (Brazis, pp. 433-436, 439-442, 552; Merritt, pp. 681-682)

155

155. Arteri-arteri yang memasok thalamus meliputi: 1. Arteri koroidal anterior 2. Arteri komunikan posterior 3. Arteri koroidal posterior medial 4. Arteri basilar

E. The thalamus receives its arterial supply from the anterior choroidal artery ( ICA) and thalamoperforating arteries (PComA and basilar artery) as well as the thalamogeniculate and posterior choroidal arteries (PCA). Infarctions may occur in each of these thalamic territories and cause various clinical syndromes, depending on which thalamic nuclei are involved (Carpenter, pp. 441- 450).

156

156. Diagnosis mana yang paling mungkin? A. Toksoplasmosis B. Penyakit Alzheimer C. Neurokistiserkosis D. Echinococcus E. Cedera urat tulang

B. Note the prominent diffuse plaques traversed by neuronal processes in this patient with Alzheimer's disease. Diffuse amyloid plaques are extracellular, ill-defined focal aggregates of amyloid and preamyloid material and are approximately 60 to 300 mm in diameter. Neuronal cell processes traversing the plaque typically appear normal and do not contain tau protein ( Ell ison, pp. 553-557)

157

157. Retak teardrop Jodohkanlah retak tulang servik dengan mekanismenya yang paling mungkin A. Beban sumbu/tekanan pada leher netral B. Hiperekstensi dan beban aksial C. Hiperekstansi dan distraksi D. Hiperfleksi dan putaran aksial E. Hiperfleksi dan Tekanan F. Hiperfleksi dan distraksi G. Hiperfleksi H. Pembungkukan dan tekanan lateral I. Jawaban A s/d H semuanya salah

E. Occipital condylar and burst fractures are often the result of purely axial compressive forces on a neutral neck, while teardrop and compression-wedge fractures result from compressive force on a flexed neck. Other injury or fracture patterns in the cervical spine include unilateral (axial rotation, flexing) and bilateral locked (hyperflexion and distraction) facets, Chance fracture (flexion, distraction), and unila teral facet fracture (lateral bending, compression) . Odontoid fractures usually result from hyperflexion injuries and result in anterior displacement of C2 on C3. (Greenberg, pp. 702- 7 14; Youmans, pp. 517-523, 4896-4897 , 4927 ; Harris, pp. 69- 91)

158

158. Sebelah faset copot Jodohkanlah retak tulang servik dengan mekanismenya yang paling mungkin A. Beban sumbu/tekanan pada leher netral B. Hiperekstensi dan beban aksial C. Hiperekstansi dan distraksi D. Hiperfleksi dan putaran aksial E. Hiperfleksi dan Tekanan F. Hiperfleksi dan distraksi G. Hiperfleksi H. Pembungkukan dan tekanan lateral I. Jawaban A s/d H semuanya salah

D Occipital condylar and burst fractures are often the result of purely axial compressive forces on a neutral neck, while teardrop and compression-wedge fractures result from compressive force on a flexed neck. Other injury or fracture patterns in the cervical spine include unilateral (axial rotation, flexing) and bilateral locked (hyperflexion and distraction) facets, Chance fracture (flexion, distraction), and unila teral facet fracture (lateral bending, compression) . Odontoid fractures usually result from hyperflexion injuries and result in anterior displacement of C2 on C3. (Greenberg, pp. 702- 7 14; Youmans, pp. 517-523, 4896-4897 , 4927 ; Harris, pp. 69- 91)

159

159. Retakan brust Jodohkanlah retak tulang servik dengan mekanismenya yang paling mungkin A. Beban sumbu/tekanan pada leher netral B. Hiperekstensi dan beban aksial C. Hiperekstansi dan distraksi D. Hiperfleksi dan putaran aksial E. Hiperfleksi dan Tekanan F. Hiperfleksi dan distraksi G. Hiperfleksi H. Pembungkukan dan tekanan lateral I. Jawaban A s/d H semuanya salah

A Occipital condylar and burst fractures are often the result of purely axial compressive forces on a neutral neck, while teardrop and compression-wedge fractures result from compressive force on a flexed neck. Other injury or fracture patterns in the cervical spine include unilateral (axial rotation, flexing) and bilateral locked (hyperflexion and distraction) facets, Chance fracture (flexion, distraction), and unila teral facet fracture (lateral bending, compression) . Odontoid fractures usually result from hyperflexion injuries and result in anterior displacement of C2 on C3. (Greenberg, pp. 702- 7 14; Youmans, pp. 517-523, 4896-4897 , 4927 ; Harris, pp. 69- 91)

160

160. Kedua belah faset dislokasi Jodohkanlah retak tulang servik dengan mekanismenya yang paling mungkin A. Beban sumbu/tekanan pada leher netral B. Hiperekstensi dan beban aksial C. Hiperekstansi dan distraksi D. Hiperfleksi dan putaran aksial E. Hiperfleksi dan Tekanan F. Hiperfleksi dan distraksi G. Hiperfleksi H. Pembungkukan dan tekanan lateral I. Jawaban A s/d H semuanya salah

F Occipital condylar and burst fractures are often the result of purely axial compressive forces on a neutral neck, while teardrop and compression-wedge fractures result from compressive force on a flexed neck. Other injury or fracture patterns in the cervical spine include unilateral (axial rotation, flexing) and bilateral locked (hyperflexion and distraction) facets, Chance fracture (flexion, distraction), and unila teral facet fracture (lateral bending, compression) . Odontoid fractures usually result from hyperflexion injuries and result in anterior displacement of C2 on C3. (Greenberg, pp. 702- 7 14; Youmans, pp. 517-523, 4896-4897 , 4927 ; Harris, pp. 69- 91)

161

161. Sebelah faset retak Jodohkanlah retak tulang servik dengan mekanismenya yang paling mungkin A. Beban sumbu/tekanan pada leher netral B. Hiperekstensi dan beban aksial C. Hiperekstansi dan distraksi D. Hiperfleksi dan putaran aksial E. Hiperfleksi dan Tekanan F. Hiperfleksi dan distraksi G. Hiperfleksi H. Pembungkukan dan tekanan lateral I. Jawaban A s/d H semuanya salah

H Occipital condylar and burst fractures are often the result of purely axial compressive forces on a neutral neck, while teardrop and compression-wedge fractures result from compressive force on a flexed neck. Other injury or fracture patterns in the cervical spine include unilateral (axial rotation, flexing) and bilateral locked (hyperflexion and distraction) facets, Chance fracture (flexion, distraction), and unila teral facet fracture (lateral bending, compression) . Odontoid fractures usually result from hyperflexion injuries and result in anterior displacement of C2 on C3. (Greenberg, pp. 702- 7 14; Youmans, pp. 517-523, 4896-4897 , 4927 ; Harris, pp. 69- 91)

162

162. Retakan wedge karena tekanan Jodohkanlah retak tulang servik dengan mekanismenya yang paling mungkin A. Beban sumbu/tekanan pada leher netral B. Hiperekstensi dan beban aksial C. Hiperekstansi dan distraksi D. Hiperfleksi dan putaran aksial E. Hiperfleksi dan Tekanan F. Hiperfleksi dan distraksi G. Hiperfleksi H. Pembungkukan dan tekanan lateral I. Jawaban A s/d H semuanya salah

E Occipital condylar and burst fractures are often the result of purely axial compressive forces on a neutral neck, while teardrop and compression-wedge fractures result from compressive force on a flexed neck. Other injury or fracture patterns in the cervical spine include unilateral (axial rotation, flexing) and bilateral locked (hyperflexion and distraction) facets, Chance fracture (flexion, distraction), and unila teral facet fracture (lateral bending, compression) . Odontoid fractures usually result from hyperflexion injuries and result in anterior displacement of C2 on C3. (Greenberg, pp. 702- 7 14; Youmans, pp. 517-523, 4896-4897 , 4927 ; Harris, pp. 69- 91)

163

163. Retak kondilar oksipital Jodohkanlah retak tulang servik dengan mekanismenya yang paling mungkin A. Beban sumbu/tekanan pada leher netral B. Hiperekstensi dan beban aksial C. Hiperekstansi dan distraksi D. Hiperfleksi dan putaran aksial E. Hiperfleksi dan Tekanan F. Hiperfleksi dan distraksi G. Hiperfleksi H. Pembungkukan dan tekanan lateral I. Jawaban A s/d H semuanya salah

A Occipital condylar and burst fractures are often the result of purely axial compressive forces on a neutral neck, while teardrop and compression-wedge fractures result from compressive force on a flexed neck. Other injury or fracture patterns in the cervical spine include unilateral (axial rotation, flexing) and bilateral locked (hyperflexion and distraction) facets, Chance fracture (flexion, distraction), and unila teral facet fracture (lateral bending, compression) . Odontoid fractures usually result from hyperflexion injuries and result in anterior displacement of C2 on C3. (Greenberg, pp. 702- 7 14; Youmans, pp. 517-523, 4896-4897 , 4927 ; Harris, pp. 69- 91)

164

164. Retak odontoid Jodohkanlah retak tulang servik dengan mekanismenya yang paling mungkin A. Beban sumbu/tekanan pada leher netral B. Hiperekstensi dan beban aksial C. Hiperekstansi dan distraksi D. Hiperfleksi dan putaran aksial E. Hiperfleksi dan Tekanan F. Hiperfleksi dan distraksi G. Hiperfleksi H. Pembungkukan dan tekanan lateral I. Jawaban A s/d H semuanya salah

G Occipital condylar and burst fractures are often the result of purely axial compressive forces on a neutral neck, while teardrop and compression-wedge fractures result from compressive force on a flexed neck. Other injury or fracture patterns in the cervical spine include unilateral (axial rotation, flexing) and bilateral locked (hyperflexion and distraction) facets, Chance fracture (flexion, distraction), and unila teral facet fracture (lateral bending, compression) . Odontoid fractures usually result from hyperflexion injuries and result in anterior displacement of C2 on C3. (Greenberg, pp. 702- 7 14; Youmans, pp. 517-523, 4896-4897 , 4927 ; Harris, pp. 69- 91)

165

165. Apa yang ditunjukkan pada fotomikrograf di bawah ini? A. papiloma pleksus koloid B. Ependimoma C. Kranioparingioma adamantinomatus D. Kordoma E. Meningioma angiomatus

C. Note the squamous cells. peripheral palisading of nuclei, and nodules of wet keratin in this adamantinomatous craniopharyngioma (Ellison, pp. 724-72 7 ; WHO, pp. 244- 246).

166

166. Semua entitas di bawah ini mungkin diperhitungkan pada berbagai diagnosis vertigo yang asalnya bersifat peripheral, KECUALI A. Penyakit Meniere B. Vertigo posisional paroksimal jinak C. Hidrop endolimpatis sekunder D. Neuronitis vestibular E. Kelainan kraniovertebral junction

E. Approximately 90% of cases of vertigo are likely secondary to lesions of the vestibular end organs or vestibular nerves, while the rest usually originate from the central nervous system, including craniocervical junction abnormalities (Merritt, pp. 28-30). .

167

167. Cabang-cabang utama saraf manakah yang menginervasi dura supratentorial 1. Saraf servikal atas 2. Saraf glosoparingeal 3. Saraf Vagus 4. Saraf trigeminal

D. The supratentorial dura is innervated primarily by branches of the trigeminal nen•E. while the infratentorial dura is innervated by branches of the vagus and lower cervical spinal nerves ( Carpenter, p. 2 )

168

168. Seorang penyanyi pesta perkawinan di kota anda dibawa ke kantor anda dengan riwayat sakit leher dan sedikit mati rasa pada lengan dan tangan kirinya. Hasil MRI pasien kami sajikan di bawah ini . Manakah Diagnosisnya yang paling mungkin? A. Kiste sinovial B. Kiste jukstafaset C. Hipertropi dari ligamentum flavum D. Herniasi disk E. Osifikasi otot lintang belakang (OPLL)

D Depicted here is an axial a n d parasagittal MRI showing a soft (mainly disc material) posterolateral disc herniation of the cervical spine that is eccentric to the left. Considering that this disc herniation is not purely central, i t may b e amenable to a posterolateral procedure in a n attempt to preserve vocal cord function (posterior keyhole laminotomy) in this wedding singer. Over 90% of patients with acute cervical radiculopathy will improve with nonsurgical therapy including adequate pain medication and antiinflammatories. Surgery is indicated for those who fail to improve or develop progressive neurologic deficits while undergoing nonsurgical therapy. A number of large series have reported good or excellent results in 90 to 96% of patients who underwent a posterior approach for such disc herniations (Greenberg, pp. 3 10-314).

169

Seorang penyanyi pesta perkawinan di kota anda dibawa ke kantor anda dengan riwayat sakit leher dan sedikit mati rasa pada lengan dan tangan kirinya. Hasil MRI pasien kami sajikan di bawah ini . Manakah Diagnosisnya yang paling mungkin? 169. Simptomatologi pasien ini tidak pulih setelah 6 minggu terapi non-bedah. A. Disektomi dan fusi servik muka B. Leminektomi servik belakang C. Laminotomi lubang kunci posterior D. Korpektomi dan fusi servik depan E. Kostotransversektomi

C Depicted here is an axial a n d parasagittal MRI showing a soft (mainly disc material) posterolateral disc herniation of the cervical spine that is eccentric to the left. Considering that this disc herniation is not purely central, i t may b e amenable to a posterolateral procedure in a n attempt to preserve vocal cord function (posterior keyhole laminotomy) in this wedding singer. Over 90% of patients with acute cervical radiculopathy will improve with nonsurgical therapy including adequate pain medication and antiinflammatories. Surgery is indicated for those who fail to improve or develop progressive neurologic deficits while undergoing nonsurgical therapy. A number of large series have reported good or excellent results in 90 to 96% of patients who underwent a posterior approach for such disc herniations (Greenberg, pp. 3 10-314).

170

170. Manakah diantara hal-hal di bawah ini yang berasosiasi dengan tumor yolk sac? 1. Positivitas AFP 2. Positivitas β-HCG 3. Badan Schiller-Dural 4. Positivitas fosfatase alkalin plasenta

B. Yolk sac tumor is a germ cell tumor that exhibits loosely arranged cells with clear cytoplasm and prominent eosinophilic bodies. Yolk sac tumors are positive for AFP, and they often exhibit Schiller-Duval bodies ( Ellison, p. 683).

171

171. Pasien dengan akromegali memerlukan penggarapan anestetis pra-bedah yang sangat cermat karena seringkali mereka memiliki temuan-temuan klinis yang mana? 1. Makroglosia 2. Enzim pengubah angeotensis tinggi 3. Kardiomiopati 4. Telangiestasia nasal

B. Meticulous preoperative anesthetic workup is extremely important for acromegalic patients, since they frequently exhibit cardiomyopathy and macroglossia , which can be associated with a difficult airway (Youmans, p. 569)

172

172. Penyakit HUNTINGTON terutama mempengaruhi proyeksi-proyeksi dari striatum ke arah segmen luar dari globus Pallidus? A. Kolinergis B. Adrenergik C. GABA/enkepalin D. Glutamat E. Serotinin

C. HD primarily affects the GABA/enkephalin projections from the striatum to the external segment of the globus pallidus (indirect pathway), resulting in thalamic facilitation of motor cortical areas and hyperkinesia (Merritt, pp. 659- 662 )

173

173. Apa yang ditunjukkan oleh Gambar di bawah ini? A. Ksantoaktrositoma pleomorfis B. Ependimoma C. Koriokarsinoma D. Medulloblastoma E. Adenohipofisis

E . Note the prominent lobules o f cells with a n intervening vascular network of sinusoids in this photomicrograph of a normal adenohypophysis ( Ellison, p. 716)

174

174. Seorang bayi yang baru dilahirkan menderita sindroma Meckel-Gruber. Etiologi manakah yang paling mungkin untuk kelainan ini? A. Ibu sang bayi menderita diabetes B. Selama tiga minggu usia kandungan, ibu sang bayi terlalu banyak mengkonsumsi alkohol C. Pada usia kandungan ke 20 sampai dengan 26 hari, sang ibu mengalami hipertermia D. Kekurangan folat E. Jawaban A, B, C dan D semuanya salah.

C. Meckel-Gruber syndrome typically includes encephalocele, microcephaly, microphthalmia, cleft lip, polydactyly, polycystic kidneys, congenital heart disease, and ambiguous genitalia; it is most often associated with maternal hyperthermia on gestational days 20 to 26 ( Rudolph, p. 156)

175

175. Pelepasan satu kuantum asetilkolin menimbulkan respons pasca-sinaptik tipe mana? A. Potensi endplate B. Penjumlahan waktu C. Penjumlahan ruang D. Potensial endplate miniatur E. Dispersi waktu

D. The release of a single quantum of acetylcholine ( 10,000 molecules of ACh) produces a miniature endplate potential (MEPP) in the postsynaptic membrane, which is not significant enough to generate an action potential. The summation of several quanta is required to induce enough depolarization in the postsynaptic cell membrane to result in an action potential ( Kandel, pp. 255-262)

176

176. Nitrit Oksida (NO) menimbulkan generasi pembawa pesan kedua yang mana? A. cAMP B. cGMP C. Diasilgliserol (DAG) D. Inositol 1, 4, 5-triosfat E. Protein kinase C

B. Nitric oxide (NO) is produced in neurons by the Ca2+/calmodulin-dependent enzyme NO synthasE. NO, in turn, stimulates the synthesis of cGMP through the action of guanylyl cyclase, an enzyme that converts GTP to cGMP. NO • acts locally and is primarily released from endothelial cells to induce smooth muscle relaxation and blood vessel dilation (Kandel, p. 239)

177

177. Fungsi-fungsi Golgi kompleks meliputi semua hal di bawah ini, KECUALI, A. Glikosilasi terkait O dan N B. Pembentukan proteoglikan C. Sulfasi residu arginine D. Melekatnya asam lemak pada protein E. Fosforilasi polisakarida

C. Neuronal cytoplasmic organelles include rough and smooth endoplasmic reticulum, endosomes, secretory vesicles, lysosomes, peroxisomes, mitochondria, and the Golgi apparatus. Proteins and phospholipids destined for secretion are initially synthesized in the rough endoplasmic reticulum (rER). These products are then transported to the Golgi apparatus via transport vesicles for processing (although N-linked glycosylation and glycolipid conjugation are initiated in the rER) . The Golgi complex further modifies these proteins by adding polysaccharides, which can direct specific proteins to secretory vesicles, lysosomes, and the plasma membranE. Golgi processing includes glycosylation reactions (0-linked and N-linked glycosylation), proteoglycan formation, polysaccharide phosphorylation, attachment of fatty acids, and sulfation of tyrosine (not arginine) and sugar residues. This processing increases the hydrophilicity (solubility) of these proteins, increases their biological activity, or helps delay their degradation by proteases. Clathrin coats facilitate the budding of vesicles from the Golgi complex. Secretory vesicles (dense-core vesicles) are targeted primarily to axon terminals, where they participate in calciumregulated exocytosis after action potential propagation (Kandel, pp. 67-7 1, 94-9 7)

178

178. Manakah yang paling bertanggung jawab atas selektivitas tinggi dari hambatan darah-ke-otak (BBB)? A. Proses-proses kaki astositik yang menutupi sel-sel endothelial terfenetrasi B. Tight junction antara sel-sel endothelial tak terfenetrasi. C. Lamina basal yang meluas dan mengelilingi sel-sel endothelial D. Selaput dasar, endothelium kapilaris, dan proses kaku atrositis E. Eksklusi antigen-antigen asing oleh selaput neuronal super-selektif

B. The EBB is primarily composed of tight junctions between nonfenestrated endothelial cells. These endothelial cells are also deficient in vesicular transport compared to endothelial cells elsewhere in the body, which further contributes to the selectivity of the EBB. The resistance provided by the tight junctions between endothelial cells in the brain is extremely high. Substances may cross the EBB by diffusion, active transport, carrier-mediated transport, and through ion channels. Lipid-soluble substances readily diffuse across endothelial cell membranes i n to the brain; hence the permeability of many substances is directly related to their lipid-solubility. Specific carrier-mediated transport is responsible for the entry of most substances into the brain. The glucose transporter (Glut1) is energy-independent, thus transporting only glucose down its concentration gradient from the bloodstream into the brain. There are also three distinct carrier systems for amino acid transport across the EBB. The L system transports large neutral branched-chain amino acids and L-DOPA into the brain. A transport system that is a member of the multiple-drug-resistance (MDR) transporter family found i n tumor cells removes a wide range of hydrophobic toxins and chemotherapeutic agents from the brain. Additionally, specific ion channels allow the movement of electrolytes across the BBB. A metabolic BBB also exists due to the presence of certain enzymes that rapidly metabolize substances as they enter the CNS. An example is the high concentration of DOPA decarboxylase i n epithelial cells that rapidly metabolize L-DOPA as it enters the brain CHAPTER 8 Multidisciplinary Self-Assessment Answers 2 77 unless a DOPA decarboxylase inhibitor (carbidopa) is also administered (Kandel, pp. 1288-1294).

179

179. Struktur otak manakah yang memiliki konsentrasi senyawa P yang tertinggi? A. Talamus B. Kelenjar pineal C. Hipotalamus D. Substantia nigra E. Amigdala

D. The substantia nigra has the highest concentration of substance P in the brain. Striatonigral projections from the caudate nucleus and putamen contain GABA, substance P, and enkephalin (Carpenter, pp. 2 15.-221)

180

180. Tn. X, 54 tahun dibawa ke UGD dg kejang tonik-klonik umum dan riwayat 6 bulan perubahan perilaku. Angiogram lateral pasien di bwh ini . Diagnosis? A. Hidrosepalus dari tumor ventrikular ketiga yang merusak foramen Monro. B. Glioblastoma C. Meningioma olfactory groove D. Kranioparingioma E. Malformasi arteri-vena

C. Note that the anterior cerebral arteries are being pushed upward on this lateral angiogram, depicting an olfactory groove meningiomA. These lesions often grow insidiously, causing gradual compression of the frontal lobes; thus they are quite large and bilateral by the time of presentation. Common signs/symptoms may include headaches, personality changes, visual loss, anosmia, and seizures. A bifrontal transbasal approach is frequently used in resecting these tumors, although a unilateral subfrontal or frontotemporal (pterional) craniotomy can also be useD. The anterior and posterior ethmoid arteries typically supply olfactory groove meningiomas (Kaye and Black, pp. 523 -532 ; Youmans, pp. 1115-1115)

181

Tn. X, 54 tahun dibawa ke UGD dg kejang tonik-klonik umum dan riwayat 6 bulan perubahan perilaku. Angiogram lateral pasien di bwh ini . Diagnosis? 181. Pasokan darah yang paling lazim untuk lesi ini berasal dari pembuluh-pembuluh darah yang mana? A. Arteri hipofiseal atas B. Cabang meningeal depan dari arteri maksilaris C. Arteri temporal permukaan D. Cabang meningeal depan dari arteri karotid dalam kavernus E. Arteri-arteri etmoidal anterior dan posterior

E. Note that the anterior cerebral arteries are being pushed upward on this lateral angiogram, depicting an olfactory groove meningiomA. These lesions often grow insidiously, causing gradual compression of the frontal lobes; thus they are quite large and bilateral by the time of presentation. Common signs/symptoms may include headaches, personality changes, visual loss, anosmia, and seizures. A bifrontal transbasal approach is frequently used in resecting these tumors, although a unilateral subfrontal or frontotemporal (pterional) craniotomy can also be useD. The anterior and posterior ethmoid arteries typically supply olfactory groove meningiomas (Kaye and Black, pp. 523 -532 ; Youmans, pp. 1115-1115)

182

182. Distropi otot Duchene (DMD) A. Resesif rantai-X B. Dominan autosomal C. Resesif autosomal

A Charcot-Marie-Tooth (GMT) disease, or peroneal muscular atrophy, accounts for about 90% of all hereditary neuropathies, of which there are three types. CMT-1 , the most common, is autosomal dominant and is a demyelinating disease that results in a distal sensorimotor neuropathy. It results from mutations in peripheral myelin protein 22 (PMP-22), exhibits slowed nerve conduction velocities, and exhibits onion-bulb formations on histopathologic studies. CMT-2 resembles CMT-1 but results in axonal degeneration instead of demyelination. GMT-3, also known as Dejerine-Sottas syndrome, is autosomal dominant and results in a hypertrophic demyelinating neuropathy. DMD is an X-li nked recessive condition that results from mutation of the dystrophin gene, located at Xp2 1 . Patients often have difficulty rising from the ground and rely heavily on the arms to raise the torso and legs (Gowers' sign ) . These patients may also exhibit toe-walking and develop an exaggerated lumbar lordosis or scoliosis as well as pseudohypertrophy of the calves from fibrosis and fatty infiltration of degenerating muscle MD is a trinucleotide repeat disorder that results from mutation of the dystrophia myotonica protein kinase gene on chromosome 1 9 . It is a pleiotropic, autosomal dominant disorder affecting the skeletal muscle, heart, eyes, and exocrine glands. The myopathy of MD affects se\'eral cranial nerves (ptosis, dysarthria, dysphagia) and the distal extremities (finger flexors and extensors) . Patients exhibit myotonia (impaired muscle relaxation), cataracts, frontal balding, testicular atrophy, retinal degeneration, cardiomyopathy, and an increased incidence of mental retardation. FSHMD is an autosomal dominant disorder that results in scapular winging, facial weakness, shoulder girdle weakness, and lower extremity weakness (Merritt, pp. 737-7 46)

183

183. Distropi otot faskioskapulohumeral (FSHMD) A. Resesif rantai-X B. Dominan autosomal C. Resesif autosomal

B Charcot-Marie-Tooth (GMT) disease, or peroneal muscular atrophy, accounts for about 90% of all hereditary neuropathies, of which there are three types. CMT-1 , the most common, is autosomal dominant and is a demyelinating disease that results in a distal sensorimotor neuropathy. It results from mutations in peripheral myelin protein 22 (PMP-22), exhibits slowed nerve conduction velocities, and exhibits onion-bulb formations on histopathologic studies. CMT-2 resembles CMT-1 but results in axonal degeneration instead of demyelination. GMT-3, also known as Dejerine-Sottas syndrome, is autosomal dominant and results in a hypertrophic demyelinating neuropathy. DMD is an X-li nked recessive condition that results from mutation of the dystrophin gene, located at Xp2 1 . Patients often have difficulty rising from the ground and rely heavily on the arms to raise the torso and legs (Gowers' sign ) . These patients may also exhibit toe-walking and develop an exaggerated lumbar lordosis or scoliosis as well as pseudohypertrophy of the calves from fibrosis and fatty infiltration of degenerating muscle MD is a trinucleotide repeat disorder that results from mutation of the dystrophia myotonica protein kinase gene on chromosome 1 9 . It is a pleiotropic, autosomal dominant disorder affecting the skeletal muscle, heart, eyes, and exocrine glands. The myopathy of MD affects se\'eral cranial nerves (ptosis, dysarthria, dysphagia) and the distal extremities (finger flexors and extensors) . Patients exhibit myotonia (impaired muscle relaxation), cataracts, frontal balding, testicular atrophy, retinal degeneration, cardiomyopathy, and an increased incidence of mental retardation. FSHMD is an autosomal dominant disorder that results in scapular winging, facial weakness, shoulder girdle weakness, and lower extremity weakness (Merritt, pp. 737-7 46)

184

184. Distropi otot miotonik (MD) A. Resesif rantai-X B. Dominan autosomal C. Resesif autosomal

B Charcot-Marie-Tooth (GMT) disease, or peroneal muscular atrophy, accounts for about 90% of all hereditary neuropathies, of which there are three types. CMT-1 , the most common, is autosomal dominant and is a demyelinating disease that results in a distal sensorimotor neuropathy. It results from mutations in peripheral myelin protein 22 (PMP-22), exhibits slowed nerve conduction velocities, and exhibits onion-bulb formations on histopathologic studies. CMT-2 resembles CMT-1 but results in axonal degeneration instead of demyelination. GMT-3, also known as Dejerine-Sottas syndrome, is autosomal dominant and results in a hypertrophic demyelinating neuropathy. DMD is an X-li nked recessive condition that results from mutation of the dystrophin gene, located at Xp2 1 . Patients often have difficulty rising from the ground and rely heavily on the arms to raise the torso and legs (Gowers' sign ) . These patients may also exhibit toe-walking and develop an exaggerated lumbar lordosis or scoliosis as well as pseudohypertrophy of the calves from fibrosis and fatty infiltration of degenerating muscle MD is a trinucleotide repeat disorder that results from mutation of the dystrophia myotonica protein kinase gene on chromosome 1 9 . It is a pleiotropic, autosomal dominant disorder affecting the skeletal muscle, heart, eyes, and exocrine glands. The myopathy of MD affects se\'eral cranial nerves (ptosis, dysarthria, dysphagia) and the distal extremities (finger flexors and extensors) . Patients exhibit myotonia (impaired muscle relaxation), cataracts, frontal balding, testicular atrophy, retinal degeneration, cardiomyopathy, and an increased incidence of mental retardation. FSHMD is an autosomal dominant disorder that results in scapular winging, facial weakness, shoulder girdle weakness, and lower extremity weakness (Merritt, pp. 737-7 46)

185

185. Sakit Gigi-Charcot-Marie A. Resesif rantai-X B. Dominan autosomal C. Resesif autosomal

B Charcot-Marie-Tooth (GMT) disease, or peroneal muscular atrophy, accounts for about 90% of all hereditary neuropathies, of which there are three types. CMT-1 , the most common, is autosomal dominant and is a demyelinating disease that results in a distal sensorimotor neuropathy. It results from mutations in peripheral myelin protein 22 (PMP-22), exhibits slowed nerve conduction velocities, and exhibits onion-bulb formations on histopathologic studies. CMT-2 resembles CMT-1 but results in axonal degeneration instead of demyelination. GMT-3, also known as Dejerine-Sottas syndrome, is autosomal dominant and results in a hypertrophic demyelinating neuropathy. DMD is an X-li nked recessive condition that results from mutation of the dystrophin gene, located at Xp2 1 . Patients often have difficulty rising from the ground and rely heavily on the arms to raise the torso and legs (Gowers' sign ) . These patients may also exhibit toe-walking and develop an exaggerated lumbar lordosis or scoliosis as well as pseudohypertrophy of the calves from fibrosis and fatty infiltration of degenerating muscle MD is a trinucleotide repeat disorder that results from mutation of the dystrophia myotonica protein kinase gene on chromosome 1 9 . It is a pleiotropic, autosomal dominant disorder affecting the skeletal muscle, heart, eyes, and exocrine glands. The myopathy of MD affects se\'eral cranial nerves (ptosis, dysarthria, dysphagia) and the distal extremities (finger flexors and extensors) . Patients exhibit myotonia (impaired muscle relaxation), cataracts, frontal balding, testicular atrophy, retinal degeneration, cardiomyopathy, and an increased incidence of mental retardation. FSHMD is an autosomal dominant disorder that results in scapular winging, facial weakness, shoulder girdle weakness, and lower extremity weakness (Merritt, pp. 737-7 46)

186

186. Penyakit DEJERINE-SOTTAS A. Resesif rantai-X B. Dominan autosomal C. Resesif autosomal

B Charcot-Marie-Tooth (GMT) disease, or peroneal muscular atrophy, accounts for about 90% of all hereditary neuropathies, of which there are three types. CMT-1 , the most common, is autosomal dominant and is a demyelinating disease that results in a distal sensorimotor neuropathy. It results from mutations in peripheral myelin protein 22 (PMP-22), exhibits slowed nerve conduction velocities, and exhibits onion-bulb formations on histopathologic studies. CMT-2 resembles CMT-1 but results in axonal degeneration instead of demyelination. GMT-3, also known as Dejerine-Sottas syndrome, is autosomal dominant and results in a hypertrophic demyelinating neuropathy. DMD is an X-li nked recessive condition that results from mutation of the dystrophin gene, located at Xp2 1 . Patients often have difficulty rising from the ground and rely heavily on the arms to raise the torso and legs (Gowers' sign ) . These patients may also exhibit toe-walking and develop an exaggerated lumbar lordosis or scoliosis as well as pseudohypertrophy of the calves from fibrosis and fatty infiltration of degenerating muscle MD is a trinucleotide repeat disorder that results from mutation of the dystrophia myotonica protein kinase gene on chromosome 1 9 . It is a pleiotropic, autosomal dominant disorder affecting the skeletal muscle, heart, eyes, and exocrine glands. The myopathy of MD affects se\'eral cranial nerves (ptosis, dysarthria, dysphagia) and the distal extremities (finger flexors and extensors) . Patients exhibit myotonia (impaired muscle relaxation), cataracts, frontal balding, testicular atrophy, retinal degeneration, cardiomyopathy, and an increased incidence of mental retardation. FSHMD is an autosomal dominant disorder that results in scapular winging, facial weakness, shoulder girdle weakness, and lower extremity weakness (Merritt, pp. 737-7 46)

187

187. Manakah diantara pernyataan di bawah ini yang benar mengenai saraf peroneal common. 1. Muncul dari devisi dorsal dari pleksus sakral (L4, L5, S1, dan S2) 2. Dimulai pada margin rostal dari fossa popliteal 3. Mengikuti batas medial otot femoris bisep 4. Meninggalkan fossa poplieal dengan melewati permukaan ke lateral kepala dari otot gastroenemius

E. The common peroneal nerve (L4-S2) innervates the extensors and adductors of the leg (and part of the biceps femoris) and gives rise to the lateral sural cutaneous nerve (to the inferolateral leg), the deep peroneal nerve, and the superficial peroneal nervE. The deep peroneal nerve innervates the tibialis anterior, extensor hallucis longus, and extensor digitorum longus muscles. The superficial peroneal nerve innervates the peroneus longus/brevis (foot eversion) and the skin of the distal anterior leg, dorsum of the foot, and digits. Lesions of the common peroneal nerve mainly result in paralysis of dorsiflexion (footdrop) and foot eversion (Patten, p. 3 1 1 ; G reenberg, pp. 522, 545).

188

188. Patologi yang paling lazim pada epilepsi lobe temporal adalah selerosis hipokampal. Jumlah kerusakan minimalnya biasanya tampak pada sektor hipokampus yang mana? A. CA1 B. CA2 C. VA3 D. CA4 E. A, B, C, dan D benar.

B. Hippocampal sclerosis usually has a very characteristic pattern in patients with mesial temporal lobe epilepsy. The greatest amount of damage is usually seen in the CAl and CA4 sectors, while the least amount of damage occurs in CA2. Synaptic reorganization of granule cell mossy fibers is usually a characteristic feature of hippocampal sclerosis (Committee on Education in Neurological Surgery, pp. 20, 110; Mathern et a l . , pp. 105-113).

189

189. Semua pernyataan di bawah ini adalah benar mengenaiproksimal asidosis tubular ginjal (tipe II) dekat, KECUALI A. Tubula ginjal prosimal tidak biasa menyerap kembali HCO3 dengan tepat. B. Biasanya rendah untuk K+ serum normal. C. Neprokalsinosis dapat menyertai gangguan ini. D. pH urine

C. Nephrocalcinosis frequently accompanies type I, or distal, renal tubular acidosis (RTA). In type 1 RTA, the proximal reabsorption of HCO; is adequate, but the ability of the distal tubule to secrete H+ ions is inadequatE. The urine pH remains above 5 . 5 , and hypokalemia, hypercalcemia, nephrocalcinosis, and osteomalacia frequently accompany this abnormality. Moderate amounts of bicarbonate therapy may correct the acidosis. With type II RTA, the ability of the proximal tubule to reabsorb HCO; is compromised; HCO; is lost in the urine and acidemia develops secondary to the inability of the distal tubule to reabsorb the flood of HCO;. Eventually, the serum HCO; decreases to a point where the proximal renal tubule can reabsorb most of the reduced HCO; load, while the remainder is reclaimed in the distal tubulE. This maintains the urine pH

190

190. Diagnosis? A. Tumor disembrioplastis neuroepitelial (DNT) B. Neurositoma sentral C. Ksantoastrositoma pleomorfik (PXA) D. Astrositoma sel besar (GCA) E. Glioma kordoid ventrikel ketiga

A This lesion i s most consistent with a DNT (WliO grade I ) . Patients usually present with long-standing drug-resistant partial seizures that begin before the age of 20. They are usually found in the temporal lobe or other supratentorial location and typically encompass the cerebral cortex. On occasion, they appear to deform the overlying calvarium, a finding that further supports the diagnosis of DNT. The histologic hallmark of this tumor is the glioneuronal element, which is shown here to consist of a free-floating neuron in a microcyst surrounded by oligodendroglial-like cells (Ellison, pp. 659-661; WHO, pp. 103-106)

191

191. Apa tanda histologis dari lesi ini? A. Seat Rosenthal B. Astrosit Alzheimer II C. Unsur glioneuronal D. Reaktivitas sinaptopisin E. Sel-sel nuklease dengan penampilan Bizarre

C This lesion i s most consistent with a DNT (WliO grade I ) . Patients usually present with long-standing drug-resistant partial seizures that begin before the age of 20. They are usually found in the temporal lobe or other supratentorial location and typically encompass the cerebral cortex. On occasion, they appear to deform the overlying calvarium, a finding that further supports the diagnosis of DNT. The histologic hallmark of this tumor is the glioneuronal element, which is shown here to consist of a free-floating neuron in a microcyst surrounded by oligodendroglial-like cells (Ellison, pp. 659-661; WHO, pp. 103-106)

192

192. Pasien yang mengalami lesi ini biasanya juga menderita A. Meningitis B. kejang-kejang C. hemorase D. diseminasi lepromeningeal E. Hidrosepalus

B This lesion i s most consistent with a DNT (WliO grade I ) . Patients usually present with long-standing drug-resistant partial seizures that begin before the age of 20. They are usually found in the temporal lobe or other supratentorial location and typically encompass the cerebral cortex. On occasion, they appear to deform the overlying calvarium, a finding that further supports the diagnosis of DNT. The histologic hallmark of this tumor is the glioneuronal element, which is shown here to consist of a free-floating neuron in a microcyst surrounded by oligodendroglial-like cells (Ellison, pp. 659-661; WHO, pp. 103-106)

193

193. Semua pernyataan di bawah ini mungkin dapat terlihat dengan anemia mikrositis hipokromis, KECUALI A. Rata-rata hitung volume korpuskular (MCV) yang rendah B. Poikilositosis C. Kapasitas pengikat besi yang tinggi D. Menurunnya secara dini rata-rata hitung konsentrasi hemoglobin korpuskular (MCHS) E. Ferritin serum rendah

D. Although the MCV progressively decreases as the anemia becomes more severe, the MCHC usually remains normal until the hematocrit values drop below 30%. As the anemia becomes more marked, the red blood cells become progressively more distorted (poikilocytosis), the TIBC begins to increase, the ferritin levels drop, the serum iron stores begin to fall, and the bone marrow iron stores become depleteD. Causes of anemia with low MCV include iron deficiency (pregnancy, GI bleeding), thalassemia, anemia of chronic inflammation, sideroblastic anemia, and aluminum toxicity ( Fishman, pp. 345-34 7 ; Barker, pp. 620-623)

194

194. Tingkat serum valproat mungkin meningkat setelah pemberian obat yang mana? 1. Penitoin 2. Klozapin 3. Penobarbital 4. Etosuksimid

B . The addition of phenytoin and phenobarbital most often increases the serum concentration of valproate (Geyer, p. 2 13 )

195

195. Semua pernyataan di bawah ini adalah benar mengenai Polimiositis dan myositis bodi inklusi (IBM), KECUALI A. IBM memiliki kemungkinan lebih tinggi untuk mempengaruhi otot jauh dari polimiositis kurus kaki B. IBM lebih jarang tampak berasosiasi dengan penyakit vaskular kolagen atau autoimun C. Polimiositis jarang memberi respons kepada steroid, sementara IBM mungkin lebih sering memberi respons. D. IBM mempengaruhi pasien dengan usia tua E. Biopsi otot pada pasien dengan IBM membuktikan peradangan dan budi inklusi dengan “rimmed vacuoles” yang mengandung amiloid.

C. IBM affects proximal limb muscles, but in contrast to polymyositis, is much more likely to affect the distal muscles of the legs. It commonly occurs in men after the age of 50 and has less of an association with autoimmune and collagen vascular diseases than polymyositis. Wl1ereas polymyositis does respond to steroids, IBM has no widely accepted therapy, as steroids have shown minimal benefit (Merritt, pp. 767 - 768).

196

196. Semua hal di bawah ini menyebabkan sindroma saluran karpal, KECUALI A. Artritis rheumatoid B. Kehamilan C. Akromegali D. Amilidosis E. Penyakit GRAVES

E. Graves' disease (hyperthyroidism) does not typically cause carpal tunnel syndrome but is more likely to produce ophthalmopathy, including a "stare" and "lid lag," and thyroid exophthalmos from inucinous and cellular infiltration of the extraocular muscles (inferior and medial recti most commonly affected) . Common etiologies of carpal tunnel syndrome include rheumatoid arthritis, pregnancy, acromegaly, amyloidosis, myxedema, and birth control pills (Greenberg, pp. 536-539)

197

197. Seorang olahragawan SMA tiba-tiba menderita sakit kepala, pusing-pusing, kram lengan dan kaki sebelah kiri, dan mati rasa pada wajah kiri dan badan sebelah kanan setelah mengikuti latihan olah raga. Diagnosis manakah yang paling mungkin? A. Labirintitis B. Vertigo posisional proksimal jinak C. Diseksi arteri vertebral D. Sakit kepala migrain kompleks E. Sklerosis majemuk

C. This constellation of signs/symptoms is most consistent with the lateral medullary syndrome (of Wallenberg) . In a young patient who was subjected to strenuous exercise and extreme neck movements, the most likely diagnosis is vertebral artery dissection (Greenberg, pp. 849-850)

198

198. ligand utama manakah yang mengikat kepada reseptor faktor pertumbuhan epidermal (EGFR) pada gioma? A. Fibronektin B. Faktor pertumbuhan epidermal (EGF) C. Faktor pertumbuhan tumor (TGF- α) D. Faktor pertumbuhan endothelial vaskula (VEGF) E. Faktor pertumbuhan fibroblast (FGF)

C. EGF and TGF-a bind to EGFR with equal affinity; however, whereas EGFR is commonly upregulated in highgrade malignancies, EGF is rarely over-expresseD. In contrast, TGF-a is frequently expressed in gliomas, which binds to EGFR and stimulates tyrosine kinase-specific activity, leading to further cell transformation. Thus, it is believed that TGF-a is the primary ligand binding to EGFR in malignant gliomas (Youmans, pp. 726-727 )

199

199. Semua mediator neurokimiawi dan sel di bawah ini bisa naik setelah terjadinya cedera memar kepala parah, KECUALI? A. TNF- α B. IL-1β C. IL-6 D. Potasium E. Magnesium

E . TNF-a, IL-lb, IL-6, and potassium levels have been shown to increase after DAI, while magnesium-which is involved in glycoly$iS, oxidative phosphorylation, cellular respiration, and the synthesis of DNA, RNA, and proteinshas been shown to decrease after severe head injury (Marion, pp. 40- 45)

200

200. Setelah denervasi, bukti pertama potensi-potensi fibrilasi pada otot manusia biasanya terjadi dalam jangka waktu berapa lama setelah terjangkit? A. 5 sampai dengan 10 hari B. 14 sampai dengan 21 hari C. 24 sampai dengan 32 hari D. 42 hari E. 6 bulan

B. Denervation of muscle results i n fibrillation potentials and positive sharp waves within approximately 2 to 3 weeks and 8 days, respectively. These findings persist until the muscle fibers are reinnervated (usually 3 to 4 months after mild insults) or until the denervated muscle undergoes complete atrophy (Youmans, p. 3856).

201

201. CT scan aksial di bawah ini gambar berikut menunjukkan A. Araknoiditis B. Hipertropi ligamentum flavum C. Kiste sinovial D. Retak laminar E. Hemangioma

A. Note the multiple prominent irregularities and loculations located circumferentially around the margins of the dura on this CT myelogram, which is most consistent with arachnoiditis (Ramsey, pp. 739-7 41)

202

202. Manakah diantara hal-hal di bawah ini yang benar mengenai hasil pemeriksaan diagnostik untuk neurosarkoidosis? 1. Naiknya IgG dan indeks IgG 2. kadar enzim pengubah angiotensin tinggi 3. Granuloma SSP menurut hasil MRI 4. Band oligoklional yang ditemukan pada CSF

E. Sarcoidosis is a systemic granulomatous disease that involves the nervous system in 5% of patients (neurosarcoidosis). CNS granulomas in neurosarcoidosis can involve the cranial nerves, meninges, hypothalamus, brain parenchyma, and spinal corD. The skull base is frequently affected, and granulomas in this location may result in obstructive hydrocephalus. Cranial nerve palsies may also occur; the facial nerve is most commonly involveD. Hypothalamic granulomas can result in diabetes insipidus, galactorrhea, amenorrhea, and changes in behavior, sleep patterns, and appetitE. Sarcoidosis can also cause peripheral neuropathies, such as mononeuropathy multiplex. MRI often reveals the presence of CNS granulomas, and CSF exhibits a lymphocytic pleocytosis with elevations in IgG and the IgG index. Oligoclonal bands and elevated angiotensin-converting enzyme (ACE) levels can also be found in the CSF. Neurosarcoidosis can present as a self-limited monophasic illness or a chronic disease with relapses and remissions. Treatment of neurosarcoidosis involves corticosteroids (prednisone), with immunosuppressant drugs added in refractory cases (azathioprine, methotrexate, cyclosporine) (Merritt pp. 180-181)

203

203. EEG di bawah ini paling sejalan dengan A. Intoksikasi alkohol B. Landas lobe depan kiri C. Cedera memar kepala mematikan D. Ensepalopati hepatic E. Irama Delta

C. Electrocerebral inactivity is consistent with brain death in the setting of a detailed brain death exam. It is defined as no cerebral electrical potentials greater than 2 1-!V. I t is not required to pronounce brain death and is used as an ancillary test when the diagnosis is not clear. Drug i ntoxication (E.g. , phenobarbital) and hypothermia may result in reversible electrocerebral inactivity (Greenberg, p . 130)

204

204. Kelainan apakah yang ditunjukan oleh EKG di bawah ini ? A. Torsades des pointes B. Hiperkalemia C. Toksisitas Digoksin D. Blok jantung derajat pertama E. Takikardia atrial multifokal

B . The most potentially serious complication of hyperkalemia is slowing of electrical heart conduction. The EGG begins to change when the serum W reaches approximately 6.0 mEq/L and is always abnormal when it is > 8.0 mEq/L. The earliest EGG abnormality is a tall, tapering T wave that is most evident in the precordial leads V2 and V3. As W levels i ncrease further, the P-wave amplitude decreases and the PR i nterval lengthens. The P waves may eventually disappear and the QRS complex widen. The final event is ventricular asYstole (Marino, p p . 654-655)

205

205. Lobe temporal

E Occlusion of the anterior choroidal artery causes a homonymous defect in the upper CHAPTER 8 Multidisciplinary Self-Assessment Answers 279 and lower quadrants, with sparing of the horizontal sector (quadruple sectoranopia, B), which is usually characteristic of a lateral geniculate body i nfarct that is supplied by the anterior choroidal artery. The central portion of the lateral geniculate body receives blood flow primarily from the lat-. era! posterior choroidal artery. Interruption of this vessel causes a horizontal homonymous sector defect (wedgeshaped, D). Superior homonymous quadrantic defects ("piein the sky," E) may result from a lesion along Meyer's loop (after temporal lobectomy) or along the inferior bank of the calcarine fissurE. The anterior chiasm or junctional syndrome results in a unilateral optic nerve defect of one eye and a superior temporal defect in the other eye (A) due to the loop made by the inferonasal retina of the other eye (Willebrand's knee). Lesions located in the most anterior portion of the calcarine cortex cause a crescent-shaped defect restricted to the temporal field of the qontralateral eye (monocular temporal crescent, C). This is the only retrochiasmatic lesion that may result in a strictly unilateral visual field defect (Brazis, pp. 132 -140).

206

206. Arteri koroidal posterior lateral

D Occlusion of the anterior choroidal artery causes a homonymous defect in the upper CHAPTER 8 Multidisciplinary Self-Assessment Answers 279 and lower quadrants, with sparing of the horizontal sector (quadruple sectoranopia, B), which is usually characteristic of a lateral geniculate body i nfarct that is supplied by the anterior choroidal artery. The central portion of the lateral geniculate body receives blood flow primarily from the lat-. era! posterior choroidal artery. Interruption of this vessel causes a horizontal homonymous sector defect (wedgeshaped, D). Superior homonymous quadrantic defects ("piein the sky," E) may result from a lesion along Meyer's loop (after temporal lobectomy) or along the inferior bank of the calcarine fissurE. The anterior chiasm or junctional syndrome results in a unilateral optic nerve defect of one eye and a superior temporal defect in the other eye (A) due to the loop made by the inferonasal retina of the other eye (Willebrand's knee). Lesions located in the most anterior portion of the calcarine cortex cause a crescent-shaped defect restricted to the temporal field of the qontralateral eye (monocular temporal crescent, C). This is the only retrochiasmatic lesion that may result in a strictly unilateral visual field defect (Brazis, pp. 132 -140).

207

207. Kiasma anterior

A Occlusion of the anterior choroidal artery causes a homonymous defect in the upper CHAPTER 8 Multidisciplinary Self-Assessment Answers 279 and lower quadrants, with sparing of the horizontal sector (quadruple sectoranopia, B), which is usually characteristic of a lateral geniculate body i nfarct that is supplied by the anterior choroidal artery. The central portion of the lateral geniculate body receives blood flow primarily from the lat-. era! posterior choroidal artery. Interruption of this vessel causes a horizontal homonymous sector defect (wedgeshaped, D). Superior homonymous quadrantic defects ("piein the sky," E) may result from a lesion along Meyer's loop (after temporal lobectomy) or along the inferior bank of the calcarine fissurE. The anterior chiasm or junctional syndrome results in a unilateral optic nerve defect of one eye and a superior temporal defect in the other eye (A) due to the loop made by the inferonasal retina of the other eye (Willebrand's knee). Lesions located in the most anterior portion of the calcarine cortex cause a crescent-shaped defect restricted to the temporal field of the qontralateral eye (monocular temporal crescent, C). This is the only retrochiasmatic lesion that may result in a strictly unilateral visual field defect (Brazis, pp. 132 -140).

208

208. Korteks kalkarin anterior

C Occlusion of the anterior choroidal artery causes a homonymous defect in the upper CHAPTER 8 Multidisciplinary Self-Assessment Answers 279 and lower quadrants, with sparing of the horizontal sector (quadruple sectoranopia, B), which is usually characteristic of a lateral geniculate body i nfarct that is supplied by the anterior choroidal artery. The central portion of the lateral geniculate body receives blood flow primarily from the lat-. era! posterior choroidal artery. Interruption of this vessel causes a horizontal homonymous sector defect (wedgeshaped, D). Superior homonymous quadrantic defects ("piein the sky," E) may result from a lesion along Meyer's loop (after temporal lobectomy) or along the inferior bank of the calcarine fissurE. The anterior chiasm or junctional syndrome results in a unilateral optic nerve defect of one eye and a superior temporal defect in the other eye (A) due to the loop made by the inferonasal retina of the other eye (Willebrand's knee). Lesions located in the most anterior portion of the calcarine cortex cause a crescent-shaped defect restricted to the temporal field of the qontralateral eye (monocular temporal crescent, C). This is the only retrochiasmatic lesion that may result in a strictly unilateral visual field defect (Brazis, pp. 132 -140).

209

209. Arteri koroidal anterior

B Occlusion of the anterior choroidal artery causes a homonymous defect in the upper CHAPTER 8 Multidisciplinary Self-Assessment Answers 279 and lower quadrants, with sparing of the horizontal sector (quadruple sectoranopia, B), which is usually characteristic of a lateral geniculate body i nfarct that is supplied by the anterior choroidal artery. The central portion of the lateral geniculate body receives blood flow primarily from the lat-. era! posterior choroidal artery. Interruption of this vessel causes a horizontal homonymous sector defect (wedgeshaped, D). Superior homonymous quadrantic defects ("piein the sky," E) may result from a lesion along Meyer's loop (after temporal lobectomy) or along the inferior bank of the calcarine fissurE. The anterior chiasm or junctional syndrome results in a unilateral optic nerve defect of one eye and a superior temporal defect in the other eye (A) due to the loop made by the inferonasal retina of the other eye (Willebrand's knee). Lesions located in the most anterior portion of the calcarine cortex cause a crescent-shaped defect restricted to the temporal field of the qontralateral eye (monocular temporal crescent, C). This is the only retrochiasmatic lesion that may result in a strictly unilateral visual field defect (Brazis, pp. 132 -140).

210

210. Saraf muskolokutanus mengendalikan aksi-aksi otot yang mana? 1. Fleksi siku 2. Pronasi telapak tangan 3. Supinasi telapak tangan 4. Fleksi pergelangan

B. The musculocutaneous nerve innervates the biceps, brachialis, and coracobrachialis muscles, which control elbow flexion and forearm supination ( Brazis, p. 60).

211

211. Di manakah benjolan yang dapat menyebabkan kelemahan anggota badan atas ipsilateral; dan kelemahan kaki kontralateral paling sering terjadi? A. Pons ventrolateral B. Pontis basis C. Kapsul dalam bagian belakang D. Cervicomedullary junction E. Pons lateral ventral

D. Where the pyramidal tract decussates at the cervicomedullary junction with segregation of arm fibers (rostral) and leg fibers (caudal) , a lesion can cause the unique combination of ipsilateral arm weakness and contralateral leg paresis (cruciate paralysis) (Brazis, p . 95; Greenberg, p . 95).

212

212. Manakah diagnosis yang paling mungkin? A. Holoproensepali Alobar B. Holoproensepali Lobar C. Hidranensepali D. Hidrosepalus parah E. Anensepali

C Hydranencephaly describes a brain replaced by CSF rather than compressed by expansion of the ventricles, as in severe hydrocephalus. Moreover, with severe hydrocephalus, there is usually a thin mantle of brain, which is absent in hydranencephaly. The absence of a cortical mantle with hydranencephaly is most often associated with angiographic evidence of supraclinoid occlusion of the carotid arteries, which strongly suggests a vascular pathogenesis. The posterior fossa and thalami are often preserved due to preserved posterior circulation. The cranium of afflicted children usually fails to grow and remains small. The incidence is estimated to be 1 in 6000, and affected infants rarely live longer than a year (Albright, pp. 155- 156)

213

213. Manakah yang merupakan etiologi yang paling mungkin untuk temuan ini? A. Hidrosepalus obstruktif B. Gagal disjungsi C. Gangguan pada migrasi sel D. Bilateral pada gangguan utero dari sirkulasi depan E. Gagal menutupnya tabung saraf

C Hydranencephaly describes a brain replaced by CSF rather than compressed by expansion of the ventricles, as in severe hydrocephalus. Moreover, with severe hydrocephalus, there is usually a thin mantle of brain, which is absent in hydranencephaly. The absence of a cortical mantle with hydranencephaly is most often associated with angiographic evidence of supraclinoid occlusion of the carotid arteries, which strongly suggests a vascular pathogenesis. The posterior fossa and thalami are often preserved due to preserved posterior circulation. The cranium of afflicted children usually fails to grow and remains small. The incidence is estimated to be 1 in 6000, and affected infants rarely live longer than a year (Albright, pp. 155- 156)

214

214. Lavase peritoneal diagnostik (DPL) relatif cepat, aman, dan handal untuk pasien-pasien dengan cedera tumpul dan tusukan dinding perut bagian depan. Prosedur diagnostik ini dianggap positif dengan semua hal di bawah ini, KECUALI A. Lebih dari 10 mL darah keluar dari perut. B. Evaluasi mikroskopis caiman yang keluar mengungkapkan adanya sel-sel darah merah lebih banyak dari 100.000/mm3 C. Sel-sel darah putih lebih besar dari 500/mm3. D. Adanya bile atau materi partikulat pada cairan yang keluar E. Kadar amylase kurang dari kadar serum normal

E. DPL is considered positive if greater than 10 mL of gross blood is aspirated from the peritoneal cavity or if 1 L of lactated Ringer's solution is infused i n to the peritoneal cavity and microscopic evaluation reveals red blood cells > 100,000/mm3, white blood cells > 500/mm3, or the presence of bile, particulate matter, or amylase greater than the normal serum valuE. It can be used for penetrating stab wounds after positive local exploration or suspected hollow viscus injury, following an abnormal ultrasound examination, or following a normal ultrasound when the patient exhibitshemodynamic instability or signs and symptoms suggestive of an intra-abdominal injury (Nwariaku, pp. 64- 65)

215

215. Apa yang ditunjukkan pada fotomikrograf di bawah ini ? A . Astrositoma gemistrositik B. Hemangioblastoma C. Kordoma D. Meningioma sel bening E. Medulloblastoma desmoplastis

A. Note the large, glassy eosinophilic cell bodies with an angular shape on this photomicrograph, which depicts a gemistocytic astrocytoma (Ellison, p. 627; WHO, p. 2 5)

216

216. Pada pasien yang menderita hilang pendengaran konduktif di sebelah kanan, manakah di antara pernyataanpernyataan di bawah ini yang paling berlaku? A. Weber lateralisasi ke arah kiri, Rinne negatif (b>a). uji Schwabach normal B. Weber lateralisasi ke arah kanan, Rinne positif (a>b) uji Schwabach normal C. Weber lateralisasi ke arah kanan, Rinne negatif, uji Schwabach normal atau sedikit lebih lama D. Weber lateralisasi ke arah kanan, Rinne positif, uji Schwabach abnormal E. Weber lateralisasi ke arah kiri, Rinne positif ( b > a ). uji Schwabach abnormal

C . I n conductive hearing loss o n the right, the Weber test lateralizes to the right, the Rinne test is negative (bone conduction is better than air conduction), and the Schwabach test is normal or prolonged (the patient can hear the tuning fork longer than the examiner can) (Brazis, pp. 298-299 )

217

217. Dalam melaksanakan manuver Nylén-Bárány, semua hal di bawah ini mengisyaratkan penyakit periferal, KECUALI A. Latensi penampilan nistagmus sekitar 2 sampai dengan 12 detik B. Vertigo dan nistagmus biasanya menghilang 10 sampai dengan 15 detik setelah penampilannya. C. Perubahan arah nistagmus dengan kepala ke bawah dan nistagmus tetap persisten D. Habituasi respons dengan manuver yang diulang-ulang. E. Reproduktibilitas kelainan-kelainan yang dicatat manuver ini semakin tidak konsisten.

C. With peripheral lesions, severe rotational vertigo associated with nausea and vomiting and nystagmus appear approximately 2 to 15 seconds after performing the NylenB

218

218. Tn. X, 35 tahun dengan fotomikrograf yang disajikan di bawah ini dibawa dalam keadaan demam, menggigil, dan kejang-kejang. Apa Diagnosisnya? A. Penyakit CREUITZFELDT-JACOB B. Ensepalitis herpes C. Malaria D. Ganglioglioma E. Limpoma

C. Note the occlusion of the blood vessel, which is due to the presence of many ghost-like red blood cells that contain parasites on this H & E section depicting malariA. Patients with this disease can present with seizures, headache, somnolence, confusion, photophobia, and almost any focal neurologic deficit. Without urgent treatment, these patients usually progress to coma and brain death (Ellison, pp. 653-656)

219

219. Benjolan yang ditunjukkan di bawah ini paling sering berasosiasi dengan kelainan lain yang mana? A. Sindroma CASTLEMAN B. Sklerosis tuberus C. Epilepsi lobe temporal D. Bintik-bintik Café au lait E. Pola kulit batu kerikil

B. This photomicrograph depicts a subependymal giant cell astrocytomA. This lesion is usually located adjacent to the foramen of Monro and is associated with tuberous sclerosis (dominant mutation in TSC 1 on 9p or TSC 2 on 1 6p ). It usually resembles gemistocytic astrocytoma, but is not infiltrativE. Note the abundant cytoplasm, abundant perivascular fibrillar zone, and prominent nucleolus in this section. The nuclei are eccentric, which distinguishes this from gemistocytic astrocytoma (Elliso n , pp. 637-639)

220

220. Kelumpuhan upward gaze, dan disosiasi pupil jika dekat cahaya, nistagmus retraksi konverge dam retraksi alis patologis paling sejalan dengan kelainan apa? A. Hidrosepalus B. Meningioma falx 3-cm C. Adenoma Hipofise D. Kiste porensepalis lobe temporal E. Malformasi arteri-vena lobe okipital

. A. This constellation of clinical findings is most consistent with Parinatid's syndrome, which is often associated with pineal region masses causing direct compression of the tecta! plate or from compression of the mesencephalic tectum by a dilated suprapineal recess in cases of hydrocephalus (Greenberg, p . . 87)

221

221. Semua pernyataan di bawah ini adalah benar mengenai korteks somatosensoris sekunder (SII), KECUALI A. Terletak di sepanjang tepi atas dari sulkus lateral dan memanjang di bagian belakangnya ke dalam lobe parietal B. Representasi bagian tubuh memiliki sekuen terbalik dengan yang ditemukan pada daerah somestetos primer dengan dua daerah permukaan yang berdekatan. C. Representasi tubuh bilateral pada SII, meskipun yang dominan adalah kontralateral D. Proyeksi-proyeksi kortikal eferen terutama ke arah SI dan korteks motorik primer. E. Lesi biasanya menyebabkan kelemahan kontralateral.

E. SII lies along the superior bank of the lateral sulcus and extends posteriorly into the parietal lobe; it has representation of body parts in the reverse sequence to that found in the primary somesthetic area, with the two face areas being adj acent. Representation of the body is bilateral in SII (although contralateral predominates) , and the efferent cortical projections are mainly to SI and the primary motor cortex (Carpenter, pp. 404- 405).

222

222. Pada sindroma kolosal (sindroma diskoneksi interhemisperis) disebabkan pembedahan, semua hal di bawah ini mungkin bisa dilihat pada pasien dominan hemisfir kiri, KECUALI A. Tidak mampu menyebut benda-benda (dengan mata tertutup) yang diraba oleh tangan kanan B. Tidak mampu menyebutkan nama benda yang ditunjukkan pada bidang pandang sebelah kiri C. Tidak ada gangguan pada hampir semua kegiatan kehidupan siang hari. D. Tidak mampu meniru desain kompleks dengan tangan kanan E. Tidak mampu menjalankan perintah dengan tangan kiri

A. The corpus callosum functions to transfer information from one hemisphere to the other. After sectioning, the patient cannot execute a command with the left hand but will do so consistently with the right. The left hemisphere understands the command but is unable to transfer that information to the right side of the brain. The right hemisphere does not typically understand the command because it lacks the ability to understand languagE. Therefore a patient presented with an obj ect with the right hand should be able to reliably name it, since these fibers are relayed to the contralateral cerebral cortex ( DeMyer, pp. 3 16, 3 19)

223

223. Manakah diantara pernyataan di bawah ini yang dengan benar memastikan hampir semua lokasi yang paling tidak lazim dari perdarahan intrakranial hipertensif? A. Pons, talamus, putamen, serebelum, lobar B. Putamen, talamus, pons, serebelum, lobar C. Putamen, talamus, serebelum, pons, lobar D. Talamus, putamen, serebelum, lobar, pons E. Talamus, putamen, serebelum, pons, lobar

B. The most common locations for hypertensive intracranial hemorrhage include the putamen, followed by the thalamus, pons, cerebellum, and lobar regions. The origin of some "hypertensive" putamina! hemorrhages are believed to result from microaneurysms of "Charcot-Bouchard, " but this is somewhat controversial (Greenberg, p. 815)

224

224. Semua ciri di bawah ini adalah ciri Hidosepalus tekanan normal, KECUALI A. Melangkah “magnetik” dengan mengangkang B. Bradiprenia C. Inkontinensi D. Sakit kepala E. Kenaikan transien pada tekanan intrakranial dengan pemantauan terus menerus

D. Hydrocephalus, gait disturbance ("magnetic gait" with short, shuffling steps), dementia (primarily memory impairment with bradyphrenia or slowness of thought) , incontinence, and transient elevations in intracranial pressure (with monitoring) may all occur with normal pressure hydrocephalus (NPH). Headache and papilledema are typically not seen in patients with NPH; their presence should raise suspicion of another diagnosis (Greenberg, pp. 191- 194)

225

225. EEG di bawah ini paling sejalan dengan diagnosis mana? A. Tumor depan kanan B. Tumor okipital kiri C. Uremia D. Tidur E. Gangguan hemisfirik besar

A . The seizure spikes are over a fairly wide area o f the right parasagittal region (maximal F4 , C4) consistent with a right frontal onset corresponding with a right parasagittal meningiomA. In order to localize seizure foci, it is imperative for clinicians to memorize standard electrode placement and designations. Note that by convention, electrodes designated with odd numbers are on the left, while with even numbers on the right. The standard electrode designations are as follows: Fp1/Fp2 = frontopolar or prefrontal; F3/F4 = midfrontal; C3/C4 = central (roughly over central sulcus); P3/P4 = parietal; 0 1/02 = occipital; F7 /F8 = inferior frontal (sometimes called anterior frontal) ; T3/T4 = midtemporal (records activity over anterior and midtemporal activity, important for temporal lobe epilepsy); T5/T6 = posterior temporal; Fz, Cz, Pz = midline electrodes in frontal and parietal regions (record mesial surfaces of hemispheres) ; A1/A2 = ear reference electrodes (while used for references also record midtemporal activity); T1/T2 = so-called true anterior temporal electrodes; Sp 1/Sp2 = sphenoidal electrodes (recordactivity from inferomesial surface of the temporal lobes) ( Rowan, pp. 4-7 )

226

226. Lentikularis ansa

D Fibers o f the ansa lenticularis (D) leave the outer part of the medial globus pallidus, pass around the internal capsule, and enter the prerubral field (field H of Fore!, not labeled) prior to merging with the lenticular fasciculus (H2) . Fibers of the lenticular fasciculus originate from the inner part of the medial globus pallidus, traverse the posterior limb of the anterior capsule, and pass medially, dorsal to the subthalamic nucleus, to also enter the prerubral fielD. The ansa lenticularis and lenticular fasciculus then travel together dorsal to the zona incerta as components of the thalamic fasciculus (A). The subthalamic fasciculus (C) is comprised of pallidosubthalamic fibers originating from the lateral or external pallidal segment and subthalamopallidal fibers that terminate in the medullary lamina of both pallidal segments. Both components of the subthalamic fasciculus cross the internal capsulE. Thalamostriate fibers from the centromedian nucleus project to the putamen ( E) (Carpenter, pp. 33 7-345)

227

227. Serat talamostriat

E Fibers o f the ansa lenticularis (D) leave the outer part of the medial globus pallidus, pass around the internal capsule, and enter the prerubral field (field H of Fore!, not labeled) prior to merging with the lenticular fasciculus (H2) . Fibers of the lenticular fasciculus originate from the inner part of the medial globus pallidus, traverse the posterior limb of the anterior capsule, and pass medially, dorsal to the subthalamic nucleus, to also enter the prerubral fielD. The ansa lenticularis and lenticular fasciculus then travel together dorsal to the zona incerta as components of the thalamic fasciculus (A). The subthalamic fasciculus (C) is comprised of pallidosubthalamic fibers originating from the lateral or external pallidal segment and subthalamopallidal fibers that terminate in the medullary lamina of both pallidal segments. Both components of the subthalamic fasciculus cross the internal capsulE. Thalamostriate fibers from the centromedian nucleus project to the putamen ( E) (Carpenter, pp. 33 7-345)

228

228. Traktus optik

F Fibers o f the ansa lenticularis (D) leave the outer part of the medial globus pallidus, pass around the internal capsule, and enter the prerubral field (field H of Fore!, not labeled) prior to merging with the lenticular fasciculus (H2) . Fibers of the lenticular fasciculus originate from the inner part of the medial globus pallidus, traverse the posterior limb of the anterior capsule, and pass medially, dorsal to the subthalamic nucleus, to also enter the prerubral fielD. The ansa lenticularis and lenticular fasciculus then travel together dorsal to the zona incerta as components of the thalamic fasciculus (A). The subthalamic fasciculus (C) is comprised of pallidosubthalamic fibers originating from the lateral or external pallidal segment and subthalamopallidal fibers that terminate in the medullary lamina of both pallidal segments. Both components of the subthalamic fasciculus cross the internal capsulE. Thalamostriate fibers from the centromedian nucleus project to the putamen ( E) (Carpenter, pp. 33 7-345)

229

229. faskikulus subtalamik

C Fibers o f the ansa lenticularis (D) leave the outer part of the medial globus pallidus, pass around the internal capsule, and enter the prerubral field (field H of Fore!, not labeled) prior to merging with the lenticular fasciculus (H2) . Fibers of the lenticular fasciculus originate from the inner part of the medial globus pallidus, traverse the posterior limb of the anterior capsule, and pass medially, dorsal to the subthalamic nucleus, to also enter the prerubral fielD. The ansa lenticularis and lenticular fasciculus then travel together dorsal to the zona incerta as components of the thalamic fasciculus (A). The subthalamic fasciculus (C) is comprised of pallidosubthalamic fibers originating from the lateral or external pallidal segment and subthalamopallidal fibers that terminate in the medullary lamina of both pallidal segments. Both components of the subthalamic fasciculus cross the internal capsulE. Thalamostriate fibers from the centromedian nucleus project to the putamen ( E) (Carpenter, pp. 33 7-345)

230

230. Faskikulus talamik (H1)

A Fibers o f the ansa lenticularis (D) leave the outer part of the medial globus pallidus, pass around the internal capsule, and enter the prerubral field (field H of Fore!, not labeled) prior to merging with the lenticular fasciculus (H2) . Fibers of the lenticular fasciculus originate from the inner part of the medial globus pallidus, traverse the posterior limb of the anterior capsule, and pass medially, dorsal to the subthalamic nucleus, to also enter the prerubral fielD. The ansa lenticularis and lenticular fasciculus then travel together dorsal to the zona incerta as components of the thalamic fasciculus (A). The subthalamic fasciculus (C) is comprised of pallidosubthalamic fibers originating from the lateral or external pallidal segment and subthalamopallidal fibers that terminate in the medullary lamina of both pallidal segments. Both components of the subthalamic fasciculus cross the internal capsulE. Thalamostriate fibers from the centromedian nucleus project to the putamen ( E) (Carpenter, pp. 33 7-345)

231

231. Faskikulus lentikular (H2)

B Fibers o f the ansa lenticularis (D) leave the outer part of the medial globus pallidus, pass around the internal capsule, and enter the prerubral field (field H of Fore!, not labeled) prior to merging with the lenticular fasciculus (H2) . Fibers of the lenticular fasciculus originate from the inner part of the medial globus pallidus, traverse the posterior limb of the anterior capsule, and pass medially, dorsal to the subthalamic nucleus, to also enter the prerubral fielD. The ansa lenticularis and lenticular fasciculus then travel together dorsal to the zona incerta as components of the thalamic fasciculus (A). The subthalamic fasciculus (C) is comprised of pallidosubthalamic fibers originating from the lateral or external pallidal segment and subthalamopallidal fibers that terminate in the medullary lamina of both pallidal segments. Both components of the subthalamic fasciculus cross the internal capsulE. Thalamostriate fibers from the centromedian nucleus project to the putamen ( E) (Carpenter, pp. 33 7-345)

232

232. Seorang laki-laki usia 31 dengan kekebalan tubuh yang telah menurun dan riwayat penyalahgunaan obat-obatan secara intravena datang mengeluh sakit punggung. Hasil MRI T1-weighted pasca-kontras sagital ditunjukkan di bawah ini. Diagnosis manakah yang paling mungkin? A. Leukimia B. Limpoma C. Abses epidural D. Lipomatosis epidural E. Hemangioblastoma

C. Note the prominent ring enhancement of this spinal epidural abscess, with compression of the adjacent spinal corD. The most likely causative organism in a patient with a history of intravenous drug abuse is Staph. aureus ( Ramsey, pp. 498-502 )

233

233. Infeksi-infeksi LUKA yang mengalami nekrotisasi paling lazim dihasilkan oleh organisme mana? 1. Clostridium 2. Staphylococcus 3. Streptococcus hemolitis-β 4. Corynebacterium

B. Necrotizing wound infections are produced by Clostridium and P-hemolytic streptococcal species. Unlike other wound infections that may appear a few days to 1 week after surgery, necrotizing infections are evident in the first few postoperative days; they are characterized by skin crepitance and fluid-filled bullaE. Spread to deeper tissues is a major concern, as this may result i n rhabdomyolysis and myoglobinuric renal failure ( M arino, p. 489)

234

234. Semua pembuluh darah di bawah ini berasal dari arteri karotid dalam intrakavernus (ICA), KECUALI A. Arteri tentorial (dari Bernasconi dan Cassinari) B. Arteri meningeal dorsal C. Arteri hipofiseal bawah D. Arteri vidian E. Arteri kapsular McConnell

D. There are three main branches that originate from the intracavernous portion of the ICA: the meningohypophyseal trunk, the artery of the inferior cavernous sinus, and the artery of McConnell. The meningohypophyseal trunk trifurcates into the tentorial artery (of Bernasconi and Cassinari), the dorsal meningeal artery (supplies dura over dorsum sellae), and the inferior hypophyseal artery, which supplies the posterior pituitary gland and sellar floor. McConnell's artery runs along the dura covering the sellar floor to supply the anterior pituitary gland, while the artery of the inferior cavernous sinus provides blood supply to the third, fourth, and sixth cranial nerves as well as the gasserian ganglion and cavernous sinus durA. The vidian artery originates from the petrous ICA (Osborn DCA, pp. 86-87).

235

235. Satu hari setelah permainan sepak bola di sekolahnya (SMU), seorang pemain utama belakang dibawa ke bagian gawat darurat karena mengeluh sakit bahu kanan yang menyebar. Pusat rasa sakitnya adalah pada scapula lateral dan bahu bagian belakang dan semakin diperparah oleh abduksi lengan bagian atas (15 derajat pertama) dan rotasi ke arah luar (khususnya jika siku ditahan pada fleksi 90 derajat). Saraf apa yang kemungkinan besar cedera? A. Supraskapular B. Aksilaris C. Aksesoris tulang D. Interoseus bagian belakang E. Skapular dorsal

. A. Patients with entrapment or trauma to the suprascapular nerve often complain of shoulder pain centered over the lateral scapula and posterior shoulder, which is most CHAPTER 8 Multidisciplinary Self-Assessment Answers 2 8 1 often aggravated by arm abduction during the first 15 degrees (supraspinatus muscle) and external arm rotation when the elbow is flexed at 90 degrees (infraspinatus muscle) . Atrophy of the supraspinatus and infraspinatus muscles may also be apparent on inspection. EMG reveals denervation potentials in the supraspinatus and i nfraspinatus muscles and is the best diagnostic test. Conservative treatment measures include shoulder exercises and local injections of steroids and analgesics. Operative decompression usually includes sectioning of the suprascapular ligament (Youmans, pp. 3932- 3933)

236

236. Seorang laki-laki berusia 33 tahun dengan riwayat sakit punggung bagian bawah yang semakin menghebat pada malam hari. Hasil CT scan tulang lumbar pasien menunjukkan 1,4 cm lesi litik di vertebral body dan pedikel L4 yang paling sejalan dengan Osteoma osteoid. Mengapa sakit ini berasosiasi dengan benjolan semacam ini biasanya merespons kepada aspirin? A. Aspirin menurunkan jumlah PDF yang disekresi oleh sel-sel tumor. B. Aspirin menurunkan sintesis prostaglandin pada semua fibroblast yang berdekatan dengan tumor yang bersangkutan C. Aspirin menghentikan produksi prostaglandin oleh sel-sel tumor. D. Aspirin menurunkan jumlah senyawa P di dalam tanduk dorsal dari sel-sel urat tulang. E. aspirin sangat menurunkan sintesis prostaglandin pada vaskulatur yang memasok benjolan yang bersangkutan

C. Patients with osteoid osteoma involving the lumbar spine typically present with back pain that is exacerbated at night. This condition is believed to result from prostaglandin production by the tumor. Aspirin has classically been shown to relieve the pain (Youmans, p. 4297)

237

237. Seorang anak laki-laki berusia 4 tahun terus menerus mengalami kejang-kejang umum refraktoris medical (“Drop attacts”) meski pun telah diberi rezim-rezim pengobatan anti-konsulvan, Opsi bedah manakah yang selanjutnya harus dilakukan untuk pasien dengan keadaan ini? A. Hemiseferektomi anatomis B. Hemiseferektomi fungsional C. Pembelahan kalosum korpus D. Transeksi subpial majemuk. E. Penempatan elektroda dalam untuk pemantauan.

C. Atonic seizures, also called "drop attacks," are characterized by total loss of muscle tonE. When they are preceded by a brief myoclonic seizure or tonic .spasm, an acceleratOT)' force is added to the fall, further contributing to the high rate of self-injUT)' with this type of seizurE. Most patients referred for corpus callosotomy have severe, medically refractory seizures usually accompanied by mental retardation and a severely abnormal EEG. Unlike lesionectomy, corpus callosotomy is palliative, not curativE. Nevertheless, this procedure can be highly effective for generalized seizures, with 80% of patients experiencing complete or nearly complete cessation of atonic, tonic, and tonic-clonic attacks in some reports (Merritt, pp. 814, 827).

238

N y. X, 67 tahun diberi rujukan ke kantor anda karena lemah pada bahu sejak menjalani lymph node biopsy. Dia sangat sulit menaikkan lengannya di atas garis horison dan agak mati rasa pada oksiput di balik telinga kanan. 238. Diagnosis manakah yang paling mungkin? A. Cedera saraf Aksilaris B. Cedera saraf Supraskapular C. Cedera saraf scapular dorsal D. Cedera saraf spinal aksesorius E. Fleksopati brachial

D The spinal accessory nerve is at particular risk during lymph node biopsies involving the posterior triangle of the neck. Patients typically present within a week \Yith a shoulder droop or inability to raise the arm. An additional sensory complaint is noted in some patients from injury to the greater auricular and lesser occipital nerves, which course behind the sternocleidomastoid muscle in close proximity to the spinal accessory nervE. Fortunately, most patients exhibit spontaneous resolution of symptoms (Committee on Education in Neurological Surgery, p. 113; Donner et a l . , pp. 907-910)

239

N y. X, 67 tahun diberi rujukan ke kantor anda karena lemah pada bahu sejak menjalani lymph node biopsy. Dia sangat sulit menaikkan lengannya di atas garis horison dan agak mati rasa pada oksiput di balik telinga kanan. 239. Apa yang paling mungkin menjadi penyebab utama mati rasa di balik telinga kanan pasien? 1. Cedera saraf aurikular besar 2. Cedera saraf aurikular kecil 3. Cedera saraf oksipital kecil 4. Cedera saraf aurikular kecil

B The spinal accessory nerve is at particular risk during lymph node biopsies involving the posterior triangle of the neck. Patients typically present within a week \Yith a shoulder droop or inability to raise the arm. An additional sensory complaint is noted in some patients from injury to the greater auricular and lesser occipital nerves, which course behind the sternocleidomastoid muscle in close proximity to the spinal accessory nervE. Fortunately, most patients exhibit spontaneous resolution of symptoms (Committee on Education in Neurological Surgery, p. 113; Donner et a l . , pp. 907-910)

240

240. Semua manfaat di bawah ini merupakan manfaat-manfaat magnetoensepalografi (EMG) dibandingkan dengan Elektroensepalografi (EEG), KECUALI A. MEG memberikan resolusi ruang dan waktu yang lebih baik untuk lokalisasi aktivitas neuronal kortikal B. Benjolan landas atau perubahan-perubahan patologis lainnya tidak begitu mendistorsi sinyal yang terdeteksi oleh MEG C. Sinyal-sinyal MEG tidak begitu mudah teraksentuasi dibandingkan dengan sinyal-sinyal EEG D. MEG mencakup semua titik data dari bawah permukaan, sementara EEG hanya merefleksikan permukaan kortikal saja E. MEG mencakup unsur tangensial dan radial dari aliran neuronal. sementara EEG hanya menyangkut unsur tangensial saja, yang sangat menurunkan kompleksitas dari sinyal tersebut

E . MEG has several advantages over E E G recording. First, unlike EEG-based techniques, which measure electrical potentials mainly from extracellular volume currents, the magnetic fields measured with MEG primarily reflect intracellular current flow and are not attenuated by the inhomogeneously conducting layers of bone, scalp, and other extracerebral tissuE. This provides excellent spatial and temporal resolution for localization of neuronal activity, and it more accurately represents the localization of eloquent cortex than EEG. Second, mass lesions or other pathologic changes in the brain, which may significantly distort the signal detectedby EEG, do not affect the signal detected by MEG. Third, because MEG includes only a tangential component of neuronal current, as opposed to EEG recording (which uses both tangential and radial component), the signal detected is less complex than the signal detected by EEG. And finally, whereas EEG reflects only surface recordings, MEG includes data points below the surface of the brain as well. Magnetic source imaging (MSI) is a technique that allows the mapping of brain function onto brain structure by combining the functional data obtained by MEG with the neuroanatomic data obtained by MRI studies. By mapping the neurophysiologic data acquired by MEG onto the neuroanatomic data acquired by MRI, the functional measures can be given an accurate anatomic reference, which can often help guide surgery. Nevertheless, despite the obvious advantages of MEG and MSI, these strategies are not widely employeD. The high financial cost of acquiring such units and the labor-intensive effort that is required by both patients and clinicians during data analysis are just two of the more noteworthy reasons these techniques have not gained universal favor (American Society of Pediatric Neurosurgeons, p p . 1048- 1049)

241

241. Manakah diagnosis yang paling mungkin? A. Meningioma sayap sphenoid B. Kondrosarkoma C. Displasia fibrous D. Estenioblastoma E. Osteokondroma

C Note the expansion of bone (sphenoid) and "ground glass appearance" on this noncontrasted CT scan in a patient with fibrous dysplasiA. Malignant degeneration, usually to osteosarcoma, has been reported to occur in approximately 0 . 5% of patients with fibrous dysplasia (Albright, pp. 456-457).

242

242. Degenerasi ganas lesi ini paling mungkin menyebabkan neoplasma tipe yang mana? A. Osteokondroma B. Osteoblastoma C. Kloroma D. Osteosarkoma E. Neuroblastoma

D Note the expansion of bone (sphenoid) and "ground glass appearance" on this noncontrasted CT scan in a patient with fibrous dysplasiA. Malignant degeneration, usually to osteosarcoma, has been reported to occur in approximately 0 . 5% of patients with fibrous dysplasia (Albright, pp. 456-457).

243

243. Muskulus stiloparingeus berasal dari busur brakial yang mana? A. Pertama B. Kedua C. Ketiga D. Keempat E. Keenam

C. The stylopharyngeus muscle is innervated by the glossopharyngeal nerve (IX) and is the only muscle derived from the third brachial arch. The muscles of facial expression are all innervated by the facial • nerve (VII) and are derived from the second brachial arch, whereas the thyroarytenoid muscle and intrinsic laryngeal musculature (except cricothyroid muscle, fourth arch derivative) are derived from the sixth brachial arch. The muscles of mastication are derived from the first brachial arch and are innervated by the mandibular division of the trigeminal nerve (Apri l , p. 556)

244

244. Seorang laki-laki usia 18 tahun dibawa ke bagian gawat darurat dengan keluhan sakit kepala pagi hari yang berasosiasi dengan mual-mual dan mati rasa pada lengan kanan; hasil CT scan pasien menunjukkan daerah densitas rendah pada daerah parietal kiri. Angiogram-nya ditunjukkan di bawah ini. Manakah diagnosis yang paling mungkin?

D. Note the paucity of blood flow in the distal internal carotid and cerebral artery vasculature and the presence of prominent collaterals that resemble a "puff of smoke" on this lateral angiogram, which depicts moyamoya (Albright, pp. 1053-1069).

245

245. Diantara sel-sel di bawah ini, sel manakah yang menumbuhkan akson yang menjadi saraf optik A. Batang dan kerucut pada retina B. Sel dua kutub C. Sel ganglion D. Sel horisontal E. Sel Amakrin (C)

C. The ganglion cells in the retina gives rise to the optic nervE. The ganglion cells receive impulses from the bipolar cells, which, in turn, receive signals from the light-sensitive rods and cones ( Kandel, .PP• 517 - 521)

246

246. Tidak terdapat masalah struktural pada akson; konduksi saraf seringkali kembali dalam jangka waktu 6 sampai dengan 8 minggu. A. Neurotmesis B. Aksonotmesis C. Neurapraksia D. A dan B E. A, B, C dan D salah

C With neurotmesis, there is complete anatomic transection of the nerve accompanied by Wallerian degeneration. These injuries almost always require surgical repair, although the timing remains unclear. For sharply divided nerves, immediate repair appears to be ideal, whereas for bluntly injured nerves, some advocate waiting approximately 3 to 4 weeks prior to intervening surgically to allow for better proximal and distal nerve stump delineation. With axonotmesis, there is a loss of axonal continuity, but the soma remains continuous. Wallerian degeneration also occurs with this type of insult. With neurapraxia, conduction ceases without structural damage to the nervE. There is a physiologic transection, which is often accompanied by defective axonal transport. This type of nerve injury frequently recovers by 6 to 8 weeks on averagE. Stimulating distal to a nerve lesion at about 1 week postinjury results in no action potentials if \Vallerian degeneration occurs (Greenberg, p. 532 ; Youmans, p p . 3825-3826)

247

247. Hilang kesinambungan akson, tapi soma masih tetap berkesinambungan A. Neurotmesis B. Aksonotmesis C. Neurapraksia D. A dan B E. A, B, C dan D salah

B With neurotmesis, there is complete anatomic transection of the nerve accompanied by Wallerian degeneration. These injuries almost always require surgical repair, although the timing remains unclear. For sharply divided nerves, immediate repair appears to be ideal, whereas for bluntly injured nerves, some advocate waiting approximately 3 to 4 weeks prior to intervening surgically to allow for better proximal and distal nerve stump delineation. With axonotmesis, there is a loss of axonal continuity, but the soma remains continuous. Wallerian degeneration also occurs with this type of insult. With neurapraxia, conduction ceases without structural damage to the nervE. There is a physiologic transection, which is often accompanied by defective axonal transport. This type of nerve injury frequently recovers by 6 to 8 weeks on averagE. Stimulating distal to a nerve lesion at about 1 week postinjury results in no action potentials if \Vallerian degeneration occurs (Greenberg, p. 532 ; Youmans, p p . 3825-3826)

248

248. Berasosiasi dengan degenerasi Wallerian A. Neurotmesis B. Aksonotmesis C. Neurapraksia D. A dan B E. A, B, C dan D salah

D With neurotmesis, there is complete anatomic transection of the nerve accompanied by Wallerian degeneration. These injuries almost always require surgical repair, although the timing remains unclear. For sharply divided nerves, immediate repair appears to be ideal, whereas for bluntly injured nerves, some advocate waiting approximately 3 to 4 weeks prior to intervening surgically to allow for better proximal and distal nerve stump delineation. With axonotmesis, there is a loss of axonal continuity, but the soma remains continuous. Wallerian degeneration also occurs with this type of insult. With neurapraxia, conduction ceases without structural damage to the nervE. There is a physiologic transection, which is often accompanied by defective axonal transport. This type of nerve injury frequently recovers by 6 to 8 weeks on averagE. Stimulating distal to a nerve lesion at about 1 week postinjury results in no action potentials if \Vallerian degeneration occurs (Greenberg, p. 532 ; Youmans, p p . 3825-3826)

249

249. Biasanya paling baik jika dikelola dengan perbaikan bedah dini. A. Neurotmesis B. Aksonotmesis C. Neurapraksia D. A dan B E. A, B, C dan D salah

A With neurotmesis, there is complete anatomic transection of the nerve accompanied by Wallerian degeneration. These injuries almost always require surgical repair, although the timing remains unclear. For sharply divided nerves, immediate repair appears to be ideal, whereas for bluntly injured nerves, some advocate waiting approximately 3 to 4 weeks prior to intervening surgically to allow for better proximal and distal nerve stump delineation. With axonotmesis, there is a loss of axonal continuity, but the soma remains continuous. Wallerian degeneration also occurs with this type of insult. With neurapraxia, conduction ceases without structural damage to the nervE. There is a physiologic transection, which is often accompanied by defective axonal transport. This type of nerve injury frequently recovers by 6 to 8 weeks on averagE. Stimulating distal to a nerve lesion at about 1 week postinjury results in no action potentials if \Vallerian degeneration occurs (Greenberg, p. 532 ; Youmans, p p . 3825-3826)

250

250. Tn. X, 67 tahun pernah menjalani fusi servik muka pada waktu yang telah lama sekali berlalu dan datang dengan riwayat serangan baru sakit leher dan lemah deltoid sebelah kanan selama tiga bulan terakhir ini. Hasil MRI T2-weighted sagital dijelaskan pada Gambar. Apa yang ditunjukkan pada MRI scan sagital yang kemungkinan menjadi penyebab utama gambaran klinis baru ini? A. Pseudoartrosis B. Osteomielitisa C. Perubahan degeneratif fusi-akhir D. Spondilolisis E. Subsidens

C. The acquisition of bony spinal fusion increases motion and stress at adjacent motion segments, which can accelerate degenerative changes. This process is further enhanced by failure to repair sagittal balance during surgery. Although not the ideal study to evaluate bony fusion, this MRI does not demonstrate pseudoarthrosis at the prior fusion site, subsidence, basilar invagination, or osteomyelitis. It shows end-fusion degenerative changes and loss of the normal lordotic curve of the cervical spine, which may be contributing to this patients' new clinical problems (Benzel, p. 130)

251

251. Bagian superior dari saraf vestibular

B This diagram shows the structures that traverse the internal auditory canal (IAC). The facial nerve (A) and nervus intermedius are separated from the superior vestibular nerve by a vertical crest of bone known as Bill's bar (F) . Bill's bar arises from the transverse crest (G) within the lateral aspect of the IAC. The cochlear nerve (C) and inferior vestibular nerve enter the IAC inferior to the transverse crest, as depicted in the diagram (Wil kins, pp. 1063-10 7 1, 1 101-1114)

252

252. Saraf koklear

C This diagram shows the structures that traverse the internal auditory canal (IAC). The facial nerve (A) and nervus intermedius are separated from the superior vestibular nerve by a vertical crest of bone known as Bill's bar (F) . Bill's bar arises from the transverse crest (G) within the lateral aspect of the IAC. The cochlear nerve (C) and inferior vestibular nerve enter the IAC inferior to the transverse crest, as depicted in the diagram (Wil kins, pp. 1063-10 7 1, 1 101-1114)

253

253. Bagian inferior saraf vestibular

D This diagram shows the structures that traverse the internal auditory canal (IAC). The facial nerve (A) and nervus intermedius are separated from the superior vestibular nerve by a vertical crest of bone known as Bill's bar (F) . Bill's bar arises from the transverse crest (G) within the lateral aspect of the IAC. The cochlear nerve (C) and inferior vestibular nerve enter the IAC inferior to the transverse crest, as depicted in the diagram (Wil kins, pp. 1063-10 7 1, 1 101-1114)

254

254. Saraf Fasial

A This diagram shows the structures that traverse the internal auditory canal (IAC). The facial nerve (A) and nervus intermedius are separated from the superior vestibular nerve by a vertical crest of bone known as Bill's bar (F) . Bill's bar arises from the transverse crest (G) within the lateral aspect of the IAC. The cochlear nerve (C) and inferior vestibular nerve enter the IAC inferior to the transverse crest, as depicted in the diagram (Wil kins, pp. 1063-10 7 1, 1 101-1114)

255

255. Nervus intermedius

E This diagram shows the structures that traverse the internal auditory canal (IAC). The facial nerve (A) and nervus intermedius are separated from the superior vestibular nerve by a vertical crest of bone known as Bill's bar (F) . Bill's bar arises from the transverse crest (G) within the lateral aspect of the IAC. The cochlear nerve (C) and inferior vestibular nerve enter the IAC inferior to the transverse crest, as depicted in the diagram (Wil kins, pp. 1063-10 7 1, 1 101-1114)

256

256. Baris Bill

F This diagram shows the structures that traverse the internal auditory canal (IAC). The facial nerve (A) and nervus intermedius are separated from the superior vestibular nerve by a vertical crest of bone known as Bill's bar (F) . Bill's bar arises from the transverse crest (G) within the lateral aspect of the IAC. The cochlear nerve (C) and inferior vestibular nerve enter the IAC inferior to the transverse crest, as depicted in the diagram (Wil kins, pp. 1063-10 7 1, 1 101-1114)

257

257. Crest transverse

G This diagram shows the structures that traverse the internal auditory canal (IAC). The facial nerve (A) and nervus intermedius are separated from the superior vestibular nerve by a vertical crest of bone known as Bill's bar (F) . Bill's bar arises from the transverse crest (G) within the lateral aspect of the IAC. The cochlear nerve (C) and inferior vestibular nerve enter the IAC inferior to the transverse crest, as depicted in the diagram (Wil kins, pp. 1063-10 7 1, 1 101-1114)

258

Laki-laki berumur 5 tahun diberi rujukan ke kantor anda untuk pemeriksaan inkontinensi urine dan lesung pipit. Lesung pipit ini sudah diketahui sejak lahir dan telah diamputasi karena ditemukan tract ke faskia lumbodorsal. Setelah dilakukan pemeriksaan, ternyata kaki kirinya lebih pendek dan membengkok, ada parut kecil yang menutupi bekas operasinya, refleks tendon dalam pada kaki-kaki yang hipoaktif, dan skoliosis ringan. Hasil MRI pasien hampir semuanya sejalan dengan lipomielomeningosel. 258. Proses pertumbuhan embrio manakah yang biasanya terganggu sehingga menimbulkan kelainan ini? A. Disjungsi / kelainan penyambungan B. Migrasi C. Mielinasi D. Cleavage E. Segmentasi transverse

A. Three forms of lipomyelomeningocele have been described that have clinical relevance: dorsal, caudal (terminal ) , and transitional. They are believed to arise from faulty disjunction of the neuroectoderm from the overlying ectoderm, which leaves gaps between these two developing layers. Subsequently, mesenchymal cells are believed to ingress through these defective areas into the central canal, where they are induced to form a bulk of lipomatous tissue, which subsequently prevents fusion or complete closure of the neural tubE. 'With dorsal lipomas, the rootlets generally lie ventrolateral to the dorsal root entry zone, a crucial anatomic landmark during surgical procedures. Embryologically, this is related to the fact that neural crest cells lie immediately ventrolateral to the point of disjunction of cutaneous and neuroectoderm. Therefore, for many of the dorsal lipomas, ifsurgeons stay dorsomedial to the dorsal root entry zone, they will likely avoid neurologic injury. Transitional and/or caudal lipomas may be more challenging: as the anatomy is usually distorted, the lipoma-cord interface is usually less predictable, and the exiting roots may be enmeshed with lipomA. SSEP, EMG, or other monitoring procedures may serve as useful adjuncts during these challenging procedures (Youmans, pp. 3229-4243 ; American Society of Pediatric Neurosurgeons, pp. 289-301; Kaye and Black, pp. 2026- 2 03 7 )

259

Laki-laki berumur 5 tahun diberi rujukan ke kantor anda untuk pemeriksaan inkontinensi urine dan lesung pipit. Lesung pipit ini sudah diketahui sejak lahir dan telah diamputasi karena ditemukan tract ke faskia lumbodorsal. Setelah dilakukan pemeriksaan, ternyata kaki kirinya lebih pendek dan membengkok, ada parut kecil yang menutupi bekas operasinya, refleks tendon dalam pada kaki-kaki yang hipoaktif, dan skoliosis ringan. Hasil MRI pasien hampir semuanya sejalan dengan lipomielomeningosel. 259. Di manakah biasanya lokasi akar-akar dorsal dalam hubungannya dengan ekor lemak pada pasien dengan lipomielomeningosel dorsal? A. Belakang B. Dorsolateral C. Ventrolateral D. Dorsomedial E. Rostral

C. Three forms of lipomyelomeningocele have been described that have clinical relevance: dorsal, caudal (terminal ) , and transitional. They are believed to arise from faulty disjunction of the neuroectoderm from the overlying ectoderm, which leaves gaps between these two developing layers. Subsequently, mesenchymal cells are believed to ingress through these defective areas into the central canal, where they are induced to form a bulk of lipomatous tissue, which subsequently prevents fusion or complete closure of the neural tubE. 'With dorsal lipomas, the rootlets generally lie ventrolateral to the dorsal root entry zone, a crucial anatomic landmark during surgical procedures. Embryologically, this is related to the fact that neural crest cells lie immediately ventrolateral to the point of disjunction of cutaneous and neuroectoderm. Therefore, for many of the dorsal lipomas, ifsurgeons stay dorsomedial to the dorsal root entry zone, they will likely avoid neurologic injury. Transitional and/or caudal lipomas may be more challenging: as the anatomy is usually distorted, the lipoma-cord interface is usually less predictable, and the exiting roots may be enmeshed with lipomA. SSEP, EMG, or other monitoring procedures may serve as useful adjuncts during these challenging procedures (Youmans, pp. 3229-4243 ; American Society of Pediatric Neurosurgeons, pp. 289-301; Kaye and Black, pp. 2026- 2 03 7 )

260

Laki-laki berumur 5 tahun diberi rujukan ke kantor anda untuk pemeriksaan inkontinensi urine dan lesung pipit. Lesung pipit ini sudah diketahui sejak lahir dan telah diamputasi karena ditemukan tract ke faskia lumbodorsal. Setelah dilakukan pemeriksaan, ternyata kaki kirinya lebih pendek dan membengkok, ada parut kecil yang menutupi bekas operasinya, refleks tendon dalam pada kaki-kaki yang hipoaktif, dan skoliosis ringan. Hasil MRI pasien hampir semuanya sejalan dengan lipomielomeningosel. 260. Lipoma-lipoma dorsal dapat dibuang dengan aman dalam hubungannya yang bagaimana dengan zona masuk akarnya? A. Ventromedial B. Dorsolateral C. Dorsomedial D. Rostral E. Ventrolateral

C. Three forms of lipomyelomeningocele have been described that have clinical relevance: dorsal, caudal (terminal ) , and transitional. They are believed to arise from faulty disjunction of the neuroectoderm from the overlying ectoderm, which leaves gaps between these two developing layers. Subsequently, mesenchymal cells are believed to ingress through these defective areas into the central canal, where they are induced to form a bulk of lipomatous tissue, which subsequently prevents fusion or complete closure of the neural tubE. 'With dorsal lipomas, the rootlets generally lie ventrolateral to the dorsal root entry zone, a crucial anatomic landmark during surgical procedures. Embryologically, this is related to the fact that neural crest cells lie immediately ventrolateral to the point of disjunction of cutaneous and neuroectoderm. Therefore, for many of the dorsal lipomas, ifsurgeons stay dorsomedial to the dorsal root entry zone, they will likely avoid neurologic injury. Transitional and/or caudal lipomas may be more challenging: as the anatomy is usually distorted, the lipoma-cord interface is usually less predictable, and the exiting roots may be enmeshed with lipomA. SSEP, EMG, or other monitoring procedures may serve as useful adjuncts during these challenging procedures (Youmans, pp. 3229-4243 ; American Society of Pediatric Neurosurgeons, pp. 289-301; Kaye and Black, pp. 2026- 2 03 7 )

261

261. Tulang-tulang primer yang menjadi septum nasal meliputi 1. Vomer 2. Nasal 3. Ethmoid 4. Frontal

B. The ethmoid bone (vertical plate) and vomer contribute to the anterosuperior and posteroinferior portions of the nasal septum, respectively. The nasal bones and nasal crests of the frontal bones make smaller contributions (Moore, p . 945)

262

262. Organisme manakah yang paling lazim menimbulkan meningitis viral (aseptic)? A. Arbovirus B. Myxovirus C. Enterovirus D. Arenavirus E. Togavirus

C. Viral infections of the CNS can result in meningitis, ventriculitis, encephalitis, and myelitis. CSF in patients with viral syndromes of the CNS reveals increased pressure, lymphocytic pleocytosis, mild elevations in protein, and normal glucose levels. Viral (aseptic) meningitis usually peaks in the summer and fall seasons, whereas bacterial meningitis is more common during the winter. The most common causes of viral meningitis are the enteroviruses, but togaviruses are also frequent pathogens. Encephalitis often results from infections with herpes simplex virus, mumps, or arboviruses (Merritt, pp. 134-138)

263

263. Tahapan tidur manakah yang berasosiasi dengan teror malam? A. Tahapan 1 B. Tahapan 3 C. Tahapan 4 D. REM E. B dan C

E. Night terrors most commonly occur during stages 3 and 4 of deep sleep. During a night terror, the child appears extremely frightened and agitated and, although seemingly awake, is actually in deep sleep (stage 3 or 4) and is difficult to rousE. Upon awakening, the child has no apparent memory of the event. Although concerning to parents, night CHAPTER 8 Multidisciplinary Self-Assessment Answers 283 terrors are felt to be benign and self-limited (Rudolph, p. 28; Merritt, p. 15).

264

264. TN. X, 77 tahun dg riwayat 4 bulan epistaksis sebelah, dan keluar cairan nasal. Hasil MRI-nya ditunjukkan pada Gambar di bawah ini. Analis histopatologis dari tumor mengungkapkan adanya sel-sel kecil seragam dengan nuklei bulat, sitoplasma kecil, inti retikular yang prominen, dan roset Homer-Wright jarang. Imunohistokimiawi positif untuk enolase khas-neuron dan S-100 tapi hanya sitokeratinm, CD20, dan CD79a negatif. Diagnosis manakah yang paling mungkin? A. Limpoma B. Karsinoma sel skuamus C. Estesioneuroblastoma D. Adenokarsinoma E. Rhabdomiosarkoma

C. The clinical history of this patient and destructive MRI appearance of this lesion are highly suggestive of a malignant neoplasm involving the paranasal sinuses. The histologic and immunohistochemical markers are most consistent with esthesioneuroblastoma (Kaye and Laws, pp. 885-889)

265

65. Palsi abdusen yang berasosiasi dengan sindroma Homer ipsilateral mengisyaratkan adanya lesi pada lokasi yang mana? A. Pontine tegmentum B. Saluran Dorello C. Kistern prapontin D. Sinus kavernosus E. Daerah ligamentum Gruber

D. Sympathetic nervous system fibers (traveling with the internal carotid artery) and cranial nerve VI are in close proximity in the cavernous sinus. Tumors' or other lesions in this location may produce oculosympathetic paralysis (without anhidrosis) (Brazis, p. 265)

266

266. Struktur pra-motorik pokok yang berhubungan dengan sakkade vertikal sadar adalah A. Formasi retikular pontine paramedian (PPRF) B. Nukleus interstitial rostral dari Faskikulus longitudinal medial (MLF) C. Nukleus interstitial rostral dari Cajal D. Nukleus Roller E. Nukleus Collier

B. Vertical and torsional saccadic eye movements are generated by the rostral interstitial nucleus of the 1v1LF (riMLF), located in the prerubral field of the ventral diencephalomesencephalic junction, rostral to the tractus retroflexus and ventral to the nucleus of Darkschewitsch. Although cells involved with downward saccades are different from the ones involved with upward saccades, they are dispersed throughout the riMLF without separation of upward and downward pools ( Brazis, pp. 199-200)

267

267. Flushing dan perspirasi setelah STN DBS Observasi atas berbagai dampak negatif selama stimulasi otak dalam (DBS) seringkali menandai sampai sejauh mana penyebaran arus ke struktur-struktur di sekitarnya. A. Anterior B. Posterior C. Medial D. Lateral E. Anterior dan lateral F. Inferior dan Medial G. Posterior dan Medial H. A - G salah

A Refer to Table 8.267-8.276A (Tarsy, pp. 192-193, 206)

268

268. Disartria setelah STN DBS Observasi atas berbagai dampak negatif selama stimulasi otak dalam (DBS) seringkali menandai sampai sejauh mana penyebaran arus ke struktur-struktur di sekitarnya. A. Anterior B. Posterior C. Medial D. Lateral E. Anterior dan lateral F. Inferior dan Medial G. Posterior dan Medial H. A - G salah

D Refer to Table 8.267-8.276A (Tarsy, pp. 192-193, 206)

269

269. Parestesia setelah Gpi DBS Observasi atas berbagai dampak negatif selama stimulasi otak dalam (DBS) seringkali menandai sampai sejauh mana penyebaran arus ke struktur-struktur di sekitarnya. A. Anterior B. Posterior C. Medial D. Lateral E. Anterior dan lateral F. Inferior dan Medial G. Posterior dan Medial H. A - G salah

G Refer to Table 8.267-8.276A (Tarsy, pp. 192-193, 206)

270

270. Fotopsia dan mual setelah Gpi DBS Observasi atas berbagai dampak negatif selama stimulasi otak dalam (DBS) seringkali menandai sampai sejauh mana penyebaran arus ke struktur-struktur di sekitarnya. A. Anterior B. Posterior C. Medial D. Lateral E. Anterior dan lateral F. Inferior dan Medial G. Posterior dan Medial H. A - G salah

A Refer to Table 8.267-8.276A (Tarsy, pp. 192-193, 206)

271

271. Diplopia setelah STN DBS Observasi atas berbagai dampak negatif selama stimulasi otak dalam (DBS) seringkali menandai sampai sejauh mana penyebaran arus ke struktur-struktur di sekitarnya. A. Anterior B. Posterior C. Medial D. Lateral E. Anterior dan lateral F. Inferior dan Medial G. Posterior dan Medial H. A - G salah

F Refer to Table 8.267-8.276A (Tarsy, pp. 192-193, 206)

272

272. Kontraksi tonik setelah Vim DBS Observasi atas berbagai dampak negatif selama stimulasi otak dalam (DBS) seringkali menandai sampai sejauh mana penyebaran arus ke struktur-struktur di sekitarnya. A. Anterior B. Posterior C. Medial D. Lateral E. Anterior dan lateral F. Inferior dan Medial G. Posterior dan Medial H. A - G salah

D Refer to Table 8.267-8.276A (Tarsy, pp. 192-193, 206)

273

273. Bleparospasme setelah STN DBS Observasi atas berbagai dampak negatif selama stimulasi otak dalam (DBS) seringkali menandai sampai sejauh mana penyebaran arus ke struktur-struktur di sekitarnya. A. Anterior B. Posterior C. Medial D. Lateral E. Anterior dan lateral F. Inferior dan Medial G. Posterior dan Medial H. A - G salah

H Refer to Table 8.267-8.276A (Tarsy, pp. 192-193, 206)

274

274. Disekuilbrium dan ataksia gait (tanpa ataksia anggota badan) setelah STN DBS Observasi atas berbagai dampak negatif selama stimulasi otak dalam (DBS) seringkali menandai sampai sejauh mana penyebaran arus ke struktur-struktur di sekitarnya. A. Anterior B. Posterior C. Medial D. Lateral E. Anterior dan lateral F. Inferior dan Medial G. Posterior dan Medial H. A - G salah

C Refer to Table 8.267-8.276A (Tarsy, pp. 192-193, 206)

275

275. Kontraksi tonik setelah STN DBS Observasi atas berbagai dampak negatif selama stimulasi otak dalam (DBS) seringkali menandai sampai sejauh mana penyebaran arus ke struktur-struktur di sekitarnya. A. Anterior B. Posterior C. Medial D. Lateral E. Anterior dan lateral F. Inferior dan Medial G. Posterior dan Medial H. A - G salah

E Refer to Table 8.267-8.276A (Tarsy, pp. 192-193, 206)

276

276. Parestesia setelah Vim DBS Observasi atas berbagai dampak negatif selama stimulasi otak dalam (DBS) seringkali menandai sampai sejauh mana penyebaran arus ke struktur-struktur di sekitarnya. A. Anterior B. Posterior C. Medial D. Lateral E. Anterior dan lateral F. Inferior dan Medial G. Posterior dan Medial H. A - G salah

B Refer to Table 8.267-8.276A (Tarsy, pp. 192-193, 206)

277

277. Temuan histologis manakah yg sifatnya patognomonik bagi denervasi yang diikuti oleh reinervasi serat-serat otot? A. Serat-serat otot atropis B. Serat-serat angular C. Infiltrasi eosinopilis D. Sel-sel target E. Pengelompokkan serat otot berdasarkan tipe-nya.

E. Denervation typically causes atrophy of muscle fibers, which eventually become angulated, as well as the formation of distinctive fibers with three unique zones often referred to as "target cells. " Reinnervation is characterized by type-specific grouping of fibers, which is in contrast to themixed, "checkerboard" pattern of types 1 and 2 skeletal fibers and the atrophic, angulated cells of denervated fibers. Eosinophils in muscle cells are often seen with parasitic infections ( Merritt, p. 736)

278

278. Fotomikrograf yang ditunjukkan di bawah ini paling sejalan dg diagnosis yg mana? A. Limpoma B. Karsinoma sel skuamus C. Estesioneuroblastoma D. Adenokarsinoma E. Rhabdomiosarkoma

A. Within this tuberculoma, note the prominent region of caseating necrosis (left), in which no cellular detail can be ascertaineD. A peripheral rim of lymphocytes and a fibrous capsule surround the granuloma, and an occasional histiocyte is observed (Ellison , pp. 339-342)

279

279. Spesimen kasar yang ditunjukkan di bawah ini mengungkapkan apa? A. Neurokistiserkosis B. Tumor ventricular ketiga C. Penyakit metastatis D. Toksoplasmosis E. Sklerosis MULTIPEL

C . Note the multiple lesions at the gray-white junction, which is most consistent with metastatic disease (Ellison, pp. 743-750)

280

280. Otot-otot mana saja yang mengabduksi urat-urat suara? 1. Krikoaritenoid lateral 2. Aritenoid transverse 3. Krikotiroid 4. Krikoaritenoid posterior

D . The right and left posterior cricoarytenoid muscles abduct the vocal cords (Moore, p. 1060)

281

281. Pemberian air dingin pada telinga kanan memicu jenis respons mana? A. nistagmus menyengat ke arah kiri B. Mata menyimpang ke kiri C. Nistagmus menyengat sebelah kanan D. Nistagmus retraksi konvergen E. Respons WEBINO

A. Injecting cold water into the right ear causes the endolymph to move away from the ampulla of the horizontal canal. This causes a decreased tone of input into the left abducens nucleus, which results in slow conjugate eye movements toward the right due to right lateral rectus and left medial rectus contraction. Subsequently, there will be compensatory fast eye movements (left-beating nystagmus) to the left. Warm water injected into the right ear will produce the opposite responsE. The mnemonic COWS (cold opposite; warm same) helps define the fast phase of eye movements during caloric testing (Kline, pp. 57-59 )

282

282. Tidak ada pengaruhnya terhadap pupil Homer A. Larutkan pilokarpin (1/8 %) B. 1% Hidroxiampetamin C. 10% kokain D. Atropin E. Larutan epineprin (1:1000)

C Refer t o discussion questions 55 -58, neuroanatomy chapter (Geyer, p. 27 4 ; Greenberg, pp. 576- 5 78)

283

283. Membuka pupil homer ordo kedua A. Larutkan pilokarpin (1/8 %) B. 1% Hidroxiampetamin C. 10% kokain D. Atropin E. Larutan epineprin (1:1000)

B Refer t o discussion questions 55 -58, neuroanatomy chapter (Geyer, p. 27 4 ; Greenberg, pp. 576- 5 78)

284

284. Membuka pupil homer ordo ketiga A. Larutkan pilokarpin (1/8 %) B. 1% Hidroxiampetamin C. 10% kokain D. Atropin E. Larutan epineprin (1:1000)

D Refer t o discussion questions 55 -58, neuroanatomy chapter (Geyer, p. 27 4 ; Greenberg, pp. 576- 5 78)

285

285. Membuka pupil normal A. Larutkan pilokarpin (1/8 %) B. 1% Hidroxiampetamin C. 10% kokain D. Atropin E. Larutan epineprin (1:1000)

D Refer t o discussion questions 55 -58, neuroanatomy chapter (Geyer, p. 27 4 ; Greenberg, pp. 576- 5 78)

286

286. Membatasi pupil Adie A. Larutkan pilokarpin (1/8 %) B. 1% Hidroxiampetamin C. 10% kokain D. Atropin E. Larutan epineprin (1:1000)

A Refer t o discussion questions 55 -58, neuroanatomy chapter (Geyer, p. 27 4 ; Greenberg, pp. 576- 5 78)

287

287. Berdasarkan pantulan gelombang suara dari target yang bergerak A. Ultrasonografi mode-B B. Ultrasonografi Doppler C. A dan B D. Bukan A, B dan C

B Brightness modulation ultrasonography (B mode) , based on reflection of sound waves off tissue interfaces, is better used to view anatomic detail and can be used to measure blood vessel diameter and evaluate plaques. It typically shows the carotid system as a pulsatile luminal structure, with a thin echogenic line representing the intimal surfacE. The basic principle underlying this mode of irriaging is the variable impedance that different body tissues naturally possess. Doppler shift ultrasonography is based on the reflection of sound waves off moving targets such as red blood cells. It is better for evaluating flow dynamics such as blood velocity, which typically increases in segments of stenosis. Although the combination of B-mode and Doppler ultrasoqography improved the ability to localize the source of the reflected signal when it was involved with complicated blood velocity patterns (vasospasm, atherosclerosis) , the signal was still quit difficult to interpret. More recently, through the use of fast Fourier transformations, the complex signal ,,•as separated into a number of single-frequency components, which made it easier to interpret. These technologies were later integrated, and duplex ultrasonography was born. The advantage of duplex scanning compared to the pre-existing technology is that it could sample flow within a vessel while simultaneously displaying vessel wall anatomy (Youmans, pp. 1561- 1565 )

288

288. Paling baik digunakan untuk menilai dinamika-dinamika aliran A. Ultrasonografi mode-B B. Ultrasonografi Doppler C. A dan B D. Bukan A, B dan C

B Brightness modulation ultrasonography (B mode) , based on reflection of sound waves off tissue interfaces, is better used to view anatomic detail and can be used to measure blood vessel diameter and evaluate plaques. It typically shows the carotid system as a pulsatile luminal structure, with a thin echogenic line representing the intimal surfacE. The basic principle underlying this mode of irriaging is the variable impedance that different body tissues naturally possess. Doppler shift ultrasonography is based on the reflection of sound waves off moving targets such as red blood cells. It is better for evaluating flow dynamics such as blood velocity, which typically increases in segments of stenosis. Although the combination of B-mode and Doppler ultrasoqography improved the ability to localize the source of the reflected signal when it was involved with complicated blood velocity patterns (vasospasm, atherosclerosis) , the signal was still quit difficult to interpret. More recently, through the use of fast Fourier transformations, the complex signal ,,•as separated into a number of single-frequency components, which made it easier to interpret. These technologies were later integrated, and duplex ultrasonography was born. The advantage of duplex scanning compared to the pre-existing technology is that it could sample flow within a vessel while simultaneously displaying vessel wall anatomy (Youmans, pp. 1561- 1565 )

289

289. Berdasarkan pantulan gelombang suara dari antar muka jaringan yang stasioner A. Ultrasonografi mode-B B. Ultrasonografi Doppler C. A dan B D. Bukan A, B dan C

A Brightness modulation ultrasonography (B mode) , based on reflection of sound waves off tissue interfaces, is better used to view anatomic detail and can be used to measure blood vessel diameter and evaluate plaques. It typically shows the carotid system as a pulsatile luminal structure, with a thin echogenic line representing the intimal surfacE. The basic principle underlying this mode of irriaging is the variable impedance that different body tissues naturally possess. Doppler shift ultrasonography is based on the reflection of sound waves off moving targets such as red blood cells. It is better for evaluating flow dynamics such as blood velocity, which typically increases in segments of stenosis. Although the combination of B-mode and Doppler ultrasoqography improved the ability to localize the source of the reflected signal when it was involved with complicated blood velocity patterns (vasospasm, atherosclerosis) , the signal was still quit difficult to interpret. More recently, through the use of fast Fourier transformations, the complex signal ,,•as separated into a number of single-frequency components, which made it easier to interpret. These technologies were later integrated, and duplex ultrasonography was born. The advantage of duplex scanning compared to the pre-existing technology is that it could sample flow within a vessel while simultaneously displaying vessel wall anatomy (Youmans, pp. 1561- 1565 )

290

290. Biasanya menunjukkan sistem karotid sebagai struktur luminal berdenyut dengan garis ekogenik mencerminkan permukaan intimal A. Ultrasonografi mode-B B. Ultrasonografi Doppler C. A dan B D. Bukan A, B dan C

A Brightness modulation ultrasonography (B mode) , based on reflection of sound waves off tissue interfaces, is better used to view anatomic detail and can be used to measure blood vessel diameter and evaluate plaques. It typically shows the carotid system as a pulsatile luminal structure, with a thin echogenic line representing the intimal surfacE. The basic principle underlying this mode of irriaging is the variable impedance that different body tissues naturally possess. Doppler shift ultrasonography is based on the reflection of sound waves off moving targets such as red blood cells. It is better for evaluating flow dynamics such as blood velocity, which typically increases in segments of stenosis. Although the combination of B-mode and Doppler ultrasoqography improved the ability to localize the source of the reflected signal when it was involved with complicated blood velocity patterns (vasospasm, atherosclerosis) , the signal was still quit difficult to interpret. More recently, through the use of fast Fourier transformations, the complex signal ,,•as separated into a number of single-frequency components, which made it easier to interpret. These technologies were later integrated, and duplex ultrasonography was born. The advantage of duplex scanning compared to the pre-existing technology is that it could sample flow within a vessel while simultaneously displaying vessel wall anatomy (Youmans, pp. 1561- 1565 )

291

291. Dapat menarik sampel aliran darah di dalam satu pembuluh dan berbarengan dengan itu menayangkan anatomi dinding pembuluhnya A. Ultrasonografi mode-B B. Ultrasonografi Doppler C. A dan B D. Bukan A, B dan C

D Brightness modulation ultrasonography (B mode) , based on reflection of sound waves off tissue interfaces, is better used to view anatomic detail and can be used to measure blood vessel diameter and evaluate plaques. It typically shows the carotid system as a pulsatile luminal structure, with a thin echogenic line representing the intimal surfacE. The basic principle underlying this mode of irriaging is the variable impedance that different body tissues naturally possess. Doppler shift ultrasonography is based on the reflection of sound waves off moving targets such as red blood cells. It is better for evaluating flow dynamics such as blood velocity, which typically increases in segments of stenosis. Although the combination of B-mode and Doppler ultrasoqography improved the ability to localize the source of the reflected signal when it was involved with complicated blood velocity patterns (vasospasm, atherosclerosis) , the signal was still quit difficult to interpret. More recently, through the use of fast Fourier transformations, the complex signal ,,•as separated into a number of single-frequency components, which made it easier to interpret. These technologies were later integrated, and duplex ultrasonography was born. The advantage of duplex scanning compared to the pre-existing technology is that it could sample flow within a vessel while simultaneously displaying vessel wall anatomy (Youmans, pp. 1561- 1565 )

292

292. Gen manakah yang menyimpang pada atropi otot spinobular (Penyakit Kennedy)? A. Gen reseptor androgen B. Gen distropia C. Gen dismutase superoksida D. Gen reseptor TGF-β E. Gen mitokondrial kompleks 1

A . Spinobulbar muscular atrophy (SBMA), or Kennedy's disease, is a trinucleotide repeat disorder (CAG) that involves mutations of the androgen receptor gene, which is located on the X chromosomE. It is an X-linked recessive disorder that typically affects adult males in the third decade of life and results in lower motor neuron degeneration only. Symptoms are similar to ALS and include dysarthria, dysphagia, limb weakness, hyporeflexia, and tongue fasciculations. SMBA progresses much more slowly than ALS, and patients may survive for extended periods after initial symptom onset (Merritt, pp. 709-7 10).

293

293. Semua pernyataan di bawah ini adalah benar mengenai levodopa, KECUALI A. Vitamin B6 menurunkan dosis efektif levodop B. Penghambat MAO dapat memperhebat efek dopamin sentral dengan menurunkan metabolisme dopamin C. Dapat menyebabkan hipotensi ortostatis D. Karbidopa dapat meningkatkan efektivitas levodopa dengan menghambat penghambat Dekarboksilase periferal E. Antipsikotik meningkatkan efektivitas levodopa

. E. Antipsychotics decrease the efficacy of levodopa by inhibiting D2 receptors. Dose-related, reversible side effects include nausea, vomiting, orthostatic hypotension, dyskinesias, restlessness, anxiety, athetosis, insomnia, hallucinations, mania, nightmares, and dystonia (Merritt, pp. 689-691)

294

294. Sindroma RAMSAY-HUNT biasanya melibatkan saraf kranial mana? A. Saraf kranial ketujuh sentral B. Saraf kranial ketujuh bawah C. Saraf ofaktoris D. Pencabangan mandibular saraf trigeminal E. Saraf troklear

B. The Ramsay Hunt syndrome is associated with herpetic infections of the geniculate ganglion. Herpetic eruptions may appear in the pinna, EAC, and possibly on the tympanic membranE. It is most often associated with a lower seventh cranial nerve palsy, although there may also be decreased hearing, tinnitus, and/or vertigo from involvement of CN VIII (Greenberg, p. 381)

295

295. Gejala-gejala positif skizofrenia merupakan akibat naiknya kegiatan dopamin pada jalur mana? A. Nigrostriatal B. Tuberoinfundibular C. Mesokortikal D. Mesolimbik E. Tuberolimbik

D. The positive symptoms of schizophrenia, such as hallucinations, are the direct result of dopamine overactivity in the mesolimbic pathway. Most antipsychotics work by blocking the dopamine receptors in this pathway and often work well for the positive symptoms of schizophreniA. The negative symptoms (flat affect, decreased motivation) are the result of decreased dopamine in the mesocortical system and are often not improved with the commencement of antipsychotics ( Kandel, p. 1203 )

296

296. Otot-otot manakah yang terlibat pada naiknya penutupan mandibel atau mulut? 1. Muskulus pterigoid medial 2. Muskulus masseter 3. Muskulus temporalis 4. Muskulus buccinato

A . The masseter, temporalis, and medial pterygoid muscles are the prime elevators of the mandible, whereas the buccinator muscle compresses the cheek (Apri l , pp. 496, 504) .

297

297. Apakah yang dijelaskan pada CT scan di bawah ini? A. Bukti darah interhemisferis belakang setelah trauma kepala B. Tanda delta kosong dari trombosis sagital atas yang berasosiasi dengan tumor kistik C. Pinesositoma D. Sebuah tanda MCA terlalu padat E. Infark temporal belakang kiri

B. Note the empty delta sign, representing an occluded superior sagittal sinus. This abnormality may be associated with pregnancy, dehydration, infections, hypercoagulable states, and tumors (as in this case) (Merritt, pp. 269- 2 7 1 )

298

298. Semua pernyataan di bawah ini adalah benar mengenai sindroma ketoasidosis diabetik nonketotis hiperglikemis (HHNS), KECUALI A. Hampir semua pasien menderita hipernatremik ringan B. HHNS seringkali dibarengi oleh azotemia perenal parah C. HHNS berasosiasi dengan celah anion D. Hampir semua pasien mengalami hipokalemia E. Insulin selalu diberikan pada masa pengelolaan awalnya

E . Insulin may or may not be used initially in patients with HHNS. Serum glucose levels may drop precipitouslywith fluid replacement alonE. Insulin is required for patients who are acidotic, hyperkalemic, or in renal failurE. If insulin is used, it must be administered in a low-dose regimen as a continuous infusion. To avoid overcorrection, glucose levels must be monitored frequently and the insulin drip stopped once glucose levels fall below 300 mg/dL or so. At this point 5% dextrose should be added to the infusion. Treatment of HHNS focuses primarily on replacing fluid losses, which may be up to 9 to 12 L in some cases, as well as correcting the CHAPTER 8 Multidisciplinary Self-Assessment Answers 285 hyperosmolarity and any electrolyte imbalance (Merritt, pp. 292-293)

299

299. Fenomenon Raynaud. fibrosis pulmonaris Jodohkanlah pengobatan di bawah ini dengan potensi toksisitasnya A. Metotreksat B. Vinkristin C. Bleomisin D. Jawaban A, B dan C semuanya salah

C Methotrexate may cause leukoencephalopathy, myelosuppression, nephrotoxicity, and mucositis; if administered intrathecally, it can cause arachnoiditis. Bleomycin is associated with Raynaud's phenomenon, myelosuppression, and pulmonary fibrosis, while vincristine can. cause a peripheral neuropathy (Kay and Laws, pp. 381-383).

300

300. Leukoensepalopati Jodohkanlah pengobatan di bawah ini dengan potensi toksisitasnya A. Metotreksat B. Vinkristin C. Bleomisin D. Jawaban A, B dan C semuanya salah

A Methotrexate may cause leukoencephalopathy, myelosuppression, nephrotoxicity, and mucositis; if administered intrathecally, it can cause arachnoiditis. Bleomycin is associated with Raynaud's phenomenon, myelosuppression, and pulmonary fibrosis, while vincristine can. cause a peripheral neuropathy (Kay and Laws, pp. 381-383).